Clinical trial NCT03600909
Conditions: Fanconi Anemia Myelodysplastic Syndrome (MDS) Acute Myelogenous Leukemia (AML)
Keywords: Blood Stem Cell Transplant busulfan cyclophosphamide fludarabine 17-498
Sponsor: Memorial Sloan Kettering Cancer Center
Start date: 2018-05-15; Completion date: 2021-04-09
Enrollment: 3 participants; Allocation: NON_RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The goal of this study is to see if the study therapy can decrease the chemotherapy-related side effects while maximizing the effectiveness of disease control. The physicians will also be studying the effect of removing T-cells from the donor"s stem cells before transplant. T-cells are a type of white blood cell that may help cause a serious side effect of transplant called Graft versus Host Disease (GVHD). The way it removes the T-cells from the donor stem cells is actually by selecting only the stem cells (called CD34 cells) by using a device called CliniMACS. This process is called CD34 selection. The CliniMACS® device is currently under the supervision of the FDA .

Detailed description:

Arms: arm 1: Patients 18 years old or younger with marrow aplasia or single lineage cytopenias (Arm A) will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.6-0.8 mg/Kg/dose q 12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 4 doses). arm 2: Patients 18 years old or younger with MDS or AML will be will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.8-1.0mg/Kg/dose q 12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 4 doses). arm 3: Patients 19 years old or older with marrow aplasia or MDS or AML will be will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.4mg/Kg/dose q 12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 4 doses).
Interventions: intervention 1: Busulfan intervention 2: Fludarabine intervention 3: Cyclophosphamide intervention 4: Anti-Thymocyte Globulin (Rabbit) intervention 5: The CliniMACS device intervention 6: G-CSF
Intervention descriptions: intervention 1: A standard dose of busulfan, associated with excellent outcomes in our previous trial will be used for young patients with marrow aplasia (arm A).

A higher dose of busulfan will be used in younger patients with MDS and AML (arm B) to maximize disease control.

A lower dose of busulfan will be used in older patients (arm C) to minimize toxicity. intervention 2: Arms A, B and C - Fludarabine will be given IV over 30 minutes daily for 4 days. The dose will be adjusted according to renal function according to Institutional guidelines. intervention 3: Arms A, B and C - Cytoxan will be given as a 1-2 hour infusion for 4 days. The dose will be adjusted according to patients ideal body weight for obese patients. intervention 4: Arms A, B and C - 4 doses will be given prior to transplant to promote engraftment intervention 5: The source of stem cells for all patients will be peripheral blood stem cells (PBSC) induced and mobilized by treatment of the donor with G-CSF for 4-6 days. T-cell depletion will be uniformly performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device) intervention 6: All patients will also receive G-CSF post-transplant to foster engraftment.

Protocol documents:
Prot_SAP_000.pdf: 
Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 1 of 55 
 
 
 
 
 
A  Phase II Trial of Hematopoietic Stem Cell Transplantation 
for the Treatment of Patients with Fanconi Anemia Lacking a 
Genotypically  Identical Donor, Using a Risk-Adjusted 
Chemotherapy Only Cytoreduction with Busulfan, 
Cyclophosphamide  and Fludarabine 
PROTOCOL FACE PAGE FOR 
MSK THERAPEUTIC/DIAGNOSTIC  PROTOCOL 
Principal 
Investigator/Department: 
Farid Boulad, M.D. 
Pediatrics 
Co-Principal 
Investigator(s)/Department: 
Maria Cancio, M.D. 
Pediatrics 
Investigator(s)/Department: 
Jaap Jan Boelens, M.D., Ph.D. 
Susan Prockop, M.D. 
Kevin Curran, M.D. 
Nancy Kernan, M.D. 
Andrew Kung, M.D., Ph.D 
Andromachi Scaradavou, M.D. 
Barbara Spitzer, M.D. 
Cheryl Goss, M.D. 
Jennifer Bieler, RN 
Victoria Szenes, NP 
Adlynn Parado, RN 
Melissa Varda, RN 
Pediatrics Pediatrics 
Pediatrics Pediatrics 
Pediatrics Pediatrics 
Pediatrics 
Laboratory Medicine 
Nursing 
Nursing 
Nursing 
Nursing 
Consenting 
Professional(s)/Department: 
Farid Boulad, M.D. 
Maria Cancio, M.D. 
Jaap Jan Boelens, M.D., Ph.D. 
Susan Prockop, M.D. 
Kevin Curran, M.D. 
Nancy Kernan, M.D. 
Andrew Kung, M.D., Ph.D 
Andromachi Scaradavou, M.D. 
Barbara Spitzer, M.D. 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
Pediatrics 
 
 
Please Note: A Consenting Professional must have completed the mandatory Human 
Subjects Education and Certification Program. 
 
 
Participating Institutions: 
PI's Name 
Site's Role 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 2 of 55 
 
 
 
 
Cincinnati Children’s  Hospital 
Medical Center 
Parinda Mehta, MD 
Data Collection/Data 
Coordinating  Center 
FRED HUTCHINSON 
CANCER CENTER 
K. Scott Baker, MD 
Data Collection 
OneMSK  Sites 
Manhattan 
 
Memorial Sloan Kettering Cancer Center 
1275 York Avenue 
New York, New York 10065 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 3 of 55 
 
 
 
Table of Contents 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA .......................................................................... 5 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS ................................................................................... 7 
3.0 
BACKGROUND AND RATIONALE ......................................................................................... 7 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ...................................................................... 10 
4.1 
Design .................................................................................................................................... 10 
4.2 
Intervention ................................................................................................................................... 10 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS ............................................................................... 12 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY .................................................................................. 17 
6.1 
Subject Inclusion Criteria ........................................................................................................ 17 
6.2 
Subject Exclusion Criteria ....................................................................................................... 19 
7.0 
RECRUITMENT PLAN ........................................................................................................................ 19 
8.0 
PRETREATMENT EVALUATION .......................................................................................... 20 
9.0 
TREATMENT/INTERVENTION PLAN ................................................................................... 21 
9.1. 
Preparative Cytoreduction ........................................................................................................... 21 
9.2 
Immunosuppressive Therapies ........................................................................................................ 23 
9.3 
Stem Cell Collection ................................................................................................................... 25 
10.0 
EVALUATION  DURING TREATMENT/INTERVENTION AND POST-TRANSPLANT  
PERIOD ................................................................................................................................................ 29 
11.0 
TOXICITIES/SIDE EFFECTS ......................................................................................................... 30 
12.0 
Primary Outcomes CRITERIAFOR THERAPEUTIC RESPONSE/OUTCOME 
ASSESSMENT ................................................................................................................................ 34 
13.0 
CRITERIA FOR REMOVAL FROM STUDY ........................................................................... 35 
15.0 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES ... 37 
15.1 Research Participant Registration ............................................................................................. 37 
15.2 
Randomization ....................................................................................................................... 37 
16.0 
DAT A M ANAGEMENT ISSUES ............................................................................................ 37 
16.1 
Quality Assurance .................................................................................................................. 38 
16.2 
Data and Safety Monitoring ......................................................................................................... 38 
17.0 
PROTECTION OF HUMAN SUBJECTS ................................................................................ 39 
17.1 
Privacy ................................................................................................................................... 39 
17.2 
Serious Adverse Event (SAE) Reporting .................................................................................... 40 
17.2.1  Serious Adverse Event (SAE) Reporting Additional Information ......................................... 41 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 4 of 55 
 
 
18.0 
INFORMED CONSENT PROCEDURES ....................................................................................... 41 
19.0 
REFERENCES .......................................................................................................................... 42 
20.0 
APPENDICES ....................................................................................................................... 45 
Appendix 1 ..................................................................................................................................... 47 
Appendix 2 ..................................................................................................................................... 48 
Performance Scores ...................................................................................................................... 48 
Appendix 3 ................................................................................................................................ 49 
Appendix 4 ..................................................................................................................................... 52 
Appendix 5 ..................................................................................................................................... 55 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 5 of 55 
 
 
 
 
 
1.0     PROTOCOL SUMMARY AND/OR SCHEMA 
 
The trial proposed is a three-arm phase II treatment protocol designed to examine engraftment, 
toxicity, graft-versus-host disease, and disease-free survival following a novel cytoreductive regimen 
including busulfan, cyclophosphamide and fludarabine and ATG for the treatment of patients with 
Fanconi anemia who have severe aplastic anemia (SAA), or myelodysplastic syndrome (MD S) or 
acute myelogenous leukemia (AML), lacking HLA-genotypically identical donors using stem cell 
transplants derived from HLA-compatible unrelated donors or HLA haplotype-mismatched related 
donors.  Therapy will be risk-adapted according to recipient age and stage of marrow disease. 
 
Candidates for this trial will include patients with Fanconi anemia who have severe aplastic anemia 
(transfusion dependent) or myelodysplastic syndrome, or acute myelogenous leukemia for whom an 
allogeneic stem cell transplant is indicated. 
 
SCHEMA 
 
 
Good Risk Patients: Arm A: Patients 18 years old or younger with marrow aplasia or single lineage 
cytopenias will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.6-0.8 
mg/Kg/dose q 12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine 
(35mg/m2/day x 4 doses). This strategy lead to survival rates > 90% in our prior study. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 6 of 55 
 
 
 
Age and weight-based Busulfan dosing: 
< 10 kg: 0.6 mg/kg/dose as a starting dose q 12 hours x 4 doses 
≥ 10 kg but ≤ 4 years old: 0.8 mg/kg/dose as a starting dose q 12 hours x 4 doses 
> 4 years: 0.6 mg/kg/dose as a starting dose q 12hours x 4 doses 
Busulfan pharmacokinetics will not be used in this good risk arm receiving a low dose of Busulfan. 
 
 
Intermediate risk patients: Arm B: Patients 18 years old or younger with MDS or AML will be will be 
conditioned for transplantation with intravenous busulfan (busulfex®) (0.8-1.0mg/Kg/dose q 12 hours 
x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 4 doses). 
A higher dose of busulfan will be used as this has been well-tolerated in younger patients with FA 
when used in conjunction with PK, and we will test whether this higher dose improves disease control, 
as these patients are at risk of relapse. 
 
The busulfan dose will be modified by recipient age and weight as described below: 
 
Age and weight-based Busulfan dosing: 
< 10 kg: 0.8 mg/kg/dose as a starting dose q 12 hours x 4 doses 
≥ 10 kg but ≤ 4 years old: 1.0 mg/kg/dose as a starting dose q 12 hours x 4 dos es 
> 4 years: 0.8 mg/kg/dose as a starting dose q 12hours x 4 doses 
Busulfan pharmacokinetics WILL be used in this arm, as the dose of busulfan is higher, to ensure that 
the Css after the first dose of busulfan does not exceed 350. 
 
 
High risk patients: Arm C: Patients 19 years old or older with marrow aplasia or MDS or AML 
will be will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.4mg/Kg/dose q 
12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 
4 doses). In our previous studies older patients had increased toxicity from transplant, and in this study 
we will test whether outcomes can be improved, yet engraftment maintained, with a reduced dose of 
busulfan. No age or weight adjustment is needed for arm C patients as all cases will be over 4 years 
old and weigh more than 10kg. 
All  Patients (Arms  A,  B and C) All  patients  will also receive rabbit  ATG (thymoglobulin®)  (2.5 
mg/Kg/dose x 4 doses) prior to transplant to promote engraftment. Cyclosporine will NOT be used for 
prophylaxis against GvHD. All patients will also receive G-CSF post-transplant to foster engraftment. 
The source of stem cells for all patients will be peripheral blood stem cells (PBSC) induced and 
mobilized by treatment of the donor with G-CSF as per institutional guidelines. T-cell depletion will be 
performed by positive CD34 selection with the use of the Miltenyi system (CliniMACS device). The 
CD34+peripheral blood progenitors will then be administered to the patients after they have completed 
cytoreduction. 
 
Patients will be carefully monitored for engraftment, chimerism, incidence and severity of acute and 
chronic GvHD, regimen-related toxicity, characteristics of hematopoietic and immune reconstitution 
and survival and disease-free survival. 
 
This phase II trial is designed to investigate the safety and efficacy of a risk-adjusted chemotherapy- 
based cytoreductive regimen plus a CD34+ selected T-cell depleted peripheral blood stem cell (PBSC) 
stem cell transplant for the treatment of patients with Fanconi anemia and severe hematologic disease. 
The study population will include two types of donors: (1) HLA-compatible unrelated donors, and (2) 
HLA–mismatched related donors. Donor preference will be determined as per institutional practice. 
 
A total of up to approximately 10 participants at MSK will enter into this study over a period of 4 years. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 7 of 55 
 
 
 
 
 
In order to reduce patient risk, the study design includes early termination in the event of excessive 
graft failure, grade 3-4 acute graft-versus-host disease or severe chronic graft-versus host disease, or 
early transplant related mortality during the accrual period. Stopping rules will be utilized. 
 
See below for approximate schema of cytoreduction and preparation for allogeneic PBSCT: 
 
 
 
 
 
2.1 
OBJECTIVES AND SCIENTIFIC AIMS 
 
 
Objectives 
The primary objectives of this trial are to establish: 
1. The incidence and quality of engraftment and hematopoietic reconstitution. 
2. The incidence of early transplant related mortality 
3. The incidence and severity of acute GvHD and chronic GVHD. 
 
Secondary objectives of this study are to establish estimates of: 
1. The incidences of overall survival and disease-free survival 2 years after transplant 
 
 
3.0     BACKGROUND AND RATIONALE 
 
Background 
Fanconi anemia (FA) is a genetic disease characterized by chromosome fragility, multiple birth 
defects, and an increased risk for hematopoietic disorders and solid tumors (1-2). Progressive bone 
marrow failure results in aplasia, myelodysplasia and/or leukemia (3). When an HLA-matched sibling 
is identified, stem cell transplantation using cytoreduction with low doses of radiation and 
chemotherapy has been successful in curing the hematologic manifestations of FA (4-17). The 
chromosome fragility of FA and its hypersensitivity to DNA cross-linking agents and radiation had for 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 8 of 55 
 
 
 
 
some time limited the ability to perform marrow transplantation using donors other than HLA-matched 
siblings (18-20). In the context of alternative donors such as unrelated marrow donors or cord blood, 
the use of a similar cytoreduction was associated with high rates of rejection/graft failure and GvHD, 
resulting in poor overall survival (21-29). 
 
Since the first report of marrow transplantation for FA in 1977 (4), approximately 200+ recipients of 
marrow transplants from HLA-matched siblings have been reported; the risk of rejection has been less 
than 10%, the risk of developing acute and/or chronic GvHD has been approximately 45%, and 69% 
of patients are alive disease-free (4-17). More recent studies however have shown improved results 
(80%) when transplants have been performed in younger patients, with fewer prior transfusions (11). 
 
Approximately 110 patients with FA were initially reported who received stem cell transplants from 
closely matched unrelated donors; 69 reported to the European Group for Blood and Marrow 
Transplantation and approximately 40 in the US (21-28). A proportion of these transplants were T-cell 
depleted for the prevention of GvHD. Overall, there was an increased risk of rejection of 17-37%, risks 
of grade II-IV GvHD and of chronic GvHD were as high as 50%, and only one third of the patients 
were alive at the time of the reports. The cytoreduction used in the majority of these transplants 
consisted of low dose TBI (450-600 cGy) (TBI), and cyclophosphamide (Cy) (10 mg/Kg x 4) with the 
addition of ATG, steroids, and cyclosporine A. In an analysis of 49 patients with FA who received stem 
cell transplants from unrelated donors reported by 12 centers, the incidence of acute GvHD grades II- 
IV was 52% in conventional grafts and 29% in T-cell-depleted grafts (23). Using elutriation to deplete 
T-cells the Minnesota group observed a 32% incidence of grade II-IV acute GvHD in 20 transplanted 
patients (28). 
 
Guardiola et al. (26) using CD34+ selection (ISOLEX) to T-cell deplete FA unrelated bone marrow, 
observed an incidence of only 15% II-IV grade acute GvHD. However, two of the 16 patients died of 
acute GvHD. Graft rejection has also been a major problem for unrelated donor transplants for FA. In 
those patients receiving T-cell-depleted transplants, the incidence of graft failure was 20-37% (22, 23, 
28). The presence of lymphocyte mosaicism (i.e. presence of DEB insensitive cells) was associated 
with a significant increased risk of graft failure (28). Escalation of TBI from 450 cGy (standard FA dose) 
to 600 cGy did not decrease the risk of graft rejection in the most recent Minnesota trial (28). In all of 
the unrelated donor trials for patients with FA, infectious mortality has been significant. In a Minnesota 
trial of 29 FA MUD transplants, eight patients succumbed to invasive Aspergillus infection despite 
aggressive antifungal therapy (28). 
 
Based on the results cited above, the problems associated with stem cell transplants for FA were: 
immune complications, including graft-versus-host disease (GvHD), graft rejection, infections,  and 
organ toxicity. The challenges to the optimization of stem cell transplants for Fanconi anemia using 
alternative donors were thus based on the need for (1) a regimen immunosuppressive enough to allow 
engraftment, with a low risk of rejection, (2) a regimen for stem cell processing (T-cell depletion) that 
can decrease the risk of GvHD, and (3) a regimen that does not give rise to excessive toxicity in 
children with FA. 
 
Three groups in the US including the University of Minnesota, Cincinnati Children’s Hospital and 
Memorial Sloan-Kettering Cancer Center have pioneered new regimens that included low dose total 
body irradiation, cyclophosphamide, ATG and the addition of fludarabine followed by T-cell depleted 
marrow or peripheral blood stem cell transplants (29-31). All three centers have had promising results 
with minimal risks of graft rejection, low rates of graft-versus-host disease and overall promising 
disease-free survival. However, with the small numbers of patients with FA who undergo allogeneic 
stem cell transplants,  results of  single  center  trials  are  difficult  to  interpret  in  terms of  optimal 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 9 of 55 
 
 
 
cytoreductive regimens and dosing. In addition, T-cell depletion methods were also different in all 
three centers. 
 
Moreover, the use of TBI in these studies also poses additional concerns with respect to widespread 
adoption of one of these approaches. It is possible (based on risks of secondary malignancies in non- 
FA patients) that irradiation plays some role in the increased risk of secondary malignancies in FA 
patients. To date, a significant number of patients with FA surviving stem cell transplantation have 
developed solid tumors (32-35). These solid tumors are mostly squamous cell carcinomas. The 
relative contributions of TBI and chronic GvHD to the development of such tumors are unknown. 
However, the elimination of TBI coupled with T-cell depletion to prevent GVHD is  an attractive 
approach to reducing long term adverse effects. 
 
In our prior multi-center study of transplant for FA we used a regimen of busulfan, fludarabine, ATG 
and cyclophosphamide together with a T-cell depleted graft to treat adults and children with Fanconi 
anemia. The study included matchedand mismatchedunrelated donors and non-genoidentical related 
donors. In this study we treated an initial 25 cases using a dose of busulfan of 0.8-1.0 mg/kg/dose. 
Outcomes at this dose level were good and the dose of busulfan was decreased to 0.6-0.8mg/kg/dose 
with the goal of reducing toxicity in the next 20 cases enrolled. 
 
The outcomes of this study, as of September 2013 are summarized below. Notably, persons aged 
less than 18 years with aplastic anemia had a survival rate of 91%, an outstanding result. As a result 
of these good outcomes, our goal for this good risk population in this successor study is toxicity 
reduction, using a lower dose of busulfan than we have previously studied, and omitting cyclosporine 
post-transplant. 
 
Survival 
% 
OS and DFS 
74.40% 
DFS by age (p = .026) 
< 10 years  old (N=26) 
88.50% 
> 10 years  old  (N=11 incl pts olderthan 20) 
46.80% 
DFS by Hematologic disease (p = .190) 
MDS (N=9) 
61.00% 
SAA/SISLC (N=28) 
79.30% 
DFS by Donor (p = .240) 
Matched Unrelated  (N=21) 
84.00% 
Mismatched related or unrelated (N=15) 
56.10% 
DFS by BU dose given  (p = .856) 
0. 8 mg/kg 
73.40% 
0.6 mg/kg 
80.00% 
 
Children with MDS remained at risk of relapse. In this successor study we will give the intial higher 
dose of busulfan that we know is tolerable from our first cohort of patients (0.8-1.0 mg/kg/dose), and 
will also omit cyclosporine post-transplant to maximize donor T-cell recovery. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 10 of 55 
 
 
 
 
 
In our first study, we have observed that brisk host lymphocyte expansion can occur in the immediate 
post-transplant period, with an associated fall in donor chimerism, raising the possibility of graft 
rejection. Lymphocyte expansion can be remedied and full donor chimerism restored with 
subcutaneous (SC) Campath administration. Weekly chimerism studies will be performed in this 
successor study to monitor for this complication. 
 
 
Rationale 
 
The purpose of the use of busulfan is to avoid the use of TBI and possibly decrease the risk of 
secondary malignancies. 
 
Cyclophosphamide / fludarabine and ATG combination is used because these drugs were successful 
in our recent trial, with limited toxicity and decreased risks of rejection. 
 
We are using peripheral blood stem cells as the stem cell source to achieve high doses of stem cells 
in order to prevent graft rejection and maximize immune reconstitution. CD34-selected stem cells 
(which are highly T cell depleted) are used to minimize the risks of GVHD. 
 
 
4.1 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
 
4.2 
Design 
 
The trial proposed is a three arm phase II treatment protocol designed to examine engraftment, 
toxicity, graft-versus-host disease, and ultimate disease-free survival following a novel risk-adjusted 
cytoreductive regimen including busulfan, cyclophosphamide and fludarabine and ATG for the 
treatment of patients with Fanconi anemia lacking HLA-genotypically identical donors using stem cell 
transplants derived from HLA-compatible unrelated donors or  HLA  haplotype-mismatched related 
donors. Candidates for this trial will include patients with Fanconi anemia and severe aplastic anemia 
(transfusion dependent) or myelodysplastic syndrome, or acute myelogenous leukemia for whom an 
allogeneic stem cell transplant is indicated. 
 
This phase II trial is designed to investigate the safety and efficacy of risk-adjusted chemotherapy- 
based cytoreductive regimen plus a CD34+ selected T-cell depleted peripheral blood stem cell (PBSC) 
stem cell transplant for the treatment of patients with Fanconi anemia and severe hematologic disease. 
The majority of patients will receive grafts derived from PBSC from HLA-compatible unrelated donors 
and HLA–mismatched related donors and will be the focus of the trial. 
 
The primary objectives of this trial are to establish (1) the incidence and quality of engraftment and 
hematopoietic reconstitution, (2) the incidence of early transplant related mortality, (3) the incidence 
and severity of acute GvHD and chronic GVHD, and (4) the probability of overall survival and disease- 
free survival over time. 
 
4.3 
Intervention 
 
A prospective phase II trial is proposed. Patients with FA who lack an HLA-genotypically matched 
related donor and have severe hematologic disorders will be eligible to receive CD34+ selected, T cell 
depleted  allogeneic  hematopoietic  stem cell  transplants  after  chemotherapy-based cytoreduction 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 11 of 55 
 
 
 
using intravenous busulfan, cyclophosphamide, fludarabine and rabbit ATG. Stem cells will be 
collected from (1) HLA-compatible unrelated donors, or (2) non genoidentical related donors. 
 
Busulfan dosing will be risk-adapted: 
 
A lower dose of busulfan (0.4 mg/kg/dose) will be used in older patients (arm C) to minimize toxicity. 
 
A standard dose of busulfan (0.6-0.8 mg/kg/dose), associated with excellent outcomes in our previous 
trial will be used for young patients with marrow aplasia (arm A). 
 
A higher dose of busulfan (0.8-1.0 mg/kg/dose) will be used in younger patients with MDS and AML 
(arm B) to maximize disease control. 
 
Cyclosporine will not be used post-transplant as no GVHD was seen in our previous trial and 
cyclosporine can cause significant toxicity. 
 
Patients will receive cytoreduction with busulfan, fludarabine, and cyclophosphamide with the addition 
of immunosuppression with ATG. They will receive a CD34+ T-cell depleted peripheral blood stem 
cell transplant. See below for approximate schema of cytoreduction and preparation for allogeneic 
PBSCT: 
 
Good Risk Patients: Arm A: Patients 18 years old or younger with marrow aplasia or single lineage 
cytopenias (Arm A) will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.6- 
0.8 mg/Kg/dose q 12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine 
(35mg/m2/day x 4 doses).   This strategy lead to survival rates > 90% in our prior study. 
 
Age and weight-based Busulfan dosing: 
< 10 kg: 0.6 mg/kg/dose as a starting dose q 12 hours x 4 doses 
 
≥ 10 kg but ≤ 4 years old: 0.8 mg/kg/dose as a starting dose q 12 hours x 4 doses 
 
> 4 years: 0.6 mg/kg/dose as a starting dose q 12hours x 4 doses 
Busulfan pharmacokinetics will not be used in this good risk arm receiving a low dose of busulfan. 
 
Intermediate risk patients: Arm B: Patients 18 years old or younger with MDS or AML will be will be 
conditioned for transplantation with intravenous busulfan (busulfex®) (0.8-1.0mg/Kg/dose q 12 hours 
x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 4 doses). 
A higher dose of busulfan will be used as this has been well-tolerated in younger patients with FA 
when used in conjunction with PK, and we will test whether this higher dose improves disease control, 
as these patients are at risk of relapse. 
 
The busulfan dose will be modified by recipient age and weight as described below: 
 
Age and weight-based Busulfan dosing: 
< 10 kg: 0.8 mg/kg/dose as a starting dose q 12 hours x 4 doses 
 
≥ 10 kg but ≤ 4 years old: 1.0 mg/kg/dose as a starting dose q 12 hours x 4 doses 
 
> 4 years: 0.8 mg/kg/dose as a starting dose q 12hours x 4 doses 
Busulfan pharmacokinetics WILL be used in this arm, as the dose of busulfan is higher, to ensure that 
the Css after the first dose of busulfan does not exceed 350. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 12 of 55 
 
 
 
 
 
High risk patients: Arm C: Patients 19 years old or older with marrow aplasia or MDS or AML 
will be will be conditioned for transplantation with intravenous busulfan (busulfex®) (0.4mg/Kg/dose q 
12 hours x 4 doses), cyclophosphamide (10 mg/Kg/dose x 4 doses) and fludarabine (35mg/m2/day x 
4 doses). In our previous studies older patients had increased toxicity from transplant, and in this study 
we will test whether outcomes can be improved, yet engraftment maintained, with a reduced dose of 
busulfan. No age or weight adjustment is needed for arm C patients as all cases will be over 4 years 
old and weigh more than 10kg. 
 
All patients will also receive rabbit ATG (thymoglobulin®) (2.5 mg/Kg/dose x  4 doses) prior to 
transplant to promote engraftment. Cyclosporine will NOT be used for prophylaxis against GvHD. All 
patients will also receive G-CSF post-transplant to foster engraftment. The source of stem cells for all 
patients will be peripheral blood stem cells (PBSC) induced and mobilized by treatment of the donor 
with G-CSF for 4-6 days. T-cell depletion will be performed by positive CD34 selection with the use of 
the Miltenyi system (CliniMACS device). The CD34+peripheral blood progenitors will then be 
administered to the patients after they have completed cytoreduction. 
 
 
 
 
5.0     THERAPEUTIC/DIAGNOSTIC AGENTS 
 
5.1. Busulfan (busulfex®) 
 
a. Source and Pharmacology: Supplier: Orphan Medical Company; Busulfan is a bifunctional 
alkylating agent known chemically as 1,4-butanediol, dimethanesulfonate. BUSULFEX® (busulfan). 
This is an agent in which two labile methanesulfonate groups are attached to opposite ends of a four 
carbon alkyl chain. In aqueous media, busulfan hydrolyzes to release the methanesulfonate groups. 
This produces reactive carbonium ions that can alkylate DNA. DNA damage is thought to be 
responsible for much of the cytotoxicity of busulfan. 
 
b. Formulation and Stability: It is supplied as a clear, colorless, sterile, solution in 10 mL single use 
ampoules. Each ampoule of BUSULFEX contains 60 mg (6 mg/mL) of busulfan, the active ingredient, 


Memorial Sloan Kettering Cancer Center 
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Administrative Update 1 : 08-Mar-2021 
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a white crystalline powder with a molecular formula of CH3SO2O(CH2)4OSO2CH3 and a molecular 
weight of 246 g/mole. Busulfan is dissolved in N,N-dimethylacetamide (DMA) 33% wt/wt and 
polyethylene glycol 400, 67% wt/wt. Busulfan’s solubility in water is 0.1 g/L and the pH of a >0.5% 
solution in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP as recommended for 
infusion reflects the pH of the diluent used and ranges from 3.4 to 3.9. 
 
c. Solution Preparation: BUSULFEX is supplied as a sterile solution in 10 mL single-use clear glass 
ampoules each containing 60 mg of busulfan at a concentration of 6 mg/mL for intravenous use. 
BUSULFEX must be diluted prior to use with either 0.9% Sodium Chloride Injection, USP (normal 
saline) or 5% Dextrose Injection, USP (D5W). The diluent quantity should be 10 times the volume of 
BUSULFEX, ensuring that the final concentration of busulfan is approximately 0.5 mg/mL. 
 
d. Storage and Stability: Unopened ampules of BUSULFEX must be stored under refrigerated 
conditions between 2° -8° C (36° -46° F). 
 
e. Administration:  Intravenous, over 2 hours. 
 
 
5.2. Fludarabine (FLUDARA®) 
 
a. Source and Pharmacology: Supplier: Berlex Laboratories, Inc. FLUDARA FOR INJECTIO N 
contains fludarabine phosphate, a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-ß- 
D-arabinofuranosyladenine (ara-A) that is relatively resistant to deamination by adenosine deaminase. 
The chemical name for fludarabine phosphate is 9H-Purin-6-amine, 2-fluoro-9-(5-O-phosphono-ß-D- 
arabinofuranosyl). Fludarabine phosphate is rapidly dephosphorylated to 2-fluoro-ara-A and then 
phosphorylated intracellularly by deoxycytidine kinase to the active triphosphate,  2-fluoro-ara-ATP. 
This metabolite appears to act by inhibiting DNA polymerase alpha, ribonucleotide reductase and DNA 
primase, thus inhibiting DNA synthesis. The mechanism of action of this antimetabolite is not 
completely characterized and may be multi-faceted. 
 
b. Formulation and Stability: Each vial of sterile lyophilized solid cake contains 50 mg of the active 
ingredient fludarabine phosphate, 50 mg of mannitol, and sodium hydroxide to adjust pH to 7.7. The 
pH range for the final product is 7.2-8.2. Reconstitution with 2 mL of Sterile Water for Injection USP 
results in a solution containing 25 mg/mL of fludarabine phosphate intended for intravenous 
administration. FLUDARA FOR INJECTION is supplied in a clear glass single dose vial (6 mL 
capacity) and packaged in a single dose vial carton in a shelf pack of five. 
 
c. Solution Preparation: FLUDARA should be prepared for parenteral use by aseptically adding 
Sterile Water for Injection USP. When reconstituted with 2 mL of Sterile Water for Injection, USP, the 
solid cake should fully dissolve in 15 seconds or less; each mL of the resulting solution will contain 25 
mg of fludarabine phosphate, 25 mg of mannitol, and sodium hydroxide to adjust the pH to 7.7. The 
pH range for the final product is 7.2-8.2. In clinical studies, the product has been diluted in 100 cc or 
125 cc of 5% Dextrose Injection USP or 0.9% Sodium Chloride USP. 
 
d. Storage and Stability: FLUDARA is supplied as a white, lyophilized solid cake. Each vial contains 
50 mg of fludarabine phosphate, 50 mg of mannitol and sodium hydroxide to adjust pH to 7.7. The pH 
range for the final product is 7.2-8.2. Store under refrigeration, between 2°-8° C (36°-46° F). 
 
e. Administration: Intravenous, over thirty minutes. 


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5.3. Cyclophosphamide (Cytoxan® ) 
 
a. Source and Pharmacology: Supplier: Bristol-Meyers. Cytoxan®,. Cyclophosphamide is an 
alkylating agent that is initially inactive but then is activated by metabolism in the liver by the mixed- 
function oxidase system of the smooth endoplasmic reticulum. The hepatic cytochrome P-450 mixed- 
function converts cyclophosphamide to 4-hydroxycyclophosphamide, which is in a steady state with 
the acyclic tautomer, aldophosphamide. 
 
b. Formulation and Stability: Injections: Each lyophilized vial contains: cyclophosphamide USP 500, 
1000 or 2000 mg with mannitol. Cartons of 6 (1 000 and 2 000 mg) and 12 (500 mg). 
 
c. Solution Preparation: Prepare Cytoxan for Injection for parenteral use by adding Sterile Water for 
Injection USP or Bacteriostatic Water for Injection USP (paraben preserved only) to the vial and 
shaking to dissolve to produce a clear colorless solution. Heating should not be used to facilitate 
dissolution. Solutions of Cytoxan for Injection may be infused i.v. in Dextrose Injection USP (5% 
Dextrose, 5% Dextrose and 0.9% Sodium Chloride) Dextrose 5% and Ringers Injection, Lactated 
Ringers Injection USP, Sodium Chloride Injection USP (0.45% sodium chloride) and Sodium Lactate 
Injection USP (1/6 molar sodium lactate). 
 
d. Storage and Stability: Reconstituted Cytoxan for Injection is chemically and physically stable at 
room temperature for 24 hours and for 6 days in the refrigerator. For solutions further diluted for i.v. 
infusion, it is recommended that the solutions be used within 24 hours at room temperature or 72 
hours under refrigeration. Solutions prepared with Sterile Water for Injection should be used for single 
dose administration and any unused solution discarded. 
 
e. Administration: Intravenous, over thirty-sixty minutes. 
 
 
5.4. Anti-Thymocyte Globulin (Rabbit)  (Thymoglobulin®) 
 
a. Source and Pharmacology: Supplier: Sangstat, The Transplant Company®. Thymoglobulin® [Anti- 
thymocyte Globulin (Rabbit)] is a purified, pasteurized, gamma immune globulin, obtained by 
immunization of rabbits with human thymocytes. This immunosuppressive product contains cytotoxic 
antibodies directed against antigens expressed on human T-lymphocytes. 
 
b. Formulation and Stability: Thymoglobulin is a sterile, freeze-dried product for intravenous 
administration after reconstitution with sterile Water for Injection, USP (WFI). Each package contains 
two 7 mL vials: Vial 1: Freeze-Dried Thymoglobulin Formulation Active ingredient: Anti-thymocyte 
Globulin (Rabbit) 25 mg - Inactive ingredients: Glycine (50 mg), mannitol (50 mg), sodium chloride (10 
mg); Vial 2: Diluent Sterile Water for Injection, USP 5 mL. The reconstituted preparation contains 
approximately 5 mg/mL of Thymoglobulin, of which >90% is rabbit gammaimmune globulin (IgG). The 
reconstituted solution has a pH of 7.0± 0.4. Human red blood cells are used in the manufacturing 
process to deplete cross-reactive antibodies to non-T-cell antigens. The manufacturing process is 
validated to remove or inactivate potential exogenous viruses. All human red blood cells are from US 
registered or FDA licensed blood banks. A viral inactivation step (pasteurization, i.e., heat treatment 
of active ingredient at 60°C/10 hr) is performed for each lot. Each Thymoglobulin lot is released 
following potency testing (lymphocytotoxicity and E-rosette inhibition assays), and cross-reactive 
antibody testing (hemagglutination, platelet agglutination, anti-human serum protein antibody, 
antiglomerular basement membrane antibody, and fibroblast toxicity assays on every 5th lot). 


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c. Solution Preparation: Each reconstituted vial contains 25 mg or 5 mg/mL of Thymoglobulin. 
Transfer the contents of the calculated number of Thymoglobulin vials into the bag of infusion solution 
(saline or dextrose). Recommended volume: per one vial of Thymoglobulin use 50 mL of infusion 
solution (total volume usually between 50 to 500 mL). Mix the solution by inverting the bag gently only 
once or twice. 
 
d. Storage and Stability: Store in refrigerator between +2° C to +8° C (36° F to 46° F). Protect from 
light. Do not freeze. Do not use after the expiration date indicated on the label. Reconstituted vials of 
Thymoglobulin should be used within 4 hours. Infusion solutions of Thymoglobulin must be used 
immediately. Any unused drug remaining after infusion must be discarded. 
 
e. Administration: Infuse through a 0.22-micron filter into a high-flow vein. Set the flow rate to deliver 
the dose over a minimum of 6 hours for the first dose and over at least 4 hours for subsequent doses. 
 
 
5.5. The CliniMACS device 
 
Drug Formulation and Procurement 
 
5.5.1. The CliniMACs device (Miltenyi Biotec, Auburn, CA) will be employed for the CD34 selection 
procedure. It consists of tubing, bags, and a pair of columns, placed at appropriate locations in the 
Tubing Set to facilitate the cell selection process. The CliniMACS System intended for selection of 
CD34+ cells is comprised of four primary components listed here. A brief description of each 
component is provided below. 
 
• 
A software controlled instrument that processes the blood sample, CliniMACS Instrument 
• 
A  single-use,  sterile  disposable  tubing  set  with  two  proprietary  cell  selection  columns, 
CliniMACS Tubing Set 
• 
A monoclonal antibody reagent specific for CD34+ cells, CliniMACS CD34 Reagent 
• 
A sterile, isotonic phosphate buffered, 1 mM EDTA, saline solution, used as external wash and 
transport fluid for the in vitro preparation of blood cells, CliniMACS PBS/EDTA Buffer. 
 
5.5.2. CliniMACS  Instrument 
 
The CliniMACS Instrument is a bench-top instrument consisting of a supporting structure to hold the 
column/tubing assembly and various bags, a series of valves through which the tubing set is fitted, a 
magnet between the poles of which the separation column is placed, a peristaltic pump through which 
a section of tubing is placed, software to control the instrument and user interface and a computer 
touchpad with a display window. The instrument is operated at ambient temperature and it is intended 
to be multi-use item. 
 
The software for the CliniMACS Instrument controls the function of the electromechanical components 
of the instrument and the user interface.  Two separate computers, one a micro-controller located on 
a control board of the CliniMACS Instrument and the second a PC compatible computer which 
operates the user interface are incorporated with the instrument. Software Version 2.31, the current 
version of software is directly traceable to the version of software utilized in pre-clinical testing and 
European Safety trials, and has been inspected and approved by TÜV product services with the CE 
Mark. 
 
5.5.3. CliniMACS Tubing Set 


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The CliniMACS Tubing Set consists of a tubing element combined with a pair of proprietary cell 
selection columns. These form a closed, sterile system for processing the cells. The separation 
column is a proprietary component of the CliniMACS System consisting of a plastic column housing 
with polypropylene frits in each end. The interior of the column housing is filled with a matrix of sub- 
millimeter iron beads coated with a heat-cured biocompatible resin. The columns are placed at 
appropriate locations in the CliniMACS Tubing Set to facilitate the cell selection process. The first 
column serves as a device to remove components that bind non-specifically to the column. The 
second column performs the actual cell selection. The columns are incorporated sterile as part of the 
tubing set and are intended for single use only. 
 
The tubing element consists of a series of tubes, connectors, spikes, Luer locks, and collection bags. 
The tubing of the tubing element is comprised of materials that have been qualified for use in this 
application by testing to ISO 10993. The principal constituents are polyvinyl chloride (PVC) and 
silicone. The connectors are made of various polymers (e.g., ABS and PVC) suitable for use in a 
blood contact environment. They are solvent bonded to the PVC tubing. The silicone pump tubing is 
softened with petroleum ether for manufacturing and mechanically fixed to connectors. The cell wash 
bags are composed of PVC. 
 
he CliniMACS Tubing Set is packaged in a thermoformed tray and heat sealed with a Tyvek® lid. The 
CliniMACS Tubing Set is sterilized by ethylene oxide gas in a validated sterilization cycleand supplied 
as a single-use component for the CliniMACS Instrument. 
 
5.5.4. CliniMACS CD34 Reagent 
 
The CliniMACS CD34 Reagent is a dark amber, nonviscous, colloidal solution containing the antibody 
conjugate in buffer. The conjugate consists of a monoclonal antibody towards the human CD34 
antigen. The murine monoclonal IgG1 antibody is covalently linked to dextran beads having an iron 
oxide/hydroxide core. The concentration of the conjugate is equivalent to 20 micrograms (µg) per mL 
of antibody protein, 800 µg/mL of dextran and 800 µg/mL of iron. The colloid is buffered in a 
phosphate-buffered saline (PBS) containing ethylenediaminetetraacetic  acid (EDTA) and Poloxamer 
188. The nominal concentrations of its components are 0.0095 M phosphate, 0.004 M potassium, 
0.163 M sodium, 0.139 M chloride, 0.005 M EDTA and 0.03 % (w/v) Poloxamer 188.  The pH is 7.4 - 
7.7. Poloxamer 188 is added to the CliniMACS CD34 Reagent to stabilize it during shipping, handling 
and storage. The CliniMACS CD34 Reagent is supplied sterile and pyrogen-free in glass vials 
containing 7.5 mL and is intended for single use and in vitro use only. 
 
 
5.5.5. The CliniMACS PBS/EDTA Buffer 
 
The CliniMACS PBS/EDTA Buffer is an isotonic and isohydric buffer solution with a pH-value of 7.2 
and osmolarity of 290 mosmol/L.   Its formulation is shown in the following table. 
 
Table 1.  Formulations of the CliniMACS PBS/EDTA Buffer 
Ingredient 
Compendial 
Amount 
NaCl 
Ph. Eur. 
8.0 
g/L 
KCl 
Ph. Eur. 
0.19 
g/L 
Na2HPO4 anhy. 
Ph. Eur. 
1.15 
g/L 
KH2PO4 
Ph. Eur. 
0.19 
g/L 
Na2EDTA 
Ph. Eur. 
0.37 
g/L 
Water for Injection 
Ph. Eur. 
ad 1L 


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The CliniMACS PBS/EDTA Buffer is used as external wash and transport fluid for the in vitro 
preparation of human heterogeneous cell populations intended to be separated with the CliniMACS 
Cell Selection System.  This is achieved by the following procedure: 
 
Mononuclear cells for separation are collected. After incubating the cells with CD34 Reagent in 
PBS/EDTA Buffer the excess of unbound reagent is removed by washing with the PBS/EDTA 
Buffer. Prior to and during incubation of the antiCD34 beads with the mobilized PBSC, intravenous 
gammaglobulin is added to the incubation fluid at a concentration of 1.5 mg IVIG/ml. 
 
During the following automated selection, using PBS/EDTA Buffer supplemented with 0.5 % human 
serum albumin (HSA), the unwanted cells are removed and, in the final step, the selected cells are 
eluted from the column by the means of the PBS/EDTA Buffer. The HSA is not a component of the 
buffer and should be supplied by the clinical site. 
 
5.5.6. Principles of Operation 
 
The function of the CliniMACS System with the CliniMACS CD34 reagent is to select CD34+ cells 
from heterogeneous cell populations. The detailed procedures are provided in the CliniMACS User 
Manual that accompanies the CliniMACS Instrument. The selection process involves two phases; cell 
labeling prior to selection (phase 1) and the automated cell selection process (phase 2). Provided 
below is a brief summary of the procedure. 
 
Phase 1 – Labeling. This phase is referred to as the cell-labeling step. This step involves combining 
the antibody reagent with the cellular harvest from the donor or patient. The antibody reagent is 
incubated for 30 minutes at room temperature with the heterogeneous cell population during which 
the antibody selectively binds to cells expressing the CD34 antigen.  The mixture is then washed twice 
in PBS/EDTA separation buffer. Following centrifugation, the resulting cell pellet is resuspended in 
the separation buffer and the labeled product is ready for cell selection. 
 
Phase 2 – Cell Selection. The labeled cell product is attached to the sterile tubing set of the CliniMACS 
system. Following a series of automated priming steps‚ the cell product is passed through a blood 
filter to remove any cell aggregates that may be present. The cell suspension is then passed through 
the first column, which serves as a pre-column separation step to eliminate cells that bind non- 
specifically. The labeled product then passes through the second column positioned within the 
magnetic field. The CD34+ cells‚ to which the antibody reagent has been bound‚ are selected and 
retained in the column matrix. All other cells flow through the column and are collected in the negative 
fraction bag. After automated buffer washes of the column containing the isolated CD34+ cells‚ the 
column is removed from the magnetic field‚ and the CD34+ cells are eluted into a positive fraction bag. 
The selected cells can be used immediately after analysis or cryopreserved for later infusion into the 
patient.  The device is non-invasive in all aspects that involve processing of the cellular harvest and 
is not connected to the patient at any time. 
 
The CliniMACS device is currently pending FDA approval. 
 
6.1 
CRITERIA FOR SUBJECT ELIGIBILITY 
 
6.2 
Subject Inclusion Criteria 
 
6.1.1. Diagnosis 
Patients must have a diagnosis of Fanconi anemia (confirmed by mitomycin C or diepoxybutane [DEB] 
chromosomal breakage testing at a CLIA approved laboratory). 


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6.1.2. Hematologic Diagnosis and Status 
Patients must have one of the following  hematologic diagnoses: 
 
1. Severe Aplastic Anemia (SAA), with bone marrow cellularity of <25% 
 
OR 
 
Severe Isolated Single lineage Cytopenia 
 
AND at least one of the following features: 
1. Platelet count <20 x 109/L or platelet transfusion dependence* 
2. ANC <1000 x 109/L 
3. Hgb <8 gm/dl or red cell transfusion dependence* 
 
 
2. Myelodysplastic  Syndrome (MDS) (Appendix 1: MDS Classification) 
 
MDS at any stage, based on either one of the following classifications: 
- W HO Classification 
- Refractory anemia and transfusion dependence* 
- Any of other stages 
- IPSS Classification 
- Low risk (score 0) and transfusion dependence* 
- Any other risk groups Score > 0.5 
Note  that  patients  with  chromosome 1q  cytogenetic  abnormalities  in  the 
absence of morphologic dysplasia will not be considered to have MDS. 
 
 
3. Acute Myelogenous  Leukemia 
Patients with acute leukemia are included in this trial untreated, in remission or 
with refractory or relapsed disease. 
 
* Transfusion dependence will be defined as greater than ONE transfusion of platelets or red blood 
cells in the last year prior to evaluation on protocol. 
 
6.1.3. Donor 
Donor choices will be determined by the investigators according to institutional criteria. Patients who 
will be enrolled on this protocol must have one of the following donor choices: 
 
HLA-compatible unrelated volunteer donors 
Patients who do not have a related HLA-matched donor but have an unrelated donor who is either 
matched at all A, B, C and DRB1 (8/8) loci or who is mismatched at no more than 2/8 loci (A, B, C or 
DRB1) (6/8) as tested by DNA analysis (high resolution), will be eligible for entry on this protocol. 
 
HLA-mismatched Related donors 
Patients who do not have a related or unrelated HLA-compatible donor must have a healthy family 
member who is at least HLA-haplotype identical to the recipient. First degree related donors must 
have a normal DEB test. 


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The donor must be healthy and willing and able to receive a 4-6 day course of G-CSF and undergo 1- 
3 daily leukaphereses, as per institutional guidelines. 
 
Related and unrelated  donors must be medically evaluated  and fulfill the criteria for collection of 
PBSCs as per institutional guidelines. 
 
6.1.4. Patients and donors may be of either gender or any ethnic background. 
 
6.1.5. Patients must have a Karnofsky adult, or Lansky pediatric performance scale 
status > 70%. 
 
6.1.6. Patients must have adequate physical function measured by : 
 
a) 
Cardiac:  asymptomatic or if symptomatic then 1) LVEF at rest must be > 50% and must 
improve with exercise or 2) Shortening Fraction > 29% 
b) 
Hepatic:  < 5 x ULN alanine transaminase (ALT) and < 2.0 mg/dl total serum bilirubin. 
c) 
Renal:  serum creatinine <1.5 mg/dl or if serum creatinine is outside the normal range, then 
CrCl > 50 ml/min/1.73 m2 
d) 
Pulmonary:   asymptomatic or if symptomatic, DLCO > 50% of predicted (corrected for 
hemoglobin) 
 
6.1.7. Each patient must be willing to participate as a research subject and must sign an informed 
consent form. Parent or legal guardians of patients who are minors will sign the informed consent 
form. Assents will be obtained as per institutional guidelines. 
 
6.1.8. Female patients and donors must not be pregnant or breastfeeding at the time of signing 
consent. Women must be willing to undergo a pregnancy test prior to transplant and avoid becoming 
pregnant while on study.  Positive pregnancy test results will be reported to the parent(s) or guardian 
of minor participants, as required per institutional guidelines. 
 
 
6.2 
Subject Exclusion Criteria 
 
6.2.1. Active CNS leukemia 
 
6.2.2. Female patients who are pregnant (positive serum or urine HCG) or breast-feeding. Women of 
childbearing age must avoid becoming pregnant while on study. 
 
6.2.3. Active uncontrolled viral, bacterial or fungal infection 
 
6.2.4. Patient seropositive for HIV-I/II;  HTLV -I/II 
 
 
 
7.0       RECRUITMENT PLAN 
 
One of the Pediatric BMT attendings will see the patient in consultation. As part of the consultation, 
the attending will present the patient and/or parent/legal guardian with the risks and benefits of 
different types of cytoreduction and transplants. One of the participating investigators authorized to 
obtain consent will obtain informed consent. A copy of the signed informed consent will be provided 
to the family, and the original will be scanned into the electronic medical record. 


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Related donors will undergo HLA-antigen testing. If related donors are identified and are 4-7/8 antigen 
matched with the patient, they will be candidates to become a stem cell donor. Donors will sign a 
separate institutional consent form for stem cell collection using marrow or peripheral blood. 
 
8.0 
PRETREATMENT EVALUATION 
 
8.1. 
Pretreatment Evaluation of the patient 
 
Prior to instituting preparatory cytoreduction, the patient will receive an extensive medical evaluation 
according to standard institutional practice. 
 
This evaluation may include the following: 
− Complete physical examination 
− Detailed history with special attention to prior medical history, allergies, previous  therapies, and 
response to treatment 
− Complete Blood Count with differential count and reticulocyte count. 
− Bone marrow aspiration and biopsy, performed within approximately 1 month from starting 
cytoreduction. Marrow aspirations will be studied by morphology. It will also be studied by 
cytogenetic analysis by karyotype and FISH studies for chromosomes 1, 3, and 7. Bone marrow 
biopsy should be performed for the determination of cellularity. 
− Coagulation profile 
− Serum chemistries including BUN, creatinine, electrolytes, Calcium, magnesium, phosphorus, 
glucose, total protein, albumin, liver function tests (AST, ALT, bilirubin, alkaline phosphatase) and 
LDH. Patients with advanced MDS or AML may also have uric acid determination. 
− Chest and other X rays as clinically indicated 
− Electrocardiogram 
− Gated pool scan or echocardiogram 
− Urinalysis if clinically indicated 
− Infectious Disease Markers will be tested as per institutional guidelines as well as at the discretion 
of the treating physician 
− In  addition,  all  patients  will  undergo  pre-transplant  complete  immunologic  evaluation  as  per 
institutional standards and at the discretion of treating physician. 
− Blood or marrow will be sent for diagnostic molecular pathology for DNA extraction for the definition 
of donor host differences. 
 
 
8.2. 
Pretransplant Evaluation of the Donor 
 
The pre-transplant evaluation of the donor will be performed as per institutional guidelines, and is not 
specific to this protocol: 
 
 
 
 
Family Donor 
 
A consenting  healthy  family donor who is HLA compatible with the recipient will be given 
highest priority as a potential donor for PBSC or marrow transplant according to institutional 


Memorial Sloan Kettering Cancer Center 
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standard of care. A prospective HLA-non-identical related donor must be at least 
genotypically HLA-A, B, C, DRB1 haploidentical to the patient, but can differ for 1-4 HLA 
alleles on the unshared haplotype. Selection of the histocompatible donor will be based on 
high resolution typings of HLA A, B, C and DRB1 loci to be carried out on the recipient, and 
his/her siblings, parents or other family members. 
 
In preparation for the stem cell donation, the donor will undergo a detailed medical history and physic al 
examination. Clinical studies may include: 
- 
DEB testing (for first degree related donors) to be performed. 
- 
Full hemogram 
- 
Coagulation profile 
- 
Complete screening biochemical profile. 
- 
Type and cross match 
- 
Infectious Disease Markers will be tested per all FDA, AABB, NY State, and FACT standards. 
- 
A chest x-ray and/or EKG or other additional  medical evaluation  will be obtained  as clinically 
indicated by the evaluating physician. 
- 
Blood or marrow will be sent for diagnostic molecular pathology for DNA extraction for the definition 
of donor host differences. 
-    Pregnancy testing will be performed as per institutional guidelines 
 
Unrelated donor 
Unrelated donors will undergo preparation for peripheral blood harvest as per the standards 
of the National Marrow Donor Program (NMDP). The donor will undergo pretransplant work- 
up and will sign consent for G-CSF administration and leukapheresis at the donor center, also 
according to standard procedure as dictated by the NMDP. 
 
9.0       TREATMENT/INTERVENTION PLAN 
 
 
9.1.    Preparative Cytoreduction 
 
The schemata below outlines cytoreduction for allogeneic PBSCT for arms A, B, and C: 
 
Arm A: Standard dose busulfan with no PK study 
 
Day 
Treatment 
Doses 
Infusion guidelines 
-7 
Busulfan 
0.6-0.8 mg/kg/dose q12 
over 2 hours 
-6 
Busulfan 
0.6-0.8 mg/kg/dose q12 
over 2 hours 
-5 
Cyclophosphamide* 
Fludarabine 
10 mg/kg IV, 
35 mg/m2 IV 
once daily 
once daily 
over 1 hour 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV once daily 
over 8 hours 
-4 
Cyclophosphamide* 
10 mg/kg IV 
once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV once daily 
over 8 hours 
-3 
Cyclophosphamide* 
10 mg/kg IV once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV once daily 
over 8 hours 


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-2 
Cyclophosphamide* 
Fludarabine 
10 mg/kg IV  once daily 
35 mg/m2 IV 
once daily 
over 1 hour 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV  once daily 
over 8 hours 
-1 
Rest day 
0** 
CD34+ PBSCT 
+1 
Start G-CSF 
 
* With Mesna per Institutional practice 
** Day 0 could extend to two days if collection requires two separation procedures. 
 
 
Arm B: Higher dose busulfan with PK study 
 
For ARM B patients Busulfan pharmacokinetics will be done with the first dose of busulfan and dose 
adjustments will be made according to institutional standard clinical practice as indicated.  Busulfan 
concentrations will be determined by the Department of Laboratory Medicine Clinical Chemistry 
Laboratory and pharmacokinetic analysis by the Department of Pharmacy.  The optimal desired 
steady state CSS target should be 300-350. The second dose of busulfan will be given after the 
results of the PK study are available, and the dose reduced if necessary. The dose of busulfan will 
NOT be increased per the PK study, but will be decreased if the Css is >350. 
 
 
Day 
- 8 
Treatment 
Busulfan PK study 
Doses 
0.8-1.0 mg/kg/dose 
Infusion guidelines 
over 2 hours 
-7 
Busulfan 
PK adjusted dose x1 
over 2 hours 
-6 
Busulfan 
PK adjusted dose x2 
over 2 hours 
-5 
Cyclophosphamide* 
10 mg/kg IV 
once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV once daily 
over 8 hours 
-4 
Cyclophosphamide* 
10 mg/kg IV 
once daily 
over 1 hour 
Fludarabine 
Rabbit ATG 
35 mg/m2 IV 
once daily 
2.5 mg/kg IV once daily 
over 30 minutes 
over 8 hours 
-3 
Cyclophosphamide* 
10 mg/kg IV  once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV  once daily 
over 8 hours 
-2 
Cyclophosphamide* 
10 mg/kg IV  once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
-1 
Rabbit ATG 
Rest day 
2.5 mg/kg IV  once daily 
over 8 hours 
0** 
CD34+ PBSCT 
+1 
Start G-CSF 
 
* With Mesna per Institutional practice 
** Day 0 could extend to two days if collection requires two separation procedures 
 
Arm C: Low dose busulfan for adult patients 19 years or older 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
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For ARM C patients a low dose of busulfan (0.4mg/kg/dose) will be used.  There will be no PK study 
required. 
 
 
Day 
Treatment 
Doses 
Infusion guidelines 
-7 
Busulfan 
0.4 mg/kg/dose q12 
over 2 hours 
 
-6 
Busulfan 
0.4 mg/kg/dose q12 
over 2 hours 
-5 
Cyclophosphamide* 
10 mg/kg IV, 
once daily 
over 1 hour 
Fludarabine 
Rabbit ATG 
35 mg/m2 IV 
once daily 
2.5 mg/kg IV once daily 
over 30 minutes 
over 8 hours 
-4 
Cyclophosphamide* 
10 mg/kg IV 
once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV once daily 
over 8 hours 
-3 
Cyclophosphamide* 
10 mg/kg IV  once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV  once daily 
over 8 hours 
-2 
Cyclophosphamide* 
10 mg/kg IV  once daily 
over 1 hour 
Fludarabine 
35 mg/m2 IV 
once daily 
over 30 minutes 
Rabbit ATG 
2.5 mg/kg IV  once daily 
over 8 hours 
-1 
Rest day 
0** 
CD34+ PBSCT 
+1 
Start G-CSF 
 
* With Mesna per Institutional practice 
** Day 0 could extend to two days if collection requires two separation procedures 
An anti-convulsant may be administered during the busulfan per institutional guidelines. 
Cyclophosphamide 
Cyclophosphamide 10 mg/kg is to be given as a 1-2 hour infusion for 4 days for a total dose of 40 
mg/kg.  Strict attention should be made to vigorous hydration, fluid balance and maintenance of 
good urine output. It is recommended that Mesna be administered prior to and after each dose of 
cyclophosphamide per institutional practice. The dose will be adjusted according to patients ideal 
body weight for obese patients. 
 
Fludarabine 
Fludarabine 35 mg/m2 will be given IV over 30 minutes daily for 4 days for a total dose of 140 mg/m 2. 
The dose will be adjusted according to renal function according to Institutional guidelines. 
 
9.2 
Immunosuppressive Therapies 
 
Failure Prophylaxis 
 
Methylprednisolone  Methylprednisolone  will be given with the infusion of ATG as per institutional 
guidelines, and will be discontinued after the completion of the ATG infusion. 
 
Rabbit antithymocyte globulin (Thymoglobulin) 2.5 mg/kg will be given once daily on days -5, -4, -3 
and -2. Premedication will include the use of methylprednisolone (as defined above). The first dose of 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 24 of 55 
 
 
 
Rabbit ATG is to be infused over 8 hours. Subsequent doses can be given over 4-6 hours based on 
institutional guidelines or at the treating physician’s discretion. In the event of a severe reaction to 
antithymocyte globulin, further doses of the agent will not be administered. In this event, Equine 
antithymocyte globulin (ATGAM, Upjohn) 15 mg/kg IV once daily can be substituted for each remaining 
day of ATG on the schema. In the event of reaction to ATGAM, Alemtuzumab (Campath 1H) at 10 
mg/m2 IV once daily may be administered for each remaining day of ATG on the schema. 
 
Other 
G-CSF will be administered to all patients post-transplant starting day +1 as per institutional 
guidelines. It will be rapidly  tapered when the ANC reaches levels ≥ 2.0 x 109/L and stabilizes 
thereafter. G-CSF doses will be rounded according to institutional guidelines. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
APPROXIMATE SCHEMA OF CYTOREDUCTION AND PREPARATION FOR ALLOGENEIC 
PBSCT: 
 
 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
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9.3 
Stem Cell Collection 
 
9.3.1    Mobilization of Donor 
 
Related Donors 
Following screening and enrollment, the donor will receive mobilization therapy with once daily 
subcutaneous G-CSF as per institutional guidelines. Mobilization will begin on prior to the conditioning 
regimen at a G-CSF dose of 10 µg/Kg/day of actual body weight (rounded off to a multiple of the 
nearest vial size of either 300 or 480 µg). Based on the volume, the dose may be split into 2 or 3 
injection sites. The mobilization phase starts on the first day of administration of G-CSF and continues 
until the final day of leukapheresis. 
 
Unrelated Donors 
For Unrelated donors, G-CSF will be administered and the leukaphereses obtained according to the 
National Marrow Donor Program protocol. If more than one leukapheresis is required, mononuclear 
cell fractions collected on the day 1 and day 2 of leukapheresis may either be pooled prior to CD34 
selection or may be CD34 selected individually,  per institutional practice. 
 
 
9.3.2. 
Progenitor Cell Collection and Processing 
 
9.3.2.1 Leukapheresis – for Related Donors 
Leukapheresis will be performed on a continuous flow cell separator according to Institutional 
standards and will commence on the morning of the 5th day of G-CSF treatment. The anti-coagulant 
used for the procedure will be acid citrate dextrose (ACD). No additional anti-coagulants or additives 
(heparin etc.) should be added beyond those normally used during leukapheresis. The volume of 
blood processed per leukapheresis session should be approximately 3-4 times the total blood volume 
as tolerated by the donor. A unique identification and labeling system shall be used to track the 
leukapheresis product from collection to infusion according to institutional guidelines. 
 
The target allograft cell doses following processing on the CliniMACS device are a CD34+ cell dose 
of > 5.0 x 106 cells/Kg recipient weight with a maximum CD3+ cell dose of < 5.0 x 104 cells/Kg of 
recipient weight. A minimum CD34+ cell dose of 2.5 x 106 cells/Kg will be targeted. If this minimum 
target CD34+ cell dose is not achieved after 2 leukaphereses, a third leukapheresis may be planned 
after discussion with the principal investigator of the Institution. 
 
This protocol requires an absolute minimum CD34+ cell dose of 2.0 x 106 cells/Kg in order to be 
evaluable for all study endpoints. If the post CD34+ selection allograft content is < 2.0 x 106 CD34+ 
cells/Kg after 2 leukapheresis procedures, a third leukapheresis collection without CD34+ selection 
should be performed in order to ensure that an adequate CD34+ cell dose is transplanted. Since this 
graft will contain a high number of CD3+ cells, such patients must also receive the addition of 
pharmacologic GvHD prophylaxis per Institutional standards. 
 
During mobilization and leukapheresis, Institutional Standards for donor supportive care should be 
maintained. 
 
 
9.3.2.2. 
CD34+Selection with the CliniMACS Device – Related or Unrelated Donors 
 
CD34+ cell selection will be performed according to procedures given in the CliniMACS Users 
Operating Manual and institutional Standard Operating Procedures (SOPs). 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
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Products will be received into the cell processing laboratories and will be either processed that day, 
or stored overnight. Products stored overnight must be processed the following day. At receipt the 
product will be accessioned and assigned a unique product identifier if not already assigned during 
collection. The product will be inspected at the time of receipt and the label information regarding 
donor name, medical record number (or other identifier) and ABO and Rh group will be compared for 
consistency to the information in the laboratory chart record and physicians order form. 
 
The product will be sampled for total nucleated cell count (TNC), and if processing is to be performed 
on the day of receipt, additional sample will be obtained for starting CD34+ cell and starting T cell 
content and product sterility. Products may be stored overnight for one of two reasons, 1) late arrival 
preventing selection and infusion the same day, or 2) low TNC content that would permit pooling of 
two collections for a single column selection. If the product is to be stored overnight, the cells will be 
diluted to < 2.0 x 108 cells/mL using either autologous plasma or the CliniMACS PBS/EDTA-1.0% 
Human Serum Albumin (HSA) (CliniMACS buffer) and stored in a monitored refrigerator as per 
institutional policy. Products that are stored overnight will be sampled the following day, prior to 
processing, for TNC, starting CD34+ cell and starting T cell content, and for sterility. 
 
Analysis of allograft 
 
Samples will be taken from each leukapheresis product pre- and post-CD34+ selection and 
characterized as follows: 
 
• Graft Evaluation (all of these tests are standard of care and performed as per institutional 
guidelines) 
▪ 
Gram stain (done locally) post-selection on each leukapheresis product 
▪ 
Total nucleated cell count (done locally) pre- and post-selection on each leukapheresis 
product 
▪ 
Endotoxin testing post-selection on each leukapheresis product 
▪ 
Flow cytometric analysis for CD34+ cells pre- and post-selection Flow cytometric 
analysis for CD3+ cells pre- and post-selection and log depletion on each 
leukapheresis product done 
▪ 
Viability testing (trypan blue dye exclusion assay) post-selection 
▪ 
14 day sterility cultures post-selection on each leukapheresis product 
 
• Criteria for release of product 
▪ 
Viability 70% after selection 
▪ 
Negative gram stain 
▪ 
CD34+ cell count of product 
 
In regards to the 14 day sterility cultures performed post-selection on each leukapheresis 
product, a Stat Gram stain is used for release as well as performing endotoxin testing.  In the 
event that a sterility test is found to be positive, post infusion the following will occur: 
a. The Medical Director for the laboratory is immediately informed, and this information 
will be conveyed to the clinical care team to evaluate the patient clinically. 
b. If any residual specimen is available, it will be submitted for confirmatory sterility 
testing. 
c. An investigation review will be performed by the Medical Director to assess all process 
steps to attempt to identify a cause if possible. This includes a review of the 
environmental monitoring data that is generated periodically. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
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d. If a source of the contamination can be identified, corrective action steps will be 
devised and implemented as appropriate to prevent recurrence. 
e. The investigator will be provided with the investigation review and will notify the FDA 
and IRB as appropriate. 
 
 
As noted above, the target optimal allograft cell doses following proc essing on the CliniMACS device 
include both a CD34+ cell count of > 5.0 x 106/kg recipient weight and a CD3+ cell dose of < 5.0 x 
104/kg recipient weight. The targeted minimum CD34+ cell dose following CD34+ selection is 2.5 x 
106/kg. If after two leukapheresis collections followed by CD34+ selection the total allograft contains 
2.5-5.0 x106 CD34+ cells/kg and < 5.0 x104 CD3+ cells/kg, a total of three leukapheresis collections 
followed by CD34+ selection are allowed as long as the total CD3+ cell dose transplanted does not 
exceed 5.0 x 104/kg. That is, a graft containing 2.5-5.0x106 CD34+ cells/kg and < 5.0 x104 CD3+ 
cells/kg is acceptable whereas a graft containing 5.0x106  CD34+ cells/kg but > 5.0 x104 CD3+ cells/kg 
is not. A major goal is to administer a CD34+ cell dose > 5.0x106/kg while limiting the CD3+ cell dose 
to < 5.0 x104 but as long as a minimum of 2.0 x106/kg CD34+ cells are infused, the CD3+ cell dose 
should be kept to < 5.0 x104 /kg. It may be possible to give only a proportion of the CD34+ selected 
product in order to maintain an adequate CD34+ cell dose while limiting the CD3+ cell dose to < 5.0 
x104  /kg. 
 
It is also possible that doses of CD34+ cells far exceeding 5.0 x 106/kg can be given without exceeding 
the maximum T cell dose of 5.0 x104 CD3+ cells/kg. High doses of CD34+ cells in extensively T cell 
depleted transplants are postulated to hasten immune reconstitution, without altering the low risk of 
GVHD. Consequently, there is no upper limit for the dose of CD34+ cells/kg as long as the dose of 
CD3+ cells does not exceed 5.0 x104 /kg. 
 
Decisions concerning the release of samples from the CD34+ selected product will be based on CD34+ 
and CD3+ cell analysis done by the flow cytometry laboratory. The attached table outlines the various 
scenarios that may be encountered after each CD34+ cell selection and indicates steps that may be 
used to achieve target allograft cell doses. The steps below are recommendations only, as the 
requirement for a second or third leukapheresis procedure will be determined by the treating attending 
and patient/donor requirements. 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
Page 28 of 55 
 
 
 
Table 9.3.2.2 – Guidelines for achieving target allograft cell doses 
 
Leuka- 
Pheresis 
Attempt 
Total CD34+  dose 
after 
Leukapheresis1  (X 
106/Kg) 
Total CD3+ 
ACTION 
after 
Leukapheresis 
1 (x 104/Kg) 
< 
1. 
0 
1.0 
- 2 
2.0 
- 4.9 
> 
5 
. 
0 
< 5.0 
> 
5.0 
Administer 
Allograft 
Proceed 
To next 
Leuka- 
Pheresis 
Leuka- 
Pheresis 
Completed 
Reduce CD3 
dose to< 5.0 
Maintain 
CD 34 dose 
> 2.0 
Begin 
GvHD 
Prophylaxis 
1 
X X 
X 
X2 
1 
X 
X 
X 
X3 
1 X 
X4 
X4 
X 
X 
X 
1 X 
X4 
X4 
X 
X 
X3 
2 
X X 
X 
X 
2 
X 
X 
X5 
2 
X4 
X4 
X 
X 
X 
2 
X4 
X4 
X 
X6 
2 X 
X7 
X7 
X 
X8 
X9 
3 
X X 
X 
X 
3 
X 
X 
X 
X 
3 
X 
X 
X10 
3 
X 
X 
X10 
3 
X 
X 
X 
X 
3 
X 
X 
X11 
3 X 
X7 
X7 
 
1. This number refers to CD34+ (x 106/Kg) or CD3+ (x 104/Kg) doses after CD34+ selection. If after 
leukapheresis 
#2 or #3, this number refers to total pooled CD34+ and CD3+ cell doses 
following all CD34+ selections 
2. If unsuccessful in reducing CD3+ cell dose to < 5.0 x 104  cells/Kg at any CD34+ cell dose, hold 
allograft overnight and proceed to leukapheresis #2. If leukapheresis #2 results in a post selection 
CD34+ cell count of > 2.0 x 106 cells/Kg with CD3+ cell dose of < 5.0 x104 cells/Kg, give that allograft, 
proceed to leukapheresis #3 and discard or cryopreserved graft from leukapheresis #1. The primary 
goal is to reduce the total CD3+ cell dose to < 5.0 x 104 cells/Kg while maintaining the total CD34+ 
cell dose to > 2.0 x 106 cells/Kg. 
3. Refers to any one of these three possible CD34+ cell doses (<1.0 – 4.9) 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
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4. If unsuccessful in reducing  CD3+ cell dose to < 5.0 x104  cells/Kg at any CD34+ cell dose, begin 
GvHD prophylaxis 
and administer allograft within 24 hours 
5. If able to reduce CD3+ cell dose to < 5.0 x 104  cells/Kg while maintaining CD34+ cell dose > 2.0 x 
106  cells/Kg, 
proceed to leukapheresis #3. If unsuccessful in reducing CD3+ cell dose to < 
5.0 x 104/Kg at any CD34+ cell dose, 
begin additional  GvHD prophylaxis  with steroids at 2.0 
mg/Kg/day or Mycophenolate  mofetil (Cellcept®)* and then administer allograft. 
6. Refers to either one of the two possible CD3+ cell doses. 
7. Proceed to leukapheresis #3, but do not perform CD34+ selection on product from leukapheresis 
#3 
8. If the CD3+ cell dose is > 5.0 x 104  /Kg, consider additional GvHD prophylaxis with steroids at 2.0 
mg/Kg/day or Mycophenolate  mofetil (Cellcept®)*  and then administer product from leukapheresis 
#2. 
9. If the patient has already received total allograft containing > 2.0 x 106/kg CD34+ cell dose and < 
5.0 x 104/kg CD3+ cell dose, hold allograft of leukapheresis  #3. If the patient has received total 
allograft containing < 2.0 x 106/kg CD34+ dose, administer product from leukapheresis #3 and begin 
additional GVHD prophylaxis with steroids at 2.0 mg/kg/day or Mycophenolate  mofetil (Cellcept®)*. 
10. Begin  additional  GvHD  prophylaxis  with steroids  at 2.0  mg/Kg/day or Mycophenolate  mofetil 
(Cellcept®)* and then administer product from leukapheresis #3. 
11. Contact the study PI to discuss options. 
12. A third leukapheresis collection without CD34+ selection should be performed in order to ensure 
that an adequate CD34+ cell dose is transplanted 
 
* Mycophenolate mofetil (Cellcept®) will be administered as per institutional guidelines and if 
needed, Mycophenolate sodium (Myfortic®) may be substituted for Mycophenolate mofetil 
(Cellcept®) after appropriate dose conversion. 
 
 
9.4. 
Stem Cell Transplantation   
 
The final CD34+ T-cell depleted product will be infused into the patient intravenously  according to 
Institutional standards. The first day of infusion will be designated as day 0 of transplant. 
 
 
9.5. 
Supportive Care 
 
Institutional standard of care guidelines will be followed for transplant related supportive  care, 
including monitoring for CMV reactivation and provision of PCP prophylaxis. CMV safe blood products 
will be administered and prophylaxis against peri-transplant infections will be used according to 
Institutional  guidelines. 
 
 
 
10.0   EVALUATION DURING TREATMENT/INTERVENTION 
 
Post-transplant Evaluation 
 
a. 
Clinical Assessments 
 
Patients will receive physical examinations daily until discharge with particular attention to 
assessments of potential toxicities induced by preparatory cytoreductive therapy, including mucositis, 
cystitis, sepsis, pneumonia, veno-occlusive disease (VOD) and transplant-associated complications 
including graft failure, acute and chronic GvHD, and transplant associated infections.  Patients are 


Memorial Sloan Kettering Cancer Center 
IRB Number: 17-498 A(3) 
Approval date: 17-Dec-2019 
Administrative Update 1 : 08-Mar-2021 
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closely monitored for alterations in vital signs, weight, oral and intravenous intake, and intestinal and 
urinary output. Cardiac assessments are obtained prior to admission to assess cardiac function and 
thereafter when clinically indicated. Pulmonary status is closely monitored when clinically indicated by 
radiographic and functional analysis. Baseline physical examinations and any subsequent, clinically 
significant abnormal new findings will be recorded. 
 
Following discharge, physical examination, will be performed at least every 2-4 weeks or as clinically 
indicated until day 100 after stem cell infusion. 
 
All timelines are approximations and adhere to good clinical practice. Certain tests may be held at the 
discretion of the treating physician and/or if deemed in the best clinical interest of the patient. 
 
b. 
Laboratory Evaluations 
Baseline laboratory evaluations and any subsequent clinically significant, abnormal new findings will 
be recorded. 
 
- 
Complete blood count daily until count recovery, then 3 times weekly until hospital discharge; at 
least every 1-2 weeks after discharge through day 100. 
 
- 
Comprehensive metabolic panel with liver function tests 
- twice weekly for the first 30 days 
- then weekly to discharge 
- more frequently if clinically indicated. 
 
- Bone marrow aspirates will be obtained as clinically indicated. Proposed time points are at 
approximately 1, 3, 6, and 12 months for patients with MDS or AML. Additional analyses will be 
done as clinically indicated. 
 
-      Chimerism studies will be performed approximately weekly as clinically indicated until at least day 
100. Additional total engraftment studies are recommended at approximately 1, 3, 6, 12, 18 and 
24 months. Sorted engraftment studies may also be performed according to institutional guidelines 
and treating physician’s discretion at above time points as clinically indicated. 
 
- 
Immunologic reconstitution will be monitored by in vitro assays and should include lymphocyte 
subpops, response to mitogens, and immunoglobulin levels. Immune studies are recommended 
at approximately 3, 6, 9, and 12 months. If immune reconstitution has not been demonstrated by 
12 months, immune studies are recommended at 15, 18, and 24 months as well. 
 
 
11.1 TOXICITIES/SIDE EFFECTS 
 
Patients recruited to this transplantation trial are individuals who are either referred by physicians or 
self-referred for marrow transplantation as a potentially curative treatment for their malignancy. Prior 
to consideration for transplant, all patients undergo a series of 1-3 hour consultations discussing the 
risks and potential benefits of an allogeneic marrow transplant and the different procedures, which will 
be a normal part of the transplant course. The risks and potential benefits of the transplant procedure, 
as well as the participation in any given research, experimental, or therapeutic protocol are also 
discussed. 


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The potential risks of an allogeneic transplant from an HLA-compatible unrelated donor or HLA- 
mismatched related donor are significant. These risks along with approaches to circumvent or 
minimize their effects on the health and wellbeing of the patient can be summarized as follows. 
 
11.1. 
General Description of Risks to Recipients 
 
Infections and hemorrhage constitute major and continuing risks throughout the period of marrow 
aplasia. These are, however, also the major risks associated with the primary disease. Certain 
opportunistic infections remain a risk in bone marrow transplant recipients beyond recovery of 
circulating leukocytes, for at least 9-12 months post-transplant, e.g. Pneumocystis carinii and 
cytomegalovirus. 
 
The above risks are carefully considered both by the physicians and by the patients prior to admission 
to a study protocol. The patients who are being considered for allogeneic peripheral blood stem cell 
transplantation are afflicted with Fanconi anemia and aplastic anemia, myelodysplastic syndrome or 
leukemias which are lethal diseases for whom a hematopoietic stem cell transplant from a an HLA- 
compatible unrelated donor or HLA-mismatched related donor currently constitutes the only curative 
option in the treatment of this disease. In the protocol proposed, use is made of an experimental device 
produced by Miltenyi Biotec, Auburn, CA. This device is approved for experimental applications under 
an IND from the Food and Drug Administration. 
 
All patients undergoing cytoreduction in the protocol will be treated with busulfan, cyclophosphamide 
and fludarabine.  They will also receive anti-human thymocyte globulin to prevent graft rejection. All 
of the treatments as well as other drugs used before and during the transplant may produce side 
effects. These risks are listed below. 
 
a. Busulfan 
- Myelosuppression, complete ablation is expected. 
- Gastrointestinal: nausea and vomiting, anorexia, diarrhea 
- Alopecia 
- Mucositis 
- Seizures: generally preventable by anti-convulsant therapy started 24 hours prior to administration 
and continued for 24 hours post busulfan 
- Abnormal liver function 
- Pulmonary fibrosis 
- Gonadal  dysfunction 
- Hyperpigmentation 
 
b. Cyclophosphamide 
- Bone marrow suppression, complete bone marrow ablation is expected. 
- Gastrointestinal: Nausea, vomiting, anorexia, diarrhea, stomatitis, esophagitis, colitis 
- Alopecia 
- Fever 
- Serious hypersensitivity reactions: Edema, rash, anaphylaxis 
- Water retention:  inappropriate secretion of ADH, usually manifested 4-8 hours after IV administration 
- Cardiomyopathy:Cyclophosphamide may cause a severe, sometimes lethal cardiomyopathy. 
- Hemorrhagic   cystitis: 
serious  complication  related  to  the  interaction  of  cyclophosphamide 
metabolites 
- Skin rash: This may develop 1-3 days post infusion and subsides thereafter 
- Hemolytic anemia 
- Sterility: This is a likely complication after puberty. Risk may be reduc ed in young children. 


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- Late effects: Late effects may occur with varying degree following cyclophosphamide and include 
growth failure, gonadal failure and sterility, hypothyroidism, and secondary malignancies. 
 
c. Fludarabine 
- Nausea, vomiting 
- Mouth sores, stomach cramps and diarrhea 
- Jaundice, and elevations of liver enzymes 
- Scaling and redness of the skin, which is usually of short duration. 
- Effects on the nervous system are not usually seen at the fludarabine dose used in this protocol, but, 
when they occur, can include cerebellar dysfunction with loss of balance and trouble walking. 
 
d. Methylprednisolone 
- Increased risk of infection 
- Increased blood pressure 
- Stomach upset including ulcers. Prophylaxis (such as antacids) will be administered as protection 
- Hyperlipidemia 
- Hyperglycemia 
 
e. Anti-Thymocyte Globulin 
- ATG is a rabbit protein, which may induce an immune response in humans. Prior exposure to rabbit 
proteins may predispose to serious allergic reactions such as anaphylaxis, generalized urticaria, or 
bronchospasm. This risk remains significant. Such reactions will be treated with epinephrine and 
anti-histamines. In the event of a severe systemic allergic reaction, a trial of an alternative equine 
ATG will be administered. If a similar reaction occurs with the equine ATG, no further ATG will be 
administered. 
 
- Serum sickness - approximately 10-30% of patients treated with rabbit ATG will develop a late 
immune reaction to the globulin resulting in serum sickness 3-10 days after administration. This is 
manifested by fever, rash, and arthralgias. Renal toxicity is rare. Prednisone for one week at 1 mg/kg 
has been shown to be effective therapy. 
 
- Fever and chills - are managed by antipyretics and meperidine but are usually only severe after first 
dose. 
 
- Leukopenia/thrombocytopenia  - ATG may also cause further decrease in leukocyte and platelet 
counts, which will be managed by transfusion therapy. 
 
f. G-CSF 
- 
Fever 
- 
Fatigue 
- 
Bone pain 
- 
Allergic reaction, mild to severe 
- 
Splenomegaly 
 
 
g. Subsequent Malignancies 
a. Patients transplanted for leukemia are at significant risk of recurrence of their original disease. 
 
b. Patients receiving T-cell depleted marrow grafts with ATG are at significant risk of developing an 
EBV lymphoproliferative disease. For patients treated with horse ATG, this risk is approximately 10- 
15%.   However, for those treated with rabbit ATG, it is less than 4%.   This complication might be 


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prevented with Acyclovir prophylaxis and may be treatable by infusions of peripheral blood leukocytes 
from the marrow donor. 
 
c. Secondary malignancies - there is a possibility that secondary malignancies may develop. The age- 
adjusted incidence of secondary cancers in transplant patients after radiation and chemotherapy has 
recently been estimated to be 6.7 times higher than that of first cancers in the general population. 
Most of these were non-Hodgkin's lymphomas. 
 
 
h. Graft Failures 
Rejection of a T-cell depleted related, HLA-disparate marrow and peripheral blood progenitor graft 
can occur. Patients rejecting their grafts may receive a secondary transplant from the same or an 
alternative donor, or may receive a reinfusion of autologous cryopreserved marrow whenever 
available. In our prior study using T-cell depleted grafts for Fanconi anemia, graft rejection leading to 
marrow aplasia did not occur. 
 
Alternatively, mixed chimerism (>10% donor cells) with lymphocytosis may occur.  Mixed chimerism 
as determined by the treating physician may be treated with Campath 0.2 mg/kg/dose SC given daily 
until the absolute lymphocyte count (ALC) is <200, to a maximum of 5 doses. A rapidly expanding 
lymphocytosis may be treated with Campath prior to the availability of chimerism data at the discretion 
of the treating physician. 
 
 
i. Graft Versus Host Disease 
Acute GvHD is  manifested by skin rash; hepatitis; ulceration of the surfaces of the oral cavity, 
esophagus, and intestines; and suppressed or delayed recovery of the hematopoietic and immune 
system. In patients transplanted and engrafted with SBA-E- T-cell depleted marrow from HLA 1-3 allele 
disparate related donors, this complication has been observed in fewer than 20% of patients and has 
rarely been severe. It may be fatal in at least 20-50% of cases and may also predispose to lethal 
infections which contribute to an additional mortality of 10-25%. Severe acute GvHD will be treated 
with intense immunosuppressive therapy according to standard clinical practice or other experimental 
protocol. In our prior study using T-cell depleted grafts for Fanconi anemia severe GVHD did not 
occur. 
 
Approximately 50% of patients with acute GvHD may also develop chronic GvHD, manifested to 
varying degrees by scleroderma-like changes of the skin, cirrhosis of the liver, sclerosis of lacrimal 
and salivary ducts, chronic inflammation and scarring of the gastrointestinal tract with consequent 
malabsorption and diarrhea, chronic bronchitis, and suppression of the immune system. This can be 
treated with standard or protocol-based experimental immunosuppression, but may be refractory. 
 
 
j. Stem cell infusions 
The volume of the T-cell depleted peripheral blood stem cells infused is approximately 30-50 cc. They 
may induce allergic reactions. Small, subclinical pulmonary emboli may occur, but these rarely if ever 
require any intervention. Standard pre-medications for blood products may be used before 
administration of the stem cell graft. 
 
Infusions of fractionated blood products may also induce allergic reactions of variable severity, many 
of which can be prevented or mitigated by premedication with antipyretics, antihistamines, and 
narcotics. These products may also serve as vectors of serious infection (e.g., CMV, hepatitis, AIDS). 
To circumvent this, prospective blood and marrow donors will be screened per institutional guidelines. 


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CMV antibody (-) blood products will be used in CMV (-) individuals, whenever possible, regardless of 
the antibody status of the marrow donor. ALL blood products are irradiated (3000r, 137Cs) to circumvent 
the risk of GvHD caused by contaminating lymphocytes in the transfused fractions. 
 
12.0   CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT 
 
Primary Outcomes 
 
Definition of events in the post-transplant course important for analysis and treatment 
 
12.1. 
Graft Failure or Rejection 
 
Graft failure or rejection will be the primary endpoint of this study: 
Primary non-engraftment is diagnosed when the patient fails to achieve an ANC 500/l at any time 
in the first 28 days post-transplant. If (1) after achievement of an ANC 500/mm3, the ANC declines 
to <500/mm3 for more than 3 consecutive days in the absence of relapse, or, (2) there is absence of 
donor cells in the marrow and/or blood as demonstrated by chimerism assayin the absence of relapse, 
a diagnosis of secondary graft failure is made. The patient is not evaluable for graft failure or rejection 
if recurrence of host MDS is detected concurrently. Patients with evidence of graft failure without 
evidence of recurrence of host MDS will have additional studies drawn to ascertain cause and define 
relevant  histoincompatibilities. 
 
These analyses may include (1) Evaluation of bone marrow aspirates and biopsies for residual or 
recurrent MDS/AML, when indicated, and (2) Culture and/or molecular analyses of marrow and/or 
blood for viral pathogens potentially causing graft failure including CMV, HHV6 and parvovirus B 19. 
 
Patients who suffer graft failure will be considered for a secondary transplant. The need for additional 
immunosuppression or treatment for viral infection prior to the secondary transplant will be determined 
by the results obtained from chimerism and viral studies. We have performed secondary transplants 
for patients with graft failure and have published our experience on rescuing patients with graft failure 
with fludarabine based regimens – including one patient with Fanconi anemia (Chewning JH, et al. 
Fludarabine-based conditioning secures engraftment of second hematopoietic stem cell allografts in 
the treatment of initial graft failure. Biol Blood Marrow Transplant. 13(11):1313-23; 2007) 
 
12.2. 
Early post-transplant severe morbidity and mortality 
 
The occurrence of severe post-transplant regimen-related severe morbidity (grade IV toxicity) and/or 
mortality will be the second endpoint of this study. In the context of the agents or agent-combination 
used for cytoreduction used, particular attention will be given to toxicity involving (1) the liver, (2) the 
lungs, (3) the oral mucosa and gastrointestinal tract, and (4) the central nervous system. The grading 
for monitoring the morbidity and mortality will be based on the NCI/CTEP common toxicity criteria 
version 4.0. 
 
12.3. 
Graft Versus Host Disease 
 
Patients will be observed for acute and/or chronic GvHD. Standard clinical criteria for the grading of 
acute and chronic GvHD will be done according to IBMTR guidelines See Appendices 3 and 4. 
 
To determine the severity of acute GvHD, data may be collected approximately weekly to characterize 
the severity of symptoms and signs caused by GvHD and to evaluate possible confounding factors. 
Real time data collection of GvHD will include grades for each organ involved and overall grade. 


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Patients with moderate to severe acute GvHD (grade II-IV) will be treated with immunosuppressive 
therapy according to standard clinical practice or other experimental protocol. 
 
Treatment of chronic GvHD will consist of corticosteroids, and other agents or modalities, according 
to Institutional standard of care guidelines and protocols. 
 
12.4. 
Leukemic Relapse 
 
For patients with MDS or AML, relapse will be analyzed as to type and genetic origin of the 
MDS/leukemic cells. These will be defined by an increasing number of blasts in the marrow over 5%, 
by the presence of circulating peripheral blasts, or by the presence of blasts in any extramedullary 
site. Cytogenetic analysis of the marrow and/or peripheral blood will also be obtained for the diagnosis 
of relapse. 
 
12.5. 
Secondary malignancies 
 
Patients may be followed indefinitely through contact with MSKCC in order to track the risk of 
developing a secondary malignancy. All clinical outcomes will be followed per standard institutional 
practice. 
 
13.0     CRITERIAFOR REMOVAL FROM STUDY 
 
Patients may be removed from study therapy at any point deemed appropriate by the principal 
investigator. However, once the busulfan is given, patients will continue on study until after 
administration of the stem cells. Failure to rescue the patient with stem cells at this point in the 
cytoreduction would most likely be fatal. 
 
 
14.0     BIOSTATISTICS 
 
The primary objectives of this phase II trial are to assess the incidence of engraftment, graft versus 
host disease, and treatment related mortality and morbidity (treatment related morbidity will is defined 
as any attributable grade 4 toxicity) in patients with Fanconi Anemia lacking genetically identical donor. 
A total of 10 MSKCC patients will be enrolled. 60 additional patients will be enrolled onto separate 
but identical studies conducted outside of MSKCC. Patient data from these sites will be aggregated 
and reviewed in total for safety and data analysis. 
 
Stopping rules and biostatistical calculations below are derived using a total of 70 patients treated at 
all 3 centers. 
 
Stopping Rules: 
Risk related to treatment regimen differs for each therapeutic arm. The recommended treatment for 
patients in Arm A is the standard of care and therefore no stopping rule is required. Stopping rules 
are: 
• 
Arm B: 4 out of the first 5 patients or 6 out of 10 patients demonstrate any attributable grade 4 
toxicity in the first 100 days. 
• 
Arm C: 4 out of the first 5 patients or 6 out of 10 patients experience graft failure within the first 
42 days of transplant as defined in section 12.1. 


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The data coordinating center is constantly in communication with participating sites, and will inform 
sites of any updates to stopping rules in real time. 
 
Sample Size Consideration: 
In Arm B the maximum number of patients enrolled will be 10. The increased dose is not expected to 
increase treatment related mortality, therefore the primary risk of interest is treatment related 
morbidity. Assuming treatment related morbidity is 40% the probability of the completion of Arm B is 
80%. 
 
In Arm C the maximum number of patients enrolled will be 10. The decreased dose is not expected to 
increase treatment related morbidity, therefore the primary risk of interest is treatment  related 
mortality. Assuming treatment related mortality is 40% the probability of the completion of Arm C is 
80%. 
 
Interpretation of the Study Results: 
For patients in Arm A, the primary risk is any treatment related death. In our previous study 85% (4/16) 
of patients who were less than 18 years, had SAA and an unrelated or mismatched related donor 
survived. In this present version of the protocol, enrollment on this arm will include up to 50 patients. 
If the study in Arm A is completed with full enrollment per original study design (i.e. 20 patients, as per 
an earlier version of this protocol) and 14 or more patients survive past 100 days this will be considered 
supporting evidence for the previous study results. Based on a conservative estimate of 80% overall 
survival the probability of 14 or more patients surviving past 100 days is 91%. The following table 
contains the estimates of overall survival and exact 95% confidence intervals for such events. 
 
 
Observed Overall 
Survival 
Estimated Survival 
Rate 
95% Exact Confidence 
Interval 
20 
1.00 
(0.861 -  1.00) 
19 
0.95 
(0.751 - 0.999) 
18 
0.90 
(0.683 – 0.988) 
17 
0.85 
(0.621 – 0.968) 
16 
0.80 
(0.563 – 0.943) 
15 
0.75 
(0.509 – 0.913) 
14 
0.70 
(0.457 – 0.881) 
 
If the study in Arm B (or Arm C) is completed with maximum enrollment then the following table 
represents the estimated treatment related morbidity (or mortality in Arm C) along with its 95% exact 
confidence interval. 
 
 
Number of treatment 
related morbidities (or 
mortalities) in 10 patients 
Estimated treatment 
related morbidities (or 
mortalities) 
Exact 95% 
Confidence Interval 
5 
0.5 
(0.186 - 0.813) 
4 
0.4 
(0.122 - 0.738) 
3 
0.3 
(0.067 - 0.651) 
2 
0.2 
(0.025 - 0.556) 
1 
0.1 
(0.003 - 0.445) 
0 
0.0 
(0.0 - 0.259) 


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Statistical analyses: 
 
Analyses will include Fisher’s exact test for categorical variables or Wilcoxon’s rank sum test for 
continuous variables. Disease free survival will be defined as time from date of transplant to relapse, 
graft rejection or graft failure, or death. Survival and cumulative incidence curves will be plotted using 
the Kaplan-Meier method. Survival will be compared for the entire study duration by group using log- 
rank tests. Confidence intervals and p-values for the difference in 1 year survival by group will be 
computed using Wald’s method with Greenwoods variance approximation. 
Quality of engraftment will be evaluated by linear specific chimerism analysis studies at 3, 6, 9 months 
post-transplant. Hematopoietic reconstitution will be evaluated by 1) neutrophil, red cell, and platelet 
counts at regular times post-transplant, 2) time to red cell and platelet transfusion independence, and 
3) time to normalization of cell counts for all three lineages. 
 
 
 
15.1 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
 
15.2 
Research Participant Registration 
 
Confirm eligibility as defined in the section entitled Inclusion/Exclusion Criteria. Obtain informed 
consent, by following procedures defined in section entitled Informed Consent Procedures. During 
the registration process registering individuals will be required to complete a protocol specific 
Eligibility Checklist. The individual signing the Eligibility Checklist is confirming whether or not the 
participant is eligible to enroll in the study. Study staff are responsible for ensuring that all 
institutional requirements necessary to enroll a participant to the study have been completed. See 
related Clinical Research Policy and Procedure #401 (Protocol Participant Registration). 
 
 
 
15.3 
Randomization 
 
N/A 
 
16.1 
DATA MANAGEMENT ISSUES 
 
The PI will be responsible for the conduct of the study, monitoring of study progress, review and 
validation of data entry, and the conduct of data analysis for MSK patients. De-identified MSKCC 
data and source documentation will be shared with Cincinnati Children’s Hospital Medical Center 
and Fred Hutchinson  Cancer Research Center for combined data analysis. 


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A Clinical Research Coordinator (CRC)will be assigned to this study. The responsibilities of the 
CRC include project compliance, data collection, abstraction and entry, data reporting, regulatory 
monitoring, problem resolution and prioritization, and coordinate the activities of the protocol study 
team. The data manager will also monitor laboratory compliance throughout the study. Laboratory 
data will be tabulated  and summarized based on MSKCC  normal ranges. 
The data for MSKCC patients  collected for this study will be entered into Medidata. 
 
 
 
 
 
16.2 
Quality Assurance 
 
Registration reports will be generated by the CRC on a regular basis to monitor patient accruals and 
completeness of the registration data. Routine data quality reports will be generated to assess missing 
data and inconsistencies. Accrual rates and extent and accuracy of evaluations and follow-up will be 
monitored periodically throughout the study period and potential problems will be brought to the 
attention of the study team for discussion and action. 
 
Random-sample data quality and protocol compliance audits will be conducted by the study team, at 
a minimum of two times per year, more frequently if indicated. 
 
In case of an FDA audit, the FDA will audit each participating site individually as each site will hold 
their own IND. Thus each center will be responsible for having all source documents, research records, 
all IRB approval documents, Drug Accountability Record forms, patient registration lists, response 
assessment scans, x-rays, etc. available for the audit. 
There will not be external monitoring of this study by CCHMC as this study is being conducted under 
a separate IND. 
 
 
16.3 
Data and Safety Monitoring 
 
The Data  and Safety  Monitoring  (DSM) Plans  at  Memorial  Sloan-Kettering  Cancer Center were 
approved by the National Cancer Institute in September 2001. The plans address the new policies set 
forth by the NCI in the document entitled “Policy of the National Cancer Institute for Data and Safety 
Monitoring 
 of 
Clinical 
 
Trials” 
which  
 
can   
be 
 
 found 
 at:  
http://cancertrials.nci.nih.gov/researchers/dsm/index.html. 
The DSM  Plans at  MSKCC were 
established and are monitored by  the Office of Clinical Research. The MSKCC Data and  Safety 
Monitoring 
Plans 
can 
be  
found 
 on 
 
the 
MSKCC  
Intranet 
 at: 
https://one.mskcc.org/sites/pub/clinresearch/Documents/MSKCC%20Data%20and%20Safety%20M 
onitoring%20Plans.pdf 
 
There are several different mechanisms by which clinical trials are monitored for data, safety and 
quality. There are institutional processes in place for quality assurance (e.g., protocol monitoring, 
compliance and data verification audits, therapeutic response, and staff education on clinical research 
QA) and departmental procedures for quality control, plus there are two institutional committees that 
are responsible for monitoring the activities of our clinical trials programs. The committees: Data and 
Safety Monitoring Committee (DSMC) for Phase I and II clinical trials, and the Data and Safety 
Monitoring Board (DSMB) for Phase III clinical trials, report to the Center’s Research Council and 
Institutional Review Board. 


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During the protocol development and review process, each protocol will be assessed for its level of 
risk and degree of monitoring required. Every  type of protocol (e.g., NIH sponsored, in-house 
sponsored, industrial sponsored, NCI cooperative group, etc.) Will be addressed and the monitoring 
procedures will be established at the time of protocol activation. 
 
MSK will submit safety monitoring reports for patients accrued at our institutions to MSK’s DSMC. 
 
 
17.1 
PROTECTION OF HUMAN SUBJECTS 
 
Risks: From the studies that have been done so far there appears to be no increase in risk to the 
patients. However, given this is a new treatment, it is possible that there are side effects that have not 
yet been seen. 
 
Benefits: The information from this study will help future patients. 
 
Possible toxicities/side effects: Toxicities and side effects of the agents used are listed in section 11 
and reporting of serious adverse events are found in section 17.2. 
 
Consent Process: Participation in this study is  voluntary. All patients will be required to sign a 
statement of informed consent which must conforming  to MSKCC’s IRB guidelines. 
 
Alternatives: Alternative treatment options will be presented to the patient prior to taking part in this 
study. Alternative treatment options may include getting a transplant from a volunteer unrelated donor, 
if one is available; getting treatment for your cancer with either chemotherapy or a transplant without 
being on a study; taking part in another study; or getting no treatment. 
 
Costs: The patient’s health plan/insurance company will need to pay for all of the costs of treatment 
in this study. The patient will be responsible for the costs of standard medical care, all hospitalizations 
and any transplant complications. Pre-authorization for the transplant will be cleared with the health 
plan/insurance company prior to admission. Patients will not be paid for taking part in this study. 
Research tests will be done at no cost to the patient. 
 
Confidentiality: Every effort will be made to maintain patient confidentiality. Research and hospital 
records are confidential. 
 
17.2 
Privacy 
 
MSK’s Privacy Office may allow the use and disclosure of protected health information pursuant to a 
completed and signed Research Authorization form. The use and disclosure of protected health 
information will be limited to the individuals described in the Research Authorization form. A 
Research Authorization form must be completed by the Principal Investigator and approved by the 
IRB and Privacy Board (IRB/PB). 
 
The consent indicates that individualized de identified information collected for the purposes of this 
study may be shared with other qualified researchers. Only researchers who have received approval 
from MSK will be allowed to access this information which will not include protected health 
information, such as the participant’s name, except for dates. It is also stated in the Research 
Authorization that their research data may be shared with others at the time of study publication. 


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Enrollment on this study is on a voluntary basis and every effort will be made to maintain privacy and 
confidentiality. The patient's records will be confidential. Only authorized individuals or agencies may 
inspect the records. No identifying information will be used in reports or publications resulting from 
this study. 
 
 
 
17.3 
Serious Adverse Event (SAE) Reporting 
 
An adverse event is considered serious if it results in ANY of the following outcomes: 
• 
Death 
• 
A life-threatening adverse event 
• 
An adverse event that results in inpatient hospitalization or prolongation of existing 
hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect 
• 
Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition 
Note: Hospital admission for a planned procedure/disease treatment is not considered an 
SAE. 
 
SAE reporting is required as soon as the participant signs consent. SAE reporting is 
required for 30-days after the participant’s last investigational treatment or intervention. Any 
events that occur after the 30-day period and that are at least possibly related to protocol 
treatment must be reported. 
 
Please note: Any SAE that occurs prior to the start of investigational treatment/intervention 
and is related to a screening test or procedure (i.e., a screening biopsy) must be reported. 
 
All SAEs must be submitted in PIMS. If an SAE requires submission to the HRPP office per 
IRB SOP RR-408 ‘Reporting of Serious Adverse Events’, the SAE report must be submitted 
within 5 calendar days of the event. All other SAEs must be submitted within 30 calendar 
days of the event. 
The report should contain the following information: 
• 
The date the adverse event occurred 
• 
The adverse event 
• 
The grade of the event 
• 
Relationship of the adverse event to the treatment(s) 
• 
If the AE was expected 
• 
Detailed text that includes the following 
o An explanation of how the AE was handled 
o A description of the participant’s condition 
o Indication if the participant remains on the study 
• 
If an amendment will need to be made to the protocol and/or consent form 


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• 
If the SAE is an Unanticipated Problem 
 
The SAE report should be completed as per above instructions. If appropriate, the report will 
be forwarded to the FDA by the IND Office 
 
 
17.2.1  Serious Adverse Event (SAE) Reporting Additional Information 
 
Attribution: 
 
• 
Unrelated: The AE is clearly NOT related to the intervention 
• 
Unlikely: The AE is doubtfully related to the intervention 
• 
Possible: The AE may be related to the intervention 
• 
Probable: The AE is likely related to the intervention 
• 
Definite: The AE is clearly related to the intervention 
Expected and Unexpected Event: 
• 
Expected:  Any  experience  previously reported  (in  nature,  severity,  or  incidence) in  the 
current Investigator’s Brochure or general investigational plan 
• 
Unexpected: Any experience not previously reported (in nature, severity, or incidence) in the 
current Investigator’s Brochure or general investigational plan 
 
UNEXPECTED EVENT: 
• 
Grades 1-2: Adverse Event Reporting NOT required. 
• 
Grades 3: Possible, Probable or Definite attribution to the drug and/or device. 
• 
Grades 4 and 5: Regardless of Attribution. This includes all deaths within 30 days of the last 
dose of treatment with an investigational agent regardless of attribution. 
 
EXPECTED EVENT 
• 
Grades 1 – 3: Adverse Event Reporting NOT required. 
• 
Grades 4 and 5: Regardless of Attribution. This includes all deaths within 30 days of the last 
dose of treatment with an investigational agent regardless of attribution. 
*Reportable events are those which occur within 30 days of the last dose of treatment on protocol. 
Events beyond 30 days will be reported at the discretion of the PI. 
 
 
 
18.1 
INFORMED CONSENT PROCEDURES 
 
Before protocol-specified procedures are carried out, consenting professionals will explain  
full details of the protocol and study procedures as well as the risks involved to participants 
prior to their inclusion in the study. Participants will also be informed that they are free to 
withdraw from the study at any time. All participants must sign an IRB/PB-approved consent 
form indicating their consent to participate. This consent form meets the requirements of the 
Code of Federal Regulations and the Institutional Review Board/Privacy Board of this Center. 
The consent form will include the following: 
1. The nature and objectives, potential risks and benefits of the intended study. 


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2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard and 
investigational therapies. In addition, patients will be offered an option of supportive 
care for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions and to 
withdraw from participation at any time. 
Before any protocol-specific procedures can be carried out, the consenting professional will 
fully explain the aspects of patient privacy concerning research specific information.  In addition 
to signing the IRB Informed Consent, all patients must agree to the Research Authorization 
component of the informed consent form. 
 
Each participant and consenting professional will sign the consent form. The participant must 
receive a copy of the signed informed consent form. Signed copies of the consent will be 
forwarded to CCHMC at the time of patient registration. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
19.0     REFERENCES 
 
1. Young, N.S., Alter B.P. Clinical features of Fanconi’s Anemia. In: Young NS, Alter BP, eds. (1994). 
Aplastic Anemia acquired and inherited. Philadelphia, PA: Saunders; pp275-309, 1994. 
 
2. Auerbach AD, Woman SR. Susceptibility of Fanconi Anemia fibroblas ts to chromosome damage 
by carcinogens. Nature 261: 494-496, 1976. 
 
3. Butturini A, Gale RP, Verlander PC, Adler-Brecher B, Gillio AP, Auerbach AD. Hematologic 
abnormalities in Fanconi Anemia: an International Fanconi Anemia Registry study. Blood 84:1650- 
1655, 1994. 
 
4. Barrett AJ, Brigden WD, Hobbs JR, Hugh-Jones K, Humble JG, James DC, Retsas S, Rogers TR, 
Selwyn S, Sneath P, Watson JG. Successful bone marrow transplant for Fanconi's anaemia. 
British Medical Journal. 1(6058):420-2, 1977. 


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5. Gluckman E., Devergie A., Schaison G., Bussel A., Berger R., Sohier J., Bernard J. Bone marrow 
transplantation for Fanconi Anemia.  Br J. Haematol.  45:557-564, 1980. 
 
6. Deeg HJ. Storb R. Thomas ED. Appelbaum F. Buckner CD. Clift RA. Doney K. Johnson L. Sanders 
JE. Stewart P. Sullivan KM. Witherspoon RP. Fanconi's anemia treated by allogeneic marrow 
transplantation. Blood. 61(5):954-9, 1983. 
 
7. Gluckman E. Auerbach AD. Horowitz MM. Sobocinski KA. Ash RC. Bortin MM. Butturini A. Camitta 
BM. Champlin RE. Friedrich W. et al. Bone marrow transplantation for Fanconi anemia. Blood. 
86(7):2856-62, 1995. 
 
8. Gluckman E. Auerbach A. Ash RC. Biggs JC. Bortin MM. Camitta BM. Champlin RE. Friedrich W. 
Gale RP. Good RA. et al. Allogeneic bone marrow transplants for Fanconi anemia. A preliminary 
report from the International Bone Marrow Transplant Registry. Bone Marrow Transplantation. 10 
Suppl 1:53-7, 1992. 
 
9. Socie G., Gluckman E., Raynal B., Petit T., Landman J., Devergie A., Brison O. Bone marrow 
transplantation for Fanconi anemia using low-dose cyclophosphamide/ thoracoabdominal 
irradiation as conditioning regimen: chimerism study by the polymerase chain reaction. Blood. 
82(7):2249-56, 1993. 
 
10. Flowers MED., Doney KC., Storb R., Sanders JE., Sullivan KM., Bryant E., Witherspoon RP., 
Appelbaum F., Buckner CD., Hansen JA., Thomas ED., Marrow transplantation for Fanconi 
Anemia with or without leukemic transformation: an update of the Seattle experience. Bone 
Marrow Transplantation 9:167-173, 1992. 
 
11. Kohli-Kumar M., Morris C., DeLaat C., Sambrano J., Masterson M., Mueller R., Shahidi N., Yanik 
G., Desantes K., Friedman DJ., Auerbach AD., Harris RE. Bone marrow transplantation in Fanconi 
Anemia using matched sibling donors.  Blood 84:2050-2054, 1994. 
 
12. Flowers MED., Zanis J., Pasquini R., Deeg JH., Ribeiro R., Longton G., Medeiros CR., Doney K., 
Sanders J., Bryant E., Hansen J., Sullivan KM., Appelbaum F., Thomas ED., Storb R. Marrow 
transplantation 
for 
Fanconi 
Anaemia: 
conditioning 
regimen 
with 
reduced 
doses 
of 
cyclophosphamide without radiation.  Brit. J. Haematol.  92:699-706, 1996. 
 
13. Dokal IS., Roberts IAG. Bone marrow transplantation for Fanconi’s  Anaemia:  conditioning 
regimen with reduced doses of cyclophosphamide without radiation. Brit. J. Haematol. 94:423- 
425, 1996. 
 
14. Solh H., Rao K., Martins da Cumba AM., Padmos A., Sackey K., Ernst P., Spence D., Clink H. 
Bone marrow transplantation in patients with Fanconi Anemia: experience with cyclophosphamide 
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15. Socie G. Devergie A. Girinski T. Piel G. Ribaud P. Esperou H. Parquet N. Maarek O. Noguera MH. 
Richard P. Brison O. Gluckman E. Transplantation for Fanconi's anaemia: long-term follow-up of 
fifty patients transplanted from a sibling donor after low-dose cyclophosphamide and thoraco- 
abdominal irradiation for conditioning.    British Journal of Haematology. 103(1):249-55, 1998. 
 
16. Guardiola P. Socie G. Pasquini R. Dokal I. Ortega JJ. van Weel-Sipman M. Marsh J. Locatelli F. 
Souillet G. Cahn JY. Ljungman P. Miniero R. Shaw J. Vermylen C. Archimbaud E. Bekassy AN. 


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Krivan G. Di Bartolomeo P. Bacigalupo A. Gluckman E. Allogeneic stem cell transplantation for 
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Timonova LA. Bogatcheva NY. Samochatova EV. Roumjantzev AG. Intermediate-dose busulfan 
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18. Auerbach AD. Adler B. O'Reilly RJ. Kirkpatrick D. Chaganti RS. Effect of procarbazine and 
cyclophosphamide on chromosome breakage in Fanconi anemia cells: relevance to bone marrow 
transplantation. Cancer Genetics & Cytogenetics. 9(1):25-36, 1983 
 
19. Gluckman E., Devergie A., Dutreix J. Radiosensitivity in Fanconi Anaemia: application to the 
conditioning regimen for bone marrow transplantation.   Brit. J. Haematol. 54:431-440, 1983. 
 
20. Yule SM., Price L., Cole M., Pearson AD., Boddy AV. Cyclophosphamide metabolism in children 
with Fanconi's anaemia. Bone Marrow Transplantation. 24(2):123-8, 1999. 
 
21. Hows JM. Unrelated donor bone marrow transplantation for severe aplastic anaemia and 
Fanconi's anaemia.  Bone Marrow Transplantation. 4 Suppl 4:126-8, 1989 
 
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donor bone marrow transplantation for Fanconi anemia. Bone Marrow Transplantation. 17(1):43- 
7, 1996 
 
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Karanes C, Chen A, Cairo A, Yeaker AM, Defor T, Wagner JE: Unrelated donor stem cell 
transplant for Fanconi anemia: Multicenter report of 49 cases. Blood 90:108a, 1997. 
 
24. Massumoto C, Moraes JR, Moraes ME, Macedo MC, Medeiros R, Chamone D, et al. Unrelated 
peripheral blood stem cell transplantation for Fanconi Anemia. Bone Marrow Transpl. 19:299-300, 
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Bittencourt M, Marollease J, Gluckman E. Results of a phase I/II multicenter prospective study 
using CD34+ selection for HLA matched unrelated transplants in Fanconi anemia. Blood 92:290a, 
1998. 
 
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Vermylen C, Skinner R, Ljungman P, Miniero R, Shaw PJ, Souillet G, Michalet M, Bekassy AN, Di 
Bartolomeo P, Heilmann C, Zanesco L, Cahn JY, Arcese W, Bacigalupo A, Gluckman E.  Outcome 
of 69 allogeneic stem cell transplantations for Fanconi Anemia using HLA-matched unrelated 
donors: A study on behalf of the European Group for Blood and Marro Transplantation. Blood 95: 
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28. MacMillan ML, Davies SM, Defor TE, Auerbach AD, Gillio A, Giller R, Harris R, Cairo M, Dusenberg 
K, Hirsch B, Ramsey NKC, Weisdorf DJ, Wagner JE: Hematopoietic cell transplantation in patients 
with Fanconi anemia using non-genotypically identical donors: Results of a TBI dose escalation 
trial. Br J Haematol. 2000 Apr;109(1):121-9. 
 
29. Tan PL, Wagner JE, Auerbach AD, Defor TE, Slungaard A, Macmillan ML. Successful 
engraftment without radiation after fludarabine-based regimen in Fanconi anemia patients 
undergoing genotypically identical donor hematopoietic cell transplantation. Pediatr  Blood 
Cancer. 2006 May 1;46(5):630-6. 
 
30. Boyer MW, Gross TG, Loechelt B, Leemhuis T, Filipovich A, Harris RE. Low risk of graft-versus- 
host disease with transplantation of CD34 selected peripheral blood progenitor cells from 
alternative donors for Fanconi anemia.  J Pediatr Hematol Oncol. 2003 Nov;25(11):890-5. 
 
31. Mehta PA, Davies SM, Leemhuis T, Myers K, Kernan NA, Prockop SE, Scaradavou A, O'Reilly 
RJ, Williams DA, Lehmann L, Guinan E, Margolis D, Baker KS, Lane A, Boulad F. Radiation- 
free, alternative-donor  HCT for Fanconi anemia patients: results from a prospective multi- 
institutional study. Blood. 2017 Apr 20;129(16):2308-2315. 
 
 
32. Somers GR. Tabrizi SN. Tiedemann K. Chow CW. Garland SM. Venter DJ. Squamous cell 
carcinoma of the tongue in a child with Fanconi anemia: a case report and review of the literature. 
Pediatr Pathol Lab Med. 15(4):597-607, 1995 
 
33. Millen FJ. Rainey MG. Hows JM. Burton PA. Irvine GH. Swirsky D. Oral squamous cell carcinoma 
after allogeneic bone marrow transplantation for Fanconi anaemia. British Journal of Haematology. 
99(2):410-4, 1997 
 
34. Socie G. Scieux C. Gluckman E. Soussi T. Clavel C. Saulnier P. Birembault P. Bosq J. Morinet F. 
Janin A. Squamous cell carcinomas after allogeneic bone marrow transplantation for aplastic 
anemia: further evidence of a multistep process. Transplantation. 66(5):667-70, 1998 
 
35. Witherspoon, R.P., Fisher, L.D., Schoch, G., Martin, P., Sullivan, K.M., Sanders, J., Deeg, H.J., 
Doney, J., Thomas, D. & Storb, R. Secondary cancers after bone marrow transplantation for 
leukemia or aplastic anemia. New England Journal of Medicine, 321, 784-789, 1989 
 
 
 
20.0 
APPENDICES 
 
Appendix 1 – WHO Classification 
Appendix 2 – Performance Scores 
Appendix 3 – Acute GVHD 
Appendix 4 – Chronic GVHD 
Appendix 5 – Toxicity 


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Appendix 1 
MDS Classification 
 
WHO Classification 
BLOOD 
BONE MARROW 
Refractory Anemia 
RA 
- 
0 or rare blasts 
- 
Anemia 
- 
< 1 x 109/L monocytes 
- 
<5% blasts 
- 
Dysplasia only Erythroid 
- 
Myeloid-MegaK  dysplasia 
< 10% of cells 
Refractory cytopenia with 
multilineage dysplasia 
RCMD 
- 
0 or rare blasts 
- 
Cytopenias (2-3  lineages) 
- 
No Auer rods 
- 
< 1 x 109/L monocytes 
- 
<5% blasts 
- 
Dysplasia in 2-3 lineages 
- 
Dysplasia in 10% of cells 
- 
No Auer rods 
Refractory anemia with 
excess blasts – 1 
RAEB-1 
- 
<5% blasts 
- 
Cytopenias (2-3  lineages) 
- 
No Auer rods 
- 
< 1 x 109/L monocytes 
- 
5-9% blasts 
- 
Dysplasia in 1-3 lineages 
- 
No Auer rods 
Refractory anemia with 
excess blasts – 2 
RAEB-2 
- 
5-19% blasts 
- 
Cytopenias (2-3  lineages) 
- 
Auer rods +/- 
- 
< 1 x 109/L monocytes 
- 
10-19%  blasts 
- 
Dysplasia in 1-3 lineages 
- 
Auer rods +/– 
Myelodysplastic  syndrome, 
unclassified 
MDS-U 
- 
0 or rare blasts 
- 
Cytopenias (2-3  lineages) 
- 
No Auer rods 
- 
<5% blasts 
- 
Myeloid-MegaK  dysplasia 
- 
No Auer rods 
 
 
IPSS Classification* 
1. Single Lineage Score 
BM Blasts 
Cytogenetics** 
Cytopenia 
0 
<5% 
Good 
0-1 
0.5 
5-10% 
Intermediate 
2-3 
1 
- 
Poor 
- 
1.5 
11-20% 
- 
- 
2 
21-30 
- 
- 
**Good: 
normal, -Y, del(5q),  del (20q); 
Poor: 
complex (   3 abnormalities) or chromosome 7 anomalies; 
Intermediate:   other abnormalities. 
 
 
2. Overall IPSS Risk Group 
Risk Group 
Combined IPSS Score 
Low 
0 
Intermediate 1 
0.5-1.0 
Intermediate 2 
1.5-2.0 
High 
> 2.0 


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Appendix 2 
Performance Scores 
 
LANSKY SCALE (<16 y.o.) 
 
The score is defined by the phrase which best describes the activity status of the recipient. 
Able to carry on normal activity; no special care is needed. 
100 
Fully active 
90 
Minor restriction in physically strenuous play 
80 
Restricted in strenuous play, tires more easily, otherwise active 
Mild to moderate restriction 
70 
Both greater restrictions of, and less time spent in, active play 
60 
Ambulatory up to 50% of time, limited active play with assistance/supervision 
50 
Considerable assistance required for any active play; fully able to engage in quiet play 
Moderate to severe restriction 
40 
Able to initiate quiet activities. 
30 
Needs considerable assistance for quiet activity 
20 
Limited to very passive activity initiated by others (e.g. TV) 
10 
Completely disabled; not even passive play 
 
 
 
KARNOFSKY SCALE (>16 y.o.) 
 
The score is defined by the phrase which best describes the activity status of the recipient. 
Able to carry on normal activity; no special care is needed. 
100 
Normal; no complaints; no evidence of disease 
90 
Able to carry on normal activity 
80 
Normal activity with effort 
Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is 
needed. 
70 
Cares for self; unable to carry on normal activity or to do active work 
60 
Requires occasional assistance but is able to care for most needs 
50 
Requires considerable assistance and frequent medical care 
.  Unable  to  care  for  self;  requires  equivalent  of  institutional  or  hospital  care; disease  may be 
progressing rapidly. 
40 
Disabled; requires special care and assistance 
30 
Severely disabled; hospitalization indicated, although death not imminent 
20 
Very sick; hospitalization necessary 
10 
Moribund; fatal process progressing rapidly. 


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Appendix 3 
Acute GvHD 
 
CLINICAL STAGING AND GRADING OF ACUTE GRAFT VERSUS HOST DISEASE 
 
ORGAN INVOLVEMENT 
STAGE 
Skin 
Liver 
Gut 
1 
maculopapular 
rash 
<25% body surface 
Bili 2.0 – 3.0 mg/dl 
Diarrhea 
500-1000 ml/d 
(children: 280-555 ml/m2/d) 
OR persistent nausea 
2 
maculopapular 
rash 
25-50 % of body 
surface 
Bili 3.1 – 6.0 mg/dl 
Diarrhea 
>1000 but < 1500 ml/d 
(children: 556-833 ml/m2/d) 
3 
maculopapular 
rash 
>50 % of body 
surface 
Bili 6.1 - 15 mg/dl 
Diarrhea 
>1500 ml/d 
(children: >834 ml/m2/d) 
4 
generalized 
erythroderma 
with bullous 
formation 
Bili > 15 mg/dl 
Severe abdominal pain + Ileus 
GRADING 
GRADE 
Skin 
Liver 
Gut 
0 
NONE 
None AND 
NONE 
I 
Stage 1-2 AND 
None AND 
NONE 
II 
Stage 3 AND/OR 
Stage 1 AND/OR 
Stage 1 
III 
None OR Stage 3 
AND 
Stage 2-3 OR 
Stage 2-4 
IV 
Stage 4 OR 
Stage 4 
NA 
STAGING 
- For skin GvHD: 
- Use “Rule of Nines or burn chart to determine extent of rash 
- For liver GvHD: 
- Range of bilirubin given as total bilirubin. 
- Downgrade one stage if an additional cause of hyperbilirubinemia is 
documented 
- For gut GvHD: 
- Downgrade one stage if an additional cause of diarrhea is documented 
- St 1: Persistent nausea, vomiting and anorexia in the 
absence of other known cause – Unless histology is negative 


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GRADING- Criteria for grading given as minimum degree of organ involvement required to confer 
that grade 
 
REF: Przepiorka et al. 1994 Consensus Conference on Acute GVHD Grading (“Keystone 
Criteria”). Bone Marrow Transplant 1995; 15:825-8. 
 
 
ADULT Rule of Nines (for GvHD 
scoring) 
(see diagram for children – varies with age) 
4.5% 
front of head 
4.5% 
back of head 
4.5% 
front of arm x 2 arms, max 
9% 
4.5% 
back of arm x 2 arms, max 
9% 
18% 
chest/trunk 
18% 
back/trunk 
9% 
front of leg x 2 legs, max 
18% 
9% 
back of leg x 2 legs, max 
18% 
1% 
Perineum 


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Clinical Manifestations  of Chronic GvHD 
 
 
 
Chronic GvHD Scoring 
Appendix 4 
Chronic GvHD 
Limited 
Either or both: 
1. localized skin involvement 
2. hepatic dysfunction due to chronic GvHD 
Extensive 
Either 
1. generalized skin involvement, OR 
2. localized skin involvement AND/OR hepatic dysfunction due to chronic 
GvHD 
PLUS 
3a. liver histology showing chronic aggressive hepatitis, bridging necrosis, or 
cirrhosis, 
OR 
3b. involvement of eye (Schirmer’s <5mm wetting) 
3c. involvement of minor salivary glands or oral mucosa demonstrated on labial 
bx 
3d. involvement of any other target organ. 
REF:  Forman et al. Bone Marrow Transplantation (text) 1994, page 350. 
 
 
 
Organ 
Clinical Manifestation 
Evaluation 
Intervention 
Skin 
Erythematous papular rash 
(lichenoid) or thickened, tight, 
fragile skin (sclerodermatous). 
Clinical and biopsy 
to confirm the 
diagnosis of GVHD. 
Moisturize (petroleum 
jelly), treat local 
infections, protect from 
further trauma. Topical 
steroid ointment may 
be used if it gives 
symptomatic relief to 
localized areas. 
Nails 
Vertical ridging, fragile. 
damage. 
Clinical. 
Nail polish may help to 
decrease further 
Sweat glands 
Destruction leading to risk of 
hyperthermia. 
Avoid excessive heat. 
Hair 
Scalp and body hair is thin and 
fragile, can be partially or 
completely lost. 
Clinical. 


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Eyes 
Dryness, photophobia, and 
burning. Progression to 
corneal abrasion. 
Regular 
ophthalmologic 
evaluation including 
Schirmer’s test. 
Preservative free tears 
during the day and 
preservative free 
ointment at night. 
Mouth 
Dry; sensitivity to mint, spicy 
food, tomato. Whitish lace-like 
plaques Avoid foods which are 
not tolerated. Regular in the 
cheeks and tongue identical to 
lichen planus. Erythema and 
dental care preceded by 
appropriate  endocardi-painful 
ulcerations, mucosal 
scleroderma with decreased 
sensitivity to temperature can 
also happen. 
Regular dental 
evaluation (with 
appropriate 
endocarditis 
prophylaxis). Viral and 
fungal cultures at 
diagnosis and at any 
worsening. tis 
prophylaxis. Topical 
steroid rinses followed 
by an antifungal agent 
for symptomatic relief. 
Respiratory tract 
Bronchiolitis Obliterans can 
manifest as dyspnea, 
wheezing, cough with normal 
CT scan and marked 
obstruction at pulmonary 
function tests. Chronic 
sinopulmonary symptoms 
and/or infections are also 
common.With abnormal chest 
CT, must rule out infections. 
Lung biopsy if clinically 
indicated. 
Pulmonary function 
tests including 
FEV1, FVC, DLCO, 
helium lung 
volumes. CT scan 
in symptomatic 
patients. 
Investigational  therapy. 
Gastrointestinal 
Abnormal motility and 
strictures. Weight loss. 
Swallowing studies, 
endoscopy if 
clinically indicated. 
Nutritional 
evaluation. 
intervention. 
Systemic treatment of 
GVHD; endoscopical/ 
surgical treatment of 
strictures. Nutritional 
Liver 
Cholestasis (increased 
bilirubin, alkaline 
phosphatase). Isolated liver 
involvement needs histologic 
confirmation. 
Liver function tests. 
Liver biopsy if 
clinically indicated. 
No specific therapy is 
proven superior. 
FK506 may 
concentrate in the 
liver. 


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Musculoskeletal 
Fasciitis. Myositis is rare. 
Osteoporosis may occur 
secondary to hormonal deficits, 
use of steroids, decreased 
activity. 
Periodical physical 
therapy evaluation 
to document the 
range of motion. 
Bone density 
evaluation 
especially in 
patients using 
steroids. 
Aggressive physical 
therapy program. 
Immune system 
Variable IgG 
levels. 
Profound 
immunodeficiency. 
Functional asplenia. High risk 
of pneumococcal sepsis, PCP, 
and invasive fungal infections. 
GVHD has resolved. 
Assume all patients 
as severely 
immuno- 
compromised and 
asplenic to 6 
months after 
vaccinations. 
PCP prophylaxis  (until 
6 months after no 
GVHD) and 
Pneumococcal 
prophylaxis (lifetime). 
Delay 
Hematopoietic 
system 
Cytopenias. Occasional 
eosinophilia. 
Counts. Bone 
marrow aspirate 
and biopsy, anti- 
neutrophil and anti- 
platelet antibodies 
when indicated. 
Systemic treatment of 
GVHD. 
Others 
Virtually all autoimmune 
disease manifestations have 
been described in association 
with chronic GVHD. 
As clinically 
indicated. 


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Appendix 5 
Toxicity 
 
 
Website: 
Refer to NCI Common Toxicity Criteria 4.0 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40