Clinical trial NCT01408563
Conditions: Non-Hodgkin's Lymphoma Hodgkin's Lymphoma Multiple Myeloma Chronic Lymphocytic Leukemia Acute Myelogenous Leukemia
Keywords: NHL lymphoma leukemia myelodysplastic disorder aplastic anemia
Sponsor: Massachusetts General Hospital
Start date: 2011-12-01; Completion date: 2017-06-01
Enrollment: 33 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This trial will use two cord blood units for transplantation using a reduced intensity regimen rather than using intense doses of chemotherapy and radiation therapy. Two cord blood units (double cord blood) are being used, as the numbers of blood cells in one unit are too few to allow successful growth of these cells.

Because the risk of infection, particularly virus infection, is high after double cord blood transplant, this study seeks to reduce the rise of virus infection by using a reduced intensity regimen without a medicine called antithymocyte globulin (ATG), as used in prior cord blood transplants. Subjects will receive two chemotherapy drugs, melphalan and fludarabine, and low dose of total body radiation (one treatment) instead of the ATG. The number of patients with virus infections in this study will be compared to our prior experience using the ATG.

Detailed description:
Subjects will receive their transplants as in-patients.

* IV-Catheter

  * one or two IV catheters will be placed on the day of hospital admission
* Conditioning

  * Fludarabine IV six days before transplant (days -7, -6, -5. -4, -3, -2)
  * Melphalan IV (day -1)
  * Total body radiation on day 0 (same day as transplant)
* Immunosuppressive Therapy

  * Tacrolimus and sirolimus beginning day -3, daily for 6-9 months post-transplant. Given IV as in-patient, orally as out-patient
* Infusion of Cord Blood units

  * 2 cord blood units IV on Day 0 Routine post-transplant supportive care will be provided

Arms: arm 1: All patients receive same therapy
Interventions: intervention 1: Fludarabine intervention 2: Melphalan intervention 3: Total Body Radiation intervention 4: Cord Blood
Intervention descriptions: intervention 1: 30 mg/m2/day IV x 6 days intervention 2: 100 mg/m2/day IV x 1 day intervention 3: 200 cGy on Day 0 intervention 4: 2 cord blood units IV

Protocol documents:
Prot_SAP_000.pdf: 


 
DF/HCC Biomedical Protocol Template for Investigator-Written Protocols 
Version -10/6/2016 
 
Protocol Version Date: 10/6/2016 
 
NCI Protocol #: N/A 
 
Local Protocol #: 11-085  
 
 
Title: A Phase II Study of Reduced Intensity,  Double Umbilical Cord Blood 
Transplantation Using Fludarabine, Melphalan, and Low Dose Total Body Radiation.  
 
Principal Investigator:  Zachariah DeFilipp, MD 
 
Coordinating Center: N/A 
  
Co-Investigators: 
Site Investigators: 
Corey Cutler MD, MPH (Dana Farber Cancer Institute) 
David Avigan, MD (Beth Israel Deaconess Medical Center) 
 
Co-Investigators: 
Massachusetts General Hospital: 
Drs. Bimalangshu Dey, Steven McAfee, Thomas Spitzer, YiBin Chen, David Kuter, Robert 
Makar, Karen Winkfield 
 
Dana Farber Cancer Institute: 
Drs. Edwin Alyea, Joseph Antin, Vincent Ho, Philippe Armand, John Koreth, Jerome Ritz, 
Robert Soiffer 
 
Beth Israel Deaconess: 
Drs. James Levine, Jacalyn Rosenblatt, Vicki Boussiotis. 
 
Agent(s). 
Fludarabine—Commerical Supply—APP and Bioniche Pharma 
Melphalan—Commercial Supply—Novation 
Total Body Radiation 
Tacrolimus—Commercial Supply—Astellas Pharma 
Sirolimus—Commercial Supply—Wyeth Pharmaceuticals 
Granulocyte Colony Stimulating Factor (G-CSF)—Commercial Supply Neupogen—Amgen 
Or Granix- Commercial Supply  
 
 
 
 
 
 
 


 
DF/HCC Biomedical Protocol Template for Investigator-Written Protocols 
Version -10/6/2016 
 
 
 
Study Synopsis 
A Phase II Study of Reduced Intensity, Double Umbilical Cord Blood Transplantation 
Using Fludarabine, Melphalan, and low dose Total Body Radiation. 
 
 
Primary Objective: 
The primary objective of this Phase II trial is to determine the one year 
significant viral infection rate (viral infections requiring medical 
intervention) after double umbilical cord blood transplant using a 
novel conditioning regimen of fludarabine/melphalan/low dose total 
body radiation.  
 
Secondary Objectives: 
Secondary objectives of this trial include the time to engraftment of 
neutrophils and platelets, primary graft failure, the rates of acute and 
chronic GVHD, relapse, 100-day treatment related mortality, post 
transplant 
lymphoma, 
measures 
of 
immune 
reconstitution, 
thrombopoietin levels, and relapse-free and overall survival at 1 and 2 
years from transplantation. 
 
Study Design: 
This is a Phase II study designed to test the new conditioning regimen.  
One year significant viral infection rate will be compared to our 
historical control population, which has a one-year significant viral 
infection rate of 53%. 
   
Accrual Objective:  
The sample size is a maximum of 31 patients. 
 
Accrual Period: 
The estimated accrual period is two and a half years. 
 
Eligibility Criteria: 
Patients ages 18-65 years old with a diagnosis of hematological 
malignancy and with two partially HLA-matched unrelated cord blood 
units would be eligible.  Patients with sibling donors and readily 
available 8/8 HLA-matched unrelated donors would not be eligible. 
Patients will have adequate measures of organ function prior to 
transplantation.  Cord blood units must be HLA allele level matched at 
4 of 6 HLA-A, B and DRB1 loci with each other and with the 
recipient.  Two units must be available such that the total combined 
nucleated cell dose ≥ 3.7 x107 nucleated cells/kg of recipient weight.  
Each single cord blood unit cell dose must be ≥ 1.5 x 107/kg of 
recipient weight. 
 
 
 


 
DF/HCC Biomedical Protocol Template for Investigator-Written Protocols 
Version -10/6/2016 
 
 
Treatment Description: 
Conditioning regimen:  
 
 
 
 
 
Fludarabine 30 mg/m2/day IV x 6 days (Day -7 to -2)  
 
Melphalan 100 mg/m2/day IV x 1 day (Day -1)  
 
 
Total Body Radiation 200 cGy Day 0. 
 
GVHD prophylaxis:  
 
 
 
 
 
 
Sirolimus oral, target range 3-12 ng/ml 
 
 
 
Tacrolimus oral or intravenous, target range 5-10 ng/ml 
 
 
  
 
 
Double sequential cord blood transplantation will occur on Day 0 
 
Routine post-transplant supportive care will be provided 
 
Study Duration: 
Patients will be followed for at least 24 months after transplantation


 DeFilipp Cord  Blood 11-085 Update  10/6/2016 
SCHEMA 
 
 
Day 
-7 
Day 
-6 
Day -
5 
Day 
-4 
Day 
-3 
Day 
-2 
Day 
-1 
Day 
0 
Day 
+5 
Fludarabine intravenous 
√ 
√ 
√ 
√ 
√ 
√ 
 
 
 
Melphalan intravenous 
 
 
 
 
 
 
√ 
 
 
TBI 
 
 
 
 
 
 
 
√ 
 
Start sirolimus oral 
 
 
 
 
√ 
 
 
 
 
Start tacrolimus intravenous 
 
 
 
 
√ 
 
 
 
 
Cord blood infusion 
 
 
 
 
 
 
 
√ 
 
Start G-CSF subcutaneous or 
intravenous 
 
 
 
 
 
 
 
 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
2
 
 
TABLE OF CONTENTS 
 
1. 
OBJECTIVES .................................................................................................................................................... 1 
1.1 
Study Design ............................................................................................................................................... 1 
1.2 
Primary Objectives ..................................................................................................................................... 1 
1.3 
Secondary Objectives ................................................................................................................................. 1 
2. 
BACKGROUND ................................................................................................................................................ 1 
2.1 
Stem Cell Transplant .................................................................................................................................. 1 
2.1.1 
Umbilical Cord Transplantation ............................................................................................................ 2 
2.1.2 
Double Umbilical Cord Transplantation ................................................................................................ 3 
2.1.3 
The Use of Low Dose Total Body Radiation in Cord Blood Conditioning ........................................... 4 
2.2 
Viral Reactivation ....................................................................................................................................... 4 
2.3 
Platelet Engraftment and Thrombopoietin ................................................................................................. 6 
2.4 
Rationale .................................................................................................................................................... 7 
3. 
PARTICIPANT SELECTION .......................................................................................................................... 9 
3.1 
Eligibility Criteria ...................................................................................................................................... 9 
3.2 
Exclusion Criteria .................................................................................................................................. 10 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ............................................ 10 
3.4 
Donor Selection ........................................................................................................................................ 10 
3.5 
Selection of Cord Blood Units .................................................................................................................. 11 
3.6 
Evaluation, Counseling and Patient Consent ........................................................................................... 11 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 12 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ..................................................................... 12 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ................................................................. 13 
4.3 
General Guidelines for Other Participating Institutions .......................................................................... 14 
4.4 
Registration Process for Other Participating Institutions ........................................................................ 14 
5. 
TREATMENT PLAN ...................................................................................................................................... 13 
5.1 
Conditioning Therapy ............................................................................................................................. 14 
5.1.1 
Fludarabine .......................................................................................................................................... 14 
5.1.2 
Melphalan. .......................................................................................................................................... 14 
5.1.3 
Total Body Irradiation. ........................................................................................................................ 14 
5.2 
GVHD Prophylaxis ................................................................................................................................... 14 
5.2.1 
Tacrolimus ........................................................................................................................................... 15 
5.2.2 
Rapamycin ........................................................................................................................................... 14 
5.3 
Umbilical Cord Blood Unit Processing and Infusion ........................................................................... 15 
5.3.1 
Cord Blood Thawing Procedure .......................................................................................................... 15 
5.3.2 
Release of Cord Blood from the Cell Processing Facility ................................................................... 15 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
3
5.3.3 
Administration of Cord Blood Units .................................................................................................... 15 
5.4 
Post transplant Supportive Care .............................................................................................................. 15 
5.5 
Duration of Therapy .................................................................................................................................. 16 
5.6 
Duration of Follow Up ............................................................................................................................. 17 
5.7 
Criteria for Removal from Study .............................................................................................................. 17 
5.8 
Suggested Guidelines for Initiation of Treatment of Significant Viral Infections: ................................... 18 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 18 
6.1 
Anticipated Toxicities ............................................................................................................................... 18 
6.1.1 
Adverse Event Lists(s) for Fludarabine ............................................................................................... 18 
6.1.2 
Adverse Event List(s) for Melphalan ................................................................................................... 18 
6.1.3 
Adverse Event List for Total Body Irradiation .................................................................................... 18 
6.1.4 
Adverse Event List for G-CSF ............................................................................................................. 18 
6.1.5 
Adverse Event List for Tacrolimus ...................................................................................................... 19 
6.1.6 
Adverse Event List for Sirolimus ........................................................................................................ 19 
6.2 
Toxicity Management: .............................................................................................................................. 19 
7. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 19 
7.1 
Fludarabine .............................................................................................................................................. 19 
7.1.1 
Description.......................................................................................................................................... 19 
7.1.2 
Form .................................................................................................................................................... 20 
7.1.3 
Storage and Stability ......................................................................................................................... 20 
7.1.4 
Compatibility ...................................................................................................................................... 20 
7.1.5 
Handling ............................................................................................................................................. 20 
7.1.6 
Availability ......................................................................................................................................... 20 
7.1.7 
Preparation ......................................................................................................................................... 21 
7.1.8 
Administration ................................................................................................................................... 21 
7.2 
Melphalan ................................................................................................................................................. 21 
7.2.1 
Description.......................................................................................................................................... 21 
7.2.2 
Form .................................................................................................................................................... 21 
7.2.3 
Storage and Stability ......................................................................................................................... 21 
7.2.4 
Compatibility ...................................................................................................................................... 21 
7.2.5 
Handling ............................................................................................................................................. 21 
7.2.6 
Availability ......................................................................................................................................... 22 
7.2.7 
Preparation ......................................................................................................................................... 22 
7.2.8 
Administration ................................................................................................................................... 22 
7.3 
Tacrolimus ................................................................................................................................................ 23 
7.3.1 
Description.......................................................................................................................................... 22 
7.3.2 
Form .................................................................................................................................................... 22 
7.3.3 
Storage and Stability ......................................................................................................................... 22 
7.3.4 
Compatibility ...................................................................................................................................... 23 
7.3.5 
Handling ............................................................................................................................................. 23 
7.3.6 
Preparation ......................................................................................................................................... 23 
7.3.7 
Administration ................................................................................................................................... 24 
7.4 
Sirolimus ................................................................................................................................................... 24 
7.4.1 
Description.......................................................................................................................................... 24 
7.4.2 
Form .................................................................................................................................................... 23 
7.4.3 
Storage and Stability ......................................................................................................................... 24 
7.4.4 
Compatibility ...................................................................................................................................... 25 
7.5 
Recombinant Human Granulocyte Colony Stimulating Factor ................................................................ 25 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
4
7.5.1 
Description.......................................................................................................................................... 25 
7.5.2 
Form .................................................................................................................................................... 25 
7.5.3 
Storage and Stability ......................................................................................................................... 25 
7.5.4 
Compatibility ...................................................................................................................................... 26 
7.5.5 
Handling ............................................................................................................................................. 26 
7.5.6 
Administration ................................................................................................................................... 26 
8. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 26 
8.1 
Functional Reconstitution of T Cell Immunity .......................................................................................... 26 
8.2 
Optional Thrombopoeitin Levels .............................................................................................................. 27 
9. 
STUDY CALENDAR ...................................................................................................................................... 28 
9.1 
Pre Transplant Evaluations ...................................................................................................................... 29 
9.2 
Post Transplant Evaluation ...................................................................................................................... 29 
10. 
MEASUREMENT OF EFFECT..................................................................................................................... 33 
10.1 
Engraftment .............................................................................................................................................. 33 
10.1.1 
Time to Neutrophil Engraftment ..................................................................................................... 33 
10.1.2 
Time to Platelet Engraftment .......................................................................................................... 33 
10.2 
Incidence of GVHD .................................................................................................................................. 33 
10.2.1 
Incidence of Acute GVHD .............................................................................................................. 33 
10.2.2 
Chronic GVHD ............................................................................................................................... 33 
10.3 
Other Response Parameters ..................................................................................................................... 34 
10.3.1 
Treatment Related Mortality ........................................................................................................... 34 
10.3.2 
Immunologic Reconstitution ........................................................................................................... 34 
10.3.3 
Relapse-Free and Overall Survival ................................................................................................. 36 
10.3.4 
FractionalChimerism of Cord Blood Units ..................................................................................... 36 
10.3.5 
Second Malignancies ...................................................................................................................... 36 
10.4 
Evaluation of Response ............................................................................................................................ 36 
11. 
ADVERSE EVENT REPORTING REQUIREMENTS .......................................................................... 36 
11.1 
Definitions ................................................................................................................................................ 36 
11.1.1 
Adverse Event (AE) ........................................................................................................................ 36 
11.1.2 
Serious adverse event (SAE) ........................................................................................................... 36 
11.1.3 
Expectedness ................................................................................................................................... 38 
11.1.3.1 
Expected adverse event .............................................................................................................. 38 
11.1.3.2 
Unexpected adverse event .......................................................................................................... 38 
11.1.4 
Attribution ....................................................................................................................................... 38 
11.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 39 
11.3 
Reporting Requirements ........................................................................................................................... 39 
11.4 
Reporting to the Study Sponsor ................................................................................................................ 39 
11.4.1 
Serious Adverse Event Reporting ................................................................................................... 40 
11.4.2 
Non-Serious Adverse Event Reporting ........................................................................................... 41 
11.5 
Reporting to the Institutional Review Board (IRB) ................................................................................... 41 
11.6 
Reporting to Hospital Risk Management .................................................................................................. 41 
12. 
DATA AND SAFETY MONITORING ..................................................................................................... 41 
12.1 
Data Reporting ......................................................................................................................................... 41 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
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5
12.1.1 
Method ............................................................................................................................................ 41 
12.1.2 
Data Submission ............................................................................................................................. 41 
12.2 
Safety Meetings ......................................................................................................................................... 41 
12.3 
Monitoring ................................................................................................................................................ 43 
13. 
REGULATORY CONSIDERATIONS ..................................................................................................... 43 
13.1 
Protocol Review and Amendments ........................................................................................................... 43 
13.2 
Informed Consent ..................................................................................................................................... 44 
13.3 
Ethics and Good Clinical Practice (GCP) ............................................................................................... 44 
13.4 
Study Documentation ................................................................................................................................ 43 
13.5 
Records Retention ..................................................................................................................................... 43 
13.6 
Multi-Center Guidelines ........................................................................................................................... 43 
14. 
STATISTICAL CONSIDERATIONS ........................................................... Error! Bookmark not defined. 
14.1 
Study Design/Endpoints .............................................................................. Error! Bookmark not defined. 
14.2 
Sample Size/Accrual Rate ......................................................................................................................... 47 
14.3 
Early Stopping Rules ................................................................................................................................ 47 
14.3.1 
Severe Acute GVHD ....................................................................................................................... 47 
14.3.2 
Primary Graft Failure ...................................................................................................................... 47 
14.3.3 
Day 100 Treatment-related Mortality ............................................................................................. 47 
14.4 
Analysis of Secondary Endpoints .............................................................................................................. 49 
14.5 
Reporting and Exclusions ......................................................................................................................... 49 
15. 
PUBLICATION PLAN ............................................................................................................................... 49 
16. 
REFERENCES ............................................................................................................................................ 50 
17. 
APPENDICES ............................................................................................................................................. 54 


 DeFilipp Cord  Blood 11-085 Update  10/6/2016 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
1 
1. OBJECTIVES 
 
1.1 Study Design 
 
This is a Phase II study designed to test the new conditioning regimen.  One year 
significant viral infection rate will be compared to our historical control population, 
which has a one-year significant viral infection rate of 53%. 
1.2 Primary Objectives 
 
The primary objective of this Phase II trial is to determine the one year significant viral 
infection rate (viral infections requiring medical intervention) after double umbilical 
cord blood transplant using a novel conditioning regimen of fludarabine/melphalan/low 
dose total body radiation. 
 
1.3 Secondary Objectives 
 
Secondary objectives of this trial include: 
 
Time to neutrophil and platelet engraftment 
 
Rate of primary graft failure 
 
Rates of Gr. II-IV and Gr. III-IV acute GVHD at 100 days 
 
The rate of chronic GVHD  
 
100-day treatment related mortality 
 
Immune reconstitution—CD 4 count at 12 months 
 
Relapse-free and overall survival at 1 and 2 years from transplantation 
 
Relapse Rate 
 
Rate of post transplant lymphoma 
 
Thrombopoieitin levels after transplant (optional correlate) 
 
2. BACKGROUND 
 
2.1 Stem Cell Transplant 
 
Myeloablative 
chemotherapy 
or 
chemoradiotherapy 
and 
allogeneic 
stem cell 
transplantation is an accepted curative therapy for many cancers, leukemias, and genetic 
disorders.  Long-term disease free survival probabilities of up to 70-80% can be achieved, 
particularly in young patients with matched donors.  Results of unrelated donor 
transplantation range from 20-30% for high-risk patients, to 60% for young patients with 
chronic myelogenous leukemia.  
 
Given the size of most American families, only 30% of patients will have a matched 
sibling donor.1 The Anthony Nolan Registry, the National Marrow Donor Program 
(NMDP), and other international registries were established to provide a source of 
volunteer marrow donors for patients without family donors.2  Although these registries 
have grown to include over twelve million volunteer bone marrow donors, approximately 
50% of patients are unable to find a suitably matched unrelated marrow donor and proceed 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
2 
 
to transplant in a timely fashion. It is particularly difficult for African Americans and other 
minorities to find matched unrelated bone marrow donors. 
 
2.1.1 Umbilical Cord Transplantation 
Placental or umbilical cord blood (UCB) has been shown to contain sufficient 
progenitor cells for hematopoietic engraftment and can sustain hematopoiesis after 
transplantation between unrelated individuals.3  Repositories of unrelated UCB 
collected from volunteer donors at the time of newborn delivery have been 
established in the United States and Europe.4-6  An estimated 400,000 cord blood 
units are available world-wide, and can be shipped for immediate use.7  
 
The first related cord blood transplant was performed in 1988, for a child with 
Fanconi’s Anemia,8 and the largest single institution UCB transplantation experience 
is at Duke University.9  Rubinstein et al reported on the results of 562 cord blood 
transplants facilitated by the New York Blood Center. Younger age and a high total 
nucleated cell dose (TNC)/kg were associated with improved survival.10 The 
European experience suggests a 30% disease-free survival in pediatric recipients of 
unrelated cord blood transplants, and again TNC dose/kg correlated with 
engraftment and survival.11  Engraftment was improved with a stem cell dose greater 
than 3.7 x 107/kg infused.  Since the average nucleated cell dose of a cord blood unit 
is approximately 1 x 109, most UCB units are only acceptable for children and small 
adults.12  
 
Laughlin et al reported that single UCB units could restore hematopoiesis in adults 
after myeloablative transplant conditioning.13  Sixty-eight patients, aged 18-55 years, 
with a median weight 69 kg, received a single UCB transplant. The median TNC 
dose at the time of transplantation was 1.6 x 107 TNC/kg.  Neutrophil engraftment 
occurred at 27 days (range 13-59) and 8 patients died prior to engraftment. Platelet 
engraftment occurred at 58 days (range 35-142) in the 30 evaluable patients.  As a 
result of this prolonged time to engraftment, the 100-day transplant related mortality 
was 41%, and only 18 patients were disease-free survivors forty months after 
transplantation.  
 
Similar clinical experiences have been reported by Spanish,14 and Eurocord,15 and 
Japanese investigators.16  In all studies, nucleated cell dose correlated with 
survival, and transplant-related mortality was high. 
The ability to transplant adults and larger children safely with UCB blood is 
therefore limited by the number of hematopoietic progenitors contained in a single 
unit of UCB. In order to circumvent this problem strategies such as the co-
transplantation of 2 or more UCB units have been proposed. 
 
 
 
 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
3 
 
2.1.2 Double Umbilical Cord Transplantation 
Early reports of patients infused with multiple, mismatched UCB units suggested 
that crossed immunologic rejection would not occur,17  prompting the further 
examination of this technique.  Recent studies of adult recipients have evaluated 
the outcome of transplantation of two cord blood units to adult recipients, thereby 
increasing the number of stem cells infused. At the University of Minnesota, 23 
patients received two UCB units, thawed and administered sequentially, with a 
minimum combined cell dose of 3 x 107 TNC/kg. Cord blood units were a 4/6 
HLA match with the patient and with each other. An ablative conditioning 
regimen of fludarabine, cyclophosphamide, and total body radiation was used. 
The median time to engraftment was 23 days, and mixed chimeric hematopoiesis 
was observed at day 21 in 24% of patients.  Using cyclosporine and 
mycophenolate mofetil as graft versus host disease (GVHD) prophylaxis, the rate 
of Grade. II-IV acute GVHD was 65%.  One year disease-free survival was 
57%.18   
 
More recently, the Minnesota group updated their clinical experience in 
a report of 110 individuals who underwent cord blood transplantation using a 
reduced intensity regimen containing low dose total body radiation (TBI).. 
Ninety-three patients received a double cord blood transplant; only those in whom 
a sufficiently large single unit was available received one unit.  Ninety-two 
percent had neutrophil recovery with a median time to engraftment in those that 
engrafted of 12 days.  Only 65% engrafted platelets by day 180.  Grade II-IV 
acute GVHD occurred in 59% of patients, with chronic GVHD noted in 23% of 
patients.  Transplant related mortality was 19% at 6 months, and 26% at 3 years. 
Event-free survival at 3 years was 38%, and there was an advantage to receiving 
two umbilical cord blood units.19 
 
 
To build upon this double umbilical cord blood experience, two Phase I-II studies 
of double cord blood transplantation using the reduced intensity conditioning 
regimen of fludarabine, melphalan and antithymocyte globulin have now been 
completed at the Dana-Farber/Harvard Cancer Center (Protocols 03-061 and 05-
154).20,21  In these trials, 53 subjects received two UCB units, matched at 4/6 
HLA loci or better to each other and to the recipient.  GVHD prophylaxis 
regimens were cyclosporine and mycophenolate mofetil (03-061) or sirolimus and 
tacrolimus (05-154).  Subjects received a combined total of 4.4 x 106 TNC/kg and 
1.9 x 105 CD34+ cells/kg pre-cryopreservation, without cohort differences. 
Engraftment kinetics did not differ based on GVHD prophylaxis, with neutrophil 
engraftment (absolute neutrophil count of 500) at a median of 21 days (13-70), 
and platelet engraftment (20 000/µL) at a median of 42 days (21-185).  Five 
patients experienced graft loss between days 35 and 102.  Transplant related 
mortality was 13% at 100 days, 24 % at one year, and 29% at two years.  Grade 
II-IV acute GVHD occurred in 40% of patients treated with Cya/MMF and 9% of 
subjects treated with sirolimus/tacrolimus, p =0.035. Chronic GVHD occurred in 
39% of patients treated with cyclosporine/cellcept and 13% of patients treated 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
4 
 
with sirolimus/tacrolimus. However, the relapse rate was higher in the 
sirolimus/tacrolimus group, 34% vs 14%, p = 0.05. Two year DFS was 55% for 
cyclosporine/MMF and 31% for sirolimus/tacrolimus, p=0.101.  As a result of 
these two studies, double umbilical cord blood transplantation has become the 
standard at the DF/HCC, when UCB transplantation is required. 
 
A preliminary study from our center compared survival after UCB using the 
conditioning regimen of melphalan, fludarabine, and antithymocyte globulin, with 
survival after a matched related donor or matched unrelated donor transplant, 
using a reduced intensity conditioning regimen. 22 Overall survival and 
progression-free survival was comparable among all three groups, with a 2 year 
overall survival of 50% and a 2 year progression-free survival of 34%. UCB 
patients had a higher transplant related mortality, mostly due to infection, but a 
decreased risk of relapse. 
2.1.3 The Use of Low Dose Total Body Radiation in Cord Blood Conditioning 
The Minnesota group has used a conditioning regimen of  cyclophosphamide, 
fludarabine, and low dose total body radiation in over 100 patients.19  The GVHD 
prophylaxis was cyclosporine and mycophenolate.Incidence of acute GVHD 
Grades II-IV was 59%. Transplant related mortality was 26% at three years. Viral 
infection rate was not analyzed in this study, but the risk of post transplant 
lymphoproliferative disorder was less without the use of antithymocyte globulin.23 
Compared to the DFCI/MGH experience on protocols 03-061 and 05-154,  in 
Minnesota, the risk of graft versus host disease was greater but the incidence of 
second malignancies was less.24 Our study outlined here utilizes low dose TBI to 
decrease the second malignancies and viral infections, but with the GVHD 
prophylaxis of sirolimus and tacrolimus to decrease GVHD. Our active cord blood 
protocol, 08-274, which is completing accrual, uses no TBI but a lower dose of 
ATG. However, that Phase I study is looking at ProstaglandinE2 incubation so the 
data is confounded. 
Recently, the CIBMTR completed a Phase II study of reduced intensity double cord 
blood transplantation with the conditioning regimen of cyclophosphamide, 
fludarabine, and low dose total body radiation and a GVHD prophylaxis of 
cyclosporine or tacrolimus and mycophenolate mofetil..25  Fifty-four patients were 
enrolled; preliminary data indicates a transplant related mortality of 20% at Day 
180. 
 
2.2 Viral Reactivation 
Post transplant lymphoma remains a significant problem after our cord blood 
protocols.24  The incidence of second cancers was 18% in the first 98 patients, with 
16 post transplant lymphomas (PTLD), and 2 patients with donor derived 
MDS/MPD.  There was a trend toward increased incidence in patients receiving 
antithymocyte globulin.  The use of antithymocyte globulin in reduced intensity cord 
blood transplantation has been associated with PTLD in the Minnesota experience. 23  
The incidence of EBV related complications was 21% with ATG and 2% in those 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
5 
 
patients who did not receive ATG. Thus, a conditioning regimen without ATG may 
improve immune reconstitution and reduce late transplant related mortality.   
Interestingly, ATG  used with myeloablative transplant had a much lower rate of 
EBV associated complications at 7%. The use of ATG was associated with a lower 
risk of GVHD. Reactivation of other viruses was not addressed in this study. 
 
In addition to EBV infections, other viral infections remain a significant cause of 
morbidity and mortality in the first year post transplant. We examined the viral 
infection rate in the 53 patients treated above, focusing on viral infections that 
required medical intervention in the first year. In these patients, there were 28/53 
viral infections requiring intervention or 53%. The infections were as follows: 11 
CMV, 9 EBV, 2 adeno, 2 HHV-6, and 4 zoster.  
 
The etiology of the increased infection rate after cord blood transplantation is 
complex, and includes factors such as a lower CD34+ dose/kg infused and 
qualitative differences in the lymphocytes in cord blood. For example, T 
lymphocytes from cord blood are CD45RA+ and express low levels of activation 
markers.26   Expression of the chemokine receptor CCR7 may be important for 
immune recovery post transplant. Higher levels of CCR7+ CD4+ T cells at Day 30 
post transplant was associated with prolonged survival.27 
   
A variety of studies have reported increased viral infection after UCB 
transplantation.  One hundred and fourteen children who were seropositive for 
varicella zoster virus underwent either cord blood transplant (n=37) or T replete bone 
marrow transplant (n=77).28  Thymoglobulin was given for all cord patients, and 22 
bone marrow patients who received an unrelated graft. Visceral dissemination 
occurred in 1 bone marrow patient and 6 cord blood patients (p=0.0005).  CD4+ 
counts were lower after cord blood transplant.  Parkman and colleagues have shown 
that children with a positive antigen response to herpes viruses post UCB 
transplantation had fewer infections and decreased relapse.29  In a combined 
pediatric and adult study, MD Anderson has reported a 40% incidence of viral 
infections, in patients treated with a variety of conditioning regimens.30 
 
Cytomegalovirus reactivation remains a significant cause of morbidity after cord 
blood transplantation. Our center, using fludarabine, melphalan, and thymoglobulin 
conditioning, reported that clearance of CMV viremia depends on the recovery of 
C4+CD45RA+ T cells and T cell receptor rearrangement excision circles (TREC) 
levels of greater than 2000 copies/ug DNA.31  Survival was improved in patients that 
attained TREC levels greater than 2000 copies/ug DNA.  The Spanish group, using 
antithymocyte based conditioning, reported a risk of CMV infection of 59% and 
CMV disease of 9% using prophylactic valganciclovir.32 The Japanese group, using 
fludarabine based regimen, reported an incidence of positive CMV antigenemia of 
55% and 16% of CMV disease.33  CMV enterocolitis was seen in the majority of 
cases with CMV disease, and graft versus host disease was a risk factor for the 
development of CMV disease.  
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
6 
 
Double UCB transplantation is associated with a faster time to neutrophil 
engraftment and decreased relapse.19,34  It is not clear if the viral infection rate, 
however, is decreased after double UCB compared to single UCB. The French group 
studied 31 adult UCB patients, of whom 27 received a double UCB transplant.35  
Patients received a variety of conditioning regimens, of which some contained 
antithymocyte globulin. The incidence of recurrent CMV infection was 21%; there 
were 2 deaths from EBV lymphoproliferative disorder and 1 from adenovirus. 
 
Several centers have compared infections after UCB transplantation to those seen 
after transplantation with other graft sources.36 Forty-eight recipients of 
myeloablative, single UCB transplantation were compared with 144 unrelated bone 
marrow/peripheral blood stem cell transplant recipients.  The UCB patients had a 
higher risk of early bacterial infection but the 100 day and 3 year incidence of 
infection related mortality was similar.  All cord blood patients received a 
myeloablative total body radiation conditioning regimen.  In our center, progression-
free survival was similar among recipients of reduced intensity double UCB, 
matched related donor, and matched unrelated donor transplants, but the transplant 
related mortality after Day 100 was higher in the UCB recipients.22   The two year 
transplant related mortality was 29% for UCB receiving fludarabine, melphalan, and 
antithymocyte globulin, 9% for unrelated donor, and 8% for matched related donor. 
Infection was the leading cause of late transplant related mortality. 
 
In this study, to improve immune reconstitution and decrease post transplant viral 
infection, we will substitute low dose total body radiation at a dose of 200 cGy for 
the antithymocyte globulin in the conditioning regimen. The fludarabine and 
melphalan doses will remain the same.  We will compare one year significant viral 
infection rates requiring intervention to our historical control population who were 
treated with fludarabine, melphalan, and antithymocyte globulin.  GVHD may be 
higher with this regimen and therefore we will utilize the GVHD prophylaxis 
regimen of sirolimus and tacrolimus that has proven to control acute GVHD at 
DF/HCC across all types of transplants and conditioning regimens. 
 
2.3 
Platelet Engraftment and Thrombopoietin 
 
Platelet engraftment is delayed after cord blood transplant, with a median day to 
platelet count >20 x 10 (9)/L of 42 days, range 21-185 days.  The death rate from CNS 
bleeding is 1-2%. Delayed platelet engraftment is also an important contributor to the 
increased morbidity, poor quality of life, and cost after double cord blood transplant. 
Therefore, as an optional correlate, we will study thrombopoietin (TPO) levels after 
cord blood transplant, to determine if further investigation of TPO receptor agonists 
post cord blood transplant is warranted. 
 
The thrombopoietin (TPO) receptor, c-Mpl, is a hematopoietic cytokine receptor and  
TPO receptors on hematopoietic stem cells and platelets.387  When platelet production 
is low, circulating levels of TPO rise.39  
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
7 
 
Two recombinant TPO molecules (rhTPO and PEG-rHuMDGF) were developed in the 
late 1990’s after the successful cloning of human TPO.  Unfortunately, paradoxically, 
some patients developed thrombocytopenia, and there was no improvement in time to 
platelet recovery in patients undergoing hematopoietic stem cell transplantation.40  
 
Recently, two thrombopoietin receptor agonists, romiplostim (N-Plate) and 
eltrombopag, have been approved for patients with immune thromobocytopenia.  
Romiplostim is composed of four peptides that bind to the thrombopoietin receptor 
cMPL fused to an Fc fragment.41   Its effectiveness in ITP was shown in two Phase III 
studies; a platelet count of >50 x 10 (9)/L was seen in 61% of non splenectomized and 
38% splenectomized patients receiving romiplostim and in <1% of placebo patients. 41 
Side effects have included rebound thrombocytopenia after drug discontinuation and 
increased bone marrow reticulum. 42 A recent randomized study showed that patients 
treated with romiplostim have a higher rate of platelet response, fewer blood 
transfusions, and a higher quality of life than patients treated with the standard of 
care.43  In patients with myelodysplasia receiving romiplostim, there was a transient 
increase in circulating blasts, but no increase in transformation to AML.42   
 
To understand the changes in TPO levels after double cord blood transplant so as to 
ascertain the potential benefit of a future clinical trial with romiplostim, we will collect 
TPO levels after cord blood transplant, as described in Section 8.2. and Appendix 1.  
Participation in the TPO level portion of the study will be optional for patients. TPO 
levels will be determined with the assistance of Dr. David Kuter and Dr. Robert Makar 
and TPO levels will be measured pre conditioning, Day 0, Day 1 after transplant, 
weekly until Day 60, Day 100, Day 180, Day 360.  TPO levels will also be measured 
pre platelet transfusion, 1 hour, 6 hours and 24 hours post platelet transfusion for the 
first 3 platelet transfusions given Monday through Thursday post transplant.  TPO 
levels will be correlated with complete blood counts, and platelet counts and platelet 
transfusions, and a timeline of TPO levels post transplant will be formulated.  
 
  
2.4 
Rationale 
DUCBT appears to reduce the incidence of early treatment related mortality when 
compared with single UCB transplantation, however, there remains a high risk of viral 
infection, with the use of antithymocyte globulin. This study will test a non antithymocyte 
globulin conditioning regimen with the use of fludarabine, melphalan, and low dose total 
body radiation.  Low dose total body radiation has been used safely in several hundred adult 
patients undergoing double cord blood transplantation.23,25 Viral infection rate was not  well 
analyzed in these studies. Sauter et al have recently reported on viral infection in a 
conditioning regimen without ATG.44  Patients in this study received either ablative (n=52) 
or nonmyeloablative (n=20) conditioning regimens followed by double cord blood 
transplant with cyclosporine and mycophenolate mofetil prophylaxis.Thirty percent of 
patients had a serious viral infection between Days 31-60 after transplant. CMV accounted 
for 45% of the  viral infections. 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
8 
 
We hypothesize a 20% reduction in clinically significant viral infections with the 
elimination of antithymocyte globulin. We will monitor for graft failure and graft versus 
host disease. While it is possible that GVHD may be increased, the risk of GVHD with our 
current ATG containing regimen and GVHD prophylaxis of sirolimus and tacrolimus is 
low.  We would not anticipate a higher risk of relapse without ATG; based on the 
Minnesota experience19 If successful, this trial will increase the safety of UCB 
transplantation in adults, by reducing the risks of treatment-related mortality due to viral 
infection. 
 
 
Selection of Primary Endpoint: 
Due to advances in cord blood transplant, such as the use of double cord blood 
transplant, engraftment has improved and thus engraftment is not a clinically 
meaningful endpoint in adult double cord blood transplant in 2011. Transplant related 
mortality (TRM) is low in the first 100 days post transplant, at <15% in our earlier 
protocols with ATG. 20,21This 100 day TRM would reflect engraftment issues. However, 
the 3 year TRM is 29% which reflects late viral infections and second cancers.22,24 
Thus, we feel that the viral reactivation is a more clinically meaningful endpoint based 
on our earlier experience. However, we include an interim analysis for the primary 
endpoint and at that time we will evaluate the neutrophil engraftment in parallel.  
 
Interim Analysis:  
As of February 12, 2013, 16 patients were enrolled, among whom 14 patients were transplanted. 
Of these 14, data for the primary endpoint was available for the first 13 patients, and these 13 
patients are included in the interim analysis. Of these 13, 8 patients experienced clinically 
significant infections (5 HHV-6, 2 CMV, 1 both CMV and HHV-6), 1 patient experienced graft 
failure, 1 patient experienced grade III-IV acute GVHD and 1 patient died of TRM within day 
100 of transplantation. Since the number of infections exceeds the threshold of 7, as specified in 
the original design, accrual was temporarily suspended and the results of the interim analysis 
reviewed with the DSMC. The team reviewed the data and has made the following adjustments. 
A more aggressive antiviral prophylaxis, monitoring, and treatment plan is outlined in the 
revised protocol. In addition, new stopping rules are outlined in the statistics.  
 
Second interim analysis: 
As of As of October 14, 2014, 11 additional patients were transplanted after the study was re-
opened. Among the first 10 patients who were subsequently enrolled, 5 patients experienced 
clinically significant infections (3 CMV, 1 CMV and Herpes Zoster, 1 Adenovirus and HHV-6), 
therefore the study met the early stopping rule which was specified in the amendment following 
the first interim analysis (≥5 clinically significant infections in 10 subsequently enrolled 
patients).  
 
The accrual to the study was temporarily suspended and the study team met on December 16, 
2014. The results of the interim analysis were reviewed with the DSMC. After reviewing 
additional outcome data, the study team felt that although the overall targeted reduction in 
infection rates will not be reached, the outcome was good among the 10 patients who were 
subsequently enrolled since the study re-opened with a more restricted age eligibility of under 
65: no 100 day TRM, 17% TRM and 83% survival at 6 months, respectively. The study team 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
9 
 
suggested to re-open the study and to complete the accrual so more data can be gathered within 
the group with age under 65 (7 more patients need to be accrued).   
 
 
 
 
3. PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
 
3.1.1 Participants with hematologic malignancies or hematologic disorders for whom 
allogeneic stem cell transplantation is deemed clinically appropriate.  Eligible 
diseases and stages include: 
1. Non-Hodgkin’s lymphoma, or Hodgkin’s lymphoma in 2nd or subsequent 
complete remission or in partial remission with documented chemosensitivity 
to the most recent chemotherapy regimen.  Prior autologous transplantation is 
required, unless deemed medically inappropriate by the treating physician. 
2. Multiple myeloma: relapsed but with chemosensitive disease.  Bone marrow 
plasma cells may not exceed 20% of the total cellularity.  
3. Chronic lymphocytic leukemia: Any Rai stage III or IV, lymphocyte doubling 
time of 6 months, or stage I-II with progression after > 2 chemotherapy 
regimens, in partial remission with documented chemosensitivity to the most 
recent chemotherapy regimen.   
4. Acute myelogenous or acute lymphoblastic leukemia in second or subsequent 
complete remission or in first remission with adverse cytogenetic/molecular 
features or a documented antecedent hematologic disorder.  
5. Myelodysplastic disorder 
6. Myeloproliferative disorder including myelofibrosis, chronic myelogeneous 
leukemia resistant to tyrosine kinase inhibitorsAplastic anemia with no response 
to immunosuppressive therapy. 
3.1.2 Patient must be appropriate for reduced intensity regimen, according to the treating 
physician. 
3.1.3 Lack of 6/6 or 5/6 HLA-matched related, 8/8 HLA-matched unrelated donor, or 
unrelated donor not available within a time frame necessary to perform a potentially 
curative stem cell transplant. 
3.1.4  Age 18 – 65 years 
 
3.1.5 ECOG performance status of 0-2 
  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
10 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be 
eligible for admission into the study. 
3.2.1 Cardiac disease: symptomatic congestive heart failure or evidence of left ventricular 
dysfunction (Ejection fraction < 40%) as measured by gated radionucleotide 
ventriculogram  or echocardiogram; active angina pectoris, or uncontrolled 
hypertension. 
3.2.2 Pulmonary disease: symptomatic chronic obstructive lung disease,   symptomatic 
restrictive lung disease, or corrected DLCO of < 50% of predicted, corrected for 
hemoglobin. 
3.2.3 Renal disease: serum creatinine > 2.0 mg/dl. 
3.2.4 Hepatic disease: serum bilirubin > 2.0 mg/dl (except in the case of Gilbert’s 
syndrome or ongoing hemolytic anemia), SGOT or SGPT > 3 x upper limit of 
normal. 
3.2.5 Neurologic disease: symptomatic leukoencephalopathy, active CNS malignancy or 
other neuropsychiatric abnormalities believed to preclude transplantation  
3.2.6 HIV antibody.  HIV-positive individuals are at increased risk of lethal infections 
when treated with marrow-suppressive therapy.  
 
3.2.7 Uncontrolled infection 
3.2.8 Pregnancy or breast feeding mother. 
3.2.9 Inability to comply with the requirements for care after allogeneic stem cell 
transplantation 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations 
 
Women and minorities are included in the eligibility criteria. Because non Caucasian 
populations have a difficult time finding matched adult volunteer donors, umbilical 
cord blood transplantation is an important alternative stem cell source for minority 
patients. We will attempt to find appropriately matched cord blood donors for all 
eligible patients, regardless of gender, race, or ethnicity. Gender, race and ethnicity will 
be recorded in our QACT database, per standard transplant procedures. 
3.4 
Donor Selection 
 
Cord blood donors are enrolled by a number of cord blood banks in the United States 
and worldwide.  Donors undergo a strict evaluation according to local cord blood bank 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
11 
 
practices and are consented by the local cord blood bank. Enrollment and consent of 
cord blood donors are not covered in this protocol.   
3.5 
Selection of Cord Blood Units 
3.5.1 The patient and the cord blood units must be a 4/6 HLA A, B, DRβ1 match or 
greater match with each other and with the patient.  HLA C and DQ will be tested 
but will not be used in the match strategy 
3.5.2 Determination of histocompatibility will be made by molecular typing of HLA class 
I and class II alleles. Cord unit to patient matching should be at the allele level (high 
resolution) whenever possible. All cord blood units will have confirmatory HLA 
typing performed. The confirmatory HLA typing may be performed at an ASHI 
accredited laboratory of the cord blood bank or at one the Dana Farber/Harvard 
Cancer Center sites. 
3.5.3 Total combined nucleated cell dose from the 2 cord blood units must be ≥ 3.7 x 107  
TNC/kg (pre-cryopreservation). Each single cord blood unit cell dose must be ≥ 1.5 
x 107 TNC/kg (pre-cryopreservation).  
3.5.4 Choice of cord blood units, when multiple suitable units are available will use the 
following algorithm:  
 
Higher cell dose triumphs over HLA match when TNC is < 2.0 x 107 NC/kg 
for each single cord blood unit 
 
Closer HLA match triumphs over cell dose when TNC is > 2.0 x NC/kg for 
each single cord blood unit unless there is a >50% higher cell dose in the 
less well matched cord blood unit 
 
For selection between equivalent units choose: 
                 CD34+ dose (higher dose preferable) 
                 Greater viability (never use a unit with viability less than 90%) 
         
3.5.5 Cord blood units to which the patient has preformed HLA A, B, C, DR antibodies 
cannot be used. 
3.5.6 Cord units must not be HLA identical, unless a 6/6 match with the patient. 
3.5.7 Double mismatches at any given locus should be avoided 
Please seen appendix 5 for more details.  
3.6 
Evaluation, Counseling and Patient Consent  
 
Patients are referred to the Dana-Farber/Harvard Cancer Center (DF/HCC) for 
consideration of allogeneic stem cell transplantation.  Patients are completely evaluated 
and presented at a group conference where the transplant team will suggests a course of 
treatment. In the appropriate clinical setting, umbilical cord blood transplantation is 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
12 
 
suggested.  The patient then undergoes a thorough pre-transplant evaluation including a 
history and physical examination and a series of studies to confirm medical eligibility.  
In addition, the patient will undergo a psychological evaluation (by the BMT social 
worker and/or psychiatrist) prior to transplantation, if indicated by the transplant 
attending. Financial aspects of the transplant will also be discussed with the patient and 
family before transplantation.  Treatment recommendations are then discussed 
thoroughly with patient and family.  The cord blood transplant procedures as well as 
alternative forms of therapy, as far as they exist, are presented as objectively as 
possible. The risks and hazards of the procedure are explained to the patient and family.  
It will be pointed out specifically that some aspects of cord blood transplantation are 
considered experimental.  Consent is obtained using forms approved by the Dana Farber 
Institutional Review Board. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must 
occur prior to the initiation of therapy. Any participant not registered to the protocol 
before treatment begins will be considered ineligible and registration will be denied.  
 
A member of the study team will confirm eligibility criteria and complete the 
protocol-specific eligibility checklist. 
  
Following registration, participants may begin protocol treatment. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If 
a participant does not receive protocol therapy following registration, the participant’s 
protocol status must be changed. Notify the QACT Registrar of participant status 
changes as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 
5:00 PM Eastern Standard Time. In emergency situations when a participant must begin 
treatment during off-hours or holidays, call the QACT registration line at 
 
and follow the instructions for registering participants after hours. 
   
The registration procedures are as follows: 
 
1. 
Obtain written informed consent from the participant prior to the performance 
of any study related procedures or assessments. 
 
2. 
Complete the protocol-specific eligibility checklist using the eligibility 
assessment documented in the participant’s medical/research record. To be 
eligible for registration to the study, the participant must meet each 
inclusion and exclusion criteria listed on the eligibility checklist. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
13 
 
  
Reminder: Confirm eligibility for ancillary studies at the same time as 
eligibility for the treatment study. Registration to both treatment and ancillary 
studies will not be completed if eligibility requirements are not met for all 
studies. 
  
3. 
Fax the eligibility checklist(s) and all pages of the consent form(s) to the 
QACT at 
. 
  
Exception: DF/PCC Affiliate sites must fax the entire signed consent form 
including HIPAA Privacy Authorization and the eligibility checklist to the 
Network Affiliate Office. The Network Affiliate Office will register the 
participant with the QACT. 
  
4. 
The QACT Registrar will (a) validate eligibility, (b) register the participant on 
the study, and (c) randomize the participant when applicable. 
  
5. 
The QACT Registrar will send an email confirmation of the registration 
and/or randomization to the person initiating the registration immediately 
following the registration and/or randomization. 
 
4.3 
General Guidelines for Other Participating Institutions 
N/A 
 
4.4 
Registration Process for Other Participating Institutions 
N/A 
  
5. TREATMENT PLAN  
 
Treatment will be administered on an inpatient basis. Expected toxicities and potential 
risks for melphalan, fludarabine, and low dose total body radiation  are described in 
Section 6 (Expected Toxicities and Dosing Delays/Dose Modification). No investigational 
or commercial agents or therapies other than those described below may be administered 
with the intent to treat the participant’s malignancy. 
 
Day 0 corresponds to the day of cord blood infusion. 
 
Table 1 
 
Day 
-7 
Day 
-6 
Day -
5 
Day 
-4 
Day 
-3 
Day 
-2 
Day 
-1 
Day 
0 
Day 
+5 
Fludarabine 
30mg/m2/day IV 
√ 
√ 
√ 
√ 
√ 
√ 
 
 
 
Melphalan 
100mg/m2/day IV 
 
 
 
 
 
 
√ 
 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
14 
 
TBI 200 cGy 
 
 
 
 
 
 
 
√ 
 
Start sirolimus PO 
 
 
 
 
√ 
 
 
 
 
Start tacrolimus IV or 
PO 
 
 
 
 
√ 
 
 
 
 
Start GCSF IV or SC 
 
 
 
 
 
 
 
 
√ 
 
 
 
5.1 
Conditioning Therapy 
 
Chemotherapy and GVHD prophylaxis medication doses will be based on actual weight in 
all circumstances. Administer chemotherapeutic agents according to institutional policies 
and procedures.  There are no dose reductions in the conditioning therapy. 
 
5.1.1 Fludarabine will be administered intravenously at a dose of 30mg/m2/day on days -7, 
-6, -5, -4, -3, and -2 (total dose 180mg/m2) 
5.1.2 Melphalan will be administered intravenously at a dose of 100mg/m2/day on day 
-1. 
5.1.3 Total Body Irradiation 200 cGy in 1 fraction on Day 0 at least 2 hours prior to cord 
blood infusions. Radiation sources and dose rates will be per institutional standards. 
   
5.2 GVHD Prophylaxis 
 
GVHD prophylaxis will begin on Day -3 
  
5.2.1 Tacrolimus 
Tacrolimus (FK-506, Prograf) will be administered at a starting dose of 0.02 
mg/kg intravenously by continuous infusion.  Subsequent dosing will be based on 
clinical toxicity, GVHD, concurrent medications, medical conditions, prior drug 
levels, drug-drug interactions and current blood levels.  The target serum 
concentration is 5-10 ng/ml. The oral formulation may be substituted at the 
treating physician’s discretion.  Doses may be re-administered if the subject 
vomits within 15 minutes of the dose, or if capsule fragments are visible in the 
vomitus. In the absence of GVHD and at the discretion of the attending physician, 
tacrolimus will begin to be tapered at approximately day +100 after 
transplantation, with the goal of discontinuation by 6-9 months post transplant.  
 
5.2.2 Rapamycin 
 
Rapamycin (Sirolimus, Rapamune) will be given as an oral loading dose of 12 mg on day -3, 
followed by a daily oral dose of 4 mg/day.  Doses may be re-administered if the subject vomits 
within 15 minutes of the dose, or if pill fragments are visible in the vomitus.  Subsequent dosing 
will be based on clinical toxicity, GVHD, concurrent medications, medical conditions, prior drug 
levels, drug-drug interactions and current blood levels.  Many medicines, including fluconazole, 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
15 
 
can affect sirolimus levels.  Patients on fluconazole should receive a loading dose of 12 mg 
followed by a daily oral dose of 2 mg/day. Patients should not start fluconazole until Day 0. The 
target serum concentration of sirolimus is 3-12 ng/ml.  In the absence of GVHD and at the 
discretion of the attending physician, sirolimus will begin to be tapered at approximately 
day +100 after transplantation, with the goal of discontinuation by 6-9 months post transplant 
5.3 
Umbilical Cord Blood Unit Processing and Infusion 
5.3.1 Cord Blood Thawing Procedure 
Cells are mixed with a hypertonic solution of Dextran 40 + 5% albumin 
(Dextran/albumin) immediately upon thawing.  Cells are then washed to remove 
DMSO, free hemoglobin and other cellular products, as per institutional practices 
5.3.2 Release of Cord Blood from the Cell Processing Facility 
All subjects will receive two cord blood units, administered sequentially, no less 
than 2 hours and no more than 5 hours apart. Cord blood units must not be 
released until after total body radiation is complete on Day 0.  The times of 
release from the stem cell processing facility for the cord blood units should be 
recorded. 
Umbilical cord blood units will always be released and administered according to 
the following sequence.  The larger cord blood unit, as measured by the pre-
cryopreservation TNC/kg, will be administered first.  If the larger cord blood unit 
is within 105% of the size of the smaller cord blood unit, the better HLA-matched 
unit will be administered first.  HLA-A, B and DRβ1 will be considered for 
matching, with preference to better DRβ1 matching, should both cord blood units 
have equivalent numbers of mismatches.  In the event that both cord blood units 
are the same size and HLA match, the cord blood unit collected most recently will 
be administered first.  
5.3.3 Administration of Cord Blood Units 
Cord blood units will be administered according to institutional policies and 
procedures. If possible, if a cord blood segment is available, the cord blood unit 
will be tested for HHV-6 by PCR. 
5.4 
Post transplant Supportive Care 
5.4.1 Infection Prophylaxis: At a minimum, the following practices will be observed: 
prophylactic antibiotics (such as levoquin or other appropriate agent) against gram 
negative organisms; ; and antifungal prophylaxis with fluconazole (or another 
appropriate agent). Patients on fluconazole should have a dose reduction in sirolimus 
as per Section 5.2.2. Fluconazole should not start until Day 0. Voriconazole should 
not be used as primary prophylaxis.  Antifungal prophylaxis should continue through 
at least hospital discharge. Prophylaxis against Pneumocystis jirovecii will begin 
upon hospital admission through the day prior to stem cell transplantation using 
trimethoprim-sulfamethoxazole (unless contraindicated due to allergy), and will 
resume upon hospital discharge.  Atovaquone is the preferred agent at all times for 
trimethoprim-sulfamethoxazole allergic patients and for all subjects at the time of 
discharge 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
16 
 
5.4.2  Extended viral monitoring will include monitoring for Cytomegalovirus (CMV), 
Epstein-Barr virus and Human Herpesvirus-6. CMV will be treated pre-emptively. 
Rising EBV titers on two sequential assays may be treated pre-emptively with 
rituximab to prevent post-transplant lymphoproliferative disorder. 
5.4.3 Recombinant Granulocyte Colony Stimulating Factor (G-CSF)-either Neupogen or 
Granix will be administered intravenously or subcutaneously from day +5 until 
engraftment of neutrophils (absolute neutrophil count of 1000 cells/µL for 2 
consecutive days).  Thereafter, G-CSF will be administered at the treating 
physician’s discretion. G-CSF dosing is as follows: patients ≤ 65 kg receive 300 
mcg/day, patients 66-100 kg receive 480 mcg/day, and patients > 100 kg receive 600 
mcg/day. 
5.4.4 Transfusion support per Dana-Farber/Harvard Cancer Center guidelines will be 
provided. 
5.4.5 Central venous access will be obtained on, or prior to, the date of admission. 
5.4.6 Hyperalimentation (TPN) will be provided at the treating physician’s discretion. 
5.4.7 Supplemental intravenous immunoglobulin will be transfused at the treating 
physician’s discretion. It is recommended that plasma immunoglobulins be 
measured at monthly intervals (at a minimum) and replacement be considered for 
levels less than 400 mg/dL. 
5.4.8 After hospitalization, subjects will be followed closely to monitor for complications 
related to transplantation. Patients will receive standard post-transplant discharge 
teaching and guidelines to prevent infection. All patients will receive the same 
treatment as outlined above. There will be no dose adjustments for chemotherapy. 
5.4.9 In an effort to reduce the risk of serious HHV-6 infection, the following antiviral 
prophylaxis will be instituted during conditioning: Famvir 500 mg tid or Valtrex 1 
gram daily unti at least Day +30 after transplant. If patients cannot take oral 
medications, then Acylovir 5 mg/kg IV every eight hours will be instituted.   Dose 
may be rounded. Antiviral prophylaxis, such as Famvir 500 mg daily or Acyclovir 
400 mg bid will continue through the longer of 1 year or until the discontinuation of 
all immunosuppression. Doses may be adjusted based on toxicity and renal 
dysfunction at the discretion of the investigator. A suggested management plan for 
HHV-6 reactivation is included in Appendix 6.  
 
 
5.5 
Duration of Therapy 
 
Duration of therapy will be as outlined in the protocol. There will be no adjustments 
in conditioning regimen, as per standard transplant care. 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
17 
 
5.6 
Duration of Follow Up  
 
Participants will be followed for at least 24 months post transplantation. Patients 
removed from the study will continue to be followed for survival. 
 
5.7 
Criteria for Removal from Study  
 
Study subjects may withdraw their consent to participate in this trial at any time.  Once 
withdrawn, the study subject will receive post-transplant care considered standard and   
routine for their individual case. 
Subjects may be removed from study treatment if: 
1. The subject wishes to be removed from the study. 
2. The investigator feels this study protocol would not be in the subject’s best 
interest.  
3. The subject needs a medication that is not part of this study (e.g. chemotherapy 
for relapsed or progressive disease, second transplantation) 
 
The reason for study removal and the date the participant was removed must be 
documented in the study-specific case report form (CRF). Alternative care 
options will be discussed with the participant. 
 
In the event of unusual or life-threatening complications, participating investigators 
must immediately notify the Principal Investigator: Dr. Zachariah DeFilipp at 
. 
5.8 
Suggested Guidelines for Initiation of Treatment of Significant Viral Infections: 
 
1. Cytomegalovirus (CMV): Patients with CMV infection, such as documented 
CMV from bronchoscopy or gastrointestinal biopsy, should be treated. Patients 
with CMV reactivation on 2 consecutive testing (CMV antigenemia >3 cells or 
positive CMV DNA) should be treated. Treatment may be ganciclovir, 
valganciclovir, foscarnet, or lymphocyte preparations (for example, third party 
Cytotoxic T lymphocytes) as determined by the treating investigator. 
2. Epstein Barr Virus (EBV): Patients with documented EBV lymphoproliferative 
disorder, such as on lymph node biopsy, should be treated. Patients with 2 
consecutive EBV DNA >1000 should also be treated. Treatment may be 
rituximab, chemotherapy, or lymphocyte preparation as determined by the 
treating investigator.. 
3. Human Herpes Virus 6 (HHV6): Suggested guidelines are given in Appendix 6.. 
4. Adenovirus: Patients with documented adenovirus in the lung should be treated. 
Patients with adenovirus in the urine should be treated if there is painful 
hemorrhagic cystitis, not relieved with IV fluids or continuous bladder irrigation. 
Treatment may be cidofovir or lymphocyte preparations, as determined by the 
treating investigator. 
5. Herpes Zoster: Patients with Herpes Zoster infection (shingles) should be treated. 
Treatment may be high dose acyclovir. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
18 
 
 
6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
CTEP Version 4 of the NCI Common Terminology Criteria for Adverse Events (CTCAE) will 
be utilized for AE reporting. The CTEP Active Version of the CTCAE is identified and 
located on the CTEP website at 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
All appropriate treatment areas should have access to a copy of the CTEP Active 
Version of CTCAE. 
 
All adverse events experienced by participants will be collected from the time of the 
first dose of study treatment, through the study and until the final study visit. 
Participants continuing to experience toxicity at the off study visit may be contacted for 
additional assessments until the toxicity has resolved or is deemed irreversible. 
 
 
6.1 
Anticipated Toxicities 
  
6.1.1 Adverse Event Lists(s) for Fludarabine 
 The most common adverse events include myelosuppression, fever and chills, and 
nausea and vomiting.  Other commonly reported events include malaise, fatigue, 
anorexia and weakness.  Serious opportunistic infections have occurred in patients 
with CLL treated with fludarabine and are due to myelosuppression and prolonged 
impairment of cell mediated immunity. 
 
 Peripheral neuropathy has been reported although would be unusual following a 
single course of therapy.  CNS toxicity is rare following a single course of therapy 
(at a dose of 125mg/m2). Possible manifestations include delirium, seizures, coma, 
and visual disturbances due to optic neuritis. Other rare toxicities include hemolytic 
anemia, respiratory distress, 
  
 
 
6.1.2 Adverse Event List(s) for Melphalan 
The most common side effects are myelosuppression, mucositis, nausea, and 
alopecia. Melphalan is a vesicant and can cause skin damage if there is skin 
infiltration. Other side effects include pulmonary fibrosis and liver damage. 
 
Rare side effects include hypersensitivity reaction and skin necrosis. 
6.1.3 Adverse Event List for Total Body Irradiation 
TBI can cause nausea, vomiting, diarrhea, skin rash, mucositis, neutropenia, 
fever. Late effects include liver damage, kidney damage, pneumonitis, cataracts, 
vertebral damage, sterility, and second cancers. 
 
6.1.4 Adverse Event List for G-CSF 
Toxicities to G-CSF commonly include:  mild to moderate bone pain, myalgia, 
vomiting, fatigue, headache, insomnia, Pain at the site of the injection, and fever.  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
19 
 
 
 There are rare reports of splenic rupture in healthy individuals receiving G-CSF to 
mobilize stem cells for transplantation. Other rare side effects include acute 
respiratory distress syndrome and alveolar hemorrhage. 
 
6.1.5 Adverse Event List for Tacrolimus 
The primary toxicities are reversible renal dysfunction (doubling of creatinine in 
82%), hypertension requiring the use of antihypertensive medications (21%), and 
hyperglycemia (12%). In addition, hypomagnesemia, hyperkalemia, hypokalemia, 
tremor, and neurologic toxicity may occur.  There is an increased risk of 
opportunistic infections and secondary malignancies. 
 
Rare side effects include seizure, posterior reversible encephalopathy. Many drugs, 
such as antifungal agents and calcium channel blockers, may alter tacrolimus levels.  
 
6.1.6 Adverse Event List for Sirolimus 
The 
primary 
toxicities 
of 
sirolimus 
are 
hypertriglyceridemia, 
hypercholesterolemia, mild thrombocytopenia, anemia, leukopenia, hypokalemia, 
elevated LDH, arthralgia, epistaxis, edema, and infections.  Clinically significant 
elevations in hepatic transaminases without sequelae have been noted and there is 
an increased incidence of veno-occlusive disease of the liver in the myeloablative 
setting, but not with this reduced-intensity conditioning regimen.  A syndrome of 
thrombotic microangiopathy, comprised of microangiopathic hemolytic anemia, 
thrombocytopenia and renal dysfunction has been described in association with 
sirolimus and tacrolimus use.  Sirolimus may increase the risk of opportunistic 
infections and post-transplant lymphoproliferative disorders. 
 
Rare side effects include hypersensitivity reactions, proteinuria, and dermatitis. 
6.2 
Toxicity Management: 
 
Significant toxicity is expected in this cord blood transplant protocol.  Patients 
will receive supportive care and medical management of toxicity. 
 
6.3 Dose Modifications/Delays: 
There will be no dose modifications or delays in the conditioning regimen treatment. 
Sirolimus and tacrolimus will be dosed based on blood level, as indication in Section 
5.2.  Sirolimus and tacrolimus may be modified based on clinical toxicity, and 
alternative immunosuppression used, at the discretion of the treating investigator. 
7. DRUG FORMULATION AND ADMINISTRATION  
 
7.1 
Fludarabine 
 
7.1.1 Description 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
20 
 
FLUDARA FOR INJECTION contains fludarabine phosphate, a fluorinated 
nucleotide analog of the antiviral agent vidarabine,  9-_-D-
arabinofuranosyladenine (ara-A) that is relatively resistant to deamination by 
adenosine deaminase. Each vial of sterile lyophilized solid cake contains 50 mg of 
the active ingredient fludarabine phosphate, 50 mg of mannitol, and sodium 
hydroxide to adjust pH to 7.7. The pH range for the final product is 7.2-8.2. 
Reconstitution with 2 mL of Sterile Water for Injection USP results in a solution 
containing 25 mg/mL of fludarabine phosphate intended for intravenous 
administration.  The chemical name for fludarabine phosphate is 9H-Purin-6-
amine, 2-fluoro-9-(5-0-phosphono-_-D-arabinofuranosyl) 
(2-fluoro-ara-AMP).  The molecular formula of fludarabine phosphate is 
C10H13FN5O7P (MW 365.2)  
  
7.1.2 Form 
 
FLUDARA FOR INJECTION is supplied as a white, lyophilized solid cake. Each 
vial contains 50 mg of fludarabine phosphate, 50 mg of mannitol, and sodium 
hydroxide to adjust pH to 7.7. The pH range for the final product is 7.2-8.2. Store 
under refrigeration, between 2°-8°C (36°-46°F). 
 
FLUDARA FOR INJECTION is supplied in a clear glass single dose vial (6 mL 
capacity) and packaged in a single dose vial carton in a shelf pack of five. 
NDC 50419-511-06 
 
 
7.1.3 Storage and Stability 
  
 Store intact vials under refrigeration at 2°C to 8°C (36°F to 46°F). Reconstituted 
vials are stable for 16 days at room temperature of 15°C to 30°C (59°F to 86°F) 
or refrigerated, although the manufacturer recommends use within 8 hours due to 
no preservatives.  Solutions diluted in saline or dextrose are stable for 48 hours at 
room temperature or under refrigeration.  
  
7.1.4 Compatibility 
Stable in D5W, NS, sterile water for injection. 
7.1.5 Handling 
 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and 
safe disposal of the chemotherapeutic agent in a self-contained and protective 
environment. 
 
7.1.6 Availability 
 
Fludarabine is commercially available. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
21 
 
Manufactured by: Ben Venue Laboratories, Bedford, OH 44146 
Manufactured for: Teva Pharmaceuticals 
 
7.1.7 Preparation 
Reconstitute vials with SWI, NS, or D5W to a concentration of 10-25 mg/mL. 
Standard I.V. dilution: 100-125 mL D5W or NS. 
  
7.1.8 Administration 
 
Fludarabine is administered intravenously as a bolus over 30 minutes or as per 
institutional guidelines 
 
7.2 
Melphalan 
7.2.1 Description 
Melphalan, also known as L-phenylalanine mustard, phenylalanine mustard, L-
PAM, or L-sarcolysin, is a phenylalanine derivative of nitrogen mustard. 
Melphalan is a bifunctional alkylating agent that is active against selected human 
neoplastic diseases. It is known chemically as 4-[bis(2-chloroethyl)amino]-L-
phenylalanine. The molecular formula is C13H18Cl2N2O2 and the molecular 
weight is 305.20.  Melphalan is the active L-isomer of the compound and was first 
synthesized in 1953 by Bergel and Stock; the D-isomer, known as medphalan, is 
less active against certain animal tumors, and the dose needed to produce effects 
on chromosomes is larger than that required with the L-isomer. The racemic (DL-
) form is known as merphalan or sarcolysin. Melphalan is practically insoluble in 
water and has a pKa1 of 2.5. 
7.2.2 Form 
ALKERAN for Injection is supplied in a carton containing one single-use clear 
glass vial of freeze-dried melphalan hydrochloride equivalent to 50 mg melphalan 
and one 10-mL clear glass vial of sterile diluent (NDC 0173-0130-93). 
7.2.3 Storage and Stability 
Store intact vials at controlled room temperature 15° to 30°C (59° to 86°F) and 
protect from light. . Complete administration within 60 minutes of reconstitution.  
7.2.4 Compatibility 
Stable in NS 
7.2.5 Handling 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
22 
 
safe disposal of the chemotherapeutic agent in a self-contained and protective 
environment. 
7.2.6 Availability 
Melphalan is commercially available 
7.2.7 Preparation 
The time between reconstitution/dilution and administration of parenteral 
melphalan must be kept to a minimum (manufacturer recommends <60 minutes) 
because reconstituted and diluted solutions are unstable. Dissolve powder initially 
with 10 mL of supplied diluent to a concentration of 5 mg/mL; shake immediately 
and vigorously to dissolve. Immediately dilute dose in NS to a concentration of 
≤0.45 mg/mL (manufacturer recommended concentration). Do not refrigerate 
solution; precipitation occurs. The manufacturer recommends administration 
within 60 minutes of reconstitution.  
7.2.8 Administration 
Melphalan is administered intravenously as a bolus over 15 minutes or as per 
institutional guidelines 
 
 
7.3 
Tacrolimus 
 
7.3.1 Description 
Tacrolimus is available for oral administration as capsules containing the 
equivalent of 0.5 mg, 1 mg or 5 mg of anhydrous tacrolimus. Inactive ingredients 
include lactose, hydroxypropyl methylcellulose, croscarmellose sodium, and 
magnesium stearate. The 0.5 mg capsule shell contains gelatin, titanium dioxide 
and ferric oxide, the 1 mg capsule shell contains gelatin and titanium dioxide, and 
the 5 mg capsule shell contains gelatin, titanium dioxide and ferric oxide.   
 
Tacrolimus is also available as a sterile solution containing the equivalent of 5 mg 
anhydrous tacrolimus in 1 mL for administration by intravenous infusion only. 
Each mL contains polyoxyl 60 hydrogenated castor oil (HCO-60), 200 mg, and 
dehydrated alcohol, USP, 80.0% v/v.  Prograf injection must be diluted with 0.9% 
Sodium Chloride Injection or 5% Dextrose Injection before use. 
7.3.2 Form 
Tacrolimus is available for oral administration as capsules in strengths of 0.5 mg, 
1 mg or 5 mg.  Injection is available as solution containing 5mg in 1 ml.   
7.3.3 Storage and Stability 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
23 
 
Injection: Prior to dilution, store at 5°C to 25°C (41°F to 77°F). Following 
dilution, stable for 24 hours in D5W or NS in glass or polyethylene containers. 
Capsules: Store at room temperature of 25°C (77°F); excursions permitted to 
15°C to 30°C (59°F to 86°F)..  
7.3.4 Compatibility 
Stable in NS or D5W 
7.3.5 Handling 
Use appropriate precautions for handling and disposal 
7.3.6 Preparation 
Dilute with 5% dextrose injection or 0.9% sodium chloride injection to a final 
concentration between 0.004 mg/mL and 0.02 mg/mL 
7.3.7 Administration 
Tacrolimus will be administered intravenously as a continuous infusion or orally at 
the discretion of the investigator 
 
7.4 
Sirolimus 
 
7.4.1 Description 
Sirolimus is indicated for the prevention acute graft-versus-host disease (GVHD) 
in allogeneic stem cell transplantation; treatment of refractory acute or chronic 
GVHD, prophylaxis for organ rejection in patients receiving renal and heart 
transplants. 
 
Inactive ingredients in RAPAMUNE Oral Solution are: Phosal 50 PG® 
(phosphatidylcholine, propylene glycol, mono- and di-glycerides, ethanol, soy 
fatty acids, and ascorbyl palmitate) and polysorbate 80. RAPAMUNE Oral 
Solution contains 1.5%-2.5% ethanol. 
 
The inactive ingredients in RAPAMUNE Tablets include: sucrose, lactose, 
polyethylene glycol 8000, calcium sulfate, microcrystalline cellulose, 
pharmaceutical glaze, talc, titanium dioxide, magnesium stearate, povidone, 
poloxamer 188, polyethylene glycol 20,000, glyceryl monooleate, carnauba wax, 
dl-alpha tocopherol, and other ingredients. The 0.5 mg and 2 mg dosage strengths 
also contain yellow iron (ferric) oxide and brown iron (ferric) oxide. 
7.4.2 Form 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
24 
 
Sirolimus is available for oral administration as an oral solution and tablets.  Oral 
solution contains 60mg per 60ml in an amber glass bottle.  Tablets contain 0.5 
mg, 1 mg, or 2 mg.  Injection is available as solution containing 5mg in 1 ml.   
7.4.3 Storage and Stability 
Solution bottles should be stored protected from light and refrigerated at 2°C to 
8°C (36°F to 46°F). Once the bottle is opened, the contents should be used within 
one month. If necessary, the patient may store the bottles at room temperatures up 
to 25°C (77°F) for a short period of time (e.g., not more than 15 days for the 
bottles). 
An amber syringe and cap are provided for dosing, and the product may be kept in 
the syringe for a maximum of 24 hours at room temperatures up to 25°C (77°F) or 
refrigerated at 2°C to 8°C (36°F to 46°F). The syringe should be discarded after 
one use. After dilution, the preparation should be used immediately. 
Solution provided in bottles may develop a slight haze when refrigerated. If 
such a haze occurs, allow the product to stand at room temperature and shake 
gently until the haze disappears. The presence of this haze does not affect the 
quality of the product. 
 
Tablets should be stored at 20° to 25°C [USP Controlled Room Temperature] 
(68° to 77°F). Use cartons to protect blister cards and strips from light. Dispense 
in a tight, light resistant container as defined in the USP. 
 
 
7.4.4 Compatibility 
Do not mix sirolimus solution with anything other than water or orange juice. Do 
not crush, split, or chew tablets. May be taken with or without food, but should be 
taken consistently with regard to food (always on an empty stomach or always 
with food).  
 
7.5 
Recombinant Human Granulocyte Colony Stimulating Factor 
 
7.5.1 Description 
Neupogen or TBO-Filgrastim (Granix) is a human granulocyte colony-stimulating 
factor (G-CSF)‚ produced by recombinant DNA technology.  Either may be used 
in this study.  
 
Colony-stimulating factors are glycoproteins which act on hematopoietic cells by 
binding to specific cell surface receptors and stimulating proliferation‚ 
differentiation commitment‚ and some end-cell functional activation. Endogenous 
G-CSF is a lineage specific colony-stimulating factor which is produced by 
monocytes‚ fibroblasts, and endothelial cells. G-CSF regulates the production of 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
25 
 
neutrophils within the bone marrow and affects neutrophil progenitor 
proliferation‚ differentiation, and selected end-cell functional activation 
(including enhanced phagocytic ability‚ priming of the cellular metabolism 
associated with respiratory burst‚ antibody dependent killing, and the increased 
expression of some functions associated with cell surface antigens. G-CSF is not 
species specific and has been shown to have minimal direct in vivo or in vitro 
effects on the production of hematopoietic cell types other than the neutrophil 
lineage. 
7.5.2 Form 
TBO-Filgrastim (Granix): A sterile‚ clear‚ colorless‚ preservative-free liquid for 
parenteral administration available as single use prefilled syringes only. The 
single use prefilled syringes contain either 300 mcg or 480 mcg TBO-Filgrastim 
(Granix) at a fill volume of 0.5 mL or 0.8 mL, respectively. 
 
 
                       
                      Filgrastim (Neupogen): A sterile‚ clear‚ colorless‚ preservative-free liquid for        
parenteral administration available as single use vials and prefilled syringes. The single use vials 
contain either 300 mcg or 480 mcg Filgrastim at a fill volume of 1.0 mL or 1.6 mL,  respectively.     
The single use prefilled syringes contain either 300 mcg or 480 mcg Filgrastim at a fill volume   
of 0.5 mL or 0.8 mL, respectively. 
7.5.3 Storage and Stability 
                        Vials and syringes should be stored at 2° to 8°C (36° to 46°F). Avoid shaking. 
May be administered by I.V. bolus, or a short infusion over 15-30 minutes in 
                        D5W, or by continuous I.V. infusion. Filgrastim diluted with D5W for I.V. 
                        infusion (5-15 mcg/mL) is stable for 7 days at 2°C to 8°C (36°F to 46°F), 
                         however, should be used within 24 hours due to the possibility for bacterial  
contamination.  
7.5.4 Compatibility 
 Stable in D5W 
7.5.5      Handling 
Use appropriate precautions for handling and disposal 
7.5.6     Administration 
G-CSF will be administered subcutaneously or intravenously per institutional 
guidelines 
 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
26 
 
8. CORRELATIVE/SPECIAL STUDIES  
8.1 
Functional Reconstitution of T Cell Immunity 
 
It is possible that elimination of ATG from the conditioning regiment may selectively 
affect certain T cell subsets and alter T cell polarization. For this reason, we will 
evaluate Th1 (producing IFN-, Th2 (IL-4) and Th17 (producing IL-17) cells by 
intracellular staining and flow cytometry by assessing expression of each of these 
cytokines on CD4+ cells. To assess and confirm polarization, we will also examine the 
expression of lineage-specific transcription factors T-bet for Th1 cells, GATA3 for Th2 
cells, Foxp3 and Runx1 for Treg, RORC and Runx1 for Th17 cells. We will also 
examine the effect of ATG elimination from the conditioning regiment on functional 
immune reconstitution, by assessing GvHD, GvL and pathogen-specific response in 
UCBT recipients.  
 We will assess the following endpoints:  
1. Thymic regeneration by assessing signal joint TCR excision circle (TREC) DNA.  
2. Quantitative reconstitution of pathogen-specific effectors (specific for CMV, EBV 
and aspergillus) by using pathogen/MHC-specific pentamers.  
3. Qualitative immune reconstitution by assessing function of pathogen-specific 
effectors by ELISpot.  
4. Quantitative reconstitution of leukemia-specific effectors by using WT1/MHC-
specific pentamers.  
5. Induction of allo-specific anergy vs. GvHD.  
 
We will use patients’ T cells -that are of donor origin- to stimulate in vitro with DC 
that we have generated from each patient prior to transplantation (specific 
allostimulator DC) or with third party allo-stimulator DC and frequency of HTLp and 
or CTLp will be examined by methods previously established in our laboratory to 
determine whether such frequencies are above or below the level predictive for 
clinical GvHD. All the data will be compared to the relevant results generated from 
patients on a previous clinical trial of UCBT treated with the same conditioning 
regiment, which in addition contained ATG.  These studies will be done in the 
laboratory of Dr. Vicki Boussiotis. 
 
15 ml of blood in yellow top tubes will be collected at the following time points as 
outlined In Table 2: 
1. Pre Transplant 
2. Days  30 +/- 3 days, 60 +/- 3 days, 100 +/- 7 days post transplant 
3. Months 6, 9, 12, and 24 post transplant, all +/- 14 days  
 
The tubes will be transported by courier from MGH and hand picked up at DFCI and 
BIDMC. (Please see Appendix 2) 
 
A secondary endpoint in this protocol is to monitor immune reconstitution after stem 
cell transplantation and to compare results with similar patients treated in previous 
protocols in which ATG was used in the conditioning regimen. Although ATG is 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
27 
 
administered before infusion of umbilical cord blood stem cells, clearance of ATG from 
the recipient is delayed and is known to affect donor cells. Preparative regimens that do 
not include ATG may therefore lead to enhanced reconstitution of donor stem cells. 
This will therefore be monitored in the current study. These studies will be performed 
under the direction of Dr. Jerome Ritz. (Please see Appendix 3) 
 
Immune reconstitution after stem cell transplantation will be monitored by analysis of 
peripheral blood samples obtained at time points outlined in Table 2. At each time 
point, numbers of circulating T, B and NK cells will be quantified using a panel of 
directly conjugated monoclonal antibodies (CD3, CD4, CD8, CD19/CD20 and CD56). 
Samples will be analyzed by flow cytometry and results compared to previous studies 
using similar methods in patients who received ATG containing transplant conditioning 
regimens. Since CD 4 has correlated with transplant outcome in our earlier studies, CD 
4 count will be a main parameter to follow. In addition to phenotypic studies outlined 
above, samples of peripheral blood mononuclear cells and plasma will be cryopreserved 
at each time point. These samples can be used for more detailed phenotypic and 
functional studies as well as measurements of plasma cytokines if indicated. 
 
 
 
8.2 Optional Thrombopoietin Levels 
Patients may elect to participate in the thrombopoietin (TPO) level portion of the study.  
 
To understand the changes in TPO levels after double cord blood transplant, we will 
measure TPO levels after transplantion. TPO levels will be determined with the assistance of Dr. 
David Kuter and Dr. Robert Makar. 
 
TPO levels will be measured: 
1. Pre conditioning 
2. Day 0 
3. Day 14, Day 30 and Day 60+/-3 days  
4. Day 100 +/- 7 days 
5. Month 6, Month 9+/-14 days  
6. Month 12, 24+/-14 days  
 
Another 4 TPO samples will be obtained in association with platelet transfusions occurring after 
transplantation.  With each eligible platelet transfusion, BOTH a CBC and a sample for TPO 
assessment will be obtained:  
 
1. Immediately prior to the platelet transfusion (TPO level only) 
2. 30-60 minutes after the completion of the transfusion 
3. 6 hours after the completion of the transfusion (+/- 60 min) 
4. 24 hours after the completion of the transfusion (+/- 60 min) 
 
TPO samples will obtained in -at least 1 and up to 3 eligible platelet transfusions in each patient. 
 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
28 
 
Due to the requirement for sample processing at the time of collection, only platelet transfusions 
administered on Mondays, Tuesdays, Wednesdays or Thursdays will be considered.  
Transfusions should be administered prior to 10 AM if possible to allow for collection of the 
TPO level specimen during normal business hours. 
 
In the event that 2 transfusions are administered within the same 24 hour period, only the first 
transfusion is eligible for TPO measurements.   
 
Since these assessments are entirely voluntary and optional, there will be no protocol deviations 
or violations for missed samples. 
 
TPO specimens will be collected in large red top tubes and must be refrigerated at 4C within 8 
hours of collection. 
 
Dr. Kuter has an MTA with Quest Nichols Institute in which they have agreed to provide TPO 
results on clinical specimens. Dr. Makar will oversee this process. 
 
. 
  
Specimens are processed as follows (Please see Appendix 1): 
1. Clotted blood from a large red top tube is spun for 15 minutes at 1500 RCF 
to separate the serum from the clot. The red top tubes may be stored at 4C 
for up to 24 hours and then batched for processing. 
2. The serum is aliquoted into tubes labeled with the date and a numerical 
identifier.  For each red top tube, prepare a minimum of 2 samples each 
containing a minimum of 1 ml of serum. 
3. If the clot is insufficiently packed down to allow easy collection of both 
serum samples, spin the red top tube again at 1500 RCF for 15 minutes. 
4. The date and numerical identifier of each serum sample prepared are 
entered into a database.  
5. Serum samples are then frozen at -20C or colder pending shipment to 
Quest Nichols Institute.  Use only a frost-free freezer for storing these 
specimens.  
6. TPO samples that have been collected and stored may be shipped for 
testing approximately once every month. 
7. A Quest Cambridge courier picks up specimens from the Core Lab at 
MGH and from the DFCI and BIDMC. 
 
 
 8.3 Pharmacokinetic Studies: 
N/A 
 
8.4 Pharmacodynamic Studies: 
N/A 
 
9.  STUDY CALENDAR 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
29 
 
9.1 
Pre Transplant Evaluations 
 
 All required tests must be performed within 42 days of admission for transplantation. 
 
 
Clinical Evaluations 
1. A complete history with full details of the patient’s previous treatment and response 
will be obtained. The complete history may be performed more than 30 days prior to 
registration. 
2. A complete physical examination.  
3. Chest and other radiographs as clinically indicated.  Patients in whom CT or PET-
CT scan has been the predominant staging modality prior to transplantation must 
have these repeated. 
4. Marrow aspiration and biopsy for staging, cytogenetics, and flow cytometry in 
patients in whom this test has previously been informative. If available to have 
procedure on site,  patients undergoing bone marrow aspirate and biopsy may have a 
bone marrow aspirate sample sent to the Pasquarello lab for future Immunologic 
Reconstitution studies. 
5. EKG 
6. Dental consult and evaluation of status of teeth and gums (may be done within 6 
months of study entry) 
7. Pulmonary function tests (excluding patients with a DLCO of < 50%). 
8. Echocardiogram or MUGA to assess ejection fraction. 
9. . 
Laboratory Evaluations 
1. HLA typing of patient and available family members.  The patient will be typed at 
HLA A, B, C and DRβ1 by high resolution molecular typing.  HLA typing may 
be performed more than 42 days prior to admission. 
2. HLA antibody testing. HLA antibody testing may be performed more than 42 
days prior to admission. 
3. ABO and Rh typing 
4. CBC with differential 
5. Comprehensive chemistry profile, including measures of hepatic and renal function.  
6. Hepatitis B surface antigen, HCV, HSV, CMV, EBV, HHV-6, HIV and HTLV-I 
antibody determinations per institutional guidelines. 
7. Genotyping samples sent to the tissue typing laboratory for future chimerism 
analysis.  A sample from the cord units prior to transplantation will be processed 
similarly. 
8. Blood sample sent for Immunologic Reconstitution assays (Dr. Ritz). 
9. Blood sample sent for T cell subsets and polarization (Dr. Boussiotis) 
10. Blood sample sent for thrombopoietin level if participating. 
11.  HHV6 by DNA will be done prior to transplant. 
12. If possible, if a cord unit segment is available, the cord units will be tested for HHV-
6 by PCR. 
 
9.2 
Post Transplant Evaluation 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
30 
 
Standard post-transplantation testing, including complete blood counts, serum 
chemistries, measurements of immunosuppressant levels will be performed per 
institutional guidelines and consistent with clinical good practice. 
 
 
 
Chimerism studies will be performed by short tandem repeats and/or flow cytometry 
according to local laboratory practices.  When feasible, fractional chimerism (total, 
myeloid, lymphoid) will be performed from peripheral blood sample 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
31 
 
 
Table 2: Required Data 
 
Pre-transplant 
 
 Weekly to 
  Day 100 
Day +14, 
+30 and 
+60
1 
Day +30, 
and  +60 
Day 
+1002 
Monthly from 
Day +100 to 1 
year3 
Month 
6 and 
93 
Months 12 
and 243 
CBC with diff9 
 
X 
X 
 
X 
 
 
X 
 
 
X 
 
X 
Comprehensive chemistry with renal 
and liver functions 
X 
 
 
X
 
 
X
 
X 
 
X 
X 
HLA typing 
X 
 
 
 
 
 
 
 
Chimerism 
X 
 
 
X
 
X 
 
X 
X 
ABO/Rh 
X 
 
 
 
X 
 
 
 
Infectious disease markers including 
HHV-6, EBV and HSV 
X 
 
 
 
 
 
 
 
T-cell subsets and polarization4 
X 
 
 
X 
X 
 
X 
X 
Optional thrombopoeitin levels5 
 
X 
 
 
X 
 
 
X 
 
 
X 
 
X 
Immune reconstitution/blood banking6 
 
X 
 
X 
 
 
X
 
 
X
 
X
Bone marrow biopsy and aspirate7 
 
X 
 
 
 
 
X 
 
 
 
 
X 
Radiologic tumor staging8 
 
X 
 
 
 
 
X 
 
 
X 
 
X 
History and physical, 
 
X 
 
 
 
X 
 
X 
X 
EKG  
 
X 
 
 
 
 
 
 
 
MUGA or ECHO 
 
X 
 
 
 
 
 
 
 
PFTS 
X 
X 
 
 
 
 
 
 
 
Dental exam 
X 
 
 
 
 
 
 
 
Chest x-ray 
X 
 
 
 
 
 
 
 
Tacrolimus and sirolimus levels 
 
 
X 
 
 
 
X 
 
 
X 
 
X 
CMV,EBV and HHv-6 assays10 
X 
 
X 
 
 
X 
 
X 
X 
X 
GVHD and toxicity assessment11 
 
           
X 
 
x 
X 
 
X 
X 
 Cord Blood Unit for HHV-6-12 
 
 
 
 
 
 
 
 
1 +/- 3 days 
2+/- 7 days 
3+/- 14 days 
415 ml of blood is required at each time point, please see appendix 2 
5Please see appendix 1 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
32 
 
6Peripheral blood will be banked and analyzed for reconstitution of immune cells after transplantation. See Appendix 
3 
7A complete marrow assessment will include an aspirate for morphology, flow cytometry, cytogenetics (with FISH where indicated), 
chimerism assays and tissue banking.  A biopsy should be performed and the marrow aspirate sample for tissue banking is sent to the 
Pasquarello lab 
 
8CT or PET-CT should be employed, consistent with the most informative test prior to transplantation.  Not required for patients with 
marrow-only disease (i.e. AML, MDS, CML) 
 
9Differentials are at the discretion of the treating MD 
10 Human herpes virus 6 (HHV-6) by PCR HHV-6 by PCR should be done prior to transplant. 
 
11  Documentation of toxicity assessments are only required weekly for the first month, then on Day 60+, 100+ +/- 7 days, Month 6, 9, 
12, 24+/- 14 days 
 
12 If possible, if a cord unit segment is available, the cord units will be tested for HHV-6 by PCR. 
 
 
 
10. MEASUREMENT OF EFFECT  
 
10.1 Engraftment 
10.1.1  Time to Neutrophil Engraftment  
The time to neutrophil engraftment is defined as the first of 3 consecutive days of 
absolute neutrophil count > 500.  
Primary graft failure is defined as the failure to achieve an ANC >500/ µL by day 42, in 
the absence of relapse.  Secondary graft failure is defined as initial neutrophil 
engraftment followed by subsequent decline in neutrophil counts >500/ µL. 
10.1.2 Time to Platelet Engraftment 
Platelet engraftment is defined as a platelet count ≥ 20,000/µL for three consecutive 
measurements over three or more days.  The first of the three days will be designated the 
day of platelet engraftment.  Subjects must not have had platelet transfusions during the 
preceding 3 days or in the following 7 days after the day of engraftment, unless the 
platelet transfusion is being given specifically to achieve a platelet threshold to allow an 
elective invasive procedure, such as a central catheter removal.  The time to a platelet 
count ≥ 100,000/µL will be collected as well.   
10.2 Incidence of GVHD 
10.2.1 Incidence of Acute GVHD 
Acute GVHD will be scored according to the Consensus Criteria (Tables 3, 4).  The 
incidence of Gr. II-IV and grade III-IV acute GVHD will be noted 
 
Table 3: Organ Staging of GVHD 
Stage Skin 
Liver 
Gut 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
33 
 
0 
No rash due to GVHD 
Bilirubin 
< 2 mg/dL 
< 500 mL diarrhea per day 
1 
Maculopapular rash < 25% of 
body surfacea 
Bilirubin 
2-3 mg/dLb 
500 to 999 mL diarrhea per dayc or persistent 
nausea with histologic evidence of GVHD in 
stomach/ duodenum 
2 
Maculopapular rash 25-50% 
of body surfacea 
Bilirubin 
3.1-6 mg/dLb 
1,000 to 1,499 mL diarrhea per day 
 
3 
Maculopapular rash > 50% of 
body surfacea 
Bilirubin 
6.1-15 mg/dLb 
1,500 or more mL diarrhea per dayc 
4 
Generalized 
erythroderma 
with bullous formation 
Bilirubin 
> 15 mg/dLb 
Severe abdominal pain with or without ileus 
a Use “Rule of Nines” to determine extent of rash. 
b Range given as total bilirubin. Downgrade one stage if an additional cause of elevated 
bilirubin has been documented. 
c Downgrade one stage if an additional cause of diarrhea has been documented. 
Table 4: Overall Clinical Grading of Severity of Acute GVHD 
Grade 
 
Degree of Organ Involvement 
0 
 
No Stage 1-4 of any organ 
I 
 
Stage 1-2 rash and no liver or gut involvement  
II 
 
Stage 3 rash, or Stage 1 liver involvement, or Stage 1 gut involvement  
III 
 
None to Stage 3 skin rash with Stage 2-3 liver involvement, or Stage 2-4 
gut involvement  
IV 
 
Stage 4 skin rash, or Stage 4 liver involvement 
 
10.2.2 Chronic GVHD 
Chronic GVHD is scored according to the NIH consensus criteria.45  The first day of 
chronic GVHD onset will be used to calculate cumulative incidence curves. 
10.3 Other Response Parameters 
10.3.1 Treatment Related Mortality 
All deaths in the absence of relapse of the primary malignancy will be considered 
treatment related mortality.  The cumulative incidence of treatment related mortality at 30 
and 100 days will be measured. 
10.3.2 Immunologic Reconstitution 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
34 
 
Blood and marrow samples will be obtained and stored in the Pasquarello tissue bank for 
future immunologic assays, under the supervision of Dr. Jerry Ritz. Immune 
reconstitution after stem cell transplantation will be monitored by analysis of peripheral 
blood samples obtained at time points outlined in Table 2. At each time point, numbers of 
circulating T, B and NK cells will be quantified using a panel of directly conjugated 
monoclonal antibodies (CD3, CD4, CD8, CD19/CD20 and CD56). Samples will be 
analyzed by flow cytometry and results compared to previous studies using similar 
methods in patients who received ATG containing transplant conditioning regimens.    
Since CD4 count has been shown to have prognostic significance after reduced intensity 
cord blood transplant, CD4 count will be the main immune reconstitution endpoint for 
this analysis. 20  
 
 
 
10.3.3 Relapse-Free and Overall Survival 
Both overall survival and relapse-free survival will be assessed one and two years from 
the date of stem cell infusion.  Patients alive at the time of last observation will be 
censored.  Testing for recurrent malignancy in the blood, marrow or other sites will be 
used to assess relapse after transplantation. Relapse is defined by either morphological or 
cytogenetic evidence of the original malignancy consistent with pre-transplant features.  
Minimal residual disease is defined by the sole evidence of malignant cells by flow 
cytometry, or fluorescent in situ hybridization (FISH), or Southern blot, or Western blot, 
or polymerase chain reaction (PCR), or other techniques, in absence of morphological or 
cytogenetic evidence of disease in blood or marrow.  Since the frequency of testing for 
minimal residual disease is highly variable, and the sensitivity is highly variable among 
laboratory techniques, evidence of minimal residual disease will not be sufficient to meet 
the definition of relapse in the context of this study. 
10.3.4 FractionalChimerism of Cord Blood Units 
Chimerism of transplanted cord blood units will be measured according to the SOPs of 
the treating institution.  At all assessments, where technically feasible, unfractionated, 
myeloid and lymphoid chimerism will be measured from peripheral blood specimens.  
Unfractionated chimerism will be measured from bone marrow specimen. 
A cord blood unit will be considered to be dominant if it contributes ≥ 50% of 
hematopoiesis as measured by chimerism at that time point.   
10.3.5 Second Malignancies 
Patients will be followed for the development of second cancers, including 
lymphoproliferative disorder and myelodysplasia/myeloproliferative disorder. Second 
malignancies will be determined to be of either donor or recipient origin by cytogenetics or 
chimerism assays where possible. 
10.4 Evaluation of Response 
All participants included in the study must be assessed for response to treatment, even if 
there are major protocol treatment deviations or if they are ineligible. Each participant 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
35 
 
should be assigned one of the following categories: 1) complete response, 2) partial 
response, 3) stable disease, 4) progressive disease, 5) early death from malignant disease, 
6) early death from toxicity, 7) early death because of other cause, or 9) unknown (not 
assessable, insufficient data). By arbitrary convention, category 9 usually designates the 
"unknown" status of any type of data in a clinical database. World Health Organization 
(WHO) criteria will be used to assess response. 
 
11. ADVERSE EVENT REPORTING REQUIREMENTS 
11.1 Definitions 
11.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or 
experience that develops or worsens in severity after starting the first dose of 
study treatment or any procedure specified in the protocol, even if the event is not 
considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms or require treatment or further 
diagnostic tests.  
11.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
 Results in death 
 Is life-threatening. Life-threatening means that the person was at 
immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction which hypothetically might have caused death had it 
occurred in a more sever form. 
 Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior to 
study entry are not considered SAEs if the illness or disease existed before 
the person was enrolled in the trial, provided that it did not deteriorate in 
an unexpected manner during the trial (e.g., surgery performed earlier than 
planned). 
 Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
 Is a congenital anomaly or birth defect; or 
 Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or surgical 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
36 
 
intervention to prevent one of the outcomes listed above. Examples of 
such medical events include allergic bronchospasm requiring intensive 
treatment in an emergency room or at home; blood dyscrasias or 
convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
 routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition, or for elective procedures 
 elective or pre-planned treatment for a pre-existing condition that did not 
worsen 
 emergency outpatient treatment for an event not fulfilling the serious 
criteria outlined above and not resulting in inpatient admission 
 respite care 
 
11.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
11.1.3.1 Expected adverse event 
 
Expected adverse events are those that have been previously identified as 
resulting from administration of the agent. For the purposes of this study, 
an adverse event is considered expected when it appears in the current 
adverse event list, the Investigator’s Brochure, the package insert or is 
included in the informed consent document as a potential risk.   
 
Refer to Section 6.1 for a listing of expected adverse events associated 
with the study agent(s). 
11.1.3.2 Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected 
when it varies in nature, intensity or frequency from information 
provided in the current adverse event list, the Investigator’s Brochure, 
the package insert or when it is not included in the informed consent 
document as a potential risk.   
11.1.4 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
 Definite – The AE is clearly related to the study treatment. 
 Probable – The AE is likely related to the study treatment. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
37 
 
 Possible – The AE may be related to the study treatment.  
 Unlikely - The AE is doubtfully related to the study treatment. 
 Unrelated - The AE is clearly NOT related to the study treatment. 
11.2 Procedures for AE and SAE Recording and Reporting 
 
Participating investigators will assess the occurrence of AEs and SAEs at all participant 
evaluation time points during the study.  
 
All AEs and SAEs whether reported by the participant, discovered during questioning, 
directly observed, or detected by physical examination, laboratory test or other means, 
will be recorded in the participant’s medical record and on the appropriate study-
specific case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0. 
A copy of the CTCAE version 4.0 can be downloaded from the CTEP website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm.  
11.3 Reporting Requirements 
 
For multi-site trials where a DF/HCC investigator is serving as the principal 
investigator, each participating investigator is required to abide by the reporting 
requirements set by the DF/HCC. The study must be conducted in compliance with 
FDA regulations, local safety reporting requirements, and reporting requirements of the 
principal investigator.  
 
Each investigative site will be responsible to report SAEs that occur at that institution 
to their respective IRB. It is the responsibility of each participating investigator to 
report serious adverse events to the study sponsor and/or others as described below.  
11.4 Reporting to the Study Sponsor 
 
The Study Team is also responsible for providing Amgen a semi-annual report of any 
reported SAEs and AEs related to these events of interest: 
  
 Thrombocytosis 
 Renal Impairment  
 Off-label use 
 Medication Error 
 Leukocytosis and Anemia 
 Immunogenicity 
 Hematopoietic Malignancy/MDS 
 Haemorrhages 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
38 
 
 Bone Marrow Reticulin/Bone Marrow Fibrosis 
  
REPORTING 
FREQUENCY 
SUSARs 
Within one business day of IRB submission 
SADRs 
Within One month of the event 
SAEs 
Semi-Annual Report of individual events 
SAE/AE 
Events of 
Interest 
Semi-Annual Report 
Pregnancy 
and/or 
Lactation 
Exposure 
Within  15 days 
  
 
11.4.1 Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, 
during treatment, or within 30 days of the last dose of treatment must be reported 
to the DF/HCC Overall Principal Investigator on the local institutional SAE form. 
This includes events meeting the criteria outlined in Section 11.1.2, as well as the 
following: 
 
 Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are 
unexpected and possibly, probably or definitely related/associated with the 
intervention. Expected Grade 3 events will NOT be routinely reported. 
 
 All Grade 4 (life-threatening or disabling) Events – Expected and 
Unexpected events will be reported, with the exception of those events 
that are routinely expected after transplantation with this conditioning 
regimen. Examples of these events include: neutropenia with fever, 
thrombocytopenia with minor bleeding, mucositis with inability to eat, 
fatigue/malaise, etc. 
 
All Grade 5 (fatal) Events – When the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the last 
study intervention. Deaths related to relapse or progression of the original 
malignancy are NOT reported as adverse events. 
Note: If the participant is in long term follow up, report the death at the 
time of continuing review.  
 
Participating investigators must report each serious adverse event to the DF/HCC 
Overall Principal Investigator within 24 hours of learning of the occurrence. In 
the event that the participating investigator does not become aware of the serious 
adverse event immediately (e.g., participant sought treatment elsewhere), the 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
39 
 
participating investigator is to report the event within 24 hours after learning of it 
and document the time of his or her first awareness of the adverse event. Report 
serious adverse events by telephone, email or facsimile to: 
 
 
 
Zachariah DeFilipp, MD  
 
 
 
 
 
Email: zdefilipp@mgh.harvard.edu  
 
 
 
 
 
Within the following 24-48 hours, the participating investigator must provide 
follow-up information on the serious adverse event. Follow-up information should 
describe whether the event has resolved or continues, if and how the event was 
treated, and whether the participant will continue or discontinue study 
participation. 
11.4.2 Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms.   
11.5 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
11.6 Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject 
safety reports or sentinel events that require reporting according to institutional policy. 
 
11.7 Reporting to the FDA, NIH Office of Biotechnology Activity (OBA), Institutional 
Biosafety Committee (IBC) 
N/A 
 
      11.8 Monitoring of Adverse Events and Period of Observation:All adverse 
events, both serious and non-serious, and deaths that are encountered from initiation of 
study intervention, throughout the study, and within 30 days of the last study 
intervention should be followed to their resolution, or until the participating 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate case 
report form and recorded in the participant’s medical record to facilitate source data 
verification.  
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
40 
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately 
evaluate the SAE report (e.g., hospital discharge summary, consultant report, or 
autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study 
12. DATA AND SAFETY MONITORING 
 
12.1 Data Reporting 
12.1.1 Method  
The QACT will , manage, and monitor data for this study.  
12.1.2 Data Submission  
The schedule for completion and submission of case report forms (paper or 
electronic) to the QACT is as follows: 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of transplant 
Adverse Event Report Form 
Within 10 days of the event 
Response Assessment Form 
Within 10 days of the completion of  response 
evaluation 
Off Treatment/Off Study Form
Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined follow 
up visit date or call 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
41 
 
12.2 Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor 
toxicity and accrual data from this trial. The committee is composed of clinical 
specialists with experience in oncology and who have no direct relationship with the 
study. Information that raises any questions about participant safety will be addressed 
with the Principal Investigator and study team. 
 
The DSMC will meet quarterly and/or more often if required to review toxicity and 
accrual data.  Information to be provided to the committee may include:  up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or 
higher unexpected adverse events that have been reported; summary of all deaths 
occurring within 30 days for Phase I or II protocols; for gene transfer protocols, 
summary of all deaths while being treated and during active follow-up; any response 
information; audit results, and a summary provided by the study team. Other 
information (e.g. scans, laboratory values) will be provided upon request.  
 
12.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of 
potential audits or inspections, including source data verification, by representatives 
designated by the DF/HCC Overall Principal Investigator (or Protocol Chair) or 
DF/HCC. The purpose of these audits or inspections is to examine study-related 
activities and documents to determine whether these activities were conducted and 
data were recorded, analyzed, and accurately reported in accordance with the protocol, 
institutional policy, Good Clinical Practice (GCP), and any applicable regulatory 
requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  
 
13. REGULATORY CONSIDERATIONS 
13.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) and 
any other necessary documents must be submitted, reviewed and approved by a 
properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
42 
 
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
13.2 Informed Consent 
 
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 
dated by the participant or the participant’s legally authorized representative, and 
by the person obtaining the consent. The participant must be given a copy of the 
signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file.  
13.3 Ethics and Good Clinical Practice (GCP) 
This study is to be conducted according to the following considerations, which 
represent good and sound research practice: 
 
E6 Good Clinical Practice: Consolidated Guidance 
www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM129515.pdf  
 
US Code of Federal Regulations (CFR) governing clinical study conduct and 
ethical principles that have their origin in the Declaration of Helsinki 
o Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx 02/21cfr11 02.html 
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx 02/21cfr56 02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
 
State laws 
 
DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-research-unit-
cru/policies-and-procedures/  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
43 
 
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such case, 
the deviation must be reported to the IRB according to the local reporting policy.  
13.4 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 
research participant. This information enables the study to be fully documented and the 
study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
13.5 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  
 
13.6 Multi-Center Guidelines  
N/A 
 
13.7 Cooperative Research and Development Agreement   N/A 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
44 
 
 
14. STATISTICAL CONSIDERATIONS  
This is a Phase II study designed to determine the significant viral infection rate at one 
year with the use of fludarabine, melphalan, and low dose radiation (LD TBI) as 
conditioning regimen for double umbilical cord blood transplantation (DUCBT). Clinically 
significant viral infection is defined as a viral infection that requires medical 
intervention..We will compare the incidence of viral infection requiring intervention to our 
historical control population of DUCBT with fludarabine (Flu), melphalan (Mel), and 
antithymocyte globulin (ATG). Viral infection requiring intervention is defined as follows: 
1. CMV reactivation or infection requiring treatment such as ganciclovir, 
valganciclovir, foscarnet, or lymphocyte preparations (for example, third party 
Cytotoxic T lymphocytes) 
2. EBV reactivation requiring rituximab, chemotherapy, or lymphocyte preparations. 
3. HHV-6 reactivation requiring Foscarnet or lymphocyte preparations. 
4. Adenovirus infection requiring treatment, such as cidofovir or lymphocyte 
preparations. 
5. Herpes Zoster infection requiring treatment, such as high dose acyclovir. 
 
 
Each patient can only be counted once toward the primary endpoint. In the event that a single 
patient has multiple viral infections, the time to the first infection will be counted for reporting 
purposes. The type of infection will also be recorded. All viral infections will be recorded, but 
only the above infections will count towards the primary endpoint. 
 
 
14.1 Study Design/Endpoints 
14.1.1 Primary Endpoint 
 
The primary endpoint is significant viral infection by one year of transplant. Several 
transplant centers reported a reduction in viral infection without ATG. Although the 
overall viral infection rate was not reported, the Minnesota group 23 reported that the 
incidence of EBV related complications was reduced from 21% with ATG to 2% 
without ATG. The Memorial Sloan-Kettering group44 has also reported a reduced viral 
infection rate (30% between day 31 and 60) without ATG in 72 patients who underwent 
myeloablative and non-myeloablative DUCBT. In  our previous DUCBT study with 
Flu/Mel/ATG (DFCI#05154), the one year significant viral infection rate was 53%. 
Based on this information and extrapolating the Minnesota and Memorial Sloan-
Kettering experience, if the one year significant viral infection rate is reduced to 33% or 
lower, the proposed conditioning regimen will be regarded as promising for reducing 
viral infections.   
 
The study for the primary endpoint is a one-stage design with the accrual goal of 31 
eligible patients.. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
45 
 
 With 31 patients, if 12 or fewer patients experience significant viral infection requiring 
intervention in the first year of transplant, the proposed conditioning regimen will be 
considered promising.  With this design, the probability of concluding this regimen 
promising is 0.81 if the true but unknown viral infection rate is 33% and 0.08 if the true 
rate is 53%.  This decision rule is calculated using an exact binomial distribution. Table 
5 presents the operating characteristics of this design.46-51 
 
 
 
 
 
Table 5 Operating Characteristics for the Primary Endpoint 
  
True but Unknown One Year Viral Infection Rate 
53% 
48% 
43% 
38% 
33% 
Prob ( ≤ 12 pts with viral 
infections within one 
year in 31 pts.) 
0.08 
0.20 
0.38 
0.61 
0.81 
 
 
 
 
14.1.2. Interim Analysis 
 
Several transplant groups reported a reduced viral infection rate without ATG. However, 
no detailed information has been provided as to the exact magnitude of the reduction 
without ATG compared to with ATG in the nonmyeloablative setting. We therefore will 
conduct an interim analysis to monitor the efficacy of the proposed conditioning regimen 
on the viral infection. The interim analysis will take place when the first 13 patients receive 
the conditioning regimen, undergo DUCBT, and followed for one year. Of these 13 
patients, if 7 or more patients experience a clinically significant viral infection within one 
year of transplant, we will provide the results of the interim analysis to the Data and Safety 
Monitoring Committee (DSMC) as a guideline for their decision on whether to proceed 
with the study. With this design, the probability of consulting with DSMC is 0.1 if the true 
but unknown one year viral infection rate is 33%, but 0.59 if the rate is 53%. 
 
In addition, when these 13 patients are followed for 42 days after the DUCBT, we will also 
evaluate the neutrophil engraftment. Although we do not anticipate that substituting LD 
TBI for ATG will delay the neutrophil engraftment (see Section 10 for the definition), we 
will monitor the neutrophil engraftment in parallel. In the previous DUCBT at DF/HCC, 
85- 90% of patients achieved neutrophil engraftment by day 42 post transplant. Based on 
this information, if 9 or fewer patients achieve neutrophil engraftment by day 42 in the first 
13 patients, we will consult with the DSMC as to whether the accrual should stop. With 
this design, the probability of consulting with the DSMC is 0.03 if the true but unknown 
rate of day 42 neutrophil engraftment is 90%, 0.12 if the rate is 85%, and 0.72 if the rate is 
65%. 
 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
46 
 
Results of Interim Analysis 
 
As of February 12, 2013, 16 patients were enrolled, among whom 14 patients were transplanted. 
Of these 14, data for the primary endpoint was available for the first 13 patients, and these 13 
patients are included in the interim analysis. Of these 13, 8 patients experienced clinically 
significant infections (5 HHV-6, 2 CMV, 1 both CMV and HHV-6), 1 patient experienced graft 
failure, 1 patient experienced grade III-IV acute GVHD and 1 patient died of TRM within  100 
days of transplantation. Since the total number of infections exceeds the threshold of 7, as 
specified in the original design, the accrual has been temporarily suspended and the results of the 
interim analysis  discussed with the DSMC. 
  
On February 27, 2013, the study team met to review the data and to discuss the future direction 
and proposed the following amendments.  1) mandatory antiviral prophylaxis with Famvir 500 
tid or Valtrex 1 gram daily (use IV Acyclovir 5mg/kg every 8 hours if patients cannot take p.o.); 
2) limiting eligibility to patients age 65 and younger; and 3) conducting an interim analysis after 
10 patients are enrolled and transplanted. 
 
Stopping rules after study re-open 
 
HHV-6 encephalitis 
Due to the unexpectedly high incidence of HHV-6 in the first 13 patients, the incidence of HHV-
6 encephalitis will be monitored closely. If in the 10 subsequently enrolled and transplanted 
patients that includes one patient who were transplanted but not included in the interim analysis, 
3 or more patients experience HHV-6 encephalitis, the study will be terminated early. With this 
design, the probability of terminating the study early is 0.62 if the true but unknown rate of 
HHV-6 encephalitis is 30%, but 0.07 if the true rate is 10%.  
 
Clinically Significant Viral infection 
The primary endpoint of clinically significant viral infection will also be monitored closely. If in 
the 10 patients, 5 or more patients experience any of clinically significant infections of CMV, 
EBV, HHV-6, Adenovirus or Herpes Zoster, the study will be terminated early. Based on this 
decision rule, the probability of terminating the study is 0.69 if the true but unknown infection 
rate is 53%, but 0.21 if the rate is 33% and 0.12 if the rate is 28%. 
 
Primary Graft failure 
The primary graft failure will be continuously monitored. If 3 or more graft failures are observed 
in the 10 subsequently enrolled patients, the study will be terminated early. With this design, the 
probability of terminating the study early is 0.07 if the true but unknown graft failure rate is 
10%, but 0.74 if the rate is 35%. 
 
 
Results of Second Interim Analysis: 
As of October 14, 2014, 11 additional patients were transplanted after the study was re-opened. 
Among the first 10 patients who were subsequently enrolled, 5 patients experienced clinically 
significant infections (3 CMV, 1 CMV and Herpes Zoster, 1 Adenovirus and HHV-6), therefore 
the study met the early stopping rule which was specified in the amendment following the first 
interim analysis (≥5 clinically significant infections in 10 subsequently enrolled patients).  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
47 
 
The accrual to the study was temporarily suspended and the study team met on December 16, 
2014. After reviewing additional outcome data, the study team felt that although the overall 
targeted reduction in infection rates will not be reached, the outcome was good among the 10 
patients who were subsequently enrolled since the study re-opened with a more restricted age 
eligibility of under 65: no 100 day TRM, 17% TRM and 83% survival at 6 months, respectively. 
The study team suggested to re-open the study and to complete the accrual so more data can be 
gathered within the group with age under 65 (7 more patients need to be accrued). Secondary 
endpoints of interest include the TPO levels, relapse rate, and GVHD with this regimen.   
 
 
 
 
 
14.2 Sample Size/Accrual Rate 
The target accrual is 31 evaluable patients. 
Based on our current practice, the accrual rate is expected to be approximately 13 
patients per year. Thus, we anticipate that the accrual will complete in 2.5 years. Of 
note, the accrual will not be suspended during the interim analysis. 
 
 
14.3 Analysis of Secondary Endpoints 
In addition to the reduction in the significant viral infection rate, we anticipate that the 
second cancer rate that includes PTLD and the non-relapse mortality (NRM) rate will 
also be decreased, but relapse rate will be unchanged. Descriptive analysis will be 
performed for the incidence of second cancer, and competing risks data analysis will be 
performed for the incidence of NRM and relapse reflecting these two events as 
competing risks. Competing risks data analysis will also be performed for the 
cumulative incidence of (acute or chronic) GVHD accounting relapse or death without 
developing GVHD for a competing risk, and for the time to neutrophil and platelet 
engraftment accounting graft failure for a competing risk. For the overall survival and 
disease-free survival, standard survival analysis will be performed. For the analysis of 
TPO levels and immune reconstitution (T, B, NK cell numbers with emphasis on CD4 
count), graphical assessment of levels over time as well as repeated measures analysis 
will be performed.  In addition, correlation analysis between TPO levels and platelet 
counts and number of platelet transfusions will be performed, and repeated 
measurements of CD4 count will be assessed as a time dependent variable in 
proportional hazards model.  
 
 
14.4 Reporting and Exclusions 
14.4.1 Evaluation of toxicity.  


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
48 
 
Adverse events will be monitored from the time of admission for pre-transplant 
conditioning through 100 days from the time of stem cell infusion (day +100).  See 
Section 11 for definitions of adverse events.  Adverse events include: 
 Death from any cause except in patients with active or recurrent malignancy after 
transplantation prior to day 100 after transplantation 
 Severe Veno-occlusive disease of the liver 
 Thrombotic Microangiopathy requiring renal replacement therapy 
 Diffuse Alveolar Hemorrhage / Idiopathic Pneumonia Syndrome 
 Other expected treatment-related toxicity related to transplantation (CTC Gr 4) 
 Other unexpected treatment-related toxicity related to transplantation (CTC Gr 4) 
 Infusional allergic reactions (CTC Gr. 3 – 4) 
 Grade III-IV Acute GVHD 
14.4.1.1 Severe VOD 
Severe VOD is defined as the presence of VOD per the Baltimore Criteria with 
evidence of multi-organ failure as follows: 
Baltimore Criteria for the Diagnosis of VOD: 
 Jaundice (bilirubin ≥ 2 mg/dL) and at least 2 of the following 3 clinical 
findings: 
o Ascites 
o Weight gain ≥ 5% above baseline weight (defined as weight on the 
first day of conditioning or the weight on the date of admission) 
o Hepatomegaly (with pre-existing hepatomegaly there must be 
documentation by physical exam or imaging that liver size is increased 
over baseline) 
 
14.4.1.2 Multi-organ failure, defined as the presence of one or both of the 
following: 
 Renal dysfunction 
o Serum creatinine ≥ 3 x value on the date of admission or ≥ 3 
x lowest value during conditioning prior to SCT (whichever 
is lowest) 
o Creatinine clearance or GFR ≤ 40% of admission value 
o Dialysis dependence 
 Pulmonary Dysfunction 
o Documentation of oxygen saturation ≤ 90% on room air or 
requirement for oxygen supplementation/ventilator 
dependence. Dysfunction must be attributable to fluid 
overload or mechanical impingement from abdominal 
distention or hepatic enlargement and not to an infection 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
49 
 
 
14.4.1.3 Thrombotic Microangiopathy 
The diagnostic criteria for thrombotic microangiopathy include the concurrent 
occurrence of: 
 Red cell fragmentation on a manual differential (2 + schistocytes) 
with a negative Coombs test 
and 
 LDH > normal 
and either 
 Renal dysfunction (doubling of serum creatinine or a decrease > 
50% in the measured creatinine clearance) 
 
  
 
 
   
 or 
 Neurological dysfunction unexplained by another etiology 
 
Thrombotic microangiopathy that requires renal replacement therapy (continuous 
or intermittent hemodialysis) will be required to define a severe adverse event.  
             
 
 
15. PUBLICATION PLAN 
 
The Principal Investigator and co investigators will plan to publish within one year of the 
end of  data collection. The information may be published in abstract form prior to the end 
of data collection. 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
50 
 
 
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4) Querol S, Gabarro M, Amat L et al. The placental blood program of the Barcelona Cord 
Blood Bank. Bone Marrow Transplant. 1998;22 Suppl 1:S3-S5. 
5) Sirchia G, Rebulla P, Lecchi L et al. Implementation of a quality system (ISO 9000 
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blood collection network for unrelated donor umbilical cord blood banking. J Matern 
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7) Bone Marrow Donors Worldwide. www.bmdw.org . 2008. 1-16-2008. Ref Type: 
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8) Gluckman E, Broxmeyer HA, Auerbach AD et al. Hematopoietic reconstitution in a 
patient with Fanconi's anemia by means of umbilical-cord blood from an HLA-identical 
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9) Long GD, Laughlin M, Madan B et al. Unrelated umbilical cord blood transplantation in 
adult patients. Biol Blood Marrow Transplant. 2003;9:772-780. 
10) Rubinstein P, Carrier C, Scaradavou A et al. Outcomes among 562 recipients of 
placental-blood transplants from unrelated donors. N Engl J Med. 1998;339:1565-1577. 
11)  Locatelli F, Rocha V, Chastang C et al. Factors associated with outcome after cord 
blood transplantation in children with acute leukemia. Eurocord-Cord Blood Transplant 
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12) Ballen KK, Wilson M, Wuu J et al. Bigger is better: maternal and neonatal predictors of 
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13) Laughlin MJ, Barker J, Bambach B et al. Hematopoietic engraftment and survival in 
adult recipients of umbilical-cord blood from unrelated donors. N Engl J Med. 
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14) Sanz GF, Saavedra S, Planelles D et al. Standardized, unrelated donor cord blood 
transplantation in adults with hematologic malignancies. Blood. 2001;98:2332-2338. 
15) Gluckman E. Current status of umbilical cord blood hematopoietic stem cell 
transplantation. Exp Hematol. 2000;28:1197-1205. 
16) Takahashi S, Iseki T, Ooi J et al. Single-institute comparative analysis of unrelated bone 
marrow transplantation and cord blood transplantation for adult patients with hematologic 
malignancies. Blood. 2004;104:3813-3820. 
17)  Barker JN, Weisdorf DJ, Wagner JE. Creation of a double chimera after the 
transplantation of umbilical-cord blood from two partially matched unrelated donors. N 
Engl J Med. 2001;344:1870-1871. 
18) Barker JN, Weisdorf DJ, DeFor TE et al. Transplantation of 2 partially HLA-matched 
umbilical cord blood units to enhance engraftment in adults with hematologic 
malignancy. Blood. 2005;105:1343-1347. 
19) Brunstein CG, Barker JN, Weisdorf DJ et al. Umbilical cord blood transplantation after 
nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with 
hematologic disease. Blood. 2007;110:3064-3070. 
20) Ballen KK, Spitzer TR, Yeap BY, et al: Double unrelated reduced intensity umbilical 
cord blood transplantation in adults. Biol Blood Marrow Transplant, 2007; 13: 82-9. 
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23) Brunstein CG, Weisdorf DJ, DeFor T, et al: Marked increased risk of Epstein-Barr virus-
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24) Ballen KK, Cutler C, Yeap BY, et al: Donor Derived Second Hematologic  Malignancies 
after Cord Blood Transplantation. Biol Blood Marrow Transplant 2010; 16: 1025-31. 
25) Brunstein CG, Carter S, Fuchs E, et al: Results of a Multi-Center, Phase II trial Non-
Myeloablative Conditioning (NST) Umbilical Cord Blood (UCB) Transplantation from 


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Unrelated Donors in Patients with Hematologic Malignancies: BMT CTN PROTOCOL 
#0604. Biol Blood Marrow Transplant 2011; 17: 4a. 
26) Brown JA, Boussiotis VA: Umbilical  cord blood transplantation: basic biology and 
clinical challenges to immune reconstitution. Clin Immunol 2008; 127: 286-97. 
27) Komanduri KV, St. John LS, de Lima M, et al: Delayed immune reconstitution after cord 
blood transplantation is characterized by impaired thymopoiesis and late memory T-cell 
skewing. Transplantation 2007; 110: 4543-51 
28) Vandenbosch K, Ovetchkine  P, Champagne MA, et al: Varicella-Zoster Virus disease is 
more frequent after cord blood than after bone marrow transplantation. Biol Blood 
Marrow Transplant 2008; 14: 867-71. 
29) Parkman R, Cohen G, Carter SL, et al: Successful immune reconstitution decreases 
leukemia relapse and improves survival in recipients of unrelated cord blood 
transplantation. Biol Blood Marrow Transplant 2006; 12: 919-27. 
30) Safdar A, Rodriguez GH, De Lima MJ,et al: Infections in 100 cord blood 
transplantations. Medicine 2007; 86: 324-333. 
31) Brown J, Stevenson K, Kim HT, et al: Clearance of CMV viremia and survival after 
double cord blood transplant. Blood 2010; 115: 4111-9 
32) Montesinos P, Sanz J, Cantera S, et al: Incidence, risk factors, and outcome of 
cytomegalovirus infection and disease in patients receiving prophylaxis with oral 
valganciclovir or intravenous ganciclovir after umbilical cord blood transplantation. Biol 
Blood Marrow Transplant 2009; 15: 730-40. 
33) Matsummura T, Narimatsu H, Kami M,et al: Cytomegalovirus infections following 
umbilical cord blood transplantation using reduced intensity regimens for adult patients. 
Biol Blood Marrow Transplant 2007; 13: 577-83. 
34) Verneris MR, Brunstein CG, Barker J, et al: Relapse risk after umbilical cord blood 
transplantation: enhanced graft-versus-leukemia effect in recipients of 2 units. Blood 
2009; 114: 4293-99. 
35) Cahu X, Rialand F, Touzeau C, et al: Infections complications after unrelated umbilical 
cord blood transplantation in adult patients with hematologic malignancies. Biol Blood 
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36) Parody R, Martino R, Rovira M, et al: Severe infections after unrelated donor allogeneic 
hematopoietic stem cell transplantation in adults: comparison of cord blood 
transplantation with peripheral blood and bone marrow transplantation. Biol Blood 
Marrow Transplant 2006; 12: 734-48 
37) Kuter DJ: New thrombopoietic growth factors. Blood 2007; 2007: 4607-4616 


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38) Li J, Xia Y, Kuter DJ: Interaction of thrombopoietin with the platelet c-mpl receptor in 
plasma: binding internalization, stability, and pharmacokinetics. Br J Hematol 1999; 106: 
345-56. 
39) Kuter DJ, Rosenberg RD. Appearance of a megakaryocyte growth-promoting activity, 
megapoietin, during acute thrombocytopenia in the rat. Blood 1994; 84: 1464-72 
40) Basser RL, O'Flaherty E, Green M, et al: Development of pancytopenia with  neutralizing 
antibodies to thrombopoietin after multicycle chemotherapy supported by megakaryocyte 
growth and development factor. Blood 2002; 99: 2599-2602 
41) Kuter DJ, Bussel B, Lyons RM, et al: Efficacy of romiplostim in patients with chronic  
immune thrombocytopenia purpura: a double-blind randomized controlled trial. Lancet 
2008; 371:395-403. 
42) Cuker A: Toxicities of the thrombopoietic growth factors. Semin Hematol 2010; 47:289-
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43) Kuter DJ, Rummel M, Boccia R, et al: Romiplostim or standard of care in patients with 
immune thrombocytopenia. New Engl J Med 2010; 363: 1889-99 
44) Sauter C,  Abboud M, Jia X et al: Serious infection risk and immune recovery after 
double unit cord blood transplantation without antithymocyte globulin. Biol Blood 
Marrow Transplant, 2011, in press. 
45)  Filipovich AH, Weisdorf D, Pavletic S et al. National Institutes of Health consensus 
development project on criteria for clinical trials in chronic graft-versus-host disease: I. 
Diagnosis and staging working group report. Biol Blood Marrow Transplant. 
2005;11:945-956. 
46) Atkinson EN and Brown BW. Confidence limits for probability of response in multistage 
phase II clinical trials  
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47) Gray RJ. A class of K-sample tests for comparing the cumulative incidence of a 
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48) Fine JP, Gray RJ. A proportional hazards model for the subdistribution of competing risk. 
J Am Stat Assoc1999;94:496-509. 
49) Kim H. Cumulative incidence in competing risks data and competing risks regression 
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applications to clinical trials. CRC Press Inc. (Boca Raton, FL) 


DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
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17. APPENDICES  
Appendix 1: Optional Thrombopoietin Levels 
 
Delayed platelet engraftment is also an important contributor to the increased morbidity, poor 
quality of life, and cost after double cord blood transplant. Therefore, as an optional correlate, we 
will study thrombopoietin (TPO) levels after cord blood transplant, to determine if further 
investigation of TPO receptor agonists post cord blood transplant is warranted. 
 
Patients may elect to participate in the thrombopoietin level portion of the study. 
 
 TPO levels will be determined with the assistance of Dr. David Kuter and Dr. Robert Makar. 
 
TPO levels will be measured: 
1. Pre conditioning 
2. Day 0 
3. Day 14+, Day 30+, Day 60+/- 3 days  
4. Day 100 +/- 7 days 
5. Month 6, Month 9+/-14 days  
6. Month 12, Month 24+/-14 days  
 
Another 4 TPO samples will be obtained in association with platelet transfusions occurring after 
transplantation.  With each eligible platelet transfusion, BOTH a CBC and a sample for TPO 
assessment will be obtained:  
 
1. Immediately prior to the platelet transfusion (TPO level only) 
2 30-60 minutes after the completion of the transfusion 
3. 6 hours after the completion of the transfusion (+/- 60 min) 
4. 24 hours after the completion of the transfusion (+/- 60 min) 
 
TPO samples will obtained in at least 1 and up to 3 eligible platelet transfusions in each patient. 
 
Due to the requirement for sample processing at the time of collection, only platelet transfusions 
administered on Mondays, Tuesdays, Wednesdays or Thursdays will be considered.  
Transfusions should be administered prior to 10 AM if possible to allow for collection of the 
TPO level specimen during normal business hours. 
 
In the event that 2 transfusions are administered within the same 24 hour period, only the first 
transfusion is eligible for TPO measurements.   
 
Since these assessments are entirely voluntary and optional, there will be no protocol deviations 
or violations for missed samples.. 
 
TPO specimens will be collected in large red top tubes and must be refrigerated at 4C within 8 
hours of collection. 
 




DeFilipp Cord  Blood 11-085 Update  10/6/2016 
 
 
 
 
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TPO Sample Collection Times* 
Pre-conditioning 
Day 0 
Day 14, Day 30, Day 60+/-3 days  
In association with 3 eligible platelet transfusions during hospitalization after transplant 
Immediately BEFORE platelet transfusion (concurrent CBC NOT required) 
30-60 minutes AFTER platelet transfusion 
6 hrs (+/- 60 minutes) AFTER platelet transfusion 
24 hrs ( +/- 60 minutes) AFTER platelet transfusion 
Day 100+/ 7 days 
Month 6, Month 9 +/ 14 days 
Month 12, Month 24 +/ 14 days 
*TPO samples collected in a large red top tube.  Collect a CBC concurrently with each TPO 
sample unless otherwise specified. Since these assessments are entirely voluntary and optional, 
there will be no protocol deviations or violations for missed samples. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 






DeFilipp Cord Blood 11-085 10/6/2016 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
59 
 
Appendix 4: Performance Status 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed < 50% of the time. 
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities. Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, 
but is able to care for most of 
his/her needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely disabled, 
hospitalization indicated. Death 
not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated. Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 
 


 
 
 
 
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Appendix 5:  Suggested Guidelines for Cord Blood Selection 
1. Cord blood search should be initiated as the time of MUD search. Patients who 
have a readily available and eligible 8/8 A, B, C, DR matched unrelated donor or 
a 8/8 or 7/8 (A, B, C, DR) related donor are not eligible for our cord blood studies. 
All available siblings and usually adult children and healthy parents should also 
be typed. Mismatches at DQ are acceptable. 
2. Patients who have an unfavorable MUD search (less than 10 likely 10/10 allele 
matched donors or obvious linkage disequilibrium issues) should have cord units 
selected for high resolution typing. 
3. The NMDP, BMDW, and all cooperative registries should be searched 
simultaneously. 
4. HLA antibodies should be checked at the time of cord blood search—we should 
not select UCB units against which patients have preformed antibodies. Antibody 
screen may need to be repeated just prior to ordering cords. 
5. Cord units must not be HLA identical, unless a 6/6 match with the patient. 
6. Double mismatches at any given locus should be avoided 
7. Cord blood units should have high resolution typing performed for Class I and 
Class II. This can be done from an attached segment or stored DNA as available. 
A, B, and DR are used in the match strategy.. Cord unit to patient matching 
should be at the allele level (high resolution) whenever possible.  Data on C and 
DQ are collected but not used in the match strategy. Is possible, cord blood 
identity should be confirmed just prior to transplant on an attached segment.  
8. Cord units are very expensive. Therefore, cord blood units should not be ordered 
until the patient has signed consent, has insurance approval, and has met 
eligibility criteria for transplant.  
9. Patients should sign the consent for NMDP IND, and when approved, from the 
New York Blood Center, at the time of search, which grants permission to use 
UCB units not licensed yet by the FDA. This consent must be signed in addition 
to any research consents. 
10. Patients must have an accurate weight at the time of search. 
11. Choices regarding cell dose vs. HLA for double cord shall be as follows: 
 
 
 Total TNC must be at least 3.7 x 107 NC/kg 
 Each unit must be at least 1.5 x  107 NC/kg 
 Higher cell dose triumphs over HLA match when TNC is 
≤ 2.0 x 107 NC/kg for each single CBU 
 Closer HLA match triumphs over cell dose when TNC is                                   
>2.0 x 107 NC/kg for each single CBU unless there is a >50% 
higher cell dose in the less well matched cord blood unit 
 
12.  For selection between equivalent units choose: 
 CD 34+ dose (higher dose preferable) 
 Greater viability (never use a unit with viability less then 
90%) 


 
 
 
 
DeFilipp Cord Blood 11-085 10/6/2016 
 
61
 
. 
 
Example: 
Cord A 4/6 match to patient, cell dose 3 x 107 NC/kg 
Cord B 5/6 match to patient, cell dose 1.7 x 107 NC/kg 
Cord C 4/6 match to patient, cell dose 5.0 x 107 NC/kg  
    Select A and C 
 
Example: 
Cord A 4/6 match to patient, cell dose 3.5 x 107 NC/kg 
Cord B 5/6 match to patient, cell dose 3.0 x 107 NC/kg 
Cord C 4/6 match to patient, cell dose 5.0 x 107 NC/kg  
   Select  B and C 
 


 
 
 
 
DeFilipp Cord Blood 11-085 10/6/2016 
 
62
Appendix 6. Suggested Management of HHV-6 Infection. 
1. If encephalitis is present, Foscarnet should be instituted immediately, even in the absence of 
results from blood or CSF HHV-6 levels. 
2.  Perform lumbar puncture; if negative for HHV-6, discontinue Foscarnet. If positive, continue 
Foscarnet. 
3. If no encephalitis but the HHV-6 blood viral load is >100, 000 copies institute Foscarnet. 
4. Asymptomatic patients with HHV-6 viral loads <100,000 copies often do not require 
treatment.