Clinical trial NCT02199041
Conditions: Hematological Malignancies
Keywords: Cord Blood Haploidentical Reduced Intensity Regimen
Sponsor: St. Jude Children's Research Hospital
Start date: 2014-07-11; Completion date: 2017-05-23
Enrollment: 24 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
In this study, participants with high-risk hematologic malignancies undergoing hematopoietic cell transplantation (HCT), who do not have a suitable human leukocyte antigen (HLA)-matched related/sibling donor (MSD), matched unrelated donor (MURD) or killer-immunoglobulin receptors (KIR) ligand mismatched haploidentical donor identified, will receive a combined T cell depleted (TCD) haploidentical peripheral blood stem cell (PBSC) and unrelated umbilical cord blood transplantation (UCBT) using a total lymphoid irradiation (TLI) based preparative regimen.

Primary objective:

* To estimate the incidence of donor derived neutrophil engraftment by day +42 post-transplant for participants with high-risk hematologic malignancies undergoing a total lymphoid irradiation (TLI)-based hematopoietic cell transplantation (HCT) using a T cell depleted (TCI) haploidentical donor peripheral blood stem cell (PBSC) donor combined with an unrelated umbilical cord blood (UCB) donor.

Secondary objectives:

* Estimate the incidence of malignant relapse, event-free survival (EFS), and overall survival (OS) at one-year post-transplantation.
* Estimate the incidence and severity of acute and chronic graft versus host disease (GVHD) in the first 100 days after transplantation.
* Estimate the incidence of secondary graft failure transplant related mortality (TRM) and transplant related morbidity in the first 100 days after HCT.

Detailed description:
Prior to stem cell infusion, participants will receive a preparative regimen of total lymphoid irradiation (TLI), fludarabine, cyclophosphamide, melphalan, and thiotepa to prepare their bone marrow. Thereafter, they will receive a hematopoietic cell graft from a haploidentical donor and an unrelated umbilical cord blood donor. Post-transplantation immunosuppressive treatment will include tacrolimus and mycophenolate mofetil.

Arms: arm 1: Interventions: cyclophosphamide, thiotepa, fludarabine, melphalan, mesna, granulocyte colony-stimulating factor (G-CSF), mycophenolate mofetil, tacrolimus, methylprednisolone, total lymphoid irradiation, and lymphocyte infusions.

Cells for infusion are prepared using the CliniMACS System.
Interventions: intervention 1: Cyclophosphamide intervention 2: Thiotepa intervention 3: Fludarabine intervention 4: Melphalan intervention 5: Mesna intervention 6: G-CSF intervention 7: Mycophenolate mofetil intervention 8: Tacrolimus intervention 9: Methylprednisolone intervention 10: Total lymphoid irradiation intervention 11: Lymphocyte infusions intervention 12: CliniMACS
Intervention descriptions: intervention 1: Given by intravenous infusion as part of the preparative regimen. intervention 2: Given by intravenous infusion as part of the preparative regimen. intervention 3: Given by intravenous infusion as part of the preparative regimen. intervention 4: Given by intravenous infusion as part of the preparative regimen. intervention 5: Mesna is generally dosed at approximately 25% of the cyclophosphamide dose. It is generally given intravenously prior to and again at 3, 6 and 9 hours following each dose of cyclophosphamide. intervention 6: Given either by intravenous infusion or subcutaneously daily until absolute neutrophil count (ANC) \>2000 for 3 consecutive days. intervention 7: Given either orally or by intravenous infusion as part of the post-transplantation immunosuppression. intervention 8: Given either orally or by intravenous infusion as part of the post-transplantation immunosuppression. intervention 9: Given either intravenously or orally, if needed to treat graft-versus-host-disease (GVHD). intervention 10: TLI will be administered in divided fractions given at a minimum of 6 hours apart. intervention 11: Donors will undergo haploidentical mobilization with G-CSF. Cells will be collected by leukapheresis over two days, then processed using the investigational CliniMACS device and CD34 Microbead reagent as directed by the manufacturer. intervention 12: The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-activated cell sorting (MACS). The CliniMACS device is a powerful tool for the isolation of many cell types from heterogeneous cell mixtures, (e.g. apheresis products). These can then be separated in a magnetic field using an immunomagnetic label specific for the cell type of interest, such as CD3+ human T cells.

Protocol documents:
Prot_SAP_001.pdf: 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 10/17/14 
 
St. Jude Children's Research Hospital 
HAPCORD 
Initial Version, dated: 04/02/13 Resubmitted to IRB 02/10/2014 (IRB Approved: 02/26/2014)     
Activated:   
Revision 0.1, dated: 08/22/14 (IRB Approved: 10/17/14) 
Activated: 
  
COMBINED HAPLOIDENTICAL AND UMBILICAL CORD BLOOD 
TRANSPLANTATION IN PATIENTS WITH HEMATOLOGIC MALIGNANCIES USING A 
REDUCED-INTENSITY PREPARATIVE REGIMEN 
 
IND: 16036  
 
Principal Investigator 
Mari Hashitate Dallas, MD1 
 
Sub-investigators 
Wing Leung, MD, PhD1 
 
Guolian Kang, PhD3 
David Shook, MD1 
 
Terrence Geiger, MD, PhD4 
Christine Hartford, MD1   
Shane Cross, PharmD5 
Brandon Triplett, MD1 
 
 Paul W. Eldridge, PhD1 
Ashok Srinivasan, MD1 
 
Matthew J. Krasin, MD6 
Paul Thomas, PhD7 
 
John Choi, MD, PhD4 
Ewelina Mamcarz, MD1  
Ping Law, PhD1 
William Janssen, PhD1 
 
Department of Bone Marrow Transplantation and Cellular Therapy1 
Department of Oncology2 
Department of Biostatistics3 
Department of Pathology4 
Department of Pharmaceutical Sciences5 
Department of Radiological Sciences6 
Department of Immunology7 
 
St. Jude Children’s Research Hospital 
262 Danny Thomas Place 
Memphis, TN  38105 
(901) 595-3300 
This is a confidential research document. 
No information may be extracted without permission of the principal investigator


Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 10/17/14 
 
COMMON ABREVIATIONS 
 
Absolute neutrophil count (ANC) 
Acute lymphocytic leukemia (ALL) 
Acute myeloid leukemia (AML) 
Adverse event (AE) 
Alanine aminotransferase (ALT) 
American 
Association 
of 
Blood 
Banks 
(AABB) 
Aspartate aminotransferase (AST) 
Body surface area (BSA) 
Bone marrow (BM) 
Bone marrow transplantation (BMT), 
Bone Marrow Transplantation Follow Up 
(BMTFU) 
Center for International Blood and Marrow 
Transplant Research (CIBMTR) 
Central Nervous System (CNS) 
Central Protocol and Data Monitoring Office 
(CPDMO) 
Chronic Myeloid Leukemia (CML) 
Clinical Data Update System (CDUS) 
Common toxicity criteria (CTC) 
Complete Remission (CR) 
Cord Blood Transplantation (COBLT) 
Creatinine Clearance (CrCL) 
Cyclosporine (CSA) 
Cytomegalovirus (CMV) 
Dimethyl sulfoxide (DMSO) 
Disease-free survival (DFS) 
Epstein-Barr 
virus 
transformed 
lymphoblastoid cell lines (EBV-LCL) 
Event-free survival (EFS) 
Forced vital capacity (FVC) 
Foundation for the Accreditation of Cellular 
Therapy (FACT) 
Graft versus host disease (GVHD) 
Granulocyte colony-stimulating factor (G-
CSF) 
Haploidentical 
HCT 
with 
NK 
infusion 
(HAPNK) 
Health Insurance Portability Act (HIPPA) 
Hematopoietic cell transplantation (HCT) 
Hematopoietic stem cell (HSC) 
Human Application Lab (HAL)  
Human Immunodeficiency Virus (HIV) 
Human leukocyte antigen (HLA) 
Human T-lymphotropic virus (HTLV)  
Institutional Biosafety Committee (IBC) 
Institutional Review Board (IRB) 
International Cord Blood Transplant Registry 
(ICBTR) 
Juvenile Myelomonocytic Leukemia (JMML) 
Killer-immunoglobulin receptors (KIR)  
Matched related/sibling donor (MSD) 
Matched unrelated donor (MURD)  
Minimal Residual Disease (MRD) 
Mycophenolate mofetil (MMF) 
Myeloid Dysplastic Syndrome (MDS) 
National Cancer Institute (NCI)  
National Marrow Donor Program (NMDP) 
Natural killer (NK) 
New York Blood Center (NYBC) 
Overall survival (OS) 
Pharmacokinetics (PK) 
Polymerase chain reaction (PCR) 
Protected health information (PHI) 
Pulmonary Function Testing (PFT) 
Reduced Intensity Conditioning (RIC) 
Shortening Fraction (SF) 
Standard operating procedures (SOP) 
T cell receptor excision circle (TREC) 
Total body irradiation (TBI) 
Total nucleated cell (TNC) 
Total Research and Knowledge System 
(TRACKS) 
Transplant related mortality (TRM) 
Umbilical cord blood (UCB) 
Umbilical 
cord 
blood 
transplantation 
(UCBT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
TABLE OF CONTENTS 
 
Study Summary 
 
1.0 
Objectives…………………………………………………………….………… 1 
 
1.1 
Primary Objective.……………………………………………………..… 
1.2 
Secondary Objectives …………………………………………………… 
1.3 
Exploratory Objectives ……………..…………………………………… 
1 
1 
1 
2.0 
Background and Rationale……………………………………………………… 1  
 
2.1 
Overview………………………………………………………………… 
2.2 
Umbilical Cord Blood Transplantation……..…………………………… 
2.3 
Haploidentical HCT…………..………………………………………….. 
2.4 
Rationale for Reduced Intensity Preparative Regimen...………………… 
2.5 
Rationale for Study………………………………………………………. 
2.6 
Minimal Residual Disease (MRD).……………………………………… 
2.7 
Rationale for the Evaluation of Immune Reconstitution After UCBT….. 
1 
2 
4 
7 
7 
9 
10 
3.0 
Protocol Eligibility Criteria……………………………………………………. 11 
 
3.1 
Inclusion Criteria for Transplant Recipient……...……………………… 
3.2 
Exclusion Criteria for Transplant Recipient……...……………………… 
3.3 
Inclusion Criteria for Haploidentical Donors…………………………… 
3.4     Enrollment on Study…………………………………………………… 
11 
12 
12 
13 
4.0 
Treatment Plan………………………………………………………………….. 15 
 
4.1 
Schema for Protocol Prioritization…………...………………………….. 
4.2 
Reduced Intensity Preparative Regimen…………..…………………….. 
4.3 
UCB Product………………………………..……………………………. 
4.4 
Haploidentical Donor Graft………..…………………...……………….. 
4.5 
Graft Preparation………..………………..……………………………… 
4.6 
Additional Progenitor Cell Graft Administration…………………….….. 
4.7 
Donor Lymphocyte Infusion………..…………………………….…..…. 
4.8 
Quality Assurance of Cellular Products..…………..….………………… 
4.9  Immunosuppressive Therapies ………………………….……………… 
4.10 Management of Pre-Engraftment Immune Reaction……………………. 
4.11  Growth Factors (G-CSF).………………………………..………………. 
4.12 Treatment and Conditioning Regimen Related Notes…………………… 
15 
16 
17 
19 
20 
21 
22 
22 
23 
24 
24 
24 
5.0 
Medication Information………………………………………………………… 25 
 
5.1  
Cyclophosphamide………….…………………………………………… 
5.2. 
Thiotepa…………………………………………………………………. 
5.3 
Fludarabine (Fludara)………………………………..…………………... 
5.4  
Melphalan……..………………………………..………………….…….. 
5.5  
Mesna……………………………………………………………………. 
5.6 
Filgrastim ……..………………………………………………………… 
5.7     Mycophenylate mofetil………………………………………………….. 
5.8     Tacrolimus……….……………………………………………………… 
25 
26 
26 
27 
28 
29 
30 
30 


 
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Protocol document date: 08/22/14 
 
5.9 
Methylprednisolone ……..……………………………………………… 
5.10   CliniMACS System……………………………………………………… 
 
32 
32 
6.0 
Required Observations and Evaluations……………...………………………… 33 
 
6.1 
Standard Pre/Peri/Post-Transplant Evaluations……………………….... 
6.2 
Long Term Follow-up Evaluations…………………………………..….. 
6.3 
Research Testing……………………………….……..……..……..…….  
6.4 
Research Testing on Haploidentical Donor…………...……..……..……. 
33 
33 
33 
35 
7.0 
Evaluation Criteria……………………………………………………………… 35 
 
7.1 
Adverse Event Monitoring.……………………………..…………..….... 
7.2 
Acute and chronic GVHD scoring………………………………….…... 
7.3 
Performance Status.………………………………..……..……..……….. 
7.4 
Hematologic Recovery………………………………..……..……..……. 
7.5 
Primary Graft Failure……….………………………..……..……..…….. 
7.6 
Secondary Graft Failure……...…………………………..……..……..… 
7.7 
Mixed Hematopoietic Chimerism……..…………………………..…….. 
35 
35 
35 
35 
35 
35 
35 
8.0 
Off-study Criteria……………………………………………………………….. 36 
 
8.1 
Recipient Off-therapy Criteria …………………..………………………. 
8.2     Recipient Off-study Criteria……………………………………………… 
8.3     Donor Off-study Criteria 
36 
36 
36 
9.0 
Reporting Criteria………………………………………………………………. 37 
 
9.1 
Reporting Adverse Experiences and Deaths……..……..……..……..….. 
9.2 
Reporting to SJCRH Institutional Review Board (IRB)………………… 
9.3 
Reporting to SJCRH Biosafety Committee (IBC)……………………….. 
9.4 
Reporting to US Food and Drug Administration (FDA)……..……..…… 
9.5 
Reporting to SJCRH Regulatory Affairs Office.…….…..……..……..…. 
9.6 
Continuing Review Reports...……..……..……..……..…..............….…. 
9.7     Reporting to the St. Jude Data Safety Monitoring Board………………... 
9.8 
Data Submission to Miltenyi Biotec…….……..……..…..............….…. 
9.9 
Reporting to Center for International Blood and Marrow Transplant 
Research (CIBMTR)….……..……..……..……..…..……..……..……. 
37 
37 
38 
38 
39 
39 
39 
39 
40 
10.0 Data Collection, Study Monitoring, and Confidentiality……………………… 40 
 
10.1 Data Collection…………………………………………....….….….…… 
10.2 Study Monitoring………………………………..….….….….….……… 
10.3   Confidentiality…………………………………………………………… 
40 
40 
41 
11.0 Statistical Considerations……………………………………….. 
41 
 
11.1 Statistical Design and Analysis for the Primary Objective……….…….. 
11.2 Statistical Analysis for the Secondary Objectives………………………. 
11.3   Analysis for Exploratory Objectives…………………………………….. 
41 
44 
45 
12.0 Obtaining Informed Consent…………………………………………………… 45 
 
12.1   Informed Consent Prior to Research Interventions……………………… 45 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
12.2   Consent at Age of Majority……………………………………………… 
12.3   Consent When English is Not the Primary Language…………………… 
45 
45 
13.0 References………………………………………………………………….…. 
46 
 
 
 
Appendix A: Karnofsky and Lansky Performance Score………………………. 
Appendix B: GVHD Grading…………………………………………………... 
Appendix C: Adverse Event Evaluation………………………………………... 
Appendix D: Testing and Evaluation…………………………………………... 
Appendix E: BMT Standard Operating Procedure.…………………………….. 
53 
54 
58 
59 
63 
 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
STUDY SUMMARY 
HAPCORD:  
Principal Investigator: Mari Hashitate Dallas, MD 
IND/IDE: 16036 
Brief Overview: In this study, participants with high-risk hematologic malignancies undergoing 
hematopoietic cell transplantation (HCT), who do not have a suitable human leukocyte antigen 
(HLA)-matched related/sibling donor (MSD), matched unrelated donor (MURD) or killer-
immunoglobulin receptors (KIR) ligand mismatched haploidentical donor identified, will receive 
an combined haploidentical and umbilical cord blood transplantation (UCBT) using a reduced 
intensity conditioning (RIC) preparative regimen.  Patients who have a suitable KIR ligand 
mismatched haploidentical donor will be preferentially enrolled in available haploidentical 
protocol (i.e. HAPNK1).  Those with a suitable HLA matched sibling or unrelated donor 
identified may be eligible for participation if the donor is not available in the necessary time.  
Participants must be ≤ 21 years old and with sufficient multi-organ function as specified in 
protocol.  
The assessments and follow-up evaluations noted in the protocol follow the St. Jude standard 
operating procedures (SOP) for all recipients of allogeneic HCT.  
Intervention: Combined haploidentical graft with an unrelated umbilical cord blood graft using 
a reduced intensity preparative regimen. 
Brief Outline of Treatment Plan:  The preparative regimen includes total lymphoid irradiation 
(TLI) (8 Gy), fludarabine (150 mg/m2), cyclophosphamide (60mg/kg), melphalan (140 mg/m2) 
and thiotepa (10mg/kg).   TLI will be administered in 4 fraction at 200 cGY/fraction over 3 days 
on day -9 to day -7, fludarabine will be given once a day at 30 mg/m2 for five days on day -8 to 
day -4, cyclophosphamide will be given once a day at 60mg/kg for one day on day -6, thiotepa 
will be given twice a day at 5 mg/kg for one day on day -3, and melphalan will be given once a 
day for 2 days on day -2 and day-1.  Post-transplantation immunosuppression with tacrolimus 
will begin on day -2 and MMF on day 0. Haploidentical donor product will be infused on day 0 
and day +1.  Cord Blood infusion will occur on day +2.  G-CSF may start on day +3, but may be 
held at the discretion of the attending physician.  
Objectives:  
Primary objective  
 Estimate the incidence of engraftment by day +42 post-transplant for participants with 
high-risk hematologic malignancies undergoing a reduced intensity conditioning (RIC) 
hematopoietic cell transplantation (HCT) using a haploidentical donor combined with a 
unrelated umbilical cord blood (UCB) donor. 
Secondary objectives: 
 Estimate the incidence of malignant relapse, event-free survival, and overall survival at 
one-year post-transplantation. 
 
Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD). 
 
Estimate the incidence of transplant related mortality (TRM) and transplant related 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
morbidity in the first 100 days after transplantation. 
Exploratory Objectives 
 
Assess the relationship between pre-transplant minimal residual disease (MRD) with 
transplant outcomes. 
 
Record 
immune 
reconstitution 
parameters, 
including 
chimerism 
analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping.  Immunophenotyping and functional assays of T, B and NK cells and 
lymphocytes will also be evaluated.  
 
Characterize the recovery of Gamma Delta T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  
 
Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility. 
Hypotheses/Estimates:  
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 30% will 
have a suitable matched related/sibling donor (MSD) and another 30% will have a matched 
unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-60% of eligible 
pediatric recipients, and the lengthy duration of the donor search process in those with high risk 
of relapse have prompted investigators to use an alternative source of HSC, namely UCB.3 
Although UCB has been shown to be a suitable source of HSC, initial studies suggested UCBT is 
associated with increase incidences of TRM when compared to recipients of MSD or MURD.5, 6 A 
pilot study in adults that combined haploidentical and an unrelated UCBT using a RIC resulted in a 
rapid engraftment with minimal GVHD and durable remission.7 Here, we propose to investigate 
the outcomes of pediatric patient with high-risk malignancies undergoing a combined 
haploidentical and UCBT using a RIC regimen at St. Jude Children’s Research Hospital.  The 
primary objective of the study is to estimate the rate of engraftment by day +42 post-transplant 
in patients undergoing a combined haploidentical and UCBT using a reduced intensity 
preparative regimen.  Secondary aims will assess overall survival, event-free survival, risk of 
relapse, graft versus host disease (GVHD), transplant related mortality (TRM), transplant 
related morbidity, and immune reconstitution. 
 
Criteria for Evaluation:    
Safety Evaluation  
 The primary measures of safety will be the rate of therapy related death and the rate of 
severe graft versus host disease. 
 Ongoing assessment of toxicity will be done using the NCI CTC version 3. Acute GVHD 
will be evaluated using the standard grading criteria (Appendix B). 
Efficacy  
 Neutrophil and platelet engraftment will be determined using the parameters put forth by 
the Center for International Blood and Marrow Registry.  Assessments will be made upon 
review of daily complete blood count and serial chimerism studies. 
 BM studies for disease status evaluation will be performed at approximately 28 days, 100 
days, and yearly post-transplant.  
 Acute GVHD will be assessed using the standard grading criteria put forth by Prezpiorkia 
et al 1995. Chronic GVHD will be assessed using the NIH Consensus Criteria for 
Chronic GVHD 2005 (Appendix B). 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
 
Study Design: Phase II - Non Randomized  
Study Population: Patients with high-risk hematologic malignancies who are in complete 
remission or AML in first relapse with less than 25% blasts at the time of evaluation are eligible 
for enrollment. Participant must be less than or equal to 21 years old.   
Candidates must have a suitable UCB product available (matched ≥ 4 of 6 to the patient  
sufficient with sufficient cell dose).  Those with a suitable HLA matched sibling, matched 
unrelated donor, or KIR mismatched haploidentical donor identified will be eligible for 
participation only if the donor is not available in the necessary time. Additional eligibility criteria 
are specified to assure sufficient multi-organ system function. 
Inclusion criteria for transplant recipient 
 Age less than or equal to 21 years old. 
 Has a partially HLA-matched single UCB product available.  
 Has a partially HLA-matched haploidentical related donor available.  
 High-risk hematologic malignancy. 
 High risk ALL in CR1, ALL in High risk CR2, ALL in CR3 or subsequent. 
 AML in high risk CR1, AML in CR2 or subsequent 
 
Therapy related AML, with prior malignancy in CR > 12mo 
 
MDS, primary or secondary 
 
NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
 
CML in accelerated phase, or in chronic phase with persistent molecular positivity or 
intolerance to tyrosine kinase inhibitor. 
 
Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous HCT, or 
unable to mobilize stem cells for autologous HCT. 
 
Non-Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous 
HCT, or unable to mobilize stem cells for autologous HCT. 
 
JMML 
 
Refractory hematologic malignancies (ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin lymphoma) due to chemoresistant relapse or primary induction failure. 
 
All patients with evidence of CNS leukemia must be treated and be in CNS CR to be 
eligible for study. 
 Patient must fulfill pre-transplant evaluation: 
 
Left ventricular ejection fraction ≥ 40% or cardiac shortening fraction ≥ 25%. 
 
Creatinine clearance or GFR ≥ 50 ml/min/1.73m2. 
 
Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry ≥ 92% on 
room air. 
 
Karnofsky (≥ 16 years) or Lansky (<16 years) performance score ≥ 50  
 
Bilirubin ≤ 3 times the upper limit of normal for age. 
 
Alanine aminotransferase (ALT) ≤ 5 times the upper limit of normal for age. 
 
Aspartate aminotransferase (AST) ≤ 5 times the upper limit of normal for age. 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
 
 
Exclusion Criteria for Transplant Recipients:  
 Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical donor (for 
HAPNK1) available in the necessary time for stem cell donation. 
 Patient has any other active malignancy other than the one for which HCT is indicated. 
 
Patient is pregnant as confirmed by positive serum or urine pregnancy test within 14 days 
prior to enrollment. 
 
Patient is breast feeding 
 
Patient has Down Syndrome 
 
Patient has a current uncontrolled bacterial, fungal, or viral infection per the judgment of 
the PI. 
Sample Size:  Up to 49 evaluable.  
Randomization: N/A 
Data Analyses: Statistical considerations and ongoing analysis will be conducted by Dr. 
Guolian Kang and designated associates within the St. Jude Department of Biostatistics.     
Anticipated Primary Completion Date:  (5 years) 
Anticipated Study Completion Date:  (6 years) 
Timeframe for Primary Outcome Measure: 42 days 
Data Management: Protocol compliance, data collection including safety data, and reporting 
will be carried out by the Department of Bone Marrow Transplantation and Cellular Therapy 
Research Office. 
Human Subjects: The risks to subject are primarily related to the infusion and the 
conditioning regimen.  The allogeneic stem cells may induce serious and possibly fatal 
disorders such as GVHD, veno-occlusive disorder and post-transplant lymphoproliferative 
disease.  Because of the required conditioning, recipients are at high-risk for serious and 
possibly life-threatening infection, bleeding, and anemia.  Adverse events will be treated, 
monitored, and reported appropriately. 
Possible benefits of participation include obtaining and/or sustaining disease remission.  In 
addition, there is the possibility of psychological benefit from knowing participation has helped 
researchers gain more understanding about the efficacy of UCBT. 
Alternatives to participation are identified as chemotherapy, research treatment if available, 
and/or supportive therapy. 
The possible benefits, alternatives to participation, and side effects, including that there may be 
unknown side effects of treatment, are detailed in lay language within the respective informed 
consent documents. 
 


 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
1.0 


HAPCORD 1 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
1.0 OBJECTIVES 
1.1 Primary objective 
1.1.1 To estimate the incidence of engraftment by day +42 post-transplant for 
participants with high-risk hematologic malignancies undergoing a reduced 
intensity conditioning (RIC) hematopoietic cell transplantation (HCT) using a 
haploidentical donor combined with a unrelated umbilical cord blood (UCB) 
donor. 
1.2 Secondary objectives  
1.2.1  Estimate the incidence of malignant relapse, event-free survival (EFS), and 
overall survival (OS) at one-year post-transplantation. 
1.2.2 Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD) in the first 100 days after transplantation. 
1.2.3 Estimate the incidence of transplant related mortality (TRM) and transplant 
related morbidity in the first 100 days after transplantation. 
1.3 Exploratory Objectives 
1.3.1 Assess the relationship between pre-transplant minimal residual disease (MRD) 
with transplant outcomes. 
1.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping.  Immunophenotyping and functional assays of T, B and NK cells 
and lymphocytes will also be evaluated.  
1.3.4 Characterize the recovery of Gamma Delta T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  
1.3.3.  Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  
2.0 BACKGROUND AND RATIONALE 
2.1 Overview 
Allogeneic HCT has become a widely accepted curative therapy for many hematologic 
malignancies that cannot be cured with chemotherapy alone.8, 9 Studies have 
demonstrated that HCT is a potentially curative therapy for patients with CML, AML, 
ALL and MDS.10-13 Furthermore, patients with non-Hodgkin or Hodgkin’s lymphoma 
who recur after an autologous HCT may be successfully treated with an allogeneic 
HCT.14, 15 
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 
30% will have a suitable matched related/sibling donor (MSD) and another 30% will have 
a matched unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-
60% of eligible pediatric recipients, and the lengthy duration of the donor search process 
in those with high risk of relapse have prompted investigators to use an alternative source 
of HSC, namely UCB.3 Recent comparative studies report no significant difference in OS 
in patients undergoing UCBT compared to MURD HCT.16-20  Thus, the number of 
patients undergoing UCBT has rapidly increased over the past 10 years. In the pediatric 


HAPCORD 2 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
population, UCB is now the most common source of HSC in unrelated donor transplant. 
However, the limited number of progenitor cell in the UCB unit result in delayed and 
unpredictable count recovery.  The delayed neutrophil recovery predisposes patients to 
infection and recipients of UCB is associated with increase incidences of TRM when 
compared to recipients of MSD or MURD.5, 6 A pilot study in adults that combined 
haploidentical and an unrelated UCBT using a RIC resulted in a rapid engraftment with 
minimal GVHD and durable remission.7 St. Jude has gained considerable expertise with 
haploidentical HCT in children 21-28 and we propose to investigate the outcomes of 
pediatric patient with high-risk malignancies undergoing a combined haploidentical and 
UCBT using a RIC regimen at St. Jude Children’s Research Hospital. 
2.2 Umbilical Cord Blood Transplantation (UCBT) 
2.2.1 Historical Background: 
The use of UCB as a clinical source of HSC was first considered in the late 
1960’s when UCB from eight donors were pooled and infused into a 16 year old 
male with acute lymphocytic leukemia (ALL).29  Although full reconstitution was 
not observed, there was evidence suggesting transient mixed chimerism. 
Thereafter, additional studies were performed that suggested that if adequate 
numbers of HSC could be collected; UCB has the potential for long-term 
reconstitution.  In 1989 the first successful matched sibling UCBT was performed 
for a child with Fanconi anemia. In 1995, the International Cord Blood Transplant 
Registry (ICBTR) reported the results of the first 44 matched sibling UCBT 
demonstrating UCB contained sufficient number of hematopoietic progenitors to 
reliably engraft transplant recipients after a myeloablative conditioning regimen.30  
The first successful unrelated UCBT in a pediatric patient occurred at Duke 
University in 1993.31, 32 In 1996, Kurtzberg et al and Wagner et al simultaneously 
published the unrelated UCBT experiences at Duke and Minnesota, 
respectively.32, 33 These initial studies showed the median time to neutrophil 
recovery was 22 and 24 days, respectively.  Combining the 43 patients, 88% 
engrafted, 54% had Grade II-IV GVHD and 9% had Grade III-IV GVHD.  The 
OS at 100 days was 53%.  Together, these studies suggested that UCB is a 
suitable alternative source of allogeneic HSC for pediatric patients.  
In nearly every large single center or registry analysis of outcomes after UCBT, 
cell dose is identified as an important factor influencing the incidence and rate of 
hematopoietic recovery, risk of TRM, and probability of survival.  Furthermore, 
data suggest that infusion of two partially HLA-matched UCB units, which 
always augments the graft cell dose, is safe and may improve neutrophil recovery 
and survival.  To determine whether the infusion of two UCB units enhances 
survival, the Blood and Marrow Transplant Clinical Trials Network (BMTCTN) 
proposed a multi-center randomized trial in 2006.  Preliminary data suggest that 
patients receiving double unit UCBT have a higher risk for acute GVHD albeit a 
lower risk for relapse.  However, until data clearly demonstrate a survival 
advantage, double UCBT is currently only recommended for those patients who 
do not have an adequate single unit.34   


HAPCORD 3 
 
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Lastly, in the past decade, large comparative studies evaluating the outcomes of 
transplantation using UCB versus other HSC sources have been performed. 
Reports demonstrate that the incidence of GVHD was lower in patients 
undergoing UCBT compared to HLA-matched bone marrow (BM) recipients.  
Furthermore, recent studies that include long-term analysis demonstrate that 
outcomes are similar for patients undergoing transplantation using MURD or 
UCB sources.14-18, 25 Thus, UCBT should be considered as a viable options for 
patients with high-risk malignancies.16-20, 35 7-11, 25 
2.2.2  Cell Dose Threshold and Interaction with HLA match 
Cell dose remains one of the single most important determinants of a successful 
UCBT.36-38 Numerous clinical studies have shown that the total nucleated cell 
(TNC) dose and the CD34+ cell dose in the UCB graft are highly correlated with 
neutrophil and platelet engraftment as well as the incidence of graft failure and 
early TRM.3, 37, 39, 40 The first Eurocord Registry report by Gluckman et al, 1997, 
demonstrated that among 527 patients undergoing UCBT, the most important 
predictor in outcome was the infusion of ≥ 3 x 107 TNC per kilogram body 
weight.36, 41 Moreover, adult recipients had increased TRM by day 180 compared 
to children (56% versus 32%), and deaths were related to the number of cells 
infused, with patients who received ≤ 1 x 107 TNC/kg having a 75% probability 
of death compared to 30% for those who received ≥ 3 x 107 TNC/kg.  Rubinstein 
et al, 1998, published the New York Blood Center experience with 562 patients 
undergoing UCBT and similarly demonstrated a strong correlation between the 
number of leukocytes infused and engraftment.38 Thus, the collective data point to 
improved outcome of UCBT for patients receiving a larger number of CD34+ 
cells.  Delayed engraftment has also been correlated with HLA mismatch at 
greater than 2 loci, but recent studies have suggested that the impact of HLA 
disparity on survival can be partially overcome by increasing cell dose.42 
Combined, these studies identified a minimum threshold for cell dose and HLA 
matching which lead to a significant reduction in TRM after UCBT.  Although the 
exact threshold criteria for each degree of HLA mismatch is not know, the 
principle for the dose algorithm is clear.34, 43, 44 
2.2.3  Role of Double UCBT 
For most adults and large children, a single UCB unit that meets the cell dose 
requirement is not available.  To overcome this obstacle, investigators at the 
University of Minnesota began infusing two partially HLA-matched units to 
augment cell dose. They found that engraftment was achieved more rapidly and in 
a higher proportion of patients than the previous cohort who received only a 
single UCB unit.45 Preliminary evidence suggests that double unit UCBT may be 
associated with a decreased risk of relapse in patients with good disease control at 
the time of transplant, but is also associated with a increased incidence of mild to 
moderate acute GVHD compared to single UCBT.46,47, 48 Currently, it is unclear 
whether double UCBT offers any benefit other than extending the application of 
UCBT by achieving the cell dose threshold.49 Until data clearly demonstrate a 
survival advantage, double UCBT is currently only recommended for those 
patients who do not have an adequate single unit.50 An adequate single unit is 


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defined as: ≥ 3.0 x 107 nucleated cells/kg for 6/6 HLA-matched units, ≥ 4.0 x 107 
nucleated cells/kg for 5/6 HLA-matched units and ≥ 6.0 x 107 nucleated cells/kg 
for 4/6 HLA-matched units.48, 50, 51Despite adequate cell dose, patients undergoing 
double UCBT continue to have delayed engraftment compared to MSD and 
MURD HCT.  
2.2.4  UCBT Results 
Engraftment: Most studies report the time to hematopoietic recovery after UCBT 
is delayed with the median time to neutrophil recovery ranging between 20 - 30 
days and the incidence of engraftment after single UCBT ranges from 65-92%.31, 
33, 37, 38, 40, 41, 52-60 Studies have consistently demonstrated the rate and incidence of 
engraftment after UCBT is slower than bone marrow transplantation (BM), 
dependent on cell dose and the threshold for cell dose depends on HLA match 
grade.  
GVHD: The first report from the New York Blood Center experience by Rubinstein 
et al indicated that GVHD after UCBT occurred at a lower rate compared to those 
with MURD transplantation.38 Thereafter, Rocha et al published the first 
comparative analysis between UCBT and MURD transplantation in pediatric 
patients that substantiated the claim that acute and chronic GVHD were less 
common in recipients of UCB.18 In larger studies, the incidence of acute GVHD is 
reported to range from 33-44% and 11-22% for grades II-IV and III-IV acute GVHD 
respectively. The incidence of chronic GVHD ranges from 0-25%.37, 38, 57, 59, 60  
Survival: Nearly all studies demonstrate a significant relationship between UCB cell 
dose and survival and the reported probability of survival after single UCBT ranges 
from 18-78%.16, 20, 40, 45, 47, 51, 61-65 One of the largest reports from the Center for 
International Blood and Marrow Transplant Research (CIBMTR) by Eapen et al in 
2007 compared the outcomes of 785 pediatric patients with acute leukemia who 
received a UCBT (n=503) or an unrelated BMT (n =282).  The most notable finding 
was that UCBT compared favorably to an 8/8 allele-matched unrelated BMT.  In 
comparison with allele-matched BMT, the 5 year disease free survival (DFS) was 
similar to that after either one or two antigen mismatched UCBT and possibly higher 
after 6/6 allele-matched UCBT.16 These and other studies support that UCB should 
be considered an acceptable source of HSC grafts in the absence of an HLA-
matched donor. 16, 17, 20, 37, 38, 40, 45, 47, 51, 57, 59-66 
2.3 Haploidentical HCT 
2.3.1 
Haploidentical HCT Background 
Haploidentical donors are another viable alternative donor source when a MSD or 
MURD are not available.  Also, family members are highly motivated, easily 
accessible, and readily available for most patients.  Along with other institutions, 
St. Jude has shown haploidentical HCT to be an effective therapy for patients with 
hematologic malignancies.67-71 Due to the high potential for GVHD with the 
degree of HLA mismatch seen in haploidentical HCT, most haploidentical grafts 
are extensively T-cell depleted (TCD) prior to infusion.72  Significant progress 
was achieved when high cells dose of CD34+ cells were infused after high-


HAPCORD 5 
 
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intensity conditioning.70 It has been well established that prompt engraftment with 
rapid immune reconstitution can be achieved with CD34+ enriched haploidentical 
cells, purified by positive (CD34+) and negative (CD3- lectin agglutination) 
selection.73,74 
Building on the initial studies above, St. Jude has gained considerable expertise with 
haploidentical HCT in children.21-26, 28, 75 Over the past decade (2001-2010), more 
than 220 mismatched related donor HCT have been performed at St. Jude.  Initially, 
most haploidentical HCT performed in this institution were for patients with 
relapsed and refractory hematologic malignancies, however as it became a more 
successful therapeutic maneuver, it has become a primary transplant option for 
patients who lack a well matched donor.27   
Recent studies suggest that alloreactive NK cells play a role in graft versus 
leukemia (GVL) and influence outcomes of patients with hematologic 
malignancies after haploidentical HCT.76-83 The NK cell alloreactivity depends on 
the balance of signals mediated through activating and inhibitory KIRs on the NK 
cell.  In patients who received haploidentical HCT for high risk leukemia at 
SJCRH the presence of KIR mismatch dramatically reduced the risk of relapse.24 
Thus, patients with high risk hematologic malignancies who lack an HLA-
matched donor but have a KIR mismatched haploidentical donor available, would 
be expected to benefit from haploidentical HCT. 
2.3.2  Rationale for immunomagnetic TCD of hematopoietic progenitor cell graft  
Donor T cells in the haploidentical graft play a major role in mediating GVHD, 
with as few as 3 x 104 T cells/kg can cause GVHD.84  TCD allows for a HSC graft 
with very low T cell content, such that the risk of GVHD is decreased. T cells can 
be removed from the HSC graft by direct removal of T cells (negative selection) 
or positive selection of CD34+ progenitors. St. Jude has had success using either 
method of TCD in haploidentical donor transplantation.  
In this study, CD34+ selection by CliniMACS will be the used for TCD of the 
haploidentical graft.  Although positive selection allows for extensive TCD, the 
graft is devoid of other important cell populations such as NK cells and myeloid 
cells such as dendritic cells and monocytes.85, 86  In addition, this extensive degree 
of TCD has significant negative effects on the time to donor immune competency.  
Donor T cells are critical for reconstituting the allogeneic host immune system, 
and lymphocyte recovery is an important determinate of outcome post-
transplant.87, 88 Transplants that employ TCD result in elimination of most 
memory T cells, leading to protracted immune dysfunction- an effect that 
becomes more severe with higher intensity conditioning regimens.21, 89 This 
results in an increased rate of opportunistic infections. Indeed, viral infections are 
the most common cause of death of children receiving haploidentical 
transplants.90 The majority of these infections occur within the first 6 months 
following transplantation, when T cell immunity is the lowest.91 Reconstitution of 
immunity can be partially restored by therapeutic infusions of donor cytotoxic 
lymphocytes.87, 92-94 However, in addition to requiring significant resources and 


HAPCORD 6 
 
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expertise, the cells must be engineered or selected for specific infections - making 
this approach impractical for broad application.95   
A more ideal approach would be to infuse a cell product with diverse lymphocyte 
repertoire capable of effectively recognizing a variety of pathogens, as well as 
malignant cells without additional GVHD risk. One strategy would be to target 
naïve T cells for lymphocyte depletion.  Naïve T cells are fully matured but do not 
proliferate until they encounter their receptor specific ligand.96  After ligand 
recognition, there is activation of proliferative signals that initiates a marked, 
antigen-specific cell expansion and inflammatory response. While many of these 
naïve T cells will undergo apoptosis after the initial response, others are rescued 
from immune retraction and will persist as memory T cells.  Once generated, 
memory cells persist in the circulation as a diverse cell pool that is critical for 
long-term infection control.97  Furthermore, memory T cells are capable of more 
rapidly responding to future infectious challenges.98 
The isoform of the leukocyte common antigen, CD45RA, selectively identifies 
naïve T cells.  Human studies have shown that sorted donor CD45RA+ naïve T 
cells are far more alloreactive than all memory subsets tested.99 In animal models, 
naïve T cells, are potent inducers of GVHD.95 Moreover, in similar models, 
lymphocyte infusions specifically depleted of CD45RA+ naïve T cells do not 
cause GVHD.100  Conversely, CD45RA- memory T cells do not cause physical or 
histologic evidence of GVHD. Among CD4+ T cells, the CD45RA- subset has 
equivalent “helper” functions as CD45RA+ cells in the generation of alloreactive 
cytotoxic T cells.101  Further, it is the CD45RA- memory cells that are responsible 
for aiding B-cell differentiation and antibody production.   
After demonstrating promising pre-clinical results, selective CD45RA depletion 
in patients undergoing HCT are underway, including two at SJCRH (RADIANT 
and HAPNK1). Depletion of CD45RA+ cells by magnetic beads has been shown 
to be a feasible and effective method for depletion of naïve T cells, with up 
greater than 3-log depletion in number of CD45RA+ cells  (Data provided by 
Miltenyi).  Furthermore, experiments were performed in the HAL to confirm and 
qualify the CD45RA+ depletion procedures.  HSC products were obtained from 
G-CSF mobilized normal donors by apheresis. The HPC, Apheresis products were 
depleted of CD45RA+ cells following a procedure provided by Miltenyi Biotech. 
Briefly, the cells were incubated with the CD45RA microbead reagent followed 
by washing to remove unbound beads. The labeled cells were then applied to the 
CliniMACS device (Depletion Tubing Set) and the CD45RA+ cells removed 
using the Depletion 3.1 program. Flow cytometric analysis before and after 
depletion was performed following procedures provided by Miltenyi Biotech. The 
results of the experiments are presented in the table below. An example flow 
cytometric analysis of CD3+ cells is also included.  We hypothesize combining a 
CD34+ enriched product (HPC, Apheresis 1) along with a CD45RA+ depleted 
product (HPC, Apheresis 2) will provide a HSC graft with good stem cell content 
(3-5 x 106 CD34+ cells/kg) and a useful memory T cell fraction without additional 
GVHD risk to the recipients on this trial.  


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DEPLETION EXPERIMENT 
 
Experiment 1 
Experiment 2 
 
Pre  (106) 
Post  (106) 
Pre (106) 
Post (106) 
TNC 
29748 
10270 
26166 
10981 
CD34+ 
636 
311 
693 
395 
CD3+ 
12238 
4555 
6353 
1985 
CD3+CD45RA+ 
7877 
4 
3520 
2.2 
CD3+ CD45RA+ Log Depletion 
 
3.28 
 
3.21 
2.4 Rationale for RIC Preparative Regimen 
RIC regimens have the potential to improve the outcomes of allogeneic HCT by 
decreasing the acute TRM.102-104  TLI was initially developed with curative intent in 
patients with Hodgkin Lymphoma, and it was its use in these patients that led to the 
discovery of TLI’s alteration of T-cell specific immune responses.  Years of pre-clinical 
research on TLI have shown that the use of TLI promotes engraftment and reduces 
GVHD.105 This work was then followed up with therapeutic trials in humans with 
hematologic malignancy, which showed that conditioning with TLI and ATG alone allowed 
a high rate of durable donor engraftment, a low rate of GVHD, and preservation of evidence 
of graft versus malignancy effect, in patients who received HLA-matched related or 
unrelated donor grafts.106, 107  We have significant institutional experience using TLI-based 
regimens for allogeneic transplantation (n=29 as of June 2012).  Importantly, TLI-based 
conditioning has allowed successful salvage HCT in patients who failed previous allo-HCT.  
Nine patients have received TLI-based conditioning with haploidentical donor HCT after 
experiencing previous allograft failure (3 had primary graft failure, 4 had initial engraftment 
with acute rejection, and 2 had late graft failure).  The same haploidentical donor was 
utilized in 5 of the 9 salvage HCT, with 4 patients receiving a new (haploidentical) donor.  
Eight of 9 patients (89%) experienced durable engraftment at a median of 12 days (range 10 
– 27 days).  The remaining patient had primary graft failure due to progressive disease.  This 
experience indicates that TLI is effective for facilitation of engraftment, even in patients 
receiving a mismatched haploidentical donor graft and with a history that indicates a very 
high risk of graft failure.  There is additional published experience from Germany in which 
TLI – given as a single 7Gy fraction – was utilized in 14 adult and pediatric patients for 
reconditioning after graft failure/rejection.108 Despite most of the patient having 
haploidentical donors, engraftment was obtained in all evaluable patients.  In addition, TLI 
was well tolerated in this pediatric population that had recently received another (typically 
myeloablative) preparative regimen.  Finally, 10 patients in Chile received TLI-containing 
preparative regimen, similar to our proposed regimen, as a part of their haploidentical donor 
preparative regimen.109 TLI was given as a single dose at 7Gy.  Nine out of 10 patients 
experienced rapid donor engraftment, with relapse as the cause of the one primary graft 
failure.  Six of 10 patients were alive and disease free at one year, 3 died of progressive 
disease, and one of infection. 
2.5 Rationale for Study 
In the past 20 years, over 20,000 UCBT have been performed worldwide and over 
400,000 UCB units have been stored in more than 100 UCB banks.32, 39, 110 The main 
practical advantages of using UCB as an alternative source of HSC are (1) rapid 
availability, (2) absence of donor risk, (3) relative ease of procurement, (4) absence of 


HAPCORD 8 
 
Initial version, dated: 08/22/14 
 
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donor attrition, (5) very low risk of transmissible infectious diseases and (5) low risk of 
acute GVHD despite HLA mismatch.  Furthermore, UCB is particularly beneficial for 
patients of ethnic and racial minority descent for whom adult marrow and blood donors 
often cannot be identified.32, 38, 39, 110 According to data from the National Marrow Donor 
Program (NMDP) donor registry, the probability of finding an 8 out of 8 HLA-matched 
donor is 51% for Caucasians, 30% for Hispanics, 20% for Asians and 17% for African 
Americans.  Since patients who do not have a MURD can undergo a mismatched 
unrelated UCB transplantation and achieve similar results, the number of patients 
undergoing UCBT has rapidly increased over the past 10 years. The CIBMTR reports 
that from 2004 to 2008, UCB is now the most common graft source and BM is no longer 
the most common unrelated donor graft source for patients 20 years or less.  Furthermore, 
in 2007 and 2008, 46% of all unrelated donor transplantations used UCB grafts for 
patients 20 years or less. 
Patients who do not have an appropriate MSD or MURD donor available in a timely manner 
often undergo transplantation using an alternative HSC source from UCB or haploidentical 
donors.  Often, the type of donor is chosen based on various factors related to urgency of 
transplantation, patient, disease, and transplant-related factors as well as the center’s 
experience. Although a prospective randomized clinical trial is the accepted standard to 
compare different treatment regimens, the feasibility and acceptability of such a clinical 
trial is problematic and has not been performed.  However, retrospective studies 
comparing the two donor sources have demonstrated no difference in survival.  
The Eurocord group performed a retrospective study comparing the outcome of pediatric 
patients with high-risk ALL undergoing either UCBT or haploidentical HCT.  Patients 
had received either haploidentical (n=118) or UCB (n=341) transplantation in Eurocord 
centers between 1998 and 2004. The median follow-up was 56 and 24 months for 
haploidentical and UCBT patients, respectively. Failure of engraftment was significantly 
higher following UCBT than after haploidentical HCT (23% vs. 11%, p=0.007). In a 
multivariate analysis, relapse incidence was higher in haploidentical HCT recipients 
compared to UCBT (relative risk 1.7, p=0.01), but TRM and DFS were not significantly 
different. In conclusion, in pediatric patients with ALL, UCBT is associated with inferior 
rate of engraftment, higher incidence of grades II–IV acute GVHD and lower incidence 
of relapse compared to haploidentical HCT; however, there was no difference in terms of 
TRM and DFS. Therefore, in the absence of an HLA-identical donor, both strategies were 
reported to be suitable options to treat a child with high-risk ALL.  
At our institution, patients who do not have an appropriate MSD or MURD donor available 
often undergo a haploidentical HCT.  Studies at St. Jude have shown the presence of 
natural killer (NK) KIR mismatch in a haploidentical donor dramatically reduced the risk 
of relapse in patients who received HCT for high-risk leukemia.24, 25 KIR mismatch is 
predictive of NK alloreactive effects in haploidentical HCT.24, 25, 78, 80 Thus, patients who 
have a KIR mismatch haploidentical donor will be enrolled into a haploidentical HCT 
with NK infusion (HAPNK1).  However, approximately one-third of all patients posses 
all relevant KIR ligands and will not have a KIR mismatched haploidentical donor. These 
patients will require an alternate donor for best clinical outcome.  Patients who require an 
alternative donor HSCT and do not have a KIR mismatched haploidentical donors are 
likely to benefit most from UCBT for best clinical outcome. Contradictory results have 


HAPCORD 9 
 
Initial version, dated: 08/22/14 
 
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been reported on the effect of KIR matching in UCBT.  The European group reported 
KIR-ligand incompatible UCBT improved DFS (hazards ratio = 2.05, p = .0016) and OS 
(hazards ratio = 2.0, p = .004) and decreased relapse incidence (hazards ratio = 0.53, p = 
.05).111 However, the Minnesota group found no advantage using KIR matching in 
UCBT.112 Currently, the effect of KIR matching in UCBT is controversial and UCB 
selection based on KIR matching is not recommended. 
To date, UCBT01, the first UCBT protocol at SJCRH has accrued 9 patients, with 5 
patients receiving a single UCB unit and 4 patients receiving two UCB units.  One patient 
on the observational arm died due to TRM before day 100.  All 8 remaining patients 
engrafted however, 2 patients would be categorized as significant graft delay/failure with 
engraftment after day +42.  One patient engrafted at day 49 and another at day 51.  The 
mean time to neutrophil engraftment is 28±13 days, (range; 12-51).  Thus, despite 
optimizing HLA match and cell dose, engraftment continues to be significantly delayed 
in patients undergoing UCBT.   
In order to abrogate the increased TRM and complication from graft failure and delayed 
engraftment, we propose to provide a combined haploidentical donor with a single 
UCBT. A pilot study reported the results of 45 adults with a mean age of 50 yrs (range; 
20-69) who underwent a RIC regimen using fludarabine, melphlan and ATG for high risk 
malignancies.  The graft consisted of a single UCB with minimum cell dose of 1.0 x 107 
TNC/kg along with a TCD haploidentical donor graft.  GVHD prophylaxis was with 
MMF and tacrolimus.  All patients engrafted and the mean time to neutrophil engraftment 
was 11 days and platelet engraftment was 19 days.  Chimerism analysis demonstrated 
that the predominant haploidentical graft early after HCT is replaced by the UCB graft by 
day 100.  The risk for GVHD was not increased with the reported cumulative incidence 
of acute GVHD of 25% and chronic GVHD of 5%.  
2.6 Minimal residual disease (MRD) 
Despite the fact that the vast majority of patients with high-risk leukemia are in clinical 
remission prior to HCT, approximately 30-40% ultimately relapse after HCT.  Detection 
of MRD and early intervention may improve the clinical outcome.  Detection of leukemic 
cells that are below the limits of detection by standard morphologic examination allow 
early interventions when the patients are MRD positive but still in remission.  By using 
flow cytometry and polymerase chain reaction (PCR) amplification of antigen receptor 
genes in tandem, investigators at our institution have been able to conduct MRD studies 
in 80 consecutive ALL cases.113 Results of St. Jude institutional studies have shown that 
detection of MRD by immunologic techniques at any point in the treatment course is a 
powerful predictor of relapse in children with ALL.113-115 However, other studies suggest 
that eradication of all acute leukemia cells may not be a prerequisite for cure.116, 117 
Similar to conventional-dose therapy, controversy also exists on the implication of MRD 
in the setting of HCT.  Unlike CML, there is a paucity of data on the natural history of 
AML and ALL patients who have MRD after HCT, and how pre-transplant MRD levels 
influence post-transplant outcomes.118, 119  It is unclear whether they are also at greater 
risk of relapse; and whether further pharmacological or immunologic therapy indeed 
prolongs survival and increases cure rates.  Thus, for the participants who are enrolled in 
this protocol who are unable to proceed to post-transplant immunomodulatory protocols, 
we will gather the MRD information together with hematopoietic chimerism in a 


HAPCORD 10 
 
Initial version, dated: 08/22/14 
 
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Protocol document date: 08/22/14 
 
descriptive manner to study the relationship between MRD and chimerism in this large 
cohort of patients. The knowledge gained from this study should allow their future 
application to guide therapeutic interventions. 
2.7 Rationale for the evaluation of immune reconstitution after UCBT 
Delayed immune reconstitution is a major complication after HCT and impacts the 
overall survival in patients. Recent studies demonstrate that the rate and quality of 
immune recovery after UCBT is an important predictor of overall outcomes.  
Unfortunately, the rate of immune reconstitution directly correlates with the number of 
infused HSC and UCB patients have delayed immune reconstitution secondary to the 
limited numbers of HSC.70, 120-122  Though transplantation with multiple unrelated UCB 
units has been used as a strategy to increase the total number of cells infused, the effect 
on immune reconstitution is not clear.  In this study, we propose to monitor the rate of 
immune reconstitution after single and double UCBT. De novo generation of thymic 
derived T cells is critical in reconstituting a functional immune system, thus newly 
derived thymic T cell will be monitored by measuring the concentration of TREC DNA 
by quantitative PCR in the peripheral blood of transplant recipients.   Furthermore, the 
time to recovery (defined as the median time to reach the normal value of age-matched 
healthy individual) of CD3+, CD4+, CD8+, CD19+ and CD56+ cells in patients undergoing 
UCBT will be investigated. Various subsets of T cells will be investigated including 
naïve, memory, central memory, effector memory, regulatory T cells as well as naïve and 
memory B cells.  Functional measures of immune recovery will be examined by T cell 
proliferative response to nonspecific and specific antigen and NK lytic function.  Antigen 
specific T cell response to various infections will be monitored in patients over time.  
Using a direct ex vivo, single-cell-based assay for clonotypic analysis of human epitope-
specific receptor, we will characterize T cell response to specific infections.  
Studies demonstrate that the rate of engraftment of a single unit was significantly 
enhanced after addition of a second unrelated UCB unit.  It is clear that infusion of a 
second UCB unit facilitates the engraftment of the dominant unit, however, the 
mechanism has yet to be investigated.  Preliminary data from the Dallas laboratory 
suggest that dendritic cells and regulatory T cells play a critical role in facilitating 
engraftment in the BM and thymus.123, 124 Data obtained from this study addresses a key 
question regarding the immunological mechanism for enhanced engraftment by 
facilitating cells. Furthermore, published studies consistently report that after a double 
UCBT, cells from only one of the UCB unit engraft.  However, recent results from a 
multi-institutional clinical trial have demonstrated that small number of patients who 
undergo a double UCBT have evidence of mixed chimerism in the BM from the two 
UCB units one-year after HCT.   Furthermore, studies performed at the Fred Hutchinson 
Cancer Research Center, demonstrated that single-unit dominance after double-unit 
UCBT coincides with NK cell dose and a specific CD8+ T-cell response against the non-
engrafted unit.125    
 
 
 


HAPCORD 11 
 
Initial version, dated: 08/22/14 
 
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3.0 PROTOCOL ELIGIBILITY CRITERIA 
3.1 Inclusion criteria for transplant recipient 
3.1.1  Age less than or equal to 21 years old. 
3.1.2 Does not have a suitable MSD or volunteer MUD available in the necessary time for 
stem cell donation.  
3.1.3 Has a suitable partially HLA-matched (≥ 3 of 6) family member donor. 
3.1.4  Has a partially HLA-matched single UCB unit (≥ 4 of 6) with adequate cell dose.  
UCB units must fulfill eligibility as outlined in 21 CFR 1271 and agency guidance.  
3.1.5 High-risk hematologic malignancy. 
3.1.5.1  High risk ALL in CR1.  
  
Examples include, but not limited to t(9;22), hypodiploid,, M2 or greater 
marrow at the end of induction, infants with MLL fusion or t(4;11). 
3.1.5.2  ALL in High risk CR2.  
  
Examples include but not limited to t(9;22), BM relapse <36 mo CR1, T-
ALL, very early (< 6mo CR1) isolated CNS relapse. 
3.1.5.3  ALL in CR3 or subsequent. 
3.1.5.4  AML in high risk CR1.   
  
Examples include but not limited to preceding MDS, 5q-, -5, -7, FAB M6, 
FAB M7 not t(1;22), MRD ≥ 5% on day 22 (AML08), M3 marrow after 
induction 1, M2 marrow after two cycles of induction, FLT3-ITD. 
3.1.5.5  AML in CR2 or subsequent. 
3.1.5.6  Therapy related AML, with prior malignancy in CR > 12mo 
3.1.5.7  MDS, primary or secondary 
3.1.5.8. NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
3.1.5.9 CML in accelerated phase, or in chronic phase with persistent molecular 
positivity or intolerance to tyrosine kinase inhibitor. 
3.1.5.10 Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous 
HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.3.11 Non-Hodgkin lymphoma in CR2 or subsequent after failure of prior 
autologous HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.5.12 JMML 
3.1.5.13 Refractory hematologic malignancies (ALL, AML, CML in blast crisis, 
Hodgkin or non-Hodgkin lymphoma) due to chemoresistant relapse or 
primary induction failure.  
3.1.5.14 All patients with evidence of CNS leukemia must be treated and be in CNS 
CR to be eligible for study. 
3.1.6  Patient must fulfill pre-transplant evaluation: 
3.1.6.1  Cardiac Function: Left ventricular ejection fraction (LVEF) ≥ 40% or 
shortening fraction (SF) ≥ 25%. 


HAPCORD 12 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
3.1.6.2  Creatinine clearance (CrCL) or glomerular filtration rate (GFR) ≥ 50 
ml/min/1.73m2. 
3.1.6.3 Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry 
(Pox) ≥ 92% on room air. 
3.1.6.4  Karnofsky or Lansky performance score ≥ 50 (See APPENDIX A). 
3.1.6.5  Bilirubin ≤ 3 times the upper limit of normal for age.  
3.1.6.6  Alanine aminotransferase (ALT) ≤ 5x the upper limit of normal for age. 
3.1.6.7  Aspartate aminotransferase (AST) ≤ 5x the upper limit of normal for age. 
3.2 Exclusion Criteria for Transplant Recipient:  
3.2.1  Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor (for HAPNK1) available in the necessary time for stem cell donation. 
3.2.2 Patient has any other active malignancy other than the one for which HCT is 
indicated. 
3.2.3  Patient is pregnant as confirmed by positive serum or urine pregnancy test within 
14 days prior to enrollment. 
3.2.6 Patient is breast feeding. 
3.2.7  Patient has Down Syndrome. 
3.2.8  Patient has a current uncontrolled bacterial, fungal, or viral infection per the 
judgment of the PI. 
3.3 Inclusion criteria for haploidentical donor 
3.3.1   At least single haplotype matched (≥ 3 of 6) family member 
3.3.2  At least 18 years of age. 
3.3.3 HIV negative. 
3.3.4 Not pregnant as confirmed by negative serum or urine pregnancy test within 14 
days prior to enrollment (if female). 
3.3.5 Not breast feeding. 
3.3.6 Regarding eligibility, is identified as either: 
3.3.6.1 Completed the process of donor eligibility determination as outlined in 21 
CFR 1271 and agency guidance; OR 
3.3.6.2 Does not meet 21 CFR 1271 eligibility requirements, but has a declaration of 
urgent medical need completed by the principal investigator or physician 
sub-investigator per 21 CFR 1271. 
 
 
 
 
 
 
 
 


HAPCORD 13 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
INCLUSION CRITERIA SUMMARY 
Donor 
Haploidentical (≥ 3 of 6) and single UCB ( ≥ 4 of 6) HLA matched donor 
Age 
≤ 21 years 
 
Malignancy 
ALL 
HR ALL CR1 
ALL CR2 
ALL CR3 or subsequent 
AML 
AML CR1 
AML CR2 or subsequent 
2° AML with prior disease in CR > 12 mo 
MDS 
Primary or Secondary  
NK leukemia 
CR1 or subsequent 
Biphenotypic leukemia 
CR1 or subsequent 
Undifferentiated leukemia 
CR1 or subsequent 
CML 
 
Accelerated Phase 
Chronic with persistent molecular positivity OR 
intolerance to tyrosine kinase inhibitor  
Hodgkins Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize HSC for auto-HCT 
Non-Hodgkin Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize for auto-HCT 
JMML 
 
Refractory disease 
ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin Lymphoma 
Pre-
Evaluation 
Cardiac Function 
LVEF ≥ 40% or SF ≥ 25% 
Renal Function 
CrCL or GFR ≥ 50 ml/min/1.73m2 
Lung Function 
FVC ≥ 50% or Pox ≥ 92% on room air 
Performance Score 
Karnofsky or Lansky ≥ 50 
Liver Function 
Bilirubin ≤ 3x upper limit of normal for age 
ALT ≤ 5x upper limit of normal for age 
AST ≤ 5x upper limit of normal for age 
EXCLUSION CRITERIA SUMMARY 
Donor 
Has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor (for HAPNK1) available in the necessary time for HSC donation  
Malignancy   Other active malignancy other than one being treated 
Pre-
Evaluation 
Pregnant - Serum or Urine pregnancy within 14 days of enrollment 
Breast feeding 
Downs Syndrome 
Uncontrolled infection 
 
3.4 Enrollment on Study 
 
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1 – 3.3, complete and sign the ‘Participant Eligibility Checklist’.  The study 


HAPCORD 14 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
team will enter the eligibility checklist information into the Patient Protocol Manager 
(PPM) system.  Eligibility will be reviewed, and a research participant-specific consent 
form and assent document (where applicable) will be generated.  The complete signed 
consent/assent document form(s) must be faxed or emailed to the CPDMO at 595-6265 to 
complete the enrollment process. 
The CPDMO is staffed 7:30 am – 5:00 pm CST, Monday through Friday.  A staff 
member is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm.  Enrollments 
may be requested during weekends or holidays by calling the CPDMO “On Call” cell 
phone (901-413-8591) or referencing the “On Call Schedule” on the intranet. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 15 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
4.0 TREATMENT PLAN 
4.1 Schema for Protocol Prioritization 
Participant with high-risk hematologic malignancies undergoing HCT, who do not have a 
suitable HLA-matched MSD, MURD or KIR ligand mismatched haploidentical donor 
identified in time, will receive a combined haploidentical and UCBT using a RIC 
preparative regimen.  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES 
PATIENT NOT 
ELIGIBLE FOR 
HAPCORD 
 PATIENTS WITH HIGH-RISK 
MALIGNANCY ELIGIBLE FOR HCT 
HLA TYPING 
DONOR SEARCH 
NO 
MATCHED SIBLING  
OR 
MATCHED UNRELATED 
DONOR AVAILABLE IN TIME 
PATIENT ELIGIBLE FOR 
ALTERNATIVE DONOR HCT 
 
  KIR MISMATCHED HAPLOIDENTICAL 
DONOR AVAILABLE 
KIR TYPING  
UCB SEARCH 
YES 
ELIGIBLE 
FOR HAPNK1 
NO 
ELIGIBLE FOR 
HAPCORD 
 
POTENTIAL DOUBLE UCBT  
ON UCBT01 OR NPTP 
NO 
YES 
SINGLE UNIT UCB  
AND HAPLOIDENTICAL DONOR  
  
ELIGIBLE FOR HAPCORD 


HAPCORD 16 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
4.2 Reduced Intensity Preparative Regimen 
DAY MEDICATION 
DOSE 
DOSE # 
-9 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 2 fractions 
1-2 of 4 
-8 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
3 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
1 of 5 
-7 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
4 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
2 of 5 
-6 
Cyclophosphamide (with mesna) 
60 mg/kg intravenous once daily  
1 of 1 
Fludarabine 
30 mg/m2 intravenous once daily  
3 of 5 
-5 
Fludarabine 
30 mg/m2 intravenous once daily  
4 of 5 
-4 
Fludarabine 
30 mg/m2 intravenous once daily  
5 of 5 
-3 
Thiotepa 
5 mg/kg intravenous twice daily  
1-2 of 2 
-2 
Melphalan 
70 mg/m2 intravenous once daily 
1 of 2 
Tacrolimus 
Maintain until at least 6 months 
start 
-1 
Melphalan 
70 mg/m2 intravenous once daily  
2 of 2 
0 
HPC A Infusion  
CD34+ selected 
HPC A1 
MMF 
Maintain until at least 45 days 
start 
+1 
HPC A Infusion  
CD45RA depleted 
HPC A2 
+2 
HPC C Infusion 
 
HPC C 
+3 
G-CSF 
5mcg/kg subcutaneous or intravenous daily 
until ANC >2000 for 3 consecutive days 
4.2.1  TLI 
A total of 800 cGy of TLI will be administered in divided fractions given at a 
minimum of 6 hours apart.  Administration of 4 fractions at 200 cGy/fraction over 
three days on day -9 to -7 for a total of 800 cGy is recommended.   
*Timing of TLI administration can vary per the Radiation Oncologist. Testicular 
boosts should be used for all males with ALL with 200 cGy per fraction over two 
days.  
4.2.2 
Fludarabine  
Fludarabine at 30 mg/m2/day will be given over 30-60 minutes intravenous infusion 
on day -8 through day -4 for a total of 5 doses (150 mg/m2 total). Fludarabine dose 
may be reduced per PI if concerns of toxicity (ie CNS).  Infant dosing will apply to 
fludarabine as follows: patients less than or equal to 10kg will receive 1 mg/kg/day 
for scheduled doses. 
4.2.3  Cyclophosphamide with Mesna 
Cyclophosphamide at 60 mg/kg/day will be administered as a 2 hour intravenous 
infusion with a high volume fluid flush on day -6 for one dose (60mg/kg total).  For 
patients weighing more than 125% of their ideal body weight should have 
cyclophosphamide dose based on the adjusted ideal body weight.  


HAPCORD 17 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
Mesna is administered prior to cyclophosphamide and after the cyclophosphamide 
infusion per institutional practice. Mesna dose and administration schedule may 
vary based on physician recommendation. 
4.2.4 
Thiotepa 
Thiotepa will be given over 30-60 minutes intravenous infusion at 5 mg/kg twice a 
day on day -3 for a total of 2 doses (10mg/kg total). 
4.2.5  Melphalan 
Melphalan will be given over 30-60 minutes intravenous infusion at 70 mg/m2 once 
a day on day -2 and -1 for a total of 2 doses (140 mg/m2 total).  Infant dosing of 
melphalan will apply as follows: patients less than or equal to 10kg will receive 2.3 
mg/kg/day for scheduled doses. 
4.3 UCB Product  
 
 
 
 
 
 
 
 
 
 
 
 
4.3.1 UCB Selection: 
 
Choose the unit with highest HLA match (6/6, 5/6 then 4/6)  
- Matching at HLA typing at HLA-A, B antigen level and DRB1 allele 
level. 
- The patient and the UCB unit(s) must be matched at least 4 of 6 loci. 
- The unit must meet cell dose threshold of 1.0 x 107 TNC/kg 
 
If > one unit is available for a HLA match grade, chose unit based on: 
- DRB1: Matching at DR takes preference, followed by  
 SELECT OPTIMAL UNIT WITHIN SAME HLA MATCH   
DR typing takes preference 
Prefer homozygous over bidirectional mismatch 
Choose the largest TNC unit.  
If TNC is similar (± 0.5 x 107 TNC/kg) 
Utilize HLA C matching if available 
Utilize higher resolution molecular typing if available. 
Utilize CD34+ cell count if available. 
CHOOSE UNIT WITH HIGHEST HLA MATCH  
 Minimum of 4 of 6 matching to the patient at 
HLA-A Antigen 
HLA-B Antigen 
HLA-DR Allele 
UCB SELECTION 


HAPCORD 18 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
- Locus of mismatch: A unit that is homozygous at the locus of mismatch 
should be chosen over a unit that is bidirectional at the locus of mismatch, 
even if the latter unit is larger, followed by 
- Cell Dose: Choose the unit containing the greatest TNC. 
 If two units are of equivalent HLA match grade, DR1 matching, locus of 
mismatch and cell dose  (± 0.5 x 107 TNC/kg), choose the unit with: 
- HLA match by higher resolution molecular typing, if data available 
- HLA-C antigen/allele level typing, if data available 
- Larger CD34+ cell dose, if data available 
- UCB banks located in the United States are preferred.  
4.3.2  UCB Unit Exclusions  
4.3.2.1 Unit fails to meet cell dose threshold criteria  
Cell dose is < 1.0 x 107 TNC per kilogram recipient weight.  
4.3.2.2 Fails screening 
 
Any UCB units without full maternal testing and negative results for hepatitis 
A, B, C, Human Immunodeficiency Virus (HIV), and Human T-lymphotropic 
virus-1 (HTLV-1) viruses. Any additional available virology results on the unit 
itself will be reviewed but are not mandated, complete or always available. The 
majority of UCB units will come from banks that operate under the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Minimally Manipulated, 
Unrelated 
Allogeneic 
Placental/Umbilical 
Cord 
Blood 
Intended 
for 
Hematopoietic Reconstitution for Specified Indications.  All NMDP banks must 
fulfill this requirement.  Foreign banks may have differing screening procedures 
even if they are American Association of Blood Banks (AABB) or Foundation 
for the Accreditation of Cellular Therapy (FACT) accredited.  It is important to 
clarify the screening process employed, and additional plasma may be requested 
if additional testing is needed to fulfill Eligibility Determination requirements.  
Currently UCB units are available for use under federal IND.  The NMDP holds 
an IND for use, and a few of the older banks hold their own IND. There is no 
need to adjust for nucleated RBCs when considering TNC.  The UCB unit(s) 
must be present at St. Jude prior to the start of conditioning. 
4.3.3  UCB Graft Preparation 
Preparation for administration will take place in the Human Applications Lab 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) of St. Jude using established Standard Operating Procedure (SOP).  
UCB units must be prepared for infusion in a manner that assures high cell 
recovery, maintains cellular viability, and avoids contamination.  When unit 
volume and Dimethyl sulfoxide (DMSO) concentration are not considered 
clinically prohibitive, and the wash procedure is deemed by the PI to have a 
potential adverse impact on the UCB unit, a reconstitutive thawing procedure may 
be utilized.  In this case, the unit is thawed, and then reconstituted at least 1:1 with 
an infusion grade solution (Dextran/albumin).  In general, a wash is desired, 
particularly when there are concerns about volume, DMSO dose, red cell replete 


HAPCORD 19 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
product, etc.  For UCB products to be washed, a modified version of the New 
York Blood Center’s Placental Blood Thaw Procedure will be used.  Briefly, the 
unit will be thawed and diluted; the plasma will then be expressed away after 
gentle centrifugation.  In each case, 1-2 mL of the final product will be removed 
for testing prior to infusion. 
4.4 Haploidentical Donor Graft 
4.4.1  Haploidentical Donor Selection 
If more than one family member donor is acceptable, then donor selection will be 
based on the preference of the primary transplant attending.  Factors in selection 
will include donor-recipient matching of CMV serology, donor-recipient red 
blood cell compatibility, degree of HLA matching, size of the potential donor, 
previous use as a donor, presence of donor-specific antibody, and overall health of 
the potential donor. 
Donor eligibility for cell collection will be determined through the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Eligibility Determination 
for Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products 
(HCT/Ps).  Potential donors will undergo an initial screening process that will 
include at least a complete physical exam, history and testing for relevant 
communicable diseases.  Physical exams to evaluate donor candidacy will be 
conducted by a non-Department of BMTCT physician (St. Jude or non-St. Jude).  
For subsequent therapeutic cell collection procedures, if a complete screening 
procedure has been performed within the previous 6 months, an abbreviated donor 
screening procedure may be used for these repeat donations.  The abbreviated 
screening procedure must determine and document any changes in the donor’s 
medical history since the previous donation that would make the donor ineligible, 
including changes in relevant social behavior. 
If a donor is determined to be ineligible, the donor is not automatically excluded. 
Part 21 CFR 1271.65 (b)(1)(i) allows use of ineligible donors who are first or 
second degree blood relatives. In this situation, the physician will document the 
necessity of using the ineligible donor by providing a statement of "Urgent 
Medical Need" as explained in the 21 CFR 1271.3 (u).  The cell therapy products 
will be labeled as required in 21 CFR 1271.65 (b)(2). Recipients or their legal 
guardians will be informed of the use of an ineligible donor. 
Please see Departmental SOP 30.05 “Determination of Eligibility and Suitability 
for Stem Cell and Therapeutic Cell Allogeneic and Autologous Donors” for 
additional information. 
4.4.2  Haploidentical Donor Mobilization and Donor HSC Graft Collections  
A G-CSF mobilized peripheral blood stem cell (PBSC) product (identified as 
HPC, Apheresis) is the preferred progenitor cell graft source.  Our desired target 
goal will be 3-5 x 106 CD34+ cells/kg.  This number of cells will be necessary to 
provide an adequate graft, following the various ex vivo manipulations, for 
prompt reconstitution. Two days of collection are typically needed to achieve this 
goal.  However, on rare occasions, additional days may be necessary.  Donors will 


HAPCORD 20 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
undergo a standard HSC mobilization regimen consisting of 6 days of G-CSF 
given subcutaneously at 10 mcg/kg. The graft will be collected by leukapheresis 
on days 5 and 6.  The HPC, Apheresis product will typically be collected and 
infused fresh, however there may be patients or logistical situations that require 
the HPC, Apheresis product to be collected early, processed, and stored frozen. 
The decision to use a fresh versus frozen HPC, Apheresis will be made by the PI 
and/or primary transplant attending based on patient and donor factors, as well as 
potential scheduling conflicts.  
MOBILIZATION TIME LINE 
DAYS 
MEDICATION 
APHERESIS 
Day -5 
G-CSF 10 mcg/kg/day SC*  
1 of 6 
 
Day -4 
G-CSF 10 mcg/kg/day SC* 
2 of 6 
 
Day -3 
G-CSF 10 mcg/kg/day SC* 
3 of 6 
 
Day -2 
G-CSF 10 mcg/kg/day SC* 
4 of 6 
 
Day -1 
G-CSF 10 mcg/kg/day SC* 
5 of 6 
Apheresis for HSC graft** 
Day 0 
G-CSF 10 mcg/kg/day SC* 
6 of 6 
Apheresis for HSC graft** 
* G-CSF may may be reduced if the donor’s WBC is >75.0 x 106/  
**Do not start apheresis if platelet count < 50,000/mm3 or hemoglobin of < 12.5 g/dL pre-phresis 
 
The dose of G-CSF may require modification based on the complete blood counts 
(CBC).  If the donor’s white blood count (WBC) is >75.0 x 106/ml the dose of 
cytokine administered will be reduced.  The guidelines for dose modification can 
be found in the St. Jude Children's Research Hospital Department of BMT and 
CT SOP 30.06.00 “The practice for the evaluation, preparation and care of 
allogeneic and autologous donors mobilized with growth factor.” Ongoing 
updates of this document can be located at the following St. Jude intranet website: 
http://home.web.stjude.org/bone_marrow/ 
The daily leukapheresed volumes for HPC, Apheresis collection is generally 3–4 
total blood volumes based on CD34+ cell counts.  Two additional days of 
leukapheresis may be performed at the physician’s discretion (no more than 4 
total) to reach the cell dose target, however, this is expected to be rare.   
Leukapheresis may be terminated early upon request of donor, or when deemed 
medically necessary per the judgment of the treating sub-investigator physician or 
PI.  All HPC, Apheresis products will be collected as per FACT guidelines. 
Donors will be monitored during the period of the mobilization and leukapheresis 
procedure with appropriate laboratory evaluation (Appendix D). 
If we are unable to collect the minimum dose of 2 x 106 CD34+ cells/kg of 
recipient weight from the first donor, and the recipient has not yet initiated the 
preparative regimen, then an alternative family member may be used if he/she 
fulfills all donor criteria described in section. If the donor is unwilling or unable 
to complete the mobilization process or leukapheresis procedure, a BM product 
may be used.  The BM product will be processed using the same cell selection 
methodology on the CliniMACS device.   
 


HAPCORD 21 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
4.5 Graft Preparation 
Graft evaluation and preparation will take place in the Human Applications Laboratory 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) using established SOP.  
The initial HPC, Apheresis product(s) will be TCD using the investigational CliniMACS 
device and CD34 Microbead reagent as directed by the manufacturer (Miltenyi Biotech).  
See section 5.2 for additional CliniMACS device information.  Briefly, HPC, Apheresis 
products from the mobilized donor will be initially assessed in the HAL and stored 
overnight at 4oC.  The next morning, the product will be washed to remove platelets and 
adjusted to an appropriate cell concentration for incubation with the CliniMACS CD34 
Microbead reagent in the manufacturer provided media.  The cells will be washed to 
remove unbound microbeads.  These cells will be applied to the CliniMACS device and 
the enrichment will be performed using the program “CD34 Enrichment 2.1” as 
described by the manufacturer. 
After enrichment is complete, the cells will be washed and resuspended in an infusion 
grade solution. The graft product will be enumerated and assessed for viable CD34+ cell 
and CD3+ T cell content by flow cytometry. The processed HPC, Aphersis CD34 
Enriched product will be infused fresh or frozen for future use after completion of release 
testing and evaluation. Cryopreservation will be performed per SOPs of the HAL.  Target 
cell doses are listed in the following table: 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
≥ 2 x 106 
2 x 106 
50 x 106 
CD3+ cells/kg 
≤ 0.5 x 105 
1 x 103 
1 x 105 
Once the target dose is obtained for the CD34+ enriched product, one additional day of 
apheresis will be performed.  This HPC, Apheresis product will be processed for 
CD45RA+ depletion using the investigational CliniMACS device as directed by the 
manufacturer (Miltenyi Biotech). See section 5.1 for additional CliniMACS device 
information.  Briefly, HPC, Apheresis products from the mobilized donor will be initially 
assessed in the HAL and stored overnight at 4oC.  The next morning, the product will be 
washed to remove platelets and adjusted to an appropriate cell concentration for 
incubation with the CliniMACS CD45RA Microbead reagent in the manufacturer 
provided media.  The cells will be washed to remove unbound microbeads. These cells 
will be applied to the CliniMACS device and the depletion will be performed using the 
"Depletion 3.1" software as described by the manufacturer.  When combined with the 
CD34+ enriched product, the target CD34+ dose will be 3-5 x 106/kg.  There is no CD3+ 
cell target dosing on the CD45RA+ depleted product, however release criteria of the 
product will include at least a ≥ 2.00 log10 depletion of CD45RA+ cells. 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
3-5 x 106 
2 x 106 
50 x 106 
CD45RA+ 
≥ 2.0 log10 depletion (CD45RA+ depleted graft only) 
 


HAPCORD 22 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
4.6 Additional Progenitor Cell Graft Administration 
Infusion of an additional HSC graft from the original or an alternative haploidentical donor 
may be performed for participants when clinically indicated for graft failure, poor immune 
reconstitution, or poor hematopoietic recovery. The use of and content of a conditioning 
regimen is left to the discretion of the PI and/or primary transplant attending such that the 
most appropriate therapy is chosen for the clinical situation. 
The HSC graft will typically be obtained by apheresis (HPC, Apheresis) and be infused 
fresh.  The target dose for this additional CD 34+ infusion is ≥5 x 106 cells/kg.  If the 
participant has quiescent or active BOOP, acute Grade III-IV GVHD, or any other reason 
that a severely T-cell depleted graft may be indicated, then a graft from the donor processed 
on the CliniMACSTM device using either CD34+ selection (using established SOPs) or CD3+ 
depletion methodology may be utilized. The boost target dose for these patients is ≥10 x 
106 CD34+cells/kg with a CD3+ cell/kg dose of ≤ 0.5 x 105 CD3+ cells/kg.   
4.7 Donor Lymphocyte Infusions 
Donor lymphocyte infusions (DLI) may be administered from the haploidentical donor 
for decreasing donor chimerism, serious viral reactivation or infection, or any evidence of 
disease (from any level of MRD to frank relapse).  The DLI collected may be collected as 
a whole blood unit donation or by leukapheresis. If the DLI is collected by standard 
phlebotomy, the volume to be collected would be approximately 300 ml whole blood.  If 
the DLI is collected by leukapheresis, the amount to be processed would be 
approximately 2 total blood volumes. 
Prior to administration of DLI, the immunosuppression should be withdrawn and the 
recipient should have no active GVHD.  The initial dose will typically be 2.5 x 104 
CD3+/kg.  Subsequent doses will be administered at approximately 2 to 4-week intervals 
with escalating doses of T cells if no moderate or severe GVHD occurs with the prior 
DLIs.  The typical initial dose escalation for patients on this protocol is presented in the 
following table: 
DLI DOSE AND SCHEDULE 
DLI 
Dose 
Comments 
Initial Dose 
2.5 x 104 CD3+/kg 
Approximately 2-4 week interval 
If no moderate or severe GVHD 
Dose #2 
5.0 x 104 CD3+/kg 
Dose #3 
10.0 x 104 CD3+/kg 
Although this algorithm will be appropriate for a majority, the treating transplant 
attending physician may alter the dose and/or interval of DLI based on response to 
previous DLI, the severity of the clinical situation, and the condition of the patient.  There 
is a low threshold for providing an initial dose of 2.5 x 104 CD3+/kg.  DLI at this dose 
level have not been associated with GVHD.  Therefore, DLI may be initiated for any 
chimerism less than 100% in a patient who is off immune suppression.  The risk of 
GvHD increases with increasing doses.  In the last 5 years, no patient has developed 
moderate or severe GVHD after haploidentical DLI dosed at 5 x 104 CD3+/kg, though 
mild GVHD has occasionally occurred.  Doses of 10 x 104 CD3+/kg should be considered 
to carry a risk of severe GVHD.  Therefore dose escalation to this level must incorporate 
the appropriate risk/benefit analysis by the treating transplant physician. 


HAPCORD 23 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
4.8 Quality Assurance of Cellular Products 
Quality assurance for cell products is overseen by independent Quality Assurance 
personnel who authorizes release of all products. Only trained stem cell processors will 
process the cell products. A labeling and product tracking system is in place to ensure 
that the correct cells are infused into the research participant. 
Assays of cell numbers and immunophenotyping will be performed both before cell 
processing and at critical stages of the process.  These values will be recorded according 
to SOP of the HAL.  All TCD products will be tested for viability, sterility (culture and 
Gram stain), and the presence of endotoxin. Culture and endotoxin results are not 
available before infusion of cell products. If the gram stain is positive, the research 
participant/parent and/or guardian will be informed of this event and of the risks of 
proceeding prior to infusion.  Positive results will be investigated as per the variance 
procedures of the HAL.  The IRB and FDA will be notified, if at any time after infusion, 
cell product was determined to be contaminated or endotoxin results exceed release 
limits.  
4.9  Immunosuppressive Therapies  
4.9.1  EBV post-transplant lymphoproliferative disease (PTLPD) prophylaxis  
Rituximab at 375 mg/m2 may be given intravenously as clinically indicated.  For all 
patients, monitoring peripheral blood EBV DNA and prophylaxis and treatment 
will be according to BMTCT standard guides and/or at the discretion of the 
treating physician as clinically indicated based on ongoing EBV copy levels and 
clinical assessment. If a positive selection methodology would be used for a 
haploidentical HCT infusion, rituximab would not be administered, unless 
otherwise clinically indicated. 
4.9.2  Tacrolimus  
Tacrolimus to start on day -2. Preferably, start tacrolimus as a continuous infusion 
until patient engrafts and able to reliably obtain therapeutic levels.   Maintain 
therapeutic levels according to institutional guidelines and practice.  May modify 
dose for decreased chimerism or positive MRD.  May convert to oral dosing when 
patient is tolerating oral and has a normal gastro-intestinal transit time.  If no 
evidence of GVHD, begin to wean by approximately 10% every week on day 100, 
and discontinue around day 180 and no sooner than 6 months post transplant.   
4.9.3  MMF 
MMF to start on day 0 at 15mg/kg intravenously TID or every 8 hours. May convert 
to oral dosing when patient is tolerating oral and has a normal gastro-intestinal 
transit time.  Adjust dose as clinically indicated. If no evidence of GVHD, MMF can 
be discontinued on day +45 or on/about 7 days after engraftment, whichever is later.  
May hold for decreased chimerism or positive MRD. Continue MMF if patient has 
no evidence of donor engraftment on bone marrow evaluation and contact PI of 
results.  
4.9.4  Methylprednisolone* 
Methylprednisolone may be used for treatment of acute GVHD*.  (2mg/kg divided 
every 12 hours intravenously is suggested as initial therapy for patient with active 


HAPCORD 24 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
acute GVHD requiring systemic therapy)  If no response after 7 days, treat with a 
second line agent according to SOP.  Methylprednisolone at 1-5 mg/kg/day can be 
used for management of pre-engraftment immune reaction as described below in 
4.10* 
*Use of methylprednisolone and dosing are recommendations and variance in 
medication, dosing and frequency can occur due to the participant’s current 
clinical condition and will not be noted as protocol deviations. 
4.10 Management of Pre-engraftment Immune Reaction 
A well recognized clinical entity consisting of skin rash, fever, loose stools and 
respiratory distress has been noted to occur prior to engraftment among UCB patients, 
generally between day 7 and 21. This clinical syndrome likely involves cytokine 
activation, and though clinically similar to acute or hyperacute GVHD, it appears to be a 
distinct entity, “pre-engraftment syndrome.” This syndrome is often controlled with brief 
steroid bursts, thus avoiding a commitment to extended steroid exposure.  Patients should 
be monitored carefully for this syndrome. If patients have moderate to severe symptoms 
as described above and alternative etiologies (i.e., infection) have been excluded or are 
being appropriately evaluated, patients may be treated with steroids. Recommendation of 
methylprednisolone is provided.  
The usage of methylprednisolone described here is a recommendation, and variations in 
medication, dosing and/or frequency can occur due to the participant’s current clinical 
condition and will not be noted as protocol deviations. 
4.10.1  For 
patients 
not 
on 
steroid 
therapy 
when 
the 
syndrome 
occurs: 
methylprednisolone should be given at 1 mg/kg intravenously once a day for three 
days. If symptoms have abated, steroids should be stopped. If symptoms persist, 1 
mg/kg can be continued through six days then stopped if symptoms have abated. 
If symptoms persist for more than six days, the patient should be considered to 
have acute/hyperacute GVHD and should be treated with prolonged steroids as 
deemed appropriate. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
4.10.2 For patients already on steroids for other reasons when the syndrome occurs: 
methylprednisolone should be given at a dose of 3-5 mg/kg intravenously (max 
dose 500 mg) every 12 hours for maximum of 48 hours, followed by a rapid taper 
to 1 mg/kg intravenously every 12 hours. Patients should be weaned after 
response as tolerated. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
4.11 Growth Factors 
4.11.1  Granulocyte colony-stimulating factor (G-CSF) 
G-CSF may start on day +3 at 5 mcg/kg/day intravenously or subcutaneously until 
absolute neutrophil count (ANC) ≥ 2,000/mm3 for three consecutive days.  G-CSF 
may be held at the discretion of the attending physician 
4.12 Treatment and Conditioning Regimen Related Notes  
The HSC infusion may be delayed by approximately 24 hours in order to accommodate 
HAL as well as the research participant clinical condition. 


HAPCORD 25 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
The term “every” used in tables is an approximate term meaning that these medications 
noted will be administered approximately “every” 12 hours (or 8 hours as applicable).  
The drug administration timing in these cases may be modified as clinically indicated 
such as in the case of surgical procedures or to accommodate other necessary medication, 
blood product delivery, or procedures. The term “day” does not refer to an absolute 
calendar day.  It refers to a general 24-hour period. 
Dosing for all protocol treatment medications may be modified for research recipients 
based upon actual body weight or adjusted ideal body weight and/or for infants weighing 
less than 10kg, when clinically indicated. Mesna will be administered for prevention of 
hemorrhagic cystitis from the medication cyclophosphamide.   
Criteria for medication calculations based on body weight/body surface area and other 
medication related information can be found in the St. Jude Formulary 
(http://www.crlonline.com/crlsql/servlet/crlonline) or the St. Jude Department of 
Pharmaceutical 
Sciences 
intranet 
website 
http://home.web.stjude.org/ 
pharmaceutical_ser/drugInfo.shtml.  Medication doses may be rounded to the nearest 
integer or to the nearest appropriate quantity when clinically or pharmaceutically 
indicated as per the MD and PharmD. 
5.0 MEDICATION INFORMATION 
5.1 Cyclophosphamide (Cytoxan) 
Source 
& 
Pharmacology  
Cyclophosphamide is a nitrogen mustard derivative.  It acts as an alkylating 
agent that causes cross-linking of DNA strands by binding with nucleic acids 
and other intracellular structures, thus interfering with the normal function of 
DNA. It is cell cycle, phase non-specific. Cyclophosphamide is well 
absorbed from the GI tract with a bioavailability of >75%.  It is a prodrug 
that requires activation. It is metabolized by mixed function oxidases in the 
liver to 4-hydroxycyclo-phosphamide, which is in equilibrium with 
aldophosfamide. Aldofosfamide spontaneously splits into nitrogen mustard, 
which is considered to be the major active metabolite, and acrolein. In 
addition, 4-hydroxycy-clophosphamide may be enzymatically metabolized to 
4-ketocyclophosphamide and aldophosfamide may be enzymatically 
metabolized to carboxyphosphamide that is generally considered inactive.  
Cyclophosphamide and its metabolites are excreted mainly in the urine. Dose 
adjustments should be made in patients with a creatinine clearance of <50 
ml/min. 
Formulation 
and Stability  
Cyclophosphamide is available in vials containing 100, 200, 500, 1000 and 
2000mg of lyophilized drug and 75 mg mannitol per 100 mg of 
cyclophosphamide.  Both forms of the drug can be stored at room 
temperature. The vials are reconstituted with 5, 10, 25, 50 or 100 ml of 
sterile water for injection, respectively, to yield a final concentration of 20 
mg/ml.  Reconstituted solutions may be further diluted in either 5% dextrose 
or 0.9% NaCl containing solutions.  Diluted solutions are physically stable 
for 24 hours at room temperature and 6 days if refrigerated, but contain no 
preservative, so it is recommended that they be used within 24 hours of 
preparation. 
Supplier 
Commercially available 


HAPCORD 26 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
Toxicities 
Dose limiting toxicities of cyclophosphamide includes BM suppression and 
cardiac toxicity.  Cardiac toxicity is typically manifested as congestive heart 
failure, cardiac necrosis or hemorrhagic myocarditis and can be fatal.  
Hemorrhagic cystitis may occur and necessitates withholding therapy. The 
incidence of hemorrhagic cystitis is related to cyclophosphamide dose and 
duration of therapy. Forced fluid intake and/or the administration of mesna 
decreases the incidence and severity of hemorrhagic cystitis.  Other toxicities 
reported commonly include nausea and vomiting (may be mild to severe 
depending on dosage), diarrhea, anorexia, alopecia, immunosuppression and 
sterility.  Pulmonary fibrosis, SIADH, anaphylaxis and secondary neoplasms 
have been reported rarely.    
Route  
Intravenous infusion  
5.2. Thiotepa (Thioplex by Immunex) (TESPA, TSPA) 
Source 
& 
Pharmacology  
Thiotepa is a cell-cycle nonspecific polyfunctional alkylating agent.  It 
reacts with DNA phosphate groups to produce cross-linking of DNA strands 
leading to inhibition of DNA, RNA and protein synthesis.  Thiotepa is 
extensively metabolized in the liver to metabolites that retain activity, 
primarily triethylene-phosphoramide (TEPA).  The main route of 
elimination is via the urine, mainly as metabolites; the elimination half-life 
of the thiotepa is 2.5 hours, and that of TEPA is 17.6 hours. 
Formulation 
and Stability 
Thiotepa is supplied in single-use vials containing 15 mg of lyophilized 
thiotepa, 80 mg NaCl and 50 mg NaHCO3.  The intact vials should be 
stored under refrigeration and protected from light.  Each vial should be 
reconstituted with 1.5 ml of sterile water for injection to yield a 
concentration of 10 mg/ml.  Further dilution with sterile water for injection 
to a concentration of 1 mg/ml yields an isotonic solution; if larger volumes 
are desired for intracavitary, intravenous infusion, or perfusion therapy, this 
solution may then be diluted with 5% dextrose or 0.9% NaCl containing 
solutions.  The 10 mg/ml reconstituted solution is chemically stable when 
stored in the refrigerator for up to 5 days, however, it is recommended that 
solutions be prepared just prior to administration since they do not contain a 
preservative.  Reconstituted solutions should be clear to slightly opaque: the 
solutions may be filtered through a 0.22 micron filter to eliminate haze. 
Supplier 
Commercially available; manufactured by Immunex. 
Toxicities 
Dose limiting toxicity is myelosuppression.  The leukocyte nadir may occur 
at any time from 10 to >30 days.  Other toxicities include pain at the 
injection site, nausea and vomiting, anorexia, mucositis, dizziness, headache, 
amenorrhea, interference with spermatogenesis, and depigmentation with 
topical use.  Allergic reactions, including skin rash and hives, have been 
reported rarely.  Rare cases of apnea, hemorrhagic cystitis, and renal failure 
have occurred.  Thiotepa is mutagenic, carcinogenic, and teratogenic in 
animals.  Pregnancy category D. 
Route    
Intravenous 
 


HAPCORD 27 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
5.3 Fludarabine (Fludara) 
Source 
& 
Pharmacology  
Fludarabine phosphate is a synthetic purine nucleoside analog and acts by 
inhibiting DNA polymerase, ribonucleotide reductase and DNA primase by 
competing with the physiologic substrate, deoxyadenosine triphosphate, 
resulting in inhibition of DNA synthesis. It can also be incorporated into 
growing DNA chains as a false base and interfere with chain elongation and 
halt DNA synthesis. Fludarabine is rapidly dephosphorylated in the blood 
and transported intracellularly by a carrier-mediated process. It is then 
phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate form.  ~23% of the dose is excreted as the active metabolite in 
the urine (with dosages of 18-25 mg/m2/day for 5 days).  Renal clearance 
appears to become more important at higher doses, with approximately 41-
60% of the dose being excreted as the active metabolite in the urine with 
dosages of 80-260 mg/m2. 
Formulation 
and Stability 
Fludarabine is supplied in single-dose vials containing 50 mg fludarabine as 
a white lyophilized powder and 50 mg of mannitol.  The intact vials should 
be stored under refrigeration.  Each vial can be reconstituted by adding 2 ml 
of sterile water for injection resulting in a final concentration of 25 mg/ml. 
Because the reconstituted solution contains no antimicrobial preservative, the 
manufacturer recommends that it should be used within 8 hours of 
preparation.  The solution should be further diluted in 5% dextrose or 0.9% 
NaCl prior to administration. 
Supplier 
Commercially available. 
Toxicities 
The major dose-limiting toxicity of fludarabine is myelosuppression.  Nausea 
and vomiting are usually mild.  Side effects reported commonly include 
anorexia, fever and chills, alopecia and rash.  Neurotoxicity can be 
manifested by somnolence, fatigue, peripheral neuropathy, mental status 
changes, cortical blindness and coma and is more common at high doses.  
Neurotoxicity is usually delayed, occurring 21-60 days after the completion 
of a course of therapy and may be irreversible.  Side effects reported less 
commonly include diarrhea, stomatitis, increased liver function tests, liver 
failure, chest pain, arrhythmias and seizures.  Pulmonary toxicity includes 
allergic pneumonitis characterized by cough, dyspnea, hypoxia and 
pulmonary infiltrates.  Drug induced pneumonitis is a delayed effect, 
occurring 3-28 days after the administration of the third or later course of 
therapy.  Administration of corticosteroids usually results in resolution of 
these symptoms. 
Route    
Intravenous 
 
5.4 Melphalan (L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin, 
Alkeranâ) 
Source 
& 
Pharmacology  
Melphalan, a derivative of nitrogen mustard, is a bifunctional alkylating 
agent.  Its chemical name is 4-[bis(2-chloroethyl)amino]-L-phenylalanine, 
and it has a molecular weight of 305.20.  Melphalan is active against tumor 
cells that are actively dividing or at rest.  Its cytotoxicity is thought to be due 
to inter-strand cross-linking with DNA, probably by binding at the N7 


HAPCORD 28 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
position of guanine.  Melphalan is highly protein bound and does not 
penetrate well into the cerebral spinal fluid. Elimination half-life after 
intravenous administration in adults is approximately 75 minutes. 
Elimination appears to be primarily by chemical hydrolysis, but caution 
should be used in patients with renal impairment.  Plasma concentrations of 
melphalan after oral administration are highly variable, possibly due to 
incomplete absorption, variable “first pass” hepatic metabolism or rapid 
hydrolysis. Area under the plasma concentration-time curves for orally 
administered melphalan is approximately 60% of intravenously administered 
melphalan in adult studies.  
Formulation 
and Stability  
Available as 2 mg tablets for oral administration. This medication is stable at 
room temperature until expiration date on the packaging.  Intravenous 
formulation is supplied as 50 mg freeze dried glass vial. Each 50 mg vial is 
supplied in a carton containing a 10 ml vial of sterile diluent. Lyophilized 
melphalan should be stored at controlled room temperature and protected 
from light. Each vial is marked with its expiration date. The melphalan for 
injection must be reconstituted immediately prior to infusion by rapidly 
adding the contents of the diluent vial (10 ml) to the freeze dried powder 
with a 20 gauge or larger sterile needle and immediately shaking vigorously 
until a clear solution is obtained.  This results in a 5 mg/ml solution.  The 
dose should then be diluted in 0.9% sodium chloride for injection to a final 
concentration of not greater than 0.45 mg/ml. The resulting admixture should 
be infused over a minimum of 15 minutes.  The infusion should be 
completed within 60 minutes of reconstitution.  Do Not Refrigerate the 
Reconstituted Melphalan.  
Supplier 
Commercially available 
Toxicities 
Melphalan is cytotoxic and caution should be used in handling and preparing 
the solution or administering the tablets. Use of gloves is recommended, and 
if contact with skin or mucosa occurs, immediately wash thoroughly. Second 
cancers such as acute non-lymphocytic leukemia, myeloproliferative 
syndrome, and carcinoma have been reported in patients taking melphalan 
alone or in combination with other chemotherapy or radiation. Melphalan 
causes suppression of ovarian function in premenopausal women, with a 
significant number of patients having amenorrhea. Testicular suppression 
(reversible and irreversible) has been reported.  The most common adverse 
reaction is myelosuppression. Irreversible bone marrow failure has been 
reported. Gastrointestinal side effects reported include nausea/vomiting, 
diarrhea and oral mucosa ulceration.  Hepatic toxicity has occurred, 
including veno-occlusive disease.  Acute hypersensitivity reactions occur in 
about 2.4% of patients, and can include anaphylaxis. Hypersensitivity 
reactions were characterized by urticaria, pruritus, and edema.  Some 
patients exhibited tachycardia, bronchospasm, dyspnea and hypotension that 
responded to antihistamines and corticosteroids. Other side effects that have 
been reported include skin ulceration or necrosis at injection site, vasculitis, 
alopecia, hemolytic anemia, pulmonary fibrosis, and interstitial pneumonitis. 


HAPCORD 29 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
Route  
Intravenous infusion  
 
5.5 Mesna (Mesnex) 
Source 
& 
Pharmacology  
Mesna is a synthetic sulfhydryl (thiol) compound. Mesna contains free 
sulfhydryl groups that interact chemically with urotoxic metabolites of 
oxaza-phosphorine derivatives such as cyclophosphamide and ifosfamide. 
Oral bioavailability is 50%. Upon injection into the blood, mesna is oxidized 
to mesna disulfide, a totally inert compound.  Following glomerular 
filtration, mesna disulfide is rapidly reduced in the renal tubules back to 
mesna, the active form of the drug.  Mesna and mesna disulfide are excreted 
primarily via the urine. 
Formulation 
and Stability 
Mesna is available in 2 ml, 4 ml and 100 ml amps containing 100 mg/ml of 
mesna solution.  The intact vials can be stored at room temperature.  Mesna 
may be further diluted in 5% dextrose or 0.9% NaCl containing solutions.  
Diluted solutions are physically and chemically stable for at least 24 hours 
under refrigeration.   
Supplier 
Commercially available 
Toxicities 
Mesna is generally well tolerated.  Nausea and vomiting, headache, diarrhea, 
rash, transient hypotension and allergic reactions have been reported.  
Patients may complain of a bitter taste in their mouth during administration. 
Mesna may cause false positive urine dipstick readings for ketones.   
Dosage 
and 
Administration 
Mesna is generally dosed at approximately 25% of the cyclophosphamide 
dose.  It is generally given intravenously prior to and again at 3, 6 and 9 
hours following each dose of cyclophosphamide. 
Route 
Intravenous 
 
5.6 G-CSF (Filgrastim, Neupogen)  
Source 
& 
Pharmacology 
G-CSF is a biosynthetic hematopoietic agent that is made using recombinant 
DNA technology in cultures of Escherichia coli. G-CSF stimulates 
production, maturation and activation of neutrophils. In addition, 
endogenous G-CSF enhances certain functions of mature neutrophils, 
including phagocytosis, chemotaxis and antibody--dependent cellular 
cytotoxicity. 
Formulation 
and Stability 
G-CSF is supplied in vials containing 300 and 480 mcg of G-CSF at a 
concentration of 300mcg/ml. The intact vials should be stored under 
refrigeration.  The vials can be left out of refrigeration for 24 hours, but 
should be discarded if left at room temperature for longer periods of time.  
G-CSF can be drawn up into tuberculin syringes for administration and 
stored under refrigeration for up to 7 days prior to usage.  G-CSF can be 
further diluted for intravenous infusion in 5% dextrose.  Do not dilute in 
saline---precipitate may form. If the final concentration of this product is <15 
mcg/ml, it is recommended that albumin be added to a final concentration of 
2mg/ml (0.2%) to minimize adsorption of the drug to infusion containers and 
equipment.   
Supplier 
Commercially available. 


HAPCORD 30 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
Toxicities 
G-CSF causes marked leukocytosis.  Common adverse reactions include 
bone pain, thrombocytopenia, diarrhea, nausea, rash, alopecia, fever, 
anorexia and pain or bruising at the injection site.  Allergic reactions, MI, 
atrial fibrillation, and splenomegaly have been reported rarely. G-CSF is 
contraindicated in participants with allergy to E. coli derived products. 
Route 
Intravenous or subcutaneous. 
 
5.7  Mycophenolate mofetil (MMF, CellCept) 
Source 
& 
Pharmacology  
MMF is hydrolyzed to mycophenolic acid (MPA), an immunosuppressive 
agent. MPA inhibits B and T-cell proliferation, T-cell synthesis, and 
antibody secretion by potent, noncompetitive reversible inhibition of inosine 
monophosphate dehydrogenase (IMPDH) in the purine biosynthesis 
pathway. Inhibition of IMPDH results in a depletion of guanosine 
triphosphate and deoxyguanosine triphosphate, important intermediates in 
the synthesis of lymphocyte DNA, RNA, proteins and glycoproteins. Oral 
formulations of MMF are rapidly and extensively absorbed when given on an 
empty stomach.  Aluminum and magnesium-containing antacids and food 
decrease absorption of MMF.  MMF is rapidly hydrolyzed to the active 
metabolite (MPA) after oral or intravenous administration.  Free MPA is 
conjugated in the liver by glucuronyl transferase to inactive mycophenolic 
acid glucuronide (MPAG) that is excreted in the urine and feces.  Time to 
peak plasma concentration is 0.8–1.3 hours, and the mean elimination half-
life is 17.9 hours. Enterohepatic recirculation of MPA contributes to plasma 
concentrations. Administration of cholestyramine interrupts the enterohepatic 
recirculation and can decrease bioavailability by as much as 40%.  Patients 
with renal insufficiency have increased plasma concentrations of MPA and 
MPAG. Acyclovir and ganciclovir may compete with MPAG for renal 
tubular secretion, resulting in increased plasma concentrations of both drugs.  
Formulation 
and Stability 
MMF is commercially available as 250 mg capsules, 500 mg tablets, 200 
mg/ml powder for oral suspension, and 500 mg vials of powder for injection.  
Supplier 
Hoffmann La Roche, Inc.    
Toxicities  
AE seen in patients taking MMF include hypertension, hypotension, 
peripheral edema, leukopenia, anemia, thrombocytopenia, hypochromic 
anemia, leukocytosis, headache, insomnia, dizziness, tremor, anxiety, 
paresthesia, hyperglycemia, hypercholesterolemia, hypokalemia, diarrhea, 
hyperkalemia, hypophosphatemia, constipation, nausea, vomiting, anorexia, 
abdominal pain, dyspepsia, urinary burning or frequency, renal tubular 
necrosis, hematuria, increase serum creatinine and BUN, a variety of 
infections due to immunosuppression, rash, acne, ocular changes (cataracts, 
blepharitis, keratitis, glaucoma, and macular abnormalities) occasional leg 
cramps or pain, bone pain, myalgias, and hand cramps.  Intravenous 
infusions have been reported to cause thrombosis and phlebitis. There have 
been occasional reports of gastrointestinal hemorrhage.  High dose therapy 
with mycophenolate in adults with psoriasis has been associated with the 
following neoplasms: adenocarcinoma of the breast and colon, basal cell 


HAPCORD 31 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
carcinoma, carcinoma of the gallbladder, histiocytic lymphoma, glioblastoma 
multiforme, and squamous cell carcinoma of the epiglottis.   
Route  
Oral or intravenous 
 
5.8  Tacrolimus (FK506, Prograf®, Protopic®) 
Source 
& 
Pharmacology  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyce 
tsukubaensis. It inhibits T-lymphocyte activation, although the exact 
mechanism of action is not known. Tacrolimus activity is primarily due to 
the parent drug.  The plasma protein binding of tacrolimus is approximately 
99% and is independent of concentration over a range of 5-50 ng/mL.  The 
t½ in adult patients ranges from 11-19 hours.  Whole blood trough 
concentrations from 31 patients less than 12 years old showed that pediatric 
patients needed higher doses than adults to achieve similar tacrolimus trough 
concentrations.  It is extensively metabolized by the mixed-function oxidase 
system, primarily the cytochrome P-450 system (CYP3A) in the liver and to 
a lesser extent in the intestinal mucosa.  The main route of elimination is via 
the biliary tract and excretion in feces.  A retrospective comparison of Black 
and Caucasian kidney transplant patients indicated that Black patients 
required higher tacrolimus doses to attain similar trough concentrations; 
there were no gender-based differences.  The absorption of tacrolimus from 
the gastrointestinal tract is incomplete and variable exhibiting large intra- and 
inter-patient variability. Administration with food significantly decreases the 
rate and extent of absorption. Drugs that stimulate or inhibit hepatic p-450 
enzymes will alter clearance of tacrolimus and close attention to potential 
drug interactions is crucial. 
Formulation 
and Stability 
Intravenous formulation: Tacrolimus is available as a sterile solution 
(tacrolimus injection) containing the equivalent of 5 mg anhydrous 
tacrolimus in 1 mL Each mL contains polyoxyl 60 hydrogenated castor oil 
(HCO-60), 200 mg, and dehydrated alcohol, USP, 80% v/v. Store between 
5°C and 25°C (41°F and 77°F). Oral formulations: It is available for oral 
administration as capsules containing the equivalent of 0.5 mg, 1 mg or 5 mg 
of anhydrous tacrolimus. Inactive ingredients include lactose, hydroxypropyl 
methylcellulose, croscarmellose sodium, and magnesium stearate. The 0.5 
mg capsule shell contains gelatin, titanium dioxide and ferric oxide, the 1 mg 
capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule 
shell contains gelatin, titanium dioxide and ferric oxide. Store at 25°C 
(77°F); excursions permitted to 15°-30°C (59°-86°F). 
Supplier 
Commercially available    
Toxicities  
Immunosuppression results in increased susceptibility to infection and 
possible development of lymphoma and other malignancies, particularly of 
the skin.  After intravenous administration, monitor closely for an acute 
allergic reaction for the first 30 minutes and at frequent intervals thereafter.  
Fetal toxicity has been noted in animals.  Common adverse effects are 
headache, hypertension, GI toxicities, fever, immunosuppression, tremor, 
renal dysfunction, hematological abnormalities, CNS abnormalities, 


HAPCORD 32 
 
Initial version, dated: 08/22/14 
 
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Protocol document date: 08/22/14 
 
electrolyte abnormalities, clotting abnormalities, alopecia.  Late effects can 
include skin disorders, delayed wound healing, and hirsutism.   Insulin-
dependent post-transplant diabetes mellitus (PTDM) was reported in 11-22% 
of tacrolimus treated transplant patients without pretransplant history of 
diabetes mellitus, several human studies. Mild to severe hyperkalemia is 
reported in 8-45% of transplant patients receiving tacrolimus, so serum 
potassium levels should be monitored and potassium-sparing diuretics should 
not be used. To avoid excess nephrotoxicity, tacrolimus should not be used 
simultaneously with cyclosporine or other drugs that may be associated with 
renal dysfunction.  Tacrolimus or cyclosporine should be discontinued at 
least 24 hours prior to initiating the other. In the presence of elevated 
tacrolimus or cyclosporine concentrations, dosing with the other drug usually 
should be further delayed.  It is not recommended that sirolimus and 
tacrolimus be given concomitantly, as serious increases in wound healing 
complications, renal function impairment and insulin-dependent post-
transplant diabetes mellitus have been observed.  Drugs that stimulate or 
inhibit p-450 enzymes will alter clearance of tacrolimus and close attention 
to potential drug interactions is crucial.   
Route  
Oral or intravenous 
 
5.9  Methylprednisolone (Medrol®, Solu-Medrol)  
Source 
& 
Pharmacology  
Adrenal corticosteroid – anti-inflammatory, immunosuppressant decreases 
inflammation by suppression of migration of polymorphonuclear leukocytes 
and reversal of increased capillary permeability. 
Formulation 
and Stability 
Tablet (4mg), Sodium Succinate powder for injection 125 mg, 500 mg. 
Supplier 
Commercially available. 
Toxicities:  
Toxicities include edema, hypertension, vertigo, seizures, psychoses, 
headache, pseudotumor cerebri, acne, skin atrophy, impaired wound healing, 
Cushing’s syndrome, pituitary adrenal axis suppression, growth suppression, 
glucose intolerance, hypokalemia, alkalosis, peptic ulcer, nausea, vomiting, 
transient leukocytosis, muscle weakness, osteoporosis, fractures, cataracts, 
glaucoma, and increased risk of infection. 
Route  
Intravenous or oral.   
5.10 CliniMACSTM System   
The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-
activated cell sorting (MACS).  The CliniMACS device is a powerful tool for the 
isolation of many cell types from heterogeneous cell mixtures, (e.g. apheresis 
products).  These can then be separated in a magnetic field using an immunomagnetic 
label specific for the cell type of interest, such as CD3+ human T cells. 
The cells to be isolated are specifically labeled with super-paramagnetic particles by an 
anti-body directed toward a cell surface antigen.  After magnetic labeling, the cells are 
separated using a high-gradient magnetic separation column as described below.  The 
magnetically labeled cells are retained in the magnetized column while the unlabeled 


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cells flow through the column for collection.  The retained cells are eluted by removing 
the magnetic field from the column, washing the cells out and collecting them in a 
separate container from the unlabeled cells. 
The super-paramagnetic particles are small in size (about 50 nm in diameter) and are 
composed 
of 
iron 
oxide/hydroxide 
and 
dextran 
conjugated 
to 
monoclonal 
antibodies.  These magnetic particles form a stable colloidal solution and do not 
precipitate or aggregate in magnetic fields.  The antibody conjugated beads used in this 
system are highly specific (e.g. CD3+ cells via OKT3 conjugated beads). High-gradient 
MACS technology has been shown to achieve rapid and highly specific depletion or 
enrichments of large numbers of target cells from BM, cord blood, and normal peripheral 
blood mononuclear cells.  
The CliniMACS device incorporates a strong permanent magnet and a separation column 
with a ferromagnetic matrix to separate the cells labeled with the magnetic particles. The 
high-gradient system allows the application of strong magnetic forces and a rapid de-
magnetization. Small ferromagnetic structures, such as the column matrix, placed in a 
magnetic field concentrate this homogenous field and thereby produce high magnetic 
gradients. In their immediate proximity, the ferromagnetic structures generate magnetic 
forces 10,000-fold greater than in the absence of those structures enabling the retention of 
magnetically labeled cells. After removing the column from the magnet, the rapid de-
magnetization of the column matrix allows the release of retained cells.  
The CliniMACS device is comprised of a computer controlled instrument incorporating a 
strong permanent magnet, a closed-system sterile tubing set containing columns with a 
coated ferromagnetic matrix and a paramagnetic, cell specific, labeling reagent. The 
instrument will separate the cells in a fully automated process yielding a cell population 
highly depleted of CD3+ cells. The CliniMACS device is not licensed by the FDA and 
therefore is investigational. 
The CliniMACS device has separate programs that allow cell selection procedures 
optimized for either depletion (e.g. CD3+ or CD45RA+) or selection of a target cell 
population (e.g. CD34+ or CD56+ cells). The basic mechanism is the same for either 
application; target cells are "tagged" with super-paramagnetic particles and eventually 
separated from the unlabeled cells using the CliniMACS device as described above. The 
desired target cells can either be infused or discarded appropriately.   
6.0  
REQUIRED OBSERVATIONS AND EVALUATIONS 
6.1 Standard Pre/Peri/Post-Transplant Evaluations 
All pre/peri/posttransplant and long-term follow-up evaluations for these participants will 
be carried out as guided by the SOPs of the SJCRH, Department of BMTCT, for 
recipients of allogeneic HCT.  Copies of these SOPs and ongoing updates can be found at 
the following site: http://home.web.stjude.org/bone_marrow/clinicalHome.shtml.  A 
schedule of these for these assessments is outlined in Appendix D. 
6.2 Long-term Follow-up Evaluations 
In general, recipients of allogeneic HCT at St. Jude are seen at least annually until 10 
years post-transplant in the Department of BMTCT outpatient clinic. For the purpose of 
this study, research participants will be followed to year 1 post-transplantation. At that 


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time, transplant recipients will be eligible for enrollment in the institutional long-term 
follow-up protocol for children and young adults who have received stem cell 
transplantation at St. Jude Children’s Research Hospital (BMTFU protocol). 
6.3 Research Testing.   
Timing for the required research tests are summarized in Appendix D.  Furthermore, to 
accommodate the studies, flexibility in the date is allowed without a deviation from 
protocol.  The degree of flexibility in the timing is also provided in Appendix D.  
6.3.1  Immune Reconstitution 
Standard measures of post-HCT immune reconstitution will be performed as 
delineated in Appendix D.  Research testing of Immune Reconstitution will 
include:  
6.3.1.1  VBETA/TREC Research: Thymic output and T cell repertoire. 
6.3.1.2  Lymphocyte Phenotypes Research: T cell and NK cell number and function. 
6.3.1.3  IR-PHENOTYPE 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care. Immunophenotypic evaluation of the UCB unit 
prior to infusion will be performed to enumerate the content of naïve, 
memory T cells, regulatory T cells, NK cells, and naïve B cells and memory 
B cells.   
Host: Immunophenotypic evaluation of immune reconstitution in the patient 
will be performed for the enumeration of naïve, memory T cells, regulatory 
T cells and naïve B cells and memory B cells.  
6.3.1.4  T-FUNCTION 
Immune function studies include antigen-specific T-lymphocyte response to 
viral infections, such as herpes viruses (CMV, HSV and VZV), intracellular 
cytokine and cytokine secretion assays.  Studies may include an optional 
skin punch biopsy, at the discretion of the PI, to be performed either at the 
time of the pre-transplant BM biopsy, during sedation for radiation 
treatment or at the time of the day 28 BM biopsy.  During viral infections, or 
reactivations detected by DNA regardless of copy number, samples to be 
collected weekly x 4 or until cleared (whichever is less).  If infection(s) are 
detected in non-blood samples (nasal wash, BAL etc), leftover samples may 
be used for research purposes.  Studies to be performed in the laboratory of 
Dr. Paul Thomas in collaboration with Dr. Dallas.  
6.3.1.5  HOST-DONOR INTERACTION 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care.  Epstein-Barr virus transformed lymphoblastoid 
cell lines (EBV-LCL) will be generated from the donor cells obtained from 
the discarded infusion bag.  UCB KIR typing and HLA-typing will be 


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performed for high resolution HLA-A, HLA-B, HLA-DR, HLA-C and 
HLA-DQ if not available.   
Host: Host and donor immunologic interaction studies may also include an 
optional skin punch biopsy to be performed with the pre-transplant BM 
biopsy to generate fibroblasts.  Prior to the start of conditioning, peripheral 
blood samples will be collected to generate EBV-LCL from the patient for 
research studies evaluating donor/host immunologic reactions. 
 
6.4 Research Testing on Haploidentical Donor (optional) 
Donors will be offered the option for participation in research studies of immune 
reconstitution of T cells, B cells, and NK cells.  These tests will be obtained after consent 
and preferably prior to growth factor administration.  Lymphocyte subset analysis of the 
donor appears to allow for the prediction of the reconstitution of the lymphocyte subsets 
in the research participant after transplantation.  Data in larger donor/research participant 
pairs will help to verify these observations. A list of these optional research studies are 
noted in Appendix D and detailed below: 
6.4.1  Lymphocyte Subset Study: Flow cytometry enumeration 
6.4.2  VBETA/TREC Research: Thymic output and T cell repertoire 
6.4.3  Lymphocyte Phenotypes Research: T cell and NK cell number and function 
7.0 EVALUATION CRITERIA 
7.1  Adverse event (AE) monitoring for on-study research participants will be assessed using the 
NCI Common Toxicity Criteria Version 3.0.  The specific criteria for adverse event 
monitoring are noted in APPENDIX C. 
7.2 GVHD scoring (acute and chronic) will be evaluated and graded using the criteria found 
in APPENDIX B of this protocol. 
7.3 Performance status will be assessed by Karnofsky/Lansky Performance Scores (age-
dependent) (see APPENDIX A). 
7.4 Hematologic recovery post-transplant will be determined using the engraftment criteria as 
follows:  
(1) Neutrophil engraftment is defined as absolute neutrophil count (ANC) recovery of ≥ 
0.5 x 109/L (500/mm3) for three consecutive laboratory values obtained on different 
days. Date of engraftment is the date of the first of the three consecutive laboratory 
values. 
(2) Platelet engraftment will be defined as platelet count ≥ 20,000/mm3 for three consecutive 
laboratory values obtained on different days with no platelet transfusions in the 
preceding 7 days.  Date of engraftment is the date of the first of the three consecutive 
laboratory values. 
7.5 Primary graft failure will be defined as an ANC never meeting or exceeding 500/mm3 for 
3 consecutive measurements after day +42 post-transplant. 


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7.6 Secondary graft failure or graft rejection will be defined as no evidence of donor chimerism 
by UCB and/or haploidentical donor (<10%), or too few cells to perform adequate 
chimerism analysis, in research participants with prior engraftment. 
7.7 Mixed hematopoietic chimerism will be defined as between 10% and 95% donor 
chimerism in the absence of immunosuppressive therapy. 
8.0 CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY 
CRITERIA 
8.1 Recipient Off-therapy Criteria – Recipient participants may remain on-study, but 
considered off therapy, for monitoring if one of the following occurs (off therapy 
participants monitored for disease status and survival only): 
8.1.1 Experiences graft failure/rejection. 
8.1.2 Noncompliance with the protocol. 
8.1.3 Positive pregnancy test after the HSC infusions. 
8.1.4 Recipient requires an additional HSC infusion, and unable to receive these cells 
due to donor issues. 
8.1.5 Physician decides that it is in the best medical interest of the participant. 
8.2 Recipient Off-study Criteria: Recipient participants will remain on study until one of the 
following occurs: 
8.2.1  Withdrawal of consent. 
8.2.2  Death. 
8.2.3  Lost to follow-up. 
8.2.4  Requires an additional transplant procedure using a different allogeneic donor. 
8.2.5 Requires enrollment on another therapeutic study or non-protocol therapy for 
disease. 
8.2.6  Study evaluations are complete (i.e. has completed the month 12 post-HSC 
infusion evaluations, and first annual post-transplant evaluation). 
8.2.7  Development of a significant change in health status at any point of therapy, 
which would render receipt of the transplantation procedure or continuation in the 
study no longer in the participant’s best interest. 
8.2.8 Unable to undergo the primary HCT procedure due to donor and/or donor center 
inability to provide the HSC product. 
8.3 Donor Off-study Criteria: Donor participants will remain on-study until one of the 
following occurs: 
8.3.1 Withdrawal of consent. 
8.3.2 Death. 
8.3.3 Development of a significant change in health status at any point of therapy, 
which would render the donor medically ineligible to serve (or continue to serve) 
as donor; or renders the donor’s continuation in the study no longer in his/her best 
interest. 


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8.3.4 Date of corresponding recipient’s off-study date. 
 
9.0 SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS 
9.1 Reporting adverse experiences and deaths 
The following definitions apply: 
Serious event – any event, in which the outcome is fatal or life-threatening, results in 
permanent disability, causes inpatient hospitalization or prolongs existing hospitalization, 
or is a congenital anomaly, cancer, or overdose. 
Unanticipated adverse event – any event, not identified in their nature, severity, or 
frequency in the current risk documents (e.g., investigator’s brochure), or consistent with 
the investigational plan. 
9.2 Reporting to St. Jude Institutional Review Board (IRB) 
Principal investigators are responsible for promptly reporting to the IRB any adverse 
events that are unanticipated, serious, and that may represent potential harm or increased 
risk to research participants.  When an unanticipated death occurs, the PI should report it 
to the Director of Human Subject’s Protection immediately, by phone: (901) 595-4359, 
cell: (901) 336-2894, fax: (901) 595-4361, or e-mail: hsp-1@stjude.org.  A reportable 
event entry into TRACKS should follow within 48 hours of notification of the event. 
Serious, unanticipated, and related or possibly related events must be reported within 10 
working days of notification of the event.  At the same time, the investigator will notify 
the study sponsor and/or the FDA, as appropriate.  All other SAEs and captured AEs will 
be reported to the IRB in the continuing review, with the following exceptions: 
 Any grade III-IV infusion reactions will be reported as soon as possible but every 
effort should be made to assure reporting is no more than within 7 business days 
of the event. 
 Any episodes of overall grade III or IV acute GVHD in participants will be 
reported to the IRB as soon as possible but no more than within approximately 10 
days of the PI’s confirmation of the diagnosis/grade of the event. 
 Clinical diagnosis of PTLPD will be reported to the IRB as soon as possible but 
no more than within 10 days of the PI’s determination of the disorder. 
The principal investigator is responsible for reviewing the aggregate toxicity reports and 
reporting to the IRB if the frequency or severity of serious toxicities exceed those 
expected as defined in the protocol or based on clinical experience or the published 
literature.  Any proposed changes in the consent form or research procedures resulting 
from the report are to be prepared by the study team and submitted with the report to the 
IRB for approval. 
Recipient participants will be followed for NCI Grade III-V, and clinically significant I-
II, adverse events from the start of conditioning and throughout the first year post HCT, 
regardless of their relationship to the treatment given.  However, all GVHD events will 
be captured on an ongoing basis regardless of stage or grade. 


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Haploidentical donor participants will be followed for any serious AE (SAE) and any 
clinically significant AEs (per judgment of PI) that are deemed related to the mobilization 
and/or apheresis procedure from the time of initiation of mobilization growth factors to 7-
days post last day of the apheresis procedure.  If the transplant recipient requires a second 
HSC infusion, meaning that the donor is required to undergo the mobilization and 
apheresis procedure again, collection of this donor safety data will restart upon the 
initiation of the subsequent mobilization procedure and continue until 7-days post the last 
day of this apheresis procedure. Timelines for reporting of these donor events to the 
institutional and federal governing agencies will be according to the same timelines noted 
in the following sections. A listing of the captured donor safety data will be provided in a 
separate table from the transplant recipients within each respective continuing review 
report.  Continuing review reports to all regulatory authorities will be structured in a 
manner so that any infusion toxicities or stem cell product related variances will be 
reported in separate listings from all other required elements. 
9.3 Reporting to St. Jude Institutional Biosafety Committee (IBC) 
Continuing review reports will be sent to the IBC on at least an annual basis using the 
most current version of the continuing review form found on the IBC website. The safety 
reports, sent to the IRB for both the donors and stem cell recipients, will be 
simultaneously forwarded to the IBC. Therefore, reporting for safety events to this 
committee will be according to the same timelines as reporting to the IRB.  This includes 
notification of achievement of MTD (if/when applicable).  As per the direction of the 
IBC, only those protocol revisions and amendments directly related to the CliniMACS 
processing and related reagent(s) will require review and consideration by the IBC.  
Other revisions/amendments will be noted in the IBC continuing review report. 
9.4 Reporting to FDA  
The FDA will be notified in writing (IDE safety report) of any serious and unexpected 
AE associated with an investigational treatment or device; or any results from laboratory 
animal tests that suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity. 
Each notification to the FDA should be made as soon as possible and no later than 15 
calendar days after the sponsor’s initial receipt of the information. The FDA may 
require additional data to be submitted.  In each written IND safety report, the sponsor 
shall identify all safety reports previously filed with the IND concerning a similar adverse 
experience, and shall analyze the significance of the adverse experience in light of the 
previous, similar reports where applicable. 
The sponsor shall also notify the FDA by telephone or by facsimile transmission of any 
unexpected fatal or life-threatening experience associated with the use of the 
investigational medication as soon as possible but no later than 7 calendar days after the 
sponsor’s initial receipt of the information.  Any grade III-IV infusion reactions will be 
reported as soon as possible but every effort should be made to assure reporting is no 
more than within 7 business days of the event.  Follow-up information to a safety 
report must be submitted as soon as the relevant information is available. 


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If the results of further investigation show an AE that was not initially determined to be 
reportable should later be deemed reportable, the sponsor shall inform the FDA of the 
event in a written safety report as soon as possible, but no later than 15 calendar days 
after the determination is made.  Results of the investigation of other safety information 
shall be submitted, as appropriate, in an information amendment or annual report.  
Continuing review reports, which will include the up-to-date clinical and safety data, will 
be submitted to the FDA at least annually. 
9.5 Reporting to St. Jude Office of Regulatory Affairs 
Copies of all correspondence to the St. Jude IRB, including SAE reports are provided to 
the St. Jude Regulatory Affairs Office. All FDA related correspondence and reporting 
will be conducted through the Regulatory Affairs Office. Adverse event reporting and 
annual reporting will be in accord with the FDA Title 21 CFR312.32 and Title 21 
CFR312.33, respectively. The Regulatory Affairs Office can be reached at 901-595-2347 
(secondary contact: St. Jude Vice President of Clinical Trials Administration 901-595-
2876). 
9.6 Continuing review reports 
Continuing review reports of protocol progress and summaries of adverse events will be 
filed with the St. Jude IRB, and IBC at least annually. 
9.7 Reporting to the St. Jude Data Safety Monitoring Board 
This study has been referred to the St. Jude Data and Safety Monitoring Board (DSMB) 
for regular monitoring.  The DSMB is charged with advising the Director and other 
senior leaders of St. Jude on the safety of clinical protocols being conducted by St. Jude 
investigators and on their continuing scientific validity.  DSMB monitoring and review 
for this study will be conducted in accordance with the NCI guidance for DSMBs on an 
approximate semiannual basis.  The St. Jude DSMB is responsible for ongoing review of 
the protocol and related information such as enrollment, issues related to participant 
safety (specifically toxicities and the risk:benefit ratio of the trial), interim analyses, and 
the overall study conduct necessary to accomplish the primary protocol objectives.  This 
includes evaluation of the accrual rate, adherence to the study design, outcome measures, 
and review of protocol related primary outcome data. The PI will meet with DSMB 
during the semiannual visits to review the information submitted and discuss the status of 
the protocol.  The DSMB may recommend that the trial be modified, suspended to 
accrual, and/or stopped based on their review.   
9.8 Data submission to Miltenyi Biotec 
Clinical and safety related data will be provided to Miltenyi Biotec, the manufacturer of 
the CliniMACS system. Data will include but is not limited to the transplant research 
participant’s age and diagnosis, donor product(s) related information including donor 
type, the stem cell mobilization, selection, and infusion procedure. Outcome data 
including lymphohematopoietic reconstitution, immunological response, disease response 
and transplant complications will be shared with Miltenyi Biotec.  Representatives from 
Miltenyi Biotec will be able to review the participant’s (donor and transplant research 
recipient) laboratory and medical record for data verification purposes.  Copies of all 
reports to the institutional and governing regulatory bodies will also be accessible upon 
request.  In the event that the protocol is placed on a clinical hold by the PI or governing 


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regulatory authorities, representatives from Miltenyi Biotec will be notified as soon as 
possible. 
 
9.9 Reporting to the Center for International Blood and Marrow Transplant Research  
The Transplant Program at St. Jude is required by the federal government to report 
transplant information to the Center for International Blood and Marrow Transplant 
Research (CIBMTR). The CIBMTR is a research partnership of the International Bone 
Marrow Transplant Registry, the National Marrow Donor Program (NMDP), and the 
Foundation for the Accreditation of Cellular Therapy (FACT).  This organization is 
responsible for the collection and maintenance of a standardized data warehouse registry 
of autologous and all allogeneic (related and unrelated donor) transplants performed in 
the United States. 
The Office of General Counsel, U.S. Department of Health and Human Services, had 
deemed the CIBMTR not a covered entity under the Privacy Rule (45 CFR 164.512), 45 
CFR Parts 160 and 164, and the Health Insurance Portability and Accountability Act 
(HIPPA) of 1996.  For this reason, the submission and disclosure of certain protected 
health information (PHI), including that required for CIBMTR, is allowable without the 
individual’s authorization (i.e. consent is waived) when such disclosure is made to public 
health authorities authorized by law for the purpose of preventing or controlling disease, 
injury, or disability. 
Data resulting from this transplant procedure will be sent for general registry purposes to 
comply with the federal government requirements.  This information for both donor and 
recipient is submitted using a unique participant identification number.  The information 
submitted for haploidentical recipients is less extensive than recipients of other donor 
products.  For this reason, variables submitted may include but are not limited to the 
transplant recipient’s date of birth, country/state of current residence, diagnosis, basic 
lympho-hematopoietic reconstitution (e.g. date of ANC and platelet engraftment), post-
HCT disease status, and basic AEs (e.g. GVHD- yes or no), survival status, date/cause of 
death. 
10.0 DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY 
10.1  Data collection 
The St. Jude Cancer Center Clinical Research Associates assigned to the Department of 
BMTCT will assure protocol compliance, and conduct all clinical and safety data 
collection. Data will be entered into an institutional database. The PI will be responsible 
for review of data for accuracy and completeness once entered into the secure 
departmental database. 
10.2  Study monitoring 
This protocol will be monitored for safety and data as per the St. Jude Data and Safety 
Monitoring Plan for Clinical Trials approved by the NCI in 2010, and is considered to be 
in the High Risk III category. The Central Protocol and Data Monitoring Office 
(CPDMO) will verify 100% of the informed consent documentation on all participants 
and verify 100% of St. Jude participants’ eligibility status.  The study team will meet at 
appropriate intervals to review case histories and data quality summaries on all 


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participants.  The St. Jude Clinical Research Monitor will assess protocol and regulatory 
compliance as well as the accuracy and completeness of all data points for the first two 
participants enrolled, then 15% of study enrollees every six months.  The protocol will be 
tracked continuously for the accrual of donors and recipients.  All AE and SAE reports 
will be reviewed by the study Principal Investigator for type, grade, attribution, duration, 
timeliness and appropriateness on all study participants.  All SAE reports will be 
reviewed by the monitor every 6 months.    
Protocol compliance monitoring will include participant status, eligibility, the informed 
consent process, demographics, staging, study objectives, subgroup assignment, 
treatments, evaluations, responses, participant protocol status, off-study, and off-therapy 
criteria.  The Monitor will generate a formal report which is shared with the Principal 
Investigator (PI), study team and the Internal Monitoring Committee (IMC).  Monitoring 
may be conducted more frequently if deemed necessary by the CPDMO or the 
IMC.  Continuing reviews by the IRB and CT-SRC will occur at least annually.  In 
addition, SAE reports in TRACKS (Total Research and Knowledge System) are reviewed 
in a timely manner by the IRB.  The Regulatory Affairs Office will assist the PI in 
reporting to the FDA and other external oversight agencies, as necessary. 
10.3 Confidentiality 
Unique participant numbers will be used in place of an identifier such as a medical record 
number when reporting any data to outside agencies.  No research participant names will 
be recorded on the data collection forms.  The list containing the unique participant 
numbers and the medical record number will be maintained in a locked file accessible 
only to the study team. 
The medical records of study participants may be reviewed by the St. Jude IRB, FDA, 
clinical research monitors, etc. 
11.0 STATISTICAL CONSIDERATIONS 
11.1 Statistical design and analysis for the primary objectives and stopping rules 
This study is designed as a phase II study. The primary objective of this study is to 
evaluate the rate of engraftment by day +42.  Engraftment for the purposes of this 
objective will be as defined in section 7. 
As detailed in section 2, the use of alternative donors such as haploidentical donors and 
unrelated UCB are frequently needed and largely successful.  However, the use of these 
alternative donors is typically complicated with additional problems, particularly poor 
hematopoietic recovery and graft failure.126    
The majority of published experience with alternative (HLA-mismatched) donor 
transplantation in children is with UCB grafts.  The COBALT study included 191 
children with hematologic malignancies who received UCB transplantation with TBI 
based (1350Gy) myeloablative conditioning.59 The cumulative incidence of neutrophil 
engraftment by day 42 was 80%.  The New York Blood Center published outcomes on 
1061 patients (78% pediatric) with hematologic malignancies who received 
myeloablative UCBT with units from their bank.62 The cumulative incidence of 
neutrophil engraftment was 74% by day 77.  The CIBMTR published a comparison of 
UCB transplantation with HLA-matched unrelated donor transplantation, in which 503 


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children with acute leukemia received UCBT.16 They confirmed that although the 
leukemia-free survival was similar, the rate of neutrophil engraftment (and TRM) were 
significantly worse with HLA-mismatched UCB grafts than with HLA-matched BM 
grafts.  For UCB recipients, the best engraftment was obtained in the rare 6/6 matched 
UCB recipients with 85% of the 35 patients achieving neutrophil recovery at day +42.  In 
addition, recipients who received a single antigen mismatch UCB unit with an 
appropriately high cell dose (n=154) had a neutrophil engraftment rate of 80% at day 
+42.  Recipients of lower cell dose or two antigen mismatch units fared worse. 
Given the data, we consider a rate of successful engraftment of less than 80% by day +42 
to be unacceptable for alternative donor transplantation.  The goal of our study is to 
develop a novel preparative regimen to facilitate successful engraftment of donor graft(s) 
at a rate of ≥91%.  We do not anticipate censoring during the 42 day time period and we 
can approximate the rate of engraftment by day +42 using a Binomial distribution. In 
order to keep the validity of Binomial distribution approximation, patients lost for follow 
up will be counted as a failure to engraft. Therefore, in this study, we propose to test the 
null hypothesis H0: P≤0.80 versus H1: P>0.80, where P is the proportion of research 
participants who engrafted by day +42 after HCT. With type I error of 10% and type II 
error of 20%, Simon’s two stage optimum design powered at alternative successful 
engraftment rate P1=0.91 requires 21 evaluable patients at the first stage and 49 evaluable 
patients in total76. The stopping rules are provided in Table 1, with the understanding that 
stopping the trial early would be suggestive of the proposed transplant strategy not being 
an effective treatment option for this group of patients. The interpretation is that if we 
observe 17 or fewer participants engrafted by day +42 in the first 21 participants, then we 
would stop the trial for lack of efficacy. However, if we observe 18 or more patients 
engrafted in the first 21 participants by day +42 in stage one, then 28 more patients will 
be enrolled in stage two. If we observe 43 or more participants engrafted by day +42 
upon completion of the trial, then we conclude that the true rate of  engraftment is at least 
80% and our novel regimen will be proposed for further development and phase III 
clinical trial.  
Table 1: Stopping rules for lack of efficacy based on the Simon’s 2-stage optimum 
design (unacceptable low rate of successful engraftment by day +42)  
Accept H0 if the number of research participants engrafted 
P0 
P1 
(≤ r1/n1 ) 
(≤ r/n ) 
EN(P0) 
PET(P0) 
0.80 
0.91 
17/21 
42/49 
31 
0.63 
Note: r1 and r denote the number of patients successfully engrafted by day +42; EN(P0) 
denotes the expected sample size under P0; PET(P0) denotes the probability of early 
termination at stage I under P0.  
All participants who receive the prescribed transplant will be evaluable for the primary 
outcome. In addition, any patient who starts the conditioning regimen but stops prior to 
receiving the graft will count as a failure, if the reason for stopping therapy is toxicity 
from the conditioning regimen.  Patients who enroll but do not initiate treatment due to 
withdraw of patient, withdraw of donor or health status change to make the treatment not 
in the patient’s best medical interest, etc., will be replaced.  Any patient who dies from 


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toxicity after engraftment but before day +42 will count as having engrafted.  Any patient 
who dies prior to engraftment will count as a graft failure.   
After the study is finished, for the first primary objective, the rate of engraftment by day 
+42 and its 95% Blyth-Still-Casella confidence interval will be estimated based on the 
binomial approximation.  
Table 2 shows the number of haploidentical HCT and the estimated number of KIR 
mismatch cases performed at our institution in last 5 years. With the initiation of UCB 
protocols at SJCRH, the number of referrals for patients requiring alternative donor HCT 
has increased.  Furthermore, HAPCORD will be a high priority protocol. Based on this 
table and PI’s estimation, it is expected that approximately 10 patients per year will be 
enrolled in this study.  Therefore, the expected accrual period for this study is maximally 
5 years.  
Table 2: The number of haploidentical HCT performed at St. Jude 2007 to 2012 
Year 
2007 
2008 
2009 
2010 
2011 
2012 
Number haploidentical HCT  
20 
17 
22 
19 
24 
22 
Estimated KIR mismatch 
14 
12 
15 
13 
17 
15 
Estimated KIR matched  
6 
5 
7 
6 
7 
7 
Number of UCBT 
3 
2 
0 
0 
2 
8 
Stopping Rules for Toxicities  
In addition to the stopping rules based on successful engraftment, we will closely monitor 
the trial for early excessive toxicities in terms of severe acute GVHD and therapy related 
death. Therapy related death is any death in remission and related to protocol therapy.  
The incidence of acute GVHD and transplant related deaths will be monitored for 100 
days from the date of transplantation for application of the stopping rules. Toxicities 
secondary to non-protocol therapy for post-transplant persistent or recurrent disease will 
not count towards the toxicity stopping rules. The safety endpoints will be monitored 
independently and a consideration to stopping the trial would be given if there is evidence 
suggesting that the rate of grades 3-4 acute GVHD is greater than 20%, or the rate of 
transplant related death is greater than 10%. Then, the planned interim evaluation time 
points and stopping rules, using group sequential design based on Pocock stopping 
boundaries after considering five interim analyses (p-value threshold = 0.0158) to ensure 
an overall type one error of 0.05127-129, for each of the two endpoints are provided in 
Tables 3 and 4:   
Table 3. Stopping Rules for Toxicities Based on Grades 3-4 aGVHD within the First 
100 Days Post-transplant  
No of of Research Participants Enrolled 
No. of Grades 3-4 aGVHD Observed 
≤ 11 
≥ 6 
≤ 21 
≥ 9 
≤ 31 
≥ 12 
≤ 41 
≥ 15 
≤ 49 
≥ 17 


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Table 4. Stopping Rules for Toxicities Based on Therapy Related Death within the 
first 100 days Post-transplant 
No. of Research Participants Enrolled   
No. of Therapy Related Death Observed  
≤ 11 
≥ 5 
≤ 21 
≥ 6 
≤ 31 
≥ 8 
≤ 41 
≥ 10 
≤ 49 
≥ 11 
Based on the above Table 3, if six grades 3-4 acute GVHD occur within the first 100 days 
post transplantation in the first eleven evaluable research participants treated, then a 
consideration will be given to temporarily stopping the trial and amending the study to 
include additional pharmacologic GVHD prophylaxis. Similarly, from Table 4 if we 
observe five deaths related to therapy within the first 100 days after transplantation in the 
first eleven evaluable research participants treated, then a consideration will be given to 
temporarily stopping the trial and amending the study appropriately.    
11.2 Statistical analysis for secondary objectives  
11.2.1  Estimate the incidence of malignant relapse, EFS and OS at one-year post-
transplantation 
The estimate of cumulative incidence of relapse will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The analysis will 
be implemented using SAS macro (bmacro252-Excel2007\cin) available in the St. 
Jude Department of Biostatistics. The Kaplan-Meier estimate of OS and EFS with 
relapse, death due to any cause and graft failure as events along with their 
standard errors will be calculated using the SAS macro (bmacro251-
Excel2007\kme) available in the Department of Biostatistics at St. Jude, where 
OS = min (date of last follow-up, date of death) – date of HCT and all participants 
surviving after 1 year post-transplant will be considered as censored, and EFS = 
min (date of last follow-up, date of relapse, date of graft failure, date of death due 
to any cause) – date of transplant, and all participants surviving at the time of 
analysis without events will be censored. The analysis for this objective will be 
performed when the last evaluable participant has been followed for one-year post 
transplant.    
11.2.2  Estimate the incidence and severity of acute and chronic GVHD 
The cumulative incidence of acute and chronic GVHD will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The SAS macro 
(bmacro252-Excel2007\cin) available in the Department of Biostatistics at St. 
Jude will be used for such analysis. The severity of acute GVHD and chronic 
GVHD will be described. The analysis for this objective will be performed when 
the last evaluable participant has been followed for 100 days post transplant.   
11.2.3 Estimate the rate of TRM in the first 100 days after HCT. 
The cumulative incidence of TRM will be estimated using the same method as 
used in evaluating Objective 10.2.2. Deaths before day 100 because of other 
reasons are the competing risk events. The analysis for this objective will be 


HAPCORD 45 
 
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performed when the last evaluable participant has been followed for 100 days post 
transplant. 
11.3 Analysis for exploratory objectives  
The final results of these exploratory objectives are expected to be available when 
the last evaluable participant has been followed for one-year post transplant. 
11.3.1  Assess the relationship between pre-transplant MRD with transplant outcomes. 
The relationship of pre-transplant MRD and transplant outcomes will be 
examined through Cox proportional hazard model or generalized linear model. 
The model can also be used to adjust for other confounding factors such as 
patient’s age at transplant. 
11.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) analysis, 
V-beta spectratyping, and phenotype and functional analysis of reconstituted 
lymphocyte subsets.  All immune reconstitution measures will be descriptively 
analyzed. 
11.3.3 Characterize the recovery of Gamma Delta T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  All Gamma Delta T cell 
measures will be descriptively analyzed. 
11.3.4 Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  All Influenza infection 
monitoring will be descriptively analyzed. 
12.0 OBTAINING INFORMED CONSENT 
The ongoing informed consent process will be carried out per the policies and procedures put 
forth in the St. Jude Investigator’s Handbook for Clinical Research (http://home.web.stjude. 
org/clinical_research/administration/doc/handbook.pdf).  The PI or physician sub-
investigator will conduct the signature authorization portion of the consent process.   
12.1 Informed consent prior to research interventions 
For protocol required research interventions (research samples for baseline immune 
reconstitution evaluation); informed consent must be obtained prior to performing these 
research interventions. 
12.2 Consent at age of majority 
The age of majority in the state of Tennessee is 18 years old.  Research participants must 
be consented at the next St. Jude clinic visit after their 18th birthday, and prior to 
performing any research interventions during that visit.   
12.3 Consent when English is not the primary language 
When English is not the patient, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter.  This 
information will be documented in the participant’s medical record.  Either a certified 
interpreter or the telephone interpreter’s service will be used to translate the consent 
information.  The process for obtaining an interpreter and for the use of an interpreter is 
outlined on the Interpreter Services, OHSP, and CPDMO websites. 
  


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the speed of immune reconstitution after stem cell transplantation. Blood 2004; 103(11): 4344-52. 
101. Yamashita N, Bullington R, Clement LT. Equivalent helper functions of human "naive" and 
"memory" CD4+ T cells for the generation of alloreactive cytotoxic T lymphocytes. Journal of 
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102. Chen YB, Spitzer TR. Current status of reduced-intensity allogeneic stem cell transplantation using 
alternative donors. Leukemia 2008; 22(1): 31-41. 
103. Aversa F, Terenzi A, Felicini R, et al. Haploidentical stem cell transplantation for acute leukemia. 
Int J Hematol 2002; 76 Suppl 1: 165-8. 


HAPCORD 51 
 
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IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
104. Aversa F, Velardi A, Tabilio A, Reisner Y, Martelli MF. Haploidentical stem cell transplantation in 
leukemia. Blood Rev 2001; 15(3): 111-9. 
105. Kohrt H, Lowsky R. Total lymphoid irradiation for graft-versus-host disease protection. Curr Opin 
Oncol 2009; 21 Suppl 1: S23-6. 
106. Kohrt HE, Turnbull BB, Heydari K, et al. TLI and ATG conditioning with low risk of graft-versus-
host disease retains antitumor reactions after allogeneic hematopoietic cell transplantation from 
related and unrelated donors. Blood 2009; 114(5): 1099-109. 
107. Lowsky R, Takahashi T, Liu YP, et al. Protective conditioning for acute graft-versus-host disease. N 
Engl J Med 2005; 353(13): 1321-31. 
108. Heinzelmann F, Lang PJ, Ottinger H, et al. Immunosuppressive total lymphoid irradiation-based 
reconditioning regimens enable engraftment after graft rejection or graft failure in patients treated 
with allogeneic hematopoietic stem cell transplantation. Int J Radiat Oncol Biol Phys 2008; 70(2): 
523-8. 
109. Palma J, Salas L, Carrion F, et al. Haploidentical stem cell transplantation for children with high-risk 
leukemia. Pediatr Blood Cancer. 
110. Gluckman E. History of cord blood transplantation. Bone Marrow Transplant 2009; 44(10): 621-6. 
111. Willemze R, Rodrigues CA, Labopin M, et al. KIR-ligand incompatibility in the graft-versus-host 
direction improves outcomes after umbilical cord blood transplantation for acute leukemia. 
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112. Brunstein CG, Wagner JE, Weisdorf DJ, et al. Negative effect of KIR alloreactivity in recipients of 
umbilical cord blood transplant depends on transplantation conditioning intensity. Blood 2009; 
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113. Coustan-Smith E, Behm FG, Sanchez J, et al. Immunological detection of minimal residual disease 
in children with acute lymphoblastic leukaemia. Lancet 1998; 351(9102): 550-4. 
114. Coustan-Smith E, Sancho J, Behm FG, et al. Prognostic importance of measuring early clearance of 
leukemic cells by flow cytometry in childhood acute lymphoblastic leukemia. Blood 2002; 100(1): 
52-8. 
115. Coustan-Smith E, Sancho J, Hancock ML, et al. Clinical importance of minimal residual disease in 
childhood acute lymphoblastic leukemia. Blood 2000; 96(8): 2691-6. 
116. Nucifora G, Larson RA, Rowley JD. Persistence of the 8;21 translocation in patients with acute 
myeloid leukemia type M2 in long-term remission. Blood 1993; 82(3): 712-5. 
117. Roberts WM, Estrov Z, Ouspenskaia MV, Johnston DA, McClain KL, Zipf TF. Measurement of 
residual leukemia during remission in childhood acute lymphoblastic leukemia. N Engl J Med 1997; 
336(5): 317-23. 
118. Knechtli CJ, Goulden NJ, Hancock JP, et al. Minimal residual disease status before allogeneic bone 
marrow transplantation is an important determinant of successful outcome for children and 
adolescents with acute lymphoblastic leukemia. Blood 1998; 92(11): 4072-9. 
119. Langebrake C, Creutzig U, Dworzak M, et al. Residual disease monitoring in childhood acute 
myeloid leukemia by multiparameter flow cytometry: the MRD-AML-BFM Study Group. J Clin 
Oncol 2006; 24(22): 3686-92. 
120. Uchida N, Tsukamoto A, He D, Friera AM, Scollay R, Weissman IL. High doses of purified stem 
cells cause early hematopoietic recovery in syngeneic and allogeneic hosts. J Clin Invest 1998; 
101(5): 961-6. 
121. Chen X, Barfield R, Benaim E, et al. Prediction of T-cell reconstitution by assessment of T-cell 
receptor excision circle before allogeneic hematopoietic stem cell transplantation in pediatric 
patients. Blood 2005; 105(2): 886-93. 
122. Weinberg K, Blazar BR, Wagner JE, et al. Factors affecting thymic function after allogeneic 
hematopoietic stem cell transplantation. Blood 2001; 97(5): 1458-66. 
123. Langfitt D, Wallace N, Dallas MH. Dendritic Cell Facilitate Thymic Recovery And Enhance 
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Transplantation 2010; 16(2, Supplement 1): S173-S. 


HAPCORD 52 
 
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IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
124. Langfitt D, Wallace N, Gaines S, Dallas M. Dendritic cells and Regulatory T cells facilitate donor 
engraftment 
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hematopoietic 
stem 
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Immunol 
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184(1_MeetingAbstracts): 145.35-. 
125. Gutman JA, Turtle CJ, Manley TJ, et al. Single-unit dominance after double-unit umbilical cord 
blood transplantation coincides with a specific CD8+ T-cell response against the nonengrafted unit. 
Blood 2010; 115(4): 757-65. 
126. Ballen KK, Koreth J, Chen YB, Dey BR, Spitzer TR. Selection of optimal alternative graft source: 
mismatched unrelated donor, umbilical cord blood, or haploidentical transplant. Blood; 119(9): 
1972-80. 
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Association 1986; 81(395): 843-55. 
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HAPCORD 53 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX A: 
PERFORMANCE STATUS SCALE 
KARNOFSKY PERFORMANCE STATUS SCALE 
Score General Description 
100 
Normal. No complaints. No evidence of disease. 
90 
Able to carry on normal activity. Minor signs or symptoms of disease. 
80 
Normal activity with effort. Some signs or symptoms of disease. 
70 
Care of self.  Unable to carry out normal activity or to do active work. 
60 
Requires occasional assistance, but is able to care for most of his needs. 
50 
Requires considerable assistance and frequent medical care. 
40 
Disabled.  Requires special care and assistance. 
30 
Severely disabled. Hospitalization is indicated although death is not imminent. 
20 
Hospitalization necessary, very sick, active support treatment necessary. 
10 
Moribund. Fatal processes progressing rapidly. 
0 
Dead. 
 
 
LANSKY PERFORMANCE STATUS SCALE 
Score  General Description 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both greater restriction of and less time spent in play activity 
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 but able to participate in 
all quiet play and 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 
No play; does not get out of bed 
0 
Unresponsive 


HAPCORD 54 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX B 
Criteria for Acute GVHD 
ORGAN STAGING FOR ACUTE GVHD 
Organ 
Stage 0 
Stage 1 
Stage 2 
Stage 3 
Stage 4 
Skin 
No rash 
 
 
Rash < 25% a 
 
 
Rash 
25 
< 
50% 
 
Rash 
>50% 
generalized 
erythroderma 
Plus bullae and 
desquamation 
 
Gastrointestinal 
Lower 
Diarrhea 
<500 
mL/day 
Diarrhea 
501 to 1000 
mL/dayc 
Diarrhea 
1001 to 1500 
mL/day 
Diarrhea 
>1500 
mL/day 
Severe abdominal 
pain 
with 
or 
without ileus 
Upper 
^ 
Persistent 
nausead 
^ 
^ 
^ 
Liver 
Bilirubin 
<2.0 
mg/dl 
Bilirubin 
2.1 
to 
3.0 
mg/dlb 
Bilirubin 
3.1 
to 
6.0 
mg/dlb 
Bilirubin 
>6.1 
to 
15 
mg/dlb 
Bilirubin 
> 15 mg/dl 
 
OVERALL GRADING FOR ACUTE GVHD 
Grade 
Skin 
Liver 
Gut 
I 
Stage 1-2 
None 
None 
II 
Stage 3 or 
Stage 1 or 
Stage 1 
III 
- 
Stage 2-3 or 
Stage 2-4 
IVf 
Stage 4 or 
Stage 4 
- 
 
a.  Use rule of Nines” or burn chart to determine extent of rash. 
b. Range given as total bilirubin. Downgrade one stage if additional cause of elevated bilirubin is documented. 
c. Volume of diarrhea applies to adults.  For pediatric patients, the volume of diarrhea should be based on body surface area. Downgrade 
one stage if additional cause of diarrhea has been documented. 
d. Persistent nausea with histological evidence of GVHD in stomach or duodenum. 
e. Criteria for grading given as minimum degree of organ involvement required conferring that grade. 
f. Grade IV may also include lesser organ involvement but with extreme decrease in performance status. 


HAPCORD 55 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
Complete weekly 
 DATE: ________ 
Score 0 
Score 1 
Score 2 
Score 3 
PERFORMANCE 
SCORE 
_________________ 
KPS  ECOG  LPS 
Asymptomatic 
and 
fully 
active (ECOG 
0: 
KPS 
or 
LPS 100%) 
 Symptomatic, fully 
ambulatory, restricted 
only 
in 
physically 
strenuous 
activity 
(ECOG 1, KPS or 
LPS 80-90%) 
 Symptomatic, 
ambulatory, 
capable of self-
care, 
>50% 
of 
waking hours out 
of bed (ECOG 2, 
KPS or LPS 60-
70%) 
 Symptomatic 
limited 
self-care, 
>50% 
of 
waking hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN 
Clinical features: 
Maculopapular rash 
Lichen planus-like  
Papuloquamous 
lesions or ichthyosis 
Hyperpigmentation 
Hypopigmentaion 
Keratosis pilaris 
Erythema 
Erythroderma 
Poikiloderma 
Sclerotic features 
Pruritus 
Hair involvement 
Nail involvement 
% BSA Involved  
 No symptoms 
 <18% 
BSA 
with 
disease signs but NO 
sclerotic features 
 ≥19-50% 
BSA 
OR involvement 
with 
superficial 
sclerotic features 
“not 
hidebound” 
(able to pinch) 
 >50% BSA OR deep 
sclerotic 
features 
“hidebound” (unable to 
pinch) 
OR 
impaired 
mobility, ulceration or 
severe pruritus 
MOUTH 
No symptoms 
 Mild symptoms with 
disease 
signs 
but 
NOT limiting oral 
intake significantly 
 Moderate 
symptoms 
with 
disease 
signs 
WITH 
partial 
limitation of oral 
intake 
 Severe symptoms with 
disease 
signs 
on 
examination 
WITH 
major limitation of oral 
intake 
EYES 
 
  Mean tear test (mm): 
  >10 
  6-10 
  ≥5 
  Not done 
No symptoms 
 Mild 
dry 
eye 
symptoms 
not 
affecting 
ADL 
(requiring eye drops 
<3 x per day) OR 
asymptomatic 
signs 
of 
keratoconjunctivitis 
sicca 
 Moderate dry eye 
symptoms 
partially affecting 
ADL 
(requiring 
drops >3x per day 
or 
punctual 
plugs), 
WITHOUT 
vision impairment 
 Severe 
dry 
eye 
symptoms significantly 
affecting ADL (special 
eyeware to relieve pain) 
OR unable to work due 
to ocular symptoms OR 
loss of vision cause by 
keratoconjunctivitis 
sicca 
GI 
No symptoms 
 Symptoms such as 
dysphagia, anorexia, 
abdominal 
pain, 
nausea, vomiting, or 
diarrhea 
w/o 
significant 
weight 
loss (<5%) 
 Symptoms 
associated 
with 
mild to moderate 
weight loss   
(5-15%) 
 Symptoms associated 
with significant weight 
loss > 15%, requires 
nutritional 
supplement 
for most calorie needs 
OR esophageal dilation 
LIVER 
 Normal LFT 
 Elevated Bilirubin, 
AP*, AST or ALT <2 
x ULN 
 Bilirubin >3 mg/dl 
or 
Bilirubin, 
enzymes 
2-3 
x 
ULN 
 Bilirubin or enzymes > 
5 x ULN 
 


HAPCORD 56 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
 
SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
LUNGS† 
 
FEV1 ______ 
DLCO ______ 
 No symptoms 
 
 
 
 FEV1 >80% OR 
LFS=2 
 Mild 
symptoms 
(shortness of breath 
after 
climbing 
one 
flight of steps) 
 FEV1 60-79%  
OR LFS 3-5 
 Moderate symptoms 
(shortness of breath 
after walking on flat 
ground) 
 FEV1 40-59% OR 
LFS 6-9 
 Severe 
symptoms 
(shortness of breath at 
rest; requiring 02 
 
 FEV1 ≥39% OR 
LFS 10-12 
JOINTS 
AND 
FASCIA 
 No symptoms 
 Mild tightness of arms 
or legs, normal or mild 
decreased 
range 
of 
motion (ROM) AND 
not affecting ADL 
 Tightness of arms or 
legs 
OR 
joint 
contractures, erythema 
thought due to fasciitis, 
moderate 
decrease 
ROM AND mild to 
moderate limitation of 
ADL 
Contractures 
WITH 
significant decrease or 
ROM AND significant 
limitation 
of 
ADL 
(unable 
to 
tie 
shoes, 
button shirts, dress self 
etc.) 
GENITAL 
TRACT 
 No symptoms 
 Symptomatic 
with 
mild signs on exam 
AND no effect on 
coitus 
and 
minimal 
discomfort 
with 
gynecologic exam 
 Symptomatic 
with 
moderate 
signs 
on 
exam AND with mild 
dyspareunia 
or 
discomfort 
with 
gynecologic exam 
 Symptomatic 
WITH 
advance signs (stricture, 
labial agglutination or 
severe ulcerations AND 
severe pain with coitus or 
inability it insert vaginal 
speculum 
Other indicators, clinical manifestations or complications related to chronic GVHD (check all that apply and assign a 
score to its severity (0-3) based on its functional impact where applicable (none = 0, mild = 1, moderate =2, severe = 3. 
Esophageal stricture or web ______ 
Pericardial Effusion  _______________Pleural Effusion(s) ________________________ 
Ascites (serositis) ________________ Nephrotic syndrome _____________ 
Peripheral Neuropathy _____________________ 
Myasthenia Gravis ______________ 
Cardiomyopathy ________________ Eosinophilia > 500/µl _____________________ 
Polymyositis  ____________________ Cardiac conduction defects _________ Coronary artery involvement ________________ 
Platelets <100,000/µl _____________ Progressive Onset  ________________ Other: Specify:__________________________ 
 Organ scoring of chronic GVHD. 
AP may be elevated in growing children, and not reflective of liver dysfunction.    
† Pulmonary scoring should be performed using both the symptom and PFT scale whenever possible. When discrepancy exists 
between pulmonary symptoms or PFT scores, the higher value should be used for final scoring. Scoring using the  LFS  is 
preferred, but if DLCO is not available, grading using FEV1 should be used.  The LFS is a global assessment of lung function 
after the diagnosis of bronchiolitis obliterans has already been established.   
The percent predicted FEV1 and DLCO (adjusted for HCT but not alveolar volume) should be converted to a numeric score as 
follows: >80% = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6.   
The LFS = FEV1 score + DLCO score, with a possible range of 2-12.   
 
PFT: Pulmonary Function Testing 
 
LFS, Lung Function Score 
 
GVHD, graft versus host disease 
ECOG, Eastern Cooperative Oncology Group 
KPS, Karnofsky Performance Status 
LPS, Lansky Performance Status 
BSA, body surface area 
 
 
ADL, activities of daily living 
LFTs, liver function tests 
AP, alkaline phosphatase 
 
 
ALT, alanine aminotransferase 
AST, aspartate aminotransferase 
ULN, upper limit of normal 


HAPCORD 57 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
GLOBAL GRADING OF CHRONIC GVHD84 
 
* 
Determined by adding the total number of organs receiving score > 0 using Figure 1, 
 
Appendix B. 
** 
Defined as the maximum score given to any organ system amongst all organs scored 
 
using Figure 1, Appendix B.  
Final Grade 
Number of 
Organs/Sites* 
Maximum Organ 
Score** 
Lung Score 
Mild 
1 - 2 
1 
0 
Moderate 
3 or more 
1 
1 
At least 1 
2 
Severe 
At least 1 
3 
2 - 3 


HAPCORD 58 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX C 
CRITERIA FOR ADVERSE EVENT (AE) EVALUATION AND REPORTING 
The St. Jude Department of BMTCT Clinical Research Office standard operating procedure for 
the documenting and reporting of adverse (SOP 10 Documenting and Reporting of Adverse 
Events) will provide guidance on the evaluation, collection and reporting of adverse events for 
this clinical trial.  The current version of this document, as well as ongoing updates, can be 
located at the following website: http://home.stjude.org/bmt/Pages/policies-research.aspx 
 


HAPCORD 59 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX D 
Recommended testing and evaluation schedule 
STANDARD OF 
CARE STUDIES 
SAMPLE 
VOLUME 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
Pregnancy test 
PB 
2 ml 
X 
As clinically indicated 
Physical exam 
N/A 
N/A 
X 
Weekly 
X 
X 
CBC with diff. 
PB 
0.5 - 2 ml 
X 
Daily until engrafted, then weekly 
X 
X 
Chemistry 
PB 
0.25- 2 ml 
X 
Weekly 
X 
X 
Viral surveillance 
(BMTPCR) 
PB 
4 ml 
X 
Weekly 
As clinically indicated 
Chimerism 
PB 
1-2 ml 
 
Weekly 
Monthly 
BM 
2 ml 
 
X 
 
X 
 
X 
Disease Status 
Evaluation 
BM 
N/A 
X 
X 
 
X 
 
X 
MRD 
PB 
5 ml 
X 
X 
 
X 
 
X 
BM 
0.2-5 ml 
X 
X 
 
X 
 
X 
Lymphocyte 
Subset Study 
PB 
2.5-4 ml 
X 
Monthly 
Quantitative 
Immunoglobulins 
PB 
2.0 ml 
X 
 
 
Every 3 months after off IVIG for minimum of one month 
 
The information derived from or noted on the physical examinations, standard tests, and other assessments that comprise standard of care for recipients are not required to 
be transcribed onto case report forms and/or entered into the database.  In reference to section 6.1 Evaluations, the above-indicated follow-up regimen for these evaluations 
is guided by the SOPs of the Department of BMTCT, for recipients of allogeneic stem cell transplantation.  As these evaluations are considered standard clinical care (non-
research), variations in frequency (more or less frequent) of these evaluations can occur due to the participant’s current clinical condition and will not be noted as protocol 
deviations. 
 
Disease status evaluations/BM testing results obtained prior to enrollment may be used for the baseline/pre-infusion assessments. 
 
 MRD PB required for T-Cell ALL only 
 
Lymphocyte subset studies may be omitted without variance when the absolute lymphocyte count (ALC) is zero. 
 
In the event of graft failure/rejection, the post failure/rejection time period BM, chimerism and several of the applicable immune studies will be held, as these 
blood/marrow tests would not be clinically indicated. 


HAPCORD 60 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX D (continued) 
Immune reconstitution testing and evaluation schedule for RECIPIENT 
RESEARCH 
STUDIES 
SAMPLE 
VOL. 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
LABORATORY 
LYMPHOCYTE 
PHENOTYPES 
RESEARCH 
PB 
17.0 ml 
X 
X 
X 
X 
X 
X 
LEUNG LAB 
VBETA/TREC 
RESEARCH 
PB 
17.0 ml 
X 
 
 
X 
X 
X 
LEUNG LAB 
HOST-DONOR 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
IR-PHENOTYPE 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
5 ml 
X 
X 
X 
X 
X 
X 
T-FUNCTION 
SKIN 
BIOPSY 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
PB – CMV+ 
7.5 ml 
 
WEEKLY x 4 DURING ACTIVE VIRAL REACTIVATION 
BM 
1ml 
X 
X 
 
X 
 
 
 
 
VBETA/TREC Research and Lymphocyte Phenotypes Research results will be maintained in a secured database in the Leung laboratory.  
 
HOST-DONOR, IR-PHENOTYPE, T-FUNCTION testing results will be maintained in a secured database in the Dallas laboratory database. 
 
T-FUNCTION testing in the presence of viral infection and/or reactivation will be obtained as directed above (weekly x4) within the first 100 days post-
transplant, however from Day 100 to Month 12 it will be obtained as possible (includes all viruses).  
 
Skin Biopsy for T-FUNCTION is an optional additional test that may be omitted at the discretion of the PI.  Skin Biopsy may be performed during sedation 
during procedures (i.e. radiation) or at Month 1 without a protocol variation.  
 
For RESEARCH studies, the posted volumes are the minimum volumes required to perform the respective protocol evaluations. 
 
 
 
 
 
 
 
 
 


HAPCORD 61 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
 
 
APPENDIX D (continued) 
Research testing for HAPLOIDENTICAL DONOR 
Prior to initial stem cell collection procedure: 
OPTIONAL research immune studies testing schedule 
Evaluation 
Volume Requirement 
Flow cytometry enumeration 
Lymphocyte Subset Study = 4 mL 
Thymic output and T cell repertoire 
VBETA/TREC Research = 17 mL 
T cell and NK cell number and function 
Lymphocyte Phenotypes Research = 17 mL 
 
 All donor research testing to be collected prior to stem cell collection – preferably prior to growth factor administration.  
These optional research tests may be collected at separate times. 


HAPCORD 62 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX D (continued) 
 
Research Study Evaluation Target Windows 
Several laboratory tests can only be processed on weekdays; therefore, if the scheduled 
evaluation falls on a weekend, or during a holiday period, an adjustment in the follow-up visit is 
expected and would not be noted as a protocol variation.  Additionally, in order to accommodate 
such logistical constraints, evaluation/collection dates of all protocol assessments (required and 
optional research), may be performed within a reasonable window of the intended date following 
the guidelines provided in the table below: 
If the Planned Evaluation 
Time Point is: 
Window 
Weekly 
+ 3 Days 
Month 1 
Week 2 to Week 6 
Month 2 
Week 7 to Week 11 
Month 3 
Week 12 to Month 4 
Month 6 
Month 5 to Month 7 
Month 9 
Month 8 to Month 10 
Month 12 
Month 10 to Month 14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 63 
 
Initial version, dated: 08/22/14 
 
IRB approval date: 10/17/14 
Protocol document date: 08/22/14 
 
APPENDIX E 
The St. Jude Department of BMTCT Clinical SOPs for standard of care for all allogeneic stem 
cell infusion recipients and stem cell donors will provide guidance on the evaluation, ongoing 
clinical care and follow up for this clinical trial.  The current versions of these SOPs, as well as 
ongoing updates, of these documents can be located at the following website: 
http://home.web.stjude.org /bone_marrow/clinicalHome.shtml.    
 

Prot_SAP_003.pdf: 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
  
 
St. Jude Children's Research Hospital 
HAPCORD – NCT02199041 
Initial Version, dated: 04/02/13 Resubmitted to IRB 02/10/2014 (IRB Approved: 02/26/2014)  
Activated:  
Revision 0.1, dated: 08/22/14 (IRB Approved: 10/17/14) 
Activated: 12/09/2014 
Amendment 1.0, dated: 12/12/14 (IRB Approved: 05/04/16) Activated: 
Amendment 2.0, dated 7/16/2016 (IRB Approved: 8/3/2016) Activated: 8/11/2016 
 
COMBINED T CELL DEPLETED HAPLOIDENTICAL PERIPHERAL BLOOD STEM 
CELL AND UNRELATED UMBILICAL CORD BLOOD TRANSPLANTATION IN 
PATIENTS WITH HEMATOLOGIC MALIGNANCIES USING A TOTAL LYMPHOID 
IRRADIATION BASED PREPARATIVE REGIMEN 
 
IND: 16036  
 
Principal Investigator 
Brandon Triplett, MD1 
 
Sub-investigators 
Guolian Kang, PhD3 
Shane Cross, PharmD5 
Ewelina Mamcarz, MD1 
Terrence Geiger, MD, PhD4 
Matthew J. Krasin, MD6 
John Choi, MD, PhD4 
Renee Madden, MD1 
Lea Cunningham, MD1 
Ashok Srinivasan, MD1 
Amr Qudeimat, MD1 
Paul Thomas, PhD7 
William Janssen, PhD1 
Benjamin Youngblood, PhD7  
 
 
 
 
 
 
Department of Bone Marrow Transplantation and Cellular Therapy1 
Department of Oncology2 
Department of Biostatistics3 
Department of Pathology4 
Department of Pharmaceutical Sciences5 
Department of Radiological Sciences6 
Department of Immunology7 
 
St. Jude Children’s Research Hospital 
262 Danny Thomas Place 
Memphis, TN 38105 
(901) 595-3300 
This is a confidential research document. 
No information may be extracted without permission of the principal investigator


Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
  
 
COMMON ABREVIATIONS 
 
Absolute neutrophil count (ANC) 
Acute lymphocytic leukemia (ALL) 
Acute myeloid leukemia (AML) 
Adverse event (AE) 
Alanine aminotransferase (ALT) 
American 
Association 
of 
Blood 
Banks 
(AABB) 
Aspartate aminotransferase (AST) 
Body surface area (BSA) 
Bone marrow (BM) 
Bone marrow transplantation (BMT), 
Bone Marrow Transplantation Follow Up 
(BMTFU) 
Center for International Blood and Marrow 
Transplant Research (CIBMTR) 
Central Nervous System (CNS) 
Central Protocol and Data Monitoring Office 
(CPDMO) 
Chronic Myeloid Leukemia (CML) 
Clinical Data Update System (CDUS) 
Common toxicity criteria (CTC) 
Complete Remission (CR) 
Cord Blood Transplantation (COBLT) 
Creatinine Clearance (CrCL) 
Cyclosporine (CSA) 
Cytomegalovirus (CMV) 
Dimethyl sulfoxide (DMSO) 
Disease-free survival (DFS) 
Epstein-Barr 
virus 
transformed 
lymphoblastoid cell lines (EBV-LCL) 
Event-free survival (EFS) 
Forced vital capacity (FVC) 
Foundation for the Accreditation of Cellular 
Therapy (FACT) 
Graft versus host disease (GVHD) 
Granulocyte colony-stimulating factor (G-
CSF) 
Haploidentical 
HCT 
with 
NK 
infusion 
(HAPNK) 
Health Insurance Portability Act (HIPPA) 
Hematopoietic cell transplantation (HCT) 
Hematopoietic stem cell (HSC) 
Human Application Lab (HAL)  
Human Immunodeficiency Virus (HIV) 
Human leukocyte antigen (HLA) 
Human T-lymphotropic virus (HTLV)  
Institutional Biosafety Committee (IBC) 
Institutional Review Board (IRB) 
International Cord Blood Transplant Registry 
(ICBTR) 
Juvenile Myelomonocytic Leukemia (JMML) 
Killer-immunoglobulin receptors (KIR)  
Matched related/sibling donor (MSD) 
Matched unrelated donor (MURD)  
Minimal Residual Disease (MRD) 
Mycophenolate mofetil (MMF) 
Myeloid Dysplastic Syndrome (MDS) 
National Cancer Institute (NCI)  
National Marrow Donor Program (NMDP) 
Natural killer (NK) 
New York Blood Center (NYBC) 
Overall survival (OS) 
Pharmacokinetics (PK) 
Polymerase chain reaction (PCR) 
Protected health information (PHI) 
Pulmonary Function Testing (PFT) 
Reduced Intensity Conditioning (RIC) 
Shortening Fraction (SF) 
Standard operating procedures (SOP) 
T cell receptor excision circle (TREC) 
Total body irradiation (TBI) 
Total lymphoid irradiation (TLI) 
Total nucleated cell (TNC) 
Total Research and Knowledge System 
(TRACKS) 
Transplant related mortality (TRM) 
Umbilical cord blood (UCB) 
Umbilical 
cord 
blood 
transplantation 
(UCBT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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TABLE OF CONTENTS 
 
Study Summary 
 
1.0 
Objectives…………………………………………………………….………… 1 
 
1.1 
Primary Objective.……………………………………………………..… 
1.2 
Secondary Objectives …………………………………………………… 
1.3 
Exploratory Objectives ……………..…………………………………… 
1 
1 
1 
2.0 
Background and Rationale……………………………………………………… 1  
 
2.1 
Overview………………………………………………………………… 
2.2 
Umbilical Cord Blood Transplantation……..…………………………… 
2.3 
Haploidentical HCT…………..………………………………………….. 
2.4 
Rationale for Total Lymphoid Irradiation Based Preparative Regimen…. 
2.5 
Rationale for Study………………………………………………………. 
2.6 
Minimal Residual Disease (MRD).……………………………………… 
2.7 
Rationale for the Evaluation of Immune Reconstitution After UCBT…. 
1 
2 
4 
7 
8 
10 
10 
3.0 
Protocol Eligibility Criteria……………………………………………………. 11 
 
3.1 
Inclusion Criteria for Transplant Recipient……...……………………… 
3.2 
Exclusion Criteria for Transplant Recipient……...……………………… 
3.3 
Inclusion Criteria for Haploidentical Donors…………………………… 
3.4  
Enrollment on Study…………………………………………………… 
11 
12 
12 
14 
4.0 
Treatment Plan………………………………………………………………….. 15 
 
4.1 
Schema for Protocol Prioritization…………...………………………….. 
4.2 
TLI-based Preparative Regimen…………..……………………………... 
4.3 
UCB Product………………………………..……………………………. 
4.4 
Haploidentical Donor Graft………..…………………...……………….. 
4.5 
Graft Preparation………..………………..……………………………… 
4.6 
Additional Progenitor Cell Graft Administration…………………….….. 
4.7 
Donor Lymphocyte Infusion………..…………………………….…..…. 
4.8 
Quality Assurance of Cellular Products..…………..….………………… 
4.9  Immunosuppressive Therapies ………………………….……………… 
4.10 Management of Pre-engraftment Immune Reaction……………………. 
4.11  Growth Factors (G-CSF).………………………………..………………. 
4.12 Treatment and Conditioning Regimen Related Notes…………………… 
15 
16 
17 
19 
21 
22 
22 
23 
23 
24 
25 
25 
5.0 
Medication Information………………………………………………………… 25 
 
5.1  
Cyclophosphamide………….…………………………………………… 
5.2. 
Thiotepa…………………………………………………………………. 
5.3 
Fludarabine (Fludara)………………………………..…………………... 
5.4  
Melphalan……..………………………………..………………….…….. 
5.5  
Mesna……………………………………………………………………. 
5.6 
Filgrastim ……..………………………………………………………… 
5.7 
Mycophenylate mofetil………………………………………………….. 
5.8  
Tacrolimus……….……………………………………………………… 
25 
26 
27 
28 
29 
29 
30 
31 


 
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5.9 
Methylprednisolone ……..……………………………………………… 
5.10  CliniMACS System……………………………………………………… 
 
32 
33 
6.0 
Required Observations and Evaluations……………...………………………… 34 
 
6.1 
Standard Pre/Peri/Post-Transplant Evaluations……………………….... 
6.2 
Long Term Follow-up Evaluations…………………………………..….. 
6.3 
Research Testing……………………………….……..……..……..…….  
6.4 
Research Testing on Haploidentical Donor…………...……..……..……. 
34 
34 
34 
35 
7.0 
Evaluation Criteria……………………………………………………………… 35 
 
7.1 
Adverse Event Monitoring.……………………………..…………..….... 
7.2 
Acute GVHD ……………………………………………………….…... 
7.3 
Performance Status.………………………………..……..……..……….. 
7.4 
Hematologic Recovery………………………………..……..……..……. 
7.5 
Primary Graft Failure……….………………………..……..……..…….. 
7.6 
Secondary Graft Failure……...…………………………..……..……..… 
7.7 
Mixed Hematopoietic Chimerism……..…………………………..…….. 
7.8     Engraftment Syndrome………………………………………………….. 
35 
35 
36 
36 
36 
36 
36 
36 
8.0 
Off-study Criteria……………………………………………………………….. 37 
 
8.1 
Recipient Off-therapy Criteria …………………..………………………. 
8.2  
Recipient Off-study Criteria…………………….……………………… 
8.3  
Donor Off-study Criteria………………………………………………… 
37 
37 
37 
9.0 
Reporting Criteria………………………………………………………………. 37 
 
9.1 
Reporting Adverse Experiences and Deaths……..……..……..……..….. 
9.2 
Reporting to SJCRH Institutional Review Board (IRB)………………… 
9.3 
Reporting to SJCRH Biosafety Committee (IBC)……………………….. 
9.4 
Reporting to US Food and Drug Administration (FDA)……..……..…… 
9.5 
Reporting to SJCRH Regulatory Affairs Office.…….…..……..……..…. 
9.6 
Continuing Review Reports...……..……..……..……..…..............….…. 
9.7  
Reporting to the St. Jude Data Safety Monitoring Board………………... 
9.8 
Data Submission to Miltenyi Biotec…….……..……..…..............….…. 
9.9 
Reporting to Center for International Blood and Marrow Transplant 
Research (CIBMTR)….……..……..……..……..…..……..……..……. 
37 
38 
39 
39 
40 
40 
40 
40 
40 
10.0 Data Collection, Study Monitoring, and Confidentiality……………………… 41 
 
10.1 Data Collection…………………………………………....….….….…… 
10.2 Study Monitoring………………………………..….….….….….……… 
10.3  Confidentiality…………………………………………………………… 
41 
41 
42 
11.0 Statistical Considerations……………………………………….. 
42 
 
11.1 Statistical Design and Analysis for the Primary Objective……….…….. 
11.2 Statistical Analysis for the Secondary Objectives………………………. 
11.3  Analysis for Exploratory Objectives…………………………………….. 
42 
45 
46 
 
 


 
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12.0 Obtaining Informed Consent…………………………………………………… 46 
 
12.1 
Informed Consent Prior to Research Interventions…………………… 
12.2 
Consent at Age of Majority…………………………………………… 
12.3 
Consent When English is Not the Primary Language………………… 
47 
47 
47 
13.0 References………………………………………………………………….…. 
48 
 
Appendix A: Karnofsky and Lansky Performance Score………………………. 
Appendix B: COG Consensus Guidelines Acute GVHD Grading……………. 
Appendix C: Chronic GVHD Grading………………………………………... 
Appendix D: Adverse Event Evaluation………………………………………... 
Appendix E: Testing and Evaluation……………..…………………………….. 
56 
57 
64 
67 
68 
 
Appendix F: BMT Standard Operating Procedure……………………………... 72 
 
 
  


 
Amendment 2.0, dated: 7/16/2016 
 
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STUDY SUMMARY 
HAPCORD:  
Principal Investigator: Brandon Triplett, MD 
IND/IDE: 16036 
Brief Overview: In this study, participants with high-risk hematologic malignancies undergoing 
hematopoietic cell transplantation (HCT), who do not have a suitable human leukocyte antigen 
(HLA)-matched related/sibling donor (MSD), matched unrelated donor (MURD) or killer-
immunoglobulin receptors (KIR) ligand mismatched haploidentical donor identified, will receive 
a combined T cell depleted (TCD) haploidentical peripheral blood stem cell (PBSC) and 
unrelated umbilical cord blood transplantation (UCBT) using a total lymphoid irradiation (TLI) 
based preparative regimen. Patients who have a suitable KIR ligand mismatched haploidentical 
donor will be preferentially enrolled in available haploidentical protocol if clinically appropriate. 
Those with a suitable HLA matched sibling, unrelated donor or KIR mismatched haploidentical 
donor identified may be eligible for participation if the donor is not available in the necessary 
time. Participants must be ≤ 21 years old and with sufficient multi-organ function as specified in 
protocol. The assessments and follow-up evaluations noted in the protocol follow the St. Jude 
standard operating procedures (SOP) for all recipients of allogeneic HCT.  
Intervention: Combined TCD haploidentical PBSC graft with an unrelated UCBT graft using a 
TLI-based preparative regimen. The haploidentical graft will undergo processing for T cell 
depletion and CD34+ stem cell selection.  
Brief Outline of Treatment Plan: The preparative regimen includes total lymphoid irradiation 
(TLI) (8 Gy), fludarabine (150 mg/m2), cyclophosphamide (60mg/kg), melphalan (140 mg/m2) 
and thiotepa (10mg/kg). TLI will be administered in 4 fraction at 200 cGy/fraction over 3 days 
on day -9 to day -7, fludarabine will be given once a day at 30 mg/m2 for five days on day -8 to 
day -4, cyclophosphamide will be given once a day at 60mg/kg for one day on day -6, thiotepa 
will be given twice a day at 5 mg/kg for one day on day -3, and melphalan will be given once a 
day for 2 days on day -2 and day-1. Post-transplantation immunosuppression with tacrolimus 
will begin on day -2 and MMF on day 0. Haploidentical donor product will be processed for 
CD45RA+ depletion and CD34+ selection and will be infused on day 0 and day +1. Cord Blood 
infusion will occur on day +2. G-CSF may start on day +3, but may be held at the discretion of 
the attending physician.  
Objectives:  
Primary objective  
 Estimate the incidence of donor derived neutrophil engraftment by day +42 post-
transplant for participants with high-risk hematologic malignancies undergoing a total 
lymphoid irradiation (TLI)-based hematopoietic cell transplantation (HCT) using a T cell 
depleted (TCD) haploidentical donor peripheral blood stem cell (PBSC) donor combined 
with a unrelated umbilical cord blood (UCB) donor. 
Secondary objectives: 
 Estimate the incidence of malignant relapse, event-free survival, and overall survival at 
one-year post-transplantation. 
 
Estimate the incidence and severity of acute and chronic graft versus host disease 


 
Amendment 2.0, dated: 7/16/2016 
 
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(GVHD). 
 
Estimate the incidence of secondary graft failure, transplant related mortality (TRM) 
and transplant related morbidity in the first 100 days after transplantation. 
Exploratory Objectives 
 
Assess the relationship between pre-transplant minimal residual disease (MRD) with 
transplant outcomes. 
 
Record 
immune 
reconstitution 
parameters, 
including 
chimerism 
analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B and NK cells and 
lymphocytes will also be evaluated.  
 
Characterize the recovery of Gamma Delta (γδ) T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  
 
Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility. 
Hypotheses/Estimates:  
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 30% will 
have a suitable matched related/sibling donor (MSD) and another 30% will have a matched 
unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-60% of eligible 
pediatric recipients, and the lengthy duration of the donor search process in those with high risk 
of relapse have prompted investigators to use an alternative source of HSC, namely UCB.3 
Although UCB has been shown to be a suitable source of HSC, initial studies suggested UCBT is 
associated with increase incidences of TRM when compared to recipients of MSD or MURD.5,6 A 
pilot study in adults that combined TCD haploidentical PBSC and an unrelated UCB graft resulted 
in rapid neutrophil engraftment with minimal GVHD and durable remission.7 Here, we propose to 
investigate the outcomes of pediatric patient with high-risk malignancies undergoing a 
combined TCD haploidentical PBSC and unrelated UCB using a TLI-based preparative regimen 
at St. Jude Children’s Research Hospital. The primary objective of the study is to estimate the 
rate of donor derived neutrophil engraftment by day +42 post-transplant. Secondary aims will 
assess graft failure, overall survival, event-free survival, risk of relapse, graft versus host 
disease (GVHD), transplant related mortality (TRM), transplant related morbidity, and immune 
reconstitution. 
 
Criteria for Evaluation:  
Safety Evaluation  
 The primary measures of safety will be the rate of therapy related death and the rate of 
severe graft versus host disease. 
 Ongoing assessment of toxicity will be done using the NCI CTC version 4. Acute GVHD 
will be evaluated using the standard grading criteria (Appendix B). 
Efficacy  
 Neutrophil and platelet engraftment will be determined using the parameters put forth by 
the Center for International Blood and Marrow Registry. Assessments will be made upon 
review of daily complete blood count and serial chimerism studies. 
 BM studies for disease status evaluation will be performed at approximately 28 days, 100 
days, and yearly post-transplant.  


 
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Protocol document date: 07/16/2016 
 
 Acute GVHD will be assessed using the standard grading criteria put forth by Prezpiorkia 
et al 1995. Chronic GVHD will be assessed using the NIH Consensus Criteria for 
Chronic GVHD 2005 (Appendix B). 
 
Study Design: Phase II - Non Randomized  
Study Population: Patients with high-risk hematologic malignancies who are in complete 
remission or AML in first relapse with less than 25% blasts at the time of evaluation are eligible 
for enrollment. Participant must be less than or equal to 21 years old.  
Candidates must have a suitable UCB product available (matched ≥ 4 of 6 to the patient 
sufficient with sufficient cell dose). Those with a suitable HLA matched sibling, matched 
unrelated donor, or KIR mismatched haploidentical donor identified will be eligible for 
participation if the donor is not suitable or available in the necessary time. For example, patients 
who have a KIR mismatched haploidentical donor but have relapsed after a KIR mismatched 
haploidentical HCT are eligible for this protocol. Additional eligibility criteria are specified to 
assure sufficient multi-organ system function. 
Inclusion criteria for transplant recipient 
 Age less than or equal to 21 years old. 
 Has a partially HLA-matched single UCB product available.  
 Has a partially HLA-matched haploidentical related donor available.  
 High-risk hematologic malignancy. 
 Very high risk ALL in CR1, ALL in High risk CR2, ALL in CR3 or subsequent. 
 AML in high risk CR1, AML in CR2 or subsequent 
 
Therapy related AML, with prior malignancy in CR > 12mo 
 
MDS, primary or secondary 
 
NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
 
CML in accelerated phase, or in chronic phase with persistent molecular positivity or 
intolerance to tyrosine kinase inhibitor. 
 
Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous HCT, or 
unable to mobilize stem cells for autologous HCT. 
 
Non-Hodgkin lymphoma in CR2 or subsequent. 
 
JMML 
 
Refractory hematologic malignancies (ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin lymphoma) due to chemoresistant relapse or primary induction failure. 
 
All patients with evidence of CNS leukemia must be treated and be in CNS CR to be 
eligible for study. 
 Patient must fulfill pre-transplant evaluation: 
 
Left ventricular ejection fraction ≥ 40% or cardiac shortening fraction ≥ 25%. 
 
Creatinine clearance or GFR ≥ 50 ml/min/1.73m2. 
 
Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry ≥ 92% on 
room air. 
 
Karnofsky (≥ 16 years) or Lansky (<16 years) performance score ≥ 50  


 
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 
Bilirubin ≤ 3 times the upper limit of normal for age. 
 
Alanine aminotransferase (ALT) ≤ 5 times the upper limit of normal for age. 
 
Aspartate aminotransferase (AST) ≤ 5 times the upper limit of normal for age. 
 
Exclusion Criteria for Transplant Recipients:  
 Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical donor 
available in the necessary time for stem cell donation. 
 Patient has any other active malignancy other than the one for which HCT is indicated. 
 
Patient is pregnant as confirmed by positive serum or urine pregnancy test within 14 days 
prior to enrollment. 
 
Patient is breast feeding 
 
Patient has Down Syndrome 
 
Patient has a current uncontrolled bacterial, fungal, or viral infection per the judgment of 
the PI. 
Sample Size: Up to 49 evaluable.  
Randomization: N/A 
Data Analyses: Statistical considerations and ongoing analysis will be conducted by Dr. 
Guolian Kang and designated associates within the St. Jude Department of Biostatistics.  
Anticipated Primary Completion Date: (5 years) 
Anticipated Study Completion Date: (6 years) 
Timeframe for Primary Outcome Measure: 42 days 
Data Management: Protocol compliance, data collection including safety data, and reporting 
will be carried out by the Department of Bone Marrow Transplantation and Cellular Therapy 
Research Office. 
Human Subjects: The risks to subject are primarily related to the infusion and the 
conditioning regimen. The allogeneic stem cells may induce serious and possibly fatal 
disorders such as GVHD, veno-occlusive disorder and post-transplant lymphoproliferative 
disease. Because of the required conditioning, recipients are at high-risk for serious and 
possibly life-threatening infection, bleeding, and anemia. Adverse events will be treated, 
monitored, and reported appropriately. 
Possible benefits of participation include obtaining and/or sustaining disease remission. In 
addition, there is the possibility of psychological benefit from knowing participation has helped 
researchers gain more understanding about the efficacy of UCBT. 
Alternatives to participation are identified as chemotherapy, research treatment if available, 
and/or supportive therapy. 
The possible benefits, alternatives to participation, and side effects, including that there may be 
unknown side effects of treatment, are detailed in lay language within the respective informed 
consent documents. 


HAPCORD 1 
 
Amendment 2.0, dated: 7/16/2016 
 
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1.0 OBJECTIVES 
1.0 Primary objective 
1.1.1 To estimate the incidence of donor derived neutrophil engraftment by day +42 
post-transplant for participants with high-risk hematologic malignancies 
undergoing a total lymphoid irradiation (TLI)-based preparative regimen using a 
T cell depleted (TCD) haploidentical peripheral blood stem cell (PBSC) combined 
with an unrelated umbilical cord blood (UCB) graft. 
1.1 Secondary objectives  
1.2.1  Estimate the incidence of malignant relapse, event-free survival (EFS), and 
overall survival (OS) at one-year post-transplantation. 
1.2.2 Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD) in the first 100 days after transplantation. 
1.2.3 Estimate the incidence of secondary graft failure, transplant related mortality 
(TRM) and transplant related morbidity in the first 100 days after transplantation. 
1.3 Exploratory Objectives 
1.3.1 Assess the relationship between pre-transplant minimal residual disease (MRD) 
with transplant outcomes. 
1.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B and NK cells 
and lymphocytes will also be evaluated.  
1.3.3 Characterize the recovery of Gamma Delta (γδ) T cells after HCT, including T 
cell receptor analysis, phenotyping and functional analysis.  
1.3.4  Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  
2.0 BACKGROUND AND RATIONALE 
2.1 Overview 
Allogeneic HCT has become a widely accepted curative therapy for many hematologic 
malignancies that cannot be cured with chemotherapy alone.9,10 Studies have 
demonstrated that HCT is a potentially curative therapy for patients with CML, AML, 
ALL and MDS.11-14 Furthermore, patients with non-Hodgkin or Hodgkin’s lymphoma 
who recur after an autologous HCT may be successfully treated with an allogeneic 
HCT.15,16 
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 
30% will have a suitable matched related/sibling donor (MSD) and another 30% will have 
a matched unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-
60% of eligible pediatric recipients, and the lengthy duration of the donor search process 
in those with high risk of relapse have prompted investigators to use an alternative source 
of HSC, namely UCB.3 Recent comparative studies report no significant difference in OS 
in patients undergoing UCBT compared to MURD HCT.17-21 Thus, the number of 
patients undergoing UCBT has rapidly increased over the past 10 years. In the pediatric 


HAPCORD 2 
 
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population, UCB is now the most common source of HSC in unrelated donor transplant. 
However, the limited number of progenitor cell in the UCB unit result in delayed and 
unpredictable count recovery. The delayed neutrophil recovery predisposes patients to 
infection and malignant relapse. Recipients of UCBT are associated with increase 
incidences of TRM when compared to recipients of MSD or MURD HCT.5,6 The goal of the 
protocol is to decrease the risks associated with delayed neutrophil recovery. 
Recently a pilot study demonstrated that by combining a TCD haploidentical PBMC 
product and an unrelated UCB graft resulted in rapid neutrophil engraftment with minimal 
GVHD and durable remission.7 St. Jude has gained considerable expertise with 
haploidentical HCT in children 22-29 and we propose to investigate the outcomes of 
pediatric patient with high-risk malignancies receiving a combine TCD haploidentical 
PBSC and UCB graft using a TLI-based preparative regimen at St. Jude Children’s 
Research Hospital. 
2.2 Umbilical Cord Blood Transplantation (UCBT) 
2.2.1 Historical Background: 
The use of UCB as a clinical source of HSC was first considered in the late 
1960’s when UCB from eight donors were pooled and infused into a 16 year old 
male with acute lymphocytic leukemia (ALL).30 Although full reconstitution was 
not observed, there was evidence suggesting transient mixed chimerism. 
Thereafter, additional studies were performed that suggested that if adequate 
numbers of HSC could be collected; UCB has the potential for long-term 
reconstitution. In 1989 the first successful matched sibling UCBT was performed 
for a child with Fanconi anemia. In 1995, the International Cord Blood Transplant 
Registry (ICBTR) reported the results of the first 44 matched sibling UCBT 
demonstrating UCB contained sufficient number of hematopoietic progenitors to 
reliably engraft transplant recipients after a myeloablative conditioning regimen.31  
The first successful unrelated UCBT in a pediatric patient occurred at Duke 
University in 1993.32,33 In 1996, Kurtzberg et al and Wagner et al simultaneously 
published the unrelated UCBT experiences at Duke and Minnesota, 
respectively.33,34 These initial studies showed the median time to neutrophil 
recovery was 22 and 24 days, respectively. Combining the 43 patients, 88% 
engrafted, 54% had Grade II-IV GVHD and 9% had Grade III-IV GVHD. The OS 
at 100 days was 53%. Together, these studies suggested that UCB is a suitable 
alternative source of allogeneic HSC for pediatric patients.  
In nearly every large single center or registry analysis of outcomes after UCBT, 
cell dose is identified as an important factor influencing the incidence and rate of 
hematopoietic recovery, risk of TRM, and probability of survival. Furthermore, 
data suggest that infusion of two partially HLA-matched UCB units, which 
always augments the graft cell dose, is safe and may improve neutrophil recovery 
and survival. To determine whether the infusion of two UCB units enhances 
survival, the Blood and Marrow Transplant Clinical Trials Network (BMTCTN) 
proposed a multi-center randomized trial in 2006. Preliminary data suggest that 
patients receiving double unit UCBT have a higher risk for acute GVHD albeit a 
lower risk for relapse. However, until data clearly demonstrate a survival 


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advantage, double UCBT is currently only recommended for those patients who 
do not have an adequate single unit.35  
Lastly, in the past decade, large comparative studies evaluating the outcomes of 
transplantation using UCB versus other HSC sources have been performed. 
Reports demonstrate that the incidence of GVHD was lower in patients 
undergoing UCBT compared to HLA-matched bone marrow (BM) recipients. 
Furthermore, recent studies that include long-term analysis demonstrate that 
outcomes are similar for patients undergoing transplantation using MURD or 
UCB sources.14-18, 25 Thus, UCBT should be considered as a viable options for 
patients with high-risk malignancies.17-21,36 7-11, 25 
2.2.2  Cell Dose Threshold and Interaction with HLA match 
Cell dose remains one of the single most important determinants of a successful 
UCBT.37-39 Numerous clinical studies have shown that the total nucleated cell 
(TNC) dose and the CD34+ cell dose in the UCB graft are highly correlated with 
neutrophil and platelet engraftment as well as the incidence of graft failure and 
early TRM.3,38,40,41 The first Eurocord Registry report by Gluckman et al, 1997, 
demonstrated that among 527 patients undergoing UCBT, the most important 
predictor in outcome was the infusion of ≥ 3 x 107 TNC per kilogram body 
weight.37,42 Moreover, adult recipients had increased TRM by day 180 compared 
to children (56% versus 32%), and deaths were related to the number of cells 
infused, with patients who received ≤ 1 x 107 TNC/kg having a 75% probability 
of death compared to 30% for those who received ≥ 3 x 107 TNC/kg. Rubinstein 
et al, 1998, published the New York Blood Center experience with 562 patients 
undergoing UCBT and similarly demonstrated a strong correlation between the 
number of leukocytes infused and neutrophil engraftment.39 Thus, the collective 
data point to improved outcome of UCBT for patients receiving a larger number 
of CD34+ cells. Delayed neutrophil engraftment has also been correlated with 
HLA mismatch at greater than 2 loci, but recent studies have suggested that the 
impact of HLA disparity on survival can be partially overcome by increasing cell 
dose.43 Combined, these studies identified a minimum threshold for cell dose and 
HLA matching which lead to a significant reduction in TRM after UCBT. 
Although the exact threshold criteria for each degree of HLA mismatch is not 
know, the principle for the dose algorithm is clear.35,44,45 
2.2.3  Role of Double UCBT 
For most adults and large children, a single UCB unit that meets the cell dose 
requirement is not available. To overcome this obstacle, investigators at the 
University of Minnesota began infusing two partially HLA-matched units to 
augment cell dose. They found that neutrophil engraftment was achieved more 
rapidly and in a higher proportion of patients than the previous cohort who 
received only a single UCB unit.46 Preliminary evidence suggests that double unit 
UCBT may be associated with a decreased risk of relapse in patients with good 
disease control at the time of transplant, but is also associated with a increased 
incidence of mild to moderate acute GVHD compared to single UCBT.47,48,49 
Currently, it is unclear whether double UCBT offers any benefit other than 


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extending the application of UCBT by achieving the cell dose threshold.50 Until 
data clearly demonstrate a survival advantage, double UCBT is currently only 
recommended for those patients who do not have an adequate single unit.51 An 
adequate single unit is defined as: ≥ 3.0 x 107 nucleated cells/kg for 6/6 HLA-
matched units, ≥ 4.0 x 107 nucleated cells/kg for 5/6 HLA-matched units and ≥ 
6.0 x 107 nucleated cells/kg for 4/6 HLA-matched units.49,51,52Despite adequate 
cell dose, patients undergoing double UCBT continue to have delayed neutrophil 
engraftment compared to MSD and MURD HCT.  
2.2.4  UCBT Results 
Neutrophil Engraftment: Most studies report the time to hematopoietic recovery 
after UCBT is delayed with the median time to neutrophil recovery ranging 
between 20 - 30 days and the incidence of neutrophil engraftment after single 
UCBT ranges from 65-92%.32,34,38,39,41,42,53-61 Studies have consistently 
demonstrated the rate and incidence of neutrophil engraftment after UCBT is 
slower than bone marrow transplantation (BM), dependent on cell dose and the 
threshold for cell dose depends on HLA match grade.  
GVHD: The first report from the New York Blood Center experience by Rubinstein 
et al indicated that GVHD after UCBT occurred at a lower rate compared to those 
with MURD transplantation.39 Thereafter, Rocha et al published the first 
comparative analysis between UCBT and MURD transplantation in pediatric 
patients that substantiated the claim that acute and chronic GVHD were less 
common in recipients of UCB.19 In larger studies, the incidence of acute GVHD is 
reported to range from 33-44% and 11-22% for grades II-IV and III-IV acute GVHD 
respectively. The incidence of chronic GVHD ranges from 0-25%.38,39,58,60,61  
Survival: Nearly all studies demonstrate a significant relationship between UCB cell 
dose and survival and the reported probability of survival after single UCBT ranges 
from 18-78%.17,21,41,46,48,52,62-66 One of the largest reports from the Center for 
International Blood and Marrow Transplant Research (CIBMTR) by Eapen et al in 
2007 compared the outcomes of 785 pediatric patients with acute leukemia who 
received a UCBT (n=503) or an unrelated BMT (n =282). The most notable finding 
was that UCBT compared favorably to an 8/8 allele-matched unrelated BMT. In 
comparison with allele-matched BMT, the 5 year disease free survival (DFS) was 
similar to that after either one or two antigen mismatched UCBT and possibly higher 
after 6/6 allele-matched UCBT.17 These and other studies support that UCB should 
be considered an acceptable source of HSC grafts in the absence of an HLA-
matched donor. 17,18,21,38,39,41,46,48,52,58,60-67 
2.3 Haploidentical HCT 
2.3.1 
Haploidentical HCT Background 
Haploidentical donors are another viable alternative donor source when a MSD or 
MURD are not available. Also, family members are highly motivated, easily 
accessible, and readily available for most patients. Along with other institutions, St. 
Jude has shown haploidentical HCT to be an effective therapy for patients with 
hematologic malignancies.68-72 Due to the high potential for GVHD with the 


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degree of HLA mismatch seen in haploidentical HCT, most haploidentical grafts 
are extensively TCD prior to infusion.73 Significant progress was achieved when 
high cells dose of CD34+ cells were infused after high-intensity conditioning.71 It 
has been well established that prompt neutrophil engraftment with rapid immune 
reconstitution can be achieved with CD34+ enriched haploidentical cells, purified by 
positive (CD34+) and negative (CD3- lectin agglutination) selection.74,75 
Building on the initial studies above, St. Jude has gained considerable expertise with 
haploidentical HCT in children.22-27,29,76 Over the past decade (2001-2010), more 
than 220 mismatched related donor HCT have been performed at St. Jude. Initially, 
most haploidentical HCT performed in this institution were for patients with 
relapsed and refractory hematologic malignancies, however as it became a more 
successful therapeutic maneuver, it has become a primary transplant option for 
patients who lack a well matched donor.28  
Recent studies suggest that alloreactive NK cells play a role in graft versus 
leukemia (GVL) and influence outcomes of patients with hematologic 
malignancies after haploidentical HCT.77-84 The NK cell alloreactivity depends on 
the balance of signals mediated through activating and inhibitory KIRs on the NK 
cell. In patients who received haploidentical HCT for high-risk leukemia at 
SJCRH the presence of KIR mismatch dramatically reduced the risk of relapse.25 
Thus, patients with high risk hematologic malignancies that lack an HLA-
matched donor but have a KIR mismatched haploidentical donor available, would 
be expected to benefit from haploidentical HCT. 
2.3.2  Rationale for immunomagnetic TCD of hematopoietic progenitor cell graft  
Donor T cells in the haploidentical graft play a major role in mediating GVHD, 
with as few as 3 x 104 T cells/kg can cause GVHD.85 TCD allows for a HSC graft 
with very low T cell content, such that the risk of GVHD is decreased. T cells can 
be removed from the HSC graft by direct removal of T cells (negative selection) 
or positive selection of CD34+ progenitors. St. Jude has had success using either 
method of TCD in haploidentical donor transplantation.  
In this study, CD34+ selection by CliniMACS will be the used for TCD of the 
haploidentical graft. Although positive selection allows for extensive TCD, the 
graft is devoid of other important cell populations such as NK cells and myeloid 
cells such as dendritic cells and monocytes.86,87 In addition, this extensive degree 
of TCD has significant negative effects on the time to donor immune competency. 
Donor T cells are critical for reconstituting the allogeneic host immune system, 
and lymphocyte recovery is an important determinate of outcome post-
transplant.88,89 Transplants that employ TCD result in elimination of most 
memory T cells, leading to protracted immune dysfunction- an effect that 
becomes more severe with higher intensity conditioning regimens.22,90 This results 
in an increased rate of opportunistic infections. Indeed, viral infections are the 
most common cause of death of children receiving haploidentical transplants.91 
The majority of these infections occur within the first 6 months following 
transplantation, when T cell immunity is the lowest.92 Reconstitution of immunity 
can be partially restored by therapeutic infusions of donor cytotoxic 


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lymphocytes.88,93-95 However, in addition to requiring significant resources and 
expertise, the cells must be engineered or selected for specific infections - making 
this approach impractical for broad application.96  
A more ideal approach would be to infuse a cell product with diverse lymphocyte 
repertoire capable of effectively recognizing a variety of pathogens, as well as 
malignant cells without additional GVHD risk. One strategy would be to target 
naïve T cells for lymphocyte depletion. Naïve T cells are fully matured but do not 
proliferate until they encounter their receptor specific ligand.97 After ligand 
recognition, there is activation of proliferative signals that initiates a marked, 
antigen-specific cell expansion and inflammatory response. While many of these 
naïve T cells will undergo apoptosis after the initial response, others are rescued 
from immune retraction and will persist as memory T cells. Once generated, 
memory cells persist in the circulation as a diverse cell pool that is critical for 
long-term infection control.98 Furthermore, memory T cells are capable of more 
rapidly responding to future infectious challenges.99 
The isoform of the leukocyte common antigen, CD45RA, selectively identifies 
naïve T cells. Human studies have shown that sorted donor CD45RA+ naïve T 
cells are far more alloreactive than all memory subsets tested.100 In animal 
models, naïve T cells, are potent inducers of GVHD.96 Moreover, in similar 
models, lymphocyte infusions specifically depleted of CD45RA+ naïve T cells do 
not cause GVHD.101 Conversely, CD45RA- memory T cells do not cause physical 
or histologic evidence of GVHD. Among CD4+ T cells, the CD45RA- subset has 
equivalent “helper” functions as CD45RA+ cells in the generation of alloreactive 
cytotoxic T cells.102 Further, it is the CD45RA- memory cells that are responsible 
for aiding B-cell differentiation and antibody production.  
After demonstrating promising pre-clinical results, selective CD45RA depletion 
in patients undergoing HCT are underway, including two at SJCRH (RADIANT 
and HAPNK1). Depletion of CD45RA+ cells by magnetic beads has been shown 
to be a feasible and effective method for depletion of naïve T cells, with up 
greater than 3-log depletion in number of CD45RA+ cells (Data provided by 
Miltenyi). Furthermore, experiments were performed in the HAL to confirm and 
qualify the CD45RA+ depletion procedures. HSC products were obtained from G-
CSF mobilized normal donors by apheresis. The HPC, Apheresis products were 
depleted of CD45RA+ cells following a procedure provided by Miltenyi Biotech. 
Briefly, the cells were incubated with the CD45RA microbead reagent followed 
by washing to remove unbound beads. The labeled cells were then applied to the 
CliniMACS device (Depletion Tubing Set) and the CD45RA+ cells removed 
using the Depletion 3.1 program. Flow cytometric analysis before and after 
depletion was performed following procedures provided by Miltenyi Biotech. The 
results of the experiments are presented in the table below. An example flow 
cytometric analysis of CD3+ cells is also included. We hypothesize combining a 
CD34+ enriched product (HPC, Apheresis 1) along with a CD45RA+ depleted 
product (HPC, Apheresis 2) will provide a HSC graft with good stem cell content 
(3-5 x 106 CD34+ cells/kg) and a useful memory T cell fraction without additional 
GVHD risk to the recipients on this trial. Although some patients will have a graft 


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derived from the UCB donor, we hypothesize that the novel TCD haploidentical 
PBSC graft may provide immune protection during the period of severe 
lymphopenia and/or help facilitate the engraftment of the new donor. 
CELL COUNTS PRE AND POST DEPLETION 
 
Experiment 1 
Experiment 2 
Pre  
Post  
Pre  
Post  
No. of TNC (106) 
29748 
10270 
26166 
10981 
No. of CD34+ (106) 
636 
311 
693 
395 
No. of CD3+ (106) 
12238 
4555 
6353 
1985 
No. of CD3+CD45RA+(106) 
7877 
4 
3520 
2.2 
CD3+ CD45RA+ Log Depletion 
 
3.28 
 
3.21 
 
2.4 Rationale for TLI-based Preparative Regimen 
TLI-based preparative regimens have the potential to improve the outcomes of allogeneic 
HCT by decreasing the acute TRM compared to regimens using total body irradiation 
(TBI).103-105 TLI was initially developed with curative intent in patients with Hodgkin 
Lymphoma, and it was its use in these patients that led to the discovery of TLI’s alteration 
of T-cell specific immune responses. Years of pre-clinical research on TLI have shown that 
the use of TLI promotes neutrophil engraftment and reduces GVHD.106 This work was then 
followed up with therapeutic trials in humans with hematologic malignancy, which showed 
that conditioning with TLI and ATG alone allowed a high rate of durable donor 
engraftment, a low rate of GVHD, and preservation of evidence of graft versus malignancy 
effect, in patients who received HLA-matched related or unrelated donor grafts.107,108 We 
have significant institutional experience using TLI-based regimens for allogeneic 
transplantation (n=29 as of June 2012). Importantly, TLI-based conditioning has allowed 
successful salvage HCT in patients who failed previous allo-HCT. Nine patients have 
received TLI-based conditioning with haploidentical donor HCT after experiencing previous 
allograft failure (3 had primary graft failure, 4 had initial neutrophil engraftment with acute 
rejection, and 2 had late graft failure). The same haploidentical donor was utilized in 5 of the 
9 salvage HCT, with 4 patients receiving a new (haploidentical) donor. Eight of 9 patients 
(89%) experienced durable neutrophil engraftment at a median of 12 days (range 10 – 27 
days). The remaining patient had primary graft failure due to progressive disease. This 
experience indicates that TLI is effective for facilitation of neutrophil engraftment, even in 
patients receiving a mismatched haploidentical donor graft and with a history that indicates 
a very high risk of graft failure. There is additional published experience from Germany in 
which TLI – given as a single 7Gy fraction – was utilized in 14 adult and pediatric patients 
for reconditioning after graft failure/rejection.109 Despite most of the patient having 
haploidentical donors, neutrophil engraftment was obtained in all evaluable patients. In 
addition, TLI was well tolerated in this pediatric population that had recently received 
another (typically myeloablative) preparative regimen. Finally, 10 patients in Chile received 
TLI-containing preparative regimen, similar to our proposed regimen, as a part of their 
haploidentical donor preparative regimen.110 TLI was given as a single dose at 7Gy. Nine 
out of 10 patients experienced rapid donor neutrophil engraftment, with relapse as the cause 
of the one primary graft failure. Six of 10 patients were alive and disease free at one year, 3 
died of progressive disease, and one of infection. 


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2.5 Rationale for Study 
In the past 20 years, over 20,000 UCBT have been performed worldwide and over 
400,000 UCB units have been stored in more than 100 UCB banks.33,40,111 The main 
practical advantages of using UCB as an alternative source of HSC are (1) rapid 
availability, (2) absence of donor risk, (3) relative ease of procurement, (4) absence of 
donor attrition, (5) very low risk of transmissible infectious diseases and (5) low risk of 
acute GVHD despite HLA mismatch. Furthermore, UCB is particularly beneficial for 
patients of ethnic and racial minority descent for whom adult marrow and blood donors 
often cannot be identified.33,39,40,111 According to data from the National Marrow Donor 
Program (NMDP) donor registry, the probability of finding an 8 out of 8 HLA-matched 
donor is 51% for Caucasians, 30% for Hispanics, 20% for Asians and 17% for African 
Americans. Since patients who do not have a MURD can undergo a mismatched 
unrelated UCB transplantation and achieve similar results, the number of patients 
undergoing UCBT has rapidly increased over the past 10 years. The CIBMTR reports 
that from 2004 to 2008, UCB is now the most common graft source and BM is no longer 
the most common unrelated donor graft source for patients 20 years or less. Furthermore, 
in 2007 and 2008, 46% of all unrelated donor transplantations used UCB grafts for 
patients 20 years or less. 
Patients who do not have an appropriate MSD or MURD donor available in a timely manner 
often undergo transplantation using an alternative HSC source from UCB or haploidentical 
donors. Often, the type of donor is chosen based on various factors related to urgency of 
transplantation, patient, disease, and transplant-related factors as well as the center’s 
experience. Although a prospective randomized clinical trial is the accepted standard to 
compare different treatment regimens, the feasibility and acceptability of such a clinical 
trial is problematic and has not been performed. However, retrospective studies 
comparing the two donor sources have demonstrated no difference in survival.  
The Eurocord group performed a retrospective study comparing the outcome of pediatric 
patients with high-risk ALL undergoing either UCBT or haploidentical HCT. Patients 
had received either haploidentical (n=118) or UCB (n=341) transplantation in Eurocord 
centers between 1998 and 2004. The median follow-up was 56 and 24 months for 
haploidentical and UCBT patients, respectively. Failure of neutrophil engraftment was 
significantly higher following UCBT than after haploidentical HCT (23% vs. 11%, 
p=0.007). In a multivariate analysis, relapse incidence was higher in haploidentical HCT 
recipients compared to UCBT (relative risk 1.7, p=0.01), but TRM and DFS were not 
significantly different. In conclusion, in pediatric patients with ALL, UCBT is associated 
with inferior rate of neutrophil engraftment, higher incidence of grades II–IV acute 
GVHD and lower incidence of relapse compared to haploidentical HCT; however, there 
was no difference in terms of TRM and DFS. Therefore, in the absence of an HLA-
identical donor, both strategies were reported to be suitable options to treat a child with 
high-risk ALL.  
At our institution, patients who do not have an appropriate MSD or MURD donor available 
often undergo a haploidentical HCT. Studies at St. Jude have shown the presence of 
natural killer (NK) KIR mismatch in a haploidentical donor dramatically reduced the risk 
of relapse in patients who received HCT for high-risk leukemia.25,26 KIR mismatch is 
predictive of NK alloreactive effects in haploidentical HCT.25,26,79,81 Thus, patients who 


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have a KIR mismatch haploidentical donor will be enrolled into an available 
haploidentical HCT. However, one-third of all patients posses all relevant KIR ligands 
and will not have a KIR mismatched haploidentical donor. These patients will require an 
alternate donor for best clinical outcome. Patients who require an alternative donor HSCT 
and do not have a KIR mismatched haploidentical donors are likely to benefit most from 
UCBT for best clinical outcome. Contradictory results have been reported on the effect of 
KIR matching in UCBT. The European group reported KIR-ligand incompatible UCBT 
improved DFS (hazards ratio = 2.05, p = .0016) and OS (hazards ratio = 2.0, p = .004) 
and decreased relapse incidence (hazards ratio = 0.53, p = .05).112 However, the 
Minnesota group found no advantage using KIR matching in UCBT.113 Currently, the 
effect of KIR matching in UCBT is controversial and UCB selection based on KIR 
matching is not recommended. Some patients may have relapsed after receiving a KIR 
mismatched haploidentical HCT and would be eligible for this protocol despite having a 
KIR mismatched donor.  
To date, UCBT01, the first UCBT protocol at SJCRH has accrued 9 patients, with 5 
patients receiving a single UCB unit and 4 patients receiving two UCB units. One patient 
on the observational arm died due to TRM before day 100. All 8 remaining patients 
engrafted however, 2 patients would be categorized as significant graft delay/failure with 
neutrophil engraftment after day +42. One patient engrafted at day 49 and another at day 
51. The mean time to neutrophil engraftment is 28±13 days, (range; 12-51). Thus, despite 
optimizing HLA match and cell dose, neutrophil engraftment continues to be 
significantly delayed in patients undergoing UCBT.  
In order to abrogate the increased TRM and complication from graft failure and delayed 
neutrophil engraftment, we propose to provide a combined haploidentical donor with a 
single UCBT. A pilot study reported the results of 45 adults with a mean age of 50 yrs 
(range; 20-69) who underwent a RIC regimen using fludarabine, melphlan and ATG for 
high risk malignancies. The graft consisted of a single UCB with minimum cell dose of 
1.0 x 107 TNC/kg along with a TCD haploidentical PBSC donor graft. GVHD 
prophylaxis was with MMF and tacrolimus. The mean time to neutrophil engraftment 
was 11 days and platelet engraftment was 19 days. Chimerism analysis demonstrated that 
the haploidentical graft dominated early after HCT and is replaced by the UCB graft by 
day 100 in majority of the patients. However, 6 of the 45 patients had neutrophil 
engraftment derived from the haploidentical donor with no evidence of UCB donor. On 
the converse, 6 patients had had neutrophil engraftment derived from the UCB donor 
with no evidence of the haploidentical donor. . The risk for GVHD was not increased 
with the reported cumulative incidence of acute GVHD of 25% and chronic GVHD of 
5%.  
The primary objective of this study is to optimize the time to donor derived neutrophil 
engraftment and decrease the risk associated with delayed neutrophil engraftment such as 
infections and relapse. Briefly, we propose to provide a CD45RA+ depleted haploidentical 
PBSC graft to allow for rapids donor derived neutrophil engraftment. The graft will contain 
“memory” T cells that may help facilitate engraftment and/or provide immune protections. 
The UCB graft provides long-term allogeneic graft and contains majority of the CD45RA 
naïve T cells.  
 


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2.6 Minimal residual disease (MRD) 
Despite the fact that the vast majority of patients with high-risk leukemia are in clinical 
remission prior to HCT, approximately 30-40% ultimately relapse after HCT. Detection 
of MRD and early intervention may improve the clinical outcome. Detection of leukemic 
cells that are below the limits of detection by standard morphologic examination allow 
early interventions when the patients are MRD positive but still in remission. By using 
flow cytometry and polymerase chain reaction (PCR) amplification of antigen receptor 
genes in tandem, investigators at our institution have been able to conduct MRD studies 
in 80 consecutive ALL cases.114 Results of St. Jude institutional studies have shown that 
detection of MRD by immunologic techniques at any point in the treatment course is a 
powerful predictor of relapse in children with ALL.114-116 However, other studies suggest 
that eradication of all acute leukemia cells may not be a prerequisite for cure.117,118 
Similar to conventional-dose therapy, controversy also exists on the implication of MRD 
in the setting of HCT. Unlike CML, there is a paucity of data on the natural history of 
AML and ALL patients who have MRD after HCT, and how pre-transplant MRD levels 
influence post-transplant outcomes.119,120 It is unclear whether they are also at greater risk 
of relapse; and whether further pharmacological or immunologic therapy indeed prolongs 
survival and increases cure rates. Thus, for the participants who are enrolled in this 
protocol who are unable to proceed to post-transplant immunomodulatory protocols, we 
will gather the MRD information together with hematopoietic chimerism in a descriptive 
manner to study the relationship between MRD and chimerism in this large cohort of 
patients. The knowledge gained from this study should allow their future application to 
guide therapeutic interventions. 
2.7 Rationale for the evaluation of immune reconstitution after UCBT 
Delayed immune reconstitution is a major complication after HCT and impacts the 
overall survival in patients. Recent studies demonstrate that the rate and quality of 
immune recovery after UCBT is an important predictor of overall outcomes. 
Unfortunately, the rate of immune reconstitution directly correlates with the number of 
infused HSC and UCB patients have delayed immune reconstitution secondary to the 
limited numbers of HSC.71,121-123 Though transplantation with multiple unrelated UCB 
units has been used as a strategy to increase the total number of cells infused, the effect 
on immune reconstitution is not clear. In this study, we propose to monitor the rate of 
immune reconstitution after single and double UCBT. De novo generation of thymic 
derived T cells is critical in reconstituting a functional immune system, thus newly 
derived thymic T cell will be monitored by measuring the concentration of TREC DNA 
by quantitative PCR in the peripheral blood of transplant recipients. Furthermore, the 
time to recovery (defined as the median time to reach the normal value of age-matched 
healthy individual) of CD3+, CD4+, CD8+, CD19+ and CD56+ cells in patients undergoing 
UCBT will be investigated. Various subsets of T cells will be investigated including 
naïve, memory, central memory, effector memory, regulatory T cells as well as naïve and 
memory B cells. Functional measures of immune recovery will be examined by T cell 
proliferative response to nonspecific and specific antigen and NK lytic function. Antigen 
specific T cell response to various infections will be monitored in patients over time. 
Using a direct ex vivo, single-cell-based assay for clonotypic analysis of human epitope-
specific receptor, we will characterize T cell response to specific infections. Along with T 


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cell receptor specificity or antigen specific responses, epigenetic regulation of immune 
recovery will be evaluated. 
Studies demonstrate that the rate of neutrophil engraftment of a single unit was 
significantly enhanced after addition of a second unrelated UCB unit. It is clear that 
infusion of a second UCB unit facilitates the neutrophil engraftment of the dominant unit, 
however, the mechanism has yet to be investigated. Preliminary data from the Dallas 
laboratory suggest that dendritic cells and regulatory T cells play a critical role in 
facilitating neutrophil engraftment in the BM and thymus.124,125 Data obtained from this 
study addresses a key question regarding the immunological mechanism for enhanced 
neutrophil engraftment by facilitating cells. Furthermore, published studies consistently 
report that after a double UCBT, cells from only one of the UCB unit engraft. However, 
recent results from a multi-institutional clinical trial have demonstrated that small number 
of patients who undergo a double UCBT have evidence of mixed chimerism in the BM 
from the two UCB units one-year after HCT. Furthermore, studies performed at the Fred 
Hutchinson Cancer Research Center, demonstrated that single-unit dominance after 
double-unit UCBT coincides with NK cell dose and a specific CD8+ T-cell response 
against the non-engrafted unit.126  
3.0 PROTOCOL ELIGIBILITY CRITERIA 
3.1 Inclusion criteria for transplant recipient 
3.1.1  Age less than or equal to 21 years old. 
3.1.2 Does not have a suitable MSD or volunteer MUD available in the necessary time for 
stem cell donation.  
3.1.3 Has a suitable partially HLA-matched (≥ 3 of 6) family member donor. 
3.1.4  Has a partially HLA-matched single UCB unit (≥ 4 of 6) with adequate cell dose. 
UCB units must fulfill eligibility as outlined in 21 CFR 1271 and agency guidance.  
3.1.5 High-risk hematologic malignancy. 
3.1.5.1  Vey high risk ALL in CR1.  
  
Examples include, but not limited to hypodiploid, M2 or greater marrow at 
the end of induction, infants with MLL fusion or t(4;11). 
3.1.5.2  ALL in High risk CR2.  
  
Examples include but not limited to BM relapse <36 mo. CR1, T-ALL, very 
early (< 6mo CR1) isolated CNS relapse. 
3.1.5.3  ALL in CR3 or subsequent. 
3.1.5.4  AML in high risk CR1.  
  
Examples include but not limited to preceding MDS, 5q-, -5, -7, FAB M6, 
FAB M7 not t(1;22), MRD ≥ 5% on day 22 (AML08), M3 marrow after 
induction 1, M2 marrow after two cycles of induction, FLT3-ITD. 
3.1.5.5  AML in CR2 or subsequent. 
3.1.5.6  Therapy related AML, with prior malignancy in CR > 12mo 
3.1.5.7  MDS, primary or secondary 
3.1.5.8. NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 


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3.1.5.9 CML in accelerated phase, or in chronic phase with persistent molecular 
positivity or intolerance to tyrosine kinase inhibitor. 
3.1.5.10 Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous 
HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.5.11 Non-Hodgkin lymphoma in CR2 or subsequent. 
3.1.5.12 JMML 
3.1.5.13 Refractory hematologic malignancies (ALL, AML, CML in blast crisis, 
Hodgkin or non-Hodgkin lymphoma) due to chemoresistant relapse or 
primary induction failure.  
3.1.5.14 All patients with evidence of CNS leukemia must be treated and be in CNS 
CR to be eligible for study. 
3.1.6  Patient must fulfill pre-transplant evaluation: 
3.1.6.1  Cardiac Function: Left ventricular ejection fraction (LVEF) ≥ 40% or 
shortening fraction (SF) ≥ 25%. 
3.1.6.2  Creatinine clearance (CrCL) or glomerular filtration rate (GFR) ≥ 50 
ml/min/1.73m2. 
3.1.6.3 Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry 
(Pox) ≥ 92% on room air. 
3.1.6.4  Karnofsky or Lansky performance score ≥ 50 (See APPENDIX A). 
3.1.6.5  Bilirubin ≤ 3 times the upper limit of normal for age.  
3.1.6.6  Alanine aminotransferase (ALT) ≤ 5x the upper limit of normal for age. 
3.1.6.7  Aspartate aminotransferase (AST) ≤ 5x the upper limit of normal for age. 
3.2 Exclusion Criteria for Transplant Recipient:  
3.2.1  Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor available in the necessary time for stem cell donation. 
3.2.2 Patient has any other active malignancy other than the one for which HCT is 
indicated. 
3.2.3  Patient is pregnant as confirmed by positive serum or urine pregnancy test within 
14 days prior to enrollment. 
3.2.6 Patient is breast feeding. 
3.2.7  Patient has Down Syndrome. 
3.2.8  Patient has a current uncontrolled bacterial, fungal, or viral infection per the 
judgment of the PI. 
3.3 Inclusion criteria for haploidentical donor 
3.3.1  At least single haplotype matched (≥ 3 of 6) family member 
3.3.2  At least 18 years of age. 
3.3.3 HIV negative. 
3.3.4 Not pregnant as confirmed by negative serum or urine pregnancy test within 14 
days prior to enrollment (if female). 
3.3.5 Not breast feeding. 
3.3.6 Regarding eligibility, is identified as either: 
3.3.6.1 Completed the process of donor eligibility determination as outlined in 21 
CFR 1271 and agency guidance; OR 


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Protocol document date: 07/16/2016 
 
3.3.6.2 Does not meet 21 CFR 1271 eligibility requirements, but has a declaration of 
urgent medical need completed by the principal investigator or physician 
sub-investigator per 21 CFR 127 
 
INCLUSION CRITERIA SUMMARY 
Donor 
Haploidentical (≥ 3 of 6) and single UCB ( ≥ 4 of 6) HLA matched donor 
Age 
≤ 21 years 
 
Malignancy 
ALL 
Very HR ALL CR1 
ALL CR2 
ALL CR3 or subsequent 
AML 
AML CR1 
AML CR2 or subsequent 
2° AML with prior disease in CR > 12 mo. 
MDS 
Primary or Secondary  
NK leukemia 
CR1 or subsequent 
Biphenotypic leukemia 
CR1 or subsequent 
Undifferentiated leukemia 
CR1 or subsequent 
CML 
 
Accelerated Phase 
Chronic with persistent molecular positivity OR 
intolerance to tyrosine kinase inhibitor  
Hodgkin’s Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize HSC for auto-HCT 
Non-Hodgkin Lymphoma 
CR2 or subsequent 
JMML 
 
Refractory disease 
ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin Lymphoma 
Pre-
Evaluation 
Cardiac Function 
LVEF ≥ 40% or SF ≥ 25% 
Renal Function 
CrCL or GFR ≥ 50 ml/min/1.73m2 
Lung Function 
FVC ≥ 50% or Pox ≥ 92% on room air 
Performance Score 
Karnofsky or Lansky ≥ 50 
Liver Function 
Bilirubin ≤ 3x upper limit of normal for age 
ALT ≤ 5x upper limit of normal for age 
AST ≤ 5x upper limit of normal for age 
EXCLUSION CRITERIA SUMMARY 
Donor 
Has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor available in the necessary time for HSC donation  
Malignancy  
Other active malignancy other than one being treated 
Pre-
Evaluation 
Pregnant - Serum or Urine pregnancy within 14 days of enrollment 
Breast feeding 
Downs Syndrome 
Uncontrolled infection 
 
 


HAPCORD 14 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
3.4 Enrollment on Study 
 
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1 – 3.3, complete and sign the ‘Participant Eligibility Checklist’. The study 
team will enter the eligibility checklist information into the Patient Protocol Manager 
(PPM) system. Eligibility will be reviewed, and a research participant-specific consent 
form and assent document (where applicable) will be generated. The complete signed 
consent/assent document form(s) must be faxed or emailed to the CPDMO at 595-6265 to 
complete the enrollment process. 
The CPDMO is staffed 7:30 am – 5:00 pm CST, Monday through Friday. A staff member 
is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm. Enrollments may be 
requested during weekends or holidays by calling the CPDMO “On Call” cell phone 
(901-413-8591) or referencing the “On Call Schedule” on the intranet. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 15 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
4.0 TREATMENT PLAN 
4.1 Schema for Protocol Prioritization 
Participant with high-risk hematologic malignancies undergoing HCT, who do not have a 
suitable HLA-matched MSD, MURD or KIR ligand mismatched haploidentical donor 
identified in time, will receive a combined TCD haploidentical PBSC product and an 
unrelated UCB graft using a TLI-based preparative regimen.  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES 
PATIENT NOT 
ELIGIBLE FOR 
HAPCORD 
 PATIENTS WITH HIGH-RISK 
MALIGNANCY ELIGIBLE FOR HCT 
HLA TYPING 
DONOR SEARCH 
NO 
MATCHED SIBLING  
OR 
MATCHED UNRELATED 
DONOR AVAILABLE IN TIME 
PATIENT ELIGIBLE FOR 
ALTERNATIVE DONOR HCT 
 
  SUITABLE/APPROPRIATE  
KIR MISMATCHED HAPLOIDENTICAL 
DONOR AVAILABLE 
KIR TYPING  
UCB SEARCH 
YES 
ELIGIBLE FOR HAPLO 
PROTOCOL 
NO 
ELIGIBLE FOR 
HAPCORD 
 
POTENTIAL DOUBLE UCBT  
ON UCBT01 OR NPTP 
NO 
YES 
SINGLE UNIT UCB  
AND HAPLOIDENTICAL DONOR  
  
ELIGIBLE FOR HAPCORD 


HAPCORD 16 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
4.2 Reduced Intensity Preparative Regimen 
DAY MEDICATION 
DOSE 
DOSE # 
-9 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 2 fractions 
1-2 of 4 
-8 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
3 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
1 of 5 
-7 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
4 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
2 of 5 
-6 
Cyclophosphamide (with mesna) 
60 mg/kg intravenous once daily  
1 of 1 
Fludarabine 
30 mg/m2 intravenous once daily  
3 of 5 
-5 
Fludarabine 
30 mg/m2 intravenous once daily  
4 of 5 
-4 
Fludarabine 
30 mg/m2 intravenous once daily  
5 of 5 
-3 
Thiotepa 
5 mg/kg intravenous twice daily  
1-2 of 2 
-2 
Melphalan 
70 mg/m2 intravenous once daily 
1 of 2 
Tacrolimus 
Maintain until at least 6 months 
start 
-1 
Melphalan 
70 mg/m2 intravenous once daily  
2 of 2 
0 
HPC A Infusion  
CD34+ selected 
HPC A1 
MMF 
Maintain until at least 45 days 
start 
+1 
HPC A Infusion  
CD45RA depleted 
HPC A2 
+2 
HPC C Infusion 
 
HPC C 
+3 
G-CSF 
5mcg/kg subcutaneous or intravenous may be 
started after Day +3 
4.2.1  TLI 
A total of 800 cGy of TLI may be administered in one fraction or in divided 
fractions given at a minimum of 6 hours apart. Administration of 4 fractions at 200 
cGy/fraction over three days on day -9 to -7 for a total of 800 cGy is recommended.  
*Timing of TLI administration can vary per the Radiation Oncologist. Testicular 
boosts should be used for all males with ALL with 200 cGy per fraction over two 
days.  
4.2.2 
Fludarabine  
Fludarabine at 30 mg/m2/day will be given over 30-60 minutes intravenous infusion 
on day -8 through day -4 for a total of 5 doses (150 mg/m2 total). Fludarabine dose 
may be reduced per PI if concerns of toxicity (i.e. CNS). Infant dosing will apply to 
fludarabine as follows: patients less than or equal to 10kg will receive 1 mg/kg/day 
for scheduled doses. Infant dosing will apply to fludarabine as follows: patients less 
than or equal to 10kg will receive 1 mg/kg/day for scheduled doses. 
 
4.2.3  Cyclophosphamide with Mesna 
Cyclophosphamide at 60 mg/kg/day will be administered as a 2 hour intravenous 
infusion with a high volume fluid flush on day -6 for one dose (60mg/kg total). For 


HAPCORD 17 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
patients weighing more than 125% of their ideal body weight should have 
cyclophosphamide dose based on the adjusted ideal body weight.  
Mesna is administered prior to cyclophosphamide and after the cyclophosphamide 
infusion per institutional practice. Mesna dose and administration schedule may 
vary based on physician recommendation. 
4.2.4 
Thiotepa 
Thiotepa will be given over 30-60 minutes intravenous infusion at 5 mg/kg twice a 
day on day -3 for a total of 2 doses (10mg/kg total). 
4.2.5  Melphalan 
Melphalan will be given over 30-60 minutes intravenous infusion at 70 mg/m2 once 
a day on day -2 and -1 for a total of 2 doses (140 mg/m2 total). Infant dosing of 
melphalan will apply as follows: patients less than or equal to 10kg will receive 2.3 
mg/kg/day for scheduled doses. Infant dosing of melphalan will apply as follows: 
patients less than or equal to 10kg will receive 2.3 mg/kg/day for scheduled doses. 
 
4.3 UCB Product  
 
 
 
 
 
 
 
 
 
 
 
 
4.3.1 UCB Selection: 
 
Choose the unit with highest HLA match (6/6, 5/6 then 4/6)  
- Matching at HLA typing at HLA-A, B antigen level and DRB1 allele 
level. 
- The patient and the UCB unit(s) must be matched at least 4 of 6 loci. 
 SELECT OPTIMAL UNIT WITHIN SAME HLA MATCH   
DR typing takes preference 
Prefer homozygous over bidirectional mismatch 
Choose the largest TNC unit.  
If TNC is similar (± 0.5 x 107 TNC/kg) 
Utilize HLA C matching if available 
Utilize higher resolution molecular typing if available. 
Utilize CD34+ cell count if available. 
CHOOSE UNIT WITH HIGHEST HLA MATCH  
 Minimum of 4 of 6 matching to the patient at 
HLA-A Antigen 
HLA-B Antigen 
HLA-DR Allele 
UCB SELECTION 


HAPCORD 18 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
- The unit must meet cell dose threshold of 1.0 x 107 TNC/kg 
 
If > one unit is available for a HLA match grade, chose unit based on: 
- DRB1: Matching at DR takes preference, followed by  
- Locus of mismatch: A unit that is homozygous at the locus of mismatch 
should be chosen over a unit that is bidirectional at the locus of mismatch, 
even if the latter unit is larger, followed by 
- Cell Dose: Choose the unit containing the greatest TNC. 
 If two units are of equivalent HLA match grade, DR1 matching, locus of 
mismatch and cell dose (± 0.5 x 107 TNC/kg), choose the unit with: 
- HLA match by higher resolution molecular typing, if data available 
- HLA-C antigen/allele level typing, if data available 
- Larger CD34+ cell dose, if data available 
- UCB banks located in the United States are preferred.  
4.3.2  UCB Unit Exclusions  
4.3.2.1 Unit fails to meet cell dose threshold criteria  
Cell dose is < 1.0 x 107 TNC per kilogram recipient weight.  
4.3.2.2 Fails screening 
 
Any UCB units without full maternal testing and negative results for hepatitis 
A, B, C, Human Immunodeficiency Virus (HIV), and Human T-lymphotropic 
virus-1 (HTLV-1) viruses. Any additional available virology results on the unit 
itself will be reviewed but are not mandated, complete or always available. The 
majority of UCB units will come from banks that operate under the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Minimally Manipulated, 
Unrelated 
Allogeneic 
Placental/Umbilical 
Cord 
Blood 
Intended 
for 
Hematopoietic Reconstitution for Specified Indications. All NMDP banks must 
fulfill this requirement. Foreign banks may have differing screening procedures 
even if they are American Association of Blood Banks (AABB) or Foundation 
for the Accreditation of Cellular Therapy (FACT) accredited. It is important to 
clarify the screening process employed, and additional plasma may be requested 
if additional testing is needed to fulfill Eligibility Determination requirements. 
Currently UCB units are available for use under federal IND. The NMDP holds 
an IND for use, and a few of the older banks hold their own IND. There is no 
need to adjust for nucleated RBCs when considering TNC. The UCB unit(s) must 
be present at St. Jude prior to the start of conditioning. 
4.3.3  UCB Graft Preparation 
Preparation for administration will take place in the Human Applications Lab 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) of St. Jude using established Standard Operating Procedure (SOP). 
UCB units must be prepared for infusion in a manner that assures high cell 
recovery, maintains cellular viability, and avoids contamination. Infants < 10 kg 
should not receive reconstitutive thawed product and the UCB unit should be 
washed. When unit volume and Dimethyl sulfoxide (DMSO) concentration are 
not considered clinically prohibitive, and the wash procedure is deemed by the PI 


HAPCORD 19 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
to have a potential adverse impact on the UCB unit, a reconstitutive thawing 
procedure may be utilized. In this case, the unit is thawed, and then reconstituted 
at least 1:1 with an infusion grade solution (Dextran/albumin). In general, a wash 
is desired, particularly when there are concerns about volume, DMSO dose, red 
cell replete product, etc. For UCB products to be washed, a modified version of 
the New York Blood Center’s Placental Blood Thaw Procedure will be used. 
Briefly, the unit will be thawed and diluted; the plasma will then be expressed 
away after gentle centrifugation. In each case, 1-2 mL of the final product will be 
removed for testing prior to infusion. 
4.4 Haploidentical Donor Graft 
4.4.1  Haploidentical Donor Selection 
If more than one family member donor is acceptable, then donor selection will be 
based on the preference of the primary transplant attending. Factors in selection 
will include donor-recipient matching of CMV serology, donor-recipient red 
blood cell compatibility, degree of HLA matching, size of the potential donor, 
previous use as a donor, presence of donor-specific antibody, and overall health of 
the potential donor. 
Donor eligibility for cell collection will be determined through the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Eligibility Determination 
for Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products 
(HCT/Ps). Potential donors will undergo an initial screening process that will 
include at least a complete physical exam, history and testing for relevant 
communicable diseases. Physical exams to evaluate donor candidacy will be 
conducted by a non-Department of BMTCT physician (St. Jude or non-St. Jude). 
For subsequent therapeutic cell collection procedures, if a complete screening 
procedure has been performed within the previous 6 months, an abbreviated donor 
screening procedure may be used for these repeat donations. The abbreviated 
screening procedure must determine and document any changes in the donor’s 
medical history since the previous donation that would make the donor ineligible, 
including changes in relevant social behavior. 
If a donor is determined to be ineligible, the donor is not automatically excluded. 
Part 21 CFR 1271.65 (b)(1)(i) allows use of ineligible donors who are first or 
second degree blood relatives. In this situation, the physician will document the 
necessity of using the ineligible donor by providing a statement of "Urgent 
Medical Need" as explained in the 21 CFR 1271.3 (u). The cell therapy products 
will be labeled as required in 21 CFR 1271.65 (b)(2). Recipients or their legal 
guardians will be informed of the use of an ineligible donor. 
Please see Departmental SOP 30.05 “Determination of Eligibility and Suitability 
for Stem Cell and Therapeutic Cell Allogeneic and Autologous Donors” for 
additional information. 
 
 
 


HAPCORD 20 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
4.4.2  Haploidentical Donor Mobilization and Donor HSC Graft Collections  
A G-CSF mobilized peripheral blood stem cell (PBSC) product (identified as 
HPC, Apheresis) is the preferred progenitor cell graft source. Our desired target 
goal will be 3-5 x 106 CD34+ cells/kg. This number of cells will be necessary to 
provide an adequate graft, following the various ex vivo manipulations, for 
prompt reconstitution. Two days of collection are typically needed to achieve this 
goal. However, on rare occasions, additional days may be necessary. Donors will 
undergo a standard HSC mobilization regimen consisting of 6 days of G-CSF 
given subcutaneously at 10 mcg/kg. The graft will be collected by leukapheresis 
on days -1 and 0. The HPC, Apheresis product will typically be collected and 
infused fresh, however there may be patients or logistical situations that require 
the HPC, Apheresis product to be collected early, processed, and stored frozen. 
The decision to use a fresh versus frozen HPC, Apheresis will be made by the PI 
and/or primary transplant attending based on patient and donor factors, as well as 
potential scheduling conflicts.  
MOBILIZATION TIME LINE 
DAYS 
MEDICATION 
APHERESIS 
Day -5 
G-CSF 10 mcg/kg/day SC*  
1 of 6 
 
Day -4 
G-CSF 10 mcg/kg/day SC* 
2 of 6 
 
Day -3 
G-CSF 10 mcg/kg/day SC* 
3 of 6 
 
Day -2 
G-CSF 10 mcg/kg/day SC* 
4 of 6 
 
Day -1 
G-CSF 10 mcg/kg/day SC* 
5 of 6 
Apheresis for HSC graft** 
Day 0 
G-CSF 10 mcg/kg/day SC* 
6 of 6 
Apheresis for HSC graft** 
* G-CSF may may be reduced if the donor’s WBC is >75.0 x 106/  
**Do not start apheresis if platelet count < 50,000/mm3 or hemoglobin of < 12.5 g/dL pre-phresis 
 
The dose of G-CSF may require modification based on the complete blood counts 
(CBC). If the donor’s white blood count (WBC) is >75.0 x 106/ml the dose of 
cytokine administered will be reduced. The guidelines for dose modification can 
be found in the St. Jude Children's Research Hospital Department of BMT and 
CT SOP 30.06.00 “The practice for the evaluation, preparation and care of 
allogeneic and autologous donors mobilized with growth factor.” Ongoing 
updates of this document can be located at the following St. Jude intranet website: 
http://home.web.stjude.org/bone_marrow/ 
The daily leukapheresed volumes for HPC, Apheresis collection is generally 3–4 
total blood volumes based on CD34+ cell counts. Two additional days of 
leukapheresis may be performed at the physician’s discretion (no more than 4 
total) to reach the cell dose target, however, this is expected to be rare.  
Leukapheresis may be terminated early upon request of donor, or when deemed 
medically necessary per the judgment of the treating sub-investigator physician or 
PI. All HPC, Apheresis products will be collected as per FACT guidelines. 
Donors will be monitored during the period of the mobilization and leukapheresis 
procedure with appropriate laboratory evaluation (Appendix D). 


HAPCORD 21 
 
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IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
If we are unable to collect the minimum dose of 2 x 106 CD34+ cells/kg of 
recipient weight from the first donor, and the recipient has not yet initiated the 
preparative regimen, then an alternative family member may be used if he/she 
fulfills all donor criteria described in section. If the donor is unwilling or unable 
to complete the mobilization process or leukapheresis procedure, a BM product 
may be used. The BM product will be processed using the same cell selection 
methodology on the CliniMACS device.  
4.5 Graft Preparation 
Graft evaluation and preparation will take place in the Human Applications Laboratory 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) using established SOP.  
The initial HPC, Apheresis product(s) will be TCD using the investigational CliniMACS 
device and CD34 Microbead reagent as directed by the manufacturer (Miltenyi Biotech). 
See section 5.2 for additional CliniMACS device information. Briefly, HPC, Apheresis 
products from the mobilized donor will be initially assessed in the HAL and stored 
overnight at 4oC. The next morning, the product will be washed to remove platelets and 
adjusted to an appropriate cell concentration for incubation with the CliniMACS CD34 
Microbead reagent in the manufacturer provided media. The cells will be washed to 
remove unbound microbeads. These cells will be applied to the CliniMACS device and 
the enrichment will be performed using the program “CD34 Enrichment 2.1” as 
described by the manufacturer. 
After enrichment is complete, the cells will be washed and resuspended in an infusion 
grade solution. The graft product will be enumerated and assessed for viable CD34+ cell 
and CD3+ T cell content by flow cytometry. The processed HPC, Aphersis CD34 
Enriched product will be infused fresh or frozen for future use after completion of release 
testing and evaluation. Cryopreservation will be performed per SOPs of the HAL. Target 
cell doses are listed in the following table: 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
≥ 2 x 106 
2 x 106 
50 x 106 
CD3+ cells/kg 
≤ 0.5 x 105 
1 x 103 
1 x 105 
Once the target dose is obtained for the CD34+ enriched product, one additional day of 
apheresis will be performed. This HPC, Apheresis product will be processed for CD45RA+ 
depletion using the investigational CliniMACS device as directed by the manufacturer 
(Miltenyi Biotech). See section 5.1 for additional CliniMACS device information. Briefly, 
HPC, Apheresis products from the mobilized donor will be initially assessed in the HAL and 
stored overnight at 4oC. The next morning, the product will be washed to remove platelets 
and adjusted to an appropriate cell concentration for incubation with the CliniMACS 
CD45RA Microbead reagent in the manufacturer provided media. The cells will be washed 
to remove unbound microbeads. These cells will be applied to the CliniMACS device and the 
depletion will be performed using the "Depletion 3.1" software as described by the 
manufacturer. When combined with the CD34+ enriched product, the target CD34+ dose will 
be 3-5 x 106/kg. Release criteria of the product will include at least a ≥ 2.00 log10 depletion of 
CD45RA+ cells and a maximum dose of CD3+CD45RA+ cells of 0.05x106/kg. 


HAPCORD 22 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
3-5 x 106 
2 x 106 
50 x 106 
CD3+CD45RA+ cells/kg 
≤0.05 x 106 
N/A 
0.05x106 
CD45RA+ 
≥ 2.0 log10 depletion (CD45RA+ depleted graft only) 
 
4.6 Additional Progenitor Cell Graft Administration 
Infusion of an additional HSC graft from the original or an alternative haploidentical donor 
may be performed for participants when clinically indicated for graft failure, poor immune 
reconstitution, or poor hematopoietic recovery. The use of and content of a conditioning 
regimen is left to the discretion of the PI and/or primary transplant attending such that the 
most appropriate therapy is chosen for the clinical situation. 
The HSC graft will typically be obtained by apheresis (HPC, Apheresis) and be infused 
fresh. The target dose for this additional CD 34+ infusion is ≥5 x 106 cells/kg. If the 
participant has quiescent or active BOOP, acute Grade III-IV GVHD, or any other reason 
that a severely T-cell depleted graft may be indicated, then a graft from the donor processed 
on the CliniMACSTM device using either CD34+ selection (using established SOPs) or CD3+ 
depletion methodology may be utilized. The boost target dose for these patients is ≥10 x 
106 CD34+cells/kg with a CD3+ cell/kg dose of ≤ 0.5 x 105 CD3+ cells/kg.  
4.7 Donor Lymphocyte Infusions 
Some patients may have neutrophil engraftment derived from the haploidentical donor. 
Patients who have engrafted with the haploidentical donor may be eligible for donor 
lymphocyte infusions (DLI) from the haploidentical donor for decreasing donor 
chimerism, serious viral reactivation or infection, or any evidence of disease (from any 
level of MRD to frank relapse). The DLI collected may be collected as a whole blood 
unit donation or by leukapheresis. If the DLI is collected by standard phlebotomy, the 
volume to be collected would be approximately 300 ml whole blood. If the DLI is 
collected by leukapheresis, the amount to be processed would be approximately 2 total 
blood volumes. 
Prior to administration of DLI, the immunosuppression should be withdrawn and the 
recipient should have no active GVHD. GVHD staging must be reviewed by PI prior to 
DLI administration. The initial dose will typically be 2.5 x 104 CD3+/kg. Subsequent 
doses will be administered at approximately 2 to 4-week intervals with escalating doses 
of T cells if no moderate or severe GVHD occurs with the prior DLIs. The typical initial 
dose escalation for patients on this protocol is presented in the following table: 
DLI DOSE AND SCHEDULE 
DLI 
Dose 
Comments 
Initial Dose 
2.5 x 104 CD3+/kg 
Approximately 2-4 week interval 
If no moderate or severe GVHD 
Dose #2 
5.0 x 104 CD3+/kg 
Dose #3 
10.0 x 104 CD3+/kg 
  


HAPCORD 23 
 
Amendment 2.0, dated: 7/16/2016 
 
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Protocol document date: 07/16/2016 
 
 
4.8 Quality Assurance of Cellular Products 
Quality assurance for cell products is overseen by independent Quality Assurance 
personnel who authorizes release of all products. Only trained stem cell processors will 
process the cell products. A labeling and product tracking system is in place to ensure 
that the correct cells are infused into the research participant. 
Assays of cell numbers and immunophenotyping will be performed both before cell 
processing and at critical stages of the process. These values will be recorded according 
to SOP of the HAL. All TCD products will be tested for viability, and sterility (culture 
and Gram stain. Culture results are not available before infusion of cell products. If the 
gram stain is positive, the research participant/parent and/or guardian will be informed of 
this event and of the risks of proceeding prior to infusion. Positive results will be 
investigated as per the variance procedures of the HAL. The IRB and FDA will be 
notified, if at any time after infusion, cell product was determined to be contaminated.  
4.9  Immunosuppressive Therapies  
4.9.1  EBV post-transplant lymphoproliferative disease (PTLPD) prophylaxis  
Rituximab at 375 mg/m2 may be given intravenously as clinically indicated. For all 
patients, monitoring peripheral blood EBV DNA and prophylaxis and treatment 
will be according to BMTCT standard guides and/or at the discretion of the 
treating physician as clinically indicated based on ongoing EBV copy levels and 
clinical assessment. If a positive selection methodology would be used for a 
haploidentical HCT infusion, rituximab would not be administered, unless 
otherwise clinically indicated. 
4.9.2  Tacrolimus  
Tacrolimus to start on day -2. Preferably, start tacrolimus as a continuous infusion 
until patient engrafts and able to reliably obtain therapeutic levels. Maintain 
therapeutic levels according to institutional guidelines and practice. May modify 
dose for decreased chimerism or positive MRD. May convert to oral dosing when 
patient is tolerating oral and has a normal gastro-intestinal transit time. If no 
evidence of GVHD, begin to wean by approximately 10% every week on day 100, 
and discontinue around day 180 and no sooner than 6 months post transplant.  
4.9.3  MMF 
MMF to start on day 0 at 15mg/kg intravenously TID or every 8 hours. May convert 
to oral dosing when patient is tolerating oral and has a normal gastro-intestinal 
transit time. Adjust dose as clinically indicated. If no evidence of GVHD, MMF can 
be discontinued on day +45 or on/about 7 days after neutrophil engraftment, 
whichever is later. May hold for decreased chimerism or positive MRD. Continue 
MMF if patient has no evidence of donor engraftment on bone marrow evaluation 
and contact PI of results.  
 
 
 


HAPCORD 24 
 
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4.9.4  Methylprednisolone* 
Methylprednisolone may be used for treatment of acute GVHD*. (2mg/kg divided 
every 12 hours intravenously is suggested as initial therapy for patient with active 
acute GVHD requiring systemic therapy) If no response after 7 days, treat with a 
second line agent according to SOP. Methylprednisolone at 1-5 mg/kg/day can be 
used for management of pre-engraftment immune reaction as described below in 
4.10* 
*Use of methylprednisolone and dosing are recommendations and variance in 
medication, dosing and frequency can occur due to the participant’s current 
clinical condition and will not be noted as protocol deviations. 
4.10 Management of Pre-engraftment Immune Reaction 
A well-recognized clinical entity consisting of skin rash, fever, loose stools and 
respiratory distress has been noted to occur prior to neutrophil engraftment among UCB 
patients, generally between day 7 and 21.127-129 This clinical syndrome likely involves 
cytokine activation, and though clinically similar to acute or hyperacute GVHD, it 
appears to be a distinct entity, “pre-engraftment syndrome.” This syndrome is often 
controlled with brief steroid bursts, thus avoiding a commitment to extended steroid 
exposure. Patients should be monitored carefully for this syndrome.. If patients have 
moderate to severe symptoms as described above and alternative etiologies (i.e., 
infection) have been excluded or are being appropriately evaluated, patients may be 
treated with steroids. Recommendation of methylprednisolone is provided.  
The usage of methylprednisolone described here is a recommendation, and variations in 
medication, dosing and/or frequency can occur due to the participant’s current clinical 
condition and will not be noted as protocol deviations.  
4.10.1  For 
patients 
not 
on 
steroid 
therapy 
when 
the 
syndrome 
occurs: 
methylprednisolone should be given at 1 mg/kg intravenously once a day for three 
days. If symptoms have abated, steroids should be stopped. If symptoms persist, 1 
mg/kg can be continued through six days then stopped if symptoms have abated. 
If symptoms persist for more than six days, the patient should be considered to 
have acute/hyperacute GVHD and should be treated with prolonged steroids as 
deemed appropriate. Must alert PI if patient is requiring methylprednisolone for > 
6 days for engraftment syndrome.  
4.10.2 For patients already on steroids for other reasons when the syndrome occurs: 
methylprednisolone should be given at a dose of 3-5 mg/kg intravenously (max 
dose 500 mg) every 12 hours for maximum of 48 hours, followed by a rapid taper 
to 1 mg/kg intravenously every 12 hours. Patients should be weaned after 
response as tolerated. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
Other syndromes of eosinophila and hyperimmune syndrome have not been well described in 
the UCB field. Thus, patients presenting with the described pre-engraftment syndrome should 
be diagnosed and treated accordingly.  
 
 


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4.11 Growth Factors 
4.11.1  Granulocyte colony-stimulating factor (G-CSF) 
G-CSF may start on day +3 at 5 mcg/kg/day intravenously or subcutaneously until 
absolute neutrophil count (ANC) ≥ 2,000/mm3 for three consecutive days. G-CSF 
may be held at the discretion of the attending physician 
4.12 Treatment and Conditioning Regimen Related Notes  
The HSC infusion may be delayed by approximately 24 hours in order to accommodate 
HAL as well as the research participant clinical condition. 
The term “every” used in tables is an approximate term meaning that these medications 
noted will be administered approximately “every” 12 hours (or 8 hours as applicable). 
The drug administration timing in these cases may be modified as clinically indicated 
such as in the case of surgical procedures or to accommodate other necessary medication, 
blood product delivery, or procedures. The term “day” does not refer to an absolute 
calendar day. It refers to a general 24-hour period. 
Dosing for all protocol treatment medications may be modified for research recipients 
based upon actual body weight or adjusted ideal body weight and/or for infants weighing 
less than 10kg, when clinically indicated. Mesna will be administered for prevention of 
hemorrhagic cystitis from the medication cyclophosphamide.  
Criteria for medication calculations based on body weight/body surface area and other 
medication related information can be found in the St. Jude Formulary 
(http://www.crlonline.com/crlsql/servlet/crlonline) or the St. Jude Department of 
Pharmaceutical 
Sciences 
intranet 
website 
http://home.web.stjude.org/ 
pharmaceutical_ser/drugInfo.shtml. Medication doses may be rounded to the nearest 
integer or to the nearest appropriate quantity when clinically or pharmaceutically 
indicated as per the MD and PharmD. 
5.0 MEDICATION INFORMATION 
5.1 Cyclophosphamide (Cytoxan) 
Source 
& 
Pharmacology  
Cyclophosphamide is a nitrogen mustard derivative. It acts as an alkylating 
agent that causes cross-linking of DNA strands by binding with nucleic acids 
and other intracellular structures, thus interfering with the normal function of 
DNA. It is cell cycle, phase non-specific. Cyclophosphamide is well 
absorbed from the GI tract with a bioavailability of >75%. It is a prodrug that 
requires activation. It is metabolized by mixed function oxidases in the liver 
to 
4-hydroxycyclo-phosphamide, 
which 
is 
in 
equilibrium 
with 
aldophosfamide. Aldofosfamide spontaneously splits into nitrogen mustard, 
which is considered to be the major active metabolite, and acrolein. In 
addition, 4-hydroxycy-clophosphamide may be enzymatically metabolized to 
4-ketocyclophosphamide and aldophosfamide may be enzymatically 
metabolized to carboxyphosphamide that is generally considered inactive. 
Cyclophosphamide and its metabolites are excreted mainly in the urine. Dose 
adjustments should be made in patients with a creatinine clearance of <50 
ml/min. 
Formulation 
Cyclophosphamide is available in vials containing 100, 200, 500, 1000 and 


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and Stability  
2000mg of lyophilized drug and 75 mg mannitol per 100 mg of 
cyclophosphamide. Both forms of the drug can be stored at room 
temperature. The vials are reconstituted with 5, 10, 25, 50 or 100 ml of 
sterile water for injection, respectively, to yield a final concentration of 20 
mg/ml. Reconstituted solutions may be further diluted in either 5% dextrose 
or 0.9% NaCl containing solutions. Diluted solutions are physically stable 
for 24 hours at room temperature and 6 days if refrigerated, but contain no 
preservative, so it is recommended that they be used within 24 hours of 
preparation. 
Supplier 
Commercially available 
Toxicities 
Dose limiting toxicities of cyclophosphamide includes BM suppression and 
cardiac toxicity. Cardiac toxicity is typically manifested as congestive heart 
failure, cardiac necrosis or hemorrhagic myocarditis and can be fatal. 
Hemorrhagic cystitis may occur and necessitates withholding therapy. The 
incidence of hemorrhagic cystitis is related to cyclophosphamide dose and 
duration of therapy. Forced fluid intake and/or the administration of mesna 
decreases the incidence and severity of hemorrhagic cystitis. Other toxicities 
reported commonly include nausea and vomiting (may be mild to severe 
depending on dosage), diarrhea, anorexia, alopecia, immunosuppression and 
sterility. Pulmonary fibrosis, SIADH, anaphylaxis and secondary neoplasms 
have been reported rarely.  
Route  
Intravenous infusion  
5.2. Thiotepa (Thioplex by Immunex) (TESPA, TSPA) 
Source 
& 
Pharmacology  
Thiotepa is a cell-cycle nonspecific polyfunctional alkylating agent. It reacts 
with DNA phosphate groups to produce cross-linking of DNA strands 
leading to inhibition of DNA, RNA and protein synthesis. Thiotepa is 
extensively metabolized in the liver to metabolites that retain activity, 
primarily triethylene-phosphoramide (TEPA). The main route of elimination 
is via the urine, mainly as metabolites; the elimination half-life of the 
thiotepa is 2.5 hours, and that of TEPA is 17.6 hours. 
Formulation 
and Stability 
Thiotepa is supplied in single-use vials containing 15 mg of lyophilized 
thiotepa, 80 mg NaCl and 50 mg NaHCO3. The intact vials should be stored 
under refrigeration and protected from light. Each vial should be 
reconstituted with 1.5 ml of sterile water for injection to yield a 
concentration of 10 mg/ml. Further dilution with sterile water for injection 
to a concentration of 1 mg/ml yields an isotonic solution; if larger volumes 
are desired for intracavitary, intravenous infusion, or perfusion therapy, this 
solution may then be diluted with 5% dextrose or 0.9% NaCl containing 
solutions. The 10 mg/ml reconstituted solution is chemically stable when 
stored in the refrigerator for up to 5 days, however, it is recommended that 
solutions be prepared just prior to administration since they do not contain a 
preservative. Reconstituted solutions should be clear to slightly opaque: the 
solutions may be filtered through a 0.22 micron filter to eliminate haze. 
Supplier 
Commercially available; manufactured by Immunex. 


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Toxicities 
Dose limiting toxicity is myelosuppression. The leukocyte nadir may occur 
at any time from 10 to >30 days. Other toxicities include pain at the injection 
site, nausea and vomiting, anorexia, mucositis, dizziness, headache, 
amenorrhea, interference with spermatogenesis, and depigmentation with 
topical use. Allergic reactions, including skin rash and hives, have been 
reported rarely. Rare cases of apnea, hemorrhagic cystitis, and renal failure 
have occurred. Thiotepa is mutagenic, carcinogenic, and teratogenic in 
animals. Pregnancy category D. 
Route  
Intravenous 
5.3 Fludarabine (Fludara) 
Source 
& 
Pharmacology  
Fludarabine phosphate is a synthetic purine nucleoside analog and acts by 
inhibiting DNA polymerase, ribonucleotide reductase and DNA primase by 
competing with the physiologic substrate, deoxyadenosine triphosphate, 
resulting in inhibition of DNA synthesis. It can also be incorporated into 
growing DNA chains as a false base and interfere with chain elongation and 
halt DNA synthesis. Fludarabine is rapidly dephosphorylated in the blood 
and transported intracellularly by a carrier-mediated process. It is then 
phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate form. ~23% of the dose is excreted as the active metabolite in 
the urine (with dosages of 18-25 mg/m2/day for 5 days). Renal clearance 
appears to become more important at higher doses, with approximately 41-
60% of the dose being excreted as the active metabolite in the urine with 
dosages of 80-260 mg/m2. 
Formulation 
and Stability 
Fludarabine is supplied in single-dose vials containing 50 mg fludarabine as 
a white lyophilized powder and 50 mg of mannitol. The intact vials should 
be stored under refrigeration. Each vial can be reconstituted by adding 2 ml 
of sterile water for injection resulting in a final concentration of 25 mg/ml. 
Because the reconstituted solution contains no antimicrobial preservative, the 
manufacturer recommends that it should be used within 8 hours of 
preparation. The solution should be further diluted in 5% dextrose or 0.9% 
NaCl prior to administration. 
Supplier 
Commercially available. 
Toxicities 
The major dose-limiting toxicity of fludarabine is myelosuppression. Nausea 
and vomiting are usually mild. Side effects reported commonly include 
anorexia, fever and chills, alopecia and rash. Neurotoxicity can be 
manifested by somnolence, fatigue, peripheral neuropathy, mental status 
changes, cortical blindness and coma and is more common at high doses. 
Neurotoxicity is usually delayed, occurring 21-60 days after the completion 
of a course of therapy and may be irreversible. Side effects reported less 
commonly include diarrhea, stomatitis, increased liver function tests, liver 
failure, chest pain, arrhythmias and seizures. Pulmonary toxicity includes 
allergic pneumonitis characterized by cough, dyspnea, hypoxia and 
pulmonary infiltrates. Drug induced pneumonitis is a delayed effect, 
occurring 3-28 days after the administration of the third or later course of 
therapy. Administration of corticosteroids usually results in resolution of 
these symptoms. 


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Route  
Intravenous 
5.4 Melphalan (L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin, 
Alkeranâ) 
Source 
& 
Pharmacology  
Melphalan, a derivative of nitrogen mustard, is a bifunctional alkylating 
agent. Its chemical name is 4-[bis(2-chloroethyl)amino]-L-phenylalanine, 
and it has a molecular weight of 305.20. Melphalan is active against tumor 
cells that are actively dividing or at rest. Its cytotoxicity is thought to be due 
to inter-strand cross-linking with DNA, probably by binding at the N7 
position of guanine. Melphalan is highly protein bound and does not 
penetrate well into the cerebral spinal fluid. Elimination half-life after 
intravenous administration in adults is approximately 75 minutes. 
Elimination appears to be primarily by chemical hydrolysis, but caution 
should be used in patients with renal impairment. Plasma concentrations of 
melphalan after oral administration are highly variable, possibly due to 
incomplete absorption, variable “first pass” hepatic metabolism or rapid 
hydrolysis. Area under the plasma concentration-time curves for orally 
administered melphalan is approximately 60% of intravenously administered 
melphalan in adult studies.  
Formulation 
and Stability  
Available as 2 mg tablets for oral administration. This medication is stable at 
room temperature until expiration date on the packaging. Intravenous 
formulation is supplied as 50 mg freeze dried glass vial. Each 50 mg vial is 
supplied in a carton containing a 10 ml vial of sterile diluent. Lyophilized 
melphalan should be stored at controlled room temperature and protected 
from light. Each vial is marked with its expiration date. The melphalan for 
injection must be reconstituted immediately prior to infusion by rapidly 
adding the contents of the diluent vial (10 ml) to the freeze dried powder 
with a 20 gauge or larger sterile needle and immediately shaking vigorously 
until a clear solution is obtained. This results in a 5 mg/ml solution. The dose 
should then be diluted in 0.9% sodium chloride for injection to a final 
concentration of not greater than 0.45 mg/ml. The resulting admixture should 
be infused over a minimum of 15 minutes. The infusion should be completed 
within 60 minutes of reconstitution. Do Not Refrigerate the Reconstituted 
Melphalan.  
Supplier 
Commercially available 
Toxicities 
Melphalan is cytotoxic and caution should be used in handling and preparing 
the solution or administering the tablets. Use of gloves is recommended, and 
if contact with skin or mucosa occurs, immediately wash thoroughly. Second 
cancers such as acute non-lymphocytic leukemia, myeloproliferative 
syndrome, and carcinoma have been reported in patients taking melphalan 
alone or in combination with other chemotherapy or radiation. Melphalan 
causes suppression of ovarian function in premenopausal women, with a 
significant number of patients having amenorrhea. Testicular suppression 
(reversible and irreversible) has been reported. The most common adverse 
reaction is myelosuppression. Irreversible bone marrow failure has been 
reported. Gastrointestinal side effects reported include nausea/vomiting, 


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diarrhea and oral mucosa ulceration. Hepatic toxicity has occurred, including 
veno-occlusive disease. Acute hypersensitivity reactions occur in about 2.4% 
of patients, and can include anaphylaxis. Hypersensitivity reactions were 
characterized by urticaria, pruritus, and edema. Some patients exhibited 
tachycardia, bronchospasm, dyspnea and hypotension that responded to 
antihistamines and corticosteroids. Other side effects that have been reported 
include skin ulceration or necrosis at injection site, vasculitis, alopecia, 
hemolytic anemia, pulmonary fibrosis, and interstitial pneumonitis. 
Route  
Intravenous infusion  
5.5 Mesna (Mesnex) 
Source 
& 
Pharmacology  
Mesna is a synthetic sulfhydryl (thiol) compound. Mesna contains free 
sulfhydryl groups that interact chemically with urotoxic metabolites of 
oxaza-phosphorine derivatives such as cyclophosphamide and ifosfamide. 
Oral bioavailability is 50%. Upon injection into the blood, mesna is oxidized 
to mesna disulfide, a totally inert compound. Following glomerular 
filtration, mesna disulfide is rapidly reduced in the renal tubules back to 
mesna, the active form of the drug. Mesna and mesna disulfide are excreted 
primarily via the urine. 
Formulation 
and Stability 
Mesna is available in 2 ml, 4 ml and 100 ml amps containing 100 mg/ml of 
mesna solution. The intact vials can be stored at room temperature. Mesna 
may be further diluted in 5% dextrose or 0.9% NaCl containing solutions. 
Diluted solutions are physically and chemically stable for at least 24 hours 
under refrigeration.  
Supplier 
Commercially available 
Toxicities 
Mesna is generally well tolerated. Nausea and vomiting, headache, diarrhea, 
rash, transient hypotension and allergic reactions have been reported. 
Patients may complain of a bitter taste in their mouth during administration. 
Mesna may cause false positive urine dipstick readings for ketones.  
Dosage 
and 
Administration 
Mesna is generally dosed at approximately 25% of the cyclophosphamide 
dose. It is generally given intravenously prior to and again at 3, 6 and 9 
hours following each dose of cyclophosphamide. 
Route 
Intravenous 
5.6 G-CSF (Filgrastim, Neupogen)  
Source 
& 
Pharmacology 
G-CSF is a biosynthetic hematopoietic agent that is made using recombinant 
DNA technology in cultures of Escherichia coli. G-CSF stimulates 
production, maturation and activation of neutrophils. In addition, 
endogenous G-CSF enhances certain functions of mature neutrophils, 
including phagocytosis, chemotaxis and antibody--dependent cellular 
cytotoxicity. 
Formulation 
and Stability 
G-CSF is supplied in vials containing 300 and 480 mcg of G-CSF at a 
concentration of 300mcg/ml. The intact vials should be stored under 
refrigeration. The vials can be left out of refrigeration for 24 hours, but 
should be discarded if left at room temperature for longer periods of time. G-
CSF can be drawn up into tuberculin syringes for administration and stored 
under refrigeration for up to 7 days prior to usage. G-CSF can be further 


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diluted for intravenous infusion in 5% dextrose. Do not dilute in saline---
precipitate may form. If the final concentration of this product is <15 
mcg/ml, it is recommended that albumin be added to a final concentration of 
2mg/ml (0.2%) to minimize adsorption of the drug to infusion containers and 
equipment.  
Supplier 
Commercially available. 
Toxicities 
G-CSF causes marked leukocytosis. Common adverse reactions include bone 
pain, thrombocytopenia, diarrhea, nausea, rash, alopecia, fever, anorexia and 
pain or bruising at the injection site. Allergic reactions, MI, atrial fibrillation, 
and splenomegaly have been reported rarely. G-CSF is contraindicated in 
participants with allergy to E. coli derived products. 
Route 
Intravenous or subcutaneous. 
 
5.7 Mycophenolate mofetil (MMF, CellCept) 
Source 
& 
Pharmacology  
MMF is hydrolyzed to mycophenolic acid (MPA), an immunosuppressive 
agent. MPA inhibits B and T-cell proliferation, T-cell synthesis, and 
antibody secretion by potent, noncompetitive reversible inhibition of inosine 
monophosphate dehydrogenase (IMPDH) in the purine biosynthesis 
pathway. Inhibition of IMPDH results in a depletion of guanosine 
triphosphate and deoxyguanosine triphosphate, important intermediates in 
the synthesis of lymphocyte DNA, RNA, proteins and glycoproteins. Oral 
formulations of MMF are rapidly and extensively absorbed when given on an 
empty stomach. Aluminum and magnesium-containing antacids and food 
decrease absorption of MMF. MMF is rapidly hydrolyzed to the active 
metabolite (MPA) after oral or intravenous administration. Free MPA is 
conjugated in the liver by glucuronyl transferase to inactive mycophenolic 
acid glucuronide (MPAG) that is excreted in the urine and feces. Time to 
peak plasma concentration is 0.8–1.3 hours, and the mean elimination half-
life is 17.9 hours. Enterohepatic recirculation of MPA contributes to plasma 
concentrations. Administration of cholestyramine interrupts the enterohepatic 
recirculation and can decrease bioavailability by as much as 40%. Patients 
with renal insufficiency have increased plasma concentrations of MPA and 
MPAG. Acyclovir and ganciclovir may compete with MPAG for renal 
tubular secretion, resulting in increased plasma concentrations of both drugs.  
Formulation 
and Stability 
MMF is commercially available as 250 mg capsules, 500 mg tablets, 200 
mg/ml powder for oral suspension, and 500 mg vials of powder for injection.  
Supplier 
Hoffmann La Roche, Inc.  
Toxicities  
AE seen in patients taking MMF include hypertension, hypotension, 
peripheral edema, leukopenia, anemia, thrombocytopenia, hypochromic 
anemia, leukocytosis, headache, insomnia, dizziness, tremor, anxiety, 
paresthesia, hyperglycemia, hypercholesterolemia, hypokalemia, diarrhea, 
hyperkalemia, hypophosphatemia, constipation, nausea, vomiting, anorexia, 
abdominal pain, dyspepsia, urinary burning or frequency, renal tubular 
necrosis, hematuria, increase serum creatinine and BUN, a variety of 
infections due to immunosuppression, rash, acne, ocular changes (cataracts, 


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blepharitis, keratitis, glaucoma, and macular abnormalities) occasional leg 
cramps or pain, bone pain, myalgias, and hand cramps. Intravenous infusions 
have been reported to cause thrombosis and phlebitis. There have been 
occasional reports of gastrointestinal hemorrhage. High dose therapy with 
mycophenolate in adults with psoriasis has been associated with the 
following neoplasms: adenocarcinoma of the breast and colon, basal cell 
carcinoma, carcinoma of the gallbladder, histiocytic lymphoma, glioblastoma 
multiforme, and squamous cell carcinoma of the epiglottis.  
Route  
Oral or intravenous 
5.8 Tacrolimus (FK506, Prograf®, Protopic®) 
Source 
& 
Pharmacology  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyce 
tsukubaensis. It inhibits T-lymphocyte activation, although the exact 
mechanism of action is not known. Tacrolimus activity is primarily due to 
the parent drug. The plasma protein binding of tacrolimus is approximately 
99% and is independent of concentration over a range of 5-50 ng/mL. The t½ 
in adult patients ranges from 11-19 hours. Whole blood trough 
concentrations from 31 patients less than 12 years old showed that pediatric 
patients needed higher doses than adults to achieve similar tacrolimus trough 
concentrations. It is extensively metabolized by the mixed-function oxidase 
system, primarily the cytochrome P-450 system (CYP3A) in the liver and to 
a lesser extent in the intestinal mucosa. The main route of elimination is via 
the biliary tract and excretion in feces. A retrospective comparison of Black 
and Caucasian kidney transplant patients indicated that Black patients 
required higher tacrolimus doses to attain similar trough concentrations; 
there were no gender-based differences. The absorption of tacrolimus from 
the gastrointestinal tract is incomplete and variable exhibiting large intra- and 
inter-patient variability. Administration with food significantly decreases the 
rate and extent of absorption. Drugs that stimulate or inhibit hepatic p-450 
enzymes will alter clearance of tacrolimus and close attention to potential 
drug interactions is crucial. 
Formulation 
and Stability 
Intravenous formulation: Tacrolimus is available as a sterile solution 
(tacrolimus injection) containing the equivalent of 5 mg anhydrous 
tacrolimus in 1 mL Each mL contains polyoxyl 60 hydrogenated castor oil 
(HCO-60), 200 mg, and dehydrated alcohol, USP, 80% v/v. Store between 
5°C and 25°C (41°F and 77°F). Oral formulations: It is available for oral 
administration as capsules containing the equivalent of 0.5 mg, 1 mg or 5 mg 
of anhydrous tacrolimus. Inactive ingredients include lactose, hydroxypropyl 
methylcellulose, croscarmellose sodium, and magnesium stearate. The 0.5 
mg capsule shell contains gelatin, titanium dioxide and ferric oxide, the 1 mg 
capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule 
shell contains gelatin, titanium dioxide and ferric oxide. Store at 25°C 
(77°F); excursions permitted to 15°-30°C (59°-86°F). 
Supplier 
Commercially available  
Toxicities  
Immunosuppression results in increased susceptibility to infection and 
possible development of lymphoma and other malignancies, particularly of 


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the skin. After intravenous administration, monitor closely for an acute 
allergic reaction for the first 30 minutes and at frequent intervals thereafter. 
Fetal toxicity has been noted in animals. Common adverse effects are 
headache, hypertension, GI toxicities, fever, immunosuppression, tremor, 
renal dysfunction, hematological abnormalities, CNS abnormalities, 
electrolyte abnormalities, clotting abnormalities, alopecia. Late effects can 
include skin disorders, delayed wound healing, and hirsutism. Insulin-
dependent post-transplant diabetes mellitus (PTDM) was reported in 11-22% 
of tacrolimus treated transplant patients without pretransplant history of 
diabetes mellitus, several human studies. Mild to severe hyperkalemia is 
reported in 8-45% of transplant patients receiving tacrolimus, so serum 
potassium levels should be monitored and potassium-sparing diuretics should 
not be used. To avoid excess nephrotoxicity, tacrolimus should not be used 
simultaneously with cyclosporine or other drugs that may be associated with 
renal dysfunction. Tacrolimus or cyclosporine should be discontinued at least 
24 hours prior to initiating the other. In the presence of elevated tacrolimus 
or cyclosporine concentrations, dosing with the other drug usually should be 
further delayed. It is not recommended that sirolimus and tacrolimus be 
given concomitantly, as serious increases in wound healing complications, 
renal function impairment and insulin-dependent post-transplant diabetes 
mellitus have been observed. Drugs that stimulate or inhibit p-450 enzymes 
will alter clearance of tacrolimus and close attention to potential drug 
interactions is crucial.  
Route  
Oral or intravenous 
5.9 Methylprednisolone (Medrol®, Solu-Medrol)  
Source 
& 
Pharmacology  
Adrenal corticosteroid – anti-inflammatory, immunosuppressant decreases 
inflammation by suppression of migration of polymorphonuclear leukocytes 
and reversal of increased capillary permeability. 
Formulation 
and Stability 
Tablet (4mg), Sodium Succinate powder for injection 125 mg, 500 mg. 
Supplier 
Commercially available. 
Toxicities:  
Toxicities include edema, hypertension, vertigo, seizures, psychoses, 
headache, pseudotumor cerebri, acne, skin atrophy, impaired wound healing, 
Cushing’s syndrome, pituitary adrenal axis suppression, growth suppression, 
glucose intolerance, hypokalemia, alkalosis, peptic ulcer, nausea, vomiting, 
transient leukocytosis, muscle weakness, osteoporosis, fractures, cataracts, 
glaucoma, and increased risk of infection. 
Route  
Intravenous or oral.  
 
5.10 CliniMACSTM System  
The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-
activated cell sorting (MACS). The CliniMACS device is a powerful tool for the isolation 
of many cell types from heterogeneous cell mixtures, (e.g. apheresis products). These can 


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then be separated in a magnetic field using an immunomagnetic label specific for the cell 
type of interest, such as CD3+ human T cells. 
The cells to be isolated are specifically labeled with super-paramagnetic particles by an 
anti-body directed toward a cell surface antigen. After magnetic labeling, the cells are 
separated using a high-gradient magnetic separation column as described below. The 
magnetically labeled cells are retained in the magnetized column while the unlabeled 
cells flow through the column for collection. The retained cells are eluted by removing 
the magnetic field from the column, washing the cells out and collecting them in a 
separate container from the unlabeled cells. 
The super-paramagnetic particles are small in size (about 50 nm in diameter) and are 
composed of iron oxide/hydroxide and dextran conjugated to monoclonal antibodies. 
These magnetic particles form a stable colloidal solution and do not precipitate or 
aggregate in magnetic fields. The antibody conjugated beads used in this system are 
highly specific (e.g. CD3+ cells via OKT3 conjugated beads). High-gradient MACS 
technology has been shown to achieve rapid and highly specific depletion or enrichments 
of large numbers of target cells from BM, cord blood, and normal peripheral blood 
mononuclear cells.  
The CliniMACS device incorporates a strong permanent magnet and a separation column 
with a ferromagnetic matrix to separate the cells labeled with the magnetic particles. The 
high-gradient system allows the application of strong magnetic forces and a rapid de-
magnetization. Small ferromagnetic structures, such as the column matrix, placed in a 
magnetic field concentrate this homogenous field and thereby produce high magnetic 
gradients. In their immediate proximity, the ferromagnetic structures generate magnetic 
forces 10,000-fold greater than in the absence of those structures enabling the retention of 
magnetically labeled cells. After removing the column from the magnet, the rapid de-
magnetization of the column matrix allows the release of retained cells.  
The CliniMACS device is comprised of a computer controlled instrument incorporating a 
strong permanent magnet, a closed-system sterile tubing set containing columns with a 
coated ferromagnetic matrix and a paramagnetic, cell specific, labeling reagent. The 
instrument will separate the cells in a fully automated process yielding a cell population 
highly depleted of CD3+ cells. The CliniMACS device is not licensed by the FDA and 
therefore is investigational. 
The CliniMACS device has separate programs that allow cell selection procedures 
optimized for either depletion (e.g. CD3+ or CD45RA+) or selection of a target cell 
population (e.g. CD34+ or CD56+ cells). The basic mechanism is the same for either 
application; target cells are "tagged" with super-paramagnetic particles and eventually 
separated from the unlabeled cells using the CliniMACS device as described above. The 
desired target cells can either be infused or discarded appropriately.  
 
 
 


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6.0  
REQUIRED OBSERVATIONS AND EVALUATIONS 
6.1 Standard Pre/Peri/Post-Transplant Evaluations 
All pre/peri/posttransplant and long-term follow-up evaluations for these participants will 
be carried out as guided by the SOPs of the SJCRH, Department of BMTCT, for 
recipients of allogeneic HCT. Copies of these SOPs and ongoing updates can be found at 
the following site: http://home.web.stjude.org/bone_marrow/clinicalHome.shtml. A 
schedule of these for these assessments is outlined in Appendix D. 
6.2 Long-term Follow-up Evaluations 
In general, recipients of allogeneic HCT at St. Jude are seen at least annually until 10 
years post-transplant in the Department of BMTCT outpatient clinic. For the purpose of 
this study, research participants will be followed to year 1 post-transplantation. At that 
time, transplant recipients will be eligible for enrollment in the institutional long-term 
follow-up protocol for children and young adults who have received stem cell 
transplantation at St. Jude Children’s Research Hospital (BMTFU protocol). 
6.3 Research Testing.  
Timing for the required research tests are summarized in Appendix D. Furthermore, to 
accommodate the studies, flexibility in the date is allowed without a deviation from 
protocol. The degree of flexibility in the timing is also provided in Appendix D.  
6.3.1  Immune Reconstitution 
Standard measures of post-HCT immune reconstitution will be performed as 
delineated in Appendix D. Research testing of Immune Reconstitution will 
include:  
6.3.1.1  VBETA/TREC Research: Thymic output and T cell repertoire. 
6.3.1.2  Lymphocyte Phenotypes Research: T cell and NK cell number and function. 
6.3.1.3  IR-PHENOTYPE 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care. Immunophenotypic evaluation of the UCB unit 
prior to infusion will be performed to enumerate the content of naïve, 
memory T cells, regulatory T cells, NK cells, and naïve B cells and memory 
B cells. Samples from haploidentical donors will be obtained if they choose 
to participate in the optional research testing (described below). 
Host: Immunophenotypic evaluation of immune reconstitution in the patient 
will be performed for the enumeration of naïve, memory T cells, regulatory 
T cells and naïve B cells and memory B cells.  
6.3.1.4  T-FUNCTION 
Immune function studies include antigen-specific T-lymphocyte response to 
viral infections, such as herpes viruses (CMV, HSV and VZV), intracellular 
cytokine and cytokine secretion assays. Studies may include an optional skin 
punch biopsy, at the discretion of the PI, to be performed either at the time 
of the pre-transplant BM biopsy, during sedation for radiation treatment or 
at the time of the day 28 BM biopsy. In order to follow viral infections, 


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and/or reactivations detected by DNA regardless of copy number, additional 
samples will be collected weekly for the first 100 days post-transplant when 
possible. If infection(s) are detected in non-blood samples (nasal wash, BAL 
etc), leftover samples may be used for research purposes. Studies to be 
performed in the laboratory of Dr. Paul Thomas in collaboration with Dr. 
Dallas.  
6.3.1.5  HOST-DONOR INTERACTION 
Donor: Donor Haploidentical samples are optional and UCB cells necessary 
for research studies will be minimized. UCB cells will also be harvested 
from the discarded bag post infusion. . Epstein-Barr virus transformed 
lymphoblastoid cell lines (EBV-LCL) will be generated from the donor cells 
obtained from the discarded infusion bag. Donor KIR typing and HLA-
typing will be performed for high resolution HLA-A, HLA-B, HLA-DR, 
HLA-C and HLA-DQ if not available.  
Host: Host and donor immunologic interaction studies may also include an 
optional skin punch biopsy to be performed with the pre-transplant BM 
biopsy to generate fibroblasts. Prior to the start of conditioning, peripheral 
blood samples will be collected to generate EBV-LCL from the patient for 
research studies evaluating donor/host immunologic reactions. 
 
6.4 Research Testing on Haploidentical Donor (optional) 
Donors will be offered the option for participation in research studies of immune 
reconstitution of T cells, B cells, and NK cells. These tests will be obtained after consent 
and preferably prior to growth factor administration. Lymphocyte subset analysis of the 
donor appears to allow for the prediction of the reconstitution of the lymphocyte subsets 
in the research participant after transplantation. Data in larger donor/research participant 
pairs will help to verify these observations. A list of these optional research studies are 
noted in Appendix D and detailed below: 
6.4.1  Lymphocyte Subset Study: Flow cytometry enumeration 
6.4.2  VBETA/TREC Research: Thymic output and T cell repertoire 
6.4.3  Lymphocyte Phenotypes Research: T cell and NK cell number and function 
7.0 EVALUATION CRITERIA 
7.1  Adverse event (AE) monitoring for on-study research participants will be assessed using the 
NCI Common Toxicity Criteria Version 3.0. The specific criteria for adverse event 
monitoring are noted in APPENDIX C. 
7.2 GVHD scoring (acute and chronic) will be evaluated and graded using the criteria found 
in APPENDIX B and Cof this protocol. The COG stem cell committee consensus 
guidelines for establishing organ stage and overall grade of acute GVHD has been 
adopted as the standard GVHD diagnostic guidelines for the Department of BMTCT, and 
will be applied to patients on this protocol (see Appendix B). In addition, acute GVHD 
will be assessed at least once a week for the first 100 days per BMTCT SOP 20.01.  


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Appendix C contains a summary of the NIH consensus development project on criteria for 
clinical trials in chronic GVHD. This table will be used for staging/grading of chronic 
GVHD. 
7.3 Performance status will be assessed by Karnofsky/Lansky Performance Scores (age-
dependent) (see APPENDIX A). 
7.4 Hematologic recovery post-transplant will be determined using the engraftment criteria as 
follows:  
(1) Neutrophil engraftment is defined as absolute neutrophil count (ANC) recovery of ≥ 
0.5 x 109/L (500/mm3) for three consecutive laboratory values obtained on different 
days (derived from either donor). Date of engraftment is the date of the first of the 
three consecutive laboratory values. 
(2) Platelet engraftment will be defined as platelet count ≥ 20,000/mm3 for three consecutive 
laboratory values obtained on different days with no platelet transfusions in the 
preceding 7 days. Date of platelet engraftment is the date of the first of the three 
consecutive laboratory values. 
7.5 Primary graft failure will be defined as donor -derived ANC (either donors) never 
meeting or exceeding 500/mm3 for 3 consecutive measurements. Neutrophil engraftment 
occurring after day +42 post-transplant is defined as delayed engraftment. 
7.6 Secondary graft failure or graft rejection will be defined as no evidence of donor chimerism 
by UCB and/or haploidentical donor (<10%), or too few cells to perform adequate 
chimerism analysis, in research participants with prior neutrophil engraftment. 
7.7 Mixed hematopoietic chimerism will be defined as between 10% and 95% donor 
chimerism in the absence of immunosuppressive therapy. 
7.8 Engraftment syndrome, characterized by fever, rash, pulmonary edema, weight gain, liver 
and renal dysfunction, and/or encephalopathy is an early complication of hematopoietic 
stem cell transplantation that occurs around neutrophil engraftment time and is attributed 
to the sudden cytokine discharge associated with robust engraftment of transplanted cells. 
When diagnosed, the following grading will apply: 
 Grade I (mild): transient (<48 hours) low grade fever with or without limited 
rash 
 Grade II (moderate): sustained fever above 39.0˚C (> 48 hours), rash >25% 
body surface area and/or evidence of pulmonary injury (infiltrate or 
hypoxia), requiring corticosteroids and/or intermittent oxygen and 
responding to interventions 
 Grade III (severe): not rapidly responding to interventions, evidence of 
multiple organ dysfunction/failure (e.g. hypoxia requiring continuous 
oxygen, renal impairment requiring HD or CVVH, evidence of 
encephalopathy) 
 Grade 4 (life threatening): pressor or ventilator support indicated 
 


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8.0 CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY 
CRITERIA 
8.1 Recipient Off-therapy Criteria – Recipient participants may remain on-study, but 
considered off therapy, for monitoring if one of the following occurs (off therapy 
participants monitored for disease status and survival only): 
8.1.1 Experiences graft failure/rejection. 
8.1.2 Noncompliance with the protocol. 
8.1.3 Positive pregnancy test after the HSC infusions. 
8.1.4 Recipient requires an additional HSC infusion, and unable to receive these cells 
due to donor issues. 
8.1.5 Physician decides that it is in the best medical interest of the participant. 
8.2 Recipient Off-study Criteria: Recipient participants will remain on study until one of the 
following occurs: 
8.2.1  Withdrawal of consent. 
8.2.2  Death. 
8.2.3  Lost to follow-up or inadequate follow-up per discretion of PI 
8.2.4  Requires an additional transplant procedure using a different allogeneic donor. 
8.2.5 Requires enrollment on another therapeutic study or non-protocol therapy for 
disease. 
8.2.6  Study evaluations are complete (i.e. has completed the month 12 post-HSC 
infusion evaluations, and first annual post-transplant evaluation). 
8.2.7  Development of a significant change in health status at any point of therapy, 
which would render receipt of the transplantation procedure or continuation in the 
study no longer in the participant’s best interest. 
8.2.8 Unable to undergo the primary HCT procedure due to donor and/or donor center 
inability to provide the HSC product. 
8.3 Donor Off-study Criteria: Donor participants will remain on-study until one of the 
following occurs: 
8.3.1 Withdrawal of consent. 
8.3.2 Death. 
8.3.3 Development of a significant change in health status at any point of therapy, 
which would render the donor medically ineligible to serve (or continue to serve) 
as donor; or renders the donor’s continuation in the study no longer in his/her best 
interest. 
8.3.4 Date of corresponding recipient’s off-study date. 
 
9.0 SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS 
9.1 Reporting adverse experiences and deaths 
The following definitions apply: 


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Serious event – any event, in which the outcome is fatal or life-threatening, results in 
permanent disability, causes inpatient hospitalization or prolongs existing hospitalization, 
or is a congenital anomaly, cancer, or overdose. 
Unanticipated adverse event – any event, not identified in their nature, severity, or 
frequency in the current risk documents (e.g., investigator’s brochure), or consistent with 
the investigational plan. 
9.2 Reporting to St. Jude Institutional Review Board (IRB) 
Principal investigators are responsible for promptly reporting to the IRB any adverse 
events that are unanticipated, serious, and that may represent potential harm or increased 
risk to research participants. When an unanticipated death occurs, the PI should report it 
to the Director of Human Subject’s Protection immediately, by phone: (901) 595-4359, 
cell: (901) 336-2894, fax: (901) 595-4361, or e-mail: hsp-1@stjude.org. A reportable 
event entry into TRACKS should follow within 48 hours of notification of the event. 
Serious, unanticipated, and related or possibly related events must be reported within 10 
working days of notification of the event. At the same time, the investigator will notify 
the study sponsor and/or the FDA, as appropriate. All other SAEs and captured AEs will 
be reported to the IRB in the continuing review, with the following exceptions: 
 Any grade III-IV infusion reactions will be reported as soon as possible but every 
effort should be made to assure reporting is no more than within 7 business days 
of the event. 
 Any episodes of overall grade III or IV acute GVHD in participants will be 
reported to the IRB as soon as possible but no more than within approximately 10 
days of the PI’s confirmation of the diagnosis/grade of the event. 
 Clinical diagnosis of PTLPD will be reported to the IRB as soon as possible but 
no more than within 10 days of the PI’s determination of the disorder. 
The principal investigator is responsible for reviewing the aggregate toxicity reports and 
reporting to the IRB if the frequency or severity of serious toxicities exceed those 
expected as defined in the protocol or based on clinical experience or the published 
literature. Any proposed changes in the consent form or research procedures resulting 
from the report are to be prepared by the study team and submitted with the report to the 
IRB for approval. 
Recipient participants will be followed for NCI Grade III-V, and clinically significant I-
II, adverse events from the start of conditioning and throughout the first year post HCT, 
regardless of their relationship to the treatment given. However, all GVHD events will be 
captured on an ongoing basis regardless of stage or grade. 
Haploidentical donor participants will be followed for any serious AE (SAE) and any 
clinically significant AEs (per judgment of PI) that are deemed related to the mobilization 
and/or apheresis procedure from the time of initiation of mobilization growth factors to 7-
days post last day of the apheresis procedure. If the transplant recipient requires a second 
HSC infusion, meaning that the donor is required to undergo the mobilization and 
apheresis procedure again, collection of this donor safety data will restart upon the 
initiation of the subsequent mobilization procedure and continue until 7-days post the last 


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day of this apheresis procedure. Timelines for reporting of these donor events to the 
institutional and federal governing agencies will be according to the same timelines noted 
in the following sections. A listing of the captured donor safety data will be provided in a 
separate table from the transplant recipients within each respective continuing review 
report. Continuing review reports to all regulatory authorities will be structured in a 
manner so that any infusion toxicities or stem cell product related variances will be 
reported in separate listings from all other required elements. 
9.3 Reporting to St. Jude Institutional Biosafety Committee (IBC) 
Continuing review reports will be sent to the IBC on at least an annual basis using the 
most current version of the continuing review form found on the IBC website. The safety 
reports, sent to the IRB for both the donors and stem cell recipients, will be 
simultaneously forwarded to the IBC. Therefore, reporting for safety events to this 
committee will be according to the same timelines as reporting to the IRB. This includes 
notification of achievement of MTD (if/when applicable). As per the direction of the 
IBC, only those protocol revisions and amendments directly related to the CliniMACS 
processing and related reagent(s) will require review and consideration by the IBC. Other 
revisions/amendments will be noted in the IBC continuing review report. 
9.4 Reporting to FDA  
The FDA will be notified in writing (IDE safety report) of any serious and unexpected 
AE associated with an investigational treatment or device; or any results from laboratory 
animal tests that suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity. 
Each notification to the FDA should be made as soon as possible and no later than 15 
calendar days after the sponsor’s initial receipt of the information. The FDA may 
require additional data to be submitted. In each written IND safety report, the sponsor 
shall identify all safety reports previously filed with the IND concerning a similar adverse 
experience, and shall analyze the significance of the adverse experience in light of the 
previous, similar reports where applicable. 
The sponsor shall also notify the FDA by telephone or by facsimile transmission of any 
unexpected fatal or life-threatening experience associated with the use of the 
investigational medication as soon as possible but no later than 7 calendar days after the 
sponsor’s initial receipt of the information. Any grade III-IV infusion reactions will be 
reported as soon as possible but every effort should be made to assure reporting is no 
more than within 7 business days of the event. Follow-up information to a safety 
report must be submitted as soon as the relevant information is available. 
If the results of further investigation show an AE that was not initially determined to be 
reportable should later be deemed reportable, the sponsor shall inform the FDA of the 
event in a written safety report as soon as possible, but no later than 15 calendar days 
after the determination is made. Results of the investigation of other safety information 
shall be submitted, as appropriate, in an information amendment or annual report. 
Continuing review reports, which will include the up-to-date clinical and safety data, will 
be submitted to the FDA at least annually. 
 


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9.5 Reporting to St. Jude Office of Regulatory Affairs 
Copies of all correspondence to the St. Jude IRB, including SAE reports are provided to 
the St. Jude Regulatory Affairs Office. All FDA related correspondence and reporting 
will be conducted through the Regulatory Affairs Office. Adverse event reporting and 
annual reporting will be in accord with the FDA Title 21 CFR312.32 and Title 21 
CFR312.33, respectively. The Regulatory Affairs Office can be reached at 901-595-2347 
(secondary contact: St. Jude Vice President of Clinical Trials Administration 901-595-
2876). 
9.6 Continuing review reports 
Continuing review reports of protocol progress and summaries of adverse events will be 
filed with the St. Jude IRB, and IBC at least annually. 
9.7 Reporting to the St. Jude Data Safety Monitoring Board 
This study has been referred to the St. Jude Data and Safety Monitoring Board (DSMB) 
for regular monitoring. The DSMB is charged with advising the Director and other senior 
leaders of St. Jude on the safety of clinical protocols being conducted by St. Jude 
investigators and on their continuing scientific validity. DSMB monitoring and review for 
this study will be conducted in accordance with the NCI guidance for DSMBs on an 
approximate semiannual basis. The St. Jude DSMB is responsible for ongoing review of 
the protocol and related information such as enrollment, issues related to participant 
safety (specifically toxicities and the risk:benefit ratio of the trial), interim analyses, and 
the overall study conduct necessary to accomplish the primary protocol objectives. This 
includes evaluation of the accrual rate, adherence to the study design, outcome measures, 
and review of protocol related primary outcome data. The PI will meet with DSMB 
during the semiannual visits to review the information submitted and discuss the status of 
the protocol. The DSMB may recommend that the trial be modified, suspended to 
accrual, and/or stopped based on their review.  
9.8 Data submission to Miltenyi Biotec 
Clinical and safety related data will be provided to Miltenyi Biotec, the manufacturer of 
the CliniMACS system. Data will include but is not limited to the transplant research 
participant’s age and diagnosis, donor product(s) related information including donor 
type, the stem cell mobilization, selection, and infusion procedure. Outcome data 
including lymphohematopoietic reconstitution, immunological response, disease response 
and transplant complications will be shared with Miltenyi Biotec. Representatives from 
Miltenyi Biotec will be able to review the participant’s (donor and transplant research 
recipient) laboratory and medical record for data verification purposes. Copies of all 
reports to the institutional and governing regulatory bodies will also be accessible upon 
request. In the event that the protocol is placed on a clinical hold by the PI or governing 
regulatory authorities, representatives from Miltenyi Biotec will be notified as soon as 
possible. 
9.9 Reporting to the Center for International Blood and Marrow Transplant Research  
The Transplant Program at St. Jude is required by the federal government to report 
transplant information to the Center for International Blood and Marrow Transplant 
Research (CIBMTR). The CIBMTR is a research partnership of the International Bone 
Marrow Transplant Registry, the National Marrow Donor Program (NMDP), and the 


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Foundation for the Accreditation of Cellular Therapy (FACT). This organization is 
responsible for the collection and maintenance of a standardized data warehouse registry 
of autologous and all allogeneic (related and unrelated donor) transplants performed in 
the United States. 
The Office of General Counsel, U.S. Department of Health and Human Services, had 
deemed the CIBMTR not a covered entity under the Privacy Rule (45 CFR 164.512), 45 
CFR Parts 160 and 164, and the Health Insurance Portability and Accountability Act 
(HIPPA) of 1996. For this reason, the submission and disclosure of certain protected 
health information (PHI), including that required for CIBMTR, is allowable without the 
individual’s authorization (i.e. consent is waived) when such disclosure is made to public 
health authorities authorized by law for the purpose of preventing or controlling disease, 
injury, or disability. 
Data resulting from this transplant procedure will be sent for general registry purposes to 
comply with the federal government requirements. This information for both donor and 
recipient is submitted using a unique participant identification number. The information 
submitted for haploidentical recipients is less extensive than recipients of other donor 
products. For this reason, variables submitted may include but are not limited to the 
transplant recipient’s date of birth, country/state of current residence, diagnosis, basic 
lympho-hematopoietic reconstitution (e.g. date of ANC and platelet engraftment), post-
HCT disease status, and basic AEs (e.g. GVHD- yes or no), survival status, date/cause of 
death. 
10.0 DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY 
10.1  Data collection 
The St. Jude Cancer Center Clinical Research Associates assigned to the Department of 
BMTCT will assure protocol compliance, and conduct all clinical and safety data 
collection. Data will be entered into an institutional database. The PI will be responsible 
for review of data for accuracy and completeness once entered into the secure 
departmental database. 
10.2  Study monitoring 
This protocol will be monitored for safety and data as per the St. Jude Data and Safety 
Monitoring Plan for Clinical Trials approved by the NCI in 2010, and is considered to be 
in the High Risk III category. The Central Protocol and Data Monitoring Office 
(CPDMO) will verify 100% of the informed consent documentation on all participants 
and verify 100% of St. Jude participants’ eligibility status. The study team will meet at 
appropriate intervals to review case histories and data quality summaries on all 
participants. The St. Jude Clinical Research Monitor will assess protocol and regulatory 
compliance as well as the accuracy and completeness of all data points 100% of study 
enrollees every three months. The protocol will be tracked continuously for the accrual of 
donors and recipients. All AE and SAE reports will be reviewed by the study Principal 
Investigator for type, grade, attribution, duration, timeliness and appropriateness on all 
study participants. All SAE reports will be reviewed by the monitor every 3 months.  
Protocol compliance monitoring will include participant status, eligibility, the informed 
consent process, demographics, staging, study objectives, subgroup assignment, 
treatments, evaluations, responses, participant protocol status, off-study, and off-therapy 


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criteria. The Monitor will generate a formal report which is shared with the Principal 
Investigator (PI), study team and the Internal Monitoring Committee (IMC). Monitoring 
may be conducted more frequently if deemed necessary by the CPDMO or the IMC. 
Continuing reviews by the IRB and CT-SRC will occur at least annually. In addition, 
SAE reports in TRACKS (Total Research and Knowledge System) are reviewed in a 
timely manner by the IRB. The Regulatory Affairs Office will assist the PI in reporting to 
the FDA and other external oversight agencies, as necessary. 
10.3 Confidentiality 
Unique participant numbers will be used in place of an identifier such as a medical record 
number when reporting any data to outside agencies. No research participant names will 
be recorded on the data collection forms. The list containing the unique participant 
numbers and the medical record number will be maintained in a locked file accessible 
only to the study team. 
The medical records of study participants may be reviewed by the St. Jude IRB, FDA, 
clinical research monitors, etc. 
11.0 STATISTICAL CONSIDERATIONS 
11.1 Statistical design and analysis for the primary objectives and stopping rules 
This study is designed as a phase II study. The primary objective of this study is to 
evaluate the rate of neutrophil engraftment by day +42. Neutrophil engraftment for the 
purposes of this objective will be as defined in section 7. 
As detailed in section 2, the use of alternative donors such as haploidentical donors and 
unrelated UCB are frequently needed and largely successful. However, the use of these 
alternative donors is typically complicated with additional problems, particularly poor 
hematopoietic recovery and graft failure.130  
The majority of published experience with alternative (HLA-mismatched) donor 
transplantation in children is with UCB grafts. The COBALT study included 191 children 
with hematologic malignancies who received UCB transplantation with TBI based 
(1350Gy) myeloablative conditioning.60 The cumulative incidence of neutrophil 
engraftment by day 42 was 80%. The New York Blood Center published outcomes on 
1061 patients (78% pediatric) with hematologic malignancies who received 
myeloablative UCBT with units from their bank.63 The cumulative incidence of 
neutrophil engraftment was 74% by day 77. The CIBMTR published a comparison of 
UCB transplantation with HLA-matched unrelated donor transplantation, in which 503 
children with acute leukemia received UCBT.17 They confirmed that although the 
leukemia-free survival was similar, the rate of neutrophil engraftment (and TRM) were 
significantly worse with HLA-mismatched UCB grafts than with HLA-matched BM 
grafts. For UCB recipients, the best neutrophil engraftment was obtained in the rare 6/6 
matched UCB recipients with 85% of the 35 patients achieving neutrophil recovery at 
day +42. In addition, recipients who received a single antigen mismatch UCB unit with 
an appropriately high cell dose (n=154) had a neutrophil engraftment rate of 80% at day 
+42. Recipients of lower cell dose or two antigen mismatch units fared worse. 
Given the data, we consider a rate of successful neutrophil engraftment of less than 80% 
by day +42 to be unacceptable for alternative donor transplantation. The goal of our study 


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is to develop a novel preparative regimen to facilitate successful neutrophil engraftment 
of donor graft(s) at a rate of ≥91%. We do not anticipate censoring during the 42 day time 
period and we can approximate the rate of neutrophil engraftment by day +42 using a 
Binomial distribution. In order to keep the validity of Binomial distribution 
approximation, patients lost for follow up will be counted as a failure to engraft. 
Therefore, in this study, we propose to test the null hypothesis H0: P≤0.80 versus H1: 
P>0.80, where P is the proportion of research participants who engrafted by day +42 after 
HCT. With type I error of 10% and type II error of 20%, Simon’s two stage optimum 
design powered at alternative successful neutrophil engraftment rate P1=0.91 requires 21 
evaluable patients at the first stage and 49 evaluable patients in total76. The stopping rules 
are provided in Table 1, with the understanding that stopping the trial early would be 
suggestive of the proposed transplant strategy not being an effective treatment option for 
this group of patients. The interpretation is that if we observe 17 or fewer participants 
engrafted by day +42 in the first 21 participants, then we would stop the trial for lack of 
efficacy. However, if we observe 18 or more patients engrafted in the first 21 participants 
by day +42 in stage one, then 28 more patients will be enrolled in stage two. If we 
observe 43 or more participants engrafted by day +42 upon completion of the trial, then 
we conclude that the true rate of neutrophil engraftment is at least 80% and our novel 
regimen will be proposed for further development and phase III clinical trial.  
Table 1: Stopping rules for lack of efficacy based on the Simon’s 2-stage optimum 
design (unacceptable low rate of successful neutrophil engraftment by day +42)  
Accept H0 if the number of research participants engrafted 
P0 
P1 
(≤ r1/n1 ) 
(≤ r/n ) 
EN(P0) 
PET(P0) 
0.80 
0.91 
17/21 
42/49 
31 
0.63 
Note: r1 and r denote the number of patients successfully engrafted by day +42; EN(P0) 
denotes the expected sample size under P0; PET(P0) denotes the probability of early 
termination at stage I under P0.  
All participants who receive the prescribed transplant will be evaluable for the primary 
outcome. In addition, any patient who starts the conditioning regimen but stops prior to 
receiving the graft will count as a failure, if the reason for stopping therapy is toxicity 
from the conditioning regimen. Patients who enroll but do not initiate treatment due to 
withdraw of patient, withdraw of donor or health status change to make the treatment not 
in the patient’s best medical interest, etc., will be replaced. Any patient who dies from 
toxicity after neutrophil engraftment but before day +42 will count as having engrafted. 
Any patient who dies prior to neutrophil engraftment will count as a graft failure.  
After the study is finished, for the first primary objective, the rate of neutrophil 
engraftment by day +42 and its 95% Blyth-Still-Casella confidence interval will be 
estimated based on the binomial approximation.  
Table 2 shows the number of haploidentical HCT and the estimated number of KIR 
mismatch cases performed at our institution in last 5 years. With the initiation of UCB 
protocols at SJCRH, the number of referrals for patients requiring alternative donor HCT 
has increased. Furthermore, HAPCORD will be a high priority protocol. Based on this 
table and PI’s estimation, it is expected that approximately 10 patients per year will be 


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enrolled in this study. Therefore, the expected accrual period for this study is maximally 
5 years. Adequate enrollment will be monitored every 6 month and if the accrual is less 
than 50% projected, protocol revision or closure will be considered. 
Table 2: The number of haploidentical HCT performed at St. Jude 2007 to 2012 
Year 
2007 
2008 
2009 
2010 
2011 
2012 
Number haploidentical HCT  
20 
17 
22 
19 
24 
22 
Estimated KIR mismatch 
14 
12 
15 
13 
17 
15 
Estimated KIR matched  
6 
5 
7 
6 
7 
7 
Number of UCBT 
3 
2 
0 
0 
2 
8 
Stopping Rules for Toxicities  
In addition to the stopping rules based on successful neutrophil engraftment, we will 
closely monitor the trial for early excessive toxicities in terms of secondary graft failure, 
severe acute grade III/IV GVHD and therapy related death/mortality (TRM). Secondary 
graft failure is defined in section 7.0. TRM is any death in remission and related to 
protocol therapy. The incidence of secondary graft failure, acute GVHD and transplant 
related deaths will be monitored for 100 days from the date of transplantation for 
application of the stopping rules. Toxicities secondary to non-protocol therapy for post-
transplant persistent or recurrent disease will not count towards the toxicity stopping 
rules.  
In 2007, Eapen et al published the CIBMTR and National Cord Blood Program outcomes 
of 503 pediatric patients undergoing UCBT for acute leukemia in the United States. The 
study reports a rate of 40% (188/468) for TRM and 23% (110/486) for acute grade III/IV 
GVHD. The rate for graft failure was 18% (89/500). Similar rates were reported for 
patients aged 16 years or over who underwent a transplant for acute leukemia in 2010.  
The safety endpoints will be monitored independently and if there is evidence suggesting 
that the rate of secondary graft failure is greater than 20% or the rate of stage III/IV acute 
GVHD is greater than 30% (type I error rate 20%), or the rate of TRM is greater than 
25%, stopping the trial or amending the therapy will be considered. The planned interim 
evaluation time points and stopping rules based on the exact upper 90% Blyth-Still-
Casella confidence bounds for each of the three endpoints are provided in Tables 3-5 
Table 3. Stopping Rules for Toxicities Based on Grades 3-4 acute GVHD within the 
First 100 Days Post-transplant  
No. of Research 
Participants Enrolled 
No. of Grades 3-4 acute 
GVHD Observed 
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 5 
0.3199 
≤ 35 
≥ 9 
0.3199 
≤ 49 
≥ 12 
0.3023 
 
 


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Table 4. Stopping Rules for Toxicities Based on TRM within the first 100 days Post-
transplant 
No. of Research 
Participants Enrolled  
No. of Therapy Related 
Death Observed  
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 3 
0.2778 
≤ 35 
≥ 6 
0.2647 
≤ 49 
≥ 9 
0.2695 
 
Table 5. Stopping Rules for Secondary Graft Failure within the First 100 Days Post-
transplant 
No. of Research 
Participants Enrolled  
No. of Secondary Graft 
Failure Observed  
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 2 
0.2178 
≤ 35 
≥ 4 
0.2103 
≤ 49 
≥ 6 
0.2011 
Based on the above Table 3, if five grades 3-4 acute GVHD occur within the first 100 
days post transplantation in the first twenty-one evaluable research participants treated, 
then stopping the trial and/or amending the study will be considered. Similarly, if we 
observe three TRMs (Table 4) or two secondary graft failures (Table 5) in the the first 
100 days after transplantation in the first twenty-one evaluable research participants, then 
temporarily stopping the trial and amending the study will be considered. It may be noted 
that the above stopping rules are “ad hoc” in nature.  
 
11.2 Statistical analysis for secondary objectives  
11.2.1  Estimate the incidence of malignant relapse, EFS and OS at one-year post-
transplantation 
The estimate of cumulative incidence of relapse will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The analysis will 
be implemented using SAS macro (bmacro252-Excel2007\cin) available in the St. 
Jude Department of Biostatistics. The Kaplan-Meier estimate of OS and EFS with 
relapse, death due to any cause and graft failure as events along with their 
standard errors will be calculated using the SAS macro (bmacro251-
Excel2007\kme) available in the Department of Biostatistics at St. Jude, where 
OS = min (date of last follow-up, date of death) – date of HCT and all participants 
surviving after 1 year post-transplant will be considered as censored, and EFS = 
min (date of last follow-up, date of relapse, date of graft failure, date of death due 
to any cause) – date of transplant, and all participants surviving at the time of 
analysis without events will be censored. The analysis for this objective will be 
performed when the last evaluable participant has been followed for one-year post 
transplant.  
11.2.2  Estimate the incidence and severity of acute and chronic GVHD in the first 100 
days after HCT. 


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The cumulative incidence of acute and chronic GVHD will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The SAS macro 
(bmacro252-Excel2007\cin) available in the Department of Biostatistics at St. 
Jude will be used for such analysis. The severity of acute GVHD and chronic 
GVHD will be described. The analysis for this objective will be performed when 
the last evaluable participant has been followed for 100 days post transplant.  
11.2.3 Estimate the incidence of secondary graft failure, transplant related mortality 
(TRM) and transplant related morbidity in the first 100 days after HCT. 
The cumulative incidence of TRM, transplant related mortality, and secondary 
graft failures will be estimated using the same method as used in evaluating 
Objective 11.2.2. Deaths before day 100 because of other reasons are the 
competing risk events for TRM and transplant related mortality. Deaths due to 
toxicity and relapse before day 100 are the competing risk events for secondary 
graft failure. The analysis for this objective will be performed when the last 
evaluable participant has been followed for 100 days post transplant. 
 
11.3 Analysis for exploratory objectives  
The final results of these exploratory objectives are expected to be available when 
the last evaluable participant has been followed for one-year post transplant. 
11.3.1  Assess the relationship between pre-transplant MRD with transplant outcomes. 
The relationship of pre-transplant MRD and transplant outcomes will be 
examined through Cox proportional hazard model or generalized linear model. 
The model can also be used to adjust for other confounding factors such as 
patient’s age at transplant. 
11.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B, and NK cells 
and lymphocytes will also be evaluated.. All immune reconstitution measures, 
immunophenotyping and functional assay measures will be descriptively 
analyzed. 
11.3.3 Characterize the recovery of Gamma Delta () T cells after HCT, including T 
cell receptor analysis, phenotyping and functional analysis. All Gamma Delta T 
cell measures will be descriptively analyzed. 
11.3.4 Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility. All Influenza infection 
monitoring will be descriptively analyzed. 
 
12.0 OBTAINING INFORMED CONSENT 
The ongoing informed consent process will be carried out per the policies and procedures put 
forth in the St. Jude Investigator’s Handbook for Clinical Research (http://home.web.stjude. 
org/clinical_research/administration/doc/handbook.pdf). The PI or physician sub-investigator 
will conduct the signature authorization portion of the consent process.  


HAPCORD 47 
 
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12.1 Informed consent prior to research interventions 
For protocol required research interventions (research samples for baseline immune 
reconstitution evaluation); informed consent must be obtained prior to performing these 
research interventions. 
12.2 Consent at age of majority 
The age of majority in the state of Tennessee is 18 years old. Research participants must 
be consented at the next St. Jude clinic visit after their 18th birthday, and prior to 
performing any research interventions during that visit.  
12.3 Consent when English is not the primary language 
When English is not the patient, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter. This 
information will be documented in the participant’s medical record. Either a certified 
interpreter or the telephone interpreter’s service will be used to translate the consent 
information. The process for obtaining an interpreter and for the use of an interpreter is 
outlined on the Interpreter Services, OHSP, and CPDMO websites. 
  


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103. 
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Heinzelmann F, Lang PJ, Ottinger H, et al. Immunosuppressive total lymphoid 
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Palma J, Salas L, Carrion F, et al. Haploidentical stem cell transplantation for children 
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121. 
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purified stem cells cause early hematopoietic recovery in syngeneic and allogeneic hosts. The 
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Langfitt D, Wallace N, Dallas MH. Dendritic Cell Facilitate Thymic Recovery And 
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Langfitt D, Wallace N, Gaines S, Dallas M. Dendritic cells and Regulatory T cells 
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Park M, Lee SH, Lee YH, et al. Pre-Engraftment Syndrome after Unrelated Cord Blood 
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Schmid I, Stachel D, Pagel P, Albert MH. Incidence, Predisposing Factors, and Outcome 
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Blood; 119(9): 1972-80. 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX A: 
PERFORMANCE STATUS SCALE 
KARNOFSKY PERFORMANCE STATUS SCALE 
Score General Description 
100 
Normal. No complaints. No evidence of disease. 
90 
Able to carry on normal activity. Minor signs or symptoms of disease. 
80 
Normal activity with effort. Some signs or symptoms of disease. 
70 
Care of self. Unable to carry out normal activity or to do active work. 
60 
Requires occasional assistance, but is able to care for most of his needs. 
50 
Requires considerable assistance and frequent medical care. 
40 
Disabled. Requires special care and assistance. 
30 
Severely disabled. Hospitalization is indicated although death is not imminent. 
20 
Hospitalization necessary, very sick, active support treatment necessary. 
10 
Moribund. Fatal processes progressing rapidly. 
0 
Dead. 
 
 
LANSKY PERFORMANCE STATUS SCALE 
Score  General Description 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both greater restriction of and less time spent in play activity 
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 but able to participate in 
all quiet play and 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 
No play; does not get out of bed 
0 
Unresponsive 
 


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APPENDIX B 
COG STEM CELL COMMITTEE CONSENSUS GUIDELINES FOR ESTABLISHING 
ORGAN STAGE AND OVERALL GRADE OF ACUTE GRAFT VERSUS HOST 
DISEASE (GVHD) 
Table 1 outlines standard criteria for GVHD organ staging. However, confounding clinical 
syndromes (such as non-GVHD causes of hyperbilirubinemia) may make staging GVHD in a 
given organ difficult. In addition, timing of organ specific symptoms affects whether that 
symptom is more or less likely to be true GVHD. Please refer to Tables 2 and 3 to assist you in 
deciding whether to attribute these clinical findings to GVHD, especially in situations where a 
biopsy is not possible. For additional help, please see the text which follows the tables. Table 4 
reviews the approach to assessing GVHD as acute, chronic, or the overlap between the two. 
 
Finally, engraftment syndrome will be reported separately from the GVHD scoring presented 
below. 
 
Engraftment Syndrome 
A clinical syndrome of fever, rash, respiratory distress, and diarrhea has been described, just 
prior to engraftment in patients undergoing unrelated cord blood and mismatched 
transplantation. If, in the judgment of the treating physician, a patient experiences this 
syndrome, details of the event will be recorded in the medical record. 
 
Modified Glucksberg Staging Criteria for Acute Graft versus Host Disease 
 
Table 1: Organ Staging (See tables and text below for details) 
Stage 
Skin 
Liver (bilirubin) 
Gut (stool output/day) 
0 
No GVHD rash 
< 2 mg/dL 
Adult: < 500 mL/day 
Child: < 10 mL/kg/day 
1 
Maculopapular rash 
< 25% BSA 
2-3 mg/dL 
Adult: 500-999 mL/day 
Child: 10-19.9 mL/kg/day. 
Or persistent nausea, vomiting, or 
anorexia, with a positive upper GI 
biopsy. 
2 
Maculopapular rash 
25-50% BSA 
3.1-6 mg/dL 
Adult: 1000-1500 mL/day 
Child: 20-30 mL/kg/day 
3 
Maculopapular rash 
> 50% BSA 
6.1-15 mg/dL 
Adult: > 1500 mL/day 
Child: > 30 mL/kg/day 
4 
Generalized 
erythroderma plus bullous 
formation and 
desquamation > 5% BSA 
>15 mg/dL 
Severe abdominal pain with or 
without ileus, or grossly bloody stool 
(regardless of stool volume). 
 


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Overall Clinical Grade (based on the highest stage obtained):  
Grade 0: No stage 1-4 of any organ 
Grade I: Stage 1-2 skin and no liver or gut involvement 
Grade II: Stage 3 skin, or Stage I liver involvement, or Stage l GI  
Grade III: Stage 0-3 skin, with Stage 2-3 liver, or Stage 2-3 GI  
Grade IV: Stage 4 skin, liver or GI involvement 
 
 
Table 2 Evaluating Liver GVHD in the Absence of Biopsy Confirmation (See Table 3.0 below) 
 
Establishing liver GVHD with no skin or GI GVHD 
No Skin/GI GVHD 
Day 0-35 
Assume no liver GVHD, unless proven by biopsy 
No Skin/GI GVHD  
Day 36-100 
If NO other etiology identified, 
NO improvement with stopping 
hepatotoxic medications/TPN: 
Stage as liver GVHD 
If other etiology identified or improves 
with stopping hepatotoxic drugs/TPN: 
Do not stage as liver GVHD 
 
Establishing liver GVHD with skin or GI GVHD and other cause of hyperbilirubinemia 
Skin and/or GI GVHD 
present 
Worsening bilirubin level 
(includes worsening just prior 
to onset of skin or GI tract 
GVHD) OR stable elevated 
bilirubin despite resolution of 
non-GVHD cause of increased 
bilirubin: 
Stage as liver GVHD 
Stable or improving bilirubin after 
diagnosis of skin or GI GVHD, 
irrespective of treatment: 
Do not stage as liver GVHD 
 
For GI staging:  The “adult” stool output values should be used for patients > 50 kg in weight.  Use 
3 day averages for GI staging based on stool output.  If stool and urine are mixed, stool output is 
presumed to be 50% of total stool/urine mix (see 3.2 below).   
 
For Stage 4 GI:  the term “severe abdominal pain” will be defined as: 
 
a) Pain control requiring institution of opioid use, or an increase in on-going opioid use, PLUS 
b) Pain that significantly impacts performance status, as determined by the treating MD. 
 
If colon or rectal biopsy is +, but stool output is < 500 mL/day (< 10 mL/kg/day), then consider as 
GI stage 0. 
 
There is no modification of liver staging for other causes of hyperbilirubinemia. 


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Changing liver GVHD stage with other cause of hyperbilirubinemia 
Skin and GI GVHD 
stable, improving, or 
absent 
Liver GVHD staging is carried forward without increase in stage until 
other disease process resolves (e.g., if TTP is diagnosed in the presence 
of stage 2 liver GVHD, the liver GVHD stage 2 is carried forward 
despite rising bilirubin level until TTP is resolved. If there is no liver 
GVHD – stage 0 – and new onset TTP, the stage 0 is carried forward 
until TTP is resolved). 
Skin and/or GI GVHD 
worsening 
Liver GVHD is staged according to the Glucksberg criteria. The 
elevated bill is attributed to GVHD alone. 
 
Thus, when skin or GI GVHD is worsening, there is no downgrading of 
liver GVHD staging for other causes of hyperbilirubinemia. (e.g., if 
TTP is diagnosed in the presence of stage 2 liver GVHD and worsening 
skin or GI GVHD, the liver is staged according to the actual bilirubin 
level even if some of the rise in bilirubin is attributed to TIP). 
 
Similarly, even if there is no liver GVHD at onset of a new process, 
(such as TPN cholestasis), but skin or GI GVHD worsen during that 
process, then liver GVHD is diagnosed and staged according to the 
height of the bilirubin. 
 
There is one exception to this: the diagnosis of TTP, with high LDH 
and unconjugated bilirubin precludes the diagnosis and staging of new 
liver GVHD in the absence of a confirmatory liver biopsy. 
 
Table 3 Evaluating GI GVHD in the Absence of Biopsy Confirmation (See Table 4.0 below) 
 
Establishing GI GVHD with new onset diarrhea and no skin or liver GVHD 
No skin/liver GVHD  
Day 0 through engraftment 
Assume no GI GVHD, unless proven by biopsy 
No skin/liver GVHD 
engraftment through Day 100 
NO other etiology of diarrhea 
identified: 
Stage as GI GVHD 
Any other etiology of diarrhea 
identified: 
Do not stage as GI GVHD 
 
Establishing GI GVHD with pre-existing diarrhea and skin or liver GVHD 
Skin and/or liver GVHD 
present 
Worsening diarrhea (includes 
worsening just prior to onset of 
skin or liver GVHD) OR 
persistent diarrhea despite 
resolution of non-GVHD cause: 
Stage as GI GVHD 
Improving diarrhea after the 
diagnosis of skin or liver 
GVHD (irrespective of 
treatment) OR persistent 
diarrhea without resolution of 
underlying non-GVHD cause: 
Do not stage as GI GVHD 
 


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Category 
Time of Symptoms 
after HCT or DLI 
Presence of Acute 
GVHD features 
Presence of Chronic 
GVHD  features 
Acute GVHD 
Classic acute GVHD 
<100 d 
Yes 
No 
Persistent, recurrent, 
or late-onset acute 
>100 d 
Yes 
No 
Chronic GVHD 
Classic chronic GVHD 
No time limit 
No 
Yes 
Overlap syndrome 
No time limit 
Yes 
Yes 
 
Differentiating Acute GVHD, Chronic GVHD, and Overlap Syndrome: 
There is often confusion differentiating acute from chronic GVHD, especially in the setting of 
reduced intensity transplants, DLI and new prophylactic treatments. The NIH Working Group 
recently published new classifications for GVHD: 
 
Table 4 Acute GVHD, Chronic GVHD, and Overlap Syndrome 
 
 
 
 
 
 
 
 
 
 
 
 
 Scoring of acute GVHD may need to occur past day 100. In particular, patients should 
continue to be scored for acute GVHD when classic acute GVHD symptoms 
(maculopapular rash, nausea, vomiting, anorexia, profuse diarrhea - particularly if bloody 
and ileus) persist past day 100 or if identical symptoms previously scored as acute 
GVHD resolve and then recur within 30 days during immunosuppression taper but past 
day 100. 
 
 Those patients being scored as having acute GVHD should NOT have diagnostic or 
distinctive signs of chronic GVHD. 
 
 Patients with both acute and chronic symptoms should be diagnosed as having 
Overlap Syndrome and scored according to their chronic GVHD score. 
 
Further Explanation of Criteria presented in Tables 2 and 3 
 
1.0 Assessment of Skin GVHD 
 
1.1 Presence or Absence of Skin GVHD: Skin GVHD will be considered present if a rash 
characteristic of acute GVHD develops after allogeneic marrow transplantation involving 
more than 25% of the body surface not clearly attributable to causes such as drug 
administration or infection. The extent of the body surface area involved can be estimated by 
the "Rule of Nines". In estimating the extent of skin GVHD, the area involved is calculated 
for individual anatomic areas, such as the arm or leg, and then the total is derived from a 
simple summation. Areas that are non-blanching should not be considered involved 
regardless of the overlying color of the rash (red, brown, etc.). Limited distribution erythema 
(with the exception of palms and soles) in the absence of associated rash elsewhere on the 
body will not be considered GVHD. 
 


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2.0 Assessment of Liver GVHD 
 
2.1 Assessing for the Presence or Absence of Liver GVHD 
 
A. Hyperbilirubinemia (total bilirubin > 2.0 mg/dL) in the absence of other signs of acute 
GVHD in the skin or GI tract: 
 
i) Day 0-35: If hyperbilirubinemia alone is present with no other signs of acute GVHD 
in other organ systems, acute GVHD will not be diagnosed based solely on laboratory 
abnormalities.  
 
Acute GVHD will be diagnosed if findings on histopathology studies of liver from a 
biopsy or autopsy are confirmatory. 
 
ii) Day 35-100: If hyperbilirubinemia (must be conjugated bilirubin) is not improving or 
is exacerbated (especially if serum alkaline phosphatase is increased), in the absence 
of acute GVHD in other organ systems, no other etiologies are identified, and does 
not improve with discontinuation of hepatotoxic drugs, acute GVHD will be 
diagnosed. However, it is distinctly unusual to develop ascites or a coagulopathy in 
the early stages of acute GVHD of the liver alone. In the absence of histopathology 
studies of liver from a biopsy or autopsy specimen, ascites or a coagulopathy 
secondary to liver dysfunction will be considered to indicate the presence of another 
disease process (e.g., veno-occlusive disease). Recommended non-invasive studies to 
define an etiology for hyperbilirubinemia are: 
 
a. Imaging of liver (CT or ultrasound) 
b. Hepatitis screen (only if ALT is elevated) 
c. PT 
d. Blood cultures 
e. Review of medication list for potentially hepatotoxic drugs 
f. Review of risk factors for viral liver infection (HSV, CMV, VZV, adenovirus, 
EBV, HBV, and HCV) 
g. Hemolysis screen 
 
B. Pre-existing hyperbilirubinemia clearly attributed to an etiology other than acute GVHD 
in the presence of signs of acute GVHD in other organ systems. 
 
i) If pre-existing non-GVHD liver disease (documented clinically, by lab assessment, or 
by imaging studies) is stable or improving at the onset of signs of acute GVHD in 
other organs, then acute GVHD of the liver will not be considered to be present 
unless proven by liver biopsy or autopsy. 
 
ii) If hyperbilirubinemia worsens several days before or at the time of onset of signs of 
acute GVHD in other organ systems, GVHD will be considered to be present unless 
histopathology studies of liver are available and negative on a biopsy during that time 
interval or autopsy results exclude GVHD. 
 


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iii) If hyperbilirubinemia persists and is not improving after resolution of a pre-existing 
non-GVHD liver disease process (e.g., localized infection of liver, systemic sepsis, 
biliary tract obstruction) when signs of acute GVHD are present in other organ 
systems or no other intervening cause has been diagnosed, then acute GVHD will be 
considered to be present in the absence of a new, clearly identifiable cause of non-
GVHD liver disease or unless a liver biopsy or autopsy specimen is negative. 
 
C. Prior acute GVHD in liver with new onset of a disease process that exacerbates pre-
existing or recently resolved hyperbilirubinemia: 
 
i) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia and acute liver GVHD has been diagnosed and has been stable, 
improving, or resolved, then the liver will not be restaged for acute GVHD until the 
resolution or stabilizing of the concurrent disease process (i.e., the liver stage prior to 
the onset of the new disease process will be carried forward until the new disease 
process resolves). Example: Acute GVHD of the liver and gut is diagnosed on day 20. 
Treatment of acute GVHD results in falling bilirubin levels to liver stage 1. Sepsis or 
TTP develops with transient worsening of the hyperbilirubinemia. The liver stage is 
not increased, despite a higher bilirubin level, because the cause of worsening 
hyperbilirubinemia is attributed to sepsis or TTP. 
 
ii) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia in the presence of already worsening acute liver GVHD or 
GVHD of the skin or GI tract is simultaneously worsening, then the liver GVHD will 
be staged according to the actual bilirubin level, even though another cause of 
hyperbilirubinemia is present. 
 
3.0 Assessment of GVHD of the Gastrointestinal Tract 
 
3.1 Assessing for the Presence or Absence of GVHD of the Gastrointestinal Tract 
 
A. Diarrhea (>500 mL/day in adults or > 10 mL/kg in pediatric patients) in the absence of 
other signs of acute GVHD in other organ systems 
 
i) Day 0-engraftment: If diarrhea alone is present without other signs of acute GVHD in 
other organ systems, acute GVHD will not be considered present. Diarrhea will be 
attributed to acute GVHD if histopathology studies of gastrointestinal tract from a 
biopsy or autopsy are diagnostic. 
 
ii) Engraftment-day 100: If diarrhea persists and is not improving, is exacerbated, or 
develops de novo in the absence of acute GVHD in other organ systems, 
histopathology studies of gut biopsies or from autopsy specimens are not available, 
and no other etiologies are clearly identified, acute GVHD will be considered to be 
the cause. A stool specimen should be examined to rule out infectious causes (e.g., 
rotavirus, adenovirus, and C. difficile toxin). It is recommended, if at all possible, that 
biopsies be obtained for diagnostic purposes. 
 


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B. Pre-existing diarrhea clearly attributed to an etiology other than acute GVHD in the 
presence of signs of acute GVHD in other organ systems: 
 
i) If pre-existing diarrhea caused by a process other than GVHD has been documented 
clinically or by lab assessment and is stable or improving at the onset of signs of 
acute GVHD in the skin or liver, then acute GVHD of the intestine will not be 
considered to be present in the absence of biopsy confirmation or autopsy report. 
 
ii) If diarrhea or gastrointestinal symptoms are already present, but worsen significantly 
at the time of onset of signs of acute GVHD in the skin or liver, GVHD will be 
considered present, unless biopsy or autopsy are negative. 
 
iii) If diarrhea persists after resolution of a pre-existing disease process with signs of 
acute GVHD present in other organ systems, GVHD will be considered present, 
unless biopsy or autopsy are negative. 
 
C. Prior or present acute GVHD in other organ systems with new onset of diarrhea: 
 
If diarrhea is clearly attributable to an etiology other than acute GVHD (e.g., infection) 
and a history of acute GVHD exists or acute GVHD is present in other organ systems and 
is stable, then the gastrointestinal tract will not be evaluable for acute GVHD until the 
resolution or stabilizing of the other disease process (e.g., infection) in the absence of 
biopsy or autopsy confirmation.  
 
D. Persistent anorexia, nausea or vomiting in the absence of signs of acute GVHD in other 
organ systems: 
 
Persistent anorexia, nausea or vomiting in the absence of other known causes of these 
symptoms will be considered stage I acute GVHD if confirmed by endoscopic biopsy. 
 
If a biopsy is not possible (e.g. secondary to thrombocytopenia) but the clinical findings 
are compatible with acute GVHD, then the patient will be treated and recorded as having 
acute GVHD. 
 
3.2 Staging of the Gastrointestinal Tract for the Severity of Acute GVHD 
 
The severity of gastrointestinal tract GVHD will be staged according to modified Glucksberg 
criteria. To minimize errors caused by large day-to-day variation, diarrhea volume is 
measured as an average over 3 days and reported as the volume in milliliters per day. When 
urinary mixing is noted the stool volume will be considered half of the total volume unless 
nursing staff is able to give a better estimate from direct observation. Abdominal cramps are 
considered significant for staging if the severity results in a clinical intervention (e.g. 
analgesia, fasting, etc.). Blood in the stools is considered significant if the blood is visible or 
hematochezia/melena is present and not clearly attributed to a cause other than GVHD (e.g., 
epistaxis/hemorrhoids). 


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APPENDIX C 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
Score 0 
Score 1 
Score 2 
Score 3 
Performance Score: 
________ 
KPS ECOG LPS 
Asymptomatic 
and fully active 
(ECOG 0: KPS 
or LPS 100%) 
 Symptomatic, fully 
ambulatory, restricted 
only in physically 
strenuous activity (ECOG 
1, KPS or LPS 80-90%) 
Symtomatic, 
ambulatory, capable 
of self-care, >50% 
of waking hours out 
of bed (ECOG 2, 
KPS or LPS 60-
70%) 
Symptomatic limited 
self-care, >50% of 
waking hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN 
Clinical features: 
Maculopapular rash 
Lichen 
planus-like 
features 
Papuloquamous lesions 
or ichthyosis 
Hyperpigmentation 
Hypopigmentaion 
Keratosis pilaris 
Erythema 
Erythroderma 
Poikiloderma 
Sclerotic features 
Pruritus 
Hair involvement 
Nail involvement 
% BSA Involved _______ 
 No 
symptoms 
<18% BSA with 
disease signs but 
NOsclerotic features 
 19-50% BSA 
OR involvement 
with superficial 
sclerotic features 
“not hidebound” 
(able to pinch) 
>50% BSA ORdeep 
sclerotic features 
“hidebound” (unable to 
pinch) OR impaired 
mobility, ulceration or 
severe pruritus 
MOUTH 
No symptoms 
 Mild symptoms with 
disease signs but 
NOTlimiting oral intake 
significantly 
 Moderate 
symptoms with 
disease signs 
WITHpartial 
limitation of oral 
intake 
 Severe symptoms 
with disease signs on 
examination WITH 
major limitation of oral 
intake 
EYES 
 
Mean tear test (mm): 
>10 
6-10 
≥5 
Not done 
No symptoms 
 Mild dry eye 
symptoms not affecting 
ADL (requiring eyedrops) 
<3 x per day) OR 
asymptomatic signs of 
keratoconjunctivitissiccca 
 Moderate dry 
eye symptoms 
partially affecting 
ADL (requiring 
drops>3x per day or 
punctual plugs), 
WITHOUTvision 
impairment 
 Severe dry eye 
symptoms significantly 
affecting ADL (special 
eyeware to relieve pain ) 
ORunable to work 
because of ocular 
symptomsOR loss of 
vision cause by 
keratoconjunctivitissicca 
GI Tract 
No symptoms 
 Symptoms such as 
dysphagia, anorexia, 
nausea, vomiting, 
abdominal pain or 
diarrhea without 
significant weight loss 
(<5%) 
 Symptoms 
associated with mild 
to moderate weight 
loss) 5-15%) 
 Symptoms 
associated with 
significant weight loss > 
15%, requires 
nutritional supplement 
for most calorie needs 
OResophageal dilation 
LIVER 
 Normal LFT 
 Elevated Bilirubin, 
AP*, AST or ALT <2 x 
ULN 
 Bilirubin >3 
mg/dl or Bilirubin, 
enzymes 2-3 x ULN 
 Bilirubin or enzymes 
> 5 x ULN 
 
 


HAPCORD 65 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
APPENDIX C (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
Lungs† 
 
 
 
FEV1 ___________ 
 
DLCO __________ 
 No symptoms 
 
 
 
 
 
 FEV1 >80% 
OR 
LFS=2 
 Mild symptoms 
(shortness of breath after 
climbing one flight of 
steps) 
 
 
 FEV1 60-79%  
OR 
LFS 3-5 
 Moderate 
symptoms (shortness 
of breath after 
walking on flat 
ground) 
 
 FEV1 40-59% 
OR 
LFS 6-9 
Severe symptoms 
(shortness of breath 
at rest; requiring 02 
 
 
 
 FEV1 ≥39% OR 
LFS 10-12 
JOINTS AND  
FASCIA 
 No symptoms 
 Mild tightness of arms 
or legs, normal or mild 
decreased range of 
motion (ROM) AND not 
affecting ADL 
 Tightness of arms 
or legs OR joint 
contractures, 
erythema thought 
due to fasciitis, 
moderate decrease 
ROM AND mild to 
moderate limitation 
of ADL 
Contractures 
WITH significant 
decrease or ROM 
AND significant 
limitation of ADL 
(unable to tie shoes, 
button shirts, dress 
self etc.) 
GENITAL TRACT 
 No symptoms 
 Symptomatic with 
mild signs on exam AND 
no effect on coitus and 
minimal discomfort with 
gynecologic exam 
 Symptomatic 
with moderate signs 
on exam AND with 
mild dyspareunia or 
discomfort with 
gynecologic exam 
 Symptomatic 
WITH advance 
signs (stricture, labial 
agglutination or 
severe ulcerations 
AND severe pain 
with coitus or 
inability it insert 
vaginal speculum 
Other indicators, clinical manifestations or complications related to chronic GVHD (check all that apply and assign a 
score to its severity (0-3) based on its functional impact where applicable (none = 0, mild = 1, moderate =2, severe = 3. 
Esophageal stricture or web ____ 
Pericarial Effusion ____ 
 
Pleural Effusion(s) ____ 
Ascites (serositis) ____ 
 
Nephrotic syndrome ____  
Peripheral Neuropathy ____ 
Myasthenia Gravis ____ 
 
Cardiomyopathy ____ 
 
Eosinophilia > 500/µl ____  
Polymyositis ____ Cardiac conduction defects ____ Coronary artery involvement ____ 
Platelets <100,000/µl ____ Progressive Onset ____ 
Other: Specify: ________________________________________________________________________________ 
Organ scoring of chronic GVHD. 
* AP may be elevated in growing children, and not reflective of liver dysfunction.  
† Pulmonary scoring should be performed using both the symptom and pulmonary function testing (PFT) scale whenever 
possible. When discrepancy exists between pulmonary symptoms or PFT scores, the higher value should be used for final 
scoring. Scoring using the Lung Function Score (LFS) is preferred, but if DLCO is not available, grading using FEV1 should be 
used. The LFS is a global assessment of lung function after the diagnosis of bronchiolitis obliterans has already been established. 
The percent predicted FEV1 and DLCO (adjusted for hematocrit but not alveolar volume) should be converted to a numeric score 
as follows: >80% = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6. The LFS = FEV1 score + DLCO score, 
with a possible range of 2-12. GVHD indicates graft versus host disease, ECOG, Eastern Cooperative Oncology Group, KPS, 
Karnofsky Performance Status; LPS, Lansky Performance Status; BSA, body surface area; ADL, activities of daily living; LFTs, 
liver function tests; AP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; ULN, upper 
limit of normal. 


HAPCORD 66 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
APPENDIX C (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
GLOBAL GRADING OF CHRONIC GVHD84 
 
*Determined by adding the total number of organs receiving score > 0 using Figure 1, 
Appendix B. 
**Defined as the maximum score given to any organ system amongst all organs scored 
using Figure 1, Appendix B.  
Final Grade 
Number of 
Organs/Sites* 
Maximum Organ 
Score** 
Lung Score 
Mild 
1 - 2 
1 
0 
Moderate 
3 or more 
1 
1 
At least 1 
2 
Severe 
At least 1 
3 
2 - 3 


HAPCORD 67 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
APPENDIX D 
CRITERIA FOR ADVERSE EVENT (AE) EVALUATION AND REPORTING 
The St. Jude Department of BMTCT Clinical Research Office standard operating procedure for 
the documenting and reporting of adverse (SOP 10 Documenting and Reporting of Adverse 
Events) will provide guidance on the evaluation, collection and reporting of adverse events for 
this clinical trial. The current version of this document, as well as ongoing updates, can be 
located at the following website: http://home.stjude.org/bmt/Pages/policies-research.aspx 
 


HAPCORD 68 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
APPENDIX E 
Recommended testing and evaluation schedule 
STANDARD OF 
CARE STUDIES 
SAMPLE 
VOLUME 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
Pregnancy test 
PB 
2 ml 
X 
As clinically indicated 
Physical exam 
N/A 
N/A 
X 
Weekly 
X 
X 
CBC with diff. 
PB 
0.5 - 2 ml 
X 
Daily until engrafted, then weekly 
X 
X 
Chemistry 
PB 
0.25- 2 ml 
X 
Weekly 
X 
X 
Viral surveillance 
(BMTPCR) 
PB 
4 ml 
X 
Weekly 
As clinically indicated 
Chimerism 
PB 
1-2 ml 
 
Weekly 
Monthly 
BM 
2 ml 
 
X 
 
X 
 
X 
Disease Status 
Evaluation 
BM 
N/A 
X 
X 
 
X 
 
X 
MRD 
PB 
5 ml 
X 
X 
 
X 
 
X 
BM 
0.2-5 ml 
X 
X 
 
X 
 
X 
Lymphocyte 
Subset Study 
PB 
2.5-4 ml 
X 
Monthly 
Quantitative 
Immunoglobulins 
PB 
2.0 ml 
X 
 
 
Every 3 months after off IVIG for minimum of one month 
 
The information derived from or noted on the physical examinations, standard tests, and other assessments that comprise standard of care for recipients are not required to 
be transcribed onto case report forms and/or entered into the database. In reference to section 6.1 Evaluations, the above-indicated follow-up regimen for these evaluations 
is guided by the SOPs of the Department of BMTCT, for recipients of allogeneic stem cell transplantation. As these evaluations are considered standard clinical care (non-
research), variations in frequency (more or less frequent) of these evaluations can occur due to the participant’s current clinical condition and will not be noted as protocol 
deviations. 
 
Disease status evaluations/BM testing results obtained prior to enrollment may be used for the baseline/pre-infusion assessments. 
 
 MRD PB required for T-Cell ALL only 
 
Lymphocyte subset studies may be omitted without variance when the absolute lymphocyte count (ALC) is zero. 
 
In the event of graft failure/rejection, the post failure/rejection time period BM, chimerism and several of the applicable immune studies will be held, as these 
blood/marrow tests would not be clinically indicated. 


HAPCORD 69 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
APPENDIX E (continued) 
Immune reconstitution testing and evaluation schedule for RECIPIENT 
RESEARCH 
STUDIES 
SAMPLE 
VOL. 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
LABORATORY 
LYMPHOCYTE 
PHENOTYPES 
RESEARCH 
PB 
17.0 ml 
X 
X 
X 
X 
X 
X 
LEUNG LAB 
VBETA/TREC 
RESEARCH 
PB 
17.0 ml 
X 
 
 
X 
X 
X 
LEUNG LAB 
HOST-DONOR 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
HAPLO* 
17.0ml 
X 
 
 
 
 
 
IR-PHENOTYPE 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
5 ml 
X 
X 
X 
X 
X 
X 
T-FUNCTION 
SKIN 
BIOPSY 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
PB – VIRAL 
7.5 ml 
 
WEEKLY 
 
 
BM 
1ml 
X 
X 
 
X 
 
 
 
 
VBETA/TREC Research and Lymphocyte Phenotypes Research results will be maintained in a secured database in the Leung laboratory.  
 
HOST-DONOR, IR-PHENOTYPE, T-FUNCTION testing results will be maintained in a secured database in the Dallas laboratory database. Donor sample 
from haploidentical donor is optional and details provides in next table (optional donor studies) 
 
The pre-transplant Skin Biopsy & Bone Marrow for T-FUNCTION are optional additional tests that may be omitted at the discretion of the PI. Skin Biopsy may 
be performed during sedation during procedures (i.e. radiation) or at Month 1 without a protocol variation. 
 
Weekly VIRAL T-FUNCTION studies will be collected Monday –Thursday ONLY (as participant is available), preferred days being Monday & Wednesday.  
 
For RESEARCH studies, the posted volumes are the minimum volumes required to perform the respective protocol evaluations. 
 
 
 
 
 
 
 
 


HAPCORD 70 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
 
 
 
APPENDIX E (continued) 
Research testing for HAPLOIDENTICAL DONOR 
Prior to initial stem cell collection procedure: 
OPTIONAL research immune studies testing schedule 
Evaluation 
Volume Requirement 
Flow cytometry enumeration 
Lymphocyte Subset Study = 4 mL 
Thymic output and T cell repertoire 
VBETA/TREC Research = 17 mL 
T cell and NK cell number and function 
Lymphocyte Phenotypes Research = 17 mL 
Donor Immune Function in Host-Donor Interaction 
HOST-Donor = 17 mL 
 
 All donor research testing to be collected prior to stem cell collection – preferably prior to growth factor administration. 
These optional research tests may be collected at separate times. 


HAPCORD 71 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
APPENDIX E (continued) 
 
Research Study Evaluation Target Windows 
Several laboratory tests can only be processed on weekdays; therefore, if the scheduled 
evaluation falls on a weekend, or during a holiday period, an adjustment in the follow-up visit is 
expected and would not be noted as a protocol variation. Additionally, in order to accommodate 
such logistical constraints, evaluation/collection dates of all protocol assessments (required and 
optional research), may be performed within a reasonable window of the intended date following 
the guidelines provided in the table below: 
If the Planned Evaluation 
Time Point is: 
Window 
Weekly 
+ 3 Days 
Month 1 
Week 2 to Week 6 
Month 2 
Week 7 to Week 11 
Month 3 
Week 12 to Month 4 
Month 6 
Month 5 to Month 7 
Month 9 
Month 8 to Month 10 
Month 12 
Month 10 to Month 14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 72 
 
Amendment 2.0, dated: 7/16/2016 
 
IRB Approval date: 08/03/2016 
Protocol document date: 07/16/2016 
 
APPENDIX F 
The St. Jude Department of BMTCT Clinical SOPs for standard of care for all allogeneic stem 
cell infusion recipients and stem cell donors will provide guidance on the evaluation, ongoing 
clinical care and follow up for this clinical trial. The current versions of these SOPs, as well as 
ongoing updates, of these documents can be located at the following website: 
http://home.web.stjude.org /bone_marrow/clinicalHome.shtml.  
 

Prot_SAP_000.pdf: 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014 
Protocol document date: 02/10/14 
 
St. Jude Children's Research Hospital 
HAPCORD – NCT02199041 
Initial Version, dated: 04/02/13 Resubmitted to IRB 02/10/2014 (IRB Approved: 02/26/2014)     
Activated:   
  
COMBINED HAPLOIDENTICAL AND UMBILICAL CORD BLOOD 
TRANSPLANTATION IN PATIENTS WITH HEMATOLOGIC MALIGNANCIES USING A 
REDUCED-INTENSITY PREPARATIVE REGIMEN 
 
IDE:  
 
Principal Investigator 
Mari Hashitate Dallas, MD1 
 
Sub-investigators 
Wing Leung, MD, PhD1 
 
Guolian Kang, PhD3 
David Shook, MD1 
 
Terrence Geiger, MD, PhD4 
Christine Hartford, MD1   
Shane Cross, PharmD5 
Brandon Triplett, MD1 
 
 Paul W. Eldridge, PhD6 
Ashok Srinivasan, MD1 
 
Matthew J. Krasin, MD7 
Paul Thomas, PhD8 
 
Department of Bone Marrow Transplantation and Cellular Therapy1 
Department of Oncology2 
Department of Biostatistics3 
Department of Pathology4 
Department of Pharmaceutical Sciences5 
Department of Therapeutics Production and Quality 6 
Department of Radiological Sciences7 
Department of Immunology8 
 
St. Jude Children’s Research Hospital 
262 Danny Thomas Place 
Memphis, TN  38105 
(901) 595-3300 
This is a confidential research document. 
No information may be extracted without permission of the principal investigator


Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014 
Protocol document date: 02/10/14 
 
COMMON ABREVIATIONS 
 
Absolute neutrophil count (ANC) 
Acute lymphocytic leukemia (ALL) 
Acute myeloid leukemia (AML) 
Adverse event (AE) 
Alanine aminotransferase (ALT) 
American 
Association 
of 
Blood 
Banks 
(AABB) 
Aspartate aminotransferase (AST) 
Body surface area (BSA) 
Bone marrow (BM) 
Bone marrow transplantation (BMT), 
Bone Marrow Transplantation Follow Up 
(BMTFU) 
Center for International Blood and Marrow 
Transplant Research (CIBMTR) 
Central Nervous System (CNS) 
Central Protocol and Data Monitoring Office 
(CPDMO) 
Chronic Myeloid Leukemia (CML) 
Clinical Data Update System (CDUS) 
Common toxicity criteria (CTC) 
Complete Remission (CR) 
Cord Blood Transplantation (COBLT) 
Creatinine Clearance (CrCL) 
Cyclosporine (CSA) 
Cytomegalovirus (CMV) 
Dimethyl sulfoxide (DMSO) 
Disease-free survival (DFS) 
Epstein-Barr 
virus 
transformed 
lymphoblastoid cell lines (EBV-LCL) 
Event-free survival (EFS) 
Forced vital capacity (FVC) 
Foundation for the Accreditation of Cellular 
Therapy (FACT) 
Graft versus host disease (GVHD) 
Granulocyte colony-stimulating factor (G-
CSF) 
Haploidentical 
HCT 
with 
NK 
infusion 
(HAPNK) 
Health Insurance Portability Act (HIPPA) 
Hematopoietic cell transplantation (HCT) 
Hematopoietic stem cell (HSC) 
Human Application Lab (HAL)  
Human Immunodeficiency Virus (HIV) 
Human leukocyte antigen (HLA) 
Human T-lymphotropic virus (HTLV)  
Institutional Biosafety Committee (IBC) 
Institutional Review Board (IRB) 
International Cord Blood Transplant Registry 
(ICBTR) 
Juvenile Myelomonocytic Leukemia (JMML) 
Killer-immunoglobulin receptors (KIR)  
Matched related/sibling donor (MSD) 
Matched unrelated donor (MURD)  
Minimal Residual Disease (MRD) 
Mycophenolate mofetil (MMF) 
Myeloid Dysplastic Syndrome (MDS) 
National Cancer Institute (NCI)  
National Marrow Donor Program (NMDP) 
Natural killer (NK) 
New York Blood Center (NYBC) 
Overall survival (OS) 
Pharmacokinetics (PK) 
Polymerase chain reaction (PCR) 
Protected health information (PHI) 
Pulmonary Function Testing (PFT) 
Reduced Intensity Conditioning (RIC) 
Shortening Fraction (SF) 
Standard operating procedures (SOP) 
T cell receptor excision circle (TREC) 
Total body irradiation (TBI) 
Total nucleated cell (TNC) 
Total Research and Knowledge System 
(TRACKS) 
Transplant related mortality (TRM) 
Umbilical cord blood (UCB) 
Umbilical 
cord 
blood 
transplantation 
(UCBT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
TABLE OF CONTENTS 
 
Study Summary 
 
1.0 
Objectives…………………………………………………………….………… 1 
 
1.1 
Primary Objective.……………………………………………………..… 
1.2 
Secondary Objectives …………………………………………………… 
1.3 
Exploratory Objectives ……………..…………………………………… 
1 
1 
1 
2.0 
Background and Rationale……………………………………………………… 1  
 
2.1 
Overview………………………………………………………………… 
2.2 
Umbilical Cord Blood Transplantation……..…………………………… 
2.3 
Haploidentical HCT…………..………………………………………….. 
2.4 
Rationale for Reduced Intensity Preparative Regimen...………………… 
2.5 
Rationale for Study………………………………………………………. 
2.6 
Minimal Residual Disease (MRD).……………………………………… 
2.7 
Rationale for the Evaluation of Immune Reconstitution After UCBT….. 
1 
2 
4 
7 
7 
9 
10 
3.0 
Protocol Eligibility Criteria……………………………………………………. 11 
 
3.1 
Inclusion Criteria for Transplant Recipient……...……………………… 
3.2 
Exclusion Criteria for Transplant Recipient……...……………………… 
3.3 
Inclusion Criteria for Haploidentical Donors…………………………… 
3.4     Enrollment on Study…………………………………………………… 
11 
12 
12 
13 
4.0 
Treatment Plan………………………………………………………………….. 15 
 
4.1 
Schema for Protocol Prioritization…………...………………………….. 
4.2 
Reduced Intensity Preparative Regimen…………..…………………….. 
4.3 
UCB Product………………………………..……………………………. 
4.4 
Haploidentical Donor Graft………..…………………...……………….. 
4.5 
Graft Preparation………..………………..……………………………… 
4.6 
Additional Progenitor Cell Graft Administration…………………….….. 
4.7 
Donor Lymphocyte Infusion………..…………………………….…..…. 
4.8 
Quality Assurance of Cellular Products..…………..….………………… 
4.9  Immunosuppressive Therapies ………………………….……………… 
4.10 Management of Pre-Engraftment Immune Reaction……………………. 
4.11  Growth Factors (G-CSF).………………………………..………………. 
4.12 Treatment and Conditioning Regimen Related Notes…………………… 
15 
16 
17 
19 
20 
21 
22 
22 
23 
24 
24 
24 
5.0 
Medication Information………………………………………………………… 25 
 
5.1  
Cyclophosphamide………….…………………………………………… 
5.2. 
Thiotepa…………………………………………………………………. 
5.3 
Fludarabine (Fludara)………………………………..…………………... 
5.4  
Melphalan……..………………………………..………………….…….. 
5.5  
Mesna……………………………………………………………………. 
5.6 
Filgrastim ……..………………………………………………………… 
5.7     Mycophenylate mofetil………………………………………………….. 
5.8     Tacrolimus……….……………………………………………………… 
25 
26 
26 
27 
28 
29 
30 
30 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
5.9 
Methylprednisolone ……..……………………………………………… 
5.10   CliniMACS System……………………………………………………… 
 
32 
32 
6.0 
Required Observations and Evaluations……………...………………………… 33 
 
6.1 
Standard Pre/Peri/Post-Transplant Evaluations……………………….... 
6.2 
Long Term Follow-up Evaluations…………………………………..….. 
6.3 
Research Testing……………………………….……..……..……..…….  
6.4 
Research Testing on Haploidentical Donor…………...……..……..……. 
33 
33 
33 
35 
7.0 
Evaluation Criteria……………………………………………………………… 35 
 
7.1 
Adverse Event Monitoring.……………………………..…………..….... 
7.2 
Acute and chronic GVHD scoring………………………………….…... 
7.3 
Performance Status.………………………………..……..……..……….. 
7.4 
Hematologic Recovery………………………………..……..……..……. 
7.5 
Primary Graft Failure……….………………………..……..……..…….. 
7.6 
Secondary Graft Failure……...…………………………..……..……..… 
7.7 
Mixed Hematopoietic Chimerism……..…………………………..…….. 
35 
35 
35 
35 
35 
35 
35 
8.0 
Off-study Criteria……………………………………………………………….. 36 
 
8.1 
Recipient Off-therapy Criteria …………………..………………………. 
8.2     Recipient Off-study Criteria……………………………………………… 
8.3     Donor Off-study Criteria 
36 
36 
36 
9.0 
Reporting Criteria………………………………………………………………. 37 
 
9.1 
Reporting Adverse Experiences and Deaths……..……..……..……..….. 
9.2 
Reporting to SJCRH Institutional Review Board (IRB)………………… 
9.3 
Reporting to SJCRH Biosafety Committee (IBC)……………………….. 
9.4 
Reporting to US Food and Drug Administration (FDA)……..……..…… 
9.5 
Reporting to SJCRH Regulatory Affairs Office.…….…..……..……..…. 
9.6 
Continuing Review Reports...……..……..……..……..…..............….…. 
9.7     Reporting to the St. Jude Data Safety Monitoring Board………………... 
9.8 
Data Submission to Miltenyi Biotec…….……..……..…..............….…. 
9.9 
Reporting to Center for International Blood and Marrow Transplant 
Research (CIBMTR)….……..……..……..……..…..……..……..……. 
37 
37 
38 
38 
39 
39 
39 
39 
40 
10.0 Data Collection, Study Monitoring, and Confidentiality……………………… 40 
 
10.1 Data Collection…………………………………………....….….….…… 
10.2 Study Monitoring………………………………..….….….….….……… 
10.3   Confidentiality…………………………………………………………… 
40 
40 
41 
11.0 Statistical Considerations……………………………………….. 
41 
 
11.1 Statistical Design and Analysis for the Primary Objective……….…….. 
11.2 Statistical Analysis for the Secondary Objectives………………………. 
11.3   Analysis for Exploratory Objectives…………………………………….. 
41 
44 
45 
12.0 Obtaining Informed Consent…………………………………………………… 45 
 
12.1   Informed Consent Prior to Research Interventions……………………… 45 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
12.2   Consent at Age of Majority……………………………………………… 
12.3   Consent When English is Not the Primary Language…………………… 
45 
45 
13.0 References………………………………………………………………….…. 
46 
 
 
 
Appendix A: Karnofsky and Lansky Performance Score………………………. 
Appendix B: GVHD Grading…………………………………………………... 
Appendix C: Adverse Event Evaluation………………………………………... 
Appendix D: Testing and Evaluation…………………………………………... 
Appendix E: BMT Standard Operating Procedure.…………………………….. 
53 
54 
58 
59 
63 
 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
STUDY SUMMARY 
HAPCORD:  
Principal Investigator: Mari Hashitate Dallas, MD 
IND/IDE: CliniMACS CD34+ Enrichment 
Brief Overview: In this study, participants with high-risk hematologic malignancies undergoing 
hematopoietic cell transplantation (HCT), who do not have a suitable human leukocyte antigen 
(HLA)-matched related/sibling donor (MSD), matched unrelated donor (MURD) or killer-
immunoglobulin receptors (KIR) ligand mismatched haploidentical donor identified, will receive 
an combined haploidentical and umbilical cord blood transplantation (UCBT) using a reduced 
intensity conditioning (RIC) preparative regimen.  Patients who have a suitable KIR ligand 
mismatched haploidentical donor will be preferentially enrolled in available haploidentical 
protocol (i.e. HAPNK1).  Those with a suitable HLA matched sibling or unrelated donor 
identified may be eligible for participation if the donor is not available in the necessary time.  
Participants must be ≤ 21 years old and with sufficient multi-organ function as specified in 
protocol.  
The assessments and follow-up evaluations noted in the protocol follow the St. Jude standard 
operating procedures (SOP) for all recipients of allogeneic HCT.  
Intervention: Combined haploidentical graft with an unrelated umbilical cord blood graft using 
a reduced intensity preparative regimen. 
Brief Outline of Treatment Plan:  The preparative regimen includes total lymphoid irradiation 
(TLI) (8 Gy), fludarabine (150 mg/m2), cyclophosphamide (60mg/kg), melphalan (140 mg/m2) 
and thiotepa (10mg/kg).   TLI will be administered in 4 fraction at 200 cGY/fraction over 3 days 
on day -9 to day -7, fludarabine will be given once a day at 30 mg/m2 for five days on day -8 to 
day -4, cyclophosphamide will be given once a day at 60mg/kg for one day on day -6, thiotepa 
will be given twice a day at 5 mg/kg for one day on day -3, and melphalan will be given once a 
day for 2 days on day -2 and day-1.  Post-transplantation immunosuppression with tacrolimus 
will begin on day -2 and MMF on day 0. Haploidentical donor product will be infused on day 0 
and day +1.  Cord Blood infusion will occur on day +2 and G-CSF will start on day +3.  
Objectives:  
Primary objective  
 Estimate the incidence of engraftment by day +42 post-transplant for participants with 
high-risk hematologic malignancies undergoing a reduced intensity conditioning (RIC) 
hematopoietic cell transplantation (HCT) using a haploidentical donor combined with a 
unrelated umbilical cord blood (UCB) donor. 
Secondary objectives: 
 Estimate the incidence of malignant relapse, event-free survival, and overall survival at 
one-year post-transplantation. 
 Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD). 
 Estimate the incidence of transplant related mortality (TRM) and transplant related 
morbidity in the first 100 days after transplantation. 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
Exploratory Objectives 
 
Assess the relationship between pre-transplant minimal residual disease (MRD) with 
transplant outcomes. 
 
Record immune reconstitution parameters, including chimerism analysis, quantitative 
lymphocyte subsets, T cell receptor excision circle (TREC) and spectratyping.  
Immunophenotyping and functional assays of T, B and NK cells and lymphocytes will 
also be evaluated.  
 
Characterize the recovery of Gamma Delta T cells after HCT, including T cell receptor 
analysis, phenotyping and functional analysis.  
 
Characterize influenza infection during HCT by monitoring viral isolates and key host 
factors associated with influenza susceptibility. 
Hypotheses/Estimates:  
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 30% will 
have a suitable matched related/sibling donor (MSD) and another 30% will have a matched 
unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-60% of eligible 
pediatric recipients, and the lengthy duration of the donor search process in those with high risk 
of relapse have prompted investigators to use an alternative source of HSC, namely UCB.3 
Although UCB has been shown to be a suitable source of HSC, initial studies suggested UCBT is 
associated with increase incidences of TRM when compared to recipients of MSD or MURD.5, 6 A 
pilot study in adults that combined haploidentical and an unrelated UCBT using a RIC resulted in a 
rapid engraftment with minimal GVHD and durable remission.7 Here, we propose to investigate 
the outcomes of pediatric patient with high-risk malignancies undergoing a combined 
haploidentical and UCBT using a RIC regimen at St. Jude Children’s Research Hospital.  The 
primary objective of the study is to estimate the rate of engraftment by day +42 post-transplant 
in patients undergoing a combined haploidentical and UCBT using a reduced intensity 
preparative regimen.  Secondary aims will assess overall survival, event-free survival, risk of 
relapse, graft versus host disease (GVHD), transplant related mortality (TRM), transplant 
related morbidity, and immune reconstitution. 
 
Criteria for Evaluation:    
Safety Evaluation  
 The primary measures of safety will be the rate of therapy related death and the rate of 
severe graft versus host disease. 
 Ongoing assessment of toxicity will be done using the NCI CTC version 3. Acute GVHD 
will be evaluated using the standard grading criteria (Appendix B). 
Efficacy  
 Neutrophil and platelet engraftment will be determined using the parameters put forth by 
the Center for International Blood and Marrow Registry.  Assessments will be made upon 
review of daily complete blood count and serial chimerism studies. 
 BM studies for disease status evaluation will be performed at approximately 28 days, 100 
days, and yearly post-transplant.  
 Acute GVHD will be assessed using the standard grading criteria put forth by Prezpiorkia 
et al 1995. Chronic GVHD will be assessed using the NIH Consensus Criteria for 
Chronic GVHD 2005 (Appendix B). 
 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
Study Design: Phase II - Non Randomized  
Study Population: Patients with high-risk hematologic malignancies who are in complete 
remission or AML in first relapse with less than 25% blasts at the time of evaluation are eligible 
for enrollment. Participant must be less than or equal to 21 years old.   
Candidates must have a suitable UCB product available (matched ≥ 4 of 6 to the patient  
sufficient with sufficient cell dose).  Those with a suitable HLA matched sibling, matched 
unrelated donor, or KIR mismatched haploidentical donor identified will be eligible for 
participation only if the donor is not available in the necessary time. Additional eligibility criteria 
are specified to assure sufficient multi-organ system function. 
Inclusion criteria for transplant recipient 
 Age less than or equal to 21 years old. 
 Has a partially HLA-matched single UCB product available.  
 Has a partially HLA-matched haploidentical related donor available.  
 High-risk hematologic malignancy. 
 High risk ALL in CR1, ALL in High risk CR2, ALL in CR3 or subsequent. 
 AML in high risk CR1, AML in CR2 or subsequent 
 Therapy related AML, with prior malignancy in CR > 12mo 
 MDS, primary or secondary 
 NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
 CML in accelerated phase, or in chronic phase with persistent molecular positivity or 
intolerance to tyrosine kinase inhibitor. 
 Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous HCT, or 
unable to mobilize stem cells for autologous HCT. 
 Non-Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous HCT, 
or unable to mobilize stem cells for autologous HCT. 
 JMML 
 Refractory hematologic malignancies (ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin lymphoma) due to chemoresistant relapse or primary induction failure. 
 All patients with evidence of CNS leukemia must be treated and be in CNS CR to be 
eligible for study. 
 Patient must fulfill pre-transplant evaluation: 
 
Left ventricular ejection fraction ≥ 40% or cardiac shortening fraction ≥ 25%. 
 
Creatinine clearance or GFR ≥ 50 ml/min/1.73m2. 
 
Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry ≥ 92% on 
room air. 
 
Karnofsky (≥ 16 years) or Lansky (<16 years) performance score ≥ 50  
 
Bilirubin ≤ 3 times the upper limit of normal for age. 
 
Alanine aminotransferase (ALT) ≤ 5 times the upper limit of normal for age. 
 
Aspartate aminotransferase (AST) ≤ 5 times the upper limit of normal for age. 
 


 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
 
Exclusion Criteria for Transplant Recipients:  
 Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical donor (for 
HAPNK1) available in the necessary time for stem cell donation. 
 Patient has any other active malignancy other than the one for which HCT is indicated. 
 Patient is pregnant as confirmed by positive serum or urine pregnancy test within 14 days 
prior to enrollment. 
 Patient is breast feeding 
 Patient has Down Syndrome 
 Patient has a current uncontrolled bacterial, fungal, or viral infection per the judgment of 
the PI. 
Sample Size:  Up to 49 evaluable.  
Randomization: N/A 
Data Analyses: Statistical considerations and ongoing analysis will be conducted by Dr. 
Guolian Kang and designated associates within the St. Jude Department of Biostatistics.     
Anticipated Primary Completion Date:  (5 years) 
Anticipated Study Completion Date:  (6 years) 
Timeframe for Primary Outcome Measure: 42 days 
Data Management: Protocol compliance, data collection including safety data, and reporting 
will be carried out by the Cancer Center’s Department of Bone Marrow Transplantation and 
Cellular Therapy Research Office. 
Human Subjects: The risks to subject are primarily related to the infusion and the 
conditioning regimen.  The allogeneic stem cells may induce serious and possibly fatal 
disorders such as GVHD, veno-occlusive disorder and post-transplant lymphoproliferative 
disease.  Because of the required conditioning, recipients are at high-risk for serious and 
possibly life-threatening infection, bleeding, and anemia.  Adverse events will be treated, 
monitored, and reported appropriately. 
Possible benefits of participation include obtaining and/or sustaining disease remission.  In 
addition, there is the possibility of psychological benefit from knowing participation has helped 
researchers gain more understanding about the efficacy of UCBT. 
Alternatives to participation are identified as chemotherapy, research treatment if available, 
and/or supportive therapy. 
The possible benefits, alternatives to participation, and side effects, including that there may be 
unknown side effects of treatment, are detailed in lay language within the respective informed 
consent documents. 
 
 


HAPCORD 1 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
1.0 OBJECTIVES 
1.1 Primary objective 
1.1.1 To estimate the incidence of engraftment by day +42 post-transplant for 
participants with high-risk hematologic malignancies undergoing a reduced 
intensity conditioning (RIC) hematopoietic cell transplantation (HCT) using a 
haploidentical donor combined with a unrelated umbilical cord blood (UCB) 
donor. 
1.2 Secondary objectives  
1.2.1  Estimate the incidence of malignant relapse, event-free survival (EFS), and 
overall survival (OS) at one-year post-transplantation. 
1.2.2 Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD) in the first 100 days after transplantation. 
1.2.3 Estimate the incidence of transplant related mortality (TRM) and transplant 
related morbidity in the first 100 days after transplantation. 
1.3 Exploratory Objectives 
1.3.1 Assess the relationship between pre-transplant minimal residual disease (MRD) 
with transplant outcomes. 
1.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping.  Immunophenotyping and functional assays of T, B and NK cells 
and lymphocytes will also be evaluated.  
1.3.4 Characterize the recovery of Gamma Delta T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  
1.3.3.  Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  
2.0 BACKGROUND AND RATIONALE 
2.1 Overview 
Allogeneic HCT has become a widely accepted curative therapy for many hematologic 
malignancies that cannot be cured with chemotherapy alone.8, 9 Studies have 
demonstrated that HCT is a potentially curative therapy for patients with CML, AML, 
ALL and MDS.10-13 Furthermore, patients with non-Hodgkin or Hodgkin’s lymphoma 
who recur after an autologous HCT may be successfully treated with an allogeneic 
HCT.14, 15 
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 
30% will have a suitable matched related/sibling donor (MSD) and another 30% will have 
a matched unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-
60% of eligible pediatric recipients, and the lengthy duration of the donor search process 
in those with high risk of relapse have prompted investigators to use an alternative source 
of HSC, namely UCB.3 Recent comparative studies report no significant difference in OS 
in patients undergoing UCBT compared to MURD HCT.16-20  Thus, the number of 
patients undergoing UCBT has rapidly increased over the past 10 years. In the pediatric 


HAPCORD 2 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
population, UCB is now the most common source of HSC in unrelated donor transplant. 
However, the limited number of progenitor cell in the UCB unit result in delayed and 
unpredictable count recovery.  The delayed neutrophil recovery predisposes patients to 
infection and recipients of UCB is associated with increase incidences of TRM when 
compared to recipients of MSD or MURD.5, 6 A pilot study in adults that combined 
haploidentical and an unrelated UCBT using a RIC resulted in a rapid engraftment with 
minimal GVHD and durable remission.7 St. Jude has gained considerable expertise with 
haploidentical HCT in children 21-28 and we propose to investigate the outcomes of 
pediatric patient with high-risk malignancies undergoing a combined haploidentical and 
UCBT using a RIC regimen at St. Jude Children’s Research Hospital. 
2.2 Umbilical Cord Blood Transplantation (UCBT) 
2.2.1 Historical Background: 
The use of UCB as a clinical source of HSC was first considered in the late 
1960’s when UCB from eight donors were pooled and infused into a 16 year old 
male with acute lymphocytic leukemia (ALL).29  Although full reconstitution was 
not observed, there was evidence suggesting transient mixed chimerism. 
Thereafter, additional studies were performed that suggested that if adequate 
numbers of HSC could be collected; UCB has the potential for long-term 
reconstitution.  In 1989 the first successful matched sibling UCBT was performed 
for a child with Fanconi anemia. In 1995, the International Cord Blood Transplant 
Registry (ICBTR) reported the results of the first 44 matched sibling UCBT 
demonstrating UCB contained sufficient number of hematopoietic progenitors to 
reliably engraft transplant recipients after a myeloablative conditioning regimen.30  
The first successful unrelated UCBT in a pediatric patient occurred at Duke 
University in 1993.31, 32 In 1996, Kurtzberg et al and Wagner et al simultaneously 
published the unrelated UCBT experiences at Duke and Minnesota, 
respectively.32, 33 These initial studies showed the median time to neutrophil 
recovery was 22 and 24 days, respectively.  Combining the 43 patients, 88% 
engrafted, 54% had Grade II-IV GVHD and 9% had Grade III-IV GVHD.  The 
OS at 100 days was 53%.  Together, these studies suggested that UCB is a 
suitable alternative source of allogeneic HSC for pediatric patients.  
In nearly every large single center or registry analysis of outcomes after UCBT, 
cell dose is identified as an important factor influencing the incidence and rate of 
hematopoietic recovery, risk of TRM, and probability of survival.  Furthermore, 
data suggest that infusion of two partially HLA-matched UCB units, which 
always augments the graft cell dose, is safe and may improve neutrophil recovery 
and survival.  To determine whether the infusion of two UCB units enhances 
survival, the Blood and Marrow Transplant Clinical Trials Network (BMTCTN) 
proposed a multi-center randomized trial in 2006.  Preliminary data suggest that 
patients receiving double unit UCBT have a higher risk for acute GVHD albeit a 
lower risk for relapse.  However, until data clearly demonstrate a survival 
advantage, double UCBT is currently only recommended for those patients who 
do not have an adequate single unit.34   


HAPCORD 3 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
Lastly, in the past decade, large comparative studies evaluating the outcomes of 
transplantation using UCB versus other HSC sources have been performed. 
Reports demonstrate that the incidence of GVHD was lower in patients 
undergoing UCBT compared to HLA-matched bone marrow (BM) recipients.  
Furthermore, recent studies that include long-term analysis demonstrate that 
outcomes are similar for patients undergoing transplantation using MURD or 
UCB sources.14-18, 25 Thus, UCBT should be considered as a viable options for 
patients with high-risk malignancies.16-20, 35 7-11, 25 
2.2.2  Cell Dose Threshold and Interaction with HLA match 
Cell dose remains one of the single most important determinants of a successful 
UCBT.36-38 Numerous clinical studies have shown that the total nucleated cell 
(TNC) dose and the CD34+ cell dose in the UCB graft are highly correlated with 
neutrophil and platelet engraftment as well as the incidence of graft failure and 
early TRM.3, 37, 39, 40 The first Eurocord Registry report by Gluckman et al, 1997, 
demonstrated that among 527 patients undergoing UCBT, the most important 
predictor in outcome was the infusion of ≥ 3 x 107 TNC per kilogram body 
weight.36, 41 Moreover, adult recipients had increased TRM by day 180 compared 
to children (56% versus 32%), and deaths were related to the number of cells 
infused, with patients who received ≤ 1 x 107 TNC/kg having a 75% probability 
of death compared to 30% for those who received ≥ 3 x 107 TNC/kg.  Rubinstein 
et al, 1998, published the New York Blood Center experience with 562 patients 
undergoing UCBT and similarly demonstrated a strong correlation between the 
number of leukocytes infused and engraftment.38 Thus, the collective data point to 
improved outcome of UCBT for patients receiving a larger number of CD34+ 
cells.  Delayed engraftment has also been correlated with HLA mismatch at 
greater than 2 loci, but recent studies have suggested that the impact of HLA 
disparity on survival can be partially overcome by increasing cell dose.42 
Combined, these studies identified a minimum threshold for cell dose and HLA 
matching which lead to a significant reduction in TRM after UCBT.  Although the 
exact threshold criteria for each degree of HLA mismatch is not know, the 
principle for the dose algorithm is clear.34, 43, 44 
2.2.3  Role of Double UCBT 
For most adults and large children, a single UCB unit that meets the cell dose 
requirement is not available.  To overcome this obstacle, investigators at the 
University of Minnesota began infusing two partially HLA-matched units to 
augment cell dose. They found that engraftment was achieved more rapidly and in 
a higher proportion of patients than the previous cohort who received only a 
single UCB unit.45 Preliminary evidence suggests that double unit UCBT may be 
associated with a decreased risk of relapse in patients with good disease control at 
the time of transplant, but is also associated with a increased incidence of mild to 
moderate acute GVHD compared to single UCBT.46,47, 48 Currently, it is unclear 
whether double UCBT offers any benefit other than extending the application of 
UCBT by achieving the cell dose threshold.49 Until data clearly demonstrate a 
survival advantage, double UCBT is currently only recommended for those 
patients who do not have an adequate single unit.50 An adequate single unit is 


HAPCORD 4 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
defined as: ≥ 3.0 x 107 nucleated cells/kg for 6/6 HLA-matched units, ≥ 4.0 x 107 
nucleated cells/kg for 5/6 HLA-matched units and ≥ 6.0 x 107 nucleated cells/kg 
for 4/6 HLA-matched units.48, 50, 51Despite adequate cell dose, patients undergoing 
double UCBT continue to have delayed engraftment compared to MSD and 
MURD HCT.  
2.2.4  UCBT Results 
Engraftment: Most studies report the time to hematopoietic recovery after UCBT 
is delayed with the median time to neutrophil recovery ranging between 20 - 30 
days and the incidence of engraftment after single UCBT ranges from 65-92%.31, 
33, 37, 38, 40, 41, 52-60 Studies have consistently demonstrated the rate and incidence of 
engraftment after UCBT is slower than bone marrow transplantation (BM), 
dependent on cell dose and the threshold for cell dose depends on HLA match 
grade.  
GVHD: The first report from the New York Blood Center experience by Rubinstein 
et al indicated that GVHD after UCBT occurred at a lower rate compared to those 
with MURD transplantation.38 Thereafter, Rocha et al published the first 
comparative analysis between UCBT and MURD transplantation in pediatric 
patients that substantiated the claim that acute and chronic GVHD were less 
common in recipients of UCB.18 In larger studies, the incidence of acute GVHD is 
reported to range from 33-44% and 11-22% for grades II-IV and III-IV acute GVHD 
respectively. The incidence of chronic GVHD ranges from 0-25%.37, 38, 57, 59, 60  
Survival: Nearly all studies demonstrate a significant relationship between UCB cell 
dose and survival and the reported probability of survival after single UCBT ranges 
from 18-78%.16, 20, 40, 45, 47, 51, 61-65 One of the largest reports from the Center for 
International Blood and Marrow Transplant Research (CIBMTR) by Eapen et al in 
2007 compared the outcomes of 785 pediatric patients with acute leukemia who 
received a UCBT (n=503) or an unrelated BMT (n =282).  The most notable finding 
was that UCBT compared favorably to an 8/8 allele-matched unrelated BMT.  In 
comparison with allele-matched BMT, the 5 year disease free survival (DFS) was 
similar to that after either one or two antigen mismatched UCBT and possibly higher 
after 6/6 allele-matched UCBT.16 These and other studies support that UCB should 
be considered an acceptable source of HSC grafts in the absence of an HLA-
matched donor. 16, 17, 20, 37, 38, 40, 45, 47, 51, 57, 59-66 
2.3 Haploidentical HCT 
2.3.1 
Haploidentical HCT Background 
Haploidentical donors are another viable alternative donor source when a MSD or 
MURD are not available.  Also, family members are highly motivated, easily 
accessible, and readily available for most patients.  Along with other institutions, 
St. Jude has shown haploidentical HCT to be an effective therapy for patients with 
hematologic malignancies.67-71 Due to the high potential for GVHD with the 
degree of HLA mismatch seen in haploidentical HCT, most haploidentical grafts 
are extensively T-cell depleted (TCD) prior to infusion.72  Significant progress 
was achieved when high cells dose of CD34+ cells were infused after high-


HAPCORD 5 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
intensity conditioning.70 It has been well established that prompt engraftment with 
rapid immune reconstitution can be achieved with CD34+ enriched haploidentical 
cells, purified by positive (CD34+) and negative (CD3- lectin agglutination) 
selection.73,74 
Building on the initial studies above, St. Jude has gained considerable expertise with 
haploidentical HCT in children.21-26, 28, 75 Over the past decade (2001-2010), more 
than 220 mismatched related donor HCT have been performed at St. Jude.  Initially, 
most haploidentical HCT performed in this institution were for patients with 
relapsed and refractory hematologic malignancies, however as it became a more 
successful therapeutic maneuver, it has become a primary transplant option for 
patients who lack a well matched donor.27   
Recent studies suggest that alloreactive NK cells play a role in graft versus 
leukemia (GVL) and influence outcomes of patients with hematologic 
malignancies after haploidentical HCT.76-83 The NK cell alloreactivity depends on 
the balance of signals mediated through activating and inhibitory KIRs on the NK 
cell.  In patients who received haploidentical HCT for high risk leukemia at 
SJCRH the presence of KIR mismatch dramatically reduced the risk of relapse.24 
Thus, patients with high risk hematologic malignancies who lack an HLA-
matched donor but have a KIR mismatched haploidentical donor available, would 
be expected to benefit from haploidentical HCT. 
2.3.2  Rationale for immunomagnetic TCD of hematopoietic progenitor cell graft  
Donor T cells in the haploidentical graft play a major role in mediating GVHD, 
with as few as 3 x 104 T cells/kg can cause GVHD.84  TCD allows for a HSC graft 
with very low T cell content, such that the risk of GVHD is decreased. T cells can 
be removed from the HSC graft by direct removal of T cells (negative selection) 
or positive selection of CD34+ progenitors. St. Jude has had success using either 
method of TCD in haploidentical donor transplantation.  
In this study, CD34+ selection by CliniMACS will be the used for TCD of the 
haploidentical graft.  Although positive selection allows for extensive TCD, the 
graft is devoid of other important cell populations such as NK cells and myeloid 
cells such as dendritic cells and monocytes.85, 86  In addition, this extensive degree 
of TCD has significant negative effects on the time to donor immune competency.  
Donor T cells are critical for reconstituting the allogeneic host immune system, 
and lymphocyte recovery is an important determinate of outcome post-
transplant.87, 88 Transplants that employ TCD result in elimination of most 
memory T cells, leading to protracted immune dysfunction- an effect that 
becomes more severe with higher intensity conditioning regimens.21, 89 This 
results in an increased rate of opportunistic infections. Indeed, viral infections are 
the most common cause of death of children receiving haploidentical 
transplants.90 The majority of these infections occur within the first 6 months 
following transplantation, when T cell immunity is the lowest.91 Reconstitution of 
immunity can be partially restored by therapeutic infusions of donor cytotoxic 
lymphocytes.87, 92-94 However, in addition to requiring significant resources and 


HAPCORD 6 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
expertise, the cells must be engineered or selected for specific infections - making 
this approach impractical for broad application.95   
A more ideal approach would be to infuse a cell product with diverse lymphocyte 
repertoire capable of effectively recognizing a variety of pathogens, as well as 
malignant cells without additional GVHD risk. One strategy would be to target 
naïve T cells for lymphocyte depletion.  Naïve T cells are fully matured but do not 
proliferate until they encounter their receptor specific ligand.96  After ligand 
recognition, there is activation of proliferative signals that initiates a marked, 
antigen-specific cell expansion and inflammatory response. While many of these 
naïve T cells will undergo apoptosis after the initial response, others are rescued 
from immune retraction and will persist as memory T cells.  Once generated, 
memory cells persist in the circulation as a diverse cell pool that is critical for 
long-term infection control.97  Furthermore, memory T cells are capable of more 
rapidly responding to future infectious challenges.98 
The isoform of the leukocyte common antigen, CD45RA, selectively identifies 
naïve T cells.  Human studies have shown that sorted donor CD45RA+ naïve T 
cells are far more alloreactive than all memory subsets tested.99 In animal models, 
naïve T cells, are potent inducers of GVHD.95 Moreover, in similar models, 
lymphocyte infusions specifically depleted of CD45RA+ naïve T cells do not 
cause GVHD.100  Conversely, CD45RA- memory T cells do not cause physical or 
histologic evidence of GVHD. Among CD4+ T cells, the CD45RA- subset has 
equivalent “helper” functions as CD45RA+ cells in the generation of alloreactive 
cytotoxic T cells.101  Further, it is the CD45RA- memory cells that are responsible 
for aiding B-cell differentiation and antibody production.   
After demonstrating promising pre-clinical results, selective CD45RA depletion 
in patients undergoing HCT are underway, including two at SJCRH (RADIANT 
and HAPNK1). Depletion of CD45RA+ cells by magnetic beads has been shown 
to be a feasible and effective method for depletion of naïve T cells, with up 
greater than 3-log depletion in number of CD45RA+ cells  (Data provided by 
Miltenyi).  Furthermore, experiments were performed in the HAL to confirm and 
qualify the CD45RA+ depletion procedures.  HSC products were obtained from 
G-CSF mobilized normal donors by apheresis. The HPC, Apheresis products were 
depleted of CD45RA+ cells following a procedure provided by Miltenyi Biotech. 
Briefly, the cells were incubated with the CD45RA microbead reagent followed 
by washing to remove unbound beads. The labeled cells were then applied to the 
CliniMACS device (Depletion Tubing Set) and the CD45RA+ cells removed 
using the Depletion 3.1 program. Flow cytometric analysis before and after 
depletion was performed following procedures provided by Miltenyi Biotech. The 
results of the experiments are presented in the table below. An example flow 
cytometric analysis of CD3+ cells is also included.  We hypothesize combining a 
CD34+ enriched product (HPC, Apheresis 1) along with a CD45RA+ depleted 
product (HPC, Apheresis 2) will provide a HSC graft with good stem cell content 
(3-5 x 106 CD34+ cells/kg) and a useful memory T cell fraction without additional 
GVHD risk to the recipients on this trial.  


HAPCORD 7 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
DEPLETION EXPERIMENT 
 
Experiment 1 
Experiment 2 
 
Pre  (106) 
Post  (106) 
Pre (106) 
Post (106) 
TNC 
29748 
10270 
26166 
10981 
CD34+ 
636 
311 
693 
395 
CD3+ 
12238 
4555 
6353 
1985 
CD3+CD45RA+ 
7877 
4 
3520 
2.2 
CD3+ CD45RA+ Log Depletion 
 
3.28 
 
3.21 
2.4 Rationale for RIC Preparative Regimen 
RIC regimens have the potential to improve the outcomes of allogeneic HCT by 
decreasing the acute TRM.102-104  TLI was initially developed with curative intent in 
patients with Hodgkin Lymphoma, and it was its use in these patients that led to the 
discovery of TLI’s alteration of T-cell specific immune responses.  Years of pre-clinical 
research on TLI have shown that the use of TLI promotes engraftment and reduces 
GVHD.105 This work was then followed up with therapeutic trials in humans with 
hematologic malignancy, which showed that conditioning with TLI and ATG alone allowed 
a high rate of durable donor engraftment, a low rate of GVHD, and preservation of evidence 
of graft versus malignancy effect, in patients who received HLA-matched related or 
unrelated donor grafts.106, 107  We have significant institutional experience using TLI-based 
regimens for allogeneic transplantation (n=29 as of June 2012).  Importantly, TLI-based 
conditioning has allowed successful salvage HCT in patients who failed previous allo-HCT.  
Nine patients have received TLI-based conditioning with haploidentical donor HCT after 
experiencing previous allograft failure (3 had primary graft failure, 4 had initial engraftment 
with acute rejection, and 2 had late graft failure).  The same haploidentical donor was 
utilized in 5 of the 9 salvage HCT, with 4 patients receiving a new (haploidentical) donor.  
Eight of 9 patients (89%) experienced durable engraftment at a median of 12 days (range 10 
– 27 days).  The remaining patient had primary graft failure due to progressive disease.  This 
experience indicates that TLI is effective for facilitation of engraftment, even in patients 
receiving a mismatched haploidentical donor graft and with a history that indicates a very 
high risk of graft failure.  There is additional published experience from Germany in which 
TLI – given as a single 7Gy fraction – was utilized in 14 adult and pediatric patients for 
reconditioning after graft failure/rejection.108 Despite most of the patient having 
haploidentical donors, engraftment was obtained in all evaluable patients.  In addition, TLI 
was well tolerated in this pediatric population that had recently received another (typically 
myeloablative) preparative regimen.  Finally, 10 patients in Chile received TLI-containing 
preparative regimen, similar to our proposed regimen, as a part of their haploidentical donor 
preparative regimen.109 TLI was given as a single dose at 7Gy.  Nine out of 10 patients 
experienced rapid donor engraftment, with relapse as the cause of the one primary graft 
failure.  Six of 10 patients were alive and disease free at one year, 3 died of progressive 
disease, and one of infection. 
2.5 Rationale for Study 
In the past 20 years, over 20,000 UCBT have been performed worldwide and over 
400,000 UCB units have been stored in more than 100 UCB banks.32, 39, 110 The main 
practical advantages of using UCB as an alternative source of HSC are (1) rapid 
availability, (2) absence of donor risk, (3) relative ease of procurement, (4) absence of 


HAPCORD 8 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
donor attrition, (5) very low risk of transmissible infectious diseases and (5) low risk of 
acute GVHD despite HLA mismatch.  Furthermore, UCB is particularly beneficial for 
patients of ethnic and racial minority descent for whom adult marrow and blood donors 
often cannot be identified.32, 38, 39, 110 According to data from the National Marrow Donor 
Program (NMDP) donor registry, the probability of finding an 8 out of 8 HLA-matched 
donor is 51% for Caucasians, 30% for Hispanics, 20% for Asians and 17% for African 
Americans.  Since patients who do not have a MURD can undergo a mismatched 
unrelated UCB transplantation and achieve similar results, the number of patients 
undergoing UCBT has rapidly increased over the past 10 years. The CIBMTR reports 
that from 2004 to 2008, UCB is now the most common graft source and BM is no longer 
the most common unrelated donor graft source for patients 20 years or less.  Furthermore, 
in 2007 and 2008, 46% of all unrelated donor transplantations used UCB grafts for 
patients 20 years or less. 
Patients who do not have an appropriate MSD or MURD donor available in a timely manner 
often undergo transplantation using an alternative HSC source from UCB or haploidentical 
donors.  Often, the type of donor is chosen based on various factors related to urgency of 
transplantation, patient, disease, and transplant-related factors as well as the center’s 
experience. Although a prospective randomized clinical trial is the accepted standard to 
compare different treatment regimens, the feasibility and acceptability of such a clinical 
trial is problematic and has not been performed.  However, retrospective studies 
comparing the two donor sources have demonstrated no difference in survival.  
The Eurocord group performed a retrospective study comparing the outcome of pediatric 
patients with high-risk ALL undergoing either UCBT or haploidentical HCT.  Patients 
had received either haploidentical (n=118) or UCB (n=341) transplantation in Eurocord 
centers between 1998 and 2004. The median follow-up was 56 and 24 months for 
haploidentical and UCBT patients, respectively. Failure of engraftment was significantly 
higher following UCBT than after haploidentical HCT (23% vs. 11%, p=0.007). In a 
multivariate analysis, relapse incidence was higher in haploidentical HCT recipients 
compared to UCBT (relative risk 1.7, p=0.01), but TRM and DFS were not significantly 
different. In conclusion, in pediatric patients with ALL, UCBT is associated with inferior 
rate of engraftment, higher incidence of grades II–IV acute GVHD and lower incidence 
of relapse compared to haploidentical HCT; however, there was no difference in terms of 
TRM and DFS. Therefore, in the absence of an HLA-identical donor, both strategies were 
reported to be suitable options to treat a child with high-risk ALL.  
At our institution, patients who do not have an appropriate MSD or MURD donor available 
often undergo a haploidentical HCT.  Studies at St. Jude have shown the presence of 
natural killer (NK) KIR mismatch in a haploidentical donor dramatically reduced the risk 
of relapse in patients who received HCT for high-risk leukemia.24, 25 KIR mismatch is 
predictive of NK alloreactive effects in haploidentical HCT.24, 25, 78, 80 Thus, patients who 
have a KIR mismatch haploidentical donor will be enrolled into a haploidentical HCT 
with NK infusion (HAPNK1).  However, approximately one-third of all patients posses 
all relevant KIR ligands and will not have a KIR mismatched haploidentical donor. These 
patients will require an alternate donor for best clinical outcome.  Patients who require an 
alternative donor HSCT and do not have a KIR mismatched haploidentical donors are 
likely to benefit most from UCBT for best clinical outcome. Contradictory results have 


HAPCORD 9 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
been reported on the effect of KIR matching in UCBT.  The European group reported 
KIR-ligand incompatible UCBT improved DFS (hazards ratio = 2.05, p = .0016) and OS 
(hazards ratio = 2.0, p = .004) and decreased relapse incidence (hazards ratio = 0.53, p = 
.05).111 However, the Minnesota group found no advantage using KIR matching in 
UCBT.112 Currently, the effect of KIR matching in UCBT is controversial and UCB 
selection based on KIR matching is not recommended. 
To date, UCBT01, the first UCBT protocol at SJCRH has accrued 9 patients, with 5 
patients receiving a single UCB unit and 4 patients receiving two UCB units.  One patient 
on the observational arm died due to TRM before day 100.  All 8 remaining patients 
engrafted however, 2 patients would be categorized as significant graft delay/failure with 
engraftment after day +42.  One patient engrafted at day 49 and another at day 51.  The 
mean time to neutrophil engraftment is 28±13 days, (range; 12-51).  Thus, despite 
optimizing HLA match and cell dose, engraftment continues to be significantly delayed 
in patients undergoing UCBT.   
In order to abrogate the increased TRM and complication from graft failure and delayed 
engraftment, we propose to provide a combined haploidentical donor with a single 
UCBT. A pilot study reported the results of 45 adults with a mean age of 50 yrs (range; 
20-69) who underwent a RIC regimen using fludarabine, melphlan and ATG for high risk 
malignancies.  The graft consisted of a single UCB with minimum cell dose of 1.0 x 107 
TNC/kg along with a TCD haploidentical donor graft.  GVHD prophylaxis was with 
MMF and tacrolimus.  All patients engrafted and the mean time to neutrophil engraftment 
was 11 days and platelet engraftment was 19 days.  Chimerism analysis demonstrated 
that the predominant haploidentical graft early after HCT is replaced by the UCB graft by 
day 100.  The risk for GVHD was not increased with the reported cumulative incidence 
of acute GVHD of 25% and chronic GVHD of 5%.  
2.6 Minimal residual disease (MRD) 
Despite the fact that the vast majority of patients with high-risk leukemia are in clinical 
remission prior to HCT, approximately 30-40% ultimately relapse after HCT.  Detection 
of MRD and early intervention may improve the clinical outcome.  Detection of leukemic 
cells that are below the limits of detection by standard morphologic examination allow 
early interventions when the patients are MRD positive but still in remission.  By using 
flow cytometry and polymerase chain reaction (PCR) amplification of antigen receptor 
genes in tandem, investigators at our institution have been able to conduct MRD studies 
in 80 consecutive ALL cases.113 Results of St. Jude institutional studies have shown that 
detection of MRD by immunologic techniques at any point in the treatment course is a 
powerful predictor of relapse in children with ALL.113-115 However, other studies suggest 
that eradication of all acute leukemia cells may not be a prerequisite for cure.116, 117 
Similar to conventional-dose therapy, controversy also exists on the implication of MRD 
in the setting of HCT.  Unlike CML, there is a paucity of data on the natural history of 
AML and ALL patients who have MRD after HCT, and how pre-transplant MRD levels 
influence post-transplant outcomes.118, 119  It is unclear whether they are also at greater 
risk of relapse; and whether further pharmacological or immunologic therapy indeed 
prolongs survival and increases cure rates.  Thus, for the participants who are enrolled in 
this protocol who are unable to proceed to post-transplant immunomodulatory protocols, 
we will gather the MRD information together with hematopoietic chimerism in a 


HAPCORD 10 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
descriptive manner to study the relationship between MRD and chimerism in this large 
cohort of patients. The knowledge gained from this study should allow their future 
application to guide therapeutic interventions. 
2.7 Rationale for the evaluation of immune reconstitution after UCBT 
Delayed immune reconstitution is a major complication after HCT and impacts the 
overall survival in patients. Recent studies demonstrate that the rate and quality of 
immune recovery after UCBT is an important predictor of overall outcomes.  
Unfortunately, the rate of immune reconstitution directly correlates with the number of 
infused HSC and UCB patients have delayed immune reconstitution secondary to the 
limited numbers of HSC.70, 120-122  Though transplantation with multiple unrelated UCB 
units has been used as a strategy to increase the total number of cells infused, the effect 
on immune reconstitution is not clear.  In this study, we propose to monitor the rate of 
immune reconstitution after single and double UCBT. De novo generation of thymic 
derived T cells is critical in reconstituting a functional immune system, thus newly 
derived thymic T cell will be monitored by measuring the concentration of TREC DNA 
by quantitative PCR in the peripheral blood of transplant recipients.   Furthermore, the 
time to recovery (defined as the median time to reach the normal value of age-matched 
healthy individual) of CD3+, CD4+, CD8+, CD19+ and CD56+ cells in patients undergoing 
UCBT will be investigated. Various subsets of T cells will be investigated including 
naïve, memory, central memory, effector memory, regulatory T cells as well as naïve and 
memory B cells.  Functional measures of immune recovery will be examined by T cell 
proliferative response to nonspecific and specific antigen and NK lytic function.  Antigen 
specific T cell response to various infections will be monitored in patients over time.  
Using a direct ex vivo, single-cell-based assay for clonotypic analysis of human epitope-
specific receptor, we will characterize T cell response to specific infections.  
Studies demonstrate that the rate of engraftment of a single unit was significantly 
enhanced after addition of a second unrelated UCB unit.  It is clear that infusion of a 
second UCB unit facilitates the engraftment of the dominant unit, however, the 
mechanism has yet to be investigated.  Preliminary data from the Dallas laboratory 
suggest that dendritic cells and regulatory T cells play a critical role in facilitating 
engraftment in the BM and thymus.123, 124 Data obtained from this study addresses a key 
question regarding the immunological mechanism for enhanced engraftment by 
facilitating cells. Furthermore, published studies consistently report that after a double 
UCBT, cells from only one of the UCB unit engraft.  However, recent results from a 
multi-institutional clinical trial have demonstrated that small number of patients who 
undergo a double UCBT have evidence of mixed chimerism in the BM from the two 
UCB units one-year after HCT.   Furthermore, studies performed at the Fred Hutchinson 
Cancer Research Center, demonstrated that single-unit dominance after double-unit 
UCBT coincides with NK cell dose and a specific CD8+ T-cell response against the non-
engrafted unit.125    
 
 
 


HAPCORD 11 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
3.0 PROTOCOL ELIGIBILITY CRITERIA 
3.1 Inclusion criteria for transplant recipient 
3.1.1  Age less than or equal to 21 years old. 
3.1.2 Does not have a suitable MSD or volunteer MUD available in the necessary time for 
stem cell donation.  
3.1.3 Has a suitable partially HLA-matched (≥ 3 of 6) family member donor. 
3.1.4  Has a partially HLA-matched single UCB unit (≥ 4 of 6) with adequate cell dose.  
UCB units must fulfill eligibility as outlined in 21 CFR 1271 and agency guidance.  
3.1.5 High-risk hematologic malignancy. 
3.1.5.1  High risk ALL in CR1.  
  
Examples include, but not limited to t(9;22), hypodiploid,, M2 or greater 
marrow at the end of induction, infants with MLL fusion or t(4;11). 
3.1.5.2  ALL in High risk CR2.  
  
Examples include but not limited to t(9;22), BM relapse <36 mo CR1, T-
ALL, very early (< 6mo CR1) isolated CNS relapse. 
3.1.5.3  ALL in CR3 or subsequent. 
3.1.5.4  AML in high risk CR1.   
  
Examples include but not limited to preceding MDS, 5q-, -5, -7, FAB M6, 
FAB M7 not t(1;22), MRD ≥ 5% on day 22 (AML08), M3 marrow after 
induction 1, M2 marrow after two cycles of induction, FLT3-ITD. 
3.1.5.5  AML in CR2 or subsequent. 
3.1.5.6  Therapy related AML, with prior malignancy in CR > 12mo 
3.1.5.7  MDS, primary or secondary 
3.1.5.8. NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
3.1.5.9 CML in accelerated phase, or in chronic phase with persistent molecular 
positivity or intolerance to tyrosine kinase inhibitor. 
3.1.5.10 Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous 
HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.3.11 Non-Hodgkin lymphoma in CR2 or subsequent after failure of prior 
autologous HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.5.12 JMML 
3.1.5.13 Refractory hematologic malignancies (ALL, AML, CML in blast crisis, 
Hodgkin or non-Hodgkin lymphoma) due to chemoresistant relapse or 
primary induction failure.  
3.1.5.14 All patients with evidence of CNS leukemia must be treated and be in CNS 
CR to be eligible for study. 
3.1.6  Patient must fulfill pre-transplant evaluation: 
3.1.6.1  Cardiac Function: Left ventricular ejection fraction (LVEF) ≥ 40% or 
shortening fraction (SF) ≥ 25%. 


HAPCORD 12 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
3.1.6.2  Creatinine clearance (CrCL) or glomerular filtration rate (GFR) ≥ 50 
ml/min/1.73m2. 
3.1.6.3 Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry 
(Pox) ≥ 92% on room air. 
3.1.6.4  Karnofsky or Lansky performance score ≥ 50 (See APPENDIX A). 
3.1.6.5  Bilirubin ≤ 3 times the upper limit of normal for age.  
3.1.6.6  Alanine aminotransferase (ALT) ≤ 5x the upper limit of normal for age. 
3.1.6.7  Aspartate aminotransferase (AST) ≤ 5x the upper limit of normal for age. 
3.2 Exclusion Criteria for Transplant Recipient:  
3.2.1  Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor (for HAPNK1) available in the necessary time for stem cell donation. 
3.2.2 Patient has any other active malignancy other than the one for which HCT is 
indicated. 
3.2.3  Patient is pregnant as confirmed by positive serum or urine pregnancy test within 
14 days prior to enrollment. 
3.2.6 Patient is breast feeding. 
3.2.7  Patient has Down Syndrome. 
3.2.8  Patient has a current uncontrolled bacterial, fungal, or viral infection per the 
judgment of the PI. 
3.3 Inclusion criteria for haploidentical donor 
3.3.1   At least single haplotype matched (≥ 3 of 6) family member 
3.3.2  At least 18 years of age. 
3.3.3 HIV negative. 
3.3.4 Not pregnant as confirmed by negative serum or urine pregnancy test within 14 
days prior to enrollment (if female). 
3.3.5 Not breast feeding. 
3.3.6 Regarding eligibility, is identified as either: 
3.3.6.1 Completed the process of donor eligibility determination as outlined in 21 
CFR 1271 and agency guidance; OR 
3.3.6.2 Does not meet 21 CFR 1271 eligibility requirements, but has a declaration of 
urgent medical need completed by the principal investigator or physician 
sub-investigator per 21 CFR 1271. 
 
 
 
 
 
 
 
 


HAPCORD 13 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
INCLUSION CRITERIA SUMMARY 
Donor 
Haploidentical (≥ 3 of 6) and single UCB ( ≥ 4 of 6) HLA matched donor 
Age 
≤ 21 years 
 
Malignancy 
ALL 
HR ALL CR1 
ALL CR2 
ALL CR3 or subsequent 
AML 
AML CR1 
AML CR2 or subsequent 
2° AML with prior disease in CR > 12 mo 
MDS 
Primary or Secondary  
NK leukemia 
CR1 or subsequent 
Biphenotypic leukemia 
CR1 or subsequent 
Undifferentiated leukemia 
CR1 or subsequent 
CML 
 
Accelerated Phase 
Chronic with persistent molecular positivity OR 
intolerance to tyrosine kinase inhibitor  
Hodgkins Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize HSC for auto-HCT 
Non-Hodgkin Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize for auto-HCT 
JMML 
 
Refractory disease 
ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin Lymphoma 
Pre-
Evaluation 
Cardiac Function 
LVEF ≥ 40% or SF ≥ 25% 
Renal Function 
CrCL or GFR ≥ 50 ml/min/1.73m2 
Lung Function 
FVC ≥ 50% or Pox ≥ 92% on room air 
Performance Score 
Karnofsky or Lansky ≥ 50 
Liver Function 
Bilirubin ≤ 3x upper limit of normal for age 
ALT ≤ 5x upper limit of normal for age 
AST ≤ 5x upper limit of normal for age 
EXCLUSION CRITERIA SUMMARY 
Donor 
Has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor (for HAPNK1) available in the necessary time for HSC donation  
Malignancy   Other active malignancy other than one being treated 
Pre-
Evaluation 
Pregnant - Serum or Urine pregnancy within 14 days of enrollment 
Breast feeding 
Downs Syndrome 
Uncontrolled infection 
 
3.4 Enrollment on Study 
 
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1 – 3.3, complete and sign the ‘Participant Eligibility Checklist’.  The study 


HAPCORD 14 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
team will enter the eligibility checklist information into the Patient Protocol Manager 
(PPM) system.  Eligibility will be reviewed, and a research participant-specific consent 
form and assent document (where applicable) will be generated.  The complete signed 
consent/assent document form(s) must be faxed or emailed to the CPDMO at 595-6265 to 
complete the enrollment process. 
The CPDMO is staffed 7:30 am – 5:00 pm CST, Monday through Friday.  A staff 
member is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm.  Enrollments 
may be requested during weekends or holidays by calling the CPDMO “On Call” cell 
phone (901-413-8591) or referencing the “On Call Schedule” on the intranet. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 15 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
4.0 TREATMENT PLAN 
4.1 Schema for Protocol Prioritization 
Participant with high-risk hematologic malignancies undergoing HCT, who do not have a 
suitable HLA-matched MSD, MURD or KIR ligand mismatched haploidentical donor 
identified in time, will receive a combined haploidentical and UCBT using a RIC 
preparative regimen.  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES 
PATIENT NOT 
ELIGIBLE FOR 
HAPCORD 
 PATIENTS WITH HIGH-RISK 
MALIGNANCY ELIGIBLE FOR HCT 
HLA TYPING 
DONOR SEARCH 
NO 
MATCHED SIBLING  
OR 
MATCHED UNRELATED 
DONOR AVAILABLE IN TIME 
PATIENT ELIGIBLE FOR 
ALTERNATIVE DONOR HCT 
 
  KIR MISMATCHED HAPLOIDENTICAL 
DONOR AVAILABLE 
KIR TYPING  
UCB SEARCH 
YES 
ELIGIBLE 
FOR HAPNK1 
NO 
ELIGIBLE FOR 
HAPCORD 
 
POTENTIAL DOUBLE UCBT  
ON UCBT01 OR NPTP 
NO 
YES 
SINGLE UNIT UCB  
AND HAPLOIDENTICAL DONOR  
  
ELIGIBLE FOR HAPCORD 


HAPCORD 16 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
4.2 Reduced Intensity Preparative Regimen 
DAY MEDICATION 
DOSE 
DOSE # 
-9 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 2 fractions 
1-2 of 4 
-8 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
3 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
1 of 5 
-7 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
4 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
2 of 5 
-6 
Cyclophosphamide (with mesna) 
60 mg/kg intravenous once daily  
1 of 1 
Fludarabine 
30 mg/m2 intravenous once daily  
3 of 5 
-5 
Fludarabine 
30 mg/m2 intravenous once daily  
4 of 5 
-4 
Fludarabine 
30 mg/m2 intravenous once daily  
5 of 5 
-3 
Thiotepa 
5 mg/kg intravenous twice daily  
1-2 of 2 
-2 
Melphalan 
70 mg/m2 intravenous once daily 
1 of 2 
Tacrolimus 
Maintain until at least 6 months 
start 
-1 
Melphalan 
70 mg/m2 intravenous once daily  
2 of 2 
0 
HPC A Infusion  
CD34+ selected 
HPC A1 
MMF 
Maintain until at least 45 days 
start 
+1 
HPC A Infusion  
CD45RA depleted 
HPC A2 
+2 
HPC C Infusion 
 
HPC C 
+3 
G-CSF 
5mcg/kg subcutaneous or intravenous daily 
until ANC >2000 for 3 consecutive days 
4.2.1  TLI 
A total of 800 cGy of TLI will be administered in divided fractions given at a 
minimum of 6 hours apart.  Administration of 4 fractions at 200 cGy/fraction over 
three days on day -9 to -7 for a total of 800 cGy is recommended.   
*Timing of TLI administration can vary per the Radiation Oncologist. Testicular 
boosts should be used for all males with ALL with 200 cGy per fraction over two 
days.  
4.2.2 
Fludarabine  
Fludarabine at 30 mg/m2/day will be given over 30-60 minutes intravenous infusion 
on day -8 through day -4 for a total of 5 doses (150 mg/m2 total). Fludarabine dose 
may be reduced per PI if concerns of toxicity (ie CNS).  
4.2.3  Cyclophosphamide with Mesna 
Cyclophosphamide at 60 mg/kg/day will be administered as a 2 hour intravenous 
infusion with a high volume fluid flush on day -6 for one dose (60mg/kg total).  For 
patients weighing more than 125% of their ideal body weight should have 
cyclophosphamide dose based on the adjusted ideal body weight.  
Mesna is administered prior to cyclophosphamide and after the cyclophosphamide 
infusion per institutional practice. Mesna dose and administration schedule may 
vary based on physician recommendation. 


HAPCORD 17 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
4.2.4 
Thiotepa 
Thiotepa will be given over 30-60 minutes intravenous infusion at 5 mg/kg twice a 
day on day -3 for a total of 2 doses (10mg/kg total). 
4.2.5  Melphalan 
Melphalan will be given over 30-60 minutes intravenous infusion at 70 mg/m2 once 
a day on day -2 and -1 for a total of 2 doses (140 mg/m2 total). 
4.3 UCB Product  
 
 
 
 
 
 
 
 
 
 
 
 
4.3.1 UCB Selection: 
 
Choose the unit with highest HLA match (6/6, 5/6 then 4/6)  
- Matching at HLA typing at HLA-A, B antigen level and DRB1 allele 
level. 
- The patient and the UCB unit(s) must be matched at least 4 of 6 loci. 
- The unit must meet cell dose threshold of 1.0 x 107 TNC/kg 
 
If > one unit is available for a HLA match grade, chose unit based on: 
- DRB1: Matching at DR takes preference, followed by  
- Locus of mismatch: A unit that is homozygous at the locus of mismatch 
should be chosen over a unit that is bidirectional at the locus of mismatch, 
even if the latter unit is larger, followed by 
- Cell Dose: Choose the unit containing the greatest TNC. 
 If two units are of equivalent HLA match grade, DR1 matching, locus of 
mismatch and cell dose  (± 0.5 x 107 TNC/kg), choose the unit with: 
- HLA match by higher resolution molecular typing, if data available 
 SELECT OPTIMAL UNIT WITHIN SAME HLA MATCH   
DR typing takes preference 
Prefer homozygous over bidirectional mismatch 
Choose the largest TNC unit.  
If TNC is similar (± 0.5 x 107 TNC/kg) 
Utilize HLA C matching if available 
Utilize higher resolution molecular typing if available. 
Utilize CD34+ cell count if available. 
CHOOSE UNIT WITH HIGHEST HLA MATCH  
 Minimum of 4 of 6 matching to the patient at 
HLA-A Antigen 
HLA-B Antigen 
HLA-DR Allele 
UCB SELECTION 


HAPCORD 18 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
- HLA-C antigen/allele level typing, if data available 
- Larger CD34+ cell dose, if data available 
- UCB banks located in the United States are preferred.  
4.3.2  UCB Unit Exclusions  
4.3.2.1 Unit fails to meet cell dose threshold criteria  
Cell dose is < 1.0 x 107 TNC per kilogram recipient weight.  
4.3.2.2 Fails screening 
 
Any UCB units without full maternal testing and negative results for hepatitis 
A, B, C, Human Immunodeficiency Virus (HIV), and Human T-lymphotropic 
virus-1 (HTLV-1) viruses. Any additional available virology results on the unit 
itself will be reviewed but are not mandated, complete or always available. The 
majority of UCB units will come from banks that operate under the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Minimally Manipulated, 
Unrelated 
Allogeneic 
Placental/Umbilical 
Cord 
Blood 
Intended 
for 
Hematopoietic Reconstitution for Specified Indications.  All NMDP banks must 
fulfill this requirement.  Foreign banks may have differing screening procedures 
even if they are American Association of Blood Banks (AABB) or Foundation 
for the Accreditation of Cellular Therapy (FACT) accredited.  It is important to 
clarify the screening process employed, and additional plasma may be requested 
if additional testing is needed to fulfill Eligibility Determination requirements.  
Currently UCB units are available for use under federal IND.  The NMDP holds 
an IND for use, and a few of the older banks hold their own IND. There is no 
need to adjust for nucleated RBCs when considering TNC.  The UCB unit(s) 
must be present at St. Jude prior to the start of conditioning. 
4.3.3  UCB Graft Preparation 
Preparation for administration will take place in the Human Applications Lab 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) of St. Jude using established Standard Operating Procedure (SOP).  
UCB units must be prepared for infusion in a manner that assures high cell 
recovery, maintains cellular viability, and avoids contamination.  When unit 
volume and Dimethyl sulfoxide (DMSO) concentration are not considered 
clinically prohibitive, and the wash procedure is deemed by the PI to have a 
potential adverse impact on the UCB unit, a reconstitutive thawing procedure may 
be utilized.  In this case, the unit is thawed, and then reconstituted at least 1:1 with 
an infusion grade solution (Dextran/albumin).  In general, a wash is desired, 
particularly when there are concerns about volume, DMSO dose, red cell replete 
product, etc.  For UCB products to be washed, a modified version of the New 
York Blood Center’s Placental Blood Thaw Procedure will be used.  Briefly, the 
unit will be thawed and diluted; the plasma will then be expressed away after 
gentle centrifugation.  In each case, 1-2 mL of the final product will be removed 
for testing prior to infusion. 
 
 


HAPCORD 19 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
4.4 Haploidentical Donor Graft 
4.4.1  Haploidentical Donor Selection 
If more than one family member donor is acceptable, then donor selection will be 
based on the preference of the primary transplant attending.  Factors in selection 
will include donor-recipient matching of CMV serology, donor-recipient red 
blood cell compatibility, degree of HLA matching, size of the potential donor, 
previous use as a donor, presence of donor-specific antibody, and overall health of 
the potential donor. 
Donor eligibility for cell collection will be determined through the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Eligibility Determination 
for Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products 
(HCT/Ps).  Potential donors will undergo an initial screening process that will 
include at least a complete physical exam, history and testing for relevant 
communicable diseases.  Physical exams to evaluate donor candidacy will be 
conducted by a non-Department of BMTCT physician (St. Jude or non-St. Jude).  
For subsequent therapeutic cell collection procedures, if a complete screening 
procedure has been performed within the previous 6 months, an abbreviated donor 
screening procedure may be used for these repeat donations.  The abbreviated 
screening procedure must determine and document any changes in the donor’s 
medical history since the previous donation that would make the donor ineligible, 
including changes in relevant social behavior. 
If a donor is determined to be ineligible, the donor is not automatically excluded. 
Part 21 CFR 1271.65 (b)(1)(i) allows use of ineligible donors who are first or 
second degree blood relatives. In this situation, the physician will document the 
necessity of using the ineligible donor by providing a statement of "Urgent 
Medical Need" as explained in the 21 CFR 1271.3 (u).  The cell therapy products 
will be labeled as required in 21 CFR 1271.65 (b)(2). Recipients or their legal 
guardians will be informed of the use of an ineligible donor. 
Please see Departmental SOP 30.05 “Determination of Eligibility and Suitability 
for Stem Cell and Therapeutic Cell Allogeneic and Autologous Donors” for 
additional information. 
4.4.2  Haploidentical Donor Mobilization and Donor HSC Graft Collections  
A G-CSF mobilized peripheral blood stem cell (PBSC) product (identified as 
HPC, Apheresis) is the preferred progenitor cell graft source.  Our desired target 
goal will be 3-5 x 106 CD34+ cells/kg.  This number of cells will be necessary to 
provide an adequate graft, following the various ex vivo manipulations, for 
prompt reconstitution. Two days of collection are typically needed to achieve this 
goal.  However, on rare occasions, additional days may be necessary.  Donors will 
undergo a standard HSC mobilization regimen consisting of 6 days of G-CSF 
given subcutaneously at 10 mcg/kg. The graft will be collected by leukapheresis 
on days 5 and 6.  The HPC, Apheresis product will typically be collected and 
infused fresh, however there may be patients or logistical situations that require 
the HPC, Apheresis product to be collected early, processed, and stored frozen. 


HAPCORD 20 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
The decision to use a fresh versus frozen HPC, Apheresis will be made by the PI 
and/or primary transplant attending based on patient and donor factors, as well as 
potential scheduling conflicts.  
MOBILIZATION TIME LINE 
DAYS 
MEDICATION 
APHERESIS 
Day -5 
G-CSF 10 mcg/kg/day SC*  
1 of 6 
 
Day -4 
G-CSF 10 mcg/kg/day SC* 
2 of 6 
 
Day -3 
G-CSF 10 mcg/kg/day SC* 
3 of 6 
 
Day -2 
G-CSF 10 mcg/kg/day SC* 
4 of 6 
 
Day -1 
G-CSF 10 mcg/kg/day SC* 
5 of 6 
Apheresis for HSC graft** 
Day 0 
G-CSF 10 mcg/kg/day SC* 
6 of 6 
Apheresis for HSC graft** 
* G-CSF may may be reduced if the donor’s WBC is >75.0 x 106/  
**Do not start apheresis if platelet count < 50,000/mm3 or hemoglobin of < 12.5 g/dL pre-phresis 
 
The dose of G-CSF may require modification based on the complete blood counts 
(CBC).  If the donor’s white blood count (WBC) is >75.0 x 106/ml the dose of 
cytokine administered will be reduced.  The guidelines for dose modification can 
be found in the St. Jude Children's Research Hospital Department of BMT and 
CT SOP 30.06.00 “The practice for the evaluation, preparation and care of 
allogeneic and autologous donors mobilized with growth factor.” Ongoing 
updates of this document can be located at the following St. Jude intranet website: 
http://home.web.stjude.org/bone_marrow/ 
The daily leukapheresed volumes for HPC, Apheresis collection is generally 3–4 
total blood volumes based on CD34+ cell counts.  Two additional days of 
leukapheresis may be performed at the physician’s discretion (no more than 4 
total) to reach the cell dose target, however, this is expected to be rare.   
Leukapheresis may be terminated early upon request of donor, or when deemed 
medically necessary per the judgment of the treating sub-investigator physician or 
PI.  All HPC, Apheresis products will be collected as per FACT guidelines. 
Donors will be monitored during the period of the mobilization and leukapheresis 
procedure with appropriate laboratory evaluation (Appendix D). 
If we are unable to collect the minimum dose of 2 x 106 CD34+ cells/kg of 
recipient weight from the first donor, and the recipient has not yet initiated the 
preparative regimen, then an alternative family member may be used if he/she 
fulfills all donor criteria described in section. If the donor is unwilling or unable 
to complete the mobilization process or leukapheresis procedure, a BM product 
may be used.  The BM product will be processed using the same cell selection 
methodology on the CliniMACS device.   
4.5 Graft Preparation 
Graft evaluation and preparation will take place in the Human Applications Laboratory 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) using established SOP.  


HAPCORD 21 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
The initial HPC, Apheresis product(s) will be TCD using the investigational CliniMACS 
device and CD34 Microbead reagent as directed by the manufacturer (Miltenyi Biotech).  
See section 5.2 for additional CliniMACS device information.  Briefly, HPC, Apheresis 
products from the mobilized donor will be initially assessed in the HAL and stored 
overnight at 4oC.  The next morning, the product will be washed to remove platelets and 
adjusted to an appropriate cell concentration for incubation with the CliniMACS CD34 
Microbead reagent in the manufacturer provided media.  The cells will be washed to 
remove unbound microbeads.  These cells will be applied to the CliniMACS device and 
the enrichment will be performed using the program “CD34 Enrichment 2.1” as 
described by the manufacturer. 
After enrichment is complete, the cells will be washed and resuspended in an infusion 
grade solution. The graft product will be enumerated and assessed for viable CD34+ cell 
and CD3+ T cell content by flow cytometry. The processed HPC, Aphersis CD34 
Enriched product will be infused fresh or frozen for future use after completion of release 
testing and evaluation. Cryopreservation will be performed per SOPs of the HAL.  Target 
cell doses are listed in the following table: 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
≥ 2 x 106 
2 x 106 
50 x 106 
CD3+ cells/kg 
≤ 0.5 x 105 
1 x 103 
1 x 105 
Once the target dose is obtained for the CD34+ enriched product, one additional day of 
apheresis will be performed.  This HPC, Apheresis product will be processed for 
CD45RA+ depletion using the investigational CliniMACS device as directed by the 
manufacturer (Miltenyi Biotech). See section 5.1 for additional CliniMACS device 
information.  Briefly, HPC, Apheresis products from the mobilized donor will be initially 
assessed in the HAL and stored overnight at 4oC.  The next morning, the product will be 
washed to remove platelets and adjusted to an appropriate cell concentration for 
incubation with the CliniMACS CD45RA Microbead reagent in the manufacturer 
provided media.  The cells will be washed to remove unbound microbeads. These cells 
will be applied to the CliniMACS device and the depletion will be performed using the 
"Depletion 3.1" software as described by the manufacturer.  When combined with the 
CD34+ enriched product, the target CD34+ dose will be 3-5 x 106/kg.  There is no CD3+ 
cell target dosing on the CD45RA+ depleted product, however release criteria of the 
product will include at least a ≥ 2.00 log10 depletion of CD45RA+ cells. 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
3-5 x 106 
2 x 106 
50 x 106 
CD45RA+ 
≥ 2.0 log10 depletion (CD45RA+ depleted graft only) 
4.6 Additional Progenitor Cell Graft Administration 
Infusion of an additional HSC graft from the original or an alternative haploidentical donor 
may be performed for participants when clinically indicated for graft failure, poor immune 
reconstitution, or poor hematopoietic recovery. The use of and content of a conditioning 
regimen is left to the discretion of the PI and/or primary transplant attending such that the 
most appropriate therapy is chosen for the clinical situation. 


HAPCORD 22 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
The HSC graft will typically be obtained by apheresis (HPC, Apheresis) and be infused 
fresh.  The target dose for this additional CD 34+ infusion is ≥5 x 106 cells/kg.  If the 
participant has quiescent or active BOOP, acute Grade III-IV GVHD, or any other reason 
that a severely T-cell depleted graft may be indicated, then a graft from the donor processed 
on the CliniMACSTM device using either CD34+ selection (using established SOPs) or CD3+ 
depletion methodology may be utilized. The boost target dose for these patients is ≥10 x 
106 CD34+cells/kg with a CD3+ cell/kg dose of ≤ 0.5 x 105 CD3+ cells/kg.   
4.7 Donor Lymphocyte Infusions 
Donor lymphocyte infusions (DLI) may be administered from the haploidentical donor 
for decreasing donor chimerism, serious viral reactivation or infection, or any evidence of 
disease (from any level of MRD to frank relapse).  The DLI collected may be collected as 
a whole blood unit donation or by leukapheresis. If the DLI is collected by standard 
phlebotomy, the volume to be collected would be approximately 300 ml whole blood.  If 
the DLI is collected by leukapheresis, the amount to be processed would be 
approximately 2 total blood volumes. 
Prior to administration of DLI, the immunosuppression should be withdrawn and the 
recipient should have no active GVHD.  The initial dose will typically be 2.5 x 104 
CD3+/kg.  Subsequent doses will be administered at approximately 2 to 4-week intervals 
with escalating doses of T cells if no moderate or severe GVHD occurs with the prior 
DLIs.  The typical initial dose escalation for patients on this protocol is presented in the 
following table: 
DLI DOSE AND SCHEDULE 
DLI 
Dose 
Comments 
Initial Dose 
2.5 x 104 CD3+/kg 
Approximately 2-4 week interval 
If no moderate or severe GVHD 
Dose #2 
5.0 x 104 CD3+/kg 
Dose #3 
10.0 x 104 CD3+/kg 
Although this algorithm will be appropriate for a majority, the treating transplant 
attending physician may alter the dose and/or interval of DLI based on response to 
previous DLI, the severity of the clinical situation, and the condition of the patient.  There 
is a low threshold for providing an initial dose of 2.5 x 104 CD3+/kg.  DLI at this dose 
level have not been associated with GVHD.  Therefore, DLI may be initiated for any 
chimerism less than 100% in a patient who is off immune suppression.  The risk of 
GvHD increases with increasing doses.  In the last 5 years, no patient has developed 
moderate or severe GVHD after haploidentical DLI dosed at 5 x 104 CD3+/kg, though 
mild GVHD has occasionally occurred.  Doses of 10 x 104 CD3+/kg should be considered 
to carry a risk of severe GVHD.  Therefore dose escalation to this level must incorporate 
the appropriate risk/benefit analysis by the treating transplant physician. 
4.8 Quality Assurance of Cellular Products 
Quality assurance for cell products is overseen by independent Quality Assurance 
personnel who authorizes release of all products. Only trained stem cell processors will 
process the cell products. A labeling and product tracking system is in place to ensure 
that the correct cells are infused into the research participant. 
Assays of cell numbers and immunophenotyping will be performed both before cell 
processing and at critical stages of the process.  These values will be recorded according 


HAPCORD 23 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
to SOP of the HAL.  All TCD products will be tested for viability, sterility (culture and 
Gram stain), and the presence of endotoxin. Culture and endotoxin results are not 
available before infusion of cell products. If the gram stain is positive, the research 
participant/parent and/or guardian will be informed of this event and of the risks of 
proceeding prior to infusion.  Positive results will be investigated as per the variance 
procedures of the HAL.  The IRB and FDA will be notified, if at any time after infusion, 
cell product was determined to be contaminated or endotoxin results exceed release 
limits.  
4.9  Immunosuppressive Therapies  
4.9.1  EBV post-transplant lymphoproliferative disease (PTLPD) prophylaxis  
Rituximab at 375 mg/m2 may be given intravenously as clinically indicated.  For all 
patients, monitoring peripheral blood EBV DNA and prophylaxis and treatment 
will be according to BMTCT standard guides and/or at the discretion of the 
treating physician as clinically indicated based on ongoing EBV copy levels and 
clinical assessment. If a positive selection methodology would be used for a 
haploidentical HCT infusion, rituximab would not be administered, unless 
otherwise clinically indicated. 
4.9.2  Tacrolimus  
Tacrolimus to start on day -2. Preferably, start tacrolimus as a continuous infusion 
until patient engrafts and able to reliably obtain therapeutic levels.   Maintain 
therapeutic levels according to institutional guidelines and practice.  May modify 
dose for decreased chimerism or positive MRD.  May convert to oral dosing when 
patient is tolerating oral and has a normal gastro-intestinal transit time.  If no 
evidence of GVHD, begin to wean by approximately 10% every week on day 100, 
and discontinue around day 180 and no sooner than 6 months post transplant.   
4.9.3  MMF 
MMF to start on day 0 at 15mg/kg intravenously TID or every 8 hours. May convert 
to oral dosing when patient is tolerating oral and has a normal gastro-intestinal 
transit time.  Adjust dose as clinically indicated. If no evidence of GVHD, MMF can 
be discontinued on day +45 or on/about 7 days after engraftment, whichever is later.  
May hold for decreased chimerism or positive MRD. Continue MMF if patient has 
no evidence of donor engraftment on bone marrow evaluation and contact PI of 
results.  
4.9.4  Methylprednisolone* 
Methylprednisolone may be used for treatment of acute GVHD*.  (2mg/kg divided 
every 12 hours intravenously is suggested as initial therapy for patient with active 
acute GVHD requiring systemic therapy)  If no response after 7 days, treat with a 
second line agent according to SOP.  Methylprednisolone at 1-5 mg/kg/day can be 
used for management of pre-engraftment immune reaction as described below in 
4.10* 
*Use of methylprednisolone and dosing are recommendations and variance in 
medication, dosing and frequency can occur due to the participant’s current 
clinical condition and will not be noted as protocol deviations. 


HAPCORD 24 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
4.10 Management of Pre-engraftment Immune Reaction 
A well recognized clinical entity consisting of skin rash, fever, loose stools and 
respiratory distress has been noted to occur prior to engraftment among UCB patients, 
generally between day 7 and 21. This clinical syndrome likely involves cytokine 
activation, and though clinically similar to acute or hyperacute GVHD, it appears to be a 
distinct entity, “pre-engraftment syndrome.” This syndrome is often controlled with brief 
steroid bursts, thus avoiding a commitment to extended steroid exposure.  Patients should 
be monitored carefully for this syndrome. If patients have moderate to severe symptoms 
as described above and alternative etiologies (i.e., infection) have been excluded or are 
being appropriately evaluated, patients may be treated with steroids. Recommendation of 
methylprednisolone is provided.  
The usage of methylprednisolone described here is a recommendation, and variations in 
medication, dosing and/or frequency can occur due to the participant’s current clinical 
condition and will not be noted as protocol deviations. 
4.10.1  For 
patients 
not 
on 
steroid 
therapy 
when 
the 
syndrome 
occurs: 
methylprednisolone should be given at 1 mg/kg intravenously once a day for three 
days. If symptoms have abated, steroids should be stopped. If symptoms persist, 1 
mg/kg can be continued through six days then stopped if symptoms have abated. 
If symptoms persist for more than six days, the patient should be considered to 
have acute/hyperacute GVHD and should be treated with prolonged steroids as 
deemed appropriate. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
4.10.2 For patients already on steroids for other reasons when the syndrome occurs: 
methylprednisolone should be given at a dose of 3-5 mg/kg intravenously (max 
dose 500 mg) every 12 hours for maximum of 48 hours, followed by a rapid taper 
to 1 mg/kg intravenously every 12 hours. Patients should be weaned after 
response as tolerated. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
4.11 Growth Factors 
4.11.1  Granulocyte colony-stimulating factor (G-CSF) 
G-CSF to start on day +1 at 5 mcg/kg/day intravenously or subcutaneously until 
absolute neutrophil count (ANC) ≥ 2,000/mm3 for three consecutive days.  
4.12 Treatment and Conditioning Regimen Related Notes  
The HSC infusion may be delayed by approximately 24 hours in order to accommodate 
HAL as well as the research participant clinical condition. 
The term “every” used in tables is an approximate term meaning that these medications 
noted will be administered approximately “every” 12 hours (or 8 hours as applicable).  
The drug administration timing in these cases may be modified as clinically indicated 
such as in the case of surgical procedures or to accommodate other necessary medication, 
blood product delivery, or procedures. The term “day” does not refer to an absolute 
calendar day.  It refers to a general 24-hour period. 
Dosing for all protocol treatment medications may be modified for research recipients 
based upon actual body weight or adjusted ideal body weight and/or for infants weighing 


HAPCORD 25 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
less than 10kg, when clinically indicated. Mesna will be administered for prevention of 
hemorrhagic cystitis from the medication cyclophosphamide.   
Criteria for medication calculations based on body weight/body surface area and other 
medication related information can be found in the St. Jude 
Formulary 
(http://www.crlonline.com/crlsql/servlet/crlonline) or the St. Jude Department of 
Pharmaceutical 
Sciences 
intranet 
website 
http://home.web.stjude.org/ 
pharmaceutical_ser/drugInfo.shtml.  Medication doses may be rounded to the nearest 
integer or to the nearest appropriate quantity when clinically or pharmaceutically 
indicated as per the MD and PharmD. 
5.0 MEDICATION INFORMATION 
5.1 Cyclophosphamide (Cytoxan) 
Source 
& 
Pharmacology  
Cyclophosphamide is a nitrogen mustard derivative.  It acts as an alkylating 
agent that causes cross-linking of DNA strands by binding with nucleic acids 
and other intracellular structures, thus interfering with the normal function of 
DNA. It is cell cycle, phase non-specific. Cyclophosphamide is well 
absorbed from the GI tract with a bioavailability of >75%.  It is a prodrug 
that requires activation. It is metabolized by mixed function oxidases in the 
liver to 4-hydroxycyclo-phosphamide, which is in equilibrium with 
aldophosfamide. Aldofosfamide spontaneously splits into nitrogen mustard, 
which is considered to be the major active metabolite, and acrolein. In 
addition, 4-hydroxycy-clophosphamide may be enzymatically metabolized to 
4-ketocyclophosphamide and aldophosfamide may be enzymatically 
metabolized to carboxyphosphamide that is generally considered inactive.  
Cyclophosphamide and its metabolites are excreted mainly in the urine. Dose 
adjustments should be made in patients with a creatinine clearance of <50 
ml/min. 
Formulation 
and Stability  
Cyclophosphamide is available in vials containing 100, 200, 500, 1000 and 
2000mg of lyophilized drug and 75 mg mannitol per 100 mg of 
cyclophosphamide.  Both forms of the drug can be stored at room 
temperature. The vials are reconstituted with 5, 10, 25, 50 or 100 ml of 
sterile water for injection, respectively, to yield a final concentration of 20 
mg/ml.  Reconstituted solutions may be further diluted in either 5% dextrose 
or 0.9% NaCl containing solutions.  Diluted solutions are physically stable 
for 24 hours at room temperature and 6 days if refrigerated, but contain no 
preservative, so it is recommended that they be used within 24 hours of 
preparation. 
Supplier 
Commercially available 
Toxicities 
Dose limiting toxicities of cyclophosphamide includes BM suppression and 
cardiac toxicity.  Cardiac toxicity is typically manifested as congestive heart 
failure, cardiac necrosis or hemorrhagic myocarditis and can be fatal.  
Hemorrhagic cystitis may occur and necessitates withholding therapy. The 
incidence of hemorrhagic cystitis is related to cyclophosphamide dose and 
duration of therapy. Forced fluid intake and/or the administration of mesna 
decreases the incidence and severity of hemorrhagic cystitis.  Other toxicities 
reported commonly include nausea and vomiting (may be mild to severe 


HAPCORD 26 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
depending on dosage), diarrhea, anorexia, alopecia, immunosuppression and 
sterility.  Pulmonary fibrosis, SIADH, anaphylaxis and secondary neoplasms 
have been reported rarely.    
Route  
Intravenous infusion  
5.2. Thiotepa (Thioplex by Immunex) (TESPA, TSPA) 
Source 
& 
Pharmacology  
Thiotepa is a cell-cycle nonspecific polyfunctional alkylating agent.  It 
reacts with DNA phosphate groups to produce cross-linking of DNA strands 
leading to inhibition of DNA, RNA and protein synthesis.  Thiotepa is 
extensively metabolized in the liver to metabolites that retain activity, 
primarily triethylene-phosphoramide (TEPA).  The main route of 
elimination is via the urine, mainly as metabolites; the elimination half-life 
of the thiotepa is 2.5 hours, and that of TEPA is 17.6 hours. 
Formulation 
and Stability 
Thiotepa is supplied in single-use vials containing 15 mg of lyophilized 
thiotepa, 80 mg NaCl and 50 mg NaHCO3.  The intact vials should be 
stored under refrigeration and protected from light.  Each vial should be 
reconstituted with 1.5 ml of sterile water for injection to yield a 
concentration of 10 mg/ml.  Further dilution with sterile water for injection 
to a concentration of 1 mg/ml yields an isotonic solution; if larger volumes 
are desired for intracavitary, intravenous infusion, or perfusion therapy, this 
solution may then be diluted with 5% dextrose or 0.9% NaCl containing 
solutions.  The 10 mg/ml reconstituted solution is chemically stable when 
stored in the refrigerator for up to 5 days, however, it is recommended that 
solutions be prepared just prior to administration since they do not contain a 
preservative.  Reconstituted solutions should be clear to slightly opaque: the 
solutions may be filtered through a 0.22 micron filter to eliminate haze. 
Supplier 
Commercially available; manufactured by Immunex. 
Toxicities 
Dose limiting toxicity is myelosuppression.  The leukocyte nadir may occur 
at any time from 10 to >30 days.  Other toxicities include pain at the 
injection site, nausea and vomiting, anorexia, mucositis, dizziness, headache, 
amenorrhea, interference with spermatogenesis, and depigmentation with 
topical use.  Allergic reactions, including skin rash and hives, have been 
reported rarely.  Rare cases of apnea, hemorrhagic cystitis, and renal failure 
have occurred.  Thiotepa is mutagenic, carcinogenic, and teratogenic in 
animals.  Pregnancy category D. 
Route    
Intravenous 
 
5.3 Fludarabine (Fludara) 
Source 
& 
Pharmacology  
Fludarabine phosphate is a synthetic purine nucleoside analog and acts by 
inhibiting DNA polymerase, ribonucleotide reductase and DNA primase by 
competing with the physiologic substrate, deoxyadenosine triphosphate, 
resulting in inhibition of DNA synthesis. It can also be incorporated into 
growing DNA chains as a false base and interfere with chain elongation and 
halt DNA synthesis. Fludarabine is rapidly dephosphorylated in the blood 
and transported intracellularly by a carrier-mediated process. It is then 


HAPCORD 27 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate form.  ~23% of the dose is excreted as the active metabolite in 
the urine (with dosages of 18-25 mg/m2/day for 5 days).  Renal clearance 
appears to become more important at higher doses, with approximately 41-
60% of the dose being excreted as the active metabolite in the urine with 
dosages of 80-260 mg/m2. 
Formulation 
and Stability 
Fludarabine is supplied in single-dose vials containing 50 mg fludarabine as 
a white lyophilized powder and 50 mg of mannitol.  The intact vials should 
be stored under refrigeration.  Each vial can be reconstituted by adding 2 ml 
of sterile water for injection resulting in a final concentration of 25 mg/ml. 
Because the reconstituted solution contains no antimicrobial preservative, the 
manufacturer recommends that it should be used within 8 hours of 
preparation.  The solution should be further diluted in 5% dextrose or 0.9% 
NaCl prior to administration. 
Supplier 
Commercially available. 
Toxicities 
The major dose-limiting toxicity of fludarabine is myelosuppression.  Nausea 
and vomiting are usually mild.  Side effects reported commonly include 
anorexia, fever and chills, alopecia and rash.  Neurotoxicity can be 
manifested by somnolence, fatigue, peripheral neuropathy, mental status 
changes, cortical blindness and coma and is more common at high doses.  
Neurotoxicity is usually delayed, occurring 21-60 days after the completion 
of a course of therapy and may be irreversible.  Side effects reported less 
commonly include diarrhea, stomatitis, increased liver function tests, liver 
failure, chest pain, arrhythmias and seizures.  Pulmonary toxicity includes 
allergic pneumonitis characterized by cough, dyspnea, hypoxia and 
pulmonary infiltrates.  Drug induced pneumonitis is a delayed effect, 
occurring 3-28 days after the administration of the third or later course of 
therapy.  Administration of corticosteroids usually results in resolution of 
these symptoms. 
Route    
Intravenous 
 
5.4 Melphalan (L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin, 
Alkeranâ) 
Source 
& 
Pharmacology  
Melphalan, a derivative of nitrogen mustard, is a bifunctional alkylating 
agent.  Its chemical name is 4-[bis(2-chloroethyl)amino]-L-phenylalanine, 
and it has a molecular weight of 305.20.  Melphalan is active against tumor 
cells that are actively dividing or at rest.  Its cytotoxicity is thought to be due 
to inter-strand cross-linking with DNA, probably by binding at the N7 
position of guanine.  Melphalan is highly protein bound and does not 
penetrate well into the cerebral spinal fluid. Elimination half-life after 
intravenous administration in adults is approximately 75 minutes. 
Elimination appears to be primarily by chemical hydrolysis, but caution 
should be used in patients with renal impairment.  Plasma concentrations of 
melphalan after oral administration are highly variable, possibly due to 
incomplete absorption, variable “first pass” hepatic metabolism or rapid 
hydrolysis. Area under the plasma concentration-time curves for orally 


HAPCORD 28 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
administered melphalan is approximately 60% of intravenously administered 
melphalan in adult studies.  
Formulation 
and Stability  
Available as 2 mg tablets for oral administration. This medication is stable at 
room temperature until expiration date on the packaging.  Intravenous 
formulation is supplied as 50 mg freeze dried glass vial. Each 50 mg vial is 
supplied in a carton containing a 10 ml vial of sterile diluent. Lyophilized 
melphalan should be stored at controlled room temperature and protected 
from light. Each vial is marked with its expiration date. The melphalan for 
injection must be reconstituted immediately prior to infusion by rapidly 
adding the contents of the diluent vial (10 ml) to the freeze dried powder 
with a 20 gauge or larger sterile needle and immediately shaking vigorously 
until a clear solution is obtained.  This results in a 5 mg/ml solution.  The 
dose should then be diluted in 0.9% sodium chloride for injection to a final 
concentration of not greater than 0.45 mg/ml. The resulting admixture should 
be infused over a minimum of 15 minutes.  The infusion should be 
completed within 60 minutes of reconstitution.  Do Not Refrigerate the 
Reconstituted Melphalan.  
Supplier 
Commercially available 
Toxicities 
Melphalan is cytotoxic and caution should be used in handling and preparing 
the solution or administering the tablets. Use of gloves is recommended, and 
if contact with skin or mucosa occurs, immediately wash thoroughly. Second 
cancers such as acute non-lymphocytic leukemia, myeloproliferative 
syndrome, and carcinoma have been reported in patients taking melphalan 
alone or in combination with other chemotherapy or radiation. Melphalan 
causes suppression of ovarian function in premenopausal women, with a 
significant number of patients having amenorrhea. Testicular suppression 
(reversible and irreversible) has been reported.  The most common adverse 
reaction is myelosuppression. Irreversible bone marrow failure has been 
reported. Gastrointestinal side effects reported include nausea/vomiting, 
diarrhea and oral mucosa ulceration.  Hepatic toxicity has occurred, 
including veno-occlusive disease.  Acute hypersensitivity reactions occur in 
about 2.4% of patients, and can include anaphylaxis. Hypersensitivity 
reactions were characterized by urticaria, pruritus, and edema.  Some 
patients exhibited tachycardia, bronchospasm, dyspnea and hypotension that 
responded to antihistamines and corticosteroids. Other side effects that have 
been reported include skin ulceration or necrosis at injection site, vasculitis, 
alopecia, hemolytic anemia, pulmonary fibrosis, and interstitial pneumonitis. 
Route  
Intravenous infusion  
 
5.5 Mesna (Mesnex) 
Source 
& 
Pharmacology  
Mesna is a synthetic sulfhydryl (thiol) compound. Mesna contains free 
sulfhydryl groups that interact chemically with urotoxic metabolites of 
oxaza-phosphorine derivatives such as cyclophosphamide and ifosfamide. 
Oral bioavailability is 50%. Upon injection into the blood, mesna is oxidized 
to mesna disulfide, a totally inert compound.  Following glomerular 


HAPCORD 29 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
filtration, mesna disulfide is rapidly reduced in the renal tubules back to 
mesna, the active form of the drug.  Mesna and mesna disulfide are excreted 
primarily via the urine. 
Formulation 
and Stability 
Mesna is available in 2 ml, 4 ml and 100 ml amps containing 100 mg/ml of 
mesna solution.  The intact vials can be stored at room temperature.  Mesna 
may be further diluted in 5% dextrose or 0.9% NaCl containing solutions.  
Diluted solutions are physically and chemically stable for at least 24 hours 
under refrigeration.   
Supplier 
Commercially available 
Toxicities 
Mesna is generally well tolerated.  Nausea and vomiting, headache, diarrhea, 
rash, transient hypotension and allergic reactions have been reported.  
Patients may complain of a bitter taste in their mouth during administration. 
Mesna may cause false positive urine dipstick readings for ketones.   
Dosage 
and 
Administration 
Mesna is generally dosed at approximately 25% of the cyclophosphamide 
dose.  It is generally given intravenously prior to and again at 3, 6 and 9 
hours following each dose of cyclophosphamide. 
Route 
Intravenous 
 
5.6 G-CSF (Filgrastim, Neupogen)  
Source 
& 
Pharmacology 
G-CSF is a biosynthetic hematopoietic agent that is made using recombinant 
DNA technology in cultures of Escherichia coli. G-CSF stimulates 
production, maturation and activation of neutrophils. In addition, 
endogenous G-CSF enhances certain functions of mature neutrophils, 
including phagocytosis, chemotaxis and antibody--dependent cellular 
cytotoxicity. 
Formulation 
and Stability 
G-CSF is supplied in vials containing 300 and 480 mcg of G-CSF at a 
concentration of 300mcg/ml. The intact vials should be stored under 
refrigeration.  The vials can be left out of refrigeration for 24 hours, but 
should be discarded if left at room temperature for longer periods of time.  
G-CSF can be drawn up into tuberculin syringes for administration and 
stored under refrigeration for up to 7 days prior to usage.  G-CSF can be 
further diluted for intravenous infusion in 5% dextrose.  Do not dilute in 
saline---precipitate may form. If the final concentration of this product is <15 
mcg/ml, it is recommended that albumin be added to a final concentration of 
2mg/ml (0.2%) to minimize adsorption of the drug to infusion containers and 
equipment.   
Supplier 
Commercially available. 
Toxicities 
G-CSF causes marked leukocytosis.  Common adverse reactions include 
bone pain, thrombocytopenia, diarrhea, nausea, rash, alopecia, fever, 
anorexia and pain or bruising at the injection site.  Allergic reactions, MI, 
atrial fibrillation, and splenomegaly have been reported rarely. G-CSF is 
contraindicated in participants with allergy to E. coli derived products. 
Route 
Intravenous or subcutaneous. 
 


HAPCORD 30 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
5.7  Mycophenolate mofetil (MMF, CellCept) 
Source 
& 
Pharmacology  
MMF is hydrolyzed to mycophenolic acid (MPA), an immunosuppressive 
agent. MPA inhibits B and T-cell proliferation, T-cell synthesis, and 
antibody secretion by potent, noncompetitive reversible inhibition of inosine 
monophosphate dehydrogenase (IMPDH) in the purine biosynthesis 
pathway. Inhibition of IMPDH results in a depletion of guanosine 
triphosphate and deoxyguanosine triphosphate, important intermediates in 
the synthesis of lymphocyte DNA, RNA, proteins and glycoproteins. Oral 
formulations of MMF are rapidly and extensively absorbed when given on an 
empty stomach.  Aluminum and magnesium-containing antacids and food 
decrease absorption of MMF.  MMF is rapidly hydrolyzed to the active 
metabolite (MPA) after oral or intravenous administration.  Free MPA is 
conjugated in the liver by glucuronyl transferase to inactive mycophenolic 
acid glucuronide (MPAG) that is excreted in the urine and feces.  Time to 
peak plasma concentration is 0.8–1.3 hours, and the mean elimination half-
life is 17.9 hours. Enterohepatic recirculation of MPA contributes to plasma 
concentrations. Administration of cholestyramine interrupts the enterohepatic 
recirculation and can decrease bioavailability by as much as 40%.  Patients 
with renal insufficiency have increased plasma concentrations of MPA and 
MPAG. Acyclovir and ganciclovir may compete with MPAG for renal 
tubular secretion, resulting in increased plasma concentrations of both drugs.  
Formulation 
and Stability 
MMF is commercially available as 250 mg capsules, 500 mg tablets, 200 
mg/ml powder for oral suspension, and 500 mg vials of powder for injection.  
Supplier 
Hoffmann La Roche, Inc.    
Toxicities  
AE seen in patients taking MMF include hypertension, hypotension, 
peripheral edema, leukopenia, anemia, thrombocytopenia, hypochromic 
anemia, leukocytosis, headache, insomnia, dizziness, tremor, anxiety, 
paresthesia, hyperglycemia, hypercholesterolemia, hypokalemia, diarrhea, 
hyperkalemia, hypophosphatemia, constipation, nausea, vomiting, anorexia, 
abdominal pain, dyspepsia, urinary burning or frequency, renal tubular 
necrosis, hematuria, increase serum creatinine and BUN, a variety of 
infections due to immunosuppression, rash, acne, ocular changes (cataracts, 
blepharitis, keratitis, glaucoma, and macular abnormalities) occasional leg 
cramps or pain, bone pain, myalgias, and hand cramps.  Intravenous 
infusions have been reported to cause thrombosis and phlebitis. There have 
been occasional reports of gastrointestinal hemorrhage.  High dose therapy 
with mycophenolate in adults with psoriasis has been associated with the 
following neoplasms: adenocarcinoma of the breast and colon, basal cell 
carcinoma, carcinoma of the gallbladder, histiocytic lymphoma, glioblastoma 
multiforme, and squamous cell carcinoma of the epiglottis.   
Route  
Oral or intravenous 
 
5.8  Tacrolimus (FK506, Prograf®, Protopic®) 
Source 
& 
Pharmacology  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyce 
tsukubaensis. It inhibits T-lymphocyte activation, although the exact 


HAPCORD 31 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
mechanism of action is not known. Tacrolimus activity is primarily due to 
the parent drug.  The plasma protein binding of tacrolimus is approximately 
99% and is independent of concentration over a range of 5-50 ng/mL.  The 
t½ in adult patients ranges from 11-19 hours.  Whole blood trough 
concentrations from 31 patients less than 12 years old showed that pediatric 
patients needed higher doses than adults to achieve similar tacrolimus trough 
concentrations.  It is extensively metabolized by the mixed-function oxidase 
system, primarily the cytochrome P-450 system (CYP3A) in the liver and to 
a lesser extent in the intestinal mucosa.  The main route of elimination is via 
the biliary tract and excretion in feces.  A retrospective comparison of Black 
and Caucasian kidney transplant patients indicated that Black patients 
required higher tacrolimus doses to attain similar trough concentrations; 
there were no gender-based differences.  The absorption of tacrolimus from 
the gastrointestinal tract is incomplete and variable exhibiting large intra- and 
inter-patient variability. Administration with food significantly decreases the 
rate and extent of absorption. Drugs that stimulate or inhibit hepatic p-450 
enzymes will alter clearance of tacrolimus and close attention to potential 
drug interactions is crucial. 
Formulation 
and Stability 
Intravenous formulation: Tacrolimus is available as a sterile solution 
(tacrolimus injection) containing the equivalent of 5 mg anhydrous 
tacrolimus in 1 mL Each mL contains polyoxyl 60 hydrogenated castor oil 
(HCO-60), 200 mg, and dehydrated alcohol, USP, 80% v/v. Store between 
5°C and 25°C (41°F and 77°F). Oral formulations: It is available for oral 
administration as capsules containing the equivalent of 0.5 mg, 1 mg or 5 mg 
of anhydrous tacrolimus. Inactive ingredients include lactose, hydroxypropyl 
methylcellulose, croscarmellose sodium, and magnesium stearate. The 0.5 
mg capsule shell contains gelatin, titanium dioxide and ferric oxide, the 1 mg 
capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule 
shell contains gelatin, titanium dioxide and ferric oxide. Store at 25°C 
(77°F); excursions permitted to 15°-30°C (59°-86°F). 
Supplier 
Commercially available    
Toxicities  
Immunosuppression results in increased susceptibility to infection and 
possible development of lymphoma and other malignancies, particularly of 
the skin.  After intravenous administration, monitor closely for an acute 
allergic reaction for the first 30 minutes and at frequent intervals thereafter.  
Fetal toxicity has been noted in animals.  Common adverse effects are 
headache, hypertension, GI toxicities, fever, immunosuppression, tremor, 
renal dysfunction, hematological abnormalities, CNS abnormalities, 
electrolyte abnormalities, clotting abnormalities, alopecia.  Late effects can 
include skin disorders, delayed wound healing, and hirsutism.   Insulin-
dependent post-transplant diabetes mellitus (PTDM) was reported in 11-22% 
of tacrolimus treated transplant patients without pretransplant history of 
diabetes mellitus, several human studies. Mild to severe hyperkalemia is 
reported in 8-45% of transplant patients receiving tacrolimus, so serum 
potassium levels should be monitored and potassium-sparing diuretics should 
not be used. To avoid excess nephrotoxicity, tacrolimus should not be used 


HAPCORD 32 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
simultaneously with cyclosporine or other drugs that may be associated with 
renal dysfunction.  Tacrolimus or cyclosporine should be discontinued at 
least 24 hours prior to initiating the other. In the presence of elevated 
tacrolimus or cyclosporine concentrations, dosing with the other drug usually 
should be further delayed.  It is not recommended that sirolimus and 
tacrolimus be given concomitantly, as serious increases in wound healing 
complications, renal function impairment and insulin-dependent post-
transplant diabetes mellitus have been observed.  Drugs that stimulate or 
inhibit p-450 enzymes will alter clearance of tacrolimus and close attention 
to potential drug interactions is crucial.   
Route  
Oral or intravenous 
 
5.9  Methylprednisolone (Medrol®, Solu-Medrol)  
Source 
& 
Pharmacology  
Adrenal corticosteroid – anti-inflammatory, immunosuppressant decreases 
inflammation by suppression of migration of polymorphonuclear leukocytes 
and reversal of increased capillary permeability. 
Formulation 
and Stability 
Tablet (4mg), Sodium Succinate powder for injection 125 mg, 500 mg. 
Supplier 
Commercially available. 
Toxicities:  
Toxicities include edema, hypertension, vertigo, seizures, psychoses, 
headache, pseudotumor cerebri, acne, skin atrophy, impaired wound healing, 
Cushing’s syndrome, pituitary adrenal axis suppression, growth suppression, 
glucose intolerance, hypokalemia, alkalosis, peptic ulcer, nausea, vomiting, 
transient leukocytosis, muscle weakness, osteoporosis, fractures, cataracts, 
glaucoma, and increased risk of infection. 
Route  
Intravenous or oral.   
5.10 CliniMACSTM System   
The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-
activated cell sorting (MACS).  The CliniMACS device is a powerful tool for the 
isolation of many cell types from heterogeneous cell mixtures, (e.g. apheresis 
products).  These can then be separated in a magnetic field using an immunomagnetic 
label specific for the cell type of interest, such as CD3+ human T cells. 
The cells to be isolated are specifically labeled with super-paramagnetic particles by an 
anti-body directed toward a cell surface antigen.  After magnetic labeling, the cells are 
separated using a high-gradient magnetic separation column as described below.  The 
magnetically labeled cells are retained in the magnetized column while the unlabeled 
cells flow through the column for collection.  The retained cells are eluted by removing 
the magnetic field from the column, washing the cells out and collecting them in a 
separate container from the unlabeled cells. 
The super-paramagnetic particles are small in size (about 50 nm in diameter) and are 
composed 
of 
iron 
oxide/hydroxide 
and 
dextran 
conjugated 
to 
monoclonal 
antibodies.  These magnetic particles form a stable colloidal solution and do not 
precipitate or aggregate in magnetic fields.  The antibody conjugated beads used in this 
system are highly specific (e.g. CD3+ cells via OKT3 conjugated beads). High-gradient 


HAPCORD 33 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
MACS technology has been shown to achieve rapid and highly specific depletion or 
enrichments of large numbers of target cells from BM, cord blood, and normal peripheral 
blood mononuclear cells.  
The CliniMACS device incorporates a strong permanent magnet and a separation column 
with a ferromagnetic matrix to separate the cells labeled with the magnetic particles. The 
high-gradient system allows the application of strong magnetic forces and a rapid de-
magnetization. Small ferromagnetic structures, such as the column matrix, placed in a 
magnetic field concentrate this homogenous field and thereby produce high magnetic 
gradients. In their immediate proximity, the ferromagnetic structures generate magnetic 
forces 10,000-fold greater than in the absence of those structures enabling the retention of 
magnetically labeled cells. After removing the column from the magnet, the rapid de-
magnetization of the column matrix allows the release of retained cells.  
The CliniMACS device is comprised of a computer controlled instrument incorporating a 
strong permanent magnet, a closed-system sterile tubing set containing columns with a 
coated ferromagnetic matrix and a paramagnetic, cell specific, labeling reagent. The 
instrument will separate the cells in a fully automated process yielding a cell population 
highly depleted of CD3+ cells. The CliniMACS device is not licensed by the FDA and 
therefore is investigational. 
The CliniMACS device has separate programs that allow cell selection procedures 
optimized for either depletion (e.g. CD3+ or CD45RA+) or selection of a target cell 
population (e.g. CD34+ or CD56+ cells). The basic mechanism is the same for either 
application; target cells are "tagged" with super-paramagnetic particles and eventually 
separated from the unlabeled cells using the CliniMACS device as described above. The 
desired target cells can either be infused or discarded appropriately.   
6.0  
REQUIRED OBSERVATIONS AND EVALUATIONS 
6.1 Standard Pre/Peri/Post-Transplant Evaluations 
All pre/peri/posttransplant and long-term follow-up evaluations for these participants will 
be carried out as guided by the SOPs of the SJCRH, Department of BMTCT, for 
recipients of allogeneic HCT.  Copies of these SOPs and ongoing updates can be found at 
the following site: http://home.web.stjude.org/bone_marrow/clinicalHome.shtml.  A 
schedule of these for these assessments is outlined in Appendix D. 
6.2 Long-term Follow-up Evaluations 
In general, recipients of allogeneic HCT at St. Jude are seen at least annually until 10 
years post-transplant in the Department of BMTCT outpatient clinic. For the purpose of 
this study, research participants will be followed to year 1 post-transplantation. At that 
time, transplant recipients will be eligible for enrollment in the institutional long-term 
follow-up protocol for children and young adults who have received stem cell 
transplantation at St. Jude Children’s Research Hospital (BMTFU protocol). 
6.3 Research Testing.   
Timing for the required research tests are summarized in Appendix D.  Furthermore, to 
accommodate the studies, flexibility in the date is allowed without a deviation from 
protocol.  The degree of flexibility in the timing is also provided in Appendix D.  


HAPCORD 34 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
6.3.1  Immune Reconstitution 
Standard measures of post-HCT immune reconstitution will be performed as 
delineated in Appendix D.  Research testing of Immune Reconstitution will 
include:  
6.3.1.1  VBETA/TREC Research: Thymic output and T cell repertoire. 
6.3.1.2  Lymphocyte Phenotypes Research: T cell and NK cell number and function. 
6.3.1.3  IR-PHENOTYPE 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care. Immunophenotypic evaluation of the UCB unit 
prior to infusion will be performed to enumerate the content of naïve, 
memory T cells, regulatory T cells, NK cells, and naïve B cells and memory 
B cells.   
Host: Immunophenotypic evaluation of immune reconstitution in the patient 
will be performed for the enumeration of naïve, memory T cells, regulatory 
T cells and naïve B cells and memory B cells.  
6.3.1.4  T-FUNCTION 
Immune function studies include antigen-specific T-lymphocyte response to 
viral infections, such as herpes viruses (CMV, HSV and VZV), intracellular 
cytokine and cytokine secretion assays.  Studies will include an optional 
skin punch biopsy to be performed either at the time of the pre-transplant 
BM biopsy, during sedation for radiation treatment or at the time of the day 
28 BM biopsy.  During viral infections, or reactivations detected by DNA 
regardless of copy number, samples to be collected weekly x 4 or until 
cleared (whichever is less).  If infection(s) are detected in non-blood 
samples (nasal wash, BAL etc), leftover samples may be used for research 
purposes.  Studies to be performed in the laboratory of Dr. Paul Thomas in 
collaboration with Dr. Dallas.  
6.3.1.5  HOST-DONOR INTERACTION 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care.  Epstein-Barr virus transformed lymphoblastoid 
cell lines (EBV-LCL) will be generated from the donor cells obtained from 
the discarded infusion bag.  UCB KIR typing and HLA-typing will be 
performed for high resolution HLA-A, HLA-B, HLA-DR, HLA-C and 
HLA-DQ if not available.   
Host: Host and donor immunologic interaction studies will also require a 
skin punch biopsy to be performed with the pre-transplant BM biopsy to 
generate fibroblasts.  Prior to the start of conditioning, peripheral blood 
samples will be collected to generate EBV-LCL from the patient for 
research studies evaluating donor/host immunologic reactions. 
 


HAPCORD 35 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
6.4 Research Testing on Haploidentical Donor (optional) 
Donors will be offered the option for participation in research studies of immune 
reconstitution of T cells, B cells, and NK cells.  These tests will be obtained after consent 
and preferably prior to growth factor administration.  Lymphocyte subset analysis of the 
donor appears to allow for the prediction of the reconstitution of the lymphocyte subsets 
in the research participant after transplantation.  Data in larger donor/research participant 
pairs will help to verify these observations. A list of these optional research studies are 
noted in Appendix D and detailed below: 
6.4.1  Lymphocyte Subset Study: Flow cytometry enumeration 
6.4.2  VBETA/TREC Research: Thymic output and T cell repertoire 
6.4.3  Lymphocyte Phenotypes Research: T cell and NK cell number and function 
7.0 EVALUATION CRITERIA 
7.1  Adverse event (AE) monitoring for on-study research participants will be assessed using the 
NCI Common Toxicity Criteria Version 3.0.  The specific criteria for adverse event 
monitoring are noted in APPENDIX C. 
7.2 GVHD scoring (acute and chronic) will be evaluated and graded using the criteria found 
in APPENDIX B of this protocol. 
7.3 Performance status will be assessed by Karnofsky/Lansky Performance Scores (age-
dependent) (see APPENDIX A). 
7.4 Hematologic recovery post-transplant will be determined using the engraftment criteria as 
follows:  
(1) Neutrophil engraftment is defined as absolute neutrophil count (ANC) recovery of ≥ 
0.5 x 109/L (500/mm3) for three consecutive laboratory values obtained on different 
days. Date of engraftment is the date of the first of the three consecutive laboratory 
values. 
(2) Platelet engraftment will be defined as platelet count ≥ 20,000/mm3 for three consecutive 
laboratory values obtained on different days with no platelet transfusions in the 
preceding 7 days.  Date of engraftment is the date of the first of the three consecutive 
laboratory values. 
7.5 Primary graft failure will be defined as an ANC never meeting or exceeding 500/mm3 for 
3 consecutive measurements after day +42 post-transplant. 
7.6 Secondary graft failure or graft rejection will be defined as no evidence of donor chimerism 
by UCB and/or haploidentical donor (<10%), or too few cells to perform adequate 
chimerism analysis, in research participants with prior engraftment. 
7.7 Mixed hematopoietic chimerism will be defined as between 10% and 95% donor 
chimerism in the absence of immunosuppressive therapy. 
 
 


HAPCORD 36 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
8.0 CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY 
CRITERIA 
8.1 Recipient Off-therapy Criteria – Recipient participants may remain on-study, but 
considered off therapy, for monitoring if one of the following occurs (off therapy 
participants monitored for disease status and survival only): 
8.1.1 Experiences graft failure/rejection. 
8.1.2 Noncompliance with the protocol. 
8.1.3 Positive pregnancy test after the HSC infusions. 
8.1.4 Recipient requires an additional HSC infusion, and unable to receive these cells 
due to donor issues. 
8.1.5 Physician decides that it is in the best medical interest of the participant. 
8.2 Recipient Off-study Criteria: Recipient participants will remain on study until one of the 
following occurs: 
8.2.1  Withdrawal of consent. 
8.2.2  Death. 
8.2.3  Lost to follow-up. 
8.2.4  Requires an additional transplant procedure using a different allogeneic donor. 
8.2.5 Requires enrollment on another therapeutic study or non-protocol therapy for 
disease. 
8.2.6  Study evaluations are complete (i.e. has completed the month 12 post-HSC 
infusion evaluations, and first annual post-transplant evaluation). 
8.2.7  Development of a significant change in health status at any point of therapy, 
which would render receipt of the transplantation procedure or continuation in the 
study no longer in the participant’s best interest. 
8.2.8 Unable to undergo the primary HCT procedure due to donor and/or donor center 
inability to provide the HSC product. 
8.3 Donor Off-study Criteria: Donor participants will remain on-study until one of the 
following occurs: 
8.3.1 Withdrawal of consent. 
8.3.2 Death. 
8.3.3 Development of a significant change in health status at any point of therapy, 
which would render the donor medically ineligible to serve (or continue to serve) 
as donor; or renders the donor’s continuation in the study no longer in his/her best 
interest. 
8.3.4 Date of corresponding recipient’s off-study date. 
 
 
 
 


HAPCORD 37 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
9.0 SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS 
9.1 Reporting adverse experiences and deaths 
The following definitions apply: 
Serious event – any event, in which the outcome is fatal or life-threatening, results in 
permanent disability, causes inpatient hospitalization or prolongs existing hospitalization, 
or is a congenital anomaly, cancer, or overdose. 
Unanticipated adverse event – any event, not identified in their nature, severity, or 
frequency in the current risk documents (e.g., investigator’s brochure), or consistent with 
the investigational plan. 
9.2 Reporting to St. Jude Institutional Review Board (IRB) 
Principal investigators are responsible for promptly reporting to the IRB any adverse 
events that are unanticipated, serious, and that may represent potential harm or increased 
risk to research participants.  When an unanticipated death occurs, the PI should report it 
to the Director of Human Subject’s Protection immediately, by phone: (901) 595-4359, 
cell: (901) 336-2894, fax: (901) 595-4361, or e-mail: hsp-1@stjude.org.  A reportable 
event entry into TRACKS should follow within 48 hours of notification of the event. 
Serious, unanticipated, and related or possibly related events must be reported within 10 
working days of notification of the event.  At the same time, the investigator will notify 
the study sponsor and/or the FDA, as appropriate.  All other SAEs and captured AEs will 
be reported to the IRB in the continuing review, with the following exceptions: 
 Any grade III-IV infusion reactions will be reported as soon as possible but every 
effort should be made to assure reporting is no more than within 7 business days 
of the event. 
 Any episodes of overall grade III or IV acute GVHD in participants will be 
reported to the IRB as soon as possible but no more than within approximately 10 
days of the PI’s confirmation of the diagnosis/grade of the event. 
 Clinical diagnosis of PTLPD will be reported to the IRB as soon as possible but 
no more than within 10 days of the PI’s determination of the disorder. 
The principal investigator is responsible for reviewing the aggregate toxicity reports and 
reporting to the IRB if the frequency or severity of serious toxicities exceed those 
expected as defined in the protocol or based on clinical experience or the published 
literature.  Any proposed changes in the consent form or research procedures resulting 
from the report are to be prepared by the study team and submitted with the report to the 
IRB for approval. 
Recipient participants will be followed for NCI Grade III-V, and clinically significant I-
II, adverse events from the start of conditioning and throughout the first year post HCT, 
regardless of their relationship to the treatment given.  However, all GVHD events will 
be captured on an ongoing basis regardless of stage or grade. 
Haploidentical donor participants will be followed for any serious AE (SAE) and any 
clinically significant AEs (per judgment of PI) that are deemed related to the mobilization 
and/or apheresis procedure from the time of initiation of mobilization growth factors to 7-


HAPCORD 38 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
days post last day of the apheresis procedure.  If the transplant recipient requires a second 
HSC infusion, meaning that the donor is required to undergo the mobilization and 
apheresis procedure again, collection of this donor safety data will restart upon the 
initiation of the subsequent mobilization procedure and continue until 7-days post the last 
day of this apheresis procedure. Timelines for reporting of these donor events to the 
institutional and federal governing agencies will be according to the same timelines noted 
in the following sections. A listing of the captured donor safety data will be provided in a 
separate table from the transplant recipients within each respective continuing review 
report.  Continuing review reports to all regulatory authorities will be structured in a 
manner so that any infusion toxicities or stem cell product related variances will be 
reported in separate listings from all other required elements. 
9.3 Reporting to St. Jude Institutional Biosafety Committee (IBC) 
Continuing review reports will be sent to the IBC on at least an annual basis using the 
most current version of the continuing review form found on the IBC website. The safety 
reports, sent to the IRB for both the donors and stem cell recipients, will be 
simultaneously forwarded to the IBC. Therefore, reporting for safety events to this 
committee will be according to the same timelines as reporting to the IRB.  This includes 
notification of achievement of MTD (if/when applicable).  As per the direction of the 
IBC, only those protocol revisions and amendments directly related to the CliniMACS 
processing and related reagent(s) will require review and consideration by the IBC.  
Other revisions/amendments will be noted in the IBC continuing review report. 
9.4 Reporting to FDA  
The FDA will be notified in writing (IDE safety report) of any serious and unexpected 
AE associated with an investigational treatment or device; or any results from laboratory 
animal tests that suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity. 
Each notification to the FDA should be made as soon as possible and no later than 15 
calendar days after the sponsor’s initial receipt of the information. The FDA may 
require additional data to be submitted.  In each written IND safety report, the sponsor 
shall identify all safety reports previously filed with the IND concerning a similar adverse 
experience, and shall analyze the significance of the adverse experience in light of the 
previous, similar reports where applicable. 
The sponsor shall also notify the FDA by telephone or by facsimile transmission of any 
unexpected fatal or life-threatening experience associated with the use of the 
investigational medication as soon as possible but no later than 7 calendar days after the 
sponsor’s initial receipt of the information.  Any grade III-IV infusion reactions will be 
reported as soon as possible but every effort should be made to assure reporting is no 
more than within 7 business days of the event.  Follow-up information to a safety 
report must be submitted as soon as the relevant information is available. 
If the results of further investigation show an AE that was not initially determined to be 
reportable should later be deemed reportable, the sponsor shall inform the FDA of the 
event in a written safety report as soon as possible, but no later than 15 calendar days 
after the determination is made.  Results of the investigation of other safety information 


HAPCORD 39 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
shall be submitted, as appropriate, in an information amendment or annual report.  
Continuing review reports, which will include the up-to-date clinical and safety data, will 
be submitted to the FDA at least annually. 
9.5 Reporting to St. Jude Office of Regulatory Affairs 
Copies of all correspondence to the St. Jude IRB, including SAE reports are provided to 
the St. Jude Regulatory Affairs Office. All FDA related correspondence and reporting 
will be conducted through the Regulatory Affairs Office. Adverse event reporting and 
annual reporting will be in accord with the FDA Title 21 CFR312.32 and Title 21 
CFR312.33, respectively. The Regulatory Affairs Office can be reached at 901-595-2347 
(secondary contact: St. Jude Vice President of Clinical Trials Administration 901-595-
2876). 
9.6 Continuing review reports 
Continuing review reports of protocol progress and summaries of adverse events will be 
filed with the St. Jude IRB, and IBC at least annually. 
9.7 Reporting to the St. Jude Data Safety Monitoring Board 
This study has been referred to the St. Jude Data and Safety Monitoring Board (DSMB) 
for regular monitoring.  The DSMB is charged with advising the Director and other 
senior leaders of St. Jude on the safety of clinical protocols being conducted by St. Jude 
investigators and on their continuing scientific validity.  DSMB monitoring and review 
for this study will be conducted in accordance with the NCI guidance for DSMBs on an 
approximate semiannual basis.  The St. Jude DSMB is responsible for ongoing review of 
the protocol and related information such as enrollment, issues related to participant 
safety (specifically toxicities and the risk:benefit ratio of the trial), interim analyses, and 
the overall study conduct necessary to accomplish the primary protocol objectives.  This 
includes evaluation of the accrual rate, adherence to the study design, outcome measures, 
and review of protocol related primary outcome data. The PI will meet with DSMB 
during the semiannual visits to review the information submitted and discuss the status of 
the protocol.  The DSMB may recommend that the trial be modified, suspended to 
accrual, and/or stopped based on their review.   
9.8 Data submission to Miltenyi Biotec 
Clinical and safety related data will be provided to Miltenyi Biotec, the manufacturer of 
the CliniMACS system. Data will include but is not limited to the transplant research 
participant’s age and diagnosis, donor product(s) related information including donor 
type, the stem cell mobilization, selection, and infusion procedure. Outcome data 
including lymphohematopoietic reconstitution, immunological response, disease response 
and transplant complications will be shared with Miltenyi Biotec.  Representatives from 
Miltenyi Biotec will be able to review the participant’s (donor and transplant research 
recipient) laboratory and medical record for data verification purposes.  Copies of all 
reports to the institutional and governing regulatory bodies will also be accessible upon 
request.  In the event that the protocol is placed on a clinical hold by the PI or governing 
regulatory authorities, representatives from Miltenyi Biotec will be notified as soon as 
possible. 
 
 


HAPCORD 40 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
9.9 Reporting to the Center for International Blood and Marrow Transplant Research  
The Transplant Program at St. Jude is required by the federal government to report 
transplant information to the Center for International Blood and Marrow Transplant 
Research (CIBMTR). The CIBMTR is a research partnership of the International Bone 
Marrow Transplant Registry, the National Marrow Donor Program (NMDP), and the 
Foundation for the Accreditation of Cellular Therapy (FACT).  This organization is 
responsible for the collection and maintenance of a standardized data warehouse registry 
of autologous and all allogeneic (related and unrelated donor) transplants performed in 
the United States. 
The Office of General Counsel, U.S. Department of Health and Human Services, had 
deemed the CIBMTR not a covered entity under the Privacy Rule (45 CFR 164.512), 45 
CFR Parts 160 and 164, and the Health Insurance Portability and Accountability Act 
(HIPPA) of 1996.  For this reason, the submission and disclosure of certain protected 
health information (PHI), including that required for CIBMTR, is allowable without the 
individual’s authorization (i.e. consent is waived) when such disclosure is made to public 
health authorities authorized by law for the purpose of preventing or controlling disease, 
injury, or disability. 
Data resulting from this transplant procedure will be sent for general registry purposes to 
comply with the federal government requirements.  This information for both donor and 
recipient is submitted using a unique participant identification number.  The information 
submitted for haploidentical recipients is less extensive than recipients of other donor 
products.  For this reason, variables submitted may include but are not limited to the 
transplant recipient’s date of birth, country/state of current residence, diagnosis, basic 
lympho-hematopoietic reconstitution (e.g. date of ANC and platelet engraftment), post-
HCT disease status, and basic AEs (e.g. GVHD- yes or no), survival status, date/cause of 
death. 
10.0 DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY 
10.1  Data collection 
The St. Jude Cancer Center Clinical Research Associates assigned to the Department of 
BMTCT will assure protocol compliance, and conduct all clinical and safety data 
collection. Data will be entered into an institutional database. The PI will be responsible 
for review of data for accuracy and completeness once entered into the secure 
departmental database. 
10.2  Study monitoring 
This protocol will be monitored for safety and data as per the St. Jude Data and Safety 
Monitoring Plan for Clinical Trials approved by the NCI in 2010, and is considered to be 
in the High Risk III category. The Central Protocol and Data Monitoring Office 
(CPDMO) will verify 100% of the informed consent documentation on all participants 
and verify 100% of St. Jude participants’ eligibility status.  The study team will meet at 
appropriate intervals to review case histories and data quality summaries on all 
participants.  The St. Jude Clinical Research Monitor will assess protocol and regulatory 
compliance as well as the accuracy and completeness of all data points for the first two 
participants enrolled, then 15% of study enrollees every six months.  The protocol will be 


HAPCORD 41 
 
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tracked continuously for the accrual of donors and recipients.  All AE and SAE reports 
will be reviewed by the study Principal Investigator for type, grade, attribution, duration, 
timeliness and appropriateness on all study participants.  All SAE reports will be 
reviewed by the monitor every 6 months.    
Protocol compliance monitoring will include participant status, eligibility, the informed 
consent process, demographics, staging, study objectives, subgroup assignment, 
treatments, evaluations, responses, participant protocol status, off-study, and off-therapy 
criteria.  The Monitor will generate a formal report which is shared with the Principal 
Investigator (PI), study team and the Internal Monitoring Committee (IMC).  Monitoring 
may be conducted more frequently if deemed necessary by the CPDMO or the 
IMC.  Continuing reviews by the IRB and CT-SRC will occur at least annually.  In 
addition, SAE reports in TRACKS (Total Research and Knowledge System) are reviewed 
in a timely manner by the IRB.  The Regulatory Affairs Office will assist the PI in 
reporting to the FDA and other external oversight agencies, as necessary. 
10.3 Confidentiality 
Unique participant numbers will be used in place of an identifier such as a medical record 
number when reporting any data to outside agencies.  No research participant names will 
be recorded on the data collection forms.  The list containing the unique participant 
numbers and the medical record number will be maintained in a locked file accessible 
only to the study team. 
The medical records of study participants may be reviewed by the St. Jude IRB, FDA, 
clinical research monitors, etc. 
11.0 STATISTICAL CONSIDERATIONS 
11.1 Statistical design and analysis for the primary objectives and stopping rules 
This study is designed as a phase II study. The primary objective of this study is to 
evaluate the rate of engraftment by day +42.  Engraftment for the purposes of this 
objective will be as defined in section 7. 
As detailed in section 2, the use of alternative donors such as haploidentical donors and 
unrelated UCB are frequently needed and largely successful.  However, the use of these 
alternative donors is typically complicated with additional problems, particularly poor 
hematopoietic recovery and graft failure.126    
The majority of published experience with alternative (HLA-mismatched) donor 
transplantation in children is with UCB grafts.  The COBALT study included 191 
children with hematologic malignancies who received UCB transplantation with TBI 
based (1350Gy) myeloablative conditioning.59 The cumulative incidence of neutrophil 
engraftment by day 42 was 80%.  The New York Blood Center published outcomes on 
1061 patients (78% pediatric) with hematologic malignancies who received 
myeloablative UCBT with units from their bank.62 The cumulative incidence of 
neutrophil engraftment was 74% by day 77.  The CIBMTR published a comparison of 
UCB transplantation with HLA-matched unrelated donor transplantation, in which 503 
children with acute leukemia received UCBT.16 They confirmed that although the 
leukemia-free survival was similar, the rate of neutrophil engraftment (and TRM) were 
significantly worse with HLA-mismatched UCB grafts than with HLA-matched BM 


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grafts.  For UCB recipients, the best engraftment was obtained in the rare 6/6 matched 
UCB recipients with 85% of the 35 patients achieving neutrophil recovery at day +42.  In 
addition, recipients who received a single antigen mismatch UCB unit with an 
appropriately high cell dose (n=154) had a neutrophil engraftment rate of 80% at day 
+42.  Recipients of lower cell dose or two antigen mismatch units fared worse. 
Given the data, we consider a rate of successful engraftment of less than 80% by day +42 
to be unacceptable for alternative donor transplantation.  The goal of our study is to 
develop a novel preparative regimen to facilitate successful engraftment of donor graft(s) 
at a rate of ≥91%.  We do not anticipate censoring during the 42 day time period and we 
can approximate the rate of engraftment by day +42 using a Binomial distribution. In 
order to keep the validity of Binomial distribution approximation, patients lost for follow 
up will be counted as a failure to engraft. Therefore, in this study, we propose to test the 
null hypothesis H0: P≤0.80 versus H1: P>0.80, where P is the proportion of research 
participants who engrafted by day +42 after HCT. With type I error of 10% and type II 
error of 20%, Simon’s two stage optimum design powered at alternative successful 
engraftment rate P1=0.91 requires 21 evaluable patients at the first stage and 49 evaluable 
patients in total76. The stopping rules are provided in Table 1, with the understanding that 
stopping the trial early would be suggestive of the proposed transplant strategy not being 
an effective treatment option for this group of patients. The interpretation is that if we 
observe 17 or fewer participants engrafted by day +42 in the first 21 participants, then we 
would stop the trial for lack of efficacy. However, if we observe 18 or more patients 
engrafted in the first 21 participants by day +42 in stage one, then 28 more patients will 
be enrolled in stage two. If we observe 43 or more participants engrafted by day +42 
upon completion of the trial, then we conclude that the true rate of  engraftment is at least 
80% and our novel regimen will be proposed for further development and phase III 
clinical trial.  
Table 1: Stopping rules for lack of efficacy based on the Simon’s 2-stage optimum 
design (unacceptable low rate of successful engraftment by day +42)  
Accept H0 if the number of research participants engrafted 
P0 
P1 
(≤ r1/n1 ) 
(≤ r/n ) 
EN(P0) 
PET(P0) 
0.80 
0.91 
17/21 
42/49 
31 
0.63 
Note: r1 and r denote the number of patients successfully engrafted by day +42; EN(P0) 
denotes the expected sample size under P0; PET(P0) denotes the probability of early 
termination at stage I under P0.  
All participants who receive the prescribed transplant will be evaluable for the primary 
outcome. In addition, any patient who starts the conditioning regimen but stops prior to 
receiving the graft will count as a failure, if the reason for stopping therapy is toxicity 
from the conditioning regimen.  Patients who enroll but do not initiate treatment due to 
withdraw of patient, withdraw of donor or health status change to make the treatment not 
in the patient’s best medical interest, etc., will be replaced.  Any patient who dies from 
toxicity after engraftment but before day +42 will count as having engrafted.  Any patient 
who dies prior to engraftment will count as a graft failure.   


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After the study is finished, for the first primary objective, the rate of engraftment by day 
+42 and its 95% Blyth-Still-Casella confidence interval will be estimated based on the 
binomial approximation.  
Table 2 shows the number of haploidentical HCT and the estimated number of KIR 
mismatch cases performed at our institution in last 5 years. With the initiation of UCB 
protocols at SJCRH, the number of referrals for patients requiring alternative donor HCT 
has increased.  Furthermore, HAPCORD will be a high priority protocol. Based on this 
table and PI’s estimation, it is expected that approximately 10 patients per year will be 
enrolled in this study.  Therefore, the expected accrual period for this study is maximally 
5 years.  
Table 2: The number of haploidentical HCT performed at St. Jude 2007 to 2012 
Year 
2007 
2008 
2009 
2010 
2011 
2012 
Number haploidentical HCT  
20 
17 
22 
19 
24 
22 
Estimated KIR mismatch 
14 
12 
15 
13 
17 
15 
Estimated KIR matched  
6 
5 
7 
6 
7 
7 
Number of UCBT 
3 
2 
0 
0 
2 
8 
Stopping Rules for Toxicities  
In addition to the stopping rules based on successful engraftment, we will closely monitor 
the trial for early excessive toxicities in terms of severe acute GVHD and therapy related 
death. Therapy related death is any death in remission and related to protocol therapy.  
The incidence of acute GVHD and transplant related deaths will be monitored for 100 
days from the date of transplantation for application of the stopping rules. Toxicities 
secondary to non-protocol therapy for post-transplant persistent or recurrent disease will 
not count towards the toxicity stopping rules. The safety endpoints will be monitored 
independently and a consideration to stopping the trial would be given if there is evidence 
suggesting that the rate of grades 3-4 acute GVHD is greater than 20%, or the rate of 
transplant related death is greater than 10%. Then, the planned interim evaluation time 
points and stopping rules, using group sequential design based on Pocock stopping 
boundaries after considering five interim analyses (p-value threshold = 0.0158) to ensure 
an overall type one error of 0.05127-129, for each of the two endpoints are provided in 
Tables 3 and 4:   
Table 3. Stopping Rules for Toxicities Based on Grades 3-4 aGVHD within the First 
100 Days Post-transplant  
No of of Research Participants Enrolled 
No. of Grades 3-4 aGVHD Observed 
≤ 11 
≥ 6 
≤ 21 
≥ 9 
≤ 31 
≥ 12 
≤ 41 
≥ 15 
≤ 49 
≥ 17 
 


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Table 4. Stopping Rules for Toxicities Based on Therapy Related Death within the 
first 100 days Post-transplant 
No. of Research Participants Enrolled   
No. of Therapy Related Death Observed  
≤ 11 
≥ 5 
≤ 21 
≥ 6 
≤ 31 
≥ 8 
≤ 41 
≥ 10 
≤ 49 
≥ 11 
Based on the above Table 3, if six grades 3-4 acute GVHD occur within the first 100 days 
post transplantation in the first eleven evaluable research participants treated, then a 
consideration will be given to temporarily stopping the trial and amending the study to 
include additional pharmacologic GVHD prophylaxis. Similarly, from Table 4 if we 
observe five deaths related to therapy within the first 100 days after transplantation in the 
first eleven evaluable research participants treated, then a consideration will be given to 
temporarily stopping the trial and amending the study appropriately.    
11.2 Statistical analysis for secondary objectives  
11.2.1  Estimate the incidence of malignant relapse, EFS and OS at one-year post-
transplantation 
The estimate of cumulative incidence of relapse will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The analysis will 
be implemented using SAS macro (bmacro252-Excel2007\cin) available in the St. 
Jude Department of Biostatistics. The Kaplan-Meier estimate of OS and EFS with 
relapse, death due to any cause and graft failure as events along with their 
standard errors will be calculated using the SAS macro (bmacro251-
Excel2007\kme) available in the Department of Biostatistics at St. Jude, where 
OS = min (date of last follow-up, date of death) – date of HCT and all participants 
surviving after 1 year post-transplant will be considered as censored, and EFS = 
min (date of last follow-up, date of relapse, date of graft failure, date of death due 
to any cause) – date of transplant, and all participants surviving at the time of 
analysis without events will be censored. The analysis for this objective will be 
performed when the last evaluable participant has been followed for one-year post 
transplant.    
11.2.2  Estimate the incidence and severity of acute and chronic GVHD 
The cumulative incidence of acute and chronic GVHD will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The SAS macro 
(bmacro252-Excel2007\cin) available in the Department of Biostatistics at St. 
Jude will be used for such analysis. The severity of acute GVHD and chronic 
GVHD will be described. The analysis for this objective will be performed when 
the last evaluable participant has been followed for 100 days post transplant.   
11.2.3 Estimate the rate of TRM in the first 100 days after HCT. 
The cumulative incidence of TRM will be estimated using the same method as 
used in evaluating Objective 10.2.2. Deaths before day 100 because of other 
reasons are the competing risk events. The analysis for this objective will be 


HAPCORD 45 
 
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performed when the last evaluable participant has been followed for 100 days post 
transplant. 
11.3 Analysis for exploratory objectives  
The final results of these exploratory objectives are expected to be available when 
the last evaluable participant has been followed for one-year post transplant. 
11.3.1  Assess the relationship between pre-transplant MRD with transplant outcomes. 
The relationship of pre-transplant MRD and transplant outcomes will be 
examined through Cox proportional hazard model or generalized linear model. 
The model can also be used to adjust for other confounding factors such as 
patient’s age at transplant. 
11.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) analysis, 
V-beta spectratyping, and phenotype and functional analysis of reconstituted 
lymphocyte subsets.  All immune reconstitution measures will be descriptively 
analyzed. 
11.3.3 Characterize the recovery of Gamma Delta T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  All Gamma Delta T cell 
measures will be descriptively analyzed. 
11.3.4 Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  All Influenza infection 
monitoring will be descriptively analyzed. 
12.0 OBTAINING INFORMED CONSENT 
The ongoing informed consent process will be carried out per the policies and procedures put 
forth in the St. Jude Investigator’s Handbook for Clinical Research (http://home.web.stjude. 
org/clinical_research/administration/doc/handbook.pdf).  The PI or physician sub-
investigator will conduct the signature authorization portion of the consent process.   
12.1 Informed consent prior to research interventions 
For protocol required research interventions (research samples for baseline immune 
reconstitution evaluation); informed consent must be obtained prior to performing these 
research interventions. 
12.2 Consent at age of majority 
The age of majority in the state of Tennessee is 18 years old.  Research participants must 
be consented at the next St. Jude clinic visit after their 18th birthday, and prior to 
performing any research interventions during that visit.   
12.3 Consent when English is not the primary language 
When English is not the patient, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter.  This 
information will be documented in the participant’s medical record.  Either a certified 
interpreter or the telephone interpreter’s service will be used to translate the consent 
information.  The process for obtaining an interpreter and for the use of an interpreter is 
outlined on the Interpreter Services, OHSP, and CPDMO websites. 
  


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HAPCORD 49 
 
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IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
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IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
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HAPCORD 51 
 
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IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
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HAPCORD 52 
 
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Protocol document date: 02/10/14 
 
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HAPCORD 53 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX A: 
PERFORMANCE STATUS SCALE 
KARNOFSKY PERFORMANCE STATUS SCALE 
Score General Description 
100 
Normal. No complaints. No evidence of disease. 
90 
Able to carry on normal activity. Minor signs or symptoms of disease. 
80 
Normal activity with effort. Some signs or symptoms of disease. 
70 
Care of self.  Unable to carry out normal activity or to do active work. 
60 
Requires occasional assistance, but is able to care for most of his needs. 
50 
Requires considerable assistance and frequent medical care. 
40 
Disabled.  Requires special care and assistance. 
30 
Severely disabled. Hospitalization is indicated although death is not imminent. 
20 
Hospitalization necessary, very sick, active support treatment necessary. 
10 
Moribund. Fatal processes progressing rapidly. 
0 
Dead. 
 
 
LANSKY PERFORMANCE STATUS SCALE 
Score  General Description 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both greater restriction of and less time spent in play activity 
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 but able to participate in 
all quiet play and 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 
No play; does not get out of bed 
0 
Unresponsive 


HAPCORD 54 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX B 
Criteria for Acute GVHD 
ORGAN STAGING FOR ACUTE GVHD 
Organ 
Stage 0 
Stage 1 
Stage 2 
Stage 3 
Stage 4 
Skin 
No rash 
 
 
Rash < 25% a 
 
 
Rash 
25 
< 
50% 
 
Rash 
>50% 
generalized 
erythroderma 
Plus bullae and 
desquamation 
 
Gastrointestinal 
Lower 
Diarrhea 
<500 
mL/day 
Diarrhea 
501 to 1000 
mL/dayc 
Diarrhea 
1001 to 1500 
mL/day 
Diarrhea 
>1500 
mL/day 
Severe abdominal 
pain 
with 
or 
without ileus 
Upper 
^ 
Persistent 
nausead 
^ 
^ 
^ 
Liver 
Bilirubin 
<2.0 
mg/dl 
Bilirubin 
2.1 
to 
3.0 
mg/dlb 
Bilirubin 
3.1 
to 
6.0 
mg/dlb 
Bilirubin 
>6.1 
to 
15 
mg/dlb 
Bilirubin 
> 15 mg/dl 
 
OVERALL GRADING FOR ACUTE GVHD 
Grade 
Skin 
Liver 
Gut 
I 
Stage 1-2 
None 
None 
II 
Stage 3 or 
Stage 1 or 
Stage 1 
III 
- 
Stage 2-3 or 
Stage 2-4 
IVf 
Stage 4 or 
Stage 4 
- 
 
a.  Use rule of Nines” or burn chart to determine extent of rash. 
b. Range given as total bilirubin. Downgrade one stage if additional cause of elevated bilirubin is documented. 
c. Volume of diarrhea applies to adults.  For pediatric patients, the volume of diarrhea should be based on body surface area. Downgrade 
one stage if additional cause of diarrhea has been documented. 
d. Persistent nausea with histological evidence of GVHD in stomach or duodenum. 
e. Criteria for grading given as minimum degree of organ involvement required conferring that grade. 
f. Grade IV may also include lesser organ involvement but with extreme decrease in performance status. 


HAPCORD 55 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
Complete weekly 
 DATE: ________ 
Score 0 
Score 1 
Score 2 
Score 3 
PERFORMANCE 
SCORE 
_________________ 
KPS  ECOG  LPS 
Asymptomatic 
and 
fully 
active (ECOG 
0: 
KPS 
or 
LPS 100%) 
 Symptomatic, fully 
ambulatory, restricted 
only 
in 
physically 
strenuous 
activity 
(ECOG 1, KPS or 
LPS 80-90%) 
 Symptomatic, 
ambulatory, 
capable of self-
care, 
>50% 
of 
waking hours out 
of bed (ECOG 2, 
KPS or LPS 60-
70%) 
 Symptomatic 
limited 
self-care, 
>50% 
of 
waking hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN 
Clinical features: 
Maculopapular rash 
Lichen planus-like  
Papuloquamous 
lesions or ichthyosis 
Hyperpigmentation 
Hypopigmentaion 
Keratosis pilaris 
Erythema 
Erythroderma 
Poikiloderma 
Sclerotic features 
Pruritus 
Hair involvement 
Nail involvement 
% BSA Involved  
 No symptoms 
 <18% 
BSA 
with 
disease signs but NO 
sclerotic features 
 ≥19-50% 
BSA 
OR involvement 
with 
superficial 
sclerotic features 
“not 
hidebound” 
(able to pinch) 
 >50% BSA OR deep 
sclerotic 
features 
“hidebound” (unable to 
pinch) 
OR 
impaired 
mobility, ulceration or 
severe pruritus 
MOUTH 
No symptoms 
 Mild symptoms with 
disease 
signs 
but 
NOT limiting oral 
intake significantly 
 Moderate 
symptoms 
with 
disease 
signs 
WITH 
partial 
limitation of oral 
intake 
 Severe symptoms with 
disease 
signs 
on 
examination 
WITH 
major limitation of oral 
intake 
EYES 
 
  Mean tear test (mm): 
  >10 
  6-10 
  ≥5 
  Not done 
No symptoms 
 Mild 
dry 
eye 
symptoms 
not 
affecting 
ADL 
(requiring eye drops 
<3 x per day) OR 
asymptomatic 
signs 
of 
keratoconjunctivitis 
sicca 
 Moderate dry eye 
symptoms 
partially affecting 
ADL 
(requiring 
drops >3x per day 
or 
punctual 
plugs), 
WITHOUT 
vision impairment 
 Severe 
dry 
eye 
symptoms significantly 
affecting ADL (special 
eyeware to relieve pain) 
OR unable to work due 
to ocular symptoms OR 
loss of vision cause by 
keratoconjunctivitis 
sicca 
GI 
No symptoms 
 Symptoms such as 
dysphagia, anorexia, 
abdominal 
pain, 
nausea, vomiting, or 
diarrhea 
w/o 
significant 
weight 
loss (<5%) 
 Symptoms 
associated 
with 
mild to moderate 
weight loss   
(5-15%) 
 Symptoms associated 
with significant weight 
loss > 15%, requires 
nutritional 
supplement 
for most calorie needs 
OR esophageal dilation 
LIVER 
 Normal LFT 
 Elevated Bilirubin, 
AP*, AST or ALT <2 
x ULN 
 Bilirubin >3 mg/dl 
or 
Bilirubin, 
enzymes 
2-3 
x 
ULN 
 Bilirubin or enzymes > 
5 x ULN 
 


HAPCORD 56 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
 
SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
LUNGS† 
 
FEV1 ______ 
DLCO ______ 
 No symptoms 
 
 
 
 FEV1 >80% OR 
LFS=2 
 Mild 
symptoms 
(shortness of breath 
after 
climbing 
one 
flight of steps) 
 FEV1 60-79%  
OR LFS 3-5 
 Moderate symptoms 
(shortness of breath 
after walking on flat 
ground) 
 FEV1 40-59% OR 
LFS 6-9 
 Severe 
symptoms 
(shortness of breath at 
rest; requiring 02 
 
 FEV1 ≥39% OR 
LFS 10-12 
JOINTS 
AND 
FASCIA 
 No symptoms 
 Mild tightness of arms 
or legs, normal or mild 
decreased 
range 
of 
motion (ROM) AND 
not affecting ADL 
 Tightness of arms or 
legs 
OR 
joint 
contractures, erythema 
thought due to fasciitis, 
moderate 
decrease 
ROM AND mild to 
moderate limitation of 
ADL 
Contractures 
WITH 
significant decrease or 
ROM AND significant 
limitation 
of 
ADL 
(unable 
to 
tie 
shoes, 
button shirts, dress self 
etc.) 
GENITAL 
TRACT 
 No symptoms 
 Symptomatic 
with 
mild signs on exam 
AND no effect on 
coitus 
and 
minimal 
discomfort 
with 
gynecologic exam 
 Symptomatic 
with 
moderate 
signs 
on 
exam AND with mild 
dyspareunia 
or 
discomfort 
with 
gynecologic exam 
 Symptomatic 
WITH 
advance signs (stricture, 
labial agglutination or 
severe ulcerations AND 
severe pain with coitus or 
inability it insert vaginal 
speculum 
Other indicators, clinical manifestations or complications related to chronic GVHD (check all that apply and assign a 
score to its severity (0-3) based on its functional impact where applicable (none = 0, mild = 1, moderate =2, severe = 3. 
Esophageal stricture or web ______ 
Pericardial Effusion  _______________Pleural Effusion(s) ________________________ 
Ascites (serositis) ________________ Nephrotic syndrome _____________ 
Peripheral Neuropathy _____________________ 
Myasthenia Gravis ______________ 
Cardiomyopathy ________________ Eosinophilia > 500/µl _____________________ 
Polymyositis  ____________________ Cardiac conduction defects _________ Coronary artery involvement ________________ 
Platelets <100,000/µl _____________ Progressive Onset  ________________ Other: Specify:__________________________ 
 Organ scoring of chronic GVHD. 
AP may be elevated in growing children, and not reflective of liver dysfunction.    
† Pulmonary scoring should be performed using both the symptom and PFT scale whenever possible. When discrepancy exists 
between pulmonary symptoms or PFT scores, the higher value should be used for final scoring. Scoring using the  LFS  is 
preferred, but if DLCO is not available, grading using FEV1 should be used.  The LFS is a global assessment of lung function 
after the diagnosis of bronchiolitis obliterans has already been established.   
The percent predicted FEV1 and DLCO (adjusted for HCT but not alveolar volume) should be converted to a numeric score as 
follows: >80% = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6.   
The LFS = FEV1 score + DLCO score, with a possible range of 2-12.   
 
PFT: Pulmonary Function Testing 
 
LFS, Lung Function Score 
 
GVHD, graft versus host disease 
ECOG, Eastern Cooperative Oncology Group 
KPS, Karnofsky Performance Status 
LPS, Lansky Performance Status 
BSA, body surface area 
 
 
ADL, activities of daily living 
LFTs, liver function tests 
AP, alkaline phosphatase 
 
 
ALT, alanine aminotransferase 
AST, aspartate aminotransferase 
ULN, upper limit of normal 
 
 


HAPCORD 57 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX B (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
GLOBAL GRADING OF CHRONIC GVHD84 
 
* 
Determined by adding the total number of organs receiving score > 0 using Figure 1, 
 
Appendix B. 
** 
Defined as the maximum score given to any organ system amongst all organs scored 
 
using Figure 1, Appendix B.  
Final Grade 
Number of 
Organs/Sites* 
Maximum Organ 
Score** 
Lung Score 
Mild 
1 - 2 
1 
0 
Moderate 
3 or more 
1 
1 
At least 1 
2 
Severe 
At least 1 
3 
2 - 3 


HAPCORD 58 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX C 
CRITERIA FOR ADVERSE EVENT (AE) EVALUATION AND REPORTING 
The St. Jude Department of BMTCT Clinical Research Office standard operating procedure for 
the documenting and reporting of adverse (SOP 10 Documenting and Reporting of Adverse 
Events) will provide guidance on the evaluation, collection and reporting of adverse events for 
this clinical trial.  The current version of this document, as well as ongoing updates, can be 
located at the following website: http://home.stjude.org/bmt/Pages/policies-research.aspx 
 


HAPCORD 59 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX D 
Recommended testing and evaluation schedule 
STANDARD OF 
CARE STUDIES 
SAMPLE 
VOLUME 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
Pregnancy test 
PB 
2 ml 
X 
As clinically indicated 
Physical exam 
N/A 
N/A 
X 
Weekly 
X 
X 
CBC with diff. 
PB 
0.5 - 2 ml 
X 
Daily until engrafted, then weekly 
X 
X 
Chemistry 
PB 
0.25- 2 ml 
X 
Weekly 
X 
X 
Viral surveillance 
(BMTPCR) 
PB 
4 ml 
X 
Weekly 
As clinically indicated 
Chimerism 
PB 
1-2 ml 
 
Weekly 
Monthly 
BM 
2 ml 
 
X 
 
X 
 
X 
Disease Status 
Evaluation 
BM 
N/A 
X 
X 
 
X 
 
X 
MRD 
PB 
5 ml 
X 
X 
 
X 
 
X 
BM 
0.2-5 ml 
X 
X 
 
X 
 
X 
Lymphocyte 
Subset Study 
PB 
2.5-4 ml 
X 
Monthly 
Quantitative 
Immunoglobulins 
PB 
2.0 ml 
X 
 
 
Every 3 months after off IVIG for minimum of one month 
 
The information derived from or noted on the physical examinations, standard tests, and other assessments that comprise standard of care for recipients are not required to 
be transcribed onto case report forms and/or entered into the database.  In reference to section 6.1 Evaluations, the above-indicated follow-up regimen for these evaluations 
is guided by the SOPs of the Department of BMTCT, for recipients of allogeneic stem cell transplantation.  As these evaluations are considered standard clinical care (non-
research), variations in frequency (more or less frequent) of these evaluations can occur due to the participant’s current clinical condition and will not be noted as protocol 
deviations. 
 
Disease status evaluations/BM testing results obtained prior to enrollment may be used for the baseline/pre-infusion assessments. 
 
 MRD PB required for T-Cell ALL only 
 
Lymphocyte subset studies may be omitted without variance when the absolute lymphocyte count (ALC) is zero. 
 
In the event of graft failure/rejection, the post failure/rejection time period BM, chimerism and several of the applicable immune studies will be held, as these 
blood/marrow tests would not be clinically indicated. 


HAPCORD 60 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX D (continued) 
Immune reconstitution testing and evaluation schedule for RECIPIENT 
RESEARCH 
STUDIES 
SAMPLE 
VOL. 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
LABORATORY 
LYMPHOCYTE 
PHENOTYPES 
RESEARCH 
PB 
17.0 ml 
X 
X 
X 
X 
X 
X 
LEUNG LAB 
VBETA/TREC 
RESEARCH 
PB 
17.0 ml 
X 
 
 
X 
X 
X 
LEUNG LAB 
HOST-DONOR 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
IR-PHENOTYPE 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
5 ml 
X 
X 
X 
X 
X 
X 
T-FUNCTION 
SKIN 
BIOPSY 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
PB – CMV+ 
7.5 ml 
 
WEEKLY x 4 DURING ACTIVE VIRAL REACTIVATION 
BM 
1ml 
X 
X 
 
X 
 
 
 
 
VBETA/TREC Research and Lymphocyte Phenotypes Research results will be maintained in a secured database in the Leung laboratory.  
 
HOST-DONOR, IR-PHENOTYPE, T-FUNCTION testing results will be maintained in a secured database in the Dallas laboratory database. 
 
T-FUNCTION testing in the presence of viral infection and/or reactivation will be obtained as directed above (weekly x4) within the first 100 days post-
transplant, however from Day 100 to Month 12 it will be obtained as possible (includes all viruses).  
 
Skin Biopsy for T-FUNCTION is an optional additional test that may be omitted at the discretion of the PI.  Skin Biopsy may be performed during sedation 
during procedures (i.e. radiation) or at Month 1 without a protocol variation.  
 
For RESEARCH studies, the posted volumes are the minimum volumes required to perform the respective protocol evaluations. 
 
 
 
 
 
 
 
 
 


HAPCORD 61 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
 
 
APPENDIX D (continued) 
Research testing for HAPLOIDENTICAL DONOR 
Prior to initial stem cell collection procedure: 
OPTIONAL research immune studies testing schedule 
Evaluation 
Volume Requirement 
Flow cytometry enumeration 
Lymphocyte Subset Study = 4 mL 
Thymic output and T cell repertoire 
VBETA/TREC Research = 17 mL 
T cell and NK cell number and function 
Lymphocyte Phenotypes Research = 17 mL 
 
 All donor research testing to be collected prior to stem cell collection – preferably prior to growth factor administration.  
These optional research tests may be collected at separate times. 


HAPCORD 62 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX D (continued) 
 
Research Study Evaluation Target Windows 
Several laboratory tests can only be processed on weekdays; therefore, if the scheduled 
evaluation falls on a weekend, or during a holiday period, an adjustment in the follow-up visit is 
expected and would not be noted as a protocol variation.  Additionally, in order to accommodate 
such logistical constraints, evaluation/collection dates of all protocol assessments (required and 
optional research), may be performed within a reasonable window of the intended date following 
the guidelines provided in the table below: 
If the Planned Evaluation 
Time Point is: 
Window 
Weekly 
+ 3 Days 
Month 1 
Week 2 to Week 6 
Month 2 
Week 7 to Week 11 
Month 3 
Week 12 to Month 4 
Month 6 
Month 5 to Month 7 
Month 9 
Month 8 to Month 10 
Month 12 
Month 10 to Month 14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 63 
 
Initial version, dated: 04/02/13 
 
IRB approval date: 02/26/2014  
Protocol document date: 02/10/14 
 
APPENDIX E 
The St. Jude Department of BMTCT Clinical SOPs for standard of care for all allogeneic stem 
cell infusion recipients and stem cell donors will provide guidance on the evaluation, ongoing 
clinical care and follow up for this clinical trial.  The current versions of these SOPs, as well as 
ongoing updates, of these documents can be located at the following website: 
http://home.web.stjude.org /bone_marrow/clinicalHome.shtml.    
 

Prot_SAP_002.pdf: 
Amendment 1.0, dated: 12/12/2014 
 
  
Protocol document date: 01/08/2016 
 
St. Jude Children's Research Hospital 
HAPCORD – NCT02199041 
Initial Version, dated: 04/02/13 Resubmitted to IRB 02/10/2014 (IRB Approved: 02/26/2014)  
Activated:  
Revision 0.1, dated: 08/22/14 (IRB Approved: 10/17/14) 
Activated: 12/09/2014 
Amendment 1.0, dated: 12/12/14 (IRB Approved: 05/04/16) 
Activated: 
  
COMBINED T CELL DEPLETED HAPLOIDENTICAL PERIPHERAL BLOOD STEM 
CELL AND UNRELATED UMBILICAL CORD BLOOD TRANSPLANTATION IN 
PATIENTS WITH HEMATOLOGIC MALIGNANCIES USING A TOTAL LYMPHOID 
IRRADIATION BASED PREPARATIVE REGIMEN 
 
IND: 16036  
 
Principal Investigator 
Mari Hashitate Dallas, MD1 
 
Sub-investigators 
Brandon Triplett, MD1 
Guolian Kang, PhD3  
Shane Cross, PharmD5 
Terrence Geiger, MD, PhD4 
Matthew J. Krasin, MD6 
John Choi, MD, PhD4 
Renee Madden, MD1 
Lea Cunningham, MD1 
Ashok Srinivasan, MD1 
Amr Qudeimat, MD1 
Paul Thomas, PhD7 
William Janssen, PhD1 
Ewelina Mamcarz, MD1 
Benjamin Youngblood, PhD7 
 
 
 
 
 
 
 
Department of Bone Marrow Transplantation and Cellular Therapy1 
Department of Oncology2 
Department of Biostatistics3 
Department of Pathology4 
Department of Pharmaceutical Sciences5 
Department of Radiological Sciences6 
Department of Immunology7 
 
St. Jude Children’s Research Hospital 
262 Danny Thomas Place 
Memphis, TN 38105 
(901) 595-3300 
This is a confidential research document. 
No information may be extracted without permission of the principal investigator


Amendment 1.0, dated: 12/12/2014 
 
  
Protocol document date: 01/08/2016 
 
COMMON ABREVIATIONS 
 
Absolute neutrophil count (ANC) 
Acute lymphocytic leukemia (ALL) 
Acute myeloid leukemia (AML) 
Adverse event (AE) 
Alanine aminotransferase (ALT) 
American 
Association 
of 
Blood 
Banks 
(AABB) 
Aspartate aminotransferase (AST) 
Body surface area (BSA) 
Bone marrow (BM) 
Bone marrow transplantation (BMT), 
Bone Marrow Transplantation Follow Up 
(BMTFU) 
Center for International Blood and Marrow 
Transplant Research (CIBMTR) 
Central Nervous System (CNS) 
Central Protocol and Data Monitoring Office 
(CPDMO) 
Chronic Myeloid Leukemia (CML) 
Clinical Data Update System (CDUS) 
Common toxicity criteria (CTC) 
Complete Remission (CR) 
Cord Blood Transplantation (COBLT) 
Creatinine Clearance (CrCL) 
Cyclosporine (CSA) 
Cytomegalovirus (CMV) 
Dimethyl sulfoxide (DMSO) 
Disease-free survival (DFS) 
Epstein-Barr 
virus 
transformed 
lymphoblastoid cell lines (EBV-LCL) 
Event-free survival (EFS) 
Forced vital capacity (FVC) 
Foundation for the Accreditation of Cellular 
Therapy (FACT) 
Graft versus host disease (GVHD) 
Granulocyte colony-stimulating factor (G-
CSF) 
Haploidentical 
HCT 
with 
NK 
infusion 
(HAPNK) 
Health Insurance Portability Act (HIPPA) 
Hematopoietic cell transplantation (HCT) 
Hematopoietic stem cell (HSC) 
Human Application Lab (HAL)  
Human Immunodeficiency Virus (HIV) 
Human leukocyte antigen (HLA) 
Human T-lymphotropic virus (HTLV)  
Institutional Biosafety Committee (IBC) 
Institutional Review Board (IRB) 
International Cord Blood Transplant Registry 
(ICBTR) 
Juvenile Myelomonocytic Leukemia (JMML) 
Killer-immunoglobulin receptors (KIR)  
Matched related/sibling donor (MSD) 
Matched unrelated donor (MURD)  
Minimal Residual Disease (MRD) 
Mycophenolate mofetil (MMF) 
Myeloid Dysplastic Syndrome (MDS) 
National Cancer Institute (NCI)  
National Marrow Donor Program (NMDP) 
Natural killer (NK) 
New York Blood Center (NYBC) 
Overall survival (OS) 
Pharmacokinetics (PK) 
Polymerase chain reaction (PCR) 
Protected health information (PHI) 
Pulmonary Function Testing (PFT) 
Reduced Intensity Conditioning (RIC) 
Shortening Fraction (SF) 
Standard operating procedures (SOP) 
T cell receptor excision circle (TREC) 
Total body irradiation (TBI) 
Total lymphoid irradiation (TLI) 
Total nucleated cell (TNC) 
Total Research and Knowledge System 
(TRACKS) 
Transplant related mortality (TRM) 
Umbilical cord blood (UCB) 
Umbilical 
cord 
blood 
transplantation 
(UCBT) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
TABLE OF CONTENTS 
 
Study Summary 
 
1.0 
Objectives…………………………………………………………….………… 1 
 
1.1 
Primary Objective.……………………………………………………..… 
1.2 
Secondary Objectives …………………………………………………… 
1.3 
Exploratory Objectives ……………..…………………………………… 
1 
1 
1 
2.0 
Background and Rationale……………………………………………………… 1  
 
2.1 
Overview………………………………………………………………… 
2.2 
Umbilical Cord Blood Transplantation……..…………………………… 
2.3 
Haploidentical HCT…………..………………………………………….. 
2.4 
Rationale for Total Lymphoid Irradiation Based Preparative Regimen…. 
2.5 
Rationale for Study………………………………………………………. 
2.6 
Minimal Residual Disease (MRD).……………………………………… 
2.7 
Rationale for the Evaluation of Immune Reconstitution After UCBT…. 
1 
2 
4 
7 
8 
10 
10 
3.0 
Protocol Eligibility Criteria……………………………………………………. 11 
 
3.1 
Inclusion Criteria for Transplant Recipient……...……………………… 
3.2 
Exclusion Criteria for Transplant Recipient……...……………………… 
3.3 
Inclusion Criteria for Haploidentical Donors…………………………… 
3.4  
Enrollment on Study…………………………………………………… 
11 
12 
12 
14 
4.0 
Treatment Plan………………………………………………………………….. 15 
 
4.1 
Schema for Protocol Prioritization…………...………………………….. 
4.2 
TLI-based Preparative Regimen…………..……………………………... 
4.3 
UCB Product………………………………..……………………………. 
4.4 
Haploidentical Donor Graft………..…………………...……………….. 
4.5 
Graft Preparation………..………………..……………………………… 
4.6 
Additional Progenitor Cell Graft Administration…………………….….. 
4.7 
Donor Lymphocyte Infusion………..…………………………….…..…. 
4.8 
Quality Assurance of Cellular Products..…………..….………………… 
4.9  Immunosuppressive Therapies ………………………….……………… 
4.10 Management of Pre-engraftment Immune Reaction……………………. 
4.11  Growth Factors (G-CSF).………………………………..………………. 
4.12 Treatment and Conditioning Regimen Related Notes…………………… 
15 
16 
17 
19 
21 
22 
22 
23 
23 
24 
25 
25 
5.0 
Medication Information………………………………………………………… 25 
 
5.1  
Cyclophosphamide………….…………………………………………… 
5.2. 
Thiotepa…………………………………………………………………. 
5.3 
Fludarabine (Fludara)………………………………..…………………... 
5.4  
Melphalan……..………………………………..………………….…….. 
5.5  
Mesna……………………………………………………………………. 
5.6 
Filgrastim ……..………………………………………………………… 
5.7 
Mycophenylate mofetil………………………………………………….. 
5.8  
Tacrolimus……….……………………………………………………… 
25 
26 
27 
28 
29 
29 
30 
31 


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
5.9 
Methylprednisolone ……..……………………………………………… 
5.10  CliniMACS System……………………………………………………… 
 
32 
33 
6.0 
Required Observations and Evaluations……………...………………………… 34 
 
6.1 
Standard Pre/Peri/Post-Transplant Evaluations……………………….... 
6.2 
Long Term Follow-up Evaluations…………………………………..….. 
6.3 
Research Testing……………………………….……..……..……..…….  
6.4 
Research Testing on Haploidentical Donor…………...……..……..……. 
34 
34 
34 
35 
7.0 
Evaluation Criteria……………………………………………………………… 35 
 
7.1 
Adverse Event Monitoring.……………………………..…………..….... 
7.2 
Acute GVHD ……………………………………………………….…... 
7.3 
Performance Status.………………………………..……..……..……….. 
7.4 
Hematologic Recovery………………………………..……..……..……. 
7.5 
Primary Graft Failure……….………………………..……..……..…….. 
7.6 
Secondary Graft Failure……...…………………………..……..……..… 
7.7 
Mixed Hematopoietic Chimerism……..…………………………..…….. 
7.8     Engraftment Syndrome………………………………………………….. 
35 
35 
36 
36 
36 
36 
36 
36 
8.0 
Off-study Criteria……………………………………………………………….. 37 
 
8.1 
Recipient Off-therapy Criteria …………………..………………………. 
8.2  
Recipient Off-study Criteria…………………….……………………… 
8.3  
Donor Off-study Criteria………………………………………………… 
37 
37 
37 
9.0 
Reporting Criteria………………………………………………………………. 37 
 
9.1 
Reporting Adverse Experiences and Deaths……..……..……..……..….. 
9.2 
Reporting to SJCRH Institutional Review Board (IRB)………………… 
9.3 
Reporting to SJCRH Biosafety Committee (IBC)……………………….. 
9.4 
Reporting to US Food and Drug Administration (FDA)……..……..…… 
9.5 
Reporting to SJCRH Regulatory Affairs Office.…….…..……..……..…. 
9.6 
Continuing Review Reports...……..……..……..……..…..............….…. 
9.7  
Reporting to the St. Jude Data Safety Monitoring Board………………... 
9.8 
Data Submission to Miltenyi Biotec…….……..……..…..............….…. 
9.9 
Reporting to Center for International Blood and Marrow Transplant 
Research (CIBMTR)….……..……..……..……..…..……..……..……. 
37 
38 
39 
39 
40 
40 
40 
40 
40 
10.0 Data Collection, Study Monitoring, and Confidentiality……………………… 41 
 
10.1 Data Collection…………………………………………....….….….…… 
10.2 Study Monitoring………………………………..….….….….….……… 
10.3  Confidentiality…………………………………………………………… 
41 
41 
42 
11.0 Statistical Considerations……………………………………….. 
42 
 
11.1 Statistical Design and Analysis for the Primary Objective……….…….. 
11.2 Statistical Analysis for the Secondary Objectives………………………. 
11.3  Analysis for Exploratory Objectives…………………………………….. 
42 
45 
46 
 
 


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
12.0 Obtaining Informed Consent…………………………………………………… 46 
 
12.1 
Informed Consent Prior to Research Interventions…………………… 
12.2 
Consent at Age of Majority…………………………………………… 
12.3 
Consent When English is Not the Primary Language………………… 
47 
47 
47 
13.0 References………………………………………………………………….…. 
48 
 
Appendix A: Karnofsky and Lansky Performance Score………………………. 
Appendix B: COG Consensus Guidelines Acute GVHD Grading……………. 
Appendix C: Chronic GVHD Grading………………………………………... 
Appendix D: Adverse Event Evaluation………………………………………... 
Appendix E: Testing and Evaluation……………..…………………………….. 
56 
57 
64 
67 
68 
 
Appendix F: BMT Standard Operating Procedure……………………………... 72 
 
 
  


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
STUDY SUMMARY 
HAPCORD:  
Principal Investigator: Mari Hashitate Dallas, MD 
IND/IDE: 16036 
Brief Overview: In this study, participants with high-risk hematologic malignancies undergoing 
hematopoietic cell transplantation (HCT), who do not have a suitable human leukocyte antigen 
(HLA)-matched related/sibling donor (MSD), matched unrelated donor (MURD) or killer-
immunoglobulin receptors (KIR) ligand mismatched haploidentical donor identified, will receive 
a combined T cell depleted (TCD) haploidentical peripheral blood stem cell (PBSC) and 
unrelated umbilical cord blood transplantation (UCBT) using a total lymphoid irradiation (TLI) 
based preparative regimen. Patients who have a suitable KIR ligand mismatched haploidentical 
donor will be preferentially enrolled in available haploidentical protocol if clinically appropriate. 
Those with a suitable HLA matched sibling, unrelated donor or KIR mismatched haploidentical 
donor identified may be eligible for participation if the donor is not available in the necessary 
time. Participants must be ≤ 21 years old and with sufficient multi-organ function as specified in 
protocol. The assessments and follow-up evaluations noted in the protocol follow the St. Jude 
standard operating procedures (SOP) for all recipients of allogeneic HCT.  
Intervention: Combined TCD haploidentical PBSC graft with an unrelated UCBT graft using a 
TLI-based preparative regimen. The haploidentical graft will undergo processing for T cell 
depletion and CD34+ stem cell selection.  
Brief Outline of Treatment Plan: The preparative regimen includes total lymphoid irradiation 
(TLI) (8 Gy), fludarabine (150 mg/m2), cyclophosphamide (60mg/kg), melphalan (140 mg/m2) 
and thiotepa (10mg/kg). TLI will be administered in 4 fraction at 200 cGy/fraction over 3 days 
on day -9 to day -7, fludarabine will be given once a day at 30 mg/m2 for five days on day -8 to 
day -4, cyclophosphamide will be given once a day at 60mg/kg for one day on day -6, thiotepa 
will be given twice a day at 5 mg/kg for one day on day -3, and melphalan will be given once a 
day for 2 days on day -2 and day-1. Post-transplantation immunosuppression with tacrolimus 
will begin on day -2 and MMF on day 0. Haploidentical donor product will be processed for 
CD45RA+ depletion and CD34+ selection and will be infused on day 0 and day +1. Cord Blood 
infusion will occur on day +2. G-CSF may start on day +3, but may be held at the discretion of 
the attending physician.  
Objectives:  
Primary objective  
 Estimate the incidence of donor derived neutrophil engraftment by day +42 post-
transplant for participants with high-risk hematologic malignancies undergoing a total 
lymphoid irradiation (TLI)-based hematopoietic cell transplantation (HCT) using a T cell 
depleted (TCD) haploidentical donor peripheral blood stem cell (PBSC) donor combined 
with a unrelated umbilical cord blood (UCB) donor. 
Secondary objectives: 
 Estimate the incidence of malignant relapse, event-free survival, and overall survival at 
one-year post-transplantation. 
 
Estimate the incidence and severity of acute and chronic graft versus host disease 


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
(GVHD). 
 
Estimate the incidence of secondary graft failure, transplant related mortality (TRM) 
and transplant related morbidity in the first 100 days after transplantation. 
Exploratory Objectives 
 
Assess the relationship between pre-transplant minimal residual disease (MRD) with 
transplant outcomes. 
 
Record 
immune 
reconstitution 
parameters, 
including 
chimerism 
analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B and NK cells and 
lymphocytes will also be evaluated.  
 
Characterize the recovery of Gamma Delta (γδ) T cells after HCT, including T cell 
receptor analysis, phenotyping and functional analysis.  
 
Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility. 
Hypotheses/Estimates:  
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 30% will 
have a suitable matched related/sibling donor (MSD) and another 30% will have a matched 
unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-60% of eligible 
pediatric recipients, and the lengthy duration of the donor search process in those with high risk 
of relapse have prompted investigators to use an alternative source of HSC, namely UCB.3 
Although UCB has been shown to be a suitable source of HSC, initial studies suggested UCBT is 
associated with increase incidences of TRM when compared to recipients of MSD or MURD.5,6 A 
pilot study in adults that combined TCD haploidentical PBSC and an unrelated UCB graft resulted 
in rapid neutrophil engraftment with minimal GVHD and durable remission.7 Here, we propose to 
investigate the outcomes of pediatric patient with high-risk malignancies undergoing a 
combined TCD haploidentical PBSC and unrelated UCB using a TLI-based preparative regimen 
at St. Jude Children’s Research Hospital. The primary objective of the study is to estimate the 
rate of donor derived neutrophil engraftment by day +42 post-transplant. Secondary aims will 
assess graft failure, overall survival, event-free survival, risk of relapse, graft versus host 
disease (GVHD), transplant related mortality (TRM), transplant related morbidity, and immune 
reconstitution. 
 
Criteria for Evaluation:  
Safety Evaluation  
 The primary measures of safety will be the rate of therapy related death and the rate of 
severe graft versus host disease. 
 Ongoing assessment of toxicity will be done using the NCI CTC version 4. Acute GVHD 
will be evaluated using the standard grading criteria (Appendix B). 
Efficacy  
 Neutrophil and platelet engraftment will be determined using the parameters put forth by 
the Center for International Blood and Marrow Registry. Assessments will be made upon 
review of daily complete blood count and serial chimerism studies. 
 BM studies for disease status evaluation will be performed at approximately 28 days, 100 
days, and yearly post-transplant.  


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 Acute GVHD will be assessed using the standard grading criteria put forth by Prezpiorkia 
et al 1995. Chronic GVHD will be assessed using the NIH Consensus Criteria for 
Chronic GVHD 2005 (Appendix B). 
 
Study Design: Phase II - Non Randomized  
Study Population: Patients with high-risk hematologic malignancies who are in complete 
remission or AML in first relapse with less than 25% blasts at the time of evaluation are eligible 
for enrollment. Participant must be less than or equal to 21 years old.  
Candidates must have a suitable UCB product available (matched ≥ 4 of 6 to the patient 
sufficient with sufficient cell dose). Those with a suitable HLA matched sibling, matched 
unrelated donor, or KIR mismatched haploidentical donor identified will be eligible for 
participation if the donor is not suitable or available in the necessary time. For example, patients 
who have a KIR mismatched haploidentical donor but have relapsed after a KIR mismatched 
haploidentical HCT are eligible for this protocol. Additional eligibility criteria are specified to 
assure sufficient multi-organ system function. 
Inclusion criteria for transplant recipient 
 Age less than or equal to 21 years old. 
 Has a partially HLA-matched single UCB product available.  
 Has a partially HLA-matched haploidentical related donor available.  
 High-risk hematologic malignancy. 
 Very high risk ALL in CR1, ALL in High risk CR2, ALL in CR3 or subsequent. 
 AML in high risk CR1, AML in CR2 or subsequent 
 
Therapy related AML, with prior malignancy in CR > 12mo 
 
MDS, primary or secondary 
 
NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 
 
CML in accelerated phase, or in chronic phase with persistent molecular positivity or 
intolerance to tyrosine kinase inhibitor. 
 
Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous HCT, or 
unable to mobilize stem cells for autologous HCT. 
 
Non-Hodgkin lymphoma in CR2 or subsequent. 
 
JMML 
 
Refractory hematologic malignancies (ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin lymphoma) due to chemoresistant relapse or primary induction failure. 
 
All patients with evidence of CNS leukemia must be treated and be in CNS CR to be 
eligible for study. 
 Patient must fulfill pre-transplant evaluation: 
 
Left ventricular ejection fraction ≥ 40% or cardiac shortening fraction ≥ 25%. 
 
Creatinine clearance or GFR ≥ 50 ml/min/1.73m2. 
 
Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry ≥ 92% on 
room air. 
 
Karnofsky (≥ 16 years) or Lansky (<16 years) performance score ≥ 50  


 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 
Bilirubin ≤ 3 times the upper limit of normal for age. 
 
Alanine aminotransferase (ALT) ≤ 5 times the upper limit of normal for age. 
 
Aspartate aminotransferase (AST) ≤ 5 times the upper limit of normal for age. 
 
Exclusion Criteria for Transplant Recipients:  
 Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical donor 
available in the necessary time for stem cell donation. 
 Patient has any other active malignancy other than the one for which HCT is indicated. 
 
Patient is pregnant as confirmed by positive serum or urine pregnancy test within 14 days 
prior to enrollment. 
 
Patient is breast feeding 
 
Patient has Down Syndrome 
 
Patient has a current uncontrolled bacterial, fungal, or viral infection per the judgment of 
the PI. 
Sample Size: Up to 49 evaluable.  
Randomization: N/A 
Data Analyses: Statistical considerations and ongoing analysis will be conducted by Dr. 
Guolian Kang and designated associates within the St. Jude Department of Biostatistics.  
Anticipated Primary Completion Date: (5 years) 
Anticipated Study Completion Date: (6 years) 
Timeframe for Primary Outcome Measure: 42 days 
Data Management: Protocol compliance, data collection including safety data, and reporting 
will be carried out by the Department of Bone Marrow Transplantation and Cellular Therapy 
Research Office. 
Human Subjects: The risks to subject are primarily related to the infusion and the 
conditioning regimen. The allogeneic stem cells may induce serious and possibly fatal 
disorders such as GVHD, veno-occlusive disorder and post-transplant lymphoproliferative 
disease. Because of the required conditioning, recipients are at high-risk for serious and 
possibly life-threatening infection, bleeding, and anemia. Adverse events will be treated, 
monitored, and reported appropriately. 
Possible benefits of participation include obtaining and/or sustaining disease remission. In 
addition, there is the possibility of psychological benefit from knowing participation has helped 
researchers gain more understanding about the efficacy of UCBT. 
Alternatives to participation are identified as chemotherapy, research treatment if available, 
and/or supportive therapy. 
The possible benefits, alternatives to participation, and side effects, including that there may be 
unknown side effects of treatment, are detailed in lay language within the respective informed 
consent documents. 


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1.0 OBJECTIVES 
1.0 Primary objective 
1.1.1 To estimate the incidence of donor derived neutrophil engraftment by day +42 
post-transplant for participants with high-risk hematologic malignancies 
undergoing a total lymphoid irradiation (TLI)-based preparative regimen using a 
T cell depleted (TCD) haploidentical peripheral blood stem cell (PBSC) combined 
with an unrelated umbilical cord blood (UCB) graft. 
1.1 Secondary objectives  
1.2.1  Estimate the incidence of malignant relapse, event-free survival (EFS), and 
overall survival (OS) at one-year post-transplantation. 
1.2.2 Estimate the incidence and severity of acute and chronic graft versus host disease 
(GVHD) in the first 100 days after transplantation. 
1.2.3 Estimate the incidence of secondary graft failure, transplant related mortality 
(TRM) and transplant related morbidity in the first 100 days after transplantation. 
1.3 Exploratory Objectives 
1.3.1 Assess the relationship between pre-transplant minimal residual disease (MRD) 
with transplant outcomes. 
1.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B and NK cells 
and lymphocytes will also be evaluated.  
1.3.3 Characterize the recovery of Gamma Delta (γδ) T cells after HCT, including T 
cell receptor analysis, phenotyping and functional analysis.  
1.3.4  Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility.  
2.0 BACKGROUND AND RATIONALE 
2.1 Overview 
Allogeneic HCT has become a widely accepted curative therapy for many hematologic 
malignancies that cannot be cured with chemotherapy alone.9,10 Studies have 
demonstrated that HCT is a potentially curative therapy for patients with CML, AML, 
ALL and MDS.11-14 Furthermore, patients with non-Hodgkin or Hodgkin’s lymphoma 
who recur after an autologous HCT may be successfully treated with an allogeneic 
HCT.15,16 
Of the patients with hematologic malignancies requiring allogeneic HCT, approximately 
30% will have a suitable matched related/sibling donor (MSD) and another 30% will have 
a matched unrelated donor (MURD) identified.1-4 The lack of an adequate MURD for 25-
60% of eligible pediatric recipients, and the lengthy duration of the donor search process 
in those with high risk of relapse have prompted investigators to use an alternative source 
of HSC, namely UCB.3 Recent comparative studies report no significant difference in OS 
in patients undergoing UCBT compared to MURD HCT.17-21 Thus, the number of 
patients undergoing UCBT has rapidly increased over the past 10 years. In the pediatric 


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population, UCB is now the most common source of HSC in unrelated donor transplant. 
However, the limited number of progenitor cell in the UCB unit result in delayed and 
unpredictable count recovery. The delayed neutrophil recovery predisposes patients to 
infection and malignant relapse. Recipients of UCBT are associated with increase 
incidences of TRM when compared to recipients of MSD or MURD HCT.5,6 The goal of the 
protocol is to decrease the risks associated with delayed neutrophil recovery. 
Recently a pilot study demonstrated that by combining a TCD haploidentical PBMC 
product and an unrelated UCB graft resulted in rapid neutrophil engraftment with minimal 
GVHD and durable remission.7 St. Jude has gained considerable expertise with 
haploidentical HCT in children 22-29 and we propose to investigate the outcomes of 
pediatric patient with high-risk malignancies receiving a combine TCD haploidentical 
PBSC and UCB graft using a TLI-based preparative regimen at St. Jude Children’s 
Research Hospital. 
2.2 Umbilical Cord Blood Transplantation (UCBT) 
2.2.1 Historical Background: 
The use of UCB as a clinical source of HSC was first considered in the late 
1960’s when UCB from eight donors were pooled and infused into a 16 year old 
male with acute lymphocytic leukemia (ALL).30 Although full reconstitution was 
not observed, there was evidence suggesting transient mixed chimerism. 
Thereafter, additional studies were performed that suggested that if adequate 
numbers of HSC could be collected; UCB has the potential for long-term 
reconstitution. In 1989 the first successful matched sibling UCBT was performed 
for a child with Fanconi anemia. In 1995, the International Cord Blood Transplant 
Registry (ICBTR) reported the results of the first 44 matched sibling UCBT 
demonstrating UCB contained sufficient number of hematopoietic progenitors to 
reliably engraft transplant recipients after a myeloablative conditioning regimen.31  
The first successful unrelated UCBT in a pediatric patient occurred at Duke 
University in 1993.32,33 In 1996, Kurtzberg et al and Wagner et al simultaneously 
published the unrelated UCBT experiences at Duke and Minnesota, 
respectively.33,34 These initial studies showed the median time to neutrophil 
recovery was 22 and 24 days, respectively. Combining the 43 patients, 88% 
engrafted, 54% had Grade II-IV GVHD and 9% had Grade III-IV GVHD. The OS 
at 100 days was 53%. Together, these studies suggested that UCB is a suitable 
alternative source of allogeneic HSC for pediatric patients.  
In nearly every large single center or registry analysis of outcomes after UCBT, 
cell dose is identified as an important factor influencing the incidence and rate of 
hematopoietic recovery, risk of TRM, and probability of survival. Furthermore, 
data suggest that infusion of two partially HLA-matched UCB units, which 
always augments the graft cell dose, is safe and may improve neutrophil recovery 
and survival. To determine whether the infusion of two UCB units enhances 
survival, the Blood and Marrow Transplant Clinical Trials Network (BMTCTN) 
proposed a multi-center randomized trial in 2006. Preliminary data suggest that 
patients receiving double unit UCBT have a higher risk for acute GVHD albeit a 
lower risk for relapse. However, until data clearly demonstrate a survival 


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advantage, double UCBT is currently only recommended for those patients who 
do not have an adequate single unit.35  
Lastly, in the past decade, large comparative studies evaluating the outcomes of 
transplantation using UCB versus other HSC sources have been performed. 
Reports demonstrate that the incidence of GVHD was lower in patients 
undergoing UCBT compared to HLA-matched bone marrow (BM) recipients. 
Furthermore, recent studies that include long-term analysis demonstrate that 
outcomes are similar for patients undergoing transplantation using MURD or 
UCB sources.14-18, 25 Thus, UCBT should be considered as a viable options for 
patients with high-risk malignancies.17-21,36 7-11, 25 
2.2.2  Cell Dose Threshold and Interaction with HLA match 
Cell dose remains one of the single most important determinants of a successful 
UCBT.37-39 Numerous clinical studies have shown that the total nucleated cell 
(TNC) dose and the CD34+ cell dose in the UCB graft are highly correlated with 
neutrophil and platelet engraftment as well as the incidence of graft failure and 
early TRM.3,38,40,41 The first Eurocord Registry report by Gluckman et al, 1997, 
demonstrated that among 527 patients undergoing UCBT, the most important 
predictor in outcome was the infusion of ≥ 3 x 107 TNC per kilogram body 
weight.37,42 Moreover, adult recipients had increased TRM by day 180 compared 
to children (56% versus 32%), and deaths were related to the number of cells 
infused, with patients who received ≤ 1 x 107 TNC/kg having a 75% probability 
of death compared to 30% for those who received ≥ 3 x 107 TNC/kg. Rubinstein 
et al, 1998, published the New York Blood Center experience with 562 patients 
undergoing UCBT and similarly demonstrated a strong correlation between the 
number of leukocytes infused and neutrophil engraftment.39 Thus, the collective 
data point to improved outcome of UCBT for patients receiving a larger number 
of CD34+ cells. Delayed neutrophil engraftment has also been correlated with 
HLA mismatch at greater than 2 loci, but recent studies have suggested that the 
impact of HLA disparity on survival can be partially overcome by increasing cell 
dose.43 Combined, these studies identified a minimum threshold for cell dose and 
HLA matching which lead to a significant reduction in TRM after UCBT. 
Although the exact threshold criteria for each degree of HLA mismatch is not 
know, the principle for the dose algorithm is clear.35,44,45 
2.2.3  Role of Double UCBT 
For most adults and large children, a single UCB unit that meets the cell dose 
requirement is not available. To overcome this obstacle, investigators at the 
University of Minnesota began infusing two partially HLA-matched units to 
augment cell dose. They found that neutrophil engraftment was achieved more 
rapidly and in a higher proportion of patients than the previous cohort who 
received only a single UCB unit.46 Preliminary evidence suggests that double unit 
UCBT may be associated with a decreased risk of relapse in patients with good 
disease control at the time of transplant, but is also associated with a increased 
incidence of mild to moderate acute GVHD compared to single UCBT.47,48,49 
Currently, it is unclear whether double UCBT offers any benefit other than 


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extending the application of UCBT by achieving the cell dose threshold.50 Until 
data clearly demonstrate a survival advantage, double UCBT is currently only 
recommended for those patients who do not have an adequate single unit.51 An 
adequate single unit is defined as: ≥ 3.0 x 107 nucleated cells/kg for 6/6 HLA-
matched units, ≥ 4.0 x 107 nucleated cells/kg for 5/6 HLA-matched units and ≥ 
6.0 x 107 nucleated cells/kg for 4/6 HLA-matched units.49,51,52Despite adequate 
cell dose, patients undergoing double UCBT continue to have delayed neutrophil 
engraftment compared to MSD and MURD HCT.  
2.2.4  UCBT Results 
Neutrophil Engraftment: Most studies report the time to hematopoietic recovery 
after UCBT is delayed with the median time to neutrophil recovery ranging 
between 20 - 30 days and the incidence of neutrophil engraftment after single 
UCBT ranges from 65-92%.32,34,38,39,41,42,53-61 Studies have consistently 
demonstrated the rate and incidence of neutrophil engraftment after UCBT is 
slower than bone marrow transplantation (BM), dependent on cell dose and the 
threshold for cell dose depends on HLA match grade.  
GVHD: The first report from the New York Blood Center experience by Rubinstein 
et al indicated that GVHD after UCBT occurred at a lower rate compared to those 
with MURD transplantation.39 Thereafter, Rocha et al published the first 
comparative analysis between UCBT and MURD transplantation in pediatric 
patients that substantiated the claim that acute and chronic GVHD were less 
common in recipients of UCB.19 In larger studies, the incidence of acute GVHD is 
reported to range from 33-44% and 11-22% for grades II-IV and III-IV acute GVHD 
respectively. The incidence of chronic GVHD ranges from 0-25%.38,39,58,60,61  
Survival: Nearly all studies demonstrate a significant relationship between UCB cell 
dose and survival and the reported probability of survival after single UCBT ranges 
from 18-78%.17,21,41,46,48,52,62-66 One of the largest reports from the Center for 
International Blood and Marrow Transplant Research (CIBMTR) by Eapen et al in 
2007 compared the outcomes of 785 pediatric patients with acute leukemia who 
received a UCBT (n=503) or an unrelated BMT (n =282). The most notable finding 
was that UCBT compared favorably to an 8/8 allele-matched unrelated BMT. In 
comparison with allele-matched BMT, the 5 year disease free survival (DFS) was 
similar to that after either one or two antigen mismatched UCBT and possibly higher 
after 6/6 allele-matched UCBT.17 These and other studies support that UCB should 
be considered an acceptable source of HSC grafts in the absence of an HLA-
matched donor. 17,18,21,38,39,41,46,48,52,58,60-67 
2.3 Haploidentical HCT 
2.3.1 
Haploidentical HCT Background 
Haploidentical donors are another viable alternative donor source when a MSD or 
MURD are not available. Also, family members are highly motivated, easily 
accessible, and readily available for most patients. Along with other institutions, St. 
Jude has shown haploidentical HCT to be an effective therapy for patients with 
hematologic malignancies.68-72 Due to the high potential for GVHD with the 


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degree of HLA mismatch seen in haploidentical HCT, most haploidentical grafts 
are extensively TCD prior to infusion.73 Significant progress was achieved when 
high cells dose of CD34+ cells were infused after high-intensity conditioning.71 It 
has been well established that prompt neutrophil engraftment with rapid immune 
reconstitution can be achieved with CD34+ enriched haploidentical cells, purified by 
positive (CD34+) and negative (CD3- lectin agglutination) selection.74,75 
Building on the initial studies above, St. Jude has gained considerable expertise with 
haploidentical HCT in children.22-27,29,76 Over the past decade (2001-2010), more 
than 220 mismatched related donor HCT have been performed at St. Jude. Initially, 
most haploidentical HCT performed in this institution were for patients with 
relapsed and refractory hematologic malignancies, however as it became a more 
successful therapeutic maneuver, it has become a primary transplant option for 
patients who lack a well matched donor.28  
Recent studies suggest that alloreactive NK cells play a role in graft versus 
leukemia (GVL) and influence outcomes of patients with hematologic 
malignancies after haploidentical HCT.77-84 The NK cell alloreactivity depends on 
the balance of signals mediated through activating and inhibitory KIRs on the NK 
cell. In patients who received haploidentical HCT for high-risk leukemia at 
SJCRH the presence of KIR mismatch dramatically reduced the risk of relapse.25 
Thus, patients with high risk hematologic malignancies that lack an HLA-
matched donor but have a KIR mismatched haploidentical donor available, would 
be expected to benefit from haploidentical HCT. 
2.3.2  Rationale for immunomagnetic TCD of hematopoietic progenitor cell graft  
Donor T cells in the haploidentical graft play a major role in mediating GVHD, 
with as few as 3 x 104 T cells/kg can cause GVHD.85 TCD allows for a HSC graft 
with very low T cell content, such that the risk of GVHD is decreased. T cells can 
be removed from the HSC graft by direct removal of T cells (negative selection) 
or positive selection of CD34+ progenitors. St. Jude has had success using either 
method of TCD in haploidentical donor transplantation.  
In this study, CD34+ selection by CliniMACS will be the used for TCD of the 
haploidentical graft. Although positive selection allows for extensive TCD, the 
graft is devoid of other important cell populations such as NK cells and myeloid 
cells such as dendritic cells and monocytes.86,87 In addition, this extensive degree 
of TCD has significant negative effects on the time to donor immune competency. 
Donor T cells are critical for reconstituting the allogeneic host immune system, 
and lymphocyte recovery is an important determinate of outcome post-
transplant.88,89 Transplants that employ TCD result in elimination of most 
memory T cells, leading to protracted immune dysfunction- an effect that 
becomes more severe with higher intensity conditioning regimens.22,90 This results 
in an increased rate of opportunistic infections. Indeed, viral infections are the 
most common cause of death of children receiving haploidentical transplants.91 
The majority of these infections occur within the first 6 months following 
transplantation, when T cell immunity is the lowest.92 Reconstitution of immunity 
can be partially restored by therapeutic infusions of donor cytotoxic 


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lymphocytes.88,93-95 However, in addition to requiring significant resources and 
expertise, the cells must be engineered or selected for specific infections - making 
this approach impractical for broad application.96  
A more ideal approach would be to infuse a cell product with diverse lymphocyte 
repertoire capable of effectively recognizing a variety of pathogens, as well as 
malignant cells without additional GVHD risk. One strategy would be to target 
naïve T cells for lymphocyte depletion. Naïve T cells are fully matured but do not 
proliferate until they encounter their receptor specific ligand.97 After ligand 
recognition, there is activation of proliferative signals that initiates a marked, 
antigen-specific cell expansion and inflammatory response. While many of these 
naïve T cells will undergo apoptosis after the initial response, others are rescued 
from immune retraction and will persist as memory T cells. Once generated, 
memory cells persist in the circulation as a diverse cell pool that is critical for 
long-term infection control.98 Furthermore, memory T cells are capable of more 
rapidly responding to future infectious challenges.99 
The isoform of the leukocyte common antigen, CD45RA, selectively identifies 
naïve T cells. Human studies have shown that sorted donor CD45RA+ naïve T 
cells are far more alloreactive than all memory subsets tested.100 In animal 
models, naïve T cells, are potent inducers of GVHD.96 Moreover, in similar 
models, lymphocyte infusions specifically depleted of CD45RA+ naïve T cells do 
not cause GVHD.101 Conversely, CD45RA- memory T cells do not cause physical 
or histologic evidence of GVHD. Among CD4+ T cells, the CD45RA- subset has 
equivalent “helper” functions as CD45RA+ cells in the generation of alloreactive 
cytotoxic T cells.102 Further, it is the CD45RA- memory cells that are responsible 
for aiding B-cell differentiation and antibody production.  
After demonstrating promising pre-clinical results, selective CD45RA depletion 
in patients undergoing HCT are underway, including two at SJCRH (RADIANT 
and HAPNK1). Depletion of CD45RA+ cells by magnetic beads has been shown 
to be a feasible and effective method for depletion of naïve T cells, with up 
greater than 3-log depletion in number of CD45RA+ cells (Data provided by 
Miltenyi). Furthermore, experiments were performed in the HAL to confirm and 
qualify the CD45RA+ depletion procedures. HSC products were obtained from G-
CSF mobilized normal donors by apheresis. The HPC, Apheresis products were 
depleted of CD45RA+ cells following a procedure provided by Miltenyi Biotech. 
Briefly, the cells were incubated with the CD45RA microbead reagent followed 
by washing to remove unbound beads. The labeled cells were then applied to the 
CliniMACS device (Depletion Tubing Set) and the CD45RA+ cells removed 
using the Depletion 3.1 program. Flow cytometric analysis before and after 
depletion was performed following procedures provided by Miltenyi Biotech. The 
results of the experiments are presented in the table below. An example flow 
cytometric analysis of CD3+ cells is also included. We hypothesize combining a 
CD34+ enriched product (HPC, Apheresis 1) along with a CD45RA+ depleted 
product (HPC, Apheresis 2) will provide a HSC graft with good stem cell content 
(3-5 x 106 CD34+ cells/kg) and a useful memory T cell fraction without additional 
GVHD risk to the recipients on this trial. Although some patients will have a graft 


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derived from the UCB donor, we hypothesize that the novel TCD haploidentical 
PBSC graft may provide immune protection during the period of severe 
lymphopenia and/or help facilitate the engraftment of the new donor. 
CELL COUNTS PRE AND POST DEPLETION 
 
Experiment 1 
Experiment 2 
Pre  
Post  
Pre  
Post  
No. of TNC (106) 
29748 
10270 
26166 
10981 
No. of CD34+ (106) 
636 
311 
693 
395 
No. of CD3+ (106) 
12238 
4555 
6353 
1985 
No. of CD3+CD45RA+(106) 
7877 
4 
3520 
2.2 
CD3+ CD45RA+ Log Depletion 
 
3.28 
 
3.21 
 
2.4 Rationale for TLI-based Preparative Regimen 
TLI-based preparative regimens have the potential to improve the outcomes of allogeneic 
HCT by decreasing the acute TRM compared to regimens using total body irradiation 
(TBI).103-105 TLI was initially developed with curative intent in patients with Hodgkin 
Lymphoma, and it was its use in these patients that led to the discovery of TLI’s alteration 
of T-cell specific immune responses. Years of pre-clinical research on TLI have shown that 
the use of TLI promotes neutrophil engraftment and reduces GVHD.106 This work was then 
followed up with therapeutic trials in humans with hematologic malignancy, which showed 
that conditioning with TLI and ATG alone allowed a high rate of durable donor 
engraftment, a low rate of GVHD, and preservation of evidence of graft versus malignancy 
effect, in patients who received HLA-matched related or unrelated donor grafts.107,108 We 
have significant institutional experience using TLI-based regimens for allogeneic 
transplantation (n=29 as of June 2012). Importantly, TLI-based conditioning has allowed 
successful salvage HCT in patients who failed previous allo-HCT. Nine patients have 
received TLI-based conditioning with haploidentical donor HCT after experiencing previous 
allograft failure (3 had primary graft failure, 4 had initial neutrophil engraftment with acute 
rejection, and 2 had late graft failure). The same haploidentical donor was utilized in 5 of the 
9 salvage HCT, with 4 patients receiving a new (haploidentical) donor. Eight of 9 patients 
(89%) experienced durable neutrophil engraftment at a median of 12 days (range 10 – 27 
days). The remaining patient had primary graft failure due to progressive disease. This 
experience indicates that TLI is effective for facilitation of neutrophil engraftment, even in 
patients receiving a mismatched haploidentical donor graft and with a history that indicates 
a very high risk of graft failure. There is additional published experience from Germany in 
which TLI – given as a single 7Gy fraction – was utilized in 14 adult and pediatric patients 
for reconditioning after graft failure/rejection.109 Despite most of the patient having 
haploidentical donors, neutrophil engraftment was obtained in all evaluable patients. In 
addition, TLI was well tolerated in this pediatric population that had recently received 
another (typically myeloablative) preparative regimen. Finally, 10 patients in Chile received 
TLI-containing preparative regimen, similar to our proposed regimen, as a part of their 
haploidentical donor preparative regimen.110 TLI was given as a single dose at 7Gy. Nine 
out of 10 patients experienced rapid donor neutrophil engraftment, with relapse as the cause 
of the one primary graft failure. Six of 10 patients were alive and disease free at one year, 3 
died of progressive disease, and one of infection. 


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2.5 Rationale for Study 
In the past 20 years, over 20,000 UCBT have been performed worldwide and over 
400,000 UCB units have been stored in more than 100 UCB banks.33,40,111 The main 
practical advantages of using UCB as an alternative source of HSC are (1) rapid 
availability, (2) absence of donor risk, (3) relative ease of procurement, (4) absence of 
donor attrition, (5) very low risk of transmissible infectious diseases and (5) low risk of 
acute GVHD despite HLA mismatch. Furthermore, UCB is particularly beneficial for 
patients of ethnic and racial minority descent for whom adult marrow and blood donors 
often cannot be identified.33,39,40,111 According to data from the National Marrow Donor 
Program (NMDP) donor registry, the probability of finding an 8 out of 8 HLA-matched 
donor is 51% for Caucasians, 30% for Hispanics, 20% for Asians and 17% for African 
Americans. Since patients who do not have a MURD can undergo a mismatched 
unrelated UCB transplantation and achieve similar results, the number of patients 
undergoing UCBT has rapidly increased over the past 10 years. The CIBMTR reports 
that from 2004 to 2008, UCB is now the most common graft source and BM is no longer 
the most common unrelated donor graft source for patients 20 years or less. Furthermore, 
in 2007 and 2008, 46% of all unrelated donor transplantations used UCB grafts for 
patients 20 years or less. 
Patients who do not have an appropriate MSD or MURD donor available in a timely manner 
often undergo transplantation using an alternative HSC source from UCB or haploidentical 
donors. Often, the type of donor is chosen based on various factors related to urgency of 
transplantation, patient, disease, and transplant-related factors as well as the center’s 
experience. Although a prospective randomized clinical trial is the accepted standard to 
compare different treatment regimens, the feasibility and acceptability of such a clinical 
trial is problematic and has not been performed. However, retrospective studies 
comparing the two donor sources have demonstrated no difference in survival.  
The Eurocord group performed a retrospective study comparing the outcome of pediatric 
patients with high-risk ALL undergoing either UCBT or haploidentical HCT. Patients 
had received either haploidentical (n=118) or UCB (n=341) transplantation in Eurocord 
centers between 1998 and 2004. The median follow-up was 56 and 24 months for 
haploidentical and UCBT patients, respectively. Failure of neutrophil engraftment was 
significantly higher following UCBT than after haploidentical HCT (23% vs. 11%, 
p=0.007). In a multivariate analysis, relapse incidence was higher in haploidentical HCT 
recipients compared to UCBT (relative risk 1.7, p=0.01), but TRM and DFS were not 
significantly different. In conclusion, in pediatric patients with ALL, UCBT is associated 
with inferior rate of neutrophil engraftment, higher incidence of grades II–IV acute 
GVHD and lower incidence of relapse compared to haploidentical HCT; however, there 
was no difference in terms of TRM and DFS. Therefore, in the absence of an HLA-
identical donor, both strategies were reported to be suitable options to treat a child with 
high-risk ALL.  
At our institution, patients who do not have an appropriate MSD or MURD donor available 
often undergo a haploidentical HCT. Studies at St. Jude have shown the presence of 
natural killer (NK) KIR mismatch in a haploidentical donor dramatically reduced the risk 
of relapse in patients who received HCT for high-risk leukemia.25,26 KIR mismatch is 
predictive of NK alloreactive effects in haploidentical HCT.25,26,79,81 Thus, patients who 


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have a KIR mismatch haploidentical donor will be enrolled into an available 
haploidentical HCT. However, one-third of all patients posses all relevant KIR ligands 
and will not have a KIR mismatched haploidentical donor. These patients will require an 
alternate donor for best clinical outcome. Patients who require an alternative donor HSCT 
and do not have a KIR mismatched haploidentical donors are likely to benefit most from 
UCBT for best clinical outcome. Contradictory results have been reported on the effect of 
KIR matching in UCBT. The European group reported KIR-ligand incompatible UCBT 
improved DFS (hazards ratio = 2.05, p = .0016) and OS (hazards ratio = 2.0, p = .004) 
and decreased relapse incidence (hazards ratio = 0.53, p = .05).112 However, the 
Minnesota group found no advantage using KIR matching in UCBT.113 Currently, the 
effect of KIR matching in UCBT is controversial and UCB selection based on KIR 
matching is not recommended. Some patients may have relapsed after receiving a KIR 
mismatched haploidentical HCT and would be eligible for this protocol despite having a 
KIR mismatched donor.  
To date, UCBT01, the first UCBT protocol at SJCRH has accrued 9 patients, with 5 
patients receiving a single UCB unit and 4 patients receiving two UCB units. One patient 
on the observational arm died due to TRM before day 100. All 8 remaining patients 
engrafted however, 2 patients would be categorized as significant graft delay/failure with 
neutrophil engraftment after day +42. One patient engrafted at day 49 and another at day 
51. The mean time to neutrophil engraftment is 28±13 days, (range; 12-51). Thus, despite 
optimizing HLA match and cell dose, neutrophil engraftment continues to be 
significantly delayed in patients undergoing UCBT.  
In order to abrogate the increased TRM and complication from graft failure and delayed 
neutrophil engraftment, we propose to provide a combined haploidentical donor with a 
single UCBT. A pilot study reported the results of 45 adults with a mean age of 50 yrs 
(range; 20-69) who underwent a RIC regimen using fludarabine, melphlan and ATG for 
high risk malignancies. The graft consisted of a single UCB with minimum cell dose of 
1.0 x 107 TNC/kg along with a TCD haploidentical PBSC donor graft. GVHD 
prophylaxis was with MMF and tacrolimus. The mean time to neutrophil engraftment 
was 11 days and platelet engraftment was 19 days. Chimerism analysis demonstrated that 
the haploidentical graft dominated early after HCT and is replaced by the UCB graft by 
day 100 in majority of the patients. However, 6 of the 45 patients had neutrophil 
engraftment derived from the haploidentical donor with no evidence of UCB donor. On 
the converse, 6 patients had had neutrophil engraftment derived from the UCB donor 
with no evidence of the haploidentical donor. . The risk for GVHD was not increased 
with the reported cumulative incidence of acute GVHD of 25% and chronic GVHD of 
5%.  
The primary objective of this study is to optimize the time to donor derived neutrophil 
engraftment and decrease the risk associated with delayed neutrophil engraftment such as 
infections and relapse. Briefly, we propose to provide a CD45RA+ depleted haploidentical 
PBSC graft to allow for rapids donor derived neutrophil engraftment. The graft will contain 
“memory” T cells that may help facilitate engraftment and/or provide immune protections. 
The UCB graft provides long-term allogeneic graft and contains majority of the CD45RA 
naïve T cells.  
 


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2.6 Minimal residual disease (MRD) 
Despite the fact that the vast majority of patients with high-risk leukemia are in clinical 
remission prior to HCT, approximately 30-40% ultimately relapse after HCT. Detection 
of MRD and early intervention may improve the clinical outcome. Detection of leukemic 
cells that are below the limits of detection by standard morphologic examination allow 
early interventions when the patients are MRD positive but still in remission. By using 
flow cytometry and polymerase chain reaction (PCR) amplification of antigen receptor 
genes in tandem, investigators at our institution have been able to conduct MRD studies 
in 80 consecutive ALL cases.114 Results of St. Jude institutional studies have shown that 
detection of MRD by immunologic techniques at any point in the treatment course is a 
powerful predictor of relapse in children with ALL.114-116 However, other studies suggest 
that eradication of all acute leukemia cells may not be a prerequisite for cure.117,118 
Similar to conventional-dose therapy, controversy also exists on the implication of MRD 
in the setting of HCT. Unlike CML, there is a paucity of data on the natural history of 
AML and ALL patients who have MRD after HCT, and how pre-transplant MRD levels 
influence post-transplant outcomes.119,120 It is unclear whether they are also at greater risk 
of relapse; and whether further pharmacological or immunologic therapy indeed prolongs 
survival and increases cure rates. Thus, for the participants who are enrolled in this 
protocol who are unable to proceed to post-transplant immunomodulatory protocols, we 
will gather the MRD information together with hematopoietic chimerism in a descriptive 
manner to study the relationship between MRD and chimerism in this large cohort of 
patients. The knowledge gained from this study should allow their future application to 
guide therapeutic interventions. 
2.7 Rationale for the evaluation of immune reconstitution after UCBT 
Delayed immune reconstitution is a major complication after HCT and impacts the 
overall survival in patients. Recent studies demonstrate that the rate and quality of 
immune recovery after UCBT is an important predictor of overall outcomes. 
Unfortunately, the rate of immune reconstitution directly correlates with the number of 
infused HSC and UCB patients have delayed immune reconstitution secondary to the 
limited numbers of HSC.71,121-123 Though transplantation with multiple unrelated UCB 
units has been used as a strategy to increase the total number of cells infused, the effect 
on immune reconstitution is not clear. In this study, we propose to monitor the rate of 
immune reconstitution after single and double UCBT. De novo generation of thymic 
derived T cells is critical in reconstituting a functional immune system, thus newly 
derived thymic T cell will be monitored by measuring the concentration of TREC DNA 
by quantitative PCR in the peripheral blood of transplant recipients. Furthermore, the 
time to recovery (defined as the median time to reach the normal value of age-matched 
healthy individual) of CD3+, CD4+, CD8+, CD19+ and CD56+ cells in patients undergoing 
UCBT will be investigated. Various subsets of T cells will be investigated including 
naïve, memory, central memory, effector memory, regulatory T cells as well as naïve and 
memory B cells. Functional measures of immune recovery will be examined by T cell 
proliferative response to nonspecific and specific antigen and NK lytic function. Antigen 
specific T cell response to various infections will be monitored in patients over time. 
Using a direct ex vivo, single-cell-based assay for clonotypic analysis of human epitope-
specific receptor, we will characterize T cell response to specific infections. Along with T 


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cell receptor specificity or antigen specific responses, epigenetic regulation of immune 
recovery will be evaluated. 
Studies demonstrate that the rate of neutrophil engraftment of a single unit was 
significantly enhanced after addition of a second unrelated UCB unit. It is clear that 
infusion of a second UCB unit facilitates the neutrophil engraftment of the dominant unit, 
however, the mechanism has yet to be investigated. Preliminary data from the Dallas 
laboratory suggest that dendritic cells and regulatory T cells play a critical role in 
facilitating neutrophil engraftment in the BM and thymus.124,125 Data obtained from this 
study addresses a key question regarding the immunological mechanism for enhanced 
neutrophil engraftment by facilitating cells. Furthermore, published studies consistently 
report that after a double UCBT, cells from only one of the UCB unit engraft. However, 
recent results from a multi-institutional clinical trial have demonstrated that small number 
of patients who undergo a double UCBT have evidence of mixed chimerism in the BM 
from the two UCB units one-year after HCT. Furthermore, studies performed at the Fred 
Hutchinson Cancer Research Center, demonstrated that single-unit dominance after 
double-unit UCBT coincides with NK cell dose and a specific CD8+ T-cell response 
against the non-engrafted unit.126  
3.0 PROTOCOL ELIGIBILITY CRITERIA 
3.1 Inclusion criteria for transplant recipient 
3.1.1  Age less than or equal to 21 years old. 
3.1.2 Does not have a suitable MSD or volunteer MUD available in the necessary time for 
stem cell donation.  
3.1.3 Has a suitable partially HLA-matched (≥ 3 of 6) family member donor. 
3.1.4  Has a partially HLA-matched single UCB unit (≥ 4 of 6) with adequate cell dose. 
UCB units must fulfill eligibility as outlined in 21 CFR 1271 and agency guidance.  
3.1.5 High-risk hematologic malignancy. 
3.1.5.1  Vey high risk ALL in CR1.  
  
Examples include, but not limited to hypodiploid, M2 or greater marrow at 
the end of induction, infants with MLL fusion or t(4;11). 
3.1.5.2  ALL in High risk CR2.  
  
Examples include but not limited to BM relapse <36 mo. CR1, T-ALL, very 
early (< 6mo CR1) isolated CNS relapse. 
3.1.5.3  ALL in CR3 or subsequent. 
3.1.5.4  AML in high risk CR1.  
  
Examples include but not limited to preceding MDS, 5q-, -5, -7, FAB M6, 
FAB M7 not t(1;22), MRD ≥ 5% on day 22 (AML08), M3 marrow after 
induction 1, M2 marrow after two cycles of induction, FLT3-ITD. 
3.1.5.5  AML in CR2 or subsequent. 
3.1.5.6  Therapy related AML, with prior malignancy in CR > 12mo 
3.1.5.7  MDS, primary or secondary 
3.1.5.8. NK cell, biphenotypic, or undifferentiated leukemia in CR1 or subsequent. 


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3.1.5.9 CML in accelerated phase, or in chronic phase with persistent molecular 
positivity or intolerance to tyrosine kinase inhibitor. 
3.1.5.10 Hodgkin lymphoma in CR2 or subsequent after failure of prior autologous 
HCT, or unable to mobilize stem cells for autologous HCT. 
3.1.5.11 Non-Hodgkin lymphoma in CR2 or subsequent. 
3.1.5.12 JMML 
3.1.5.13 Refractory hematologic malignancies (ALL, AML, CML in blast crisis, 
Hodgkin or non-Hodgkin lymphoma) due to chemoresistant relapse or 
primary induction failure.  
3.1.5.14 All patients with evidence of CNS leukemia must be treated and be in CNS 
CR to be eligible for study. 
3.1.6  Patient must fulfill pre-transplant evaluation: 
3.1.6.1  Cardiac Function: Left ventricular ejection fraction (LVEF) ≥ 40% or 
shortening fraction (SF) ≥ 25%. 
3.1.6.2  Creatinine clearance (CrCL) or glomerular filtration rate (GFR) ≥ 50 
ml/min/1.73m2. 
3.1.6.3 Forced vital capacity (FVC) ≥ 50% of predicted value or pulse oximetry 
(Pox) ≥ 92% on room air. 
3.1.6.4  Karnofsky or Lansky performance score ≥ 50 (See APPENDIX A). 
3.1.6.5  Bilirubin ≤ 3 times the upper limit of normal for age.  
3.1.6.6  Alanine aminotransferase (ALT) ≤ 5x the upper limit of normal for age. 
3.1.6.7  Aspartate aminotransferase (AST) ≤ 5x the upper limit of normal for age. 
3.2 Exclusion Criteria for Transplant Recipient:  
3.2.1  Patient has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor available in the necessary time for stem cell donation. 
3.2.2 Patient has any other active malignancy other than the one for which HCT is 
indicated. 
3.2.3  Patient is pregnant as confirmed by positive serum or urine pregnancy test within 
14 days prior to enrollment. 
3.2.6 Patient is breast feeding. 
3.2.7  Patient has Down Syndrome. 
3.2.8  Patient has a current uncontrolled bacterial, fungal, or viral infection per the 
judgment of the PI. 
3.3 Inclusion criteria for haploidentical donor 
3.3.1  At least single haplotype matched (≥ 3 of 6) family member 
3.3.2  At least 18 years of age. 
3.3.3 HIV negative. 
3.3.4 Not pregnant as confirmed by negative serum or urine pregnancy test within 14 
days prior to enrollment (if female). 
3.3.5 Not breast feeding. 
3.3.6 Regarding eligibility, is identified as either: 
3.3.6.1 Completed the process of donor eligibility determination as outlined in 21 
CFR 1271 and agency guidance; OR 


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3.3.6.2 Does not meet 21 CFR 1271 eligibility requirements, but has a declaration of 
urgent medical need completed by the principal investigator or physician 
sub-investigator per 21 CFR 127 
 
INCLUSION CRITERIA SUMMARY 
Donor 
Haploidentical (≥ 3 of 6) and single UCB ( ≥ 4 of 6) HLA matched donor 
Age 
≤ 21 years 
 
Malignancy 
ALL 
Very HR ALL CR1 
ALL CR2 
ALL CR3 or subsequent 
AML 
AML CR1 
AML CR2 or subsequent 
2° AML with prior disease in CR > 12 mo. 
MDS 
Primary or Secondary  
NK leukemia 
CR1 or subsequent 
Biphenotypic leukemia 
CR1 or subsequent 
Undifferentiated leukemia 
CR1 or subsequent 
CML 
 
Accelerated Phase 
Chronic with persistent molecular positivity OR 
intolerance to tyrosine kinase inhibitor  
Hodgkin’s Lymphoma 
CR2 or subsequent after failure of auto-HCT OR 
unable to mobilize HSC for auto-HCT 
Non-Hodgkin Lymphoma 
CR2 or subsequent 
JMML 
 
Refractory disease 
ALL, AML, CML in blast crisis, Hodgkin or 
non-Hodgkin Lymphoma 
Pre-
Evaluation 
Cardiac Function 
LVEF ≥ 40% or SF ≥ 25% 
Renal Function 
CrCL or GFR ≥ 50 ml/min/1.73m2 
Lung Function 
FVC ≥ 50% or Pox ≥ 92% on room air 
Performance Score 
Karnofsky or Lansky ≥ 50 
Liver Function 
Bilirubin ≤ 3x upper limit of normal for age 
ALT ≤ 5x upper limit of normal for age 
AST ≤ 5x upper limit of normal for age 
EXCLUSION CRITERIA SUMMARY 
Donor 
Has a suitable MSD, volunteer MURD, or KIR mismatched haploidentical 
donor available in the necessary time for HSC donation  
Malignancy  
Other active malignancy other than one being treated 
Pre-
Evaluation 
Pregnant - Serum or Urine pregnancy within 14 days of enrollment 
Breast feeding 
Downs Syndrome 
Uncontrolled infection 
 
 


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3.4 Enrollment on Study 
 
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1 – 3.3, complete and sign the ‘Participant Eligibility Checklist’. The study 
team will enter the eligibility checklist information into the Patient Protocol Manager 
(PPM) system. Eligibility will be reviewed, and a research participant-specific consent 
form and assent document (where applicable) will be generated. The complete signed 
consent/assent document form(s) must be faxed or emailed to the CPDMO at 595-6265 to 
complete the enrollment process. 
The CPDMO is staffed 7:30 am – 5:00 pm CST, Monday through Friday. A staff member 
is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm. Enrollments may be 
requested during weekends or holidays by calling the CPDMO “On Call” cell phone 
(901-413-8591) or referencing the “On Call Schedule” on the intranet. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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4.0 TREATMENT PLAN 
4.1 Schema for Protocol Prioritization 
Participant with high-risk hematologic malignancies undergoing HCT, who do not have a 
suitable HLA-matched MSD, MURD or KIR ligand mismatched haploidentical donor 
identified in time, will receive a combined TCD haploidentical PBSC product and an 
unrelated UCB graft using a TLI-based preparative regimen.  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES 
PATIENT NOT 
ELIGIBLE FOR 
HAPCORD 
 PATIENTS WITH HIGH-RISK 
MALIGNANCY ELIGIBLE FOR HCT 
HLA TYPING 
DONOR SEARCH 
NO 
MATCHED SIBLING  
OR 
MATCHED UNRELATED 
DONOR AVAILABLE IN TIME 
PATIENT ELIGIBLE FOR 
ALTERNATIVE DONOR HCT 
 
  SUITABLE/APPROPRIATE  
KIR MISMATCHED HAPLOIDENTICAL 
DONOR AVAILABLE 
KIR TYPING  
UCB SEARCH 
YES 
ELIGIBLE FOR HAPLO 
PROTOCOL 
NO 
ELIGIBLE FOR 
HAPCORD 
 
POTENTIAL DOUBLE UCBT  
ON UCBT01 OR NPTP 
NO 
YES 
SINGLE UNIT UCB  
AND HAPLOIDENTICAL DONOR  
  
ELIGIBLE FOR HAPCORD 


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4.2 Reduced Intensity Preparative Regimen 
DAY MEDICATION 
DOSE 
DOSE # 
-9 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 2 fractions 
1-2 of 4 
-8 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
3 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
1 of 5 
-7 
Total Lymphoid Irradiation (TLI)* 2Gy per fraction x 1 fraction 
4 of 4 
Fludarabine 
30 mg/m2 intravenous once daily  
2 of 5 
-6 
Cyclophosphamide (with mesna) 
60 mg/kg intravenous once daily  
1 of 1 
Fludarabine 
30 mg/m2 intravenous once daily  
3 of 5 
-5 
Fludarabine 
30 mg/m2 intravenous once daily  
4 of 5 
-4 
Fludarabine 
30 mg/m2 intravenous once daily  
5 of 5 
-3 
Thiotepa 
5 mg/kg intravenous twice daily  
1-2 of 2 
-2 
Melphalan 
70 mg/m2 intravenous once daily 
1 of 2 
Tacrolimus 
Maintain until at least 6 months 
start 
-1 
Melphalan 
70 mg/m2 intravenous once daily  
2 of 2 
0 
HPC A Infusion  
CD34+ selected 
HPC A1 
MMF 
Maintain until at least 45 days 
start 
+1 
HPC A Infusion  
CD45RA depleted 
HPC A2 
+2 
HPC C Infusion 
 
HPC C 
+3 
G-CSF 
5mcg/kg subcutaneous or intravenous may be 
started after Day +3 
4.2.1  TLI 
A total of 800 cGy of TLI may be administered in one fraction or in divided 
fractions given at a minimum of 6 hours apart. Administration of 4 fractions at 200 
cGy/fraction over three days on day -9 to -7 for a total of 800 cGy is recommended.  
*Timing of TLI administration can vary per the Radiation Oncologist. Testicular 
boosts should be used for all males with ALL with 200 cGy per fraction over two 
days.  
4.2.2 
Fludarabine  
Fludarabine at 30 mg/m2/day will be given over 30-60 minutes intravenous infusion 
on day -8 through day -4 for a total of 5 doses (150 mg/m2 total). Fludarabine dose 
may be reduced per PI if concerns of toxicity (i.e. CNS). Infant dosing will apply to 
fludarabine as follows: patients less than or equal to 10kg will receive 1 mg/kg/day 
for scheduled doses. Infant dosing will apply to fludarabine as follows: patients less 
than or equal to 10kg will receive 1 mg/kg/day for scheduled doses. 
 
4.2.3  Cyclophosphamide with Mesna 
Cyclophosphamide at 60 mg/kg/day will be administered as a 2 hour intravenous 
infusion with a high volume fluid flush on day -6 for one dose (60mg/kg total). For 


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patients weighing more than 125% of their ideal body weight should have 
cyclophosphamide dose based on the adjusted ideal body weight.  
Mesna is administered prior to cyclophosphamide and after the cyclophosphamide 
infusion per institutional practice. Mesna dose and administration schedule may 
vary based on physician recommendation. 
4.2.4 
Thiotepa 
Thiotepa will be given over 30-60 minutes intravenous infusion at 5 mg/kg twice a 
day on day -3 for a total of 2 doses (10mg/kg total). 
4.2.5  Melphalan 
Melphalan will be given over 30-60 minutes intravenous infusion at 70 mg/m2 once 
a day on day -2 and -1 for a total of 2 doses (140 mg/m2 total). Infant dosing of 
melphalan will apply as follows: patients less than or equal to 10kg will receive 2.3 
mg/kg/day for scheduled doses. Infant dosing of melphalan will apply as follows: 
patients less than or equal to 10kg will receive 2.3 mg/kg/day for scheduled doses. 
 
4.3 UCB Product  
 
 
 
 
 
 
 
 
 
 
 
 
4.3.1 UCB Selection: 
 
Choose the unit with highest HLA match (6/6, 5/6 then 4/6)  
- Matching at HLA typing at HLA-A, B antigen level and DRB1 allele 
level. 
- The patient and the UCB unit(s) must be matched at least 4 of 6 loci. 
 SELECT OPTIMAL UNIT WITHIN SAME HLA MATCH   
DR typing takes preference 
Prefer homozygous over bidirectional mismatch 
Choose the largest TNC unit.  
If TNC is similar (± 0.5 x 107 TNC/kg) 
Utilize HLA C matching if available 
Utilize higher resolution molecular typing if available. 
Utilize CD34+ cell count if available. 
CHOOSE UNIT WITH HIGHEST HLA MATCH  
 Minimum of 4 of 6 matching to the patient at 
HLA-A Antigen 
HLA-B Antigen 
HLA-DR Allele 
UCB SELECTION 


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- The unit must meet cell dose threshold of 1.0 x 107 TNC/kg 
 
If > one unit is available for a HLA match grade, chose unit based on: 
- DRB1: Matching at DR takes preference, followed by  
- Locus of mismatch: A unit that is homozygous at the locus of mismatch 
should be chosen over a unit that is bidirectional at the locus of mismatch, 
even if the latter unit is larger, followed by 
- Cell Dose: Choose the unit containing the greatest TNC. 
 If two units are of equivalent HLA match grade, DR1 matching, locus of 
mismatch and cell dose (± 0.5 x 107 TNC/kg), choose the unit with: 
- HLA match by higher resolution molecular typing, if data available 
- HLA-C antigen/allele level typing, if data available 
- Larger CD34+ cell dose, if data available 
- UCB banks located in the United States are preferred.  
4.3.2  UCB Unit Exclusions  
4.3.2.1 Unit fails to meet cell dose threshold criteria  
Cell dose is < 1.0 x 107 TNC per kilogram recipient weight.  
4.3.2.2 Fails screening 
 
Any UCB units without full maternal testing and negative results for hepatitis 
A, B, C, Human Immunodeficiency Virus (HIV), and Human T-lymphotropic 
virus-1 (HTLV-1) viruses. Any additional available virology results on the unit 
itself will be reviewed but are not mandated, complete or always available. The 
majority of UCB units will come from banks that operate under the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Minimally Manipulated, 
Unrelated 
Allogeneic 
Placental/Umbilical 
Cord 
Blood 
Intended 
for 
Hematopoietic Reconstitution for Specified Indications. All NMDP banks must 
fulfill this requirement. Foreign banks may have differing screening procedures 
even if they are American Association of Blood Banks (AABB) or Foundation 
for the Accreditation of Cellular Therapy (FACT) accredited. It is important to 
clarify the screening process employed, and additional plasma may be requested 
if additional testing is needed to fulfill Eligibility Determination requirements. 
Currently UCB units are available for use under federal IND. The NMDP holds 
an IND for use, and a few of the older banks hold their own IND. There is no 
need to adjust for nucleated RBCs when considering TNC. The UCB unit(s) must 
be present at St. Jude prior to the start of conditioning. 
4.3.3  UCB Graft Preparation 
Preparation for administration will take place in the Human Applications Lab 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) of St. Jude using established Standard Operating Procedure (SOP). 
UCB units must be prepared for infusion in a manner that assures high cell 
recovery, maintains cellular viability, and avoids contamination. Infants < 10 kg 
should not received reconstitutive thawed product and the UCB unit should be 
washed. When unit volume and Dimethyl sulfoxide (DMSO) concentration are 
not considered clinically prohibitive, and the wash procedure is deemed by the PI 


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to have a potential adverse impact on the UCB unit, a reconstitutive thawing 
procedure may be utilized. In this case, the unit is thawed, and then reconstituted 
at least 1:1 with an infusion grade solution (Dextran/albumin). In general, a wash 
is desired, particularly when there are concerns about volume, DMSO dose, red 
cell replete product, etc. For UCB products to be washed, a modified version of 
the New York Blood Center’s Placental Blood Thaw Procedure will be used. 
Briefly, the unit will be thawed and diluted; the plasma will then be expressed 
away after gentle centrifugation. In each case, 1-2 mL of the final product will be 
removed for testing prior to infusion. 
4.4 Haploidentical Donor Graft 
4.4.1  Haploidentical Donor Selection 
If more than one family member donor is acceptable, then donor selection will be 
based on the preference of the primary transplant attending. Factors in selection 
will include donor-recipient matching of CMV serology, donor-recipient red 
blood cell compatibility, degree of HLA matching, size of the potential donor, 
previous use as a donor, presence of donor-specific antibody, and overall health of 
the potential donor. 
Donor eligibility for cell collection will be determined through the guidelines 
outlined in 21 CFR 1271 and the Guidance for Industry: Eligibility Determination 
for Donors of Human Cells, Tissues, and Cellular and Tissue-Based Products 
(HCT/Ps). Potential donors will undergo an initial screening process that will 
include at least a complete physical exam, history and testing for relevant 
communicable diseases. Physical exams to evaluate donor candidacy will be 
conducted by a non-Department of BMTCT physician (St. Jude or non-St. Jude). 
For subsequent therapeutic cell collection procedures, if a complete screening 
procedure has been performed within the previous 6 months, an abbreviated donor 
screening procedure may be used for these repeat donations. The abbreviated 
screening procedure must determine and document any changes in the donor’s 
medical history since the previous donation that would make the donor ineligible, 
including changes in relevant social behavior. 
If a donor is determined to be ineligible, the donor is not automatically excluded. 
Part 21 CFR 1271.65 (b)(1)(i) allows use of ineligible donors who are first or 
second degree blood relatives. In this situation, the physician will document the 
necessity of using the ineligible donor by providing a statement of "Urgent 
Medical Need" as explained in the 21 CFR 1271.3 (u). The cell therapy products 
will be labeled as required in 21 CFR 1271.65 (b)(2). Recipients or their legal 
guardians will be informed of the use of an ineligible donor. 
Please see Departmental SOP 30.05 “Determination of Eligibility and Suitability 
for Stem Cell and Therapeutic Cell Allogeneic and Autologous Donors” for 
additional information. 
 
 
 


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4.4.2  Haploidentical Donor Mobilization and Donor HSC Graft Collections  
A G-CSF mobilized peripheral blood stem cell (PBSC) product (identified as 
HPC, Apheresis) is the preferred progenitor cell graft source. Our desired target 
goal will be 3-5 x 106 CD34+ cells/kg. This number of cells will be necessary to 
provide an adequate graft, following the various ex vivo manipulations, for 
prompt reconstitution. Two days of collection are typically needed to achieve this 
goal. However, on rare occasions, additional days may be necessary. Donors will 
undergo a standard HSC mobilization regimen consisting of 6 days of G-CSF 
given subcutaneously at 10 mcg/kg. The graft will be collected by leukapheresis 
on days -1 and 0. The HPC, Apheresis product will typically be collected and 
infused fresh, however there may be patients or logistical situations that require 
the HPC, Apheresis product to be collected early, processed, and stored frozen. 
The decision to use a fresh versus frozen HPC, Apheresis will be made by the PI 
and/or primary transplant attending based on patient and donor factors, as well as 
potential scheduling conflicts.  
MOBILIZATION TIME LINE 
DAYS 
MEDICATION 
APHERESIS 
Day -5 
G-CSF 10 mcg/kg/day SC*  
1 of 6 
 
Day -4 
G-CSF 10 mcg/kg/day SC* 
2 of 6 
 
Day -3 
G-CSF 10 mcg/kg/day SC* 
3 of 6 
 
Day -2 
G-CSF 10 mcg/kg/day SC* 
4 of 6 
 
Day -1 
G-CSF 10 mcg/kg/day SC* 
5 of 6 
Apheresis for HSC graft** 
Day 0 
G-CSF 10 mcg/kg/day SC* 
6 of 6 
Apheresis for HSC graft** 
* G-CSF may may be reduced if the donor’s WBC is >75.0 x 106/  
**Do not start apheresis if platelet count < 50,000/mm3 or hemoglobin of < 12.5 g/dL pre-phresis 
 
The dose of G-CSF may require modification based on the complete blood counts 
(CBC). If the donor’s white blood count (WBC) is >75.0 x 106/ml the dose of 
cytokine administered will be reduced. The guidelines for dose modification can 
be found in the St. Jude Children's Research Hospital Department of BMT and 
CT SOP 30.06.00 “The practice for the evaluation, preparation and care of 
allogeneic and autologous donors mobilized with growth factor.” Ongoing 
updates of this document can be located at the following St. Jude intranet website: 
http://home.web.stjude.org/bone_marrow/ 
The daily leukapheresed volumes for HPC, Apheresis collection is generally 3–4 
total blood volumes based on CD34+ cell counts. Two additional days of 
leukapheresis may be performed at the physician’s discretion (no more than 4 
total) to reach the cell dose target, however, this is expected to be rare.  
Leukapheresis may be terminated early upon request of donor, or when deemed 
medically necessary per the judgment of the treating sub-investigator physician or 
PI. All HPC, Apheresis products will be collected as per FACT guidelines. 
Donors will be monitored during the period of the mobilization and leukapheresis 
procedure with appropriate laboratory evaluation (Appendix D). 


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If we are unable to collect the minimum dose of 2 x 106 CD34+ cells/kg of 
recipient weight from the first donor, and the recipient has not yet initiated the 
preparative regimen, then an alternative family member may be used if he/she 
fulfills all donor criteria described in section. If the donor is unwilling or unable 
to complete the mobilization process or leukapheresis procedure, a BM product 
may be used. The BM product will be processed using the same cell selection 
methodology on the CliniMACS device.  
4.5 Graft Preparation 
Graft evaluation and preparation will take place in the Human Applications Laboratory 
(HAL) in the Department of Bone Marrow Transplantation and Cellular Therapy 
(BMTCT) using established SOP.  
The initial HPC, Apheresis product(s) will be TCD using the investigational CliniMACS 
device and CD34 Microbead reagent as directed by the manufacturer (Miltenyi Biotech). 
See section 5.2 for additional CliniMACS device information. Briefly, HPC, Apheresis 
products from the mobilized donor will be initially assessed in the HAL and stored 
overnight at 4oC. The next morning, the product will be washed to remove platelets and 
adjusted to an appropriate cell concentration for incubation with the CliniMACS CD34 
Microbead reagent in the manufacturer provided media. The cells will be washed to 
remove unbound microbeads. These cells will be applied to the CliniMACS device and 
the enrichment will be performed using the program “CD34 Enrichment 2.1” as 
described by the manufacturer. 
After enrichment is complete, the cells will be washed and resuspended in an infusion 
grade solution. The graft product will be enumerated and assessed for viable CD34+ cell 
and CD3+ T cell content by flow cytometry. The processed HPC, Aphersis CD34 
Enriched product will be infused fresh or frozen for future use after completion of release 
testing and evaluation. Cryopreservation will be performed per SOPs of the HAL. Target 
cell doses are listed in the following table: 
HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
≥ 2 x 106 
2 x 106 
50 x 106 
CD3+ cells/kg 
≤ 0.5 x 105 
1 x 103 
1 x 105 
Once the target dose is obtained for the CD34+ enriched product, one additional day of 
apheresis will be performed. This HPC, Apheresis product will be processed for CD45RA+ 
depletion using the investigational CliniMACS device as directed by the manufacturer 
(Miltenyi Biotech). See section 5.1 for additional CliniMACS device information. Briefly, 
HPC, Apheresis products from the mobilized donor will be initially assessed in the HAL and 
stored overnight at 4oC. The next morning, the product will be washed to remove platelets 
and adjusted to an appropriate cell concentration for incubation with the CliniMACS 
CD45RA Microbead reagent in the manufacturer provided media. The cells will be washed 
to remove unbound microbeads. These cells will be applied to the CliniMACS device and the 
depletion will be performed using the "Depletion 3.1" software as described by the 
manufacturer. When combined with the CD34+ enriched product, the target CD34+ dose will 
be 3-5 x 106/kg. Release criteria of the product will include at least a ≥ 2.00 log10 depletion of 
CD45RA+ cells and a maximum dose of CD3+CD45RA+ cells of 0.05x106/kg. 


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HPC Graft 
Target Dose 
Minimum Dose 
Maximum Dose 
CD34+ cells/kg 
3-5 x 106 
2 x 106 
50 x 106 
CD3+CD45RA+ cells/kg 
≤0.05 x 106 
N/A 
0.05x106 
CD45RA+ 
≥ 2.0 log10 depletion (CD45RA+ depleted graft only) 
 
4.6 Additional Progenitor Cell Graft Administration 
Infusion of an additional HSC graft from the original or an alternative haploidentical donor 
may be performed for participants when clinically indicated for graft failure, poor immune 
reconstitution, or poor hematopoietic recovery. The use of and content of a conditioning 
regimen is left to the discretion of the PI and/or primary transplant attending such that the 
most appropriate therapy is chosen for the clinical situation. 
The HSC graft will typically be obtained by apheresis (HPC, Apheresis) and be infused 
fresh. The target dose for this additional CD 34+ infusion is ≥5 x 106 cells/kg. If the 
participant has quiescent or active BOOP, acute Grade III-IV GVHD, or any other reason 
that a severely T-cell depleted graft may be indicated, then a graft from the donor processed 
on the CliniMACSTM device using either CD34+ selection (using established SOPs) or CD3+ 
depletion methodology may be utilized. The boost target dose for these patients is ≥10 x 
106 CD34+cells/kg with a CD3+ cell/kg dose of ≤ 0.5 x 105 CD3+ cells/kg.  
4.7 Donor Lymphocyte Infusions 
Some patients may have neutrophil engraftment derived from the haploidentical donor. 
Patients who have engrafted with the haploidentical donor may be eligible for donor 
lymphocyte infusions (DLI) from the haploidentical donor for decreasing donor 
chimerism, serious viral reactivation or infection, or any evidence of disease (from any 
level of MRD to frank relapse). The DLI collected may be collected as a whole blood 
unit donation or by leukapheresis. If the DLI is collected by standard phlebotomy, the 
volume to be collected would be approximately 300 ml whole blood. If the DLI is 
collected by leukapheresis, the amount to be processed would be approximately 2 total 
blood volumes. 
Prior to administration of DLI, the immunosuppression should be withdrawn and the 
recipient should have no active GVHD. GVHD staging must be reviewed by PI prior to 
DLI administration. The initial dose will typically be 2.5 x 104 CD3+/kg. Subsequent 
doses will be administered at approximately 2 to 4-week intervals with escalating doses 
of T cells if no moderate or severe GVHD occurs with the prior DLIs. The typical initial 
dose escalation for patients on this protocol is presented in the following table: 
DLI DOSE AND SCHEDULE 
DLI 
Dose 
Comments 
Initial Dose 
2.5 x 104 CD3+/kg 
Approximately 2-4 week interval 
If no moderate or severe GVHD 
Dose #2 
5.0 x 104 CD3+/kg 
Dose #3 
10.0 x 104 CD3+/kg 
  


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4.8 Quality Assurance of Cellular Products 
Quality assurance for cell products is overseen by independent Quality Assurance 
personnel who authorizes release of all products. Only trained stem cell processors will 
process the cell products. A labeling and product tracking system is in place to ensure 
that the correct cells are infused into the research participant. 
Assays of cell numbers and immunophenotyping will be performed both before cell 
processing and at critical stages of the process. These values will be recorded according 
to SOP of the HAL. All TCD products will be tested for viability, sterility (culture and 
Gram stain), and the presence of endotoxin. Culture and endotoxin results are not 
available before infusion of cell products. If the gram stain is positive, the research 
participant/parent and/or guardian will be informed of this event and of the risks of 
proceeding prior to infusion. Positive results will be investigated as per the variance 
procedures of the HAL. The IRB and FDA will be notified, if at any time after infusion, 
cell product was determined to be contaminated or endotoxin results exceed release 
limits.  
4.9  Immunosuppressive Therapies  
4.9.1  EBV post-transplant lymphoproliferative disease (PTLPD) prophylaxis  
Rituximab at 375 mg/m2 may be given intravenously as clinically indicated. For all 
patients, monitoring peripheral blood EBV DNA and prophylaxis and treatment 
will be according to BMTCT standard guides and/or at the discretion of the 
treating physician as clinically indicated based on ongoing EBV copy levels and 
clinical assessment. If a positive selection methodology would be used for a 
haploidentical HCT infusion, rituximab would not be administered, unless 
otherwise clinically indicated. 
4.9.2  Tacrolimus  
Tacrolimus to start on day -2. Preferably, start tacrolimus as a continuous infusion 
until patient engrafts and able to reliably obtain therapeutic levels. Maintain 
therapeutic levels according to institutional guidelines and practice. May modify 
dose for decreased chimerism or positive MRD. May convert to oral dosing when 
patient is tolerating oral and has a normal gastro-intestinal transit time. If no 
evidence of GVHD, begin to wean by approximately 10% every week on day 100, 
and discontinue around day 180 and no sooner than 6 months post transplant.  
4.9.3  MMF 
MMF to start on day 0 at 15mg/kg intravenously TID or every 8 hours. May convert 
to oral dosing when patient is tolerating oral and has a normal gastro-intestinal 
transit time. Adjust dose as clinically indicated. If no evidence of GVHD, MMF can 
be discontinued on day +45 or on/about 7 days after neutrophil engraftment, 
whichever is later. May hold for decreased chimerism or positive MRD. Continue 
MMF if patient has no evidence of donor engraftment on bone marrow evaluation 
and contact PI of results.  
 
 


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4.9.4  Methylprednisolone* 
Methylprednisolone may be used for treatment of acute GVHD*. (2mg/kg divided 
every 12 hours intravenously is suggested as initial therapy for patient with active 
acute GVHD requiring systemic therapy) If no response after 7 days, treat with a 
second line agent according to SOP. Methylprednisolone at 1-5 mg/kg/day can be 
used for management of pre-engraftment immune reaction as described below in 
4.10* 
*Use of methylprednisolone and dosing are recommendations and variance in 
medication, dosing and frequency can occur due to the participant’s current 
clinical condition and will not be noted as protocol deviations. 
4.10 Management of Pre-engraftment Immune Reaction 
A well recognized clinical entity consisting of skin rash, fever, loose stools and 
respiratory distress has been noted to occur prior to neutrophil engraftment among UCB 
patients, generally between day 7 and 21.127-129 This clinical syndrome likely involves 
cytokine activation, and though clinically similar to acute or hyperacute GVHD, it 
appears to be a distinct entity, “pre-engraftment syndrome.” This syndrome is often 
controlled with brief steroid bursts, thus avoiding a commitment to extended steroid 
exposure. Patients should be monitored carefully for this syndrome.. If patients have 
moderate to severe symptoms as described above and alternative etiologies (i.e., 
infection) have been excluded or are being appropriately evaluated, patients may be 
treated with steroids. Recommendation of methylprednisolone is provided.  
The usage of methylprednisolone described here is a recommendation, and variations in 
medication, dosing and/or frequency can occur due to the participant’s current clinical 
condition and will not be noted as protocol deviations.  
4.10.1  For 
patients 
not 
on 
steroid 
therapy 
when 
the 
syndrome 
occurs: 
methylprednisolone should be given at 1 mg/kg intravenously once a day for three 
days. If symptoms have abated, steroids should be stopped. If symptoms persist, 1 
mg/kg can be continued through six days then stopped if symptoms have abated. 
If symptoms persist for more than six days, the patient should be considered to 
have acute/hyperacute GVHD and should be treated with prolonged steroids as 
deemed appropriate. Must alert PI if patient is requiring methylprednisolone for > 
6 days for engraftment syndrome.  
4.10.2 For patients already on steroids for other reasons when the syndrome occurs: 
methylprednisolone should be given at a dose of 3-5 mg/kg intravenously (max 
dose 500 mg) every 12 hours for maximum of 48 hours, followed by a rapid taper 
to 1 mg/kg intravenously every 12 hours. Patients should be weaned after 
response as tolerated. Please alert PI if patient is requiring methylprednisolone for 
> 6 days for engraftment syndrome.  
Other syndromes of eosinophila and hyperimmune syndrome have not been well described in 
the UCB field. Thus, patients presenting with the described pre-engraftment syndrome should 
be diagnosed and treated accordingly.  
 
 


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4.11 Growth Factors 
4.11.1  Granulocyte colony-stimulating factor (G-CSF) 
G-CSF may start on day +3 at 5 mcg/kg/day intravenously or subcutaneously until 
absolute neutrophil count (ANC) ≥ 2,000/mm3 for three consecutive days. G-CSF 
may be held at the discretion of the attending physician 
4.12 Treatment and Conditioning Regimen Related Notes  
The HSC infusion may be delayed by approximately 24 hours in order to accommodate 
HAL as well as the research participant clinical condition. 
The term “every” used in tables is an approximate term meaning that these medications 
noted will be administered approximately “every” 12 hours (or 8 hours as applicable). 
The drug administration timing in these cases may be modified as clinically indicated 
such as in the case of surgical procedures or to accommodate other necessary medication, 
blood product delivery, or procedures. The term “day” does not refer to an absolute 
calendar day. It refers to a general 24-hour period. 
Dosing for all protocol treatment medications may be modified for research recipients 
based upon actual body weight or adjusted ideal body weight and/or for infants weighing 
less than 10kg, when clinically indicated. Mesna will be administered for prevention of 
hemorrhagic cystitis from the medication cyclophosphamide.  
Criteria for medication calculations based on body weight/body surface area and other 
medication related information can be found in the St. Jude Formulary 
(http://www.crlonline.com/crlsql/servlet/crlonline) or the St. Jude Department of 
Pharmaceutical 
Sciences 
intranet 
website 
http://home.web.stjude.org/ 
pharmaceutical_ser/drugInfo.shtml. Medication doses may be rounded to the nearest 
integer or to the nearest appropriate quantity when clinically or pharmaceutically 
indicated as per the MD and PharmD. 
5.0 MEDICATION INFORMATION 
5.1 Cyclophosphamide (Cytoxan) 
Source 
& 
Pharmacology  
Cyclophosphamide is a nitrogen mustard derivative. It acts as an alkylating 
agent that causes cross-linking of DNA strands by binding with nucleic acids 
and other intracellular structures, thus interfering with the normal function of 
DNA. It is cell cycle, phase non-specific. Cyclophosphamide is well 
absorbed from the GI tract with a bioavailability of >75%. It is a prodrug that 
requires activation. It is metabolized by mixed function oxidases in the liver 
to 
4-hydroxycyclo-phosphamide, 
which 
is 
in 
equilibrium 
with 
aldophosfamide. Aldofosfamide spontaneously splits into nitrogen mustard, 
which is considered to be the major active metabolite, and acrolein. In 
addition, 4-hydroxycy-clophosphamide may be enzymatically metabolized to 
4-ketocyclophosphamide and aldophosfamide may be enzymatically 
metabolized to carboxyphosphamide that is generally considered inactive. 
Cyclophosphamide and its metabolites are excreted mainly in the urine. Dose 
adjustments should be made in patients with a creatinine clearance of <50 
ml/min. 
Formulation 
Cyclophosphamide is available in vials containing 100, 200, 500, 1000 and 


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and Stability  
2000mg of lyophilized drug and 75 mg mannitol per 100 mg of 
cyclophosphamide. Both forms of the drug can be stored at room 
temperature. The vials are reconstituted with 5, 10, 25, 50 or 100 ml of 
sterile water for injection, respectively, to yield a final concentration of 20 
mg/ml. Reconstituted solutions may be further diluted in either 5% dextrose 
or 0.9% NaCl containing solutions. Diluted solutions are physically stable 
for 24 hours at room temperature and 6 days if refrigerated, but contain no 
preservative, so it is recommended that they be used within 24 hours of 
preparation. 
Supplier 
Commercially available 
Toxicities 
Dose limiting toxicities of cyclophosphamide includes BM suppression and 
cardiac toxicity. Cardiac toxicity is typically manifested as congestive heart 
failure, cardiac necrosis or hemorrhagic myocarditis and can be fatal. 
Hemorrhagic cystitis may occur and necessitates withholding therapy. The 
incidence of hemorrhagic cystitis is related to cyclophosphamide dose and 
duration of therapy. Forced fluid intake and/or the administration of mesna 
decreases the incidence and severity of hemorrhagic cystitis. Other toxicities 
reported commonly include nausea and vomiting (may be mild to severe 
depending on dosage), diarrhea, anorexia, alopecia, immunosuppression and 
sterility. Pulmonary fibrosis, SIADH, anaphylaxis and secondary neoplasms 
have been reported rarely.  
Route  
Intravenous infusion  
5.2. Thiotepa (Thioplex by Immunex) (TESPA, TSPA) 
Source 
& 
Pharmacology  
Thiotepa is a cell-cycle nonspecific polyfunctional alkylating agent. It reacts 
with DNA phosphate groups to produce cross-linking of DNA strands 
leading to inhibition of DNA, RNA and protein synthesis. Thiotepa is 
extensively metabolized in the liver to metabolites that retain activity, 
primarily triethylene-phosphoramide (TEPA). The main route of elimination 
is via the urine, mainly as metabolites; the elimination half-life of the 
thiotepa is 2.5 hours, and that of TEPA is 17.6 hours. 
Formulation 
and Stability 
Thiotepa is supplied in single-use vials containing 15 mg of lyophilized 
thiotepa, 80 mg NaCl and 50 mg NaHCO3. The intact vials should be stored 
under refrigeration and protected from light. Each vial should be 
reconstituted with 1.5 ml of sterile water for injection to yield a 
concentration of 10 mg/ml. Further dilution with sterile water for injection 
to a concentration of 1 mg/ml yields an isotonic solution; if larger volumes 
are desired for intracavitary, intravenous infusion, or perfusion therapy, this 
solution may then be diluted with 5% dextrose or 0.9% NaCl containing 
solutions. The 10 mg/ml reconstituted solution is chemically stable when 
stored in the refrigerator for up to 5 days, however, it is recommended that 
solutions be prepared just prior to administration since they do not contain a 
preservative. Reconstituted solutions should be clear to slightly opaque: the 
solutions may be filtered through a 0.22 micron filter to eliminate haze. 
Supplier 
Commercially available; manufactured by Immunex. 


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Toxicities 
Dose limiting toxicity is myelosuppression. The leukocyte nadir may occur 
at any time from 10 to >30 days. Other toxicities include pain at the injection 
site, nausea and vomiting, anorexia, mucositis, dizziness, headache, 
amenorrhea, interference with spermatogenesis, and depigmentation with 
topical use. Allergic reactions, including skin rash and hives, have been 
reported rarely. Rare cases of apnea, hemorrhagic cystitis, and renal failure 
have occurred. Thiotepa is mutagenic, carcinogenic, and teratogenic in 
animals. Pregnancy category D. 
Route  
Intravenous 
5.3 Fludarabine (Fludara) 
Source 
& 
Pharmacology  
Fludarabine phosphate is a synthetic purine nucleoside analog and acts by 
inhibiting DNA polymerase, ribonucleotide reductase and DNA primase by 
competing with the physiologic substrate, deoxyadenosine triphosphate, 
resulting in inhibition of DNA synthesis. It can also be incorporated into 
growing DNA chains as a false base and interfere with chain elongation and 
halt DNA synthesis. Fludarabine is rapidly dephosphorylated in the blood 
and transported intracellularly by a carrier-mediated process. It is then 
phosphorylated intracellularly by deoxycytidine kinase to the active 
triphosphate form. ~23% of the dose is excreted as the active metabolite in 
the urine (with dosages of 18-25 mg/m2/day for 5 days). Renal clearance 
appears to become more important at higher doses, with approximately 41-
60% of the dose being excreted as the active metabolite in the urine with 
dosages of 80-260 mg/m2. 
Formulation 
and Stability 
Fludarabine is supplied in single-dose vials containing 50 mg fludarabine as 
a white lyophilized powder and 50 mg of mannitol. The intact vials should 
be stored under refrigeration. Each vial can be reconstituted by adding 2 ml 
of sterile water for injection resulting in a final concentration of 25 mg/ml. 
Because the reconstituted solution contains no antimicrobial preservative, the 
manufacturer recommends that it should be used within 8 hours of 
preparation. The solution should be further diluted in 5% dextrose or 0.9% 
NaCl prior to administration. 
Supplier 
Commercially available. 
Toxicities 
The major dose-limiting toxicity of fludarabine is myelosuppression. Nausea 
and vomiting are usually mild. Side effects reported commonly include 
anorexia, fever and chills, alopecia and rash. Neurotoxicity can be 
manifested by somnolence, fatigue, peripheral neuropathy, mental status 
changes, cortical blindness and coma and is more common at high doses. 
Neurotoxicity is usually delayed, occurring 21-60 days after the completion 
of a course of therapy and may be irreversible. Side effects reported less 
commonly include diarrhea, stomatitis, increased liver function tests, liver 
failure, chest pain, arrhythmias and seizures. Pulmonary toxicity includes 
allergic pneumonitis characterized by cough, dyspnea, hypoxia and 
pulmonary infiltrates. Drug induced pneumonitis is a delayed effect, 
occurring 3-28 days after the administration of the third or later course of 
therapy. Administration of corticosteroids usually results in resolution of 
these symptoms. 


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Route  
Intravenous 
5.4 Melphalan (L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin, 
Alkeranâ) 
Source 
& 
Pharmacology  
Melphalan, a derivative of nitrogen mustard, is a bifunctional alkylating 
agent. Its chemical name is 4-[bis(2-chloroethyl)amino]-L-phenylalanine, 
and it has a molecular weight of 305.20. Melphalan is active against tumor 
cells that are actively dividing or at rest. Its cytotoxicity is thought to be due 
to inter-strand cross-linking with DNA, probably by binding at the N7 
position of guanine. Melphalan is highly protein bound and does not 
penetrate well into the cerebral spinal fluid. Elimination half-life after 
intravenous administration in adults is approximately 75 minutes. 
Elimination appears to be primarily by chemical hydrolysis, but caution 
should be used in patients with renal impairment. Plasma concentrations of 
melphalan after oral administration are highly variable, possibly due to 
incomplete absorption, variable “first pass” hepatic metabolism or rapid 
hydrolysis. Area under the plasma concentration-time curves for orally 
administered melphalan is approximately 60% of intravenously administered 
melphalan in adult studies.  
Formulation 
and Stability  
Available as 2 mg tablets for oral administration. This medication is stable at 
room temperature until expiration date on the packaging. Intravenous 
formulation is supplied as 50 mg freeze dried glass vial. Each 50 mg vial is 
supplied in a carton containing a 10 ml vial of sterile diluent. Lyophilized 
melphalan should be stored at controlled room temperature and protected 
from light. Each vial is marked with its expiration date. The melphalan for 
injection must be reconstituted immediately prior to infusion by rapidly 
adding the contents of the diluent vial (10 ml) to the freeze dried powder 
with a 20 gauge or larger sterile needle and immediately shaking vigorously 
until a clear solution is obtained. This results in a 5 mg/ml solution. The dose 
should then be diluted in 0.9% sodium chloride for injection to a final 
concentration of not greater than 0.45 mg/ml. The resulting admixture should 
be infused over a minimum of 15 minutes. The infusion should be completed 
within 60 minutes of reconstitution. Do Not Refrigerate the Reconstituted 
Melphalan.  
Supplier 
Commercially available 
Toxicities 
Melphalan is cytotoxic and caution should be used in handling and preparing 
the solution or administering the tablets. Use of gloves is recommended, and 
if contact with skin or mucosa occurs, immediately wash thoroughly. Second 
cancers such as acute non-lymphocytic leukemia, myeloproliferative 
syndrome, and carcinoma have been reported in patients taking melphalan 
alone or in combination with other chemotherapy or radiation. Melphalan 
causes suppression of ovarian function in premenopausal women, with a 
significant number of patients having amenorrhea. Testicular suppression 
(reversible and irreversible) has been reported. The most common adverse 
reaction is myelosuppression. Irreversible bone marrow failure has been 
reported. Gastrointestinal side effects reported include nausea/vomiting, 


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diarrhea and oral mucosa ulceration. Hepatic toxicity has occurred, including 
veno-occlusive disease. Acute hypersensitivity reactions occur in about 2.4% 
of patients, and can include anaphylaxis. Hypersensitivity reactions were 
characterized by urticaria, pruritus, and edema. Some patients exhibited 
tachycardia, bronchospasm, dyspnea and hypotension that responded to 
antihistamines and corticosteroids. Other side effects that have been reported 
include skin ulceration or necrosis at injection site, vasculitis, alopecia, 
hemolytic anemia, pulmonary fibrosis, and interstitial pneumonitis. 
Route  
Intravenous infusion  
5.5 Mesna (Mesnex) 
Source 
& 
Pharmacology  
Mesna is a synthetic sulfhydryl (thiol) compound. Mesna contains free 
sulfhydryl groups that interact chemically with urotoxic metabolites of 
oxaza-phosphorine derivatives such as cyclophosphamide and ifosfamide. 
Oral bioavailability is 50%. Upon injection into the blood, mesna is oxidized 
to mesna disulfide, a totally inert compound. Following glomerular 
filtration, mesna disulfide is rapidly reduced in the renal tubules back to 
mesna, the active form of the drug. Mesna and mesna disulfide are excreted 
primarily via the urine. 
Formulation 
and Stability 
Mesna is available in 2 ml, 4 ml and 100 ml amps containing 100 mg/ml of 
mesna solution. The intact vials can be stored at room temperature. Mesna 
may be further diluted in 5% dextrose or 0.9% NaCl containing solutions. 
Diluted solutions are physically and chemically stable for at least 24 hours 
under refrigeration.  
Supplier 
Commercially available 
Toxicities 
Mesna is generally well tolerated. Nausea and vomiting, headache, diarrhea, 
rash, transient hypotension and allergic reactions have been reported. 
Patients may complain of a bitter taste in their mouth during administration. 
Mesna may cause false positive urine dipstick readings for ketones.  
Dosage 
and 
Administration 
Mesna is generally dosed at approximately 25% of the cyclophosphamide 
dose. It is generally given intravenously prior to and again at 3, 6 and 9 
hours following each dose of cyclophosphamide. 
Route 
Intravenous 
5.6 G-CSF (Filgrastim, Neupogen)  
Source 
& 
Pharmacology 
G-CSF is a biosynthetic hematopoietic agent that is made using recombinant 
DNA technology in cultures of Escherichia coli. G-CSF stimulates 
production, maturation and activation of neutrophils. In addition, 
endogenous G-CSF enhances certain functions of mature neutrophils, 
including phagocytosis, chemotaxis and antibody--dependent cellular 
cytotoxicity. 
Formulation 
and Stability 
G-CSF is supplied in vials containing 300 and 480 mcg of G-CSF at a 
concentration of 300mcg/ml. The intact vials should be stored under 
refrigeration. The vials can be left out of refrigeration for 24 hours, but 
should be discarded if left at room temperature for longer periods of time. G-
CSF can be drawn up into tuberculin syringes for administration and stored 
under refrigeration for up to 7 days prior to usage. G-CSF can be further 


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diluted for intravenous infusion in 5% dextrose. Do not dilute in saline---
precipitate may form. If the final concentration of this product is <15 
mcg/ml, it is recommended that albumin be added to a final concentration of 
2mg/ml (0.2%) to minimize adsorption of the drug to infusion containers and 
equipment.  
Supplier 
Commercially available. 
Toxicities 
G-CSF causes marked leukocytosis. Common adverse reactions include bone 
pain, thrombocytopenia, diarrhea, nausea, rash, alopecia, fever, anorexia and 
pain or bruising at the injection site. Allergic reactions, MI, atrial fibrillation, 
and splenomegaly have been reported rarely. G-CSF is contraindicated in 
participants with allergy to E. coli derived products. 
Route 
Intravenous or subcutaneous. 
 
5.7 Mycophenolate mofetil (MMF, CellCept) 
Source 
& 
Pharmacology  
MMF is hydrolyzed to mycophenolic acid (MPA), an immunosuppressive 
agent. MPA inhibits B and T-cell proliferation, T-cell synthesis, and 
antibody secretion by potent, noncompetitive reversible inhibition of inosine 
monophosphate dehydrogenase (IMPDH) in the purine biosynthesis 
pathway. Inhibition of IMPDH results in a depletion of guanosine 
triphosphate and deoxyguanosine triphosphate, important intermediates in 
the synthesis of lymphocyte DNA, RNA, proteins and glycoproteins. Oral 
formulations of MMF are rapidly and extensively absorbed when given on an 
empty stomach. Aluminum and magnesium-containing antacids and food 
decrease absorption of MMF. MMF is rapidly hydrolyzed to the active 
metabolite (MPA) after oral or intravenous administration. Free MPA is 
conjugated in the liver by glucuronyl transferase to inactive mycophenolic 
acid glucuronide (MPAG) that is excreted in the urine and feces. Time to 
peak plasma concentration is 0.8–1.3 hours, and the mean elimination half-
life is 17.9 hours. Enterohepatic recirculation of MPA contributes to plasma 
concentrations. Administration of cholestyramine interrupts the enterohepatic 
recirculation and can decrease bioavailability by as much as 40%. Patients 
with renal insufficiency have increased plasma concentrations of MPA and 
MPAG. Acyclovir and ganciclovir may compete with MPAG for renal 
tubular secretion, resulting in increased plasma concentrations of both drugs.  
Formulation 
and Stability 
MMF is commercially available as 250 mg capsules, 500 mg tablets, 200 
mg/ml powder for oral suspension, and 500 mg vials of powder for injection.  
Supplier 
Hoffmann La Roche, Inc.  
Toxicities  
AE seen in patients taking MMF include hypertension, hypotension, 
peripheral edema, leukopenia, anemia, thrombocytopenia, hypochromic 
anemia, leukocytosis, headache, insomnia, dizziness, tremor, anxiety, 
paresthesia, hyperglycemia, hypercholesterolemia, hypokalemia, diarrhea, 
hyperkalemia, hypophosphatemia, constipation, nausea, vomiting, anorexia, 
abdominal pain, dyspepsia, urinary burning or frequency, renal tubular 
necrosis, hematuria, increase serum creatinine and BUN, a variety of 
infections due to immunosuppression, rash, acne, ocular changes (cataracts, 


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blepharitis, keratitis, glaucoma, and macular abnormalities) occasional leg 
cramps or pain, bone pain, myalgias, and hand cramps. Intravenous infusions 
have been reported to cause thrombosis and phlebitis. There have been 
occasional reports of gastrointestinal hemorrhage. High dose therapy with 
mycophenolate in adults with psoriasis has been associated with the 
following neoplasms: adenocarcinoma of the breast and colon, basal cell 
carcinoma, carcinoma of the gallbladder, histiocytic lymphoma, glioblastoma 
multiforme, and squamous cell carcinoma of the epiglottis.  
Route  
Oral or intravenous 
5.8 Tacrolimus (FK506, Prograf®, Protopic®) 
Source 
& 
Pharmacology  
Tacrolimus is a macrolide immunosuppressant produced by Streptomyce 
tsukubaensis. It inhibits T-lymphocyte activation, although the exact 
mechanism of action is not known. Tacrolimus activity is primarily due to 
the parent drug. The plasma protein binding of tacrolimus is approximately 
99% and is independent of concentration over a range of 5-50 ng/mL. The t½ 
in adult patients ranges from 11-19 hours. Whole blood trough 
concentrations from 31 patients less than 12 years old showed that pediatric 
patients needed higher doses than adults to achieve similar tacrolimus trough 
concentrations. It is extensively metabolized by the mixed-function oxidase 
system, primarily the cytochrome P-450 system (CYP3A) in the liver and to 
a lesser extent in the intestinal mucosa. The main route of elimination is via 
the biliary tract and excretion in feces. A retrospective comparison of Black 
and Caucasian kidney transplant patients indicated that Black patients 
required higher tacrolimus doses to attain similar trough concentrations; 
there were no gender-based differences. The absorption of tacrolimus from 
the gastrointestinal tract is incomplete and variable exhibiting large intra- and 
inter-patient variability. Administration with food significantly decreases the 
rate and extent of absorption. Drugs that stimulate or inhibit hepatic p-450 
enzymes will alter clearance of tacrolimus and close attention to potential 
drug interactions is crucial. 
Formulation 
and Stability 
Intravenous formulation: Tacrolimus is available as a sterile solution 
(tacrolimus injection) containing the equivalent of 5 mg anhydrous 
tacrolimus in 1 mL Each mL contains polyoxyl 60 hydrogenated castor oil 
(HCO-60), 200 mg, and dehydrated alcohol, USP, 80% v/v. Store between 
5°C and 25°C (41°F and 77°F). Oral formulations: It is available for oral 
administration as capsules containing the equivalent of 0.5 mg, 1 mg or 5 mg 
of anhydrous tacrolimus. Inactive ingredients include lactose, hydroxypropyl 
methylcellulose, croscarmellose sodium, and magnesium stearate. The 0.5 
mg capsule shell contains gelatin, titanium dioxide and ferric oxide, the 1 mg 
capsule shell contains gelatin and titanium dioxide, and the 5 mg capsule 
shell contains gelatin, titanium dioxide and ferric oxide. Store at 25°C 
(77°F); excursions permitted to 15°-30°C (59°-86°F). 
Supplier 
Commercially available  
Toxicities  
Immunosuppression results in increased susceptibility to infection and 
possible development of lymphoma and other malignancies, particularly of 


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the skin. After intravenous administration, monitor closely for an acute 
allergic reaction for the first 30 minutes and at frequent intervals thereafter. 
Fetal toxicity has been noted in animals. Common adverse effects are 
headache, hypertension, GI toxicities, fever, immunosuppression, tremor, 
renal dysfunction, hematological abnormalities, CNS abnormalities, 
electrolyte abnormalities, clotting abnormalities, alopecia. Late effects can 
include skin disorders, delayed wound healing, and hirsutism. Insulin-
dependent post-transplant diabetes mellitus (PTDM) was reported in 11-22% 
of tacrolimus treated transplant patients without pretransplant history of 
diabetes mellitus, several human studies. Mild to severe hyperkalemia is 
reported in 8-45% of transplant patients receiving tacrolimus, so serum 
potassium levels should be monitored and potassium-sparing diuretics should 
not be used. To avoid excess nephrotoxicity, tacrolimus should not be used 
simultaneously with cyclosporine or other drugs that may be associated with 
renal dysfunction. Tacrolimus or cyclosporine should be discontinued at least 
24 hours prior to initiating the other. In the presence of elevated tacrolimus 
or cyclosporine concentrations, dosing with the other drug usually should be 
further delayed. It is not recommended that sirolimus and tacrolimus be 
given concomitantly, as serious increases in wound healing complications, 
renal function impairment and insulin-dependent post-transplant diabetes 
mellitus have been observed. Drugs that stimulate or inhibit p-450 enzymes 
will alter clearance of tacrolimus and close attention to potential drug 
interactions is crucial.  
Route  
Oral or intravenous 
5.9 Methylprednisolone (Medrol®, Solu-Medrol)  
Source 
& 
Pharmacology  
Adrenal corticosteroid – anti-inflammatory, immunosuppressant decreases 
inflammation by suppression of migration of polymorphonuclear leukocytes 
and reversal of increased capillary permeability. 
Formulation 
and Stability 
Tablet (4mg), Sodium Succinate powder for injection 125 mg, 500 mg. 
Supplier 
Commercially available. 
Toxicities:  
Toxicities include edema, hypertension, vertigo, seizures, psychoses, 
headache, pseudotumor cerebri, acne, skin atrophy, impaired wound healing, 
Cushing’s syndrome, pituitary adrenal axis suppression, growth suppression, 
glucose intolerance, hypokalemia, alkalosis, peptic ulcer, nausea, vomiting, 
transient leukocytosis, muscle weakness, osteoporosis, fractures, cataracts, 
glaucoma, and increased risk of infection. 
Route  
Intravenous or oral.  
 
5.10 CliniMACSTM System  
The mechanism of action of the CliniMACS Cell Selection System is based on magnetic-
activated cell sorting (MACS). The CliniMACS device is a powerful tool for the isolation 
of many cell types from heterogeneous cell mixtures, (e.g. apheresis products). These can 


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then be separated in a magnetic field using an immunomagnetic label specific for the cell 
type of interest, such as CD3+ human T cells. 
The cells to be isolated are specifically labeled with super-paramagnetic particles by an 
anti-body directed toward a cell surface antigen. After magnetic labeling, the cells are 
separated using a high-gradient magnetic separation column as described below. The 
magnetically labeled cells are retained in the magnetized column while the unlabeled 
cells flow through the column for collection. The retained cells are eluted by removing 
the magnetic field from the column, washing the cells out and collecting them in a 
separate container from the unlabeled cells. 
The super-paramagnetic particles are small in size (about 50 nm in diameter) and are 
composed of iron oxide/hydroxide and dextran conjugated to monoclonal antibodies. 
These magnetic particles form a stable colloidal solution and do not precipitate or 
aggregate in magnetic fields. The antibody conjugated beads used in this system are 
highly specific (e.g. CD3+ cells via OKT3 conjugated beads). High-gradient MACS 
technology has been shown to achieve rapid and highly specific depletion or enrichments 
of large numbers of target cells from BM, cord blood, and normal peripheral blood 
mononuclear cells.  
The CliniMACS device incorporates a strong permanent magnet and a separation column 
with a ferromagnetic matrix to separate the cells labeled with the magnetic particles. The 
high-gradient system allows the application of strong magnetic forces and a rapid de-
magnetization. Small ferromagnetic structures, such as the column matrix, placed in a 
magnetic field concentrate this homogenous field and thereby produce high magnetic 
gradients. In their immediate proximity, the ferromagnetic structures generate magnetic 
forces 10,000-fold greater than in the absence of those structures enabling the retention of 
magnetically labeled cells. After removing the column from the magnet, the rapid de-
magnetization of the column matrix allows the release of retained cells.  
The CliniMACS device is comprised of a computer controlled instrument incorporating a 
strong permanent magnet, a closed-system sterile tubing set containing columns with a 
coated ferromagnetic matrix and a paramagnetic, cell specific, labeling reagent. The 
instrument will separate the cells in a fully automated process yielding a cell population 
highly depleted of CD3+ cells. The CliniMACS device is not licensed by the FDA and 
therefore is investigational. 
The CliniMACS device has separate programs that allow cell selection procedures 
optimized for either depletion (e.g. CD3+ or CD45RA+) or selection of a target cell 
population (e.g. CD34+ or CD56+ cells). The basic mechanism is the same for either 
application; target cells are "tagged" with super-paramagnetic particles and eventually 
separated from the unlabeled cells using the CliniMACS device as described above. The 
desired target cells can either be infused or discarded appropriately.  
 
6.0  
REQUIRED OBSERVATIONS AND EVALUATIONS 
6.1 Standard Pre/Peri/Post-Transplant Evaluations 


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All pre/peri/posttransplant and long-term follow-up evaluations for these participants will 
be carried out as guided by the SOPs of the SJCRH, Department of BMTCT, for 
recipients of allogeneic HCT. Copies of these SOPs and ongoing updates can be found at 
the following site: http://home.web.stjude.org/bone_marrow/clinicalHome.shtml. A 
schedule of these for these assessments is outlined in Appendix D. 
6.2 Long-term Follow-up Evaluations 
In general, recipients of allogeneic HCT at St. Jude are seen at least annually until 10 
years post-transplant in the Department of BMTCT outpatient clinic. For the purpose of 
this study, research participants will be followed to year 1 post-transplantation. At that 
time, transplant recipients will be eligible for enrollment in the institutional long-term 
follow-up protocol for children and young adults who have received stem cell 
transplantation at St. Jude Children’s Research Hospital (BMTFU protocol). 
6.3 Research Testing.  
Timing for the required research tests are summarized in Appendix D. Furthermore, to 
accommodate the studies, flexibility in the date is allowed without a deviation from 
protocol. The degree of flexibility in the timing is also provided in Appendix D.  
6.3.1  Immune Reconstitution 
Standard measures of post-HCT immune reconstitution will be performed as 
delineated in Appendix D. Research testing of Immune Reconstitution will 
include:  
6.3.1.1  VBETA/TREC Research: Thymic output and T cell repertoire. 
6.3.1.2  Lymphocyte Phenotypes Research: T cell and NK cell number and function. 
6.3.1.3  IR-PHENOTYPE 
Donor: Donor UCB cells necessary for research studies will be harvested 
from the discarded bag post infusion, ensuring that UCB cells will not be 
diverted from patient care. Immunophenotypic evaluation of the UCB unit 
prior to infusion will be performed to enumerate the content of naïve, 
memory T cells, regulatory T cells, NK cells, and naïve B cells and memory 
B cells. Samples from haploidentical donors will be obtained if they choose 
to participate in the optional research testing (described below). 
Host: Immunophenotypic evaluation of immune reconstitution in the patient 
will be performed for the enumeration of naïve, memory T cells, regulatory 
T cells and naïve B cells and memory B cells.  
6.3.1.4  T-FUNCTION 
Immune function studies include antigen-specific T-lymphocyte response to 
viral infections, such as herpes viruses (CMV, HSV and VZV), intracellular 
cytokine and cytokine secretion assays. Studies may include an optional skin 
punch biopsy, at the discretion of the PI, to be performed either at the time 
of the pre-transplant BM biopsy, during sedation for radiation treatment or 
at the time of the day 28 BM biopsy. In order to follow viral infections, 
and/or reactivations detected by DNA regardless of copy number, additional 
samples will be collected weekly for the first 100 days post-transplant when 
possible. If infection(s) are detected in non-blood samples (nasal wash, BAL 


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etc), leftover samples may be used for research purposes. Studies to be 
performed in the laboratory of Dr. Paul Thomas in collaboration with Dr. 
Dallas.  
6.3.1.5  HOST-DONOR INTERACTION 
Donor: Donor Haploidentical samples are optional and UCB cells necessary 
for research studies will be minimized. UCB cells will also be harvested 
from the discarded bag post infusion. . Epstein-Barr virus transformed 
lymphoblastoid cell lines (EBV-LCL) will be generated from the donor cells 
obtained from the discarded infusion bag. Donor KIR typing and HLA-
typing will be performed for high resolution HLA-A, HLA-B, HLA-DR, 
HLA-C and HLA-DQ if not available.  
Host: Host and donor immunologic interaction studies may also include an 
optional skin punch biopsy to be performed with the pre-transplant BM 
biopsy to generate fibroblasts. Prior to the start of conditioning, peripheral 
blood samples will be collected to generate EBV-LCL from the patient for 
research studies evaluating donor/host immunologic reactions. 
 
6.4 Research Testing on Haploidentical Donor (optional) 
Donors will be offered the option for participation in research studies of immune 
reconstitution of T cells, B cells, and NK cells. These tests will be obtained after consent 
and preferably prior to growth factor administration. Lymphocyte subset analysis of the 
donor appears to allow for the prediction of the reconstitution of the lymphocyte subsets 
in the research participant after transplantation. Data in larger donor/research participant 
pairs will help to verify these observations. A list of these optional research studies are 
noted in Appendix D and detailed below: 
6.4.1  Lymphocyte Subset Study: Flow cytometry enumeration 
6.4.2  VBETA/TREC Research: Thymic output and T cell repertoire 
6.4.3  Lymphocyte Phenotypes Research: T cell and NK cell number and function 
7.0 EVALUATION CRITERIA 
7.1  Adverse event (AE) monitoring for on-study research participants will be assessed using the 
NCI Common Toxicity Criteria Version 3.0. The specific criteria for adverse event 
monitoring are noted in APPENDIX C. 
7.2 GVHD scoring (acute and chronic) will be evaluated and graded using the criteria found 
in APPENDIX B and Cof this protocol. The COG stem cell committee consensus 
guidelines for establishing organ stage and overall grade of acute GVHD has been 
adopted as the standard GVHD diagnostic guidelines for the Department of BMTCT, and 
will be applied to patients on this protocol (see Appendix B). In addition, acute GVHD 
will be assessed at least once a week for the first 100 days per BMTCT SOP 20.01.  
Appendix C contains a summary of the NIH consensus development project on criteria for 
clinical trials in chronic GVHD. This table will be used for staging/grading of chronic 
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7.3 Performance status will be assessed by Karnofsky/Lansky Performance Scores (age-
dependent) (see APPENDIX A). 
7.4 Hematologic recovery post-transplant will be determined using the engraftment criteria as 
follows:  
(1) Neutrophil engraftment is defined as absolute neutrophil count (ANC) recovery of ≥ 
0.5 x 109/L (500/mm3) for three consecutive laboratory values obtained on different 
days (derived from either donor). Date of engraftment is the date of the first of the 
three consecutive laboratory values. 
(2) Platelet engraftment will be defined as platelet count ≥ 20,000/mm3 for three consecutive 
laboratory values obtained on different days with no platelet transfusions in the 
preceding 7 days. Date of platelet engraftment is the date of the first of the three 
consecutive laboratory values. 
7.5 Primary graft failure will be defined as donor -derived ANC (either donors) never 
meeting or exceeding 500/mm3 for 3 consecutive measurements. Neutrophil engraftment 
occurring after day +42 post-transplant is defined as delayed engraftment. 
7.6 Secondary graft failure or graft rejection will be defined as no evidence of donor chimerism 
by UCB and/or haploidentical donor (<10%), or too few cells to perform adequate 
chimerism analysis, in research participants with prior neutrophil engraftment. 
7.7 Mixed hematopoietic chimerism will be defined as between 10% and 95% donor 
chimerism in the absence of immunosuppressive therapy. 
7.8 Engraftment syndrome, characterized by fever, rash, pulmonary edema, weight gain, liver 
and renal dysfunction, and/or encephalopathy is an early complication of hematopoietic 
stem cell transplantation that occurs around neutrophil engraftment time and is attributed 
to the sudden cytokine discharge associated with robust engraftment of transplanted cells. 
When diagnosed, the following grading will apply: 
 Grade I (mild): transient (<48 hours) low grade fever with or without limited 
rash 
 Grade II (moderate): sustained fever above 39.0˚C (> 48 hours), rash >25% 
body surface area and/or evidence of pulmonary injury (infiltrate or 
hypoxia), requiring corticosteroids and/or intermittent oxygen and 
responding to interventions 
 Grade III (severe): not rapidly responding to interventions, evidence of 
multiple organ dysfunction/failure (e.g. hypoxia requiring continuous 
oxygen, renal impairment requiring HD or CVVH, evidence of 
encephalopathy) 
 Grade 4 (life threatening): pressor or ventilator support indicated 
 
8.0 CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY 
CRITERIA 


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8.1 Recipient Off-therapy Criteria – Recipient participants may remain on-study, but 
considered off therapy, for monitoring if one of the following occurs (off therapy 
participants monitored for disease status and survival only): 
8.1.1 Experiences graft failure/rejection. 
8.1.2 Noncompliance with the protocol. 
8.1.3 Positive pregnancy test after the HSC infusions. 
8.1.4 Recipient requires an additional HSC infusion, and unable to receive these cells 
due to donor issues. 
8.1.5 Physician decides that it is in the best medical interest of the participant. 
8.2 Recipient Off-study Criteria: Recipient participants will remain on study until one of the 
following occurs: 
8.2.1  Withdrawal of consent. 
8.2.2  Death. 
8.2.3  Lost to follow-up or inadequate follow-up per discretion of PI 
8.2.4  Requires an additional transplant procedure using a different allogeneic donor. 
8.2.5 Requires enrollment on another therapeutic study or non-protocol therapy for 
disease. 
8.2.6  Study evaluations are complete (i.e. has completed the month 12 post-HSC 
infusion evaluations, and first annual post-transplant evaluation). 
8.2.7  Development of a significant change in health status at any point of therapy, 
which would render receipt of the transplantation procedure or continuation in the 
study no longer in the participant’s best interest. 
8.2.8 Unable to undergo the primary HCT procedure due to donor and/or donor center 
inability to provide the HSC product. 
8.3 Donor Off-study Criteria: Donor participants will remain on-study until one of the 
following occurs: 
8.3.1 Withdrawal of consent. 
8.3.2 Death. 
8.3.3 Development of a significant change in health status at any point of therapy, 
which would render the donor medically ineligible to serve (or continue to serve) 
as donor; or renders the donor’s continuation in the study no longer in his/her best 
interest. 
8.3.4 Date of corresponding recipient’s off-study date. 
 
9.0 SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS 
9.1 Reporting adverse experiences and deaths 
The following definitions apply: 
Serious event – any event, in which the outcome is fatal or life-threatening, results in 
permanent disability, causes inpatient hospitalization or prolongs existing hospitalization, 
or is a congenital anomaly, cancer, or overdose. 


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Unanticipated adverse event – any event, not identified in their nature, severity, or 
frequency in the current risk documents (e.g., investigator’s brochure), or consistent with 
the investigational plan. 
9.2 Reporting to St. Jude Institutional Review Board (IRB) 
Principal investigators are responsible for promptly reporting to the IRB any adverse 
events that are unanticipated, serious, and that may represent potential harm or increased 
risk to research participants. When an unanticipated death occurs, the PI should report it 
to the Director of Human Subject’s Protection immediately, by phone: (901) 595-4359, 
cell: (901) 336-2894, fax: (901) 595-4361, or e-mail: hsp-1@stjude.org. A reportable 
event entry into TRACKS should follow within 48 hours of notification of the event. 
Serious, unanticipated, and related or possibly related events must be reported within 10 
working days of notification of the event. At the same time, the investigator will notify 
the study sponsor and/or the FDA, as appropriate. All other SAEs and captured AEs will 
be reported to the IRB in the continuing review, with the following exceptions: 
 Any grade III-IV infusion reactions will be reported as soon as possible but every 
effort should be made to assure reporting is no more than within 7 business days 
of the event. 
 Any episodes of overall grade III or IV acute GVHD in participants will be 
reported to the IRB as soon as possible but no more than within approximately 10 
days of the PI’s confirmation of the diagnosis/grade of the event. 
 Clinical diagnosis of PTLPD will be reported to the IRB as soon as possible but 
no more than within 10 days of the PI’s determination of the disorder. 
The principal investigator is responsible for reviewing the aggregate toxicity reports and 
reporting to the IRB if the frequency or severity of serious toxicities exceed those 
expected as defined in the protocol or based on clinical experience or the published 
literature. Any proposed changes in the consent form or research procedures resulting 
from the report are to be prepared by the study team and submitted with the report to the 
IRB for approval. 
Recipient participants will be followed for NCI Grade III-V, and clinically significant I-
II, adverse events from the start of conditioning and throughout the first year post HCT, 
regardless of their relationship to the treatment given. However, all GVHD events will be 
captured on an ongoing basis regardless of stage or grade. 
Haploidentical donor participants will be followed for any serious AE (SAE) and any 
clinically significant AEs (per judgment of PI) that are deemed related to the mobilization 
and/or apheresis procedure from the time of initiation of mobilization growth factors to 7-
days post last day of the apheresis procedure. If the transplant recipient requires a second 
HSC infusion, meaning that the donor is required to undergo the mobilization and 
apheresis procedure again, collection of this donor safety data will restart upon the 
initiation of the subsequent mobilization procedure and continue until 7-days post the last 
day of this apheresis procedure. Timelines for reporting of these donor events to the 
institutional and federal governing agencies will be according to the same timelines noted 
in the following sections. A listing of the captured donor safety data will be provided in a 


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separate table from the transplant recipients within each respective continuing review 
report. Continuing review reports to all regulatory authorities will be structured in a 
manner so that any infusion toxicities or stem cell product related variances will be 
reported in separate listings from all other required elements. 
9.3 Reporting to St. Jude Institutional Biosafety Committee (IBC) 
Continuing review reports will be sent to the IBC on at least an annual basis using the 
most current version of the continuing review form found on the IBC website. The safety 
reports, sent to the IRB for both the donors and stem cell recipients, will be 
simultaneously forwarded to the IBC. Therefore, reporting for safety events to this 
committee will be according to the same timelines as reporting to the IRB. This includes 
notification of achievement of MTD (if/when applicable). As per the direction of the 
IBC, only those protocol revisions and amendments directly related to the CliniMACS 
processing and related reagent(s) will require review and consideration by the IBC. Other 
revisions/amendments will be noted in the IBC continuing review report. 
9.4 Reporting to FDA  
The FDA will be notified in writing (IDE safety report) of any serious and unexpected 
AE associated with an investigational treatment or device; or any results from laboratory 
animal tests that suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity. 
Each notification to the FDA should be made as soon as possible and no later than 15 
calendar days after the sponsor’s initial receipt of the information. The FDA may 
require additional data to be submitted. In each written IND safety report, the sponsor 
shall identify all safety reports previously filed with the IND concerning a similar adverse 
experience, and shall analyze the significance of the adverse experience in light of the 
previous, similar reports where applicable. 
The sponsor shall also notify the FDA by telephone or by facsimile transmission of any 
unexpected fatal or life-threatening experience associated with the use of the 
investigational medication as soon as possible but no later than 7 calendar days after the 
sponsor’s initial receipt of the information. Any grade III-IV infusion reactions will be 
reported as soon as possible but every effort should be made to assure reporting is no 
more than within 7 business days of the event. Follow-up information to a safety 
report must be submitted as soon as the relevant information is available. 
If the results of further investigation show an AE that was not initially determined to be 
reportable should later be deemed reportable, the sponsor shall inform the FDA of the 
event in a written safety report as soon as possible, but no later than 15 calendar days 
after the determination is made. Results of the investigation of other safety information 
shall be submitted, as appropriate, in an information amendment or annual report. 
Continuing review reports, which will include the up-to-date clinical and safety data, will 
be submitted to the FDA at least annually. 
 
9.5 Reporting to St. Jude Office of Regulatory Affairs 


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Copies of all correspondence to the St. Jude IRB, including SAE reports are provided to 
the St. Jude Regulatory Affairs Office. All FDA related correspondence and reporting 
will be conducted through the Regulatory Affairs Office. Adverse event reporting and 
annual reporting will be in accord with the FDA Title 21 CFR312.32 and Title 21 
CFR312.33, respectively. The Regulatory Affairs Office can be reached at 901-595-2347 
(secondary contact: St. Jude Vice President of Clinical Trials Administration 901-595-
2876). 
9.6 Continuing review reports 
Continuing review reports of protocol progress and summaries of adverse events will be 
filed with the St. Jude IRB, and IBC at least annually. 
9.7 Reporting to the St. Jude Data Safety Monitoring Board 
This study has been referred to the St. Jude Data and Safety Monitoring Board (DSMB) 
for regular monitoring. The DSMB is charged with advising the Director and other senior 
leaders of St. Jude on the safety of clinical protocols being conducted by St. Jude 
investigators and on their continuing scientific validity. DSMB monitoring and review for 
this study will be conducted in accordance with the NCI guidance for DSMBs on an 
approximate semiannual basis. The St. Jude DSMB is responsible for ongoing review of 
the protocol and related information such as enrollment, issues related to participant 
safety (specifically toxicities and the risk:benefit ratio of the trial), interim analyses, and 
the overall study conduct necessary to accomplish the primary protocol objectives. This 
includes evaluation of the accrual rate, adherence to the study design, outcome measures, 
and review of protocol related primary outcome data. The PI will meet with DSMB 
during the semiannual visits to review the information submitted and discuss the status of 
the protocol. The DSMB may recommend that the trial be modified, suspended to 
accrual, and/or stopped based on their review.  
9.8 Data submission to Miltenyi Biotec 
Clinical and safety related data will be provided to Miltenyi Biotec, the manufacturer of 
the CliniMACS system. Data will include but is not limited to the transplant research 
participant’s age and diagnosis, donor product(s) related information including donor 
type, the stem cell mobilization, selection, and infusion procedure. Outcome data 
including lymphohematopoietic reconstitution, immunological response, disease response 
and transplant complications will be shared with Miltenyi Biotec. Representatives from 
Miltenyi Biotec will be able to review the participant’s (donor and transplant research 
recipient) laboratory and medical record for data verification purposes. Copies of all 
reports to the institutional and governing regulatory bodies will also be accessible upon 
request. In the event that the protocol is placed on a clinical hold by the PI or governing 
regulatory authorities, representatives from Miltenyi Biotec will be notified as soon as 
possible. 
9.9 Reporting to the Center for International Blood and Marrow Transplant Research  
The Transplant Program at St. Jude is required by the federal government to report 
transplant information to the Center for International Blood and Marrow Transplant 
Research (CIBMTR). The CIBMTR is a research partnership of the International Bone 
Marrow Transplant Registry, the National Marrow Donor Program (NMDP), and the 
Foundation for the Accreditation of Cellular Therapy (FACT). This organization is 
responsible for the collection and maintenance of a standardized data warehouse registry 


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of autologous and all allogeneic (related and unrelated donor) transplants performed in 
the United States. 
The Office of General Counsel, U.S. Department of Health and Human Services, had 
deemed the CIBMTR not a covered entity under the Privacy Rule (45 CFR 164.512), 45 
CFR Parts 160 and 164, and the Health Insurance Portability and Accountability Act 
(HIPPA) of 1996. For this reason, the submission and disclosure of certain protected 
health information (PHI), including that required for CIBMTR, is allowable without the 
individual’s authorization (i.e. consent is waived) when such disclosure is made to public 
health authorities authorized by law for the purpose of preventing or controlling disease, 
injury, or disability. 
Data resulting from this transplant procedure will be sent for general registry purposes to 
comply with the federal government requirements. This information for both donor and 
recipient is submitted using a unique participant identification number. The information 
submitted for haploidentical recipients is less extensive than recipients of other donor 
products. For this reason, variables submitted may include but are not limited to the 
transplant recipient’s date of birth, country/state of current residence, diagnosis, basic 
lympho-hematopoietic reconstitution (e.g. date of ANC and platelet engraftment), post-
HCT disease status, and basic AEs (e.g. GVHD- yes or no), survival status, date/cause of 
death. 
10.0 DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY 
10.1  Data collection 
The St. Jude Cancer Center Clinical Research Associates assigned to the Department of 
BMTCT will assure protocol compliance, and conduct all clinical and safety data 
collection. Data will be entered into an institutional database. The PI will be responsible 
for review of data for accuracy and completeness once entered into the secure 
departmental database. 
10.2  Study monitoring 
This protocol will be monitored for safety and data as per the St. Jude Data and Safety 
Monitoring Plan for Clinical Trials approved by the NCI in 2010, and is considered to be 
in the High Risk III category. The Central Protocol and Data Monitoring Office 
(CPDMO) will verify 100% of the informed consent documentation on all participants 
and verify 100% of St. Jude participants’ eligibility status. The study team will meet at 
appropriate intervals to review case histories and data quality summaries on all 
participants. The St. Jude Clinical Research Monitor will assess protocol and regulatory 
compliance as well as the accuracy and completeness of all data points 100% of study 
enrollees every three months. The protocol will be tracked continuously for the accrual of 
donors and recipients. All AE and SAE reports will be reviewed by the study Principal 
Investigator for type, grade, attribution, duration, timeliness and appropriateness on all 
study participants. All SAE reports will be reviewed by the monitor every 3 months.  
Protocol compliance monitoring will include participant status, eligibility, the informed 
consent process, demographics, staging, study objectives, subgroup assignment, 
treatments, evaluations, responses, participant protocol status, off-study, and off-therapy 
criteria. The Monitor will generate a formal report which is shared with the Principal 
Investigator (PI), study team and the Internal Monitoring Committee (IMC). Monitoring 


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may be conducted more frequently if deemed necessary by the CPDMO or the IMC. 
Continuing reviews by the IRB and CT-SRC will occur at least annually. In addition, 
SAE reports in TRACKS (Total Research and Knowledge System) are reviewed in a 
timely manner by the IRB. The Regulatory Affairs Office will assist the PI in reporting to 
the FDA and other external oversight agencies, as necessary. 
10.3 Confidentiality 
Unique participant numbers will be used in place of an identifier such as a medical record 
number when reporting any data to outside agencies. No research participant names will 
be recorded on the data collection forms. The list containing the unique participant 
numbers and the medical record number will be maintained in a locked file accessible 
only to the study team. 
The medical records of study participants may be reviewed by the St. Jude IRB, FDA, 
clinical research monitors, etc. 
11.0 STATISTICAL CONSIDERATIONS 
11.1 Statistical design and analysis for the primary objectives and stopping rules 
This study is designed as a phase II study. The primary objective of this study is to 
evaluate the rate of neutrophil engraftment by day +42. Neutrophil engraftment for the 
purposes of this objective will be as defined in section 7. 
As detailed in section 2, the use of alternative donors such as haploidentical donors and 
unrelated UCB are frequently needed and largely successful. However, the use of these 
alternative donors is typically complicated with additional problems, particularly poor 
hematopoietic recovery and graft failure.130  
The majority of published experience with alternative (HLA-mismatched) donor 
transplantation in children is with UCB grafts. The COBALT study included 191 children 
with hematologic malignancies who received UCB transplantation with TBI based 
(1350Gy) myeloablative conditioning.60 The cumulative incidence of neutrophil 
engraftment by day 42 was 80%. The New York Blood Center published outcomes on 
1061 patients (78% pediatric) with hematologic malignancies who received 
myeloablative UCBT with units from their bank.63 The cumulative incidence of 
neutrophil engraftment was 74% by day 77. The CIBMTR published a comparison of 
UCB transplantation with HLA-matched unrelated donor transplantation, in which 503 
children with acute leukemia received UCBT.17 They confirmed that although the 
leukemia-free survival was similar, the rate of neutrophil engraftment (and TRM) were 
significantly worse with HLA-mismatched UCB grafts than with HLA-matched BM 
grafts. For UCB recipients, the best neutrophil engraftment was obtained in the rare 6/6 
matched UCB recipients with 85% of the 35 patients achieving neutrophil recovery at 
day +42. In addition, recipients who received a single antigen mismatch UCB unit with 
an appropriately high cell dose (n=154) had a neutrophil engraftment rate of 80% at day 
+42. Recipients of lower cell dose or two antigen mismatch units fared worse. 
Given the data, we consider a rate of successful neutrophil engraftment of less than 80% 
by day +42 to be unacceptable for alternative donor transplantation. The goal of our study 
is to develop a novel preparative regimen to facilitate successful neutrophil engraftment 
of donor graft(s) at a rate of ≥91%. We do not anticipate censoring during the 42 day time 


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period and we can approximate the rate of neutrophil engraftment by day +42 using a 
Binomial distribution. In order to keep the validity of Binomial distribution 
approximation, patients lost for follow up will be counted as a failure to engraft. 
Therefore, in this study, we propose to test the null hypothesis H0: P≤0.80 versus H1: 
P>0.80, where P is the proportion of research participants who engrafted by day +42 after 
HCT. With type I error of 10% and type II error of 20%, Simon’s two stage optimum 
design powered at alternative successful neutrophil engraftment rate P1=0.91 requires 21 
evaluable patients at the first stage and 49 evaluable patients in total76. The stopping rules 
are provided in Table 1, with the understanding that stopping the trial early would be 
suggestive of the proposed transplant strategy not being an effective treatment option for 
this group of patients. The interpretation is that if we observe 17 or fewer participants 
engrafted by day +42 in the first 21 participants, then we would stop the trial for lack of 
efficacy. However, if we observe 18 or more patients engrafted in the first 21 participants 
by day +42 in stage one, then 28 more patients will be enrolled in stage two. If we 
observe 43 or more participants engrafted by day +42 upon completion of the trial, then 
we conclude that the true rate of neutrophil engraftment is at least 80% and our novel 
regimen will be proposed for further development and phase III clinical trial.  
Table 1: Stopping rules for lack of efficacy based on the Simon’s 2-stage optimum 
design (unacceptable low rate of successful neutrophil engraftment by day +42)  
Accept H0 if the number of research participants engrafted 
P0 
P1 
(≤ r1/n1 ) 
(≤ r/n ) 
EN(P0) 
PET(P0) 
0.80 
0.91 
17/21 
42/49 
31 
0.63 
Note: r1 and r denote the number of patients successfully engrafted by day +42; EN(P0) 
denotes the expected sample size under P0; PET(P0) denotes the probability of early 
termination at stage I under P0.  
All participants who receive the prescribed transplant will be evaluable for the primary 
outcome. In addition, any patient who starts the conditioning regimen but stops prior to 
receiving the graft will count as a failure, if the reason for stopping therapy is toxicity 
from the conditioning regimen. Patients who enroll but do not initiate treatment due to 
withdraw of patient, withdraw of donor or health status change to make the treatment not 
in the patient’s best medical interest, etc., will be replaced. Any patient who dies from 
toxicity after neutrophil engraftment but before day +42 will count as having engrafted. 
Any patient who dies prior to neutrophil engraftment will count as a graft failure.  
After the study is finished, for the first primary objective, the rate of neutrophil 
engraftment by day +42 and its 95% Blyth-Still-Casella confidence interval will be 
estimated based on the binomial approximation.  
Table 2 shows the number of haploidentical HCT and the estimated number of KIR 
mismatch cases performed at our institution in last 5 years. With the initiation of UCB 
protocols at SJCRH, the number of referrals for patients requiring alternative donor HCT 
has increased. Furthermore, HAPCORD will be a high priority protocol. Based on this 
table and PI’s estimation, it is expected that approximately 10 patients per year will be 
enrolled in this study. Therefore, the expected accrual period for this study is maximally 


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5 years. Adequate enrollment will be monitored every 6 month and if the accrual is less 
than 50% projected, protocol revision or closure will be considered. 
Table 2: The number of haploidentical HCT performed at St. Jude 2007 to 2012 
Year 
2007 
2008 
2009 
2010 
2011 
2012 
Number haploidentical HCT  
20 
17 
22 
19 
24 
22 
Estimated KIR mismatch 
14 
12 
15 
13 
17 
15 
Estimated KIR matched  
6 
5 
7 
6 
7 
7 
Number of UCBT 
3 
2 
0 
0 
2 
8 
Stopping Rules for Toxicities  
In addition to the stopping rules based on successful neutrophil engraftment, we will 
closely monitor the trial for early excessive toxicities in terms of secondary graft failure, 
severe acute grade III/IV GVHD and therapy related death/mortality (TRM). Secondary 
graft failure is defined in section 7.0. TRM is any death in remission and related to 
protocol therapy. The incidence of secondary graft failure, acute GVHD and transplant 
related deaths will be monitored for 100 days from the date of transplantation for 
application of the stopping rules. Toxicities secondary to non-protocol therapy for post-
transplant persistent or recurrent disease will not count towards the toxicity stopping 
rules.  
In 2007, Eapen et al published the CIBMTR and National Cord Blood Program outcomes 
of 503 pediatric patients undergoing UCBT for acute leukemia in the United States. The 
study reports a rate of 40% (188/468) for TRM and 23% (110/486) for acute grade III/IV 
GVHD. The rate for graft failure was 18% (89/500). Similar rates were reported for 
patients aged 16 years or over who underwent a transplant for acute leukemia in 2010.  
The safety endpoints will be monitored independently and if there is evidence suggesting 
that the rate of secondary graft failure is greater than 20% or the rate of stage III/IV acute 
GVHD is greater than 30% (type I error rate 20%), or the rate of TRM is greater than 
25%, stopping the trial or amending the therapy will be considered. The planned interim 
evaluation time points and stopping rules based on the exact upper 90% Blyth-Still-
Casella confidence bounds for each of the three endpoints are provided in Tables 3-5 
Table 3. Stopping Rules for Toxicities Based on Grades 3-4 acute GVHD within the 
First 100 Days Post-transplant  
No. of Research 
Participants Enrolled 
No. of Grades 3-4 acute 
GVHD Observed 
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 5 
0.3199 
≤ 35 
≥ 9 
0.3199 
≤ 49 
≥ 12 
0.3023 
 
 
Table 4. Stopping Rules for Toxicities Based on TRM within the first 100 days Post-
transplant 


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No. of Research 
Participants Enrolled  
No. of Therapy Related 
Death Observed  
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 3 
0.2778 
≤ 35 
≥ 6 
0.2647 
≤ 49 
≥ 9 
0.2695 
 
Table 5. Stopping Rules for Secondary Graft Failure within the First 100 Days Post-
transplant 
No. of Research 
Participants Enrolled  
No. of Secondary Graft 
Failure Observed  
Exact Upper Confidence 
Bounds 
≤ 21 
≥ 2 
0.2178 
≤ 35 
≥ 4 
0.2103 
≤ 49 
≥ 6 
0.2011 
Based on the above Table 3, if five grades 3-4 acute GVHD occur within the first 100 
days post transplantation in the first twenty-one evaluable research participants treated, 
then stopping the trial and/or amending the study will be considered. Similarly, if we 
observe three TRMs (Table 4) or two secondary graft failures (Table 5) in the the first 
100 days after transplantation in the first twenty-one evaluable research participants, then 
temporarily stopping the trial and amending the study will be considered. It may be noted 
that the above stopping rules are “ad hoc” in nature.  
 
11.2 Statistical analysis for secondary objectives  
11.2.1  Estimate the incidence of malignant relapse, EFS and OS at one-year post-
transplantation 
The estimate of cumulative incidence of relapse will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The analysis will 
be implemented using SAS macro (bmacro252-Excel2007\cin) available in the St. 
Jude Department of Biostatistics. The Kaplan-Meier estimate of OS and EFS with 
relapse, death due to any cause and graft failure as events along with their 
standard errors will be calculated using the SAS macro (bmacro251-
Excel2007\kme) available in the Department of Biostatistics at St. Jude, where 
OS = min (date of last follow-up, date of death) – date of HCT and all participants 
surviving after 1 year post-transplant will be considered as censored, and EFS = 
min (date of last follow-up, date of relapse, date of graft failure, date of death due 
to any cause) – date of transplant, and all participants surviving at the time of 
analysis without events will be censored. The analysis for this objective will be 
performed when the last evaluable participant has been followed for one-year post 
transplant.  
11.2.2  Estimate the incidence and severity of acute and chronic GVHD in the first 100 
days after HCT. 
The cumulative incidence of acute and chronic GVHD will be estimated using 
Kalbfleisch-Prentice method. Death is the competing risk event. The SAS macro 
(bmacro252-Excel2007\cin) available in the Department of Biostatistics at St. 


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Jude will be used for such analysis. The severity of acute GVHD and chronic 
GVHD will be described. The analysis for this objective will be performed when 
the last evaluable participant has been followed for 100 days post transplant.  
11.2.3 Estimate the incidence of secondary graft failure, transplant related mortality 
(TRM) and transplant related morbidity in the first 100 days after HCT. 
The cumulative incidence of TRM, transplant related mortality, and secondary 
graft failures will be estimated using the same method as used in evaluating 
Objective 11.2.2. Deaths before day 100 because of other reasons are the 
competing risk events for TRM and transplant related mortality. Deaths due to 
toxicity and relapse before day 100 are the competing risk events for secondary 
graft failure. The analysis for this objective will be performed when the last 
evaluable participant has been followed for 100 days post transplant. 
 
11.3 Analysis for exploratory objectives  
The final results of these exploratory objectives are expected to be available when 
the last evaluable participant has been followed for one-year post transplant. 
11.3.1  Assess the relationship between pre-transplant MRD with transplant outcomes. 
The relationship of pre-transplant MRD and transplant outcomes will be 
examined through Cox proportional hazard model or generalized linear model. 
The model can also be used to adjust for other confounding factors such as 
patient’s age at transplant. 
11.3.2 Record immune reconstitution parameters, including chimerism analysis, 
quantitative lymphocyte subsets, T cell receptor excision circle (TREC) and 
spectratyping. Immunophenotyping and functional assays of T, B, and NK cells 
and lymphocytes will also be evaluated.. All immune reconstitution measures, 
immunophenotyping and functional assay measures will be descriptively 
analyzed. 
11.3.3 Characterize the recovery of Gamma Delta () T cells after HCT, including T 
cell receptor analysis, phenotyping and functional analysis. All Gamma Delta T 
cell measures will be descriptively analyzed. 
11.3.4 Characterize influenza infection during HCT by monitoring viral isolates and key 
host factors associated with influenza susceptibility. All Influenza infection 
monitoring will be descriptively analyzed. 
 
12.0 OBTAINING INFORMED CONSENT 
The ongoing informed consent process will be carried out per the policies and procedures put 
forth in the St. Jude Investigator’s Handbook for Clinical Research (http://home.web.stjude. 
org/clinical_research/administration/doc/handbook.pdf). The PI or physician sub-investigator 
will conduct the signature authorization portion of the consent process.  
12.1 Informed consent prior to research interventions 


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For protocol required research interventions (research samples for baseline immune 
reconstitution evaluation); informed consent must be obtained prior to performing these 
research interventions. 
12.2 Consent at age of majority 
The age of majority in the state of Tennessee is 18 years old. Research participants must 
be consented at the next St. Jude clinic visit after their 18th birthday, and prior to 
performing any research interventions during that visit.  
12.3 Consent when English is not the primary language 
When English is not the patient, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter. This 
information will be documented in the participant’s medical record. Either a certified 
interpreter or the telephone interpreter’s service will be used to translate the consent 
information. The process for obtaining an interpreter and for the use of an interpreter is 
outlined on the Interpreter Services, OHSP, and CPDMO websites. 
  


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36. 
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53. 
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59. 
Gluckman E, Wagner J, Hows J, Kernan N, Bradley B, Broxmeyer HE. Cord blood 
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103. 
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APPENDIX A: 
PERFORMANCE STATUS SCALE 
KARNOFSKY PERFORMANCE STATUS SCALE 
Score General Description 
100 
Normal. No complaints. No evidence of disease. 
90 
Able to carry on normal activity. Minor signs or symptoms of disease. 
80 
Normal activity with effort. Some signs or symptoms of disease. 
70 
Care of self. Unable to carry out normal activity or to do active work. 
60 
Requires occasional assistance, but is able to care for most of his needs. 
50 
Requires considerable assistance and frequent medical care. 
40 
Disabled. Requires special care and assistance. 
30 
Severely disabled. Hospitalization is indicated although death is not imminent. 
20 
Hospitalization necessary, very sick, active support treatment necessary. 
10 
Moribund. Fatal processes progressing rapidly. 
0 
Dead. 
 
 
LANSKY PERFORMANCE STATUS SCALE 
Score  General Description 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both greater restriction of and less time spent in play activity 
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 but able to participate in 
all quiet play and 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 
No play; does not get out of bed 
0 
Unresponsive 
 


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APPENDIX B 
COG STEM CELL COMMITTEE CONSENSUS GUIDELINES FOR ESTABLISHING 
ORGAN STAGE AND OVERALL GRADE OF ACUTE GRAFT VERSUS HOST 
DISEASE (GVHD) 
Table 1 outlines standard criteria for GVHD organ staging. However, confounding clinical 
syndromes (such as non-GVHD causes of hyperbilirubinemia) may make staging GVHD in a 
given organ difficult. In addition, timing of organ specific symptoms affects whether that 
symptom is more or less likely to be true GVHD. Please refer to Tables 2 and 3 to assist you in 
deciding whether to attribute these clinical findings to GVHD, especially in situations where a 
biopsy is not possible. For additional help, please see the text which follows the tables. Table 4 
reviews the approach to assessing GVHD as acute, chronic, or the overlap between the two. 
 
Finally, engraftment syndrome will be reported separately from the GVHD scoring presented 
below. 
 
Engraftment Syndrome 
A clinical syndrome of fever, rash, respiratory distress, and diarrhea has been described, just 
prior to engraftment in patients undergoing unrelated cord blood and mismatched 
transplantation. If, in the judgment of the treating physician, a patient experiences this 
syndrome, details of the event will be recorded in the medical record. 
 
Modified Glucksberg Staging Criteria for Acute Graft versus Host Disease 
 
Table 1: Organ Staging (See tables and text below for details) 
Stage 
Skin 
Liver (bilirubin) 
Gut (stool output/day) 
0 
No GVHD rash 
< 2 mg/dL 
Adult: < 500 mL/day 
Child: < 10 mL/kg/day 
1 
Maculopapular rash 
< 25% BSA 
2-3 mg/dL 
Adult: 500-999 mL/day 
Child: 10-19.9 mL/kg/day. 
Or persistent nausea, vomiting, or 
anorexia, with a positive upper GI 
biopsy. 
2 
Maculopapular rash 
25-50% BSA 
3.1-6 mg/dL 
Adult: 1000-1500 mL/day 
Child: 20-30 mL/kg/day 
3 
Maculopapular rash 
> 50% BSA 
6.1-15 mg/dL 
Adult: > 1500 mL/day 
Child: > 30 mL/kg/day 
4 
Generalized 
erythroderma plus bullous 
formation and 
desquamation > 5% BSA 
>15 mg/dL 
Severe abdominal pain with or 
without ileus, or grossly bloody stool 
(regardless of stool volume). 
 


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Overall Clinical Grade (based on the highest stage obtained):  
Grade 0: No stage 1-4 of any organ 
Grade I: Stage 1-2 skin and no liver or gut involvement 
Grade II: Stage 3 skin, or Stage I liver involvement, or Stage l GI  
Grade III: Stage 0-3 skin, with Stage 2-3 liver, or Stage 2-3 GI  
Grade IV: Stage 4 skin, liver or GI involvement 
 
 
Table 2 Evaluating Liver GVHD in the Absence of Biopsy Confirmation (See Table 3.0 below) 
 
Establishing liver GVHD with no skin or GI GVHD 
No Skin/GI GVHD 
Day 0-35 
Assume no liver GVHD, unless proven by biopsy 
No Skin/GI GVHD  
Day 36-100 
If NO other etiology identified, 
NO improvement with stopping 
hepatotoxic medications/TPN: 
Stage as liver GVHD 
If other etiology identified or improves 
with stopping hepatotoxic drugs/TPN: 
Do not stage as liver GVHD 
 
Establishing liver GVHD with skin or GI GVHD and other cause of hyperbilirubinemia 
Skin and/or GI GVHD 
present 
Worsening bilirubin level 
(includes worsening just prior 
to onset of skin or GI tract 
GVHD) OR stable elevated 
bilirubin despite resolution of 
non-GVHD cause of increased 
bilirubin: 
Stage as liver GVHD 
Stable or improving bilirubin after 
diagnosis of skin or GI GVHD, 
irrespective of treatment: 
Do not stage as liver GVHD 
 
For GI staging:  The “adult” stool output values should be used for patients > 50 kg in weight.  Use 
3 day averages for GI staging based on stool output.  If stool and urine are mixed, stool output is 
presumed to be 50% of total stool/urine mix (see 3.2 below).   
 
For Stage 4 GI:  the term “severe abdominal pain” will be defined as: 
 
a) Pain control requiring institution of opioid use, or an increase in on-going opioid use, PLUS 
b) Pain that significantly impacts performance status, as determined by the treating MD. 
 
If colon or rectal biopsy is +, but stool output is < 500 mL/day (< 10 mL/kg/day), then consider as 
GI stage 0. 
 
There is no modification of liver staging for other causes of hyperbilirubinemia. 


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Changing liver GVHD stage with other cause of hyperbilirubinemia 
Skin and GI GVHD 
stable, improving, or 
absent 
Liver GVHD staging is carried forward without increase in stage until 
other disease process resolves (e.g., if TTP is diagnosed in the presence 
of stage 2 liver GVHD, the liver GVHD stage 2 is carried forward 
despite rising bilirubin level until TTP is resolved. If there is no liver 
GVHD – stage 0 – and new onset TTP, the stage 0 is carried forward 
until TTP is resolved). 
Skin and/or GI GVHD 
worsening 
Liver GVHD is staged according to the Glucksberg criteria. The 
elevated bill is attributed to GVHD alone. 
 
Thus, when skin or GI GVHD is worsening, there is no downgrading of 
liver GVHD staging for other causes of hyperbilirubinemia. (e.g., if 
TTP is diagnosed in the presence of stage 2 liver GVHD and worsening 
skin or GI GVHD, the liver is staged according to the actual bilirubin 
level even if some of the rise in bilirubin is attributed to TIP). 
 
Similarly, even if there is no liver GVHD at onset of a new process, 
(such as TPN cholestasis), but skin or GI GVHD worsen during that 
process, then liver GVHD is diagnosed and staged according to the 
height of the bilirubin. 
 
There is one exception to this: the diagnosis of TTP, with high LDH 
and unconjugated bilirubin precludes the diagnosis and staging of new 
liver GVHD in the absence of a confirmatory liver biopsy. 
 
Table 3 Evaluating GI GVHD in the Absence of Biopsy Confirmation (See Table 4.0 below) 
 
Establishing GI GVHD with new onset diarrhea and no skin or liver GVHD 
No skin/liver GVHD  
Day 0 through engraftment 
Assume no GI GVHD, unless proven by biopsy 
No skin/liver GVHD 
engraftment through Day 100 
NO other etiology of diarrhea 
identified: 
Stage as GI GVHD 
Any other etiology of diarrhea 
identified: 
Do not stage as GI GVHD 
 
Establishing GI GVHD with pre-existing diarrhea and skin or liver GVHD 
Skin and/or liver GVHD 
present 
Worsening diarrhea (includes 
worsening just prior to onset of 
skin or liver GVHD) OR 
persistent diarrhea despite 
resolution of non-GVHD cause: 
Stage as GI GVHD 
Improving diarrhea after the 
diagnosis of skin or liver 
GVHD (irrespective of 
treatment) OR persistent 
diarrhea without resolution of 
underlying non-GVHD cause: 
Do not stage as GI GVHD 
 


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Category 
Time of Symptoms 
after HCT or DLI 
Presence of Acute 
GVHD features 
Presence of Chronic 
GVHD  features 
Acute GVHD 
Classic acute GVHD 
<100 d 
Yes 
No 
Persistent, recurrent, 
or late-onset acute 
>100 d 
Yes 
No 
Chronic GVHD 
Classic chronic GVHD 
No time limit 
No 
Yes 
Overlap syndrome 
No time limit 
Yes 
Yes 
 
Differentiating Acute GVHD, Chronic GVHD, and Overlap Syndrome: 
There is often confusion differentiating acute from chronic GVHD, especially in the setting of 
reduced intensity transplants, DLI and new prophylactic treatments. The NIH Working Group 
recently published new classifications for GVHD: 
 
Table 4 Acute GVHD, Chronic GVHD, and Overlap Syndrome 
 
 
 
 
 
 
 
 
 
 
 
 
 Scoring of acute GVHD may need to occur past day 100. In particular, patients should 
continue to be scored for acute GVHD when classic acute GVHD symptoms 
(maculopapular rash, nausea, vomiting, anorexia, profuse diarrhea - particularly if bloody 
and ileus) persist past day 100 or if identical symptoms previously scored as acute 
GVHD resolve and then recur within 30 days during immunosuppression taper but past 
day 100. 
 
 Those patients being scored as having acute GVHD should NOT have diagnostic or 
distinctive signs of chronic GVHD. 
 
 Patients with both acute and chronic symptoms should be diagnosed as having 
Overlap Syndrome and scored according to their chronic GVHD score. 
 
Further Explanation of Criteria presented in Tables 2 and 3 
 
1.0 Assessment of Skin GVHD 
 
1.1 Presence or Absence of Skin GVHD: Skin GVHD will be considered present if a rash 
characteristic of acute GVHD develops after allogeneic marrow transplantation involving 
more than 25% of the body surface not clearly attributable to causes such as drug 
administration or infection. The extent of the body surface area involved can be estimated by 
the "Rule of Nines". In estimating the extent of skin GVHD, the area involved is calculated 
for individual anatomic areas, such as the arm or leg, and then the total is derived from a 
simple summation. Areas that are non-blanching should not be considered involved 
regardless of the overlying color of the rash (red, brown, etc.). Limited distribution erythema 
(with the exception of palms and soles) in the absence of associated rash elsewhere on the 
body will not be considered GVHD. 
 


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2.0 Assessment of Liver GVHD 
 
2.1 Assessing for the Presence or Absence of Liver GVHD 
 
A. Hyperbilirubinemia (total bilirubin > 2.0 mg/dL) in the absence of other signs of acute 
GVHD in the skin or GI tract: 
 
i) Day 0-35: If hyperbilirubinemia alone is present with no other signs of acute GVHD 
in other organ systems, acute GVHD will not be diagnosed based solely on laboratory 
abnormalities.  
 
Acute GVHD will be diagnosed if findings on histopathology studies of liver from a 
biopsy or autopsy are confirmatory. 
 
ii) Day 35-100: If hyperbilirubinemia (must be conjugated bilirubin) is not improving or 
is exacerbated (especially if serum alkaline phosphatase is increased), in the absence 
of acute GVHD in other organ systems, no other etiologies are identified, and does 
not improve with discontinuation of hepatotoxic drugs, acute GVHD will be 
diagnosed. However, it is distinctly unusual to develop ascites or a coagulopathy in 
the early stages of acute GVHD of the liver alone. In the absence of histopathology 
studies of liver from a biopsy or autopsy specimen, ascites or a coagulopathy 
secondary to liver dysfunction will be considered to indicate the presence of another 
disease process (e.g., veno-occlusive disease). Recommended non-invasive studies to 
define an etiology for hyperbilirubinemia are: 
 
a. Imaging of liver (CT or ultrasound) 
b. Hepatitis screen (only if ALT is elevated) 
c. PT 
d. Blood cultures 
e. Review of medication list for potentially hepatotoxic drugs 
f. Review of risk factors for viral liver infection (HSV, CMV, VZV, adenovirus, 
EBV, HBV, and HCV) 
g. Hemolysis screen 
 
B. Pre-existing hyperbilirubinemia clearly attributed to an etiology other than acute GVHD 
in the presence of signs of acute GVHD in other organ systems. 
 
i) If pre-existing non-GVHD liver disease (documented clinically, by lab assessment, or 
by imaging studies) is stable or improving at the onset of signs of acute GVHD in 
other organs, then acute GVHD of the liver will not be considered to be present 
unless proven by liver biopsy or autopsy. 
 
ii) If hyperbilirubinemia worsens several days before or at the time of onset of signs of 
acute GVHD in other organ systems, GVHD will be considered to be present unless 
histopathology studies of liver are available and negative on a biopsy during that time 
interval or autopsy results exclude GVHD. 
 


HAPCORD 62 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
iii) If hyperbilirubinemia persists and is not improving after resolution of a pre-existing 
non-GVHD liver disease process (e.g., localized infection of liver, systemic sepsis, 
biliary tract obstruction) when signs of acute GVHD are present in other organ 
systems or no other intervening cause has been diagnosed, then acute GVHD will be 
considered to be present in the absence of a new, clearly identifiable cause of non-
GVHD liver disease or unless a liver biopsy or autopsy specimen is negative. 
 
C. Prior acute GVHD in liver with new onset of a disease process that exacerbates pre-
existing or recently resolved hyperbilirubinemia: 
 
i) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia and acute liver GVHD has been diagnosed and has been stable, 
improving, or resolved, then the liver will not be restaged for acute GVHD until the 
resolution or stabilizing of the concurrent disease process (i.e., the liver stage prior to 
the onset of the new disease process will be carried forward until the new disease 
process resolves). Example: Acute GVHD of the liver and gut is diagnosed on day 20. 
Treatment of acute GVHD results in falling bilirubin levels to liver stage 1. Sepsis or 
TTP develops with transient worsening of the hyperbilirubinemia. The liver stage is 
not increased, despite a higher bilirubin level, because the cause of worsening 
hyperbilirubinemia is attributed to sepsis or TTP. 
 
ii) If an etiology other than acute GVHD is clearly identified as causing or exacerbating 
hyperbilirubinemia in the presence of already worsening acute liver GVHD or 
GVHD of the skin or GI tract is simultaneously worsening, then the liver GVHD will 
be staged according to the actual bilirubin level, even though another cause of 
hyperbilirubinemia is present. 
 
3.0 Assessment of GVHD of the Gastrointestinal Tract 
 
3.1 Assessing for the Presence or Absence of GVHD of the Gastrointestinal Tract 
 
A. Diarrhea (>500 mL/day in adults or > 10 mL/kg in pediatric patients) in the absence of 
other signs of acute GVHD in other organ systems 
 
i) Day 0-engraftment: If diarrhea alone is present without other signs of acute GVHD in 
other organ systems, acute GVHD will not be considered present. Diarrhea will be 
attributed to acute GVHD if histopathology studies of gastrointestinal tract from a 
biopsy or autopsy are diagnostic. 
 
ii) Engraftment-day 100: If diarrhea persists and is not improving, is exacerbated, or 
develops de novo in the absence of acute GVHD in other organ systems, 
histopathology studies of gut biopsies or from autopsy specimens are not available, 
and no other etiologies are clearly identified, acute GVHD will be considered to be 
the cause. A stool specimen should be examined to rule out infectious causes (e.g., 
rotavirus, adenovirus, and C. difficile toxin). It is recommended, if at all possible, that 
biopsies be obtained for diagnostic purposes. 
 


HAPCORD 63 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
B. Pre-existing diarrhea clearly attributed to an etiology other than acute GVHD in the 
presence of signs of acute GVHD in other organ systems: 
 
i) If pre-existing diarrhea caused by a process other than GVHD has been documented 
clinically or by lab assessment and is stable or improving at the onset of signs of 
acute GVHD in the skin or liver, then acute GVHD of the intestine will not be 
considered to be present in the absence of biopsy confirmation or autopsy report. 
 
ii) If diarrhea or gastrointestinal symptoms are already present, but worsen significantly 
at the time of onset of signs of acute GVHD in the skin or liver, GVHD will be 
considered present, unless biopsy or autopsy are negative. 
 
iii) If diarrhea persists after resolution of a pre-existing disease process with signs of 
acute GVHD present in other organ systems, GVHD will be considered present, 
unless biopsy or autopsy are negative. 
 
C. Prior or present acute GVHD in other organ systems with new onset of diarrhea: 
 
If diarrhea is clearly attributable to an etiology other than acute GVHD (e.g., infection) 
and a history of acute GVHD exists or acute GVHD is present in other organ systems and 
is stable, then the gastrointestinal tract will not be evaluable for acute GVHD until the 
resolution or stabilizing of the other disease process (e.g., infection) in the absence of 
biopsy or autopsy confirmation.  
 
D. Persistent anorexia, nausea or vomiting in the absence of signs of acute GVHD in other 
organ systems: 
 
Persistent anorexia, nausea or vomiting in the absence of other known causes of these 
symptoms will be considered stage I acute GVHD if confirmed by endoscopic biopsy. 
 
If a biopsy is not possible (e.g. secondary to thrombocytopenia) but the clinical findings 
are compatible with acute GVHD, then the patient will be treated and recorded as having 
acute GVHD. 
 
3.2 Staging of the Gastrointestinal Tract for the Severity of Acute GVHD 
 
The severity of gastrointestinal tract GVHD will be staged according to modified Glucksberg 
criteria. To minimize errors caused by large day-to-day variation, diarrhea volume is 
measured as an average over 3 days and reported as the volume in milliliters per day. When 
urinary mixing is noted the stool volume will be considered half of the total volume unless 
nursing staff is able to give a better estimate from direct observation. Abdominal cramps are 
considered significant for staging if the severity results in a clinical intervention (e.g. 
analgesia, fasting, etc.). Blood in the stools is considered significant if the blood is visible or 
hematochezia/melena is present and not clearly attributed to a cause other than GVHD (e.g., 
epistaxis/hemorrhoids). 


HAPCORD 64 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 
APPENDIX C 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
Score 0 
Score 1 
Score 2 
Score 3 
Performance Score: 
________ 
KPS ECOG LPS 
Asymptomatic 
and fully active 
(ECOG 0: KPS 
or LPS 100%) 
 Symptomatic, fully 
ambulatory, restricted 
only in physically 
strenuous activity (ECOG 
1, KPS or LPS 80-90%) 
Symtomatic, 
ambulatory, capable 
of self-care, >50% 
of waking hours out 
of bed (ECOG 2, 
KPS or LPS 60-
70%) 
Symptomatic limited 
self-care, >50% of 
waking hours in bed 
(ECOG 3-4, KPS or 
LPS <60%) 
SKIN 
Clinical features: 
Maculopapular rash 
Lichen 
planus-like 
features 
Papuloquamous lesions 
or ichthyosis 
Hyperpigmentation 
Hypopigmentaion 
Keratosis pilaris 
Erythema 
Erythroderma 
Poikiloderma 
Sclerotic features 
Pruritus 
Hair involvement 
Nail involvement 
% BSA Involved _______ 
 No 
symptoms 
<18% BSA with 
disease signs but 
NOsclerotic features 
 19-50% BSA 
OR involvement 
with superficial 
sclerotic features 
“not hidebound” 
(able to pinch) 
>50% BSA ORdeep 
sclerotic features 
“hidebound” (unable to 
pinch) OR impaired 
mobility, ulceration or 
severe pruritus 
MOUTH 
No symptoms 
 Mild symptoms with 
disease signs but 
NOTlimiting oral intake 
significantly 
 Moderate 
symptoms with 
disease signs 
WITHpartial 
limitation of oral 
intake 
 Severe symptoms 
with disease signs on 
examination WITH 
major limitation of oral 
intake 
EYES 
 
Mean tear test (mm): 
>10 
6-10 
≥5 
Not done 
No symptoms 
 Mild dry eye 
symptoms not affecting 
ADL (requiring eyedrops) 
<3 x per day) OR 
asymptomatic signs of 
keratoconjunctivitissiccca 
 Moderate dry 
eye symptoms 
partially affecting 
ADL (requiring 
drops>3x per day or 
punctual plugs), 
WITHOUTvision 
impairment 
 Severe dry eye 
symptoms significantly 
affecting ADL (special 
eyeware to relieve pain ) 
ORunable to work 
because of ocular 
symptomsOR loss of 
vision cause by 
keratoconjunctivitissicca 
GI Tract 
No symptoms 
 Symptoms such as 
dysphagia, anorexia, 
nausea, vomiting, 
abdominal pain or 
diarrhea without 
significant weight loss 
(<5%) 
 Symptoms 
associated with mild 
to moderate weight 
loss) 5-15%) 
 Symptoms 
associated with 
significant weight loss > 
15%, requires 
nutritional supplement 
for most calorie needs 
OResophageal dilation 
LIVER 
 Normal LFT 
 Elevated Bilirubin, 
AP*, AST or ALT <2 x 
ULN 
 Bilirubin >3 
mg/dl or Bilirubin, 
enzymes 2-3 x ULN 
 Bilirubin or enzymes 
> 5 x ULN 
 
 


HAPCORD 65 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 
APPENDIX C (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
 
SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
Lungs† 
 
 
 
FEV1 ___________ 
 
DLCO __________ 
 No symptoms 
 
 
 
 
 
 FEV1 >80% 
OR 
LFS=2 
 Mild symptoms 
(shortness of breath after 
climbing one flight of 
steps) 
 
 
 FEV1 60-79%  
OR 
LFS 3-5 
 Moderate 
symptoms (shortness 
of breath after 
walking on flat 
ground) 
 
 FEV1 40-59% 
OR 
LFS 6-9 
Severe symptoms 
(shortness of breath 
at rest; requiring 02 
 
 
 
 FEV1 ≥39% OR 
LFS 10-12 
JOINTS AND  
FASCIA 
 No symptoms 
 Mild tightness of arms 
or legs, normal or mild 
decreased range of 
motion (ROM) AND not 
affecting ADL 
 Tightness of arms 
or legs OR joint 
contractures, 
erythema thought 
due to fasciitis, 
moderate decrease 
ROM AND mild to 
moderate limitation 
of ADL 
Contractures 
WITH significant 
decrease or ROM 
AND significant 
limitation of ADL 
(unable to tie shoes, 
button shirts, dress 
self etc.) 
GENITAL TRACT 
 No symptoms 
 Symptomatic with 
mild signs on exam AND 
no effect on coitus and 
minimal discomfort with 
gynecologic exam 
 Symptomatic 
with moderate signs 
on exam AND with 
mild dyspareunia or 
discomfort with 
gynecologic exam 
 Symptomatic 
WITH advance 
signs (stricture, labial 
agglutination or 
severe ulcerations 
AND severe pain 
with coitus or 
inability it insert 
vaginal speculum 
Other indicators, clinical manifestations or complications related to chronic GVHD (check all that apply and assign a 
score to its severity (0-3) based on its functional impact where applicable (none = 0, mild = 1, moderate =2, severe = 3. 
Esophageal stricture or web ____ 
Pericarial Effusion ____ 
 
Pleural Effusion(s) ____ 
Ascites (serositis) ____ 
 
Nephrotic syndrome ____  
Peripheral Neuropathy ____ 
Myasthenia Gravis ____ 
 
Cardiomyopathy ____ 
 
Eosinophilia > 500/µl ____  
Polymyositis ____ Cardiac conduction defects ____ Coronary artery involvement ____ 
Platelets <100,000/µl ____ Progressive Onset ____ 
Other: Specify: ________________________________________________________________________________ 
Organ scoring of chronic GVHD. 
* AP may be elevated in growing children, and not reflective of liver dysfunction.  
† Pulmonary scoring should be performed using both the symptom and pulmonary function testing (PFT) scale whenever 
possible. When discrepancy exists between pulmonary symptoms or PFT scores, the higher value should be used for final 
scoring. Scoring using the Lung Function Score (LFS) is preferred, but if DLCO is not available, grading using FEV1 should be 
used. The LFS is a global assessment of lung function after the diagnosis of bronchiolitis obliterans has already been established. 
The percent predicted FEV1 and DLCO (adjusted for hematocrit but not alveolar volume) should be converted to a numeric score 
as follows: >80% = 1; 70-79% = 2; 60-69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6. The LFS = FEV1 score + DLCO score, 
with a possible range of 2-12. GVHD indicates graft versus host disease, ECOG, Eastern Cooperative Oncology Group, KPS, 
Karnofsky Performance Status; LPS, Lansky Performance Status; BSA, body surface area; ADL, activities of daily living; LFTs, 
liver function tests; AP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; ULN, upper 
limit of normal. 


HAPCORD 66 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 
APPENDIX C (continued) 
CRITERIA FOR GRADING CHRONIC GVHD GRADE 
GLOBAL GRADING OF CHRONIC GVHD84 
 
*Determined by adding the total number of organs receiving score > 0 using Figure 1, 
Appendix B. 
**Defined as the maximum score given to any organ system amongst all organs scored 
using Figure 1, Appendix B.  
Final Grade 
Number of 
Organs/Sites* 
Maximum Organ 
Score** 
Lung Score 
Mild 
1 - 2 
1 
0 
Moderate 
3 or more 
1 
1 
At least 1 
2 
Severe 
At least 1 
3 
2 - 3 


HAPCORD 67 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
APPENDIX D 
CRITERIA FOR ADVERSE EVENT (AE) EVALUATION AND REPORTING 
The St. Jude Department of BMTCT Clinical Research Office standard operating procedure for 
the documenting and reporting of adverse (SOP 10 Documenting and Reporting of Adverse 
Events) will provide guidance on the evaluation, collection and reporting of adverse events for 
this clinical trial. The current version of this document, as well as ongoing updates, can be 
located at the following website: http://home.stjude.org/bmt/Pages/policies-research.aspx 
 


HAPCORD 68 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
APPENDIX E 
Recommended testing and evaluation schedule 
STANDARD OF 
CARE STUDIES 
SAMPLE 
VOLUME 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
Pregnancy test 
PB 
2 ml 
X 
As clinically indicated 
Physical exam 
N/A 
N/A 
X 
Weekly 
X 
X 
CBC with diff. 
PB 
0.5 - 2 ml 
X 
Daily until engrafted, then weekly 
X 
X 
Chemistry 
PB 
0.25- 2 ml 
X 
Weekly 
X 
X 
Viral surveillance 
(BMTPCR) 
PB 
4 ml 
X 
Weekly 
As clinically indicated 
Chimerism 
PB 
1-2 ml 
 
Weekly 
Monthly 
BM 
2 ml 
 
X 
 
X 
 
X 
Disease Status 
Evaluation 
BM 
N/A 
X 
X 
 
X 
 
X 
MRD 
PB 
5 ml 
X 
X 
 
X 
 
X 
BM 
0.2-5 ml 
X 
X 
 
X 
 
X 
Lymphocyte 
Subset Study 
PB 
2.5-4 ml 
X 
Monthly 
Quantitative 
Immunoglobulins 
PB 
2.0 ml 
X 
 
 
Every 3 months after off IVIG for minimum of one month 
 
The information derived from or noted on the physical examinations, standard tests, and other assessments that comprise standard of care for recipients are not required to 
be transcribed onto case report forms and/or entered into the database. In reference to section 6.1 Evaluations, the above-indicated follow-up regimen for these evaluations 
is guided by the SOPs of the Department of BMTCT, for recipients of allogeneic stem cell transplantation. As these evaluations are considered standard clinical care (non-
research), variations in frequency (more or less frequent) of these evaluations can occur due to the participant’s current clinical condition and will not be noted as protocol 
deviations. 
 
Disease status evaluations/BM testing results obtained prior to enrollment may be used for the baseline/pre-infusion assessments. 
 
 MRD PB required for T-Cell ALL only 
 
Lymphocyte subset studies may be omitted without variance when the absolute lymphocyte count (ALC) is zero. 
 
In the event of graft failure/rejection, the post failure/rejection time period BM, chimerism and several of the applicable immune studies will be held, as these 
blood/marrow tests would not be clinically indicated. 


HAPCORD 69 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
APPENDIX E (continued) 
Immune reconstitution testing and evaluation schedule for RECIPIENT 
RESEARCH 
STUDIES 
SAMPLE 
VOL. 
PRE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 6 
MONTH 12 
LABORATORY 
LYMPHOCYTE 
PHENOTYPES 
RESEARCH 
PB 
17.0 ml 
X 
X 
X 
X 
X 
X 
LEUNG LAB 
VBETA/TREC 
RESEARCH 
PB 
17.0 ml 
X 
 
 
X 
X 
X 
LEUNG LAB 
HOST-DONOR 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
HAPLO* 
17.0ml 
X 
 
 
 
 
 
IR-PHENOTYPE 
UCB 
- 
X 
 
 
 
 
 
DALLAS LAB 
PB 
5 ml 
X 
X 
X 
X 
X 
X 
T-FUNCTION 
SKIN 
BIOPSY 
X 
 
 
 
 
 
DALLAS LAB 
PB 
7.5 ml 
X 
X 
X 
X 
X 
X 
PB – VIRAL 
7.5 ml 
 
WEEKLY 
 
 
BM 
1ml 
X 
X 
 
X 
 
 
 
 
VBETA/TREC Research and Lymphocyte Phenotypes Research results will be maintained in a secured database in the Leung laboratory.  
 
HOST-DONOR, IR-PHENOTYPE, T-FUNCTION testing results will be maintained in a secured database in the Dallas laboratory database. Donor sample 
from haploidentical donor is optional and details provides in next table (optional donor studies) 
 
The pre-transplant Skin Biopsy & Bone Marrow for T-FUNCTION are optional additional tests that may be omitted at the discretion of the PI. Skin Biopsy may 
be performed during sedation during procedures (i.e. radiation) or at Month 1 without a protocol variation. 
 
Weekly VIRAL T-FUNCTION studies will be collected Monday –Thursday ONLY (as participant is available), preferred days being Monday & Wednesday.  
 
For RESEARCH studies, the posted volumes are the minimum volumes required to perform the respective protocol evaluations. 
 
 
 
 
 
 
 


HAPCORD 70 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
 
 
 
 
APPENDIX E (continued) 
Research testing for HAPLOIDENTICAL DONOR 
Prior to initial stem cell collection procedure: 
OPTIONAL research immune studies testing schedule 
Evaluation 
Volume Requirement 
Flow cytometry enumeration 
Lymphocyte Subset Study = 4 mL 
Thymic output and T cell repertoire 
VBETA/TREC Research = 17 mL 
T cell and NK cell number and function 
Lymphocyte Phenotypes Research = 17 mL 
Donor Immune Function in Host-Donor Interaction 
HOST-Donor = 17 mL 
 
 All donor research testing to be collected prior to stem cell collection – preferably prior to growth factor administration. 
These optional research tests may be collected at separate times. 


HAPCORD 71 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
APPENDIX E (continued) 
 
Research Study Evaluation Target Windows 
Several laboratory tests can only be processed on weekdays; therefore, if the scheduled 
evaluation falls on a weekend, or during a holiday period, an adjustment in the follow-up visit is 
expected and would not be noted as a protocol variation. Additionally, in order to accommodate 
such logistical constraints, evaluation/collection dates of all protocol assessments (required and 
optional research), may be performed within a reasonable window of the intended date following 
the guidelines provided in the table below: 
If the Planned Evaluation 
Time Point is: 
Window 
Weekly 
+ 3 Days 
Month 1 
Week 2 to Week 6 
Month 2 
Week 7 to Week 11 
Month 3 
Week 12 to Month 4 
Month 6 
Month 5 to Month 7 
Month 9 
Month 8 to Month 10 
Month 12 
Month 10 to Month 14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


HAPCORD 72 
 
Amendment 1.0, dated: 01/08/2016 
 
IRB Approval date: 05/04/2016 
Protocol document date: 01/08/2016 
 
 
  
 
APPENDIX F 
The St. Jude Department of BMTCT Clinical SOPs for standard of care for all allogeneic stem 
cell infusion recipients and stem cell donors will provide guidance on the evaluation, ongoing 
clinical care and follow up for this clinical trial. The current versions of these SOPs, as well as 
ongoing updates, of these documents can be located at the following website: 
http://home.web.stjude.org /bone_marrow/clinicalHome.shtml.