Clinical trial NCT00520130
Conditions: Myelodysplastic Syndrome Hodgkin's Lymphoma Non-Hodgkin's Disease Acute Leukemia Multiple Myeloma
Keywords: Unrelated Donors Reduced Intensity Stem Cell Transplant Leukemia Lymphoma Allogeneic Stem Cell Transplant Myelodysplastic Syndrome Multiple Myeloma
Sponsor: National Cancer Institute (NCI)
Start date: 2007-10-30; Completion date: 2018-12-31
Enrollment: 92 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Background:

Major problems with stem cell transplantation (SCT) for cancer treatment are a lack of suitable donors for patients without a human leukocyte-antigen (HLA) tissue-matched sibling and graft-versus-host disease (GVHD), a serious side effects of immune-suppressing chemotherapy that is given to bring the cancer under control before SCT. In GVHD, the patients immune system attacks the transplanted donor cells.

This study will try to improve the results of SCT from unrelated HLA-matched donors using targeted immune-depleting chemotherapy to bring the cancer under control before transplantation and to lower the chance of graft rejection, followed by reduced-intensity transplant chemotherapy to make the procedure less toxic.

Objectives:

To evaluate the safety and effectiveness of targeted immune-depleting chemotherapy followed by reduced-intensity transplant chemotherapy in patients with advanced cancers of the blood and immune system.

To evaluate the safety and effectiveness of two different drug combinations to prevent GVHD. Both regimens have been successful in preventing GVHD, but they work by different mechanisms and affect the rebuilding of the immune system after the transplant.

Eligibility:

People 18 to 74 years of age with advanced or high-risk cancers of the blood and immune system who do not have a suitable HLA-matched sibling.

Design:

All patients receive chemotherapy before transplant to treat the cancer and suppress immune function.

All patients receive a conditioning regimen of cyclophosphamide for 4 days and fludarabine for 4 days before SCT to prepare for the transplant.

Patients are randomly assigned to one of two combination drug treatments to prevent GHVD as follows:

* Group 1: Tacrolimus starting 3 days before SCT and continuing for 6 months, plus methotrexate on days 1, 3, 6, and 11 post-SCT, plus sirolimus starting 3 days before the SCT and continues for 6 months following SCT.
* Group 2: Alemtuzumab for 4 days starting 8 days before SCT, plus cyclosporine starting 1 day before SCT and continuing for 6 months.

Patients receive the donors stem cells and immune cells 2 days after completing the conditioning regimen.

Patients are followed at the clinic regularly for the first 6 months after SCT, and then less often for at least 5 years. Some visits may include bone marrow aspirates and biopsies, blood draws, and other tests to monitor disease status.

A skin biopsy, oral mucosa biopsy, and saliva collection are done to study chronic GVHD.

...

Detailed description:
Background:

* The major limitations to the broader applicability of allogeneic hematopoietic stem cell transplantation (HSCT) for the treatment of malignancies are lack of suitable donors and therapy-related toxicities which include delayed and incomplete immune reconstitution and graft-versus-host disease (GVHD). Based on the theory that the rapid establishment of donor chimerism was essential for an optimal graft-versus-tumor effect, we have employed a strategy of targeted immune depleting chemotherapy prior to reduced-intensity allogeneic HSCT. It is our intent to investigate this approach in the setting of human leukocyte-antigen (HLA)-matched unrelated donors in a pilot manner.
* A clearly superior GVHD prophylaxis regimen has not been established in the unrelated donor transplant setting. The best results that have been reported are with the combination of alemtuzumab plus cyclosporine \[AC\] and the combination of tacrolimus, methotrexate, and sirolimus \[TMS\]. These two regimens work by mechanisms which are biologically distinct and potentially have markedly different effects upon immune reconstitution that have not been well studied. In addition, neither of these regimens has been assessed for their effects on chronic GVHD using the National Institutes of Health (NIH) Consensus Conference Criteria. It is our intent to study the effects that these two regimens have on immune reconstitution and chronic GVHD in the setting sequential targeted immune-depleting chemotherapy and reduced-intensity allogeneic HSCT from HLA-matched unrelated donors.

Objectives:

* Primary objectives:

  1. to assess the effects of two biologically distinct GVHD prophylaxis regimens, TMS and AC, on immune reconstitution in patients receiving targeted-immune depletion and reduced-intensity allogeneic HSCT from HLA-matched unrelated donors. As part of a comprehensive assessment of immune reconstitution, the primary immunologic endpoint will be the determination of cluster of differentiation 4 (CD4)+ T cell receptor V BETA repertoire by complementarity determining region 3 (CDR3) spectratyping at 3 months post-transplant.
  2. to assess overall safety of these two regimens in this setting, as determined by engraftment, acute GVHD, early and late treatment-related mortality, and overall survival.
  3. to determine and monitor incidence, organ severity and overall severity of chronic GVHD prospectively using the newly developed NIH Consensus Conference diagnosis and staging criteria and preliminarily validate those tools for use in clinical practice and trials.
* Secondary objectives include further assessment of immune reconstitution, study of engraftment kinetics, and assessment of those patients who receive higher doses of anthracyclines for long and short term toxicities

Eligibility:

* Adults (18-74 years) with advanced or high risk hematologic malignancies including acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), myelodysplastic syndrome (MDS), chronic lymphocytic leukemia (CLL), non-hodgkin lymphoma (NHL), hodgkin lymphoma (HL), chronic myelogenous leukemia (CML), multiple myeloma, and myeloproliferative disorder (MPD) who lack a suitable HLA matched sibling.
* An unrelated donor matched at a minimum of 7 of 8 alleles (HLA-A,-B,-C, and DRB1) by high resolution typing, identified through the National Marrow Donor Program.
* Life expectancy of at least 3 months, Eastern Cooperative Oncology Group (ECOG) less than or equal to 2 and relatively normal major organ functions.

Design:

* Patients will receive disease-specific induction chemotherapy (etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (EPOCH-fludarabine (F)/rituximab (R) or fludarabine, cytarabine, and granulocyte colony-stimulating factor (FLAG)) prior to transplant for disease control and immune depletion. If disease is controlled (greater than partial response (PR)) and immune depletion objectives have been met, patients may forgo induction chemotherapy and move forward to the transplant conditioning regimen.
* All patients will receive an identical conditioning regimen consisting of cyclophosphamide 1200 mg/m(2)/day intravenous (IV) for 4 days and fludarabine 30 mg/m(2)/day for 4 days.
* Patients will be stratified according to degree of HLA-match and randomized at the time of enrollment to one of two GHVD prophylaxis regimens:

  * Group 1: Tacrolimus starting 3 days before stem cell transplant (SCT), and continuing for 6 months, plus methotrexate on days 1, 3, 6, and 11 post-SCT, plus sirolimus starting 3 days before the SCT and continues for 6 months following SCT.
  * Group 2: Alemtuzumab for 4 days starting 8 days before SCT, plus cyclosporine starting 1 day before SCT and continuing for 6 months.
* A maximum of 105 patients will be enrolled and randomly assigned to the two arms in order to yield 44 patients per arm (88 total patients) who are able to be evaluated for development of severe chronic GVHD.

Arms: arm 1: TMS Arm arm 2: AC Arm
Interventions: intervention 1: Rituximab intervention 2: Cyclosporine intervention 3: Allogenic stem cell transplant (ASCT) intervention 4: Conditioning Chemotherapy intervention 5: TMS intervention 6: FLAG intervention 7: EPOCH-F intervention 8: Alemtuzumab
Intervention descriptions: intervention 1: Rituximab: 375 mg/m(2) intravenous (IV), day 1 for patients with cluster of differentiation 20 (CD20)-positive disease. intervention 2: Cyclosporine: IV over 2 hours or orally every 12 hours on days -1 to 100, followed by a taper if graft versus host disease (GVHD) does not develop. intervention 3: Allogenic stem cell transplant intervention 4: Fludarabine:30 mg/m(2) per day IV infusion over 30 minutes, daily. On days -6, -5, -4, and -3.

Cyclophosphamide:1200 mg/m(2) per day IV infusion over 2 hours on Days 6, -5, -4, -3 Mesna: 1200 mg/m(2) per day IV infusion, Daily on days 6, -5,-4, and -3 intervention 5: Tacrolimus: starting day -3 before transplant, given initially at 0.02 mg/kg/day CIV. Continue IV and then switch to an equivalent oral dose (when patient taking po) titrated for a goal level of 5 to 10 ng/ml; Sirolimus: given as an initial loading dose of 12 mg p.o. on day -3 pre-transplant, 4 mg starting day -2 pre-transplant and titrated for levels 3-12 ng/ml; Methotrexate 5 mg/m2 IV on days +1, +3, +6, and +11 post-transplant. Tacrolimus and sirolimus will be tapered at day +63, day +119 and day +180 post-transplant as tolerated. intervention 6: Fludarabine:25 mg/m(2) per day IV over 30 minutes, Daily on days 1-5 Cytarabine: 2,000 mg/m(2) IV over 4 hours,on Days 1, 2, 3, 4, 5 Filgrastim: 5 mcg/kg per day subcutaneous (SC) beginning 24 hours PRIOR to initiation of chemotherapy intervention 7: Fludarabine:25 mg/m(2) per day IV infusion over 30 minutes, daily on days 1-4 Etoposide :50 mg/m(2) per day continuous IV infusion over 24 hours on days 1-4 Doxorubicin:10 mg/m(2)/day CIV, days 1-4 Vincristine:0.4 mg/m(2) per day continuous IV infusion over 24 hours daily on days 1-4 Cyclophosphamide:750 mg/m(2) IV infusion over 30 minutes on day 5 intervention 8: Alemtuzumab:20 mg/day IV over 8 h on days 8 to 4 pre-transplant.

Protocol documents:
Prot_SAP_000.pdf: 
Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
                                                                                                                                       1 
 
Abbreviated Title: RIST using Unrelated Donors 
NCI Protocol Number: 07-C-0195 X 
Version Date: September 14, 2018 
NCT Number: NCT00520130 
 
PROTOCOL TITLE: Phase II Trial of Targeted Immune-Depleting Chemotherapy and 
Reduced-Intensity Allogeneic Hematopoietic Stem Cell Transplantation Using 8/8 and 7/8 HLA-
matched Unrelated Donors and Utilizing Two Graft-versus-Host Disease Prophylaxis Regimens 
for the Treatment of Leukemias, Lymphomas, and Pre-malignant Blood Disorders 
 
NCI Principal Investigator:   
 
Steven Pavletic, MD, MS, ETIB, CCR 
 
10 Center Drive, Room 4-3130 
 
Bethesda, MD 20892 
 
Telephone:  240-760-6174 
                                             
E-mail: pavletis@mail.nih.gov 
 
 
 
 
Investigator Roles: 
A. Obtain information by intervening or interacting with living individuals for research purposes 
B. Obtaining identifiable private information about living individuals 
C. Obtaining the voluntary informed consent of individuals to be subjects 
D. Makes decisions about subject eligibility 
E. Studying, interpreting, or analyzing identifiable private information or data/specimens for 
research purposes 
F. Studying, interpreting, or analyzing coded (linked) data or specimens for research purposes 
G. Some/all research activities performed outside NIH 
 
  
 
 
 
Commercial Agents:  Cyclophosphamide, Mesna, Fludarabine, Etoposide, Vincristine, 
Doxorubicin, Rituximab, Cytarabine, Methotrexate, Sirolimus, Tacrolimus, Alemtuzumab


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PRÉCIS 
Background: 
• The major limitations to the broader applicability of allogeneic hematopoietic stem cell 
transplantation (HSCT) for the treatment of malignancies are lack of suitable donors and 
therapy-related toxicities which include delayed and incomplete immune reconstitution and 
graft-versus-host disease (GVHD). Based on the theory that the rapid establishment of donor 
chimerism was essential for an optimal “graft-versus-tumor” effect, we have employed a 
strategy of targeted immune-depleting chemotherapy prior to reduced-intensity allogeneic 
HSCT. It is our intent to investigate this approach in the setting of HLA-matched unrelated 
donors in a pilot manner.  
• A clearly superior GVHD prophylaxis regimen has not been established in the unrelated 
donor transplant setting. The best results that have been reported are with the combination of 
alemtuzumab plus cyclosporine [AC] and the combination of tacrolimus, methotrexate, and 
sirolimus [TMS]. These two regimens work by mechanisms which are biologically distinct 
and potentially have markedly different effects upon immune reconstitution that have not 
been well studied. In addition neither of these regimens has been assessed for their effects on 
chronic GVHD using the NIH Consensus Conference Criteria. It is our intent to study the 
effects that these two regimens have on immune reconstitution and chronic GVHD in the 
setting sequential targeted immune-depleting chemotherapy and reduced-intensity allogeneic 
HSCT from HLA-matched unrelated donors. 
Objectives: 
• Primary objectives:  
1) To assess the effects of two biologically distinct GVHD prophylaxis regimens, TMS and 
AC, on immune reconstitution in patients receiving targeted-immune depletion and 
reduced-intensity allogeneic HSCT from HLA-matched unrelated donors. As part of a 
comprehensive assessment of immune reconstitution, the primary immunologic endpoint 
will be the determination of CD4+ T cell receptor Vβ repertoire by CDR3 spectratyping 
at 3 months, 6 months, and 12 months post-transplant. Samples will be collected on each 
of the patients enrolled in the study. However, due to the time and cost involved in the 
spectratyping analysis, a comprehensive assessment will initially be limited to the first 10 
patients on each arm receiving 10 of 10 HLA-matched unrelated donors After completion 
of this assessment, it will be determined whether or not the analysis should be continued.  
2) To assess overall safety of these two regimens in this setting, as determined by 
engraftment, acute GVHD, early and late treatment-related mortality, and overall 
survival. 
3) To determine and monitor incidence, organ severity and overall severity of chronic 
GVHD prospectively using the newly developed NIH Consensus Conference diagnosis 
and staging criteria and preliminarily validate those tools for use in clinical practice and 
trials (Pavletic, Imanguli, and Cowen). 
Eligibility: 


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
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• Adults (18 – 74 years) with advanced or high risk hematologic malignancies including 
AML, ALL, MDS, CLL, NHL, HL, CML, multiple myeloma, and MPD who lack a 
suitable HLA-matched sibling. 
• An unrelated donor matched at a minimum of 7 of 8 alleles (HLA-A,-B,-C, and DRB1) 
by high-resolution typing, identified through the National Marrow Donor Program. 
• Life expectancy of at least 3 months, ECOG < 2 and relatively normal major organ 
functions. 
Design: 
• Patients will receive disease-specific induction chemotherapy (EPOCH-F/R or FLAG) 
prior to transplant for disease control and immune depletion. If disease is controlled (≥ 
SD) and immune depletion objectives have been met, patients may forgo induction 
chemotherapy and move forward to the transplant conditioning regimen. 
• All 
patients 
will 
receive 
an 
identical 
conditioning 
regimen 
consisting 
of 
cyclophosphamide 1200 mg/m2/day IV for 4 days and fludarabine 30 mg/m2/day for 4 
days. 
• Patients will be stratified according to degree of HLA-match and randomized at the time 
of enrollment to one of two GHVD prophylaxis regimens: 
➢ Arm A (TMS): Tacrolimus, starting day -3 before transplant, given initially at 0.02 
mg/kg/day CIV and then an equivalent oral dose (when patient taking po) titrated for 
a goal level of 5-10 ng/ml; sirolimus given as an initial loading dose of 12 mg p.o. 
on day -3 pre-transplant, 4 mg starting day -2 pre-transplant titrated for levels 3-12 
ng/ml; and methotrexate 5 mg/m2 IV on days +1, +3, +6, and +11 post-transplant. 
Tacrolimus and sirolimus will be tapered at day +63, day +119 and day +180 post-
transplant as tolerated. 
➢ Arm B (AC): Alemtuzumab at 20 mg/day IV over 8 h on days −8 to −4 pre-
transplant and cyclosporine, starting day -1 before transplant, given initially at 2 
mg/kg IV every 12 hours and then an equivalent oral dose (goal level 150-250 
ng/ml) until day 100. Cyclosporine will be tapered by 10% per week between day 
100 and six months). 
• A maximum of 105 patients will be enrolled and randomly assigned to the two arms in 
order to yield 44 patients per arm (88 total patients) who are able to be evaluated for 
development of severe chronic GVHD. This represents an increase of 20 patients over the 
number permitted prior to this amendment: 25 patients (50 total) randomly assigned to 
each arm within the 8/8 match group and 13/arm (26 total) within the 7/8 match group 
(maximum study enrollment = 76 transplanted patients from among up to 85 patients 
registered). 


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TABLE OF CONTENTS 
PRÉCIS ........................................................................................................................................... 2 
TABLE OF CONTENTS ................................................................................................................ 4 
1 
INTRODUCTION .................................................................................................................. 8 
1.1 
Study Objectives .............................................................................................................. 8 
1.2 
Background and Rationale ............................................................................................... 9 
1.3 
Primary Aims ................................................................................................................. 21 
1.4 
Background on Secondary Objectives ........................................................................... 23 
1.5 
Summary ........................................................................................................................ 24 
1.6 
Amendment K Background and Rationale..................................................................... 25 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT ....................................................... 26 
2.1 
Eligibility Criteria – Recipient on Standard Care Therapy: ........................................... 26 
2.2 
Exclusion Criteria – Recipient on Standard Care Therapy: ........................................... 26 
2.3 
Inclusion Criteria - Recipient ......................................................................................... 27 
2.4 
Exclusion Criteria - Recipient ........................................................................................ 31 
2.5 
Inclusion Criteria – Donor.............................................................................................. 32 
2.6 
Exclusion Criteria – Donor ............................................................................................ 33 
2.7 
Research Eligibility Evaluation - Recipient ................................................................... 33 
2.8 
Research Eligibility Evaluation - Donor ........................................................................ 34 
2.9 
Patient Registration ........................................................................................................ 35 
3 
STUDY IMPLEMENTATION ............................................................................................ 37 
3.1 
Study Design .................................................................................................................. 37 
3.2 
Donor Stem Cell Mobilization and Collection (as per NMDP Guidelines) ................... 38 
3.3 
The following items should be obtained within 48 hours before starting induction 
chemotherapy: ........................................................................................................................... 39 
3.4 
The following tests may be performed at any time prior to Treatment Arm enrollment 39 
3.5 
Induction Chemotherapy for the Recipient .................................................................... 39 
3.6 
Transplant Conditioning Regimen ................................................................................. 47 
3.7 
Allogeneic Peripheral Blood Stem Cell Transplantation ............................................... 49 
3.8 
Graft-Versus-Host Disease (GVHD) Prophylaxis ......................................................... 50 
3.9 
Evaluation During Transplantation ................................................................................ 52 
3.10 
Off Study Criteria ....................................................................................................... 53 


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3.11 
Post-Transplantation Evaluation................................................................................. 54 
4 
SUPPORTIVE CARE ........................................................................................................... 55 
4.1 
Infection Prophylaxis ..................................................................................................... 55 
4.2 
Management of Engraftment Syndrome ........................................................................ 56 
4.3 
Treatment Of Mixed Chimerism Or Persistent/Progressive Disease Post-Transplant ... 56 
4.4 
Treatment of Graft-Versus-Host Disease ....................................................................... 58 
4.5 
Menses Suppression and Contraception ......................................................................... 58 
4.6 
Blood Product Support ................................................................................................... 58 
4.7 
Nutritional Support ......................................................................................................... 59 
4.8 
Anti-emetics ................................................................................................................... 59 
4.9 
Hematopoietic Growth Factor Support .......................................................................... 59 
5 
BIOSPECIMEN COLLECTION .......................................................................................... 59 
5.1 
Correlative Studies for Research .................................................................................... 59 
6 
DATA COLLECTION AND EVALUATION ..................................................................... 63 
6.1 
Data Collection ............................................................................................................... 63 
6.2 
Response Criteria ........................................................................................................... 65 
6.3 
Toxicity Criteria ............................................................................................................. 68 
6.4 
Statistical Considerations ............................................................................................... 68 
7 
HUMAN SUBJECT PROTECTIONS ................................................................................. 75 
7.1 
Rationale for Subject Selection ...................................................................................... 75 
7.2 
Participation of Children ................................................................................................ 75 
7.3 
Participation of NIH Subjects Unable to Give Consent ................................................. 75 
7.4 
Risks/Benefits Analysis.................................................................................................. 76 
7.5 
Informed Consent Process and Documentation ............................................................. 76 
8 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
 
77 
8.1 
Definitions ...................................................................................................................... 77 
8.2 
NCI-IRB and Clinical Director Reporting ..................................................................... 78 
8.3 
Data Safety and Monitoring Plan ................................................................................... 79 
8.4 
Record Keeping .............................................................................................................. 80 
9 
PHARMACEUTICAL INFORMATION ............................................................................. 80 
9.1 
CYCLOPHOSPHAMIDE (CTX, Cytoxan, NSC-26271).............................................. 80 


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9.2 
MESNA (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) ........ 81 
9.3 
FILGRASTIM (G-CSF, Neupogen) ........................................................................... 81 
9.4 
CYCLOSPORINE (Gengraf, Sandimmune, Neoral) ..................................................... 82 
9.5 
FLUDARABINE (Fludara, Berlex Laboratories) .......................................................... 83 
9.6 
ETOPOSIDE, DOXORUBICIN, and VINCRISTINE (in EPOCH) ............................. 84 
9.7 
PREDNISONE ............................................................................................................... 85 
9.8 
RITUXIMAB (Rituxan) ................................................................................................. 85 
9.9 
CYTARABINE (Cytosine Arabinoside, Cytosar, ARA-C) ........................................... 87 
9.10 
DIPHENHYDRAMINE ............................................................................................. 88 
9.11 
ACETAMINOPHEN .................................................................................................. 89 
9.12 
VALACYCLOVIR (Valtrex®) .................................................................................. 89 
9.13 
FLUCONAZOLE (Diflucan®) ................................................................................... 89 
9.14 
TRIMETHOPRIM/SULFAMETHOXAZOLE (TMP/SMX, Cotrimoxazole, Bactrim, 
Septra) 90 
9.15 
FUROSEMIDE (Lasix) .............................................................................................. 91 
9.16 
METHOTREXATE (Methotrexate sodium, MTX, NSC-740) .................................. 91 
9.17 
SIROLIMUS (Rapamycin) (Rapamune®, Wyeth-Ayerst Laboratories) ................... 91 
9.18 
Alemtuzumab (CAMPATH-1H, Campath®) ............................................................. 92 
9.19 
Ursodeoxycholic acid (Ursodiol, Actigall®) .............................................................. 93 
9.20 
TACROLIMUS (FK-506, Prograf®) ......................................................................... 94 
10 REFERENCES ..................................................................................................................... 96 
11 APPENDICES .................................................................................................................... 107 
11.1 
Appendix A - PROPHYLAXIS and Treatment of Infectious Complications in 
Allogeneic HSCT Recipients .................................................................................................. 107 
11.2 
Appendix B:  Management of Engraftment Syndrome ............................................ 114 
11.3 
Appendix C - Grading and Management of Acute Graft-Versus-Host Disease ....... 116 
11.4 
Appendix D – NMDP Standards (20th Edition) and NMDP Standard Policies and 
Procedures ............................................................................................................................... 118 
11.5 
Appendix E - NMDP Peripheral Blood Stem Cell Collection Protocol ................... 118 
11.6 
Appendix F - Chronic GVHD Score Sheet [57] ....................................................... 119 
11.7 
Appendix G - Experimental Transplantation and Immunology Branch Preclinical 
Service Policy for Sample Handling ....................................................................................... 123 
11.8 
Appendix H: Flow Sheet......................................................................................... 125 


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11.9 
Appendix I: Risk of relapse Assessment .................................................................. 128 
11.10 
Appendix J: Comobidity Index .............................................................................. 132 
11.11 
Appendix K Case Report Forms ........................................................................... 141 
 


Abbreviated Title: RIST using Unrelated Donors 
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1 
 INTRODUCTION 
1.1 
STUDY OBJECTIVES 
1.1.1 Primary Objectives: 
1.1.1.1 To assess in a pilot manner the effects of two biologically distinct graft-versus-
host disease (GVHD) prophylaxis regimens (tacrolimus/methotrexate/sirolimus 
[TMS] and alemtuzumab/cyclosporine [AC]) on immune reconstitution in 
patients receiving targeted-immune depletion and reduced-intensity allogeneic 
hematopoietic stem cell transplantation (HSCT) from HLA-matched unrelated 
donors. As part of a comprehensive assessment of immune reconstitution, the 
primary immunologic endpoint will be the determination of CD4+ T cell 
receptor Vβ repertoire by CDR3 spectratyping at 3 months and 12 months post-
transplant (Friedman and Korngold). This data will be complemented by 
additional analyses on immune reconstitution as defined by the first five 
secondary objectives. 
1.1.1.2 To assess in a pilot manner the overall safety, as determined by engraftment, 
severe (Grade III-IV) acute GVHD, early and late treatment-related mortality, 
and overall survival, of targeted sequential immune-depleting chemotherapy 
followed by reduced-intensity allogeneic HSCT from HLA-matched unrelated 
donors in the treatment of patients with advanced hematologic malignancies. 
1.1.1.3 To determine and monitor incidence, organ severity and overall severity of 
chronic GVHD prospectively using the  NIH Consensus Conference diagnosis 
and staging criteria and preliminarily validate those tools for use in clinical 
practice and trials (Pavletic, Imanguli, and Cowen). 
1.1.2 Secondary Objectives: 
1.1.2.1 To assess effects of two different GVHD prophylaxis regimens, TMS and AC, 
on CD4+ T cell receptor Vβ repertoire by CDR3 spectratyping at 1, 3, 6, and 12 
months post-transplant (Hakim Lab). 
1.1.2.2 To assess effects of two different GVHD prophylaxis regimens, TMS and AC, 
on CD8+ T cell receptor Vβ repertoire by CDR3 spectratyping at 1, 3, 6, and 12 
months post-transplant (Hakim Lab). 
1.1.2.3 To assess effects of two different GVHD prophylaxis regimens, TMS and AC, 
on the kinetics of CD4+ and CD8+ T-cells and NK cell depletion and recovery 
following the use of two different GVHD prophylaxis regimens, TMS and AC, 
in the setting of reduced-intensity allogeneic HSCT from HLA-matched 
unrelated donors (Hakim, Gress, and Hardy). 
1.1.2.4 To correlate serum interleukin-7 and interleukin-15 levels during early immune 
reconstitution after two different GVHD prophylaxis regimens, TMS and AC, 
in the setting of sequential targeted immune-depleting chemotherapy followed 
by reduced-intensity allogeneic HSCT from HLA-matched unrelated donors 
(Mackall and Hakim). 


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1.1.2.5 To characterize the pattern of post-transplant CD14+ monocyte production of 
inflammatory cytokines IL-1-α and TNF-α following the use of two different 
GVHD prophylaxis regimens, TMS and AC, in the setting of reduced-intensity 
allogeneic HSCT from HLA-matched unrelated donors (Hakim lab). 
1.1.2.6 To assess the impact of two different GVHD prophylaxis regimens (TMS and 
AC) on donor/recipient chimerism in the setting of sequential targeted immune-
depleting chemotherapy followed by reduced-intensity allogeneic HSCT from 
HLA-matched unrelated donors. 
1.1.2.7 To determine the incidence and severity of acute GVHD following sequential 
targeted immune-depleting chemotherapy and reduced-intensity allogeneic 
HSCT from HLA-matched unrelated donors using two different GVHD 
prophylaxis regimens, TMS and AC. 
1.1.2.8 To evaluate the feasibility of isolating and expanding clinically relevant 
numbers of tumor derived lymphocytes from patients’ bone marrow or lymph 
nodes (Hardy). 
1.1.2.9 To prospectively evaluate the pathogenesis of chronic GVHD by examining the 
immune cell reconstitution in the target tissues and cellular and molecular 
events preceding and coinciding with the clinical onset of chronic GVHD 
(Imanguli, Mays, Cowen, Gress, Hakim and Pavletic). 
1.1.2.10 To prospectively assess long and short term cardiac toxicities of EPOCH-F in 
patients who have received greater than 450mg/m2 of anthracyclines prior to 
study enrollment. 
1.2 
BACKGROUND AND RATIONALE  
Allogeneic hematopoietic stem cell (a.k.a. bone marrow) transplantation (HSCT) is capable of 
producing sustained remissions in a number of hematologic malignancies. However, therapy-
related toxicities, primarily related to the conditioning regimen and GVHD, and the availability 
of suitable allogeneic stem cell donors have limited the broader application of allogeneic HSCT. 
1.2.1 Reduced-Intensity Conditioning Regimens in Allogeneic HSCT 
Early studies of allogeneic HSCT utilized conditioning regimens containing high doses of 
alkylating agents often in combination with total body irradiation [1].  The use of such regimens, 
which are considered “myeloablative”, was perceived as essential both for eradication of 
malignant disease and for suppression of the host-versus-graft response to the donor stem cells 
(i.e. rejection). These myeloablative conditioning regimens caused severe damage to normal 
organs within the body resulting in a high degree and incidence of patient morbidity and 
mortality [2]. This limited the application of allogeneic HSCT to younger (< 60 years) patients, 
who could withstand and recover from these toxicities. However, subsequent studies and 
observations challenged assumptions that myeloablative conditioning regimens were necessary 
to eliminate malignancy and to create the state of immunosuppression to permit the engraftment 
of the donor hematopoietic and immune systems within the recipient. The high frequency of 
relapse observed in the setting of T-cell-depleted allogeneic HSCT suggested that a significant 
proportion of the curative potential of allogeneic HSCT resulted from a T-cell-mediated graft-
versus-tumor (GVT) [3]. The observation that delayed administration of donor lymphocytes 


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could induce complete remissions remote from the preparative regimen provided further 
evidence that an immune mechanism primarily mediates an anti-leukemic effects after allogeneic 
HSCT [4]. With respect to graft rejection, it is also now known that conventional myeloablative 
regimens do not consistently completely eliminate the host response to the allograft, even in 
recipients of HLA-matched allografts.  For example, 30 to 40% of patients will reject a T-cell-
depleted, HLA-matched allogeneic stem cell graft after myeloablative conditioning [5]. In 
addition, there are certain clinical situations where the malignancy is very susceptible to the 
allogeneic GVT effect (e.g. AML in complete remission, chronic leukemias or low-grade 
lymphomas). In these clinical situations the use of a myeloablative conditioning regimen may be 
causing significant toxicity without actually adding any clinical benefit in regard to elimination 
of the malignancy. These limitations of myeloablative conditioning regimens, combined with the 
high levels of morbidity and mortality associated with myeloablation, result in a low therapeutic 
index for this form of allogeneic HSCT. Reducing treatment-related toxicity would improve the 
therapeutic index of allogeneic HSCT, permitting the broader application and potential benefit of 
this treatment to more patients.  This principle led to the development of less intensive (“non-
myeloablative” and “reduced-intensity”) conditioning regimens for allogeneic HSCT, which 
were designed with the purpose of allowing engraftment of donor cells to exploit the potential 
allogeneic GVT effect [6-10]. The early reports of studies employing non-myeloablative and 
reduced-intensity conditioning regimens prior to allogeneic HSCT demonstrated that 
engraftment occurred in the majority of patients, early (first 100 days after transplantation) 
transplant-related toxicities were reduced, and that this treatment could be applied to older 
patients and patients with co-morbidities. However, it was also observed that both non-
myeloablative and reduced-intensity conditioning were associated with high incidences of 
incomplete donor chimerism, higher incidences of graft rejection/failure, and increased relapse 
rates, as compared to results with myeloablative conditioning regimens [11,12]. Mixed 
chimerism and graft rejection has been associated with HLA-disparity, use of unrelated donors, 
and inversely correlated with amount of therapy prior to transplant [13-15].  It was also observed 
that a GVT effect was not observed until full donor chimerism was achieved [16-19]. For this 
reason, a central hypothesis in the design of our transplantation protocols has been that attaining 
full donor chimerism early after transplantation is central to achieving an enhanced GVT effect, 
and that accomplishing this goal with a reduced-intensity preparative regimen depends upon the 
degree of host immunosuppression at the time of HSCT. 
1.2.2 Rationale for Targeted Immune Depletion Induction Prior to Reduced-Intensity 
Conditioning in the Setting of AlloHSCT from Unrelated Donors; Data from HLA-
matched Siblings - CC 99-C-0143, CC 00-C-0119, and CC 03-C-0077   
The objective to achieve rapid and complete donor chimerism following allogeneic HSCT led 
our group to adopt a strategy of sequential targeted immune depletion before transplant 
conditioning. Murine data from the Fowler Laboratory (NCI) demonstrated that daily 
administration of a combination of fludarabine and cyclophosphamide resulted in severe 
reductions in the number of circulating host CD8+ and CD4+ T cells to levels comparable to 
those achieved with myeloablative doses of total body irradiation [20]. This level of T cell 
depletion was sufficient to permit the engraftment of fully MHC-mismatched (i.e. haplo-
identical) allografts (F1-into-parent murine model). The degree of myelosuppression with the 
extended administration of fludarabine and cyclophosphamide was significantly less than with 
total body irradiation (TBI). Taken together, these studies indicated that extended administration 


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                                                                                                                                       11 
 
of agents, which were highly immune-depleting yet had nominal myelosuppressive effects, could 
result in a level of host T cell depletion that would permit the engraftment of haplo-identical 
stem cells. 
We used these preclinical murine data as the basis for our clinical trials design. It was our 
specific intent to design transplantation protocols that would rapidly result in complete donor 
chimerism, in order to optimize the GVT 
effect, since these protocols would be 
used to treat advanced malignancies. For 
many malignancies, however, the GVT 
effect may be inadequate by itself, and the 
cytotoxic effects of the conditioning 
regimen may therefore play a beneficial, 
if not necessary, role in the efficacy of 
allogeneic HSCT [21,22]. 
As such, we elected to employ a reduced-
intensity conditioning regimen, consisting 
of fludarabine and cyclophosphamide, 
rather than a TBI-based non-
myeloablative conditioning regimen. This reduced-intensity conditioning regimen has been 
utilized in all of our transplant protocols for clinical consistency and to permit comparison 
between protocols. Due to the variability of patients’ immune status, we surmised that the level 
of host T cell depletion required to permit the rapid and complete engraftment of allogeneic stem 
cells would not be consistently achieved with the reduced-intensity conditioning regimen alone, 
especially if alternative donor stem cells (e.g. HLA-matched unrelated donors) and/or if T cell 
depletion of the allograft were to be utilized. To achieve uniform immune depletion, we elected 
to employ repetitive doses of immunosuppressive agents that had anti-tumor activity, as patients 
would require disease control prior to receiving a reduced-intensity conditioning regimen. 
However, we determined that the daily administration of these agents, as given in our murine 
model, was clinically impractical. As such, we elected to administer these agents at conventional 
doses in repetitive cycles, similar to how second-line or “salvage” regimens are given prior to 
autologous HSCT [23]. We refer to these as “induction regimens”, as they have the two specific 
goals of inducing severe host T cell depletion as well as inducing disease remission. The most 
unique potential advantage is that the induction regimen would permit us to adjust or “target” the 
level of T cell depletion based upon a patient’s pre- existing immune status. Specifically, the 
number of cycles of the induction regimen is determined by quantification of circulating host T 
cells after each cycle. In summary the rationale for incorporating “targeted immune-depletion” 
using induction chemotherapy in our protocol design (Figure 1) was that it: 1) allows us to 
achieve host T cell depletion in a patient-specific manner, 2) provides disease control, and 3) 
utilizes chemotherapy at doses with minimal levels of toxicity. The targeted immune-depletion 
approach has been applied to all of our allogeneic HSCT protocols. 
We set out to evaluate our targeted immune-depleting approach in a series of sequential trials in 
which one of the factors that affects engraftment was altered in a step-wise fashion. In each 
successive study, the barriers to engraftment (e.g. T cell depletion, HLA-disparity) were 
increased, yet other engraftment variables (e.g. conditioning regimen and stem cell dose) were 
kept consistent to permit comparisons among protocols. Specifically in our first trial, 99-C-0143, 


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we investigated whether our targeted immune-depletion approach would result in rapid and 
complete donor chimerism in patients who received T cell replete (TCR; i.e. T cells were not 
removed from the allograft after collection) allografts from HLA-matched siblings. In 99-C-
0143, we developed a novel induction chemotherapy regimen consisting of fludarabine in 
combination with the agents contained in the EPOCH regimen.  The main purpose of 
administering this induction regimen was to achieve a high level of host immunosuppression 
prior to allogeneic HSCT, in order to attain rapid conversion to full donor chimerism and to 
facilitate the development of a GVT effect soon after transplantation. As a surrogate marker for 
the level of immune depletion necessary to achieve this goal, we chose a peripheral blood CD4 
count of less than 50 cells/l before administration of the transplant preparative regimen. Our 
hypothesis was that this level of host CD4+ T cell depletion, would predict for robust 
engraftment after reduced-intensity allogeneic HSCT and be attainable with up to 3 cycles of 
induction chemotherapy before transplantation. Twenty patients were enrolled onto pilot arm 99-
C-0143. In these 20 patients, the EPOCH-F regimen was very effective at reducing circulating T 
cell numbers, as it was observed that the goal of reducing the host circulating CD4+ T cell 
numbers to less than 50 cells/l was met after one to three cycles of this regimen in the majority 
of patients. All but one patient had a CD4+ T cell value below 100 cells/l after completing the 
last cycle of EPOCH-F. Nineteen patients received a TCR allograft from an HLA-matched 
sibling following the reduced-intensity conditioning regimen consisting of fludarabine and 
cyclophosphamide. Single agent cyclosporine was given as GVHD prophylaxis. Hematopoietic 
recovery was brisk with a median time to an absolute neutrophil count greater than 1.0 x 109/L of 
10 days. All 19 patients were engrafted and there were no late graft failures. Evaluation of 
peripheral blood mononuclear cells for chimerism, as determined by a PCR-based typing of 
variable number tandem repeat (VNTR) polymorphisms for donor and host elements, 
demonstrated that 18 of 19 patients had greater than 95% donor cells by day +14 post-transplant. 
Subsequent analyses at days +28 and +100 post-transplant demonstrated that this level of 
engraftment was sustained.  Subset chimerism analysis demonstrated that there was complete 
donor chimerism in both myeloid (CD15+ or CD33+) and T lymphoid (CD3+) compartments, 
which were also maintained. Thus, with our approach of targeted immune-depletion we were 
able to achieve consistent, rapid, complete donor engraftment of TCR, HLA-matched related 
allogeneic stem cells. However, rapid and complete donor engraftment was also associated with 
a relatively high incidence (~70%) of clinically significant, defined as Grade II-IV, acute GVHD. 
Overall treatment-related mortality was acceptable at approximately 20% at one year post-
transplant. 
In light of these observations, in a subsequent trial, 03-C-0077, we employed a standard dual-
agent GVHD prophylaxis regimen, cyclosporine + methotrexate, to determine the impact of this 
change on hematopoietic recovery, donor/recipient chimerism, and the incidence of acute 
GVHD. Methotrexate, in addition to its known anti-inflammatory activity, is believed to exert its 
immunosuppressive effects by inducing apoptosis and clonal deletion of activated T cells [24]. 
As such, the addition of methotrexate to our prior GVHD prophylaxis of single agent 
cyclosporine could have theoretically increased the frequency of mixed chimerism after 
transplantation, as well as the risk of graft rejection. The other transplant variables were 
otherwise kept the same, as patients again received TCR allografts from HLA-matched siblings. 
Thirty-one patients with advanced hematologic malignancies, primarily lymphomas were 
enrolled onto study and underwent allogeneic HSCT after targeted-immune depletion and 


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reduced-intensity conditioning (Bishop – unpublished data). All patients engrafted; there have 
been no late graft failures with a minimum of two years of follow-up. As had been hypothesized, 
there was a higher percentage (26%) of patients with early (day +14) mixed donor chimerism, 
defined as less than 95% donor chimerism; the median donor chimerism at this time point was 
90% (range: 35-100%). However, by day+100 post-transplant 94% of patients had achieved full 
donor chimerism. The incidence of grade II-III acute GVHD was 42%, and there were no cases 
of Grade IV acute GVHD. The one- and two-year treatment-related mortality rates were 3% and 
8%, respectively. At a minimum of two years of follow-up, 19 patients (61%) are alive of which 
16 are in a complete remission at the time of this writing. Thus, this study demonstrated that the 
addition of methotrexate to the sequential targeted immune depletion approach still permitted 
rapid and complete donor engraftment in the majority of patients and resulted in a lower 
incidence of acute GVHD, improved treatment-related mortality, and beneficial overall outcomes 
in patients with high-risk hematologic malignancies. 
1.2.3 Donor Availability for Allogeneic Hematopoietic Stem Cell Transplantation   
Allogeneic HSCT is curative for many hematologic malignancies, but, as previously stated, stem 
cell donor availability limits the broader application of this treatment.  Only 25 to 30% of 
patients have a sibling donor who is fully matched at the class I and II major histocompatibility 
complex (MHC) loci, which encode for the human leukocyte antigens (HLA-A, B, C, DRB1, 
DQB1, and DPB1).  This limitation prompted the exploration of alternative stem cell sources for 
allogeneic HSCT including the use HLA-matched unrelated donors [25]. Enrollment of volunteer 
donors in national and international registries, such as National Marrow Donor Program 
(NMDP) in the United States, has facilitated the identification of unrelated stem cell donors for 
patients without HLA-matched sibling donors.  However, transplants from unrelated donors are 
complicated by higher rates of graft rejection, acute and chronic GVHD, immune dysregulation, 
and treatment-related mortality. These complications are partially balanced by lower relapse 
rates attributed to increased histocompatibility differences. These complications have limited the 
application of myeloablative allogeneic HSCT from HLA-matched unrelated donors to patients 
less than 55 years of age and without any significant co-morbidities. 
1.2.4 Effect of HLA on Transplant Outcomes:  
Since its inception, the NMDP has required evaluation of donor-recipient histocompatibility 
matching (HLA-A, -B, and –DRB1) prior to unrelated donor HSCT [26]. The minimum 
acceptable match was originally defined by serologic testing at these 3 loci (6 possible antigens) 
and required at least 5 matches, that is, a “5 of 6 match”. This requirement has changed little 
over the years. Currently, to request a donor for transplantation, the minimal acceptable level of 
matching remains a 5 of 6 match for HLA-A, -B, and -DRB1. Although only evaluated at 
antigen level of resolution (“low resolution”) for donor release, each of these 3 loci must now be 
typed at high-resolution by DNA-based methods. High-resolution typing is defined as the 
identification of alleles based on differences in the antigen recognition site (ARS) domains 
(Exons 2 and 3 of Class I and exon 2 of Class II genes). In 2005, a requirement for HLA-C 
typing was added. The most recent studies have clearly shown that transplant outcomes can be 
improved by matching strategies that increase the overall degree of HLA compatibility above the 
minimum accepted level by matching also for HLA-C, -DPB1, -DQB1, and haplotypes [27]. 
As data on high resolution accumulated, the NMDP performed an analysis on the effects of HLA 
matching (low or high resolution or both) on engraftment, graft-versus-host disease (GVHD), 


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                                                                                                                                       14 
 
and mortality in 1874 donor-recipient pairs that were retrospectively typed using high resolution 
techniques for HLA-A, -B, -C, -DRB1, -DQB1, and –DPB1 [28].  There was no effect of any 
mismatch on engraftment, and only a mismatch at HLA-A affected whether the patients 
experienced Grade II-IV acute GVHD or chronic GVHD. Single mismatches at HLA-A, -B, -C, 
and -DRB1 each had similar adverse effects on mortality (relative risk 1.23 - 1.33), as compared 
to individuals matched at all four loci. The 5-year overall survival rates for a match at all four 
loci (“8 of 8” as compared to a single mismatch (“7 of 8”) was 39% and 31%, respectively. In 
this analysis, mismatches at HLA-DQ or -DP did not appear to exert any significant effect on 
survival (5-year overall survival = 39%) or any other outcome. The observed adverse effects on 
outcome were more evident in transplants with low-resolution versus only high-resolution 
mismatches. When high-resolution mismatches at HLA-A, -B, -C, and -DRB1 were considered 
together, adverse effects on survival and GVHD were observed. The authors concluded that 
matching for HLA-C should be incorporated into algorithms for unrelated donor selection, along 
with HLA-A, -B, and -DRB1 (i.e. “8 of 8”). 
In a subsequent analysis, the NMDP looked at data from 3857 transplantations. Patient-donor 
pairs were fully typed for HLA-A, -B, -C, -DRB1, -DQB1, -DQA1, -DPB1, and -DPA1 alleles 
[29]. High-resolution DNA matching for HLA-A, -B, -C, and -DRB1 (8 of 8 match) was the 
minimum level of matching associated with the highest survival. A single mismatch detected by 
low- or high-resolution DNA testing at HLA-A, -B, -C or -DRB1 (7/8 match) was associated 
with higher mortality (relative risk = 1.25; 95% CI, 1.13-1.38; P < 0.001) and 1-year survival of 
43% compared with 52% for 8 of 8 matched pairs. Single mismatches at HLA-B or HLA-C 
appeared to be better tolerated than mismatches at HLA-A or HLA-DRB1. Mismatching at 2 or 
more loci compounded the risk. Mismatching at HLA-DP or -DQ loci and donor factors other 
than HLA type were not associated with survival. In multivariate modeling, patient age, race, 
disease stage, and cytomegalovirus status were as predictive of survival as donor HLA matching. 
The authors concluded that high-resolution DNA matching for HLA-A, -B, -C, and -DRB1 
alleles is associated with higher rates of survival. 
Based on these results, the NMDP has established guidelines relative to donor selection based on 
HLA-typing [26]. The optimal donor should be matched at HLA-A, -B, -C, and -DRB1 by high-
resolution typing. When there are multiple donors with this degree of matching, further matching 
at HLA-DQ may be utilized; however, the clinical utility does not reach statistical significance. 
If a mismatch is unavoidable, a single mismatch at HLA-A, -B, -C, and -DRB1 should be sought. 
In the NMDP data, mismatches at HLA-B and -C may be less detrimental than those at HLA-A 
and -DRB1. 
1.2.5 Experience with Non-myeloablative and Reduced-Intensity Conditioning Regimens from 
Matched Unrelated Donors:  
In light of the high treatment-related morbidity and mortality associated with myeloablative 
allogeneic HSCT from unrelated donors, clinical studies utilizing non-myeloablative and 
reduced-intensity conditioning regimens were initiated after encouraging results with these 
regimens for HLA-matched siblings had been reported. However, because of greater genetic 
disparity between the donors and recipients, it was hypothesized that non-myeloablative 
conditioning regimens for unrelated donor transplantation might require more intense 
immunosuppression than a transplant from an HLA-matched sibling. Since 2001, there have 
been a number of relatively large single-institution and multi-institutional studies on non-


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                                                                                                                                       15 
 
myeloablative and reduced-intensity allogeneic HSCT utilizing unrelated donors (Tables 2A and 
2B) [14,30-34]. It is of significant note that the median ages of recipients have ranged from 44 to 
59 years with patients as old as 72 years successfully undergoing this procedure. As had been 
hypothesized the incidence of graft rejection, ranging from 0 to 21%, was increased. The primary 
adverse factors related to graft rejection were related to use of non-myeloablative (as opposed to 
reduced-intensity) conditioning regimens, HLA-mismatching, use of bone marrow rather than 
mobilized peripheral blood, and a minimal amount of prior therapy prior to transplant. In 
particular, the incidence of graft rejection was as high as 44% among patients who received 
unrelated bone marrow after a TBI-based non-myeloablative conditioning regimen in the 
experience of the Fred Hutchinson Cancer Research Center [14]. Using a variety of GVHD 
prophylaxis regimens, the reported incidences of Grade II-IV and Grade III-IV acute GVHD 
have been 21-63% and 6-39%, respectively. The lowest acute GVHD rates have been achieved 
with regimens employing in vivo T cell depletion with anti-T cell monoclonal antibodies, 
particularly alemtuzumab [31]. This latter approach has also been associated with increased late 
rejections and opportunistic infections. The reported incidence of chronic GVHD have varied 
from 8% to 68% with the lowest rates reported with the use of alemtuzumab. Early (< 100 days 
post-transplant) treatment-related mortality rates have varied from 10 to 48%; one-year 
treatment-related mortality rates have varied from 17 to 55%. One-year overall survival rates 
have been reported to be 32 to 75%. 
 


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Table 2A - Patient and Treatment Characteristics of Reported Trials of Non-myeloablative and Reduced-
intensity Allogeneic HSCT Utilizing HLA-matched Unrelated Donors 
Author/Institute 
Journal/Date 
Patient # 
Median 
Age 
HLA  
Loci 
Degree 
match 
Level of HLA Match 
Conditioning Regimen 
GVHD 
Prophylaxis 
Stem Cell  
Source 
CD34 
Dose 
(106/kg) 
CD3 Dose  
( 108/kg) 
Class I 
Class II 
Giralt et al. MDACC  
Blood 2001 
[Ref #30] 
N = 86  
(URD = 
40) 
52 years  
(22-70) 
6 
6/6 
Serologic Molecular Flu (25 mg/m2/d) x 5d 
Mel 90–140 mg/m2 
Clad (12 mg/m2/d) x 5d  
Mel 90–140 mg/m2 
FK506 x 6 months 
MTX (5 mg/m2) 
+1,+3,+6,+11 
NA 
NA 
NA 
Chakraverty et al. UK 
multi-institute Blood 
2002 
[Ref #31] 
 N = 47 
44 years  
(18–62) 
10 
9-10/10 (s) 
8-10/10 
(m) 
serologic 
– A,B 
molecula
r – C 
Molecular Flu (30 mg/m2/d) x 5d 
Mel 140 mg/m2 
CAMPATH (20 mg/kg)  
-8,-7,-6,-5,-4,-3 
CsA x 3 months 
[CAMPATH] 
BM = 46 
PB = 1 
NA 
NA 
Kroger et al. German 
multi-institute  
Blood 2002 
[Ref #32] 
N = 21 (all 
multiple 
myeloma) 
50 years 
(32-61) 
8 
HLA-A,B, 
DRB1,DQB1 
7-8/8 
Serologic Molecular Flu (30 mg/m2/d) x 5d 
Mel 100 mg/m2 
ATG (10 mg/kg) -3,-2,-1 
CsA x 3 months 
MTX (10 mg/m2) 
+1,+3,+6 
BM = 6 
PB = 15 
3.9 
(0.4 - 12.5) 
NA 
Niederwieser et al. 
FHCRC Consortium  
Blood 2003 
[Ref #33] 
N = 52 
48 years 
(6–65) 
8 (10) 
HLA-A,B,C, 
DRB1, 
(DQB1) 
7-8/8 (s) 
6-8/8 (m) 
Serologic Molecular Flu (30 mg/m2/d) x 3d 
TBI 200 cGy 
CsA x 2-3  months, 
taper until +180) 
MMF x 40d,taper 
BM = 13 
PB = 39 
6.0 (1.5 – 
21.6) 
(BM = 2.7) 
3.4 (0.8 – 
10.0) 
(BM = 0.3) 
Maris et al. FHCRC 
Consortium  
Blood 2003 
[Ref #14] 
N = 85 
53 years 
(5–69) 
10 
HLA-A,B,C, 
DRB1,DQB1 
10/10 
serologic 
(81% 
molecula
r at Class 
I) 
Molecular Flu (30 mg/m2/d) x 3d 
TBI 200 cGy 
CsA x 3 months, 
taper until +180 
MMF x 40d,taper 
BM = 18 
PB = 71 
6.99 (1.26 
-16.4) 
2.61  
(0.8 -37.7) 
Wong et al. MDACC  
Blood 2003 
[Ref #34] 
N = 29 
59 years  
(55-69) 
6 
6/6 
5/6 (n = 2) 
Serologic Molecular Flu (25 mg/m2/d) x 5d 
Mel 90–140 mg/m2 
+/- ATG (n = 17) 
FK506 x 6 - 8 
months 
MTX (5 mg/m2) 
+1,+3,+6,+11 
BM = 28 
PB = 1 
4.46 (0.37 
– 8.6) 
NA 
 
Table 2B. Clinical Outcomes of Reported Trials of Non-myeloablative and Reduced-intensity Allogeneic 
HSCT Utilizing HLA-matched Unrelated Donors 
Author/Institute 
Journal/Date 
Graft 
Rejection and 
Failure 
Acute GVHD 
Chronic 
GVHD 
TRM 
OAS 
II-IV 
III-IV 
Day 100 
1 year 
2 year 
1 year 
2 year 
Giralt et al. 
MDACC Blood 
2001 
5% (n =2) 
62% 
(11 deaths) 
39% 
68% 
37.4% 
NA 
45% (all 
patients)  
32% 
(URD) 
28% (all 
patients) 


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                                                                                                                                       17 
 
Chakraverty et al. 
UK multi-institute 
Blood 2002 
3% (n= 2) 
21.3% 
6.4% 
8% (all 
limited) 
15% 
20% 
(~25%) 
75% 
NA 
Kroger et al. 
German multi-
institute Blood 
2002 
0 
38% 
19% 
37% 
Limited = 
25% 
Extensive = 
12% 
10% 
26% 
NA 
74% 
74% 
Niederwieser et al. 
FHCRC 
Consortium Blood 
2003 
12% 
(low CD3; 
low CD34) 
63% 
21% 
60% 
Limited = 
30% 
Extensive = 
30% 
11% 
29% 
40% 
44% 
35% 
(19 mo) 
Maris et al. 
FHCRC 
Consortium Blood 
2003 
21% (PB vs. 
BM: 15% vs. 
44%) 
52% 
10% 
45% (85) 
Extensive = 
37% 
11% 
17% 
NA 
52% 
(~42%) 
Wong et al. 
MDACC Blood 
2003 
14% (n= 4)  
41% 
20% 
62.5% 
48% 
55% 
NA 
44% 
(~44%) 
 
In regard to specific disease outcomes, data (Figure 2A) from the Center for International Blood 
and Marrow Transplant Research (CIBMTR) demonstrate two-year overall survival rates varying 
between approximately 25-40% depending of the specific hematologic malignancy. CIBMTR 
data (Figure 2B) on one-year treatment mortality rates (26-36%) were consistent with reports 
from single-institution and multi-institutional studies. These data demonstrated that the use of 
non-myeloablative and reduced-intensity conditioning regimens could successfully be performed 
in older patient; however, there is a need for significant correlative studies and clinical 
improvements relative to engraftment, reductions in GVHD, immune reconstitution, treatment-
related mortality, and overall survival, as a clearly superior approach to this treatment has yet to 
emerge. 
Figures 2A and 2B:  CIBMTR Analysis of Overall Survival and Treatment-related Mortality after Non-
Ablative or Reduced-Intensity HSCT with Unrelated Donors 
 
 
 
 
 
 
 
 
1.2.6 GVHD Prophylaxis following Targeted Immune Depletion Induction Prior to Reduced-
Intensity Conditioning in the Setting of AlloHSCT from Unrelated Donors  
Octoer 2001
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
1
2
3
4
Years After Transplant
S
u
r
v
i
v
a
l
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
S
u
r
v
i
v
a
l
CML &MPD   (n = 55)
ALL, AML, MDS  (n = 116)
CLL, Lymphoma  (n = 98)
PCD  (n = 34)
P-Value = 0.29
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
36
72
108
144
180
216
252
288
324
360
Days After Transplant
T
R
M
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
T
R
M
ALL, AML, MDS  (n = 116) 
CML & MPD (n = 55)
CLL, Lymphoma (n = 98)
PCD (n = 34)
July 1999 - August 2000
P–Value = 0.36
Fig 1A: Overall Survival 
Figure 1B: Treatment-related 
Mortality


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                                                                                                                                       18 
 
As described above, the use of a standard dual-agent GVHD prophylaxis regimen, cyclosporine 
+ methotrexate, in 03-C-0077 permitted relative rapid and complete donor engraftment and 
resulted in an acceptable incidence of clinically significant GVHD and a relatively low overall 
treatment-related mortality following our approach of targeted immune depletion prior to 
reduced-intensity conditioning in the setting of allogeneic HSCT from HLA-matched siblings. 
Similar calcineurin-inhibitor-based GVHD prophylaxis regimens (i.e. FK506)/methotrexate) 
have been investigated in the setting of reduced-intensity allogeneic stem cell transplantation 
utilizing unrelated donors [30]. They have been associated with relatively higher rates of GVHD, 
as compared to other regimens that have been employed, particularly alemtuzumab (Table 2B). It 
is predicted that the combination of cyclosporine + methotrexate will be inadequately 
immunosuppressive to prevent clinically severe (grade III-IV) acute GVHD if our targeted 
immune depletion approach were employed in the setting of reduced-intensity allogeneic HSCT 
from unrelated donors. 
The two regimens which have been reported to be most successful at preventing acute GVHD 
following reduced-intensity allogeneic HSCT from unrelated donors have been the combination 
of alemtuzumab and cyclosporine [31] and the combination of tacrolimus, methotrexate, and 
sirolimus [36]. Both regimens have distinct clinical advantages and disadvantages, as well as 
distinct mechanisms of action. 
1.2.7 Tacrolimus/Methotrexate/Sirolimus as Graft-Versus-Host Disease Prophylaxis  
More recently, the immunosuppressive drug sirolimus, which is effective in the prevention of 
renal allograft rejection [31], has been evaluated as a third agent for GVHD prophylaxis after 
allogeneic HSCT from unrelated donors [32]. Sirolimus uniquely inhibits T cell and dendritic 
cell function through inhibition of mTOR, which in contrast to the mRNA inhibition associated 
with calcineurin blockade, operates via a post-transcriptional mechanism to reduce cell signaling 
and modulate protein translation and phosphorylation in T cells [37]. Clinical studies have not 
evaluated single-agent sirolimus for GVHD prophylaxis, and in fact, murine data indicate that 
single-agent sirolimus potently abrogates CD8+ T cell mediated GVHD, but not CD4+ T cell 
mediated GVHD [38].  As such, sirolimus is likely to represent an adjunct to, but not a 
replacement of, calcineurin inhibitor mediated GVHD prophylaxis. Initial results indicate that 
addition of sirolimus to GVHD prophylaxis is effective for the prevention of acute GVHD. 
Investigators at the Dana-Farber Cancer Institute (DFCI) performed a single arm study, which 
involved unrelated donor or mismatched family member bone marrow transplantation, the 
GVHD prophylaxis regimen consisted of calcineurin-inhibitor tacrolimus, methotrexate, and 
sirolimus [36].  Sirolimus was initiated at a loading dose of 12 mg, with a maintenance dose of 4 
mg per day throughout the first 100 days post-transplant.  The incidence of grade II-IV acute 
GVHD associated with this regimen was 26% (11/41), which is reduced relative to historical 
controls previously described above. Sirolimus was also reported to be well-tolerated at this 
dosing schedule, with hyper-triglyceridemia representing the primary specific drug toxicity. 
Sirolimus has been of significant interest and investigation in the Fowler Laboratory. In an 
ongoing clinical protocol, 04-C-0055, short-course sirolimus administration (fourteen day 
treatment interval) has been evaluated in combination with cyclosporine with and without Th2 
cells as GVHD prophylaxis in the setting of non-myeloablative targeted immune depletion and 
TCR allogeneic HSCT from HLA-matched siblings. The Fowler Laboratory hypothesized that 
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within the allograft, thereby resulting in preferential in vivo expansion of sirolimus generated 
Th2 cells.  However, it is also possible that sirolimus alone (i.e. without Th2 cells) would 
contribute to GVHD prophylaxis, as murine allogeneic bone marrow transplantation experiments 
in the Fowler Laboratory demonstrated that short-course sirolimus administration in the peri-
transplant period significantly reduced fully-MHC mismatched graft-versus-host reaction. 
Preliminary results from 04-C-0055 suggest that the arm (III) of this trial receiving only 
cyclosporine and sirolimus (i.e. no Th2 cells) has resulted in an incidence of acute GVHD 
similar to that achieved with cyclosporine + methotrexate. In the first 11 evaluable patients on 
arm III of 04-C-0055, there have only been two case acute GVHD, which were grade I and grade 
II, respectively (D. Fowler - personal communication). 
1.2.8 Alemtuzumab/Cyclosporine as Graft-Versus-Host Disease Prophylaxis:  
Alemtuzumab is a humanized monoclonal antibody that targets the CD52 antigen, which is 
highly expressed on both B and T lymphocytes, and has a relatively long half-life that is 
measured in weeks. Alemtuzumab has been utilized, both ex-vivo and in vivo, to prevent GVHD 
in individuals undergoing allogeneic HSCT from unrelated donors for over 20 years [39]. More 
recently has alemtuzumab has been utilized as part of non-myeloablative conditioning regimens. 
Alemtuzumab has been administered along with non-myeloablative and reduced-intensity 
conditioning regimens to provide pan-depletion of both host and donor B- and T-cells [31,40-
42]. These actions may promote engraftment through the depletion of host T cells and prevent 
GVHD through the in vivo T cell depletion of the allograft. 
Kottardis and colleagues reported on their use of alemtuzumab in high-risk 44 patients with 
hematologic malignancies undergoing non-myeloablative allogeneic HSCT [36]. The 
conditioning regimen consisted of alemtuzumab (20 mg/day on days -8 to -4, fludarabine (30 
mg/m2 on days -7 to -3), and melphalan (140 mg/m2 on day -2). Thirty-six recipients received 
unmanipulated G-CSF mobilized peripheral blood stem cells from HLA-identical siblings, and 8 
received unmanipulated marrow from matched unrelated donors. Additional GVHD prophylaxis 
consisted of cyclosporine alone for 38 patients and cyclosporine plus methotrexate for 6 sibling 
recipients. Forty-two of the 43 evaluable patients had sustained engraftment. Results of 
chimerism analysis demonstrated that 18 of 31 patients studied were full-donor chimeras, while 
the other patients were mixed chimeras in one or more lineages. There were no cases of grades 
III-IV acute GVHD. Only 2 patients developed grade II acute GVHD, and only 1 had chronic 
GVHD. The estimated probability of non-relapse mortality was 11%. Four patients died of 
regimen-related complications. At a median follow-up of 9 months (range: 3 - 29 months), 33 
patients were alive in complete remission or with no evidence of disease progression. Seven 
patients relapsed or progressed post-transplantation, and four of them subsequently died. 
Chakraverty reported on 47 patients with hematological malignancy who underwent allogeneic 
HSCT from HLA-matched, unrelated donors following a non-myeloablative conditioning 
regimen containing alemtuzumab [31]. Additional GVHD prophylaxis consisted of cyclosporine 
alone. The median patient age was 44 years. Twenty of the transplants were mismatched for 
HLA class I and/or class II alleles. Primary graft failure occurred in only 2 of 44 evaluable 
patients (4.5%). Chimerism studies in 34 patients indicated that the majority (85.3%) attained 
initial full donor chimerism. Only 3 patients developed grade III to IV acute GVHD, and no 
patients had developed chronic extensive GVHD at the time of this report. The estimated 
probability of non-relapse mortality at day +100 post-transplant was 14.9%. At a median follow-


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up of 344 days (range: 79-830), the overall and progression-free survival rates at 1 year were 
75.5% and 61.5%, respectively. 
The Spanish and United Kingdom Collaborative Groups for Nonmyeloablative Transplantation 
investigated the efficacy of alemtuzumab as compared with methotrexate for GVHD prophylaxis 
in 129 recipients of a non-myeloablative allogeneic HSCT from an HLA-matched sibling 
enrolled in 2 prospective studies for chronic lymphoproliferative disorders [41]. The 
conditioning regimens in both studies were based on the same combination of fludarabine and 
melphalan, but the United Kingdom (UK) study utilized a GVHD regimen consisting of 
cyclosporine plus alemtuzumab, whereas the Spanish study used cyclosporine plus methotrexate 
for GVHD prophylaxis. Patients receiving alemtuzumab had a higher incidence of 
cytomegalovirus (CMV) reactivation (85% vs. 24%, p < 0.001) and a significantly lower 
incidence of acute GVHD (21.7% vs. 45.1%, p = 0.006) and chronic GVHD (5% vs. 66.7%, p < 
0.001). Twenty-one percent of patients in UK study group and 67.5% in Spanish study group had 
complete or partial responses three months after transplantation (p < 0.001). Eighteen patients in 
the UK study group received donor lymphocyte infusions to achieve disease control. There was 
no difference in disease status between the groups with 71% versus 67.5% (p = 0.43) of patients 
showing complete or partial responses in the UK and Spanish groups, respectively. No 
significant differences were observed in event-free or overall survival between the two groups. 
The use of alemtuzumab in the non-myeloablative transplant setting has been complicated with a 
relative high incidence of cytomegalovirus (CMV) re-activation and infections [42,43]. CMV 
was monitored by polymerase chain reaction-based assays and treated preemptively in 101 
patients who underwent allogeneic HSCT following a non-myeloablative conditioning 
containing alemtuzumab [39]. Fifty-one patients (50%) were observed to have CMV re-
activation at a median of 27 days after transplantation. All three patients who developed clinical 
CMV disease died of this complication in this series. The median time to CD4+ T-cell count 
more than 200/microL was 9 months in the 48 patients studied. The probabilities of overall 
survival and non-relapse mortality at 18 months were 65% and 27.8%, respectively, with no 
significant difference in survival between patients with and without CMV infection. 
1.2.9 Ex vivo T-cell Depletion in Non-myeloablative and Reduced-intensity Allogeneic HSCT  
Relative to other methods of preventing acute GVHD, there have been reports on the use of ex 
vivo T cell depletion following myeloablative allogeneic HSCT from unrelated donors, 
beginning with the first reports on the use unrelated donors [40,41]. Ex vivo T cell depletion 
resulted in decreased acute GVHD, but it was associated with increased graft failure and 
opportunistic infections resulting in no clear survival advantage over unmanipulated grafts in the 
myeloablative setting. This led to a phase III multi-institutional trial in which 405 patients were 
randomized to either ex-vivo T-cell depletion of the marrow with cyclosporine alone (n = 201) 
versus an unmanipulated marrow with methotrexate and cyclosporine (n = 204) as GVHD 
prophylaxis [42]. The primary outcome was 3-year disease-free survival, which was analyzed by 
intention to treat. Disease-free survival at 3 years was 27% and 34% in recipients of T cell 
deplete arm and the methotrexate and cyclosporine arm, respectively (p = 0.16). T cell depletion 
was associated with significantly more rapid neutrophil recovery (15 days vs. 20 days, p < 
0.0001), less grade III-IV acute GVHD (18% vs. 37%, p < 0.0001), reduced grade III-IV 
toxicities (19% vs. 29%, p = 0.017), reduced duration of initial hospitalization, but a higher risk 
of chronic myelogenous leukemia relapse (20%vs 7%, p=0.009) and CMV infection (28% vs. 


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17%, p = 0.023) than patients receiving methotrexate and cyclosporine. In a follow-up paper to 
this trial, the impact of ex vivo T cell depletion on chronic GVHD was analyzed by Pavletic and 
collaborators [47]. The incidence of chronic GVHD at 2 years was similar between the two arms 
(T cell depletion = 29% vs. methotrexate/cyclosporine = 34%, p = 0.27). Survival at 3 years from 
diagnosis of chronic GVHD was also similar (T cell depletion = 51% vs. 
methotrexate/cyclosporine = 58%; p = 0.29). The incidence of serious infections and leukemia 
relapse were similar on both treatment arms. In spite of a significant reduction of acute GVHD, T 
cell depletion did not reduce the incidence of chronic GVHD or improve survival in patients who 
developed chronic GVHD. There have only been anecdotal reports on the use of ex vivo T cell 
depletion after either non-myeloablative or reduced-intensity conditioning regimens utilizing 
either HLA-matched or unrelated donors. One of the larger experiences came from the National 
Cancer Institute [48]. In this trial, planned, sequential donor lymphocyte infusions given early 
(day +42) post-transplant resulted in an incidence of acute GHVD similar to that observed with a 
T cell replete allograft. 
1.3 
PRIMARY AIMS 
1.3.1 Assessment of immune reconstitution following reduced-intensity allogeneic HSCT from 
unrelated donors.  
Immune reconstitution following allogeneic HSCT is a prolonged process, influenced by a 
number of factors including, the age and corresponding thymic function of the transplant 
recipient, and degree histocompatibility between the donor the recipient, as well as the presence 
or absence of GVHD.  However, immune reconstitution has not been well studied in the setting 
of reduced-intensity allogeneic HSCT from unrelated donors. It is our interpretation of the available 
medical literature that both of the AC and TMS GVHD prophylaxis regimens are effective in preventing 
acute GVHD in the setting of reduced-intensity allogeneic HSCT using HLA-matched unrelated 
donors. However, due to their distinctive biologic differences, it is hypothesized that these two 
regimens have significantly different effects upon immune reconstitution, which has significant 
implications to other factors affecting outcomes after transplantation (e.g. infections and relapse). 
A detailed, prospective analysis on the effects of either of these regimens on immune 
reconstitution has not been performed, and such an analysis is warranted relative to both 
transplant biology and clinical outcomes. It is our intent to assess and compare in a pilot manner 
immune reconstitution following the combination of alemtuzumab and cyclosporine, as 
employed by the United Kingdom Collaborative Groups for Nonmyeloablative Transplantation 
group [31] and the combination of tacrolimus, methotrexate, and sirolimus, developed at DFCI 
[36], in the setting of reduced-intensity allogeneic HSCT from HLA-matched unrelated donors. 
Immune reconstitution will be assessed in a variety of techniques with which we and our 
collaborators are recognized for specific expertise. One assessment of immune reconstitution will 
be an analysis of T-Cell Receptor Vβ repertoire using CDR3 spectratyping. The 
complementarity-determining region (CDR3) of the T-cell receptor (TCR) is of most importance 
for the extensive diversity of the TCR [49,50]. The CDR3 plays a key role in defining the 
specificity of antigen recognition because the region forms the contact site for binding to peptide 
major histocompatibility complexes (MHCs) expressed by antigen-presenting cells. The CDR3 
of both TCRα and TCRβ genes is generated by extensive rearrangement and fusion between the 
V, D, and J segments and by random insertion and deletion of junctional nucleotides, which 
yields final products that are quite heterogeneous in size. As a result of these gene 


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rearrangements, each T cell has a unique TCR and the diversity of the T-cell repertoire at any 
specific time can be characterized by the examination of CDR3 within that population. Healthy 
individuals demonstrate a diverse and polyclonal TCR repertoire reflected by a Gaussian size 
distribution of CDR3 regions composed from the TCR Vβ gene [47]. Amplification of the Vβ 
region expressed in circulating T cells has been used by the technique called CDR3 spectratyping 
to monitor the Vβ gene expression as a measurement of the level of immune competence in 
allogeneic HSCT recipients in both the myeloablative and reduced-intensity settings [52,53]. 
Factors such as T cell depletion, the development of GVHD, high recipient age, and infections 
are known to impair immune competence after allogeneic HSCT and correlate to oligoclonal or 
monoclonal CDR3 patterns [54-56]. Different CDR3 sizes and a Gaussian distribution of these 
peaks should be present in a normal polyclonal expression of a Vβ subfamily [51]. These 
differences can be quantified and compared. The overall complexity within a Vβ subfamily can 
be determined by counting the number of discrete peaks per subfamily. Subfamilies can then be 
graded on a score based on the degree of complexity. Normal complexity is characterized by a 
Gaussian distribution of transcript sizes, reflecting the presence of polyclonal cDNA species. 
CDR3 spectratype analysis provides a sensitive method for characterization of the T-cell 
repertoire as well as for following changes in individual patients over time. CDR3 spectratype 
analysis is an ideal method to assess differences in immune reconstitution after the 
administration of these two regimens, which have distinct effects upon T cells over time post-
transplant. 
As part of the comprehensive primary objective of assessing the effects of these two GVHD 
regimens on immune reconstitution, we will specifically assess differences in CD4+ T cell 
receptor Vβ repertoire by CDR3 spectratyping at 3 months post-transplant. This specific T cell 
subset was selected as this population generally recovers relative to its effects on other 
lymphocyte populations (i.e. CD8+ T cells and B lymphocytes). In addition, the homeostatic 
mechanisms which influence CD4+ T cell reconstitution (i.e. IL-7) are less perturbed by other 
host environmental factors. We chose three months post-transplant as this is time point at which 
repertoire diversity previously has been demonstrated to increase. Three months is also the time 
point at which scheduled tapering of immunosuppression is planned and clinical assessments and 
decisions are made relative to GVHD and disease status. These data will be complemented by 
spectratype analysis on both CD4+ and CD8+ T cells at various time points as well as the 
additional data on immune reconstitution which will be performed as part of the secondary aims. 
This extensive and extremely unique data set on immune reconstitution will be of value to the 
general transplantation field and in the design of our future protocols utilizing unrelated donors. 
1.3.2 
Assessment of chronic GVHD in the setting of sequential targeted immune-depleting 
chemotherapy followed by reduced-intensity allogeneic HSCT from HLA-matched 
unrelated donors  
In addition to acute GVHD, chronic GVHD contributes to the morbidity and mortality associated 
with allogeneic HSCT from unrelated donors [56]. Chronic GVHD has not been well 
characterized in either the non-myeloablative and reduced-intensity allogeneic HSCT settings, 
particularly related to the use of unrelated donors. The reported incidences of chronic GVHD 
following non-myeloablative and reduced-intensity allogeneic HSCT from unrelated donors has 
varied from 8 – 65% (Table 2B), depending on patient age, degree of HLA-matching, and form 
of GVHD prophylaxis [14,30-34]. Chronic GVHD has become a specific area of intent research 
within ETIB. Led by Dr. Steven Pavletic, the Chronic Graft-versus-Host Disease Program is a 


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multi-institutional and extramural collaborative effort which incorporates laboratory and clinical 
studies including the establishment of one of the world’s largest multi-disciplinary clinic for 
chronic GVHD, utilizing the unique resources and expertise available at the NIH. The efforts by 
Dr. Pavletic and his NIH collaborators were highlighted by the 2005 NIH-sponsored Chronic 
GVHD Consensus Project, which has unified the transplant community's approach to chronic 
GVHD through the activities of focused working groups [61-63]. Patients will be specifically 
monitored within the Chronic GVHD Clinic, will be offered potential participation on the 
Chronic GVHD Natural History protocol (04-C-0281), and will potentially be offered 
participation on therapeutic trials which are currently submitted for review and under 
development in the NIH. (Please see section 1.6) 
1.4 
BACKGROUND ON SECONDARY OBJECTIVES 
1.4.1 Assessment of serum Interleukin-7 and Interleukin-15 following Reduced-Intensity 
Allogeneic HSCT from Unrelated Donors  
Immune reconstitution has been a primary research focus of both the Gress and Mackall 
Laboratories, both of whom are associate investigators on this study [57-61]. Secondary 
endpoints will continue according to prior studies performed as part of 99-C-0143, 00-C-0119, 
and 03-C-0077. These studies have included the kinetics of CD4+ and CD8+ T-cells and NK cell 
depletion and recovery in the setting of sequential immune depletion and reduced-intensity 
allogeneic HSCT. They have also included, as part of 03-C-0077, the correlation of serum IL-7 
and IL-15 levels with lymphocyte subpopulations prior to transplantation and during immune 
recovery after transplant, and during the development of clinical GVHD, which had never been 
determined previously in the clinical setting. Preliminary analysis of data from 03-C-0077 
demonstrates that there is an association of post-transplant serum IL-7 levels with the 
development of acute GVHD. The continuation of these studies in the setting of allogeneic 
HSCT from unrelated donors will potentially provide valuable insights relative to immune 
reconstitution as it relates to post-transplant toxicities, particularly GVHD and immune 
dysregulation. 
1.4.2 Characterization of post-transplant monocyte production of inflammatory cytokines IL-1-
α and TNF-α after reduced-intensity allogeneic HSCT  
Characterization of the inflammatory cytokine cascade after allogeneic HSCT, aptly termed 
"cytokine storm" GVHD [60], has identified IL-1-α and TNF-α as potential targets for GVHD 
prevention or therapy.  Indeed, neutralization of these cytokines can reduce murine gut GVHD 
[61,62], and importantly, this approach to GVHD prevention can be accomplished without 
abrogating an allogeneic T cell mediated graft-versus-leukemia (GVL) effect [67,68]. 
The existence of a similar non-T cell mediated inflammatory cytokine phase of GVHD in human 
transplantation has been more difficult to prove. Given the role of the macrophage as cell source 
for inflammatory cytokine-mediated murine GVHD, Fowler and colleagues reasoned that 
clinical "cytokine storm" might be monitored in a sensitive manner through sequential post-
transplant evaluation of circulating monocyte production of IL-1-α and TNF-α using an 
intracellular flow cytometry assay [65]. Seventeen patients with refractory hematologic 
malignancy received reduced-intensity conditioning, HLA-matched sibling HSCT, and GVHD 
prophylaxis consisting of cyclosporine alone.  After HSCT, monocyte IL-1-α and TNF-α were 
measured by intracellular flow cytometry (IC-FCM), and results were correlated with acute 


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GVHD.  Post-transplant monocyte IL-1-α increased significantly (p = 0.0065) from week 2 to 
week 4 post-transplant; however, it was not associated with GVHD severity (p = 1.00).  In 
contrast, increases in monocyte TNF-α were quantitatively reduced and temporally delayed, from 
week 2 to week 6 (p = 0.076). Elevation of monocyte TNF-α correlated with increased gut 
GVHD severity (p = 0.0041), with increases in monocyte TNF-α typically preceding the onset of 
gut GVHD symptoms.  Serial measurement of monocyte cytokines, in particular, TNF-α, by IC-
FCM represents a non-invasive method for GVHD monitoring, potentially allowing 
identification of patients appropriate for early intervention strategies. 
1.4.3 Tumor derived lymphocytes 
The prognosis for most patients with hematologic malignancies that have persistent disease or 
relapse after allogeneic HSCT is poor. Effective therapy for patients who fail withdrawal of 
immune suppression and administration of donor lymphocyte infusions (DLI) has not been 
identified. Even when DLI are effective, the response is often not durable and can be 
accompanied by GVHD. Generation of donor lymphocytes that mediate more potent and specific 
GVT effects while minimizing GVHD is a major laboratory and clinical effort of the ETIB. We 
have hypothesized that lymphocytes found in tumor after alloHSCT are of donor origin, and 
because they are tumor-derived, they may be tumor-specific in their homing and antigen 
specificity characteristics.  In preclinical studies we have developed a method for the activation 
and expansion of tumor-derived lymphocytes (TDL) through CD3/CD28 co-stimulation and 
further expansion in IL-2. This approach is being piloted in patients with B cell malignancies 
who have persistent disease or relapse after AlloHSCT, including recipients of URD allografts. 
In parallel, ongoing preclinical efforts are focusing on optimization of the TDL cell product 
development, including cell yields and tumor specificity. Research samples obtained from 
subjects enrolled on this protocol will provide valuable data that may be of benefit to URD 
allograft recipients for whom DLI are not always readily available. 
1.5 
SUMMARY  
The major limitations to the broader applicability of allogeneic HSCT for the treatment of 
malignancies are lack of suitable donor and therapy related toxicities. The use of stem cells from 
unrelated donors partially alleviates the need for donors, but their use is associated with a higher 
incidence of graft rejection and mixed donor chimerism, due to histocompatibility difference 
between the donor cells and the recipient. Based on the theory that the rapid establishment of 
donor chimerism was essential for an optimal GVT effect, we have employed a strategy of 
targeted immune-depleting chemotherapy prior to reduced-intensity allogeneic HSCT in a series 
of sequential trials in which one of the factors that affects engraftment was altered in a step-wise 
fashion. A recently completed trial, 03-C-0077, demonstrated that targeted immune depletion 
permitted rapid and complete donor engraftment, a lower incidence of acute GVHD, improved 
treatment-related mortality, and beneficial overall outcomes in patients with high-risk 
hematologic malignancies who received a reduced-intensity allogeneic T cell replete HSCT from 
HLA-matched sibling, using a GVHD prophylaxis regimen consisting of cyclosporine and 
methotrexate. It is our intent to investigate this approach in the setting of HLA-matched 
unrelated donors. 
A clearly superior GVHD prophylaxis regimen has not been established in the unrelated donor 
setting. The two GVHD prophylaxis regimens with which best results have been reported are 
alemtuzumab with cyclosporine [31] and the combination of tacrolimus, methotrexate, and 


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sirolimus [36]. Both of these regimens are likely to provide adequate prophylaxis against the 
development of clinically severe acute GVHD in the setting of targeted immune-depleting 
chemotherapy prior to reduced-intensity allogeneic HSCT from HLA-matched unrelated donors. 
However, the two regimens work through biologically distinct mechanisms, and their effects 
upon immune reconstitution, which have not previously been well studied with either regimen, 
are predicted to be markedly different, regardless of the presence or absence of acute GVHD. 
The study design provides a unique opportunity to investigate and compare in a preliminary 
fashion post-transplant immune reconstitution related to each of these GVHD prophylaxis 
regimens, which have distinct biologic properties relative to their ability to prevent GVHD. 
Immune reconstitution will be determined by a variety of techniques with an emphasis on CDR3 
spectratyping. There has not been a report on post-transplant immune reconstitution in the 
available medical literature, as extensive or prospectively performed, as the studies planned in 
this protocol.  These studies are a natural extension of our prior work and take advantage of the 
unique expertise and resources within the laboratories of the ETIB, intramural programs of the 
NCI, and the internationally recognized expertise on CDR3 spectratyping at Hackensack 
University with whom we have formed a formal collaboration. This study will provide 
preliminary data relative to multiple aspects of immune reconstitution after allogeneic HSCT 
from unrelated donors, which is important and essential to the understanding of this biology and 
development of strategies to improve the most important complications after this procedure, 
specifically GVHD and immune dysregulation. 
Although both of these GVHD regimens are likely to provide adequate prophylaxis against the 
development of clinically severe acute GVHD in the setting of targeted immune-depleting 
chemotherapy prior to reduced-intensity allogeneic HSCT from HLA-matched unrelated donors, 
this needs to be documented, as well as other clinical endpoints relative to the safety of the 
procedure. To this end, we will assess, as a primary objective, engraftment, early and late 
treatment-related mortality, and overall survival and have established stringent stopping rules for 
each parameter.  
The results of this pilot trial will be used for the development of subsequent studies related to 
allogeneic HSCT from unrelated donors incorporating techniques and approaches that are 
currently under investigation in the ETIB and POB. 
1.6 
AMENDMENT K BACKGROUND AND RATIONALE  
At the time of this submission (October 2010) we have accrued 55 patients to this protocol of 
which 48 patients have undergone transplant (3 were removed either due to personal request [n 
=1] or disease progression prior to transplant [n = 2]; the other 4 enrollees are awaiting 
transplant. As per prior communication, clinical outcomes have either met or exceeded 
predictions. Relative to safety, all of the criteria for proceeding with the trial (i.e. stopping rules; 
section 6.4.3) have been met. Among the 48 transplants there has been one graft failure, which 
was attributed directly to a poor quality graft, as a second collection from the donor engrafted 
promptly. The level of acute GVHD has been as expected with grade II-IV acute GVHD being 
22% and 33% on the TMS and AC arms, respectively. Grade III-IV acute GVHD has been 11% 
and 17% on the two arms respectively. Early (< Day +100) treatment-related mortality has been 
5% for the entire patient population; the one-year treatment-related mortality has been 17% with 
no statistical difference in the two arms. Overall survival at one year is greater than 60% on both 
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As we had hypothesized engraftment was not only nearly universal but was prompt with median 
full donor chimerism being 100% at day+28 on both arms. We continue to collect data relative to 
the primary and secondary aims of immune reconstitution and acute GVHD. In regard to the 
latter our acute are similar to the results reported in the available medical literature for both the 
TMS and AC arms. A unique aspect is that we continue to prospectively collect data in regard to 
chronic GVHD using the NIH Consensus Conference diagnosis and staging criteria [61-63]. 
There are few if any trials comparing two different GVHD regimens which are prospectively 
studying chronic GVHD using these criteria, which have become internationally accepted and 
validated retrospectively. The incidence of chronic GVHD among the first 20 evaluable patients 
have been 60% and 70% on the TMS and AC arms respectively. The incidence of “severe” 
chronic GVHD, as defined by NIH Consensus Conference criteria, has been 20% on both arms. 
As previously stated, chronic GVHD has become a significant research focus in ETIB. These 
initial chronic results are encouraging, the method of evaluation is unique as the NIH Consensus 
Conference criteria have been utilized, and a number of highly unique correlative studies have 
been utilized in this evaluation. Although the data are unique, the number of patients that would 
potentially be evaluable with the current accrual cap is felt to be insufficient to provide clinically 
relevant information. Specifically it would be of significant interest to the transplantation 
community to know if there is (or is not) a difference in severe chronic GVHD between the two 
GVHD prophylaxis regimens being utilized. In light of the excellent clinical results that have 
been obtained, we have the unique opportunity to prospectively chronic GVHD and as such have 
made this a primary objective and have increased accrual number to provide adequate patient 
numbers to study this clinically important component of allogeneic HSCT.   
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1 
ELIGIBILITY CRITERIA – RECIPIENT ON STANDARD CARE THERAPY: 
2.1.1 The patient is 18 – 74 years of age [14,30,34]. 
2.1.2 The patient has a potentially suitable 8/8  donor if they are between the ages of 69-74 
years of age or a potentially suitable 8/8 or 7/8 unrelated donor(s) in the National Marrow 
Registry or Other Available Registry if they are between the ages of 18-74. 
2.1.3 The patient currently does not meet the protocol’s eligibility/enrollment criteria for any 
reason. 
2.1.4 There is a high likelihood that the patient, in the opinion of the PI will meet the protocol’s 
eligibility/enrollment criteria to proceed to transplant after standard therapy is completed. 
2.1.5  The patient or legal guardian is able to give informed consent. 
 
2.2 
EXCLUSION CRITERIA – RECIPIENT ON STANDARD CARE THERAPY: 
2.2.1 HIV infection.  There is theoretical concern that the degree of immune suppression 
associated with the treatment may result in progression of HIV infection.   
2.2.2 Pregnant or lactating.  Patients of childbearing potential must use an effective method of 
contraception (section 4.5). The effects of the chemotherapy, the subsequent transplant 


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and the medications used after the transplant are highly likely to be harmful to a fetus.  
The effects upon breast milk are also unknown and may be harmful to the infant. 
 
2.3 
INCLUSION CRITERIA - RECIPIENT 
Disease 
Disease Status 
B-Chronic Lymphocytic Leukemia (CLL) 
Small Lympho(plasma)cytic Lymphoma  
(B-SLL, B-LPL) [70,71,72] 
a) Relapse/progression after fludarabine and at least one 
other salvage regimen or 2 standard regimens 
b) If 17p deletion present, one standard regimen is 
sufficient 
Prolymphocytic Leukemia (PLL) 
T-CLL [73] 
a) T-PLL:  Treatment failure after Campath-1H and at 
least one other regimen  
b) B-PLL:  Treatment failure after fludarabine and at 
least one other salvage regimen  
Hodgkin’s Lymphoma [74] 
a) Primary treatment failure ineligible for autologous 
HSCT. Relapse/progression after autologous HSCT. 
Follicular Lymphoma, Marginal Zone 
Lymphomas (splenic, nodal, or 
extranodal/MALT type) [72,75] 
a) Chemotherapy-refractory disease 
b) Relapse after > 2 prior regimens 
c) Relapse/progression after autologous HSCT 
Burkitt or Acute Lymphoblastic 
Lymphomas [76,77] 
a) High-risk disease in remission 
b) Primary refractory disease 
c) Recurrent disease 
d) Relapse/progression after autologous HSCT 
Diffuse Large B-cell Lymphoma, 
Follicular Large cell Lymphoma, 
Peripheral T-cell Lymphoma, mantle cell 
lymphoma, Anaplastic Large Cell 
Lymphoma [78-82] 
a) Primary refractory disease. 
b) Relapse/progression after autologous HSCT after 
autologous HSCT 
c) Stable disease or better response to last therapy 
Cutaneous T-cell Lymphomas (Mycosis 
Fungoides, Sezary Syndrome) [83] 
a) > Stage III 
b) Disease progression > 2 prior regimens, including at 
least one systemic therapy. 
Multiple Myeloma [32,84-86] 
a) Relapse/progression after autologous HSCT. 
b) Plasma cell leukemia 
c) Adverse cytogenetics: del(13q) or 11q translocation. 


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Acute Myelogenous Leukemia [87,88] 
a) In first complete Remission with high-risk 
cytogenetics. 
b) Primary induction failure. 
c) In second or greater complete remission. 
d) Secondary AML. 
e) In first complete Remission with hyperleukocytosis 
at diagnosis  
Acute Lymphocytic Leukemia [89,90] 
a) First Complete Remission, with high-risk 
cytogenetics. 
b) Primary induction failure. 
c) Second or greater complete remission. 
Myelodysplastic Syndrome [88,91] 
a) RAEB I or II 
b) High-risk IPSS 
c) Secondary MDS 
Myeloproliferative disorders (Idiopathic 
myelofibrosis, polycythemia vera, 
essential thrombocytosis, chronic 
myelomonocytic leukemia, agnogenic 
myeloid metaplasia) [92,93] 
a) Agnogenic myeloid metaplasia with adverse-risk 
features  
b) Polycythemia vera or essential thrombocythemia in 
transformation to secondary AML 
Chronic Myelogenous Leukemia [94] 
a)    Chronic phase CML  
b)    Accelerated phase CML  
Not eligible for myeloablative allogeneic HSCT 
NK Cell Neoplasms  
 
a) First CR for patients with high risk natural killer cell 
neoplasms including myeloid/NK cell precursor acute 
leukemia, blastic NK-cell lymphoma, aggressive NK-
cell leukemia and nasal-type extranodal NK-cell 
lymphoma in first complete remission.   
b) Primary induction failure. 
c) Second or greater CR. 
T-cell Neoplasm: Adult T-Cell 
leukemia/lymphoma, hepatosplenic T-Cell 
lymphoma, and enteropathy associated T-
Cell Lymphoma 
a) First CR 
b) Chemotherapy-refractory disease 
c) Relapse after greater than or equal to 1 prior regimen 
 
 


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2.3.1 Diagnosis of hematologic malignancy and at least one of the criteria in the “Disease 
Status” column as specified in the table above. 
2.3.2 Recipients with AML in CR1 must have one of the following: 
2.3.2.1 Adverse cytogenetics with residual disease detectable by flow cytometry, 
cytogenetic analysis, FISH, or PCR.  Adverse cytogenetics in AML are defined 
as complex karyotype (> 3 abnormalities); inv(3) or t(3;3); t(6;9); t(6;11); 
monosomy 7; trisomy 8, alone or with an abnormality other than t(8;21), 
t(9;11), inv(16) or t(16;16); or t(11;19)(q23;p13.1) [95]. 
2.3.2.2 Primary induction failure, defined as failure to achieve CR with primary 
induction chemotherapy [96]. 
2.3.2.3 Secondary AML, defined as AML related to antecedent MDS, MPD, or 
cytotoxic chemotherapy. 
2.3.2.4 Hyperleukocytosis, WBC > 100,000, at diagnosis. 
2.3.2.5 Mutations in the FMS-like tyrosine kinase 3 (FLT3) gene (FLT3-LM; FLT-
ITDs) [125, 126, 127]  
2.3.3 Recipients with ALL in CR1 must have one of the following: 
2.3.3.1 Adverse cytogenetics or residual disease detectable by flow cytometry, 
cytogenetic analysis, FISH, or PCR.  Adverse cytogenetics in ALL are defined 
as translocations involving t(4;11), t(1;19), t(8;14), 11q23, t(9;22) or bcr-abl 
rearrangement or complex cytogenetic abnormalities. 
2.3.3.2 Primary induction failure, defined as failure to achieve CR with primary 
induction chemotherapy [97]. 
2.3.4 Patients with Cutaneous T-cell Lymphomas (e.g. mycosis fungoides, Sezary syndrome) 
must have: 
2.3.4.1 Stage III or greater disease 
2.3.4.2 Disease which has progressed on or failed to respond to at least 2 therapies 
including one systemic therapy. 
2.3.5 Recipients with agnogenic myeloid metaplasia must have at least 2 of the following 
features [98,99]: 
2.3.5.1 Hemoglobin < 10 g/dl, or > 10 g/dl with transfusion dependence. 
2.3.5.2 WBC < 4,000 or > 30,000/mm3 or requires cytoreductive therapy to maintain. 
2.3.5.3 WBC < 30,000/mm. 
2.3.5.4 Abnormal cytogenetics including +8, 12p-. 
2.3.6 Recipients with primary or secondary acute leukemia, refractory anemia with excess 
blasts (RAEB), CML, or other eligible diagnosis in transformation to acute leukemia 
must have < 5% blasts in bone marrow and no circulating blasts in peripheral blood at 
study entry.  Recipients who do not meet these criteria may be re-evaluated for study 


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eligibility after receiving standard induction therapy for acute leukemia and determined 
to be in remission. 
2.3.7 For recipients with CLL or PLL, treatment failure for a specified therapy is defined as 
relapse within 6 months or failure to achieve remission.   
2.3.7.1 Recipients who are ineligible for a specified therapy (e.g., due to refractory 
cytopenias) may be considered for enrollment in this protocol. 
2.3.7.2 Recipients who have a 17p/p53 deletion who have never received fludarabine 
will be eligible. [128, 129, 130] 
2.3.7.3 Recipients who have had Richter’s transformation who have not received prior 
chemotherapy for their CLL will be eligible.[131] 
2.3.8 For patient with NK cell neoplasms:  1) Patients with high risk natural killer cell 
neoplasms including myeloid/NK cell precursor acute leukemia, blastic NK-cell 
lymphoma, aggressive NK-cell leukemia and nasal-type extranodal NK-cell lymphoma in 
first complete remission.  2) All NK cell neoplasms can be transplanted in:  a) Primary 
induction failure or b) Second or greater complete remission. 
2.3.9 
For patients with T-Cell Neoplasms including adult T-cell leukemia/lymphoma, 
heptosplenic T-Cell lymphoma and enteropathy associated T-cell lymphoma. 
2.3.9.1 First CR. 
2.3.9.2 Chemotherapy-refractory disease. 
2.3.9.3 Relapse after greater than or equal to 1 prior regimen. 
2.3.10 For patients with non-Hodgkin’s lymphoma, they must be determined to have at least 
stable disease to last therapy [82]. 
2.3.11 For patients with chronic phase chronic myelogenous leukemia, patient’s disease must 
have evidence of never responded to or progressed after receiving a tyrosine-kinase 
inhibitor (e.g. imatinib mesylate). 
2.3.12 Patients with accelerated phase chronic myelogenous leukemia may have < 10% blasts in 
the peripheral smear or bone marrow at study entry. 
2.3.13 Patients 18 - 74years of age [14,30,34]. 
2.3.14 Patient or legal guardian must be able to give informed consent. 
2.3.15 All previous cytotoxic chemotherapy must be completed at least 2 weeks prior to study 
entry, with the exception of the tyrosine kinase inhibitors Imatinib, Nilotinib and 
Dasatinib which may be continued through induction therapy.  Any grade 3 or 4 non-
hematologic toxicity of any previous therapy must have resolved to grade 2 or less, 
unless specified elsewhere in Section 2.1. 
2.3.16 ECOG performance status equal to 0, 1, or 2, and Karnofsky performance status greater 
than or equal to 60%. 
2.3.17 Life expectancy of at least 3 months. 


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2.3.18 Patients with acute leukemia or myelodysplastic syndrome or chronic myelomonocytic 
leukemia must be in a hematologic remission, defined as <5% blasts present in both 
blood and marrow to be referred for evaluation.  Should a patient have >5% blasts or a 
donor not be available by the time the patient is ready for enrollment, the patient will be 
referred back to their primary hematologist-oncologist for treatment.  Patients with 
diseases other than acute leukemia including but not limited to Hodgkin’s and Non-
Hodgkin’s lymphoma, CLL/SLL, NKTCL, PTCL, must have stable disease to their most 
recent regimen received within 8 weeks if chemo/radiotherapy or within 12 weeks after 
prior autologous stem cell transplantation. Should a patient in either of these scenarios 
have progressive disease or a donor not be available after enrollment, the patient will be 
referred back to their primary hematologist-oncologist for treatment. If either of these 
scenarios are not in the best interest of the patient according to the clinical judgment of 
the PI, then the patient may receive standard treatment for the malignant disease under 
the current study. If under either of these settings, it becomes apparent that the patient 
will not be able to proceed to transplant, then he/she must come off study. Recipient-
Subjects receiving a standard therapy will be told about the therapy, associated risks, 
benefits alternatives of the proposed therapy, and availability of receiving the same 
treatment elsewhere, outside of a research protocol. 
2.3.19 Left ventricular ejection fraction > 45% by either MUGA or 2-D echo, obtained within 
28 days of enrollment. Patients who have a prior cumulative anthracycline dose greater 
than 450 mg/m2 will also have a cardiology consult to determine if further anthracycline 
administration is an absolute contraindication in patients who may require induction 
chemotherapy with EPOCH-F. 
2.3.20 DLCO > 50% of the expected value when corrected for Hb, obtained within 28 days of 
enrollment. 
2.3.21 Creatinine < 1.5 mg/dl and creatinine clearance > 50 ml/min/1.73 m2. 
2.3.22 Serum total bilirubin less than 2.5 mg/dl, and serum ALT and AST values less than or 
equal to 2.5 times the upper limit of normal. Patients with elevations of serum total 
bilirubin up to 10 mg/dl and/or ALT or AST up to 10 times the upper limit of normal may 
be considered for participation if such elevations are thought to be due to liver 
involvement by malignancy.  However, in these latter patients, if these values do not 
decrease to less than or equal to 2.5 times the upper limit of normal during induction 
chemotherapy, such patients will not be eligible for the transplant phase of the protocol, 
and will thus be taken off study. 
2.3.23 Minimum absolute neutrophil count of 1,000 cells/μl and minimum platelet count 
(without transfusion) of 20,000/mm3.  Values below these levels may be accepted at the 
discretion of the PI if thought to be due to bone marrow involvement by malignancy. 
2.4 
EXCLUSION CRITERIA - RECIPIENT 
2.4.1 Active infection that is not responding to antimicrobial therapy. 
2.4.2 Active CNS involvement by malignancy (patients with known positive CSF cytology or 
parenchymal lesions visible by CT or MRI).  


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2.4.3 Progressive disease within 8 weeks of prior therapy or within 12 weeks after prior 
autologous stem cell transplantation. 
2.4.4 Active or recent second malignancies unless they have undergone potentially curative 
therapy for that malignancy and (1) have had no evidence of that disease for 5 years, 
and/or (2) be deemed at low risk for recurrence (less than or equal to 20% at 5 years). 
2.4.5 HIV infection.  There is theoretical concern that the degree of immune suppression 
associated with the treatment may result in progression of HIV infection.   
2.4.6 Chronic active hepatitis B.  Patients may be hepatitis B core antibody positive. For 
patients with concomitant positive hepatitis B surface antigen, patient will require a 
hepatology consultation. The risk/benefit profile of transplant and hepatitis B will be 
discussed with the patient and eligibility determined by the principal investigator. 
2.4.7 Hepatitis C infection. Patient may have a hepatitis C infection. However, each patient 
will require a hepatology consultation. The risk/benefit profile of transplant and hepatitis 
C will be discussed with the patient and eligibility determined by the principal 
investigator and lead associate investigator. 
2.4.8 Pregnant or lactating.  Patients of childbearing potential must use an effective method of 
contraception (section 4.5). The effects of the chemotherapy, the subsequent transplant 
and the medications used after the transplant are highly likely to be harmful to a fetus.  
The effects upon breast milk are also unknown and may be harmful to the infant. 
2.4.9 History of psychiatric disorder which may compromise compliance with transplant 
protocol, or which does not allow for appropriate informed consent (as determined by 
principal investigator or lead associate investigator). 
2.4.10 No available suitably HLA- matched unrelated donor. 
2.4.11 Available suitably HLA- matched  unrelated donor is unwilling to donate PBSC, and no 
alternate donor is found. 
2.5 
INCLUSION CRITERIA – DONOR 
2.5.1 General donor inclusion criteria specified in the NMDP Standards (20th Edition). 
(Appendix D)  
2.5.2 The evaluation of donors shall be in accordance with existing NMDP Standard Policies 
and Procedures (Appendix D). 
2.5.3 Volunteer unrelated donor matched at a minimum of seven of eight loci (HLA-A, B, C, 
DRB1), by high resolution typing (>7/8 allele match) are acceptable donors [14, 26, 
28,29]. 
2.5.3.1 The preferred donor-recipient pair would be matched at all eight loci (8/8 allele 
match). 
2.5.3.2 When an 8/8 allele-matched unrelated donor is not available, a single mismatch 
at HLA-A, -B, -C, or DRB1 will be acceptable in patients who meet all eligility 
criteria and are 18-69 years of age. 


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In the situation where more than one 7/8 match is available donor recipient pairs matched at 
HLA-DQ will be used. 
2.5.4 Ability to give informed consent.   
2.5.5 Age 18 years or older. 
2.5.6 Donors must be HIV negative, hepatitis B surface antigen negative, and hepatitis C 
antibody negative.  This is to prevent the possible transmission of these infections to the 
recipient. 
 
2.6 
EXCLUSION CRITERIA – DONOR  
2.6.1 Donor exclusion will be in accordance with existing NMDP Standards (20th  Edition). 
(Appendix D) 
2.6.2 In addition to NMDP donor exclusion criteria, for the purposes of this protocol, donors 
who are unwilling to donate PBSC and only wish to pursue a bone marrow donation will 
be excluded.  An alternate donor will be selected if possible, but in the event that no 
alternate donor is available, the patient will be removed from the trial. 
2.6.3 Current treatment with lithium. 
2.6.4 Presence of sickle hemoglobin as demonstrated by appropriate testing such as 
hemoglobin electrophoresis. 
2.7 
RESEARCH ELIGIBILITY EVALUATION - RECIPIENT 
2.7.1 Typing for HLA-A, -B, -C, -DRB1, and –DQB1. 
2.7.2 The following clinical, laboratory and radiologic assessments must be performed in the 
patient (recipient) within 28 days before the initiation of induction or conditioning 
chemotherapy (Section 3.3) to determine disease status: 
2.7.2.1 Complete medical history and physical examination. 
2.7.2.2 Nutritional assessment (initial consult). 
2.7.2.3 Dental consultation to assess need for teeth cleaning or removal. 
2.7.2.4 Social work consultation. 
2.7.2.5 Antibody screen for hepatitis A, B, and C; HIV, HTLV-I/II, CMV, adenovirus, 
EBV, HSV, Toxoplasma, and syphilis. 
2.7.2.6 PPD test (if considered to be in a high-risk group). 
2.7.2.7 PT, PTT, and ABO typing. 
2.7.2.8 Urinalysis. 
2.7.2.9 24-hour urine collection for determination of creatinine clearance.  
2.7.2.10 Unilateral bone marrow aspirate and biopsy.  Flow cytometry, cytogenetics, 
and molecular testing via polymerase chain reaction (PCR) should be 


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performed on marrow aspirates as deemed clinically appropriate for specific 
diseases. 
2.7.2.11 Chest radiograph. 
2.7.2.12 Electrocardiogram and 2D ECHO or MUGA scan. 
2.7.2.13 Pulmonary Function Test including DLCO 
2.7.2.14 CT scans of chest, abdomen, and pelvis (neck included if measurable disease is 
present). 
2.7.2.15 CT or MRI of the head. 
2.7.2.16 Examination of CSF cytology, cell counts and routine chemistries (i.e. glucose 
and protein) for patients at risk for CNS involvement. 
2.7.2.17 PET scan for recipients with non-Hodgkin’s lymphoma or Hodgkin’s 
lymphoma. 
2.7.2.18 Skeletal survey (for multiple myeloma patients only). 
2.7.2.19 Other specific serum or urine diagnostic studies clinically appropriate for the 
evaluation of recipient’s malignancy (e.g., SPEP and UPEP for multiple 
myeloma). 
2.7.2.20 All biopsy specimens will be reviewed by the Laboratory of 
Pathology/CCR/NCI, for confirmation of the histologic diagnosis prior to 
enrollment on study. 
2.7.2.21 Biopsy material or blood samples from patients with B-cell malignancies will 
be tested for CD20 expression, to confirm eligibility for rituximab with 
induction chemotherapy. CD20 expression will be determined by 
immunohistochemistry or flow cytometry in the Laboratory of 
Pathology/CCR/NCI. 
2.7.2.22 Flow cytometric analysis of peripheral blood for baseline measurement of CD3, 
CD4, CD8, and CD56 positive lymphocyte populations. 
2.7.2.23 Baseline determination of serum IL-7 and IL-15 levels, for correlation with NK 
and T-cell subpopulations. 
2.8 
RESEARCH ELIGIBILITY EVALUATION - DONOR 
2.8.1 Donor eligibility will be determined by the NMDP-affiliated Donor Center Physician 
according to the most recent and stringent FDA, NMDP, and AABB regulations. 
2.8.2 Exceptions to donor eligibility (e.g. foreign travel, tattoos) which do not automatically 
exclude the donor will be reviewed by the Principal Investigator.  The recipient will be 
informed and consented to any exceptions which could potentially increase the risk of 
their transplant. 
2.8.3 The following clinical, laboratory and radiologic assessments will be performed by the 
NMDP donor center.  Documentation of donor clearance and consent will be delivered to 
the transplant center through the NMDP search coordinating unit. 


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2.8.3.1 Complete medical history and physical examination. 
2.8.3.2 Antibody screen for hepatitis B, and C; HIV, HTLV-I/II, CMV, HSV, and 
syphilis.   Hepatitis A, Adenovirus, EBV, and Toxoplasma screens will be 
performed upon receipt of the PBSC product if additional donor blood is 
available at the time of collection.  The results of these screens do not affect the 
eligibility of the donor for collection or inclusion on this protocol. 
 . 
2.8.3.3 CBC with differential, PT, PTT, and ABO typing. 
2.8.3.4 Acute care panel, hepatic panel, and mineral panel. 
2.8.3.5 Urinalysis. 
2.8.3.6 Urine HCG in women of childbearing potential. 
2.8.3.7 Chest radiograph. 
2.8.3.8 Electrocardiogram. 
2.8.3.9 PCR test of DNA mini-satellite regions for future determination of chimerism 
will be performed at NIH 
2.8.3.10 Data on donor characteristics will be entered in the C3D database for later 
assessment 
 
2.9 
PATIENT REGISTRATION 
2.9.1 Protocol Entry 
The patient's entry date on protocol is considered to be the day that consent form has been signed 
by the recipient and confirmation from the NMDP that the requested donor is available, meets 
the inclusion criteria, and had provided informed consent relative to stem cell donation.  The 
treatment start date is considered to be the day the recipient begins his/her initial induction cycle 
(Section 3.3). 
2.9.2 Registration 
Authorized staff must register an eligible candidate with the NCI Central Registration Office 
(CRO) within 24 hours of the patient (recipient) signing consent. The CRO will provide the 
randomized treatment assignment to the PI based on random assignments determined by the 
study statistician. Following amendment F, patients will be stratified for 7/8 or 8/8 HLA allele 
matches, and will be randomized separately according to this stratification. The patient may not 
sign consent before the patient has been determined to be eligible and confirmation of donor 
clearance has been received from the NMDP. The patient will not be registered before she/he has 
signed consent and confirmation from the NMDP that the donor has signed the NMDP 
“Statement of Intent to Donate” form at the respective institution at which the donor stem cells 
will be collected. A registration Eligibility Checklist from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 
encrypted email to: NCI Central Registration Office (HOIS) ncicentralregistration-
l@mail.nih.gov. After confirmation of eligibility at the CRO, the CRO staff will call Pharmacy 


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to advise them of the acceptance of the patient on the protocol prior to the release of any 
investigational agents and their randomized treatment assignment. Verification of Registration 
will be forwarded electronically via e-mail. Please note, it is very important for all registrars to 
acquire encrypted e-mail from NIH Help Desk, since the verification of registration includes 
patient’s information. A recorder is available during non-working hours.  
 
2.9.3 Off Protocol Therapy and Off-Study Procedure  
Authorized staff must notify Central Registration Office (CRO) when a patient is taken off 
protocol therapy and when a subject is taken offstudy. A Participant Status Updates form from 
the web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be 
completed and sent via encrypted email to:  NCI Central Registration Office (HOIS) 
ncicentralregistration-l@mail.nih.gov. 
 


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EPOCH-F/R (q21 days) 
a) 
Rituximab, 375 mg/m2/day IV, day 1 (for CD20+ 
malignancies only) 
b) 
Fludarabine, 25 mg/m2/day IV, days 1-4 
c) 
Etoposide, 50 mg/m2/day CIV, days 1-4 
d) 
Doxorubicin, 10 mg/m2/day CIV, days 1-4 
e) 
Vincristine, 0.4 mg/m2/day CIV, days 1-4 
f) 
Cyclophosphamide, 750 mg/m2/day IV, day 5 
FLAG (q28 days) 
a) 
Filgrastim, 5 mcg/kg/day SC 
• Start 24 hours before initiation of 
chemotherapy 
• Continue until ANC > 1000 x 2 
b) Fludarabine, 25 mg/m2/day IV, days 1-5 
c) 
Cytarabine, 2000 mg/m2/day IV, days 1-5 
Transplant Preparative Regimen Chemotherapy 
a) Fludarabine, 30 mg/m2/day IV x 4 days (days –6, -5, -4, -3) 
b) Cyclophosphamide, 1200 mg/m2/day IV x 4 days (days –6, -5, -4, -3) 
Remission? 
Responsive or 
Stable Disease? 
Yes 
NO 
NO
OFF 
STUDY 
OFF 
STUDY 
Induction Chemotherapy 
Recipient to receive either EPOCH-F/R 1-3 cycles q21 days or FLAG 1-2 cycles q28 days; 
target CD4 level < 100 cells/l 
3 
STUDY IMPLEMENTATION 
3.1 
STUDY DESIGN 
GVHD Prophylaxis (randomized at enrollment) 
• Hodgkin’s Lymphoma (HL) 
• Non-Hodgkin’s Lymphoma (NHL) 
• Chronic Lymphocytic Leukemia (CLL) 
• Prolymphocytic Leukemia (PLL) 
• Acute Myelogenous Leukemia (AML) 
• Acute Lymphocytic Leukemia (ALL) 
• Myelodysplastic Syndromes (MDS) 
• Chronic Myelogenous Leukemia (CML) 
• Myeloproliferative disorder (MPD) 
Stratification based on HLA typing: 7/8 vs. 8/8 allele match at HLA-A, -B, -C, and -DRB1 


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GVHD Prophylaxis (Arm TMS) 
a) Tacrolimus 0.02 mg/kg CIV, start day –3. Continue IV or PO. 
Taper will begin at day +63 if no acute GVHD then at day 
+119 and discontinue at day +180 as tolerated. 
b) Methotrexate 5 mg/m2 IV, days +1, +3, +6, and +11. 
b) c) 
Sirolimus - initial loading dose of 12 mg p.o. on day -
3 pre-transplant and subsequently 4 mg/day. If no acute 
GVHD then taper at day, +63, 
Allogeneic Hematopoietic Stem Cell Transplantation 
a) Mobilized PBSCT, day 0 (requested dose > 7 x 106 CD34+ cells/kg) 
b) Filgrastim, 10 mcg/kg/day SC, starting day 0, Continue until ANC > 5000 x 1 day and 1000 x 3 days 
Study accrual: number transplanted = 44arm (88 total) for 8/8 and 13/arm (26 total) for 7/8.  
 Study total = 76 transplanted patients  
GVHD Prophylaxis (Arm AC) 
a) 
Cyclosporine 2 mg/kg IV Q12h, start day –1.  Continue IV 
or PO. If no acute GVHD at day +100, taper cyclosporine 
by 10% per week between day 100 and 6 months. 
b) 
Alemtuzumab (Campath®) at 20 mg/day IV over 8 h on 
days −8 to −4 pre-transplant. 
 
 
 
 
 
 
 
 
 
 
3.2 
DONOR STEM CELL MOBILIZATION AND COLLECTION (AS PER NMDP GUIDELINES) 
3.2.1 Donors will receive filgrastim for stem cell mobilization at a dose of 10 to 12 μg/kg/day 
by subcutaneous injection, according to the NMDP PBSC Protocol (Appendix E). The 
filgrastim dose will not exceed 1200μg/day.  Per NMDP standards, filgrastim will be 
administered at approximately the same time each day for the first four days.  The fifth 
dose will be given at least one hour prior to apheresis. There will be an additional, sixth 
dose of filgrastim in cases where a second PBSC is performed on day 6.  
3.2.2 Apheresis will start on the fifth day of filgrastim administration. 12-24 liters will be 
processed daily based on recipient weight (Table 3). The actual volume processed may be 
adjusted by the NMDP Donor Center or Transplant Center Medical Director based on the 
pre-collection CD34+ count in order to meet the desired cell dose. 
3.2.3 The target cell dose will be greater than or equal to 7 x 106 CD34+ cells/kg-recipient 
weight. 
3.2.4 In the event that the donor collection is terminated early for donor-related medical 
concerns, the donor will be offered the opportunity to consent to a bone marrow donation, 
and this protocol will allow the infusion of a bone marrow graft.  This is considered only 
in the unlikely circumstance where the recipient has already received conditioning and 
the product is being collected simultaneously. The recipient will be removed from the 
study, but will be continued to be managed for all transplant-related care issues and 
complications.   
 
Table 3. Blood Volume Processed in Relation to Recipient Weight 
Recipient Weight (kg) 
Volume Processed (L) 
Procedure 
< 35 
12 
Single 12 liter apheresis. 
36 – 45 
15 
Single 15 liter apheresis. 


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46 – 55 
18 
Single 18 liter apheresis or two 12 L aphereses. 
56 – 65 
22 
Single 22 liter apheresis or two 12 liter aphereses. 
> 65 
24 
Single 24 liter apheresis or two 12 liter aphereses. 
 
3.2.5 Cells may be processed, cryopreserved, and stored in liquid nitrogen until the day of 
transplant upon delivery to the NIH Department of Transfusion Medicine (DTM). In the 
event that cryopreservation is required, special permission will be obtained from NMDP. 
3.2.6 If an ABO incompatibility exists between the donor and patient, the graft will be 
processed in the cell processing laboratory, according to standard DTM operating 
procedures. 
3.3 
THE FOLLOWING ITEMS SHOULD BE OBTAINED WITHIN 48 HOURS BEFORE STARTING 
INDUCTION CHEMOTHERAPY:  
3.3.1 Adequate central venous access is required for all patients undergoing transplantation on 
this protocol. 
3.3.2 CBC with differential. 
3.3.3 Acute care panel, hepatic panel, and mineral panel. 
3.3.4 Urine HCG in women of childbearing potential. 
3.4 
THE FOLLOWING TESTS MAY BE PERFORMED AT ANY TIME PRIOR TO TREATMENT ARM 
ENROLLMENT 
3.4.1 Typing for HLA-A, -B, -C, -DRB1, and –DQB1 
3.4.2 Risk of relapse assessment (see Appendix I) 
3.4.3 Comorbidity Index assessment (see Appendix J) 
3.5 
INDUCTION CHEMOTHERAPY FOR THE RECIPIENT 
3.5.1  A major goal of the induction chemotherapy is to establish severe host immune T cell 
depletion prior to the allogeneic HSCT.  However, there may be individuals who have 
already experienced severe host T cell depletion with their most recent therapy and 
additional chemotherapy prior to the transplant conditioning regimen may be placing 
additional, unnecessary toxicities upon these individuals.  As such, patients meeting all of 
the following criteria will not receive induction chemotherapy and proceed directly to 
transplant: 
3.5.1.1 Fewer than 100 CD4+ cells/ μl and/or within the statistical margin of error of 
the CD4+ T-lymphocyte depletion goal ≤  115 CD4 cells/l of blood at study 
enrollment, which must be at least 28 days beyond the start of last cycle of 
therapy prior to enrollment. 
3.5.1.2 Demonstration of response that is at least 28 days beyond the start of cycle of 
therapy prior to enrollment. 


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3.5.2 Induction Chemotherapy - After enrollment, recipients will receive either EPOCH-F/R or 
FLAG induction chemotherapy according to their underlying diagnosis, as indicated in 
the following table [96,97]: 
 
Diagnosis 
Induction Chemotherapy Regimen 
Acute myelogenous leukemia (AML) 
Secondary AML 
Acute lymphocytic leukemia (ALL) 
Lymphoblastic lymphoma 
Myelodysplastic syndrome (RAEB) 
Myeloproliferative disorder (MPD) 
Chronic myelomonocytic leukemia (CMML) 
Chronic myelogenous leukemia (CML) 
FLAG 
Hodgkin’s lymphoma 
Non-Hodgkin’s lymphoma (NHL) 
  (except lymphoblastic lymphoma) 
Chronic lymphocytic leukemia (CLL) 
Prolymphocytic leukemia (PLL) 
Multiple myeloma 
EPOCH-F/R 
 
 
 
3.5.3 EPOCH-Fludarabine/Rituximab Induction Chemotherapy (EPOCH-F/R): 
Drug 
Dose 
Days 
Rituximab 
375 mg/m2 IV infusion via specified 
rate titration. (Patients with CD20+ 
malignancies only) 
Day 1 only 
Fludarabine 
25 mg/m2 per day IV infusion over 30 
minutes, daily for 4 days 
Days 1, 2, 3, 4 


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3.5.3.1 Only patients with CD20+ B-cell malignancies will receive rituximab as part of 
the induction chemotherapy regimen, as per Section 2.5.2.20. The initial 
infusion should begin at a rate of 50 mg/hr; if no hypersensitivity reaction is 
observed after the first 30 minutes, the infusion rate may be escalated in 50 
mg/hr increments every 30 minutes, to a maximum rate of 400 mg/hr.  If a 
hypersensitivity reaction occurs, the infusion should be temporarily slowed or 
halted, with resumption at half the previous rate upon improvement in patient 
symptoms.  If the first infusion is tolerated well, infusions during subsequent 
cycles of EPOCH-F/R can begin at 100 mg/hr and be increased by 100 mg/hr 
increments at 30-minute intervals to a maximum rate of 400 mg/hr.  However, 
if the first infusion is not tolerated well, then the guidelines for the initial 
infusion should be followed for subsequent administration.  Pre-medication 
with acetaminophen 650 mg PO and diphenhydramine 25 to 50 mg I.V./p.o. 
will be administered 30 to 60 minutes prior to the beginning of each rituximab 
infusion.  Rituximab should be infused prior to the administration of 
fludarabine and the start of infusional EPOCH chemotherapy on the first day of 
each cycle. 
3.5.3.2 Fludarabine will be given immediately after the rituximab infusion is 
completed on day 1.  If venous access permits, fludarabine may be given 
concurrently with the start of infusional EPOCH chemotherapy on days 1 
through 4 of each cycle (preferred); otherwise, fludarabine will be given before 
the start of EPOCH infusional agents on days 1-4. 
3.5.3.3 Etoposide, doxorubicin, and vincristine will be prepared and administered 
according to NIH Clinical Center Pharmacy standard guidelines. 
3.5.3.4 The total vincristine dose per cycle will not be capped, even if it exceeds 2.0 
mg over four days. 
Etoposide 
50 mg/m2 per day continuous IV 
infusion over 24 hours daily for 4 days 
Days 1, 2, 3, 4 
Doxorubicin 
10 mg/m2 per day continuous IV 
infusion over 24 hours daily for 4 days 
Days 1, 2, 3, 4 
Vincristine 
0.4 mg/m2 per day continuous IV 
infusion over 24 hours daily for 4 days 
Days 1, 2, 3, 4 
Cyclophosphamide 
750 mg/m2 IV infusion over 30 minutes 
Day 5 only 
Prednisone 
60 mg/m2 per day PO daily for 5 days 
Days 1, 2, 3, 4, 5 
Filgrastim 
5 g/kg per day SC 
Daily from day 6 until ANC 
> 1000/l x 2 following 
nadir. 


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3.5.3.5 Fluconazole should not be taken during the period of EPOCH-F/R 
administration. 
3.5.3.6 Cyclophosphamide will be administered on day 5 of each cycle immediately 
after the prior day’s infusion is completed.  Hydration with 1 liter of 0.9% 
sodium chloride is recommended to begin one hour prior to cyclophosphamide, 
infused over two hours. 
3.5.3.7 Filgrastim will be initiated on day 6 at a dose of 5 μg/kg/day; it will be 
continued until the ANC is greater than 1000 cells/μl on two consecutive 
biweekly measurements following the ANC nadir, or greater than 5000 cells/μl 
on 1 biweekly measurement.  Biweekly measurements are obtained at least 3 
days apart (e.g., Monday and Thursday).  Only biweekly CBC values will be 
used to determine the duration of filgrastim administration during each cycle, 
even if additional CBC’s are obtained. 
3.5.3.8 EPOCH-F/R Dose Modification for Cycles 2 and 3: 
• Dose adjustments above starting dose level (level 1) consist of a 20% escalation in the 
daily doses of etoposide, doxorubicin, and cyclophosphamide, relative to the last cycle 
administered on study. 
• Dose adjustments below starting dose level (level 1) consist of a 20% reduction in the 
cyclophosphamide dose only, relative to the last cycle administered on study. 
• Dose adjustments are based on non-hematologic toxicities and the duration of ANC nadir 
during the previous cycle, using consecutive biweekly CBC/differential (> 3 days apart).  
Only biweekly CBC values will be used to determine dose adjustment, even if additional 
CBC’s are obtained. 
3.5.3.9 Fludarabine will be reduced by 20% for patients with creatinine clearance less 
than 70 ml/minute/1.73 m2. 
3.5.3.10 The number of cycles of EPOCH-F/R are specified in section 3.5.5. 
 
Rules for dose adjustment are summarized in the following table: 
• ANC < 500/l on 1 or fewer measurements 
• No grade III or IV non-hematologic toxicity 
 
Increase 1 dose level above 
previous cycle. 
• ANC < 500/l on 2 measurements, or 
transient (< 7 days) grade III non-
hematologic toxicity 
• No persistent (> 7days) grade III non-
hematologic toxicity 
• No grade IV non-hematologic toxicity 
 
Same dose level as previous cycle. 


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• ANC < 500/l on 3 measurements, or 
 
persistent grade III non-hematologic 
toxicity, or 
 
transient grade IV non-hematologic toxicity 
 
Decrease 1 dose level below 
previous cycle. 
• ANC < 500/l on 4 or more measurements, 
at dose level 1 or lower; or 
• Persistent grade IV non-hematologic 
toxicity 
 
Discontinue EPOCH-F/R; proceed 
to transplant conditioning regimen. 
 
 
3.5.4 Fludarabine/Cytarabine/Filgrastim Induction Chemotherapy (FLAG): 
 
Drug 
Dose 
Days 
Fludarabine 
25 mg/m2 per day IV 
infusion over 30 minutes, 
Daily for 5 days 
Days 1, 2, 3, 4, 5 
Cytarabine 
2,000 mg/m2 IV 
infusion over 4 hours, 
Daily for 5 days 
Days 1, 2, 3, 4, 5 
Filgrastim 
5 g/kg per day SC 
beginning 24 hours PRIOR to 
initiation of chemotherapy 
Daily from day 0 
until ANC >1000/l x 2 
following nadir (Section 3.3.4.1) 
 
3.5.4.1 Filgrastim will be initiated within 24 hours prior to the initiation of cytarabine 
and fludarabine (the day prior to the first day of chemotherapy or Day 0). 
Filgrastim will be administered at a dose of 5 μg/kg/day will be continued until 
the ANC is greater than 1000 cells/μl on two consecutive days following ANC 
nadir. 
3.5.4.2 Begin each cytarabine dose 3.5 hours after completion of the preceding 
fludarabine dose. 
3.5.4.3 Corticosteroid ophthalmic drops will be administered 2 drops to each eye every 
6 hours, starting prior to first dose of cytarabine and continuing until 24 hours 
after the last dose of cytarabine has been completed. 


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3.5.4.4 In the event of signs of CNS toxicity, the cytarabine infusion will be interrupted 
and the M.D. notified.  No further cytarabine will be administered if there is 
CNS toxicity (any grade) deemed related to cytarabine. 
3.5.4.5 FLAG Dose Modification for Cycle 2 (individual recipients) 
• If the prior cycle of induction chemotherapy is associated with reversible grade 4 
non-hematologic toxicity, dose reduction for that patient’s subsequent cycles will 
be performed.  Dose reduction will be as follows: 
• Fludarabine and cytarabine will be reduced from 5 days to 4 days of 
administration. The doses of all other medications will remain unchanged. 
3.5.4.6 FLAG Dose Reduction (study population): 
• If any 2 of 4 consecutive recipients experience the same grade 4 non-hematologic 
toxicity, dose reduction will be performed for all subsequent cycles for all 
patients.  Dose reduction will be as follows: 
• Fludarabine and cytarabine will be reduced from 5 days to 4 days of 
administration. The doses of all other medications will remain unchanged. 
3.5.4.7 Fludarabine will be reduced by 20% for patients with creatinine clearance less 
than 70 ml/minute/1.73 m2. 
3.5.4.8 The number of cycles of FLAG are specified in 3.3.5. 
3.5.5 Determination of Number of Cycles of Induction (FLAG or EPOCH-F/R) Chemotherapy: 
3.5.5.1 Because a major goal of the induction chemotherapy is to establish severe host 
immune T cell depletion prior to the allogeneic HSCT, the number of induction 
chemotherapy cycles administered will be determined principally by the level 
of host T cell depletion achieved. 
3.5.5.2 The CD4 count will be measured by FACS analysis at least 48 hours after the 
cycle’s last dose of filgrastim and within three days before the next scheduled 
cycle (i.e. day 22).  FACS analysis will be performed by a CLIA certified 
laboratory using a flow cytometry methodology to determine the percentage of 
circulating CD4+ cells.  A simultaneous CBC will be drawn in order to 
calculate the absolute CD4 number. 
3.5.5.3 If a patient has fewer than 100 CD4 cells/l and/or within the statistical margin 
of error of the CD4+ T-lymphocyte depletion goal ≤  115 CD4 cells/l of blood 
on the final CD4 determination of the induction chemotherapy cycle, then that 
patient will receive the transplant preparative regimen.  If there are ≥ 100 CD4 
cells/l, an additional cycle of induction chemotherapy will be administered.  
These criteria may be used for each induction chemotherapy cycle.  A 
minimum of one cycle of induction chemotherapy will be administered. 
However, a maximum of three cycles of induction chemotherapy can be 
administered. 
3.5.5.4 Patients will receive the second cycle of chemotherapy as specified: 


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• EPOCH-F/R will begin the second cycle of chemotherapy on day 22 after the first 
cycle was initiated.  Patients must have a post-nadir ANC >500/µL and post-nadir 
platelet count >50,000/µL in order to proceed to next cycle. However, up to two 
weeks of additional recovery time may be provided if medically indicated before 
administration of the second cycle (e.g., for delay in neutrophil or platelet 
recovery, documented infection, or grade III or higher III non-hematologic 
toxicity resulting from the induction chemotherapy regimen). 
• FLAG will begin on day 28 after the first cycle was initiated.  However, up to two 
weeks of additional recovery time may be provided if medically indicated before 
administration of the second cycle (e.g., for delay in neutrophil recovery to 1000 
cells/l, documented infection or other complication resulting from the induction 
chemotherapy regimen).  
3.5.5.5 Patients who develop excessive neutropenia during chemotherapy will go 
straight to transplantation 
• If a patient receiving EPOCH-F/R develops neutropenia of less than 500 cells/l 
on 4 or more consecutive biweekly CBC’s during any cycle of induction 
chemotherapy administered at dose level 1 or lower, the patient will receive no 
further induction chemotherapy.  At that point, the patient will receive the 
transplant preparative regimen, even if the CD4 count is > 100 cells/l.  Only 
biweekly CBC values (at least 3 days apart, e.g. Monday and Thursday) will be 
used to define the duration of neutropenia during each cycle, even if additional 
CBC’s are obtained. 
• If a patient receiving FLAG chemotherapy continues to have neutropenia defined 
as ANC<500 which continues until ≥ day 28 of treatment, the patient will receive 
no further induction chemotherapy even if the CD4 count at the time of recovery 
is ≥ 100 cells/l.   
3.5.5.6 In patients who previously have received a total anthracycline dose > 
450mg/m2 a MUGA or 2-D echo will be repeated after each cycle of EPOCH-
FR. If the ejection fraction is less than 45% and/or new wall motion 
abnormalities have occurred the next planned cycle will be held for 2 weeks 
and a repeat MUGA or 2-D echo will be performed. If the abnormalities persist 
the patient will be removed from protocol. If they have resolved the patient 
may proceed with the next planned course of EPOCH-FR however the 
Adriamycin will be removed. 
3.5.5.7 If the maximum cycles (3 for EPOCH-F/R and 2 for FLAG) of induction 
chemotherapy has been administered on the study or prior to the study 
enrollment, then the patients may proceed to the transplant preparative regimen, 
even if the CD4 count is still ≥ 100 cells/l. 
3.5.5.8 Patients who develop progressive disease or relapse during or after the 
completion of the induction chemotherapy will not be eligible for the transplant 
phase of the protocol, and will be removed from the study (Section 3.10). 
3.5.6 
Concurrent Therapy for Extramedullary Leukemia or CNS Lymphoma:  


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3.5.6.1 Concurrent therapy or prophylaxis for testicular leukemia, CNS leukemia, and 
CNS lymphoma including standard intrathecal chemotherapy and/or radiation 
therapy will be allowed as clinically indicated after approval by the PI. Such 
treatment may continue until the planned course is completed. Subjects must be 
in CNS remission at the time of protocol enrollment. 
3.5.7 Concurrent Therapy for bcr-abl (+) CML, AML or ALL 
3.5.7.1 Patients receiving tyrosine kinase inhibitors (e.g. imatinib, nilotinib, and 
dasatinib) may continue through induction therapy. Such treatments must be 
discontinued one week prior to initiating the conditioning regimen.  
There has been an increasing amount of data over the past three years showing that the 
administration of TKI’s with induction and consolidative chemotherapy provides clinical benefit 
relative to remission.  The proposed amendment would allow for the continued use of tyrosine 
kinase inhibitors though induction therapy. The concomitant use of TKI with conventional 
chemotherapy is becoming the standard of care for patients with bcr-abl(+) leukemias.  The 
Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL) treated 45 patients 
with newly diagnosed Ph+ ALL and initiated imatinib with consolidative chemotherapy (HAM: 
mitoxantrone with intermediate-dose cytarabine) consolidation in good early responders (cortico-
sensitive and chemo-sensitive ALL) or earlier during the induction course in combination with 
dexamethasone and vincristine in poor early responders (cortico-resistant and/or chemo-resistant 
ALL). Imatinib was then continuously administered until stem cell transplantation. Overall, 
complete remission (CR) and BCR-ABL real-time quantitative polymerase chain reaction (RQ-
PCR) negativity rates were 96% and 29%, respectively. All of the 22 CR patients (100%) with a 
donor actually received allogeneic SCT in first CR. At 18 months, the estimated cumulative 
incidence of relapse, disease-free survival, and overall survival were 30%, 51%, and 65%, 
respectively. These 3 end points compared very favorably with results obtained in the pre-
imatinib LALA-94 trial. The authors of the paper concluded that their study confirmed the value 
of the combined approach and encourages prospective trials to define the optimal chemotherapy 
that has to be combined with imatinib. In addition, it appears that the use of TKI prior to 
transplant is not associated with increased transplant-related morbidity (TRM) or poorer 
outcomes [122, 123]. 
3.5.8 Interim Evaluation During Induction Chemotherapy 
3.5.8.1 The following studies will be obtained in all EPOCH-F/R or FLAG recipients 
during each cycle of induction chemotherapy on a biweekly basis, at least 3 
days apart: 
3.5.8.1.1 Complete blood count with differential 
3.5.8.1.2  Acute care, mineral and liver panel & LDH. 
3.5.8.2 The following studies will be obtained in recipients with lymphoma, CLL, 
PLL, or multiple myeloma at the end of each cycle of EPOCH-F/R induction 
chemotherapy: 
3.5.8.2.1 Routine chemistry hematology panels and 24 hour Creatinine Clearance (if 
clinically indicated). 


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3.5.8.2.2  Urine or serum HCG in women of childbearing potential 
3.5.8.2.3 For recipients with lymphoma: computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated). 
3.5.8.2.4 For recipients with multiple myeloma:  serum protein electrophoresis; 
serum Ig level (free light chains); 24h collection of urine for urine protein 
electrophoresis, immunofixation, albumin, and creatinine clearance; β2-
microglobulin; immunofixation if M protein is undetectable; CRP  
3.5.8.3 The following studies will be obtained in recipients with acute leukemia, 
lymphoblastic lymphoma, MDS, MPD, CMML, or CML at the end of each 
cycle of FLAG induction chemotherapy: 
3.5.8.3.1 Routine chemistry hematology panels and 24 hour Creatinine Clearance (if 
clinically indicated). 
3.5.8.3.2 Urine or serum HCG in women of childbearing potential 
3.5.8.3.3 For recipients with lymphoblastic lymphoma:  computed tomography scans 
of chest/abdomen/pelvis (and neck, if clinically indicated). 
3.5.8.3.4 Bone marrow aspirate and biopsy, with flow cytometry, cytogenetics, FISH 
and/or PCR as clinically appropriate to monitor disease status. 
3.6 
TRANSPLANT CONDITIONING REGIMEN 
3.6.1 The following studies will be obtained in the recipient within 28 days before the initiation 
of the conditioning regimen: 
3.6.1.1 Bone marrow aspiration and biopsy; flow cytometry, cytogenetics, and 
molecular studies as clinically appropriate 
3.6.1.2 For recipients with lymphoma, CLL, or PLL:  computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated); FDG-PET scan, if 
evaluable disease was present on baseline PET. 
3.6.1.3 For recipients with multiple myeloma:  serum protein electrophoresis; serum Ig 
level; 24h collection of urine for urine protein electrophoresis; B2-
microglobulin; immunofixation if M protein is undetectable; bone marrow 
biopsy; skeletal survey. 
3.6.1.4 Pulmonary function testing including DLCO 
3.6.1.5 2-D echo or MUGA scan 
3.6.2 The following studies will be obtained in the recipient within 48 hours of the initiation of 
the transplantation conditioning regimen: 
3.6.2.1 CBC with differential. 
3.6.2.2 PT, PTT. 


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3.6.2.3 Acute care panel, hepatic panel, and mineral panel. 
3.6.2.4 Urinalysis and 24 hour Creatinine Clearance. 
3.6.2.5 Urine or serum HCG in women of childbearing potential. 
             6.2.1.6 PCR test of DNA mini-satellite regions for future determination of chimerism 
3.6.3 On day 22 after the start of the last cycle of  EPOCH-F/R or day 28 after the start of the 
last cycle of FLAG chemotherapy, patients will be eligible to start the transplant 
conditioning regimen and should meet the following criteria (performed after completion 
of induction therapy) Patients who already met all these criteria at the study enrollment 
may be considered for proceeding with transplant conditioning per PI decision and in 
consultation with relevant sub-specialist services when pertinent: 
3.6.3.1 ECOG performance status equal to 0, 1, or 2, and Karnofsky performance 
status greater than or equal to 60%. 
3.6.3.2 Left ventricular ejection fraction > 45% by either MUGA or 2-D echo.  
3.6.3.3 DLCO > 50% of the expected value when corrected for Hb. 
3.6.3.4 Creatinine < 1.5 mg/dl and creatinine clearance > 50 ml/min/1.73 m2. 
3.6.3.5 Serum total bilirubin less than 2.5 mg/dl, and serum ALT and AST values less 
than or equal to 2.5 times the upper limit of normal. 
3.6.3.6 No evidence of active infection that is not responding to antimicrobial therapy. 
3.6.3.7 Verification of donor eligibility received from NMDP. 
3.6.3.8 Verification of disease status: 
a) Recipients with primary or secondary acute leukemia, myelodysplastic syndrome, 
blastic phase CML, myeloproliferative disorders, or other eligible diagnoses in 
transformation to acute leukemia must have < 5% blasts in bone marrow and no 
circulating blasts after induction therapy. 
b) Recipients with chronic or accelerated phase CML must have < 10% blasts in the 
peripheral smear or bone marrow after induction therapy. 
c) For patients with non-Hodgkin’s lymphoma, Hodgkin’s disease, multiple 
myeloma, CLL, PLL, or other lymphoid malignancy must be determined to have at 
least stable disease to induction therapy. 
3.6.4 Non-hematologic toxicities of induction chemotherapy must resolve to <grade 2 in order 
to proceed.  If more than 14 days of additional recovery time is required for resolution of 
toxicity or other medical complications (for example, prolonged neutropenia or 
documented infection), PI approval is required prior to initiation of the transplant 
conditioning regimen. 
3.6.5 Fludarabine/Cyclophosphamide/Mesna: 
Drug 
Dose 
Days 


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Drug 
Dose 
Days 
Fludarabine 
30 mg/m2 per day 
IV infusion over 30 minutes, 
daily for 4 days 
Transplant Days –6, -5, -4, -3 
Cyclophosphamide 
1200 mg/m2 per day 
IV infusion over 2 hours, 
daily for 4 days 
Transplant Days –6, -5, -4, -3 
Mesna 
1200 mg/m2 per day 
Continuous IV infusion, 
Daily for 4 days 
Transplant Days –6, -5, -4, -3 
3.6.5.1 Mesna infusion should start concurrently with cyclophosphamide on day –6. 
3.6.5.2 Fludarabine will be reduced by 20% for patients with creatinine clearance less 
than 70 ml/min/1.73 m2. 
3.6.6 Hydration during the conditioning regimen: 
3.6.6.1 Hydration will be initiated 12 hours prior to cyclophosphamide infusion (on 
day –7 of the transplant), consisting of 0.9% sodium chloride supplemented 
with 10 mEq/liter potassium chloride (KCl) at an initial rate of 100 ml/hour.  
For recipients with poor oral intake, the rate of hydration may be increased as 
clinically indicated to meet fluid requirements.  Hydration will continue until 
24 hours after the last cyclophosphamide dose has been completed. 
3.6.6.2 During hydration, serum potassium level will be monitored every 12 hours.  If 
serum potassium is > 4.5 mEq/l, KCl will be removed from the saline infusion.  
If serum potassium is < 3.0, KCl concentration in the saline will be increased to 
20 mEq/l. 
3.6.6.3 During hydration, 20 mg of furosemide will be administered daily by IV route 
to maintain diuresis, with additional doses of furosemide to be given as needed 
for weight gain due to fluid retention.  In general, furosemide doses should be 
separated by at least a four-hour observation interval. 
3.6.6.4 During hydration, if fluid intake exceeds urine output by greater than 500 ml 
during an 8-hour period, an additional 20 mg of furosemide will be 
administered. 
3.6.6.5 Routine hematologic monitoring, cardiac monitoring, and urinalysis will be 
performed as deemed clinically necessary. 
 
3.7 
ALLOGENEIC PERIPHERAL BLOOD STEM CELL TRANSPLANTATION 


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3.7.1 On day 0, the recipient will receive PBSC.  If the PBSC product is cryopreserved, it will 
be administered intravenously immediately after thawing. Infused CD3 cell dose per kg 
recipient weight will be recorded 
3.7.2 Diphenhydramine and/or meperidine are preferred for the treatment of acute DMSO 
toxicities (e.g. chills, myalgias); steroids are not permitted. 
3.8 
GRAFT-VERSUS-HOST DISEASE (GVHD) PROPHYLAXIS 
3.8.1 GVHD Prophylaxis Arm Assignment – At the time of study enrollment, the CRO will 
inform the investigators of the patient’s assignment to their respective GVHD 
prophylaxis arm. Patients will be randomized to receive one of two specific GVHD 
prophlaxis regimens at the time of enrollment: Tacrolimus + Methotrexate + Sirolimus 
(TMS) versus Alemtuzumab + Cyclosporine (AC). 
3.8.1.1 Tacrolimus + Methotrexate + Sirolimus (TMS Arm) [36]: 
a) Tacrolimus will be initiated on day -3 before the transplant. Tacrolimus will be 
administered continuous intravenous infusion at 0.02 mg/kg/day.  Subsequently doses 
will be adjusted according to trough levels monitored at least biweekly and/or upon 
symptoms or alteration in renal function.  The target serum level for tacrolimus will be 5 
to 10 ng/mL. 
b) When the recipient is able to take oral medications (typically 10 to 21 days after 
transplantation), tacrolimus will be converted to an equivalent oral dose.  The total daily 
dose will be divided into two equal doses, one dose given approximately every 12 hours. 
c) This dose of tacrolimus will continue until day +63 (+/- 2 days), and then reduced by 
one-third as long as the severity of GVHD is less than grade 2 and patient is not requiring 
systemic steroids.  Tacrolimus will be subsequently reduced by one third on day +119 
(+/- 2 days). Tacrolimus will then be completely discontinued by day +180 (i.e. 6 
months) discontinued if there are no signs of GVHD. 
d) Methotrexate will be given at 5 mg/m2 IV over 15 minutes on days +1, +3, +6, and +11.  
Each day’s dose of methotrexate will not be administered until approved that day by the 
transplant attending after the transplant team has evaluated the patient.  Doses will be 
withheld for the development of grade III or IV mucositis or clinical evidence of veno-
occlusive disease. Administration of the combination of trimethoprim and 
sulfamethoxazole (i.e., Bactrim) or non-steroidal anti-inflammatory drugs is 
contraindicated during methotrexate administration.  Methotrexate administration will be 
assessed on each planned day of administration, and dose adjustments will be based upon 
the following criteria: 
 
Creatinine 
Total Bilirubin 
Methotrexate Dose 
< 2.0 mg/dL 
<5.0 mg/dL 
100% 
2.0 – 3.0 mg/dL 
---- 
50% 
> 3.0 mg/dL 
> 5.0 mg/dL 
Hold Dose 


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e) Methotrexate may also be held or dose adjusted at the discretion of attending physician or 
P.I. for severe mucositis or third space fluid collection (e.g. pleural effusion, ascites, or 
edema. In addition, leucovorin (folinic acid) rescue may be considered under the 
direction of the attending physician or PI. The recommended dose regimen of leucovorin 
is 10mg IV or PO every 6 hours starting 24 hours after methotrexate administration and 
continued until undetectable methotrexate levels or upon the discretion of the attending 
physician or P.I.. Leucovorin should be held 12 hours prior to the any subsequent 
methotrexate dose and not resumed (if indicated) for 24 hours after a methotrexate dose. 
f) Sirolimus will be initiated on day –3 before the transplant procedure. Sirolimus will be 
administered by mouth as sirolimus tablets at an initial “loading dose” of 12 mg, p.o., on 
day –3 of transplantation. 
g) On day –3 pre-transplant and subsequently, sirolimus dosing will be 4 mg, p.o., each day. 
Sirolimus dose should be adjusted to maintain therapeutic concentrations in the range of 
3 to 12 ng/ml, with sirolimus trough levels drawn on a Monday, Wednesday, Friday 
schedule (if inpatient) or a Monday, Thursday schedule (if outpatient). 
h) This dose of sirolimus will continue until day +63 (+/- 2 days), and then reduced by one-
third as long as the severity of GVHD is less than grade 2 and patient is not requiring 
systemic steroids.  Sirolimus will be subsequently reduced by one third on day +119 (+/- 
2 days). Sirolimus will then be completely discontinued by day +180 (i.e. 6 months) if 
there are no signs of GVHD. 
i) Because voriconazole greatly reduces sirolimus clearance via cytochrome p450 
inhibition, the use of voriconazole should be avoided in recipients of sirolimus. However, 
if voriconazole is deemed necessary while the patient is receiving sirolimus, the dose of 
sirolimus will be reduced by 90% [98]. 
j) Fluconazole has less of an effect on sirolimus clearance, and therefore will be used for 
fungal prophylaxis in all patients. 
k) For sirolimus levels, 2.5 cc of blood will be collected into EDTA tubes and analyzed at 
the NIH Clinical Center. 
3.8.1.2 Alemtuzumab and Cyclosporine (AC Arm) [31]: 
3.8.1.2.1 Alemtuzumab (CAMPATH-1H, Campath®) at 20 mg/day by intravenous 
(IV) infusion over 8 h on days −8 to −4 (total alemtuzumab = 100 mg).  
3.8.1.2.1.1 Patients are to be pre-medicated with diphenhydramine 50 mg p.o. 
and acetaminophen 650 mg p.o. 30 minutes prior to each 
alemtuzumab infusion. 
3.8.1.2.1.2 In light of the relatively high risk of infusion-related toxicities, the 
initial infusion rate should be 0.5 mg/hour, which may increased 
every 15 minutes as tolerated by increments of 0.5 mg/hour until the 
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3.8.1.2.1.3 In cases where severe infusion-related events occur, the rate should 
be slowed or discontinued and patients should receive 
hydrocortisone 200 mg intravenously after approval by treating 
physician. Once determined by the treating responsible physician 
that the patient is stable, the infusion can be re-initiated or advanced 
as per guidelines in 3.6.1.2.1.2. 
3.8.1.2.1.4 Other drug substances should not be added or simultaneously infused 
through the same intravenous line that alemtuzumab is administered. 
3.8.1.2.2 Cyclosporine will be initiated on the day –1 before the transplant. 
Cyclosporine will be administered by IV infusion at 2 mg/kg/dose every 12 
hours; infusion will be over a 2-hour period.  Subsequently doses will be 
adjusted according to trough levels monitored at least biweekly and/or upon 
symptoms or alteration in renal function.  The target range for serum 
cyclosporine levels will be 150–250 g/ml. 
3.8.1.2.3 When the recipient is able to take oral medications (typically 10 to 21 days 
after transplantation), cyclosporine will be converted to an equivalent oral 
dose.  The total daily dose will be divided into two equal doses, one dose 
given approximately every 12 hours. 
3.8.1.2.4 This dose of cyclosporine will continue until day +100, and then will be 
tapered as long as the severity of GVHD is less than grade 2.  Cyclosporine 
will be tapered by reducing the dose by approximately 10% from the last 
dose administered each week to a dose of 25 mg/day. Cyclosporine will 
then be completely discontinued by six months if there are no signs of 
GVHD. 
3.9 
EVALUATION DURING TRANSPLANTATION 
3.9.1 The following studies will be obtained in the recipient during hospitalization for 
transplantation: 
3.9.1.1 CBC twice daily; differential count daily 
3.9.1.2 Acute care and mineral panels twice daily; hepatic panel and LDH daily 
3.9.1.3 Type and screen every 4 days 
3.9.1.4 GVHD prophylaxis (cyclosporine, tacrolimus, sirolimus) trough level twice 
weekly, starting day +1 or day +2. 
3.9.2 Donor/recipient chimerism studies: 
3.9.2.1 Baseline determination in donor and recipient (prior to start of respective 
induction chemotherapy). 
3.9.2.2 After transplantation in recipient (+/- 3 days): 
a) Peripheral blood lymphoid, myeloid, and total chimerism on day +14, +28, +42, +60, if 
lymphoid and myeloid are ≥ 95% then will check again at day +100. It will then be 


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obtained monthly until day +180, and every three months thereafter until day +365(+/- 3 
days at all timepoint intervals).  . 
b) Bone marrow chimerism on days +28, +100, and 12 months.  Lymphoid & myeloid 
subset chimerism will also be measured at these time-points if donor chimerism was < 
95% on the previous study. 
3.9.2.3 Chimerism may be measured at other time-points if clinically indicated (e.g., to 
determine effect of manipulating immune suppression in order to increase 
donor chimerism). 
3.9.3 The patient will be evaluated at least twice a week during the first 100 days after 
transplantation for the development of acute GVHD. 
3.10 OFF STUDY CRITERIA 
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy. 
3.10.1 The recipient will be removed from protocol for any of the following reasons: 
3.10.1.1 Inadequate stem cell collection from the selected donor defined as less than or 
equal to 2 x 106 CD34+ cells/kg. If this rare event should occur, another 
eligible donor may be enrolled and may undergo filgrastim mobilization and 
PBSC collection as outlined in Section 0.  If no other eligible donor is available 
or if there is insufficient time to arrange donor cell collection, then the recipient 
will be removed from the trial; however, the available cells will be infused and 
the patient will receive standard post-transplant care. 
3.10.1.2 Recipients with acute leukemia (primary or secondary), MDS, MPD, CMML-2, 
or blastic phase CML must be in remission after FLAG induction 
chemotherapy (section 3.3.4), defined as < 5% blasts on bone marrow aspirate 
and the absence of circulating blasts in peripheral blood. 
3.10.1.3 Progressive disease during or after completion of EPOCH-F/R induction 
chemotherapy (section 3.3.3). 
3.10.1.4 Non-hematologic toxicity of > grade 3 for the recipient while receiving 
induction chemotherapy (EPOCH-F/R or FLAG), that does not resolve within 
14 days after the next cycle of induction chemotherapy or the transplant 
conditioning regimen is due to be administered.  However, recipients with 
grade 3 or higher infections may remain on study and continue with protocol 
treatment, if the infection or infections are responding to antimicrobial therapy 
and are not felt to pose an excessive risk in the opinion of an infectious diseases 
consultant. 
3.10.1.5 Failure to meet pre-transplant eligibility criteria defined in section2.7. 
3.10.1.6 The donor or recipient refuses to continue therapy. 
3.10.1.7 Lost to Follow-Up 
3.10.1.8 Death 


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3.10.2 In all cases, the reason(s) for withdrawal will be documented. 
3.10.3 In addition, a patient may at any time be removed from protocol at the principal 
investigator’s discretion, if the P.I. deems the subject to be at unacceptable risk to remain 
on study.  Reasons for this action may include (but are not limited to) disease progression 
with declining organ function/performance status before transplantation; inadequate 
family/caregiver support; noncompliance. 
3.11 POST-TRANSPLANTATION EVALUATION 
3.11.1 After completion of therapy the recipient will be followed for potential complications 
related to allogeneic SCT.  The recipient will be followed at least twice weekly in the 
outpatient setting until at least Day +100 after discharge from the hospital. 
3.11.2 The recipient will be seen in follow-up at the Clinical Center to evaluate disease status 
and late complications of allogeneic HSCT, at days +28 and +100; and at 6, 9, 12, 18, 24 
months and then annually post-transplant thereafter up until the 5 year timepoint unless 
earlier evaluation is clinically indicated.  At these times recipients will undergo the 
following tests to determine clinical response: 
3.11.2.1 Routine chemistry and hematologic panels. 
3.11.2.2 Bone marrow aspiration and biopsy with flow cytometry, cytogenetics, and 
molecular studies as clinically appropriate. 
3.11.2.3 For recipients with lymphoma: computed tomography scans of 
chest/abdomen/pelvis (and neck, if clinically indicated).  FDG-PET scan will 
be obtained 28 and 100 days post transplant in all patients with lymphoma (if 
indicated).  For recipients who enter into CR or CRu with negative PET, 
follow-up evaluation will include a PET scan at 6 and 12 months post 
transplant.  Other time points may be included if clinically indicated. 
3.11.2.4 For recipients with multiple myeloma:  serum protein electrophoresis with M 
protein; serum Ig level; 24h collection of urine for urinary protein excretion, 
protein electrophoresis and M protein; B2-microglobulin; immunofixation if M 
protein is undetectable; skeletal survey will be performed as clinically 
indicated.. 
3.11.2.5 Pulmonary Function Test (PFT): (exception: D28 evaluation is only if clinically 
indicated). 
 
3.11.2.6 Patients who have previously received a total anthracycline dose > 450mg/m2 
will also have a MUGA or 2-D echo will at these timepoints. 
3.11.3 Any patient who develops chronic GVHD (before or after day 100) and all patients with 
acute GVHD manifestations at 6, 9, 12, 15, 18, 21 and 24 months will be referred in the 
Chronic GVHD Clinic as part of their scheduled routine follow-up. 
3.11.4 Any patient who experiences post-transplant relapse will be referred to the Natural 
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protocol 11-C-0125. Patients will not be taken off study in this case but can be enrolled 
on both studies concurrently. 
3.11.5 After 5 year follow up all key protocol research endpoints are achieved  there would be 
no protocol scheduled follow up visits and all further follow up would be based solely on 
clinical decisions by the PI or LAI.  
4 
SUPPORTIVE CARE 
4.1 
INFECTION PROPHYLAXIS  
(For a full description of infection prophylaxis please refer to the NIH BMT Consortium 
Supportive Care Guidelines at http://intranet.cc.nih.gov/bmt/clinicalcare/guidelines.shtml) 
4.1.1 All recipients will receive prophylaxis against Pneumocystis jiroveci (previously known 
as Pneumocystis carinii) pneumonia, beginning with the first cycle of the induction 
therapy, continuing until transplantation, and resuming at the time of platelet recovery.  
Pneumocystis prophylaxis will continue until immunosuppression is discontinued and the 
CD4 count is > 200 for 3 months.  Trimethoprim/sulfamethoxazole is the preferred 
regimen.   
4.1.2 All recipients will receive fluconazole for prophylaxis against yeast infections. Because 
of its interaction with vincristine, fluconazole should not be taken concurrently with 
EPOCH-F/R chemotherapy.  Therefore, fluconazole will start on day 6 of the first cycle 
of pre-transplant induction chemotherapy and will be held on days 1 through 5 of each 
subsequent cycle.  Fluconazole will then continue through transplantation until day +100 
and immunosuppression is discontinued.  Fluconazole may be stopped during therapy 
with an alternative antifungal agent. 
4.1.2.1 Although there is evidence that ketoconazole can raise the AUC of imatinib, as 
well as cyclosporine, there are no specific recommendations within the medical 
literature that any of these agents require a specific dose modification. 
However, it is advised to monitor more closely for the known adverse effects of 
these agents and to adjust or discontinue these agents as appropriate if an 
adverse event occur. 
4.1.3 During the peri-transplant period, recipients will receive prophylactic broad-spectrum 
antibiotics with ceftazidime from the onset of neutropenia (ANC < 500/μl) or first fever 
(T > 38.3°C) until neutropenia resolves.  Recipients with allergy to cephalosporin 
antibiotics will receive an alternative regimen for prophylaxis as recommended by the 
infectious diseases consultant.  This practice is adopted in recognition of the historically 
high infectious morbidity and mortality associated with allogeneic HSCT from unrelated 
donors.  At other times, antibiotic therapy for neutropenic recipients will be managed in 
accordance with CDC guidelines.  Recipients with neutropenia and fever that persists for 
longer than 4 days despite broad-spectrum antibiotics will receive empiric antifungal 
therapy with caspofungin, liposomal amphotericin B, poseconazole, or voriconazole, in 
accordance with standard practices. Empiric antifungal therapy may be started at other 
times, if clinically indicated. Voriconazole should not be administered during the time of 
sirolimus in patients randomized to that arm (section 3.8.1.1).  


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4.1.4 All recipients will receive valacyclovir for prophylaxis against herpes simplex virus and 
Varicella zoster virus infection/reactivation.  This therapy will start on day 1 of pre-
transplant induction chemotherapy, continuing through transplantation until day +100 
and immunosuppression is discontinued. Valacyclovir will be discontinued while patients 
are receiving IV acyclovir, valganciclovir, ganciclovir, or foscarnet. 
4.1.5 Recipients with positive pre-transplant serology for Cytomegalovirus (CMV) and/or 
CMV-sero-positive donors will be monitored for CMV reactivation by clinical evaluation 
and weekly testing with CMV antigenemia or PCR assays as clinically appropriate.  
CMV reactivation or disease will be treated according to the schema in Appendix A.  
Weekly monitoring will continue through 6 months post transplant (longer for recipients 
on continued immunosuppression). 
4.1.6 All recipients will undergo monitoring for reactivation of Epstein-Barr virus (EBV) by 
weekly quantitative PCR assays.  Pre-emptive treatment with rituximab and/or donor 
lymphocyte infusion (DLI) will be considered for recipients with EBV reactivation, in 
consultation with infectious diseases staff.  Monitoring will continue through day +180 
post transplantation (longer for recipients deemed at continued high risk by infectious 
diseases staff). 
4.1.7 All patients will receive ursodeoxycholic acid (Ursodiol) for the prevention of hepatic 
complications after allogeneic stem cell transplantation [99,100].  Ursodiol will start day 
-6 prior to the transplant and will continue until day +98 post-transplant. Patients 
weighing less than 90kg will receive 300mg orally twice daily (600mg total dose each 
day). Those patients weighing more than 90kg will receive 300mg orally each morning 
and 600mg orally each evening (900mg total dose each day). 
4.1.8 Recipients receiving immunosuppression for chronic GVHD will receive penicillin V for 
prophylaxis against bacterial infections.  All recipients will undergo vaccinations as 
indicated in Appendix A, beginning 6 months after transplantation.  Administration of 
live vaccines will be avoided during the first 2 years after transplantation or in patients 
with ongoing chronic GVHD or immunosuppression. 
4.2 
MANAGEMENT OF ENGRAFTMENT SYNDROME   
Engraftment syndrome may occur at the time of neutrophil recovery.  Its clinical manifestations 
include noninfectious fever, rash, and vascular leak causing non-cardiogenic pulmonary edema, 
weight gain, and renal insufficiency [101].  Diagnostic criteria and a treatment schema for 
engraftment syndrome are included in Appendix B. 
4.3 
TREATMENT OF MIXED CHIMERISM OR PERSISTENT/PROGRESSIVE DISEASE POST-
TRANSPLANT 
4.3.1 Donor Lymphocyte Infusion 
4.3.1.1 Patients with persistent or progressive malignancy post-HSCT, or mixed 
chimerism that does not improve after tapering or discontinuing immune 
suppression may be eligible to receive donor lymphocytes (donor lymphocyte 
infusion, or “DLI”) if they can be obtained from their respective donor.  


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4.3.1.2 Additional lymphocytes will be collected by apheresis from the patient’s 
original stem cell donor, either in steady state (i.e. no donor therapy) or after 
filgrastim administration. 
4.3.1.3 DLI may be administered alone or after chemotherapy. DLI may be 
sequentially administered for mixed chimerism or disease progression 
Recipients with mixed chimerism or disease progression may receive DLI 
consisting of unmanipulated donor T cells.    Alternatively, in cases where 
additional donor stem cells are desired, the donor product may be administered 
without lymphocyte purification. 
4.3.1.4 Recipients with mixed chimerism at day +28 will undergo repeat chimerism 
assessment at day +42 (+/- 3 days) and every two weeks thereafter as deemed 
necessary.  If there is evidence of declining donor chimerism on consecutive 
determinations or if <50% donor chimerism on whole blood, lymphoid, or 
myeloid subsets at a single determination, recipients without GVHD will be 
eligible to receive DLI.   DLI may be repeated every 4 weeks with dose 
escalation as indicated above, until donor chimerism > 95% is achieved or until 
GVHD develops.  Cyclosporine, tacrolimus, and sirolimus will be maintained 
at planned specific doses through day +100 for recipients with mixed 
chimerism while DLI are administered.  Recipients with mixed chimerism 
beyond day +100 may undergo withdrawal of respective immunosuppressive 
agents (i.e. cyclosporine, tacrolimus, and/or sirolimus) over 28 days, followed 
by DLI administration at escalating doses as outlined. 
4.3.1.5 Recipients with disease progression and without GVHD will be eligible to 
receive DLI. DLI may be repeated every 4 weeks with dose escalation as 
indicated above, until donor chimerism > 95% is achieved or until GVHD 
develops.  For disease progression occurring after day +42 and before day 
+100, cyclosporine will be withdrawn over 28 days prior to administration of 
the first DLI. 
4.3.2 Other Post-Transplant Therapy - In addition to DLI, persistent or progressive disease may 
be treated with any approved therapy thought to be in the best interest of the patient, such 
as chemotherapy, cytokines, or monoclonal antibodies.  Alternatively, such patients may 
be offered therapy on other NCI protocols. 
4.3.3 For patients with bcr-abl (+) CML, AML or ALL who were previously receiving tyrosine 
kinase inhibitors (e.g. imatinib, nilotinib and dasatinib) prior to transplant may resume 
this therapy at Day 28. 
As part of a prospective study, Carpenter and colleagues at the Fred Hutchinson Cancer research 
Center in Seattle administered imatinib from the time of engraftment until 365 days after 
allogeneic stem cell transplant in 22 patients, 15 with Ph+ acute lymphoblastic leukemia = 15; 
chronic myelogenous leukemia = 7). Before day 90, adults (n = 19) tolerated a median average 
daily imatinib dose of 400 mg/d (range, 200-500 mg/d), and children (n = 3) tolerated 265 
mg/m2/d (range, 200-290 mg/m2/ d). The most common adverse events related to imatinib 
administration were grade 1-3 nausea, emesis, and serum transaminase elevations. The 


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conclusion of this trial was that imatinib could be safely administered early after myeloablative 
allogeneic HCT at a dose intensity comparable to that used in primary therapy [124]. 
4.4 
TREATMENT OF GRAFT-VERSUS-HOST DISEASE 
4.4.1 In recipients with suspected GVHD, standard clinical criteria and biopsy findings (when 
clinically indicated) will be used to establish the diagnosis.  Acute GVHD will be 
assessed according to 1994 Consensus Conference on Acute GVHD Grading criteria 
[106].  See Appendix C for details concerning the grading and management of acute 
GVHD. Chronic GVHD will be assessed according to 2005 Chronic GVHD Consensus 
Project [61]. See Appendix Ffor details concerning the assessment of chronic GVHD. 
4.4.2 Recipients with clinical Stage 1 or 2 (Grade I) GVHD of the skin without any other organ 
involvement will be treated with a topical corticosteroid cream. 
4.4.3 In general, recipients with  Grade II acute GVHD will be treated with high-dose, 
systemic corticosteroids. 
4.4.4 Recipients who fail to respond satisfactorily to corticosteroids will be considered for 
second-line immunosuppressive therapy, e.g., tacrolimus, mycophenolic acid, 
monoclonal antibodies, or experimental GVHD protocols, if they are available. 
4.5 
MENSES SUPPRESSION AND CONTRACEPTION  
(For a full description of menses suppression and contraception please refer to the NIH BMT 
Consortium Supportive Care Guidelines at:  
http://intranet.cc.nih.gov/bmt/clinicalcare/guidelines.shtml)  
4.5.1 Pre-menopausal women who have not undergone hysterectomy will be placed on a 
monophasic oral contraceptive to provide both menses suppression and contraception.  
This therapy will begin with the first cycle of induction therapy and continue until 
platelet recovery after transplantation. (>50,000/mm3 without transfusion). Start 
treatment prior to the onset of thrombocytopenia usually when withdrawal bleeding 
begins. Once thrombocytopenia occurs therapy is less likely to be effective. As general 
recommendations: 
• Prescribe Lo-Ovral (300mcg norgestrol and 30 mcg ethinyl estradiol)  
• 1 tablet daily. Instruct patient not to take placebo tablets.  
• If the patient is on another oral contraceptive, switch her to Lo-Ovral  
If Lo-Ovral is started when the patient is bleeding and bleeding persists for more than 2-3 days, 
increase the dose to 1 tablet twice daily. If bleeding persists for more than an additional 2-3 days 
(total 5 to 6 days after starting hormones), consult the NIH Gynecology Consult Service. 
4.5.2 Female transplant recipients will be advised to use contraception for at least 1 year after 
transplantation and to have their male partners use condoms.  Male transplant recipients 
will be advised to use contraception, preferably condoms, for 1 year after transplantation. 
4.6 
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4.6.1 Recipients will receive packed red blood cells and platelets as needed to maintain Hb > 
8.0 gm/dl, and platelets > 10,000/mm3 (or higher, if clinically indicated). All blood 
products except for the stem cell product and DLI will be irradiated. 
4.6.2 Leukocyte filters will be utilized for all blood and platelet transfusions to decrease 
sensitization to transfused leukocytes and decrease the risk of CMV infection [107]. 
4.7 
NUTRITIONAL SUPPORT  
When mucositis or GVHD prevents adequate PO intake, parenteral hyperalimentation will be 
instituted and discontinued under the direction of the dietary service.  Oral intake will resume 
when clinically appropriate under the supervision of the dietary service of the Clinical Center. 
4.8 
ANTI-EMETICS  
Anti-emetic usage will follow Clinical Center Guidelines as well as recommendations from the 
Pharmacy service. 
4.9 
HEMATOPOIETIC GROWTH FACTOR SUPPORT   
All patients will start filgrastim 10g/kg/day on day 0 starting after the stem cell infusion.  The 
dose will be given subcutaneously (SC).  Filgrastim will be continued until the absolute 
neutrophil count (ANC) is > 5000/l for at least one day and > 1000/l for three consecutive 
days. Filgrastim may be resumed if ANC drops below 1000/l. 
5 
BIOSPECIMEN COLLECTION 
5.1 
CORRELATIVE STUDIES FOR RESEARCH 
5.1.1 Immunological Studies 
5.1.1.1 T-Cell Receptor Vβ Repertoire Analysis by CDR3 Spectratyping ((Hakim lab).  
5.1.1.1.1 40 ml of blood will be drawn from the donor and placed into yellow top 
ACD tubes at a time before administration of G-CSF for stem cell 
mobilization. This sample permits calculation of spectratype complexity 
index [53]. 
5.1.1.1.2 50 ml of blood will be drawn into yellow top ACD tubes at 1, 3, 6, and 12 
months post-transplant from the recipient (Hakim Lab). 
5.1.1.1.3 These samples will be ficolled and magnetic cell sorting will be used to 
separate the CD4+ and CD8+ T cell subsets. RNA will be isolated and RT-
PCR followed by Vβ spectratype analysis will be performed. 
5.1.2 Correlation between recipient T-cell subpopulations, serum IL-7 and IL-15 levels 
(Gress/Hakim & Mackall laboratories): 
5.1.2.1 Baseline evaluation of donor lymphocytes:  aliquot of donor apheresis product 
containing ~50 x 106 mononuclear cells.  Performed in Gress/Hakim lab 
(10/CRC 3-3288; 301-402-3627). 
5.1.2.2 For all subjects, in vitro studies of immune characterization will focus on 
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Specifically, peripheral blood mononuclear cells (PBMC) will be analyzed by 
flow cytometry for expression of markers indicative of hematopoietic lineage, 
immune functional subsets, and activation state. 
               Cell subsets may be analyzed for T cell receptor rearrangement circles (TREC). 
Cells may be activated in vitro with a number of different stimuli including 
specific antigens and mitogens which are known to activate distinct pathways 
of T lymphocyte function. Assays may include T cell proliferation, cytokine 
production and gene expression, cytotoxic T lymphocyte generation, and 
antigen presenting cell function. 
              The specific assays to be used in the on-going data analyses are subject to be 
modified, deleted or replaced as technology and knowledge in the field evolve 
during the course of the study without constituting a change in research aims. 
These assays apply also to those samples received from outside institutions.  If 
a significant departure from this “Immune Characterization” is contemplated 
based on accumulated data, then the protocol and consent will be amended 
accordingly to cover the new line of investigation and its potential risks to 
subjects.  
5.1.2.3 60 ml heparinized whole blood for FACS to Gress/Hakim lab (10/CRC 3-3288; 
301-402-3627).  Baseline before start of respective (EPOCH-F/R or FLAG) 
induction chemotherapy; days +7, +14, +28, +60, +100; 6 months, 9 months, 
12 months, 18 months, 24 months, annually thereafter, and at the onset of either 
acute and/or chronic GVHD. 
5.1.2.4 20 ml sodium heparinized whole blood (two 10 ml green top tube) for FACS to 
Gress/Hakim lab (10/CRC 3-3288).  At end of each cycle of the respective 
induction regimen; day 0 following administration of transplant preparative 
regimen. 
5.1.2.5 Recipient IL-7 and IL-15 levels, for correlation with NK and T-cell 
subpopulations (above):  10 ml whole blood (1 10 ml red top tube), to be sent to 
Frederick for storage.  IL-7 levels will be performed in Mackall laboratory 
(10/CRC 1-3940; 301-402-0215); IL-15 levels will be performed in Gress/ 
Hakim lab (10/CRC 3-3288; 301-402-3627).  Baseline before start of the 
respective induction chemotherapy; immediately before the initiation of the 
conditioning regimen; day 0 following administration of transplant 
conditioning regimen; days +7, +14, +28, +60, +100; 6 months, 9 months, 12 
months, 18 months, 24 months, and annually thereafter.  Note:  IL-7 levels will 
not include day +60 or time points after day 100. 
5.1.2.6 Lymphocyte subpopulations, IL-7, and IL-15 levels may be obtained at other 
time points of interest (e.g., development of GVHD, attainment of complete 
remission, progression of disease, etc…). 
5.1.3 Correlation of monocyte cytokine expression patterns with GVHD in recipients (Fowler 
Laboratory, 10/CRC 3-3224; 301-594-4536): 


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5.1.3.1 40 ml of blood will be drawn in heparinized tubes on day +14 post-SCT. 20 ml 
of blood will be drawn in heparinized tubes; days +28, +60,+100   Samples will 
be sent to the Hakim lab.  These samples will be ficolled, cultured overnight in 
media containing the golgi inhibitor monensin, and evaluated for monocyte 
surface markers and intracellular cytokine markers for CD14 monocyte 
production of IL-1 alpha, TNF alpha, and IL-15. 
5.1.3.2 50 ml of blood will be drawn into green top heparinized tubes on day 7 post-
transplant.  Samples will be sent to the Hakim Lab.  These samples will be 
ficolled, and evaluated either fresh (day +7 sample) or after CD3, CD28 
stimulation (day 6 sample) for T cell cytokine secretion profile.  This assay will 
be by cytokine capture flow cytometry, with surface markers of CD4 and CD8 
evaluated.  Cytokine capture staining of these populations will evaluate both T1 
(IL-2, IFN-) and T2 (IL-4, IL-10) cytokine secretion. 
5.1.4 Tumor acquisition for generation of activated tumor derived lymphocytes (Optional). 
5.1.4.1 An important research objective is to determine whether the curative aspect of 
transplantation involves an immune component that is specifically directed 
towards tumor cells. Identification of tumor reactive T cells generated in the 
allogeneic context may help in the development of new therapies to improve 
anti-tumor potency and is on ongoing project in ETIB (Hardy*). 
5.1.4.2 To facilitate this evaluation of tumor reactive T cells, patients will be asked to 
undergo an optional excisional or core biopsy procedure to obtain tumor tissue 
(i.e. lymph nodes or masses) or additional bone marrow prior to chemotherapy 
administration and potentially after transplant, if there is residual tumor. 
5.1.4.3 The excisional/core biopsy procedure will be primarily applicable to patients 
with solid tumor masses (lymphomas, plasmacytomas, etc.). The Surgical 
Consult Service and/or Interventional Radiology Department of NIH Clinical 
Center will evaluate each case for their capacity to obtain tumor tissue; only 
cases that they deem at low risk for complication and can be performed without 
general anesthesia will be asked to undergo the biopsy procedure. 
5.1.4.4 For all patients, an additional 5 ml (heparinized syringe) bone marrow aspirate 
will be obtained at the times scheduled for bone marrow examination as per 
protocol. 
5.1.4.5 Biopsy or bone marrow specimen samples obtained from the O.R. or 
Interventional Radiology, or after the bone marrow aspiration procedure, 
respectively, will be sent to the Hakim Lab.  This material will be utilized in 
subsequent in vitro T cell assays. 
5.1.4.6 Patients may be asked to undergo a one-to-two liter single line apheresis 
procedure for lymphocyte acquisition for comparison with the tumor-derived 
product. 
5.1.5 Analysis of post-transplant antibodies that selectively recognize tumor cell surface 
antigens (Hakim Laboratory). 


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5.1.5.1 Post-transplant antibodies that selectively recognize tumor cell surface antigens 
may be capable of mediating antibody-dependent cellular cytotoxicity (ADCC) 
or complement-dependent cytotoxicity (CDC) and, thereby, contribute to the 
allogeneic GVT effect.  In addition, these antibodies may serve as tools for the 
discovery of new targets for human monoclonal antibody therapy.  Based on 
03-C-0077, the Rader laboratory developed a sensitive flow cytometry assay 
for detection of post-transplant serum antibodies against B-CLL tumor cell 
surface antigens.  In order to identify these antibodies and subsequently the 
tumor cell surface antigens they recognize, the Rader laboratory has generated 
human antibody libraries from post-transplant peripheral blood mononuclear 
cells (PBMCs) for selection on primary B-CLL tumor cells by phage display.  
The inclusion of post-transplant serum antibodies and PBMCs from B-CLL 
patients with (i) HLA-matched unrelated donors and (ii) different GVHD 
prophylaxis regimens provides an important extension of this ongoing study. 
5.1.5.2 Only for accrued B-CLL patients on either GVHD prophylaxis regimen arm, 50 
ml heparinized whole blood before start of induction chemotherapy as well as 
20 ml heparinized whole blood on days 0, +60, +100; 6 months, 9 months, 12 
months, 18 months, 24 months, and annually thereafter to be sent to the Rader 
laboratory (10/CRC 3-3248) to the attention of Dr. Baskar (301-451-8361). 
5.1.6 Analysis of changes in immune cell populations and molecular events in the target tissues 
of chronic GVHD (Gress Lab 10/CRC 3-3288 301-402-3627; 12C121 301-594-5340). 
5.1.6.1 The pathogenesis of chronic GVHD is poorly understood and no studies 
rigorously evaluated cellular and molecular changes that occur in the target 
tissues of chronic GVHD. Heterogeneity in patient and treatment related factors 
complicate the group comparisons. Prospectively designed study with planned 
sequential sample collection is the ideal format that would give the best chance 
of success in study of this complex problem.  
              We will focus on the skin and oral cavity as the two most common target organs 
of chronic GVHD. Standard 6 mm punch biopsies will be performed in the skin 
and buccal mucosa in all patients at the time of initiation of immunosuppressive 
taper prior to onset of clinical chronic GVHD. Another biopsy will be 
performed at the onset of clinical chronic GVHD and at 6 months post- 
transplant in patients who do not develop chronic GVHD by this time point. 
Whole saliva will be collected at the same time as the buccal mucosal biopsies 
are performed to evaluate the changes in the salivary proteome at the onset of 
chronic GVHD. The samples will be analyzed using a variety of methods 
including immunofluorescence and confocal microscopy, gene expression 
profiles, and protein based assays in order to better understand the 
reconstitution of resident immune cell populations following HSCT and how 
they change with the onset of chronic GVHD. 
5.1.7 Sample Management and Storage (For more information see section 11.7 for 
Experimental Transplantation and Immunology Branch Preclinical Service Policy for 
Sample Handling) 


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5.1.7.1 All samples will be coded and the key will be available to a restricted number 
of investigators.  However, the nature of the study requires that clinical 
correlation be feasible as part of hypothesis generation.  No change in research 
subject risk is foreseen from the knowledge acquired from study data.  
However, if in the judgment of the PI, this should change in the course of the 
study, NCI IRB will be informed to evaluate the eventual need for modification 
in subject consent process or for re-contacting subjects. 
5.1.7.2 Coded samples will be stored frozen at -20 to -180 C in a single location under 
the restricted control of the Clinical Core laboratory of ETIB. 
6 
DATA COLLECTION AND EVALUATION 
6.1 
DATA COLLECTION 
Data will be prospectively collected and entered in real time into the Cancer Center Clinical Data 
System database (NCI C3D database) (information at http://ccrtrials.nci.nih.gov).  It is expected 
that clinical data be entered into C3D no later than after 10 business days of the occurrence.  The 
NCI PI and research nurse will have access to these data via web access. 
Adverse Events will not be collected or reported to the IRB during the Standard Therapy 
(EPOCH or FLAG) administered prior to the preparative chemotherapy (conditioning) and 
transplant phase (if applicable) except grade 5 events.  
6.1.1 Adverse Events during the Pre-Transplant conditioning therapy phase (Flu-Cy): 
6.1.1.1 Grade 1, 2, and 3 adverse events will not be recorded, with the exception of all 
Grade 3 events that are unexpected, but are possibly, probably or definitely 
related to the research 
6.1.1.2 All expected and unexpected Grade 4 adverse events possibly, probably or 
definitely related to the research will be recorded with the exception of: 
a) 
Blood/Marrow abnormalities (will include grade 3 & 4 hemolysis) 
6.1.1.3 All grade 5 adverse events will be recorded regardless of attribution. 
6.1.2 Adverse Events during the Transplant phase (Day 0 to +180): 
6.1.2.1 Grade 1, 2 and 3 adverse events will not be recorded, with the exception of all 
Grade 3 events that are unexpected, but are possibly, probably or definitely 
related to the research. 
6.1.2.2 All expected and unexpected Grade 4 adverse events possibly, probably or 
definitely related to the research will be recorded with the exception of: 
a) Blood/Marrow abnormalities (will include grade 3 &4 hemolysis and 
cytopenia related to graft failure) 
6.1.2.3 All grade 5 adverse events will be recorded regardless of attribution. 
6.1.3 Due to time distance from transplant conditioning and inconsistent patient monitoring 
once they leave NIH, adverse events grade 1-4 during the follow-up phase (beyond Day 
+180) will not be recorded. 


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6.1.3.1 However, all patients will be monitored  for GVHD and the dates of onset will 
be recorded for GVHD, which is the main and only relevant transplant related 
complication after day +180 
6.1.3.2 Blood/Marrow abnormalities due to grade 3 &4 hemolysis and cytopenia 
related to graft failure will be recorded   
6.1.3.3 All grade 5 adverse events will be recorded regardless of attribution. 
6.1.4 Adverse Events once patient experiences progressive malignancy 
In the event of progressive malignancy only Grade 5 adverse events will be recorded. GVHD 
will also be recorded. 
6.1.5 Data collection procedures 
6.1.5.1 After obtaining Informed Consent, a file will be created in the database with 
standardized forms.  The NCI C3D will maintain data for described endpoints 
in the protocol.  The medical record will maintain complete records on each 
patient including any pertinent supplementary information obtained from 
outside laboratories, outside hospitals, radiology reports, laboratory reports, or 
other patient records.  The NCI C3D will serve as the primary source from 
which all research analyses will be performed. 
6.1.5.2 Each subject’s record will be reviewed for verification of eligibility by the 
research nurse, transplant coordinator, and P.I. or authorized designee prior to 
consent signing. Documentation of this review will be made on the eligibility 
checklist and a copy kept in each subject’s research record.  The research nurse 
will verify enrollment data entered into the C3D database for each subject 
within 4 weeks of signing consent.  Ongoing data entered into C3D will be 
verified by the research nurse at completion of induction chemotherapy, after 
day 28 and day 100 post transplant then bi-annually prior to each continuing 
review submission. Documentation of data verification will be tracked in the 
C3D database. Also no data will be collected beyond 5 years except for 
survival. 
6.1.5.3 Data will also be sent to the International Bone Marrow Transplant Registry 
(IBMTR). 
6.1.5.4 Additional baseline and follow-up data may be requested by the NMDP which 
are not required for this protocol.  Recipients will be offered the opportunity to 
participate in a cross-institute, NIH NMDP Research Data Collection protocol 
available to all recipients of NMDP hematopoietic stem cell products for which 
consent is optional.  This optional data collection protocol ensures compliance 
with standards described in the Transplant Center Agreement between the NIH 
Clinical Center and the NMDP. 
All data obtained during the conduct of the protocol will be kept in secure network drives or in 
approved alternative sites that comply with NIH security standards. Primary and final analyzed 
data will have identifiers so that research data can be attributed to an individual human subject 
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All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. Patients 
will be followed for adverse events for a minimum of 30 days after the last administration of 
investigational agent/intervention and have an attribution of at least possibly related to the 
agent/intervention should be recorded and reported as per section 8.2 or until removal from study 
treatment, whichever comes first. 
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following: 
• Results in discontinuation from the study 
• Is associated with clinical signs or symptoms  
• Requires treatment or any other therapeutic intervention 
• Is associated with death or another serious adverse event, including hospitalization.  
• Is judged by the Investigator to be of significant clinical impact 
• If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, the IRB will be notified.  
6.1.6 Long term follow-up guidelines 
Patients may obtain these studies within 2 months of desired date and these may be done in other 
institutions than NIH with documentation.  Please note that these should be performed yearly 
after transplantation either as part of this protocol or in another setting. 
a) Dental evaluations day +365 
b) TSH, Ferritin and iron studies on day +180, +365, 24 months, 3, 4, 5 years 
c) FSH, LH, estradiol, on day +365 and 24 months (females only) 
d) Ophthalmological evaluation on day +365 
e) DEXA scan on day +365, then yearly if abnormal or on steroids 
f) Echocardiogram on day +100, then only if clinically indicated 
g) GYN examination (female patients) day +365 
h) Urinalysis/protein screening day +180, +365 
i) Pulmonary Function Test on day +100; and at 6, 9, 12, 18, 24 months and 
then annually post-transplant thereafter up until the 5 year timepoint. 
6.2 
RESPONSE CRITERIA 
6.2.1 Complete Response (CR): 


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6.2.1.1 Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  complete disappearance 
of all detectable signs and symptoms of lymphoma for a period of at least one 
month.  All lymph nodes and nodal masses must have regressed to normal size 
(< 1.5 cm in greatest transverse diameter for nodes > 1.5 cm before therapy). 
Previously involved nodes that were 1.1 to 1.5 cm in greatest transverse 
diameter before treatment must have decreased to < 1 cm in their greatest 
transverse diameter after treatment or by more than 75% in the sum of the 
products of the greatest diameters (SPD).  The spleen (or any other organ), if 
considered to be enlarged due to involvement by lymphoma before therapy and 
on the basis of a CT scan, must have regressed in size and must not be palpable 
on physical examination.  Any macroscopic nodules in any organs detectable 
on imaging techniques should no longer be present.  If bone marrow was 
involved by lymphoma before treatment, the infiltrate must be cleared on repeat 
bone marrow aspirate and biopsy of the same site [104]. Response criteria may 
be modified upon publication of revised response criteria [109]. 
6.2.1.2 Chronic lymphocytic leukemia:  complete resolution of all detectable signs and 
symptoms for at least 2 months, with peripheral blood lymphocytes < 4K/l, 
neutrophils > 1.5K/l, platelets > 100K/l, hemoglobin > 11g/dl 
(untransfused), bone marrow lymphocytes < 30% without lymphoid nodules. 
6.2.1.3 Chronic myelogenous leukemia:  Hematologic CR – normalization of 
peripheral blood counts (WBC < 10K/l, platelets < 450K/l), no immature 
cells on peripheral smear (blasts, promyelocytes, metamyelocytes).  
Cytogenetic CR – hematologic CR, with cytogenetic studies negative for 
Philadelphia chromosome (Ph).  Molecular CR – hematologic and cytogenetic 
CR, with PCR studies negative for bcr-abl. 
6.2.1.4 Other leukemias, myeloproliferative disorders, or myelodysplastic syndrome:  
hematologic remission is defined as normalization of peripheral blood counts 
(ANC > 1,500/μl and platelets > 100,000/mm3) without circulating blasts, bone 
marrow cellularity > 20% with normal maturation, fewer than 5% blasts in 
bone marrow; and no detectable Auer rods  [106].  Extramedullary leukemia 
may not be present.  The absence of specific molecular or cytogenetic markers 
of disease that were previously present further defines molecular or cytogenetic 
remission, respectively.  In the case of myeloproliferative disorders, there must 
be absence of bone marrow fibrosis with normal hematologic parameters. 
6.2.1.5 Multiple myeloma [111]:  absence of urine and serum M-components by 
immunofixation and electrophoresis; normalization of immunoglobulins is not 
required.  Clonal plasma cells in bone marrow <1% by PCR or flow cytometry.  
Normal serum calcium.  No new bone lesions; no enlargement of existing 
lesions. Vertebral collapse or other pathological fracture due to osteoporosis or 
existing lesion does not prevent categorization as CR. 
6.2.2 Complete Response/unconfirmed (CRu): 
6.2.2.1 Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  A residual lymph node 
mass > 1.5 cm in greatest transverse diameter will be considered CRu if it has 


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regressed by more than 75% in the SPD, does not change over at least one 
month, is negative by PET or gallium, and is negative on any biopsies obtained 
(biopsy not required).  Individual nodes that were previously confluent must 
have regressed by more than 75% in their SPD compared with the size of the 
original mass and be stable for at least one month. Any residual lesions in 
involved organs must have decreased by more than 75% in the SPD or be < 1 
cm, be clinically consistent with residual scarring, and be stable for at least one 
month.  Indeterminate bone marrow, if previously involved with lymphoma, 
will also be considered CRu. 
6.2.3 Partial Response (PR): 
6.2.3.1 Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  a 50% or greater decrease 
in SPD of all measured lesions lasting for a period of at least one month.  No 
individual lesion may increase in size, and no new lesions may appear [108]. 
6.2.3.2 Chronic lymphocytic leukemia:  a 50% or greater decrease in SPD of measured 
lymph nodes, hepatomegaly, or splenomegaly lasting at least 2 months, plus 
one or more of neutrophils > 1.5K/l, platelets > 100K/l, or hemoglobin > 
11g/dl (or 50% improvement). 
6.2.3.3 Chronic myelogenous leukemia:  Hematologic PR – as for hematologic CR, 
except for (1) persistence of immature cells, or (2) platelets < 50% pretreatment 
level but > 450K/l, or (3) persistent splenomegaly but > 50% of pretreatment 
size.  Cytogenetic PR – hematologic CR, with 1-34% Ph-positive cells (major 
response).  Cytogenetic minor response – hematologic CR, with 35-90% Ph-
positive cells. 
6.2.3.4 Acute leukemias, MDS or myeloproliferative disorders in transformation:  All 
criteria for complete remission are satisfied (Section 6.2.1), except that the 
bone marrow may contain > 5% but < 25% blasts, or < 5% blasts are present 
with Auer rods or abnormal morphology. 
6.2.3.5 Multiple myeloma:   
a) Very good partial response - reduction by > 75% in serum myeloma protein 
production, with decrease in Bence-Jones proteinuria by > 90%.  Clonal 
marrow plasmacytosis < 5%.  No new lytic bone lesions. 
b) Partial response – Reduction by > 50% in serum myeloma protein 
production maintained for a minimum of six weeks. 
6.2.4 Stable Disease (SD): 
6.2.4.1 Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  tumor measurements not 
meeting the criteria for CR, CRu, PR, or PD. 
6.2.4.2 Chronic lymphocytic leukemia:  response parameters not meeting criteria for 
CR, PR, or PD. 
6.2.5 Relapsed or Progressive Disease (PD): 


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6.2.5.1 Non-Hodgkin’s lymphoma or Hodgkin’s lymphoma:  a 50% or greater increase 
in SPD of all measured lesions compared to the smallest previous 
measurements, or appearance of any new lesion(s). 
6.2.5.2 Chronic lymphocytic leukemia:  a 50% or greater increase in SPD of all 
measured lesions compared to the smallest previous measurements, or 
appearance of any new lesion(s); a > 50% increase in circulating lymphocytes; 
Richter’s syndrome. 
6.2.5.3 Chronic myelogenous leukemia:  Increase in the number of metaphases 
demonstrating Ph by cytogenetics or t(9:22) by FISH; return to PCR positivity 
for bcr-abl after previously becoming negative. 
6.2.5.4 Other leukemias, myeloproliferative disorders, or myelodysplastic syndrome:  
bone marrow and peripheral blood morphological features consistent with 
relapse or progression, including rising blast count and re-emergence of 
specific molecular or cytogenetic markers. 
6.2.5.5 Multiple myeloma (requires 2 of the following):  an increase in serum M-
protein to > 50% above the lowest level or a rise > 2 g/dl; an increase in urine 
light chain excretion to 50% above the lowest value (at least 250 mg/24 hours) 
or an increase > 2 g/24 hours of light chain excretion; an increase in soft tissue 
plasmacytomas by 50% or new or increasing lytic bone lesions; the above 
protein criteria for relapse, plus hypercalcemia > 12 mg/dl, anemia with 
hemoglobin decrease > 2 g/dl, increased bone marrow plasma cells by 50%, or 
generalized bone pain. 
6.3 
TOXICITY CRITERIA 
6.3.1 The NCI Common Terminology Criteria for Adverse Events Version 3.0 (CTCAEv3, 
available via NCI web site (http://ctep.cancer.gov/forms/CTCAEv3.pdf) will be utilized for 
evaluation of toxicity. 
6.3.2 Acute and chronic graft-versus-host disease (GVHD) will be graded according to criteria 
specified in Appendix C. 
6.4 
STATISTICAL CONSIDERATIONS 
6.4.1 Primary objectives: 
6.4.1.1 Determination of CD4+ T cell receptor Vβ repertoire  - A primary objective of 
this study is to conduct a pilot trial to determine the effects of two biologically 
distinct GVHD prophylaxis regimens (tacrolimus/methotrexate/sirolimus 
[TMS] and alemtuzumab/ cyclosporine [AC]) on immune reconstitution in 
patients receiving targeted-immune depletion and reduced-intensity allogeneic 
HSCT from HLA-matched unrelated donors. As part of a comprehensive 
assessment of immune reconstitution, the study will primarily focus on 
differences in CD4+ T cell receptor Vβ repertoire and try to determine in a pilot 
setting if a) use of either of the two regimens in this trial will have a substantial 
impact on this parameter at three or 12 months post-transplant, and b) if, again 
within the context of a pilot study, if there is a difference between the two arms 
with respect to the magnitude of the change from baseline in this parameter at 3 


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and 12 months. These will data will be complemented by additional analyses on 
immune reconstitution which include determination of CD4+ T cell receptor 
Vβ repertoire at other time points (1, 3, 6, and 12 months), changes in CD8+ T 
cell receptor Vβ repertoire at 1, 3, 6 and 12 months, the kinetics of CD4+ and 
CD8+ T-cells and NK cell depletion and recovery, IL-7 and IL-15 cytokine 
levels, and monocyte production of inflammatory cytokines, as part of the 
secondary objectives. 
6.4.1.1.1 This trial was initially designeded to be a pilot study, with patients  stratified 
according to whether they have 7/8 or 8/8 matches. To meet the primary 
objective of immune reconstitution, a total of 50 patients with 8/8 matches 
will undergo transplantation, 25 per arm, and be randomized to receive 
either an alemtuzumab-based prophylaxis (AC) or triple agent prophylaxis 
(TMS) based on the order they enrolled onto the study. In addition, 26 
patients with 7/8 matches, 13 per arm, will also be randomized to undergo 
transplantation, and will be evaluated separately. In the situation where a 
patient is assigned to an arm which is temporarily closed as it is being 
assessed for toxicities relative to early stopping rules (section 6.4.3), the 
patient will be randomized to the arm for which accrual is open. The 
primary evaluation, for which this number was selected, will be with respect 
to the change in the CD4+ T cell repertoire diversity, as determined by 
spectratype complexity index, at 3 and 12 months post-transplant as 
compared to normal healthy donors. The recipient spectratype complexity 
index within a Vβ family will be determined as a percentage of the number 
of peaks in its spectratype histogram compared to the number of peaks in 
the corresponding donor Vβ family spectratype histogram [49]. Any Vβ 
family with a complexity index of ≥85% was considered to be fully 
complex. Histogram peaks will be defined by the Genotyper Genescan 
software analysis program. 
6.4.1.1.2 The study was initially designed to allow for 10 patients per arm, in order to 
have 91% power to detect a difference between the arms that is equal to 1.5 
standard deviations of the intra-arm difference in the single primary 
parameter, spectratype complexity index at 3 months, with a 0.10 two-sided 
alpha level test. It will be assumed that the comparison will be made with a 
two-sample t-test, but if the data in either arm are not normally distributed 
(p<0.05 by a Shapiro-Wilks test), then a Wilcoxon rank sum test will be 
used. Amendment F will increase the size of the study in order to enroll 20 
evaluable patients per arm who have 8/8 matches. With 20 patients per arm 
who have no mismatches, there will be 86% power to detect a difference 
between the two arms equal to 1.0 standard deviations of the intra-arm 
difference of the 3 month and 12 month CD4+ T cell repertoire diversity 
measures, with a 0.05 two-sided alpha level test. It will be assumed that the 
comparisons will be made with a two-sample t-test. However, if the data on 
either arm is not normally distributed (p<0.05 by a Shapiro-Wilks test), then 
a Wilcoxon rank sum test will be used. The 20 evaluable patients (10/arm) 


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from among 26 transplanted who have 7/8 matches will have results 
compared between the two arms using the same criteria as in the original 
protocol design. 
6.4.1.1.3 Secondly, the difference in CD4+ T cell repertoire diversity between 
baseline and 3 months, and baseline and 12 months will be made using a 
paired t-test if the data are normally distributed. The study originally noted 
that with 10 patients on a given arm, there is 80% power to detect a 1 SD 
effect size with a two-sided original design, although there are two arms 
with this comparison being made within each arm, no formal correction for 
the two comparisons was required. If the data are not normally distributed, 
then a Wilcoxon signed rank test would be used. With Amendment F, with 
20 evaluable patients per arm from among 25 transplanted, there is 80% 
power to detect a 0.75 SD effect size for each of the two endpoints within an 
arm, with a two-sided 0.025 alpha level test for each evaluation. This will 
allow for an overall 0.05 level test for the two comparisons within each arm, 
assuming that a Bonferroni adjustment is used. Because of the pilot nature 
of the original design, although there are two arms with these comparisons 
being made within each arm, no formal correction for the two comparisons 
will be required. If the data are not normally distributed, then a Wilcoxon 
signed rank test will be used. The 20 evaluable patients (10/arm) from 
among 26 transplanted who have 7/8 matches will have results compared 
within each arm using the same criteria as in the original protocol design. In 
order to allow for up to 20% of patients who may die prior to the time of the 
treatment evaluation point, accrual of up to 25 patients per arm will be 
permitted for the patients with 8/8 matches and 13/arm for the 7/8 matches 
in order to yield 20/arm and 10/arm who are evaluable for the two strata. 
6.4.2 Determine and monitor incidence, organ severity and overall severity of chronic GVHD - 
As stated above (section 6.4.1.1.1) the study was originally intended as a pilot, but it was 
expanded upon meeting initial safety criteria to  50 patients with 8/8 HLA-matched 
donors and to study patients with 7/8 HLA-matched donors in a pilot manner. Results 
from this expanded trial indicate that there is an opportunity to study chronic GVHD in a 
detailed manner (please refer to section 1.5). Specifically it is a primary arm of this study 
to determine the incidence of severe chronic using the NIH Consensus Conference 
diagnosis and staging criteria. 
6.4.2.1 Patients will continue to be randomized between these two arms as they have 
been prior to the amendment. Patients will continue to be stratified according to 
the degree of matching: 7/8 vs. 8/8 matches. This portion of the trial will be 
conducted in order to obtain modestly precise estimates of the rates of chronic 
GVHD in patients treated on either AC or TMS so that we may learn more 
about the effect of AC vs. TMS on this disease and to permit development of a 
subsequent, more definitive trial in this patient population. As such, patients 
enrolled on this trial prior to this amendment will be included in the total 
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6.4.2.2 Based on data prior to the initiation of this amendment, is has been estimated 
that approximately 20% of the patients on each arm will eventually develop 
severe chronic GVHD.  If there were 44 evaluable patients on each arm who 
survive beyond 100 days post transplant, this would allow a 90% two-sided 
confidence interval around the observed proportion to have a width of +/-10% 
from the observed proportion when the expected proportion of patients with 
severe cGVHD is estimated to be 20%. 
6.4.2.3 It is anticipated that 90% of all patients enrolled will be evaluable for 
evaluation of chronic GVHD in that they survive 100 days post transplant or 
longer. Thus, in order to enroll 88 total evaluable patients, it is expected that 
approximately 100 would be needed. If 105 were enrolled and if the true 
fraction surviving to 100 days was 90%, the probability that 88 or more would 
survive beyond 100 days is 98.3%; if 100 were enrolled, the probability that 88 
or more would survive beyond 100 days is 80%. As such, we will plan to set an 
accrual ceiling at 105 in order to assure accrual of 88 evaluable patients. 
Approximately 3-5 patients per month are expected to be able to be randomized 
to this trial if one or two institutions are participating. Thus, with approximately 
50 of the 105 already enrolled, it is anticipated that an additional 1-2 years may 
be required to complete the enrollment of the 105 randomized patients. 
6.4.3 In addition, it will be important to determine the overall safety of both of these regimens 
in the setting of targeted sequential immune-depleting chemotherapy followed by 
reduced-intensity allogeneic HSCT from HLA-matched unrelated donors, separately for 
the patients with 8/8 matches and 7/8 matches. An evaluation of engraftment, severe 
acute GVHD, early and late treatment-related mortality and overall survival  will be 
performed relative to each arm of this trial, for the 7/8 match and 8/8 match strata 
separately: 
6.4.3.1 Graft Rejection - Early stopping for graft rejection based on CD3 chimerism 
will also be implemented. Any patient for whom the percentage of CD3 cells is 
<10% at day 100 will be considered to have rejected the graft. A maximum of 
15% of patients with graft rejection is the greatest fraction tolerable.   
Patients will continue to be accrued to a specific arm provided that no greater than 2 patients in 
the 10 within that arm have rejected their graft (and no other stopping rules are implemented). 
The following table, based on binomial probability calculations, shows the probability of having 
2 or more patients rejecting their grafts by 10 patients, for a set of possible underlying true 
probabilities. 
 
Probability of 
graft Rejection 
Probability of early termination 
due to graft rejection 
.05 
.09 
.10 
.26 


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.15 
.46 
.20 
.62 
.25 
.72 
Thus, if the true probability of graft rejection is about 15%, there is a 46% probability that 2 or 
more patients will have this occur within the 10 patients on a specific arm and thus need to end 
accrual to this arm as soon as this can be determined. 
6.4.3.2 Acute GVHD - Acute GVHD will be determined actuarially. Kaplan-Meier 
curves will be constructed for each arm separately. Acute GVHD will be 
determined by standard criteria [106]. Stopping rules for grade III or IV acute 
GVHD will also be implemented. It has been noted that 20% grade III or IV 
acute GVHD is the upper limit for an acceptable rate, so a stopping rule based 
on exceeding this rate will be implemented. 
 
Patients will continue to be accrued to a specific arm provided that no greater than 2 patients in 
the 10 within that arm have developed grade III or IV acute GVHD (and no other stopping rules 
are implemented). The following table, based on binomial probability calculations, shows the 
probability of having 2 or more patients develop grade III or IV acute GVHD by 10 patients, for 
a set of possible underlying true probabilities. 
 
Probability of grade 
III or IV acute GVHD 
Probability of early termination  
due to grade III or IV acute GVHD 
.05 
.09 
.10 
.26 
.15 
.46 
.20 
.62 
.25 
.72 
Thus, if the true probability of grade III or IV acute GVHD is about 20%, there is a 62% 
probability that 2 or more patients will have this occur within the 10 patients on a specific arm 
and thus need to end accrual to this arm as soon as this can be determined. 
6.4.3.3 Early treatment-related mortality - It will be important to continuously monitor 
the treatment-related mortality, and to have a stopping rule in the event that this 
is excessive. It has been noted that 20% 100-day treatment-related mortality is 
the upper limit for an acceptable rate, so a stopping rule based on attaining this 
rate or exceeding or rate will be implemented, separately for each arm. 
Treatment-related mortality (TRM) is defined as any death occurring within 28 


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days after transplantation and any death occurring 28 days or more after 
transplantation in a patient in continuous remission. 
Patients will continue to be accrued to a specific arm provided that no greater than 2 patients in 
the 10 within that arm have died by day 100 due to treatment-related causes (and no other 
stopping rules are implemented). The following table, based on binomial probability 
calculations, shows the probability of having 2 or more patients die from treatment-related 
causes by 10 patients, for a set of possible underlying true probabilities.  
Probability of 
100 day TRM 
Probability of early termination  
due to 100 day TRM 
.05 
.09 
.10 
.26 
.15 
.46 
.20 
.62 
.25 
.72 
Thus, if the true probability of day 100 TRM is about 20%, there is a 62% probability that 2 or 
more patients will have this occur within the 10 patients on a specific arm and thus need to end 
accrual to this arm as soon as this can be determined. 
6.4.3.4 Late mortality - One year treatment-related mortality and one year overall 
survival will also be evaluated and used to determine accrual may proceed to a 
given arm. If greater than approximately 33% of patients are determined to 
have died due to treatment by one year on a specific arm, then that arm of the 
trial as originally designed will no longer accrue patients. 
6.4.3.5 Late treatment-related mortality - Accrual to the particular arm of the trial will 
stop if 2 or more patients in the first 6 with that arm have treatment-related 
mortality within the first year, or this has not been met, if 3 or more in the 10 
with that arm have TRM within the first year.  The following table, based on 
binomial probability calculations, shows the probability of having 2 or more 
patients in the first 6 dying from TRM in the first year, or 3 or more of the first 
10 dying from TRM in the first year, for a set of possible underlying true 
probabilities. 
Probability of 1 year 
treatment-related mortality 
Probability of early termination due 
to 1 year treatment-related mortality 
.1 
.07 
.2 
.33 
.35 
.73 


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.4 
.82 
.5 
.94 
 
Thus, if the true probability of one year TRM is 35%, there is a 73% probability that this rule 
will be invoked within the 10 patients on a specific arm and thus need to end accrual to this arm 
as soon as this can be determined. 
6.4.3.6 Overall Survival - Monitoring of overall survival will be performed and if 50% 
or greater patients within 10 or fewer enrolled on a specific arm are ever 
determined to not survive until one year for whatever reason, then that arm will 
no longer accrue patients as it was originally designed. 
 
Accrual to the particular arm of the trial will stop if 3 or more patients in the first 6 within that 
arm have died from any cause within the first year, or this has not been met, if 5 or more in the 
10 in that arm have died from any cause within the first year.  The following table, based on 
binomial probability calculations, shows the probability of having 3 or more patients in the first 6 
on a specific arm dying from any cause in the first year, or 5 or more of the 10 in that arm dying 
from any cause in the first year, for a set of possible underlying true probabilities. 
Probability of 1 
year mortality 
Probability of early termination  
due to 1 year mortality 
.3 
.16 
.4 
.39 
.5 
.64 
.6 
.84 
6.4.3.7 Although ideally, there would be no additional patients accrued pending 
determination of whether a specific stopping rule must be invoked for a specific 
arm, to allow continuity of patients being referred into the trial, up to three 
additional patients may be permitted to be accrued beyond that needed to 
evaluate the particular stopping rule. 
6.4.3.8 It should be noted for any of the above monitoring plans, that observation of the 
maximum number of events in 10 patients within a specific arm means that 
subsequent study of this arm, as specified on this protocol, is inadvisable from a 
safety perspective, although technically the arm was allowed to continue until 
the full 10 patient accrual goal within an arm has been met. 
6.4.3.9 If one arm of the study is temporarily or permanently closed, then accrual will 
be permitted to the remaining open arm. 


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6.4.4 Secondary objectives – As secondary endpoints, additional immune reconstitution 
parameters will be evaluated at multiple time points in an exploratory fashion within the 
context of a pilot study. Since these will be considered secondary endpoints, no formal 
adjustment for multiple comparisons will be undertaken, and the comparisons will be 
reported in the context of a hypothesis generating setting.  
6.4.4.1 It is anticipated that approximately 1-2 patients per month may be enrolled onto 
this study. Thus, to accrue a total of 60 evaluable patients to both arms (up to 
25 per arm for the patients with no mismatches and 13 per arm for the arms 
with 7/8 matches) it is anticipated that up to 3 years will be required. To allow 
for the possibility of a small number of patients who may be inevaluable (e.g. 
disease progression prior to transplant), the accrual ceiling will be set at 85 
patients or 76 patients who receive a transplant, whichever comes first. 
6.4.5 There are no gender or racial/ethnic restrictions on patient selection.  This protocol is 
open to both genders and all racial/ethnic groups. 
7 
HUMAN SUBJECT PROTECTIONS 
7.1 
RATIONALE FOR SUBJECT SELECTION   
Patients with high-risk hematologic malignancies will be the subjects for this study.  Allogeneic 
HSCT represents a potentially curative treatment for patients with the disease characteristics 
selected for inclusion (section 2.1.1).  The expected survival of such patients with conventional 
chemotherapy is approximately one year or shorter.  Eligibility in this protocol is limited to 
adults (age > 18-74 years). 
7.2 
PARTICIPATION OF CHILDREN   
Children will not be enrolled in this study.  Immune reconstitution is different between children 
and adults, which is the primary endpoint of this study.   
7.3 
PARTICIPATION OF NIH SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol.  However re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 7.4), all subjects ≥ age 18 will be offered the opportunity to fill in 
their wishes for research and care, and assign a substitute decision maker on the “NIH Advance 
Directive for Health Care and Medical Research Participation” form so that another person can 
make decisions about their medical care in the event that they become incapacitated or 
cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH 
Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate.  For those subjects that become incapacitated and do not have 
pre-determined substitute decision maker, the procedures described in MEC Policy 87-4 and 
NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) 
decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, 
will be followed. 


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7.4 
RISKS/BENEFITS ANALYSIS   
There is a potential benefit to the transplant recipient, as demonstrated by the published literature 
documenting long-term disease-free survival for patients with high-risk hematologic 
malignancies following allogeneic HSCT.  This carefully defined patient population is a 
reasonable one in which to explore strategies to improve the results of allogeneic HSCT from 
unrelated donors, which historically has achieved prolonged remission and survival for some 
patients but has been associated with significant morbidity and high transplant-related mortality.  
The strategies chosen in this protocol extend our previous work to develop a platform for 
consistent engraftment of allogeneic cells through immunoablative induction chemotherapy, host 
T cell depletion, and reduced-intensity conditioning.  Studying this platform in the setting of 
allogeneic HSCT from unrelated donors is a logical, planned extension of our previous efforts. 
The potential risks to the transplant recipient have been carefully considered and are felt to be 
potentially less than would otherwise occur with myeloablative allogeneic HSCT.  The risks 
graft rejection, acute and chronic GVHD, infection, and relapse will be present, as discussed 
previously. 
7.5 
INFORMED CONSENT PROCESS AND DOCUMENTATION 
The procedures and treatments involved in this protocol, with their attendant risks and 
discomforts, potential benefits, and potential alternative therapies will be carefully explained to 
the recipient.  Similarly, the procedures and treatments involved in this protocol, with their 
attendant risks and discomforts, will be carefully explained to the donor at the respective donor 
center as required by NMDP. A signed informed consent document will be obtained from both 
the recipient and the donor. 
Consent forms: The original signed consent goes to Medical Records; a copy will be placed in 
research record, as per NIH policy, and a copy will be kept with the patient's chart. A copy of the 
informed consent documents will also be given to the recipient. 
The Clinical Coordinator, Data Management Section, will ascertain the date of IRB approval 
before registering the first patient. 
The informed consent document contains all elements required for consent.  In addition, the 
Principal Investigatoror their designee will obtain oral consent and will be available to answer all 
patient questions. 
7.5.1 Telephone re-consent procedure 
Re-consent on this study may be obtained via telephone according to the following procedure:  
The informed consent document will be sent to the subject.  An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form.  
The subject will sign and date the informed consent. A witness to the subject’s signature will 
sign and date the consent. 
The original informed consent document will be sent back to the consenting investigator who 
will sign and date the consent form with the date the consent was obtained via telephone.   
A fully executed copy will be returned via mail for the subject’s records. 


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The informed consent process will be documented on a progress note by the consenting 
investigator. 
8 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN 
8.1 
DEFINITIONS 
8.1.1 Adverse Event   
Any untoward medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research. 
8.1.2  Suspected adverse reaction 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the drug caused the adverse event. For the purposes of IND safety reporting, ‘reasonable 
possibility’ means there is evidence to suggest a causal relationship between the drug and the 
adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug. 
8.1.3 Unexpected adverse reaction 
An adverse event or suspected adverse reaction is considered “unexpected” if it is not listed in 
the investigator brochure or is not listed at the specificity or severity that has been observed; or, 
if an investigator brochure is not required or available, is not consistent with the risk information 
described in the general investigational plan or elsewhere in the current application. 
"Unexpected”, also refers to adverse events or suspected adverse reactions that are mentioned in 
the investigator brochure as occurring with a class of drugs or as anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation. 
8.1.4 Serious  
An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of a Serious 
Adverse Event or if it compromises the safety, welfare or rights of subjects or others. 
8.1.5 Serious Adverse Event 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following: 
• Death, 
• A life-threatening adverse drug experience 
• Inpatient hospitalization or prolongation of existing hospitalization 
• Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• A congenital anomaly/birth defect. 


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• Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
8.1.6 Disability 
 A substantial disruption of a person’s ability to conduct normal life functions. 
8.1.7 Life-threatening adverse drug experience 
Any adverse event or suspected adverse reaction that places the patient or subject, in the view of 
the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that had it occurred in a more severe form, might have caused death. 
8.1.8 Protocol Deviation (NIH Definition) 
Any change, divergence, or departure from the IRB approved research protocol. 
8.1.9 Non-compliance (NIH Definition) 
The failure to comply with applicable NIH Human Research Protections Program (HRPP) 
policies, IRB requirements, or regulatory requirements for the protection of human research 
subjects. 
8.1.10 Unanticipated Problem 
Any incident, experience, or outcome that: 
• Is unexpected in terms of nature, severity, or frequency in relation to  
a)  the research risks that are described in the IRB-approved research protocol and 
informed consent document; Investigator’s Brochure or other study documents, and 
b)  the characteristics of the subject population being studied; AND 
• Is related or possibly related to participation in the research; AND 
• Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
8.1.11  MedWatch Reporting 
Serious adverse events that occur with commercially available agents will be reported directly to 
the FDA via Medwatch (http://www.fda.gov/medwatch). 
8.2 
NCI-IRB AND CLINICAL DIRECTOR REPORTING 
8.2.1 NCI-IRB and NCI Clinical Director Expedited Reporting of Unanticipated Problems and 
Deaths 
The Protocol PI will report in an NIH Problem Form to the NCI-IRB and the NCI Clinical 
Director: 
• All deaths, except deaths due to progressive disease  


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• All Protocol Deviations 
• All Unanticipated Problems 
• All non-compliance 
Reports must be received within 7 days of PI awareness via iRIS. 
8.2.2 NCI-IRB Requirements for PI Reporting at Continuing Review 
The protocol PI will report to the NCI-IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation 
occurred, a brief description of the deviation and any corrective action. 
2. A summary of any instances of non-compliance 
3. A tabular summary of the following adverse events: 
• All Grade 2 unexpected events that are possibly, probably or definitely related to the 
research;  
• All Grade 3 and 4 events that are possibly, probably or definitely related to the 
research;  
• All Grade 5 events regardless of attribution;  
• All Serious Events regardless of attribution.  
NOTE: Grade 1 events are not required to be reported.  
8.3 
DATA SAFETY AND MONITORING PLAN 
8.3.1 Principal Investigator/Research Team  
The clinical research team will meet on a weekly basis when patients are being actively treated 
on the trial to discuss each patient. Decisions about dose level enrollment and dose escalation if 
applicable will be made based on the toxicity data from prior patients.  
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Adverse events will be reported as required above. Any safety concerns, 
new information that might affect either the ethical and or scientific conduct of the trial, or 
protocol deviations will be immediately reported to the IRB using iRIS.  
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff.  
8.3.2 Safety Monitoring Committee (SMC) 
This protocol will require oversight from the Safety Monitoring Committee (SMC).  Initial 
review will occur as soon as possible after the annual NCI-IRB continuing review date.   
Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting 
schedule permits or more frequently as may be required by the SMC.   For initial and subsequent 
reviews, protocols will not be reviewed if there is no accrual within the review period. Written 


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outcome letters will be generated in response to the monitoring activities and submitted to the 
Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI. 
8.4 
RECORD KEEPING 
8.4.1 All patients must have signed an Informed Consent, and on-study eligibility checklist will 
be filled out by the Research RN and faxed to the Central Registration Office (CRO) 
before patient is entered on the study. 
8.4.2 Complete records must be maintained on patients; these will consist of the hospital chart 
with any supplementary information obtained from outside laboratories, radiology 
reports, or physician’s records.  These records will serve as the primary source material 
that forms the basis for the research record.  All relevant data will also be entered on the 
NCI C3D database from which formal analyses are done.  The primary source 
documentation will assure the following: on-study information, including patient 
eligibility data and patient history; flowsheets, specialty forms for pathology, radiation, or 
surgery; adverse event assessment; and off-study summary sheet, including a final 
assessment by the treating physician. 
8.4.3 Paper CRFs (see Appendix K) will be used to aid in data collection on this study. 
9 
PHARMACEUTICAL INFORMATION 
9.1 
CYCLOPHOSPHAMIDE (CTX, CYTOXAN, NSC-26271) 
9.1.1 Supply – Cyclophosphamide will be purchased by the NIH Clinical Center Pharmacy 
Department from commercial sources and is supplied as a lyophilized powder in various 
vial sizes. 
9.1.2 Preparation - will be reconstituted with sterile water for injection to yield a final 
concentration of 20 mg/ml as described in the package insert. 
9.1.3 Storage and Stability - The vials are stored at room temperature.  Following 
reconstitution as directed, solutions of cyclophosphamide are stable for 24 hours at room 
temperature, or 6 days when refrigerated at 2-8 C. 
9.1.4 Route of Administration - The cyclophosphamide used in this regimen will be mixed in 
100 ml 0.9% sodium chloride, Inj., and given as an IVPB over 30 minutes in the 
induction regimen (i.e. EPOCH-F/R; Section 3.5.3). In the preparative regimen (Section 
3.6.5), it is given over two hours. 
9.1.5 Toxicities 
a) Nausea and vomiting - variable; symptomatically improved with standard anti-emetics 
and/or benzodiazepines [e.g., lorazepam]. 
b) Water retention – cyclophosphamide may rarely provoke the syndrome of inappropriate 
antidiuretic hormone secretion and resultant hyponatremia, usually manifested 12-48 hrs 
after IV administration, necessitating frequent accurate assessment [q 1-2 hrs] of intake, 
urine output and urine specific gravity.  This effect can be counteracted by furosemide.  
Fluid restriction is not feasible during administration of high dose cyclophosphamide. 


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c) Cardiomyopathy - cyclophosphamide may cause severe, sometimes lethal, hemorrhagic 
myocardial necrosis or congestive cardiomyopathy.  Patients may present with congestive 
cardiomyopathy as late as 2 weeks after the last dose of cyclophosphamide.  The clinical 
syndrome has been observed in patients receiving the dose of cyclophosphamide used in 
this protocol.  In an attempt to minimize this complication, patients with significant 
cardiac dysfunction are excluded from this protocol [see patient eligibility].  Congestive 
failure is managed according to standard medical therapeutics. 
d) Hemorrhagic cystitis – this is a serious, potentially life-threatening complication related 
to injury of the bladder epithelium by cyclophosphamide metabolites.  Although sub-
clinical hematuria is not uncommon at this dose level, clinically significant hematuria or 
serious hemorrhage can usually be avoided by maintaining a high urine volume and 
frequent voidings and the administration of Mesna.  Diuresis is maintained for 24 hrs 
after completion of last dose by parenteral infusions of normal saline with potassium 
chloride, as specified in section 3.6.6.  Careful monitoring of serum and urine electrolytes 
is mandated.  Furosemide may be required to ensure this diuresis.  Continuous bladder 
irrigation may be used for control of significant hematuria. 
e) Sterility 
f) Less common but serious complications include pulmonary fibrosis and secondary 
malignancies. Less common but reversible toxicities include alopecia and skin rash. 
9.2 
MESNA (SODIUM 2-MERCAPTOETHANESULFONATE, MESNUM, MESNEX, NSC-113891) 
9.2.1 Supply – Mesna will be will be purchased by the NIH Clinical Center Pharmacy 
Department from commercial sources and is supplied as a 100mg/ml solution. 
9.2.2 Preparation – Dilute up to 20 mg Mesna/ml fluid in D5W or 0.9% sodium chloride, Inj.  
Mesna should be started concurrently with the cyclophosphamide in the preparative 
regimen (Section 3.4.3).  Mesna will be given at 1200 mg/m2 in 500 ml by continuous IV 
infusion over 24 hour infusion for four doses (days -6, -5, -4, and -3). 
9.2.3 Storage and Stability – Intact ampules are stored at room temperature.  Diluted solutions 
(1 to 20 mg/dl) are physically and chemically stable for at least 24 hours under 
refrigeration.  Mesna is chemically stable at room temperature for 48-72 hours in D5W, 
48-72 hour in D5W/0.45% sodium chloride injection, or 24 hours in 0.9% sodium 
chloride injection. 
9.2.4 Administration - To be administered intravenously as continuous infusion. 
9.2.5 Toxicities - Nausea, vomiting, diarrhea. 
9.3 
FILGRASTIM (G-CSF, NEUPOGEN) 
9.3.1 Supply – Commercially available as filgrastim injection in a concentration of 300g/ml 
in 1ml (300g) and 1.6ml (480g) vials. 
9.3.2 Preparation – For subcutaneous administration, the appropriate prescribed dose is drawn 
up from the vial with no further dilution prior to administration.  For intravenous 
administration, the commercial solution for injection should be diluted prior to 
administration.  It is recommended that the prescribed dose be diluted with dextrose 5% 


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in water to a concentration greater than 5g/ml.  Dilution of filgrastim to a final 
concentration of less than 5g/ml is not recommended at any time.  Do not dilute with 
saline at any time; product may precipitate. Filgrastim diluted to concentrations between 
5 and 15g/ml should be protected from absorption to plastic materials by the addition of 
Albumin (Human) to a final concentration of 2mg/ml.  When diluted in 5% dextrose or 
5% dextrose plus Albumin (Human), filgrastim is compatible with glass bottles, PVC and 
polyolefin IV bags, and polypropylene syringes.  The dose may be “rounded down” to 
within 10% of patient’s calculated dose to use the drug cost-effectively. 
9.3.3 Storage and Stability – Filgrastim for injection should be stored in the refrigerator at 2o to 
8oC (36o to 46oF).  Avoid shaking. 
9.3.4 Administration – Subcutaneous injection is preferred.  If clinically indicated, filgrastim 
may be administered as an intravenous infusion over 15 to 30 minutes. 
9.3.5 Toxicities – Medullary bone or skeletal pain is the most commonly reported toxicity.  In 
addition, reversible elevations in uric acid, lactate dehydrogenase, and alkaline 
phosphatase are common laboratory abnormalities.  Four cases of splenic rupture have 
been reported in healthy donors when given filgrastim or other myeloid growth factors 
for peripheral blood stem cell mobilization; 1 of these cases resulted in fatality.  Five 
additional cases of splenic rupture have been reported in cancer patients undergoing 
chemotherapy or peripheral blood stem cell mobilization; splenic rupture may have 
contributed to deaths in 2 of these cases.  One additional death due to splenic rupture 
after filgrastim therapy was reported to the manufacturer without additional information.  
According to the manufacturer, the reporting rate for splenic rupture with filgrastim is 
less than 1 in 486,000. 
9.4 
CYCLOSPORINE (GENGRAF, SANDIMMUNE, NEORAL) 
9.4.1 Supply – Cyclosporine will be obtained by the NIH Clinical Center Pharmacy 
Department from commercial sources and is available in capsules (25 mg and 100 mg), 
USP [MODIFIED], oral solution (100 mg/ml), USP [MODIFIED], and as a parenteral 
concentrate for injection (50 mg/ml).  When oral capsules are prescribed for this protocol, 
the cyclosporine capsules, USP [NON-MODIFIED] should NOT be used. 
9.4.2 Preparation – For parenteral doses, each milliliter of concentrate (50mg/ml) should be 
diluted in 20 to 100ml of dextrose 5% in water or sodium chloride 0.9%.  Parenteral 
doses of cyclosporine will be prepared in non-PVC containers and infused with non-PVC 
administration sets/tubing (see Storage and Stability, section 8.4.3).  Oral cyclosporine 
solution may be mixed in orange juice or other beverages, but not milk. 
9.4.3 Storage and Stability – Capsules, oral solution, and ampules of parenteral concentrate 
bear expiration dates and are stored at room temperature and protected from light.  
Cyclosporine concentrate for injection that has been diluted to a final concentration of 
approximately 2mg/ml is stable for 24 hours in 5% dextrose or 0.9% sodium chloride 
injection in glass, PVC or non-PVC plastic containers.  To minimize the potential for 
sorption to PVC plastic bags and tubing as well the leaching of phthalate plasticizer 
(DEHP) into the solution, only non-PVC plastic bags and intravenous administration sets 
should be utilized. 


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9.4.4 Administration – Cyclosporine may be given intravenously over 2 hours or orally. 
9.4.5 Toxicities – Acute cyclosporine nephrotoxicity is usually manifested by a moderate 
decline in renal excretory function, which is readily reversible by a decrease in drug 
dosage.  Although some degree of transient renal dysfunction may occur in patients with 
therapeutic levels of cyclosporine, significant renal toxicity is associated with elevated 
trough levels.  In addition to an increase in BUN and creatinine, hyperkalemic 
hyperchloremic acidosis, low fractional excretion of sodium and the onset of 
hypertension with hypomagnesemia are seen with cyclosporine nephrotoxicity.  
Hypertension occurs in up to 60% of patients.  Hypomagnesemia can be associated with 
neurologic symptoms, including seizures, cerebellar ataxia and depression.  Dose-related 
hepatotoxicity, manifested by elevation of serum transaminases and bilirubin, has been 
reported. 
9.5 
FLUDARABINE (FLUDARA, BERLEX LABORATORIES) 
9.5.1 Supply - Fludarabine monophosphate will be purchased by the NIH Clinical Center 
Pharmacy Department from commercial sources and is supplied as a white, lyophilized 
powder.  Each vial contains 50 mg of fludarabine phosphate, 50 mg of mannitol, and 
sodium hydroxide to adjust pH.  Fludara is stored at room temperature. 
9.5.2 Preparation - FLUDARA IV should be prepared for parenteral use by aseptically adding 
Sterile Water for Injection, USP.  When reconstituted with 2 ml of Sterile Water for 
Injection, each ml of the resulting solution will contain 25 mg of Fludarabine Phosphate, 
25 mg of mannitol, and sodium hydroxide to adjust the pH to 7–8.5.  Fludarabine will be 
diluted in 100 to 125ml of either 5% dextrose in water or 0.9% sodium chloride, and 
infused IV over 30 minutes. 
9.5.3 Storage and Stability - Reconstituted FLUDARA IV is chemically and physically stable 
for 24 hours at room temperature or for 48 hours if refrigerated.  Because reconstituted 
FLUDARA IV contains no antimicrobial preservative, care must be taken to assure the 
sterility of the prepared solution; for this reason, reconstituted FLUDARA IV should be 
used or discarded within 8 hours. 
9.5.4 Administration - Parenteral drug products should be inspected visually for particulate 
matter and discoloration prior to administration. 
9.5.5 Toxicities – Fludarabine toxicities include myelosuppression (dose limiting toxicity), 
fever, nausea, vomiting, stomatitis, diarrhea, gastrointestinal bleeding, anorexia, edema, 
skin rashes, myalgia, headache, agitation, hearing loss, transient episodes of somnolence 
and fatigue, auto-immune hemolytic anemia, auto-immune thrombocytopenia, 
paresthesias, peripheral neuropathy, renal, and pulmonary toxicity (interstitial 
pneumonitis).  Severe fatal CNS toxicity presenting with loss of vision and progressive 
deterioration of mental status were encountered almost exclusively after very high doses 
of fludarabine monophosphate.  Such toxicity has only rarely been demonstrated at the 
25-30 mg/m2/day dosage of fludarabine.  Very rarely described complications include 
transfusion-associated graft-versus-host disease, thrombotic thrombocytopenic purpura, 
and liver failure.  Tumor lysis syndrome following fludarabine administration has been 
observed, especially in patients with advanced bulky disease.  Opportunistic infections 
(protozoan, viral, fungal, and bacterial) have been observed post-fludarabine, especially 


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in heavily pre-treated individuals, and in individuals receiving fludarabine combined with 
other agents. 
9.6 
ETOPOSIDE, DOXORUBICIN, AND VINCRISTINE (IN EPOCH) 
9.6.1 Supply – Etoposide, doxorubicin, and vincristine will be purchased by the NIH Clinical 
Center Pharmacy Department from commercial sources. 
9.6.2 Preparation and Administration - Etoposide, doxorubicin, and vincristine will be 
combined in a single (‘3-in-1’) admixture [108]. All 3-in-1 admixtures dispensed from 
the Pharmacy will contain a 24-hour supply of etoposide, doxorubicin, and vincristine 
PLUS 40 mL overfill (excess) fluid and a proportional amount of drug to compensate for 
volume lost in administration set tubing. 
 
Etoposide 
Dose 
Volume of Fluid 
Containing a 
Daily Dose 
Volume of 
Overfill 
(fluid + drug) 
Volume To 
Infuse 
(over 24 hours) 
Administration 
Rate 
< 130 mg 
528 mL 
40 mL 
528 mL 
22 mL/hour 
≥ 130 mg 
1056 mL 
40 mL 
1056 mL 
44 mL/hour 
 
Before dispensing 3-in-1 admixtures, Pharmacy staff will (1) purge all air from the drug 
product container, (2) attach an administration set appropriate for use with a portable 
pump and the set will be (3) primed close to its distal tip and (4) capped with a Luer-
locking cap.  Bags will be exchanged daily for 4 consecutive days to complete a 96-
hour drug infusion. 
Portable pumps used to administer etoposide + doxorubicin + vincristine admixtures 
will be programmed to deliver one of two fixed volumes at one of two corresponding 
fixed rates based on the amount of etoposide and fluid that is ordered (see table, above).  
At the end of an infusion, some residual fluid is expected because overfill fluid and 
drug were added; however, nurses are asked to return to the Pharmacy for measurement 
any drug containers that appear to contain a greater amount of residual drug than 
expected. 
9.6.3 Storage and Stability - Studies conducted by the Pharmaceutical Development Service, 
Pharmacy Department, NIH Clinical Center, have demonstrated that admixtures of 
vincristine, doxorubicin, and etoposide in 0.9% Sodium Chloride for Injection (at 
concentrations, respectively, of 1, 25, and 125 mcg/ml; 2, 50, and 250 mcg/ml; and 2.8, 
70, and 350 mcg/ml) are stable for at least 48 hours at room temperature when protected 
from light [108]. 
9.6.4 Toxicities: 
9.6.4.1 Etoposide:  nausea, vomiting, stomatitis, diarrhea, thrombocytopenia, 
neutropenia, and alopecia.  Secondary AML has been associated with 


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etoposide.  Bradycardia and hypotension are sometimes observed with 
etoposide administration. 
9.6.4.2 Doxorubicin:  Cardiotoxicity is particularly noted after cumulative doses of 
greater than 550 mg/m2.  Other toxicities include myelosuppression, nausea, 
vomiting, stomatitis, diarrhea, and alopecia.  Skin infiltration of doxorubicin 
causes tissue necrosis. 
9.6.4.3 Vincristine causes neurological toxicities such as paresthesias, jaw pain, ataxia, 
foot-drop, cranial nerve palsies, paralytic ileus, constipation, abdominal pain, 
and loss of deep tendon reflexes.  It is also a vesicant, and occasionally causes 
alopecia and myelosuppression. 
9.7 
PREDNISONE 
9.7.1 Supply – Prednisone will be purchased by the NIH Clinical Center Pharmacy Department 
from commercial sources.  Prednisone is commercially available as tablets, in strengths 
of 1, 2.5, 5, 20, and 50 mg. 
9.7.2 Storage and Stability - Prednisone tablets should be stored in the container provided away 
from heat.  The product labeling bears the manufacturer's expiration dating for stability. 
9.7.3 Administration - Prednisone will be administered at a dose of 60 mg/m2 orally on days 1, 
2, 3, 4, and 5 of the induction chemotherapy regimen.  In patients unable to tolerate oral 
medication, methylprednisolone can be substituted at an equivalent dosage, diluted in a 
small volume (e.g. 25-50ml) of 5% dextrose in water or 0.9% sodium chloride and 
infused over 15 minutes.  To reduce gastrointestinal side effects, prednisone should be 
taken with food. 
9.7.4 Toxicities - Prednisone frequently causes gastritis, immunosuppression, muscle wasting, 
fluid retention, and hyperglycemia. 
9.8 
RITUXIMAB (RITUXAN) 
9.8.1 Supply – Rituximab will be obtained commercially and is supplied as a 10 mg/ml sterile, 
preservative-free solution for injection, in vials of 100 mg and 500 mg. 
9.8.2 Preparation – The desired dose will be diluted to a final concentration of 1 to 4 mg/mL in 
either 0.9% Sodium Chloride or D5W. 
9.8.3 Storage and Stability – Rituximab vials should be stored at 2–8°C (36–46°F) and should 
be protected from direct sunlight. 
9.8.4 Administration – First Infusion: The rituximab solution for infusion should be 
administered intravenously at an initial rate of 50 mg/hr. Rituximab should not be mixed 
or diluted with other drugs.  If hypersensitivity or infusion reactions do not occur, 
escalate the infusion rate in 50 mg/hr increments every 30 minutes, to a maximum of 400 
mg/hr.  If hypersensitivity (non-IgE-mediated) or an infusion reaction develops, the 
infusion should be temporarily slowed or interrupted. The infusion can continue at one-
half the previous rate upon improvement of patient symptoms.  If the first infusion is 
tolerated well, infusions during subsequent cycles of EPOCH-F/R can begin at a rate of 
100 mg/hr and be increased by 100 mg/hr increments at 30-minute intervals.  However, if 
the first infusion is not tolerated well, then the guidelines for the initial infusion should be 


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followed for subsequent administration.  Pre-medication will routinely be administered 
30 to 60 minutes prior to the beginning of each rituximab infusion, consisting of 
acetaminophen 650 mg PO and diphenhydramine 25 to 50 mg i.v./p.o.. 
9.8.5 Toxicities – The most serious adverse reactions caused by rituximab include infusion 
reactions, tumor lysis syndrome, mucocutaneous reactions, hypersensitivity reactions, 
cardiac arrhythmias and angina, and renal failure. 
9.8.5.1 Fatal and Severe Infusion Reactions:  Deaths within 24 hours of rituximab 
infusion have been reported.  Approximately 80% of fatal infusion reactions 
occurred in association with the first infusion.  Severe reactions typically 
occurred during the first infusion with time to onset of 30 to 120 minutes.  
Signs and symptoms of severe infusion reactions may include hypotension, 
angioedema, hypoxia or bronchospasm, and may require interruption of 
rituximab administration.  The most severe manifestations and sequelae include 
pulmonary infiltrates, acute respiratory distress syndrome, myocardial 
infarction, ventricular fibrillation, and cardiogenic shock.  In the reported cases, 
the following factors were more frequently associated with fatal outcomes:  
female gender, pulmonary infiltrates, and chronic lymphocytic leukemia or 
mantle cell lymphoma. 
9.8.5.2 Management of severe infusion reactions:  The rituximab infusion should be 
interrupted for severe reactions and supportive care measures instituted as 
medically indicated (e.g., intravenous fluids, vasopressors, oxygen, 
bronchodilators, diphenhydramine, and acetaminophen).  In most cases, the 
infusion can be resumed at a 50% reduction in rate (e.g., from 100 mg/hr to 50 
mg/hr) when symptoms have completely resolved.  Patients requiring close 
monitoring during first and all subsequent infusions include those with pre-
existing cardiac and pulmonary conditions, those with prior clinically 
significant cardiopulmonary adverse events and those with high numbers of 
circulating malignant cells (= 25,000/mm3) with or without evidence of high 
tumor burden. 
9.8.5.3 Tumor Lysis Syndrome (TLS):  Acute renal failure requiring dialysis with 
instances of fatal outcome has been reported in the setting of TLS following 
treatment with rituximab.  Rapid reduction in tumor volume followed by acute 
renal failure, hyperkalemia, hypocalcemia, hyperuricemia, or 
hyperphosphatasemia, have been reported within 12 to 24 hours after the first 
rituximab infusion.  Rare instances of fatal outcome have been reported in the 
setting of TLS following treatment with rituximab.  The risks of TLS appear to 
be greater in patients with high numbers of circulating malignant cells (= 
25,000/mm3) or high tumor burden.  Prophylaxis for TLS should be considered 
for patients at high risk.  Correction of electrolyte abnormalities, monitoring of 
renal function and fluid balance, and administration of supportive care, 
including dialysis, should be initiated as indicated.  Following complete 
resolution of the complications of TLS, rituximab has been tolerated when re-
administered in conjunction with prophylactic therapy for TLS in a limited 
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9.8.5.4 Severe Mucocutaneous Reactions:  Mucocutaneous reactions, some with fatal 
outcome, have been reported in patients treated with rituximab.  These reports 
include paraneoplastic pemphigus (an uncommon disorder which is a 
manifestation of the patient’s underlying malignancy), Stevens-Johnson 
syndrome, lichenoid dermatitis, vesiculobullous dermatitis, and toxic epidermal 
necrolysis.  The onset of the reaction in the reported cases has varied from 1 to 
13 weeks following rituximab exposure. Patients experiencing a severe 
mucocutaneous reaction should not receive any further infusions and seek 
prompt medical evaluation.  Skin biopsy may help to distinguish among 
different mucocutaneous reactions and guide subsequent treatment.  The safety 
of re-administration of RITUXAN to patients with any of these mucocutaneous 
reactions has not been determined. 
9.8.5.5 Infusion reactions and lymphopenia are the most commonly occurring adverse 
reactions.  Mild to moderate infusion reactions consisting of fever and 
chills/rigors occur in the majority of patients during the first rituximab infusion.  
Other frequent infusion reaction symptoms included nausea, pruritus, 
angioedema, asthenia, hypotension, headache, bronchospasm, throat irritation, 
rhinitis, urticaria, rash, vomiting, myalgia, dizziness, and hypertension.  These 
reactions generally occur within 30 to 120 minutes of beginning the first 
infusion, and resolved with slowing or interruption of the rituximab infusion 
and with supportive care (diphenhydramine, acetaminophen, IV saline, and 
vasopressors).  In an analysis of data from 356 patients with relapsed or 
refractory, low-grade NHL who received 4 (N = 319) or 8 (N = 37) weekly 
infusions of rituximab, the incidence of infusion reactions was highest during 
the first infusion (77%) and decreased with each subsequent infusion (30% with 
fourth infusion and 14% with eighth infusion). 
9.9 
CYTARABINE (CYTOSINE ARABINOSIDE, CYTOSAR, ARA-C) 
9.9.1 Supply – Cytarabine will be purchased by the NIH Clinical Center Pharmacy Department 
from commercial sources and is supplied as un-reconstituted lyophilized powder (100 
mg, 500 mg, 1 g, and 2 g vials).  Cytarabine for injection is available for subcutaneous, 
intravenous, and intrathecal administration. 
9.9.2 Preparation – To prepare high dose (2 gm/m2) cytarabine intravenous infusions, each vial 
of drug should be reconstituted with sterile water for injection USP (containing no 
preservative) with the diluent volumes listed below.  Note that the manufacturers 
recommended diluent for cytarabine is bacteriostatic water for injection containing 
benzyl alcohol. For preparation of intrathecal injection doses and for high dose 
intravenous dosing regimens, ONLY a preservative-free diluent should be used.  The 
recommended volumes for reconstitution include the following: 
 
Vial Size 
Volume of Diluent 
Concentration 
100 mg 
5 ml 
20 mg/ml 
500 mg 
10 ml 
50 mg/ml 


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1 g 
10 ml 
100 mg/ml 
2 g 
20 ml 
100 mg/ml 
The drug will be further diluted in 500 ml of 5% Dextrose Injection or 0.9% Sodium 
Chloride Injection prior to administration. 
9.9.3 Storage and Stability – Vials should be stored at room temperature (25oC or 77oF); 
excursions permitted to 15-30o C (59-86oF). [See USP Controlled Room Temperature.]  
Once reconstituted with sterile water for injection, USP the reconstituted vial should be 
used within 24 hours. After final dilution with 0.9% Sodium Chloride Injection or 5% 
Dextrose Injection, the prepared dose should be used within 24 hours if stored at room 
temperature or 48 hours if refrigerated. 
9.9.4 Administration – Begin each cytarabine dose 3.5 hours after completion of the preceding 
fludarabine dose.  Intravenous doses should be infused over at least 2 hours. 
9.9.5 Toxicity – Acute dose-limiting toxicity with IV administration consists of severe 
leukopenia and thrombocytopenia.  Nausea and vomiting may be dose limiting at higher 
doses.  Other adverse reactions include diarrhea, immunosuppression, anorexia, 
stomatitis, oral ulceration, flu-like syndrome, fever, hepatic dysfunction, and alopecia. At 
high doses, as in this protocol, keratoconjunctivitis, dermatitis, and central nervous 
system toxicity (e.g., ataxia, somnolence, coma, dysarthria) may occur. Occasionally, the 
CNS impairment is not fully reversible. Renal impairment will enhance toxicity.  In the 
event that signs of CNS toxicity occur, the cytarabine will be interrupted and the M.D. 
notified.  No further cytarabine will be administered if there is CNS toxicity (any grade) 
deemed related to cytarabine.  
9.9.6 Conjunctivitis Prophylaxis: Corticosteroid ophthalmic drops will be administered 2 drops 
to each eye every 6 hours starting prior to first dose and continuing until 24 hours after 
the last dose of cytarabine has been completed. 
9.10 DIPHENHYDRAMINE 
9.10.1 Supply – Commercially available.  Diphenhydramine HCl injection is available in an 
injectable solution at a 50mg/ml concentration in single dose ampules, syringes and vials 
as well as multi-dose vials from multiple manufacturers. 
9.10.2 Preparation – Diphenhydramine HCl may be given by direct intravenous injection 
without additional dilution.  Alternatively the prescribed dose may be diluted in a small 
volume (e.g. 25-50ml) of 5% dextrose in water (D5W) or 0.9% sodium chloride (NS) and 
infused over 10-15 minutes. 
9.10.3 Storage and Stability – Store commercially available injectable product at controlled 
room temperature. 
9.10.4 Administration – Diphenhydramine HCl injection may be administered by direct IV 
injection (IV push) at a rate generally not exceeding 25mg/min.  Alternatively, 
diphenhydramine HCl injection may be diluted and given over 10-15 minutes (see 
Preparation). 
9.10.5 Toxicities – Sedation, sleepiness, dizziness, disturbed coordination, epigastric distress, 
thickening of bronchial secretions.  Diphenhydramine  can provide additive effects with 


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alcohol or other CNS depressants.  Diphenhydramine can cause anticholinergic side 
effects (e.g. dry mouth, fixed or dilated pupils, flushing, urinary retention).  
Diphenhydramine should be used with caution in patients with a history of bronchial 
asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease or 
hypertension. 
9.11 ACETAMINOPHEN 
9.11.1 Supply – Commercially available as 325 mg or 500 mg tablets for oral administration 
from multiple manufacturers. 
9.11.2 Storage – Store at controlled room temperature. 
9.11.3 Administration – Oral.  For analgesia and antipyresis, the usual dose is 650 to 1000 
milligrams every 4 to 6 hours, to a maximum of 4 grams/day. 
9.11.4 Toxicities – No toxicities are anticipated to result from single doses of acetaminophen 
administered as pre-medication for rituximab infusions. 
9.12 VALACYCLOVIR (VALTREX®) 
9.12.1 Supply – Commercially available as 500mg tablets and 1gm tablets.  Dose adjustment is 
necessary in patients with significant renal impairment (refer to the manufacturer's 
labeling for dose adjustment guidelines.) 
9.12.2 Pharmacology – Valacyclovir is the hydrochloride salt of L-valyl ester of the antiviral 
drug acyclovir. After oral administration, valacyclovir is rapidly absorbed from the GI 
tract and nearly completely converted to acyclovir and L-valine by first-pass intestinal or 
hepatic metabolism. 
9.12.3 Storage and Stability – Oral tablets should be stored at 15o to 25oC (59o to 77oF). 
9.12.4 Administration – Oral. 
9.12.5 Toxicities – Nausea and/or vomiting, headache, dizziness, abdominal pain, 
dysmenorrhea, arthralgia, acute hypersensitivity reactions, elevations in liver enzyme 
laboratory values (e.g. AST).  Renal failure and CNS symptoms have been reported in 
patients with renal impairment who received valacyclovir or acyclovir at greater than the 
recommended dose. Dose reduction is recommended in this patient population (refer to 
the manufacturer's labeling for dose adjustment guidelines). 
9.13 FLUCONAZOLE (DIFLUCAN®) 
9.13.1 Supply – Commercially available as 50 mg, 100 mg, 150 mg and 200 mg tablets, or as a 
powder for oral suspension for reconstitution at a concentration of 10mg/ml or 40 mg/ml.  
Parenteral fluconazole is available in a solution for injection at a concentration of 2 
mg/ml in glass bottles and Viaflex® Plus plastic containers containing either 100ml (200 
mg) or 200ml (400 mg). 
9.13.2 Preparation – For parenteral administration, the commercial solution for injection is 
available in its final form for administration (concentration of 2 mg/ml). 
9.13.3 Storage and Stability – Oral tablets and oral suspension should be stored at temperatures 
below 30oC (86oF).  Store reconstituted oral suspension between 5o to 30oC (41o to 86oF) 


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and discard unused portion after 2 weeks.  Fluconazole for injection in glass bottles 
should be stored between 5o to 30oC (41o to 86oF).  Fluconazole for injection in Viaflex® 
Plus plastic containers should be stored between 5o to 25oC (41o to 77oF). 
9.13.4 Administration – Oral and parenteral.  Parenteral doses should be administered by an 
intravenous infusion at a maximum rate of 200mg/hr. 
9.13.5 Toxicities – Nausea, vomiting, headache, skin rash, abdominal pain, diarrhea have been 
reported at an incidence of 1% or greater in clinical trials.  In combined clinical trials and 
marketing experience, there have been rare cases of serious hepatic reactions during 
treatment with fluconazole.  The spectrum of these hepatic reactions has ranged from 
mild transient elevation in transaminases to clinical hepatitis, cholestasis and fulminant 
hepatic failure, including fatalities. 
9.13.6 Drug Interactions – Fluconazole is a potent inhibitor of the cytochrome P450 3A4 
isoenzyme system.  Co-administration of fluconazole with other drugs metabolized by the 
same enzyme system may result in increased plasma concentrations of the drugs, which 
could increase or prolong therapeutic and adverse effects.  Refer to the package literature 
or other drug information resources for additional information on identification and 
management of potential drug interactions. 
9.14 TRIMETHOPRIM/SULFAMETHOXAZOLE (TMP/SMX, COTRIMOXAZOLE, BACTRIM, 
SEPTRA) 
9.14.1 Supply – Commercially available as a single strength tablet  containing trimethoprim 
80mg and sulfamethoxazole 400mg and a double strength (DS) tablet containing 
trimethoprim 160mg and sulfamethoxaole 800mg.  It is also available in a oral 
suspension at a concentration of 40mg of trimethoprim and 200mg sulfamethoxazole per 
5ml.  Parenteral TMP/SMX is available in a solution for injection at a concentration of 
80mg of trimethoprim and 400mg of sulfamethoxazole per 5ml. 
9.14.2 Preparation – For parenteral administration, the commercial solution for injection  must 
be diluted prior to administration.  It is recommended that each 5ml of the solution for 
injection be diluted with 100-125 ml or, if fluid restriction is required, in 75ml of 
dextrose 5% in water.  0.9% sodium chloride, Inj. may be substituted as a diluent but the 
resulting solutions have reduced stability.  Consult with pharmacy for questions regarding 
diluent, volume, and expiration. 
9.14.3 Storage and Stability – Oral tablets and oral suspension should be stored at 15o to 30oC 
(59o to 86oF) in a dry place and protected from light.  TMP/SMX for injection should be 
stored at room temperature between 15o to 30oC (59o to 86oF) and should not be 
refrigerated.  Stability of intravenous doses after final dilution is dependent on 
concentration and diluent.  Consult with pharmacy for questions regarding stability and 
expiration dating. 
9.14.4 Administration – Oral and parenteral.  Parenteral doses should be administered by an 
intravenous infusion over 60 to 90 minutes. 
9.14.5 Toxicities – The most common adverse effects from TMP/SMX are gastrointestinal 
disturbances (nausea, vomiting, anorexia) and allergic skin reactions (such as rash and 
urticaria).  Fatalities associated with the administration of sulfonamides, although rare, 


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have occurred due to severe reactions, including Stevens-Johnson syndrome, toxic 
epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia and 
other blood dyscrasias.  For TMP/SMX injection, local reaction, pain and slight irritation 
on IV administration are infrequent. Thrombophlebitis has rarely been observed. 
9.15 FUROSEMIDE (LASIX) 
9.15.1 Supply – Commercially available as 20mg, 40mg, and 80mg tablets or as an injectable 
solution of 10mg/ml, from multiple manufacturers. 
9.15.2 Preparation – Furosemide may be given by direct intravenous injection without additional 
dilution.  Alternatively the prescribed dose may be diluted in a small volume (e.g. 25-
50ml) of 5% dextrose in water (D5W) or 0.9% sodium chloride (NS). 
9.15.3 Storage and Stability – Store commercially available injectable product at controlled 
room temperature and protect from light exposure. 
9.15.4 Administration – Furosemide injection may be administered by direct IV injection (IV 
push) over 1 to 2 minutes, and by intravenous infusion at a rate not exceeding 4mg/min. 
9.15.5 Toxicities – Common toxicities include hypokalemia, hypomagnesemia, hyperuricemia, 
hyperglycemia, glycosuria, anorexia, constipation, cramping, diarrhea, blurred vision, 
dizziness, headache, parathesias, vertigo, muscle spasms, weakness, purpura, 
photosensitivity, pruritus, urticaria, and rash.  Uncommon but serious adverse effects 
include cytopenias, hemolytic anemia, erythema multiforme, Stevens Johnson syndrome, 
hypotension, and pancreatitis. 
9.16 METHOTREXATE (METHOTREXATE SODIUM, MTX, NSC-740) 
9.16.1 Supply – Methotrexate will be obtained commercially and is supplied as a 25 mg/ml 
preservative-free isotonic solution for injection. 
9.16.2 Preparation – The desired dose will be diluted in 5% dextrose in water or 0.9% sodium 
chloride. 
9.16.3 Storage and Stability – Methotrexate should be stored at room temperature and protected 
from light.  Once the prepared dose is diluted for administration, the solution is stable for 
24 hours refrigerated or at room temperature when protected from light. 
9.16.4 Administration – Methotrexate will be given as IV infusion over 15 minutes. 
9.16.5 Toxicities - The toxicity associated with methotrexate primarily involves the 
gastrointestinal tract.  Severe mucositis can occur, particularly in patients who have 
received an intensive preparative regimen. Other gastrointestinal symptoms include 
nausea, vomiting and diarrhea.  Transient elevations in serum transaminases have been 
seen. The myelosuppression associated with methotrexate often results in delayed 
engraftment.  Folinic acid can effectively circumvent the enzymatic block produced by 
methotrexate. 
9.17 SIROLIMUS (RAPAMYCIN) (RAPAMUNE®, WYETH-AYERST LABORATORIES) 
9.17.1 Supply - For patient administration, oral tablets will be purchased by the NIH Clinical 
Center Pharmacy Department from commercial sources. 


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9.17.2 Storage and Stability - Oral tablets should be stored 20-25 C° (68-77 F°). Oral solution 
should be refrigerated (2-8 C° or 36-46 F°). 
9.17.3 Administration: Because food, in particular fatty foods, can decrease the absorption of 
sirolimus, it is suggested the tablets should be administered consistently between meals. 
9.17.4 Toxicities: 1) Sirolimus induces immune suppression, which has been associated with 
opportunistic infection and an increased rate of malignancy, particularly skin cancer. 2) 
Some individuals may develop hypersensitivity to sirolimus.  3) May cause an increase in 
cholesterol and triglycerides, which may be associated with pancreatitis.  4) With long-
term administration, may result in impaired renal function.  4) Metabolism is via the 
cytochrome p450 pathway, and as such, co-administration of voriconazole is prohibited 
with sirolimus can result in prolonged blood levels of sirolimus. As such, if the 
administration of voriconazole is required the dose of sirolimus will be reduced by 90% 
and close attention must be given relative to serum sirolimus levels and associated 
toxicities [98].  
9.18 ALEMTUZUMAB (CAMPATH-1H, CAMPATH®) 
9.18.1 Supply –Available through the Campath Distribution Program (The Sanofi Foundation 
for North America 1-877-422-6728). Vials are provided through this program upon 
completion of a patient specific request form. Prior to submission of a drug request the 
patient must provide authorization for the release of medical information (NIH-527). 
Refer to the Pharmacy Department or Clinical Pharmacy Specialist for additional details 
on drug procurement. Each single use, clear glass vial of Campath contains 30 mg 
Alemtuzumab in 1 mL of solution (8.0 mg sodium chloride, 1.44 mg dibasic sodium 
phosphate, 0.2 mg potassium chloride, 0.2 mg monobasic potassium phosphate, 0.1 mg 
polysorbate 80, and .0187 mg disodium edetate dehydrate). No preservatives are added. 
Each carton contains three Campath vials (NDC 50419-357-03) or one Campath vial 
(NDC 50419-357-01). 
9.18.2 Storage and stability – Vials of Alemtuzumab should be stored at 2-8°C (36-46°F) and 
protected from sunlight. The vial should not be frozen; if the vial has been frozen it 
should be discarded. Alemtuzumab contains no antimicrobial preservative. An internal 
NIH Pharmacy (Pharmaceutical Development Section) conducted study demonstrated 24 
hour stability of alemtuzumab when diluted in 0.9% sodium chloride to a concentration 
range of  6.67 mcg/mL to 120 mcg/mL at room temperature (Goldspiel JT, et.al. Stability 
of alemtuzumab solutions at room temperature. Am J Health –Syst Pharm, accepted for 
publication 2012) .. Alemtuzumab solutions prepared in the concentration range 
described above may be stored at room temperature (15-30°C) for up to 24 hours. 
Alemtuzumab solutions should be protected from light.   
9.18.3 Preparation – The vial should be inspected for visible particulate matter and discoloration 
prior to administration. If particulate matter is present or the solution is discolored, the 
vial should not be used. The vial should not be shaken prior to use. The necessary amount 
of Alemtuzumab should be withdrawn from the vial into a syringe. The vial contains no 
preservatives and is intended for single use only; the vial should be discarded with any 
unused portion after 6 hours. The desired dose of 20 mg is then injected into 250 mL 


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sterile 0.9% Sodium Chloride USP. The bag should be gently inverted to mix the 
solution. The  syringe is discarded. 
9.18.4 Administration - Alemtuzumab should be administered intravenously only. The infusion 
should be administered over an 8 hour period.. Other drug substances should not be 
added or simultaneously infused through the same intravenous line. 
9.18.5 Toxicities: 
9.18.5.1 Infusion-related adverse events are very common (>80%) with Alemtuzumab 
administration. The most commonly reported infusion-related adverse events 
on this study included rigors, fever, nausea, vomiting, and hypotension. Other 
frequently reported infusion-related events include rash, fatigue, urticaria, 
dyspnea, pruritus, headache, and diarrhea. Serious infusion-related events that 
have been reported include syncope, pulmonary infiltrates, ARDS, respiratory 
arrest, cardiac arrhythmias, myocardial infarction and cardiac arrest. 
9.18.5.2 The following serious adverse events have been were reported in at least one 
patient treated on studies where Alemtuzumab was used as a single agent to 
treat malignant (e.g. chronic lymphocytic leukemia) and non-malignant 
diseases (e.g. rheumatoid arthritis): allergic and anaphylactoid reactions, 
ascites, cyanosis, atrial and ventricular arrhythmias, angina pericarditis, 
abnormal gait, aphasia, coma, seizures,  hyperthyroidism, duodenal ulcer, GI 
hemorrhage, intestinal obstruction, intestinal perforation, pancreatitis, 
hepatocellular damage, respiratory alkalosis,  arthritis or worsening arthritis, 
arthropathy, osteomyelitis, polymyositis,  malignant lymphoma, secondary 
leukemia, disseminated intravascular coagulation, thrombocythemia 
agranulocytosis, aplasia, lymphadenopathy, hemolytic anemia, splenic 
infarction, splenomegaly, cervical dysplasia, bacterial infections, Herpes zoster 
infection, Pneumocystis carinii infection, otitis media, asthma, pleural effusion, 
pleurisy, pulmonary edema, pulmonary fibrosis, acute renal failure, cerebral 
hemorrhage, and deep vein thrombosis. 
9.19 URSODEOXYCHOLIC ACID (URSODIOL, ACTIGALL®) 
9.19.1 Supply – Commercially available as 300 mg capsules. 
9.19.2 Pharmacology - About 90% of a therapeutic dose of Ursodiol is absorbed in the small 
bowel after oral administration. After absorption, Ursodiol enters the portal vein and 
undergoes efficient extraction from portal blood by the liver where it is conjugated with 
either glycine or taurine and is then secreted into the hepatic bile ducts. Only small 
quantities of Ursodiol appear in the systemic circulation and very small amounts are 
excreted into urine. The sites of the drug's therapeutic actions are in the liver, bile, and 
gut lumen. 
9.19.3 Storage and Stability – Oral capsules should be stored at 15°C-30°C (59°F-86°F). 
9.19.4 Administration – Oral. 
9.19.5 Toxicities – Nausea, vomiting, dyspepsia, metallic taste, abdominal pain, biliary pain, 
cholecystitis, constipation, stomatitis, flatulence, diarrhea, pruritus, rash, dry skin, 


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urticaria, headache, fatigue, anxiety, depression, sleep disorders. Less common side 
effects include sweating, thinning of hair, back pain, arthralgia, myalgia, rhinitis, cough. 
9.19.6 Drug Interactions - Bile acid sequestering agents such as cholestyramine and colestipol 
may interfere with the action of Ursodiol by reducing its absorption. Aluminum-based 
antacids have been shown to adsorb bile acids in vitro and may be expected to interfere 
with Ursodiol in the same manner as the bile acid sequestering agents. Estrogens, oral 
contraceptives, and clofibrate increase hepatic cholesterol secretion, and encourage 
cholesterol gallstone formation and hence may counteract the effectiveness of Ursodiol. 
9.20 TACROLIMUS (FK-506, PROGRAF®) 
9.20.1 Supply – Tacrolimus will be obtained by the NIH Clinical Center Pharmacy Department 
from commercial sources and is available for oral administration as capsules (tacrolimus 
capsules) containing the equivalent of 0.5 mg, 1 mg or 5 mg of anhydrous tacrolimus. 
Tacrolimus is also available as a sterile solution (tacrolimus injection) containing the 
equivalent of 5 mg anhydrous tacrolimus in 1 mL for administration by intravenous 
infusion only. Each mL contains polyoxyl 60 hydrogenated castor oil (HCO-60), 200 mg, 
and dehydrated alcohol, USP, 80.0% v/v. 
9.20.2 Preparation – For parenteral doses, tacrolimus injection must be diluted with 0.9% 
Sodium Chloride Injection or 5% Dextrose Injection before use. Parenteral doses of 
tacrolimus will be prepared in non-PVC containers and infused with non-PVC 
administration sets/tubing (see Storage and Stability, section 8.4.3).   
9.20.3 Storage and Stability – Capsules, oral solution, and ampules of parenteral concentrate 
bear expiration dates and are stored at room temperature and protected from light. 
9.20.4 Administration – Tacrolimus will be administered as a continuous intravenous infusion 
over 24 hours or given orally in divided doses every 12 hours. 
9.20.5 Toxicities – Tacrolimus can cause neurotoxicity and nephrotoxicity, particularly when 
used in high doses. Mild to severe hyperkalemia has been observed following tacrolimus 
administration. Serum potassium levels should be monitored and potassium-sparing 
diuretics should not be used during tacrolimus therapy. Neurotoxicity, including tremor, 
headache, and other changes in motor function,0 mental status, and sensory function have 
been reported with tacrolimus administration. Tremor and headache have been associated 
with high whole-blood concentrations of tacrolimus and may respond to dosage 
adjustment. Seizures have occurred in adult and pediatric patients receiving tacrolimus. 
Coma and delirium also have been associated with high plasma concentrations of 
tacrolimus. The most common adverse reactions reported with tacrolimus administration 
include infection, tremor, hypertension, abnormal renal function, constipation, diarrhea, 
headache, abdominal pain and insomnia. Less common adverse reactions reported with 
tacrolimus administration include anorexia, cholangitis, jaundice, diarrhea, dyspepsia, 
hepatitis, ALT (SGPT) increased, AST (SGOT) increased, abnormal ECG, angina 
pectoris, arrhythmia, acute kidney failure, acidosis, alkaline phosphatase increased, 
alkalosis, bicarbonate decreased, bilirubinemia, BUN increased, dehydration, edema, 
hypercalcemia, , hypocalcemia, hypercholesterolemia, hyperlipemia, hyperphosphatemia, 
hyperuricemiahypoglycemia, hypomagnesemia, hyponatremia, hypophosphatemia, 
hypoproteinemia, lactic dehydrogenase increase, peripheral edema, weight gain, 


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Cushing’s syndrome, diabetes mellitus, anemia, allergic reaction, and photosensitivity 
reaction. 


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105. Spitzer TR. Engraftment syndrome following hematopoietic stem cell transplantation. 
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Welk K, Fisher L, McCullough J, Miller W.A comparison of filtered leukocyte-reduced 
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Fisher RI, Hagenbeek A, Zucca E, Rosen ST, Stroobants S, Lister TA, Hoppe RT, 
Dreyling M, Tobinai K, Vose JM, Connors JM, Federico M, Diehl V; The International 
Harmonization Project on Lymphoma. Revised response criteria for malignant lymphoma. 
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International Working Group for Diagnosis, Standardization of Response Criteria, 
Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid 
Leukemia. J Clin Oncol. 2003; 21:4642-9. [Erratum in: J Clin Oncol 2004; 22:576]. 
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hydrochloride, and etoposide in 0.9% sodium chloride injection. Am J Health-System 
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for empirical antifungal therapy in patients with neutropenia and persistent fever. N Engl J 
Med. 2002; 346:225-34. 
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virus reactivation after allogeneic hematopoietic stem cell transplantation. Bone Marrow 
Transplant. 2001; 28:689-92. 
116. Steer CB, Szer J, Sasadeusz J, Matthews JP, Beresford JA, Grigg A. Varicella-zoster 
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DR.Varicella zoster virus infections following allogeneic bone marrow transplantation: 
frequency, risk factors, and clinical outcome. Biol Blood Marrow Transplant. 2000; 6:44-9. 
118. Nichols WG, Corey L, Gooley T, Drew WL, Miner R, Huang M, Davis C, Boeckh M. 
Rising pp65 antigenemia during preemptive anticytomegalovirus therapy after allogeneic 
hematopoietic stem cell transplantation: risk factors, correlation with DNA load, and 
outcomes. Blood. 2001; 97867-74. 
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Meller S, Saso R, Mehta J. Chronic graft versus host disease is associated with long-term 
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Corticosteroids as adjunctive therapy for diffuse alveolar hemorrhage associated with bone 
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Forman SJ, Negrin RS, Appelbaum FR, Radich JP. The effects of imatinib mesylate 
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Bornhauser M, Ritter M, Neubauer A, Ehninger G, Illmer T. Analysis of FLT3-activating 
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2343-2351). 
11 APPENDICES 
11.1 APPENDIX A - PROPHYLAXIS AND TREATMENT OF INFECTIOUS COMPLICATIONS IN 
ALLOGENEIC HSCT RECIPIENTS  
(Note:  The practice guidelines primarily follow the Guidelines for Infection Management as 
outlined by the NIH Blood and Marrow Transplant Consortium’s Supportive Care Guidelines for 
Allogeneic Hematopoietic Stem Cell Transplant Recipients 
(http://intranet.cc.nih.gov/bmt/clinicalcare/guidelines.shtml). The practice guidelines included in 
this Appendix are based upon the best available clinical evidence and may change as additional 
data become available.) 
11.1.1 Pneumocystis jiroveci pneumonia 
11.1.1.1 At the start of pre-transplant induction chemotherapy, all patients will receive 
trimethoprim 160 mg/sulfamethoxazole 800 mg (TMP/SMX 160/800), one 
tablet PO QD on three days per week.  This will continue until completion of 
induction chemotherapy. 
11.1.1.2 Upon admission for the transplant conditioning regimen (day –7), all patients 
will receive TMP/SMX 160/800, one tablet PO BID, continuing daily through 
the evening of day –2. 
11.1.1.3 Prophylaxis is resumed when the absolute neutrophil count is greater than 
1,000/l and the platelet count is consistently above 50,000/mm3 for two 
consecutive days without transfusion.  Note: TMP/SMX should not be resumed 
before the last day of methotrexate administration (day +11 – see section 
3.6.1.1.4).  The dose for post-transplant prophylaxis is TMP/SMX 160/800, one 
tablet PO QD on three days per week, continuing until the recipient’s CD4 


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count is above 200 cells/μl for 3 months and all immunosuppressive agents are 
discontinued. 
11.1.1.4 For patients allergic to sulfa, options include aerosolized pentamidine 300 mg 
by inhalation Q4 weeks, dapsone 100 mg PO QD, or atovaquone 1,500 mg PO 
QD.  Prior to instituting dapsone therapy, G6PD deficiency must be excluded. 
11.1.2 FUNGAL PATHOGENS 
11.1.2.1 Prophylaxis –  Candida infections: 
a) On day 6 of the first cycle of EPOCH-F/R induction chemotherapy, recipients will begin 
fluconazole 400 mg PO daily.  Because of its interaction with vincristine, fluconazole 
will be discontinued during subsequent cycles of induction chemotherapy on days 1 
through 5.  Fluconazole will then be restarted on day 6 of each cycle. 
b) Recipients receiving FLAG induction chemotherapy will receive fluconazole 400 mg PO 
daily, beginning with day 1 of the first cycle of FLAG. 
c) Recipients will continue fluconazole 400 mg PO daily throughout the transplant 
conditioning regimen (day –6) until 100 days after transplantation and 
immunosuppression is discontinued.  Intravenous dosing will be substituted when 
patients are unable to tolerate oral medications.  Fluconazole will be discontinued when 
an alternative antifungal is started. 
d) Alternatives to fluconazole include caspofungin, posaconazole or itraconazole. 
Caspofungin dosing is 70 mg IV loading dose on day 1, then 50 mg IV QD.  
Posaconazole dosing is 200mg PO q 6-8h. Itraconazole dosing is 200 mg IV Q12 hours 
for 2 days (loading dose), then 200 mg IV Q24 hours for 12 days, then 200 mg PO Q12 
hours to maintain levels (itraconazole plus hydroxy-itraconazole) greater than 1 μg/ml.  
Triazoles should be avoided in recipients with fluconazole hepatotoxicity.  In such cases, 
consult the infectious diseases service.  
11.1.2.2 Prophylaxis – Aspergillus infections: 
a) During Neutropenia:  Neutropenic recipients who are febrile for more than 5 days despite 
broad-spectrum antibiotics and have no clinical evidence of invasive fungal disease will 
receive caspofungin 70 mg IV loading dose, then 50 mg IV Q24 hours. An alternative 
regimen is liposomal amphotericin B (Ambisome) 5 mg/kg/day or voriconazole 6 mg/kg 
q12h for two doses and then 4 mg/kg q12h.  This therapy will continue until the patient 
attains an ANC > 500/μl AND is afebrile for 24 hours.  Fluconazole prophylaxis will be 
discontinued during this therapy.  Empiric antifungal therapy may be started at other 
times, if clinically indicated. 
b) During Steroid Therapy for GVHD:  Recipients with GVHD receiving corticosteroids at 
a dose equivalent to > 1 mg/kg/day for > 6 days will receive posaconazole 200mg PO q6-
8h. An alternative regimen is voriconazole 6 mg/kg IV Q12 hours x 2 doses, then 3 
mg/kg IV Q12 hours.  Voriconazole therapy will be converted to oral dosing at 200 mg 
PO Q12 hours when tolerated.  Alternatively, voriconazole may be initiated with oral 
dosing at 400 mg PO Q12 hours x 2 doses, then 200 mg PO Q12 hours.  Antifungal 
prophylaxis with activity against Aspergillus should be continued until the corticosteroid 
dose is reduced to < 0.6 mg/kg/day.  Alternative regimens include: 


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• Amphotericin B lipid complex (ABLC) 5 mg/kg IV QD 
• Caspofungin 70 mg IV loading dose followed by 50 mg IV QD 
• Itraconazole 200 mg IV Q12 hours x 2 days (loading dose), then 200 mg IV Q24 hours x 
12 days.  When tolerated, itraconazole may be converted to oral dosing at 200 mg PO 
Q12 hours to maintain levels (itraconazole + hydroxy-itraconazole) greater than 1 μg/ml. 
 
Notes: 
Empirical antifungal therapy during neutropenia is controversial.  Less than 
10% of patients with persistent fever during neutropenia have a documented 
fungal infection.  Only one RCT has shown decreased fungal infection-related 
death with the empirical addition of amphotericin B in neutropenic fever, and 
this study actually failed to show an overall survival advantage [113].  The 
relevance of these results to patients with neutropenia of short duration who 
are receiving fluconazole prophylaxis is questionable.  In the most recent trial 
of empirical antifungal therapy, breakthrough fungal infections were more 
prevalent in high-risk patients with relapsed leukemia and/or allogeneic bone 
marrow transplant than in other febrile neutropenic patients [114].  If 
persistent fever during neutropenia is a manifestation of occult fungal 
infection in our patients (severely immunosuppressed, with short neutropenia 
and long-term use of fluconazole), then the most likely pathogens 
(fluconazole-resistant Candida and Aspergillus) are probably better treated 
with caspofungin or high-dose amphotericin B (at least 5 mg/kg).  As our 
allogeneic HSCT recipients receive cyclosporine, a known nephrotoxic 
drug,after transplantation, amphotericin B lipid formulations are preferred.  
Voriconazole is a valid alternative, and in the mentioned study was associated 
with significantly fewer breakthrough fungal infections than Ambisome [114]. 
11.1.3 Viral Pathogens 
11.1.3.1 Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) 
a) All patients will receive valacyclovir 500 mg PO QD for suppression of HSV and VZV 
infection/reactivation.  This prophylaxis will begin when recipients start induction 
chemotherapy (EPOCH-F/R) and continue throughout transplantation.  Valacylovir will 
continue until 100 days after transplantation and immunosuppression is discontinued.  If 
a recipient cannot take oral medications, acyclovir 250 mg/m2 IV q12h will be substituted 
for valacyclovir. 
 


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11.1.3.2 Cytomegalovirus (CMV) 
a) Preemptive Therapy:  Recipients with positive pre-transplant serologies for CMV, or 
whose donors have positive serologies, will undergo weekly monitoring of CMV by 
polymerase chain reaction (PCR). CMV monitoring by PCR will begin at the time of 
engraftment after transplantation and continue through day +180.  Recipients who 
continue to require systemic immunosuppression after day +180 will continue to have 
CMV monitoring performed weekly. 
b) Non-scheduled CMV monitoring may also be warranted for clinical circumstances such 
as: 
• Fever of unknown origin 
• Cytopenias post-transplant 
• Pulmonary changes 
c) If PCR becomes positive, then recipients will be treated with IV ganciclovir or IV 
foscarnet according to the following algorithm: 
 
 
 
Notes: 
• 
HSV is an important cause of morbidity after high-dose 
chemotherapy.  Several effective regimens are available.  Every 
recipient receives prophylaxis regardless of HSV serology because 
of the possibility of primary infection after the test, and the fact that 
valacyclovir may also prevent VZV reactivation (see below).  Our 
recipients will remain on valacyclovir for a minimum of 6 months. 
• 
VZV reactivates in a significant proportion of allogeneic HSCT 
recipients once antiviral agents are stopped (30-60% in the first 
year).  The morbidity associated with VZV reactivation is high.  
Hence, prophylaxis with antiviral agents is accepted practice.  
Acyclovir 
(400 
mg/d) 
administered 
until 
the 
end 
of 
immunosuppressive therapy has been reported to significantly 
decrease the incidence of reactivation [115].  It is not known which 
antiviral and what dose are best to prevent VZV, or for how long to 
administer it.  The universal experience seems to be that 
reactivation is unusual for as long as patients are on any 
prophylactic anti-herpesvirus agent [116,117].  We prefer 
valacyclovir for the convenience of once daily dosing, although it 
i
t FDA
d f
thi i di
ti


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Preferred Agents 
Alternatives 
IV GANCICLOVIR 
IV FOSCARNET 
VALGANCICLOVIR 
CIDOFOVIR 
Induction: 
5 mg/kg IV q12h 
for 7 days, then 
maintenance: 
5 mg/kg IV QD,  
5 days/week 
Induction: 
60 mg/kg IV q12h 
for 7 days, then 
maintenance: 
60 mg/kg IV QD 
Induction: 
900 mg PO q12h 
for 7 days, then 
maintenance: 
900 mg/24h 
Induction: 
5 mg/kg IV weekly, 
then 
maintenance: 
5 mg/kg every other 
week. 
Include probenecid 
and hydration. 
 
All patients receive one week of induction. Maintenance therapy should continue until 
one negative or two “low positive” PCR results (henceforth “DNAemia”).? Patients with 
persistent or rising DNAemia during or after induction therapy for CMV will continue or 
resume ganciclovir at induction doses (5 mg/kg IV q12 hours for 7 consecutive days), 
because an increase in DNAemia does not indicate ganciclovir-resistant CMV in most 
patients during or after initial induction If possible, the virus will be sent for sequencing 
to rule out the presence of mutations associated with ganciclovir or foscarnet resistance 
(this is not often possible, as the virus must be isolated and grown in culture). If after 
reinduction there is no improvement, the patient will be changed to another appropriate 
antiviral therapy (e.g. foscarnet). Otherwise, the patient will be switched to maintenance 
therapy as described in the table above. If renal adjustment is required for ganciclovir or 
foscarnet, see http://druginfo.cc.nih.gov or contact unit pharmacist. 
 
NOTES: 
 
• Valganciclovir and ganciclovir may cause bone marrow suppression.  If ANC < 1000:  
Start filgrastim (G-CSF) 5-10 µg/kg/d 
• Weekly IVIG infusion has no proven benefit in the setting of CMV reactivation without 
established infection.  Therefore, its use will be limited to patients with CMV 
pneumonitis. 
Indications for foscarnet: 
• ANC < 500/μl despite G-CSF 
• Platelets < 20,000/mm3 
• Resistance to ganciclovir:  rising antigenemia after 3 weeks with no response to 
ganciclovir re-induction. 
11.1.4 Bacterial Pathogens 


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11.1.4.1 Hypogammaglobulinemia:  Recipients will undergo biweekly monitoring of 
serum IgG levels beginning prior to transplant and continuing until IgG is > 
500 mg/dL for at least 3 consecutive months without supplemental IVIG 
administration.  Recipients with IgG < 400 mg/dL AND a history of repeated 
sinopulmonary infections (≥ 2 respiratory infections requiring systemic 
antibiotics over 6 months) will receive IVIG 400-500 mg/kg every 2-4 weeks. 
11.1.4.2 Prophylaxis During Chronic GVHD:  All recipients receiving treatment for 
chronic GVHD will receive penicillin V 500 mg PO BID until treatment for 
chronic GVHD is discontinued.  For penicillin-allergic recipients, TMP/SMX 
80/400 PO QD can be used.  For recipients allergic to both penicillin and sulfa, 
clarithromycin 500 mg PO QD can be used. 
 
 
 
 
 
 
 
 
 
11.1.4.3 Immunizations:  All recipients will receive immunizations after transplant, 
according to the following table: 
 
Rationale: 
There is an increased risk of infection caused by encapsulated organisms, 
particularly Streptococcus pneumoniae in patients with chronic GVHD [119].  
Functional hyposplenism has been considered, and some investigators have 
attempted to monitor it by ultrasound [120].  Current recommendations support 
the use of antibiotic prophylaxis with penicillin to prevent these infections. 
TMP/SMX could be substituted, but only when administered daily. 


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11.2 APPENDIX B:  MANAGEMENT OF ENGRAFTMENT SYNDROME 
 
11.2.1 Clinical Definition of Engraftment Syndrome 
A constellation of clinical symptoms and signs has been observed during neutrophil recovery 
following HSCT, most commonly termed “engraftment syndrome” (ES), but interchangeably 
termed “capillary leak syndrome” and “autoaggression syndrome”.  Engraftment syndromes 
have been observed after both autologous and allogeneic HSCT; in the latter setting, the clinical 
sequelae of neutrophil recovery were historically attributed to an early, sometimes “hyperacute” 
graft-versus-host reaction.  Our current understanding of ES holds the overproduction of pro-
inflammatory cytokines at the time of neutrophil recovery to be the initiating event.  The study of 
ES has been somewhat hindered by the lack of uniform definition for this clinical entity; 
therefore, the following criteria have been proposed [105]: 
 
Major criteria: 
Fever > 38.3 with no identifiable infectious etiology 
Erythrodermatous rash involving more than 25% of body 
surface area and not attributable to a medication 
Noncardiogenic pulmonary edema, manifested by diffuse 
pulmonary infiltrates and hypoxia 
Minor criteria 
Hepatic dysfunction with either total bilirubin > 2 mg/dl or 
transaminases levels > two times normal 
Renal insufficiency (serum creatinine > two times baseline) 
Weight gain > 2.5% of baseline body weight 
Transient encephalopathy unexplainable by other causes 
 
A diagnosis of ES is established by the presence of all three major criteria, or two major criteria 
and one or more minor criteria; the clinical signs and symptoms should appear within 96 hours of 
neutrophil recovery, according to the above proposed definition. 
 
11.2.2 Treatment of Engraftment Syndrome 
The mainstay of therapy for ES is high-dose corticosteroids, based upon the literature on diffuse 
alveolar hemorrhage [121] in the setting of bone marrow transplantation – a complication that 
many investigators now believe to be part of the spectrum of ES.  Our group has adopted the 
following treatment schema for patients diagnosed with ES, with satisfactory results: 
Day 1: 
Methylprednisolone 250 mg IV Q6 hours x 4 doses 


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Day 2: 
Methylprednisolone 250 mg IV Q8 hours x 3 doses 
Day 3: 
Methylprednisolone 250 mg IV Q12 hours x 2 doses 
Day 4: 
Methylprednisolone 125 mg IV Q12 hours x 2 doses 
Day 5: 
Methylprednisolone 60 mg IV Q12 hours x 2 doses 
Day 6: 
Methylprednisolone 30 mg IV Q12 hours x 2 doses 
Days 7-8: 
Prednisone 60 mg PO QD x 2 days 
Days 9-10: 
Prednisone 50 mg PO QD x 2 days 
Days 11-12: 
Prednisone 40 mg PO QD x 2 days 
Days 13-14: 
Prednisone 30 mg PO QD x 2 days 
Days 15-16: 
Prednisone 20 mg PO QD x 2 days 
Days 17-18: 
Prednisone 10 mg PO QD x 2 days 
Day 19: 
Discontinue prednisone 
 
In the event that symptoms or clinical signs of ES recur during the steroid taper, patients should 
be retreated with methylprednisolone at a minimum dose of 60 mg IV QD.  This schema is 
intended to serve as a guideline and to promote consistency in our clinical practice; it may be 
modified for individual patients as clinical circumstances warrant. 
 


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11.3 APPENDIX C - GRADING AND MANAGEMENT OF ACUTE GRAFT-VERSUS-HOST DISEASE 
11.3.1 Clinical Staging of Acute GVHD [102] 
 
Stage 
Skin 
Liver 
Gut 
+ 
Rash < 25% BSA 
Total bilirubin 2-3 mg/dl 
Diarrhea 500-1000ml/d 
++ 
Rash 25-50% BSA 
Total bilirubin 3-6 mg/dl 
Diarrhea 1000-
1500ml/d 
+++ 
Generalized erythoderma 
Total bilirubin 6-15 mg/dl 
Diarrhea >1500ml/d 
++++ 
Desquamation and bullae 
Total bilirubin > 15 mg/dl 
Pain +/- ileus 
BSA = body surface area; use “rule of nines” or burn chart to determine extent of rash. 
 
11.3.2 Clinical Grading of Acute GVHD [102] 
 
 
Stage 
Grade 
Skin 
Liver 
Gut 
PS 
0 (none) 
0 
0 
0 
0 
I 
+ to ++ 
0 
0 
0 
II 
+ to +++ 
+ 
+ 
+ 
III 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++ 
11.3.3 Treatment of Acute GVHD 
This schema is intended to serve as a guideline and to promote consistency in our clinical practice; it may 
be modified for individual patients as clinical circumstances warrant. 
 
Grade 0-I GVHD:  
1) Topical corticosteroids (usually 0.1% triamcinolone; 1% hydrocortisone to face) applied to rash BID. 
Grade II-IV GVHD: 
 
1) Methylprednisolone (MP) 1 mg/kg per dose IV, BID for 4 consecutive days. 


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2) If no response after 4 days, continue until response (7-day maximum trial); the dose may be doubled 
(4 mg/kg/day). 
3) If response within 7 days, taper as follows: 
a) 0.75 mg/kg per dose IV BID for 2 days. 
b) 0.5 mg/kg per dose IV BID for 2 days. 
c) 0.375 mg/kg per dose IV BID for 2 days. 
d) If clinically appropriate, change MP to oral prednisone to equivalent of IV dose) daily for 2 days.  
MP may be converted to prednisone later in the taper at the investigators’ discretion. 
e) After this, steroids will be reduced by 10% of starting oral dose each week until a dose of 10 
mg/day is reached.  Subsequent reductions will be made at the investigators’ discretion. 
f) If GVHD worsens during taper, steroids should be increased to previous dose. 
g) During steroid taper, maintain cyclosporine at therapeutic levels (Section 3.5.1). 
4) If no response is observed within 7 days of MP treatment: 
a) Increase Methylprednisolone to 10 mg/kg per dose IV, BID for 2 days. 
b) If there is no improvement, consideration will be given to using second-line immunosuppressive 
therapy, e.g., tacrolimus, mycophenolic acid, monoclonal antibodies, or studies of investigational 
agents for acute GVHD, if they are available. 
5) Antifungal prophylaxis with agents effective against mould will be started when it is anticipated that 
the patient will be receiving steroids at > 1 mg/kg/day of methylprednisolone (or equivalent) for > 2 
weeks.  (See section 9.1.2.2)  Voriconazole, caspofungin, liposomal amphotericin B (Ambisome), 
posaconazole or amphotericin B lipid complex (Abelcet) are valid alternatives.  During prophylaxis with 
any of the above agents, fluconazole should be discontinued.  In patients with therapeutic cyclosporine 
levels at the initiation of voriconazole therapy, the cyclosporine or tacrolimus dose should be decreased 
by approximately 50%. In patients with therapeutic sirolimus levels at the initiation of voriconazole 
therapy, the sirolimus dose should be decreased by approximately 90%. 
6) Determination of GVHD treatment response should be made within 96 hours of starting the treatment.  
The following are criteria to determine definitions of response to GVHD treatment: 
Complete response:  Complete resolution of all clinical signs and symptoms of acute GVHD. 
Partial Response: 50% reduction in skin rash, stool volume or frequency, and/or total bilirubin.  
Maintenance of adequate performance status (Karnofsky Score > 70%). 
Non-responder: < 50% reduction in skin rash, stool volume or frequency, and/or total bilirubin.  Failure to 
maintain adequate performance status (Karnofsky Score  70%). 
Progressive disease:  Further progression of signs and symptoms of acute GVHD, and/or decline in 
performance status after the initiation of therapy. 


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11.4 APPENDIX D – NMDP STANDARDS (20TH EDITION) AND NMDP STANDARD POLICIES AND 
PROCEDURES  
(Please see attached). 
 
11.5 APPENDIX E - NMDP PERIPHERAL BLOOD STEM CELL COLLECTION PROTOCOL  
(Please see attached). 


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11.6 APPENDIX F - CHRONIC GVHD SCORE SHEET [57] 
 
 
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 
features 
  Papulosquamous 
lesions or ichthyosis 
 Hyperpigmentation 
  Hypopigmentation 
  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 


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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  
keratoconjunctivitis 
sicca 
  Moderate dry 
eye symptoms 
partially affecting 
ADL (requiring 
drops > 3 x per day 
or punctal plugs), 
WITHOUT vision 
impairment 
  Severe dry eye 
symptoms 
significantly 
affecting ADL 
(special eyeware to 
relieve pain) OR 
unable to work 
because of ocular 
symptoms OR loss of 
vision caused by 
keratoconjunctivitis 
sicca 
 


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SCORE 0 
SCORE 1 
SCORE 2 
SCORE 3 
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 OR 
esophageal dilation 
LIVER 
 
  Normal LFT 
 Elevated 
Bilirubin, AP*, AST 
or ALT <2 x ULN 
  Bilirubin >3 
mg/dl or Bilirubin, 
enzymes 2-5 x 
ULN  
  Bilirubin or 
enzymes > 5 x ULN 
 
 
 
 
 
 
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 due to 
fasciitis, moderate 
decrease ROM 
AND mild to 
moderate limitation 
of ADL 
  Contractures 
WITH significant 
decrease of 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 advanced 
signs (stricture, labial 
agglutination or 
severe ulceration) 
AND severe pain 
with coitus or 
inability to insert 
vaginal speculum 


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* AP may be elevated in growing children, and not reflective of liver dysfunction 
 
Other indicators, clinical manifestations or complications related to cGVHD (check all that apply and assign a score 
to its severity (0-3) based on its functional impact (none – 0,mild -1, moderate -2, severe – 3) 
 
ٱ Esophageal stricture or web___ ٱ Pericardial Effusion___  ٱ Pleural Effusion(s)___ 
ٱ Ascites (serositis)___ ٱ Nephrotic syndrome___  ٱ Peripheral Neuropathy___ 
 ٱMyasthenia Gravis___ ٱ Cardiomyopathy___ 
 ٱ Eosinophilia > 500μl___ 
ٱ Polymyositis___                ٱ Cardiac conduction defects___ ٱ Coronary artery involvement___ 
ٱ Platelets <100,000/μl ___ ٱ Progressive onset ____ 
Others_____ 
 


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123 
11.7 APPENDIX G 
- EXPERIMENTAL TRANSPLANTATION AND IMMUNOLOGY BRANCH 
PRECLINICAL SERVICE POLICY FOR SAMPLE HANDLING 
11.7.1 Storage/Tracking 
 
Normal donor and patient blood and tissue samples, collected for the purpose of research 
under IRB approved protocols of the Experimental Transplantation and Immunology Branch, 
may be archived by the ETIB Preclinical Service. All data associated with archived clinical 
research samples is entered into the ETIB Preclinical Services’ Microsoft Excel databases on 
frozen cells and plasma. These databases are stored on the NCI group drive in the ETIB 
Preclinical Service folder. Access to this folder is limited to ETIB clinical staff, requiring 
individual login and password. All staff in the Preclinical Service laboratory have received 
annually updated NIH/CIT training and maintain standards of computer security. 
 
The data recorded for each sample includes the patient ID, trial name/protocol number, date 
drawn, treatment cycle/post-transplant time point, cell source (e.g. peripheral blood, 
lymphapheresis, mobilized peripheral blood stem cells, marrow, pleural fluid) as well as box and 
freezer location. Patient demographics that correlate treatment outcomes and therapies with the 
samples can be obtained only through the NCI/ETIB clinical records. As of January 2007, all 
newly received samples will receive a unique bar code number, which will be added to the 
sample Preclinical Service database. Only this bar code will be recorded on the sample vial and 
the vials will not be traceable back to patients without authorized access to the Preclinical 
Service database. All non-coded samples previously archived will be stripped of identifiers prior 
to distribution for any use other than as a primary objective of the protocol under which they 
were collected. 
 
Samples are stored in locked freezers at -85C (sera and plasma) or under liquid nitrogen (cells), 
according to stability requirements.  These freezers are located onsite at the Preclinical Service 
laboratory (12C216) (-85° freezer) or in ETIB common equipment space (CRC/3-3273). Access 
to samples from a protocol for research purposes will be by permission of the Principal  
Investigator of that protocol or through his/her submission and IRB approval of the NCI IRB 
Authorization Form (appended) stipulating whether IRB review is not necessary or IRB approval 
is granted for the pursuit of this new research activity. All researchers are required to sign a form 
(attached) stating that the samples are only to be used for research purposes associated with 
objectives of the original protocol for which the samples were collected, or (using only unlinked 
or coded samples) for an IRB approved protocol as stipulated on the IRB Authorization Form, 
and that any unused samples must be returned to the Preclinical Service laboratory. 
  
11.7.2 Protocol Completion/Sample Destruction  
 
Once primary research objectives for the protocol are achieved, researchers can request 
access to remaining samples, providing they have both approval of the Principal Investigator of 
the original protocol under which the samples or data were collected and either an IRB approved 
protocol and patient consent or the IRB Authorization Form stipulating that the activity is 
exempt from IRB review (see attached authorization form from the NCI IRB). 


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124 
Samples, and associated data, can only be permanently archived if the subject has provided 
informed consent. If researchers have samples remaining once they have completed all studies 
associated with the protocol, they must be returned to the Preclinical Service laboratory. 
The Preclinical Service staff will report to the Principal Investigators any destroyed samples, if 
samples become unsalvageable because of environmental factors (ex. broken freezer or lack of 
dry ice in a shipping container), lost in transit between facilities or misplaced by a researcher. 
The Principal Investigators will annually report this information to the IRB.


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11.8 APPENDIX H: FLOW SHEET 
*If Clinically Indicated 
Observation 
Eligibility within 
28 days 
Within 48 hrs 
Pre-induction 
BiWk during 
induction 
After each 
induction 
Within 28 days 
pre- condition/Tx 
arm 
48 hours pre - 
condition 
Day 0--DOT 
During Inpatient 
Post Therapy 
Day 7 
Post Therapy 
Day 14 
Post Therapy 
Day 28 
Post Therapy 
Day 42 
Post Therapy 
Day 60 
Day 100 
Day 180 
9 month 
Post Therapy 12 
Post Therapy 18 
Post Therapy 24 
Post Therapy 3, 
4, 5 yrs 
Clinical Note 
X 
 
 
 
X 
X 
 
 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
NIH Advanced 
Directives Form (see 
section 7.3)1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nutrition & Social Work
Consult 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dental Consult 
X 
 
 
 
 
 
 
 
 
 
 
 
TMS 
(biopsy) 
AC 
(biopsy) 
X 
(biopsy) 
 
X 
X* 
X* 
X* 
CMV, adenovirus, 
EBV, Toxo 
X 
 
 
 
 
 
 
Weekly Post transplant while on 
immunosuppression 
 
 
 
 
 
 
 
 
 
Ab for Hep A,B, C,HIV,
HTLV1, Syphilis 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PPD 
X* 
ABO typing 
X 
 
 
 
X 
X 
 
ABO Q4 days 
 
 
 
 
 
 
 
 
 
Urinalysis & UPC 
X 
 
 
 
X 
X 
 
 
 
 
 
 
 
X 
 
 
X 
 
 
 
24 Urine for Cr 
clearance 
X 
X* 
 
X* 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bone Marrow  
X 
 
 
FLAG & 
MM 
X* 
 
 
 
 
 
X* 
 
 
X* 
X* 
X* 
X* 
X* 
X* 
X* 
EKG 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT chest, abd, 
pelvis & NECK* 
X 
 
 
lymphoma 
& CLL 
X 
 
 
 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
CT/MRI head 
X 
 
 
 
X? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CSF cytology, cell 
counts, chemistries, 
flow* 
X* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PET scan for 
patients with 
Hodgkins and NHL* 
X 
 
 
 
X if disease 
presentat 
baseline 
 
 
 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
MM panel and workup X 
 
 
x 
x 
 
 
 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 


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126
Observation 
Eligibility within 
28 days 
Within 48 hrs 
Pre-induction 
BiWk during 
induction 
After each 
induction 
Within 28 days 
pre- condition/Tx 
arm 
48 hours pre - 
condition 
Day 0--DOT 
During Inpatient 
Post Therapy 
Day 7 
Post Therapy 
Day 14 
Post Therapy 
Day 28 
Post Therapy 
Day 42 
Post Therapy 
Day 60 
Day 100 
Day 180 
9 month 
Post Therapy 12 
Post Therapy 18 
Post Therapy 24 
Post Therapy 3, 
4, 5 yrs 
CBC with Diff, Acute 
Care Panel, 
Hepatitis Panel, Mineral 
Panel, PT, PTT 
X 
X 
X 
X 
X 
X 
 
BID* 
 
BiWk post 
transplant 
untilD+100 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine/Serum Pregnancy X 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PCR of DNA for 
future chimerism 
determination 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PFTs 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
ECHO 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X* 
X* 
X* 
X* 
X* 
X* 
GVHD prophylaxis 
levels 
 
 
 
 
 
 
 
2X per 
week 
 
 
 
 
 
 
 
 
 
 
 
 
Peripheral Blood 
Chimerism 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
x* 
X* 
X* 
X* 
PRN 
PRN 
PRN if no 
100% 
chimerism 
Bone Marrow 
Chimerism 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
 
X 
PRN 
PRN 
PRN if no 
100% 
chimerism 
Acute GVHD 
Assessment 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Chronic GVHD 
Assessment--NIH 
Staging 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
DEXA Scan 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
yearly if 
abnornal 
 
Dermatology 
Consult 
 
 
 
 
 
 
 
 
 
 
 
 
TMS 
(biopsy) 
AC 
(biopsy) 
X 
(biopsy) 
 
X 
X* 
X* 
X* 
Ophthamology 
Consult 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X* 
X* 
Gynecology 
Consult* 
X
* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X* 
X* 
FSH, LH (females) 
Testosterone Level 
(males only) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
TSH, Free T4, 
Ferritin, Vit D, 
Quantitative 
Immunoglobulins 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
TBNK 
X 
 
 
X 
 
X 
 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
Research 
specimens  
X 
X 
 
X 
 
X 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 


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127
Observation 
Eligibility within 
28 days 
Within 48 hrs 
Pre-induction 
BiWk during 
induction 
After each 
induction 
Within 28 days 
pre- condition/Tx 
arm 
48 hours pre - 
condition 
Day 0--DOT 
During Inpatient 
Post Therapy 
Day 7 
Post Therapy 
Day 14 
Post Therapy 
Day 28 
Post Therapy 
Day 42 
Post Therapy 
Day 60 
Day 100 
Day 180 
9 month 
Post Therapy 12 
Post Therapy 18 
Post Therapy 24 
Post Therapy 3, 
4, 5 yrs 
Immunizations 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X* 
 
X* 
X* 
X* 
X (if catch 
up 
needed) 
1. 
As indicated in section 7.3, all subjects ≥ age 18 will be offered the opportunity to complete an NIH advance directives form.  This should be done preferably at baseline but can be done at any time during the study 
as long as the capacity to do so is retained.  The completion of the form is strongly recommended, but is not required. 


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11.9 APPENDIX I: RISK OF RELAPSE ASSESSMENT 
 


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11.10 APPENDIX J: COMOBIDITY INDEX 
 


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11.11 APPENDIX K CASE REPORT FORMS 
Please enter this Data in Protocol Visit Transplant Note  
ACUTE GVHD  
Date of Visit:_____________ 
 
 
 
 
Time point: Day 100    6 Mos     9Mos     12 Mos   18 Mos    24 Mos     36 Mos     48 Mos     Other 
___________ 
 
Does the patient have aGVHD ___________Y/N 
 
Type of aGVHD (Classic or Late Acute)___________ 
 
Late aGVHD type (Recurrent, Persistent, Late Onset)____________ 
 
aGVHD Organ 
involved 
(GI, Liver, Skin) 
Date of Diagnosis 
Biopsy 
Proven? 
(Y/N) 
Date of Biopsy 
Gluckbergs Organ 
Stage 
(0,1,2,3,4,unknown) 
Overall Grade 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Glucksberg Scoring System: 
 
Stage  
Skin  
Liver  
Gut 
+  
Rash < 25% BSA 
. Total bilirubin 2-3 mg/dl 
Diarrhea 500-1000ml/d 
++  
Rash 25-50% BSA 
Total bilirubin 3-6 mg/dl 
Diarrhea 1000-1500ml/d 
+++  
Generalized erythoderma  
Total bilirubin 6-15 mg/dl  
Diarrhea >1500ml/d 
++++  
Desquamation and bullae  
Total bilirubin > 15 mg/dl  
Pain +/- ileus 
BSA = body surface area; use “rule of nines” or burn chart to determine extent of rash 
 
Grade 
Skin 
Liver 
Gut 
PS 
0 (none) 
0 
0 
0 
0 
I 
+ to ++ 
0 
0 
0 
II 
+ to +++ 
+ 
+ 
+ 


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
 
142 
III 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV 
+ +to ++++ 
+ +to ++++ 
+ +to ++++ 
+++ 
 
Current Therapy 
(topical and systemic) 
 
Current Dose 
Date started 
Date Ended 
Response from Treatment 
(CR, PR, NR, PD) 
 
 
 
 
 
 
 
 
 
 
 
 
PI Signature:  _______________________________   RN Signature:  _______________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please enter Data in Protocol Visit Transplant Note 
 
CHRONIC GVHD  


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
 
143 
Date of Visit: __________ 
Time point:   Day :100     6 Mos     9Mos     12 Mos   18 Mos    24 Mos     36 Mos     48 Mos     
Other _______ 
 
Does the patient have cGVHD ___________Y/N? 
 
Type of cGVHD (Classic or Overlap)___________ 
 
Type of Onset (De Novo, Progressive, Quiescent)  
___________ 
cGVHD 
Anatomic Site: 
Grade 
Date of 
Diagnosis
: 
Biopsy 
Proven? 
(Y/N) 
Date of 
Biopsy: 
Current Therapy (Topical 
and systemic) 
Intensity of Immunosuppression 
□ None 
□ Mild (single agent prednisone < 0.5 
mg/kg/day) 
□ Moderate (prednisone ≥ 0.5 
mg/kg/day and/or any single 
agent/modality) 
□ High (2 or more agents/ modalities 
± prednisone ≥ 0.5 mg/kg/day) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Global Stage (Mild, Moderate, Severe)_______________ 
If 1-2 Grade 1=Mild  If at least 1 Grade 3=severe Anything between=Moderate EXCEPT if Lung Grade 1=moderate 
Lung Grade 2=severe 
 
Therapeutic intent at time of visit: Circle one 
Does not require systemic therapy 
Continue current systemic therapy 
Alter systemic therapy due to toxicity 
Decrease systemic therapy b/c cGVHD is better 
Increase systemic therapy b/c cGVHD is stable or worse 
Substitute systemic therapy due to lack of response 
Withdraw systemic therapy due to lack of response 
 


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
 
144 
Clinician’s Impression of Activity: Circle one 
Active, irrespective of the level of current therapy 
Highly active, irrespective of the level of current therapy 
Inactive, off systemic therapy or immunosuppression 
Inactive, on systemic therapy or immunosuppression 
 
BOS Y/N__________________ 
PI Signature:  _______________________________   RN Signature:  _______________________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please enter this Data in Transplant Note 
 
Response Assessment  
 


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
 
145 
Date of Assessment:  ____ ________ 
 
Date of transplant: ________________ 
 
Select Time point  
Day 28     Day 100     3 Mos     6 Mos     9Mos     12 Mos 
 
18 Mos     24 Mos     36 Mos     48 Mos     Other ______________ 
 
 
A. Current Response Assessment: N/A       N/E       CR       CRu       PR      SD      PD        Date___________ 
 
B.  Minimal residual disease (circle one): Positive    Negative      Date___________ 
 
 
C.  Central nervous system involvement (circle one):    Yes    No      Unknown    
      
 Describe positive results below________________________________________ 
 
D.  Radiology response assessment: 
 
Pet Scan Response Assessment: Y/N?________If yes: CR/PR/SD/PD/NA/NE---------------  
CT Scan Response Assessment: Y/N?___________If yes: CR/PR/SD/PD/NA/NE--------------   
Other diagnostic studies_______________________________________________ 
 
E.  Pathology response assessment (complete for all performed evaluations):  
 
➢ 
Bone Marrow Response Assessment:  Positive     Negative     NE 
 
Morphology:  Positive    Negative     Unknown 
 
a. 
Flow Cytometry: Positive    Negative     Unknown  
 
b. 
Molecular: Positive    Negative     Unknown  
 
c. 
Cytogenetics:  Positive    Negative     Unknown   
 
 
➢ LP Response Assessment:  Positive     Negative     NE 


Abbreviated Title: RIST using Unrelated Donors 
Version Date: September 14, 2018 
 
146 
 
Morphology:  Positive    Negative     Unknown 
 
a. 
Flow Cytometry: Positive    Negative     Unknown  
 
b. 
Molecular: Positive    Negative     Unknown  
 
c. 
Cytogenetics:  Positive    Negative     Unknown   
 
➢ 
Blood Response Assessment: Positive     Negative     NE 
 
Morphology:  Positive    Negative     Unknown 
 
a. 
Flow Cytometry: Positive    Negative     Unknown  
 
b. 
Molecular: Positive    Negative     Unknown  
 
c. 
Cytogenetics:  Positive    Negative     Unknown   
 
➢ 
Tissue Response Assessment: Positive     Negative     NE 
 
Morphology:  Positive    Negative     Unknown 
 
a. 
Flow Cytometry: Positive    Negative     Unknown  
 
b. 
Molecular: Positive    Negative     Unknown  
 
c. 
Cytogenetics:  Positive    Negative     Unknown   
 
 
➢ Other pathology studies response assessment (name study): ____________________________ 
 
Positive    Negative     NE 
 
 
PI Signature:  _______________Date_____________  
 
RN Signature:  ________________Date_______________ 


Abbreviated Title: RIST using Unrelated Donors 
CC Protocol Number: 07-C-0195 
                                                                                             113  
 
132.  

ICF_001.pdf: 
MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
INSTITUTE: 
National Cancer Institute 
STUDY NUMBER: 
07-C-0195 
PRINCIPAL INVESTIGATOR: 
Steven Pavletic, M.D. 
STUDY TITLE:  
Phase II Trial of Targeted Immune-Depleting Chemotherapy and Reduced-Intensity 
Allogeneic Hematopoietic Stem Cell Transplantation Using 8/8 and 7/8 HLA-matched 
Unrelated Donors and Utilizing Two Graft-versus-Host Disease Prophylaxis Regimens 
for the Treatment of Leukemias, Lymphomas, and Pre-malignant Blood Disorders 
Continuing Review Approved by the IRB on 10/29/18 
Amendment Approved by the IRB on 10/29/18 (X) 
             Date posted to web: 11/08/18 
Standard 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent (1) 
 
 
 
INTRODUCTION 
 
We are asking you to take part in a research study at the National Institutes of Health (NIH). 
 
First, we want you to know that: 
 
 
Taking part in NIH research is entirely voluntary. 
 
 
You may choose not to take part, or you may withdraw from the study at any time.  In 
either case, you will not lose any benefits to which you are otherwise entitled.  However, 
to receive care at the NIH, you must be taking part in a study or be under evaluation for 
study participation. 
 
 
You may receive no benefit from taking part.  The research may give us knowledge that 
may help people in the future. 
 
Second, some people have personal, religious or ethical beliefs that may limit the kinds of 
medical or research treatments they would want to receive (such as blood transfusions).  If you 
have such beliefs, please discuss them with your NIH doctors or research team before you agree 
to the study. 
 
Now we will describe this research study.  Before you decide to take part, please take as much 
time as you need to ask any questions and discuss this study with anyone at NIH, or with family, 
friends or your personal physician or other health professional. 
 
Why is this study being done? 
We are conducting a study of allogeneic stem cell transplantation from HLA-matched unrelated, 
volunteer donors for cancers of the blood and immune system.  Because you have one of the 
cancers with which we are concerned, and an HLA-matched unrelated donor has been identified, 
we are inviting you to participate in this pilot trial of Targeted Immune-Depleting Chemotherapy 
and Reduced-Intensity Allogeneic Hematopoietic Stem Cell Transplantation (abbreviated RIST). 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  2  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
The cancers with which are concerned include non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, 
multiple myeloma, chronic lymphocytic leukemia, chronic myelogenous leukemia, acute 
myelogenous leukemia, acute lymphocytic leukemia, NK cell neoplasms, and T-cell neoplasms 
(e.g. adult T-cell leukemia lymphoma, hepatosplenic T-cell lymphoma and enteropathy 
associated T-cell lymphoma).  It also includes pre-cancerous blood conditions including 
myelodysplasia, idiopathic myelofibrosis, polycythemia vera, and chronic myelomonocytic 
leukemia.   
Why are you being asked to take part in this study? 
This research study is for patients who do not have an HLA-matched sibling and who have had a 
potential HLA-matched unrelated donor identified through one of the bone marrow donor 
registries such as the National Marrow Donor Program.  To be eligible to participate on this 
study you must match on 8/8 or 7/8 HLA markers with your potential unrelated donor to enroll 
in the study.  
How many people will take part in this study? 
Up to 210 people (105 patients/105 donors) will take part in this research study. 
Description of Research Study 
About 5 to 10 tablespoons of blood will be drawn to check how closely you and your donor are 
genetically matched. Often this blood test has already been performed at your home medical 
office prior to a visit to the NIH or it will be performed at the NIH Clinical Center.  In this study, 
we will accept patients 18 to 69 years of age. 
 
Rarely, a volunteer donor may become unavailable or the donor apheresis center is unable to 
collect enough stem cells to perform the transplant.  If this happens, you will be removed from 
the study before transplantation unless we are able to identify another suitable unrelated donor.  
If you have already received the conditioning chemotherapy, you will still be removed from the 
study, but we will continue to care for you. 
 
 “Stem cells” are immature blood cells, like seeds; they grow in the bone marrow and produce all 
of the cells needed for normal blood and immunity.  When these stem cells are taken from one 
person (called the “donor”) and given to another person (called the “recipient”), it is known as 
“allogeneic” stem cell transplantation (SCT).  Originally, stem cells were collected for 
transplantation by taking samples of bone marrow from the donor.  This was commonly called 
“bone marrow transplantation.”  Now, most allogeneic transplants use stem cells collected from 
the donor’s blood.   
 
Allogeneic stem cell transplantation (SCT) has been used successfully to treat, and sometimes 
cure, many kinds of cancer or pre-cancerous conditions that develop in blood or immune system 
cells.  Large doses of chemotherapy drugs and/or radiation have been traditionally used to 
eliminate most of the cancerous or abnormal cells from the recipient’s system, along with most 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  3  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
of his or her own stem cells and immune cells.  Donor stem cells can then replace the recipient’s 
stem cells in the bone marrow, restoring normal blood production and immunity; this process is 
called “engraftment”.  In this way, an allogeneic SCT provides not only new blood cells but an 
entire new immune system.  Immune cells from the donor are important not only to protect the 
transplant recipient from infections; these transplanted cells can sometimes eliminate the 
abnormal cells that caused the patient’s disease.  This type of immune attack is called the “graft-
versus-tumor” (GVT) effect, and it is thought to be the main reason that allogeneic SCT cures 
some patients of these conditions. 
 
If the recipient’s immune system remains strong enough after large doses of chemotherapy or 
radiation, it may attack and destroy the donor’s cells after the transplant.  This is called “graft 
rejection.”  When this happens, the transplant recipient’s own stem cells may be so severely 
damaged after chemotherapy or radiation that they cannot produce blood cells, usually leading to 
death. Another serious complication can occur if donor immune cells recognize and attack the 
recipient’s normal tissues, damaging the liver, intestinal tract, and skin.  This type of immune 
attack is called “graft-versus-host disease”, or GVHD. 
 
Graft rejection or GVHD after allogeneic SCT are less likely when the transplant recipient and 
donor are very similar genetically.  To measure how genetically similar a recipient and donor 
are, both persons are tested to identify protein markers on the surface of their blood cells and 
other body tissues.  These markers are called “human leukocyte antigens”, or HLA.  A person 
inherits half of his or her HLA markers from each parent.  Your immune system uses HLA 
proteins on your body’s cells to tell the difference between normal, healthy tissues and foreign 
organisms like bacteria or viruses.  Differences in HLA proteins between a donor and recipient 
make it more likely that one person’s immune system will recognize the other person’s cells as 
foreign, causing graft rejection or GVHD.  A donor and recipient who share all 8 of their HLA 
markers are called “HLA-identical”.  A transplant from an HLA-identical sibling (brother or 
sister) has a lower chance of graft rejection or GVHD, compared with other donors for allogeneic 
SCT.  Many people have cancers that could be treated with allogeneic SCT, but only 20-30% of 
people have HLA-identical sibling donors.  For some people without HLA-identical sibling 
donors, an HLA-matched unrelated donor can be used, but the risk of graft rejection and GVHD 
is higher.  Patients on this study with a partial genetic match (7/8 HLA genes) with their 
unrelated donor may have a modestly higher risk of complications compared to subjects with a 
full genetic match with their unrelated donor (8/8 HLA genes). 
 
Severe GVHD is the leading cause of death in patients who receive an allogeneic SCT.  Drugs 
can prevent GVHD after allogeneic SCT, but they do not work all the time. 
 
We are trying to improve the results of allogeneic SCT from HLA-matched unrelated donors.  
The methods we are testing in this research study include: 
• Immune-depleting chemotherapy (also known as chemotherapy that lowers your immune 
system) will be given to you to try to stabilize the cancer before your transplant, and to 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  4  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
lower the chance of graft rejection.  Then you will receive reduced-intensity transplant 
chemotherapy (also called “conditioning regimen”) this will help make the SCT less 
harmful for transplant recipients. All patients on this study will receive chemotherapy to 
weaken your immune system that matches the type of disease you have prior to the 
transplant. 
• This study will use two different combinations of drugs to prevent GVHD. Both of these 
drug combinations have been successful in preventing GVHD, but they work in different 
ways and affect the rebuilding of the immune system after the transplant. The purpose of 
this study is to study differences in how the immune system is rebuilt after these two 
different combinations of drugs. The specific combination of drugs that you will receive 
to prevent GVHD is determined randomly (similar to flipping a coin) at the time you 
agree to participate in this study. 
 
Each of these methods will be explained in the following pages. 
 
Immune-Depleting Chemotherapy and Reduced-Intensity Allogeneic Stem Cell 
Transplantation (RIST) 
 
In the past, allogeneic SCT was performed with very high doses of chemotherapy and/or 
radiation.  This thorough treatment was used to get rid of as much of the recipient’s cancer as 
possible, and it also helped to prevent graft rejection by weakening the recipient’s immune 
system.  However, such intensive chemotherapy or radiation can cause serious side effects, 
including death.  Because of these risks, only relatively young and healthy patients were 
considered for this form of treatment.  A newer method uses smaller, less toxic doses of 
chemotherapy and/or radiation before allogeneic SCT.  This method is often called “reduced-
intensity”, or “nonmyeloablative”.  It was first studied in patients who could not receive high-
intensity (“myeloablative”) allogeneic SCT because of their age or other medical conditions.  In 
reduced-intensity stem cell transplants (also called RIST), the recipient’s stem cells and 
immunity are not completely eliminated, but they are weakened enough to prevent the donor’s 
cells from being rejected.  In most studies of RIST, serious complications are less common than 
for myeloablative allogeneic SCT.  However, GVHD can still be a significant side effect with 
RIST.  Also, graft rejection and relapses of cancer have happened more often in some studies of 
RIST than with myeloablative transplants. These problems may have occurred because the lower 
doses of treatment in RIST can leave the recipient’s immune system strong enough to resist 
being replaced completely by the donor’s cells, and more cancer cells may survive after reduced-
intensity chemotherapy or radiation than after myeloablative treatment.  As part of this research 
study you will receive a reduced-intensity allogeneic stem cell transplant (RIST). 
 
We have been studying RIST to try to improve the results of allogeneic SCT for patients with 
hematologic (blood-related) cancers and pre-cancerous conditions.  In previous studies, we gave 
patients 1 to 3 cycles of “induction chemotherapy” before transplantation.  This induction 
chemotherapy was designed to stabilize their cancer and slowly weaken their immune system to 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  5  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
help prevent graft rejection.  Patients then received reduced-intensity transplant chemotherapy, 
followed by transplantation from an HLA-matched sibling.  With this approach, we were able to 
perform RIST without any patients having graft rejection.  Nearly all recipients treated in this 
manner had total replacement of their own stem cells and immune system by the donor’s cells 
(called “full donor chimerism”) within 4 weeks after transplantation. 
 
This research study will use induction chemotherapy that will weaken your immune system that 
is similar to what we have used in our earlier studies.  The type of induction chemotherapy you 
will receive is based on what type of disease you have.  We believe that this chemotherapy will 
decrease the chance of graft rejection after RIST from a HLA-matched unrelated donor. If the 
study doctors feel your immune system is already weakened and your disease is well controlled 
you will not receive “induction chemotherapy”. This study will also use reduced-intensity 
transplant chemotherapy to try to decrease the side effects of the transplant.  The reduced-
intensity transplant chemotherapy we will use in this study is the same as in our previous studies, 
and will be described in more detail in the following sections.  All patients in this study will 
receive the same type of transplant chemotherapy. 
 
Prevention of Graft-Versus-Host Disease 
 
A clearly superior treatment to prevent GVHD has not been established in patients who have 
received SCT from HLA-matched unrelated donors. The best results that have been reported in 
the available medical literature are with the combination of a drugs called alemtuzumab plus 
cyclosporine [also called: AC], and the combination of drugs called tacrolimus, methotrexate, 
and sirolimus [also called:  TMS]. These two drug combinations work in very different ways, 
and potentially have very different effects upon how the immune system rebuilds itself after 
transplant. This has not been well studied after either of these drug combinations. It is our intent 
to study the effects that these two drug combinations have on the immune system as it rebuilds 
itself after receiving immune-depleting chemotherapy and reduced-intensity allogeneic SCT 
from HLA-matched unrelated donors. This study is considered experimental.  It is hoped that 
experimental studies like this one will lead to a better understanding of the biologies associated 
with this form of transplantation and allow doctors and scientists to develop new strategies and 
treatments to improve results after transplant.     
 
What will happen if you take part in this research study? 
The following will be done as part of this research study (details are included in later sections): 
 
• First, we must establish proof of a full genetic match (8/8 HLA genes) or partial genetic 
match (7/8 HLA genes) between you and your potential unrelated donor. 
• We will arrange to have your donor’s stem cells collected at a center in cooperation with the 
National Marrow Donor Program. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  6  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
• You will receive one, two, or three cycles of “induction chemotherapy” (based on the type of 
disease you have; described below) to treat your disease and to weaken your immune system. 
If the study doctors feel your immune system is already weakened and your disease is well 
controlled you will not receive “induction chemotherapy”.   
• After you have finished receiving induction chemotherapy, you will receive 4 days of 
reduced-intensity transplant chemotherapy, also called the “conditioning regimen,” to 
prepare you for the transplant. 
• Two days after this transplant chemotherapy, you will receive the transplant with your 
unrelated donor’s stem cells and immune cells. 
• Before and after the transplant you will receive one of two possible combinations of drugs 
(AC or TMS) to prevent GVHD. The regimen you receive is randomly decided (“flip of a 
coin”) at the time you agree to participate on the study. 
• You will be hospitalized approximately 3-4 weeks after your transplant. 
• When the study doctors think your condition is stable, you will be discharged from the 
hospital and be seen frequently at the NIH as an outpatient. 
• You will continue on medications at home to lower the risk of GVHD and infections. 
• You may receive additional cells from the donor, also called a “donor lymphocyte infusion” 
or DLI, after the transplant, these additional cells are given to help to rebuild or enhance your 
immune system. 
• You will visit our clinic regularly for the first six months after the transplant, and then less 
often for at least five years. 
 
Pre-Transplant Evaluation 
 
Once it is determined that you have a potential donor, you will be seen at the NIH Clinical 
Center, at which time you will have a complete medical history and physical examination in the 
NCI Medical Oncology Clinic.  Members of the transplant team will review your medical history 
and explain the transplant procedure.  A blood sample will also be used to check the health of 
your kidneys and liver.  We will also test for exposure to a variety of infections, including 
hepatitis B and C, syphilis, and a virus called cytomegalovirus (CMV).  As part of this study, we 
will test you for infection with the human immunodeficiency virus (HIV), the virus that causes 
AIDS.  If you are infected with HIV you will not be able to participate in this study.  We will tell 
you what the results mean, how to find care, how to avoid infecting others, how we report newly 
diagnosed HIV infection, and the importance of informing your partners at possible risk because 
of your HIV infection.  You will also be tested for the following viruses: hepatitis A, HTLV-1 
and -2, adenovirus, Epstein-Barr virus, herpes simplex virus, and the parasite Toxoplasma. A 
total of approximately 4-12 teaspoons of blood will be collected.  If the study doctor feels it is 
necessary, you will have a PPD skin test (to test for tuberculosis).  You will be asked to collect 
your urine for 24 hours to measure your kidney function.  If you are a woman, you will have a 
urine test for pregnancy. If you are a woman who is breast-feeding or pregnant, you may not take 
part in this study because we don’t know how the transplant will affect your baby or unborn 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  7  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
child.  If you think that you or your partner is pregnant, you should tell your study doctor or 
nurse immediately.   
 
In addition, you will have a special breathing test, a test for heart health, and several X-ray 
studies, including a CT scan of your chest, abdomen, pelvis, and possibly your neck.  You will 
have a CT scan or MRI of your head.  If you have lymphoma, we will obtain a test called a 
positron emission tomography (PET) scan.  You may also have a bone marrow aspiration and 
biopsy.  This test is performed by numbing the iliac (hip) bone with a local numbing medicine 
called lidocaine.  A small cut will be made in the skin, a needle is inserted into the hip bone, and 
about two tablespoons of liquid samples are removed from the bone marrow through the needle.  
A small fragment of the bone marrow may also be removed with the needle. If you are at risk of 
having your cancer involve the brain or central nervous system, you may also have a spinal tap 
(also known as a lumbar puncture). This test is performed by numbing an area over the lower 
portion (lumbar) of your spine with a numbing medicine called lidocaine. A thin needle is then 
inserted into your spinal canal and a small amount (about 5 tablespoons) of spinal fluid is 
removed. You will also be seen by a dentist, and meet with a social worker.  You will be 
encouraged to name someone as your “durable power of attorney”.  This should be someone 
whom you trust to make medical decisions for you if you become physically or mentally unable 
to make your own treatment decisions.  You should know that being in this study may keep you 
from being in other research studies that limit the number or types of treatments that you are 
allowed to have received previously. 
 
The Central Venous Catheter 
 
If you do not already have one before you enroll in this study, you will receive an intravenous 
(I.V.) line placed in the upper part of your chest and tunneled under the skin into a neck vein.  
This line is called a central venous catheter that can be used throughout your transplant 
procedure and follow-up treatment.  This kind of catheter is sometimes called a “Hickman 
catheter”.  If the catheter becomes infected or clogged, it can be replaced.  It will be flushed once 
daily to prevent clogging.  The nursing staff will teach you how to do this yourself. 
 
The catheter will be used to give you chemotherapy, your transplant, DLI (if needed), blood 
transfusions (if needed), and other medications such as antibiotics.  It can also be used for 
drawing blood samples for tests.  Since blood will be drawn often during your treatment, the 
catheter will make it easier and less painful.   
 
Induction Chemotherapy 
In this study you will receive one, two, or three cycles of “induction chemotherapy” to treat your 
disease and to weaken your immune system.  For patients with chronic lymphocytic leukemia, 
prolymphocytic leukemia, multiple myeloma, and most forms of lymphoma, this chemotherapy 
will include the following drugs: fludarabine, cyclophosphamide, etoposide, doxorubicin, 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  8  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
vincristine, and prednisone (also called:  “EPOCH-F”).  Patients with lymphoblastic lymphoma, 
acute myelogenous leukemia, acute lymphocytic leukemia, chronic myelogenous leukemia, and 
other “pre-leukemic” diseases will receive induction chemotherapy with fludarabine, cytarabine, 
and filgrastim (also called:  “FLAG”).  Patients with certain forms of lymphoma and leukemia 
may also receive a drug called rituximab. Each of these medications have been approved by the 
Food and Drug Administration (FDA). The study doctors will test a biopsy specimen from your 
cancer to help them decide if you should receive rituximab with your induction chemotherapy.  
To start, you will receive common doses of these drugs for five days followed by a 16-day 
(EPOCH-F) or 23-day (FLAG) rest period (this time period is 1 cycle).  The EPOCH-F regimen 
is generally given in outpatient setting. The FLAG regimen is given in the hospital, so you will 
be admitted as an inpatient, and you will remain in the hospital until your blood counts recover, 
usually 3 to 4 weeks. The effect of the chemotherapy on your immune system and on your 
disease will determine how many cycles of induction chemotherapy you receive.  If blood tests 
show that your immune system is weakened enough after one cycle, you will go directly to the 
transplant.  If your immune system is not very weakened and your disease is not growing after 
one cycle of induction chemotherapy, you will receive one or two more cycles (5 days of the 
same chemotherapy you received for cycle 1, followed by 16 (EPOCH-F) or 23 (FLAG) days of 
rest per cycle).  If your disease grows in spite of the induction chemotherapy then the induction 
chemotherapy will be stopped, and you will be removed from the study. If your white blood cell 
count remains low for a long time after induction chemotherapy, meaning your immune system 
has weakened, you will go directly to the transplant.  At most, you will receive 3 cycles of 
chemotherapy. 
 
Transplantation of the Blood Stem Cells From Your Donor 
Before you begin your induction chemotherapy, your unrelated donor will have had a medical 
examination by a doctor in the National Marrow Donor Program (NMDP) network that includes 
extensive testing to make sure they do not have any of the following: HIV, Hepatitis B, Hepatitis 
C, and possible infectious diseases that may be transmitted by stem cell donation.  The donor’s 
exam will also ensure that they remain available and are physically well enough to undergo the 
donation procedure.  The NMDP will notify NIH if there are any abnormalities that increase the 
risk of transmitting infectious diseases to you during the transplant.  These findings will be 
discussed with you.  The donor’s medical clearance will be verified by the NIH study doctor 
before you receive any chemotherapy. 
 
The stem cells from your donor will be given to you within 48 hours from the time of their 
donation.  This means that your conditioning chemotherapy will begin prior to the donor’s cells 
being collected.  The donor will receive daily injections of a medication that stimulates the stem 
cells to be released from the bone marrow and into the bloodstream.  One or two days before 
your transplant, the donor will have these cells removed through a process called apheresis.  The 
donor will have blood removed through an intravenous catheter and circulated through a 
machine which separates the peripheral blood stem cells.  These cells are removed, and the rest 


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of the blood is returned through the catheter.  This collection occurs at the NMDP apheresis 
center closest to the donor.  The cells are hand-carried by a trained courier to NIH.  Once they 
arrive at NIH, the cells will be infused through your catheter within 24 hours.  In rare cases, the 
stem cells may be frozen before they are given to you. 
 
Unrelated donor transplants are confidential and the identity of the donor will be anonymous.  
This means that you will not know who your donor is or where they are.  You will know the age 
and gender of the donor and any history or medical exam findings that could possibly change the 
risk of your transplant.  Likewise, the donor will not know who you are or where you are.  
He/she will know your age, gender, and the type of disease that you have.  The donor will be 
given basic updates about your condition 30 days, 6 months, and 1 year after your transplant.  
The only information they will receive is whether or not the stem cells “engrafted” (taken hold), 
and if you have been discharged from the hospital.  The donor will also be notified in the event 
of your death.  
 
Depending on the policy of the particular donor center, you may be able to communicate without 
revealing your identities in an anonymous manner with your donor beginning at the time of your 
transplant.  In some cases, if both you and the donor agree, you may be able to learn who your 
donor is after one year.   There are some cases when a donor and patient may never communicate 
or meet.  Your transplant coordinator will tell you the details of if and how you may contact the 
donor once the donor has completed his or her medical exam. 
 
Transplant Procedures 
You will be admitted into the hospital approximately seven days before transplantation to the 
NCI’s Experimental Transplantation Unit at the NIH Clinical Center.  You will receive 4 days of 
transplant chemotherapy called the “conditioning regimen,” which will permit you to accept your 
donor’s stem cells.  This regimen uses fludarabine and cyclophosphamide at higher doses than 
were given as part of induction chemotherapy.  Two days after completing this chemotherapy, 
you will receive the stem cell transplant.  Your donor’s stem cells will be infused through your 
central venous catheter.  This is referred to as “day 0”. 
 
While you are in the hospital for your transplant, you will be monitored very closely for possible 
complications, which are described below.  You will receive drugs to help prevent and/or treat 
infection, growth factors (G-CSF), blood transfusions, and intravenous nutrition (if needed).  
Blood will be drawn frequently during your treatment.  Your blood will be tested to monitor your 
health during and after the chemotherapy and transplant procedure.   In general, 4 to 10 
teaspoons of blood will be drawn an average of 2 to 3 times per week.  Some blood will be 
drawn for research purposes.  In general, 3 to 4 tablespoons of blood will be drawn for research 
on average of once per week for the first 100 days after transplant. 
 


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The average time you will stay in the hospital is three to four weeks after transplant, but it could 
be longer if there any complications. 
 
You will receive one of two combinations of drugs to prevent GVHD before and after your 
transplant. The combination of drugs that you will receive is randomly assigned at the time of 
enrollment onto the study.   
 
One of the possible combinations of drugs to help prevent GVHD that you may receive contains 
drugs called: tacrolimus, methotrexate, and sirolimus. Beginning three days before you receive 
the stem cell transplant, you will receive the drugs tacrolimus and sirolimus to help prevent 
GVHD. Sirolimus is given by mouth once a day for approximately six months after transplant. 
Tacrolimus is given either through an I.V. or by mouth once a day for approximately six months 
after transplant.  Methotrexate is given for four doses intravenously (through the vein) before 
you are discharged from the hospital, shortly after the transplant.   
 
The other possible combination of drugs to prevent GVHD that you may receive contains 
alemtuzumab and cyclosporine. Alemtuzumab is started eight days before your stem cell 
transplant and is given for five daily doses through an I.V. Cyclosporine is given through an I.V. 
the day before the transplant. Cyclosporine is given either through an I.V. or by mouth every day 
for approximately six months after transplant.   
 
Once the stem cells have taken hold and you are strong enough, you will be discharged from the 
hospital and followed closely as an outpatient.    You will be required to remain in the 
Washington, D.C. area for approximately three months after transplantation so the NIH doctors 
can monitor you in case of any complications.  You may require re-admission to the hospital for 
complications.  You will be followed by the doctors in the NCI clinic for the first six months 
after transplant, and then you will be followed less frequently for at least five years.  
 
After the transplant, if tests show that your blood and immune cells have not fully converted to 
your donor’s type (“mixed chimerism”), then the drugs you are taking to prevent GVHD 
(depending on which arm that you are assigned to), will be lowered to help change your blood 
and immunity to full donor chimerism.  Sometimes a donor lymphocyte infusion (DLI) may be 
given to you intravenously (I.V.) to reach a state of full donor chimerism, as described above.  If 
your cancer is still present or grows after the transplant, cyclosporine or tacrolimus may be 
reduced in an attempt to permit a stronger graft-versus-tumor effect.  After this, if there are no 
signs of significant GVHD, then you may receive one or more DLI at increasing doses.  These 
DLI are intended to “boost” your new immune system and can enhance the graft-versus-tumor 
effect in some, but not all, patients.  DLI can sometimes lead to the development of GVHD, so 
we will monitor you very closely for signs of GVHD after these infusions.  If you experience 
significant GVHD after a DLI, we will give you treatment for GVHD, but you will not receive 
any further DLI.  You may also be eligible to receive chemotherapy or other standard therapy 


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(like radiation therapy or immune therapies) after the transplant if your cancer requires further 
treatment.  This therapy can be given alone or combined with DLI. 
 
If we are required to stop this study because too many patients have serious side effects, we will 
continue to provide care for you according to the study protocol. 
 
The skin and mouth are the two organs most commonly affected by chronic GVHD.  In order to 
better understand chronic GVHD, the following tests will be performed. 
 
• Punch Skin Biopsy: This is performed so that a piece of skin may be examined under the 
microscope to get a closer look at what is going on in your skin and for diagnostic purposes. 
After cleaning the skin with alcohol and/or another antiseptic, a local numbing medicine 
(Lidocaine with or without epinephrine)--similar to what a dentist injects to numb your 
gums--is injected into the planned biopsy site. A sharp instrument which looks like a 
miniature cookie-cutter is used to remove a round plug of skin about the size of a pencil 
eraser. The biopsy site may be left open or may be closed by putting in one or two stitches, 
and a small dressing is applied. Sometimes more than one such skin sample may be needed. 
You will be expected to keep the dressing over the biopsy site dry for 1 to 2 days. Thereafter, 
the dressing may be changed daily until the suture(s) are ready to come out, usually in 7 
days. Depending on circumstances, the suture(s) may be removed by one of us, by your own 
doctor and/or your doctor’s assistant. 
• Oral mucosa biopsy: The procedure is done in a similar manner as a skin biopsy, except that 
a dressing cannot be applied, because it is not possible to keep the area dry enough to keep 
the dressing on.   
• Collection of saliva (natural mouth fluid). We will collect saliva from you after swabbing 
your tongue with a solution that tastes like lemon juice. We will collect the saliva that pools 
in your mouth, the saliva that collects under your tongue, and the saliva that comes into the 
mouth next to your upper back teeth. The techniques we use are non-invasive, and 
investigators at NIH have been collecting saliva with these methods for more than 20 years.  
This is a simple procedure that does not have any risks or discomforts. We will use saliva 
samples to study in our laboratory factors that may be associated with the development of 
GVHD including the types of bacteria that live in the mouth. We believe these studies will 
help us understand more about oral GVHD and lead to better treatments for this painful 
condition.   
 
These tests will be performed on in all patients at the time of start of decrease of medicines that 
suppress your immune system, prior to the time a clinical diagnosis of chronic GVHD is made. If 
you do not develop GVHD, these tests will be performed for the second time at 6 months post 
transplant. It is important for you to know that both the skin and mouth biopsies are being 
performed for research purposes to help us with our understanding of chronic GVHD. They 
would not routinely be performed unless they were needed to confirm the presence of chronic 
GVHD. 


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Frequent Follow-up at the NCI in the First Year after Transplant 
If you are in good health after the three month period after your transplant, you will then be 
allowed to return home to the care of your primary physician.  You will be required to return to 
the NIH monthly until approximately six months after transplantation so you can be monitored 
for late transplant complications including GVHD and infection.  Thereafter you will be seen at 
NIH at 9, 12, 18 and 24 months after your transplant and then every year following your 
transplant, unless an earlier visit is required, per the study doctors.  After 5 years after the 
transplant, you will no longer be asked to return to NIH.  We will still contact you by phone 
annually. At each visit when you return to NIH, you will have a physical exam and blood draws 
(approximately 4-10 teaspoons of blood will be taken).  During some visits you may have a bone 
marrow aspirate and biopsies, and other appropriate tests (for example:  CT, MRI, PET scan) to 
monitor disease status.  Study-related medications will be provided by the NIH during your 
hospital stay and after you leave the NIH. 
 
Risks or Discomforts of Participation 
Risk of Death from Allogeneic SCT:  Patients undergoing allogeneic SCT are at risk of dying 
from the transplant procedure and its possible complications.  In some studies of allogeneic SCT, 
as many as half of the patients have died as a direct result of the transplant or its complications.  
In transplant studies similar to this one, up to 50 percent of patients have died from the transplant 
procedure.  The risk of death or other complications can vary greatly, depending on the age of 
the patient, the way the transplant is performed, and other factors.   
 
Other risks from allogeneic SCT include: 
Veno-Occlusive Disease (VOD) - A severe liver complication known as VOD occurs in less 
than 5 percent of allogeneic transplants.  VOD is a chemotherapy side effect that causes blood 
vessels in the liver to be blocked.  Severe VOD can lead to liver failure and death. 
 
Graft Rejection:  There is a chance that you may reject your donor’s stem cells.  If that were to 
happen, you would most likely recover your own blood cells.  However, there is the rare 
possibility that your own cells may not recover.  This may result in prolonged low blood counts, 
which may result in infection or bleeding and may lead to death.  In this event, we would attempt 
to support you with transfusions, growth factors and antibiotics until your own blood counts 
recover.  A blood test will be performed at 14, 28, 42, 70 and 98 days after your transplant to 
find out if your body has accepted the donor cells.  If no donor cells can be found, then we will 
conclude that you rejected them.  In that case, your blood counts will probably return to the same 
levels as before the transplant in about 2 to 3 weeks.  You will receive the growth factor 
filgrastim to help the cells engraft.  In the event that your cells do not engraft, we may ask your 
donor to donate more cells. 
 


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Graft-Versus-Host Disease (GVHD):  You will be at risk for the development of GVHD for 
the rest of your life after transplantation.  GVHD occurring within the first 100 days after 
transplantation is referred to as acute GVHD.  Acute GVHD most commonly attacks the liver, 
intestines, and skin.  Symptoms of skin GVHD may be as mild as a rash with itching, or as 
severe as blistering and loss of the skin.  Symptoms of intestinal GVHD may be as mild as 
heartburn and mild diarrhea, or as severe as cramping abdominal pain and bloody diarrhea.  
Liver GVHD may be as mild as slight disturbances in liver function, or severe as jaundice 
(yellowing of the skin) with liver failure.  Mild GVHD (skin rash only) can be treated with 
steroid creams that you apply on your skin.  Severe GVHD can be very dangerous and needs to 
be treated aggressively.  Treatment of severe GVHD initially includes weakening of the immune 
system, usually with intravenous (I.V.) steroids.  Weakening of the immune system increases the 
risk of infection. 
 
A delayed form of GVHD, known as chronic GVHD, may occur after day 100 post-transplant.  
Some degree of chronic GVHD affects about half of patients after transplantation.  It most 
commonly attacks the skin, the liver and the intestines, but it may also affect other organs such 
as the lungs, eyes, muscles, joints, and the bone marrow.  Symptoms of chronic GVHD may 
include dryness of the mouth and eyes, a loss of appetite, weakness, hair loss, weight loss, liver 
damage (including yellowing of the skin), and lung damage leading to shortness of breath and 
cough.  Patients with severe chronic GVHD are also at increased risk of infection and death.  
Chronic GVHD is also treated with drugs that weaken the immune system such as steroids.  
Taking steroids may increase your risk of infection. 
 
Late Transplant Complications:  There are other potential complications that can occur long 
after transplantation.  These complications could affect any organ in the body including the heart, 
lungs, kidneys, liver, muscles, and brain.  Rarely, patients who receive an allogeneic SCT are at 
risk for developing a second cancer such as leukemia or lung cancer. 
 
Other complications are also possible following your transplant.  The most common 
complication is infections.  Because you will be receiving drugs (e.g. cyclosporine) that weaken 
the immune system, you are at greater risk to develop infections from uncommon organisms.  
These infections can be life-threatening, and could cause death. 
 
There is about a 40 percent chance of death from complications of conventional allogeneic bone 
marrow transplants.  Although we will use new/unconventional ways to try to reduce these odds, 
it is possible that our approach may not work or that it may even increase the chances of death.  
There is also the risk of complications that cannot be predicted. 
 
Bone Marrow Aspiration and Biopsy:  This procedure usually causes only mild pain for a 
short time at the biopsy site.  Very rarely, bleeding or an infection may occur at the biopsy site. 
 


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Blood Draws: Side effects of blood draws include pain and bruising in the area where the needle 
was placed, lightheadedness and rarely, fainting.  When a large amount of blood is drawn, your 
red blood cell count may drop causing anemia. Anemia can cause a lack of energy and other 
symptoms.  Transfusions of red blood cells are sometimes needed to treat anemia.     
 
Central Venous Catheter:  Side effects of placing a central venous line in your chest wall 
include bleeding, bruising, blood clot, or pain in the area of insertion.  This line will be placed by 
physicians with experience in this procedure.   These physicians will discuss the above risks at 
the time of the line insertion.  Rarely, placement of a central venous catheter can result in a 
collapsed lung.  If a collapsed lung occurs, it may require hospitalization and temporary insertion 
of a plastic tube in your chest to re-expand the lung. 
 
Skin Punch Biopsies: Whenever possible, we will perform biopsies on covered areas of the 
body.  There may be minor bleeding right after the procedure and this can easily be controlled by 
applying pressure on the spot for a few minutes.  
Rarely, a bruise might form and this eventually goes away on its own. Sometimes a small 
infection may occur at the biopsy site. This can usually be treated with topical antibiotics. On the 
very rare occasion that a larger or deeper infection occurs, oral antibiotics may be needed for 7-
10 days. An infection can be recognized by redness, soreness, and pus at the site. It generally 
starts 2 days or more after the procedure and does not clear up in another couple of days. These 
biopsy/excision sites generally heal very well, leaving red, white, dark or skin-colored flat scars. 
Sometimes, the scar that forms may be a bit thicker than usual. Rarely, a keloid (large, painful or 
itchy scar) may form. Keloids are more likely to form on the chin, earlobes, chest and upper 
backs of Blacks and Asians between adolescence and the 30’s. 
 
Oral mucosa biopsy: There may be minor bleeding, bruising, numbness and slight swelling.  
There is also the possibility of infection.  Mouth sores have occurred in some patients, but this is 
uncommon. 
  
Induction Chemotherapy:  As described previously, the type of induction chemotherapy you 
will receive depends on the type of disease you have.  Some patients will receive fludarabine, 
cyclophosphamide, etoposide, doxorubicin, vincristine, and prednisone (called:  EPOCH-F), 
while others will receive fludarabine, cytarabine, and filgrastim (called:  FLAG).  In addition, 
some patients will receive rituximab, as discussed before.    It is important for you to know that 
this type of induction chemotherapy is likely to reduce your white blood cells for many days.  
This will place you at increased risk of infection.  Such infections can be very serious and may 
result in death.  For this reason, if you develop a fever higher than 101° F, you must see your 
doctor immediately.  If necessary, you will be treated with antibiotics.  Also, this chemotherapy 
will likely cause your platelet count to fall.  This may place you at increased risk of bleeding.  If 
your platelet count becomes dangerously low, you will receive platelet transfusions.  The 
chemotherapy may also cause you to develop a low red blood cell count, called anemia.  Anemia 
can cause a lack of energy and other symptoms.  Transfusions of red blood cells are sometimes 


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needed to treat anemia.  Because the induction chemotherapy on this protocol is a new 
combination of drugs, there is a chance that unexpected toxic effects will occur.  The following 
are known specific risks of each drug used within the specific regimen that you will receive: 
 
EPOCH-F (with or without rituximab): 
 
 
Etoposide:  
Likely: 
Less Likely: 
Rare: 
• low blood counts,  
• hair loss 
• nausea and vomiting,  
• diarrhea, 
•  mouth sores 
• low blood pressure,  
• shortness of breath,  
• secondary leukemia (a 
different type of 
cancer) 
 
Prednisone:  
Likely: 
Less Likely: 
Rare: 
• weight gain,  
• sodium and water 
retention,  
• mood changes,  
• elevated blood 
sugar,  
• increased risk of 
infection 
 
• stomach or bowel 
ulcers,  
• high blood pressure,  
• diabetes,  
• thinning of bones with 
greater risk of fracture 
(long term use);  
• puffing of the face 
(long term use);  
• acne,  
• thinning of skin,  
• muscle wasting 
• none 
 
Vincristine (a.k.a Oncovin®):  
Likely: 
Less Likely: 
Rare: 
• nerve damage 
resulting in a 
feeling of “pins and 
needles” in hands 
and feet;  
• constipation,  
• hair loss 
 
• nerve damage leading 
to pain or weakness in 
hands or feet;   
• loss of reflexes (foot 
drop),  
• low blood counts, 
• hoarseness and pain in 
the jaw 
• paralytic ileus 
(bowel function 
completely stops),  
• water retention 
 


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Doxorubicin (which contains a chemical Hydroxyl group):  
Likely: 
Less Likely: 
Rare: 
• low blood counts,  
• hair loss 
• nausea and 
vomiting,  
• diarrhea,  
• mouth sores  
 
• heart damage,  
• secondary leukemia (a 
different type of cancer),  
• tissue damage if the 
drug leaks from the vein 
into surrounding tissue,  
• bleeding bowel or 
stomach 
 
Cyclophosphamide:  
Likely: 
Less Likely: 
Rare: 
• low blood counts,  
• hair loss 
• nausea and vomiting,  
• painful and bloody 
urination,  
• sterility,  
• water retention 
• heart damage,  
• secondary leukemia 
(a different type of 
cancer),  
• skin rash 
 
Mesna is a drug given with cyclophosphamide to prevent bladder injury, and side effects may 
include:  nausea, vomiting, and diarrhea. 
 
Fludarabine:  
Likely: 
Less Likely: 
Rare: 
• low blood 
counts,  
• lowered level 
of immune 
cells,   
• increased risk 
of infection 
 
• nausea and vomiting  
• diarrhea,  
• fever,  
• mouth sores,  
• loss of appetite,  
• swelling (edema),  
• skin rash,  
• muscle aches,  
• headache,  
• agitation.  
• hearing loss,  
• fatigue,  
• weakness,  
• numbness / tingling 
(“pins and needles”) 
• GI bleeding,  
• lung damage,  
• kidney damage,  
• severe neurologic 
(brain and/or spinal 
cord) toxicity has 
occurred after very 
high doses including: 
blindness, 
deterioration of mental 
status, and death. 
 
 
 


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Rituximab:  
Likely: 
Less Likely: 
Rare: 
• mild infusion 
reactions (fever, 
chills) 
• severe infusion / 
hypersensitivity 
reactions (e.g. lowering 
of blood pressure, 
shortness of breath or 
difficulty breathing) 
• tumor lysis 
syndrome 
(metabolic 
complications),  
• severe skin 
reaction/rash,  
• kidney failure,  
• death,  
• chest pain,  
• cardiac arrhythmias 
(heart beating 
irregularly) 
 
 
FLAG: 
 
FLudarabine:  
Likely: 
Less Likely: 
Rare: 
• low blood counts,  
• lowered level of 
immune cells,   
• increased risk of 
infection 
 
• nausea and vomiting  
• diarrhea,  
• fever,  
• mouth sores,  
• loss of appetite,  
• swelling (edema),  
• skin rash,  
• muscle aches,  
• headache,  
• agitation.  
• hearing loss,  
• fatigue,  
• weakness,  
• numbness / tingling 
(“pins and needles”) 
• GI bleeding,  
• lung damage,  
• kidney damage,  
• severe neurologic 
(brain and/or spinal 
cord) toxicity has 
occurred after very 
high doses 
including: 
blindness, 
deterioration of 
mental status, and 
death. 
 
 
 
 


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CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
Cytarabine (Ara-C): 
Likely: 
Less Likely: 
Rare: 
• low blood counts,  
• lowered level of 
immune cells,  
• nausea and 
vomiting, 
• mouth sores,  
• hair loss 
 
• diarrhea,  
• loss of appetite,  
• flu-like symptoms 
• fevers,  
• liver damage 
• eye irritation 
• loss of coordination 
or balance 
• sleepiness 
• speech difficulties 
• coma 
 
Filgrastim (G-CSF):  
Likely: 
Less Likely: 
Rare: 
• bone pain,  
• reversible lab 
abnormalities 
 
• headache,  
• pain at the needle site,  
• fevers,  
• tiredness 
• G-CSF can cause 
rupture of the 
spleen, which can 
cause death 
 
Transplantation Chemotherapy:  The main side effect of fludarabine and cyclophosphamide at 
these doses is severe bone marrow and immune system weakening, which decreases the 
production of red blood cells, white blood cells, and platelets.  The doses that will be used could 
cause longer than normal bone marrow weakening, if the transplanted stem cells were rejected.  
Until the transplanted stem cells start to produce adequate numbers of blood cells, you will be at 
significant risk for infections, bleeding and severe fatigue.  These conditions will be treated with 
antibiotics and transfusions.  Other potential side effects of fludarabine and cyclophosphamide 
are described above. 
 
Graft-versus-Host Disease Prevention: 
As described above, you will receive one of two 
combinations of drugs to prevent GVHD; the combination of drugs that you will receive is 
randomly assigned at the time of enrollment onto the study. One of the possible combinations of 
drugs to help prevent GVHD that you may receive contains tacrolimus, methotrexate, and 
sirolimus. The other possible combination of drugs to prevent GVHD that you may receive 
contains alemtuzumab and cyclosporine. 
 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  19  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
Tacrolimus, Methotrexate, and Sirolimus: 
Tacrolimus:  
Likely: 
Less Likely: 
Rare: 
• decrease in kidney 
function 
• headache 
• tremors* 
• high blood 
pressure 
• increased infection 
 
• gum inflammation, 
• seizures*,  
• high blood potassium levels,  
• nausea 
• diarrhea or constipation 
• loss of appetite 
• abdominal pain 
• insomnia 
• high blood sugar 
• increase in blood lipid levels,  
• lowering of body magnesium 
levels requiring 
supplementation 
• liver damage 
• numbness or tingling in 
hands or feet 
• coma 
• delirium 
*Because of the risk of seizures and decreased reflexes while taking this medicine, 
you should not drive a car while taking tacrolimus. 
 
Methotrexate:   
Likely: 
Less Likely: 
Rare: 
• delay in the return 
of blood cells 
after transplant 
• mouth sores 
• minor liver damage 
• nausea 
• vomiting 
• diarrhea 
  
Sirolimus:  
Likely: 
Less Likely: 
Rare: 
• your infection 
risk is likely 
increased. 
Because 
sirolimus as an 
immune 
suppression drug, 
it is likely the risk 
for some 
infections may be 
increased. 
• diarrhea 
• nausea 
• damage to the liver 
• low blood counts 
• very high levels of fats 
(triglycerides) 
• increased cholesterol 
(increased lipid blood 
levels) 
• mouth ulcers 
• headache 
• increased risk of infection 
• red blood cell lysis with 
associated reduced kidney 
function 
• severe swelling 
of the pancreas 
• secondary 
cancers (a 
different type of 
cancer) 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  20  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
Alemtuzumab and Cyclosporine: 
Alemtuzumab: 
Likely: 
Less Likely: 
Rare: 
• fever 
• chills 
• rigors 
• nausea 
• vomiting 
• low blood counts 
• lowered level of 
immune cells, 
• increased risk of 
infection 
• low blood pressure 
• rash 
• hives or wheals 
• itching 
• shortness of breath 
• cough 
• headache 
• diarrhea 
• fainting 
• heart arrhythmias 
• heart attack 
• heart or lung failure 
  
     Cyclosporine:  
Likely: 
Less Likely: 
Rare: 
• decrease in kidney 
function 
• high blood 
pressure 
• increased facial 
hair 
• lowering of body 
magnesium levels 
requiring 
supplementation 
• increased risk of 
infection 
• tremor 
• gum hyperplasia 
• seizures* 
• liver damage 
• flushing or lowering 
blood pressure with 
intravenous 
administration 
• depression 
• coma 
*Because of the risk of seizures while taking this medicine, you should not drive a 
car while taking cyclosporine. 
 
Stem Cell Infusion:  The donor cells may be frozen with a chemical called DMSO to protect 
them from the effects of freezing.  Patients receiving thawed cells often develop side effects from 
the DMSO.  DMSO side effects may include fever and allergic reactions, such as skin rash, 
itching, difficulty breathing, and low blood pressure.  These reactions are usually mild and 
temporary, and they can be easily treated with IV fluids and medications. 
  
Other Medications:  You will routinely receive several other drugs to prevent or treat various 
infections and other transplant-related complications.  These medications and their common side 
effects are listed as follows: 
 
Ursodeoxycholic acid: Ursodeoxycholic acid, also known as ursodiol, can cause nausea, 
vomiting, “heartburn”, a metallic taste, abdominal pain, an inflamed gallbladder, constipation, 
mouth pain, flatulence, diarrhea, itching, rash, dry skin, hives, headache, fatigue, anxiety, 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  21  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
depression, and sleep disorders. Less common side effects include sweating, thinning of hair, 
back pain, muscle and joint pains, runny noses, and cough. 
 
Diphenhydramine may cause tiredness, dizziness, upset stomach, disturbed coordination, dry 
mouth, flushing, or difficulty urinating. 
 
Valacyclovir can cause nausea, vomiting, headache, dizziness, abdominal pain, bone pain, 
allergic reactions, mild liver inflammation, kidney injury, and abnormal nervous system 
function. 
 
Fluconazole can cause nausea, vomiting, headache, skin rash, abdominal pain, and diarrhea.  
Rare but sometimes serious liver toxicity has also been reported.  Fluconazole can increase the 
blood levels of other drugs, which can increase their effectiveness and/or their side effects. 
 
Trimethoprim/sulfamethoxazole (Bactrim) may cause nausea, vomiting, loss of appetite, allergic 
skin rashes, and suppression of bone marrow function.  Rare but severe reactions may affect the 
skin and bone marrow; these have sometimes been fatal. 
 
Additional Therapies:  Treatments covered under this protocol which are standard therapies 
given for disease control may include a single medication or a combination of medications, 
surgery or radiation. The treatment to be used will be determined by your NIH doctors based on 
your diagnosis, the type and extent of your illness, your prior treatments, and your ability to 
tolerate additional treatment. These treatments will not be experimental. Your doctors will 
describe their treatment plan to you in detail including the name of the treatment(s), the schedule, 
the possible harmful effects, the potential benefit, and possible alternatives to you before having 
you sign this consent form. If surgery or radiation therapy are required to treat your illness, you 
may be asked to sign a separate consent form by the surgeon or radiation therapist. 
 
Reproductive Risks:  This treatment is likely to result in sterility (the inability to produce 
children).  However, we cannot predict for certain that you will become sterile during this 
treatment.  It is unknown what effects the chemotherapy and other drugs included in this 
treatment may have on an unborn child, but they would most likely be harmful.  For this reason, 
if you have not been placed on a contraceptive (birth control) as part of this study, you will need 
to use an effective form of contraception while on this study, and for one year after transplant 
(examples include: intrauterine device (IUD), hormonal (birth control pills, injections, or 
implants), tubal ligation/hysterectomy (self or partner), partner’s vasectomy, barrier methods 
(condom, diaphragm, or cervical cap), or abstinence.   
Use of Specimens and Data for Future Research 
To advance science, it is helpful for researchers to share information they get from studying 
human samples.  They do this by putting it into one or more scientific databases, where it is 
stored along with information from other studies. A researcher who wants to study the 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  22  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
information must apply to the database and be approved.  Researchers use specimens and data 
stored in scientific databases to advance science and learn about health and disease.   
We plan to keep some of your specimens and data that we collect and use them for future 
research and share them with other researchers. We will not contact you to ask about each of 
these future uses.  These specimens and data will be stripped of identifiers such as name, address 
or account number, so that they may be used for future research on any topic and shared broadly 
for research purposes. Your specimens and data will be used for research purposes only and will 
not benefit you.  It is also possible that the stored specimens and data may never be used.  
Results of research done on your specimens and data will not be available to you or your doctor.  
It might help people who have cancer and other diseases in the future.   
If you do not want your stored specimens and data used for future research, please contact us in 
writing and let us know that you do not want us to use your specimens and/or data.  Then any 
specimens that have not already been used or shared will be destroyed and your data will not be 
used for future research. However, it may not be possible to withdraw or delete materials or data 
once they have been shared with other researchers. 
Potential Benefits of Participation 
The chemotherapy you receive may cause improvement in your cancer, although it is not likely 
to result in a cure by itself.  The allogeneic SCT may improve the chance that your disease will 
enter into a long remission and possibly be cured.  However, you should understand that this 
cannot be guaranteed.  All of the evaluations, tests, and hospitalizations that you receive at the 
NIH will be free of charge to you.  In addition, your participation in this study may contribute to 
understanding and developing new ways of using allogeneic SCT for the treatment of cancer. 
Alternative Treatment 
To be eligible for this study, you must have already received the standard treatment for your 
disease, but there are other options other than participating on this trial: 
• You may consider other treatments such as other forms of chemotherapy, radiation, 
surgery, or immune therapies.  In some cases, you may be eligible for an autologous bone 
marrow or stem cell transplant, in which your own stem cells are returned to your body 
following high dose chemotherapy treatment.   
• Taking part in another research study 
• Instead of participating in a research study such as this, you may also be eligible to 
receive a standard allogeneic stem cell transplant with high dose chemotherapy and/or 
radiation therapy to completely wipe out your bone marrow before donor cells are 
transplanted. 
• Getting comfort care, also called palliative care. This type of care helps reduce pain, 
tiredness, appetite problems, and other problems caused by cancer. It does not treat the 
cancer directly, but instead tries to improve how you feel. Comfort care tries to keep you 
as active and comfortable as possible. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  23  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
• Another option is not to receive any further treatment at all.  
 
You should discuss with your referring doctor and your doctors at the NCI whether or not any of 
these other treatments might be a reasonable choice for your disease. 
Stopping Therapy 
Your doctor may decide to stop your therapy for the following reasons: 
• If he/she believes that it is in your best interest 
• If your disease comes back after treatment 
• If you have side effects from the treatment that your doctor thinks are too severe 
• If new information shows that another treatment would be better for you 
 
In this case, you will be informed of the reason therapy is being stopped. 
 
Participation in this research study is voluntary.  You may stop your participation in the study at 
any time.  There are no penalties for withdrawing from the study.  However, if you withdraw 
after the transplant chemotherapy (“conditioning regimen”) without receiving the infusion of 
donor stem cells, you would be at high risk for serious complications, including death.  If you 
decide to stop taking part in the study, we would like you to talk to the study doctor and your 
regular doctor first. 
 
If you decide at any time to withdraw your consent to participate in the trial, we will not collect 
any additional medical information about you. However, according to FDA guidelines, 
information collected on you up to that point may still be provided to Dr. Pavletic or designated 
representatives. If you withdraw your consent and leave the trial, any samples of yours that have 
been obtained for the study and stored at the NCI can be destroyed upon request. However, any 
samples and data generated from the samples that have already been distributed to other 
researchers or placed in the research databases cannot be recalled and destroyed. 
Research Subject’s Rights 
What are the costs of taking part in this study?  
If you choose to take part in the study, the following will apply, in keeping with the NIH policy: 
• 
You will receive study treatment at no charge to you. This may include surgery, 
medicines, laboratory testing, x-rays or scans done at the Clinical Center, National 
Institutes of Health (NIH), or arranged for you by the research team to be done 
outside the Clinical Center, NIH if the study related treatment is not available at the 
NIH.  
• 
There are limited funds available to cover the cost of some tests and procedures 
performed outside the Clinical Center, NIH.  You may have to pay for these costs if 
they are not covered by your insurance company. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  24  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
• 
Medicines that are not part of the study treatment will not be provided or paid for by 
the Clinical Center, NIH. 
• 
Once you have completed taking part in the study, medical care will no longer be 
provided by the Clinical Center, NIH. 
Will your medical information be kept private?  
We will do our best to make sure that the personal information in your medical record will be 
kept private.  However, we cannot guarantee total privacy.  Organizations that may look at 
and/or copy your medical records for research, quality assurance, and data analysis include: 
 
• The National Cancer Institute (NCI) and other government agencies, like the Food and 
Drug Administration (FDA), which are involved in keeping research safe for people. 
• National Cancer Institute Institutional Review Board 
• We may share data from this study with a blood and bone marrow registry called:  The 
Center for International Blood and Marrow Transplant Research (CIBMTR). The 
CIBMTR (Hwww.cibmtr.org) is committed to respecting your privacy and the data we 
share with is sent without revealing any personal information. The information that is 
sent to the CIBMTR is combined with information from other transplant centers to better 
understand how transplants work and to improve patient care. 
 
A description of this clinical trial will be available on http://www.Clinicaltrials.gov, as required 
by U.S. Law.  This Web site will not include information that can identify you.  At most the Web 
site will include a summary of the results.  You can search this Web site at any time. 
Certificate of Confidentiality  
To help us protect your privacy, we have obtained a Certificate of Confidentiality. The 
researchers can use this Certificate to legally refuse to disclose information that may identify you 
in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings, for 
example, if there is a court subpoena. The researchers will use the Certificate to resist any 
demands for information that would identify you, except as explained below. 
You should also know that there are several circumstances in which the Certificate does not 
provide coverage. These include when information:  
• will be used for auditing or program evaluation internally by the NIH; or  
• must be disclosed to meet the legal requirements of the federal Food and Drug 
Administration (FDA).  
• is necessary for your medical treatment and you have consented to this disclosure;  
• is for other research.  
 
In addition, identifiable, sensitive information protected by this Certificate cannot be admissible 
as evidence or used for any purpose in any action, suit, or proceeding without your consent.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 07-C-0195 
CONTINUATION: page  25  of  27  pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.:  09-25-0099 
File in Section 4:  Protocol Consent 
 
You should understand that a Certificate of Confidentiality does not prevent you or a member of 
your family from voluntarily releasing information about yourself or your involvement in this 
research. If an insurer, employer, or other person obtains your written consent to receive research 
information, then the researchers will not use the Certificate to withhold that information. 
The Certificate of Confidentiality will not protect against the required reporting by hospital staff 
of information on suspected child abuse, reportable communicable diseases, and/or possible 
threat of harm to self or others. 
Conflict of Interest 
The National Institutes of Health (NIH) reviews NIH staff researchers at least yearly for conflicts 
of interest.  This process is detailed in a Protocol Review Guide.  You may ask your research 
team for a copy of the Protocol Review Guide or for more information.  Members of the research 
team who do not work for NIH are expected to follow these guidelines but they do not need to 
report their personal finances to the NIH. 
 
Members of the research team working on this study may have up to $15,000 of stock in the 
companies that make products used in this study.  This is allowed under federal rules and is not a 
conflict of interest.  
Use of Specimens and Data for Future Research 
To advance science, it is helpful for researchers to share information they get from studying 
human samples.  They do this by putting it into one or more scientific databases, where it is 
stored along with information from other studies. A researcher who wants to study the 
information must apply to the database and be approved.  Researchers use specimens and data 
stored in scientific databases to advance science and learn about health and disease.   
We plan to keep some of your specimens and data that we collect and use them for future 
research and share them with other researchers. We will not contact you to ask about each of 
these future uses.  These specimens and data will be stripped of identifiers such as name, address 
or account number, so that it may be used for future research on any topic and shared broadly for 
research purposes. Your specimens and data will be used for research purposes only and will not 
benefit you.  It is also possible that the stored specimens and data may never be used.  Results of 
research done on your specimens and data will not be available to you or your doctor.  It might 
help people who have cancer and other diseases in the future.   
If you do not want your stored specimens and data used for future research, please contact us in 
writing and let us know that you do not want us to use your specimens and/or data.  Then any 
specimens that have not already been used or shared will be destroyed and your data will not be 
used for future research. However, it may not be possible to withdraw or delete materials or data 
once they have been shared with other researchers. 
 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
STUDY NUMBER:  07-C-0195 
CONTINUATION: page  26  of  27  pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
 
File in Section 4:  Protocol Consent 
 
 
 
 
OTHER PERTINENT INFORMATION 
1. Confidentiality.  When results of an NIH research study are reported in medical journals or 
at scientific meetings, the people who take part are not named and identified.  In most cases, the 
NIH will not release any information about your research involvement without your written 
permission.  However, if you sign a release of information form, for example, for an insurance 
company, the NIH will give the insurance company information from your medical record.  This 
information might affect (either favorably or unfavorably) the willingness of the insurance 
company to sell you insurance. 
 
The Federal Privacy Act protects the confidentiality of your NIH medical records.  However, you 
should know that the Act allows release of some information from your medical record without 
your permission, for example, if it is required by the Food and Drug Administration (FDA), 
members of Congress, law enforcement officials, or authorized hospital accreditation 
organizations. 
 
2. Policy Regarding Research-Related Injuries.  The Clinical Center will provide short-term 
medical care for any injury resulting from your participation in research here.  In general, no 
long-term medical care or financial compensation for research-related injuries will be provided 
by the National Institutes of Health, the Clinical Center, or the Federal Government.  However, 
you have the right to pursue legal remedy if you believe that your injury justifies such action. 
 
3. Payments.  The amount of payment to research volunteers is guided by the National 
Institutes of Health policies.  In general, patients are not paid for taking part in research studies at 
the National Institutes of Health. Reimbursement of travel and subsistence will be offered 
consistent with NIH guidelines. 
 
4.   Problems or Questions.  If you have any problems or questions about this study, or about 
your rights as a research participant, or about any research-related injury, contact the Principal 
Investigator, Steven Pavletic, M.D.; Building 10-CRC, Room 4-3130, Telephone: 240-760-6174.    
If you have questions about the use of your specimens or data for future research studies, you 
may contact the NIH Clinical Director at 240-760-6070. You may also call the Clinical Center 
Patient Representative at 301-496-2626. 
 
5. Consent Document.  Please keep a copy of this document in case you want to read it again. 
 
 
 
 
 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
STUDY NUMBER:  07-C-0195 
CONTINUATION: page  27  of  27  pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• 
Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.:  09-25-0099 
 
File in Section 4:  Protocol Consent 
 
 
 
 
COMPLETE APPROPRIATE ITEM(S) BELOW: 
A. Adult Patient’s Consent 
B. Parent’s Permission for Minor Patient. 
I have read the explanation about this study 
and have been given the opportunity to discuss 
it and to ask questions.  I hereby consent to 
take part in this study. 
I have read the explanation about this study 
and have been given the opportunity to discuss 
it and to ask questions.  I hereby give 
permission for my child to take part in this 
study.   
(Attach NIH 2514-2, Minor’s Assent, if 
applicable.) 
 
  
  
 
 
 
Signature of Adult Patient/ 
Legal Representative 
Date 
Signature of Parent(s)/ Guardian Date 
 
 
Print Name 
 
 
Print Name 
C. Child’s Verbal Assent (If Applicable) 
The information in the above consent was described to my child and my child agrees to 
participate in the study. 
 
  
  
 
Signature of Parent(s)/Guardian 
Date 
Print Name 
THIS CONSENT DOCUMENT HAS BEEN APPROVED FOR USE  
OCTOBER 29, 2018 THROUGH NOVEMBER 12, 2019. 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
Date 
Signature of Witness 
Date 
 
 
Print Name 
 
 
Print Name