Clinical trial NCT03531918
Conditions: Acute Myeloid Leukemia
Sponsor: Fred Hutchinson Cancer Center
Start date: 2018-09-14; Completion date: 2021-11-01
Enrollment: 66 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This phase I/II trial studies the side effects and best dosing frequency of gemtuzumab ozogamicin when given in combination with granulocyte colony stimulating factor (G-CSF), cladribine, cytarabine and mitoxantrone (GCLAM) and to see how well they work in treating participants with acute myeloid leukemia or high-grade myeloid tumors (neoplasms) that have not been previously treated. Antibody-drug conjugates, such as gemtuzumab ozogamicin, act by directly delivering toxic chemotherapy to cancer cells. Granulocyte colony stimulating factor is a growth factor used to stimulate leukemia cells and render them more sensitive to chemotherapy drugs. Drugs used in chemotherapy, such as cladribine, cytarabine and mitoxantrone, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving gemtuzumab ozogamicin in combination with G-CSF, cladribine, cytarabine and mitoxantrone hydrochloride may work better in treating participants with acute myeloid leukemia or high-grade myeloid neoplasm.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the maximum-tolerated dose (MTD) of gemtuzumab ozogamicin (GO) when added to GCLAM in patients with newly-diagnosed AML requiring induction chemotherapy. (Phase I) II. To evaluate the 6-month and 1-year event-free survival (EFS) rate with GO + GCLAM treated at the MTD. (Phase II)

SECONDARY OBJECTIVES:

I. Describe, within the limits of a phase 1/2 study, the toxicity profile of the study regimen.

II. Compare, within the limits of a phase 1/2 study, measurable residual disease (MRD) rates with GO + GCLAM at the MTD to patients treated previously with GCLAM alone.

III. Estimate, within the limits of a phase 1/2 study, the relationship between MRD status after induction therapy and relapse risk/time to relapse as well as relapse-free and overall survival.

IV. Compare, within the limits of a phase 1/2 study, complete remission rates with GO + GCLAM at the MTD to patients treated previously with GCLAM alone.

V. Compare, within the limits of a phase 1/2 study, overall survival rates with GO + GCLAM at the MTD to patients treated previously with GCLAM alone VI. Evaluate, within the limits of a phase 1/2 study, the impact of GO dosing regimens on the duration of cytopenias.

VII. Collect biological specimens for use for the future laboratory investigation of biomarkers for response to GO.

OUTLINE: This is a phase I dose escalation study of gemtuzumab ozogamicin followed by a phase II study.

INDUCTION THERAPY: Participants receive gemtuzumab ozogamicin intravenously (IV) either as a single dose on day 1, or as three doses on days 1, 4, and 7. Participants also receive G-CSF subcutaneously (SC) on days 0-5, cladribine IV over 2 hours on days 1-5, cytarabine IV over 2 hours on days 1-5, and mitoxantrone hydrochloride IV on days 1-3. Patients who do not achieve a CR or CRi following the first cycle of induction are eligible for a second cycle, which is given without gemtuzumab ozogamicin. Participants with a complete remission (CR) or complete remission with incomplete count recovery (CRi) may then proceed to Post-Remission Therapy.

POST-REMISSION THERAPY: Participants receive G-CSF, cladribine, and cytarabine as in Induction Therapy during cycle 1, and cytarabine IV every 12 hours on days 1-6 of cycles 2-3. Treatment repeats every month for up to 3 cycles in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, participants are followed up every 3 months for 5 years.

Arms: arm 1: INDUCTION THERAPY: Participants receive gemtuzumab ozogamicin IV either as a single dose on day 1, or as three doses on days 1, 4, and 7. Participants also receive G-CSF SC on days 0-5, cladribine IV over 2 hours on days 1-5, cytarabine IV over 2 hours on days 1-5, and mitoxantrone hydrochloride IV on days 1-3. Patients who do not achieve a CR or CRi following the first cycle of induction are eligible for a second cycle, which is given without gemtuzumab ozogamicin. Participants with a CR or CRi may then proceed to Post-Remission Therapy.

POST-REMISSION THERAPY: Participants receive G-CSF, cladribine, and cytarabine as in Induction Therapy during cycle 1, and cytarabine IV every 12 hours on days 1-6 of cycles 2-3. Treatment repeats every month for up to 3 cycles in the absence of disease progression or unacceptable toxicity.
Interventions: intervention 1: Cladribine intervention 2: Cytarabine intervention 3: Gemtuzumab Ozogamicin intervention 4: Recombinant Granulocyte Colony-Stimulating Factor intervention 5: Laboratory Biomarker Analysis intervention 6: Mitoxantrone Hydrochloride
Intervention descriptions: intervention 1: Given IV intervention 2: Given IV intervention 3: Given IV intervention 4: Given SC intervention 5: Correlative studies intervention 6: Given IV

Protocol documents:
Prot_SAP_002.pdf: 
A Single-Center Phase 1/2 Study of Single- or 
Fractioned-Dose Gemtuzumab Ozogamicin in 
Combination with G-CSF, Cladribine, Cytarabine 
and Mitoxantrone (GCLAM) for Previously 
Untreated Adult Acute Myeloid Leukemia or 
High-Grade Myeloid Neoplasm 
Short title: Gemtuzumab ozogamicin plus GCLAM for AML 
NCT03531918 
April 17, 2022 


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FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
 
Current version: 11/10/2020 
Previous version: 08/27/2019 
 
A Single-Center Phase 1/2 Study of Single- or Fractioned-Dose Gemtuzumab Ozogamicin 
in Combination with G-CSF, Cladribine, Cytarabine and Mitoxantrone (GCLAM) for 
Previously Untreated Adult Acute Myeloid Leukemia or High-Grade Myeloid Neoplasm 
 
 
Principal Investigator: 
• Roland B. Walter, MD PhD MS: Associate Professor, Fred Hutch; Associate Professor, 
UW 
 
 
Sub-Investigators: 
• Colin D. Godwin, MD MPhil: Research Associate, Fred Hutch; Acting Instructor, UW 
 
 
• Anna B. Halpern, MD, Assistant Professor, Fred Hutch; Assistant Professor, UW 
 
 
• Elihu H. Estey, MD: Professor, Fred Hutch; Professor, UW 
 
 
Biostatistician: 
• Megan Othus, PhD: Professor, Fred Hutch 
 
 
 
 
Emergency Phone (24 hours): 
Call the paging operator at the University of Washington Medical Center at 
, and 
ask for the Fellow on call for Hematology/Oncology.  
IRO received 03/22/22
FHCRC IRB Approval  
APR 17 2022 
Document Released Date


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OVERVIEW OF THE TREATMENT PLAN 
 
 
 
DOSE ESCALATION SCHEME (PHASE 1 PORTION) 
 
 
Abbreviations: G-CSF, granulocyte colony stimulating factor; GO 
gemtuzumab ozogamicin. 
Abbreviations: DLTs, dose-limiting toxicities; GO, gemtuzumab ozogamicin; GO1, single dose gemtuzumab ozogamicin; 
GO3, fractionated-dose ozogamicin; R2PD, recommended phase 2 dose. 


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TABLE OF CONTENTS 
 
OVERVIEW OF THE TREATMENT PLAN  
 
 
 
 
  2 
DOSE-ESCALATION SCHEME  
 
 
 
 
 
 
  2 
 
1.0 
 
Background and Rationale  
 
 
 
 
 
  4 
2.0 
 
Objectives  
 
 
 
 
 
 
 
  6 
3.0 
 
Patient Eligibility  
 
 
 
 
 
 
  7 
4.0 
 
Evaluation and Counseling of Patient  
 
 
 
  8 
5.0 
 
Protocol Registration   
 
 
 
 
 
  8 
6.0 
 
Treatment Plan 
 
 
 
 
 
 
  9 
7.0 
 
Information on Study Drugs   
 
 
 
 
13 
8.0 
 
Evaluations and Endpoint Definitions  
 
 
 
20 
9.0 
 
Records 
 
 
 
 
 
 
 
21 
10.0 
 
Correlative Studies 
 
 
 
 
 
 
22 
11.0 
 
Protocol Enrollment and Special Considerations  
 
 
23 
12.0 
 
Guidelines for Serious Adverse Event Reporting  
 
 
23 
13.0 
 
Data and Safety Monitoring Plan  
 
 
 
 
25 
14.0 
 
Investigator Obligations 
 
 
 
 
 
26 
15.0 
 
Administrative and Regulatory Considerations  
 
 
26 
16.0 
 
Statistical Considerations 
 
 
 
 
 
27 
17.0 
 
Study Termination  
 
 
 
 
 
 
29 
18.0 
 
References  
 
 
 
 
 
 
 
30 
 
Appendix A:  Treatment-Related Mortality (TRM) Score  
 
 
32 
Appendix B: Research Subject Registration Form  
 
 
 
33 
Appendix C:  General Specimen Submission Instructions  
 
 
37 


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1.0 
BACKGROUND AND RATIONALE 
Despite some recent improvements in treatment, adult acute myeloid leukemia (AML) 
remains difficult-to-treat, with only gradual improvements over the last 3-4 decades.1,2 Although 
many patients will achieve a complete remission (CR) with 1 or 2 courses of curative-intent, 
intensive induction chemotherapy, the majority will ultimately relapse, and few patients will be 
alive 2-5 years after diagnosis. Thus, the need for new, effective first-line therapies which are 
more effective at preventing later relapse is unquestioned.  
 
1.1  
GCLAM as intensive chemotherapy for adults with newly-diagnosed AML 
Since 2012, we have used a combination of G-CSF, cladribine, high-dose cytarabine, and 
mitoxantrone (GCLAM) extensively in patients with newly-diagnosed AML. This use was 
motivated by data suggesting that GCLAM might be superior to other chemotherapies such as 
mitoxantrone, etoposide, and high-dose cytarabine (MEC) for relapsed disease.3 In a large, 
institutional phase 1/2 trial (FH #2734; NCT02044796), we have established the safety of 
GCLAM with an escalated dose of mitoxantrone (18 mg/m2 rather than 10 mg/m2 as used in the 
original GCLAM regimen).4 Between June 2014 and March 2017, we enrolled 121 medically-fit 
patients with newly-diagnosed AML with a median age of 60 (range: 21-81) years on this trial. 
Because all dose levels were well tolerated, mitoxantrone at 18mg/m2, the highest dose, was 
declared the recommended phase 2 dose (RP2D). Among 88 patients treated at the RP2D, 72 
achieved a complete remission (CR; 82%, 66/72 [92%] without measurable residual disease 
[MRD]) and 6 achieved a CR with incomplete count recovery (CRi; 7%, 5 without MRD) for a 
CR/CRi rate of 78/88 (89%). 4- and 8-week mortality was 2% and 3%. After multivariable 
adjustment, the MRDneg CR rate and CR/CRi rate compared favorably to 97 matched historical 
controls at our center treated with 7+3 (odds ratio [OR]=4.40, p<0.001, and OR=3.86, p<0.01) as 
well as to 300 patients treated with 7+3 on a cooperative group trial.4 Together, our trial found 
GCLAM with mitoxantrone up to 18 mg/m2/day to be safe and effective in inducing high-quality 
remissions (MRDneg CR) in adults with newly-diagnosed AML. These results have established 
GCLAM as our institutional standard for upfront treatment of AML. 
 
1.2  
Gemtuzumab ozogamicin (GO) for the treatment of adults with AML 
Building on our experience with GCLAM for previously untreated AML, our goal is to further 
improve outcomes with this chemotherapy backbone by integrating the CD33 antibody-drug 
conjugate gemtuzumab ozogamicin (GO). As demonstrated in several randomized trials, GO 
reduces relapse risks and prolongs survival in adults with newly-diagnosed AML when added to 
intensive chemotherapy (even though remission rates are unchanged), firmly establishing its 
value in medically fit adults with previously untreated AML.5,6 An initial meta-analysis 
published in 2014 has indicated the overall survival benefit is most pronounced in patients with 
favorable-risk disease but is, to a less degree, also seen in intermediate-risk disease whereas no 
benefit was found in adverse-risk disease.6 While confirming these results, extended updated 
analyses showed a statistically-significant benefit of GO with regard to relapse-risk, event-free 
survival, and relapse-free survival across all cytogenetic risk groups with essentially identical 
benefit in intermediate and adverse-risk disease (R.K. Hills; personal communication). 
Consistent with data from the meta-analysis, a randomized trial found that GO doses of 3 mg/m2 
were less toxic (as estimated by 30- and 60-day mortality and rate of SOS/VOD) than doses of 6 
mg/m2 but were equally effective.7 While these data suggest that the optimal dose might be 3 
mg/m2, there remains uncertainty as to the optimal dosing schedule of GO, with some data 


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provided by the meta-analysis suggesting that fractionated dosing, i.e. administration of GO 3 
mg/m2 on days 1, 4, and 7 – a dosing schedule that takes advantage of re-expression of CD33 
binding sites 48-72 hours after antibody exposure – may have substantially better anti-leukemia 
activity than a single dose without increase in toxicity, but no controlled study has so far 
compared 1 vs. 3 doses of GO at 3 mg/m2.6 
 
1.3  
Rationale for combining GCLAM with GO for the treatment of newly-diagnosed 
AML 
Benefit of GO in combination with intensive induction chemotherapy has been demonstrated 
with several chemotherapy backbones, including 7+3 and FLAG-Ida.5 However, GO has so far 
not been combined with GCLAM. We therefore conduct a phase 1/2 trial to determine the 
feasibility, and estimate the efficacy, of integrating one or three (i.e “fractionated”) doses of GO 
in the GCLAM regimen. This trial is built on the following considerations/hypotheses: 
• Data from randomized trials indicate that a single dose of GO of 3 mg/m2 is tolerated 
without significant increase in toxicities when added to intensive chemotherapy, whereas 
a single dose of 6 mg/m2 adds toxicity without treatment benefit beyond what is obtained 
with 3 mg/m2.5-7 The data further suggest that fractionated dosing with GO 3 mg/m2 on 
days 1, 4, and 7 may have superior efficacy than a single dose of 3 mg/m2 albeit at the 
expense of greater hematologic (and possibly non-hematologic) toxicities.6 This trial will 
therefore determine the safety of adding 1 dose or 3 fractionated doses of GO 3 mg/m2 to 
intensive chemotherapy. Since a single dose is likely well tolerated, our study will only 
enroll 6 patients at single dose GO (GO1) but cohorts of 6+6 patients when 3 doses are 
given (GO3). Once the recommended phase 2 dose (RP2D) is determined, the treatment 
cohort will then be expanded to a total of 60 patients. Preference for this approach over 
the classic 3+3 dose escalation scheme is given to have greater ability to characterize 
toxicity profiles at different GO dose levels, better estimate the relationship between GO 
dose and duration of cytopenias and have a higher chance of capturing less common but 
clinically significant toxicities. 
• When added to intensive induction chemotherapy, GO improves outcomes even though 
the specific chemotherapy backbone varied significantly between individual trials.5,6 
Thus, though the combination of GCLAM and GO is novel, we hypothesize that GO will 
provide similar incremental benefit over GCLAM alone. The substantial number of 
newly-diagnosed AML patients treated on protocol #2734 provides a large “historical” 
cohort of patients treated with GCLAM alone.4 This control cohort will allow us to 
accurately estimate the benefit of adding GO to GCLAM chemotherapy. 
• In prior trials investigating the use of GO, addition of GO had little to no impact on early 
endpoints such as remission rates, and changes in remission rates did not consistently 
translate to changes in survival, arguing against using remission rates as a primary 
endpoint. Instead, we will use 6-month event-free survival (EFS) to compare the 
outcomes of patients treated on our trial with patients treated previously at our institution 
with GCLAM. In protocol #2734, EFS at 6 months (68%) was similar to 1-year EFS 
(57%), supporting the use of this earlier endpoint for comparison of patients treated with 
GO + GCLAM and GCLAM alone.4 A total of 60 patients treated with GO + GCLAM in 
the current protocol will allow for 80% power to detect an improvement in 6-month EFS 
to 80%. Subsequent analysis of protocol #2734 with longer follow-up demonstrated a 
revised 1-year EFS estimate of 60%. Given the late emerging benefits in patients treated 


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with GO in randomized clinical trials compared to patients not treated with GO,6 we will 
also include 1-year EFS as a second primary endpoint.  
• Study eligibility will be based on explicit criteria for medical fitness, using a treatment-
related mortality (TRM score) that we developed in over 2,200 patients with AML,8 and 
now widely use in our clinical trials. 
• We will ask patients to agree to collection of peripheral blood and bone marrow 
specimens to be used in future laboratory assays to study biologic predictors of response 
to GO therapy. The collection is voluntary, and declining will not affect a patient’s 
participation in this study. Some of these potential biomarker assays may be centered 
around CD33 expression levels, presence of CD33 splice isoforms that reduce GO 
efficacy, and other genes which determine response to the calicheamicin toxin component 
of GO.5 
 
1.4  
Interim data update: phase 1 experience with GCLAM/GO 
Between 9/1/2018 and 5/29/2019, the first 18 patients, median age 66 (range: 28-77) years, 
median TRM score 3.92 (range: 0.14-10.3) with newly-diagnosed AML (n=14) or other high-
grade myeloid neoplasm (n=4) were enrolled. Among these, 7 were “favorable”, 4 “intermediate 
and 7 “adverse” by 2017 European LeukemiaNet (ELN) criteria. The first 6 patients were treated 
at GO1. Because there was only 1 DLT (left ventricular systolic dysfunction) the subsequent 12 
patients were treated at GO3. Three dose-limiting toxicities (DLTs) occurred at this second dose 
level (aminotransferase level increase, posterior reversible encephalopathy syndrome, treatment 
delay by >14 days). Since ≤4/12 DLTs were observed, the MTD was not reached and GO3 was 
declared the recommended phase 2 dose. Among 18 evaluable patients, 13 achieved CR and 2 
CRi for a CR/CRi rate of 83% (95% confidence interval: 59-96%). 13 of these 15 CR/CRi 
patients were negative for MRD by MFC and cytogenetics, for an MRDneg CR/CRi rate of 72% 
(49-88%). The 3 patients not achieving CR/CRi had marrow aplasia without MFC evidence of 
AML when they went off study. Two underwent allogeneic hematopoietic cell transplantation in 
aplasia or MLFS; the other received no further therapy, with disease recurrence 2.5 months 
following induction therapy. 4/18 patients did not have platelet recovery to 50,000/µL prior to 
the second cycle of therapy. Among the 14 patients with hematopoietic recovery, median times 
to an absolute neutrophil count of 500/µL and platelet count of 50,000/µL were 30.5 (range: 22-
42) days and 28.5 (range: 24-41) days, respectively. Besides infections and neutropenic fever, 
hypertension and left ventricular systolic dysfunction were the most common adverse events. 
One patient had liver toxicity not meeting typical clinical criteria for sinusoidal obstructive 
syndrome. There were no deaths within 28 or 56 days of starting induction in this study cohort. 
 
2.0  
OBJECTIVES 
 
2.1  
Primary objectives 
2.1.1 Phase 1 objective: to determine the maximum-tolerated dose (MTD) of GO when 
added to GCLAM in patients with newly-diagnosed AML requiring induction 
chemotherapy. 
2.1.2 Phase 2 objective: to evaluate the 6-month and 1-year event-free survival (EFS) 
rate with GO + GCLAM treated at the MTD. 
 


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2.2  
Secondary objectives 
2.2.1 Describe, within the limits of a phase 1/2 study, the toxicity profile of the study 
regimen. 
2.2.2 Compare, within the limits of a phase 1/2 study, measurable residual disease 
(MRD) rates with GO + GCLAM at the MTD to patients treated previously with 
GCLAM alone. 
2.2.3 Estimate, within the limits of a phase 1/2 study, the relationship between MRD 
status after induction therapy and relapse risk/time to relapse as well as relapse-
free and overall survival.  
2.2.4 Compare, within the limits of a phase 1/2 study, complete remission rates with 
GO + GCLAM at the MTD to patients treated previously with GCLAM alone. 
2.2.5 Compare, within the limits of a phase 1/2 study, overall survival rates with GO + 
GCLAM at the MTD to patients treated previously with GCLAM alone 
2.2.6 Evaluate, within the limits of a phase 1/2 study, the impact of GO dosing 
regimens on the duration of cytopenias. 
2.2.7 Collect biological specimens for use for the future laboratory investigation of 
biomarkers for response to GO. 
 
3.0  
PATIENT ELIGIBILITY 
 
3.1. 
 
Inclusion criteria 
3.1.1 Age ≥18 years 
3.1.2 Diagnosis of untreated “high-grade” myeloid neoplasm (≥10% blasts in blood or 
bone marrow) or AML other than acute promyelocytic leukemia (APL) with 
t(15;17)(q22;q12) or variants according to the 2016 WHO classification.9 Outside 
diagnostic material is acceptable to establish diagnosis; submission of peripheral 
blood specimen for  flow cytometry performed at the study institution should be 
considered. Diagnostic material must have been submitted for cytogenetic and/or 
molecular testing as clinically appropriate.  
3.1.3 Medically fit, as defined by treatment-related mortality (TRM) score ≤13.1 
calculated with simplified model.8 (see Appendix A) 
3.1.4 The use of hydroxyurea prior to study registration is allowed. Patients with 
symptoms/signs of hyperleukocytosis, WBC >100,000/μL or with concern for 
other complications of high tumor burden (e.g. disseminated intravascular 
coagulation) can be treated with leukapheresis or may receive up to 2 doses of 
cytarabine (up to 500 mg/m2/dose) prior to enrollment. 
3.1.5  Patients may have received low-intensity treatment (e.g. azacitidine/decitabine, 
lenalidomide, growth factors) for antecedent low-grade myeloid neoplasm (i.e. 
<10% blasts in blood and bone marrow). 
3.1.6 Adequate organ function. 


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3.1.6.1 Bilirubin ≤2.5 x Institutional Upper Limit of Normal (IULN) unless 
elevation is thought to be due to hepatic infiltration by AML, Gilbert’s syndrome, 
or hemolysis (assessed within 14 days prior to study day 0). 
3.1.6.2 Serum creatinine ≤2.0 mg/dL (assessed within 14 days prior to study day 
0). 
3.1.6.3 Left ventricular ejection fraction ≥45%, assessed within 12 months prior 
to study day 0, e.g. by MUGA scan or echocardiography, or other appropriate 
diagnostic modality and no clinical evidence of congestive heart failure. 
3.1.7 Women of childbearing potential and men must agree to use adequate 
contraception. 
3.1.8 Provide written informed consent. 
 
3.2  
Exclusion criteria 
3.2.1 Myeloid blast crisis of chronic myeloid leukemia (CML), unless patient is not 
considered candidate for tyrosine kinase inhibitor treatment. 
3.2.2 Concomitant illness associated with a likely survival of <1 year. 
3.2.3 Active systemic fungal, bacterial, viral, or other infection, unless disease is under 
treatment with anti-microbials, and/or controlled or stable (e.g. if specific, 
effective therapy is not available/feasible or desired [e.g. known chronic viral 
hepatitis, HIV]). Patient needs to be clinically stable as defined as being afebrile 
and hemodynamically stable for 24 hours. Patients with fever thought to be likely 
secondary to leukemia are eligible. 
3.2.4  Known hypersensitivity to any study drug. 
3.2.5  Confirmed or suspected pregnancy or active breast feeding. 
3.2.6  Treatment with any other investigational anti-leukemia agent. In phase 2, 
treatment with a tyrosine kinase inhibitor for patients with FLT3-mutated AML is 
permissible. 
 
 
4.0  
EVALUATION AND COUNSELING OF PATIENT 
 
 
The patient will be completely evaluated with a history, physical examination, diagnostic 
testing if necessary, and review of outside slides and records if available. The protocol will be 
discussed thoroughly with the patient and family (if present), with description of all known risks 
to the patient. Alternative forms of treatment will be presented objectively, and the risks and 
hazards of the study explained to the patient. Consent will be obtained using forms approved by 
the Institutional Review Board (IRB). 
 
 
5.0  
PROTOCOL REGISTRATION 
 
 
To register, the provider(s) involved in the care of the potential study participant must 
contact a Study Investigator or the Study Coordinator and fax the Research Subject Registration 
Form (Appendix B) to the study team (
). For registration, a completed 
Research Subject Registration Form including completed eligibility checklist (Appendix B), a 


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copy of the signed consent form, and a signed HIPAA authorization must be available, and all 
eligibility requirements according to section 3.0 must be met. To complete the registration 
process, the Principal Investigator or his designee will assign a patient study number and register 
the patient on the study.  
 
 
6.0  
TREATMENT PLAN 
 
This study is an open-label, Phase 1/2 dose escalation trial to attempt to estimate the 
maximum tolerated dose (MTD) of GO when used concomitantly with GCLAM in patients with 
newly-diagnosed AML or other high-grade myeloid neoplasm. Bone marrows will be reassessed 
upon blood count recovery or between day Days +25 to +31 after start of chemotherapy, 
whichever occurs first. If an MRD-negative CR is not achieved with the first cycle of 
chemotherapy (a response associated with particularly favorable outcome in a recent institutional 
study10,11), patients are eligible for re-induction with GCLAM without GO provided all non-
hematologic toxicities have resolved to grade <2. Patients achieving a CR or CRi with 1-2 
courses of induction therapy can receive post-remission (“consolidation”) therapy with GCLA 
(i.e. mitoxantrone omitted) for one cycle and high-dose cytarabine (HiDAC) for 2 additional 
cycles. No GO will be given during post-remission therapy.   
 
6.1  
Baseline/pre-treatment assessment 
The following studies should be obtained at baseline before initiation of study therapy to 
establish trial eligibility and allow patient characterization and disease prognostication: 
6.1.1 History and physical examination (assessed within 14 days prior to study day 0). 
6.1.2 Bone marrow examination with morphologic and flow cytometric assessment, 
routine cytogenetic analysis, and molecular testing (e.g. FLT3/ITD, NPM1, 
CEBPA) as appropriate; a bone marrow biopsy should be obtained if spicules are 
absent from the aspirate sample. Bone marrow examination is not required if there 
are immunophenotypically malignant blasts comprising ≥10% of total white 
blood cells in the peripheral blood or pathologically-confirmed extramedullary 
disease as per International Working Group recommendations2,12 (assessed up to 2 
months prior to study day 0). If diagnosis is based on outside diagnostic material, 
submission of peripheral blood specimen for flow cytometric assessment at 
UW/SCCA should be considered to establish leukemia-associated 
immunophenotype. 
6.1.2 Complete blood counts with differential blood count, including immature 
cells/blasts; platelet count (assessed within 14 days prior to study day 0). 
6.1.3 Metabolic panel, including bilirubin, albumin, and creatinine (assessed within 14 
days prior to study day 0). 
6.1.4 MUGA scan or echocardiography, or other appropriate diagnostic modality to 
assess left ventricular ejection fraction (LVEF; assessed within 12 months prior to 
study day 0). 
 
 
 


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6.2 
Pre-treatment 
 
 
At the discretion of the treating physician, allopurinol may be considered in all patients 
without known allergies to allopurinol to reduce the risk of tumor lysis. Patients may receive 
rasburicase, a recombinant urate oxidase, for the prevention and/or treatment of tumor lysis 
syndrome at the discretion of the treating physician. All patients should be adequately hydrated 
and receive anti-emetics as necessary. 
 
6.3 
Administration of GO  
 
 
6.3.1 Patients will receive GO at 1 of two schedules: a single dose of 3 mg/m2 on Day 1 
(GO1) or three doses of 3 mg/m2 on Days 1, 4, 7 (GO3), not to exceed 4.5 mg per 
dose as per 6.3.2. If GO1 is found to be too toxic as per section 16, addition of 
GO to GCLAM will be considered not feasible, and the study will be terminated.  
 
 
6.3.2 The dose of GO is calculated using the patient’s actual weight but will be capped 
at 4.5 mg per dose (equivalent to 1 vial of GO).13 
 
 
6.3.3 The following medications should be used before GO administration as per the 
package label: acetaminophen, benadryl, and/or solumedrol or dexamethasone. 
Demerol may be given if the patient experiences severe chills. GO should be 
infused as per the package label (over approximately 2 hours). 
6.3.4 All treatment is given as intent-to-treat; missed doses will not be made up. 
 
6.4 
Administration of GCLAM 
 
 
6.4.1  The doses of the individual elements of GCLAM chemotherapy will be as 
follows: G-CSF 300 or 480 μg (based on actual weight: <76 kg vs. ≥76 kg) 
subcutaneously daily on Days 0-5; cladribine 5 mg/m2 daily IV over 2 hours on 
Days 1-5; cytarabine 2,000 mg/m2 daily IV over 2 hours on Days 1-5; and 
mitoxantrone 18 mg/m2 daily IV on Days 1-3. Note that we refer to the first day 
of GCLAM chemotherapy as Day +1 for this regimen. Note that day 0 G-CSF is 
often given as outpatient and the remainder of therapy is given as inpatient. Thus, 
a >24 hour delay between day 0 G-CSF and the start of day 1 therapy is allowed. 
 
 
6.4.2 The doses of G-CSF, cladribine, cytarabine, and mitoxantrone are calculated 
using the patient’s actual weight as recorded in the electronic medical record. 
 
 
6.4.3 If WBC >20,000/µL, or if the patient has recently required cytoreductive therapy 
with cytarabine and/or hydroxyurea, Day 0 and Day 1 G-CSF may be omitted at 
provider discretion. 
 
 
6.4.4 Administration in the outpatient clinic can be considered but should be discussed 
with the study investigators. 
6.4.5 All treatment is given as intent-to-treat; missed doses will not be made up. 
6.4.6 For phase 2 only: for patients with FLT3 internal tandem duplication mutations 
(FLT3-ITD) or FLT3 tyrosine kinase domain (FLT3-TKD) mutations, use of 
clinically-available tyrosine kinase inhibitors such as midostaurin or sorafenib on 
published schedules14-16 is allowed. 


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6.4.7 No investigational or commercial agents or therapies other than those described 
herein may be administered with the intent to treat the patient's malignancy.  
 
6.5  
Monitoring during/after induction therapy 
For patient monitoring, the following assessments and study intervals are suggested: 
6.5.1 Complete blood counts with differential blood count, including immature 
cells/blasts, and platelet count at least 3 times weekly until ANC >500/µL and 
self-sustained platelet count >20,000/µL. 
6.5.2 Metabolic panel, including electrolytes (Na, K), bilirubin, ALT/AST, and 
creatinine at least weekly until ANC >500/µL and self-sustained platelet count 
>20,000/µL. 
6.5.3 If patients develop signs or symptoms suggestive of cardiac dysfunction, LVEF 
should be assessed using the same method to evaluate baseline LVEF status 
(MUGA scan or echocardiography, or another appropriate diagnostic modality). 
 
6.6  
Assessment for response after first induction course 
 
 
A bone marrow aspirate should be obtained upon blood count recovery (i.e. ANC 
>1,000/µL and platelet count >100,000/µL) or between Days +25 to +35 after start of GCLAM 
chemotherapy, whichever occurs first. A bone marrow biopsy should be obtained if spicules are 
absent from the aspirate sample. In patients with unclear response status, the bone marrow 
examination should be repeated every 7-10 days until the response can be assessed or until Day 
+42. Responses are defined in section 8.1. 
6.6.1 Achievement of MRD-negative CR: Patients are eligible for consolidation 
chemotherapy, as described in section 6.8. 
6.6.2 Response other than MRD-negative CR: patients are eligible for a second course 
of induction chemotherapy provided all non-hematologic toxicities have resolved 
to Grade <2. Treatment will be with GCLAM (and possibly tyrosine kinase 
inhibitor as per section 6.4.6) at identical doses as given during the first cycle of 
chemotherapy. No GO will be given for re-induction. For patients who 
experienced ≥Grade 3 non-hematologic toxicities during the first induction, a 
dose reduction is recommended as described in section 6.7. 
6.6.3 Persistent severe cytopenias (as defined in section 8.1) without evidence of 
disease after Day +42: Patients will be removed from the treatment portion of the 
protocol.  
 
6.7 
Dose modifications of chemotherapeutic drugs for subsequent treatment cycles 
 
 
The following dose modifications are suggested for subsequent treatment cycles: 
6.7.1 If a patient develops Grade ≥3 non-hematologic toxicity, other than Grade 3 
infections, within 21 days from the last dose of GCLAM, subsequent doses of 
cladribine and cytarabine will be reduced by 25% and dose of mitoxantrone will 
drop by 2 mg/m2.  
The patient may receive future cycles using this dose-reduced regimen if he/she 
demonstrated potential response and once the non-hematologic toxicity has 
resolved to a level of Grade ≤2.  


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If a patient develops Grade ≥3 non-hematologic toxicity, other than Grade 3 
infection, within 21 days from the last dose of the dose-reduced regimen, the dose 
of the cladribine and cytarabine for subsequent cycles will be reduced by 50% and 
the dose of mitoxantrone will drop by 4 mg/m2.  
The patient may receive future cycles using the new dose-reduced regimen, if the 
patient demonstrated potential response and once the non-hematologic toxicity 
has resolved to a level of < Grade 2. If, however, at any time, a patient displays 
Grade ≥3 non-hematologic toxicity other than Grade 3 infections while receiving 
the new dose-reduced regimen, the patient will not be eligible for additional 
therapy as part of the protocol. If patients require treatment interruption of > 21 
days from the planned start of the next cycle, the patient will not be eligible for 
additional therapy on this study.  
 
6.7.2 Mitoxantrone: Consider dose reduction of mitoxantrone by 50% if the bilirubin 
concentration is 1.5-4.5 x IULN. The dose of mitoxantrone will be reduced to 
25% if the bilirubin concentration is >4.5 x IULN.  
 
6.7.3 Cladribine: If the serum creatinine exceeds 2.0 mg/dL and/or estimated creatinine 
clearance (calculated by Cockcroft-Gault) decreases to less than 50 mL/min 
during therapy, we will consider dose reduction in discussion with the Oncology 
Pharmacist. 
 
6.7.4 Cytarabine: If the serum creatinine exceeds 2.0 mg/dL and/or estimated creatinine 
clearance (calculated by Cockcroft-Gault) decreases significantly during therapy, 
dose reduction will be considered in discussion with the Oncology Pharmacist 
and/or attending physician. 
 
6.8 
Post-remission therapy 
After a maximum of 2 cycles of induction therapy, patients are eligible for post-remission 
therapy if CR/CRi is achieved by the end of induction. 
 
 
6.8.1 Patients can receive up to 3 courses of post-remission therapy. No GO will be 
given during consolidation. 
 
 
 
6.8.1.1 The first cycle of post-remission treatment is similar to GCLAM given in 
induction but without mitoxantrone (i.e. G-CSF, cladribine, and cytarabine, 
“GCLA”), provided the patient had <Grade 3-4 non-hematologic toxicity during 
induction. If there was such toxicity, doses should be reduced as described in 
section 6.7. 
 
 
 
6.8.1.2 The second and third cycle of post-remission treatment is given with high-
dose cytarabine alone. Cytarabine should be given as 1,000 mg/m2 every 12 hours 
on days 1-6 for a total of 12 doses. 
 
 
6.8.2 For phase 2 only: for patients with FLT3 internal tandem duplication mutations 
(FLT3-ITD) or FLT3 tyrosine kinase domain (FLT3-TKD) mutations, use of 
clinically-available tyrosine kinase inhibitors such as midostaurin or sorafenib on 
published schedules14-16 is allowed. 
 
 
6.8.3 Post-remission courses should start within 6 weeks of achieving CR/CRp/CRi 
once patients have recovered to ≤Grade 2 toxicities from the previous course of 
therapy. 


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6.8.4 Patients can proceed to transplantation barring contraindications and if a suitable 
donor is available. 
 
6.9  
Supportive Therapy 
 
 
6.9.1 All patients will be adequately hydrated and receive appropriate anti-emetics 
based upon institutional standard of care guidelines. 
 
 
6.9.2 Additional growth factors may be used according to institutional standard of care 
guidelines or the preference of the attending physician.  
 
 
6.9.3 Antimicrobial prophylaxis should be used according to institutional standard of 
care guidelines. In case of neutropenic fever, standard of care diagnostic testing 
will be performed, and empiric antibiotic coverage will be utilized as per standard 
of care institutional practices. 
 
 
6.9.4 Transfusion support should be carried out according to institutional standard of 
care guidelines. 
 
6.10  Treatment of CNS Disease 
 
 
Treatment of CNS disease is done according to institutional practice guidelines or the 
preference of the attending physician.  
 
6.11  Recommended Follow-up Care 
 
 
After completion of protocol treatment or early termination of treatment (see section 
6.12), patients should be evaluated according to institutional and/or national guidelines or the 
discretion of the attending physician. These evaluations may include peripheral blood studies 
and/or bone marrow examinations, as clinically indicated. 
 
6.12  Criteria for removal from treatment prior to completion of protocol treatment 
All reasons for discontinuation of treatment must be documented:   
6.12.1 Consolidation with HCT after achievement of CR or CRi. 
6.12.2 Failure to achieve CR or CRi after up to 2 cycles of induction therapy. 
6.12.3 Persistent severe cytopenias (as defined in section 8.1) without evidence of 
leukemia after Day +42. 
6.12.4 Relapse after achievement of CR or CRi during treatment. 
6.12.5 Adverse toxicities that prevent continuation with study treatment. 
6.12.6 Withdrawal of consent; the patient may withdraw from the study at any time for 
any reason. 
 
7.0  
INFORMATION ON STUDY DRUGS 
 
7.1  
Drug information on G-CSF (granulocyte colony-stimulating factor) 
7.1.1 Mechanism of action: G-CSF is a growth factor that stimulates the production, 
maturation, and activation of neutrophils. Further, it promotes premature release 
of neutrophils from the bone marrow and enhances their phagocytic capacity.  


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7.1.2  Pharmacokinetics: Peak G-CSF concentrations after sub-cutaneous dosing occur 
in 2 to 8 hours, though the onset of action is approximately 24 hours, with plateau 
concentrations in 3-5 days, and elimination over an 11-20 day period. G-CSF is 
cleared by systemic degradation. Notably, as G-CSF binds neutrophils, plasma 
levels are controlled in large part by the absolute neutrophil count.17   
7.1.3  Adverse effects (AEs): Common drug-related AEs (occurring in >10% of 
patients) include fever, petechiae, elevated uric acid, splenomegaly, bone pain, 
and epistaxis.  
Less common drug-related AEs (occurring in 1% -10% of patients) include hyper- 
or hypotension, arrhythmias, headache, nausea, vomiting, leukocytosis, and 
transfusion reaction.  
Infrequent drug-related AEs (occurring in <1% of patients) include acute 
respiratory distress syndrome, allergic reactions, alopecia, alveolar hemorrhage, 
arthralgia, bone density decrease, capillary leak syndrome, cerebral hemorrhage, 
vasculitis, dyspnea, edema, erythema nodosum, hematuria, hemoptysis, 
hepatomegaly, hypersensitivity, injection site reaction, pericarditis, proteinuria, 
psoriasis exacerbation, pulmonary infiltrates, renal insufficiency, sickle cell crisis, 
splenic rupture, Sweet’s syndrome, tachycardia, and thrombophlebitis. 
7.1.4 Recommended dose adjustments for organ dysfunction: There is limited or no 
data examining the toxicity of G-CSF in patients with renal or liver dysfunction. 
Therefore, administration of G-CSF to patients with liver or kidney disease must 
be done with caution. 
 
7.2  
Drug Information on cladribine (2-chloro-2’-deoxyadenosine, 2-CdA) 
7.2.1 Mechanism of action: Cladribine is a prodrug that is converted to an adenosine 
deaminase-resistant triphosphate derivative (2-CdATP). This molecule is then 
activated by deoxycytidine kinase to a 5’-triphosphate derivative (2-CdAMP), 
which is incorporated into DNA where it acts as a transcription regulator. In 
addition to its cytotoxic properties in dividing cells, cladribine induces death in 
quiescent cells of lymphoid origin through an unknown mechanism.18  
7.2.2 Pharmacokinetics: Cladribine is renally excreted, with 18-35% as unchanged 
drug. It is able to penetrate the CSF, where it achieves 25% of plasma 
concentrations. It is 20% protein-bound. The half-life for elimination after a 2-
hour infusion is 6.7±2.5 hours in patients with normal renal function.   
7.2.3 Adverse effects: Common adverse effects (occurring in >10% of patients) include 
fever, fatigue, headache, rash, nausea, anorexia, vomiting, myelosuppression 
(including grade 3/4 neutropenia/thrombocytopenia), injection site reaction, and 
infection.  
Less common adverse effects (occurring in 1 to 10% of patients) include edema, 
tachycardia, thrombosis, chills, dizziness, insomnia, malaise, diarrhea or 
constipation, weakness, myalgias and arthralgias, cough, dyspnea, epistaxis, and 
diaphoresis.  


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Rare adverse effects (occurring in <1% of patients) include aplastic anemia, 
bacteremia, opportunistic infections, lymphocytopenia, altered mental status, 
hemolytic anemia, hypersensitivity, myelodysplastic syndrome, quadriparesis, and 
renal dysfunction/failure. 
7.2.4 Reconstitution: Cladribine is supplied as a sterile, preservative-free, isotonic 
solution containing 10 mg of cladribine (1 mg/mL) in 10 mL single-use vials. 
Cladribine should be passed through a sterile 0.22μm filter prior to introduction 
into the infusion bag containing 0.9% Sodium Chloride Injection, USP. 
7.2.5 Administration and compatibility: The use of 5% dextrose is not recommended as 
a diluent because of increased degradation of cladribine. The infusion solution is 
stable for 24 hours at room temperature. 
7.2.6 Storage and stability: Store refrigerated 2° to 8°C (36° to 46°F). Protect from light 
during storage. 
7.2.7 Recommended dose adjustments for organ dysfunction: Specific guidelines for 
cladribine dosing in patients with hepatic/renal dysfunction or hypoalbuminemia 
are not clearly defined. Because of the potential for compensatory elimination of 
cladribine in patients with hepatic and/or renal dysfunction, specific guidelines for 
dosing are difficult to define. Thus, when deciding whether to adjust cladribine 
doses for renal dysfunction, the risks for potential toxicities (e.g., 
myelosuppression, neurotoxicity) against the benefits and goals of treatment must 
be considered. 
 
7.3 
Drug information on cytarabine (cytosine arabinoside) 
7.3.1  Mechanism of action: Cytarabine is a synthetic pyrimidine analog, in which the 
sugar moiety (normally a ribose or deoxyribose) has been replaced with 
arabinose. Although its mechanism of action is not completely understood, the 
active form of cytarabine is probably incorporated into the DNA and interferes 
with DNA synthesis. As such, cytarabine has been found to primarily effect 
dividing cells, blocking their progression from G1 to S phase.  
7.3.2 Pharmacokinetics: Cytarabine is metabolized by deoxycytidine kinase and other 
kinases into its most active form (aracytidine triphosphate). Aracytidine 
triphosphate is converted to nontoxic uracil derivatives by pyrimidine nucleoside 
deaminases. This balance between the levels of kinases and deaminases is critical 
for regulating the sensitivity/resistance of cells to the drug. The plasma clearance 
of cytarabine is biphasic, with an initial rapid phase and more prolonged second 
clearance phase. The rapid clearance phase has a relatively short half-life (t1/2α = 
10 minutes), while the half- life of the second clearance phase is slightly longer 
(t1/2β = 1-3 hours). The nontoxic metabolites from the drug are excreted in the 
urine, and within 24 hours after the infusion, approximately 80% of these 
nontoxic metabolites can be recovered from the urine.  
7.3.3  Adverse effects: The dose-limiting toxicity for cytarabine is myelosuppression. 
Adverse Events Associated with Standard Dose Cytarabine: Frequent AEs (not 
definitely quantified) include the following: myelosuppression (leucopenia, 
anemia, neutropenia, thrombocytopenia), pyrexia, rash, anorexia, diarrhea, 


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Page 16 of 37 
nausea, vomiting, mucositis, anal inflammation or ulceration, hepatic dysfunction 
or increased liver enzymes, and local thrombophlebitis.  
Less frequent AEs (not definitely quantified) include chest pain, pericarditis, 
dyspnea dizziness, headache, neural toxicity, neuritis, alopecia, pruritis, skin 
freckling, skin ulceration, urticaria, abdominal pain, bowel necrosis, esophageal 
ulceration, esophagitis, pancreatitis, sore throat, urinary retention, 
jaundice/hyperbilirubinemia, local site cellulites, renal dysfunction, allergic 
edema or anaphylaxis, sepsis, and sudden respiratory distress syndrome.  
Infrequent AEs (not definitely quantified) include aseptic meningitis, 
cardiopulmonary arrest, cerebral dysfunction, cytarabine syndrome (bone pain, 
chest pain, conjunctivitis, fever, maculopapular rash, malaise, myalgia), 
exanthematous pustulosis, hyperuricemia, intestinal pneumonitis, increased lipase, 
paralysis with intrathecal and IV combination therapy, rhabdomyolysis, veno-
occlusive disorder, and death.  
Adverse Events Associated with High Dose Cytarabine include cardiomegaly and 
cardiomyopathy, coma, severe neurotoxicity, personality change, somnolence, 
total body alopecia, severe rash or skin desquamation, gastrointestinal ulceration, 
peritonitis, intestinal pneumatosis, necrotizing colitis, liver abscess or damage, 
peripheral neuropathy, corneal toxicity, hemorrhagic conjunctivitis, pulmonary 
edema, sudden respiratory distress syndrome, and sepsis.  
7.3.4 Reconstitution: Cytarabine should be reconstituted in sterile water and can be 
further diluted using either 5% dextrose or sodium chloride solutions into 
appropriate concentrations for infusion.  
7.3.5  Administration and compatibility:  The diluted cytarabine solution should be 
inspected for particulate matter, discoloration, and haze prior to infusion.  If there 
is evidence of particulate matter, discoloration, or haze the solution should not be 
infused. Patients should be medicated with standard anti-emetic therapy. 
Cytarabine is not compatible (1) during Y-site administration with allopurinol, 
amphotericin B, ganciclovir; (2) in syringe with metoclopropamide; or (3) 
admixed with fluorouracil, heparin, insulin (regular), nafcillin, oxacillin, 
penicillin G. Cytarabine may have variable compatibility when admixed with 
gentamycin, hydrocortisone, and methylpredinsone. 
7.3.6 Storage and stability: Vials of non-reconstituted cytarabine should be stored at 
room temperature 15°C - 30°C (59°F - 86°F). The diluted cytarabine solution may 
be stable for up to 48 hours if stored at room temperature.  
7.3.7 Drug-drug interaction: Reversible decreases in the plasma steady-state 
concentration for digoxin and cardiac glycosides may occur. Cytarabine may 
diminish the therapeutic effect of flucytosine. There is ex vivo data suggesting that 
cytarabine may reduce the effectiveness gentamycin for killing K. pneumoniae.  
7.3.8  Warnings and precautions: Ex vivo and in vivo studies have found that cytarabine 
causes extensive chromosomal damage and potential malignant transformation.  
Although there have been some case reports describing cytarabine use in pregnant 
humans, these cases reports are few. Thus, cytarabine is considered Pregnancy 


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Page 17 of 37 
Category D. Women should be advised not to become pregnant while receiving 
cytarabine, and men should be advised not to father a child while receiving 
cytarabine and for at least 3 months after completing the therapy. It is not known 
whether cytarabine or its metabolites are excreted in breast milk; thus, it is not 
recommended for lactating females who are breast-feeding. As with any highly 
immunosuppressive medication, cytarabine may diminish the effectiveness of 
dead and live vaccines and enhance the toxic/adverse effect of live vaccines. One 
should avoid use of live vaccines while receiving it. A small percentage of 
patients will have a hypersensitivity reaction to cytarabine, and these individuals 
should not receive the drug again. 
7.3.9  Recommended dose adjustments for organ dysfunction: Guidelines for adjusting 
cytarabine dose due to renal or liver dysfunction are not standardized, but many 
clinicians will adjust the dose based upon the function of these organs.   
 
7.4 
Drug information on mitoxantrone 
7.4.1 Mechanism of action: Mitoxantrone (dihydroxyanthracenedione) is an 
anthracenedione derivative that intercalates with DNA, resulting in inhibition of 
nucleic acid synthesis.  
7.4.2 Pharmacokinetics: Mitoxantrone is 78% bound to plasma proteins. A three-
compartment model was described after a single intravenous dose of 
mitoxantrone. The mean alpha half-life is 6 to 12 minutes, the mean beta half-life 
is 1.1 to 3.1 hours, and the mean terminal (gamma) or elimination half-life is 23 to 
215 hours (median 75 hours). Mitoxantrone has extensive distribution into body 
tissues and is metabolized in the liver to two main inactive metabolites 
(monocarboxylic acid derivative and dicarboxylic acid derivative). The major 
route of excretion for mitoxantrone appears to be biliary into the feces; 
approximately 11% of the dose is recovered in the urine within 5 days of drug 
administration, with 65% of this being unchanged drug. 
7.4.3 Adverse effects: Common adverse effects (occurring in >10% of patients) include 
edema, fever, fatigue, headache, alopecia, nausea/vomiting, diarrhea, 
mucositis/stomatitis, myelosuppression, weakness, dyspnea, cough, and infection.  
Less common adverse effects (occurring in 1 to 10% of patients) include 
congestive heart failure, decreased left ventricular ejection fraction (LVEF), 
hypertension, chills, anxiety, cutaneous mycosis, hypcalcemia, hypokalemia, 
hyponatremia, menorrhagia, jaundice, myalgia, arthralgia, renal failure, 
proteinuria, rhinitis, diaphoresis, and infection.  
 
Mitoxantrone may cause cardiac toxicity with prolonged administration and doses 
exceeding 80 to 100 mg/m2. When used after doxorubicin, cardiotoxicity is more 
frequent; an analysis by the Southwest Oncology Group revealed a risk of 6% at 
134 mg/m2 prior doxorubicin and 60 mg/m2 mitoxantrone, rising to a 15% risk at 
120 mg/m2 mitoxantrone. Cardiac events reported included arrhythmias, 
decreased left ventricular function, chronic heart failure, tachycardia, ECG 
changes, and, infrequently, myocardial infarction. Bradycardia has been rarely 
reported. Patients with prior treatment with anthracyclines, prior mediastinal 


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Page 18 of 37 
radiotherapy, or with preexisting cardiovascular disease may have more frequent 
occurrences of cardiac toxicity. 
7.4.4 Reconstitution: Mitoxantrone must be diluted prior to use. The dose of 
mitoxantrone should be to at least 50 mL with either 0.9% Sodium Chloride 
Injection (USP) or 5% Dextrose Injection (USP). Mitoxantrone may be further 
diluted into Dextrose 5% in Water, Normal Saline or Dextrose 5% with Normal 
Saline and used immediately.  
7.4.5 Administration and compatibility: Care in the administration of mitoxantrone will 
reduce the chance of extravasation. Mitoxantrone should be administered into the 
tubing of a freely running intravenous infusion of 0.9% Sodium Chloride 
Injection, USP or 5% Dextrose Injection, USP.  Care should be taken to avoid 
extravasation at the infusion site and to avoid contact of mitoxantrone with the 
skin, mucous membranes, or eyes. If any signs or symptoms of extravasation have 
occurred, including burning, pain, pruritis, erythema, swelling, blue discoloration, 
or ulceration, the injection or infusion should be immediately terminated and 
restarted in another vein. 
 
Mitoxantrone should not be mixed in the same infusion as heparin since a 
precipitate may form. 
7.4.6 Storage and stability: Mitoxantrone should be stored between 15°C - 25°C (59°F - 
77°F). 
 
7.5 
Drug information on GO 
7.5.1  Mechanism of action: GO is directed against the CD33 antigen expressed by 
hematopoietic cells; binding of the CD33 antibody portion with the antigen results 
in the formation of a complex that is internalized. Upon internalization, the 
calicheamicin derivative is released inside the lysosomes of the myeloid cell. The 
released calicheamicin derivative binds to DNA in the minor groove resulting in 
DNA double strand breaks and cell death. 
7.5.2 Human pharmacokinetics: After administration of a first 9 mg/m2 dose of GO, 
given as a 2-hour infusion, the elimination half-lives of total and unconjugated 
calicheamicin were about 41 and 143 hours, respectively. After the second 9 
mg/m2 dose, the half-life of total calicheamicin was increased to about 64 hours 
and the area under the concentration-time curve (AUC) was about twice that in 
the first dose period. The AUC for the unconjugated calicheamicin increased 30% 
after the second dose. Age, gender, body surface area (BSA), and weight did not 
affect the pharmacokinetics of GO. Patients, especially patients previously treated 
with stem cell transplantation, have an underlying risk of sinusoidal obstruction 
syndrome (SOS; previously known as veno-occlusive disease [VOD]). The AUC 
of total calicheamicin was correlated with additional risk of hepatomegaly and the 
risk of SOS. No pharmacokinetic studies have been performed after 
administration of a 3 mg/m2 dose of GO. 
7.5.3 Hypersensitivity reactions: GO administration can result in severe 
hypersensitivity reactions (including anaphylaxis), and other infusion-related 
reactions which may include severe pulmonary events. Infrequently, 
hypersensitivity reactions and pulmonary events have been fatal. In most cases, 


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Page 19 of 37 
infusion-related symptoms occurred during the infusion or within 24 hours of 
administration of GO and resolved. GO infusion should be interrupted for patients 
experiencing dyspnea or clinically significant hypotension. Patients should be 
monitored until signs and symptoms completely resolve. Discontinuation of 
further GO treatment should be strongly considered for patients who develop 
anaphylaxis, pulmonary edema, or acute respiratory distress syndrome. Patients 
with high peripheral blast counts may be at greater risk for such reactions. 
7.5.4  Human toxicology: The following toxicities have been observed in patients aged 
≥60 years (n=157) treated with GO at 9 mg/m2, generally given as two 
intravenous infusions separated by 14 days (the side effect profile of GO given at 
3 mg/m2 has not been studied in detail): abdominal pain 26%, asthenia 36%, back 
pain 12%, chills 64% (NCI grade 3 or 4 toxicity: 11%), fever 78% (13%), 
headache 27%, infection 10%, neutropenic fever 19%, pain 18%, sepsis 25% 
(15%), hemorrhage 9%, hypertension 17%, hypotension 18%, tachycardia 11%, 
anorexia 27%, constipation 23%, diarrhea 30%, dyspepsia 8%, gum hemorrhage 
5%, liver function test abnormalities 20% (7%), nausea 63%, stomatitis 22%, 
vomiting 53%, anemia 22% (12%), ecchymosis 11%, leukopenia 43% (43%), 
petechiae 19%, thrombocytopenia 49% (48%), alkaline phosphatase elevation 
10%, bilirubinemia 11%, hyperglycemia 11%, hypocalcemia 10%, hypokalemia 
24%, hypomagnesemia 3%, hypophosphatemia 6%, LDH elevation 18%, 
peripheral edema 19%, myalgia 3%, anxiety 10%, depression 10%, dizziness 
10%, insomnia 11%, increased cough 18%, dypsnea 26% (10%), epistaxis 24%, 
pharyngitis 10%, pneumonia 13%, abnormal pulmonary physical findings 8%, 
rhinitis 7%, herpes simplex skin infection 18%, pruritus 4%, rash 18%, 
metrorrhagia 2%, vaginal hemorrhage 5%, local reaction 17%.  
7.5.5 Formulation: Powder for injection: 4.5 mg. 
7.5.6 Storage and stability: The drug product is light sensitive and must be protected 
from direct and indirect sunlight and unshielded fluorescent light during the 
preparation and administration of the infusion. Vials are stored under refrigeration 
2° to 8°C or 36° to 46°F.  
7.5.7 Reconstitution: All preparation should take place in a biologic safety hood with 
shielded fluorescent light. Contents of each vial are reconstituted with 5 mL 
Sterile Water for Injection, USP, using sterile syringes, by gently swirling each 
vial. Each vial should be inspected for complete dissolution of the drug. The final 
concentration of the reconstituted drug solution is 1 mg/mL. Reconstituted vials 
may be stored under refrigeration for up to 2 hours.  
7.5.8 Dilution and compatibility: An admixture corresponding to 3 mg/m2 dose of GO 
is prepared by injecting the reconstituted solution into a 100 mL 0.9% sodium 
chloride injection solution in either a polyvinyl chloride (PVC) or 
ethylene/polypropylene copolymer (non-PVC) IV bag covered by an ultraviolet 
(UV) light protector. GO should only be diluted with 0.9% sodium chloride 
solution, and must not be diluted with any other electrolyte solutions or 5% 
dextrose or mixed with other drugs. Diluted GO may be stored under refrigeration 
for up to 16 hours.  
7.5.9  Administration: Once the reconstituted GO is diluted into the IV bag containing 
normal saline, the resulting solution should be infused over a 2-hour period. GO 


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Page 20 of 37 
may be given peripherally or through a central line. During the infusion, only the 
IV bag needs to be protected from light. An in-line, low protein binding filter 
must be used for the infusion of GO. The following filter membranes are 
qualified: 0.22 μm or 1.2 μm polyether sulfone (PES); 1.2 μm acrylic copolymer 
hydrophilic filter; 0.8 μm cellulose mixed ester (acetate and nitrate) membrane; 
0.2 μm cellulose acetate membrane. GO must not be co-administered with other 
drugs through the same infusion line. Premedication, consisting of acetaminophen 
and diphenhydramine, should be given before each infusion to reduce the 
incidence of a post-infusion symptom complex. The infusion must be completed 
within 20 hours of initial reconstitution of the drug. 
 
 
8.0  
EVALUATION AND END POINT DEFINITIONS 
 
8.1 
Treatment response and outcome 
Treatment response (e.g. morphologic/cytogenetic/molecular complete remission, partial 
remission) or treatment failure (e.g. resistant disease, morphologic leukemia-free state, 
morphological or molecular/cytogenetic relapse) as well as treatment outcome (e.g. overall 
survival, relapse-free survival, event-free survival, and remission duration) are categorized 
according to criteria recommended by International Working Groups.2,12 Since persistent severe 
cytopenias are not defined per International Working Groups, here we define persistent severe 
cytopenias as ANC<200/µL AND platelets <20,000/µL (self-sustained without transfusion) 
without evidence of leukemia on bone marrow aspirate beyond day +42 after therapy. 
 
8.2 
Toxicity criteria 
 
 
This study will use the CTCAE (NCI Common Terminology Criteria for Adverse Events) 
Version 5.0 for Toxicity and Adverse Event reporting. A copy of the CTCAE v5.0 can be 
downloaded from the CTEP home page (http://ctep.cancer.gov). Only grade ≥3 adverse events 
other than hematologic toxicities will be graded and recorded. 
 
8.3  
Definition of dose-limiting toxicities (DLTs) 
Reported adverse events and potential risks for G-CSF, cladribine, cytarabine, 
mitoxantrone, and GO are described in section 7. Dose-limiting toxicities (DLTs) used for trial 
monitoring are defined as follows and apply only to cycle 1 of therapy: 
8.3.1 Any Grade 3 non-hematologic toxicity lasting >48 hours that results in >7-day 
delay of the subsequent treatment cycle, with the exception of febrile neutropenia 
or infection or toxicities secondary to febrile neutropenia or infection. 
8.3.2 Any Grade ≥4 non-hematologic toxicity except febrile neutropenia/infection (or 
toxicities secondary to febrile neutropenia or infection) unless felt to be a direct 
consequence of treatment-related toxicity (e.g. intestinal infection following 
mucosal barrier breakdown), and with the exception of constitutional symptoms if 
recovery to Grade ≤2 within 14 days. 
 
 
 


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8.4 
Multi-parameter flow cytometric detection of MRD 
Patients are routinely assessed for the presence of MRD as detected by multi-parameter 
flow cytometry,19-22 as per institutional practice and any measurable level of MRD will be 
considered positive.19-22  
 
8.5 
Quantification of CD33 expression on AML blasts and normal myeloid cells 
 
 
In patients with pretreatment bone marrow and/or peripheral blood specimens analyzed in 
the UW/SCCA Hematopathology laboratory, CD33 expression on AML blasts as well as on 
normal myeloid cells (monocytes, granulocytes) will be quantified by multi-parameter flow 
cytometry both as percentage of CD33+ cells as well as median CD33 fluorescence intensity. 
 
8.6 
Duration of cytopenias 
 
 
The duration of neutropenia and thrombocytopenia will be determined as time from day 1 
of treatment until an absolute neutrophil count of 500 or a self-sustained platelet count of 50,000 
is reached, respectively. Time to achievement of absolute neutrophil count >1,000/µL and 
platelet count >100,000/µL will also be recorded. 
 
8.7 
Duration of follow-up 
 
 
After removal from protocol, patients will be followed to determine event-free survival 
and disease-free survival (for patients achieving CR or CRi) as well as overall survival (for all 
patients) for a maximum of 5 years. Follow-up may include periodic (e.g. every 3 months) 
review of medical records, and, only if absolutely necessary, direct contact of the study 
participant. 
 
9.0  
RECORDS 
Research data will be recorded in a study-specific, password protected database using a 
unique study ID for each patient to assure patient confidentiality. Data from source documents 
will be transcribed into this database. Source documents are documents where patient data are 
recorded and documented for the first time. They include, but are not limited to, hospital records, 
clinical and office charts, laboratory notes, memoranda, quality of life assessments, pharmacy 
dispensing records, recorded data from automated instruments, copies of transcriptions that are 
certified after verification as being accurate and complete, X-rays, patient files, and records kept 
at the pharmacy, laboratories, and medico-technical departments involved in the clinical trial. 
There will be no case reports forms (CRFs) used for this trial. 
 
The Principal Investigator will ensure that data collected conform to all established guidelines. 
Each subject is assigned a unique subject number to protect subject confidentiality. Subjects will 
not be referred to by this number, by name, or by any other individual identifier in any 
publication or external presentation. The licensed medical records department, affiliated with the 
institution where the subject receives medical care, maintains all original inpatient and outpatient 
chart documents. Patient research files will be maintained under control of the Principal 
Investigator and/or study team and kept in a locked office or file room within a secure 
building. Access to the study database will be restricted by electronic password protection and 
restricted access to computers (i.e., locked offices). 
 
 
 


Protocol 10000 
 
 
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10.0 CORRELATIVE STUDIES 
Trial participants will be encouraged to participate in correlative studies. From patients 
who agree to providing biospecimens for correlative research (opt-in/out option in consent form), 
extra bone marrow and/or peripheral blood specimens will be collected at baseline before 
initiation of study therapy and at various time points throughout the study when marrow/blood 
specimens are obtained for routine clinical reasons and then stored in a study-specific sample 
repository located at Fred Hutchinson Cancer Research Center. See Appendix C for instructions 
on specimen preparation. 
 
 


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11.0 PROTOCOL ENROLLMENT AND SPECIAL CONSIDERATIONS 
All eligible patients will be included in this study without regard to gender or ethnicity. 
The incidence of AML is slightly higher in men, so it is expected that the distribution of these 
patients will reflect a slight male predominance of the disease as well as the general demographic 
distribution of AML patients seen at our institution. Based on our statistical approach, we will 
require no more than 60 patients treated at the MTD to compare with patients treated historically 
at our institution with GCLAM. Depending on DLTs observed in the phase 1 portion, up to an 
additional 12 patients may be treated for a maximum possible patient accrual of 72 patients. 
 
Projected Target Accrual 
ETHNIC AND GENDER DISTRIBUTION CHART 
 
TARGETED / PLANNED ENROLLMENT:  Number of Subjects = 72 
 
Ethnic Category 
 
Sex / Gender 
 
Females 
Males 
Total 
Hispanic or Latino 
2 
4 
6 
Not Hispanic or Latino 
27 
39 
66 
Ethnic Category Total of All Subjects* 
29 
43 
72 
 
Racial Categories 
American Indian/Alaska Native 
0 
1 
1 
Asian 
2 
2 
4 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
1 
3 
4 
White 
25 
37 
62 
Other/More Than One Race/Unknown 
0 
1 
1 
Racial Categories: Total of All Subjects* 
28 
44 
72 
 
 
12.0  GUIDELINES FOR SERIOUS ADVERSE EVENT REPORTING 
 
12.1  Expedited reporting requirements 
In accordance with Fred Hutch/UW Cancer Consortium IRB policy, all adverse events 
(AEs; whether occurring on-site or off-site), which in the opinion of the principal investigator 
(PI) are (1) unexpected, and (2) related or possibly related to the research, and (3) serious or 
suggests that the research places research participants or others at a greater risk of physical or 
psychological harm than was previously known or recognized, will be submitted to the IRB 
within ten (10) calendar days of learning of the problem. Both the “Expedited Reporting Form 
for Unanticipated Problems or Noncompliance” and the “Adverse Event Reporting Form”, or 
equivalent forms, will be completed for this reporting.  


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12.2 
Definitions 
12.2.1 Adverse event (AE): Any harm or untoward medical occurrence in a research 
participant administered a medical product, medical treatment or procedure even 
if it does not necessarily have a causal relationship with the product, treatment, or 
procedure. An adverse event can be any unfavorable and unintended sign 
(including an abnormal laboratory finding, for example), symptom, or disease 
temporally associated with the use of a medical product, medical treatment, or 
procedure whether or not considered to be related. Mechanisms of obtaining 
information on AE include monthly transcripts, assessment forms obtained after 
each clinic visit, and hospital progress and discharge notes. Grade ≥3 adverse 
events other than hematologic toxicities will be recorded, graded, and reported as 
appropriate. While grade >=3 hematologic AEs are anticipated and are thus not 
recorded, we will record duration of cytopenias as well as episodes of febrile 
neutropenia. Medical conditions present before treatment are not AEs and should 
not be recorded. On the other hand, pre-existing conditions that worsen during 
treatment will be recorded. 
12.2.2 Related or possibly related AE: An AE is “related or possibly related to the 
research procedures” if in the opinion of the principal investigator, it was more 
likely than not caused by the research procedures. AEs that are solely caused by 
an underlying disease, disorder or condition of the subject or by other 
circumstances unrelated to either the research or any underlying disease, disorder 
or condition of the subject are not “related or possibly related”. If there is any 
question whether or not an AE is related or possibly related, the AE should be 
reported. 
12.2.3 Serious AE (SAE): An adverse event that results in any of the following 
outcomes: 
• Death 
• Life-threatening adverse event (real risk of dying)  
• Prolongation of hospitalization* 
• Persistent or significant disability/incapacity/or change in psychosocial status 
• Congenital anomaly 
• Requires intervention to prevent permanent impairment of damage 
*Hospitalization itself will not be considered a serious adverse event if required 
for complications of AML or comorbid conditions. Hospitalization will be 
considered a SAE if it fulfills the criteria for a serious and unexpected adverse 
event as otherwise described. 
12.2.4 Unexpected AE: An unexpected adverse event is defined as an event that has a 
nature or severity, or frequency that is not consistent (a) the known or foreseeable 
risk of adverse events associated with the research procedures described in the 
protocol-related documents, such as the IRB-approved research protocol, 
informed consent document and other relevant sources of information such as 
product labeling and package inserts; and also are not consistent with (b) the 
characteristics of the subject population being studied including the expected 
natural progression of any underlying disease, disorder or condition or any 
predisposing risk factor profile. with the applicable investigator brochure, or the 


Protocol 10000 
 
 
Page 25 of 37 
prior medical condition of the subject or other treatment given to the subject. 
“Unexpected,” as used in this definition, refers to an adverse drug experience that 
has not been previously observed and reported in preclinical or clinical studies 
rather than an experience that has not been anticipated based on the 
pharmacological properties of the study drug. 
 
12.3 
Grading adverse event severity 
All AEs will be graded in severity according to the NCI Common Terminology Criteria 
for Adverse Events (CTCAE) Version 5.0 (http://ctep.cancer.gov). If a CTCAE criterion does 
not exist, the investigator should use the grade or adjectives: Grade 1 (mild), Grade 2 (moderate), 
Grade 3 (severe), Grade 4 (life-threatening), or Grade 5 (fatal) to describe the maximum intensity 
of the adverse event.  
 
12.4 
Monitoring, recording, and standard reporting of adverse events 
Only grade ≥3 adverse events (AEs) other than hematologic toxicities will be recorded, 
graded, and reported as appropriate per 12.1. AEs will be collected only for the first cycle 
treatment as detailed in 12.5. If a subject decides to terminate the study early the medical record 
will continue to be followed for AEs for up to 4 weeks after initial response assessment or a new 
anti-leukemia therapy is started, whichever occurs first.  
 
Adverse events that do not meet the requirement for expedited reporting will be reported to the 
IRB as part of the annual renewal of the protocol. Myelosuppression and associated 
complications are expected events during leukemia therapy; therefore, myelosuppression and 
associated complications such as fever, infections, bleeding, and related hospitalizations will not 
be reported as individual AE but will be summarized in the annual report to the IRB.  
 
12.5 
Adverse event recording period 
AEs will be monitored and recorded in the study database only for the first cycle of 
therapy since this represents the only experimental therapy. Patients will be monitored from the 
time of first exposure to the therapy in this study (i.e., the start of the first drug administration 
infusion on day 0 or day 1) until the start of the second cycle of therapy is initiated, or until 1 
month following the initial response assessment, whichever is sooner. AEs with an onset date 
prior to the first exposure to an investigational product will not be recorded. However, in the case 
of clinically significant worsening of the AE during the specified AE monitoring time frame, the 
AE will be recorded.  
 
 
13.0.  DATA AND SAFETY MONITORING PLAN 
Institutional support of trial monitoring will be in accordance with the Fred 
Hutch/University of Washington Cancer Consortium Institutional Data and Safety Monitoring 
Plan (DSMP). Under the provisions of this plan, Fred Hutch Clinical Research Support (CRS) 
coordinates data and compliance monitoring conducted by consultants, contract research 
organizations, or Fred Hutch employees unaffiliated with the conduct of the study. Independent 
monitoring visits occur at specified intervals determined by the assessed risk level of the study 
and the findings of previous visits per the institutional DSMP. In addition, protocols are 
reviewed at least annually and as needed by the Consortium Data and Safety Monitoring 


Protocol 10000 
 
 
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Committee (DSMC), Fred Hutch Scientific Review Committee (SRC) and the Fred Hutch 
/University of Washington Cancer Consortium Institutional Review Board (IRB). The review 
committees evaluate accrual, adverse events, stopping rules, and adherence to the applicable data 
and safety monitoring plan for studies actively enrolling or treating subjects. The IRB reviews 
the study progress and safety information to assess continued acceptability of the risk-benefit 
ratio for human subjects. Approval of committees as applicable is necessary to continue the 
study. The trial will comply with the standard guidelines set forth by these regulatory committees 
and other institutional, state and federal guidelines. 
 
 
14.0  INVESTIGATOR OBLIGATIONS 
The Principal Investigator (PI) is responsible for the conduct of the clinical trial at the site 
and is responsible for personally overseeing the treatment of all study subjects. The PI must 
assure that all study site personnel, including sub-Investigators and other study staff members, 
adhere to the study protocol and to all applicable regulations and guidelines regarding clinical 
trials both during and after study completion. All subjects are informed of the nature of the 
program, its possible hazards, and their right to withdraw at any time, and each subject signs a 
form indicating their consent to participate prior to receiving any study-related procedures. 
 
 
15.0  ADMINISTRATIVE AND REGULATORY CONSIDERATIONS 
 
15.1  Protocol interpretation and compliance 
The procedures defined in the protocol are carefully reviewed by the PI and his/her staff 
prior to the time of study initiation to ensure accurate representation and implementation. 
Protocol amendments, if any, are reviewed and implemented promptly following IRB/EC and 
relevant Competent Authorities approval. 
 
15.2  Ethical considerations 
The Investigator agrees to conduct this study in accordance with applicable United States 
FDA clinical trial regulations and guidelines, the ICH (E6) GCP guidelines, the IRB/EC and 
local legal requirements and with the Declaration of Helsinki (1989). The Investigator will 
conduct all aspects of this study in accordance with all national, state, and local laws of the 
applicable regulatory agencies. 
 
15.3  Informed consent 
The PI and qualified designees assume the responsibility of obtaining written Informed 
Consent for each subject or the subject’s legally authorized representative before any study-
specific procedures are performed. Subjects meeting the criteria set forth in the protocol will be 
offered the opportunity to participate in the study. To avoid introduction of bias, the Investigator 
must exercise no selectivity with regard to offering eligible subjects the opportunity to 
participate in the study. Subjects or parents/legal guardians of all candidate subjects will receive 
a comprehensive explanation of the proposed treatment, including the nature of the therapy, 
alternative therapies available, any known previously experienced adverse reactions, the 
investigational status of the study drug, and other factors that are part of obtaining a proper 
Informed Consent. Subjects will be given the opportunity to ask questions concerning the study, 


Protocol 10000 
 
 
Page 27 of 37 
and adequate time to consider their decision to or not to participate. Informed Consent will be 
documented by the use of a written Consent Form that includes all the elements required by FDA 
regulations and ICH guidelines. The form is to be signed and dated by the subject or subject's 
legally authorized representative and by the person who administers the consent process. A copy 
of the signed form will be given to the person who signed it, the original signed Consent Form 
will be filed with the subject’s medical records, and copy maintained with the subject’s study 
records. If an amendment to the protocol changes the subject participation schedule in scope or 
activity, or increases the potential risk to the subject, the Informed Consent Form must be 
amended. Any amended Informed Consent must be approved by the IRB/EC prior to use. The 
revised Informed Consent Form must be used to obtain re-consent from any subjects currently 
enrolled in the study if the subject is affected by the amendment, and must be used to document 
consent from any new subjects enrolled after the approval date of the amendment. 
 
15.4  Institutional Review Board/Ethics Committee 
The PI will assure that an appropriately constituted IRB/EC that complies with the 
requirements of 21 CFR Section 56 or written assurance of compliance with ICH (E6) guidelines 
will be responsible for the initial and continuing review and approval of the clinical study. 
Before initiation of the study, the PI or designee will forward copies of the protocol and Consent 
Form to be used for the study to the IRB/EC for its review and approval. The PI or designee will 
also assure that all changes in the research activity and all unanticipated problems involving risks 
to human subjects or others will be reported promptly to the IRB/EC, and that no changes will be 
made to the protocol without prior IRB/EC approval, except where necessary to eliminate 
apparent immediate hazards to human subjects. The Investigator or designee will be responsible 
for submitting periodic progress reports to the IRB/EC at intervals appropriate to the degree of 
subject risk involved in the study, but not less than once per year and at the completion or 
termination of the study. 
 
15.5  Publication statement 
The results of this clinical trial may be used for public dissemination in the form of 
papers, abstracts, posters, or other informational materials to be presented at scientific meetings, 
or published in professional journals, or as a part of an academic thesis by an investigator. 
Identifiable patient data may not be used for any of these presentations, manuscripts, or reports 
unless directed by law.  
 
 
16.0  STATISTICAL CONSIDERATIONS  
 
16.1 
Phase 1 Statistical Considerations 
DLTs are defined in Section 8.3. Only DLTs occurring during Cycle 1 will be used to 
guide dose escalation. However, before the phase 2 portion is begun, all grade 3 and 4 adverse 
events of all patients treated in the phase 1 portion will be reviewed to assess for late and 
cumulative toxicities that were not captured during the DLT observation period. The Principal 
Investigator reserves the right to select a recommended phase 2 dose lower than the MTD if the 
drug doses identified in the phase 1 portion of this assessment suggest a significant risk of 
late/cumulative toxicities. Patients will be considered evaluable for DLT if they received at least 
75% of the assigned doses of each chemotherapeutic during Cycle 1 or if they developed a DLT. 


Protocol 10000 
 
 
Page 28 of 37 
If a patient does not develop a DLT but does not receive at least 75% of treatment during Cycle 
1, the patient will be considered not evaluable for DLT and will be replaced. The dose escalation 
scheme to define the maximum tolerated dose (MTD).  
 
The dose escalation scheme is as follows: 
 
A. Evaluate 6 patients at GO1 
• If 0/6 or 1/6 have DLT, change to GO3 and move to (B)  
• If 2 have DLT, declare GO1=MTD and expand cohort to 12 patients and reassess: 
if ≤4/12 have DLT, proceed with GO1 as MTD, otherwise terminate study, 
concluding that GO cannot be added to GCLAM chemotherapy. 
• If ≥3/6 have DLT, terminate study, concluding that GO cannot be added to 
GCLAM chemotherapy. 
B. Evaluate 6 patients at GO3   
• If ≤2/6 patients have DLT, expand cohort to 12 patients and reassess: if ≤4/12 
have DLT, move forward with GO3 as MTD; if >4/12 have DLT, decrease 
schedule to GO1, expand GO1 cohort to 12 patients, and reassess: if ≤4/12 have 
DLT, declare GO1 R2PD. If >4/12 have DLT, terminate study. 
• If ≥3/6 have DLT, decrease schedule to GO1, expand GO1 cohort to 12 patients, 
and reassess: if ≤4/12 have DLT, declare GO1 MTD. If >4/12 have DLT, 
terminate study. 
 
Once the MTD has been determined, all toxicities for all dose levels will be reviewed.  If the 
regimen is considered safe, additional patients be treated at the MTD for the Phase 2 portion of the 
trial. 
 
16.2 
Phase 2 Statistical Considerations 
The primary Phase 2 objective will be to evaluate 6-month event-free survival (EFS) at the 
MTD. EFS will be measured from the date of study registration to the first of: off protocol 
therapy without a response (morphologic complete remission [CR] with or without measurable 
residual disease [MRD]; best response of CR without complete count recovery will be 
considered an event), relapse from a response, or death from any cause with patients last known 
to be alive without event censored at the date of last contact. The primary endpoints will be 6-
month and 1-year EFS (both binary).  For the primary endpoints, patients censored before 6 
months or 1-year (as appropriate) will be considered a failure. If censoring occurs, secondary 
analyses analyzing 6-month or 1-year EFS accounting for censoring will be done, including 
estimating 6-month and 1-year EFS using the Kaplan-Meier method. 
 
Patients treated at the MTD from the Phase 1 portion of the trial will be used in the Phase 2 
analysis. Patients with newly-diagnosed AML previously treated at our institution with GCLAM 
had a 6-month EFS of 68% and 1-year EFS of 60% (null hypothesis).  We are interested in 
whether the proposed regimen can improve 6-month EFS to 81% and/or improve 1-year EFS to 
73% (alternative hypothesis).  
 
A two-stage design will be used to evaluate the Phase 2 six-month EFS endpoint.  The first stage 
of the 2 design will evaluate 30 patients.  If 20 or more of the first 30 patients are alive without 


Protocol 10000 
 
 
Page 29 of 37 
event at 6-months after study registration, an additional 30 patients will be enrolled. If 46 or 
more of the 60 patients treated at the MTD are alive and without event at 6-months after study 
registration, we will consider the regimen of interest for further investigation. If 45 or fewer 
patients treated that the MTD have an EFS event before 6-months after study registration, we 
will additionally evaluate 1-year EFS motivated by prior research with GO showing late-
emerging benefits of the addition of GO.6 If 42 or more patients are alive without event at 1 year, 
we will consider the regimen of interest for further investigation. Accrual will not be held while 
waiting for outcome data for the first-stage analysis.  This design has a one-sided type-1 error 
rate of 13% and a power of 95%.  Under the null hypothesis of 6-month EFS = 68%, the 
probability we stop the trial based the first stage evaluation is 35%.  Under the alternative 
hypothesis of 6-month EFS = 81%, the probability we stop accrual after the first stage is 2%. 
Under the alternative hypothesis, the probability of considering the regimen of interest for further 
investigation based on 6-month EFS is 84% and under the null hypothesis is 9%.   
 
16.3 
Secondary objectives 
Remission rates, MRD rates, and toxicity rates will be estimated and 95% confidence intervals 
will be calculated.  Event-free survival, relapse-free survival, and overall survival will be 
estimated using the Kaplan-Meier method.  Time to relapse will be estimated using non-
parametric estimates of the cumulative incidence curve with death analyzed as a competing 
event.  Regression models (logistic regression for binary endpoints, Cox regression for time-to-
event endpoints [Cox models for the hazard of the subdistribution for events with competing 
risks]) will be used to compare outcomes with patients who have received GCLAM without GO 
at our institution, controlling for measured prognostic factors.   
 
 
17.0 STUDY TERMINATION 
 
The study will terminate as described in section 16.0. The Principal Investigator reserves 
the right to terminate this study at any time.  
 
 


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18.0  REFERENCES 
1. 
Dohner H, Weisdorf DJ, Bloomfield CD. Acute Myeloid Leukemia. N Engl J Med. 
2015;373(12):1136-1152. 
2. 
Dohner H, Estey E, Grimwade D, et al. Diagnosis and management of AML in adults: 
2017 ELN recommendations from an international expert panel. Blood. 2017;129(4):424-447. 
3. 
Price SL, Lancet JE, George TJ, et al. Salvage chemotherapy regimens for acute myeloid 
leukemia: Is one better? Efficacy comparison between CLAG and MEC regimens. Leuk Res. 
2011;35(3):301-304. 
4. 
Halpern AB, Othus M, Huebner EM, et al. Phase 1/2 trial of GCLAM with dose-
escalated mitoxantrone for newly diagnosed AML or other high-grade myeloid neoplasms. 
Leukemia. 2018;32(11):2352-2362. 
5. 
Godwin CD, Gale RP, Walter RB. Gemtuzumab ozogamicin in acute myeloid leukemia. 
Leukemia. 2017;31(9):1855-1868. 
6. 
Hills RK, Castaigne S, Appelbaum FR, et al. Addition of gemtuzumab ozogamicin to 
induction chemotherapy in adult patients with acute myeloid leukaemia: a meta-analysis of 
individual patient data from randomised controlled trials. Lancet Oncol. 2014;15(9):986-996. 
7. 
Burnett A, Cavenagh J, Russell N, et al. Defining the dose of gemtuzumab ozogamicin in 
combination with induction chemotherapy in acute myeloid leukemia: a comparison of 3 mg/m2 
with 6 mg/m2 in the NCRI AML17 Trial. Haematologica. 2016;101(6):724-731. 
8. 
Walter RB, Othus M, Borthakur G, et al. Prediction of early death after induction therapy 
for newly diagnosed acute myeloid leukemia with pretreatment risk scores: a novel paradigm for 
treatment assignment. J Clin Oncol. 2011;29(33):4417-4423. 
9. 
Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health 
Organization classification of myeloid neoplasms and acute leukemia. Blood. 
2016;127(20):2391-2405. 
10. 
Walter RB. Should acute myeloid leukemia patients with actionable targets be offered 
investigational treatment after failing one cycle of standard induction therapy? Curr Opin 
Hematol. 2016;23(2):102-107. 
11. 
Chen X, Xie H, Wood BL, et al. Relation of clinical response and minimal residual 
disease and their prognostic impact on outcome in acute myeloid leukemia. J Clin Oncol. 
2015;33(11):1258-1264. 
12. 
Cheson BD, Bennett JM, Kopecky KJ, et al. Revised recommendations of the 
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(24):4642-4649. 
13. 
FDA. FDA approves Mylotarg for treatment of acute myeloid leukemia. Vol. 2018; 2017. 


Protocol 10000 
 
 
Page 31 of 37 
14. 
Stone RM, Mandrekar SJ, Sanford BL, et al. Midostaurin plus Chemotherapy for Acute 
Myeloid Leukemia with a FLT3 Mutation. N Engl J Med. 2017;377(5):454-464. 
15. 
Schlenk RF, Weber D, Fiedler W, et al. Midostaurin added to chemotherapy and 
continued single-agent maintenance therapy in acute myeloid leukemia with FLT3-ITD. Blood. 
2019;133(8):840-851. 
16. 
Rollig C, Serve H, Huttmann A, et al. Addition of sorafenib versus placebo to standard 
therapy in patients aged 60 years or younger with newly diagnosed acute myeloid leukaemia 
(SORAML): a multicentre, phase 2, randomised controlled trial. Lancet Oncol. 
2015;16(16):1691-1699. 
17. 
Carton E, Bellesoeur A, Mir O. Colony-stimulating factors for febrile neutropenia. N 
Engl J Med. 2013;369(3):285-286. 
18. 
Reiss AL, Aylward E, Freund LS, Joshi PK, Bryan RN. Neuroanatomy of fragile X 
syndrome: the posterior fossa. Ann Neurol. 1991;29(1):26-32. 
19. 
Walter RB, Gooley TA, Wood BL, et al. Impact of pretransplantation minimal residual 
disease, as detected by multiparametric flow cytometry, on outcome of myeloablative 
hematopoietic cell transplantation for acute myeloid leukemia. J Clin Oncol. 2011;29(9):1190-
1197. 
20. 
Wood BL. Principles of minimal residual disease detection for hematopoietic neoplasms 
by flow cytometry. Cytometry B Clin Cytom. 2016;90(1):47-53. 
21. 
Araki D, Wood BL, Othus M, et al. Allogeneic hematopoietic cell transplantation for 
acute myeloid leukemia: time to move toward a minimal residual disease-based definition of 
complete remission? J Clin Oncol. 2016;34(4):329-336. 
22. 
Zhou Y, Othus M, Araki D, et al. Pre- and post-transplant quantification of measurable 
('minimal') residual disease via multiparameter flow cytometry in adult acute myeloid leukemia. 
Leukemia. 2016;30(7):1456-1464. 
 


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APPENDIX A: TREATMENT-RELATED MORTALITY (TRM) SCORE 
 
Calculation of Simplified Treatment-Related Mortality (TRM) Score 
 
Includes covariates: performance status (PS), age, platelet count, albumin, secondary AML, 
white blood cell count (WBC), peripheral blood blast percentage, and creatinine 
 
Score = 100/(1+e(-x)), with x = -4.08 + 0.89*PS + 0.03*age - 0.008*platelet count - 0.48*albumin 
+ 0.47*(have secondary AML) + 0.007*WBC - 0.007*(peripheral blood blast percentage) + 
0.34*creatinine 
 
 
Probability of TRM Above and Below Various Simplified TRM Score Cut-offs 
TRM Score 
Interval 
Patients below/ 
within/above TRM 
Score Interval (%) 
TRM Probability if 
below TRM Score 
Interval (%) 
TRM 
Probability if 
within TRM 
Score Interval 
(%) 
TRM 
Probability if 
above TRM 
Score Interval 
(%) 
0 – 1.9 
0/20/80 
- 
1 
12 
1.91 – 3.9 
20/20/60 
1 
2 
16 
3.91 – 6.9 
40/20/40 
1 
7 
20 
6.91 – 9.2 
60/10/30 
3 
7 
24 
9.21 – 13.1 
70/10/20 
4 
12 
31 
13.11 – 22.8 
80/10/10 
5 
20 
41 
22.81 – 100 
90/10/0 
6 
41 
- 
 
From: Walter RB, Othus M, Borthakur G, Ravandi F, Cortes JE, Pierce SA, Appelbaum FR, 
Kantarjian HM, Estey EH. Prediction of early death after induction therapy for newly diagnosed 
acute myeloid leukemia with pretreatment risk scores: a novel paradigm for treatment 
assignment. J Clin Oncol. 2011;29(33):4417-4424.  
 
 
 


Protocol #10000 
 
 
Page 33 of 37 
APPENDIX B: RESEARCH SUBJECT REGISTRATION FORM 
 
Protocol 10000 Patient Demographics and Eligibility Form 
Please fax this completed form to 
 for patient registration. 
Questions regarding eligibility should go to Roland B. Walter, pager: 
 or Colin D. Godwin, pager: 
 
 
 
UPN#:_____________________________________ 
 
Patient Name:  
___________________  
_____________ 
___ 
 
 
 
Last 
 
 
 
First 
 
 
MI 
Date of Birth:    
___  ___/___ ___/ ___ ___ ___ ___ 
 
 
 
Month     Day          Year 
 
Planned starting day of treatment: ___  ___/___ ___/ ___ ___ ___ ___ 
 
 
 
 
 
Month     Day          Year 
 
 
Ethnicity (choose one): instruct the patient to select one of the following: 
 
  Hispanic or Latino  (A person of Cuban, Mexican, Puerto Rican, South or Central American, or 
other Spanish culture or origin, regardless of race). Term “Spanish Origin” can also be used in addition to 
“Hispanic” or “Latino”  
 
 
 
  Not Hispanic or Latino 
 
 
 
  Declined to Report 
 
Race (check all that apply): instruct the patient to select one or more of the following: 
 
  American Indian/Alaska Native  (A person having origins in any of the original peoples of 
North, Central, or South America, and who maintains tribal affiliations or community attachment)  
 
 
  Asian  (A person having origins in any of the original peoples of the Far East, Southeast, Asia, or the 
Indian subcontinent including, for example, Cambodia, China, India Japan, Korea, Malaysia, Pakistan, the 
Philippine Islands, Thailand and Vietnam) 
  Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of 
Hawaii, Guam, Samoa or other Pacific Islands) 
 
 
 
  Black/African American (A person having origins in any of the black racial groups of Africa.   
  White  (A person having origins in any of the original peoples of Europe, the Middle East or North 
Africa) 
 
 
 
 
 
  Research Subject does not know race 
 
 
  Declined to Report 
 
Gender: 
 
  Male 
 
 
 
  Female 
  Unknown 
 
 
 
 
 
 
 
 
ATTACH SIGNED CONSENT AND HIPAA AUTHORIZATION FORMS, AND SEND TO PRINCIPAL INVESTIGATOR FOR 
REGISTRATION. 


Protocol #10000 
 
 
Page 34 of 37 
APPENDIX B cont’d 
Protocol FH #10,000 Eligibility 
 
I) Inclusion Criteria:   
Each of the following questions (1-10) must be marked "Yes" for the patient to enroll on Protocol 
FH #10,000  
 
1)  Yes 
 No 
 
Patient signed and dated consent form 
           
 
 
Date:  ___________  
 
2)   Yes 
 No 
 
Patient signed and dated HIPAA authorization 
 
3)   Yes 
 No 
 
Age ≥18 years 
 
4)   Yes 
 No 
 
Diagnosis of untreated “high-risk” myeloid neoplasm (≥10% blasts in blood or 
bone marrow) or AML other than acute promyelocytic leukemia (APL). 
 
5)   Yes 
 No 
 
Treatment-related mortality (TRM) score ≤13.1 as calculated by simplified 
 
 
model available at https://cstaging.fhcrc-research.org/TRM 
 
Age: 
WBC: 
Date: 
Secondary AML 
 YES    
 NO 
Creatinine: 
Date: 
Platelets: 
Date: 
% PB Blasts:                     Date: 
Albumin: 
Date: 
Performance Status:         Date: 
TRM score: 
 
 
 
6)   Yes 
 No 
 
No prior therapy for AML other than hydroxyurea or prior low-intensity therapy 
for low-grade hematologic disorder. Patients with symptoms/signs of 
hyperleukocytosis or WBC>100,000/μL can be treated with leukapheresis or 
may receive up to 2 doses of cytarabine (up to 500 mg/m2/dose) prior to 
enrollment 
 
7)   Yes 
 No 
 
Bilirubin ≤2.5 x Institutional Upper Limit of Normal (IULN) unless elevation is  
 
 
 
 
thought to be due to hepatic infiltration by AML, Gilbert’s syndrome, or  
 
 
 
 
hemolysis (assessed within 14 days prior to study day 0) 
 
8)   Yes 
 No 
 
Serum creatinine ≤2.0 mg/dL (assessed within 14 days prior to study day 0) 
 
9)   Yes 
 No 
 
Left ventricular ejection fraction ≥45%, assessed within 12 months prior to 
 
 
 
 
study day 0, e.g. by MUGA scan or echocardiography, or other appropriate  
 
 
 
 
diagnostic modality and no clinical evidence of congestive heart failure.  
  
10)  Yes 
 No 
 
Women of childbearing potential and men must agree to use adequate  
       N/A 
  
 
contraception. 


Protocol #10000 
 
 
Page 35 of 37 
II) Exclusion Criteria:    
The following question (11-16) must be marked "No" for the patient to enroll on Protocol FH 
#10,000  
 
11)  Yes 
 No 
 
Myeloid blast crisis of chronic myeloid leukemia (CML), unless patient is not  
 
 
 
 
considered candidate for tyrosine kinase inhibitor treatment 
 
12)  Yes 
 No 
 
Concomitant illness associated with a likely survival of <1 year 
 
13)  Yes 
 No 
 
Active systemic fungal, bacterial, viral, or other infection, unless disease is  
 
 
 
 
under treatment with anti-microbials and/or controlled or stable (e.g. if specific,  
 
 
 
 
effective therapy is not available/feasible or desired [e.g. chronic viral hepatitis,  
 
 
 
 
HIV]).  
 
14)  Yes 
 No 
 
Known hypersensitivity to any study drug 
 
15)  Yes 
 No 
 
Confirmed or suspected pregnancy or active breast feeding. 
 
16)  Yes 
 No 
 
Treatment with any other investigational anti-leukemia agent. In phase 2, 
treatment with a tyrosine kinase inhibitor for patients with FLT3-mutated AML is permissible. 
 
 
 
 
 
 
 
 
 
 
Name of person completing form:_______________________________________________ 
 
Signature of Study Investigator:__________________________________Date:___________       
 
 
 


Protocol #10000 
 
 
Page 36 of 37 
 
 
FAX COVER LETTER 
 
 
DATE:______________________________ 
 
 
TO: Roland B. Walter or Colin D. Godwin 
 
 
 
RE: RESEARCH SUBJECT REGISTRATION FORM 
PROTOCOL FH #10,000 
 
FROM:____________________________________ 
 
FAX:______________________________________ 
 
PHONE:___________________________________ 
 
 
 
 
 
 
 
 
THE INFORMATION CONTAINED IN THIS TRANSMISSION IS INTENDED ONLY FOR THE ADDRESSEE OR THE ADDRESSEE’S 
AUTHORIZED AGENT.  THE FAX CONTAINS INFORMATION THAT MAY BE PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM 
DISCLOSURE.  IF THE READER OF THE MESSAGE IS NOT THE INTENDED RECIPIENT OR RECIPIENT’S AUTHORIZED AGENT THEN 
YOU ARE NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS INFORMATION IS PROHIBITED. 
 
IF YOU HAVE RECEIVED THIS INFORMATION IN ERROR, PLEASE NOTIFY THE SENDER BY TELEPHONE, AND RETURN THE 
ORIGINAL AND ANY COPIES OF THE MESSAGE BY MAIL TO THE SENDER AT FRED HUTCHINSON CANCER RESEARCH CENTER, 
1100 FAIRVIEW AVE N.  LF-229, SEATTLE, WA 98109 
 
 
 
 


Protocol #10000 
 
 
Page 37 of 37 
APPENDIX C: GENERAL SPECIMEN SUBMISSION INSTRUCTIONS 
 
As secondary objectives of this study (see sections 2 and 10), in vitro correlative studies will be 
performed. For this purpose, pre-treatment peripheral blood and bone marrow specimens will be 
collected and stored in a study-specific repository at Fred Hutch. 
 
D.1.  Labeling 
All submitted specimens must be labeled with the protocol number (FH #10000), source 
of material (i.e. bone marrow or peripheral blood), study-specific patient number, patient’s 
initials, and date/time of specimen collection. 
 
D.2.  Guidelines for transport 
 
D.2.1  The specimen must be wrapped in an absorbable material. 
D.2.2  The specimen must be placed in an airtight container (e.g., ziplock bag), which 
must be marked as “BIOHAZARD”. 
 
D.2.3 Store and send samples at room temperature. Send fresh to the Walter laboratory: 
 
 
 
 
Contact person: Colin D. Godwin, MD, pager 
 
colindg@uw.edu 
 
D.2.5 Saturday or Sunday deliveries are not permissible. 
D.2.6 Send each specimen individually on the day of its collection; maximum time from 
sample collection to shipment should be no greater than 24 hours. Exceptions: 
- 
Samples collected on weekends or holidays should be shipped the first 
working day following collection 
 
D.3.  Specimens for laboratory studies and banking 
D.3.1 Submission of a pre-treatment peripheral blood sample is strongly requested if the 
patient has agreed to participate in correlative studies.  
D.3.1.1 
10 mL of PERIPHERAL BLOOD collected into preservative-free 
heparin (green top tubes) or EDTA (purple top tubes). 
D.3.2 Submission of a pre-treatment bone marrow sample is strongly requested if a bone 
marrow aspirate/biopsy is obtained for routine clinical purposes and if the patient 
has agreed to participate in correlative studies 
D.3.2.1 
4-5 mL of BONE MARROW; use approximately 0.2 mL 
preservative-free heparin (green top tube) or EDTA (purple top 
tubes) for 4-5 mL of bone marrow per tube. 
D.3.2.2 
If marrow is not aspirable (“dry tap”), submit 10 mL of peripheral 
blood only. 
 
If the amounts specified cannot be obtained on any individual patient, then please 
send the actual sample obtained and as many studies as possible will be done. 

ICF_003.pdf: 
A Single-Center Phase 1/2 Study of Single- or 
Fractioned-Dose Gemtuzumab Ozogamicin in 
Combination with G-CSF, Cladribine, Cytarabine 
and Mitoxantrone (GCLAM) for Previously 
Untreated Adult Acute Myeloid Leukemia or 
High-Grade Myeloid Neoplasm 
Short title: Gemtuzumab ozogamicin plus GCLAM for AML 
NCT03531918 
April 10, 2019