Clinical trial NCT01251575
Conditions: Adult Acute Lymphoblastic Leukemia Adult Acute Myeloid Leukemia Adult Diffuse Large B-Cell Lymphoma Adult Myelodysplastic Syndrome Adult Non-Hodgkin Lymphoma Aggressive Non-Hodgkin Lymphoma Childhood Acute Lymphoblastic Leukemia Childhood Acute Myeloid Leukemia Childhood Diffuse Large B-Cell Lymphoma Childhood Myelodysplastic Syndrome Childhood Non-Hodgkin Lymphoma Chronic Lymphocytic Leukemia Chronic Lymphocytic Leukemia in Remission Chronic Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive Hematopoietic and Lymphoid Cell Neoplasm Mantle Cell Lymphoma Plasma Cell Myeloma Prolymphocytic Leukemia Recurrent Chronic Lymphocytic Leukemia Refractory Chronic Lymphocytic Leukemia T-Cell Prolymphocytic Leukemia Waldenstrom Macroglobulinemia Recurrent Diffuse Large B-Cell Lymphoma Recurrent Hodgkin Lymphoma
Sponsor: Fred Hutchinson Cancer Center
Start date: 2010-12-01; Completion date: 2019-02-11
Enrollment: 77 participants; Allocation: NA; Intervention model: SINGLE_GROUP

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

Detailed description:
PRIMARY OBJECTIVES:

I. To determine whether the incidence of acute GVHD grades II-IV can be reduced to less than the historical rate of 70% with the triple-immunosuppressant combination of cyclosporine (CSP)/mycophenolate mofetil (MMF) with sirolimus in human leukocyte antigens (HLA) class I or class II mismatched related or unrelated donor hematopoietic cell transplantation (HCT) using nonmyeloablative conditioning. The evaluation will be carried out separately among class I and class II mismatched patients.

SECONDARY OBJECTIVES:

I. To evaluate the incidence of non-relapse mortality before day 100.

II. To evaluate the incidences of grades III-IV acute GVHD.

OUTLINE:

CONDITIONING: Patients receive fludarabine phosphate intravenously (IV) over 30 minutes on days -4 to -2. Patients also undergo total-body irradiation on day 0.

TRANSPLANTATION: Patients undergo allogeneic peripheral blood stem cell transplantation.

IMMUNOSUPPRESSION: Patients receive sirolimus orally (PO) once daily (QD) on days -3 to 180 with taper to day 365; cyclosporine PO twice daily (BID) on days -3 to 150 with taper to day 180; and mycophenolate mofetil PO thrice daily (TID) on days 0-30 and then BID to day 100 with taper to day 150.

After completion of study treatment, patients are followed up at 6 months and every year thereafter.

Arms: arm 1: CONDITIONING: Patients receive fludarabine phosphate IV over 30 minutes on days -4 to -2. Patients also undergo total-body irradiation on day 0.

TRANSPLANTATION: Patients undergo allogeneic peripheral blood stem cell transplantation.

IMMUNOSUPPRESSION: Patients receive sirolimus PO QD on days -3 to 180 with taper to day 365; cyclosporine PO BID on days -3 to 150 with taper to day 180; and mycophenolate mofetil PO TID on days 0-30 and then BID to day 100 with taper to day 150.
Interventions: intervention 1: Allogeneic Hematopoietic Stem Cell Transplantation intervention 2: Cyclosporine intervention 3: Fludarabine Phosphate intervention 4: Laboratory Biomarker Analysis intervention 5: Mycophenolate Mofetil intervention 6: Peripheral Blood Stem Cell Transplantation intervention 7: Sirolimus intervention 8: Total-Body Irradiation
Intervention descriptions: intervention 1: Undergo allogeneic peripheral blood stem cell transplant intervention 2: Given PO or IV intervention 3: Given IV intervention 4: Correlative studies intervention 5: Given PO intervention 6: Undergo allogeneic peripheral blood stem cell transplant intervention 7: Given PO intervention 8: Undergo total-body irradiation

Protocol documents:
Prot_SAP_000.pdf: 
Protocol 2206.00 
Current Version:09/26/2018  -1- 
FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
SEATTLE CHILDREN’S HOSPITAL 
Current version: 09/26/2018 
Previous version: 08/31/2018 
 
 
A Phase II Study to Assess Immunosuppression with Sirolimus Combined with Cyclosporine 
(CSP) and Mycophenolate mofetil (MMF) for Prevention of Acute GVHD after Non-
myeloablative HLA Class I or II Mismatched Donor Hematopoietic Cell Transplantation–  
A Multi-Center Trial 
 
 
Investigators List: 
Brenda M. Sandmaier, MD 
Member, FHCRC, Professor of Medicine, UW  
(206) 667-4961 
David Maloney, MD, PhD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-5616 
Ann Woolfrey, MD 
Member, FHCRC, Professor of Pediatrics, UW 
(206) 667-4453 
Mary E. D, Flowers MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-6557 
Effie Petersdorf, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-5244 
Paul J. Martin, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-4798 
Marco Mielcarek, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-2827 
Rainer Storb, MD 
Member, FHCRC, Professor of Medicine, UW 
(206) 667-4407 
Biostatistician: 
Barry Storer, PhD 
Member, FHCRC, Professor of Biostatistics, UW 
(206) 667-6151 
Radiation Oncologist 
 
 
Ralph Ermoian, MD 
Assistant Professor, Radiation Oncology,  UW  
(206)-598-4100 
Research Staff: 
Michelle Bouvier, RN 
Research Nurse 
(206) 667-6993; 
pager: (206)995-7658 
 
 
Additional Performance Sites 
Investigators 
Emergency Phone 
Numbers 
Veterans Affairs Puget Sound Health 
Care System  
Thomas Chauncey MD, PhD      
(206)-762-1010  
 
HealthONE Presbyterian St. Luke’s 
Medical Center  
Michael Maris, MD 
(720)-754-4800 
Rigshospitalet 
Niels Andersen, MD 
+45 35 45 1134 
 
 
 
 
 
 
 
 
  
Emergency Phone Numbers: 
FHCRC  
  
 
 
 
  
  
 
 
(206) 598-8902;  
Children’s 
  
 
 
 
  
  
 
 
(206) 987-2032;  
 
 
  
  
 
 
 
 
 
 
 


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TABLE OF CONTENTS 
1. Title Page……………………………………………………………………………………  
1 
2. Introduction …………………………………………………………………………………  
3 
3. Background data……………………………………………………………………………… 3 
4. Proposal …………………………………………………………………………………….    14 
5. Primary Objective ………………………………………………………………………….    15 
6. Secondary Objective ……………………………………………………………………….    15 
7. Patient Selection ……………………………………………………………………………    15 
8. Donor Selection ……………………………………………………………………………    18 
9. Informed Consent       ……………………………………….……………………………      18 
10. Protocol Registration ………………………………………………………………………    19 
11. Plan of Treatment ………………………………………………………………………….    20 
12. Assessment of Disease Response …………………………………………………………..    31 
13. Clinical and Laboratory Evaluations ………………………………………………………     31 
14. Drugs and Toxicities……………………………………………..…….……………………    51  
15. Records …………………………………………………………………………………….    55 
16. Statistical Consideration and Termination of the Study …………………………………..    55 
17. Data Safety Monitoring Board and Adverse Event Reporting …………………………….    56 
18. Targeted/Planned Enrollment………………………………………………………………    59 
19. References …………………………………………………………………………………    60 
20. Table of Appendices 
A. Eligibility Guidelines For Donor PBSC Apheresis for Transfusion ………….. 
   65 
B. Karnofsky Performance Scale ……………………………………………………    66 
C. Lansky Play-Performance Scale ………………………………………………….    67 
D. ABO Incompatibility …………………………………………………………….    68 
E. Infectious Disease Guidelines ……………………………………………………    70 
F. Acute Graft-Versus-Host-Disease Grading ………………………………………    71 
G. Chronic GVHD Grading ………………………………………………………….    72 
H. Evaluation of Disease Response for MM, NHL and CLL ………………………..    76 
I. Study Coordinator’s Manual Including Procedure for Reporting Adverse Events.    79 
J. Adverse Event Report Form ……………………………………………………...    82 
K. Notice of Death Form …………………………………………………………….    84 
L. Patient Demographics and Registration Form ……………………………………    85 
M. Core Case Report Form …………………………………………………………..    92 
N. Intrathecal Diagnostic Study and Therapy ……………………………………….    93 
O. HLA Matching Requirements for donors…………………………………………  94 
P. Adapted Common Toxicity Criteria ……………………………………………...    96 
Q. The Hematopoietic Cell Transplant-Comorbidity Index (HCT-CI)………………  103 
R. Clinically Significant Inducers/Inhibitors of Cytochrome P450 Enzyme System   105 
S. Standard Donor Consent……………………………………………………………106 
T. Weight/Adjusted Body Weight for Drug Dosing…………………………………   107 
U. Coordinating Center Functions……………………………………………………   108 
V. Radiotherapy Treatment Guidelines……………………………………………….  110 
 


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2. Introduction  
 
Hematopoietic cell transplantation (HCT) after nonmyeloablative conditioning is a major 
curative strategy for patients with hematologic malignancies, who are ineligible for high dose 
conditioning because of age or medical infirmities (1,2). One of the most important factors 
associated with the successful outcome of allogeneic HCT is the extent of HLA matching between 
patient and donor. Although these observations mainly stem from high dose conditioning HCT (3-
8), similar observations of HLA mismatch being associated with graft rejection, graft-versus-host 
disease and non-relapse mortality, have been observed in smaller studies of patients transplanted 
after nonmyeloablative or reduced intensity conditioning HCT (9,10). FHCRC protocol 1591 was a 
phase I/II clinical trial designed to extend the availability of nonmyeloablative conditioning HCT 
with 90 mg/m2 and 2 Gy TBI to patients with HLA class I mismatched donors (11). To prevent 
graft rejection and provide additional GVHD prophylaxis patients were treated with cyclosporine 
(CSP) and mycophenolate mofetil (MMF) for extended periods of time compared to the standard 
care for patients transplanted with unrelated HLA matched donors. Of the 59 patients who were 
enrolled in the study only 2 rejected, showing that sustained engraftment is attainable in HLA 
mismatched HCT after minimal conditioning. However, rates of GVHD (grade II-IV acute GVHD 
69%, grade III-IV acute GVHD 26%, extensive chronic GVHD 41%) were high with a two-year 
non-relapse mortality at 47%.  
 
The primary goal of the proposed protocol is to determine whether the incidence of grade II-IV 
acute GVHD after non-myeloablative HLA class I or II mismatched donor HCT can be reduced to 
less than the historical rate of 70%, by extending the immunosuppressive regimen to encompass 
sirolimus in addition to CSP and MMF. Sirolimus has previously been shown to be effective as 
prophylaxis after HLA-matched and mismatched unrelated HCT (12-17), and recently in FHCRC 
protocol 1938, superior GVHD control was observed with a combination of sirolimus, MMF and 
tacrolimus compared to MMF and tacrolimus alone.  
 
3. Background data 
 
3A. HLA class I or II-mismatched myeloablative transplant 
 
HLA class I (HLA-A, B, C) mismatching stimulates CD8+ T cells, whereas HLA class II 
(HLA-DR, DP, DQ) mismatching stimulates CD4+ T cells.  Theoretically each pathway of T cell 
stimulation can cause both graft-versus-host reactions and host-versus-graft reactions. Clinical 
studies evaluating the role of HLA disparity have shown that both HLA class I and II disparities 
have similar adverse impacts on outcome in unrelated HCT. However, they have shown that the 
magnitude of the contribution of HLA class I and II disparities to GVHD or graft rejection is not 
equal. Furthermore, recent reports show that the risk of graft failure, GVHD and mortality are 
correlated with the number of HLA inconsistencies in HLA class I, class II and the combination of 
class I and II. 
 
Within the past decade, high resolution typing techniques have been developed to allow 
identification of polymorphic alleles among class I and class II HLA antigens. When donors that 
were matched for HLA-A and –B by serologic typing and for HLA-DRB1 were typed 
retrospectively by DNA techniques, only half were matched at the allele level for all 5 loci (HLA-
A, B, C, DRB1, DQB1), and one-quarter were mismatched for multiple alleles (4). The ability to 
distinguish allele level mismatches has allowed investigation of the relevancy of patient-donor 
mismatching. Subsequent studies show that impact of patient-donor mismatching depends on the 
disease being treated, and within disease risk groups depends upon the degree of HLA mismatch 
and the locus of HLA mismatch. 
 


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Initial studies of patients with chronic myeloid leukemia (CML) found an increased risk for 
graft failure when donors had multiple mismatches that involved at least one class I allele 29% 
when the mismatch involved more than one class I allele mismatch and 12% for mismatched pairs 
involving both class I and class II alleles (p=0.003 and 0.01, respectively), compared to 2% or less 
when either no mismatch or a mismatch confined to a single HLA-A, B, C, DRB1 and DQB1 allele 
was present (3-6). The highest risk for severe acute GVHD was observed for multiple mismatches 
involving both class I and class II alleles (2.0 hazard ratio, p=0.02). Pairs with a single class I 
mismatch did not have a significant increase in acute GVHD compared with matched recipients, but 
a single class II mismatch or multiple class I mismatches both appeared to confer a higher (though 
not significant) hazard of severe GVHD. An important limitation of these studies was that patients 
were mainly Caucasian, therefore results may not be transferable to other ethnic populations. For 
example, studies from Japan found that mismatching of HLA-A and B, but not class II HLA, 
decreased survival (5).  
 
The effects of HLA-mismatch on outcome have been shown by several sequential analyses 
conducted through the National Marrow Donor Program. The first analysis of 1874 patient-donor 
pairs examined the endpoints of engraftment, acute GVHD, chronic GVHD and mortality according 
to locus of donor-recipient HLA disparity (7). Disparity of class I HLA loci HLA-A, -B, -C, and 
HLA-DRB1 were independently associated with a statistically significant increase in the risk for 
mortality. In addition, mismatching at HLA-A was associated with higher risk for both acute and 
chronic GVHD. In this study, class I HLA allele mismatches (detectable only with high-resolution 
typing) did not appear to increase the risk for poor outcome. This study employed multivariate 
modeling whereas the subsequent NMDP/CIBMTR study used subset analysis (8). In this study of  
3,857 AML, ALL, CML, and MDS patients, a single mismatch for HLA-A, B, C, or DRB1 was 
associated with a higher risk for TRM and acute GVHD, and mismatch for HLA-A, C, and DRB1, 
but not HLA-B, was associated with statistically worse survival compared to the 8 of 8 HLA allele 
matched pairs. In contrast to the previous NMDP report, the effect of a mismatch at the allele level 
was equivalent to a serologic or antigen mismatch.  A donor with multiple HLA mismatches 
increased the risk for mortality, in a degree dependent fashion, hazard ratio 1.25 and 1.65 
(p<0.0001) for 7 and 6 of 8 loci mismatch, respectively compared to 8 of 8 matched pairs. The 
Japanese Marrow Donor Program analysis also supports the idea that disparities involving HLA-
class I alleles are independent risk factors for acute GVHD, TRM, and overall survival. In the 
Japanese study, the addition of HLA-C allele disparity with other HLA allele mismatches increased 
the risk of acute GVHD in a synergistic fashion (5,18). HLA class I allele mismatches also were 
associated with a significantly higher incidence of graft failure when compared to patients with 
allele matched donors.  
 
Most patients included in the sequential retrospective studies of high-resolution HLA matching 
received bone marrow grafts. Compared to marrow, G-CSF-mobilized peripheral blood stem cells 
(PBSC) contains on average 10-fold more CD3+ cells and 4-fold higher CD34+ cells, as well as 
differences in the relative contribution of cell subsets (19). Accordingly the NMDP/CIBMTR 
recently completed an analysis of the effects of HLA-mismatch among 1933 recipients of unrelated 
PBSC grafts. HLA-mismatched pairs that contained at least one antigen mismatch had statistically 
worse survival (RR 1.23, 95% CI 1.12-1.55, p=0.0007) and disease-free survival (RR 1.54, 95% CI 
1.10-1.51, p=0.0013) compared to pairs who were 8/8 matched; however, survival of 7/8 allele 
mismatches was not statistically different than 8/8 matched pairs. Locus-specific analysis of single 
mismatched pairs found that mismatch of a single HLA-C antigen was associated with a statistically 
significant higher risk for mortality, TRM and grade III-IV acute GVHD and lower disease-free 
survival. At two years, survival was 32% for HLA-C mismatches compared to 44% of 8/8 matches 


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(p=0.003). DFS was 26% compared to 40% (p=0.003), and TRM was 40% compared to 28% 
(p=0.002), respectively. Mismatching at a single HLA-B allele or antigen also was associated with 
increased grade III-IV acute GVHD. The risks of relapse and chronic GVHD, were not statistically 
different for recipients of 8/8 matches compared to any locus-specific mismatch, including HLA-C 
antigen mismatched pairs.   
 
In the myeloablative setting, the number of tolerated mismatches appears to differ according to 
the disease being treated. In the Seattle analysis of marrow recipients, patients with early stage 
disease had a significant decrease in survival and increase in NRM when the graft was mismatched 
for a single antigen or allele (20). In contrast, the relevance of HLA mismatching among 
intermediate-stage or advanced-stage patients could be appreciated only when two or more 
disparities existed (HR 1.40, CI 1.08-1.82). The Lee study also showed a relatively greater negative 
effect of HLA-mismatching for patients according to disease stage: early > intermediate> advanced 
(8). 
 
3B. HLA-mismatched Transplantation with minimal or reduced toxicity conditioning 
 
Most data that is available on the role of HLA class I or II mismatches in allogeneic HCT are 
derived from patients transplanted after high dose conditioning. Apart from our own experience 
from FHCRC protocol 1591, only few studies deal with the specific question of HLA mismatch in 
the nonmyeloablative setting. However, data is to some extent attainable from studies of mainly 
HLA-matched cohorts which include smaller subsets of mismatched transplants. 
 
In a retrospective study published by Teshima et al (9), data was reported from a cohort of 341 
transplant patients, which included 57 single HLA-locus mismatches (5/6) and 34 two or three loci 
mismatches (3-4/6). Patients were transplanted for hematological malignancies with PBSC from 
related donors after reduced intensity conditioning. The most frequently used conditioning regimens 
were fludarabine-based (150–180 mg/m2 with either cyclophosphamide 60 mg/kg, busulphan 8 
mg/kg or melphalan 80–140 mg/m2) with or without TBI 2–4 Gy or ATG 5–10 mg/kg. The most 
frequently used regimens for GVHD prophylaxis were CSP alone or CSP plus MTX. Patient and 
donor pairs were serologically typed for HLA-A, -B and –DR, and if a mismatch was observed, 
subsequent intermediate level DNA typing was performed for all three loci. In patients with a 6/6 
matched donor the incidence of graft failure was 3.7% (N=9), while it was 5.7% (N=3) in those 
with a one-locus-mismatched donor, and 10.3% (N=3) in those with a two- to three-loci-
mismatched donor. In multivariate analysis the risk of graft rejection increased with increasing 
number of mismatches (1 mismatch HR 1.18, P= 0.86; 2 or more mismatches 8.58, P= 0.02; P for 
trend 0.03). The incidence of http://www3.interscience.wiley.com/cgi-
bin/fulltext/118642867/main.html,ftx_abs - qt8#qt8grade II-IV GVHD was 39% in recipients with 
matched donors, 44% in one-locus mismatched and 50% in two- to three-loci mismatched. In 
multivariate Cox regression analyzes increasing HLA disparity was associated with increased risk 
of developing grade II-IV acute GVHD (1 mismatch HR 1.83, P= 0.04; 2 or more mismatches 2.44, 
P= 0.02; P for trend 0.01). The cumulative incidence of extensive cGVHD was 38%, 34% and 60% 
after transplantation with a matched donor, one-locus mismatched or two- to three-loci-
mismatched, respectively. In the multivariate analyzes only a tendency towards increasing chronic 
GVHD with increasing HLA disparity was observed. Overall survival was 48%, 51% and 18%, in 
patients transplanted with matched donors, one-locus mismatched or two- to three-loci mismatched 
donors, respectively. Hundred-seventy-eight of the study patients died and no difference was 
observed in relapse or non-relapse related mortalities in relation to the degree of HLA disparity. 
 
 
 


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In a study from the DNA-Farber Cancer Institute, Ho et al. reported on the impact of HLA-C 
mismatch in a cohort of 111 patients transplanted with PBSC from unrelated donors after non-
myeloablative conditioning with busulfan (3.2 mg/kg) and fludarabine (120 mg/m2) (10). GVHD 
prophylaxis included cyclosporine/prednisone-based regimens and tacrolimus/mini-methotrexate-
based regimens. Seventy-eight of the patients were 10/10 matched (HLA-A, B, C, DRB1 and 
DQB1), 21 were mismatched at a single HLA-C locus, three were double mismatched at HLA-C, 
and nine were mismatched at HLA-C plus another locus. Mismatching at HLA-C did not 
compromise engraftment, with median neutrophil and platelet nadir times being similar in all 
groups. Graft rejection only occurred in two patients in the mismatch group as compared to one 
patient in the matched group. Patients with HLA-C mismatch had higher incidence of grade II-IV  
and III-IV acute GVHD as compared to 10/10 matched patients (grade II-IV 42% vs 26%, P=0.04; 
grade III-IV 33% vs 12%, P=0.01). There was no difference in chronic GVHD between the two 
groups. Non-relapse mortality was significantly higher in the HLA-C mismatched patients (48% vs. 
16%, P=0.0001), while a trend was observed toward higher relapse mortality in the matched 
patients (55% vs 35%, P=0.09). Overall survival at 2 years was significantly lower in mismatched 
patients (30% vs 51%, P=0.008) and presence of HLA-C mismatch was an independent risk factor 
for death (HR 1.85, P=0.04).  
 
Ogawa et al. (21) reported a series of 26 patients transplanted with PBSC from haploidentical 
donors with 2-3 HLA antigen mismatches in the graft versus host vector. The conditioning regimen 
consisted of fludarabine (180 mg/m2), busulfan (8 mg/kg) and ATG (8 mg/kg). Both to prevent 
ATG associated anaphylaxis and GVHD, methylprednisolone was administered from day -4 and 
tapered from day +15 to +30. Tacrolimus was started on day -1 (I.V. infusion 0.02 mg/kg; oral dose 
0.08 mg/kg; target blood concentration 10–15 ng/mL) and tapered from day +30. All but one 
patient engrafted, and ten out of 25 evaluable patients developed acute GVHD (grade I, N=5; grade 
II, N=5). Out 20 patients evaluable, five developed extensive chronic GVHD. Four patients died of 
treatment related mortality and the 3-year relapse rate was 27.1% for patients in CR at time of 
transplantation and 29.8% in for patients not in CR. Overall survival was 55%.  
 
In a recent study of 274 patients with AML the cohort included 34 who were transplanted with 
HLA mismatched donors (22). All patients were treated with PBSC after non-myeloablative 
conditioning (fludarabine 90 mg/m2 and 2 Gy TBI) and calcineurin/MMF based 
immunosuppression. Of the 12 patients who experienced graft rejection only one was transplanted 
with a HLA mismatched donor. Rates of acute GVHD were higher in patients with HLA 
mismatched unrelated grafts as compared to patients with matched related or unrelated grafts (grade 
II, 50% vs 28% and 43%, respectively; grade III-IV, 24% vs 12% and 12%), while no difference 
was observed in chronic GVHD. In the multivariate analysis, increased HLA disparity between 
patient and donor was associated with increased risk of non-relapse mortality (HLA matched 
related, HR 1.00; HLA matched unrelated, HR 1.86; HLA-mismatched unrelated 3.91; P=0.003). 
Although HLA-mismatched unrelated recipients seemed to have less 5-year relapse/progression 
than HLA-matched related or unrelated recipients (25% vs 47% and 42%, respectively), these 
differences were not statistically significant. Furthermore, patients with HLA-mismatched unrelated 
donors had a slightly worse 5-year OS than patients with HLA-matched related or unrelated donors 
(22% v 37% and 33%, respectively; P = 0.37). 
 
 
The locus-specific effect of HLA-mismatch was shown in a recent NMDP analysis of unrelated 
PBSC [Woolfrey, unpublished]. Among the subset of 616 patients given reduced intensity or 
nonmyeloablative conditioning, mismatching of HLA-C antigen (n=65) was associated with an 
increase in the risk of mortality compared to 8/8 matches (RR 1.40 [1.01-1.95], p=0.04). In contrast, 


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other 7/8 (non-C) antigen mismatched pairs and 7/8 allele mismatched pairs did not have 
statistically higher mortality than 8/8 matched pairs in either myeloablative or nonmyeloablative 
groups. 
 
 
Although these studies are heterogeneous in all aspects of their design, collectively they 
demonstrate that sustained engraftment is achievable using reduced intensity or non-myeloablative 
conditioning. However, incidences of treatment related mortality and GVHD remain high.  
    
3C. FHCRC Protocol 1591: Campath® [Alemtuzumab] 
Dose Escalation, Low-Dose TBI and Fludarabine 
Followed by HLA Class I Mismatched Donor Stem Cell 
Transplantation for Patients with Hematologic 
Malignancies - A Multi-Center Trial (11) 
The purpose of this protocol was to test the feasibility 
of extending allogeneic HCT after non-myeloablative 
conditioning (fludarabine 90 mg/m2 and 2 Gy TBI) to 
include donor grafts from HLA class I mismatched related 
or unrelated donors. Immunosuppression consisted CSP (5 
mg/kg b.i.d.) from day -3 with taper from +180 to day 
+365 and MMF (15 mg/kg t.i.d.) from day 0 with taper 
from day +100 (11% weekly for eight weeks). Fifty-nine 
patients were enrolled on the protocol. All patients received 
PBSC from either a related (N=5) or unrelated donor 
(N=54). All recipient/donor pairs were mismatched for at 
least one HLA class I locus (A, B or C) at the antigen level, 
except for a single unrelated pair that had two mismatches 
at the allele level. In the subset of unrelated pairs, 10 had 
an additional class I allele mismatch, while no additional allele level mismatches were observed in 
related recipient/donor pairs. The study design included a provision for the addition of 
alemtuzumab to CSP and MMF, if the rejection rate exceeded 20%. However, all patients were 
transplanted without alemtuzumab, as the sustained engraftment rate was 95%. Only 43 patients 
were evaluable for rejection because 4 died less than 30 days after transplantation (2 of treatment 
related toxicity and 2 of disease progression), 8 recipient/donor pairs were mismatched in the 
GVHD vector only and 4 received planned tandem auto-allo transplants. The median neutrophil and 
platelet nadirs were 100 cells/L (range 0-860 cell/L) and 23x103 /L (range 4-110x103 /L), 
respectively. Ninety-one percent of the patients developed neutropenia for median of 9 days (range 
0-33), while 38% of the patients developed thrombocytopenia for a median of 0 days (0-23). The 
cumulative incidences of grade II-IV acute, grade III-IV acute and extensive chronic GVHD were 
69%, 26% and 41%, respectively (figures 1A-B). The cumulative probabilities of non-relapse 
mortality were 22% at day 100 and 36% at 1 year (figure 2A). Twenty-six patients died of non-
relapse mortality with the most common causes being infection with (N=8) or without GVHD 
(N=4) (Table 1). Two-year overall and progression-free survivals were 29% and 28%, respectively 
(figure 2B). In summary, protocol 1591 demonstrated that sustained engraftment of HLA class I 
single antigen mismatched donor grafts is achievable with non-myoablative conditioning. However, 
cumulative incidences of non-relapse mortality and GVHD were high, and further studies 
addressing these issues are warranted.    
 
 
Figure 1 


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Table 1. Causes of non-relapse mortality in 26 patients 
Diagnose   
 
Within the 1st year after 
HCT, no. 
More the 1st year after 
HCT, no. 
Infection with GVHD 
 
6 
2 
Infection without GVHD  
2 
2 
GVHD* 
 
3 
1 
Multiorgan failure 
 
3 
0 
Secondary AML 
 
1 
0 
Diffuse alveolar 
damage, ARDS 
 
2 
0 
Cardiac failure 
 
2 
1 
Leukoencephalopathy 
 
1 
0 
*Includes 2 patients with bronchiolitis obliterans 
              
 
3D. Relationship between GVHD and graft versus tumor effects 
 
We analyzed GVT effects in 322 patients with hematological malignancies given grafts from 
HLA-matched related (n=192) or unrelated donors (n=130) (23). Two-hundred and twenty-one 
patients had measurable disease at HCT and 126 of them (57%) achieved partial (n=28) or complete 
(n=98) remissions. In multivariate analysis, there was a trend for a higher probability of achieving 
complete remissions in patients with chronic extensive GVHD (p=0.07). One hundred and eight 
patients (34%) have relapsed or progressed. In multivariate analysis, grade II-IV acute GVHD had 
no statistically significant impact on the risk of relapse/progression, but was associated with 
increased risk of non-relapse mortality and decreased probability of progression-free survival. 
Conversely, extensive chronic GVHD was associated with decreased risk of relapse/progression 
(p=0.006) and improved probability of progression-free survival (p=0.003). These data suggest that 
outcomes of nonmyeloablative conditioning and unrelated HCT could be improved by more 
intensive post-grafting immunosuppression aimed at suppressing acute GVHD, while allowing 
chronic GVHD to occur 
Figure 2 


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3E. Postgrafting immunosuppression 
  
1. CSP and MMF  
 
CSP and MMF will be used in the current protocol as this combination enabled sustained 
engraftment in protocol 1591. However, the exact schedule for their administration will be adjusted 
due to experiences derived from FHCRC protocols 1463, 1641, 1668 and 1938. All patients 
enrolled in these protocols were transplanted with unrelated donors after non-myeloablative 
conditioning with fludarabine 90mg/m2 and 2 Gy TBI. Three patients with CML on protocol 1668 
received 3 Gy of TBI. Protocol 1938, which is a randomized phase II study investigating MMF, 
tacrolimus and sirolimus, will be discussed in section 3E.2.b. 
 
 a) FHCRC Protocol 1463(2) and 1641(24) 
 
Eighty-nine patients were enrolled on protocol 1463. All patients were transplanted with PBSC 
or bone marrow from fully matched unrelated donors (10/10 HLA-A, -B, -C, -DR, and –DQ). Post-
grafting immunosuppression consisted of MMF and CSP. MMF was given b.i.d. (15 mg/kg) from 
day 0 to +40 and then tapered off by day +96, while CSP that was given b.i.d. (6.25 mg/kg) from 
day –3 to +100 and tapered off by day +180.The cumulative incidence of grade II-IV acute GVHD 
was 52% and 37% for extensive chronic GVHD. The probabilities of 1-year overall survival and 
progression free survival were 52% and 38%, respectively. Data from protocol 1463 demonstrated 
significant differences in outcome between recipients of PBSC or bone marrow. Although the 
sustained engraftment rate in the whole cohort only was 79%, engraftment was significantly higher 
in recipients of PBSC than recipients of bone marrow (85% vs 45%, P=0.007). Progression free 
survival was also higher in recipients of PBSC (44% vs. 17%, P=0.02), despite an increased 
cumulative incidence of grade III-IV acute GVHD (11% vs. 0%, P=0.05). Pharmacokinetic studies 
of MMF, demonstrated that the halflife of its active metabolite was 3 hours, suggesting that better 
immunosuppression could be obtained by more frequent dosing of MMF. 
 
Based on the data derived from protocol 1463 protocol 1641 was developed. It was essentially 
the same as the original, however to ensure engraftment and reduce acute GVHD, the MMF dosing 
schedule was changed to t.i.d. and all patients were transplanted with PBSC.  Ninety-nine patients 
were enrolled on protocol 1641. With three daily doses of MMF the median day +28 T-cell 
chimerism increased to 92% compared to 75% (P=0.02) and sustained engraftment was 95%. 
Cumulative incidences of acute (52%) and chronic (40%) GVHD were similar to protocol 1463. 
One-year overall survival, progression-free survival, relapse/progression, and non-relapse mortality 
were 64%, 54%, 27%, and 19%, respectively. 
 In a combined analysis of PBSC recipients in both protocols (N=174) the diagnoses of 
CML and MDS/MPS were associated with a greater risk of graft rejection (P=0.0006) relative to all 
other diagnoses. Furthermore the 1-year non-relapse and relapse related mortalities were 25% and 
35%, respectively for MDS/MPS patients, which translated into an inferior 1-year overall survival 
(40% vs. 60-80% for leukemia, lymphoma and multiple myeloma). One-year progression free 
survival was also inferior for both MDS/MPS and CML patients (30% vs. 55-60% for leukemia, 
lymphoma and multiple myeloma). The reason for the poor progression free survival for MDS/MPS 
patients was high relapse and nonrelapse mortality rates and for CML patients, disease progression 
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b) FHCRC Protocol 1668(25) 
Several studies have suggested that CSP prevented activation induced death of T-cells, and thus 
potentially delayed eradication of alloreactive donor T-cells, hereby preventing tolerance induction 
(26,27). Conversely, antimetabolites such as MMF could delete autoreactive T cells by inducing 
apoptosis (28, 29). The goal of protocol 1668 was to reduce the incidence of GVHD by translating 
these experimental findings into the clinical setting. The period of CSP administration was 
shortened (5mg/kg b.i.d. from day -3 to +80) while  the duration of MMF was prolonged (15mg/kg 
t.i.d from day 0 to +30, then b.i.d. until day +150 and taper to day 180). Seventy-one patients were 
enrolled, all transplanted with PBSC from fully matched unrelated donors. Sustained engraftment 
was observed in 96%, with lower overall survival and progressionfree survival as compared to a 
cohort 103 of historical controls (overall survival: 55% vs. 68%, P=0.05; progression free survival 
47% vs. 56%, P=0.05 (adjusted for pre-transplant risk factors)). One-year relapse incidence was 
similar between the two cohorts (23% vs 26%). However, nonrelapse mortality was significantly 
higher in the current protocol (29% vs 18%, P=0.02). The patients who were without grade II-IV 
acute GVHD at day+80, and therefore had their CSP stopped, had significantly higher risk of 
experiencing non-relapse mortality (HR 10.1, P<0.0001), as compared to patients  who were 
continued on CSP due to GVHD. Current and historical non-relapse mortalities prior to CSP 
cessation at day +80 were comparable. Furthermore cumulative incidences of grade  
II-IV and III-IV acute GVHD were 77% and 26% among current patients versus 52% and 15% 
among historical patients, respectively. Among the current patients, 7 experienced grade III-IV 
acute GVHD, of which 4 were in immediate relation to cessation of CSP administration (3 at day 
+80 and 1 due to disease progression). The cumulative incidence of chronic GVHD in the current 
protocol was 45%, and similar to the historical cohort. In summary, we observed that prolonging 
MMF and truncating CSP increased the cumulative incidence of acute GVHD instead of reducing 
it. Thus, suggesting that administration of a calcineurin inhibitor for at least 6 months is needed to 
establish graft-host-tolerance (25). 
 
2. Sirolimus (Rapamune ®) 
a) Mechanism of action.  
i) Immunomodulatory effect. Sirolimus was isolated in a discovery program for novel antifungal 
agents. It is a macrocyclic lactone fermentation product of Streptomyces hygroscopicus, an 
actinomycete that was isolated from a soil sample collected from Rapa Nui (Easter Island). 
Although, the activity of sirolimus depends on its binding to the same class of cytosolic binding 
proteins (immunophilins) as CSP and tacrolimus, its mechanism of action is unique. The complex 
of CSP or tacrolimus with their respective immunophilins inhibit calcineurin, which in turn impairs 
signaling through the T-cell receptor, reducing the expression of cytokines important for the antigen 
specific expansion of T-cells (e.g. IL-2, IL-3, IL4 and TNFα.), hereby arresting their cell cycle in 
G0 to G1. Sirolimus has no effect on the calcineurin pathway, but inhibits the mammalian target of 
rapamycin (mTOR) protein kinase, which promotes cell proliferation and is a key regulatory kinase 
in cell cycle control. In contrast to CSP and tacrolimus inhibition of T-cell receptor induced 
activation and cytokine secretion, the sirolimus-immunophilin complex inhibits the T-cell’s 
response to cytokines, hereby arresting the cell cycle at a later stage (G1 to S phase) (30). Although 
the mechanism is not fully understood, mTOR inhibition has the ability to promote antigen specific 
expansion of regulatory T-cells (Treg) and skew the CD4+ phenotype towards the tolerance inducing 
CD4+CD25high (31)[Gao1]. Evidence points to that mTOR inhibition mainly blocks signaling 
pathways important for the expansion of T effector cells, while IL-2 dependent JAK/STAT 
signaling which is important for Treg proliferation is unaffected [Frank1] (32,33). The preferential 


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expansion of Treg is attenuated when sirolimus is used in combination with CSP[Gao1]. In a murine 
bone marrow transplantation model transfer of Treg could prevent GVHD induced by non-regulatory 
T-cells, without interfering with engraftment or the graft versus leukemia effect (34)[ Hanash1] 
(35).   
 
 
Another immunomodulatory property of sirolimus is its ability to inhibit dendritic cell activity. 
The mTOR pathway has been demonstrated to be important for the in vitro development of CD34-
derived dendritic cells, with inhibition by sirolimus reducing antigen uptake, lipopolysaccharide 
induced cytokine secretion, CCR7 expression and T-cell stimulation (36). 
 
ii) Viral amplification. Inhibition of mTOR may also have effects on viral amplification, as CMV 
specifically upregulates the mTOR pathway during replication (37). In allogeneic HCT and solid 
organ transplantation lower risk of CMV activation has been reported in patients treated with 
sirolimus (13,38).  
 
iii) Antineoplastic effects. The mTOR signaling pathway is often constitutively activated in 
various human cancers. The efficacy of sirolimus as an antiangiogenetic antineoplastic agent has 
been demonstrated in several experimental cancer models (39-41). In the context of solid organ 
transplantation, a retrospective analysis of transplant registry data from 33249 recipients of necro-
kidney allografts, showed a decreased risk of developing any de novo cancer in recipients treated 
with mTOR based immunosuppression (sirolimus or an analog), as compared to recipients treated 
with non-mTOR inhibitor based immunosuppression (hazard ratio: 0.39; 95% CI: 0.24-0.64; 
P=0.0002) (42).  
 
b) Sirolimus for acute GVHD prophylaxis. Four clinical trials with sirolimus have been published 
from the Dana-Farber Cancer Institute (Table 2) ((12), (13),(14),(15)). In all 4 trials similar GVHD 
prevention with sirolimus in combination with tacrolimus ± abbreviated MTX dosing (5 mg/m2 
given every other day starting on day +1 for 3 to 4 days), was used. Sirolimus was started at day -3 
with a oral loading dose of 12 mg, and followed by a single daily dose of 4 mg, with a target serum 
concentration of 3-12 ng/ml. Tacrolimus was administrated at 0.02 – 0.05 mg/kg/day intravenously 
by continuous infusion beginning on day-3 with a target serum concentration of 5-10 ng/ml. 
Control of GVHD was excellent independently of conditioning regimen (MAC vs RIC (fludarabine 
120 mg/m2 and busulfan 3.2 mg/kg)), donor source (related vs unrelated) and stem cell source 
(bone marrow vs. peripheral blood stem cells) (Table 2).  
 


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Table 2. Summary of clinical trials 
 
 
In a small study of 15 patients receiving primarily PBSC from 9 unrelated and 6 related fully 
HLA matched donors after RIC (FLAMSA-RIC), the GVHD prevention was comprised of a 
combination of sirolimus (4 mg daily starting on day -1, with a target concentration of 5-10 ng/ml 
and taper at day +60 to +90) and MMF (1000 mg administered 6-12 hrs after transplantation, 
hereafter 2000 mg daily with reduction and termination at day +50) (16). Although sirolimus was 
started  as late as one day prior to the transplant, satisfactory GVHD control was obtained, with 
only two patients experiencing acute GVHD (1 grade II and one grade IV) and three experiencing 
chronic GVHD.  
 
In a recent study by Snyder et al. (17), 23 patients with myelofibrosis were transplanted using a 
primarily fludarabine and melphalane based RIC regimen. The first nine patients received 
CSP/MMF based immunosuppression, while the last 14 received a combination of sirolimus and 
tacrolimus analogous to the studies by Antin et al. and Cutler et al. All patients were transplanted 
with PBSC and 15 out of 23 with grafts from unrelated donors (7 out of 9 in the CSP/MMF group 
and 8 out of 14 in sirolimus/tacrolimus group). 13 out of the 15 patients transplanted with unrelated 
donors received additional immunosuppression with MTX 5 mg/m2 on day +1, +3 and +6 (6 in the 
CSP/MMF group and 7 in sirolimus/tacrolimus group).  Sixteen of the 23 patients experienced 
acute GVHD with no significant difference between the CSP/MMF and sirolimus/tacrolimus 
groups. However in the subset of patients who developed grade III-IV acute GVHD (N=5) the 
 
Antinet al. (12)1 
Cutler et al. (13) 
Cutler et al. (14) 
Alyea et al. (15) 
FHCRC protocol 
1938 
Sample size 
41 
30 
83 
91 
62 
Median age, yrs (range) 
42 (19-62) 
42 (19-54) 
42 (18-59)* 
44 (22-54)** 
57 (20-69) 
60 (13-75) 
HLA match 
 
 
 
 
 
 
HLA matched, related 
 
30 
(1 HLA matched parent) 
53 
46 
(1 HLA-C  MM) 
 
 
HLA matched, unrelated 
29 
 
30 
45 
(7 HLA-C  MM) 
62 
Hematopoietic cell source 
BM 
PBSC 
PBSC 
PBSC 
PBSC 
Conditioning 
MAC 
MAC 
MAC 
RIC 
NMA 
Immunosuppression 
 
 
 
 
 
 
Sirolimus, daily dose (mg/kg) 
(start day/start taper/end) 
4 
(-3/+63/+182) 
4 
(-3/+100/+182) 
4 
(-3/+100/+182) 
4 
(-3/NA/NA) 
2 
(-3/NA/+80) 
 
Tacrolimus, daily dose (mg/kg) 
(start day/start taper/end) 
0.02 
(-3/+63/+182) 
0.02 
(-3/+100/+182) 
0.02 
(-3/+100/+182) 
0.05 
(-3/NA/NA) 
0.12 
(-3/+100/+150) 
 
MMF, dose (mg/kg) 
(start day/start taper/end) 
 
 
 
 
0.45/0.30 
(-3/+100/+180) 
 
Other 
MTX 
 
 
MTX 
 
GVHD (%) 
 
 
 
 
 
 
Acute grade. II-IV, %  
26 
10 (only gr. II) 
21 
10 
45 
 
Acute grade. III-IV, %  
13 
0 
NA 
NA 
11 
 
Chronic, % 
44 
11 out of 28 patients 
59 
40 
46 
Survival 
 
 
 
 
 
 
treatment-related mortality, %  
15 (day 100) 
6 (1 yr) 
5 (day 100) 
6 (2 yrs) 
3 (day 200) 
 
1 year relapse-free survival, % 
46 
71 
72 
47 
NA 
 
1 year overall survival, % 
51 
67 
77 
74 
47 (2 yrs) 
BM, bone marrow; PBSC, peripheral blood stem cells; MAC, myeloablative conditioning; RIC, reduced intensity 
conditioning; NMA, non-myeloablative conditioning; MMF, mycophenolate mofetil ; MTX, methotrexate; GVHD, 
graft versus host disease; NA, not available; *, patients transplanted with matched related donors; **, patients 
transplanted with matched unrelated donors. 


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cumulative incidence was significantly higher in the CSP/MMF group as compared to the 
sirolimus/tacrolimus group (60% vs. 10%, P=0.01). No patients in the sirolimus/tacrolimus group 
succumbed to treatment related causes (day 100 treatment related mortality 0% vs 33%, P=0.02), 
which translated into a superior overall 
survival at 2 years (93% vs 56%, 
P=0.05).  
 
FHCRC protocol 1938 is a 
randomized 3-arm phase II study 
comparing the efficacy of different 
combinations of MMF, tacrolimus and 
sirolimus in preventing acute GVHD 
(Figure 3). By May 2010 183 patients 
had been accrued (arm #1 (control), 
N=60; arm #2, N=61: arm #3, N=61). 
Most were transplanted with PBSC from 
fully matched unrelated donors (single 
HLA class I mismatch in 9%) after non-
myeloablative conditioning (90 mg/m2 
and TBI 200 cGy). Sirolimus was 
administered in combination with MMF 
and tacrolimus, from day -3 to +80, with 
a daily dose of 2 mg and a target 
concentration of 3-12 ng/ml (figure 3). The cumulative incidence of grade II-IV acute GVHD was 
lower in the sirolimus arm as compared to the tacrolimus/MMF only arms, although the difference 
was only significant when compared to the control arm (figure 4A). Dividing acute GVHD into 
separate grades, the addition 
of sirolimus lowered the 
cumulative incidence of 
grade II acute GVHD as 
compared to the 
tacrolimus/MMF only arms 
(figure 4A). No difference 
between treatment arms was 
observed for grade III-IV 
acute GVHD (arm #1 12%; 
arm #2 13%; arm #3 11%) or 
chronic GVHD (arm #1 
43%; arm #2 42%; arm #3 
46%). Furthermore no 
differences between 
treatment arms were 
observed for nonrelapse 
mortality and 
relapse/progression (figure 
4C-D). When the results of 
protocol 1938 were 
compared to a historical 
Figure 3 


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cohort 174 unrelated non-myeloablative transplants treated with a combination of CSP and MMF, 
no difference was observed in the cumulative incidences of nonrelapse mortality, 
relapse/progression, and acute (figure 4A) and chronic GVHD as compared to the tacrolimus/MMF 
only arms. Thus, suggesting that the substitution of CSP for tacrolimus did not entail additional 
GVHD control. 
 
 All patients in the four studies from Dana-Farber Cancer Institute and in FHCRC protocol 
1938 engrafted. Median times to neutrophil and platelet engraftment were between 13-18 days and 
13-29, respectively.  
 
There has been a concern that sirolimus treatment added to the toxicity of the calcineurin 
inhibitors. In a retrospective analysis by Cutler et al. (43) from 2005, post transplant toxicities were 
compared between 111 and 216 patients treated with sirolimus and non-sirolimus based 
immunosuppression. Patients in the sirolimus group had a significantly higher incidence of 
thrombotic microangiopathy post-transplant (10.8% vs 4.2%, P=0.03). However, in the trial by 
Cutler et al. from 2007(14) the incidence was not increased, and in FHCRC protocol 1938 there was 
no difference in the incidence of toxicities across the three treatment arms.    
 
c) The rationale for the use of sirolimus in combination with CSP and MMF for acute GVHD 
prophylaxis after related or unrelated donor HCT and nonmyeloablative conditioning.  
 
The rationale for the current proposal is that sirolimus induced mTOR inhibition, provides 
immunosuppression at a different point in T-cell activation than MMF and the calcineurin inhibitors 
leading to synergistic effects(30,44-47). Data from FHCRC protocol 1938 have already 
demonstrated that the addition of sirolimus elicits improved control of acute GVHD, as compared 
to the combination of MMF and a calcineurin inhibitor alone. Furthermore, due to the unique effect 
on mTOR, which is involved in numerous cellular processes, the addition of sirolimus may also 
have an adventitious influence on CMV activation and tumor control.   
 
 
3F. The use of 3 Gy TBI in place of 2 Gy TBI for patients at higher risk of rejection. 
 
We have shown that the risk of rejection increases for certain diseases (MDS, MPD and CML), 
as well as for those patients previously transplanted with either syngeneic or allogeneic stem cells. 
Thus, for these scenarios and while maintaining a non-myeloablative platform, the following 
patients will receive 3 Gy (rather than 2 Gy) TBI. 
 
4. Proposal 
 
 
The goal of the current trial is to determine whether the incidence of acute GVHD can be 
reduced after non-myeloablative HLA class I or II mismatched donor HCT to less than the 
historical rate of 70%  by adding sirolimus to CSP and MMF. A combination of CSP and MMF will 
be used, as this combination enabled sustained engraftment after non-myeloablative HLA class I 
mismatched donor HCT, without the need for additional alemtuzumab (FHCRC protocol 1591). As 
a result of insufficient GVHD prevention in protocol 1591, sirolimus will be added to the 
combination of CSP and MMF, as data from protocol 1938 demonstrated better GVHD control with 
this combination. The choice of CSP over tacrolimus is also derived from data from protocol 1938, 
which showed no significant difference in transplantation outcome, between patients treated with 
the tacrolimus and MMF combination compared to a historical cohort treated with CSP and MMF. 
Furthermore, the MMF scheme from protocol 1938 with administration three times daily for the 
first 30 days post-transplant, and then twice daily for the remaining period enabled engraftment 


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without increasing GVHD. To avoid the detrimental effect of CSP on the possible sirolimus 
induced selective expansion of Treg, the duration of CSP treatment will be shorter than sirolimus. 
However due to development of grade III-IV acute GVHD coinciding with early termination of 
CSP in protocol 1668, CSP taper will first start at day 150 in the current protocol. The treatment 
schedule is outlined in figure 5 (page 20). 
 
 
5. Primary Objective 
 
 
To determine whether the incidence of acute GVHD grades II-IV can be reduced to less than  
the historical rate of 70% with the triple-immunosuppressant combination of CSP/MMF with 
sirolimus in HLA class I or class II mismatched related or unrelated donor HCT using 
nonmyeloablative conditioning. The evaluation will be carried out separately among class I and 
class II mismatched patients. 
 
6. Secondary Objectives 
 
• To evaluate the incidence of non-relapse mortality before day 100 
• 
To evaluate the incidences of grades III-IV acute GVHD 
 
7. Patient Selection 
• 
A. Inclusions 
 
Ages >50 years with hematologic malignancies treatable by related or unrelated HCT.  
 
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who through 
pre-existing medical conditions or prior therapy are considered to be at high risk for regimen 
related toxicity associated with a high dose transplant (>40% risk of TRM). This criterion can 
include patients with a HCT-CI score of >1 (see Appendix Q). Transplants should be 
approved for these inclusion criteria by the principal investigators at the collaborating centers 
and at FHCRC. All children < 12 years must be discussed with the FHCRC PI (Brenda 
Sandmaier, MD 206 667 4961) prior to registration. 
 
 Ages  50 years of age with chronic lymphocytic leukemia (CLL).  
 
Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who refuse a 
high-dose HCT. Transplants must be approved for these inclusion criteria by the principal 
investigators at the collaborating centers and at FHCRC. 
 
The following diseases will be permitted although other diagnoses can be considered if 
approved by PCC or the participating institutions’ patient review committees and the principal 
investigators. 
• Aggressive nonHodgkin lymphomas (NHL) and Other Histologies Such as Diffuse 
large B cell NHL– not eligible for autologous HCT, not eligible for high-dose allogeneic 
HCT, or after failed autologous HCT.  
• Mantle Cell NHL -may be treated in first CR. (Diagnostic LP required pre-transplant) 
• Low grade NHL– with < 6 month duration of CR between courses of conventional therapy 


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• CLL – must have either 1) failed to meet NCI Working Group criteria for complete or 
partial response after therapy with a regimen containing FLU (or another nucleoside 
analog, e.g. 2-CDA, pentostatin) or experience disease relapse within 12 months after 
completing therapy with a regimen containing FLU (or another nucleoside analog); 2) 
failed FLU-CY-Rituximab (FCR) combination chemotherapy at any time point; or 3) have 
“17p deletion” cytogenetic abnormality. Patients should have received induction 
chemotherapy but could be transplanted in 1st CR; 4) Patients with a diagnosis of CLL (or 
small lymphocytic lymphoma) that progresses to prolymphocytic leukemia (PLL); or 5) 
patients with T-cell CLL or PLL. 
• Hodgkin Lymphoma – must have received and failed frontline therapy. 
• Multiple Myeloma – must have received prior chemotherapy.  Consolidation of 
chemotherapy by autografting prior to nonmyeloablative HCT is permitted. 
• Acute Myeloid Leukemia (AML) – must have < 5% marrow blasts at the time of 
transplant.  
• Acute Lymphocytic Leukemia (ALL) – must have <5% marrow blasts at the time of 
transplant. 
• Chronic Myeloid Leukemia (CML) – Patients in CP1 must have failed or be intolerant of 
TKIs.  Patients beyond CP1 will be accepted if they have <5% marrow blasts at time of 
transplant.   
• Myelodysplasia (MDS)/Myeloproliferative Syndrome (MPS) – Patients must have <5% 
marrow blasts at time of transplant.  
• Waldenstrom’s Macroglobulinemia – must have failed 2 courses of therapy. 
 
Patients with related or unrelated donors for whom the best available donor is: 
a. Mismatched at antigen level for any single class I locus (HLA-A, -B, -C) ± an additional 
class I mismatch at the allele level 
 
OR 
  mismatched at the allele level for any 2 class I loci (if typed at the molecular level). 
   
  
 
 
OR 
mismatched at the antigen or allele level for class II loci HLA-DRB1 and/or –DQB1. Must 
be matched for at least one DRB1 allele and one DQB1 allele 
 
b. there is a likelihood of rapid disease progression while HLA typing and results of a 
preliminary search and the donor pool suggests that a 10/10 HLA-A, B, C, DRB1 and 
DQB1 matched donor will not be found 
 
c. there is no HLA-A, -B or -C one locus allelic mismatched donor available 
 
B. Exclusions  
 
1. Patients for whom the best available donor is mismatched at both HLA class I and class II. 
2. A positive cross-match exists between the donor and recipient.  
3. Patients with rapidly progressive intermediate or high grade NHL 
4. Patients with a diagnosis of CMML. 
5. Patients with RAEB-2 who have not received myelosuppressive chemotherapy i.e. induction 
chemotherapy. 


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6. Presence of circulating leukemic blasts (in the peripheral blood) detected by standard 
pathology for patients with AML, ALL or CML. 
7. Presence of ≥ 5% circulating leukemic blasts (in the peripheral blood) detected by standard 
pathology for patients with MDS/MPS 
8. CNS involvement with disease refractory to intrathecal chemotherapy.  For LP requirement 
see Appendix N. 
9. Fertile men or women unwilling to use contraceptives during and for up to 12 months  
following treatment 
10. Female patients who are pregnant or breast-feeding 
11. HIV positive patients 
12. Patients with active non-hematologic malignancies (except non-melanoma skin cancers) or 
those with non-hematologic malignancies (except non-melanoma skin cancers) who have 
been rendered with no evidence of disease, but have a greater than 20% chance of having 
disease recurrence within 5 years. 
This exclusion does not apply to patients with non-hematologic malignancies that do not 
require therapy. 
13. Fungal infections with radiological progression after receipt of amphotericin B or active 
triazole for greater than 1 month 
14. Patients with active bacterial or fungal infections unresponsive to medical therapy. 
15. Organ Dysfunction. 
a.  Cardiac ejection fraction < 35% (or, if unable to obtain ejection fraction, shortening 
fraction of < 26%).  Ejection fraction is required if the patient is > 50 years of age, or 
history of cardiac disease or anthracycline exposure.  Patients with a shortening fraction 
< 26% may be enrolled if approved by a cardiologist. 
  
b. Pulmonary: 
i. corrected DLCO < 40%, TLC <40%, FEV1 <40% and/or receiving supplementary 
continuous oxygen.  If unable to perform complete PFTs, patients will be excluded 
if their oxygen saturation is <95% with a formal six-minute walk test (ambulatory 
oximetry). 
ii. The FHCRC PI of the study must approve of enrollment of all patients with 
pulmonary nodules. 
 
c.  Liver function abnormalities: Patients with clinical or laboratory evidence of liver disease 
would be evaluated for the cause of liver disease, its clinical severity in terms of liver 
function, and the degree of portal hypertension. Patients will be excluded if they are 
found to have fulminant liver failure, cirrhosis of the liver with evidence of portal 
hypertension, alcoholic hepatitis, esophageal varices, a history of bleeding esophageal 
varices, hepatic encephalopathy, uncorrectable hepatic synthetic dysfunction evinced by 
prolongation of the prothrombin time, ascites related to portal hypertension, bridging 
fibrosis, bacterial or fungal liver abscess, biliary obstruction, chronic viral hepatitis with 
total serum bilirubin >3 mg/dL, or symptomatic biliary disease. 
16. Patients with poorly controlled hypertension on multiple antihypertensives 
17. Karnofsky scores < 60 (see appendix B) or Lansky Score <50 (see appendix C). 
18. All patients receiving antifungal therapy voriconazole, posaconazole, or fluconazole must 
have sirolimus reduced according to the Standard Practice Antifungal Therapy Guidelines in 
Appendix E. 
19. The addition of cytotoxic agents for “cytoreduction” with the exception of tyrosine kinase 
inhibitors (such as imatinib), cytokine therapy, hydroxyurea, low dose cytarabine, 


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chlorambucil, or rituxan will not be allowed within three weeks of the initiation of 
conditioning. 
 
8. Donor Selection 
 
A. Inclusions 
1.  Related or unrelated volunteer donors who are mismatched with the recipient within one of 
the following limitations: 
a. mismatch for one HLA class I antigen with or without an additional mismatch for one 
HLA-class I allele, but matched for HLA-DRB1 and HLA-DQ, OR 
b.  mismatched for two HLA class I alleles, but matched for HLA-DRB1 and HLA-DQ, OR 
 
 
c.   HLA class I HLA-A, -B, -C allele matched donors allowing for any   
 
 
    one or two DRB1 and/or DQB1 antigen/allele mismatch  
2. HLA-matching must be based on results of high resolution typing at HLA-A, –B, -C, -
DRB1, and –DQB. 
3.  If the patient is homozygous at the mismatch HLA class I locus or II locus, the donor must 
be heterozygous at that locus and one allele must match the patient (i.e., patient is 
homozygous A*01:01 and donor is heterozygous A*01:01, A*02:01). This mismatch will 
be considered a one-antigen mismatch for rejection only. 
4. Donors are excluded when preexisting immunoreactivity is identified that would jeopardize 
donor hematopoietic cell engraftment. This determination is based on the standard practice 
of the individual institution. The donor should be excluded if any of the flow cytometric 
B and T cell cytotoxic cross match assays are positive.   
5. Only G-CSF mobilized PBSC only will be permitted as a HSC source on this protocol. 
 
B. Exclusions 
 
1. Donor (or centers) who will exclusively donate marrow.  
2. Donors who are HIV-positive and/or, medical conditions that would result in increased risk 
for G-CSF mobilization and harvest of PBSC. 
3. Patients who are homozygous at the mismatched HLA class I locus or II locus, the donor is 
excluded if homozygous at the mismatched locus (i.e., patient is homozygous A*01:01 and 
donor is homozygous A*02:01); this type of mismatch is considered a two-antigen 
mismatch and is not allowed 
 
9. Informed Consent 
 
Both patient and donor (and their parents/guardians) will meet with a physician to thoroughly 
discuss treatment recommendations regarding this protocol and alternative treatment options for the 
underlying disease. The physician will explicitly address the potential known risks associated with 
the use of fludarabine, low-dose TBI and immune suppressive drugs (CSP/MMF/sirolimus). Risks 
should be addressed as objectively as possible. Patients should be informed that they have advanced 
malignancy with life expectancy of months to no more than 1 or 2 years with conventional 
treatments, that they would unlikely benefit from autologous transplant and are at very high risk of 
early treatment related mortality from high dose transplants (if a high dose transplant would be 
applicable at all). For the related stem cell donor, the procedure for collecting peripheral 
mononuclear cells and toxicity of G-CSF treatment will be explained as well as the potential need 


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and risks for several time points of leukapheresis. A summary of the conference should be dictated 
for the medical record detailing what was covered. Informed consent from the patient will be 
obtained using forms approved by the Institutional Review Board (IRB) of the Fred Hutchinson 
Cancer Research Center or the performing center if the patient is treated in a collaborating 
institution. 
 
 
10. Protocol Registration  
 
 
FHCRC patients:  Eligible patients will be identified by the Clinical Coordinators Office.  Patients 
will be registered with the Registration Office (206-667-4728) between 8:30 am and 4:00 PM, 
Monday through Friday. After hours, the Registration office can be reached by paging (206) 995-
7437. 
 
Collaborating institutions: Eligible patients will be identified by the principal investigators of the 
collaborating institutions who will register the patient with the FHCRC. Registration will include 
completion of the eligibility checklist/demographic form (Appendix L).  This form will be faxed to 
the Trial Coordinator (206-667-5378).  Questions regarding eligibility or protocol information 
should be directed to Brenda Sandmaier, MD (206-667-4961) 


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11. Plan of Treatment  
 
A. Outline Treatment Plan (Figure 5)  
 
Figure 5. *, evaluation of T-cell chimerism; If T-cell chimerism is < 50% on day +28, then repeat only day +56, 
+84, +180 and +365. If T-cell chimerism is > 50% on day +28, then repeat only day +84 and +365. Granulocyte 
(CD33+) chimerism on day +84 only. Natural Killer cell (CD56+) chimerism will be obtained on day +28. Bone 
Marrow chimerism will be obtained on day +84 and 365 (See Patients Post-transplant Evaluation For more 
detail)  
 
Table 3: Conditioning and Immunosuppression Schedule  
Day 
-4 
-3 
-2 
-1 
0 
30 
100 
150 
180 
365 
fludarabine 
(30mg/m2/day) 
▼ 
▼ 
▼ 
  
  
  
  
  
  
  
TBI (Gy) 

  
  
  
2 or 3  
  
  
  
  
  
PBSC transfusion 
  

  
  
▼ 
  
  
  
  
  
CSP (5mg/kg, PO 
q12 hr) 
  
Start 





TaperA 
Stop 
 
MMF               
(15mg/kg, q8hrs) 
  
  
  
  
StartB 
q8hrs 
q12hrsCTaperD 
Stop 
 
  
Sirolimus         
(2mg QD) 
  
Start 




 
  
Taper   
StopE  
A. CSP should only be tapered on day 180 in patients without preceding acute GVHD requiring therapy. 
B. The first dose of MMF is to be given 4-6 hours after the stem cell infusion. 
C. Dosing schedule is changed from 15mg/kg T.I.D to 15mg/kg B.I.D. 
D. The MMF taper will be a weekly dose reduction of approximately 11-12%. 
E. The continuation of sirolimus for patients with severe acute GVHD is at the discretion of the attending physician.
 


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B. HCT 
 
Please refer to section 11.I.1 for information regarding the collection and infusion of related and 
unrelated donors.  
 
C. Cytoreduction 
 
Cytoreduction and /or radiation therapy may be given by the referring physician or the attending 
physician as determined on clinical grounds or to meet eligibility requirements of the protocol for 
patients with advanced malignancy or to reduce tumor bulk. However, no intensive chemotherapy can 
be given within three weeks (or the interval in which a cycle of standard chemotherapy would be 
administered in a non-transplant setting) prior to initiating the nonmyeloablative transplant 
conditioning (see exclusion criteria pages 16-17). The need for this therapy should be discussed with 
the principal investigator. The referring oncologist may be asked to administer this therapy.  
 
D. Definition of Preceding Chemotherapy and Biologic Modifiers 
 
For the purposes of this protocol, preceding chemotherapy is defined as any exposure to systemic 
chemotherapy. Exceptions to this definition include BCR/ABL tyrosine kinase inhibitors (Imatinib 
Mesylate, Dasatinib, etc.), cytokine therapy, hydroxyurea, low dose cytarabine, chlorambucil, or 
rituxan. 
 
E. Definition of Disease, Based on Risk of Progression 
 
Patients will be classified as being at standard-risk, high-risk or very high risk of progression. 
Standard-risk includes AML in first complete remission, ALL in first complete remission, MDS-
refractory anemia, CML in first chronic phase, CLL, low-grade NHL, high or intermediate grade 
NHL in complete remission, Hodgkin lymphoma in complete remission, multiple myeloma in 
complete remission or with minimal residual disease. Very high-risk includes acute leukemia beyond 
second complete remission, CML beyond chronic phase and MDS syndrome-refractory anemia with 
blast excess or above. High-risk includes other all diagnoses. 
 
F. Pre-transplant tyrosine kinase inhibitors (imatinib mesylate, dasatinib, nilotinib etc.).  
 
1. All patients with the diagnosis of CML or Ph+ ALL may continue treatment with imatinib 
mesylate, dasatinib, nilotinib or other BCR/ABL tyrosine kinase inhibitors until two days 
prior to HCT.  The tyrosine kinase inhibitors should then be stopped to prevent possible 
inhibition of engraftment of donor stem cells. 
  
2. Imatinib mesylate, dasatinib, or nilotinib and CNS prophylaxis and treatment: For 
patients who require cranial-spinal irradiation, imatinib mesylate or dasatinib will need to be 
discontinued 48 hours prior to initiating cranial spinal irradiation. This discontinuation is 
necessary because the combined effects of cranial-spinal irradiation and imatinib mesylate, 
dasatinib, or nilotinib on the CNS are not known. 
 
G. Conditioning Regimen (Refer to Figure 5 and Table 3) 
 
1. Days –4, -3, and –2: Fludarabine 30mg/m2/day IV, administered over 30 min. 
 


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2. Day 0: TBI 2 or 3 Gy at 6-7cGy/min from linear accelerator (Appendix V) followed by HCT. 
TBI to be administered between 10:00 a.m. and 2:00 p.m. to avoid proximity to MMF 
administration. 
 
CRITERIA FOR 3 GY TBI: Patients need to fulfill one or more of the following criteria for 3 
Gy TBI: 
 
a)  Patients with MDS, MPD, CML, or other hematologic malignancies not previously treated 
with myelosuppressive chemotherapy 
  
b)  Patients who have had a previous allogeneic transplant. 
  
c)  Patients who had a prior syngeneic transplant without subsequent myelosuppressive 
chemotherapy. 
  
d)  Patients who have not had myelosuppressive chemotherapy within 3-6 months of HCT may be 
at higher risk of rejection depending on treatment history and underlying diagnosis. Confirm TBI 
dose (200 vs 300 cGy) with PI. 
 
 
H. Immunosuppression  
 
a. Cyclosporine  
1. Starting dose: 
i. 
Adult dose: CSP is given based on adjusted body weight, at 5.0 mg/kg PO q12 
hours from day –3.  If there is nausea and vomiting at anytime during CSP 
treatment the drug should be given intravenously at the appropriate dose that 
was used to obtain a therapeutic level.  See guidelines for PO to IV conversion 
below. 
ii. Pediatric dose: Due to the variable and increased metabolism in children, CSP 
will be started intravenously on day –3 at the doses listed below.  
 
 i. Age <6 years old: 1.6 mg/kg IV q8 hours 
   
 
 
  
 ii. Age >6 years old: 2.0 mg/kg IV q12 hours 
iii. 
Sirolimus should be given at least 4 hours after an oral dose of CSP as 
concurrent administration leads to elevation of sirolimus levels. 
2. Cyclosporine discontinuation: 
i. 
In the absence of acute or chronic GVHD, CSP is tapered at day 150 over 30 days (to 
be completed on Day +180). 
ii. 
The referring physician, who will receive instructions and guidelines for detecting 
and managing GVHD, may manage this. Modifications of the taper schedule may be 
indicated if significant disease progression (increase in serum or urine paraprotein by 
≥25%) occurs posttransplant. The type of modification will depend on where a patient 
is relative to the standard tapering schedule. Options regarding early discontinuation 
of CSP therapy are summarized below (section 11.O). 
 
 
 


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3. Guidelines for CSP Dose Adjustment and Monitoring.  
i. 
Blood pressure, renal function (serum creatinine, BUN), electrolytes and magnesium 
need to be followed at least three times per week during the first month, twice 
weekly until day +100, then once per week until CSP is stopped, unless clinical 
circumstances suggest the need for more frequent evaluations. 
 
Table 4:  CSP Dose Adjustment 
 
 
CSP Level to Target 
Using LC-MS/MS 
Method 
CSP Level to Target Using 
Immunoassay Method 
Day “0”- Day +28 
Whole blood “trough” (11-12 hrs 
from prior dose) 
 
350 ng/ml 
 
400 ng/ml 
(upper end therapeutic range for this 
method) 
 
After Day +28 
 
 
120 - 300 ng/ml 
 
 
150 - 350 ng/ml 
 
Levels exceeding upper limits of 
target by >20% 
• 
with or without CSP toxicity 
• 
decrease in GFR >50% 
• 
increase in creatinine 2x 
baseline due to CSP 
 
 
 
 
25% dose reduction 
 
 
 
25% dose reduction 
Patients on Hemodialysis 
320 ng/ml 
400 ng/ml 
 
ii. 
Do not exceed cyclosporine levels > 350 ng/mL to reduce risk of sirolimus toxicity. 
iii. 
CSP Monitoring: CSP determinations should be performed on a twice weekly basis 
for the first month and then weekly until day +100 unless high levels are detected 
(i.e., >400ng/ml), or toxicity is suspected in which case more frequent monitoring 
will be performed as clinically indicated. Routine monitoring of CSP will not be 
required for patients on a CSP taper unless clinically indicated. 
iv. 
CSP Dose Adjustment: Initial high Cyclosporine (CSP) doses are required based on 
the pre clinical nonmyeloablative canine studies, which used an equivalent dose to 
establish an allograft.  After day +28, CSP levels typical for unrelated HCT will be 
targeted.  Dose reduction should only be made if CSP toxicity is present, and/or 
levels exceed values provided in Table 4.  There are two methods for calculating 
CSP levels. Table 4 provides desired levels for specific methods.  To avoid 
inadequate immune suppression, dose reductions should be conservative.  
Therapeutic levels of CSP should be maintained. 
v. 
After day +28, typical serum CSP transplant levels for related or unrelated HCT will 
be targeted. 
vi. 
Dose reductions should only be made if CSP toxicity is present and/or levels exceed 
values provided in Table 4.  Dose reductions for high levels without toxicity should 
be conservative e.g. 25%, to avoid inadequate immunosuppression. 
vii. 
If there is nausea and vomiting at anytime during CSP treatment the drug should be 
given intravenously at the dose that was used to obtain a therapeutic level.  Oral to 
IV conversion: Oral CSP dose  2.5 = IV dose.  
viii. Oral Sandimmune may be substituted for oral Neoral. 


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ix. 
Patients requiring hemodialysis should be have CSP levels maintained in the high 
therapeutic range (Table 4). 
x. 
Drugs that may affect CSP levels are (table 5):  
 
Table 5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
**Discontinuation of fluconazole or itraconazole may lower CSP levels, and if used for 
antifungal prophylaxis, then changes in these drugs should be avoided during the first 2 
months posttransplant. 
 
b.   MMF 
 
1. Initiating MMF therapy: Oral administration of MMF will be given based on adjusted body 
weight at 15 mg/kg Q8 hours (45 mg/kg/day) from the evening of day 0 (i.e. first dose to 
follow 4-6 hours after HCT). Doses will be rounded to the nearest 250 mg (capsules are 250 
mg). If there is nausea and vomiting at any time preventing the oral administration of MMF, 
MMF should be administered intravenously based on adjusted body weight at 15 mg/kg Q8 
hours 
 
2.  MMF discontinuation: MMF will be given daily at 15 mg/kg Q8 hours until day +30, and 
then in the absence of GVHD, the dose will be changed to 15 mg/kg Q12 hours until day 
Decrease CSP levels Increase CSP levels 
Enhance Potential for 
Nephrotoxicity 
Phenytoin 
Phenobarbital 
Carbamazepine 
Primidone 
Rifampicin 
Nafcillin 
Octreotide 
Sulfonamides 
Trimethoprim 
Metoclopramide 
Erythromycin        Diltiazem       
Alcohol                 Doxycycline 
Ketoconazole        Verapamil   
Azetazolamide      Nifedipine 
Fluconazole*        Nicardipine 
Colchicine            Azithromycin 
Itraconazole*        Imipenem      
Fluoroquinolones Posaconazole 
Voriconazole              
Caspofungin             
Clarithromycin 
Aminoclycosides 
Loop diuretics (furosemide)  
Amphotericin formulations 
 


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100. In the absence of GVHD, MMF will be tapered at day 100 by 11-12% per week and 
discontinued at day +150. 
 
3. Maintaining MMF: Markedly low (<40%) donor T cell chimerism after HCT may indicate 
impending graft rejection. MMF should be continued at full dose or, if MMF taper has been 
initiated, reinstitution of full dose MMF should occur. Consideration of graft salvage with use 
of DLI should be considered. In the setting of acute GVHD, continuation of MMF is 
recommended (see 14.G GVHD treatment guidelines).  
4. Guidelines for MMF dose adjustment due to drug toxicity:  
i. If in the clinical judgment of the investigator or Attending the observed toxicity is related to 
MMF administration, a dose adjustment may occur.  The discontinuation of MMF at any 
point should be discussed with the Study PI and should be documented in the permanent 
medical record and all Case Report Forms (CRF). 
ii. Gastrointestinal Toxicity. Severe gastrointestinal toxicities such as gastrointestinal 
hemorrhage have been very rare after nonmyeloablative HCT. In the event of 
gastrointestinal toxicity that requires medical intervention including medication for control 
of persistent vomiting or diarrhea that is considered to be due to MMF after day 28, a 20% 
dose reduction will be made or the drug may be given IV. If severe refractory diarrhea or 
overt gastrointestinal bleeding occurs, MMF may be temporarily stopped. The MMF should 
be restarted at 20% reduced dose when the underlying toxicity subsides. 
iii. Neutropenia. Based on previous experience in patients after nonmyeloablative HCT, dose 
adjustments are likely to occur because of hematopoietic adverse effects, in particular 
neutropenia. A thorough evaluation of neutropenia should occur including peripheral blood 
chimerism studies, marrow aspiration and review of marrow suppressive medications (e.g. 
bactrim). If all other potential causes of marrow toxicity are ruled out, dose adjustments will 
only be made for grade IV neutropenia that persists after day 21 post-transplant. Dose 
reductions should be conservative (20%). After day 21, the use of G-CSF will be permitted 
for neutropenia. For severe toxicity related to MMF (grade IV neutropenia > 5 days 
refractory to G-CSF), MMF may be temporarily stopped.  The MMF should be restarted at 
20% reduced dose when the underlying toxicity subsides. 
 
c.   Sirolimus 
 
1. Sirolimus dosing: 
i. Sirolimus should be given at least 4 hours after an oral dose of CSP as concurrent 
administration leads to elevation of sirolimus levels. In a study in renal transplant 
recipients, there was no significant pharmacokinetic interaction between sirolimus and 
CSP (37,48,49). However, the timing of CSP dosing affects sirolimus pharmacokinetics. 
Sirolimus whole-blood peak/trough levels and area under the concentration-time curve 
(AUC) have been significantly higher following concomitant administration of these 
agents compared to their administration four hours apart. Whole-blood trough levels 
increased by about 30% with concomitant dosing; the time to peak levels was also shorter 
in this group (1.8 versus 2.5 hours) (48). The most likely explanation for higher sirolimus 
levels during concomitant administration is an increase in sirolimus bioavailability. 
Clinically significant immunosuppressive synergy is observed during combined therapy 
with sirolimus and cyclosporine (50). 


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ii. Patients with BSA > 1.5: Sirolimus will be started on day –3 at 2.0 mg every day orally 
through day 180. In the absence of GVHD, Sirolimus should be tapered at day +180 with 
an adapted dose reduction and discontinued on day + 365. In the presence of GVHD or if 
the patient is receiving glucocorticoid therapy, continuation of sirolimus will be at the 
discretion of the attending physician or GVHD attending/team (see 14.G GVHD 
treatment guidelines).  
iii. Patients with BSA < 1.5: For children and patients with BSA of  1.5 m2, the dose will 
be based on BSA as follows: 1 mg/m2/day to be rounded at the nearest 0.1mg.  
iv. To minimize variability of exposure to sirolimus, the drug should be taken consistently 
with or without food. Grapefruit juice reduces CYP3A4-mediated metabolism of 
sirolimus and should not be administered with sirolimus or used for dilution. 
2. 
Dosing will be adjusted to maintain a target blood level of 3-12 ng/mL until day 80. Dose 
adjustments are based on clinical toxicity, blood levels, and GVHD. For levels <3 ng/mL, 
the dose is increased by increments of 25% until the target range is achieved. Conversely, 
for levels >12 ng/mL, the dose is decreased by 25% until target range is achieved. All 
dose adjustments will be rounded to the nearest whole number. Levels will be drawn 
twice a week or as clinically indicated. Levels should also be drawn after changing the 
dose of sirolimus or adding any of the medications known to interfere with the sirolimus 
metabolism (Appendix R). 
3. 
The dosage will be replaced if the patient vomits within 15 minutes of taking a dose. 
Premedication with clinically indicated antiemetics is acceptable if vomiting occurs. 
4. 
If there is evidence of disease progression and no evidence of GVHD, patients will stop 
sirolimus and MMF without a taper per Attending discretion. Taper CSP within 2 weeks, 
and be observed for 1-2 weeks off of immunosuppression. If no GVHD occurs, patients 
with progressive disease will be offered chemotherapy (either standard or on a research 
trial). If appropriate, DLI (other institutional protocols for DLI) will be offered either in 
place of or after chemotherapy, depending upon disease and tempo of 
relapse/progression. 
5. 
Patients who are experiencing either suspected or documented fungal infection, 
alternative therapy should be administered whenever possible.  If voriconazole, 
posaconazole, or fluconazole are deemed necessary, sirolimus dosing reductions must be 
followed according to the Standard Practice Antifungal Therapy Guidelines in Appendix 
E due to contraindications.   
6. 
Severe neutropenia or thrombocytopenia. The combination of sirolimus and cyclosporine 
interaction is that there is an increase risk of sirolimus toxicity such as anemia, diarrhea, 
hypokalemia, and thrombocytopenia. A thorough evaluation cause of marrow 
suppression should occur including peripheral blood chimerism studies, marrow 
aspiration and review of marrow suppressive medications (e.g. bactrim). If all other 
potential causes of marrow toxicity are ruled out, dose adjustments will only be made for 
grade IV neutropenia and thrombocytopenia that persists after day 21 post-transplant, and 
in the case of neutropenia is refractory to G-CSF therapy dose reductions of sirolimus of 
approximately 50% should occur. For severe persistent toxicity despite sirolimus dose 
reduction, sirolimus should be held until blood counts recover to ANC > 1500/l and 
platelets >100,000/l. At that point, sirolimus may be reintroduced at a 1 mg PO QD and 
dose increased to 2 mg/qd as long as severe hematopoietic toxicity does not occur 


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I. Collection and Infusion of Donor cells 
 
1. G-CSF Administration to Donors and PBSC collection 
 
Related Donor (RD): 
All related donors will receive G-CSF 16g/kg SQ q.d. for 5 consecutive days from day –4 to 
day 0. Doses will be administered before 10:00 a.m. and after 4:00 p.m. each day in the 
Ambulatory Clinic. The schedule of G-CSF administration and PBSC collections can only be 
ascertained once day 0 is identified. Once a treatment schedule has been fixed and the schedule 
of G-CSF administration and PBSC collections is made, the plan has to be confirmed with the 
personnel in the apheresis room. Day 0 should be fixed on a Tuesday – Thursday. PBSC will be 
collected in the afternoon of day –1, stored in the refrigerator at 4C overnight. A second 
collection will be performed the following afternoon and both collections will be infused on day 
0. The physician responsible for HCT collection will obtain informed consent from the donor. 
Unrelated Donor (URD): 
Timing of PBSC collection will be prearranged through the National Marrow Donor Program 
(NMDP) or other international donor centers in the case of an unrelated donor. Day 0 should be 
fixed on a Monday – Thursday when possible. G-CSF will be administered by subcutaneous 
injection to the donors starting 5 days prior to the day 0 according to the current NDMP protocol. 
Donors will receive approximately 10µg/kg of G-CSF each day of mobilization. A 12 liter 
apheresis will be obtained on day –1 and possibly on day 0 for a total of 12 to 24 liters of 
apheresis collection that will be infused on day 0.  
 
Table 6 Treatment Schema for Related (RD) and Unrelated Donors (URD) 
Day 
-5 
-4 
-3 
-2 
-1 
0 
G-CSF SQ 
(~10µg/kg for URD) 
(16µg/kg for RD) 
 
X 
 
 
X 
X 
 
X 
X 
 
X 
X 
 
X 
X 
 
[X] 
X 
PBSC collection 
 
 
 
 
X 
X 
 a.  Immunophenotyping of the PBSC graft.  
Immunophenotyping of the PBSC product for the Seattle patients will be performed by the 
CTL and will include CD34, CD3/4 and CD3/8 cells. The residual specimen will be sent to 
the Heimfeld lab to do phenotypic characterization of cellular subsets.  
 
   
b. Collection of DLI. Donor lymphocytes will be collected from unrelated donor PBSC 
products prior to transplant for potential future use of DLI on other protocol or treatment 
plans. A portion of the PBSC product from the donors will be frozen according to standard 
cryopreservation for DLI. Donor PBSC products will be frozen in an aliquot of 3.0 x 107 
CD3+ cells/kg.  
 
2.  HCT infusion: All patients will receive unmodified PBSC infusion on day 0 of the treatment 
regimen (Refer to institutional practice guidelines for methods of infusion). 
 
J.  ABO incompatibility 
 


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 All patients with ABO incompatibility should be evaluated and treated as according to the 
standard practice of the individual institution. Recommendations are provided in Appendix D. It 
should be noted that two cases of recipient hemolysis have been documented in patients with 
minor ABO mismatch with their donor. The suspected cause is donor anti-host hemagglutinin 
production from “passenger lymphocytes” in the donor PBSC that may expand posttransplant 
(52). Therefore, these patients should be monitored and treated aggressively when there is any 
evidence of hemolysis. 
 
K. Post-transplant growth factors 
  
 
Patients should in general not receive post-transplant growth factors during the first 3 weeks after 
HCT. Growth factors should not be given unless neutropenia develops or persists past day 21 
post-transplant (ANC <500/L). 
 
L. Post-transplant Maintenance Therapy with Tyrosine kinase inhibitors (imatinib, dasatinib, 
nilotinib, etc.) for Ph (+) CML or A.L.L. patients.  
 
Tyrosine kinase inhibitors may be reinitiated after HCT when ANC is >500/l or on day +14 if 
there is no neutropenia.  Tyrosine kinase inhibitor trials may also be considered. 
 
1.  Imatinib mesylate (Gleevac): the suggested starting dose is: 
  Patients ≥ 18 years: Imatinib at 600 mg orally each day.  
  Patients < 18 years: Imatinib at 340 mg/m2 orally each day, not to exceed 600 mg per day. 
 
2.  Dasatinib (Sprycel): The suggested starting dose is: 
  Patients ≥ 18 years: Dasatinib at 70 mg orally BID (twice per day).   
 
 
   Patients < 18 years:  who are potential candidates for BCR/ABL tyrosine kinase inhibitor  
 
 
   therapy (other than Imatinib or Nilotinib) after HCT should be presented to PCC for   
 
 
   discussion, and PI approval.   
 
3. Nilotinib (Tasigna): the suggested starting dose is: 
 
 
     Patients ≥ 18 years: Nilotinib at 400 mg orally BID (twice per day).  
 
 
     Patients < 18 years: Nilotinib at 230 mg/m2 orally BID, not to exceed 400 mg po BID.  
 
NOTE: Per FDA guidelines, patients treated with Dasatinib and Nilotinib should have 
hypokalemia and hypomagnesemia corrected prior to initiation in all patients. 
 
NOTE: Per FDA guidelines, patients treated with Nilotinib should have periodic EKG 
  
monitoring, (though not required). 
 
 
    NOTE:  All TKI dose reductions are allowed due to clinician judgment  
 
4.  Dose Reductions of Tyrosine kinase inhibitors for Grade 4 neutropenia (ANC < 500/l) 
and /or thrombocytopenia (platelets < 10,000/l) (for patients in whom platelet support 
is unavailable/ineffective): 
After HCT, G-CSF will not be permitted for the first 21 days. G-CSF administration is 
acceptable after that time, but clinical and pathological evaluation is recommended. To assess 
cellularity and percentage of blasts, a bone marrow aspirate should be performed in those 


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


Protocol 2206.00 
Current Version: 09/26/2018 
-30-
blood. For the purposes of this protocol, rejection is defined as the inability to detect or loss 
of detection of greater than 5% donor T cells (CD3+) as a proportion of the total T cell 
population, respectively, after nonmyeloablative HCT. Also for the purposes of this 
protocol, graft failure is defined as grade IV thrombocytopenia and neutropenia after day 
21 that lasts > 2 weeks and is refractory to growth factor support.  
 
2. Evaluation of chimerism  Patients will have peripheral blood and whole bone marrow 
evaluations for chimerism at various time points through one year post transplant. If the 
patient has not obtained > 95% donor chimerism in CD+3 by one year to continue to 
evaluate through 5 years post transplant as clinically necessary. Peripheral blood will be 
sorted to evaluate T-cell (CD+3), granulocyte (CD+33), and/or NK cell (CD+56) 
compartments (see Patient Post-Transplant Evaluation section for instructions and 
exceptions). 
 
3. Continuation of immunosuppression. In the setting of low donor chimerism, 
immunosuppression may be continued or reinitiated at full dose so that DLI can be 
administered on a separate protocol. If there is disease progression in the setting of low 
donor chimerism, the algorithm for disease progression (below) should be followed. 
Patients who reject their graft may be eligible for a second allogeneic transplant on other 
protocols. 
 
4. Discontinuation of immunosuppression. Immunosuppression should be discontinued as 
per protocol unless the patient develops GVHD, has falling donor chimerism or has 
progressive or substantial persistent disease (see below). In the setting of GVHD, CSP, 
MMF and sirolimus may be continued. GVHD at any time should be treated as per 
standard practice.  
 
5. Disease progression or persistence and mixed chimerism. Evidence of substantial 
persistent disease at day 80 or beyond may be indication for therapeutic intervention while 
disease progression, at any time point will always be an indication for therapeutic 
intervention. Intervention for persistent disease at day 80 or beyond should be discussed 
with the Principal Investigator (B.Sandmaier) of the protocol and the guideline in 
Appendix H for progressive disease should be followed. If the attending physician 
believes that the patient requires very aggressive therapy for rapidly progressive disease, 
the case will be presented to the institutions’ patient review committee. Otherwise, priority 
should be given to rapid reduction of immunosuppression, option (a) below.  Therapeutic 
options include:  
 
6.  a. Discontinuation of immunosuppression: This should be considered the first 
therapeutic maneuver. If there is no GVHD, MMF and sirolimus are to be stopped. 
CSP should be tapered over 2 weeks. Bone marrow aspirate and blood chimerism 
studies will be performed when off immunosuppression after 2 weeks. If there is no 
response to stopping immunosuppression, < 20% increase in donor chimerism and 
there is no GVHD, patients will be considered as treatment failures. DLI will not be 
offered for disease progression or relapse on this protocol. In this situation patients 
may receive further therapy as per institutional protocols for disease relapse or 
progression after allogeneic HCT.  If no GVHD occurs, patients with progressive 
disease may be offered enrollment in other institutional protocols for DLI treatment. 


Protocol 2206.00 
Current Version: 09/26/2018 
-31-
If there is  20% absolute increase in donor chimerism, patients should be observed 
for additional 2 weeks and chimerism studies then repeated. If there is progressive 
disease that requires therapy before 4 weeks or progressive disease occurs despite 
onset of GVHD then patients can be treated off protocol with DLI or be considered 
for (b) or (c) below 
b. Intercurrent treatment with chemotherapy or radiation: Conventional 
chemotherapy or radiation therapy should be considered in the setting of life threatening 
disease progression. Patients in this situation would be considered treatment failures. After 
therapy is completed chimerism should be evaluated and the administration of DLI off 
protocol considered. 
c. High dose allogeneic HCT: This option should be discussed with the institutions’ 
patient review committee and the principal investigator. Patients who undergo high dose 
allogeneic HCT will be removed from the protocol at that time. 
d. CML or Ph(+) A.L.L. patients with Persistent or Increased Minimal Residual 
Disease: At day +84 or beyond, if the patient has persistent or increased MRD disease, 
dose escalation of BCR/ABL tyrosine kinase inhibitor therapy or DLI should be 
considered  
e. CML and Ph (+) A.L.L. patients with Relapse and Disease Progression: See above 
sections for withdrawal of immunosuppression based on treatment arm.  If there is no 
response to stopping immunosuppression and there is no GVHD, dose escalation of 
BCR/ABL tyrosine kinase inhibitor therapy and or DLI should be considered). (Suggested 
doses for adults are Imatinib to 800 mg QD or dasatinib to 90 mg BID). 
 
12.    Assessment of Disease Responses 
 
The initial anti-tumor effect of allogeneic HCT will be evaluated with the intermittent analysis of tumor 
markers: Responses will be classified as complete, partial response or no response.  Response criteria 
for MM, NHL, CLL, CML, ALL, AML and MDS to be used in this study are described in Appendix H. 
Standard response criteria specific to other diseases will be used in assessing disease response for other 
patients on study. 
 
 
13.    Patient Evaluation 
 
A. Patient Pre-transplant Evaluation for All Diseases 
 
1. History: A complete history with full details of the patient’s prior treatment and response. 
2. Careful physical exam with documentation of Karnofsky or Lansky score, HCT CI score 
(Appendix Q) and findings related to underlying malignancy. 
3. CBC, creatinine, BUN, uric acid, chem 1 (Na+, K+, Cl_, Bun, creatinine, glucose), chem 2 
(liver function tests), and 3(Mg+2 and Ca+2), ABO/Rh typing, hepatitis screen, CMV and 
toxoplasmosis serology, anti-HIV serology, and serum LDH. 
4. Pulmonary function tests with corrected DLCO.  If unable to perform complete PFTs with a 
DLCO, patients will be evaluated with a formal six-minute walk test (ambulatory oximetry). 
5. CXR (PA and LAT). 
6. ECHO or MUGA for patients > 50 years of age, or history of cardiac disease or anthracycline 
exposure. 
7. Evaluation and prophylaxis of CNS disease.  


Protocol 2206.00 
Current Version: 09/26/2018 
-32-
Please refer to Appendix N for recommendations for intrathecal diagnostic evaluation and 
prophylaxis for specific malignant diseases. In those patients that undergo intrathecal 
diagnostic evaluation cerebral spinal fluid should be sent for cell count and differential, 
cytospin, cytology, total protein, and glucose.  
 
 
Additionally, see the following tables (Tables 7, 8, 9, 10) for disease specific pre-transplant 
evaluations. 


Protocol 2206.00 
Current Version: 09/26/2018 
-33-
Table 7: Disease-Specific Pre-Transplant Evaluations for Ph (-) ALL, Ph (+) ALL, CML 
 Note: All bone marrow aspirates and biopsies are unilateral and must be collected within 21 days 
of treatment. See Tables 11 and 12 for post-transplant evaluations and additional lab instructions 
 
 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
PCR for bcr/abl, p.210 breakpoint - *see comment 
Clinical 
*CML only- reflexive 
testing for FHCRC patients 
only 
PCR for bcr/abl, p.190 and p.210 breakpoints - *see 
comment  
Clinical 
*Ph (+) ALL only- reflexive 
testing for FHCRC patients 
only 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*CML only 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
PCR for bcr/abl, p.210 breakpoint- *see comment 
Clinical 
*CML only 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-34-
 
 
Table 8: Disease-Specific Pre-Transplant Evaluations for AML and MDS/MPD 
 Note: All bone marrow aspirates and biopsies are unilateral and must be collected within 21 days 
of treatment. See Tables 11 and 12 for post-transplant evaluations and additional lab instructions 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*MDS/MPD only 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-35-
 
Table 9: Disease-Specific Pre-Transplant Evaluations for CLL, HL, NHL 
 Note: All bone marrow aspirates and biopsies are bilateral and must be collected within 30 days of 
treatment. See Tables 11 and 12 for post-transplant evaluations and additional lab instructions 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry- *see comment 
Clinical 
*No HL 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
PCR for t(11:14) - *see comment 
Clinical 
*Mantle Cell NHL only 
PCR for t(14:18) - *see comment 
Clinical 
*Follicular NHL only 
Bone marrow biopsy 
 
Pathology- *see comment 
Clinical 
*HL – only if history of BM 
involvement 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
Quantitative Ig levels 
Clinical 
 
β-2 microglobulin 
Clinical 
 
LDH 
Clinical 
 
ZAP – 70 by flow cytometry- *see comment 
Clinical 
*CLL only– for patients not in CR 
Imaging 
 
CT of chest, abdomen, pelvis (neck if indicated) 
Clinical 
 
 


Protocol 2206.00 
Current Version:09/26/2018  -36- 
Table 10: Disease-Specific Pre-Transplant Evaluations for MM and Waldenstrom’s Macroglobulinemia 
Note: All bone marrow aspirates and biopsies are bilateral and must be collected within 30 days of 
treatment. See Tables 11 and 12 for post-transplant evaluations and additional lab instructions. 
Specimen / Test / Imaging 
Clinical / 
Research 
Comment 
Bone marrow aspirate 
 
Pathology 
Clinical 
 
Flow Cytometry 
Clinical 
 
Cytogenetics 
Clinical 
 
FISH for clonal abnormalities 
Clinical 
*If previously abnormal 
Bone marrow biopsy 
 
Pathology 
Clinical 
 
Peripheral Blood 
 
Storage for chimerism analysis 
Clinical 
 
SPEP/IFIX 
Clinical 
 
Quantitative Ig levels 
Clinical 
 
β-2 microglobulin 
Clinical 
 
Cryoglobulins, c-reactive protein, serum viscosity 
- *see comment 
Clinical 
*Serum viscosity only for patients with 
>3gm/dL IgM monoclonal protein or 
>4gm/dL IgA or IgG protein 
Urine 
 
UPEP/IFIX 
Clinical 
 
Protein / creatinine clearance 
Clinical 
 
Imaging 
 
MRI –  *see comment 
Clinical 
*MM only 
Skeletal survey –  *see comment 
Clinical 
*MM only 
CT of chest, abdomen, pelvis (neck if indicated) –  
*see comment 
Clinical 
*Waldenstrom’s Macroglobulinemia 
only 
 
B. Patient Post-transplant Evaluation  
1. See Table 11 for disease specific post-transplant evaluation on Day +28, 56, 84, etc. This is a 
recommended evaluation schedule. 
 
Additionally, include the following for all diseases: 
2. History and physical exam to assess Karnofsky performance status and GVHD weekly until day 
+84, thereafter monthly or as indicated. If GVHD develops refer to Toxicity section. 
3. CBC three times a week, or more often if clinically indicated, from day 0 until day +28, and twice  
weekly until 2 months post-transplant or later if clinically indicated 
4. Cyclosporine trough levels on day “0” and then twice a week until taper begins.  Weekly 
thereafter if levels are stable. 
5. Sirolimus trough levels on day “0” and then twice a week for the first month and weekly 
thereafter to maintain therapeutic serum levels. 
6. Chem 1(Na+, K+, Cl_, Bun, Cr, glucose) and chem 3 (Mg+2, Ca+2) 3x per week until CSP taper 
begins. 
7. a) Serum triglyceride levels (fasting) every two weeks post transplant until Day +56, then once 
per month until off sirolimus, or more often if clinically indicated. 
b) Haptoglobin every other week until Day +56, then as indicated. Evaluation of schistocytes 
weekly with CBC through Day + 56. 


Protocol 2206.00 
Current Version: 09/26/2018 
-37-
8. Evaluate at Day +84 
Patient Discharge to the Care of Referring Hematologist/Oncologist. After the day +84 work-up and 
screening for chronic GVHD are completed and analyzed, a patient with an uncomplicated HCT 
would be eligible for discharge. Since the patient may be discharged prior to starting CSP taper, 
instructions should be provided for preventing and detecting GVHD as per standard practice of 
collaborating institution.  
 
GVHD evaluation guidelines are as follows: 
• History and physical exam (see Appendix G) 
• Skin biopsy 
• Schirmer's tear test 
• Pulmonary function test 
• Oral exam  
• CXR 
• Dietician assessment 
• Gynecological departure assessment (adult female)  
 
Patients should be evaluated for GVHD per Appendix G prior to DLI. 
 
9. Patients should be assessed for the need of bisphosphonates and IVIG monitoring and 
replacement therapy per Institutional Guidelines 
 


Protocol 2206.00 
Current Version:09/26/2018  -38- 
Table 11: Post-Transplant Evaluation 
This is a recommended evaluation schedule.  
See Tables 7-10 for pre-transplant evaluations. Additional lab instructions in Table 12. 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Ph (-) ALL 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-
transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-
transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-39-
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Ph (+) ALL 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
FISH for  bcr/abl and other 
clonal abnormalities 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
PCR for bcr/abl, p.190 and 
p.210 breakpoints 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
PCR for bcr-abl, p.190 and 
p.210 breakpoints 
Clinical 
* If bone marrow not 
done and reflexive 
testing for FHCRC 
patients only 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-40-
 
Disease Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
AML 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-
transplant 
*See comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-
transplant 
*See comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only 
if <50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-41-
 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
MDS/ 
MPD 
 
 
BM aspirate *see biopsy 
                   ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal  pre-
transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal  pre-
transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
*For pts. with evidence 
or history of 
myelofibrosis 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
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Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
CML 
BM aspirate *see biopsy 
                    ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
FISH for bcr-abl and other 
clonal abnormalities 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
PCR for bcr-abl, and p.210 
breakpoint 
Clinical 
* Reflexive testing for 
FHCRC patients only 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
*If abnormal pre-
transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
PCR for bcr-abl, and p.210 
breakpoint 
Clinical 
* If  bone marrow not done 
and reflexive testing for 
FHCRC patients only 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-43-
 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
CLL 
BM aspirate *see biopsy 
                    ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant 
AND bone marrow not done 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  
pre-transplant 
 
*See 
comment 
x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-44-
 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
HL - 
No history 
of BM 
involvement 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
 
 
x 
 
x 
 
 
Cytogenetics 
Clinical 
*If abnormal pre-
transplant  
 
 
*See 
comment 
 
*See 
comment 
 
 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-
transplant 
 
 
*See 
comment 
 
*See 
comment 
 
 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only 
if <50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if 
abnormal  pre-transplant 
 
*See 
comment  x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
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Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
HL- 
History of 
BM 
involvement 
BM aspirate *see biopsy 
                   ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant  *See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant  *See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, 
pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  
pre-transplant 
 
*See 
comment  x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
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Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
NHL – 
No History 
of BM 
involvement  
 
*see separate 
section for 
additional 
PCR on 
Mantle Cell 
and 
Follicular 
NHLs in 
suspected CR 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate * If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
 
 
x 
 
x 
 
 
Flow cytometry 
Clinical 
 
 
 
x 
 
x 
 
 
Cytogenetics 
Clinical 
*If abnormal pre-transplant   
 
*See 
comment 
 
*See 
comment 
 
 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK 
CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant, 
if bone marrow not 
obtained 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
x 
 
 
 
 
LDH 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Imaging 
 
CT chest, abdomen, 
pelvis (neck if indicated) 
Clinical 
*Day 56 only if abnormal  
pre-transplant 
 
*See 
comment  
x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-47-
Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
NHL – 
History of 
BM 
involvement  
 
*see separate 
section for 
additional 
PCR on 
Mantle Cell 
and 
Follicular 
NHLs in 
suspected CR 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate *see biopsy 
                    ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism  
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical 
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical 
*If abnormal pre-transplant  *See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for clonal 
abnormalities 
Clinical 
*If abnormal pre-transplant  *See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
BM biopsy 
 
Pathology 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Peripheral blood 
 
 
 
 
 
 
 
 
 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment x 
 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
 
Chimerism  (NK 
CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
 
Flow cytometry 
Clinical 
* If peripheral blood 
involvement pre-transplant, 
if bone marrow not 
obtained 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
 
 
β-2 microglobulin 
Clinical 
 
 
 
x 
 
x 
 
 
 
LDH 
Clinical 
 
 
x 
x 
x 
x 
x 
 
Imaging 
 
CT chest, abdomen, 
pelvis (neck if 
indicated) 
Clinical 
*Day 56 only if abnormal  
pre-transplant 
 
*See 
comment  
x 
x 
x 
x 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
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Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
 
 
 
 
 
 
 
 
Mantle Cell 
NHL in 
suspected CR 
BM aspirate *in addition to complete NHL restaging 
                    ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
PCR for t(11:14) 
Clinical 
*If abnormal pre-
transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood  *in addition to complete NHL restaging 
 
PCR for t(11:14) 
Clinical 
*If abnormal pre-
transplant, if bone marrow 
not obtained  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Follicular 
Cell 
BM aspirate *in addition to complete NHL restaging 
                    ** If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
NHL in 
 
PCR for t(14:18) 
Clinical  
*If abnormal pre-
transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
suspected CR  
Peripheral blood  *in addition to complete NHL restaging 
 
 
PCR for t(14:18) 
Clinical  
*If abnormal pre-
transplant, if bone marrow 
not obtained  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
  
 
 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-49-
 
 
 
 
 
 
 
 
 
 
 
Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
MM 
 
 
Omit 
SPEP/IFIX 
and 
UPEP/IFIX 
for non-
secretory 
MM 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical   
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical  
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for chrom. 13 (and 
other clonal) abnormalities  
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
 
 
 
 
 
 
 
 
 
 
Peripheral blood 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
SPEP and IFIX 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Cryoglobulins, C-reactive 
protein, viscosity 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
 
*See comment 
Urine 
 
Protein/creatinine 
clearance 
Clinical 
 
 
 
x 
x 
x 
x 
x 
UPEP and IFIX 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 


Protocol 2206.00 
Current Version: 09/26/2018 
-50-
Disease 
Specimen/ Test/ 
Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
 
 
 
 
 
 
 
Imaging 
 
Complete skeletal survey 
Clinical 
 
 
 
 
 
x 
 
x 
Skeletal MRI 
Clinical 
 
 
 
 
 
x 
 
x 
GVHD evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-51-
 
Disease 
Specimen/ Test/ Imaging 
Clinical/ 
Research 
Comment 
Days 
Years 
Annual x 
5 years 
28 
56 
84 
180 
1 
1.5 
Waldenstrom’
s Macro-
globulinemia 
 
Omit 
SPEP/IFIX and 
UPEP/IFIX for 
non-secretory 
Waldenstrom’s 
Macro-
globulinemia 
 
BM aspirate* If CR documented at one year, and there is recovery of normal blood counts, bone marrow after one year may be obtained based on clinical 
judgment 
 
Chimerism 
Clinical 
 
 
 
x 
 
x 
 
 
Pathology 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Flow cytometry 
Clinical  
 
x 
x 
x 
x 
x 
x 
x 
Cytogenetics 
Clinical  
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
FISH for chrom. 13 (and 
other clonal) abnormalities  
Clinical 
*If abnormal pre-transplant  
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Peripheral blood 
 
 
Chimerism (CD3+) 
Clinical 
*Days 56 and 180 only if 
<50% on day 28 
x 
*See 
comment 
x 
*See 
comment 
x 
 
 
Chimerism (CD33+) 
Clinical 
 
 
 
x 
 
 
 
 
Chimerism  (NK CD56+) 
Clinical 
Optional for outside 
institutions 
x 
 
 
 
 
 
 
SPEP and IFIX 
Clinical 
 
 
 
x 
x 
x 
x 
x 
Quantitative Ig levels 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
β-2 microglobulin 
Clinical 
 
 
 
 
x 
x 
x 
x 
Cryoglobulins, C-reactive 
protein, viscosity 
Clinical 
*If abnormal pre-transplant 
 
 
*See 
comment 
*See 
comment 
*See 
comment 
 
*See comment 
Urine 
 
 
Protein/ creatinine clearance 
Clinical 
 
 
 
x 
x 
x 
x 
x 
UPEP and IFIX 
Clinical 
*If abnormal pre-transplant  
 
 
*See 
comment 
*See 
comment 
*See 
comment 
*See 
comment 
*See comment 
Imaging 
 
 
 
 
 
 
 
 
 
 
CT chest, abdomen, pelvis 
(neck if indicated) 
Clinical 
*Day 56 only if abnormal  
pre-transplant 
 
*See 
comment 
x 
x 
x 
x 
x 
GVHD  evaluation 
Clinical 
See text for details 
 
 
x 
 
 
 
 
 
 
 


Protocol 2206.00 
Current Version:09/26/2018  -52- 
Table 12: Additional Lab Instructions 
Note: All bone marrow tests are done on aspirate unless specifically identified as biopsy. All instructions apply to 
both pre- and post-transplant evaluations unless specifically identified otherwise. 
 
Off-site providers may use local facilities for the tests..  
 
Volumes represent desired amounts 
Specimen / 
Test 
Type 
Instructions 
Lab Name 
Contact Information 
Bone marrow 
 
Chimerism  
Clinical 
1-3mL bone marrow in 
green-top tube 
Clinical Immunogenetics 
Lab 
Seattle Cancer Care Alliance 
 (206) 288-7700 
Pathology 
(aspirate) 
Clinical 
2mL bone marrow in EDTA 
formalin 
SCCA Pathology Lab 
Seattle Cancer Care Alliance 
(206) 288-1355 
Pathology (biopsy) 
Clinical 
1cm bone marrow in 
formalin OR mounted in 
paraffin 
SCCA Pathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-1355 
Flow Cytometry 
Clinical 
2mL bone marrow in green-
top tube 
UW Hematopathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-7060 
Cytogenetics 
Clinical 
3mL bone marrow in green-
top tube 
SCCA Cytogenetics Lab 
Seattle Cancer Care Alliance 
 (206) 288-1390 
FISH 
Clinical 
2mL bone marrow in green-
top tube 
SCCA Cytogenetics Lab 
Seattle Cancer Care Alliance 
 (206) 288-1390 
PCR  for bcr-abl 
and p190 and/or 
p210 
Clinical 
3mL bone marrow in 
lavender-top tube 
Label “protocol 2206” 
 UW Molecular 
Hematopathology Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
PCR t(11:14) or 
t(14:18) 
Clinical 
2mL bone marrow in 
lavender-top tube 
UW Molecular 
Hematopathology Lab  
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
Peripheral blood 
 
Chimerism  
(CD3+), (CD33+) 
NK(CD56+) 
Clinical 
10mL blood in green-top 
tube for Flow sorting, then 
to CIL 
UW Hematopathology Lab, 
routed to Clinical 
Immunogenetics Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
Flow Cytometry 
Clinical 
10mL blood in green-top 
tube 
UW Hematopathology Lab 
Seattle Cancer Care Alliance 
 (206) 288-7060 
SPEP/IFIX 
Clinical 
3mL blood in red-top tube 
UW Department of 
Laboratory Medicine 
University of Washington 
(800) 713-5198 
Quantitative Ig 
Levels 
Clinical 
3mL blood in red-top tube 
SCCA Alliance Lab 
Seattle Cancer Care Alliance 
(206) 288-2057 
β-2 Microglobulin 
Clinical 
3mL blood in red-top tube 
UW Department of 
Laboratory Medicine 
University of Washington 
(800) 713-5198 
LDH 
Clinical 
3mL blood in red-top tube 
SCCA Alliance Lab 
Seattle Cancer Care Alliance 
(206) 288-2057 
PCR for bcr-abl 
and p190 and/or 
p210 
Clinical 
7mL blood in lavender-top 
tube 
Label “protocol 2206” 
UW Molecular 
Hematopathology Lab  
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
PCR for t(11:14) or 
t(14:18) 
Clinical 
5mL blood in lavender-top 
tube 
UW Molecular 
Hematopathology Lab  
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
ZAP – 70 by Flow 
cytometry 
(pre-transplant only) 
Clinical 
5mL blood in green-top 
tube 
UW Hematopathology Lab 
Mailstop G7-800 825 Eastlake Ave, 
East Seattle, WA 98109 
(206) 288-7060 
 
Outside institutions may use VNTR analysis (sex- matched transplants) or sex chromosome FISH-
analysis (sex-mismatched transplants) for chimerism analysis. 


Protocol 2206.00 
Current Version: 09/26/2018 
-53-
 
C. Donor Evaluations 
 
   Donors will undergo evaluation for allogeneic hematopoietic cell donation at the collection 
center by NMDP standard. The attending physician of the collection center will review the 
results of the donor evaluation. Evaluations typically include: 
1. 
Complete history and physical examination. 
2. 
Lab tests: CBC with reticulocytes and platelet counts, SMAC 12, hepatitis screen, 
CMV, syphilis, HIV and HTLV I serologies and ABO Rh blood typing. If the donor 
has antibodies against red cell antigens of the recipient, the titers will be determined. 
Cytotoxic crossmatch between patient and donor (HLA Laboratory) will be 
performed. 
3. 
No placement of a central line is necessary for G-CSF stimulated PBSC collection unless 
it is determined that the donor has poor venous access.  If necessary, a temporary 
apheresis (e.g. Mahurkar) catheter will be placed at the time of leukapheresis. 
4. 
A CBC will be checked prior to and after leukapheresis collection, and daily while on 
G-CSF. CBCs will be checked thereafter if clinically indicated. 
5. 
The donor will be reevaluated the day after the apheresis is completed. 
 
 
14. Drugs and Toxicities 
 
  
Sirolimus, CSP, MMF and fludarabine are all commercially available. They should be stored 
and mixed according to manufacturer's recommendations. 
A. For the purposes of this protocol, toxicity will be graded using the modified NCI common 
toxicity scale (Appendix P). 
B. TBI: TBI will be given in one 200-300 cGy fraction from linear accelerator at a rate of 6 - 7 
cGy/min. Dosimetry calculations are performed by the radiation therapist. At the dosage used, 
side effects are not expected. Nevertheless, there may be fever, alopecia, parotitis, diarrhea, 
reversible skin pigmentation, mucositis and late effects including cataract formation, growth 
retardation, pulmonary damage, carcinogenesis, and sterilization. 
C. Cyclosporine: See section 11.H.a.3 for information about administration and dosage 
adjustments. Side effects are generally reversible, and may include renal insufficiency, 
hypomagnesemia, paresthesias, tremor, seizures, visual disturbances, paresis, disorientation, 
depression, confusion, somnolence, coma, nausea, hypertension, hemolytic-uremic syndrome, 
hyperglycemia, gynecomastia, and hypertrichosis 
 
D. Sirolimus 
 
 
1) Formulation and Administration 
a. 
Sirolimus is supplied as oral solution (Rapamune Oral Solution) 1 mg/mL or as 1 mg 
tablets. 
b. 
Rapamune Oral Solution pouches should be stored protected from light and refrigerated 
at 2°C to 8°C. If necessary, the patient may store the pouches at room temperatures up 
to 25°C (77°F) for a short period of time (e.g., several days, but no longer than 30 
days). The tablets should be stored at 20-25°C and be protected from light. 
c. 
Sirolimus is to be administered orally once daily at the doses described in Section 
11.H.c.1. To minimize variability of exposure to sirolimus, this drug should be taken 
consistently with or without food. Grapefruit juice reduces CYP3A4-mediated 


Protocol 2206.00 
Current Version: 09/26/2018 
-54-
metabolism of sirolimus and should not be administered with sirolimus or used for 
dilution. 
d. 
If patients are receiving Rapamune Oral Solution, the dose should be mixed well with 
60 mL of water or orange juice and taken immediately. It is recommended that the 
container be refilled with a minimum of 120 mL of water or orange juice, mixed well, 
and this rinse solution should be swallowed. 
 
 
2) Adverse Reactions 
 
 
 
The incidence of adverse reactions was determined in two randomized, double-blind 
multicenter controlled trials in which 499 renal transplant recipients received Rapamune oral 
solution 2 mg/day and 477 received 5 mg/day. Specific adverse reactions associated with the 
administration of Rapamune oral solution included hypocholesterolemia, hyperlipidemia, 
hypertension, and rash. At the higher dose of 5 mg, these adverse effects included anemia, 
arthralgia, diarrhea, hypokalemia, and thrombocytopenia. Additional toxicities from our 
study in stem cell transplantation include: hemolytic uremic syndrome, seizures, and 
neutropenia. 
 
 
 
Appendix R lists medications including voriconazole, posaconazole, and fluconazole that 
may affect metabolism of sirolimus.  In patients receiving sirolimus, these drugs should be 
used with caution and sirolimus levels should be monitored closely. The Standard Practice 
Antifungal Therapy Guidelines in Appendix E may be used as a reference for dosing 
instructions  
 
 
3) Management of Toxicities 
 
 
 
a. All toxicities will be scored as per common toxicity criteria (Appendix P) and unless 
specified in this protocol, treated as per our Standard Practice Guidelines. 
 
 
 
b. Toxicities thought to be associated with sirolimus will be treated as follows: 
i. Engraftment will be considered 3 consecutive days of ANC >500/L on day 30. If 
ANC <500 on day 30 remains below 500, graft failure evaluation should be initiated 
as per our Standard Practice Guidelines. 
ii. Severe neutropenia or thrombocytopenia. A thorough evaluation cause of marrow 
suppression should occur including peripheral blood chimerism studies, marrow 
aspiration and review of marrow suppressive medications (e.g. bactrim). If all other 
potential causes of marrow toxicity are ruled out, dose adjustments will only be made 
for grade IV neutropenia and thrombocytopenia that persists after day 21 post-
transplant, and in the case of neutropenia is refractory to G-CSF therapy. Dose 
reductions of sirolimus of approximately 50% should occur. For severe persistent 
toxicity despite sirolimus dose reduction, sirolimus should be held until blood counts 
recover to ANC > 1500/l and platelets >100,000/l. At that point, sirolimus may be 
reintroduced at a 1 mg po q.d. and dose increased to 2 mg/qd as long as severe 
hematopoietic toxicity does not occur 
iii. Hyperlipidemia: Sirolimus is known to cause elevations in serum cholesterol and 
triglyceride levels.  Serum triglyceride levels (fasting) should be drawn every two 
weeks through Day + 56, then monthly while on Sirolimus, or more often if clinically 
indicated.  Cholesterol levels will be drawn at Day + 84 departure workup.  In 
general, triglyceride levels remained below 1000 mg/dL. However, in 2/14 patients in 
our previous study, levels reached 2145 and 2152. To avoid complications due to 
pancreatitis, patients should be treated with gemfibrozil, 600 mg BID p.o., or 
atorvastatin, 10 mg q.d. for triglyceride levels >800 mg/dL.   


Protocol 2206.00 
Current Version: 09/26/2018 
-55-
 
E. MMF: See section 11.H.b for information about administration and dosage adjustments.  
Mycophenolate mofetil (MMF): is supplied in 250mg hard gelatin capsules. Capsules 
may be stored at room temperature. 
 
Precautions:  MMF has been studied extensively among patients after nonmyeloablative HCT. 
Previous clinical studies in patients after allografting suggest that the principal adverse 
reactions associated with the administration of MMF include nausea, vomiting, neutropenia, 
diarrhea, and on one occasion bloody diarrhea. In the setting of marrow transplantation, several 
etiologic factors may contribute to alterations in gastrointestinal and hematologic parameters.  
MMF has an increased incidence of digestive system adverse events, including GI tract 
ulceration, and hemorrhage (3% of patients receiving MMF). GI tract perforations have rarely 
been observed. Most patients in these studies were also on other drugs known to be associated 
with these complications. Up to 2% of patients receiving MMF for prevention of rejection 
developed severe neutropenia (ANC <500). The development of neutropenia may be related to 
MMF itself, concomitant medications, viral infections or some combination of these causes. 
MMF dose adjustments will be made if clinically indicated if in the opinion of the attending 
physician, no other cause is thought to be responsible for the abnormality. These adjustments 
should be discussed with the principal investigator and documented in the medical records and 
the clinical reporting form (CRF). Dose adjustments are described in Section 11.H.b.4. 
 
F. Fludarabine: The dose of fludarabine used in this protocol is nonmyeloablative, but does cause 
significant immunosuppression. Fludarabine can lower the white blood cell count, in particular 
the CD4+ T-cells. The immunosuppression observed with the use of fludarabine increases the 
risk of infection, which can be life threatening. 
 
G.   GVHD:  
1. 
Diagnosis: Skin involvement will be assessed by biopsy with percentage of body surface 
area involved recorded. GI symptoms suspicious for GVHD will be evaluated by biopsy 
as indicated. Acute GVHD and chronic GVHD will be graded according to established 
criteria (Appendix F and G). 
2. 
Recommended Treatment: 
a. Patients developing acute GVHD > grade II off immunosuppression or while on 
a CSP taper: 
i. CSP 5 mg/kg PO q12hrs.  If there is concern of GI absorption use IV 
route (1.5mg/kg q12hrs). 
ii. Prednisone (2mg/kg/day) is to be added if there is no response by 72 
hours or progression of GVHD during the 24 hours after the start of 
CSP 5.0 mg/kg PO q12hrs. Patients who respond to steroids after 10 to 
14 days of treatment, should begin a 6-week steroid taper. 
iii. Patients may also be eligible for institutional trials of GVHD therapy. 
b. Patients who develop acute GVHD > grade II prior to day +100: 
• Patients who develop acute GVHD > grade II should receive 
prednisone (1-2 mg/kg/day) or intravenous equivalent. Continuation 
of sirolimus (Arms 2 and 3) beyond day 80 in patients with active 
GVHD is at the discretion of the treating attending. A suggested 
sequence for immunosuppression discontinuation is as follows. 
Patients who respond to steroids after 10 to 14 days of treatment, 


Protocol 2206.00 
Current Version: 09/26/2018 
-56-
should begin a 6 week steroid taper. When steroids are tapered to less 
than 0.5 mg/kg, then a MMF taper should be initiated no sooner than 
day +100 and such that the completion of the taper is NOT prior to 
Day + 150. After successful discontinuation of MMF and 
corticosteroids, the suggested sequence for tapering CSP is to taper 
the CSP such that the completion of the taper is NOT prior to Day + 
180 post transplant. After successful discontinuation of CSP, it is 
suggested that sirolimus should be tapered such that the completion of 
the taper is NOT prior to Day +365. 
• If nausea and/or vomiting prevent the oral administration of CSP or 
MMF, then CSP and MMF should be administered intravenously.  
The timing of these tapers depends on the day post transplant that 
acute GVHD develops, the severity of the GVHD and the clinical 
discretion of the attending physician. 
• Patients may be eligible for institutional trials of GVHD therapy. 
c. 
Patients with clinical extensive chronic GVHD: CSP 5.0 mg/kg PO q12hrs 
and prednisone 1mg/kg QD or eligible protocols at the time.  The patient 
should receive antibiotic prophylaxis with daily double strength Bactrim.  
d. 
Patients off immunosuppression who develop concurrent manifestations of 
GVHD that satisfy criteria for acute GVHD > grade II (e.g. erythematous 
rash, diarrhea, hyperbilirubinemia) and are pathognomonic of clinical 
extensive chronic GVHD (e.g. lichenoid oral changes, occular sicca, 
scleroderma, bronchiolitis obliterans, contractures), should receive 
prolonged immunosuppressive therapy similar to that for clinical extensive 
chronic GVHD. 
 
H. Myelosuppression 
Grade IV myelosuppression will be defined as a decrease in ANC to <500/uL and/or platelet 
count to  20,000/uL. If myelosuppression occurs, a bone marrow aspirate and biopsy should 
be considered to exclude disease progression. Samples should be sent for chimerism analysis 
by a DNA-based assay that compares the profile of amplified fragment length polymorphisms 
(ampFLP) (or FISH studies or VNTR) of the patient and donor. Myelosuppression may occur in this 
patient population for a number of reasons such as direct toxic effect of drugs (MMF, 
gancyclovir etc.), rejection, relapse or after DLI.  
 
Patients with myelosuppression may be managed as follows:  
1. Suspected MMF toxicity: refer to sections 11.H.b Guidelines for MMF dose adjustment 
above for management recommendations.  
2. Suspected sirolimus toxicity: refer to sections 11.H.c for management recommendations. 
3. Suspected ganciclovir toxicity: consider changing to foscarnet.  
4. Patients who are > 21 days after HCT with an ANC of <500/uL may receive G-CSF 
5g/kg/day S.C. 
5. Thrombocytopenic patients will receive platelet transfusion as per standard care. 
6. Suspected BCR/ABL tyrosine kinase inhibitor therapy (such as imatinib mesylate or 
dasatinib) toxicity:  refer to sections 11.L.4 above for management recommendations.  
 
 
 


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15. Records 
Clinical records will be maintained as confidentially as possible by all collaborating institutions. 
Collection of Case Report Forms (CRF) at standard intervals is the primary method of collecting 
data from collaborating centers. Clinical Statistics at FHCRC maintains a patient database to allow 
storage and retrieval of patient data collected from a wide variety of sources. The principal 
investigator will ensure that data collected conform to all established guidelines for coding 
collection, key entry and verification. These data are then entered into a secure dedicated database 
operated by a data manager.  Any publication or presentation will refer to patients by a unique 
patient number and not by name to assure patient confidentiality. The licensed medical records 
department, affiliated with the institution where the patient receives medical care, maintains all 
original inpatient and outpatient chart documents. 
 
At the FHCRC, patient research files are kept in a locked room. They are maintained by the 
FHCRC data collection staff that is supervised by an A.R.T. Access is restricted to personnel 
authorized by the Division of Clinical Research. 
 
16.   Statistical Considerations  
The primary objective of this study is to evaluate the efficacy of CSP, MMF and sirolimus in 
reducing the rate of grade II-IV acute GVHD in HLA class I or II mismatched nonmyeloablative 
transplants. The rate of grade II-IV acute GVHD in previous studies in this patient population has 
been approximately 70% at day 100.   The rate of grade III-IV acute GVHD was approximately 
25%. 
 
Fifty-five patients will be enrolled. If grade II-IV acute GVHD occurs in 33 or fewer patients by 
day 100, then we can be at least 90% confident that the true rate of GVHD is less than 70%. The 
probability of achieving this outcome (power) is 95%, if the true rate of GVHD is lowered to 50%, 
and 81% if the true rate is 55%.   
 
If grade III-IV acute GVHD occurs in 10 or fewer patients by day 100, then we can be at least 85% 
confident that the true rate of GVHD is less than 25%.  The probability of achieving this outcome 
(power) is 81% if the true rate of GVHD is lowered to 15%. 
 
Modified accrual target:  As of November, 2015 the protocol is modified to increase target 
accrual to 80 patients, to enable separate evaluation of class I and class II mismatches. Although 
we have no reason to believe that the potential efficacy of the regimen will differ between classes, 
it will be of benefit if we can assert with some degree of confidence that acute GVHD is reduced 
for either kind of mismatch.  Based on current accrual, class II mismatches comprise about 30% of 
enrollment; thus, with 80 patients we anticipate 55 patients with a class I mismatch and 25 patients 
with a class II mismatch.  The statistical considerations for the group with class I mismatch will be 
as previously described above for the overall cohort.  For the group with class II mismatch, 14 or 
fewer patients out of 25 with grade II-IV acute GVHD by day 100 will allow us to be at least 90% 
confident that the true rate is less than the 70% historical rate.  The probability of achieving this 
outcome is 79%, if the true rate of acute GVHD is 50%.  If grade III-IV acute GVHD by day 100 
occurs in 4 or fewer patients, then we can be at least 80% confident that the true rate is less than 
the historical rate of 25%.  The probability of achieving this outcome is 68% if the true rate is 
lowered to 15%.  Stopping rules will continue to be monitored for the overall patient group, 
regardless of type of mismatch. 
 


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Although we have no expectation that the addition of sirolimus to the immunosuppressive regimen 
will impact graft rejection, a stopping rule for graft rejection will be imposed, with a threshold rate 
of 5% by day 100. Rejection is defined as the inability to detect or loss of detection of greater than 
5% donor T cells (CD3+) as a proportion of the total T cell population. The study will stop 
whenever there is reasonable evidence that the true rate of graft rejection exceeds this threshold. 
Reasonable evidence will be taken to mean that the lower bound of a 1-sided 90% confidence 
interval for the rate of graft rejection is greater than 5%. Operationally, this rule will be evaluated 
at least every 5 patients, and will be triggered by the following outcomes:  2 rejections within the 
first 10 patients, 3 rejections within the first 20 patients, 4 rejections within the first 35 patients, 5 
rejections within the first 45 patients, 6 rejections within the first 60 patients, 7 rejections within 
the first 75 patients, or 8 rejections in any number of patients. 
 
A stopping rule will also be imposed for non-relapse mortality (NRM) at day 100, which was 
approximately 20% in protocol 1591.  The study will suspend accrual for review by the DSMB 
whenever there is reasonable evidence that the true rate of NRM exceeds the historical rate. 
Reasonable evidence will be taken to mean that the lower bound of a 1-sided 90% confidence 
interval for the rate of day 100 NRM is greater than 20%.  Operationally, this rule will be 
evaluated at least every 5 patients, and will be triggered by the following outcomes:  3 NRM 
deaths within the first 5 patients, 5 deaths in 10 patients, 6 deaths in 15 patients, 7 deaths in 20 
patients, 9 deaths in 25 patients, 10 deaths in 30 patients,  11 deaths in 35 patients, 12 deaths in 40 
patients, 13 deaths in 45 patients, 15 deaths in 50 patients, 16 deaths in 55 patients, 17 deaths in 60 
patients, 18 deaths in 65 patients, 19 deaths in 70 patients, 20 deaths in 75 patients, or 22 deaths in 
80 patients. 
 
 
Stopping rules will be imposed for: 
 
• 
Graft Rejection of  5% by day 100  
• 
NRM of > 20% at day 100  
 
Enrollment may continue pending evaluation of these outcomes in currently enrolled patients, but 
the outcome of these additional patients will not override the stopping rule if triggered in an earlier 
number. The operating characteristics of the stopping rules are provided in the table below. 
 
True rate of 
graft rejection 
Probability 
of stopping1 
Average 
n enrolled1 
True rate of 
Day 100 NRM 
Probability 
of stopping1 
Average 
n enrolled1 
0.05 
21% 
69 
.20 
25% 
67 
0.10 
75% 
42 
.25 
58% 
52 
0.15 
97% 
23 
.30 
86% 
35 
0.20 
>99% 
15 
.35 
98% 
24 
1 estimated from 10,000 Monte Carlo simulations 
 
17.  Data and safety Monitoring Plan 
 
 
FHCRC Protocol 2206 Data and Safety Monitoring Plan 
 
1. Monitoring the progress of trials and the safety of participants 
Protocol 2206 is a multi-institutional clinical trial that is monitored by the principal investigator 
(PI), Dr. Sandmaier, with oversight by a Data Safety and Monitoring Board (DSMB), the Data and 


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Safety Monitoring Committee (DSMC) and the Institutional Review Board (IRB). The PI reviews 
outcome data for each individual patient at a minimum of 3 months after mismatched donor HCT 
and the updated data are presented at Mixed Chimerism Meetings (includes co- investigators). 
 
Please see Appendix I for definitions of adverse events, serious adverse events (SAE) and serious 
and unexpected events as well as mechanisms for reporting these events.  SAEs are reported to the 
trial coordinator. The trial coordinators at collaborating centers or the local PIs will fax an official 
report of a SAE to the coordinating center (FHCRC) within ten days. The SAE report is reviewed 
by Dr. Sandmaier. If the SAE meets the FHCRC criteria for expedited reporting then an official 
signed report is submitted to the FHCRC Institutional Review Office (IRO). All deaths, regardless 
of the cause, are reported to the IRB. Protocol 2206 has a dedicated independent DSMB responsible 
for monitoring patient safety on this clinical trial. The DSMB will meet at six month intervals for 
this protocol and all outcome data is reviewed including all adverse events and SAEs reported to the 
coordinating center (FHCRC) along with those officially reported to the FHCRC IRO. The DSMB 
confirms that the trial has met any stopping rules and reviews any patient safety problems 
necessitating discontinuation of the trial. A report from the DSMB is submitted to the FHCRC IRB 
as well as the trial coordinators/local PIs of this protocol. The DSMB will discontinue the review of 
outcomes when this protocol is closed to accrual and the last patient treated is past day +180. 
Furthermore, the FHCRC also has a DSMC that reviews the progress of the protocol with respect to 
the monitoring plan at the time of each annual renewal. As with initial review, annual IRB review 
and approval is also required.  
  
Flow of information concerning clinical trial participants originates with the clinicians and nurses in 
the clinic or referring clinicians at other institutions and is transmitted to the trial coordinator. At 
the FHCRC, health care providers and rotating attending physicians assess patients and record their 
observations regarding toxicity and response outcomes in the medical record.  This documentation 
is extracted by the study nurse within 140 days +/- after HCT via chart review and collection of 
copies of source documents and entered into a hard copy or electronic Case Report Form (CRF). 
The PI reviews the official CRF and primary source documents. When the CRFs are verified, they 
are signed by the PI.  Thus, multiple health care providers provide independent observations and 
participate in monitoring this trial.  The PI may be a clinician for some patients entered on this trial. 
However, assessments are the sum total of the primary health care provider (fellow or physician 
assistant), floor or outpatient nurse and the PI or other attending clinician involved with the patient 
averting possible conflict of interest having the PI as the attending clinician for protocol patients. If 
determination of adverse events is controversial, co-investigators will convene on an ad hoc basis as 
necessary to review the primary data and render a decision.  
 
Protocol 2206 will be a multi-institutional protocol and all collaborating centers sign an agreement 
with the FHCRC stating that data generated from patients from the protocol will be reported 
accurately in a timely manner to the FHCRC. All centers have an IRB that reviews the protocol and 
that the local PIs contact when an adverse event on the protocol occurs. Most of the centers have 
internal auditing mechanisms that assure accurate assessment of clinical outcomes. Clinical 
outcome data are summarized and transmitted from collaborating centers as CRFs. When possible, 
primary source documents regarding patient outcomes are collected with patients’ names removed 
and replaced by Unique Patient Numbers (UPNs). The CRFs are generated from the collaborating 
centers at defined time points (100 days, 6 months, and yearly).   The local PI reviews the official 
CRF and primary source documents. When the CRFs are verified, they are signed and the data are 
entered into a central database managed by the FHCRC trial coordinator.  


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2. Plans for assuring compliance with requirements regarding the reporting of Serious Adverse 
Events SAEs 
The adverse event reporting in this multi institution clinical trial will follow the FHCRC Guidelines 
for s SAE reporting. These guidelines (attached in Appendix I.) detail the expedited reporting 
requirements, definitions of particular events. All SAEs that meet expedited reporting criteria are 
reported to the IRO within 10 days by the investigator, trial coordinator, or research nurse upon 
learning of the event. A completed SAE report form, signed by the PI, must be received by the IRO 
within 10 calendar days. For patients being cared for at the FHCRC, health care providers 
communicate with the PI, trial coordinator or research nurses as events occur triggering subsequent 
reporting. For patients not being cared for at FHCRC the outside facilities communicate with the PI, 
trial coordinator, or research nurse for these reporting purposes. All other deaths and expected 
serious adverse events are reported to the IRB at the time of annual renewal and at the biannual 
mixed chimerism meeting.  The PI for a study is responsible for this reporting and the IRO assures 
adverse event reporting on an annual basis. The PI in the annual application for grant continuation 
will summarize reports of toxicity. Furthermore, an additional safeguard for adverse event analysis 
and reporting in this protocol is provided by stopping rules that are monitored at least every 10 
patients in each arm.  All collaborating PIs have fulfilled all NIH requirements for training in 
human subjects protection. 
 
3. Plans for assuring that any action resulting in a temporary or permanent suspension of an NCI-
funded clinical trial is reported to the NCI grant program director responsible for the grant 
This clinical research trial uses commercial agents and there is no associated Investigational New 
Drug (IND) or Investigational Device Exemption (IDE). Any temporary or permanent suspension, 
as determined by the PI, IRB, or DSMC, of this clinical research trial will be reported to the NCI 
grant program director by the PI.  
 
4. Plans for assuring data accuracy and protocol compliance 
Collaborating sites send signed consents, eligibility forms, and CRFs with source documents 
demonstrating eligibility, treatment, and serious adverse events (if applicable) to the study staff. 
These are reviewed for eligibility, adherence to the protocol, accuracy, and completeness by the 
study staff. Queries are sent to the collaborating investigators if CRFs are inaccurate or incomplete.  
 
The study is monitored under the FHCRC Monitoring Plan. The FHCRC Data and Safety 
Monitoring Plan details the full scope and extent of monitoring and provides for immediate action 
in the event of the discovery of major deviations.  
 
 
 
 


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18.  Targeted/Planned Enrollment  
 
TARGETED / PLANNED ENROLLMENT:  Number of Subjects 
 Ethnic Category 
 Sex / Gender  
 
Females 
Males 
Total 
Hispanic or Latino 
1 
2 
3 
Not Hispanic or Latino 
33 
44 
77 
Ethnic Category Total of All Subjects* 
34 
46 
80 
                              Racial Categories  
American Indian / Alaska Native 
0 
0 
0 
Asian 
1 
2 
3 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
1 
1 
2 
White 
32 
42 
75 
Racial Categories:  Total of All Subjects* 
34 
46 
80 
*The “Ethnic Category Total of All Subjects” must be equal to the “Racial Categories Total of All Subjects.” 
 


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microemulsion formulation coadministration on the pharmacokinetics of each agent.  Clin.Pharmacol.Ther.  
1998;63(1):48-53. 
 49.  Ferron GM, Mishina EV, Zimmerman JJ, Jusko WJ. Population pharmacokinetics of sirolimus in kidney transplant 
patients.  Clin.Pharmacol.Ther.  1997;61(4):416-28. 
 50.  Kelly PA, Gruber SA, Behbod F, Kahan BD. Sirolimus, a new, potent immunosuppressive agent (Review).  
Pharmacotherapy  1997;17(6):1148-56. 
 51.  Marty FM, Lowry CM, Cutler CS, Campbell BJ, Fiumara K, Baden LR, Antin JH. Voriconazole and sirolimus 
coadministration after allogeneic hematopoietic stem cell transplantation.  Biol Blood Marrow Transplant  
2006;12(5):552-9. 
 52.  Bolan CD, Childs RW, Procter JL, Barrett AJ, Leitman SF. Massive immune haemolysis after allogeneic peripheral 
blood stem cell transplantation with minor ABO incompatibility.  Br.J.Haematol.  2001;112(3):787-95. 


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APPENDICES – TABLE OF CONTENTS 
 
 
I. 
APPENDIX A  
ELIGIBILITY GUIDELINES FOR DONOR PBSC APHERESIS FOR 
TRANSFUSION 
 
II. 
APPENDIX B 
THE KARNOFSKY PERFORMANCE STATUS SCALE  
 
III. 
APPENDIX C 
THE LANSKY PLAY-PERFORMANCE SCALE 
  
IV.  
APPENDIX D  
ABO INCOMPATIBILITY  
 
V.       APPENDIX E         INFECTIOUS DISEASE GUIDELINES 
 
VI.        APPENDIX F    
ACUTE GRAFT-VERSUS-HOST DISEASE GRADING 
 
VII.       APPENDIX G         CHRONIC GRAFT-VERSUS-HOST DISEASE GRADING       
 
VIII. 
APPENDIX H  
EVALUATION OF DISEASE RESPONSE FOR MM, NHL, CLL, AND MDS  
 
IX.   
APPENDIX I  
STUDY COORDINATOR’S MANUAL INCLUDING PROCEDURE FOR 
REPORTING ADVERSE EVENTS 
 
X.  
APPENDIX J  
ADVERSE EVENT REPORT 
 
 
 
XI.  
APPENDIX K  
NOTICE OF DEATH FORM 
 
XII.      APPENDIX L          PATIENT DEMOGRAPHICS AND REGISTRATION FORM 
 
 
XIII.    APPENDIX M  
CORE CASE REPORT FORM 
 
XIV. 
APPENDIX N  
INTRATHECAL DIAGNOSTIC STUDY AND THERAPY 
 
XV.      APPENDIX O   
HLA MATCHING REQUIREMENTS FOR DONORS  
 
XVI. 
APPENDIX P  
ADAPTED COMMON TOXICITY CRITERIA 
 
XVII. APPENDIX Q         THE HEMATOPOIETIC CELL TRANSPLANT-COMORBIDITY INDEX                           
                                               (HCT-CI) 
 
XVIII. APPENDIX R         CLINICALLY SIGNIFICANT INDUCERS/INHIBITORS OF  
 
 
 
 
 
 
        CYTOCHROME P450 ENZYME SYSTEM 
 
XIX. 
APPENDIX S         STANDARD DONOR CONSENT 
     
XX.      APPENDIX T         WEIGHT / ADJUSTED BODY WEIGHT FOR DRUG DOSING 
 
XXI. 
APPENDIX U         COORDINATING CENTER FUNCTIONS 
 
XXII APPENDIX V  
RADIOTHERAPY TREATMENT GUIDELINES (FHCRC Protocol 
 
 
  
  
 
 
2206.00) 
 


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


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


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


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


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MAJOR ABO INCOMPATIBLE 
Recipient anti-
Donor titer 
> 1:32 
<20ml RBC total 
  Infuse without modification 
>20ml RBC total 
  RBC depletion of component 
< 1:16 
  
Infuse without modification 
MINOR ABO INCOMPATIBLE 
Donor anti-
Recipient titer 
> 1:256 
Plasma depletion of component 
< 1:128 
Infuse without modification 
 
 


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Appendix E 
 
Infectious Disease Guidelines: Monitoring, Prevention and Treatment 
 
Herpes Simplex and Varicella Zoster Virus Prevention and Treatment 
hsv-vzv.pdf
 
CMV Prevention: Surveillance and Preemptive Therapy 
 
cmvprevention.pdf
 
CMV Disease: Diagnosis and Treatment 
cmvdiseasetreatmen
t.pdf
 
 
Antifungal Therapy Guidelines 
 
antifungal_therapy.p
df
 
Pneumonia / Pneumocystis Carinii Prophylaxis 
pneumocystisjiroveci
.pdf
 
Antibiotic Prophylaxis for Encapsulated Bacteria in Allogeneic Patients with Chronic GvHD 
Requiring Immunosuppressive Therapy 
antibioticprophylaxisf
orencapsulatedbacter 
 
Vaccinations  
Vaccines
 
Foscarnet 


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foscarnet.pdf
 


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


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APPENDIX G 
 
CHRONIC GRAFT-VERSUS-HOST DISEASE (GVHD) 
 
Chronic GVHD in allogeneic transplant recipients resembles autoimmune disorders such as 
scleroderma, Sjogren syndrome, primary biliary cirrhosis, lichen planus, wasting syndrome, 
bronchiolitis obliterans among others manifestations (see below). Approximately 50% of 
patients will develop this complication within 6 months after the transplant despite continued 
treatment with immunosuppressive medications. Close monitoring is recommended during 
the first 2 years after allogeneic stem cell transplantation so that appropriate treatment can be 
instituted promptly in patients who develop chronic GVHD. Debilitation, joint contractures 
and profound immunosuppression resulting in recurrent bacterial infections are prominent 
characteristics of untreated chronic GVHD. 
 
A. Classification of Chronic GVHD 
The purpose of this classification is to identify patients with cGVHD who need long-term 
systemic immunosuppression according to clinical and laboratory findings and risk factors at 
the time of initial diagnosis. In addition, a morbidity scale has been developed to help grade 
the severity of manifestation of chronic GVHD (Appendix D) at the time of diagnosis, when 
changes in treatment are made and when assessing treatment response. 
 
1.  
Chronic GVHD not requiring systemic treatment: mild abnormalities involving a 
single site, with platelet count >100,000 and no steroid treatment at the onset of 
chronic GVHD 
a)  Oral abnormalities consistent with cGVHD, a positive skin or lip biopsy, and no other 
manifestations of cGVHD 
b)  Mild liver test abnormalities (alkaline phosphatase ≤2 x upper limit of normal, AST or 
ALT ≤3 x upper limit of normal and total bilirubin ≤1.6) with positive skin or lip biopsy, 
and no other manifestations of cGVHD 
c)  Less than 6 papulosquamous plaques, macular-papular or lichenoid rash involving <20% 
of body surface area (BSA), dyspigmentation involving <20% BSA, or erythema 
involving <50% BSA, positive skin biopsy, and no other manifestations of cGVHD 
d)  Ocular sicca (Schirmer’s test ≤5mm with no more than minimal ocular symptoms), 
positive skin or lip biopsy, and no other manifestations of cGVHD 
e)  Vaginal or vulvar abnormalities with positive biopsy, and no other manifestations of 
cGVHD 
 
2.  
Chronic GVHD requiring systemic treatment: more severe abnormalities or 
involvement of multiple sites, or platelet count <100,000, or steroid treatment 
at the onset of chronic GVHD 
a)  Involvement of two or more organs with symptoms or signs of cGVHD, with biopsy 
documentation of cGVHD in any organ 
b)  ≥15% base line body weight loss not due to other causes, with biopsy documentation of 
cGVHD in any organ 
c)  Skin involvement more extensive than defined for clinical limited cGVHD, confirmed by 
biopsy 
d)  Scleroderma or morphea 
e)  Onycholysis or onychodystrophy thought to represent cGVHD, with documentation of 


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cGVHD in any organ 
f)  Decreased range of motion in wrist or ankle extension due to fasciitis caused by cGVHD 
g)  Contractures thought to represent cGVHD 
h) Oral involvement with functional impairment, refractory to topical treatment 
i)  Vaginal involvement with functional impairment, refractory to topical treatment 
j)  Bronchiolitis obliterans not due to other causes 
k)  Positive liver biopsy; or abnormal liver function tests not due to other causes with 
alkaline phosphatase >2 x upper limit of normal, AST or ALT >3 x upper limit of 
normal, or total bilirubin >1.6, and documentation of cGVHD in any organ 
l)  Positive upper or lower GI biopsy 
m)  Fasciitis or serositis thought to represent cGVHD and not due to other causes 
 
B. Physical manifestations of Chronic GVHD 
Manifestations that are distinctive for chronic GVHD can begin before day 100 after the 
transplant, and manifestations that are typical of acute GVHD can persist long after day 100. 
For this reason, the differential diagnosis between acute and chronic GVHD cannot be made 
solely according to the time interval from transplant. The diagnosis of chronic GVHD 
requires at least one manifestation that is distinctive for chronic GVHD (identified by italic 
print below) as opposed to acute GVHD. In all cases, infection and others causes must be 
ruled out in the differential diagnosis of chronic GVHD. 
 
Karnofsky or Lansky Clinical Performance scores <60%, ≥15% weight loss, and recurrent 
infections are usually signs of clinical extensive chronic GVHD. Abnormalities that could 
indicate chronic GVHD are categorized by organ system are listed below (italic print 
identifies manifestation more distinct of chronic GVHD): 
 
Skin 
Erythema, dryness, pruritis, macular-papular or urticarial rash, pigmentary 
changes (i.e., hyperpigmentation, vitiligo), mottling, papulosquamous or 
lichenoid plaques, hyperkeratosis, exfoliation (ichtyosis), nodules, scleroderma, 
morphea (one or several circumscribed, indurated and shiny lesions). The extent 
of skin involvement and the skin thickness score for patients with scleroderma 
needs to be recorded at the time of diagnosis, when changes in treatment are 
made and when assessing treatment response. Medical photos are also useful for 
assessing the extent of skin involvement and response to treatment. 
Nails 
B.     Ridging, onychodystrophy, onycholysis 
Hair 
Premature graying (scalp hair, eyelashes, eyebrows), thinning scalp hair, 
alopecia, decreased body hair 
Mouth 
Dryness, burning, gingivitis, mucositis, striae, dryness, atrophy, erythema, 
lichenoid changes, ulcers, labial atrophy or pigmentary changes, tightness 
around the mouth, sensitivity to acidic, strong flavors, heat or cold, tooth decay 
Eyes 
Dryness, burning, blurring, gritty eyes, photophobia, pain 
Vagina/vulva 
Dryness, dyspareunia, stricture or stenosis, erythema, atrophy or lichenoid 
changes not induced by ovarian failure or other causes 
Liver 
Jaundice and elevated liver function tests not due to other causes (see laboratory 
tests) 
Lung 
Bronchiolitis obliterans (see diagnostic indicators), cough, wheezing, dyspnea on 
exertion, history of recurrent bronchitis or sinusitis 
GI 
Anorexia, nausea, vomiting, diarrhea, malabsorption, dysphagia, odynophagia 


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Myofascial 
Stiffness and tightness with restriction of movement, occasionally with swelling, 
pain, cramping, erythema and induration, most commonly affecting the forearms, 
wrists and hands, ankles, legs and feet, inability to extend the wrists without 
flexing the fingers or the elbows, contractures 
Muscle 
Proximal muscle weakness, cramping 
Skeletal 
Arthralgia of large proximal girdle joints and sometimes smaller joints 
Serosal 
Unexplained effusions involving the pleural, pericardial, or peritoneal cavities 
not due to venocclusive disease of the liver, cardiac insufficiency, malignancy, 
infection, GM-CSF toxicity or other causes 
 
C. Laboratory Testing and Diagnostic Indicators of Chronic GVHD 
 
Eye 
Schirmer’s test with a mean value ≤ 5 mm at 5 minutes, or values of 6-10 mm in 
patients who have sicca symptoms, or keratitis detected by slit lamp examination 
Liver 
Elevated liver function tests not due to other causes (alkaline phosphatase ≥2 x 
upper limit, of normal, AST or ALT >3 x upper limit of normal or total serum 
bilirubin ≥1.6) 
Lung 
New obstructive lung defect defined as an FEV1 <80% of predicted with either an 
FEF 25-75 <65% of predicted or RV >120% of predicted, or a decrease of 
FEV1/FVC by >12% within a period of less than 1 year, thought not to be caused 
by an infectious process, asthma or recurrent aspiration from the sinuses or from 
gastroesophageal reflux. In the absence of GVHD in any other organ, the 
diagnosis of bronchiolitis obliterans requires negative microbiological tests from 
bronchoalveolar lavage, evidence of air trapping by high resolution end-
expiratory and end-inspiratory CAT scan of the lungs, or confirmation by 
thoracoscopic biopsy. 
Esophagus 
Esophageal web formation, stricture or dysmotility demonstrated by barium 
swallow, endoscopy or manometry 
Intestine 
Endoscopic findings of mucosal edema and erythema or focal erosions with 
histological changes of apoptotic epithelial cells and crypt cell drop out. Patients 
with unresolved acute GVHD may have more severe intestinal mucosal lesions 
including ulcers and mucosal sloughing. 
Muscle 
Elevated CPK or aldolase, EMG findings consistent with myositis with biopsy 
revealing no other etiological process 
Blood 
Thrombocytopenia (usually 20,000-100,000/l), eosinophilia (> 0.4 x 103/uL), 
hypogammaglobulinemia. Hypergammaglobulinemia and autoantibodies occur in 
some cases. 
 
D. Guidelines for Treatment of Chronic GVHD after allogeneic HCT 
 
We strongly recommend that you consult the LTFU office before beginning treatment for chronic GVHD 
and before making changes in immunosuppressive treatment. Clinical trials should always be considered 
because current standard therapies are associated with high morbidity and decreased survival for patients 
with high risk chronic GVHD. 
 
Standard treatment of chronic GVHD usually begins with administration of glucocorticoids 
(1mg/kg/day) followed by taper to eventually reach an alternate-day regimen, with or without daily 
cyclosporine or tacrolimus (FK506). Other medications used for treatment of corticosteroid-resistant 


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chronic GVHD are summarized on the next page. Telephone consultation with the LTFU medical team 
is available to you, seven days a week, to discuss appropriate treatment and provide other follow up 
recommendations. In addition to immunosuppressive treatment, antibiotic prophylaxis for encapsulated 
bacterial infections and PCP must be given to all patients being treated for chronic GVHD. 
 
The duration of systemic immunosuppressive treatment of chronic GVHD varies but requires at least 
one year of therapy. Approximately 80% of patients require systemic immunosuppressive for 2 years 
and 40% of them requires therapy for at least 4 years. 
 
 
Adapted From: Long-Term Followup After Hematopoietic Stem Cell Transplant General Guidelines For Referring 
Physicians, Fred Hutchinson Cancer Research Center Standard Practice Manual, Section X, Chronic Graft Versus Host 
Disease (GVHD), Nov/2003 Version 


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Appendix H 
Evaluation of Disease Response: 
 
Chronic myeloid Leukemia (CML) 
Complete response: 
Normalization of the white count with complete disappearance of the Ph 
chromosome in 20 out of 20 metaphases whenever possible. Molecular 
response is defined by negative RT-PCR for the BCR/ABL transcripts in 
bone marrow or blood. 
Partial response: 
Normalization of the white count with >0% but 35% Ph  
 
metaphases. 
No response: 
Persistence of 80% Ph-positive metaphases. 
Progressive disease: 
Acquisition of a new cytogenetic abnormality and/or development of 
accelerated phase or blast crisis. The criteria for accelerated phase will be 
defined as unexplained fever greater than 38.3° C, new clonal cytogenetic 
abnormalities in addition to a single Ph-positive chromosome, marrow 
blasts and promyelocytes in access of 20%. 
 
Acute leukemia (AML, ALL) 
Complete response: 
<5% marrow blasts by pathology and no circulating leukemic  
 
blasts. 
Partial response: 
5-30% marrow blasts, or <5% marrow blasts with circulating blasts. 
Stable disease: 
>30% marrow blasts without definite deterioration of performance  
 
status or worsening of anemia, neutropenia, or thrombocytopenia. 
Progressive disease: 
Evidence of relapse (>5% blasts) by morphologic or flow cytometric 
 
evaluation of  the bone marrow aspirate or appearance of extramedullary 
 
disease . 
 
Chronic lymphocytic leukemia (CLL) 
Complete remission: 
Normal imaging studies (X-ray, CT, MRI) (nodes, liver, and spleen), 
peripheral blood by flow cytometry has no clonal lymphocytes, bone 
marrow by flow cytometry has no clonal lymphocytes, bone marrow by 
morphology has no nodules (or if present, nodules are free from CLL cells 
by immunohistochemistry), and the duration is ≥2 months. 
CR with minimal   
residual disease:  
 
 Peripheral blood or bone marrow by flow cytometry >0 - <1 CLL 
cells/1000 leukocytes (0.1%) 
Partial remission: 
 
 Absolute lymphocyte count in peripheral blood 50% decrease3 and 
physical exam/Imaging studies (nodes, liver, and/or spleen) 50% 
decrease3, 4. Duration is ≥2 months. 
Progressive disease:  
 1 of: Physical exam/imaging studies (nodes, liver, and/or spleen) ≥50% 
increase or new, circulating lymphocytes by morphology and/or flow 
cytometry 50% increase, and lymph node biopsy with Richter’s 
transformation 
Stable disease: 
 Did not meet any of the above criteria for complete or partial remission or 
progression. 
Relapsed disease: 
 
 Criteria of progression occurring 6 months after achievement of complete 
or partial remission. 


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Lymphoma [Hodgkin's Disease, Non-Hodgkin's Lymphoma (NHL)] 
Complete response: 
Disappearance of all clinically detectable disease. 
Partial response: 
50% reduction of the sum of the products of the perpendicular  
 diameters of marker lesions, no progression of any existing lesions, and no 
new lesions. 
Stable disease: 
Stabilization of all existing lesions with no new lesions (i.e. a <25% 
increase or <50% decrease in disease parameters defined above throughout 
the treatment period). 
Progressive disease: 
>25% increase in the sum of the products of the perpendicular diameters of 
marker lesions, or the appearance of new lesions. 
 
Multiple Myeloma (MM) 
Complete response: 
Disappearance of plasmacytomas; decrease in marrow plasmacytosis to 
less than 10%; 75% reduction of the monoclonal serum protein. 
Reduction of the 24 hour urine M-component to 10% or less of the initial 
prestudy value and to less than 0.2 gm/day; no increase in the size or 
number of lytic skeletal lesions; and normal serum calcium. 
Partial response: 
50%, <75% reduction of the monoclonal serum protein and  
 reduction of the 24 hour urine M-component to less than  
0.2 gm/day; no increase in serum calcium, or in the size or number of 
plasmacytomas or lytic skeletal lesions. 
Stable disease: 
<50% reduction or <100% increase of the serum myeloma protein. 
Progressive Disease: 
100% increase of the serum myeloma protein from its lowest  
 level, or reappearance of myeloma peaks that had disappeared with 
treatment; or definite increase in the size or number of plasmacytomas or 
lytic bone lesions. 
 
Myelodysplasia (MDS) 
Progressive Disease:  
 
Any evidence by morphologic or flow cytometric evaluation of the bone 
marrow aspirate of new blasts (>5%). 
 
1 Without granulocyte colony stimulating factor support. 
2 Without red blood cell transfusions or erythropoietin support. 
3 Compared to before starting therapy. 
4 Defined by the sum of the products of up to 6 lymph nodes with no increase in the size of any single lymph node (ie, an increase of <25 percent in a lymph 
node <2cm is not considered significant) and no new enlarged lymph nodes. 
 
1.  Cheson BD, Bennett JM, Grever M, Kay N, Keating MJ, O'Brien S, Rai KR.  National Cancer Institute-sponsored 
Working Group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment.  
Blood 87: 4990-4997, 1996. 
 2.  Hallek M, Cheson BD, Catovsky D, Caligaris-Cappio F, Dighiero G, Dohner H, Hillmen P, Keating MJ, Montserrat E, 
Rai KR, Kipps TJ, International Workshop on Chronic Lymphocytic Leukemia.  Guidelines for the diagnosis 
and treatment of chronic lymphocytic leukemia: a report from the International Workshop on Chronic 
Lymphocytic Leukemia updating the National Cancer Institute-Working Group 1996 guidelines [Erratum 
appears in Blood. 2008 Dec 15;112(13):5259].  Blood 111: 5446-5456, 2008. 
  3.   Chronic lymphocytic leukemia: recommendations for diagnosis, staging, and response criteria. International Workshop 
on Chronic Lymphocytic Leukemia.  Ann Intern Med 110: 236-238, 1989. 


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


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APPENDIX I cont’d. 
Expedited Reporting Requirements  
All adverse events (whether occurring on-site or off-site), which in the opinion of the principal 
investigator are (1) unexpected, and (2) related or possibly related to the research and (3) 
serious or suggests that the research places research participants or others at a greater risk of 
physical or psychological harm than was previously known or recognized must be submitted to 
the IRB within ten (10) calendar days of becoming aware of the event. 
 
Definitions 
 
Adverse Event - Any untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product, medical treatment or procedure and which does not necessarily 
have to have a causal relationship with this treatment.  An adverse event can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding, for example), symptom, or 
disease temporally associated with the use of a medicinal product, medical treatment or procedure 
whether or not considered related.  
 
Related or Possibly Related Adverse Event – An adverse event is “related or possibly related to the 
research procedure” if in the opinion of the principal investigator, it was more likely than not caused by 
the research procedures. Adverse events that are solely caused by an underlying disease, disorder or 
condition of the subject or by other circumstances unrelated to either the research or any underlying 
disease, disorder or condition of the subject are not “related or possibly related.” If there is any question 
whether or not an adverse event is related or possibly related, the adverse event should be reported.  
 
Serious Adverse Event: An adverse event that results in any of the following outcomes: Death, a life-
threatening adverse event (real risk of dying), inpatient hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity/or change in psychosocial status, a 
congenital anomaly or, requires intervention to prevent permanent impairment or damage.  
 
 
Unexpected Adverse Event – An adverse event is “unexpected” when its nature (specificity), severity, 
or frequency are not consistent with (a) the known or foreseeable risk of adverse events associated with 
the research procedures described in the protocol-related documents, such as the IRB-approved research 
protocol, informed consent document and other relevant sources of information such as product labeling 
and package inserts; and are also not consistent with (b) the characteristics of the subject population 
being studied including the expected natural progression of any underlying disease, disorder or condition 
or any predisposing risk factor profile for the adverse event.  
 
To ensure no confusion or misunderstanding exist of the differences between the terms “serious” and 
“severe,” which are not synonymous the following note of clarification is provided: 
 
The term “severe” is often used to describe the intensity (severity) or a specific event (as in mild, 
moderate or severe myocardial infarction); the event itself, however, may be of relatively minor medical 
significance (such as severe headache).  This is not the same as “serious,” which is based on 
patient/event outcome or action criteria usually associated with events that pose a threat to a patient’s 
life or functioning.  Seriousness (not severity) serves as a guide for defining regulatory obligations. 


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For example, hospitalization, in general, will not be considered a serious adverse event as approximately 
half of evaluable MRD patients AND the majority of evaluable URD patients receiving non-
myeloablative transplants were hospitalized.  Hospitalization will be considered a serious adverse event 
if it fulfills the criteria for a serious and unexpected adverse event as described above. 
 
Serious events, including deaths, due to GVHD and/or infections will not be reported on an expedited 
basis.  These are well documented, expected, post transplant complications and will be reported 
biannually to the DSMB. 
 
FHCRC is acting as the Coordinating Center for this multi-institutional study, and it is the responsibility 
of the FHCRC Principal Investigator (or designee) to complete the FHCRC Serious Adverse Event 
Report for all serious adverse events that meet the expedited reporting requirements that are received 
from the participating sites. It is the responsibility of the FHCRC Principal Investigator to notify the 
sponsor, NIH, FDA or other agencies of serious adverse events as required in the protocol. 
 
Procedure for Reporting Serious and Unexpected Adverse Events (SAE) from Participating Sites 
Regulations defining the responsibilities for reporting serious and unexpected adverse reactions are 
defined above.  SAEs or any death regardless of cause (serious, unexpected, and related/possibly 
related) within 180 days after HCT must be reported to the FHCRC Investigator within 10 days of 
learning of the event.  The immediate telephone report must be followed by faxed comments to the 
FHCRC trial coordinator at (206) 667-5378. This will be followed by detailed written report (See 
Appendix “J”) within 10 days.  The report must include the date and time of onset, severity and duration 
of the event, the relationship to the study, the treatment given and eventual outcome.  Follow-up 
information to a SAE report must be submitted as soon as the relevant information is available. 
 
Reporting of Adverse Events on Case Report Forms (CRF) All grade 3 or 4 adverse events (or 
highly unusual grade 2 adverse events) which occur between start of conditioning to day100 during the 
study will be recorded on the Case Report Form (Appendix M).  These adverse events which are 
observed by the Investigator or reported by the patient, whether or not attributed to the study, will be 
recorded on the Case Report Form using the selected (for this protocol) NCI Common Toxicity Criteria 
(NCI-CTC) version 4 (Appendix P) . Attributes will include a description, date of onset, maximum 
severity, and assessment of relationship to the study agent or other suspect agent(s).  These grade 3 or 4 
adverse events will be reported to the DSMB as part of the biannual review of the protocol. The DSMB 
report is submitted with the annual IRB renewal. 
Reporting of Unanticipated Problems that Involve Risk to Research Participants or Others:  
Any incident, experience, or outcome that meets both of the following criteria:  
• Unexpected (in terms of nature [specificity], severity, or frequency) given (a) the 
research procedures that are described in the protocol-related documents, such as the 
IRB-approved research protocol and informed consent document; and (b) the 
characteristics of the subject population being studied; 
• Indicates that the research places research participants or others at a greater risk of 
harm (including physical, psychological, economic, or social harm) than was 
previously known or recognized.  
 
These must be reported to the FHCRC Investigator within 10 days of learning of the event as described 
above for reporting of SAE. 
 


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


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2. Accurate determination of cancer progression 


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


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


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


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APPENDIX L 
Protocol 2206 Patient Demographics and Eligibility Form 
Please Fax this completed form to (206) 667-5378 for patient registration. 
Questions regarding eligibility should go to Brenda Sandmaier, M.D., 206-667-4961. 
 
UPN: _____________ 
Patient Name: 
_______________________________ 
(Last) 
________________________  
(First) 
_____  
(MI) 
Date of Birth: 
_____ / _____ / __________  Age:________ 
 (Mo)    (Day)         (Year) 
Gender (choose one): 
 Male    
 Female   
 Unknown 
Patient Diagnosis: ______________________________________  
Status at Transplant:_____________________________  
Planned Day 0: _____/______/_____ 
 
(Mo) 
(Day)  (Year) 
Ethnicity (choose one):  Instruct the patient to select one of the following. 
 Hispanic (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture 
or origin, regardless of race.  Term “Spanish Origin” can also be used in addition to “Hispanic” or 
“Latino”.) 
 Not Hispanic or Latino 
 
 Declined to Report 
Race (check all that apply):  Instruct the patient to select one or more of the following. 
 American Indian/Alaska Native (A person having origins in any of the original peoples of North, Central, 
or South America, and who maintains tribal affiliations or community attachment). 
 Asian (A person having origins in any of the original peoples of the Far East, Southeast, Asia, or the Indian 
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the 
Philippine Islands, Thailand and Vietnam). 
  Black/African American (A person having origins in any of the black racial groups of Africa). 
 Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of Hawaii, 
Guam, Samoa or other Pacific Islands). 
 White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa). 
 Research subject does not know race 
 Declined to report 
 
 
 


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CRITERIA FOR 3 GY TBI: Patients need to fulfill one or more of the following criteria for 3 
Gy TBI: 
 
 Patients with MDS, MPD, CML, or other hematologic malignancies not previously treated 
with myelosuppressive chemotherapy 
Patients who have had a previous allogeneic transplant. 
Patients who had a prior syngeneic transplant without subsequent myelosuppressive 
chemotherapy. 
 Patients who have not had myelosuppressive chemotherapy within 3-6 months of HCT may 
be at higher risk of rejection depending on treatment history and underlying diagnosis. 
Confirm TBI dose (2 vs 3 Gy) with PI. 
 
 
 TBI 2 Gy 
 
OR 
 
 TBI 3 Gy:  
 
 
      PI Signature:  
__________                                       Date: ___                     __


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Protocol 2206 Eligibility  
I)  Inclusion Criteria:  
 
 
1) Yes 
 No 
 Patient signed and dated consent form.   
 
 
  
  
Date:  ___________ 
 
 
  
  
Date of IRB approval of consent form: ___________ 
 
 
  
  
IRB file:  ___________ 
 
2) Yes 
 No 
 Related or unrelated donors who are prospectively:  
a. Mismatched at antigen level for any single class I locus (HLA-A, -B or –C) ± an 
additional class mismatch at the allele level 
 
 
  
  
 
 
 
  
 OR 
mismatched at the allele level for any 2 class I loci (if typed at the molecular 
level) 
 
 
  
  OR 
mismatched at the antigen or allele level for class II loci HLA-DRB1 and/or –
DQB1. Must be matched for at least one DRB1 allele and one DQB1 allele 
b. There is a likelihood of rapid disease progression while HLA typing and results of 
a preliminary search and the donor pool suggests that a 10/10 HLA-A,B,C, DRB1 
and DQB1 matched donor will not be found 
c. There is no HLA-A, -B, or –C one locus allelic mismatched donor available 
d. If the patient is homozygous at the mismatched HLA class I locus, the donor must 
be heterozygous at that locus and one allele must match the patient (i.e., patient is 
homozygous A*01:01 and donor is heterozygous A*01:01, A*02:01). This 
mismatch will be considered a one-antigen mismatch for rejection only 
e. There is no mismatch both at a class I and II locus 
f. There is no indication for an autologous transplantation as a treatment option 
g. Yes 
 No 
 Have negative anti-donor cytotoxic crossmatch 
 
  
 
 
 
  
  
Patient 
 
 
 
 
 
A: ____________ 
A: ____________ 
C: ___________ 
C: ____________ 
B: _________ 
B: _________ 
DRB1: _________ DRB1: _________ DQB1: ________ DQB1: _________ 
Donor 
A: ____________ 
A:_____________ 
C: ____________ C: ____________ 
B: _________ 
B: _________ 
DRB1: _________ DRB1: _________ DQB1: ________ DQB1: _________ 
 
 
 
 
One of the following criteria questions (3-6) must be marked “Yes” for the patient to enter on 2206 
 
3) Yes 
 No 
  Ages >50 years with hematologic malignancies treatable by related or unrelated 
allogeneic HCT.   
 


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4) Yes 
 No 
  Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who 
through pre-existing medical conditions or prior therapy are considered to be at high 
risk for regimen related toxicity associated with a high dose transplant (>40% risk of 
TRM). This criterion can include patients with a HCT-CI score of >1 (see Appendix 
Q). Transplants should be approved for these inclusion criteria by the principal 
investigators at the collaborating centers and at FHCRC.   
 
 
 
              Pre-existing condition(s) precluding high dose tx:  _______________________ 
     
  
 
  
 *. All children < 12 years must be discussed with the FHCRC PI (Brenda Sandmaier, MD 206-667-
4961) prior to registration.  
 
5) Yes 
 No 
  Ages  50 years of age with chronic lymphocytic leukemia (CLL.  
 
6) Yes 
 No 
   Ages  50 years of age with hematologic diseases treatable by allogeneic HCT who 
refuse a high dose HCT. Transplants must be approved for these inclusion criteria by 
the principal investigators at the collaborating centers and at FHCRC. 
 
One of the following criteria questions (7-17) must be marked “Yes” for the patient to enter on 2206. 
The following diseases will be permitted although other diagnoses can be considered if approved by 
PCC or the participating institution’s patient review committees and the principal investigator. 
 
7) Yes 
 No 
  
Aggressive nonHodgkin lymphomas (NHL) and Other Histologies Such as 
Diffuse large B cell NHL– not eligible for autologous HCT, not eligible for high 
dose allogeneic HCT, or after failed autologous HCT. 
 
8) Yes 
 No 
  
Mantle Cell NHL -may be treated in first CR (Diagnostic LP required pre-
transplant) 
 
9) Yes 
 No 
  
Low grade NHL– with < 6 month duration of CR between courses of 
conventional therapy. 
 
10) Yes 
 No 
  
CLL – must have either 1) failed to meet NCI Working Group criteria for 
complete or partial response after therapy with a regimen containing FLU (or 
another nucleoside analog, e.g. 2-CDA, pentostatin) or experience disease relapse 
within 12 months after completing therapy with a regimen containing FLU (or 
another nucleoside analog); 2) failed FLU-CY-Rituximab (FCR) combination 
chemotherapy at any time point; or 3) have “17p deletion” cytogenetic 
abnormality. Patients should have received induction chemotherapy but could be 
transplanted in 1st CR; 4) Patients with a diagnosis of CLL (or small lymphocytic 
lymphoma) that progresses to prolymphocytic leukemia (PLL); or 5) T-cell CLL 
or PLL. 
 
 
 
 
 
Describe which inclusion is specific for this 
patient:__________________________________________________________. 
 
11) Yes 
 No 
  
Hodgkin lymphoma – must have received and failed frontline therapy. 
 


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12) Yes 
 No 
  
Multiple Myeloma – must have received prior chemotherapy.  Consolidation of 
chemotherapy by autografting prior to nonmyeloablative HCT is permitted. 
 
13) Yes 
 No 
 
Acute Myeloid Leukemia (AML)– must have < 5% marrow blasts at the time of 
transplant. 
 
14) Yes 
 No 
 
Acute Lymphocytic Leukemia (ALL) – must have <5% marrow blasts at the 
time of transplant. 
 
15) Yes 
 No 
  
Chronic Myeloid Leukemia (CML) – Patients in CP1 must  have failed or be 
intolerant of TKIs. Patients beyond CP1 will be accepted if they have <5% 
marrow blasts at time of transplant.   
 
16) Yes 
 No 
  
Myelodysplasia (MDS)/Myeloproliferative Syndrome (MPS) – Patients must 
have <5% marrow blasts at time of transplant. 
 
17) Yes 
 No 
      Waldenstrom’s Macroglobulinemia – must have failed 2 courses of therapy. 
 
 
II) EXCLUSION CRITERIA:  
 
Each of the following questions must be marked “No” Or “NA” for the patient to enroll on 2206. 
 
18) Yes 
 No 
        
Patients for whom the best available donor is mismatched at both HLA class I and class II 
 
19) Yes 
 No 
        
A positive cross-match exists between the donor and recipient. 
  
20) Yes 
 No 
  NA 
 Patients with rapidly progressive intermediate or high grade NHL. 
 
21) Yes 
 No 
  NA 
 Patients with a diagnosis of CMML. 
 
22) Yes 
 No 
  NA 
 Patients with RAEB-2 who have not received myelosuppressive 
chemotherapy i.e. induction chemotherapy. 
 
23) Yes 
 No 
              CNS involvement with disease refractory to intrathecal chemotherapy. For LP 
requirement, see Appendix N. 
 
24)  Yes 
 No 
  NA 
   Presence of circulating leukemic blasts (in the peripheral blood) detected by 
standard pathology for patients with AML, ALL or CML.  
 
25) Yes 
 No 
  NA 
 Presence of ≥ 5% circulating leukemic blasts (in the peripheral blood) 
detected by standard pathology for patients with MDS/MPS 
 
26) Yes 
 No 
  NA 
 Fertile men or women unwilling to use contraceptive techniques during and 
for 12 months following treatment. 
 
27) Yes 
 No 
  NA 
 Females who are pregnant or breast-feeding.  
 


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28) Yes 
 No 
           
Patients with active non-hematological malignancies (except non-melanoma 
skin cancers) or those with non-hematological malignancies (except non-
melanoma skin cancers) who have been rendered with no evidence of disease, 
but have a greater than 20% chance of having disease recurrence within 5 
years. 
 This exclusion does not apply to patients with non-hematologic malignancies 
that do not require therapy. 
 
29) Yes 
 No 
     
Fungal infections with radiological progression after receipt of amphotericin 
B or active triazole for greater than 1 month. 
 
 
All patients receiving antifungal therapy voriconazole, posaconazole, or 
fluconazole must have sirolimus dosing reduced according to the Standard 
Practice Antifungal Therapy Guidelines in Appendix E. 
 
 
PI Signature:   
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
  
 
 
 
30) Yes 
 No 
              Cytotoxic agents for “cytoreduction” with the exception of imatinib (imatinib 
mesylate), cytokine therapy, hydroxyurea, low dose cytarabine, chlorambucil, 
or rituxan within three weeks of the initiation of conditioning 
 
31) Yes 
 No 
             Organ dysfunction. Please check yes if patient meets any of the following. 
  
 
 
 
  
 
Yes 
 No 
 
Cardiac: ejection fraction < 35% (or, if unable to obtain 
ejection fraction, shortening fraction of < 26%).  Ejection 
fraction is required if age > 50 years or there is a 
history of anthracycline exposure or history of cardiac 
disease. 
 NOTE: If shortening fraction is <26%, a cardiology 
consult is required.  The PI of the study must approve 
eligibility  
 
  
  
   
     
   
      
  
 
PI Signature:  
_______________Date: __ __ 
 
  
 
 
 
  
 
Yes 
 No 
 
Pulmonary: DLCO < 40%, TLC <40%, FEV1 <40% 
and/or    receiving supplementary continuous oxygen.  
 NOTE: The FHCRC PI of the study must approve of 
enrollment of all patients with pulmonary nodules.  If 
unable to perform complete PFTs, patients will be 
excluded if their oxygen saturation is <95% with a 
formal six-minute walk test (ambulatory oximetry). 
 
PI Signature:  
_______________Date: _____ 
 
 
 
 
Yes 
 No 
 
Liver function abnormalities:  Patients with clinical 
or laboratory evidence of liver disease would be 
evaluated for the cause of liver disease, its clinical 
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portal hypertension.  Patients will be excluded if they 
are found to have fulminant liver failure, cirrhosis of 
the liver with evidence of portal hypertension, alcoholic 
hepatitis, esophageal varices, a history of bleeding 
esophageal varices, hepatic encephalopathy, 
uncorrectable hepatic synthetic dysfunction evinced by 
prolongation of the prothrombin time, ascites related to 
portal hypertension, bridging fibrosis, bacterial or 
fungal liver abscess, biliary obstruction, chronic viral 
hepatitis with total serum bilirubin >3 mg/dL, or 
symptomatic biliary disease.  
 
32) Yes 
 No 
               Karnofsky score < 60 or Lansky score <50. 
 
33) Yes 
 No 
               Patient has poorly controlled hypertension and on multiple antihypertensives. 
 
34) Yes 
 No 
               HIV positive patients. 
 
35) Yes 
 No 
              Active bacterial or fungal infections unresponsive to medical therapy. 
 
 
 
Note – the HCT-Comorbidity score is:  _______________ 
 
 FHCRC Patients:  
 
Signature of person completing form:    
 
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
 
 
Signature of Principal Investigator:  _________________  
 
 
 
 
 
Date:  
 
 
 
 
 
 
____________________________________________________________________________________ 
 
OR 
 
Outside Center Patients:  
 
Signature of person completing form:    
 
 
 
 
 
 
 
 
 
 
Date:  
 
 
 
 
 
 
Signature of Local Principal Investigator   
_________________  
 
 
 
Date:  
 
 
 
 
 
 
Signature of FHCRC Principal Investigator   
_________________  
 
 
Date:  
 
______ 
 
 


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APPENDIX M 
Core Case Report Forms (CRFs) 
 
 
 


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APPENDIX N 
 
Intrathecal Diagnostics and Therapeutics 
intrathecaltherapy-c
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Appendix O 
HLA MATCHING REQUIREMENTS FOR DONORS  
AT THE SCCA / FRED HUTCHINSON ALLIED SYSTEM 
 
Human Leukocyte Antigen (HLA) Terminology. The HLA region consists of genes that encode two classes of 
HLA molecules. HLA class I molecules, HLA-A, -B, and –C, are composed of a single glycoprotein chain that is 
expressed in association with 2-microglobulin on most tissue cells. HLA class II molecules, HLA-DR, -DQ, 
and –DP, are heterodimers consisting of  and  glycoprotein chains. HLA class I and HLA class II molecules are 
highly polymorphic. 
 
HLA Typing Methods. At the Seattle Cancer Care Alliance Clinical Immunogenetics Laboratory (CIL) DNA-
based methods of HLA-A, B, C, DRB1, DQB1 typing are now performed routinely. High resolution typing is 
required to define individual alleles and the level of mismatching between donor and recipient. High resolution 
data are reported with four or more digits (e.g., A*0201, A*0205, B*1504, or DRB1*0401). A current listing of 
recognized HLA alleles and their sequences can be found at the Immunogenetics/HLA sequence database 
website at www.anthonynolan.org.uk/HIG/data.html. 
 
Initial typing reports obtained through the international marrow donor registries may consist of intermediate 
resolution typing. Intermediate resolution defines alleles in groups of related families historically defined as 
antigens by alloantisera. Intermediate resolution typing results are reported as two digits (e.g., A*02, B*15, or 
DRB1*04). In cases where the HLA-A, B and C loci are typed at intermediate resolution and high resolution data 
are not available, it should be understood that unidentified allele disparity might be present. 
 
Donor Selection. Final selection of donor should be based upon results of high resolution typing of HLA-A, B, 
C, DRB1, DQB1 alleles. Cross match assay is not required when high resolution typing indicates matching for 
HLA-A, B, C, DRB1 and DQB1 AND the platelet reactive antibody (PRA) screen is not elevated (defined as 
≤10%). A negative cross match test result is required for final donor selection in the following situations: 1) PRA 
screen is positive (>10%), or 2) high resolution typing indicates mismatching for one or more HLA-A, B, C, 
DRB1 and DQB1 alleles. A positive anti-donor cytotoxic crossmatch absolutely excludes the donor. 
 
Donor Selection Criteria. Protocols and treatment plans must specify donor inclusion and exclusion criteria, 
using terminology indicated below. 
 
Donor inclusion criteria must specify 1) the allowable genetic relationship between the patient and donor (related 
and/or unrelated), 2) the allowable limits of mismatch, and if applicable 3) any modification of mismatch criteria 
according to type of disease or patient characteristics. 
 
Acceptable levels of recipient-donor mismatch for research related treatment protocols or standard treatment plans 
include the following: 
Allele-match for HLA-A, B, C, DRB1 and DQB1. 
Single allele disparity for HLA-A, B, C, or DRB1 or DQB1 
Two allele disparities for HLA-A, B, or C. 
Single allele disparity for HLA-DRB1, with or without a single DQB1 antigen or allele disparity. 
Single antigen plus single allele disparity for HLA-A, B, or C. 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-99-
Appendix O (cont’d) 
HLA MATCHING REQUIREMENTS FOR DONORS  
AT THE SCCA / FRED HUTCHINSON ALLIED SYSTEM 
hla_testing_donors-r
ecipients.pdf
 


Protocol 2206.00 
Current Version: 09/26/2018 
-100-
APPENDIX P 
 
Adapted from 
COMMON TOXICITY CRITERIA (CTC) 
Version 4.0 
 
Grade 
Adverse Event 
3 
4 
5 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
Disseminated intravascular 
coagulation 
Laboratory findings and 
bleeding 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Febrile neutropenia 
ANC <1000/mm3 with a 
single temperature of >38.3 
degrees C (101 degrees F) or 
a sustained temperature of 
>=38 degrees C (100.4 
degrees F) for more than one 
hour 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Hemolysis 
Transfusion or medical 
intervention indicated (e.g., 
steroids) 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Hemolytic uremic syndrome 
Laboratory findings with 
clinical consequences (e.g., 
renal insufficiency, 
petechiae) 
Life-threatening 
consequences, (e.g., CNS 
hemorrhage or 
thrombosis/embolism or 
renal failure) 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
CARDIAC DISORDERS 
 
Atrial fibrillation 
Symptomatic and 
incompletely controlled 
medically, or controlled 
with device (e.g., 
pacemaker), or ablation 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Atrial flutter 
Symptomatic and 
incompletely controlled 
medically, or controlled 
with device (e.g., 
pacemaker), or ablation 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Atrioventricular block 
complete 
Symptomatic and 
incompletely controlled 
medically, or controlled 
with device (e.g., 
pacemaker) 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Constrictive pericarditis 
Symptomatic heart failure or 
other cardiac symptoms, 
responsive to intervention 
Refractory heart failure or 
other poorly controlled 
cardiac symptoms 
Death 


Protocol 2206.00 
Current Version: 09/26/2018 
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Heart failure 
Severe with symptoms at 
rest or with minimal activity 
or exertion; intervention 
indicated 
Life-threatening 
consequences; urgent 
intervention indicated (e.g., 
continuous IV therapy or 
mechanical hemodynamic 
support) 
Death 
Left ventricular systolic 
dysfunction 
Symptomatic due to drop in 
ejection fraction responsive 
to intervention 
Refractory or poorly 
controlled heart failure due to 
drop in ejection fraction; 
intervention such as 
ventricular assist device, 
intravenous vasopressor 
support, or heart transplant 
indicated 
Death 
Myocardial infarction 
Severe symptoms; cardiac 
enzymes abnormal; 
hemodynamically stable; 
ECG changes consistent 
with infarction 
Life-threatening 
consequences; 
hemodynamically unstable 
Death 
Myocarditis 
Severe with symptoms at 
rest or with minimal activity 
or exertion; intervention 
indicated 
Life-threatening 
consequences; urgent 
intervention indicated (e.g., 
continuous IV therapy or 
mechanical hemodynamic 
support) 
Death 
Pericardial effusion 
Effusion with physiologic 
consequences 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Pericardial tamponade 
 - 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Ventricular arrhythmia 
Medical intervention 
indicated 
Life-threatening 
consequences; hemodynamic 
compromise; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
GASTROINTESTICAL DISORDERS 
 
Ascites 
Severe symptoms; invasive 
intervention indicated 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 
Diarrhea 
Increase of >=7 stools per 
day over baseline; 
incontinence; hospitalization 
indicated; severe increase in 
ostomy output compared to 
baseline; limiting self care 
ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Duodenal ulcer 
Severely altered GI 
function; TPN indicated; 
elective operative or 
endoscopic intervention 
indicated; limiting self care 
ADL; disabling 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 


Protocol 2206.00 
Current Version: 09/26/2018 
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Gastric ulcer 
Severely altered GI 
function; TPN indicated; 
elective operative or 
endoscopic intervention 
indicated; limiting self care 
ADL; disabling 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 
Gastritis 
Severely altered eating or 
gastric function; TPN or 
hospitalization indicated 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 
Lower gastrointestinal 
hemorrhage 
Transfusion, radiologic, 
endoscopic, or elective 
operative intervention 
indicated 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Mucositis oral 
Severe pain; interfering with 
oral intake 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Oral hemorrhage 
Transfusion, radiologic, 
endoscopic, or elective 
operative intervention 
indicated 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Pancreatitis 
Severe pain; vomiting; 
medical intervention 
indicated (e.g., analgesia, 
nutritional support) 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Typhlitis 
Symptomatic (e.g., 
abdominal pain, fever, 
change in bowel habits with 
ileus); peritoneal signs 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
GENERAL DISORDERS AND ADMINISTARTION SITE CONDITIONS 
 
Multi-organ failure 
Shock with azotemia and 
acid-base disturbances; 
significant coagulation 
abnormalities 
Life-threatening 
consequences (e.g., 
vasopressor dependent and 
oliguric or anuric or ischemic 
colitis or lactic acidosis) 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
HEPATOBILIARY DISORDERS 
 
Cholecystitis 
Severe symptoms; 
radiologic, endoscopic or 
elective operative 
intervention indicated 
Life-threatening 
consequences; urgent 
operative intervention 
indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
IMMUNE SYSTEM DISORDERS 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-103-
Allergic reaction 
Prolonged (e.g., not rapidly 
responsive to symptomatic 
medication and/or brief 
interruption of infusion); 
recurrence of symptoms 
following initial 
improvement; 
hospitalization indicated for 
clinical sequelae (e.g., renal 
impairment, pulmonary 
infiltrates) 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Immune system disorders - 
Other, specify 
Severe or medically 
significant but not 
immediately life-
threatening; hospitalization 
or prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
INFECTIONS AND INFESTATIONS 
 
Enterocolitis infectious 
IV antibiotic, antifungal, or 
antiviral intervention 
indicated; radiologic, 
endoscopic, or operative 
intervention indicated; 
profuse watery diarrhea with 
signs of hypovolemia;  
bloody diarrhea; fever; 
severe abdominal pain; 
hospitalization indicated 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Infections and infestations - 
Other, specify 
Severe or medically 
significant but not 
immediately life-
threatening; hospitalization 
or prolongation of existing 
hospitalization indicated; 
disabling; limiting self care 
ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
INVESTIGATIONS 
 
Alanine aminotransferase 
increased 
>5.0 - 20.0 x ULN 
>20.0 x ULN 
 - 
Aspartate aminotransferase 
increased 
>5.0 - 20.0 x ULN 
>20.0 x ULN 
 - 
Blood bilirubin increased 
>3.0 - 10.0 x ULN 
>10.0 x ULN 
 - 


Protocol 2206.00 
Current Version: 09/26/2018 
-104-
Carbon monoxide diffusing 
capacity decreased 
Asymptomatic decrease  of 
>8 units drop;  >5 units drop 
along with the presence of 
pulmonary symptoms (e.g. , 
>Grade 2  hypoxia or 
>Grade 2 or higher dyspnea) 
 - 
 - 
Cardiac troponin I increased 
Levels consistent with 
myocardial infarction as 
defined by the manufacturer 
 - 
 - 
Cardiac troponin T increased 
Levels consistent with 
myocardial infarction as 
defined by the manufacturer 
 - 
 - 
Creatinine increased 
>3.0 baseline; >3.0 - 6.0 x 
ULN 
>6.0 x ULN 
 - 
Weight gain 
>=20% from baseline 
 - 
 - 
Grade 
Adverse Event 
3 
4 
5 
 
METABOLISM AND NUTRITIONAL DISORDERS 
 
Hypercalcemia 
Corrected serum calcium of 
>12.5 - 13.5 mg/dL;>3.1 - 
3.4 mmol/L;  Ionized 
calcium  >1.6 - 1.8 mmol/L; 
hospitalization indicated 
Corrected serum calcium of 
>13.5 mg/dL; >3.4 mmol/L;  
Ionized calcium  >1.8 
mmol/L; life-threatening 
consequences 
Death 
Hypertriglyceridemia 
>500 mg/dL - 1000 mg/dL;  
>5.7 mmol/L - 11.4 mmol/L 
>1000 mg/dL; >11.4 
mmol/L;  life-threatening 
consequences 
Death 
Hyperuricemia 
>ULN - 10 mg/dL (0.59 
mmol/L) with physiologic 
consequences 
>10 mg/dL; >0.59 mmol/L; 
life-threatening 
consequences 
Death 
Tumor lysis syndrome 
Present 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
NEOPLASMS BENIGN, MALIGNANT, AND UNSPECIFIED (INC CYSTS AND POLYPS) 
 
Treatment related secondary 
malignancy 
Non life-threatening 
secondary malignancy 
Acute life-threatening 
secondary malignancy; blast 
crisis in leukemia 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
NERVOUS SYSTEM DISORDERS 
 
Dysarthria 
Severe impairment of 
articulation or slurred 
speech 
 - 
 - 
Intracranial hemorrhage 
Ventriculostomy, ICP 
monitoring, intraventricular 
thrombolysis, or operative 
intervention indicated 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Ischemia cerebrovascular 
 - 
 - 
 - 


Protocol 2206.00 
Current Version: 09/26/2018 
-105-
Leukoencephalopathy 
Severe symptoms; extensive 
T2/FLAIR hyperintensities, 
involving periventricular 
white matter involving 2/3 
or more of susceptible areas 
of cerebrum +/- moderate to 
severe increase in SAS 
and/or moderate to severe 
ventriculomegaly 
Life-threatening 
consequences; extensive 
T2/FLAIR hyperintensities, 
involving periventricular 
white matter involving most 
of susceptible areas of 
cerebrum +/- moderate to 
severe increase in SAS 
and/or moderate to severe 
ventriculomegaly 
Death 
Seizure 
Multiple seizures despite 
medical intervention 
Life-threatening; prolonged 
repetitive seizures 
Death 
Syncope 
Fainting; orthostatic 
collapse 
 - 
 - 
Nervous system disorders - 
Other, specify 
Severe or medically 
significant but not 
immediately life-
threatening; hospitalization 
or prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
RENAL AND URINARY DISORDERS 
 
Chronic kidney disease 
eGFR or CrCl 29 - 15 
ml/min/1.73 m2 
eGFR or CrCl <15 
ml/min/1.73 m2; dialysis or 
renal transplant indicated 
Death 
Renal and urinary disorders - 
Other, specify 
Severe or medically 
significant but not 
immediately life-
threatening; hospitalization 
or prolongation of existing 
hospitalization indicated; 
disabling;  limiting self care 
ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS 
 
Grade 
Adverse Event 
3 
4 
5 
 
RESPIRATORY, THORACIC, AND MEDIASTINAL DISORDERS 
 
Adult respiratory distress 
syndrome 
Present with radiologic 
findings; intubation not 
indicated 
Life-threatening respiratory 
or hemodynamic 
compromise; intubation or 
urgent intervention indicated 
Death 
Apnea 
Present; medical 
intervention indicated 
Life-threatening respiratory 
or hemodynamic 
compromise; intubation or 
urgent intervention indicated 
Death 


Protocol 2206.00 
Current Version: 09/26/2018 
-106-
Bronchopulmonary 
hemorrhage 
Transfusion, radiologic, 
endoscopic, or operative 
intervention indicated (e.g., 
hemostasis of bleeding site) 
Life-threatening respiratory 
or hemodynamic 
compromise; intubation or 
urgent intervention indicated 
Death 
Hypoxia 
Decreased oxygen saturation 
at rest (e.g., pulse oximeter 
<88% or PaO2 <=55 mm 
Hg) 
Life-threatening airway 
compromise; urgent 
intervention indicated (e.g., 
tracheotomy or intubation) 
Death 
Pleural effusion 
Symptomatic with 
respiratory distress and 
hypoxia; surgical 
intervention including chest 
tube or pleurodesis indicated 
Life-threatening respiratory 
or hemodynamic 
compromise; intubation or 
urgent intervention indicated 
Death 
Pneumonitis 
Severe symptoms; limiting 
self care ADL; oxygen 
indicated 
Life-threatening respiratory 
compromise; urgent 
intervention indicated (e.g., 
tracheotomy or intubation) 
Death 
Pulmonary edema 
Severe dyspnea or dyspnea 
at rest; oxygen indicated; 
limiting self care ADL 
Life-threatening respiratory 
compromise; urgent 
intervention or intubation 
with ventilatory support 
indicated 
Death 
Respiratory failure 
 - 
Life-threatening 
consequences; urgent 
intervention, intubation, or 
ventilatory support indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
 
Erythema multiforme 
Target lesions covering 
>30% BSA and associated 
with oral or genital erosions 
Target lesions covering 
>30% BSA; associated with 
fluid or electrolyte 
abnormalities; ICU care or 
burn unit indicated 
Death 
Grade 
Adverse Event 
3 
4 
5 
 
VASCULAR DISORDERS 
 
Capillary leak syndrome 
Severe symptoms; 
intervention indicated 
Life-threatening 
consequences; urgent 
intervention indicated 
Death 
Hypotension 
Medical intervention or 
hospitalization indicated 
Life-threatening and urgent 
intervention indicated 
Death 
Thromboembolic event 
Thrombosis (e.g., 
uncomplicated pulmonary 
embolism [venous], non-
embolic cardiac mural 
[arterial] thrombus), medical 
intervention indicated 
Life-threatening (e.g., 
pulmonary embolism, 
cerebrovascular event, 
arterial insufficiency); 
hemodynamic or neurologic 
instability; urgent 
intervention indicated 
Death 
Vasculitis 
Severe symptoms, medical 
intervention indicated (e.g., 
steroids) 
Life-threatening; evidence of 
peripheral or visceral 
ischemia; urgent intervention 
indicated 
Death 


Protocol 2206.00 
Current Version: 09/26/2018 
-107-
 
APPENDIX Q 
 
The Hematopoietic Cell Transplant-Comorbidity Index (HCT-CI) 9/7/10 
 
Assign scores appropriately if the patient has any of these comorbidities 
  
UPN______________ Date_____________ 
 
Comorbidities 
Definitions 
HCT-CI 
scores 
Actual Lab 
Values/Comments 
Arrhythmia 
Atrial fibrillation or flutter, sick sinus syndrome, and 
ventricular arrhythmias requiring treatment in the patient’s 
past history 
1 
 
Cardiac 
Coronary artery disease†, congestive heart failure, 
myocardial infarction in patient’s past history or EF of 
50% at time of HCT 
1 
 
Inflammatory bowel 
disease 
Crohn’s disease or ulcerative colitis requiring treatment in 
the patient’s past history 
1 
 
Diabetes 
Requiring treatment with insulin or oral hypoglycemic, but 
not diet alone, at time of HCT 
1 
 
Cerebro-vascular 
disease 
Transient ischemic attack or cerebro-vascular accident in 
patient’s past history 
1 
 
Psychiatric 
disturbance 
Depression/anxiety requiring psychiatric consult or 
treatment at time of HCT 
1 
 
Hepatic – mild 
Chronic hepatitis, Bilirubin >ULN- 1.5 X ULN, or 
AST/ALT >ULN-2.5XULN at time of HCT 
1 
 
Obesity 
Patients with a BMI of 
>35 for adults or with BMI-for-age percentile of ≥ 95th 
percentile for children at time of HCT 
1 
 
Infection 
Documented infection or fever of unknown etiology 
requiring anti-microbial treatment before, during and after 
the start of conditioning regimen 
1 
 
Rheumatologic 
SLE, RA, polymyositis, mixed CTD, polymyalgia 
rheumatica in patient’s past history  
2 
 
Peptic ulcer 
Requiring treatment in patient’s past history 
2 
 
Renal 
Serum creatinine >2 mg/dl, on dialysis, or prior renal 
transplantation at time of HCT 
2 
 
Moderate pulmonary 
DLco and/or FEV1 >65%-80% or 
Dyspnea on slight activity at time of HCT 
2 
 
Prior solid tumor 
Treated at any time point in the patient’s past history, 
excluding non-melanoma skin cancer 
3 
 
Heart valve disease 
At time of HCT excluding mitral valve prolapse 
3 
 
Severe pulmonary 
DLco and/or FEV1 65% or 
Dyspnea at rest or requiring oxygen at time of HCT 
3 
 
Moderate/severe 
hepatic 
Liver cirrhosis, Bilirubin >1.5 X ULN, or AST/ALT 
>2.5XULN at time of HCT 
3 
 
Please provide (KPS): 
 
Karnofsky Performance Score = _______% 
Total 
Score 
=________ 
Signature of 
Provider: 
________________ 
 
†One or more vessel-coronary artery stenosis, requiring medical treatment, stent, or bypass graft. 


Protocol 2206.00 
Current Version: 09/26/2018 
-108-
EF indicates ejection fraction; ULN, upper limit of normal; SLE, systemic lupus erythmatosis; RA, rheumatoid arthritis; CTD, connective tissue 
disease; DLco, diffusion capacity of carbon monoxide; FEV1, forced expiratory volume in one second; AST, aspartate aminotransferase; ALT, alanine 
aminotransferase. 
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-109-
                
APPENDIX R 
 
 
CLINICALLY SIGNIFICANT INDUCERS/INHIBITORS OF 
CYTOCHROME P450 ENZYME SYSTEM 
 
Agents likely to increase 
Rapamycin (Sirolimus) 
levels 
Agents which may 
increase Rapamycin 
(Sirolimus) levels 
Agents likely to decrease 
Rapamycin (Sirolimus) 
levels 
Agents which may 
decrease Rapamycin 
(Sirolimus) levels 
Diltiazem 
Nicardipine 
Verapamil 
Erythromycin 
Ketoconazole 
Voriconazole 
Clarithromycin 
Cimetidine 
 
Carbamazepine 
Phenobarbital 
Phenytoin 
Rifampin 
 
Primidone 
Valproic acid 
Rifabutin 
 
 
 
*Fluconazole, Posaconazole, itraconazole, CSP, methylprednisolone, and tacrolimus may increase levels 


Protocol 2206.00 
Current Version: 09/26/2018 
-110-
APPENDIX S 
 
Standard Donor Consent  
standard donor 
consent.pdf
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-111-
Appendix T 
 
Weight / Adjusted Body Weight for Drug Dosing 
weight_for_drug_d
osing.pdf
 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-112-
Appendix U 
 
COORDINATING CENTER FUNCTIONS 
 
Outside Center – PI Communication in Hematologic Malignancies 
 
I. 
Study Management, data analysis, and Data and Safety Monitoring 
 
a. Study Management: 
i. 
Each local PI is responsible for selection, training and oversight of local study 
coordinators 
ii. 
The Coordinating Center registers subjects on the study and assigns study IDs 
iii. 
One copy of the research data is retained by the site. Another data set (identified only 
by study IDs) is transmitted to the Coordinating Center to create the master data file. 
All data are kept in locked areas and password protected databases accessible only to 
study staff 
iv. 
The quality of data is monitored in an ongoing fashion with the study team and 
corrective action plans instituted as necessary  
b. Data Analysis: 
i. 
Study staff review data for completeness as it is submitted by the sites 
ii. 
The study statistician is responsible for data cleaning and the conduct of analyses as 
outlined in the protocol and grant 
c. Data Safety and Monitoring: 
i. 
The trial coordinators at collaborating centers or the local PIs will fax an official 
report of an SAE (as defined by the protocol) to the Coordinating Center within ten 
days. 
ii. 
The SAE report is reviewed by the Overall PI. If the SAE meets the FHCRC criteria 
for reporting then an official signed report is submitted to the IRB 
iii. 
An independent DSMB will meet at six-month intervals and all outcome data is 
reviewed including all adverse events and SAEs reported to the Coordinating Center 
along with those officially reported to the IRB 
iv. 
A report from the DSMB is submitted to the IRB as well as the trial 
coordinators/local PIs participating in the protocol 
 
II.  Protocol and informed consent document management 
a. A master protocol is maintained by the Coordinating Center and distributed to the sites for 
customization and local IRB review 
b. All protocol and consent modifications initiated by the Coordinating Center are sent to the 
Collaborating Sites following approval by the Coordinating Center IRB, for review and 
approval by the local IRB 
c. Changes required by local IRBs are reviewed by the Coordinating Center and approved 
prior to implementation at local sites 
 
III. Assurance of local IRB OHRP-approved assurance 
a. Each site provides their OHRP assurance number and evidence of IRB certification 
b. Study staff monitor maintenance of institutional assurance and IRB certification 
 
IV. Assurance of local IRB approvals 


Protocol 2206.00 
Current Version: 09/26/2018 
-113-
a. The Coordinating Center maintains copies of the most current collaborating site Consent 
Forms and IRB approval documentation 
b. No site may enroll subjects until the Coordinating Center has received confirmation of 
local IRB approval 
c. Each site is responsible for preparation and submission of their continuing reviews. Any 
changes to the protocol or consent form will be communicated to the Coordinating Center 
d. Sites are required to have active IRB approvals to participate in any study related activities 
 
V. Any substantive modification by the Collaborating Institution related to risks or alternative 
procedures is appropriately justified 
a.   The Coordinating Center reviews any modifications to consent forms to ensure that site 
consents do not delete or change the basic or additional elements or alternatives required in 
the sample consent form 
 
VI. Informed consent is obtained from each subject in compliance with HHS regulations 
a. Subjects must provide written informed consent prior to study participation 
b. The Coordinating Center verifies eligibility and signed consent prior to assigning a study 
ID number 
 


Protocol 2206.00 
Current Version: 09/26/2018 
-114-
Appendix V 
 
Radiotherapy Treatment Guidelines per Standard Practice  
 
TBI_Adult_Non_Myel
oablative.pdf
 
 
TBI_Pediatric_NON_
Myeloablative.pdf