Clinical trial NCT01231412
Conditions: Acute Lymphoblastic Leukemia Acute Myeloid Leukemia Aggressive Non-Hodgkin Lymphoma Chronic Lymphocytic Leukemia Diffuse Large B-Cell Lymphoma Hematopoietic and Lymphoid Cell Neoplasm Indolent Non-Hodgkin Lymphoma Mantle Cell Lymphoma Myelodysplastic Syndrome Myeloproliferative Neoplasm Prolymphocytic Leukemia Recurrent Chronic Lymphocytic Leukemia Recurrent Plasma Cell Myeloma Refractory Chronic Lymphocytic Leukemia Refractory Chronic Myelogenous Leukemia, BCR-ABL1 Positive Refractory Hodgkin Lymphoma Small Lymphocytic Lymphoma T-Cell Chronic Lymphocytic Leukemia Waldenstrom Macroglobulinemia
Sponsor: Fred Hutchinson Cancer Center
Start date: 2010-11-01; Completion date: 2017-06-30
Enrollment: 174 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This randomized phase III trial studies how well graft-vs-host disease (GVHD) prophylaxis works in treating patients with hematologic malignancies undergoing unrelated donor peripheral blood stem cell transplant. Giving chemotherapy and total-body irradiation before a donor peripheral blood stem cell transplant (PBSCT) helps stop the growth of cancer cells. It may also stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving total-body irradiation (TBI) together with fludarabine phosphate (FLU), cyclosporine (CSP), mycophenolate mofetil (MMF), or sirolimus before transplant may stop this from happening.

Detailed description:
PRIMARY OBJECTIVES:

I. To compare the effectiveness of 2 GVHD prophylaxis regimens in preventing acute grades II-IV GVHD.

SECONDARY OBJECTIVES:

I. Compare non-relapse mortality in the 2 arms.

II. Compare survival and progression-free survivals in the 2 arms.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

All patients receive FLU intravenously (IV) over 30 minutes on days -4 to -2 followed by 2-3 Gy TBI on day 0.

ARM 0: Patients receive CSP orally (PO) twice daily (BID) on days -3 to 96 with taper to day 150 and and sirolimus PO once daily (QD) on days -3 to 150 with taper to day 180. Arm removed as of 14-Sep-2011

ARM I: Patients receive CSP orally (PO) twice daily (BID) on days -3 to 96 with taper to day 150 and MMF PO three times daily (TID) on days 0-29 and then BID on days 30-150 with taper to day 180.

ARM II: Patients receive CSP as in Arm I and sirolimus PO once daily (QD) on days -3 to 150 with taper to day 180. Patients also receive MMF PO TID on days 0-29 and then BID on days 30-40. MMF will then be discontinued without taper unless GVHD or disease relapse/progression occurs.

TRANSPLANTATION: Patients undergo allogeneic PBSCT on day 0 following the TBI.

After completion of study treatment, patients are followed up periodically.

Arms: arm 1: Patients receive FLU IV over 30 minutes on days -4 to -2. Patients also receive CSP PO BID on days -3 to 96 with taper to day 150 and MMF PO TID daily on days 0-29 and then BID on days 30-150 with taper to day 180. Patients undergo allogeneic PBSCT on day 0 following the TBI. arm 2: Patients receive FLU and CSP as in Arm I and sirolimus PO QD on days -3 to 150 with taper to day 180. Patients also receive MMF PO TID on days 0-29 and then BID on days 30-40. MMF will then be discontinued without taper unless GVHD or disease relapse/progression occurs. Patients undergo allogeneic PBSCT on day 0 following the TBI. arm 3: Patients receive CSP orally (PO) twice daily (BID) on days -3 to 96 with taper to day 150 and and sirolimus PO once daily (QD) on days -3 to 150 with taper to day 180. Arm removed as of 14-Sep-2011
Interventions: intervention 1: Allogeneic Hematopoietic Stem Cell Transplantation intervention 2: Cyclosporine intervention 3: Fludarabine Phosphate intervention 4: Mycophenolate Mofetil intervention 5: Peripheral Blood Stem Cell Transplantation intervention 6: Sirolimus intervention 7: Total-Body Irradiation
Intervention descriptions: intervention 1: Undergo allogeneic PBSCT intervention 2: Given PO or IV intervention 3: Given IV intervention 4: Given PO intervention 5: Undergo allogeneic PBSCT intervention 6: Given PO intervention 7: Undergo TBI

Protocol documents:
Prot_SAP_000.pdf: 
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FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
SEATTLE CHILDREN’S  
 
Current Version:  07/20/2016 
 
Previous Version: 10/29/2015 
 
1. 
A Randomized Phase III Study to Determine the Most Promising Postgrafting Immunosuppression 
for Prevention of Acute GVHD after Unrelated Donor Hematopoietic Cell Transplantation using 
Nonmyeloablative Conditioning for Patients with Hematologic Malignancies: A Multi-Center Trial 
 
Investigators:  
Investigators                                                                                                                                   Phone 
Brenda M. Sandmaier, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-4961 
David Maloney, MD, PhD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-5616 
Mary E. D, Flowers, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-5115 
Effie Petersdorf, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-5244 
Ann Woolfrey, MD 
Member, FHCRC, Professor of Pediatrics, UW 
(206) 667-4453 
Paul J. Martin, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-4798 
Marco Mielcarek, MD 
Associate Member, FHCRC, Associate Professor, UW 
(206) 667-2827 
Rainer Storb, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-4407 
Statistician: 
 
 
Barry Storer, PhD 
Member, FHCRC, Affiliated Associate Professor of 
Biostatistics, UW 
(206) 667-6151 
Radiation Oncologist: 
 
 
Ralph Ermoian, MD 
Assistant Professor, Radiation Oncology, UW 
(206) 589-4100 
 
Research Nurses: Michelle Bouvier, RN (206) 667-6993, pager (206) 995-7658 
 
Additional Performance Sites 
Investigators 
Emergency Phone 
Numbers 
University of Colorado 
Jonathan Gutman, MD 
(303) 266-0763 
University of Utah 
Michael Boyer, MD 
(801) 585-3229 
Rigshospitalet 
Søren Lykke Petersen, MD 
+45 35 45 1134  
Aarhus Hospital 
Gitte Olesen, MD 
+45 78 46 1152 
Emory University 
Amy Langston, MD 
(404) 778-4189 
HealthONE Presbyterian St. Luke’s 
Medical Center 
Michael Maris, MD 
(720) 754-4800 
Veterans Affairs Puget Sound Health 
Care System 
Thomas Chauncey, MD, PhD 
(206) 762-1010 
University of Tubingen 
Wolfgang Bethge, MD 
49-7071-2982711 
University of Leipzig 
Georg-Nikolaus Franke, MD 
0341-97-13842 
University of Koln 
Kai Huebel, MD 
0221-4785133 
                                                                
Emergency Phone FHCRC: (206) 598-8902, FAX (206) 598-4034 
 
 
 
 
 SEATTLE CHILDREN’S: (206) 987-2000*, FAX (206) 987-2764 
*Ask Seattle Children’s Operator for “Transplant Provider On-Call” 
 


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Table of Contents 
2. 
Introduction ................................................................................................................................................... 3 
3.     Background ................................................................................................................................................... 4 
4. 
Proposal ....................................................................................................................................................... 10 
5. 
Primary Objective ....................................................................................................................................... 11 
6. 
Secondary Objectives.................................................................................................................................. 11 
7. 
Patient Selection .......................................................................................................................................... 11 
8. 
Donor Selection ........................................................................................................................................... 13 
9.     Informed Consent ....................................................................................................................................... 14 
10.   Protocol Registration .................................................................................................................................. 14 
11.   Plan of Treatment ....................................................................................................................................... 15 
12.   Assessment of Disease Responses .............................................................................................................. 28 
13.   Patient Evaluation ....................................................................................................................................... 30 
14.  Drugs and Toxicities .................................................................................................................................... 50 
15.  Records.......................................................................................................................................................... 54 
16.  Statistical Consideration and Termination of Study ................................................................................ 54 
17.  Data and Safety Monitoring Plan ............................................................................................................... 55 
18.  TARGETED / PLANNED ENROLLMENT ............................................................................................. 58 
19.  References ..................................................................................................................................................... 59 
20.  Table of Appendices ..................................................................................................................................... 63 
 
 
 


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2. Introduction  
 
  Hematopoietic cell transplantation (HCT) from unrelated donors after nonmyeloablative conditioning is 
effective therapy for patients with advanced hematologic malignancies who are considered at high risk for 
treatment related mortality with high dose conditioning because of older age or comorbidities 1,2. The 
nonmyeloablative regimen currently used consists of fludarabine (FLU) (90mg/m2), 2 Gy total body 
irradiation (TBI) and post-grafting immunosuppression with a calcineurin inhibitor [cyclosporine (CSP) or 
tacrolimus] and mycophenolate mofetil (MMF). For patients transplanted with HLA-matched unrelated 
donors CSP is started on day –3 on MMF on day 0. This immunosuppressive regimen has been proven 
successful in enabling sustained engraftment of granulocyte colony stimulating factor (G-CSF) mobilized 
peripheral blood stem cells (PBSC) from unrelated donors, with a rejection rate as low as 5 % 3. However, 
graft versus host disease (GVHD) rates remain high with cumulative incidences of grade II-IV acute and 
extensive chronic GVHD of 52% and 40%, respectively. In a analysis of GVT effects in 322 patients with 
hematological malignancies, multivariate analyses showed an association between extensive chronic GVHD 
and a decreased risk of relapse/progression (p=0.003), while acute GVHD only was associated with non-
relapse mortality without any statistically significant impact on the risk of relapse/progression 4. These data 
suggest that outcomes of nonmyeloablative conditioning and unrelated HCT could be improved by more 
intensive post-grafting immunosuppression aimed at suppressing acute GVHD, while allowing chronic 
GVHD to occur. Protocol 1938 was a randomized phase II study designed to determine the most promising 
postgrafting immunosuppression for prevention of acute GVHD after unrelated donor transplantation using 
nonmyeloablative conditioning. Patients were randomized into three arms, where two of the arms consisted 
of different MMF and tacrolimus schedules, while the third arm had sirolimus added to the combination of 
tacrolimus and MMF. By May 2010 183 patients had been accrued. The cumulative incidence of grade II-
IV acute GVHD was significantly lower (p=0.03) in the sirolimus arm (45%) as compared to the reference 
arm (65%), which consisted of tacrolimus and MMF, administered in a schedule similar to the above 
mentioned current standard of care. In the analysis of the impact of sirolimus on the individual grades of 
acute GVHD, the benefit was only observed for grade II. No difference between treatment arms was 
observed for grade III-IV acute GVHD, chronic GVHD, nonrelapse mortality and relapse/progression. The 
rationale for substituting tacrolimus for CSP in protocol 1938 was derived from two large randomized trials 
of myeloablative conditioned transplants showing decreased incidences of acute and chronic GVHD in the 
favor of tacrolimus as compared to CSP, both in combination with methotrexate (MTX)5,6. However, when 
the results of protocol 1938 were compared to a historical cohort 174 unrelated non-myeloablative 
transplants treated with a combination of CSP and MMF, no difference was observed in any of the outcome 
parameters. Thus, suggesting that the substitution of CSP for tacrolimus did not entail additional GVHD 
control. In a retrospective analysis performed in recipients of high-dose conditioning, there was a finding 
that there was a higher risk of grades 3-4 GVHD in the tacrolimus cohort as compared to the CSP cohort. 
However, this analysis was confounded by the fact that the two cohorts differed both in time (majority of 
patients before 2004 were treated with CSP and with tacrolimus after 2004). Also, starting in 2003, all 
patients were treated with ursodiol which significantly reduces the rate of grades 2-4 and 3-4 acute and 
chronic GVHD (personal communication, Paul Martin). 
  The results using triple therapy with the addition of sirolimus to the “standard” immunosuppressive 
regimen was very promising and there was a significant reduction in acute GVHD. The goal of the current 
protocol is to compare in a phase III randomized trial, the effectiveness of 2 GVHD prophylaxis regimens in 
preventing acute grades II-IV GVHD. Both arms will use CSP until day 96 then tapered off by day 150. 
Arm 1 (similar to the former unrelated donor nonmyeloablative protocol 1938 Arm 2) will be the “reference 
arm” in which MMF is given tid until day 30, then bid until day 150 with a taper through day 180. In Arm 2 
MMF will be given through day 40, and then discontinued without a taper and sirolimus will be given until 
day 150 with a taper though day 180. The current protocol’s primary objective is to reduce the incidence of 
acute GVHD after unrelated nonmyeloablative HCT. 


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3.  Background 
 
The proposed approach to establish sustained engraftment and GVHD control after nonmyeloablative 
conditioning in this protocol is derived from preclinical work performed at the FHCRC in the canine 
model7-9 and clinical protocols 1463, 1641, 1668 and 1938.  
 
A. Postgrafting immunosuppression in the canine model with CSP and MMF 
 
The canine studies demonstrated that the use of immunosuppression after transplant with CSP and MMF 
could substitute for pre-transplant TBI otherwise required as pre-transplant immunosuppression for 
establishing allografts in major histocompatibility complex (MHC)-identical littermate recipients. In these 
studies, the administration of CSP for 35 days post-transplant resulted in stable engraftment of marrow from 
7 of 7 MHC-identical littermates after conditioning with 450 cGy of TBI 10. In contrast, without post-
grafting CSP, 60% of dogs rejected their grafts after this radiation dose. In subsequent studies using marrow 
grafts from MHC-identical littermates given sublethal TBI (200 cGy), CSP alone was ineffective for 
establishing donor grafts 9. However, combination therapy consisting of MMF or methotrexate (MTX) and 
CSP was successful in achieving stable grafts.  The combination of MMF/CSP proved more effective than 
MTX/CSP. Of the 12 dogs that received MMF/CSP, 11 became long-term stable mixed chimeras without 
GVHD. Given that comparable rate of engraftment in dogs not administered post-grafting 
immunosuppression could only be achieved with 920 cGy, the combination of CSP/MMF given post-
grafting appeared to provide immunosuppression approximately equivalent to that achieved with 720 cGy 
pre-transplant TBI10. 
 
B. Clinical FHCRC protocols 
All patients enrolled in protocols 1463, 1641, 1668 and 1938 were transplanted with unrelated donors 
after nonmyeloablative conditioning with fludarabine 90mg/m2 and 2 Gy TBI. Three patients with CML on 
protocol 1668 received 3 Gy of TBI. 
 
i. Protocol 14632 and 16413 
Eighty-nine patients were enrolled on protocol 1463. All patients were transplanted with PBSC or bone 
marrow from fully matched unrelated donors (10/10 HLA-A, -B, -C, -DR, and –DQ). Postgrafting 
immunosuppression consisted of MMF and CSP. MMF was given b.i.d. (15 mg/kg) from day 0 to +40 and 
then tapered off by day +96, while CSP was given (b.i.d. 6.25 mg/kg) from day –3 to +100 and tapered off 
by day +180.  The cumulative incidence of grade II-IV acute GVHD was 52% and 37% for extensive 
chronic GVHD. The probabilities of 1-year overall survival and progression free survival were 52% and 
38%, respectively. Data from protocol 1463 demonstrated significant differences in outcome between 
recipients of PBSC or bone marrow. Although the sustained engraftment rate in the whole cohort only was 
79%, engraftment was significantly higher in recipients of PBSC than recipients of bone marrow (85% vs 
45%, p=0.007). Progression free survival was also higher in recipients of PBSC (44% vs. 17%, p=0.02), 
despite an increased cumulative incidence of grade III-IV acute GVHD (11% vs. 0%, p=0.05). 
Pharmacokinetic studies of MMF, demonstrated that the half-life of its active metabolite was 3 hours, 
suggesting that better immunosuppression could be obtained by more frequent dosing of MMF. 
 Based on the data derived from protocol 1463 protocol 1641 was developed. It was essentially the same as 
the original, however to ensure engraftment and reduce acute GVHD, the MMF dosing schedule was 
changed to t.i.d. and all patients were transplanted with PBSC.  Ninety-nine patients were enrolled on 
protocol 1641. With three daily doses of MMF the median day +28 T-cell chimerism increased to 92% 
compared to 75% when MMF was given twice a day (p=0.02), and sustained engraftment was 95%. 
Cumulative incidences of acute (52%) and chronic (40%) GVHD were similar to protocol 1463. One-year 
overall survival, progression-free survival, relapse/progression, and non-relapse mortality were 64%, 54%, 
27%, and 19%, respectively. 


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 In a combined analysis of PBSC recipients in both protocols (n=174) the diagnoses of CML and 
MDS/MPS were associated with a greater risk of graft rejection (p=0.0006) relative to all other diagnoses. 
For MDS/MPS patients the 1-year non-relapse and relapse related mortalities were 25% and 35%, 
respectively, which translated into an inferior 1-year overall survival (40% vs. 60-80% for leukemia, 
lymphoma and multiple myeloma). One-year progression free survival was also inferior for both MDS/MPS 
and CML patients (30% vs. 55-60% for leukemia, lymphoma and multiple myeloma). The reason for the 
poor progression free survival for MDS/MPS patients was high relapse and nonrelapse mortality rates and 
for CML patients, disease progression after graft rejection.  
 
ii. FHCRC Protocol 166811 
Several studies have suggested that CSP prevented activation induced death of T-cells, and thus 
potentially delayed eradication of alloreactive donor T-cells, hereby preventing tolerance induction 12,13. 
Conversely, antimetabolites such as MMF could delete autoreactive T cells by inducing apoptosis 14,15. The 
goal of protocol 1668 was to reduce the incidence of GVHD by translating these experimental findings into 
the clinical setting. The period of CSP administration was shortened (5mg/kg b.i.d. from day -3 to +80) 
while  the duration of MMF was prolonged (15mg/kg t.i.d from day 0 to +30, then b.i.d. until day +150 and 
taper to day 180). Seventy-one patients were enrolled, all transplanted with PBSC from fully matched 
unrelated donors. Sustained engraftment was observed in 96%, with lower overall survival and progression 
free survival as compared to a cohort 103 of historical controls (overall survival: 55% vs. 68%, p=0.05; 
progression free survival 47% vs. 56%, p=0.05 (adjusted for pre-transplant risk factors)). One-year relapse 
incidence was similar between the two cohorts (23% vs 26%). However, nonrelapse mortality was 
significantly higher in protocol 1668 (29% vs 18%, P=0.02). The patients who were without grade II-IV 
acute GVHD at day+80, and therefore had their CSP stopped, had significantly higher risk of experiencing 
non-relapse mortality (HR 10.1, P<0.0001), as compared to patients  who were continued on CSP due to 
GVHD. Current and historical non-relapse mortalities prior to CSP cessation at day +80 were comparable. 
Furthermore, cumulative incidences of grade II-IV and III-IV acute GVHD were 77% and 26% among 
protocol 1668 patients versus 52% and 15% among historical patients, respectively. Among the protocol 
1668 patients, 7 experienced grade III-IV acute GVHD, of which 4 were in immediate relation to cessation 
of CSP administration (3 at day +80 and 1 due to disease progression). The cumulative incidence of chronic 
GVHD in the current protocol was 45%, and similar to the historical cohort. In summary, we observed that 
prolonging MMF and truncating CSP increased the cumulative incidence of acute GVHD instead of 
reducing it. Thus, suggesting that administration of a calcineurin inhibitor for at least 6 months is needed to 
establish graft-host-tolerance11. 
 
iii. FHCRC Protocol 193811 
The goal of Protocol 1938 was to evaluate in a phase II randomized trial, which of three 
immunosuppression drug combinations was most promising in preventing acute GVHD. Figure 1 shows the 
treatment schema. Each of the combinations used MMF every 8 hours through day 30 and then MMF was 
given every 12 hours. The duration of MMF administration varied between the three arms. In each arm CSP 
was substituted for tacrolimus based on the previously observed lower incidence of acute GVHD when 
MTX was combined with tacrolimus instead of CSP after high-dose allogeneic HCT16.  .Also patients given 
tacrolimus in those randomized studies who developed chronic GVHD required significantly shorter periods 
of therapy before chronic GVHD resolved in an analysis carried out in the FHCRC only patients. However, 
this finding did not hold out in subsequent analysis including the patients from the other Centers that 
participated in the trial (personal communication, Paul Martin). Arm 1 (similar to protocols 1463 and 1641) 
was the “reference arm” that gave MMF until day 40 with a taper over 2 months and tacrolimus until day 
100 with a taper over 80 days. Arm II and III discontinued tacrolimus on day 100 with a taper over 50 days 
and on day 150 MMF was tapered off over a month. In Arm III, sirolimus was added to the GVHD 
prophylaxis regimen until day 80 in an attempt to further prevent acute GVHD. By May 2010 183 patients 


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had been accrued (arm #1 (reference), n=60; arm #2, n=61: arm #3, n=61), which were transplanted with 
PBSC from unrelated donors (10/10 HLA match in 91% and single HLA class I mismatch in 9%) after 
nonmyeloablative conditioning (90 mg/m2 and TBI 200 cGy). Sirolimus was administered in combination 
with MMF and tacrolimus, from day -3 to +80, with a daily dose of 2 mg and a target concentration of 3-12 
ng/ml (figure 1). The cumulative incidence of grade II-IV acute GVHD was lower in the sirolimus arm as 
compared to the tacrolimus/MMF only arms, although the difference was only significant when compared to 
the control arm (figure 1A). Detailed analysis showed that the benefit of adding sirolimus restricted to 
lowering the incidence of grade II acute GVHD (figure 1B). No difference between treatment arms was 
observed for grade III-IV acute GVHD (arm #1 12%; arm #2 13%; arm #3 11%) or chronic GVHD (arm #1 
43%; arm #2 42%; arm #3 46%). Furthermore no differences between treatment arms were observed for 
nonrelapse mortality and relapse/progression (figure 1C-D). When the results of protocol 1938 were 
compared to a historical cohort 174 unrelated nonmyeloablative transplants treated with a combination of 
CSP and MMF, no difference was observed in the cumulative incidences of nonrelapse mortality, 
relapse/progression, and acute (figure 1A) and chronic GVHD as compared to the tacrolimus/MMF only 
arms. Thus, suggesting that the substitution of CSP for tacrolimus did not entail additional GVHD control. 


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C.  Relationship between GVHD and graft versus tumor effects 
 We analyzed GVT effects in 322 patients with hematological malignancies given grafts from HLA-
matched related (n=192) or unrelated donors (n=130)4. Two-hundred and twenty-one patients had 
measurable disease at HCT and 126 of them (57%) achieved partial (n=28) or complete (n=98) remissions. 
In multivariate analysis, there was a trend for a higher probability of achieving complete remissions in 
patients with chronic extensive GVHD (p=0.07). One hundred and eight patients (34%) have relapsed or 
progressed. In multivariate analysis, grade II-IV acute GVHD had no statistically significant impact on the 
risk of relapse/progression, but was associated with increased risk of non-relapse mortality and decreased 
probability of progression-free survival. Conversely, extensive chronic GVHD was associated with 
decreased risk of relapse/progression (p=0.006) and improved probability of progression-free survival 
(p=0.003). These data suggest that outcomes of nonmyeloablative conditioning and unrelated HCT could be 


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improved by more intensive post-grafting immunosuppression aimed at suppressing acute GVHD, while 
allowing chronic GVHD to occur.  
 
D. Sirolimus (Rapamune ®)  
1. Mechanism of action.  
i. Immunomodulatory effect. Sirolimus was isolated in a discovery program for novel antifungal agents. It 
is a macrocyclic lactone fermentation product of Streptomyces hygroscopicus, an actinomycete that was 
isolated from a soil sample collected from Rapa Nui (Easter Island). Although, the activity of sirolimus 
depends on its binding to the same class of cytosolic binding proteins (immunophilins) as CSP and 
tacrolimus, its mechanism of action is unique. The complex of CSP or tacrolimus with their respective 
immunophilins inhibit calcineurin, which in turn impairs signaling through the T-cell receptor, reducing the 
expression of cytokines important for the antigen specific expansion of T-cells (e.g. IL-2, IL-3, IL4 and 
TNFα.), hereby arresting their cell cycle in G0 to G1. Sirolimus has no effect on the calcineurin pathway, but 
inhibits the mammalian target of rapamycin (mTOR) protein kinase, which promotes cell proliferation and 
is a key regulatory kinase in cell cycle control. In contrast to CSP and tacrolimus inhibition of T-cell 
receptor induced activation and cytokine secretion, the sirolimus-immunophilin complex inhibits the T-
cell’s response to cytokines, hereby arresting the cell cycle at a later stage (G1 to S phase) 17. 
  Although 
the mechanism is not fully understood, mTOR inhibition has the ability to promote antigen specific 
expansion of regulatory T-cells (Treg) and skew the CD4+ phenotype towards the tolerance inducing 
CD4+CD25high 18,19. Evidence points to that mTOR inhibition mainly blocks signaling pathways important 
for the expansion of T effector cells, while IL-2 dependent JAK/STAT signaling which is important for Treg 
proliferation is unaffected20,21. The preferential expansion of Treg is attenuated when sirolimus is used in 
combination with CSP19. In a murine bone marrow transplantation model transfer of Treg could prevent 
GVHD induced by non-regulatory T-cells, without interfering with engraftment or the graft versus leukemia 
effect 22-24.   
 
Another immunomodulatory property of sirolimus is its ability to inhibit dendritic cell activity. The mTOR 
pathway has been demonstrated to be important for the in vitro development of CD34-derived dendritic 
cells, with inhibition by sirolimus reducing antigen uptake, lipopolysaccharide induced cytokine secretion, 
CCR7 expression and T-cell stimulation25. 
 
ii. Viral amplification. Inhibition of mTOR may also have effects on viral amplification, as CMV 
specifically upregulates the mTOR pathway during replication26. In allogeneic HCT and solid organ 
transplantation lower risk of CMV activation has been reported in patients treated with sirolimus 27,28.  
 
iii. Antineoplastic effects. The mTOR signaling pathway is often constitutively activated in various human 
cancers. Sirolimus has been shown to induce cell cycle arrest in-vitro in both B-CLL and diffuse large B-
cell lymphoma cells, and its efficacy as an antiangiogenic agent has been demonstrated in several 
experimental cancer models 29-33. In the context of solid organ transplantation, a retrospective analysis of 
transplant registry data from 33249 recipients of necro-kidney allografts, showed a decreased risk of 
developing any de novo cancer in recipients treated with mTOR based immunosuppression (sirolimus or an 
analog), as compared to recipients treated with non-mTOR inhibitor based immunosuppression (hazard 
ratio: 0.39; 95% CI: 0.24-0.64; P=0.0002)34.  
 
2. Sirolimus for acute GVHD prophylaxis. Four clinical trials with sirolimus have been published from 
the Dana-Farber Cancer Institute 27,35-37. In all 4 trials similar GVHD prevention with sirolimus in 
combination with tacrolimus ± abbreviated MTX dosing (5 mg/m2 given every other day starting on day +1 
for 3 to 4 days), was used. Sirolimus was started at day -3 with a oral loading dose of 12 mg, and followed 
by a single daily dose of 4 mg, with a target serum concentration of 3-12 ng/ml. Tacrolimus was 


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administrated at 0.02 – 0.05 mg/kg/day intravenously by continuous infusion beginning on day-3 with a 
target serum concentration of 5-10 ng/ml. Control of GVHD was excellent independently of conditioning 
regimen (myeloablative vs reduced intensity conditioning (fludarabine 120 mg/m2 and busulfan 3.2 mg/kg)), 
donor source (related vs unrelated) and stem cell source (bone marrow vs. peripheral blood stem cells) 
(Table 1). In a retrospective study by Armand et al.38 190 patients undergoing transplantation for lymphoma 
were analyzed. The cohort consisted of patients treated with myeloablative (n=64) or reduced intensity 
conditioning (n=126) and transplanted with bone marrow (n=15), PBSC (n=168) or umbilical cord (n=7) 
grafts from either related (n=78) or unrelated donors (n=112). One-hundred-and-twenty six of the patients 
were treated with a combination of sirolimus with tacrolimus ± MTX, similar to the above mentioned Dana-
Farber trials, while the remaining 90 patients received calcineurin inhibitor and MTX based 
immunosuppression. Although overall survival was superior in patients treated with sirolimus when the 
whole cohort was analyzed, multivariate analyses revealed that the benefit was restricted to patients 
undergoing reduced intensity conditioning (sirolimus group (n=103) 66% vs non-sirolimus (n=23) 38%; 
p=0.007) independently of MTX.  In the same subgroup of patients sirolimus treatment was also associated 
with lower probability of progression (42% vs 74%, p=0.001), while no effect was observed on non-relapse 
mortality (sirolimus group 14% vs non-sirolimus group 9%, p=0.6). No statistically significant associations 
between sirolimus and the incidences of GVHD were observed (sirolimus-group vs non-sirolimus: acute 
GVHD: grade II-IV 14% vs 22%, p=0.6; grade III-IV 6% vs 13%, p=0.4, chronic GVHD 63% vs 48%, 
p=0.2). In a small study of 15 patients receiving primarily PBSC from 9 unrelated and 6 related fully HLA 
matched donors after reduced intensity conditioning (FLAMSA-RIC), the GVHD prevention was comprised 
of a combination of sirolimus (4 mg daily starting on day -1, with a target concentration of 5-10 ng/ml and 
taper at day +60 to +90) and MMF (1000 mg administered 6-12 hrs after transplantation, hereafter 2000 mg 
daily with reduction and termination at day +50)39. Although sirolimus was started as late as one day prior 
to the transplant, satisfactory GVHD control was obtained, with only two patients experiencing acute 
GVHD (1 grade II and one grade IV) and three experiencing chronic GVHD. In a recent study by Snyder et 
al.40, 23 patients with myelofibrosis were transplanted using a primarily fludarabine and melphalane based 
reduced intensity conditioning regimen. The first nine patients received CSP/MMF based 
immunosuppression, while the last 14 received a combination of sirolimus and tacrolimus analogous to the 
studies by Antin et al. and Cutler et al. All patients were transplanted with PBSC and 15 out of 23 with 
grafts from unrelated donors (7 out of 9 in the CSP/MMF group and 8 out of 14 in sirolimus/tacrolimus 
group). 13 out of the 15 patients transplanted with unrelated donors received additional immunosuppression 
with MTX 5 mg/m2 on day +1, +3 and +6 (6 in the CSP/MMF group and 7 in sirolimus/tacrolimus group). 
Sixteen of the 23 patients experienced acute GVHD with no significant difference between the CSP/MMF 
and sirolimus/tacrolimus groups. However, in the subset of patients who developed grade III-IV acute 
GVHD (n=5), the cumulative incidence was significantly higher in the CSP/MMF group as compared to the 
sirolimus/tacrolimus group (60% vs. 10%, P=0.01). Five out of six evaluable patients developed chronic 
GVHD in the CSP/MMF group, compared to nine out of 14 in the sirolimus/tacrolimus group. No patients 
in the sirolimus/tacrolimus group succumbed to treatment related causes (day 100 treatment related 
mortality 0% vs 33%, P=0.02), which translated into a superior overall survival at 2 years (93% vs 56%, 
P=0.05). 


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Table 1. Summary of clinical trials 
 
 
E. The use of 3 Gy TBI in place of 2 Gy TBI for patients at higher risk of rejection: 
 
We have shown that the risk of rejection increases for certain diseases, as well as for those patients 
previously transplanted with either syngeneic or allogeneic stem cells.  Please see section 11.H 
(Conditioning Regimen) for criteria for 3 Gy TBI.  
  
4. Proposal   
 
The addition of sirolimus in protocol 1938 produced promising results in lowering grades 2-4 acute GVHD but 
did not achieve our goal of reducing grades 2-4 acute GVHD to less than 40%. However, the results using triple 
therapy with the addition of sirolimus to the “standard” immunosuppressive regimen was very promising and 
there was a significant reduction in acute GVHD. The goal of the current protocol is to compare in a phase III 
randomized trial, the effectiveness of 2 GVHD prophylaxis regimens in preventing acute grades II-IV GVHD. 
Each of the combinations will use CSP every 12 hours through day 96 then tapered off by day 150. Arm 1 
(similar to the former unrelated donor nonmyeloablative protocol 1938 Arm 2) will be the “reference arm” in 
which MMF is given three times a day until day 30 then dropped to twice a day until day 40 with a taper from 
day 150 through day 180. In Arm 2, sirolimus will be given until day 150 with a taper though day 180. In Arm 
2, in addition to CSP and sirolimus, MMF will be given three times a day until day 30, dropped to twice a day 
 
Antin et al.35  
Cutler et al.27 
Cutler et al.36 
Alyea et al.37 
FHCRC protocol 
1938 
Sample size 
41 
30 
83 
91 
62 
Median age, yrs (range) 
42 (19-62) 
42 (19-54) 
42 (18-59)* 
44 (22-54)** 
57 (20-69) 
60 (13-75) 
HLA match 
 
 
 
 
 
 
HLA matched, related 
 
30 
(1 HLA matched parent) 
53 
46 
(1 HLA-C  MM) 
 
 
HLA matched, unrelated 
29 
 
30 
45 
(7 HLA-C  MM) 
62 
Hematopoietic cell source 
BM 
PBSC 
PBSC 
PBSC 
PBSC 
Conditioning 
MAC 
MAC 
MAC 
RIC 
NMA 
Immunosuppression 
 
 
 
 
 
 
Sirolimus, daily dose (mg/kg) 
(start day/start taper/end) 
4 
(-3/+63/+182) 
4 
(-3/+100/+182) 
4 
(-3/+100/+182) 
4 
(-3/NA/NA) 
2 
(-3/NA/+80) 
 
Tacrolimus, daily dose (mg/kg) 
(start day/start taper/end) 
0.02 
(-3/+63/+182) 
0.02 
(-3/+100/+182) 
0.02 
(-3/+100/+182) 
0.05 
(-3/NA/NA) 
0.12 
(-3/+100/+150) 
 
MMF, dose (mg/kg) 
(start day/start taper/end) 
 
 
 
 
0.45/0.30 
(-3/+100/+180) 
 
Other 
MTX 
 
 
MTX 
 
GVHD (%) 
 
 
 
 
 
 
Acute grade. II-IV, % 
26 
10 (only gr. II) 
21 
10 
45 
 
Acute grade. III-IV, % 
13 
0 
NA 
NA 
11 
 
Chronic, % 
44 
11 out of 28 patients 
59 
40 
46 
Survival 
 
 
 
 
 
 
treatment-related mortality, % 
15 (day 100) 
6 (1 yr) 
5 (day 100) 
6 (2 yrs) 
3 (day 200) 
 
1 year relapse-free survival, % 
46 
71 
72 
47 
NA 
 
1 year overall survival, % 
51 
67 
77 
74 
47 (2 yrs) 
BM, bone marrow; PBSC, peripheral blood stem cells; MAC, myeloablative conditioning; RIC, reduced intensity conditioning; 
NMA, non-myeloablative conditioning; MMF, mycophenolate mofetil ; MTX, methotrexate; GVHD, graft versus host disease; 
NA, not available; *, patients transplanted with matched related donors; **, patients transplanted with matched unrelated donors. 


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and then discontinued on day 40. The current protocol’s primary objective is to reduce the incidence of acute 
GVHD after unrelated nonmyeloablative HCT.  
The specific design of the protocol is as follows. Patients with hematologic malignancies will be 
randomly assigned to one of two postgrafting immunosuppression schedules to determine which is the most 
effective at reducing the incidence of acute GVHD below the current incidence of 50%. Randomization is based 
upon transplant center (FHCRC vs other). We will study which of the treatment arms offers the best post-
grafting immunosuppression regimen capable of achieving the primary objective of reducing the incidence of 
grades II-IV acute GVHD.  Secondary outcomes will be 1) compare the non-relapse mortality, and 2) 
comparing overall and progression-free survivals in the 2 arms.  
 
5. Primary Objective  
 
1. To compare the effectiveness of 2 GVHD prophylaxis regimens in preventing acute grades II-IV 
GVHD. 
 
6. Secondary Objectives 
 
1. Compare non-relapse mortality in the 2 arms 
2. Compare survival and progression-free survivals in the 2 arms. 
 
7. 
Patient Selection 
• 
A. Inclusions 
 
 
Ages >50 years with hematologic malignancies treatable by unrelated HCT.  
 
 
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who through 
pre-existing medical conditions or prior therapy are considered to be at high risk for regimen 
related toxicity associated with a high dose transplant (>40% risk of TRM). This criterion 
can include patients with a HCT-CI score of >1 (see Appendix Q). Transplants should be 
approved for these inclusion criteria by the principal investigators at the collaborating centers 
and at FHCRC.. All children < 12 years must be discussed with the FHCRC PI (Brenda 
Sandmaier, MD 206 667 4961) prior to registration. 
 
 
 Ages  50 years of age with chronic lymphocytic leukemia (CLL).  
 
 
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who refuse a 
high-dose HCT. Transplants must be approved for these inclusion criteria by the principal 
investigators at the collaborating centers and at FHCRC. 
 
 
The following diseases will be permitted although other diagnoses can be considered if 
approved by PCC or the participating institutions’ patient review committees and the 
principal investigators. 
• Aggressive nonHodgkin lymphomas (NHL) and Other Histologies Such as 
Diffuse large B cell NHL– not eligible for autologous HCT, not eligible for high-
dose allogeneic HCT, or after failed autologous HCT.  
• Mantle Cell NHL -may be treated in first CR. (Diagnostic LP required pre-
transplant) 


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• Low grade NHL– with < 6 month duration of CR between courses of conventional 
therapy 
• CLL – must have either 1) failed to meet NCI Working Group criteria for complete 
or partial response after therapy with a regimen containing FLU (or another 
nucleoside analog, e.g. 2-CDA, pentostatin) or experience disease relapse within 12 
months after completing therapy with a regimen containing FLU (or another 
nucleoside analog); 2) failed FLU-CY-Rituximab (FCR) combination chemotherapy 
at any time point; or 3) have “17p deletion” cytogenetic abnormality. Patients should 
have received induction chemotherapy but could be transplanted in 1st CR; or 4) 
Patients with a diagnosis of CLL (or small lymphocytic lymphoma) or diagnosis of 
CLL that progresses to prolymphocytic leukemia (PLL), or T-cell CLL or PLL. 
• Hodgkin Lymphoma – must have received and failed frontline therapy. 
• Multiple Myeloma – must have received prior chemotherapy.  Consolidation of 
chemotherapy by autografting prior to nonmyeloablative HCT is permitted. 
• Acute Myeloid Leukemia (AML) – must have < 5% marrow blasts at the time of 
transplant.  
• Acute Lymphocytic Leukemia (ALL) – must have <5% marrow blasts at the time 
of transplant. 
• Chronic Myeloid Leukemia (CML) – Patients in CP1 must have failed or be 
intolerant of TKIs.  Patients beyond CP1 will be accepted if they have <5% marrow 
blasts at time of transplant.   
• Myelodysplasia (MDS)/Myeloproliferative Syndrome (MPS) – Patients must have 
<5% marrow blasts at time of transplant.  
• Waldenstrom’s Macroglobulinemia – must have failed 2 courses of therapy. 
  
B. Exclusions:  
 
 
 
 
1. Patients with rapidly progressive intermediate or high grade NHL. 
2. Patients with a diagnosis of CMML. 
3. Patients with RAEB who have not received myelosuppressive chemotherapy i.e. induction 
chemotherapy. 
4. CNS involvement with disease refractory to intrathecal chemotherapy. For LP requirement, see 
Appendix N. 
5. Presence of circulating leukemic blasts (in the peripheral blood) detected by standard pathology 
for patients with AML, ALL or CML. 
6. Presence of ≥ 5% circulating leukemic blasts (in the peripheral blood) detected by standard 
pathology for patients with MDS/MPS 
7. Fertile men or women unwilling to use contraceptive techniques during and for 12 months 
following treatment. 
8. Females who are pregnant or breast-feeding. 
9. Patients with active non-hematological malignancies (except non-melanoma skin cancers) or 
those with non-hematological malignancies (except non-melanoma skin cancers) who have been 
rendered with no evidence of disease, but have a greater than 20% chance of having disease 
recurrence within 5 years. 
This exclusion does not apply to patients with non-hematologic malignancies that do not require 
therapy. 
10. Fungal infections with radiological progression after receipt of amphotericin B or active triazole 
for greater than 1 month. 


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11. Organ dysfunction. 
a. Cardiac ejection fraction < 35% (or, if unable to obtain ejection fraction, shortening fraction 
of < 26%).  Ejection fraction is required if age > 50 years or there is a history of 
anthracycline exposure or history of cardiac disease.  Patients with a shortening fraction < 
26% may be enrolled if approved by a cardiologist.  
b.  Pulmonary:  
i) DLCO < 40%, TLC <40%, FEV1 <40% and/or receiving supplementary continuous 
oxygen.  
ii) The FHCRC PI of the study must approve of enrollment of all patients with pulmonary 
nodules. 
c. Liver function abnormalities: Patients with clinical or laboratory evidence of liver disease 
would be evaluated for the cause of liver disease, its clinical severity in terms of liver 
function, and the degree of portal hypertension.  Patients will be excluded if they are found to 
have fulminant liver failure, cirrhosis of the liver with evidence of portal hypertension, 
alcoholic hepatitis, esophageal varices, a history of bleeding esophageal varices, hepatic 
encephalopathy, uncorrectable hepatic synthetic dysfunction evinced by prolongation of the 
prothrombin time, ascites related to portal hypertension, bridging fibrosis, bacterial or fungal 
liver abscess, biliary obstruction, chronic viral hepatitis with total serum bilirubin >3 mg/dL, 
or symptomatic biliary disease. 
12. Karnofsky scores < 60 (see appendix B) or Lansky Score <50 (see appendix C). 
                  13. Patient has poorly controlled hypertension and on multiple antihypertensives 
14. HIV positive patients. 
15. Active bacterial or fungal infections unresponsive to medical therapy. 
16. All patients receiving antifungal therapy voriconazole, posaconazole, or fluconazole and who are 
then randomized to ARM 2 must have sirolimus reduced according to the Standard Practice 
Antifungal Therapy Guidelines in Appendix E. 
17. The addition of cytotoxic agents for “cytoreduction” with the exception of tyrosine kinase 
inhibitors (such as imatinib), cytokine therapy, hydroxyurea, low dose cytarabine, chlorambucil, 
or rituxan will not be allowed within three weeks of the initiation of conditioning. 
 
8. Donor Selection 
A. Inclusions 
1. FHCRC matching allowed will be Grades 1.0 to 2.1 (Appendix O): Unrelated donors who are 
prospectively: 
i) 
Matched for HLA-A, B, C, DRB1 and DQB1 by high resolution typing;  
ii) 
Only a single allele disparity will be allowed for HLA-A, B, or C as defined by high 
resolution typing (see Appendix O for other donor selection details). 
2. Donors are excluded when preexisting immunoreactivity is identified that would jeopardize 
donor hematopoietic cell engraftment. This determination is based on the standard practice of the 
individual institution. The recommended procedure for patients with 10 of 10 HLA allele level 
(phenotypic) match is to obtain a panel reactive antibody (PRA) screens to class I and class II 
antigens for all patients before HCT. If the PRA shows >10% activity, then flow cytometric or B 
and T cell cytotoxic cross matches should be obtained. The donor should be excluded if any of 
the cytotoxic cross match assays are positive.  For those patients with an HLA Class I allele 
mismatch, flow cytometric or B and T cell cytotoxic cross matches should be obtained regardless 
of the PRA results. A positive anti-donor cytotoxic crossmatch is an absolute donor exclusion.  
3. Patient and donor pairs homozygous at a mismatched allele in the graft rejection vector are 
considered a two-allele mismatch, i.e., the patient is A*0101 and the donor is A*0102, and this 
type of mismatch is not allowed.  


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      4.   Only G-CSF mobilized PBSC only will be permitted as a HSC source on this protocol. 
 
 
B. Exclusions 
1. Donor (or centers) who will exclusively donate marrow.  
2. Donors who are HIV-positive and/or, medical conditions that would result in increased risk for 
G-CSF mobilization and harvest of PBSC. 
 
 9.  Informed Consent 
 
A conference will be held with the patient and family to discuss this study and alternative treatments available 
for the underlying disease.  The conference will be conducted by the outpatient-attending physician. All 
potential risks associated with the use of fludarabine, low dose TBI, immunosuppressive drugs, HCT, GVHD, 
infections, rejection, disease progression/recurrence and donor lymphocyte infusion (DLI) should be discussed 
as objectively as possible. It should be explained that patients offered this protocol most likely have advanced 
malignancy with life expectancy of months to no more than 1-2 years with conventional treatments, would be 
unlikely to benefit from, or tolerate an autologous transplant, and are at high risk of early transplant mortality 
from high dose allogeneic transplant. Informed consent from the patient will be obtained using a form approved 
by the Institutional Review Board (IRB) of the Fred Hutchinson Cancer Research Center and the local IRB if 
the patient is treated in a collaborating institution. 
 
10. 
Protocol Registration 
 
FHCRC patients:  Eligible patients will be identified by the Clinical Coordinators Office.  Patients will be 
registered with the Registration Office (206-667-4728) between 8:30 am and 4:00 PM, Monday through Friday. 
After hours, the Registration office can be reached by paging (206) 995-7437. 
 
Collaborating institutions: Eligible patients will be identified by the principal investigators of the collaborating 
institutions who will register the patient with the FHCRC. Registration will include completion of the eligibility 
checklist/demographic form (Appendix L).  This form will be faxed to the Trial Coordinator (206-667-5378).  
Questions regarding eligibility or protocol information should be directed to Brenda Sandmaier, MD (206-667-
4961), M.D 


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Figure 2. Protocol 2448 Schema. 
 
 
11. Plan of Treatment  
 
A. Outline of treatment plan (refer to Figure 2 and Tables 2, and 3)  
 
 
 
 
 
 
If T-Cell (CD3) chimerism is >50% on day +28, then repeat only on days +84 and +365. 
*If T-Cell (CD3) chimerism is 50% on day +28, then repeat on days +56, +84, +180, & +365.   
Granulocyte (CD33) chimerism on day +84 only.  
Natural killer (NK) cell (CD56+) chimerism will be obtained on day +28.  
Bone Marrow chimerism will be obtained on days +84 & +365 
 (See Patient Post-Transplant Evaluation for more details) 
 
B. Randomization: Patients will be registered at the FHCRC. Please see Statistical Considerations for 
criteria used to randomly assign patients.  
 
C. HCT: Transplant will be PBSCs collected as per NMDP standard. Twelve liter leukapheresis will be 
obtained on two consecutive days, and both collections will be infused on day “0”. Because of 
logistical issues, PBSC infusions are usually performed in the hospital, but otherwise patients will 
only be admitted as medically necessary for control of transplant complications. Standard 
cryopreservation of a portion of PBSC will take place for potential DLI. A portion of the PBSC 
product will be removed for DLI that is equivalent to 3x10^7 CD3 cells/kg recipient weight and 
cryopreserved (see 11.I.1).  If the product arrives after 6pm, 10% will be removed and held 
overnight prior to cryopreservation. 
D. Cytoreduction: Cytoreduction and /or radiation therapy may be given by the referring physician or the 
attending physician as determined on clinical grounds or to meet eligibility requirements of the 
protocol for patients with advanced malignancy or to reduce tumor bulk. However, no intensive 
chemotherapy can be given within three weeks before conditioning (see exclusion criteria page 12). 


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The need for this therapy should be discussed with the principal investigator. The referring 
oncologist may be asked to administer this therapy.  
 
E. Definition of Preceding Chemotherapy and Biologic Modifiers: For the purposes of this protocol, 
preceding chemotherapy is defined as any exposure to systemic chemotherapy. Exceptions to this 
definition include BCR/ABL tyrosine kinase inhibitors (Imatinib Mesylate, Dasatinib, etc.), cytokine 
therapy, hydroxyurea, low dose cytarabine, chlorambucil, or rituxan. 
 
F. Definition of Disease, Based on Risk of Progression: Patients will be classified as being at standard-
risk, high-risk or very high risk of progression. Standard-risk includes AML in first complete 
remission, ALL in first complete remission, MDS-refractory anemia, CML in first chronic phase, 
CLL, low-grade NHL, high or intermediate grade NHL in complete remission, Hodgkin lymphoma 
in complete remission, multiple myeloma in complete remission or with minimal residual disease. 
Very high-risk includes acute leukemia beyond second complete remission, CML beyond chronic 
phase and MDS syndrome-refractory anemia with blast excess or above. High-risk includes other all 
diagnoses. 
G. Pre-transplant tyrosine kinase inhibitors (Imatinib mesylate, Dasatinib, etc.).  
 
1. All patients with the diagnosis of CML or Ph+ ALL may continue treatment with imatinib 
mesylate, dasatinib or other BCR/ABL tyrosine kinase inhibitors until two days prior to HCT.  
The tyrosine kinase inhibitors should then be stopped to prevent possible inhibition of 
engraftment of donor stem cells. 
2. Imatinib mesylate or dasatinib and CNS prophylaxis and treatment: For patients who require 
cranial-spinal irradiation, imatinib mesylate or dasatinib will need to be discontinued 48 hours 
prior to initiating cranial spinal irradiation. This discontinuation is necessary because the 
combined effects of cranial-spinal irradiation and imatinib mesylate or dasatinib on the CNS are 
not known. 
 
H. Conditioning Regimen: (refer to Figure 2 and Tables 2 and 3) 
1. Days -4, -3 and –2: Fludarabine 30 mg/m2/day IV, administered over 30 minutes. 
2.   Day 0: TBI 2 or 3 Gy at 6-7 cGy/min from linear accelerator (Appendix U) followed by HCT.  
Regardless of the actual time of TBI administration on Day 0, immunosuppression should be 
given per schedule and prior to the infusion of PBSCs 
 
CRITERIA FOR 3 GY TBI: Patients need to fulfill one or more of the following criteria for 3 Gy TBI: 
 
 a)  Patients with MDS, MPD, CML, or other hematologic malignancies not previously treated with 
myelosuppressive chemotherapy 
b)  Patients who have had a previous allogeneic transplant. 
c) Patients who had a prior syngeneic transplant without subsequent myelosuppressive chemotherapy. 
d) Patients who have not had myelosuppressive chemotherapy within 3-6 months of HCT may be at 
higher risk of rejection depending on treatment history and underlying diagnosis. Confirm TBI dose 
(200 vs 300 cGy) with PI. 


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Table 2: Arm 1 - Conditioning Schema and Immunosuppression Schedule 
Day Number 
-4 
-3 
-2 
-1 
0 
+1-29 
+30-39 
+40 
+96 
+150 
+180 
Fludarabine 
(30 mg/m2/day) 
X 
X 
X 
 
 
 
 
 
 
 
 
TBI 
 
 
 
 
2-3 Gy 
 
 
 
 
 
 
Stem Cell infusion 
 
 
 
 
Infusion 
 
 
 
 
 
 
CSP 
(5.0 mg/kg q12hrs) 
 
START 
→ 
→ 
→ 
→ 
→ 
→ 
TAPERA 
STOP  
 
MMF 
(15 mg/kg) 
 
 
 
 
STARTB 
q8hr 
→ 
Q12hr 
→ 
→ 
TAPERC  
STOP 
A CSP should be tapered off over 55 days in patients without preceding acute GVHD requiring therapy.  
B The first dose of MMF is to be given 4-6 hours after the stem cell infusion. 
  
 
 
 
C MMF should be tapered off over 30 days in patients without preceding acute GVHD requiring therapy.  
 
Table 3: Arm 2 - Conditioning Schema and Immunosuppression Schedule 
Day Number 
-4 
-3 
-2 
-1 
0 
+1-29 
+30-39 
+40 
+96 
+150 
+180 
Fludarabine 
(30 mg/m2/day) 
X 
X 
X 
 
 
 
 
 
 
 
 
TBI 
 
 
 
 
2-3 Gy 
 
 
 
 
 
 
Stem Cell infusion 
 
 
 
 
Infusion 
 
 
 
 
 
 
CSP 
(5.0 mg/kg q12hrs) 
 
START 
→ 
→ 
→ 
→ 
→ 
→ 
 
TAPERA 
STOP  
 
MMF 
(15 mg/kg) 
 
 
 
 
STARTB 
q8hr 
→ 
Q12hr 
STOP 
 
 
 
Sirolimus 
(2 mg QD) 
 
START  
→ 
→ 
→ 
→ 
→ 
→ 
→ 
TAPERC 
STOP 
A CSP should only be tapered on day 96 in patients without preceding acute GVHD requiring therapy.  
B The first dose of MMF is to be given 4-6 hours after the stem cell infusion. 
C The continuation of sirolimus for patients with severe acute GVHD is at the discretion of the attending physician.  
  


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3.  Immunosuppression  
• Day –3.  All patients: Commence cyclosporine at 5.0 mg/kg PO Q12 
hours, continue to day +96 and then taper until day +150. 
• Day –-3.  Arm  2 patients: Sirolimus daily dose of 2.0 mg PO QD, 
continue to day +150 and then taper until day +180 
• Day 0: Arm 1 and 2 patients: After HCT on day 0, mycophenolate 
mofetil (MMF) will be given based on adjusted body weight, at 15 mg/kg 
PO at 4-6 hours after SCT infusion is complete, then to be given at 15 
mg/kg PO Q8 hours and then reduce to Q12 hours on day +30. Arm 1: 
Continue MMF Q12 hours until day +150 then taper until day +180. Arm 
2: Continue MMF Q12 hours until day +40, MMF will then be 
discontinued without taper unless GVHD or disease relapse/progression 
occurs.  
 
a. Cyclosporine (Arms 1 and 2 patients). 
1. Starting dose: 
i. Adult dose: CSP is given based on adjusted body weight, at 5.0 
mg/kg PO q12 hours from day –3.  If there is nausea and vomiting at 
anytime during CSP treatment the drug should be given intravenously 
at the appropriate dose that was used to obtain a therapeutic level.  
See guidelines for PO to IV conversion below. 
ii. Pediatric dose: Due to the variable and increased metabolism in 
children, CSP will be started intravenously on day –3 at the doses 
listed below.  
  
i. Age <6 years old: 1.6 mg/kg IV q8 hours 
                                  ii. Age >6 years old: 2.0 mg/kg IV q12 hours 
iii. For Arm 2 patients, sirolimus should be given at least 4 hours 
after an oral dose of cyclosporine as concurrent administration 
leads to elevation of sirolimus levels. 
2. Cyclosporine discontinuation: 
i. 
Arms 1 and 2: In the absence of acute or chronic GVHD, CSP is 
tapered at day 96 over 55 days (to be completed on Day +150). 
ii. 
The referring physician, who will receive instructions and 
guidelines for detecting and managing GVHD, may manage this. 
Modifications of the taper schedule may be indicated if significant 
disease progression (increase in serum or urine paraprotein by 
≥25%) occurs posttransplant. The type of modification will 
depend on where a patient is relative to the standard tapering 
schedule. Options regarding early discontinuation of CSP (and 
MMF) therapy are summarized below (section O). 
                        3.   Guidelines for CSP Dose Adjustment and Monitoring.  
i. 
Blood pressure, renal function (serum creatinine, BUN), 
electrolytes and magnesium need to be followed at least three 
times per week during the first month, twice weekly until day 


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+100, then once per week until CSP is stopped, unless clinical 
circumstances suggest the need for more frequent evaluations. 
ii. 
CSP, whole blood "trough" levels (i.e., just prior to the next dose) 
will be evaluated on day 0 and twice weekly post-transplant until 
the initiation of the taper and adjusted if necessary to maintain 
blood levels that target upper end of therapeutic range (see Table 
4) during the first 28 days. After taper, dose levels will be 
measured weekly if stable. 
 
Table 4:  CSP Dose Adjustment 
 
 
iii. 
For Arm 2 patients Do not exceed cyclosporine levels > 350 
ng/mL to reduce risk of sirolimus toxicity. 
iv. 
CSP Dose Adjustment: Initial high Cyclosporine (CSP) doses are 
required based on the pre clinical nonmyeloablative canine 
studies, which used an equivalent dose to establish an allograft.  
After day +28, CSP levels typical for unrelated HCT will be 
targeted.  Dose reduction should only be made if CSP toxicity is 
present, and/or levels exceed values provided in Table 4.  There 
are two methods for calculating CSP levels. Table 4 provides 
desired levels for specific methods.  To avoid inadequate immune 
 
Patients on Arm 1 
Patients receiving sirolimus on 
Arm 2 
CSP Level to 
Target Using LC-
MS/MS Method 
CSP Level to Target 
Using Immunoassay 
Method 
CSP Level to 
Target Using LC-
MS/MS Method 
CSP Level to Target 
Using Immunoassay 
Method 
Day “0”- Day +28 
Whole blood “trough” 
(11-12 hrs from prior 
dose) 
400 ng/ml 
 
500 ng/ml 
(upper end therapeutic 
range for this method) 
350 ng/ml 
 
400 ng/ml 
(upper end therapeutic 
range for this method) 
 
After Day +28 
 
 
120 - 360 ng/ml 
 
150 - 450 ng/ml 
 
120 - 300 ng/ml 
 
150 - 350 ng/ml 
Levels exceeding upper 
limits of target by >20% 
• 
with or without 
CSP toxicity 
• 
decrease in GFR 
>50% 
• 
increase in 
creatinine 2x 
baseline due to 
CSP 
 
25% dose reduction 
25% dose reduction  
25% dose reduction 
25% dose reduction  
Patients on Hemodialysis 
320 ng/ml 
400 ng/ml 
320 ng/ml 
400 ng/ml 


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suppression, dose reductions should be conservative.  Therapeutic 
levels of CSP should be maintained. 
v. 
After day +28, typical serum CSP transplant levels for related or 
unrelated HCT between 120 and 360 will be targeted for patients 
on Arm 1, and between 120 and 300 for patients on Arm 2. 
vi. 
Dose reductions should only be made if CSP toxicity is present or 
levels exceed upper limits of target by 20%, depending on method 
(see Table 4), in the absence of toxicity.  Dose reductions for high 
levels without toxicity should be conservative e.g. 25%, to avoid 
inadequate immunosuppression. 
vii. 
If there is nausea and vomiting at anytime during CSP treatment 
the drug should be given intravenously at the dose that was used 
to obtain a therapeutic level.  Oral to IV conversion: Oral CSP 
dose  2.5 = IV dose.  
viii. Oral Sandimmune may be substituted for oral Neoral. 
ix. 
Patients requiring hemodialysis should be have CSP levels 
maintained in the high therapeutic range (Table 4). 
x. 
Drugs that may affect CSP levels are:  
 
Table 5 
Decrease CSP levels Increase CSP levels 
Enhance Potential for 
Nephrotoxicity 
Phenytoin 
Phenobarbital 
Carbamazepine 
Primidone 
Rifampicin 
Nafcillin 
Octreotide 
Sulfonamides 
Trimethoprim 
Metoclopramide 
Erythromycin        Diltiazem       
Alcohol         Doxycycline 
Ketoconazole        Verapamil   
Acetazolamide      Nifedipine 
Fluconazole*        Nicardipine 
Colchicine            Azithromycin 
Itraconazole*        Imipenem     
Fluoroquinolones Posaconazole 
Voriconazole              
Caspofungin             
Clarithromycin 
Aminoglycosides 
Loop diuretics (furosemide)  
Amphotericin formulations 
 
**Discontinuation of fluconazole or itraconazole may lower CSP 
levels, and if used for antifungal prophylaxis, then changes in 
these drugs should be avoided during the first 2 months 
posttransplant. 
 
 
b.  MMF (Patients in arms 1 and 2) 
 
1. Patients on Arms 1 and 2 will receive MMF 
2. Initiating MMF therapy: Oral administration of MMF will be given 
based on adjusted body weight at 15 mg/kg Q8 hours (45 mg/kg/day) 
from the evening of day 0 (i.e. first dose to follow 4-6 hours after 
HCT). Doses will be rounded to the nearest 250 mg (capsules are 250 


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mg). If there is nausea and vomiting at any time preventing the oral 
administration of MMF, MMF should be administered intravenously 
based on adjusted body weight at 15 mg/kg Q8 hours. 
3. MMF discontinuation:  
i. Arm 1: MMF will be given daily at 15 mg/kg Q8 hours until day 
+30, at and then in the absence of GVHD, the dose will be 
changed to 15 mg/kg Q12 hours until day 96. In the absence of 
GVHD, MMF will be tapered at day +150 by 25% per week with 
MMF discontinued after day + 180. 
ii. Arm 2: MMF will be given daily at 15 mg/kg Q8 hours until day 
30 post transplant, at and then in the absence of GVHD, the dose 
will be changed to 15 mg/kg Q12 hours until day 40. MMF will 
then be discontinued without taper unless GVHD or disease 
relapse/progression occurs 
4. Maintaining MMF: Markedly low (<40%) donor T cell chimerism 
after HCT may indicate impending graft rejection. MMF should be 
continued at full dose or, if MMF taper has been initiated, 
reinstitution of full dose MMF should occur. Consideration of graft 
salvage with use of DLI should be considered. In the setting of acute 
GVHD, continuation of MMF is recommended (see 14.G GVHD 
treatment guidelines).  
5. Guidelines for MMF dose adjustment due to drug toxicity:  
i. If in the clinical judgment of the investigator the observed toxicity 
is related to MMF administration, a dose adjustment may occur.  
The discontinuation of MMF at any point should be discussed 
with the Study PI and should be documented in the permanent 
medical record and all Case Report Forms (CRF). 
ii. Gastrointestinal Toxicity. Severe gastrointestinal toxicities such as 
gastrointestinal hemorrhage have been very rare after 
nonmyeloablative HCT. In the event of gastrointestinal toxicity 
that requires medical intervention including medication for control 
of persistent vomiting or diarrhea that is considered to be due to 
MMF after day 28, a 20% dose reduction will be made or the drug 
may be given IV. If severe refractory diarrhea or overt 
gastrointestinal bleeding occurs, MMF may be temporarily 
stopped. The MMF should be restarted at 20% reduced dose when 
the underlying toxicity subsides. 
iii. Neutropenia. Based on previous experience in patients after 
nonmyeloablative HCT, dose adjustments are likely to occur 
because of hematopoietic adverse effects, in particular 
neutropenia. A thorough evaluation of neutropenia should occur 
including peripheral blood chimerism studies, marrow aspiration 
and review of marrow suppressive medications (e.g. bactrim). If 
all other potential causes of marrow toxicity are ruled out, dose 
adjustments will only be made for grade IV neutropenia that 
persists after day 21 post-transplant. Dose reductions should be 


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conservative (20%). After day 21, the use of G-CSF will be 
permitted for neutropenia. For severe toxicity related to MMF 
(grade IV neutropenia > 5 days refractory to G-CSF), MMF may 
be temporarily stopped.  The MMF should be restarted at 20% 
reduced dose when the underlying toxicity subsides.  
c. Sirolimus (Arm 2 patients only)  
1. Only patients on Arm 2 will receive sirolimus.  
2. Sirolimus dosing: 
i. Sirolimus should be given at least 4 hours after an oral dose of 
CSP as concurrent administration leads to elevation of 
sirolimus levels. In a study in renal transplant recipients, there 
was no significant pharmacokinetic interaction between 
sirolimus and CSP 41-43. However, the timing of CSP dosing 
affects sirolimus pharmacokinetics. Sirolimus whole-blood 
peak/trough levels and area under the concentration-time 
curve (AUC) have been significantly higher following 
concomitant administration of these agents compared to their 
administration four hours apart. Whole-blood trough levels 
increased by about 30% with concomitant dosing; the time to 
peak levels was also shorter in this group (1.8 versus 2.5 
hours) 41. The most likely explanation for higher sirolimus 
levels during concomitant administration is an increase in 
sirolimus bioavailability. Clinically significant 
immunosuppressive synergy is observed during combined 
therapy with sirolimus and cyclosporine 44. 
ii. Patients with BSA > 1.5 m2: Sirolimus will be started on day 
–3 at 2.0 mg every day orally through day 150. In the absence 
of GVHD, Sirolimus should be tapered at day 150 by 25% per 
week for 4 weeks and discontinued on day + 180. In the 
presence of GVHD or if the patient is receiving glucocorticoid 
therapy, continuation of sirolimus will be at the discretion of 
the attending physician or GVHD attending/team (see 14.G 
GVHD treatment guidelines).  
iii. Patients with BSA < 1.5 m2: For children and patients with 
BSA of  1.5 m2, the dose will be based on BSA as follows: 1 
mg/m2/day to be rounded at the nearest 0.1mg.  
iv. To minimize variability of exposure to sirolimus, the drug 
should be taken consistently with or without food. Grapefruit 
juice reduces CYP3A4-mediated metabolism of sirolimus and 
should not be administered with sirolimus or used for dilution. 
3. Dosing will be adjusted to maintain a target blood level of 3-12 
ng/mL until day 80. Dose adjustments are based on clinical 
toxicity, blood levels, and GVHD. For levels <3 ng/mL, the dose 


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is increased by increments of 25% until the target range is 
achieved. Conversely, for levels >12 ng/mL, the dose is decreased 
by 25% until target range is achieved. All dose adjustments will 
be rounded to the nearest whole number. Levels will be drawn 
twice weekly starting on day 0, Mondays through Fridays only. 
Levels should also be drawn after changing the dose of sirolimus 
or adding any of the medications known to interfere with the 
sirolimus metabolism (Appendix R). 
4. The dosage will be replaced if the patient vomits within 15 
minutes of taking a dose. Premedication with clinically indicated 
antiemetics is acceptable if vomiting occurs. 
5. If there is evidence of disease progression and no evidence of 
GVHD, patients will stop sirolimus and MMF without a taper 
(Arm 2 patients), taper CSP within 2 weeks, and be observed for 
1-2 weeks off of immunosuppression. If no GVHD occurs, 
patients with progressive disease will be offered enrollment in 
other institutional protocols for DLI treatment. 
6. Patients who are experiencing either suspected or documented 
fungal infection, alternative therapy should be administered 
whenever possible.  If voriconazole, posaconazole, or fluconazole 
are deemed necessary, sirolimus dosing reductions must be 
followed according to the Standard Practice Antifungal Therapy 
Guidelines in Appendix E due to contraindications.  
7. Severe neutropenia or thrombocytopenia. The combination of 
sirolimus and cyclosporine interaction is that there is an increased 
risk of sirolimus toxicity such as anemia, diarrhea, hypokalemia, 
and thrombocytopenia. A thorough evaluation cause of marrow 
suppression should occur including peripheral blood chimerism 
studies, marrow aspiration and review of marrow suppressive 
medications (e.g. bactrim). If all other potential causes of marrow 
toxicity are ruled out, dose adjustments will only be made for 
grade IV neutropenia and thrombocytopenia that persists after day 
21 post-transplant, and in the case of neutropenia is refractory to 
G-CSF therapy. Dose reductions of sirolimus of approximately 
50% should occur. For severe persistent toxicity despite sirolimus 
dose reduction, sirolimus should be held until blood counts 
recover to ANC > 1500/l and platelets >100,000/l. At that 
point, sirolimus may be reintroduced at a 1 mg PO QD and dose 
increased to 2 mg/qd as long as severe hematopoietic toxicity does 
not occur 
 
I. Collection and infusions of Donor PBSC 
 
 
 
1. G-CSF Administration to Donors: Timing of PBSC collection is prearranged 
through the NMDP. Day 0 should be fixed on a Monday-Thursday when 
possible. G-CSF will be administered by subcutaneous injection to the 


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unrelated donor starting 5 days prior to the day of HCT (see Table 6) as per 
NMDP protocol. Donors will receive approximately 10 g/kg of G-CSF each 
day of mobilization. A 12 liter apheresis will be obtained on day –1 and 
possibly on day 0 for a total of 12 to 24 liters of apheresis collection that will 
be infused on day 0.   
 
  
 
 
a. Immunophenotyping of the PBSC product for the Seattle patients will be 
performed by the Cellular Therapy Laboratory and will include CD34, 
CD3/4 and CD3/8 cells. The residual specimen will be sent to the 
Heimfeld lab to do phenotypic characterization of cellular subsets. 
  
  
 
 
b. Collection of DLI. Donor lymphocytes will be collected from unrelated 
donor PBSC products prior to transplant for potential future use of DLI 
on other protocol or treatment plans. A portion of the PBSC product from 
unrelated donors will be frozen according to standard cryopreservation 
for DLI.  
 
Table 6. Treatment Schema for Donor 
Day 
-5 
-4 
-3 
-2 
-1 
0 
G-CSF (~10 g/kg) 
X 
X 
X 
X 
X 
[X] 
PBSC collection 
 
 
 
 
X 
X 
 
2. HCT Collection: HCT scheduling and collection is arranged through 
unrelated donor registries. The schedule of G-CSF administration and 
collection of PBSC is determined as per NMDP protocol. The physician 
responsible for HSC collection will obtain informed consent from the donor. 
 
3.  HCT infusion: All patients will receive unmodified HCT (PBSC) infusion on 
day 0 of the treatment regimen (Refer to institutional practice guidelines for 
methods of infusion). 
 
 
 
J. ABO incompatibility 
 
All patients with ABO incompatibility should be evaluated and treated as 
according to the standard practice of the individual institution. Recommendations 
are provided in Appendix D. It should be noted that two cases of recipient 
hemolysis have been documented in patients with minor ABO mismatch with 
their donor. The suspected cause is donor anti-host hemagglutinin production 
from “passenger lymphocytes” in the donor PBSC that may expand 
posttransplant 46. Therefore, these patients should be monitored and treated 
aggressively when there is any evidence of hemolysis. 
 
 
 
 


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K. Post-transplant growth factors.   
 
Patients should in general not receive post-transplant growth factors during the 
first 3 weeks after HCT. Growth factors should not be given unless neutropenia 
develops or persists past day 21 post-transplant (ANC <500/L). 
 
 
L.  Post-transplant Maintenance Therapy with Tyrosine kinase inhibitors 
(Imatinib, Dasatinib, etc.) for Ph (+) CML or A.L.L. patients.  
 
Tyrosine kinase inhibitors may be reinitiated after HCT when ANC is >500/l or 
on day +14 if there is no neutropenia.  Tyrosine kinase inhibitor trials may also 
be considered. 
 
1.  Imatinib mesylate (Gleevac): the suggested starting dose is: 
Patients ≥ 18 years: Imatinib at 600 mg orally each day.  
Patients < 18 years: Imatinib at 340 mg/m2 orally each day, not to exceed    
600 mg per day. 
 
2.  Dasatinib (Sprycel): The suggested starting dose is: 
Patients ≥18 years: Dasatinib at 70 mg orally BID (twice per day).   
 
Patients <18 years:  who are potential candidates for BCR/ABL tyrosine kinase 
inhibitor therapy (other than Imatinib or Nilotinib) after HCT should be 
presented to PCC for discussion, and PI approval.   
 
3. Nilotinib (Tasigna): the suggested starting dose is: 
Patients ≥ 18 years: Nilotinib at 400 mg orally BID (twice per day).  
 
Patients < 18 years: Nilotinib at 230 mg/m2 orally BID, not to exceed 400 
mg po BID.  
 
NOTE: Per FDA guidelines, patients treated with Dasatinib and Nilotinib 
should have hypokalemia and hypomagnesemia corrected prior to initiation 
in all patients. 
 
NOTE: Per FDA guidelines, patients treated with Nilotinib should have 
periodic EKG monitoring, (though not required). 
 
NOTE:  All TKI dose reductions are allowed due to clinician judgment. 
 
4.  Dose Reductions of Tyrosine kinase inhibitors for Grade 4 neutropenia 
(ANC < 500/l) and /or thrombocytopenia (platelets < 10,000/l) (for 
patients in whom platelet support is unavailable/ineffective): 
After HCT, G-CSF will not be permitted for the first 21 days. G-CSF 
administration is acceptable after that time, but clinical and pathological 
evaluation is recommended. To assess cellularity and percentage of blasts, a 
bone marrow aspirate should be performed in those patients who develop 


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Grade 4 neutropenia (ANC < 500/l) and/or thrombocytopenia (platelets < 
10,000/l) that has lasted for ≥ 2 weeks.  
a. If the bone marrow cellularity is < 10%, and blasts < 5%, 
consideration should be made to reducing the dose or holding the 
tyrosine kinase inhibitor therapy.  
If Grade 4 neutropenia and/or thrombocytopenia persists for an 
additional two weeks, repeat the bone marrow aspirate to assess 
cellularity and percentage of blasts.  
b. If bone marrow cellularity is >10% and/or blasts >5%, the tyrosine 
kinase inhibitor therapy can be increased or other therapy considered 
(see section 11.O.6.e).  
 
M. Patients are eligible for trials using post-transplant therapy (such as Rituximab, 
FLT3 inhibitors, etc) to reduce the risk of relapse. 
 
N. Infection Prophylaxis. Recommended prophylaxis for PCP, VZV, and HSV are 
listed in Appendix E. As antifungal prophylaxis strategies are evolving, patients 
may receive antifungal prophylaxis as per the standard practice of the treatment 
institution. Standard CMV monitoring and prophylaxis should commence at the 
time of initial transplant.  Patients who do not become mixed or full donor 
chimeras can discontinue this infection prophylaxis. 
 
O. Modifications of Immunosuppression for Low Donor T cell Chimerism, and 
Persistent or Progressive Disease  
This section provides guidelines for management of patients with low donor 
chimerism and persistent or progressive disease. Those patients with significant 
amount of stable disease or progression of disease will undergo more rapid 
reduction of immunosuppression. DLI will not be given on this protocol, and 
patients with low chimerism or disease progression would be eligible for 
ongoing DLI protocols or treatment plans. Note that persistence of disease in 
itself does not mandate accelerated taper of immunosuppression.  
 
1.Definition of mixed donor/host chimerism, engraftment, graft failure and 
rejection. For the purposes of this protocol, mixed chimerism will be defined 
as the detection of donor T cells (CD3+) and granulocytes (CD 33+), as a 
proportion of the total T cell and granulocyte population, respectively, of 
greater than 5% and less than 95% in the peripheral blood. Full donor 
chimerism is defined as > 95% donor CD3+ T cells. Mixed or full donor 
chimerism will be evidence of donor engraftment. Increasing donor 
chimerism is defined as an absolute increase of 20% of CD3+ T cells over the 
previous chimerism evaluation. . Decreasing donor chimerism is defined as 
an absolute decrease of 20% of CD3+ T cell chimerism over the previous 
month. Low donor chimerism is defined as < 40% CD3+ T cells after HCT. 
Low donor chimerism should always be confirmed with repeat peripheral 
blood T cell and granulocyte chimerism analysis.  A DNA-based assay that 
compares the profile of amplified fragment length polymorphisms (ampFLP) 


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(or FISH studies or VNTR) of the patient and donor will be used to quantitate 
chimerism of sorted peripheral blood T-cells (CD3+) and granulocytes (CD 
33+). The same assay should be used in a given patient for repeated studies of 
chimerism.  This DNA-based analysis will also be performed on the whole 
nucleated cell fraction from marrow aspirates. Therapeutic decisions (i.e. 
DLI) will be made based on the results of sorted T-cell studies of peripheral 
blood. For the purposes of this protocol, rejection is defined as the inability to 
detect or loss of detection of greater than 5% donor T cells (CD3+) as a 
proportion of the total T cell population, respectively, after nonmyeloablative 
HCT. Also for the purposes of this protocol, graft failure is defined as grade 
IV thrombocytopenia and neutropenia after day 21 that lasts > 2 weeks and is 
refractory to growth factor support.  
                     
2. Evaluation of chimerism  Patients will have peripheral blood and whole bone 
marrow evaluations for chimerism at various time points through one year 
post transplant.  If the patient has not obtained > 95% donor chimerism in 
CD+3 by one year continue to evaluate through 5 years post transplant as 
clinically necessary. Peripheral blood will be sorted to evaluate T-cell 
(CD+3), granulocyte (CD+33), and/or NK cell (CD+56) compartments (see 
Patient Post-Transplant Evaluation section for instructions and exceptions). 
 
3. Continuation of immunosuppression. In the setting of low donor 
chimerism, immunosuppression may be continued or reinitiated at full dose 
so that DLI can be administered on a separate protocol.  If there is disease 
progression in the setting of low donor chimerism, the algorithm for disease 
progression (below) should be followed. Patients who reject their graft may 
be eligible for a second allogeneic transplant on other protocols. 
 
4. Discontinuation of immunosuppression. Immunosuppression should be 
discontinued as per protocol unless the patient develops GVHD, has falling 
donor chimerism or has progressive or substantial persistent disease (see 
below). In the setting of GVHD, CSP, MMF and sirolimus may be continued. 
GVHD at any time should be treated as per standard practice.  
 
5. Disease progression or persistence and mixed chimerism. Evidence of 
substantial persistent disease at day 80 or beyond may be indication for 
therapeutic intervention while disease progression, at any time point will 
always be an indication for therapeutic intervention. Intervention for 
persistent disease at day 80 or beyond should be discussed with the Principal 
Investigator (B. Sandmaier) of the protocol and the guideline in Appendix H 
for progressive disease should be followed. If the attending physician 
believes that the patient requires very aggressive therapy for rapidly 
progressive disease, the case will be presented to the institutions’ patient 
review committee. Otherwise, priority should be given to rapid reduction of 
immunosuppression, option (a) below.  Therapeutic options include:  
 
 


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6.  a. Discontinuation of immunosuppression. This should be considered 
the first therapeutic maneuver. If there is no GVHD, MMF (Arms 1 and 
2) and sirolimus (Arm 2) are to be stopped. CSP should be tapered over 
2 weeks. Bone marrow aspirate and blood chimerism studies will be 
performed when off immunosuppression after 2 weeks. If there is no 
response to stopping immunosuppression, < 20% increase in donor 
chimerism and there is no GVHD, patients will be considered as 
treatment failures. DLI will not be offered for disease progression or 
relapse on this protocol.  In this situation patients may receive further 
therapy as per institutional protocols for disease relapse or progression 
after allogeneic HCT.  If no GVHD occurs, patients with progressive 
disease may be offered enrollment in institutional protocols for DLI 
treatment.  If there is  20% absolute increase in donor chimerism, 
patients should be observed for additional 2 weeks and chimerism 
studies then repeated.  If there is progressive disease that requires 
therapy before 4 weeks or progressive disease occurs despite onset of 
GVHD then patients can be treated off protocol with DLI or be 
considered for (b) or (c) below 
b. Intercurrent treatment with chemotherapy or radiation. Conventional 
chemotherapy or radiation therapy should be considered in the setting of life 
threatening disease progression. Patients in this situation would be considered 
treatment failures. After therapy is completed chimerism should be evaluated 
and the administration of DLI off protocol considered. 
c. High dose allogeneic HCT This option should be discussed with the 
institutions’ patient review committee and the principal investigator. Patients 
who undergo high dose allogeneic HCT will be removed from the protocol at 
that time. 
d. CML or Ph (+) A.L.L. patients with Persistent or Increased Minimal 
Residual Disease: At day +84 or beyond, if the patient has persistent or 
increased MRD disease, dose escalation of BCR/ABL tyrosine kinase 
inhibitor therapy or DLI should be considered  
e. CML and PH (+) A.L.L. patients with Relapse and Disease 
Progression: See above sections for withdrawal of immunosuppression 
based on treatment arm.  If there is no response to stopping 
immunosuppression and there is no GVHD, dose escalation of BCR/ABL 
tyrosine kinase inhibitor therapy and or DLI should be considered (Suggested 
doses for adults are Imatinib to 800 mg QD or dasatinib to 90 mg BID). 
 
12.    Assessment of Disease Responses 
 
The initial anti-tumor effect of allogeneic unrelated HCT will be evaluated with the 
intermittent analysis of tumor markers: Responses will be classified as complete, partial 
response or no response.  Response criteria for MM, NHL, CLL, CML, ALL, AML and 
MDS to be used in this study are described in Appendix H. Standard response criteria 


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specific to other diseases will be used in assessing disease response for other patients on 
study      
 
 
13.    Patient Evaluation 
 
  A. Patient Pre-transplant Evaluation for All Diseases 
 
 
1. History: A complete history with full details of the patient’s prior treatment and 
response. 
2. Careful physical exam with documentation of Karnofsky or Lansky score, HCT CI 
score (Appendix Q) and findings related to underlying malignancy. 
3. CBC, creatinine, BUN, uric acid, chem 1 (Na+, K+, Cl_, Bun, creatinine, glucose), 
chem 2 (liver function tests), and 3(Mg+2 and Ca+2), ABO/Rh typing, hepatitis 
screen, CMV and toxoplasmosis serology, anti-HIV serology, and serum LDH. 
4. Pulmonary function tests with corrected DLCO.  
5. CXR (PA and LAT). 
6. ECHO or MUGA for patients > 50 years of age, or history of cardiac disease or 
anthracycline exposure. 
7. Evaluation and prophylaxis of CNS disease.  
Please refer to Appendix N for recommendations for intrathecal diagnostic 
evaluation and prophylaxis for specific malignant diseases. In those patients that 
undergo intrathecal diagnostic evaluation cerebral spinal fluid should be sent for 
cell count and differential, cytospin, cytology, total protein, and glucose.  
 
Immunophenotyping of the PBSC graft.  
Immunophenotyping of the PBSC product for the Seattle patients will be performed by the 
Cellular Therapy Laboratory and will include CD34, CD3/4 and CD3/8 cells. The residual 
specimen will be sent to the Heimfeld lab to do phenotypic characterization of cellular 
subsets. 
 
Additionally, see the following tables (Tables 7, 8. 9, 10) for disease specific pre-
transplant evaluations. 


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Table 7: Disease-Specific Pre-Transplant Evaluations for Ph (-) ALL, Ph (+) ALL, CML 
 
Note: All bone marrow aspirates and biopsies are unilateral and must be collected within 21 days of 
treatment. See Tables 12 and 13 for post-transplant evaluations and additional lab instructions 
 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
PCR for bcr/abl, p.210 breakpoint - *see comment 
Clinical 
*CML only - reflexive 
testing for FHCRC patients 
only 
PCR for bcr/abl, p.190 and p.210 breakpoints - *see 
comment  
Clinical 
*Ph (+) ALL only - 
reflexive testing for 
FHCRC patients only 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*CML only 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
PCR for bcr/abl, p.210 breakpoint- *see comment 
Clinical 
*CML only 


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Table 8: Disease-Specific Pre-Transplant Evaluations for AML and MDS/MPD 
 
Note: All bone marrow aspirates and biopsies are unilateral and must be collected within 21 days of 
treatment. See Tables 12 and 13 for post-transplant evaluations and additional lab instructions 
 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*MDS/MPD only 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
 


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Table 9: Disease-Specific Pre-Transplant Evaluations for CLL, HL, NHL 
 
Note: All bone marrow aspirates and biopsies are bilateral and must be collected within 30 days of 
treatment. See Tables 12 and 13 for post-transplant evaluations and additional lab instructions 
 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry- *see comment 
Clinical 
*No HL 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
PCR for t(11:14) - *see comment 
Clinical 
*Mantle Cell NHL only 
PCR for t(14:18) - *see comment 
Clinical 
*Follicular NHL only 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*HL – only if history of BM 
involvement 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
Quantitative Ig levels 
Clinical 
 
β-2 microglobulin 
Clinical 
 
LDH 
Clinical 
 
ZAP – 70 by flow cytometry- *see comment 
Clinical 
*CLL only – for patients not in CR 
Imaging 
 
CT of chest, abdomen, pelvis (neck if indicated) 
Clinical 
 
 


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Table 10: Disease-Specific Pre-Transplant Evaluations for MM and Waldenstrom’s 
Macroglobulinemia 
 
Note: All bone marrow aspirates and biopsies are bilateral and must be collected within 30 days of 
treatment. See Tables 11 and 12 for post-transplant evaluations and additional lab instructions. 
 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
Bone marrow biopsy 
 
Pathology 
Clinical 
 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
SPEP/IFIX 
Clinical 
 
Quantitative Ig levels 
Clinical 
 
β-2 microglobulin 
Clinical 
 
Cryoglobulins, c-reactive protein, serum viscosity - 
*see comment 
Clinical 
*Serum viscosity only for patients with 
>3gm/dL IgM monoclonal protein or 
>4gm/dL IgA or IgG protein 
Urine 
 
UPEP/IFIX 
Clinical 
 
Protein / creatinine clearance 
Clinical 
 
Imaging 
 
MRI –  *see comment 
Clinical 
*MM only 
Skeletal survey –  *see comment 
Clinical 
*MM only 
CT of chest, abdomen, pelvis (neck if indicated) –  
*see comment 
Clinical 
*Waldenstrom’s Macroglobulinemia only 


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B. Patient Post-transplant Evaluation  
1. See Table 11 for disease specific post-transplant evaluation on Day +28, 56, 84, etc. 
This is a recommended evaluation schedule. 
 
Additionally, include the following for all diseases: 
2. History and physical exam to assess Karnofsky performance status and GVHD 
weekly until day +84, thereafter monthly or as indicated. If GVHD develops refer to 
Toxicity section. 
3. CBC three times a week, or more often if clinically indicated, from day 0 until 
ANC>500 for 2 days post nadir 
4. Cyclosporine trough levels on day “0” and then twice a week until taper begins. 
Weekly thereafter if levels are stable.  
5. Chem 1(Na+, K+, Cl_, Bun, Cr, glucose) and chem 3 (Mg+2, Ca+2) 3x per week 
until CSP taper begins. 
6. FOR PATIENTS ON ARM 2 ONLY:  
7. 
a) Sirolimus trough levels on day “0” and then twice a week for the first month 
and weekly thereafter to maintain therapeutic serum levels. 
b) Serum triglyceride levels every two weeks post transplant until Day +56, 
then once per month until off sirolimus, or more often if clinically indicated. 
c) Haptoglobin every other week until Day +56, then as indicated. Evaluation 
of schistocytes weekly with CBC through Day + 56. 
8. Evaluate at Day +84 
Patient Discharge to the Care of Referring Hematologist/Oncologist. After the 
day +84 work-up and screening for chronic GVHD are completed and 
analyzed, a patient with an uncomplicated unrelated HCT would be eligible for 
discharge. Since the patient may be discharged prior to starting CSP taper, 
instructions should be provided for preventing and detecting GVHD as per 
standard practice of collaborating institution.  
 
GVHD evaluation guidelines are as follows: 
• History and physical exam (see Appendix G) 
• Skin biopsy 
• Schirmer's tear test 
• Pulmonary function test 
• Oral exam  
• CXR 
• Dietician assessment 
• Gynecological departure assessment (adult female)  
 
Patients should be evaluated for GVHD per Appendix G prior to DLI. 
 


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-35- 
9. Patients should be assessed for the need of IVIG monitoring and replacement therapy per 
Institutional Guidelines and patients with MM should be assessed for the need of 
bisphosphonates per Institutional Guidelines


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Table 11: Post-Transplant Evaluation 
This is a recommended evaluation schedule. See Tables 7 - 10 for pre-transplant evaluations. Additional lab instructions in Table 12. 
 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Ph (-) ALL 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Ph (+) ALL 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
FISH for  bcr/abl and other 
clonal abnormalities 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
PCR for bcr/abl, p.190 and 
p.210 breakpoints 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
PCR for bcr-abl, p.190 and 
p.210 breakpoints 
Clinical 
* If bone marrow not done and 
reflexive testing for FHCRC 
patients only 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
AML 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
MDS/ MPD 
 
 
BM aspirate *see biopsy 
                   ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal  pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal  pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
*For pts. with evidence or 
history of myelofibrosis 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
CML 
BM aspirate *see biopsy 
                   ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
FISH for bcr-abl and other 
clonal abnormalities 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
PCR for bcr-abl, and p.210 
breakpoint 
Clinical 
*Reflexive testing for FHCRC 
patients only 
x 
x 
x 
x 
x 
x 
x 
BM biopsy 
 
Pathology 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
PCR for bcr-abl, and p.210 
breakpoint 
Clinical 
*If  bone marrow not done and 
reflexive testing for FHCRC 
patients only 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
CLL 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate *see biopsy 
                       ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant 
AND bone marrow not done 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  pre-
transplant 
 
*See 
comment x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
HL - 
No history of 
BM 
involvement 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
 
 
x 
 
x 
 
 
Cytogenetics 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment  
*See 
comment  
 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment  
*See 
comment  
 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if <50% on 
day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions 
x 
 
 
 
 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  pre-
transplant 
 
*See 
comment  x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
-43- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
HL - 
History of BM 
involvement 
BM aspirate *see biopsy 
                      ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  pre-
transplant 
 
*See 
comment  x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


2448.00 
FHCRC Current Version: 07/20/2016 
-44- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
NHL - No 
history of BM 
involvement 
 
*see separate 
section for 
additional PCR 
on Mantle Cell 
and Follicular 
NHLs in 
suspected CR 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
 
 
x 
 
x 
 
 
Flow cytometry 
Clinical 
 
 
 
x 
 
x 
 
 
Cytogenetics 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment  
*See 
comment  
 
Peripheral blood 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if <50% 
on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions 
x 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant AND 
bone marrow not done 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 Microglobulin 
Clinical 
 
 
 
x 
 
 
 
 
LDH 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Imaging 
CT of chest, abdomen, 
pelvis (neck if indicated) 
Clinical 
*If abnormal pre-transplant 
 
*See 
comment x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


2448.00 
FHCRC Current Version: 07/20/2016 
-45- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
NHL – 
History of BM 
involvement  
 
*see separate 
section for 
additional PCR 
on Mantle Cell 
and Follicular 
NHLs in 
suspected CR 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate *see biopsy 
                      ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant, if 
bone marrow not obtained 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
x 
 
x 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  pre-
transplant 
 
*See 
comment  x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
-46- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Mantle Cell 
NHL in 
suspected CR 
BM aspirate *in addition to complete NHL restaging 
                      ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
PCR for t(11:14) 
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood  *in addition to complete NHL restaging 
 
PCR for t(11:14) 
Clinical 
*If abnormal pre-transplant, if 
bone marrow not obtained  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Follicular Cell 
NHL in 
suspected CR 
BM aspirate *in addition to complete NHL restaging 
                      ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
PCR for t(14:18) 
Clinical  
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood  *in addition to complete NHL restaging 
 
PCR for t(14:18) 
Clinical  
*If abnormal pre-transplant, if 
bone marrow not obtained  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


2448.00 
FHCRC Current Version: 07/20/2016 
-47- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
MM 
 
 
Omit 
SPEP/IFIX and 
UPEP/IFIX for 
non-secretory 
MM 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical   
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical  
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for chrom. 13 (and 
other clonal) abnormalities  
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
SPEP and IFIX 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Cryoglobulins, C-reactive 
protein, viscosity 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
 
*See comment 
Urine 
 
Protein/creatinine clearance Clinical 
 
 
 
x 
x 
x 
x 
x 
UPEP and IFIX 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Imaging 
 
Complete skeletal survey 
Clinical 
 
 
 
 
 
x 
 
x 
Skeletal MRI 
Clinical 
 
 
 
 
 
x 
 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 


2448.00 
FHCRC Current Version: 07/20/2016 
-48- 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Waldenstrom’s 
Macro-
globulinemia 
 
Omit SPEP/IFIX 
and UPEP/IFIX 
for non-secretory 
Waldenstrom’s 
Macro-
globulinemia 
 
BM aspirate**If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical  
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for chrom. 13 (and 
other clonal) abnormalities  
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside institutions x 
 
 
 
 
 
 
SPEP and IFIX 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
 
x 
x 
x 
x 
Cryoglobulins, C-reactive 
protein, viscosity 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
 
*See comment 
Urine 
 
 
Protein/ creatinine 
clearance 
Clinical 
 
 
 
x 
x 
x 
x 
x 
UPEP and IFIX 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Imaging 
 
 
 
 
 
 
 
 
 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  pre-
transplant 
 
*See 
comment 
x 
x 
x 
x 
x 
GVHD  evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 


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FHCRC Current Version: 07/20/2016 
- 49 - 
Table 12: Additional Lab Instructions 
Note: All bone marrow tests are done on aspirate unless specifically identified as biopsy. All instructions apply to both 
pre- and post-transplant evaluations unless specifically identified otherwise. 
 
Off-site providers may use local facilities for the tests.  
Volumes represent desired amounts. 
Specimen / 
Test 
Type 
Instructions 
Lab Name 
Contact Information 
Bone marrow 
 
Chimerism  
Clinical 
1-3mL bone marrow in 
green-top tube 
Clinical Immunogenetics 
Lab 
Seattle Cancer Care Alliance 
 (206) 288-7700 
Pathology 
(aspirate) 
Clinical 
2mL bone marrow in EDTA 
formalin 
SCCA Pathology Lab 
Seattle Cancer Care Alliance 
(206) 288-1355 
Pathology (biopsy) 
Clinical 
1cm bone marrow in 
formalin OR mounted in 
paraffin 
SCCA Pathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-1355 
Flow Cytometry 
Clinical 
2mL bone marrow in green-
top tube 
UW Hematopathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-7060 
Cytogenetics 
Clinical 
3mL bone marrow in green-
top tube 
SCCA Cytogenetics Lab 
Seattle Cancer Care Alliance 
 (206) 288-1390 
FISH 
Clinical 
2mL bone marrow in green-
top tube 
SCCA Cytogenetics Lab 
Seattle Cancer Care Alliance 
 (206) 288-1390 
PCR  for bcr-abl 
and p190 and/or 
p210 
Clinical 
3mL bone marrow in 
lavender-top tube 
Label “protocol 2448” 
UW Molecular 
Hematopathology Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
PCR t(11:14) or 
t(14:18) 
Clinical 
2mL bone marrow in 
lavender-top tube 
UW Molecular 
Hematopathology Lab  
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
Peripheral blood 
 
Chimerism  
(CD3+), (CD33+) 
NK(CD56+) 
Clinical 
10mL blood in green-top 
tube for Flow sorting, then 
to CIL 
UW Hematopathology Lab, 
routed to Clinical 
Immunogenetics Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
Flow Cytometry 
Clinical 
10mL blood in green-top 
tube 
UW Hematopathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-7060 
SPEP/IFIX 
Clinical 
3mL blood in red-top tube 
UW Department of 
Laboratory Medicine 
University of Washington 
(800) 713-5198 
Quantitative Ig 
Levels 
Clinical 
3mL blood in red-top tube 
SCCA Alliance Lab 
Seattle Cancer Care Alliance 
(206) 288-2057 
β-2 Microglobulin 
Clinical 
3mL blood in red-top tube 
UW Department of 
Laboratory Medicine 
University of Washington 
(800) 713-5198 
LDH 
Clinical 
3mL blood in red-top tube 
SCCA Alliance Lab 
Seattle Cancer Care Alliance 
(206) 288-2057 
PCR for bcr-abl 
and p190 and/or 
p210 
Clinical 
7mL blood in lavender-top 
tube 
Label “protocol 2448” 
UW Molecular 
Hematopathology Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
PCR for t(11:14) or 
t(14:18) 
Clinical 
5mL blood in lavender-top 
tube 
UW Molecular 
Hematopathology Lab  
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
ZAP – 70 by Flow 
cytometry 
(pre-transplant only) 
Clinical 
5mL blood in green-top 
tube 
UW Hematopathology Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
 


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Outside institutions may use VNTR analysis (sex- matched transplants) or sex chromosome FISH-analysis (sex-
mismatched transplants) for chimerism analysis. 
 
C. Donor Evaluations 
     Unrelated donors will undergo evaluation for allogeneic hematopoietic cell donation at the collection      
center by NMDP standard. The attending physician of the collection center will review the results of       
the donor evaluation.  Evaluations typically include: 
1. Complete history and physical examination. 
2. Lab tests: CBC with reticulocytes and platelet counts, SMAC 12, hepatitis screen, CMV, 
syphilis, HIV and HTLV I serologies and ABO Rh blood typing. If the donor has antibodies 
against red cell antigens of the recipient, the titers will be determined. Cytotoxic crossmatch 
between patient and donor (HLA Laboratory) will be performed. 
3. No placement of a central line is necessary for G-CSF stimulated PBSC collection unless it is 
determined that the donor has poor venous access.  If necessary, a temporary apheresis (e.g. 
Mahurkar) catheter will be placed at the time of leukapheresis. 
4. A CBC will be checked prior to and after leukapheresis collection, and daily while on G-CSF. 
CBCs will be checked thereafter if clinically indicated. 
5. The donor will be reevaluated the day after the apheresis is completed. 
 
14. 
Drugs and Toxicities 
  
Sirolimus, CSP, MMF and fludarabine are all commercially available. They should be stored and 
mixed according to manufacturer's recommendations. 
A. For the purposes of this protocol, toxicity will be graded using the modified NCI common toxicity 
scale (Appendix P). 
B. TBI: TBI will be given in one 200-300 cGy fraction from linear accelerator at a rate of 6 - 7 cGy/min. 
Dosimetry calculations are performed by the radiation therapist. At the dosage used, side effects are 
not expected. Nevertheless, there may be fever, alopecia, parotitis, diarrhea, reversible skin 
pigmentation, mucositis and late effects including cataract formation, growth retardation, pulmonary 
damage, carcinogenesis, and sterilization. 
C. Cyclosporine: See section 11.H.3.a. for information about administration and dosage adjustments. 
Side effects are generally reversible, and may include renal insufficiency, hypomagnesemia, 
paresthesias, tremor, seizures, visual disturbances, paresis, disorientation, depression, confusion, 
somnolence, coma, nausea, hypertension, hemolytic-uremic syndrome, hyperglycemia, gynecomastia, 
and hypertrichosis 
 
 
D. Sirolimus 
 
 1) Formulation and Administration 
a. 
Sirolimus is supplied as oral solution (Rapamune Oral Solution) 1 mg/mL or as 1 mg tablets. 
b. 
Rapamune Oral Solution pouches should be stored protected from light and refrigerated at 2°C 
to 8°C. If necessary, the patient may store the pouches at room temperatures up to 25°C (77°F) 
for a short period of time (e.g., several days, but no longer than 30 days). The tablets should be 
stored at 20-25°C and be protected from light. 
c. 
Sirolimus is to be administered orally once daily at the doses described in Section 11.H.3.c.  To 
minimize variability of exposure to sirolimus, this drug should be taken consistently with or 


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without food. Grapefruit juice reduces CYP3A4-mediated metabolism of sirolimus and should 
not be administered with sirolimus or used for dilution. 
d. 
If patients are receiving Rapamune Oral Solution, the dose should be mixed well with 60 mL 
of water or orange juice and taken immediately. It is recommended that the container be 
refilled with a minimum of 120 mL of water or orange juice, mixed well, and this rinse 
solution should be swallowed. 
 
 2) Adverse Reactions 
 
  
The incidence of adverse reactions was determined in two randomized, double-blind multicenter 
controlled trials in which 499 renal transplant recipients received Rapamune oral solution 2 mg/day 
and 477 received 5 mg/day. Specific adverse reactions associated with the administration of 
Rapamune oral solution included hypocholesterolemia, hyperlipidemia, hypertension, and rash. At 
the higher dose of 5 mg, these adverse effects included anemia, arthralgia, diarrhea, hypokalemia, 
and thrombocytopenia. Additional toxicities from our study in stem cell transplantation include: 
hemolytic uremic syndrome, seizures, and neutropenia. 
 
  
Appendix R lists medications including voriconazole, posaconazole, and fluconazole that may 
affect metabolism of sirolimus.  In patients receiving sirolimus, these drugs should be used with 
caution and sirolimus levels should be monitored closely.  The Standard Practice Antifungal Therapy 
Guidelines in Appendix E may be used as a reference for dosing instructions. 
 
 3) Management of Toxicities 
 
 
 
a. All toxicities will be scored as per common toxicity criteria (Appendix P) and unless 
specified in this protocol, treated as per our Standard Practice Guidelines. 
 
  
b. Toxicities thought to be associated with sirolimus will be treated as follows: 
i. Engraftment will be considered 3 consecutive days of ANC >500/L on day 30. If ANC 
<500 on day 30 remains below 500, graft failure evaluation should be initiated as per our 
Standard Practice Guidelines. 
ii. Severe neutropenia or thrombocytopenia. A thorough evaluation cause of marrow 
suppression should occur including peripheral blood chimerism studies, marrow aspiration 
and review of marrow suppressive medications (e.g. bactrim). If all other potential causes of 
marrow toxicity are ruled out, dose adjustments will only be made for grade IV neutropenia 
and thrombocytopenia that persists after day 21 post-transplant, and in the case of 
neutropenia is refractory to G-CSF therapy. Dose reductions of sirolimus of approximately 
50% should occur. For severe persistent toxicity despite sirolimus dose reduction, sirolimus 
should be held until blood counts recover to ANC > 1500/l and platelets >100,000/l. At 
that point, sirolimus may be reintroduced at a 1 mg po q.d. and dose increased to 2 mg/qd as 
long as severe hematopoietic toxicity does not occur 
iii. Hyperlipidemia: Sirolimus is known to cause elevations in serum cholesterol and triglyceride 
levels.  Serum triglyceride levels should be drawn every two weeks through Day + 56, then 
monthly while on Sirolimus, or more often if clinically indicated.  Cholesterol levels will be 
drawn at Day + 84 departure workup.  In general, triglyceride levels remained below 1000 
mg/dL. However, in 2/14 patients in our previous study, levels reached 2145 and 2152. To 
avoid complications due to pancreatitis, patients should be treated with gemfibrozil, 600 mg 
BID p.o., or atorvastatin, 10 mg q.d. for triglyceride levels >800 mg/dL.   
E. MMF:   See section 11.H.3.b for information about administration and dosage adjustments.  
Mycophenolate mofetil (MMF): is supplied in 250mg hard gelatin capsules. Capsules 


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may be stored at room temperature. 
 
i. 
Precautions:  MMF has been studied extensively among patients after nonmyeloablative 
HCT. Previous clinical studies in patients after allografting suggest that the principal adverse 
reactions associated with the administration of MMF include nausea, vomiting, neutropenia, 
diarrhea, and on one occasion bloody diarrhea. In the setting of marrow transplantation, 
several etiologic factors may contribute to alterations in gastrointestinal and hematologic 
parameters.  MMF has an increased incidence of digestive system adverse events, including 
GI tract ulceration, and hemorrhage (3% of patients receiving MMF). GI tract perforations 
have rarely been observed. Most patients in these studies were also on other drugs known to 
be associated with these complications. Up to 2% of patients receiving MMF for prevention 
of rejection developed severe neutropenia (ANC <500). The development of neutropenia 
may be related to MMF itself, concomitant medications, viral infections or some combination 
of these causes. MMF dose adjustments will be made if clinically indicated if in the opinion 
of the attending physician, no other cause is thought to be responsible for the abnormality.  
These adjustments should be discussed with the principal investigator and documented in the 
medical records and the clinical reporting form (CRF). Dose adjustments are described in 
Section 11.H.3.b.5. 
 
F. Fludarabine: The dose of fludarabine used in this protocol is nonmyeloablative, but does cause 
significant immunosuppression. Fludarabine can lower the white blood cell count, in particular the 
CD4+ T-cells. The immunosuppression observed with the use of fludarabine increases the risk of 
infection, which can be life threatening. 
 
G. GVHD:  
1. Diagnosis: Skin involvement will be assessed by biopsy with percentage of body surface 
area involved recorded. GI symptoms suspicious for GVHD will be evaluated by biopsy as 
indicated. Acute GVHD and chronic GVHD will be graded according to established criteria 
(Appendix F and G).  Acute GVHD will graded by an independent reviewer blinded to 
study arm and patient identity. 
2. Recommended Treatment: 
a. 
Patients developing acute GVHD > grade II off immunosuppression or while on 
a CSP taper: 
i. CSP 5mg/kg PO q12hrs.  If there is concern of GI absorption use IV route 
(1.5mg/kg q12hrs). 
ii. Prednisone (2mg/kg/day) is to be added if there is no response by 72 hours or 
progression of GVHD during the 24 hours after the start of CSP 5.0 mg/kg PO 
q12hrs. Patients who respond to steroids after 10 to 14 days of treatment, 
should begin a 6-week steroid taper. 
iii. Patients may also be eligible for institutional trials of GVHD therapy. 
b. Patients who develop acute GVHD > grade II prior to day +100: 
i. Patients who develop acute GVHD > grade II should receive prednisone (1-2 
mg/kg/day) or intravenous equivalent. Continuation of sirolimus (Arm 2) beyond day 
80 in patients with active GVHD is at the discretion of the treating attending. A 
suggested sequence for immunosuppression discontinuation is as follows. Patients 
who respond to steroids after 10 to 14 days of treatment, should begin a 6 week 


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steroid taper. ALL Arms: When steroids are tapered to less than 0.5 mg/kg, then a 
CSP taper should be initiated no sooner then day +96 and such that the completion of 
the taper is NOT prior to Day + 150. 
• Arm 1 Patients:   After successful discontinuation of CSP and 
corticosteroids, the suggested sequence for tapering MMF is to taper the 
MMF such that the completion of the taper is NOT prior to Day + 180 post 
transplant. 
• Arm 2 Patients: If patient still receiving MMF, it should be discontinued 
without a taper prior to initiating a CSP taper. After successful 
discontinuation of MMF, CSP and corticosteroids, the suggested sequence 
for tapering sirolimus is to taper the sirolimus such that the completion of 
the taper is NOT prior to Day + 180 post transplant. 
• If nausea and/or vomiting prevent the oral administration of CSP or MMF, 
then CSP and MMF should be administered intravenously.  The timing of 
these tapers depends on the day post transplant that acute GVHD develops, 
the severity of the GVHD and the clinical discretion of the attending 
physician. 
• Patients may be eligible for institutional trials of GVHD therapy 
c. 
Patients with clinical extensive chronic GVHD: CSP 5.0 mg/kg PO q12hrs and 
prednisone 1mg/kg QD or eligible protocols at the time.  The patient should receive 
antibiotic prophylaxis with daily double strength Bactrim.  
d. 
Patients off immunosuppression who develop concurrent manifestations of GVHD 
that satisfy criteria for acute GVHD > grade II (e.g. erythematous rash, diarrhea, 
hyperbilirubinemia) and are pathognomonic of clinical extensive chronic GVHD 
(e.g. lichenoid oral changes, occular sicca, scleroderma, bronchiolitis obliterans, 
contractures), should receive prolonged immunosuppressive therapy similar to that 
for clinical extensive chronic GVHD. 
H. Myelosuppression 
Grade IV myelosuppression will be defined as a decrease in ANC to <500/uL and/or platelet 
count to  20,000/uL. If myelosuppression occurs, a bone marrow aspirate and biopsy should be 
considered to exclude disease progression. Samples should be sent for chimerism analysis by a 
DNA-based assay that compares the profile of amplified fragment length polymorphisms (ampFLP) (or 
FISH studies or VNTR) of the patient and donor. Myelosuppression may occur in this patient 
population for a number of reasons such as direct toxic effect of drugs (MMF, ganciclovir etc.), 
rejection, relapse or after DLI.  
 
Patients with myelosuppression may be managed as follows:  
1. Suspected MMF toxicity: refer to sections 11.H.3.b Guidelines for MMF dose adjustment 
above for management recommendations.  
2. Suspected sirolimus toxicity: refer to sections 11.H.3.c for management recommendations. 
3. Suspected ganciclovir toxicity: consider changing to foscarnet.  
4. Patients who are > 21 days after HCT with an ANC of <500/uL may receive G-CSF 
5g/kg/day S.C. 
5. Thrombocytopenic patients will receive platelet transfusion as per standard care. 
6. Suspected BCR/ABL tyrosine kinase inhibitor therapy (such as imatinib mesylate or 
dasatinib) toxicity:  refer to sections 11.L.4.a-b above for management recommendations.  


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15. 
 
Records 
Clinical records will be maintained as confidentially as possible by all collaborating institutions. 
Collection of Case Report Forms (CRF) at standard intervals is the primary method of collecting data 
from collaborating centers. Clinical Statistics at FHCRC maintains a patient database to allow storage and 
retrieval of patient data collected from a wide variety of sources. The principal investigator will ensure 
that data collected conform to all established guidelines for coding collection, key entry and verification. 
These data are then entered into a secure dedicated database operated by a data manager.  Any publication 
or presentation will refer to patients by a unique patient number and not by name to assure patient 
confidentiality. The licensed medical records department, affiliated with the institution where the patient 
receives medical care, maintains all original inpatient and outpatient chart documents. 
 
At the FHCRC, patient research files are kept in a locked room. They are maintained by the FHCRC data 
collection staff that is supervised by an A.R.T. Access is restricted to personnel authorized by the Division 
of Clinical Research. 
 
16.  Statistical Consideration and Termination of Study 
This is a randomized phase III study whose primary objective is to compare two immunosuppressive 
regimens for their ability to prevent grades II-IV acute GVHD.  Since the two arms differ in the number of 
drugs and the duration of administration, it is not feasible to blind the study; however, the assignment of 
GVHD grades will be performed by an independent evaluator who will be blinded as to the study arm. 
 
A. Primary Endpoint 
The primary endpoint for this trial will be the rate of acute grade II-IV GHVD at day 100 post-transplant, 
exclusive of GVHD that occurs as a result of alterations to immunosuppressive therapy in response to 
relapse or progression. 
 
B.    Sample size/Power 
One hundred fifty patients will be randomized to each arm, for a total sample size of 300 patients, 
including patients who were randomized to the corresponding arms of the original 3-arm trial.  The 
randomization will be stratified on institution. This sample size is sufficient to detect differences between 
arms in a range considered to be clinically significant – which is a difference of 15-20% percentage points.  
For such a difference the power ranges from 74% to 94%, at the 2-sided 0.05 level of significance, 
assuming a chi-squared test.  For purposes of sample size analysis we have assumed a rate of 52% grade II-
IV GVHD in one arm, which corresponds to our historical experience with MMF/CSP; however, the power 
calculations are not particularly sensitive to this rate.   At a projected accrual rate of approximately 60 
patients per year it will take 5 years to complete the study. 
 
To better account for the competing risks of early death and relapse, the actual analysis will be a time-to-
event analysis using a log-rank statistic.  Patients dying or relapsing within the first 100 days post-
transplant in the absence of acute GVHD will be censored at that time.   
 
C.   Interim Analysis for Futility 
After 150 patients have been randomized and evaluated for 100 days post-transplant, an interim analysis 
for futility will be conducted.   This analysis will estimate the conditional power of the study, given the 
data available at that time and assuming that going forward the rates of GVHD will differ by 15% between 
arms, with the rates for each arm centered around the pooled estimate of the rate from the combined arms.   


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The conditional power will be estimated by Monte 
Carlo simulation.  If the estimated conditional power 
is <33.3% then the trial will be stopped, otherwise the 
trial will continue to completion.   No adjustment to 
the final significance level is required.  The overall 
properties of this rule are summarized in the figure as 
a function of the true difference (delta) between arms.  
The blue line indicates the nominal power of the study 
without the futility stopping rule.  The green line 
indicates the probability of completing the trial and 
rejecting the hypothesis of equality at the 0.05 
significance level.  The red line indicates the 
probability of stopping the trial for futility.  This rule 
preserves the nominal power of the study while still 
providing a reasonable likelihood of stopping the trial when the true difference between arms is clinically 
negligible. 
 
D. Secondary Endpoints 
Secondary endpoints that will be analyzed include grade III-IV acute GVHD, chronic extensive GVHD, 
non-relapse mortality, relapse, and overall survival.  The small number of patients that were treated on the 
discontinued arm of the original protocol will be followed for primary and secondary endpoints, but will 
not be part of any comparative analysis. 
 
17. Data and Safety Monitoring Plan  
 
A. FHCRC Protocol 2448 Data and Safety Monitoring Plan 
 
1. Monitoring the progress of trials and the safety of participants 
 
Protocol 2448 is a multi-institutional clinical trial that is monitored by the principal investigator (PI), Dr. 
Sandmaier, with oversight by a Data Safety and Monitoring Board (DSMB), the Data and Safety 
Monitoring Committee (DSMC) and the Institutional Review Board (IRB). The PI reviews outcome data for 
each individual patient at a minimum of 3 months after unrelated donor HCT and the updated data are 
presented at Mixed Chimerism Meetings (includes co-investigators).  
 
Please see appendix I for definitions of adverse events, serious adverse events (SAE) and serious and 
unexpected events as well as mechanisms for reporting these events. SAEs are reported to the trial 
coordinator. The trial coordinators at collaborating centers or the local PIs will fax an official report of an 
SAE to the coordinating center (FHCRC) within ten days. The SAE report is reviewed by Dr. Sandmaier. If 
the SAE meets the FHCRC criteria for expedited reporting then an official signed report is submitted to the 
FHCRC Institutional Review Office (IRO). All deaths, regardless of the cause, are reported to the IRB. 
Protocol 2448 has a dedicated independent DSMB responsible for monitoring patient safety on this clinical 
trial. The DSMB will meet at six month intervals for this protocol and all outcome data is reviewed 
including all adverse events and SAEs reported to the coordinating center (FHCRC) along with those 
officially reported to the FHCRC IRO. The DSMB confirms that the trial has met any stopping rules and 
reviews any patient safety problems necessitating discontinuation of the trial. A report from the DSMB is 


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submitted to the FHCRC IRB as well as the trial coordinators/local PIs of this protocol. The DSMB will 
discontinue the review of outcomes when this protocol is closed to accrual and the last patient treated is past 
day +180. Furthermore, the FHCRC also has a DSMC that reviews the progress of the protocol with respect 
to the monitoring plan at the time of each annual renewal. As with initial review, annual IRB review and 
approval is also required.  
  
Flow of information concerning clinical trial participants originates with the clinicians and nurses in the 
clinic or referring clinicians at other institutions and is transmitted to the trial coordinator. At the FHCRC, 
health care providers and rotating attending physicians assess patients and record their observations 
regarding toxicity and response outcomes in the medical record.  This documentation is extracted by the 
study nurse within 140 days +/- after HCT via chart review and collection of copies of source documents 
and entered into a hard copy or electronic Case Report Form (CRF). The PI reviews the official CRF and 
primary source documents. When the CRFs are verified, they are signed by the PI.  Thus, multiple health 
care providers provide independent observations and participate in monitoring this trial.  The PI may be a 
clinician for some patients entered on this trial.  However, assessments are the sum total of the primary 
health care provider (fellow or physician assistant), floor or outpatient nurse and the PI or other attending 
clinician involved with the patient averting possible conflict of interest having the PI as the attending 
clinician for protocol patients.  If determination of adverse events is controversial, co-investigators will 
convene on an ad hoc basis as necessary to review the primary data and render a decision.  
 
Protocol 2448 will be a multi-institutional protocol and all collaborating centers sign an agreement with the 
FHCRC stating that data generated from patients from the protocol will be reported accurately in a timely 
manner to the FHCRC. All centers have IRBs that review the protocol and who local PIs contact when an 
adverse event on the protocol occurs. Most of the centers have internal auditing mechanisms that assure 
accurate assessment of clinical outcomes. Clinical outcome data are summarized and transmitted from 
collaborating centers as CRFs. When possible, primary source documents regarding patient outcomes are 
collected with patients’ names removed and replaced by Unique Patient Numbers (UPNs). The CRFs are 
generated from the collaborating centers at defined time points (100 days, 6 months, and yearly). The local 
PI reviews the official CRF and primary source documents. When the CRFs are verified, they are signed by 
the PI.  
 
2. Plans for assuring compliance with requirements regarding the reporting of Serious Adverse Events SAEs 
 
The adverse event reporting in this multi-institutional clinical trial will follow the FHCRC Guidelines for 
SAE reporting. These guidelines (attached in appendix I.) detail the expedited reporting requirements, 
definitions of particular events. All SAEs that meet expedited criteria are reported to the IRO within 10 days 
by the investigator, trial coordinator, or research nurse upon learning of the event.  A completed SAE report 
form, signed by the PI, must be received by the IRO within 10 calendar days.  The PI reviews all SAEs and 
annual reports at the time of submission. For patients being cared for at the FHCRC, health care providers 
communicate with the PI, trial coordinator or research nurses as events occur triggering subsequent 
reporting. For patients not being cared for at FHCRC the outside facilities communicate with the PI, trial 
coordinator, or research nurse for these reporting purposes. All other deaths and expected serious adverse 
events are reported to the IRB at the time of annual renewal and at the biannual mixed chimerism meeting.  
The PI for a study is responsible for this reporting and the IRO assures adverse event reporting on an annual 
basis.  The PI in the annual application for grant continuation will summarize reports of toxicities.  All 
collaborating PIs have fulfilled all NIH requirements for training in human subjects protection. 


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3.  Plans for assuring that any action resulting in a temporary or permanent suspension of an NCI-funded 
clinical trial is reported to the NCI grant program director responsible for the grant 
 
This clinical research trial uses commercial agents and there is no associated Investigational New Drug 
(IND) or Investigational Device Exemption (IDE). Any temporary or permanent suspension, as determined 
by the PI, IRB, or DSMC, of this clinical research trial will be reported to the NCI grant program director by 
the PI.  
 
4.  Plans for assuring data accuracy and protocol compliance 
Collaborating sites send signed consents, eligibility forms, and CRFs with source documents demonstrating 
eligibility, treatment, and serious adverse events (if applicable) to the study staff. These are reviewed for 
eligibility, adherence to the protocol, accuracy, and completeness by the study staff. Queries are sent to the 
collaborating investigators if CRFs are inaccurate or incomplete.  
 
The study is monitored under the FHCRC Monitoring Plan. The FHCRC Data and Safety Monitoring Plan 
details the full scope and extent of monitoring and provides for immediate action in the event of the 
discovery of major deviations.   
 
 


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18.  TARGETED / PLANNED ENROLLMENT 
 
*The “Ethnic Category Total of All Subjects” must be equal to the “Racial Categories Total of All Subjects.” 
 
Ethnic Category 
Gender 
Females 
Males 
Total 
Hispanic or Latino 
4 
5 
9 
Not Hispanic or Latino 
123 
168 
291 
Ethnic Category Total of All Subjects 
127 
173 
300 
                      Racial Categories 
American Indian / Alaska Native 
1 
2 
3 
Asian 
3 
4 
7 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
3 
5 
8 
White 
120 
162 
282 
Racial Categories:  Total of All Subjects 
127 
173 
300 


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19. References 
Reference List 
 
 1.  Niederwieser D, Maris M, Shizuru JA, et al.  Low-dose total body irradiation (TBI) and fludarabine followed by hematopoietic 
cell transplantation (HCT) from HLA-matched or mismatched unrelated donors and postgrafting immunosuppression 
with cyclosporine and mycophenolate mofetil (MMF) can induce durable complete chimerism and sustained 
remissions in patients with hematological diseases. Blood 2003;101(4):1620-1629.  
Reference ID: 21841 
 2.  Maris MB, Niederwieser D, Sandmaier BM, et al.  HLA-matched unrelated donor hematopoietic cell transplantation after 
nonmyeloablative conditioning for patients with hematologic malignancies. Blood 2003;102(6):2021-2030.  
Reference ID: 23067 
 3.  Maris MB, Sandmaier BM, Storer BE, et al.  Unrelated donor granulocyte colony-stimulating factor-mobilized peripheral blood 
mononuclear cell transplantation after nonmyeloablative conditioning: the effect of postgrafting mycophenolate 
mofetil dosing. Biol Blood Marrow Transplant 2006;12:454-465.  
Reference ID: 29095 
 4.  Baron F, Maris MB, Sandmaier BM, et al.  Graft-versus-tumor effects after allogeneic hematopoietic cell transplantation with 
nonmyeloablative conditioning. J Clin Oncol 2005;23(9):1993-2003.  
Reference ID: 25864 
 5.  Nash RA, Antin J, Karanes C, et al. Phase III study comparing tacrolimus (FK506) with cyclosporine (CSP) for prophylaxis of 
acute graft-versus-host-disease (GVHD) after marrow transplantation from unrelated donors [abstract]. Blood. 1997;90 
(Suppl. 1)561a. 
Reference ID: 14922 
 6.  Horowitz MM, Przepiorka D, Bartels P, et al.  Tacrolimus vs. cyclosporine immunosuppression: results in advanced-stage 
disease compared with historical controls treated exclusively with cyclosporine. Biol Blood Marrow Transplant 
1999;5:180-186.  
Reference ID: 16311 
 7.  Yu C, Storb R, Deeg HJ, Schuening FG, Nash RA, Graham T. Synergism between mycophenolate mofetil and cyclosporine in 
preventing graft-versus-host disease in lethally irradiated dogs given DLA-nonidentical unrelated marrow grafts 
[abstract]. Blood. 1995;86 (Suppl 1)577a. 
Reference ID: 11655 
 8.  Sandmaier BM, Storb R, Santos EB, et al.  Allogeneic transplants of canine peripheral blood stem cells mobilized by 
recombinant canine hematopoietic growth factors. Blood 1996;87(8):3508-3513.  
Reference ID: 11289 
 9.  Storb R, Yu C, Wagner JL, et al.  Stable mixed hematopoietic chimerism in DLA-identical littermate dogs given sublethal total 
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Reference ID: 12941 
 10.  Storb R, Raff RF, Appelbaum FR, et al.  DLA-identical bone marrow grafts after low-dose total body irradiation: the effect of 
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 12.  Shi Y, Sahai BM, Green DR.  Cyclosporin A inhibits activation-induced cell death in T-cell hybridomas and thymocytes. 
Nature 1989;339:625-626.  
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 13.  Blaha P, Bigenzahn S, Koporc Z, et al.  The influence of immunosuppressive drugs on tolerance induction through bone 
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and in vivo. Nat Med 2000;6(7):762-768.  
Reference ID: 23162 
 15.  Izeradjene K, Revillard JP.  Apoptosis of superantigen-activated T cells induced by mycophenolate mofetil treatment. 
Transplantation 2001;71(1):118-125.  
Reference ID: 21431 
 16.  McSweeney P, Abhyankar S, Foran J, et al.  Favorable early tranpslant outcomes using tacrolimus and mycophenolate mofetil 
for GVHD prevention after matched sibling allografting. Blood 2003;102 (Part 1)(11):714a, #2641-  
Reference ID: 24069 
 17.  Sehgal SN.  Rapamune (RAPA, rapamycin, sirolimus): mechanism of action immunosuppressive effect results from blockade 
of signal transduction and inhibition of cell cycle progression (Review) [reprint in Clin Biochem. 2006 
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functional CD4+CD25+FOXP3+ regulatory T cells of both healthy subjects and type 1 diabetic patients. J Immunol 
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generation of alloantigen-specific regulatory T cells. Am J Transplant 2007;7(7):1722-1732.  
Reference ID: 38844 
 20.  Frank DA, Robertson MJ, Bonni A, Ritz J, Greenberg ME.  Interleukin 2 signaling involves the phosphorylation of Stat 
proteins. PNAS 1995;92(17):7779-7783.  
Reference ID: 38814 
 21.  Zeiser R, Leveson-Gower DB, Zambricki EA, et al.  Differential impact of mammalian target of rapamycin inhibition on 
CD4+CD25+Foxp3+ regulatory T cells compared with conventional CD4+ T cells. Blood 2008;111(1):453-462.  
Reference ID: 34022 
 22.  Hoffmann P, Ermann J, Edinger M, Fathman CG, Strober S.  Donor-type CD4(+)CD25(+) regulatory T cells suppress lethal 
acute graft-versus-host disease after allogeneic bone marrow transplantation. J Exp Med 2002;196(3):389-399.  
Reference ID: 22725 
 23.  Hanash AM, Levy RB.  Donor CD4+CD25+ T cells promote engraftment and tolerance following MHC-mismatched 
hematopoietic cell transplantation. Blood 2005;105(4):1828-1836.  
Reference ID: 38845 
 24.  Edinger M, Hoffmann P, Ermann J, et al.  CD4+CD25+ regulatory T cells preserve graft-versus-tumor activity while inhibiting 
graft-versus-host disease after bone marrow transplantation. Nat Med 2003;9(9):1144-1150.  
Reference ID: 31079 


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 25.  van de Laar L, Buitenhuis M, Wensveen FM, Janssen HL, Coffer PJ, Woltman AM.  Human CD34-derived myeloid dendritic 
cell development requires intact phosphatidylinositol 3-kinase-protein kinase B-mammalian target of rapamycin 
signaling. J Immunol 2010;184(12):6600-6611.  
Reference ID: 38816 
 26.  Johnson RA, Wang X, Ma XL, Huong SM, Huang ES.  Human cytomegalovirus up-regulates the phosphatidylinositol 3-kinase 
(PI3-K) pathway: inhibition of PI3-K activity inhibits viral replication and virus-induced signaling. J Virol 
2001;75(13):6022-6032.  
 Reference ID: 38813 
 27.  Cutler C, Kim HT, Hochberg E, et al.  Sirolimus and tacrolimus without methotrexate as graft-versus-host disease prophylaxis 
after matched related donor peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2004;10(5):328-
336.  
Reference ID: 30176 
 28.  Fortun J, Martin-Davila P, Pascual J, et al.  Immunosuppressive therapy and infection after kidney transplantation. Transplant 
Infectious Disease 9999;prepublished online June 11, 2010; doi: 10.1111/j.1399-3062.2010.00526.x-  
Reference ID: 38824 
 29.  Decker T, Hipp S, Ringshausen I, et al.  Rapamycin-induced G1 arrest in cycling B-CLL cells is associated with reduced 
expression of cyclin D3, cyclin E, cyclin A, and survivin. Blood 2003;101(1):278-285.  
Reference ID: 38872 
 30.  Wanner K, Hipp S, Oelsner M, et al.  Mammalian target of rapamycin inhibition induces cell cycle arrest in diffuse large B cell 
lymphoma (DLBCL) cells and sensitises DLBCL cells to rituximab. Br J Haematol 2006;134(5):475-484.  
Reference ID: 38871 
 31.  Geissler EK, Schlitt HJ, Thomas G.  mTOR, cancer and transplantation (Review). Am J Transplant 2008;8(11):2212-2218.  
Reference ID: 38817 
 32.  Koehl GE, Andrassy J, Guba M, et al.  Rapamycin protects allografts from rejection while simultaneously attacking tumors in 
immunosuppressed mice. Transplantation 2004;77(9):1319-1326.  
Reference ID: 38819 
 33.  Guba M, von Breitenbuch P, Steinbauer M, et al.  Rapamycin inhibits primary and metastatic tumor growth by 
antiangiogenesis: involvement of vascular endothelial growth factor. Nat Med 2002;8(2):128-135.  
Reference ID: 38820 
 34.  Kauffman HM, Cherikh WS, Cheng Y, Hanto DW, Kahan BD.  Maintenance immunosuppression with target-of-rapamycin 
inhibitors is associated with a reduced incidence of de novo malignancies. Transplantation 2005;80(7):883-889.  
Reference ID: 38818 
 35.  Cutler C, Antin JH.  Sirolimus for GVHD prophylaxis in allogeneic stem cell transplantation (Review). Bone Marrow 
Transplant 2004;34(6):471-476.  
Reference ID: 38812 
 36.  Cutler C, Li S, Ho VT, et al.  Extended follow-up of methotrexate-free immunosuppression using sirolimus and tacrolimus in 
related and unrelated donor peripheral blood stem cell transplantation. Blood 2007;109(7):3108-3114.  
Reference ID:  34740 
 37.  Alyea EP, Li S, Kim HT, et al.  Sirolimus, tacrolimus, and low-dose methotrexate as graft-versus-host disease prophylaxis in 
related and unrelated donor reduced-intensity conditioning allogeneic peripheral blood stem cell transplantation. Biol 
Blood Marrow Transplant 2008;14(8):920-926.  
Reference ID: 35728 


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 38.  Armand P, Gannamaneni S, Kim HT, et al.  Improved survival in lymphoma patients receiving sirolimus for graft-versus-host 
disease prophylaxis after allogeneic hematopoietic stem-cell transplantation with reduced-intensity conditioning. J 
Clin Oncol 2008;26(35):5767-5774.  
Reference ID: 37064 
 39.  Schleuning M, Judith D, Jedlickova Z, et al.  Calcineurin inhibitor-free GVHD prophylaxis with sirolimus, mycophenolate 
mofetil and ATG in Allo-SCT for leukemia patients with high relapse risk: an observational cohort study. Bone 
Marrow Transplant 2009;43(9):717-723.  
Reference ID: 38811 
 40.  Snyder DS, Palmer J, Gaal K, et al.  Improved outcomes using tacrolimus/sirolimus for graft-versus-host disease prophylaxis 
with a reduced-intensity conditioning regimen for allogeneic hematopoietic cell transplant as treatment of 
myelofibrosis. Biol Blood Marrow Transplant 2010;16(2):281-286.  
Reference ID: 38627 
 41.  Kaplan B, Meier-Kriesche HU, Napoli KL, Kahan BD.  The effects of relative timing of sirolimus and cyclosporine 
microemulsion formulation coadministration on the pharmacokinetics of each agent. Clin Pharmacol Ther 
1998;63(1):48-53.  
Reference ID: 38821 
 42.  Ferron GM, Mishina EV, Zimmerman JJ, Jusko WJ.  Population pharmacokinetics of sirolimus in kidney transplant patients. 
Clin Pharmacol Ther 1997;61(4):416-428.  
Reference ID: 38822 
 43.  Johnson EM, Zimmerman J, Duderstadt K, et al.  A randomized, double-blind, placebo-controlled study of the safety, tolerance, 
and preliminary pharmacokinetics of ascending single doses of orally administered sirolimus (rapamycin) in stable 
renal transplant recipients. Transplant Proc 1996;28(2):987-  
Reference ID: 38823 
 44.  Kelly PA, Gruber SA, Behbod F, Kahan BD.  Sirolimus, a new, potent immunosuppressive agent (Review). Pharmacotherapy 
1997;17(6):1148-1156.  
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 45.  Marty FM, Lowry CM, Cutler CS, et al.  Voriconazole and sirolimus coadministration after allogeneic hematopoietic stem cell 
transplantation. Biol Blood Marrow Transplant 2006;12(5):552-559.  
Reference ID: 35925 
 46.  Bolan CD, Childs RW, Procter JL, Barrett AJ, Leitman SF.  Massive immune haemolysis after allogeneic peripheral blood stem 
cell transplantation with minor ABO incompatibility. Br J Haematol 2001;112(3):787-795.  
Reference ID: 19140 
 
 


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20. 
Table of Appendices 
 
APPENDIX A 
ELIGIBILITY GUIDELINES FOR DONOR PBSC APHERESIS FOR 
TRANSFUSION 
APPENDIX B 
THE KARNOFSKY PERFORMANCE STATUS SCALE 
APPENDIX C 
THE LANSKY PLAY-PERFORMANCE SCALE 
APPENDIX D 
ABO INCOMPATIBILITY 
APPENDIX E 
INFECTIOUS DISEASE GUIDELINES 
APPENDIX F 
ACUTE GRAFT-VERSUS-HOST DISEASE GRADING 
APPENDIX G 
CHRONIC GRAFT-VERSUS-HOST DISEASE GRADING 
APPENDIX H 
EVALUATION OF DISEASE RESPONSE FOR MM, LYMPHOMA, CLL, AND 
MDS 
 
APPENDIX I 
STUDY COORDINATOR’S MANUAL INCLUDING PROCEDURES FOR 
REPORTING ADVERSE EVENTS 
APPENDIX J 
ADVERSE EVENT REPORT 
APPENDIX K 
NOTICE OF DEATH FORM 
APPENDIX L 
PATIENT DEMOGRAPHICS AND REGISTRATION FORM 
APPENDIX M 
CORE CASE REPORT FORM 
APPENDIX N 
INTRATHECAL DIAGNOSTIC STUDY AND THERAPY 
APPENDIX O 
HLA TESTING OF DONORS AND RECIPIENTS PRIOR TO 
HEMATOPOIETIC STEM CELLTRANSPLANTATION 
APPENDIX P 
ADAPTED COMMON TOXICITY CRITERIA 
APPENDIX Q 
THE HEMATOPOIETIC CELL TRANSPLANT-COMORBIDITY INDEX 
(HCT-CI)  
APPENDIX R 
CLINICALLY SIGNIFICANT INDUCERS/INHIBITORS OF 
 CYTOCHROME P450 ENZYME SYSTEM 
APPENDIX S 
WEIGHT / ADJUSTED BODY WEIGHT FOR DRUG DOSING 
APPENDIX T 
COORDINATING CENTER FUNCTIONS 
APPENDIX U 
RADIOTHERAPY TREATMENT GUIDELINES 


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APPENDIX A 
 
ELIGIBILITY GUIDELINES FOR DONOR PBSC APHERESIS FOR TRANSFUSION 
 
Immunization 
Donor Eligibility 
Cholera 
No wait 
Diphtheria 
No wait 
Flu 
24 hour wait 
Gamma globulin (Immune 
serum globulin) 
No wait unless for hepatitis 
Hepatitis B vaccine 
No wait unless given for hepatitis exposure 
Measles (Rubella) 
1 month wait 
Mumps 
2 week wait 
Polio – Sabin (inj) 
No wait 
Plague 
No wait 
Rabies 
1 year wait if given as treatment for bite.  2 week 
wait if given as prophylaxis (DMV’s or zoo 
workers) 
Smallpox 
2 week wait 
Tetanus toxoid 
No wait 
Typhoid 
No wait 
Typhus 
No wait 
Yellow Fever 
2 week wait 


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APPENDIX B 
THE KARNOFSKY PERFORMANCE STATUS SCALE 
 
General 
Index 
Specific Criteria 
Able to carry on normal activity; no 
special care needed 
100 
Normal, no complaints, no evidence of 
disease 
 
90 
Able to carry on normal activity, minor 
signs or symptoms of disease 
 
80 
Normal activity with effort, some signs 
or symptoms of disease 
Unable to work, able to live at home and 
care for most personal needs, varying 
amount of assistance needed 
70 
Care for self, unable to carry on normal 
activity or to do work 
 
60 
Requires occasional assistance from 
others but able to care for most needs 
 
50 
Requires considerable assistance from 
others and frequent medical care 
Unable to care for self, requires 
institutional or hospital care or 
equivalent; disease may be rapidly 
progressing 
40 
Disabled; requires special care and 
assistance 
 
30 
Severely disabled, hospitalization 
indicated, death not imminent 
 
20 
Very sick, hospitalization 
necessary, active supportive 
treatment necessary 
 
10 
Moribund 
 
0 
Dead 
 


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APPENDIX C 
THE LANSKY PLAY-PERFORMANCE SCALE 
(FOR USE WITH PERSONS AGES 1 – 16 YEARS) 
 
Score (%) 
Description 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both, greater restrictions of, and less time spend in play activities 
60 
Up and around, but minimal active play, keeps busy with quieter activities 
50 
Gets dressed but lies around much of the day, no active play; able to 
participate in all quiet play activities 
40 
Mostly in bed; participates in quiet activities 
30 
In bed; needs assistance even for quiet play 
20 
Often sleeping; play entirely limited to very passive activities 
10 
Unresponsive 
0 
Dead 


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APPENDIX D 
 
 
ABO INCOMPATIBILITY 
 
Red Blood Cell - Incompatibility (Major): 
Occasional patients may have antibodies directed against red blood cell antigens found on the donor's cells. 
These are generally ABO or Rh antigens, although incompatibility with other red cell antigens identified by 
donor-recipient crossmatch may occur. Although the volume of red blood cells (RBC) in most PBMC products 
will only be 2-5% of the product volume before infusion, the small quantity may cause a hemolytic transfusion 
reaction. According to the FHCRC policy it is generally acceptable to infuse a volume of about 10ml RBCs per 
product. If the recipient shows an anti-donor titer of  1:32 or the RBC volume is greater than 10ml (or > 20ml 
in two products combined) the PBMC components should be RBC depleted by Starch Sedimentation (flowsheet 
below). Refer to the Clinical Coordinator's Patient Information Sheet for instructions regarding management of 
a specific patient.  
Post transplant blood component support will be according to Standard Practice Guidelines. 
 
Timing: Every attempt should be made to infuse red cell depleted PBMC products within 2 hours of depletion. 
Expected Results: Red blood cell depleted PBMC products will contain < 10ml of red blood cells and  90% 
nucleated cell recovery. 
 
Red Blood Cell - Incompatibility (Minor): 
Occasional donors may have antibodies directed against red blood cell antigens (ABO, Rh, or other antigen 
system) found on the recipient's cells. The risk of hemolysis of recipient red cells immediately after transplant is 
not of very much clinical import. Due to the high number of lymphocytes in the PBMC inoculum, recipients 
may be at much greater risk for a delayed type of hemolysis that can be severe. PBMC products contain < 
200ml of plasma according to FHCRC policy and no deleterious effects have been observed so far. However, if 
donors show an anti-recipient titer  1:256, the PBMC component should be plasma depleted (see flowsheet 
below). Refer to the Clinical Coordinator's Patient Information Sheet for instructions regarding management of 
a specific patient.  
Post transplant blood component support will be according to Standard Practice Guidelines. 
 
Timing: Every attempt should be made to infuse plasma-depleted PBMC within 2 hours of depletion. 
Expected Results: The plasma depletion should not affect the nucleated cell recovery. 
 
Red Blood Cell – Bidirectional Incompatibility: 
Patients undergoing transplants for bidirectional RBC incompatibility should be managed according to both 
algorithms shown below. Most red cell depletion techniques also deplete plasma from the PBMC component 
with no additional cell loss. Refer to the Clinical Coordinator's Patient Information Sheet for instructions 
regarding management of a specific patient.  
 


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Post transplant blood component support will be according to Standard Practice Guidelines. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MAJOR ABO INCOMPATIBLE 
Recipient anti-
Donor titer 
> 1:32 
<20ml RBC total 
  Infuse without modification 
>20ml RBC total 
  RBC depletion of component 
< 1:16 
  
Infuse without modification 
MINOR ABO INCOMPATIBLE 
Donor anti-
Recipient titer 
> 1:256 
Plasma depletion of component 
< 1:128 
Infuse without modification 
 
 
 
 
 
 
 
 


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APPENDIX E 
INFECTIOUS DISEASE GUIDELINES 
 
Please note that the content of these PDFs is from the Fred Hutchinson Clinical Research Division Standard 
Practice Manual and does not contain research related procedures. 
 
Herpes Simplex and Varicella Zoster Virus Prevention and Treatment 
 
HSV-VZV.pdf
 
CMV Prevention: Surveillance and Preemptive Therapy 
cmvprevention.pdf
 
CMV Disease: Diagnosis and Treatment 
cmvdiseasetreatmen
t.pdf
 
Antifungal Therapy Guidelines 
antifungal_therapy.p
df
 
Pneumonia / Pneumocystis Carinii Prophylaxis 
pneumocystisjiroveci
.pdf
 
Antibiotic Prophylaxis for Encapsulated Bacteria in Allogeneic Patients with Chronic GvHD Requiring 
Immunosuppressive Therapy 
Antibiotic.prophylaxi
s-Encapsulated.pdf  
Vaccinations 
Vaccines
 
Foscarnet 
foscarnet.pdf
 


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APPENDIX F 
GRADING OF ACUTE GRAFT-VERSUS-HOST DISEASE a  
Severity of Individual Organ Involvement 
Skin 
+1 
a maculopapular eruption involving less than 25% of the body 
surface 
+2 
a maculopapular eruption involving 25-50% of the body surface 
+3 
generalized erythroderma 
+4 
generalized erythroderma with bullous formation and often with 
desquamation 
Liver 
+1 
bilirubin (2.0-3.0 mg/100 ml) 
+2 
bilirubin (3-5.9 mg/100 ml) 
+3 
bilirubin (6-14.9 mg/100 ml) 
+4 
bilirubin > 15 mg/100 ml 
Gut 
Diarrhea is graded +1 to +4 in severity. Nausea and vomiting and/or 
anorexia caused by GVHD is assigned as +1 in severity 
The severity of gut involvement is assigned to the most severe involvement 
noted.  Patients with visible bloody diarrhea are at least stage +2 gut and 
grade +3 overall 
Diarrhea 
+1 
 1000 ml of liquid stool/day* ( 15ml of stool/kg/day)† 
+2 
>1,000 ml of stool/day* (> 15ml of stool/kg/day)† 
+3 
>1,500 ml of stool/day* (> 20ml of stool/kg/day)† 
+4 
2,000 ml of stool/day* ( 25ml of stool/kg/day)† 
*In the absence of infectious/medical cause 
†For pediatric patients 
 
Severity of GVHD 
Grade I 
+1 to +2 skin rash 
No gut or liver involvement 
Grade II 
+1 to +3 skin rash 
+1 gastrointestinal involvement and/or +1 liver involvement 
Grade III 
+2 to +4 gastrointestinal involvement and/or 
+2 to +4 liver involvement with or without a rash 
Grade IV 
Pattern and severity of GVHD similar to grade 3 with extreme 
constitutional symptoms or death 
 
_______________ 
a From “Graft-vs-host disease” Sullivan, Keith M. Hematopoietic Cell Transplantation Ed: D. Thomas, K. Blume, S. Forman, Blackwell Sciences; 
1999, pages 518-519


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 APPENDIX G 
 
CHRONIC GRAFT-VERSUS-HOST DISEASE (GVHD) 
 
Chronic GVHD in allogeneic transplant recipients resembles autoimmune disorders such as 
scleroderma, Sjogren syndrome, primary biliary cirrhosis, lichen planus, wasting syndrome, 
bronchiolitis obliterans among others manifestations (see below). Approximately 50% of 
patients will develop this complication within 6 months after the transplant despite continued 
treatment with immunosuppressive medications. Close monitoring is recommended during 
the first 2 years after allogeneic stem cell transplantation so that appropriate treatment can be 
instituted promptly in patients who develop chronic GVHD. Debilitation, joint contractures 
and profound immunosuppression resulting in recurrent bacterial infections are prominent 
characteristics of untreated chronic GVHD. 
 
A. Classification of Chronic GVHD 
The purpose of this classification is to identify patients with cGVHD who need long-term 
systemic immunosuppression according to clinical and laboratory findings and risk factors at 
the time of initial diagnosis. In addition, a morbidity scale has been developed to help grade 
the severity of manifestation of chronic GVHD (Appendix D) at the time of diagnosis, when 
changes in treatment are made and when assessing treatment response. 
 
1.  Chronic GVHD not requiring systemic treatment: mild abnormalities involving a 
single site, with platelet count >100,000 and no steroid treatment at the onset of 
chronic GVHD 
a)  Oral abnormalities consistent with cGVHD, a positive skin or lip biopsy, and no other 
manifestations of cGVHD 
b)  Mild liver test abnormalities (alkaline phosphatase ≤2 x upper limit of normal, AST or 
ALT ≤3 x upper limit of normal and total bilirubin ≤1.6) with positive skin or lip biopsy, 
and no other manifestations of cGVHD 
c)  Less than 6 papulosquamous plaques, macular-papular or lichenoid rash involving <20% of body 
surface area (BSA), dyspigmentation involving <20% BSA, or erythema 
involving <50% BSA, positive skin biopsy, and no other manifestations of cGVHD 
d)  Ocular sicca (Schirmer’s test ≤5mm with no more than minimal ocular symptoms), 
positive skin or lip biopsy, and no other manifestations of cGVHD 
e)  Vaginal or vulvar abnormalities with positive biopsy, and no other manifestations of 
cGVHD 
 
2.  Chronic GVHD requiring systemic treatment: more severe abnormalities or 
involvement of multiple sites, or platelet count <100,000, or steroid treatment 
at the onset of chronic GVHD 
a)  Involvement of two or more organs with symptoms or signs of cGVHD, with biopsy 
documentation of cGVHD in any organ 
b)  ≥15% base line body weight loss not due to other causes, with biopsy documentation of 
cGVHD in any organ 
c)  Skin involvement more extensive than defined for clinical limited cGVHD, confirmed by 
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d)  Scleroderma or morphea 
e)  Onycholysis or onychodystrophy thought to represent cGVHD, with documentation of 
cGVHD in any organ 
f)  Decreased range of motion in wrist or ankle extension due to fasciitis caused by cGVHD 
g)  Contractures thought to represent cGVHD 
h) Oral involvement with functional impairment, refractory to topical treatment 
i)  Vaginal involvement with functional impairment, refractory to topical treatment 
j)  Bronchiolitis obliterans not due to other causes 
k)  Positive liver biopsy; or abnormal liver function tests not due to other causes with 
alkaline phosphatase >2 x upper limit of normal, AST or ALT >3 x upper limit of 
normal, or total bilirubin >1.6, and documentation of cGVHD in any organ 
l)  Positive upper or lower GI biopsy 
m)  Fasciitis or serositis thought to represent cGVHD and not due to other causes 
 
B. Physical manifestations of Chronic GVHD 
Manifestations that are distinctive for chronic GVHD can begin before day 100 after the 
transplant, and manifestations that are typical of acute GVHD can persist long after day 100. 
For this reason, the differential diagnosis between acute and chronic GVHD cannot be made 
solely according to the time interval from transplant. The diagnosis of chronic GVHD 
requires at least one manifestation that is distinctive for chronic GVHD (identified by italic 
print below) as opposed to acute GVHD. In all cases, infection and others causes must be 
ruled out in the differential diagnosis of chronic GVHD. 
 
Karnofsky or Lansky Clinical Performance scores <60%, ≥15% weight loss, and recurrent 
infections are usually signs of clinical extensive chronic GVHD. Abnormalities that could 
indicate chronic GVHD are categorized by organ system are listed below (italic print 
identifies manifestation more distinct of chronic GVHD): 
 
Skin 
Erythema, dryness, pruritis, macular-papular or urticarial rash, pigmentary 
changes (i.e., hyperpigmentation, vitiligo), mottling, papulosquamous or 
lichenoid plaques, hyperkeratosis, exfoliation (ichthyosis), nodules, scleroderma, 
morphea (one or several circumscribed, indurated and shiny lesions). The extent 
of skin involvement and the skin thickness score for patients with scleroderma 
needs to be recorded at the time of diagnosis, when changes in treatment are 
made and when assessing treatment response. Medical photos are also useful for 
assessing the extent of skin involvement and response to treatment. 
Nails 
B.     Ridging, onychodystrophy, onycholysis 
Hair 
Premature graying (scalp hair, eyelashes, eyebrows), thinning scalp hair, 
alopecia, decreased body hair 
Mouth 
Dryness, burning, gingivitis, mucositis, striae, dryness, atrophy, erythema, 
lichenoid changes, ulcers, labial atrophy or pigmentary changes, tightness 
around the mouth, sensitivity to acidic, strong flavors, heat or cold, tooth decay 
Eyes 
Dryness, burning, blurring, gritty eyes, photophobia, pain 
Vagina/vulva 
Dryness, dyspareunia, stricture or stenosis, erythema, atrophy or lichenoid 
changes not induced by ovarian failure or other causes 
Liver 
Jaundice and elevated liver function tests not due to other causes (see laboratory 


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tests) 
Lung 
Bronchiolitis obliterans (see diagnostic indicators), cough, wheezing, dyspnea on 
exertion, history of recurrent bronchitis or sinusitis 
GI 
Anorexia, nausea, vomiting, diarrhea, malabsorption, dysphagia, odynophagia 
Myofascial 
Stiffness and tightness with restriction of movement, occasionally with swelling, 
pain, cramping, erythema and induration, most commonly affecting the forearms, 
wrists and hands, ankles, legs and feet, inability to extend the wrists without 
flexing the fingers or the elbows, contractures 
Muscle 
A. 
Proximal muscle weakness, cramping 
Skeletal 
Arthralgia of large proximal girdle joints and sometimes smaller joints 
Serosal 
Unexplained effusions involving the pleural, pericardial, or peritoneal cavities 
not due to venocclusive disease of the liver, cardiac insufficiency, malignancy, 
infection, GM-CSF toxicity or other causes 
 
 
 
C. Laboratory Testing and Diagnostic Indicators of Chronic GVHD 
 
Eye 
Schirmer’s test with a mean value ≤ 5 mm at 5 minutes, or values of 6-10 mm in 
patients who have sicca symptoms, or keratitis detected by slit lamp examination 
Liver 
Elevated liver function tests not due to other causes (alkaline phosphatase ≥2 x 
upper limit, of normal, AST or ALT >3 x upper limit of normal or total serum 
bilirubin ≥1.6) 
Lung 
New obstructive lung defect defined as an FEV1 <80% of predicted with either an 
FEF 25-75 <65% of predicted or RV >120% of predicted, or a decrease of 
FEV1/FVC by >12% within a period of less than 1 year, thought not to be caused 
by an infectious process, asthma or recurrent aspiration from the sinuses or from 
gastroesophageal reflux. In the absence of GVHD in any other organ, the 
diagnosis of bronchiolitis obliterans requires negative microbiological tests from 
bronchoalveolar lavage, evidence of air trapping by high resolution end-
expiratory and end-inspiratory CAT scan of the lungs, or confirmation by 
thoracoscopic biopsy. 
Esophagus 
Esophageal web formation, stricture or dysmotility demonstrated by barium 
swallow, endoscopy or manometry 
Intestine 
Endoscopic findings of mucosal edema and erythema or focal erosions with 
histological changes of apoptotic epithelial cells and crypt cell drop out. Patients 
with unresolved acute GVHD may have more severe intestinal mucosal lesions 
including ulcers and mucosal sloughing. 
Muscle 
Elevated CPK or aldolase, EMG findings consistent with myositis with biopsy 
revealing no other etiological process 
Blood 
Thrombocytopenia (usually 20,000-100,000/l), eosinophilia (> 0.4 x 103/uL), 
hypogammaglobulinemia. Hypergammaglobulinemia and autoantibodies occur in 
some cases. 
 
 
 
 


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D. Guidelines for Treatment of Chronic GVHD after allogeneic HCT 
 
We strongly recommend that you consult the LTFU office before beginning treatment for chronic GVHD and 
before making changes in immunosuppressive treatment. Clinical trials should always be considered because 
current standard therapies are associated with high morbidity and decreased survival for patients with high risk 
chronic GVHD. 
 
Standard treatment of chronic GVHD usually begins with administration of glucocorticoids (1mg/kg/day) 
followed by taper to eventually reach an alternate-day regimen, with or without daily cyclosporine or tacrolimus 
(FK506). Other medications used for treatment of corticosteroid-resistant chronic GVHD are summarized on 
the next page. Telephone consultation with the LTFU medical team is available to you, seven days a week, to 
discuss appropriate treatment and provide other follow up recommendations. In addition to immunosuppressive 
treatment, antibiotic prophylaxis for encapsulated bacterial infections and PCP must be given to all patients 
being treated for chronic GVHD (see Appendix E). 
 
The duration of systemic immunosuppressive treatment of chronic GVHD varies but requires at least one year 
of therapy. Approximately 80% of patients require systemic immunosuppressive for 2 years and 40% of them 
requires therapy for at least 4 years. 
 
 
Adapted From: Long-Term Followup After Hematopoietic Stem Cell Transplant General Guidelines For Referring Physicians, Fred 
Hutchinson Cancer Research Center Standard Practice Manual, Section X, Chronic Graft Versus Host Disease (GVHD), Nov/2003 
Version 
 


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Appendix H 
 
Evaluation of Disease Response: 
 
Chronic myeloid Leukemia (CML) 
Complete response: 
Normalization of the white count with complete disappearance of the Ph 
chromosome in 20 out of 20 metaphases whenever possible. Molecular response is 
defined by negative RT-PCR for the BCR/ABL transcripts in bone marrow or 
blood. 
Partial response: 
Normalization of the white count with >0% but 35% Ph  
 
metaphases. 
No response: 
Persistence of 80% Ph-positive metaphases. 
Progressive disease: 
Acquisition of a new cytogenetic abnormality and/or development of accelerated 
phase or blast crisis. The criteria for accelerated phase will be defined as 
unexplained fever greater than 38.3° C, new clonal cytogenetic abnormalities in 
addition to a single Ph-positive chromosome, marrow blasts and promyelocytes in 
access of 20%. 
 
Acute leukemia (AML, ALL) 
Complete response: 
<5% marrow blasts by pathology and no circulating leukemic  
 
blasts. 
Partial response: 
5-30% marrow blasts, or <5% marrow blasts with circulating blasts. 
Stable disease: 
>30% marrow blasts without definite deterioration of performance  
 
status or worsening of anemia, neutropenia, or thrombocytopenia. 
Progressive disease: 
Evidence of relapse (>5% blasts) by morphologic or flow cytometric evaluation of 
 
the bone marrow aspirate or appearance of extramedullary disease  
 
Chronic lymphocytic leukemia (CLL) 
Complete remission: 
Normal imaging studies (X-ray, CT, MRI) (nodes, liver, and spleen) , peripheral 
blood by flow cytometry has no clonal lymphocytes, bone marrow by flow 
cytometry has no clonal lymphocytes, bone marrow by morphology has no 
nodules (or if present, nodules are free from CLL cells by immunohistochemistry), 
and the duration is ≥2 months. 
CR with minimal   
residual disease: 
 Peripheral blood or bone marrow by flow cytometry >0 - <1 CLL cells/1000 
leukocytes (0.1%) 
 
Partial remission: 
Absolute lymphocyte count in peripheral blood 50% decrease3 and physical 
exam/Imaging studies (nodes, liver, and/or spleen) 50% decrease3, 4.  Duration is 
≥2 months. 
Progressive disease: 
1 of: Physical exam/imaging studies (nodes, liver, and/or spleen) ≥50% increase 
or new, circulating lymphocytes by morphology and/or flow cytometry 50% 
increase, and lymph node biopsy with Richter’s transformation 
Stable disease: 
Did not meet any of the above criteria for complete or partial remission or 
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Relapsed disease: 
Criteria of progression occurring 6 months after achievement of complete or 
partial remission. 
 
Lymphoma [Hodgkin's Disease, Non-Hodgkin's Lymphoma (NHL)] 
Complete response: 
Disappearance of all clinically detectable disease. 
Partial response: 
50% reduction of the sum of the products of the perpendicular  
 diameters of marker lesions, no progression of any existing lesions, and no new 
lesions. 
Stable disease: 
Stabilization of all existing lesions with no new lesions (i.e. a <25% increase or 
<50% decrease in disease parameters defined above throughout the treatment 
period). 
Progressive disease: 
>25% increase in the sum of the products of the perpendicular diameters of marker 
lesions, or the appearance of new lesions. 
 
Multiple Myeloma (MM) 
Complete response: 
Disappearance of plasmacytomas; decrease in marrow plasmacytosis to less than 
10%; 75% reduction of the monoclonal serum protein. Reduction of the 24 hour 
urine M-component to 10% or less of the initial prestudy value and to less than 0.2 
gm/day; no increase in the size or number of lytic skeletal lesions; and normal 
serum calcium. 
Partial response: 
50%, <75% reduction of the monoclonal serum protein and  
 reduction of the 24 hour urine M-component to less than  
0.2 gm/day; no increase in serum calcium, or in the size or number of 
plasmacytomas or lytic skeletal lesions. 
Stable disease: 
<50% reduction or <100% increase of the serum myeloma protein. 
Progressive Disease: 
100% increase of the serum myeloma protein from its lowest  
 level, or reappearance of myeloma peaks that had disappeared with treatment; or 
definite increase in the size or number of plasmacytomas or lytic bone lesions. 
Myelodysplasia (MDS) 
Progressive Disease: 
Any evidence by morphologic or flow cytometric evaluation of the bone marrow 
aspirate of new blasts (>5%). 
 
1 Without granulocyte colony stimulating factor support. 
2 Without red blood cell transfusions or erythropoietin support. 
3 Compared to before starting therapy. 
4 Defined by the sum of the products of up to 6 lymph nodes with no increase in the size of any single lymph node (ie, an increase of <25 percent in a lymph node <2cm 
is not considered significant) and no new enlarged lymph nodes. 
 
1.  Cheson BD, Bennett JM, Grever M, Kay N, Keating MJ, O'Brien S, Rai KR.  National Cancer Institute-sponsored Working Group 
guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment.  Blood 87: 4990-4997, 
1996. 
  2.   Hallek M, Cheson BD, Catovsky D, Caligaris-Cappio F, Dighiero G, Dohner H, Hillmen P, Keating MJ, Montserrat E, Rai KR, 
Kipps TJ, International Workshop on Chronic Lymphocytic Leukemia.  Guidelines for the diagnosis and treatment of 
chronic lymphocytic leukemia: a report from the International Workshop on Chronic Lymphocytic Leukemia updating 
the National Cancer Institute-Working Group 1996 guidelines [Erratum appears in Blood. 2008 Dec 15;112(13):5259].  
Blood 111: 5446-5456, 2008. 
  3.   Chronic lymphocytic leukemia: recommendations for diagnosis, staging, and response criteria. International Workshop on 
Chronic Lymphocytic Leukemia.  Ann Intern Med 110: 236-238, 1989. 


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APPENDIX I 
 
Study Coordinator’s Manual 
I. Introduction 
The mixed chimerism protocols have been opened to multiple sites to increase the referral base and accrual. 
Because of this expansion of collaborators, the data collection procedures are being revised. The procedure 
manual was created to assure consistency of data reporting across the centers and to assure compliance with 
regulations. General expectations of collaborators are that they will comply with appropriate regulatory 
requirements, specified protocol requirements, and provide outcome data. 
 
The manual translates working procedures for study coordination. Its goal is to describe the procedures with 
sufficient clarity to ensure that all study centers will use the same procedures and follow-up schedules for 
participant data management and reporting. Changes to the manual and relevant forms will be made as soon as 
practical and will become effective on receipt of the revised procedures at the study centers, unless otherwise 
noticed. 
 
II. Institutional Review Board Review of Protocols and Modifications 
All research protocols proposed for use that involves human subjects must be reviewed and approved by the 
Institutional Review Board (IRB) prior to implementation. New protocols will undergo review at the FHCRC 
IRB and then will be distributed to sites that wish to participate for their IRB’s review. For Centers that have a 
Federal Wide Assurance (FWA), formal collaboration includes submission of a form 310 and a copy of the IRB 
approved protocol and consent forms to the FHCRC.  For sites without a FWA, an FWA form needs to be filed. 
Once the paperwork is submitted to the Office for Human Research Protection, the approval process can take up 
to a couple of months, and must be completed before collaboration on a protocol can begin.  
 
In addition, all amendments and/or revisions to on-going, approved activities must be submitted for review and 
approved prior to implementation at an institution.  No revisions may be implemented at outside institutions 
without the prior approval of the FHCRC Principal Investigator.  The FHCRC and the local site’s IRB must 
review all protocol activities at least once annually. This must be done within 365 days of the last review 
regardless of the policies of the institution. A copy of annual renewal approvals must be received for 
collaboration to continue for the next year. 
 
III. Registrations 
Collaborating Institutions: The principal investigator of the collaborating institution who will register the patient 
with the FHCRC will identify eligible patients. Registration will include completion of the eligibility 
checklist/demographic form. This form will be faxed (206-667-5378) prior to treatment initiation. Patients 
should be registered prior to treatment initiation for valid registration 
 
IV. Reporting Adverse Events 
The following guidelines are the minimum serious adverse event (SAE) reporting guidelines for Category 1 and 
2 studies conducted at the Fred Hutchinson Cancer Research Center.   
 
Expedited Reporting Requirements  
All adverse events (whether occurring on-site or off-site), which in the opinion of the principal 
investigator are (1) unexpected, and (2) related or possibly related to the research and (3) serious or 
suggests that the research places research participants or others at a greater risk of physical or 


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psychological harm than was previously known or recognized must be submitted to the IRB within ten 
(10) calendar days of becoming aware of the event. 
 
Definitions 
 
An Adverse Event - Any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product, medical treatment or procedure and which does not necessarily have to 
have a causal relationship with this treatment.  An adverse event can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding, for example), symptom, or disease temporally 
associated with the use of a medicinal product, medical treatment or procedure whether or not considered 
related.  
 
Related or Possibly Related Adverse Event:  An adverse event is “related or possibly related to the research 
procedure” if in the opinion of the principal investigator, it was more likely than not caused by the research 
procedures. Adverse events that are solely caused by an underlying disease, disorder or condition of the subject 
or by other circumstances unrelated to either the research or any underlying disease, disorder or condition of the 
subject are not “related or possibly related.” If there is any question whether or not an adverse event is related or 
possibly related, the adverse event should be reported.  
 
Serious Adverse Event: An adverse event that results in any of the following outcomes: Death, a life-
threatening adverse event (real risk of dying), inpatient hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity/or change in psychosocial status, a congenital 
anomaly or, requires intervention to prevent permanent impairment or damage.  
 
Unexpected Adverse Event: An adverse event is “unexpected” when its nature (specificity), severity, or 
frequency are not consistent with (a) the known or foreseeable risk of adverse events associated with the 
research procedures described in the protocol-related documents, such as the IRB-approved research protocol, 
informed consent document and other relevant sources of information such as product labeling and package 
inserts; and are also not consistent with (b) the characteristics of the subject population being studied including 
the expected natural progression of any underlying disease, disorder or condition or any predisposing risk factor 
profile for the adverse event.  
 
To ensure no confusion or misunderstanding exist of the differences between the terms “serious” and “severe,” 
which are not synonymous the following note of clarification is provided: 
 
The term “severe” is often used to describe the intensity (severity) or a specific event (as in mild, moderate or 
severe myocardial infarction); the event itself, however, may be of relatively minor medical significance (such 
as severe headache).  This is not the same as “serious,” which is based on patient/event outcome or action 
criteria usually associated with events that pose a threat to a patient’s life or functioning.  Seriousness (not 
severity) serves as a guide for defining regulatory obligations. 
 
For example, hospitalization, in general, will not be considered a serious adverse event as approximately half of 
evaluable MRD patients AND the majority of evaluable URD patients receiving non-myeloablative transplants 
were hospitalized.  Hospitalization will be considered a serious adverse event if it fulfills the criteria for a 
serious and unexpected adverse event as described above. 
 


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Serious events, including deaths, due to GVHD and/or infections will not be reported on an expedited basis.  
These are well documented, expected, post transplant complications and will be reported biannually to the 
DSMB. 
 
FHCRC is acting as the Coordinating Center for this multi-institutional study, and it is the responsibility of the 
FHCRC Principal Investigator (or designee) to complete the FHCRC Serious Adverse Event Report for all 
serious adverse events that meet the expedited reporting requirements that are received from the participating 
sites. It is the responsibility of the FHCRC Principal Investigator to notify the sponsor, NIH, FDA or other 
agencies of serious adverse events as required in the protocol. 
 
Procedure for Reporting Serious and Unexpected Adverse Events (SAE) from Participating Sites 
Regulations defining the responsibilities for reporting serious and unexpected adverse reactions are defined 
above. SAEs or any death regardless of cause (serious, unexpected, and related/possibly related) within 180 
days after HCT must be reported to the FHCRC Investigator within 10 days of learning of the event. The 
immediate telephone report must be followed by faxed comments to the FHCRC Trial Coordinator at (206) 
667-5378. This will be followed by detailed written report (See Appendix J) within 10 working days.  The 
report must include the date and time of onset, severity and duration of the event, the relationship to the study, 
the treatment given and eventual outcome.  Follow-up information to a SAE report must be submitted as soon 
as the relevant information is available.  
 
Reporting of Adverse Events on Case Report Forms (CRF)  
All grade 3 or 4 adverse events (or highly unusual grade 2 adverse events), which occur between the start of any 
protocol intervention and day 100 during the study will be recorded on the CRF (Appendix M). These adverse 
events which are observed by the Investigator or reported by the patient, whether or not attributed to the study, 
will be reported on the Case Report Form using the selected (for this protocol) NCI Common Toxicity Criteria 
(NCI-CTC) version 4 (Appendix P). Attributes will include a description, date of onset, maximum severity, and 
assessment of relationship to the study agent or other suspect agent(s). These grade 3 or 4 adverse events will be 
reported to the DSMB as part of the biannual review of the protocol. The DSMB report is submitted with the 
annual IRB renewal. 
 
Reporting of Unanticipated Problems that Involve Risk to Research Participants or Others:  
Any incident, experience, or outcome that meets both of the following criteria:  
• Unexpected (in terms of nature [specificity], severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-approved 
research protocol and informed consent document; and (b) the characteristics of the subject 
population being studied; 
• Indicates that the research places research participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously known 
or recognized.  
 
These must be reported to the FHCRC Investigator within 10 days of learning of the event as described above 
for reporting of SAE. 
 
V. Case Report Forms 
Clinical outcome data are summarized and transmitted from collaborating centers as CRFs.  Case report forms 
must be completed for all patients registered onto the protocol and submitted to the FHCRC data coordinating 


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center. When possible, primary source documents regarding patient outcomes are collected with patients’ names 
removed and replaced by Unique Patient Numbers (UPNs). The CRFs are generated from the collaborating 
centers at defined time points (day 28, 56, 84, 100, 6 months, 1 year, 18 months and annually). The local PI 
reviews the official CRF and primary source documents. For Outside Centers, case report forms are expected to 
be submitted no later than 30 days following the scheduled follow up date. When the CRFs are verified, the data 
is entered into a central database managed by the trial coordinator. 
 
VI. Protocol Monitoring 
As the coordinating center, FHCRC will monitor accrual at the outside institutions. The guidelines below are 
intended to guide the reviewers in their assessment of items that significantly alter the clinical effectiveness of 
the treatment or the evaluation of its toxicity. 
 
A. Registration/Randomization 
1. Patient was registered prior to treatment and approval by FHCRC PI occurs prior to randomization.  
2. Information given at registration represents actual data in medical records (stage, diagnosis, cell type, 
etc.) 
 
B. Informed Consent/IRB Approval Dates 
1. The consent was signed prior to registration 
2. The consent is in language was approved by the institution’s IRB. IRB approval and reapproval are 
documented including appropriate use of full-board review and proper review of appropriate 
amendments or revisions 
3. Consent was dated and has written witness signature. IRB approval was obtained prior to the patient 
signing the consent form and start of treatment. 
 
C. Patient Eligibility 
1. Eligibility criteria and exclusion criteria were met 
2. Treatment/Intervention Administration 
3. Doses were modified according to protocol 
4. Accurate documentation of drug administration 
 
D. Study Tests/Evaluation 
1. Protocol specified laboratory tests or diagnostic studies are available 
2. Appropriate record of protocol intervention is documented. 
 
E. Study Events/Adverse Drug Experience 
1. Serious Adverse Evens reported according to protocol specifications 
 
F. Follow-Up 
1. Disease status assessed according to the required protocol guidelines documenting response to 
treatment. 
2. Accurate determination of cancer progression 
 
 
 
 


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APPENDIX J 
Fred Hutchinson Cancer Research Center 
SERIOUS ADVERSE EVENT REPORT (SAE) Form IRO-08 
 
FHCRC IR File Number: 
 
FHCRC Protocol Number: 
 
FHCRC Unique Patient #  
 FHCRC/SCCA   
  Other 
Gender:  
 Male  
 Female 
Age:   
FHCRC Principal Investigator:  
  
Phone Number: 
Mailstop: 
 
Date of Report:                                   
 
 
 Initial Report 
 Follow-Up Report #  
 Other 
Date Study Staff became aware of event: __________________ 
Date Serious Adverse Event Started:______________________ 
Date Ended:      
Or 
 Ongoing (if ongoing – must submit follow up report) 
Adverse Event: 
 
 
Describe the Serious Adverse Event including a summary of all relevant clinical information. 
(Or attach a MedWatch Form or other SAE reporting form if one has been completed.)  Use Page 2, if 
necessary: 
 
Outcomes Attributed to adverse event:  (Check all that apply) 
 Death            /           /     
 Life-Threatening 
 Hospitalization (initial or prolonged) 
 
 Disability 
 Congenital Anomaly 
 Required intervention to prevent permanent             
impairment/damage 
Specify Agent(s) and/or Procedure(s) involved in this protocol: 
#1 
Pharmaceutical product/medical 
treatment/procedure 
 
#2 
Pharmaceutical product/medical treatment/procedure 
 Not Related (Unrelated, Unlikely) 
 Not Related (Unrelated, Unlikely) 
 Related (Possible, Probable, Definite) 
 Related (Possible, Probable, Definite) 
 
 
 Follow-up Report Required 
 Final Report (PI must sign final report) 
Report Completed by: 
 
Date: 
 
The PI has determined that the consent form must be revised: 
 Yes      
 No 
Does this study involve the deliberate transfer of recombinant DNA or DNA or RNA derived from 
recombinant DNA, into human subjects (human gene transfer)? 
 yes  
 no  If yes and the activity 
involves the SCCA outpatient clinic, a copy of this Protocol Modification Form and any supporting 
documents to be reviewed and approved, will be forwarded to the FHCRC’s Institutional Biosafety 
Committee (IBC) by the Protocol Office (Mailstop:  LM-230). 
 
 
Signature of Principal Investigator 
 
Date: 


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Fred Hutchinson Cancer Research Center 
Clinical Research Division 
Institutional Review Office 
SERIOUS ADVERSE EVENT REPORT (SAE) Form IRO-08 
page 2 
 
 
FHCRC IR File Number: 
 
FHCRC Protocol Number: 
 
FHCRC Unique Patient #  
Date of Report:              
Describe the Serious Adverse Event including a summary of all relevant clinical information. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX K 
 
NOTICE OF DEATH 
 
Patient ID:  __________________ Date of Death:  ______________ 
 
Place of Event:  ___________________________________________    
 
 
Apparent cause of death (Please be specific.  Attach hospital summary or death summary when possible): 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Form completed by:  ________________________________Date:   ______________ 
 
 
 


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Appendix L 
Protocol 2448 Patient Demographics and Eligibility Form 
Please Fax this completed form to (206) 667-5378 for patient registration. 
Questions regarding eligibility should go to Brenda Sandmaier, MD 206-667-4961. 
 
 
UPN#:____________________ 
Patient Name: 
_______________________________ 
(Last) 
________________________  
(First) 
_____  
(MI) 
Date of Birth: 
_____ / _____ / __________  Age:________ 
 (Mo)    (Day)         (Year) 
Gender (choose one): 
 Male    
 Female   
 Unknown 
Patient Diagnosis: ______________________________________   Planned Day 0: _____/______/_____ 
 
(Mo) 
(Day)  (Year) 
Ethnicity (choose one):  Instruct the patient to select one of the following. 
 Hispanic (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture 
or origin, regardless of race.  Term “Spanish Origin” can also be used in addition to “Hispanic” or 
“Latino”.) 
 Not Hispanic or Latino 
 
 
Declined to Report 
Race (check all that apply):  Instruct the patient to select one or more of the following. 
 American Indian/Alaska Native (A person having origins in any of the original peoples of North, 
Central, or South America, and who maintains tribal affiliations or community attachment). 
 Asian (A person having origins in any of the original peoples of the Far East, Southeast, Asia, or the Indian 
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the 
Philippine Islands, Thailand and Vietnam). 
       
   Black/African American (A person having origins in any of the black racial groups of Africa).  
 Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of Hawaii, 
Guam, Samoa or other Pacific Islands). 
 White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa). 
 Research subject does not know race 
 Declined to report 
 
 
 


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CRITERIA FOR 3 GY TBI: Patients need to fulfill one or more of the following criteria for 3 Gy TBI: 
 
 Patients with MDS, MPD, CML, or other hematologic malignancies not previously treated with 
myelosuppressive chemotherapy 
Patients who have had a previous allogeneic transplant. 
Patients who had a prior syngeneic transplant without subsequent myelosuppressive chemotherapy. 
 Patients who have not had myelosuppressive chemotherapy within 3-6 months of HCT may be at 
higher risk of rejection depending on treatment history and underlying diagnosis. Confirm TBI dose 
(2 vs 3 Gy) with PI. 
 
 
TBI Dose: 
 TBI 2 Gy          
 
OR 
 TBI 3 Gy: 
   
Signature of Local Principal Investigator:  
__________                           Date:                  ___            
 
 
Transplant Center: ___________________________________________________________________ 
 
 
Signature of FHCRC Principal Investigator   
_________________ 
 
 
 
Date:  
 
______ 
  
 
 
 
      __________________________________________________________________________________ 
FHCRC Use Only 
 
 
Study UPN#: _____________________________ 
 
Internal B#:___________________________ 
 
 
Randomization Arm 
 
 Arm 1:  CSP to day +96 and then tapered to day +150, MMF tapered at day +150 and discontinued after day +180. 
 Arm 2:  CSP to day +96 and then tapered to day +150 , MMF to be discontinued on day + 40, and Sirolimus to be tapered at day 
+150 and discontinued on day +180.  
 
 
_____________________________________  
 
 
 
________________ 
Signature  
 
 
 
 
 
 
 
Date 


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APPENDIX L cont’d 
 
Protocol 2448 Eligibility  
I) 
Inclusion Criteria:  
 
1) Yes 
 No 
 Unrelated donors who are prospectively: 
                     **FHCRC matching allowed will be Grades 1.0 to 2.1 (Appendix O). 
i) Matched for HLA-A, B, C, DRB1 and DQB1 alleles by high resolution typing AND 
ii) Only a single allele disparity will be allowed for HLA-A, B, or C as defined by high 
resolution typing (See appendix O for other donor selection details) 
 
Patient 
 
 
 
 
 
A: ____________ 
A: ____________ 
C: ___________ 
C: ____________ 
B: _________ 
B: _________ 
DRB1: _________ DRB1: _________ DQB1: ________ DQB1: _________ 
Donor 
A: ____________ 
A:_____________ 
C: ____________ C: ____________ 
B: _________ 
B: _________ 
DRB1: _________ DRB1: _________ DQB1: ________ DQB1: _________ 
 
 
 
 
iii) Yes 
 No 
 Have a negative anti-donor cytotoxic crossmatch.  
NA 
 Cytotoxic crossmatch not done as patient and donor are phenotypically identical         
by molecular methods. 
 
iv) Yes 
 No 
 Patient and donor pairs are not homozygous at a mismatched allele in the graft 
rejection vector.  
 
One of the following criteria questions (2-5) must be marked “Yes” for the patient to enter on 2448. 
2) Yes 
 No 
  
Ages >50 years with hematologic malignancies treatable by allogeneic HCT.   
 
3) Yes 
 No 
  
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who 
through pre-existing medical conditions or prior therapy are considered to be at high 
risk for regimen related toxicity associated with a high dose transplant (>40% risk of 
TRM). This criterion can include patients with a HCT-CI score of >1 (see Appendix 
Q). Transplants should be approved for these inclusion criteria by the principal 
investigators at the collaborating centers and at FHCRC. 
 
 
 
 
 
 
 
            Pre-existing condition(s) precluding high dose tx:  ____________ 
 
 
 
 
 
 
 
 
 
All children < 12 years must be discussed with the FHCRC PI (Brenda Sandmaier, MD 206-667-4961) 
prior to registration.  
 
4) Yes 
 No 
 
 
Ages  50 years of age with chronic lymphocytic leukemia (CLL).  
 


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5) Yes 
 No 
  
 
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who 
refuse a high dose HCT. Transplants must be approved for these inclusion criteria by 
the principal investigators at the collaborating centers and at FHCRC. 
 
II) One of the following criteria questions (6-16) must be marked “Yes” for the patient to enter on 2448. (The 
following diseases will be permitted although other diagnoses can be considered if approved by PCC or the 
participating institution’s patient review committees and the principal investigator.) 
 
6) Yes 
 No 
  
Aggressive nonHodgkin lymphomas (NHL) and Other Histologies Such as Diffuse 
large B cell NHL– not eligible for autologous HCT, not eligible for high dose 
myeloablative HCT, or after failed autologous HCT. 
 
7) Yes 
 No 
  
Mantle Cell NHL -may be treated in first CR (Diagnostic LP required pre-transplant) 
 
8) Yes 
 No 
  
Low grade NHL– with < 6 month duration of CR between courses of conventional 
therapy. 
 
9) Yes 
 No 
  
CLL – must have either 1) failed to meet NCI Working Group criteria for complete or 
partial response after therapy with a regimen containing FLU (or another nucleoside 
analog, e.g. 2-CDA, pentostatin) or experience disease relapse within 12 months after 
completing therapy with a regimen containing FLU (or another nucleoside analog); 2) 
failed FLU-CY-Rituximab (FCR) combination chemotherapy at any time point; or 3) 
have “17p deletion” cytogenetic abnormality. Patients should have received induction 
chemotherapy but could be transplanted in 1st CR; or 4) Patients with a diagnosis of CLL 
(or small lymphocytic lymphoma) or diagnosis of CLL that progresses to prolymphocytic 
leukemia (PLL), or T-cell CLL or PLL 
 
 
 
 
 
Describe which inclusion is specific for this patient:__________________________ 
 
 
 
 
 
_____________________________________________________________________. 
 
10) Yes 
 No 
  
Hodgkin lymphoma – must have received and failed frontline therapy. 
 
11) Yes 
 No 
  
Multiple Myeloma – must have received prior chemotherapy.  Consolidation of 
chemotherapy by autografting prior to nonmyeloablative HCT is permitted. 
 
12) Yes 
 No 
 
Acute Myeloid Leukemia (AML) – must have < 5% marrow blasts at the time of 
transplant. 
 
13) Yes 
 No 
 
Acute Lymphocytic Leukemia (ALL) – must have <5% marrow blasts at the time of 
transplant. 
14) Yes 
 No 
  
Chronic Myeloid Leukemia (CML) – Patients in CP1 must have failed or be intolerant 
of TKIs. Patients beyond CP1 will be accepted if they have <5% marrow blasts at time of 
transplant.   
 
15) Yes 
 No 
  
Myelodysplasia (MDS)/Myeloproliferative Syndrome (MPS) –Patients must have <5% 
marrow blasts at time of transplant. 
 


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16) Yes 
 No 
      Waldenstrom’s Macroglobulinemia – must have failed 2 courses of therapy. 
 
 
III) 
Exclusion criteria:  
 
Each of the following questions must be marked “No” Or “NA” for the patient to enroll on 2448. 
 
17) Yes 
 No 
  NA 
 Patients with rapidly progressive intermediate or high grade NHL. 
 
18) Yes 
 No 
  NA 
 Patients with a diagnosis of CMML. 
 
19) Yes 
 No 
  NA 
 Patients with RAEB who have not received myelosuppressive chemotherapy i.e. 
induction chemotherapy. 
 
20) Yes 
 No 
              CNS involvement with disease refractory to intrathecal chemotherapy. For LP 
requirement, see Appendix N. 
 
21)  Yes 
 No 
  NA 
   Presence of circulating leukemic blasts (in the peripheral blood) detected by 
standard pathology for patients with AML, ALL or CML. 
 
22) Yes 
 No 
  NA 
 Presence of ≥ 5% circulating leukemic blasts (in the peripheral blood) detected by  
 
 
 
 
 
 
standard pathology for patients with MDS/MPS 
 
23) Yes 
 No 
  NA 
 Fertile men or women unwilling to use contraceptive techniques during and for 12 
months following treatment. 
 
24) Yes 
 No 
  NA 
 Females who are pregnant or breast-feeding.  
 
25) Yes 
 No 
           
Patients with active non-hematological malignancies (except non-melanoma skin 
 
 
 
 
 
 
 
cancers) or those with non-hematological malignancies (except non-melanoma skin 
 
 
 
 
 
 
 
cancers) who have been rendered with no evidence of disease, but have a greater than  
 
 
 
 
 
 
 
20% chance of having disease recurrence within 5 years. 
This exclusion does not apply to patients with non-hematologic malignancies that do 
not require therapy. 
 
26) Yes 
 No 
     
Fungal infections with radiological progression after receipt of amphotericin B or 
active triazole for greater than 1 month. 
 
 
All patients receiving antifungal therapy voriconazole, posaconazole, or fluconazole 
and who are then randomized to ARM 2 must have sirolimus dosing reduced 
according to the Standard Practice Antifungal Therapy Guidelines in Appendix E. 
 
 
PI Signature:   
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
  
 
 
 


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27) Yes 
 No 
              Cytotoxic agents for “cytoreduction” with the exception of tyrosine kinase inhibitors 
(such as imatinib), cytokine therapy, hydroxyurea, low dose cytarabine, chlorambucil, 
or rituxan will not be allowed within three weeks of the initiation of conditioning 
 
28) Yes 
 No 
             Organ dysfunction. Please check yes if patient meets any of the following. 
  
 
 
 
  
 
Yes 
 No 
 
Cardiac: ejection fraction < 35% (or, if unable to obtain 
ejection fraction, shortening fraction of < 26%).  Ejection 
fraction is required if age > 50 years or there is a history of 
anthracycline exposure or history of cardiac disease. 
 
 
   NOTE: If shortening fraction is <26%,   a cardiology consult is required.      
 
 
   The PI of the study must approve eligibility 
  
 
 
 
  
 
  
 
 
 
 
 
PI Signature:  
 
 
                  Date:               
 
  
 
 
 
  
 
Yes 
 No 
 
Pulmonary: DLCO < 40%, TLC <40%, FEV1 <40% and/or    
receiving supplementary continuous oxygen.  
NOTE: The FHCRC PI of the study must approve of enrollment of all 
patients with pulmonary nodules.  
 
 
PI Signature:  
_______________Date: _____ 
 
 
 
 
Yes 
 No 
 
Liver function abnormalities:  Patients with clinical or 
laboratory evidence of liver disease would be evaluated for the 
cause of liver disease, its clinical severity in terms of liver 
function, and the degree of portal hypertension.  Patients will 
be excluded if they are found to have fulminant liver failure, 
cirrhosis of the liver with evidence of portal hypertension, 
alcoholic hepatitis, esophageal varices, a history of bleeding 
esophageal varices, hepatic encephalopathy, uncorrectable 
hepatic synthetic dysfunction evinced by prolongation of the 
prothrombin time, ascites related to portal hypertension, 
bridging fibrosis, bacterial or fungal liver abscess, biliary 
obstruction, chronic viral hepatitis with total serum bilirubin >3 
mg/dL, or symptomatic biliary disease.  
 
29) Yes 
 No 
               Karnofsky score < 60 or Lansky score <50. 
 
30) Yes 
 No 
               Patient has poorly controlled hypertension and on multiple antihypertensives. 
 
31) Yes 
 No 
               HIV positive patients. 
 
32) Yes 
 No 
              Active bacterial or fungal infections unresponsive to medical therapy. 
 
 
 
Note – the HCT-Comorbidity score is:  _______________ 
 
 
 


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 FHCRC Patients:  
 
Signature of person completing form:   
 
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
 
 
Signature of Principal Investigator (pre-randomization and signing of consent): 
 
  _________________ 
 
 
 
 
 
 
Date:  
 
 
 
 
 
Patient signed IRB approved consent form.  Date:   
 
 
 
 
 
 
 
 
 
IRB file number:   
 
 
 
 
 
 
     Date of IRB approval:   
 
 
_______ 
 
Signature of Principal Investigator (post-randomization and signing of consent): 
 
  _________________ 
 
 
 
 
 
 
Date:  
 
 
 
 
 
__________________________________________________________________________________________ 
 
OR 
 
Outside Center Patients:  
 
Signature of person completing form:   
 
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
 
 
Patient signed IRB approved consent form.    Date:    
 
 
 
 
 
 
 
 
 
IRB file number:   
 
 
 
 
 
 
     Date of IRB approval:   
 
 
_______ 
 
 
Signature of Local Principal Investigator   
_________________ 
 
 
 
 
Date:  
 
 
 
 
 
 
Signature of FHCRC Principal Investigator   
_________________ 
 
 
 
Date:  
 
______ 
 


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APPENDIX M 
Core Case Report Forms 
 


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APPENDIX N 
 
Intrathecal Therapy Administration 
 
intrathecaltherapy-c
ombined.pdf


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Appendix O 
 
HLA Testing of Donors and Recipients Prior to Hematopoietic Stem Cell 
Transplantation 
 
 
hlatype.pdf
 


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APPENDIX P  
Adapted from 
COMMON TOXICITY CRITERIA (CTC)  
Version 4.0 
 
 
Grade 
Adverse Event 
3 
4 
5 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
Disseminated intravascular 
coagulation 
Laboratory findings and 
bleeding 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Febrile neutropenia 
ANC <1000/mm3 with a single 
temperature of >38.3 degrees C 
(101 degrees F) or a sustained 
temperature of >=38 degrees C 
(100.4 degrees F) for more 
than one hour 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Hemolysis 
Transfusion or medical 
intervention indicated (e.g., 
steroids) 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Hemolytic uremic syndrome 
Laboratory findings with 
clinical consequences (e.g., 
renal insufficiency, petechiae) 
Life-threatening consequences, 
(e.g., CNS hemorrhage or 
thrombosis/embolism or renal 
failure) 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
CARDIAC DISORDERS 
 
Atrial fibrillation 
Symptomatic and incompletely 
controlled medically, or 
controlled with device (e.g., 
pacemaker), or ablation 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Atrial flutter 
Symptomatic and incompletely 
controlled medically, or 
controlled with device (e.g., 
pacemaker), or ablation 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Atrioventricular block 
complete 
Symptomatic and incompletely 
controlled medically, or 
controlled with device (e.g., 
pacemaker) 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Constrictive pericarditis 
Symptomatic heart failure or 
other cardiac symptoms, 
responsive to intervention 
Refractory heart failure or 
other poorly controlled cardiac 
symptoms 
Death 
Heart failure 
Severe with symptoms at rest 
or with minimal activity or 
exertion; intervention indicated 
Life-threatening consequences; 
urgent intervention indicated 
(e.g., continuous IV therapy or 
mechanical hemodynamic 
support) 
Death 


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Left ventricular systolic 
dysfunction 
Symptomatic due to drop in 
ejection fraction responsive to 
intervention 
Refractory or poorly controlled 
heart failure due to drop in 
ejection fraction; intervention 
such as ventricular assist 
device, intravenous 
vasopressor support, or heart 
transplant indicated 
Death 
Myocardial infarction 
Severe symptoms; cardiac 
enzymes abnormal; 
hemodynamically stable; ECG 
changes consistent with 
infarction 
Life-threatening consequences; 
hemodynamically unstable 
Death 
Myocarditis 
Severe with symptoms at rest 
or with minimal activity or 
exertion; intervention indicated 
Life-threatening consequences; 
urgent intervention indicated 
(e.g., continuous IV therapy or 
mechanical hemodynamic 
support) 
Death 
Pericardial effusion 
Effusion with physiologic 
consequences 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Pericardial tamponade 
 - 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Ventricular arrhythmia 
Medical intervention indicated 
Life-threatening consequences; 
hemodynamic compromise; 
urgent intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
GASTROINTESTICAL DISORDERS 
 
Ascites 
Severe symptoms; invasive 
intervention indicated 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Diarrhea 
Increase of >=7 stools per day 
over baseline; incontinence; 
hospitalization indicated; 
severe increase in ostomy 
output compared to baseline; 
limiting self care ADL 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Duodenal ulcer 
Severely altered GI function; 
TPN indicated; elective 
operative or endoscopic 
intervention indicated; limiting 
self care ADL; disabling 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Gastric ulcer 
Severely altered GI function; 
TPN indicated; elective 
operative or endoscopic 
intervention indicated; limiting 
self care ADL; disabling 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Gastritis 
Severely altered eating or 
gastric function; TPN or 
hospitalization indicated 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Lower gastrointestinal 
hemorrhage 
Transfusion, radiologic, 
endoscopic, or elective 
operative intervention 
indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 


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Mucositis oral 
Severe pain; interfering with 
oral intake 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Oral hemorrhage 
Transfusion, radiologic, 
endoscopic, or elective 
operative intervention 
indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Pancreatitis 
Severe pain; vomiting; medical 
intervention indicated (e.g., 
analgesia, nutritional support) 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Typhlitis 
Symptomatic (e.g., abdominal 
pain, fever, change in bowel 
habits with ileus); peritoneal 
signs 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
GENERAL DISORDERS AND ADMINISTARTION SITE CONDITIONS 
 
Multi-organ failure 
Shock with azotemia and acid-
base disturbances; significant 
coagulation abnormalities 
Life-threatening consequences 
(e.g., vasopressor dependent 
and oliguric or anuric or 
ischemic colitis or lactic 
acidosis) 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
HEPATOBILIARY DISORDERS 
 
Cholecystitis 
Severe symptoms; radiologic, 
endoscopic or elective 
operative intervention 
indicated 
Life-threatening consequences; 
urgent operative intervention 
indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
IMMUNE SYSTEM DISORDERS 
 
Allergic reaction 
Prolonged (e.g., not rapidly 
responsive to symptomatic 
medication and/or brief 
interruption of infusion); 
recurrence of symptoms 
following initial improvement; 
hospitalization indicated for 
clinical sequelae (e.g., renal 
impairment, pulmonary 
infiltrates) 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Immune system disorders - 
Other, specify 
Severe or medically significant 
but not immediately life-
threatening; hospitalization or 
prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Grade 


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Adverse Event 
3 
4 
5 
 
INFECTIONS AND INFESTATIONS 
 
Enterocolitis infectious 
IV antibiotic, antifungal, or 
antiviral intervention indicated; 
radiologic, endoscopic, or 
operative intervention 
indicated; profuse watery 
diarrhea with signs of 
hypovolemia;  bloody diarrhea; 
fever; severe abdominal pain; 
hospitalization indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Infections and infestations - 
Other, specify 
Severe or medically significant 
but not immediately life-
threatening; hospitalization or 
prolongation of existing 
hospitalization indicated; 
disabling; limiting self care 
ADL 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
INVESTIGATIONS 
 
Alanine aminotransferase 
increased 
>5.0 - 20.0 x ULN 
>20.0 x ULN 
 - 
Aspartate aminotransferase 
increased 
>5.0 - 20.0 x ULN 
>20.0 x ULN 
 - 
Blood bilirubin increased 
>3.0 - 10.0 x ULN 
>10.0 x ULN 
 - 
Carbon monoxide diffusing 
capacity decreased 
Asymptomatic decrease  of >8 
units drop;  >5 units drop along 
with the presence of pulmonary 
symptoms (e.g. , >Grade 2  
hypoxia or >Grade 2 or higher 
dyspnea) 
 - 
 - 
Cardiac troponin I increased 
Levels consistent with 
myocardial infarction as 
defined by the manufacturer 
 - 
 - 
Cardiac troponin T increased 
Levels consistent with 
myocardial infarction as 
defined by the manufacturer 
 - 
 - 
Creatinine increased 
>3.0 baseline; >3.0 - 6.0 x 
ULN 
>6.0 x ULN 
 - 
Weight gain 
>=20% from baseline 
 - 
 - 
Grade 
Adverse Event 
3 
4 
5 
 
METABOLISM AND NUTRITIONAL DISORDERS 
 
Hypercalcemia 
Corrected serum calcium of 
>12.5 - 13.5 mg/dL;>3.1 - 3.4 
mmol/L;  Ionized calcium  
>1.6 - 1.8 mmol/L; 
hospitalization indicated 
Corrected serum calcium of 
>13.5 mg/dL; >3.4 mmol/L;  
Ionized calcium  >1.8 mmol/L; 
life-threatening consequences 
Death 


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Hypertriglyceridemia 
>500 mg/dL - 1000 mg/dL;  
>5.7 mmol/L - 11.4 mmol/L 
>1000 mg/dL; >11.4 mmol/L;  
life-threatening consequences 
Death 
Hyperuricemia 
>ULN - 10 mg/dL (0.59 
mmol/L) with physiologic 
consequences 
>10 mg/dL; >0.59 mmol/L; 
life-threatening consequences 
Death 
Tumor lysis syndrome 
Present 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
NEOPLASMS BENIGN, MALIGNANT, AND UNSPECIFIED (INC CYSTS AND POLYPS) 
 
Treatment related secondary 
malignancy 
Non life-threatening secondary 
malignancy 
Acute life-threatening 
secondary malignancy; blast 
crisis in leukemia 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
NERVOUS SYSTEM DISORDERS 
 
Dysarthria 
Severe impairment of 
articulation or slurred speech 
 - 
 - 
Intracranial hemorrhage 
Ventriculostomy, ICP 
monitoring, intraventricular 
thrombolysis, or operative 
intervention indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Ischemia cerebrovascular 
 - 
 - 
 - 
Leukoencephalopathy 
Severe symptoms; extensive 
T2/FLAIR hyperintensities, 
involving periventricular white 
matter involving 2/3 or more of 
susceptible areas of cerebrum 
+/- moderate to severe increase 
in SAS and/or moderate to 
severe ventriculomegaly 
Life-threatening consequences; 
extensive T2/FLAIR 
hyperintensities, involving 
periventricular white matter 
involving most of susceptible 
areas of cerebrum +/- moderate 
to severe increase in SAS 
and/or moderate to severe 
ventriculomegaly 
Death 
Seizure 
Multiple seizures despite 
medical intervention 
Life-threatening; prolonged 
repetitive seizures 
Death 
Syncope 
Fainting; orthostatic collapse 
 - 
 - 
Nervous system disorders - 
Other, specify 
Severe or medically significant 
but not immediately life-
threatening; hospitalization or 
prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
RENAL AND URINARY DISORDERS 
 
Chronic kidney disease 
eGFR or CrCl 29 - 15 
ml/min/1.73 m2 
eGFR or CrCl <15 ml/min/1.73 
m2; dialysis or renal transplant 
indicated 
Death 


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Renal and urinary disorders - 
Other, specify 
Severe or medically significant 
but not immediately life-
threatening; hospitalization or 
prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS 
 
Grade 
Adverse Event 
3 
4 
5 
 
RESPIRATORY, THORACIC, AND MEDIASTINAL DISORDERS 
 
Adult respiratory distress 
syndrome 
Present with radiologic 
findings; intubation not 
indicated 
Life-threatening respiratory or 
hemodynamic compromise; 
intubation or urgent 
intervention indicated 
Death 
Apnea 
Present; medical intervention 
indicated 
Life-threatening respiratory or 
hemodynamic compromise; 
intubation or urgent 
intervention indicated 
Death 
Bronchopulmonary 
hemorrhage 
Transfusion, radiologic, 
endoscopic, or operative 
intervention indicated (e.g., 
hemostasis of bleeding site) 
Life-threatening respiratory or 
hemodynamic compromise; 
intubation or urgent 
intervention indicated 
Death 
Hypoxia 
Decreased oxygen saturation at 
rest (e.g., pulse oximeter <88% 
or PaO2 <=55 mm Hg) 
Life-threatening airway 
compromise; urgent 
intervention indicated (e.g., 
tracheotomy or intubation) 
Death 
Pleural effusion 
Symptomatic with respiratory 
distress and hypoxia; surgical 
intervention including chest 
tube or pleurodesis indicated 
Life-threatening respiratory or 
hemodynamic compromise; 
intubation or urgent 
intervention indicated 
Death 
Pneumonitis 
Severe symptoms; limiting self 
care ADL; oxygen indicated 
Life-threatening respiratory 
compromise; urgent 
intervention indicated (e.g., 
tracheotomy or intubation) 
Death 
Pulmonary edema 
Severe dyspnea or dyspnea at 
rest; oxygen indicated; limiting 
self care ADL 
Life-threatening respiratory 
compromise; urgent 
intervention or intubation with 
ventilatory support indicated 
Death 
Respiratory failure 
 - 
Life-threatening consequences; 
urgent intervention, intubation, 
or ventilatory support indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
 


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Erythema multiforme 
Target lesions covering >30% 
BSA and associated with oral 
or genital erosions 
Target lesions covering >30% 
BSA; associated with fluid or 
electrolyte abnormalities; ICU 
care or burn unit indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
VASCULAR DISORDERS 
 
Capillary leak syndrome 
Severe symptoms; intervention 
indicated 
Life-threatening consequences; 
urgent intervention indicated 
Death 
Hypotension 
Medical intervention or 
hospitalization indicated 
Life-threatening and urgent 
intervention indicated 
Death 
Thromboembolic event 
Thrombosis (e.g., 
uncomplicated pulmonary 
embolism [venous], non-
embolic cardiac mural [arterial] 
thrombus), medical 
intervention indicated 
Life-threatening (e.g., 
pulmonary embolism, 
cerebrovascular event, arterial 
insufficiency); hemodynamic 
or neurologic instability; 
urgent intervention indicated 
Death 
Vasculitis 
Severe symptoms, medical 
intervention indicated (e.g., 
steroids) 
Life-threatening; evidence of 
peripheral or visceral ischemia; 
urgent intervention indicated 
Death 
 


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Appendix Q 
The Hematopoietic Cell Transplant-Comorbidity Index (HCT-CI) 9/7/10 
Assign scores appropriately if the patient has any of these comorbidities 
Patient ___________________________________ (name), UPN______________ Date_____________ 
 
Comorbidities 
Definitions 
HCT-CI 
scores 
Actual Lab 
Values/Comments 
Arrhythmia 
Atrial fibrillation or flutter, sick sinus syndrome, and 
ventricular arrhythmias requiring treatment in the patient’s 
past history 
1 
 
Cardiac 
Coronary artery disease†, congestive heart failure, 
myocardial infarction in patient’s past history or EF of 
50% at time of HCT 
1 
 
Inflammatory bowel 
disease 
Crohn’s disease or ulcerative colitis requiring treatment in 
the patient’s past history 
1 
 
Diabetes 
Requiring treatment with insulin or oral hypoglycemic, but 
not diet alone, at time of HCT 
1 
 
Cerebro-vascular 
disease 
Transient ischemic attack or cerebro-vascular accident in 
patient’s past history 
1 
 
Psychiatric 
disturbance 
Depression/anxiety requiring psychiatric consult or 
treatment at time of HCT 
1 
 
Hepatic – mild 
Chronic hepatitis, Bilirubin >ULN- 1.5 X ULN, or 
AST/ALT >ULN-2.5XULN at time of HCT 
1 
 
Obesity 
Patients with a BMI of 
>35 for adults or with BMI-for-age percentile of ≥ 95th 
percentile for children at time of HCT 
1 
 
Infection 
Documented infection or fever of unknown etiology 
requiring anti-microbial treatment before, during and after 
the start of conditioning regimen 
1 
 
Rheumatologic 
SLE, RA, polymyositis, mixed CTD, polymyalgia 
rheumatica in patient’s past history  
2 
 
Peptic ulcer 
Requiring treatment in patient’s past history 
2 
 
Renal 
Serum creatinine >2 mg/dl, on dialysis, or prior renal 
transplantation at time of HCT 
2 
 
Moderate pulmonary 
DLco and/or FEV1 >65%-80% or 
Dyspnea on slight activity at time of HCT 
2 
 
Prior solid tumor 
Treated at any time point in the patient’s past history, 
excluding non-melanoma skin cancer 
3 
 
Heart valve disease 
At time of HCT excluding mitral valve prolapse 
3 
 
Severe pulmonary 
DLco and/or FEV1 65% or 
Dyspnea at rest or requiring oxygen at time of HCT 
3 
 
Moderate/severe 
hepatic 
Liver cirrhosis, Bilirubin >1.5 X ULN, or AST/ALT 
>2.5XULN at time of HCT 
3 
 
Please provide (KPS): 
 
Karnofsky Performance Score = _______% 
Total 
Score 
=________ 
Signature of 
Provider: 
________________ 
†One or more vessel-coronary artery stenosis, requiring medical treatment, stent, or bypass graft.  EF indicates ejection 
fraction; ULN, upper limit of normal; SLE, systemic lupus erythmatosis; RA, rheumatoid arthritis; CTD, connective tissue disease; DLco, diffusion 
capacity of carbon monoxide; FEV1, forced expiratory volume in one second; AST, aspartate aminotransferase; ALT, alanine aminotransferase. 
 
 


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Appendix R 
  
 
CLINICALLY SIGNIFICANT INDUCERS/INHIBITORS OF 
 CYTOCHROME P450 ENZYME SYSTEM 
 
 
Agents likely to increase 
Rapamycin (Sirolimus) 
levels 
Agents which may 
increase Rapamycin 
(Sirolimus) levels 
Agents likely to decrease 
Rapamycin (Sirolimus) 
levels 
Agents which may 
decrease Rapamycin 
(Sirolimus) levels 
Diltiazem 
Nicardipine 
Verapamil 
Erythromycin 
Ketoconazole 
Voriconazole 
Clarithromycin 
Cimetidine 
Carbamazepine 
Phenobarbital 
Phenytoin 
Rifampin 
Primidone 
Valproic acid 
Rifabutin 
 
 
*Fluconazole, itraconazole, CSP, methylprednisolone, and tacrolimus may increase levels 
 
 
 


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Appendix S 
 
Weight / Adjusted Body Weight for Drug Dosing 
weight_for_drug_do
sing.pdf
 
 
 


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Appendix T 
 
COORDINATING CENTER FUNCTIONS 
 
Outside Center – PI Communication in Hematologic Malignancies 
 
I. Study Management, data analysis, and Data and Safety Monitoring 
 
a. Study Management: 
i. 
Each local PI is responsible for selection, training and oversight of local study coordinators 
ii. 
The Coordinating Center registers subjects on the study and assigns study IDs 
iii. 
One copy of the research data is retained by the site. Another data set (identified only by 
study IDs) is transmitted to the Coordinating Center to create the master data file. All data 
are kept in locked areas and password protected databases accessible only to study staff 
iv. 
The quality of data is monitored in an ongoing fashion with the study team and corrective 
action plans instituted as necessary  
b. Data Analysis: 
i. 
Study staff review data for completeness as it is submitted by the sites 
ii. 
The study statistician is responsible for data cleaning and the conduct of analyses as outlined 
in the protocol and grant 
c. Data Safety and Monitoring: 
i. 
The trial coordinators at collaborating centers or the local PIs will fax an official report of an 
SAE (as defined by the protocol) to the Coordinating Center within ten days. 
ii. 
The SAE report is reviewed by the Overall PI. If the SAE meets the FHCRC criteria for 
reporting then an official signed report is submitted to the IRB 
iii. 
An independent DSMB will meet at six-month intervals and all outcome data is reviewed 
including all adverse events and SAEs reported to the Coordinating Center along with those 
officially reported to the IRB 
iv. 
A report from the DSMB is submitted to the IRB as well as the trial coordinators/local PIs 
participating in the protocol 
 
II.  
Protocol and informed consent document management 
a. A master protocol is maintained by the Coordinating Center and distributed to the sites for 
customization and local IRB review 
b. All protocol and consent modifications initiated by the Coordinating Center are sent to the 
Collaborating Sites following approval by the Coordinating Center IRB, for review and approval 
by the local IRB 
c. Changes required by local IRBs are reviewed by the Coordinating Center and approved prior to 
implementation at local sites 
 
III. Assurance of local IRB OHRP-approved assurance 
a. Each site provides their OHRP assurance number and evidence of IRB certification 
b. Study staff monitor maintenance of institutional assurance and IRB certification 
 
 
IV. Assurance of local IRB approvals 


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a. The Coordinating Center maintains copies of the most current collaborating site Consent Forms 
and IRB approval documentation 
b. No site may enroll subjects until the Coordinating Center has received confirmation of local IRB 
approval 
c. Each site is responsible for preparation and submission of their continuing reviews. Any changes 
to the protocol or consent form will be communicated to the Coordinating Center 
d. Sites are required to have active IRB approvals to participate in any study related activities 
 
V. 
Any substantive modification by the Collaborating Institution related to risks or alternative 
procedures is appropriately justified 
a.   The Coordinating Center reviews any modifications to consent forms to ensure that site consents 
do not delete or change the basic or additional elements or alternatives required in the sample 
consent form 
 
VI. 
Informed consent is obtained from each subject in compliance with HHS regulations 
a. Subjects must provide written informed consent prior to study participation 
b. The Coordinating Center verifies eligibility and signed consent prior to assigning a study ID 
number 


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Appendix U 
Radiotherapy Treatment Guidelines (FHCRC Protocol 2448.00) 
Brenda M. Sandmaier, RSO Docket 2010-305 
 
 
1.5    Total Body Irradiation  
 
1.5.1 Patients 
Every patient will receive total body irradiation as part of the preparatory regimen for stem cell transplantation.   
 
1.5.1.1 Most Patients 
The treatment dose regimen will be 200 cGy in one fraction.  No lung shielding will be used for this TBI 
scheme. 
 
1.5.1.2 Patients with certain diseases at greater risk of rejection, or patients previously transplanted with either 
syngeneic or allogeneic stem cells: 
 
a) Patients with MDS, MPD, CML, or other hematologic malignancies not previously treated with 
myelosuppressive chemotherapy, 
 
b) Patients who have had a previous allogeneic transplant and have >5% donor CD3 chimerism, 
 
c) Patients who had a prior syngeneic transplant without subsequent myelosuppressive chemotherapy, 
 
d) Patients who have not had myelosuppressive chemotherapy within 3-6 months of HCT may be at 
higher risk of rejection depending on treatment history and underlying diagnosis.  Confirm TBI dose 
(200 vs 300 cGy) with PI. 
The treatment dose regimen will be 300 cGy in one fraction.  No lung shielding will be used for this TBI 
scheme. 
 
1.5.2 Equipment 
 
1.5.2.1 Modality: 
High-energy photons with energy ≥ 6MV photons should be utilized. Although there is no upper limit on the 
energy as long as the skin dose requirements can be met, it is recommended that 18MV or lower be used. 
 
The selection of energy is determined by the dose uniformity criterion. 
 
1.5.3 Target Volume 
The total body will be treated including the head and feet in one field (except in certain circumstances).  Care 
should be taken to ensure that the patient is entirely within the 90% isodose decrement line of the beam (i.e., not 
in the penumbra region of the beam). 


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1.5.4 Target Dose 
The prescription point is defined as the point along the longitudinal axis of the patient at the midline at the level 
of the umbilicus (see Point 5, Section 1.5.4.1).  No tissue inhomogeneity correction will be made in the 
calculation of dose to the prescription point.  The absorbed dose along the patient’s head to toe axis (line formed 
by the intersection of the midsagittal plane and the midcoronal plane) shall be within 10% of the prescribed 
dose.  The dose at selected anatomical points shall be calculated and these calculations are to be submitted as 
part of the quality assurance.  Measurements of patient dimensions needed for the calculation of the prescription 
dose will be made at the time of the simulation for lung blocks.  Measurement and calculations of required 
monitor units necessary for each treatment will be performed for both the expected upright treatment position 
(AP-PA fields) and the reclining, lateral decubitus position (AP-PA fields). In the event the patient proves too 
ill to receive a fraction in the upright position, dose calculation will have been pre-calculated to permit 
treatment in the lateral decubitus position). 
 
1.5.4.1 Prescription Point: 
1. Head (Point 1): this reference point is defined along the longitudinal axis of the skull at the greatest mid-
separation (immediately superior to the nasal bridge).  The depth should be taken as midway between the 
entrance and exit points of the opposed radiation beams. 
2.  Neck (Point 2): this reference point is defined along the patient’s longitudinal axis at the level of C3/C4 
(approximate mid-neck, but chosen for the thinnest mid-separation of the neck).  The point is taken to be 
midway between the entrance and exit point of the beam. 
3.  Upper Mediastinum (Point 3):  this reference point is defined along the patient’s longitudinal axis at the 
level of the angle of Louis.  The reference point is midway between the entrance and the exit points of the 
opposed beams. 
4. Lower Mediastinum (Point 4):  this reference point is defined along the patient’s longitudinal axis at the 
level of the xiphisternal notch.  The reference point is midway between the entrance and exit points of the 
opposed beams 
5. Umbilicus (Point 5): THE PRESCRIPTION POINT is defined along the patient’s longitudinal axis at the 
level of the umbilicus.  The prescription point is midway between the entrance and exit points of the opposed 
beams. 
6. Knee (Point 6):  this reference point is defined along the midline in the midplane of the knee at the level of 
the patella. 
7.  Ankle (Point 7):  this reference point is defined along the midline at the midplane of the ankle at the level of 
the lateral malleolus. 
8.  Shielded Lung Dose (Point 8):  this reference point is located on the right chest wall under the lung block.  
It is centered (both medial/lateral and cephalocaudad) under the lung block as projected on the patient’s skin.  
The depth should be taken as midway between the entrance and exit points of the opposed radiation beams.  
Dose measurements at this location will be taken during a fraction with lung shielding in place. 
9.  Unshielded Lung Dose (Point 9): This reference point is the same as point 8.  Dose measurements at this 
location will be taken during a fraction without lung shielding in place.  The depth should be taken as midway 
between the entrance and exit points of the opposed radiation beams. 


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1.5.4.2 Dose Definition: 
The absorbed dose is specified as centigray (cGy)-to-muscle. 
 
1.5.4.3 Prescribed Dose, and Fractionation, and Timing: Recommended Fractionation Scheme 
 
1.5.4.3.1 Most Patients 
The total dose to the prescription point shall be 200 cGy given in a single fraction.  All fields should be treated 
each fraction. 
 
1.5.4.3.2 Patients at greater risk of rejection 
The total dose to the prescription point shall be 300 cGy given in a single fraction. All fields should be treated 
each fraction. 
 
1.5.4.4 Dose Rate: 
A mid-plane dose rate of between 6 and 15 cGy per minute is required. 
 
1.5.4.5 Dose Uniformity: 
The objective is to keep the dose throughout the body, defined to extend to within 2 mm of the skin surface, to 
at least 90% of the prescription dose. In addition, the brain dose shall not exceed 107% of the prescription dose.  
 
For AP/PA treatments, partial transmission lung blocks will be used to limit the overall total lung dose. The 
dose at the midpoint of the thickest part of the body while in the treatment position should be determined and if 
necessary, modifications made to the treatment to raise the dose in this region to at least 90% of the prescription 
dose. 
 
In order to satisfy the requirement that the skin dose at a depth of 2 mm is within at least 90% of the 
prescription dose, beam spoilers or other equally effective devices should be used. The field size shall be such 
that no part of the patient extends into the portion of the penumbra region where the dose is less than 90% of the 
central axis dose. 
 
1.5.5 Treatment Technique 
Patients will be treated using AP/PA fields in an upright seated or standing position in a TBI positioning device.  
Treatment will be delivered with equally weighted parallel opposed portals, with each treatment including both 
AP and PA fields.  If the patient is unable to tolerate the upright position, acceptable alternate arrangements will 
include equally weighted AP-PA parallel opposed fields delivered to the patient in a lateral decubitus position 
on a treatment couch or gurney. 
 
Changes in patient positioning after the patient has started TBI are discouraged.  When unavoidable, to ensure 
compliance to the overall dose and lung shielding parameters, appropriate changes in lung blocking and dose 
recalculation will be required. 
 
Young patients requiring anesthesia will be treated in an AP/PA configuration at extended distance.  If more 
than a single field is needed to accomplish treatment, the field junction should occur at the level of the thighs 
and be shifted every 2 fractions. 


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1.5.5.1 Dose Calculation for the Prescription Point 
The calculation of the treatment time or the monitor units for the prescribed dose can be carried out using 
standard techniques. However, TBI presents special problems relative to the routine treatment situation in that 
the field sizes are much larger and the treatment distances much longer.  The TBI percent depth dose (PDD) or 
Tissue Maximum Ratio (TMR) and output factors should be measured under TBI treatment conditions for a 
range of phantom sizes to establish the database for TBI beam-on time calculations or to validate the calculation 
methodology. 
 
Typically, a calculation methodology will be adopted which uses PDD or TMR and output factors measured 
under standard conditions but then modified to account for the larger treatment distance. For example, modified 
values for inverse square corrected percentage depth dose or tissue-air ratios and tissue-phantom ratios are 
necessary for some treatment units when the patient is positioned at a long distance from the photon source and 
near the floor or one wall of the room. Also, some deviation from an exact inverse square decrease with 
distance has been demonstrated for certain geometries. 
 
Measurements of dose at the center of a phantom about the size of the typical patient should be performed and 
compared to the calculated dose. If differences are found, additional correction factors should be introduced to 
the calculation method. 
 
1.5.5.2 Critical Organ Dose Points 
The required dose calculations should be performed for the 9 points referenced above (1.5.4.1). The midline 
dose at these locations should be recorded on the TBI Summary Form. 
 
The dose can be calculated based on the thickness at each location and factors appropriate to the TBI treatment 
conditions. 
 
It is recommended that entrance and exit TLDs or diodes be placed on the patient at each required dose 
assessment location.  The midline dose can be calculated from these measurements making the appropriate 
corrections to the readings and then averaging the corrected values. 
 
In younger patients it is also recommended that TLDs or diodes be placed underneath the lung blocks to 
document the transmission dose and scatter dose. 
 
1.6 Lung Shielding 
No Lung shielding will be used 


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1.7. QA Documentation for Total Body Irradiation 
 
1.7.1. Questions regarding the radiotherapy section of this protocol should be directed to the radiation oncology 
study coordinator: 
 
Ralph Ermoian, MD, 
University of Washington Cancer Center 
Department of Radiation Oncology 
1959 NE Pacific St. 
Box 356043 
Seattle, WA 98195 
Work: (206)598-4100 
Fax:   (206)598-3786 
Email: ralphpe@uw.edu 
 
1.7.2 Definitions Of Deviation In Protocol Performance 
 
 
Prescription Dose 
 
 
Minor Deviation: 
 
 
 
The dose to the prescription point differs from that in the protocol by between 6% and 10%. 
 
 
Major Deviation: 
 
 
 
The dose to the prescription point differs from that in the protocol by more than 10%. 
 
 
Dose Uniformity 
 
 
Minor Deviation: 
 
 
 
The dose to any of the reference points in Section 16.5.5.1 differs from the protocol dose by more 
than 10% but less than 20%. 
 
 
Major Deviation: 
 
 
 
The dose to any of the reference points in Section 16.5.5.1 differs from the protocol dose by more 
than 20%.