Clinical trial NCT02345850
Conditions: Acute Leukemia Myelodysplasia
Keywords: Acute Leukemia Myelodysplasia GVHD Prophylaxis Chronic GVHD
Sponsor: National Heart, Lung, and Blood Institute (NHLBI)
Start date: 2015-08-01; Completion date: 2020-10-05
Enrollment: 346 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The study is designed as a three arm randomized Phase III, multicenter trial comparing two calcineurin inhibitor (CNI)-free strategies for Graft-versus-Host Disease (GVHD) prophylaxis to standard tacrolimus and methotrexate (Tac/Mtx) in patients with hematologic malignancies undergoing myeloablative conditioning hematopoietic stem cell transplantation.

Detailed description:
Chronic Graft-versus-Host Disease (GVHD) is a complication that affects many hematopoietic stem cell transplant (HSCT) survivors; it occurs when the new cells from a transplant attack the recipient's body. The current standard GVHD prophylaxis regimen for patients with hematologic malignancies undergoing HSCT involves a combination of immunosuppressive agents given for the first 6 months after transplant. Often, patients develop GVHD and continue on these agents for much longer periods. The combination of calcineurin inhibitors (tacrolimus and cyclosporine A) with methotrexate (MTX) is the most common GVHD prophylaxis used worldwide in the context of myeloablative conditioning transplants. This regimen demonstrates better control of acute GVHD, but is less effective against chronic GVHD. Management of chronic GVHD remains a challenge and it has become a significant health problem in transplant survivors with more frequent use of mobilized peripheral blood stem cells. Additionally, several issues arise with the standard approach including various toxicity symptoms and side effects, increased risk of thrombotic microangiopathy due to CNI, no prevention of other infectious diseases, and no prevention for disease relapse.

This standard strategy of Tac/MTX will be used as a control in comparison to two other treatment plans both utilizing CNI-free methods: CD34 selected T-cell depletion in peripheral blood stem cell (PBSC) grafts, and infusion of bone marrow (BM) grafts followed by post-transplant Cyclophosphamide (PTCy). Study participants will be randomized to one of these three treatment arms.

Arms: arm 1: Unmanipulated bone marrow graft with Tacrolimus/Methotrexate GVHD prophylaxis. Tacrolimus will be maintained at therapeutic doses for a minimum of 90 days. Methotrexate will be dosed at 5-15mg/m\^2 for a maximum of 4 doses post-transplant.

Cyclosporine may be substituted for tacrolimus if the patient is intolerant of tacrolimus or per institutional practice. arm 2: Mobilized CD34-selected Peripheral Blood Stem Cell graft

Following screening and enrollment, the donor of patients randomized to the CD34-selection arm will receive mobilization therapy with once daily Granulocyte Colony Stimulating Factor (G-CSF). Mobilization will begin on Day -5 prior to the patient's transplant date.

Leukapheresis will be performed on a continuous flow cell separator according to institutional standards and will commence on the morning of the fifth day of G-CSF treatment. The anti-coagulant used for the procedure will be acid citrate dextrose (ACD).

Decisions concerning the need for further product collection will be based on the known or projected enriched CD34+ cell content of the previously collected products. arm 3: Unmanipulated Bone Marrow Graft with Cyclophosphamide
Interventions: intervention 1: Unmanipulated Bone Marrow Graft with Tacrolimus/Methotrexate intervention 2: Mobilized CD34-selected Peripheral Blood Stem Cell graft intervention 3: Unmanipulated Bone Marrow Graft with Cyclophosphamide intervention 4: Cyclophosphamide intervention 5: Tacrolimus intervention 6: Methotrexate
Intervention descriptions: intervention 1: Unmanipulated BM grafts will be administered on Day 0 to all patients according to individual institutional guidelines after appropriate processing and quantification has been performed by the local laboratory. Stem cells are administered through an indwelling central venous catheter. If infusion occurs over two days, Day 0 is the first day the infusion is initiated. intervention 2: Mobilized CD34-selected PBSC grafts will be administered on Day 0 to all patients according to individual institutional guidelines after appropriate processing and quantification has been performed by the local laboratory. Stem cells are administered through an indwelling central venous catheter. If infusion occurs over two days, Day 0 is the first day the infusion is initiated. intervention 3: Unmanipulated BM grafts will be administered on Day 0 to all patients according to individual institutional guidelines after appropriate processing and quantification has been performed by the local laboratory. Stem cells are administered through an indwelling central venous catheter. If infusion occurs over two days, Day 0 is the first day the infusion is initiated. intervention 4: Mesna will be given in divided doses IV 30 min pre- and at 3, 6, and 8 hours post-cyclophosphamide or administered per institutional standards. Mesna dose will be based on the cyclophosphamide dose being given. The total daily dose of Mesna is equal to 80% of the total daily dose of cyclophosphamide.

Cyclophosphamide 50 mg/kg will be given on Day 3 post-transplant (between 60 and 72 hours after marrow infusion) and on Day 4 post-transplant (approximately 24 hours after Day 3 cyclophosphamide). Cyclophosphamide will be given as an IV infusion over 1-2 hours (depending on volume). intervention 5: Tacrolimus will be given orally or intravenously per institutional standards starting Day -3. The dose of tacrolimus may be rounded to the nearest 0.5 mg for oral formulations. Subsequent dosing will be based on blood levels, with a target of 5-15 ng/ml. If patients are on medications which alter the metabolism of tacrolimus (e.g. azoles), the initial starting dose and subsequent doses should be altered as per institutional practices. Tacrolimus taper can be initiated at a minimum of 90 days post HSCT if there is no evidence of active GVHD. The rate of tapering will be done according institutional practices but patients should be off tacrolimus by Day 180 post HSCT if there is no evidence of active GVHD. intervention 6: Methotrexate will be administered at the doses of 15 mg/m\^2 IV bolus on Day +1, and 10 mg/m\^2 IV bolus on Days +3, +6 and +11 after hematopoietic stem cell infusion. The Day +1 dose of methotrexate should be given at least 24 hours after the hematopoietic stem cell infusion. Dose reduction of MTX due to worsening creatinine clearance after initiation of conditioning regimen, high serum levels or development of oral mucositis is allowed according to institutional practices. Leucovorin rescue is allowed according to institutional practices.

Protocol documents:
Prot_SAP_ICF_000.pdf: 


 
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Core Study Participants: 
 
 
 
Affiliate Study Participants: 
Baylor College of Medicine  
BMT Program at Northside Hospital 
Case Western Reserve University Consortium  
   University Hospitals of Cleveland 
   Oregon Health & Sciences University 
   Cleveland Clinic 
City of Hope National 
Dana-Farber Cancer Institute 
    Brigham and Women’s Hospital 
    Massachusetts General Hospital 
Duke University Medical Center 
Johns Hopkins University 
University of Michigan Consortium 
Mayo Clinic - Rochester 
Memorial Sloan-Kettering Cancer Center 
Ohio State Consortium 
Ohio State University 
Roswell Park Cancer Institute 
Virginia Commonwealth University 
PBMTC Consortium 
     Columbia University Medical Center 
University of Florida Consortium 
     University of Florida 
University of Nebraska Consortium 
     University of Kansas 
     University of Nebraska 
University of Pennsylvania Cancer Center 
Washington University in St. Louis 
 
Loyola University Medical Center 
Medical College of Wisconsin 
Medical University of South Carolina 
University of Iowa Hospitals and Clinics  
University of Kentucky 
University of Wisconsin 
Weill Cornell Medical College/NY 
Presbyterian Hospital 
 
 
 
 
 


 
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PROTOCOL SYNOPSIS 
 
A Randomized, Multi-Center, Phase III Trial of Calcineurin Inhibitor-Free Interventions  
for Prevention of Graft-versus Host-Disease  
 
Co-Principal Investigators: 
Leo Luznik, Miguel-Angel Perales, Marcelo Pasquini 
 
Study Design: 
The study is designed as a three arm randomized Phase III, 
multicenter trial comparing two calcineurin inhibitor (CNI)-free 
strategies for GVHD prophylaxis to standard calcineurin 
inhibitor tacrolimus and methotrexate (Tac/Mtx) in patients with 
acute leukemia or myelodysplasia undergoing myeloablative 
conditioning hematopoietic stem cell transplantation. 
 
Primary Objective: 
The primary objective of the randomized trial is to compare 
chronic GVHD/relapse-free survival [CRFS] as a time to event 
endpoint after hematopoietic stem cell transplant (HSCT) 
between each of the CNI-free interventions and a Tac/Mtx 
control.  
 
Secondary Objectives: 
Secondary objectives are: comparison of rates of grade II-IV and 
III-IV acute GVHD, chronic GVHD, chronic GVHD-free 
survival, immunosuppression-free survival at one year, primary 
and secondary graft failure, neutrophil and platelet engraftment, 
disease relapse, transplant-related mortality, rates of Grade ≥ 3 
toxicity according to the Common Terminology Criteria for 
Adverse Events (CTCAE) Version 4.0; incidence of CMV and 
EBV 
reactivation, 
incidence 
of 
infections; 
immune 
reconstitution, quality of life and overall survival. 
 
Eligibility Criteria: 
Patients ≥ 1 year and < 66 years undergoing HSCT for treatment 
of acute leukemia in morphologic complete remission with or 
without hematologic recovery or myelodysplasia with < 5% 
blasts in the marrow and no circulating blasts, and who are 
eligible for a myeloablative allogeneic transplant. Patients with 
CMML must have a WBC count ≤ 10,000 cells/µL and < 5% 
blasts in the marrow. Patients with > 5% blasts due to a 
regenerating marrow must contact the protocol chairs for review. 
Patients must have a related or unrelated donor. Related donor 
must be an 8/8 match for HLA-A, -B and -C at intermediate (or 
higher) resolution, and -DRB1 at high resolution using DNA-
based typing. Pediatric related donors must weigh ≥ 25.0 kg, must 
have 
adequate 
peripheral 
venous 
catheter 
access 
for 
leukapheresis or must agree to placement of a central catheter, 
must be willing to (1) donate bone marrow and (2) receive G-CSF 


 
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followed by donation of peripheral blood stem cells (product to 
be determined by randomization post enrollment), and must meet 
institutional criteria for donation. Unrelated donor must be an 8/8 
match at HLA-A, -B, -C and –DRB1 at high resolution using 
DNA-based typing. Unrelated donor must be medically eligible 
to donate according to NMDP (or equivalent donor search 
organization) criteria. At time of enrollment, the donor should not 
have any known preferences or contraindications to donate bone 
marrow or peripheral blood stem cells.  
 
Treatment Description: 
Patients will be randomized to receive one of the three specified 
interventions: 1) CD34 selected T-cell depleted peripheral blood 
stem cell (PBSC) graft; 2) unmanipulated bone marrow (BM) 
graft followed by cyclophosphamide (Cy) 50mg/kg Day +3 and 
+4 post HSCT; or, 3) unmanipulated BM graft with Tac/Mtx 
GVHD prophylaxis. Tac will be maintained at therapeutic doses 
for a minimum of 90 days. Methotrexate will be dosed at 10-
15mg/m2 for a maximum of 4 doses post-transplant.   
 
Accrual Objective: 
The clinical trial will enroll 345 patients or 115 per arm, in an 
adaptive design for futility evaluated at time of interim analysis.  
 
Accrual Period: 
The estimated accrual period is 42 months. 
 
Study Duration: 
Patients will be followed for 2 years following hematopoietic cell 
transplantation. 
 
Interim Analysis: 
No formal interim analyses for efficacy will be used. There is also 
not included in the design an option for closure of the control 
group while keeping the two treatment arms open, in the event 
that at least one of the treatments demonstrate early efficacy. 
Interim analyses for futility will be conducted at times coincident 
with regularly scheduled meetings of the DSMB, starting when 
approximately 45-50% of the targeted number of events have 
been observed. 
 
Stopping Guidelines: 
Monitoring of a key safety endpoint (mortality) will be conducted 
monthly up to 100 days post-randomization separately in each of 
the three treatment arms. At least three events must be observed 
in order to trigger review. 
 
Correlative Studies: 
Comparison of immune reconstitution using a panel of clinically 
available tests across all treatment arms. Advanced immune 
reconstitution assays.  
 


 
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STUDY SCHEMA 
 
Aim: To determine if either CNI-free approach improves the rate of chronic GVHD and relapse free 
survival after transplant compared to standard Tac/Mtx control.  
 
Inclusion Criteria 
1. Males and females aged ≥ 1.0 year and < 66.0 years 
2. Patients with acute leukemia, in morphologic complete 
remission with or without hematologic recovery or 
myelodysplasia with < 5% blasts in the marrow and no 
circulating blasts. Patients with CMML must have a WBC 
count ≤10,000 cells/µL and < 5% blasts in the marrow. 
Patients with > 5% blasts due to a regenerating marrow 
must contact the protocol chairs for review. 
3. Planned myeloablative conditioning regimen (see eligible 
regimens in Table 2.4). 
4.  Patients must have a related or unrelated donor as follows: 
a. 
Related donor must be an 8/8 match for HLA-A, -B 
and -C at intermediate (or higher) resolution, and -
DRB1 at high resolution using DNA-based typing. 
Pediatric related donors must weigh ≥ 25.0 kg, must 
have adequate peripheral venous catheter access for 
leukapheresis or must agree to placement of a central 
catheter, must be willing to (1) donate bone marrow 
and (2) receive G-CSF followed by donation of 
peripheral blood stem cells (product to be determined 
by randomization post enrollment), and must meet 
institutional criteria for donation.  
b. Unrelated donor must be an 8/8 match at HLA-A, -B, 
-C and –DRB1 at high resolution using DNA-based 
typing. Unrelated donor must be medically eligible to 
donate according to NMDP (or equivalent donor 
search organization) criteria. At time of enrollment, 
the donor should not have any known preferences or 
contraindications to donate bone marrow or peripheral 
blood stem cells. 
i. 
Selection of unrelated donors is to be 
performed according to institutional 
practice. It is recommended that the time 
from collection to initiation of the cell 
processing be considered when prioritizing 
donors as data shows better results for 
CD34 selection when processing is started 
within 36 hours of the end of collection as 
indicated in section 2.5.1.2. 
5. Cardiac function: Ejection fraction at rest ≥ 45% or 
shortening fraction of ≥ 27% by echocardiogram or 
radionuclide scan (MUGA). 
6. Estimated creatinine clearance (for patients > 12 years) 
greater than 50 mL/minute (using the Cockcroft-Gault 
Exclusion Criteria 
1. Prior autologous or allogeneic hematopoietic stem 
cell transplant 
2. Karnofsky or Lansky Performance Score < 70% 
3. Active CNS involvement by malignant cells 
4. Patients with uncontrolled bacterial, viral or fungal 
infections (currently taking medication and with 
progression or no clinical improvement) at time of 
enrollment 
5. Presence of fluid collection (ascites, pleural or 
pericardial effusion) that interferes with methotrexate 
clearance or makes methotrexate use contraindicated 
6. Patients seropositive for HIV-1 or -2 
7. Patients seropositive for HTLV-I or –II 
8. Patients with active Hepatitis B or C viral replication 
by PCR 
9. Documented allergy to iron dextran or murine 
proteins 
10. Women who are pregnant (positive serum or urine 
βHCG) or breastfeeding 
11. Females of childbearing potential (FCBP) or men 
who have sexual contact with FCBP unwilling to use 
2 effective forms of birth control or abstinence for 
one year after transplantation 
12. History of uncontrolled autoimmune disease or on 
active treatment 
13. Patient with prior malignancies, except resected non-
melanoma or treated cervical carcinoma in situ. 
Cancer treated with curative intent ≥ 5 years 
previously will be allowed. Cancer treated with 
curative intent < 5 years previously will not be 
allowed unless approved by the Protocol Officer or 
one of the Protocol Chairs.  
14. Patient unable to comply with the treatment protocol, 
including appropriate supportive care, follow-up and 
research tests 
15. Planned post-transplant maintenance therapy except 
for FLT3 inhibitors or TKIs 
a. 
Must be declared prior to 
randomization 


 
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formula and actual body weight); for pediatric patients (≥ 1 
year to 12 years), GFR estimated by the updated Schwartz 
formula ≥ 90 ml/min/1.73 m2. If the estimated creatinine 
clearance is < 90 ml/min/1.73 m2, then renal function must 
be measured by 24-hour creatinine clearance or nuclear 
GFR, and must be > 70 mL/minute/1.73m2. 
7. Pulmonary function: DLCO ≥50% (adjusted for 
hemoglobin), and FVC and FEV1≥50%; for children who 
are unable to perform for PFTs due to age or 
developmental ability, there must be no evidence of 
dyspnea and no need for supplemental oxygen as 
evidenced by O2 saturation ≥ 92.0% on room air. 
8. Liver function: total bilirubin < 2x the upper limit of 
normal (unless elevated bilirubin is attributed to Gilbert’s 
Syndrome) and ALT/AST < 2.5x the upper normal limit. 
9. Signed informed consent 
16. Planned use of cryopreserved hematopoietic stem 
cells 
17.  German centers only: Treatment with any known 
non-marketed drug substance or experimental 
therapy within 5 terminal half lives or 4 weeks prior 
to enrollment, whichever is longer, or participation in 
any other interventional clinical study. 
 
Primary endpoint: 
- Chronic GVHD/relapse-free survival (CRFS): this time to 
event outcome is defined as moderate to severe chronic GVHD 
by the NIH consensus criteria, disease relapse, or death by any 
cause.  
Secondary endpoints: 
- Grades II-IV and III-IV acute GVHD 
- Chronic GVHD 
- Chronic GVHD-free survival  
- Immunosuppression-free survival at 1 year 
- Hematologic recovery 
- Primary and secondary graft failure 
- Immune reconstitution 
- Disease relapse  
- Transplant-related mortality 
- Toxicity (SOS and IPS) and rates of infections (CMV and 
EBV reactivation) 
- Relapse-Free and overall survival 
- Quality of life 
 
 
Allowed Myeloablative Conditioning Regimens 
CD 34 Selected Arm 
PTCy Arm 
Control Arm 
Cy/TBI/Thiotepa/ ATG  
Bu/Mel/Flu/ATG 
Cy/TBI  
Flu/Bu  
Bu/Cy  
Cy/TBI  
TBI/Etoposide 
Flu/Bu  
Bu/Cy  
*Busulfan dose >8mg/kg or IV equivalent 
 
Immunosuppression Taper: 
Patients without GVHD 
Tacrolimus 
- 
Taper to initiate at least by Day 90 and 
completely off at Day 180. 


 
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Outline of Treatment Plan 
 
 
 
 
 
STUDY SCHEMA 
 
 
≥ 1 year and < 66 years 
Controlled Acute Leukemia and MDS 
Myeloablative Conditioning 
Related or Unrelated 8/8 HLA-matched bone 
marrow or peripheral blood stem cell donor  
Tac/MTX/ 
Bortezomib 
Tac/MTX/ 
Maraviroc 
Tac/MMF/ 
Cyclophosphamid
 
Tac/MTX CIBMTR 
Controls 
CD34 selected 
PBSC 
BM/PTCy 
BM  
Tac/Mtx 
 
cGVHD/Relapse-Free Survival 
(CRFS) 


 
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TABLE OF CONTENTS 
 
1. 
BACKGROUND AND RATIONALE ......................................................................... 1-1 
1.1. 
Introduction .................................................................................................................... 1-1 
1.2. 
CD34+ Selection and T-Cell Depletion ........................................................................ 1-1 
1.2.1. 
Both Acute and Chronic GVHD are Decreased .......................................................... 1-2 
1.2.2. 
CD34 Selection Impact on Graft Rejection and Relapse ............................................ 1-2 
1.2.3. 
Immune Reconstitution after CD34 Selection ............................................................ 1-3 
1.2.4. 
Advantages of CD34- Selection .................................................................................. 1-4 
1.3. 
Post-Transplant Cyclophosphamide ............................................................................ 1-5 
1.3.1. 
Rationale of Post-Transplant Cyclophosphamide ....................................................... 1-5 
1.3.2. 
Post-Transplant Cyclophosphamide in Haploidentical Donor Transplants ................ 1-5 
1.3.3. 
PTCy in HLA Matched Donor .................................................................................... 1-6 
1.3.4. 
Immune Reconstitution after PTCy ............................................................................ 1-8 
1.4. 
Benchmark Analysis and Composite Endpoint .......................................................... 1-8 
1.5. 
Rationale ....................................................................................................................... 1-10 
2. 
STUDY DESIGN ............................................................................................................ 2-1 
2.1. 
Study Overview .............................................................................................................. 2-1 
2.2. 
Hypothesis and Specific Objectives .............................................................................. 2-1 
2.2.1. 
Hypothesis ................................................................................................................... 2-1 
2.2.2. 
Study Objectives ......................................................................................................... 2-1 
2.3. 
Patient Eligibility ........................................................................................................... 2-1 
2.3.1. 
Inclusion Criteria ......................................................................................................... 2-1 
2.3.2. 
Exclusion Criteria........................................................................................................ 2-2 
2.4. 
Conditioning Regimens ................................................................................................. 2-4 
2.4.1. 
TBI, Cyclophosphamide, Thiotepa, and rATG (Cy/TBI/Thio/rATG) ........................ 2-6 
2.4.2. 
Busulfan, Melphalan, Fludarabine, and rATG ............................................................ 2-7 
2.4.3. 
Busulfan and cyclophosphamide (Bu/Cy) .................................................................. 2-8 
2.4.3.1. 
The allowable Bu/Cy regimen for the Post-Transplant Cy Arm is the following: 2-8 
2.4.3.2. 
The allowable Bu/Cy regimen for the Control Arm is the following: ................... 2-8 
2.4.4. 
Busulfan and fludarabine (Bu/Flu) ............................................................................. 2-9 
2.4.5. 
Cyclophosphamide and total body irradiation (Cy/TBI) ............................................ 2-9 
2.4.5.1. 
The allowable Cy/ TBI regimen for the Post-Transplant Cy Arm is the  
following: ............................................................................................................... 2-9 
2.4.5.2. 
The allowable Cy/ TBI regimen for the Control Arm is the following: .............. 2-10 
2.4.6. 
Total body irradiation and etoposide (TBI/Etoposide) – for the Control Arm only . 2-10 
2.5. 
Hematopoietic Stem Cell Graft Collection ................................................................ 2-11 
2.5.1. 
CD34 Selection Arm ................................................................................................. 2-11 
2.5.1.1. 
Mobilization of Donor .......................................................................................... 2-11 
2.5.1.2. 
Progenitor Cell Collection and Processing ........................................................... 2-11 
2.5.1.3. 
Bone Marrow Collection and Processing ............................................................. 2-14 
2.6. 
GVHD Prophylaxis ...................................................................................................... 2-14 
2.6.1. 
Post-Transplant Cyclophosphamide.......................................................................... 2-14 
2.6.2. 
CNI/Methotrexate Control Arm ................................................................................ 2-15 


 
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2.6.2.1. 
Tacrolimus ............................................................................................................ 2-15 
2.6.2.2. 
Methotrexate ......................................................................................................... 2-16 
2.7. 
Transplant Procedures ................................................................................................ 2-16 
2.8. 
Supportive Care ........................................................................................................... 2-16 
2.8.1. 
Growth Factors .......................................................................................................... 2-16 
2.8.2. 
Seizure Prophylaxis ................................................................................................... 2-16 
2.8.3. 
Blood Products .......................................................................................................... 2-17 
2.8.4. 
Prophylaxis Against Infections ................................................................................. 2-17 
2.8.5. 
Intravenous Immune Globulin (IVIG) ...................................................................... 2-18 
2.8.6. 
Sinusoidal Obstruction Syndrome (SOS)/Veno-occlusive Disease (VOD) of the Liver 
Prophylaxis ................................................................................................................ 2-18 
2.8.7. 
Donor Lymphocyte Infusions – Viral-specific Cytotoxic T-Lymphocytes (CTLs) . 2-18 
2.9. 
Participant Risks .......................................................................................................... 2-18 
2.9.1. 
Potential Sensitization to Murine Proteins ................................................................ 2-18 
2.9.2. 
Graft Infusion ............................................................................................................ 2-19 
2.9.3. 
Infections ................................................................................................................... 2-19 
2.9.4. 
Graft-Versus-Host Disease........................................................................................ 2-19 
2.9.5. 
Sinusoidal Obstruction Syndrome (SOS)/Veno-occlusive Disease (VOD) of the Liver
 ................................................................................................................................... 2-19 
2.9.6. 
End Organ Damage ................................................................................................... 2-19 
2.9.7. 
Lymphoproliferative Syndrome ................................................................................ 2-19 
2.9.8. 
Death ......................................................................................................................... 2-20 
2.9.9. 
Therapy Toxicities .................................................................................................... 2-20 
2.9.10. 
Busulfan .................................................................................................................... 2-20 
2.9.11. 
Cyclophosphamide .................................................................................................... 2-21 
2.9.12. 
Etoposide ................................................................................................................... 2-21 
2.9.13. 
Fludarabine ................................................................................................................ 2-22 
2.9.14. 
Rabbit Anti-Thymocyte Globulin ............................................................................. 2-22 
2.9.15. 
Melphalan .................................................................................................................. 2-22 
2.9.16. 
Total Body Irradiation ............................................................................................... 2-22 
2.9.17. 
Thiotepa..................................................................................................................... 2-23 
2.9.18. 
Tacrolimus................................................................................................................. 2-23 
2.9.19. 
Methotrexate ............................................................................................................. 2-23 
2.9.20. 
Cyclosporine ............................................................................................................. 2-23 
2.9.21. 
MESNA (Sodium -2-Mercaptoethane Sulphonate) .................................................. 2-24 
2.10. Quality of Life Assessments ........................................................................................ 2-24 
2.10.1. 
Instruments ................................................................................................................ 2-24 
2.10.2. 
Administration .......................................................................................................... 2-25 
3. 
STUDY ENDPOINTS .................................................................................................... 3-1 
3.1. 
Primary Endpoint .......................................................................................................... 3-1 
3.2. 
Secondary Endpoints ..................................................................................................... 3-1 
3.2.1. 
Overall Survival .......................................................................................................... 3-1 
3.2.2. 
Disease Relapse ........................................................................................................... 3-1 
3.2.3. 
Relapse-Free Survival ................................................................................................. 3-2 
3.2.4. 
Transplant-related Mortality ....................................................................................... 3-2 


 
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3.2.5. 
Immunosuppression-free Survival .............................................................................. 3-2 
3.2.6. 
Hematologic Recovery ................................................................................................ 3-2 
3.2.7. 
Acute GVHD ............................................................................................................... 3-3 
3.2.8. 
Chronic GVHD ........................................................................................................... 3-3 
3.2.9. 
Chronic GVHD-Free Survival .................................................................................... 3-3 
3.2.10. 
Toxicity ....................................................................................................................... 3-3 
3.2.11. 
Infections ..................................................................................................................... 3-4 
3.2.12. 
Immune Reconstitution ............................................................................................... 3-4 
3.2.13. 
Health-Related Quality of Life.................................................................................... 3-4 
4. 
PATIENT ENROLLMENT AND EVALUATIONS .................................................. 4-1 
4.1. 
Approaching Patients, Eligibility Screening and Obtaining Consent ....................... 4-1 
4.2. 
Randomization ............................................................................................................... 4-1 
4.3. 
Treatment Scheduling ................................................................................................... 4-2 
4.4. 
Study Monitoring ........................................................................................................... 4-2 
4.4.1. 
Patient Assessments .................................................................................................... 4-2 
4.4.1.1. 
Pre-Transplant Evaluations .................................................................................... 4-5 
4.4.1.2. 
Post-Transplant Evaluations ................................................................................... 4-6 
4.4.2. 
Criteria for Forms Submission .................................................................................... 4-7 
4.4.2.1. 
Electronic Case Report Forms (eCRFs) ................................................................. 4-7 
4.4.2.2. 
Reporting Patient Deaths ........................................................................................ 4-8 
4.4.2.3. 
CIBMTR Data Reporting ....................................................................................... 4-8 
4.4.3. 
Access to Data ............................................................................................................. 4-8 
4.4.4. 
Record Retention ......................................................................................................... 4-8 
4.4.5. 
Study Monitoring ........................................................................................................ 4-8 
4.4.6. 
Adverse Events............................................................................................................ 4-9 
4.4.6.1. 
Adverse Event Definitions ..................................................................................... 4-9 
4.4.6.2. 
Device Effect Reporting ....................................................................................... 4-11 
4.4.6.3. 
Adverse Event Reporting ..................................................................................... 4-11 
5. 
STATISTICAL CONSIDERATIONS ......................................................................... 5-1 
5.1. 
Study Design and Objectives......................................................................................... 5-1 
5.1.1. 
Accrual ........................................................................................................................ 5-1 
5.1.2. 
Randomization ............................................................................................................ 5-1 
5.1.3. 
Primary Endpoint ........................................................................................................ 5-1 
5.1.4. 
Primary Hypothesis ..................................................................................................... 5-1 
5.1.5. 
Duration of Follow-Up ................................................................................................ 5-2 
5.2. 
Sample Size and Power Considerations ....................................................................... 5-2 
5.3. 
Interim Analysis and Stopping Guidelines .................................................................. 5-3 
5.3.1. 
Guidelines for Safety Monitoring ............................................................................... 5-3 
5.4. 
Demographic and Baseline Characteristics ................................................................. 5-4 
5.5. 
Analysis Plan .................................................................................................................. 5-5 
5.5.1. 
Analysis of the Primary Endpoint ............................................................................... 5-5 
5.5.2. 
Analysis of Secondary Endpoints ............................................................................... 5-5 
5.5.2.1. 
Relapse-Free Survival ............................................................................................ 5-6 
5.5.2.2. 
Overall Survival ..................................................................................................... 5-6 


 
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5.5.2.3. 
Transplant-Related Mortality ................................................................................. 5-6 
5.5.2.4. 
Immunosuppression-Free Survival ........................................................................ 5-6 
5.5.2.5. 
Disease Relapse ...................................................................................................... 5-6 
5.5.2.6. 
Hematologic Recovery ........................................................................................... 5-6 
5.5.2.7. 
Acute GVHD of Grades II-IV and III-IV ............................................................... 5-7 
5.5.2.8. 
Chronic GVHD ...................................................................................................... 5-7 
5.5.2.9. 
Chronic GVHD-Free Survival ............................................................................... 5-7 
5.5.2.10. 
Incidence of Toxicities Grade ≥ 3 per CTCAE Version 4.0 .................................. 5-7 
5.5.2.11. 
Incidence of Infections ........................................................................................... 5-7 
5.5.2.12. 
Immune Reconstitution .......................................................................................... 5-8 
5.5.2.13. 
Health-Related Quality of life ................................................................................ 5-8 
5.5.2.14. 
Subgroup Analysis ................................................................................................. 5-9 
6. 
eTHICS AND REGULATORY .................................................................................... 6-1 
6.1. 
Good Clinical Practice Guidelines ................................................................................ 6-1 
6.1.1. 
Patient Consent ........................................................................................................... 6-1 
6.1.2. 
Patient Withdrawal ...................................................................................................... 6-1 
6.1.2.1. 
Patient Withdrawal from Intervention .................................................................... 6-1 
6.1.2.2. 
Patient Withdrawal from Data Collection .............................................................. 6-1 
6.1.2.3. 
Patient Removal from Study .................................................................................. 6-1 
6.1.3. 
Confidentiality ............................................................................................................ 6-2 
6.1.4. 
Participation of Women and Minorities ...................................................................... 6-2 
6.1.5. 
NMDP Unrelated Donors ............................................................................................ 6-2 
6.1.6. 
International Unrelated Donor Consent ...................................................................... 6-2 
6.2. 
Protocol Amendments ................................................................................................... 6-2 
6.3. 
Protocol Deviations ........................................................................................................ 6-3 
6.4. 
Premature Termination of the Trial ............................................................................ 6-3 
6.5. 
Publication Policy........................................................................................................... 6-3 
6.6. 
German Transfusion Law ............................................................................................. 6-4 
 
LIST OF APPENDICES 
APPENDIX A 
 
LIST OF ABBREVIATIONS 
APPENDIX B 
 
INFORMED CONSENTS 
APPENDIX C 
 
LABORATORY PROCEDURES 
APPENDIX D 
 
ESTIMATED CREATININE CLEARANCE FORMULAS 
APPENDIX E 
KARNOFSKY AND LANSKY PERFORMANCE STATUS 
SCALES 
APPENDIX F 
 
HCT-SPECIFIC COMORBIDITY INDEX SCORE 
APPENDIX G 
DERIVATION OF A SEQUENTIAL TEST STATISTIC FOR 
CENSORED EXPONENTIAL DATA 
APPENDIX H 
REFERENCES 


 
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1-1 
CHAPTER 1 
 
 
1. 
BACKGROUND AND RATIONALE 
 
1.1. 
Introduction 
 
Chronic graft versus host disease (GVHD) is a devastating complication that affects hematopoietic 
cell transplant (HCT) survivors and may offset the associated benefits of reducing rates of post-
transplant disease relapse. 1, 2 GVHD prevention regimens are a required component of any 
allogeneic HCT approach, and most commonly use a combination of immunosuppressive agents 
given for the first 6 months after transplant. Often, patients develop GVHD and continue on these 
agents for much longer periods. The combination of calcineurin inhibitors (tacrolimus and 
cyclosporine A) with methotrexate (MTX) is the most common GVHD prophylaxis used 
worldwide in the context of myeloablative conditioning transplants. This regimen, implemented 
more than 3 decades ago, demonstrated better control of acute GVHD.3 ,4 However, this strategy 
is ineffective against chronic GVHD. Management of chronic GVHD remains a challenge and it 
has become a significant health problem in transplant survivors with more frequent use of 
mobilized peripheral blood stem cells. Additionally, several issues arise with this treatment 
approach including: 1) MTX accentuated risk of conditioning regimen-related oral mucositis and 
renal toxicity; 2) Increased risk of thrombotic microangiopathy due to CNI; 3) Requirement for 
chronic monitoring of CNI serum levels; and, 4) Chronic immunosuppression is not a conducive 
platform for post HCT cellular therapies for treatment or prevention of infections or disease 
relapse. 
 
In vivo graft manipulation with anti thymocyte globulin (ATG)5, 6 or alemtuzumab,7 , 8, 9 ex vivo 
graft manipulation with CD34 selection and T-cell depletion10 and, most recently, use of high 
doses of cyclophosphamide after transplant (PTCy) are strategies that are associated with lower 
rates of chronic GVHD. In addition a benchmark analysis of novel approaches to prevent GVHD 
using data from the Center for International Blood and Marrow Transplantation Research 
(CIBMTR) identified two strategies for T-cell depletion using either CD34-selection or 
administration of post-transplantation Cy cyclophosphamide (PTCy) as the most effective in 
preventing both acute and chronic GVHD after HCT. This clinical trial further explores these 
approaches to prevent chronic GVHD that have the additional benefit of not requiring prolonged 
immunosuppression.  
 
1.2. 
CD34+ Selection and T-Cell Depletion 
 
The recognition that GVHD is mediated by donor derived T-cells led to pre-clinical and clinical 
exploration of T-cell depletion to reduce the risk of GVHD. The use of ex vivo T-cell depleted 
(TCD) grafts has significantly reduced the risk of GVHD without the need for post-transplant 
immunosuppression.11, 12, 13, 14, 15, 16, 17, 18 Although several different approaches have been used 
over the years, more recently, removal of T-cells from the graft has been achieved through positive 
selection of CD34+ cells using immunomagnetic beads.12, 13, 14, 18, 19, 20, 21 In earlier studies, CD34+ 
selection of PBSCs was performed on the ISOLEX 300i magnetic cell selection system (Baxter, 


 
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Deerfield, IL), followed by E-rosetting.12, 13, 20 Current studies are using super-paramagnetic 
particle-conjugated antibodies on the CliniMACS Cell Separation System (Miltenyi Biotec, 
Gladbach, Germany) for CD34+ selection.14, 20, 21 The CliniMACS System can also be used to 
negatively select grafts through depletion of CD3 and CD19 cells or depletion of TCRαβ T-cells.22 
When assessing data from clinical trials reporting the use of TCD grafts it is critical to review the 
specific approach used. The degree of T-cell depletion is a particularly critical factor. In recipients 
of TCD marrow grafts from HLA-identical donors, the risk of GVHD was shown to increase if the 
graft contained > 1x105 T-cells/kg.23 For example, the CliniMACS System can achieve a 5-log 
reduction in T-cells, whereas the ISOLEX 300i system (no longer available in the US) achieves a 
3.5- to 5 log reduction, depending on the settings, and may require additional T-cell depletion 
through E-rosetting in the case of the lower log reduction. The CliniMACS® CD34 Reagent 
System was approved as a humanitarian device and authorized by U.S. Federal law for use in the 
treatment of patients with acute myeloid leukemia (AML) in first complete remission.  The 
effectiveness of the device for this use has not been demonstrated. 
 
1.2.1. Both Acute and Chronic GVHD are Decreased 
 
The main goal of using a TCD or CD34-selected grafts is to reduce the risk of both acute and 
chronic GVHD. This result has been achieved in most studies, although to varying degrees. The 
risk of GVHD generally has correlated with the extent of T-cell depletion. The risk of both acute 
and chronic GVHD decreases significantly when the degree of T-cell depletion is 3-log using bone 
marrow or 4-5 log using PBSC.11, 12, 13, 14, 18, 24, 25 For example, studies performed at MSKCC that 
achieved a 5-log reduction in T-cells using CD34-selection followed by E-rosetting have reported 
incidences of acute GVHD (limited to grade II) of 8%, and chronic GVHD of 9% in recipients of 
matched related grafts and incidences of acute and chronic GVHD of 9% and 29%, respectively, 
in recipients of matched unrelated donors.12, 13 None of the patients received GVHD prophylaxis 
beyond T-cell depletion of the graft. Results from single-center studies have been validated in 
BMT CTN 0303 in which 44 patients with AML in CR1 or CR2 were conditioned with TBI, 
thiotepa, and cyclophosphamide with rabbit ATG followed by a single step TCD, PBSC allogeneic 
graft from an HLA-identical sibling donor. The incidence of acute GVHD grade II-IV was 22.7%, 
and the incidence of extensive chronic GVHD was 6.8% at 24 months.14 Importantly, these results 
are in the setting of peripheral blood stem cell grafts. 
 
1.2.2. CD34 Selection Impact on Graft Rejection and Relapse 
 
A potential consequence of T-cell depletion is a higher risk of graft rejection. In fact, early studies 
of T-cell depletion were associated with higher rates of graft rejection than observed in recipients 
of conventional grafts, with reported graft failure rates as high as 27%.26, 27, 28 These clinical results 
confirmed pre-clinical data that donor-derived T-cells facilitate engraftment. Following 
modifications of the conditioning regimen, and in particular the use of ATG to promote 
engraftment, several centers have reported consistent engraftment with TCD grafts using a variety 
of approaches for T-cell depletion, including CD34-selection.11, 12, 13, 14, 24, 25  
 
Another potential and significant limitation of T-cell depleting the graft is an increase in relapse, 
due to elimination of the recognition of the tumor by donor-derived T-cells, the so-called graft 


 
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versus leukemia (GVL) effect. This was illustrated in patients with CML, where a retrospective 
study of 46 patients who underwent TCD transplants were compared to 40 patients who had 
conventional grafts.29 The 3-year probability of relapse was higher in the TCD group than in the 
non-TCD group (62% v 24%, p = .0003). After donor lymphocyte infusion (DLI), however, 17 of 
20 patients in the TCD group and 2 of 3 patients in the non-TCD group achieved a complete 
remission. While the CML experience clearly supports the critical role of GVL in allogeneic HCT, 
results in studies with patients with AML or ALL report comparable low rates of relapse after TCD 
HCT.11, 12, 13, 14, 17, 18 For example, in the BMT CTN 0303 study, the relapse rate for patients with 
AML in CR1 was 17.4% at 36 months.14 The MSKCC group recently reported results in 56 adult 
patients with ALL, including 27 patients in CR1, 18 in CR2, 11 in CR3 or greater.17 With a median 
follow-up of 6.1 years, the cumulative incidence of relapse for the entire cohort was 23%. These 
results are consistent with those reported by the Perugia group who found a probability of relapse 
of 0.12 for patients with AML and 0.28 for patients with ALL who underwent TCD HCT in CR1 
or CR2.25 To further assess the impact of T-cell depletion on relapse in patients with AML in CR1, 
a retrospective analysis of 115 patients who received TCD grafts after ablative conditioning at 
MSKCC were compared to a cohort of 181 patients who received unmodified grafts after 
conditioning with busulfan/ fludarabine and GVHD prophylaxis with tacrolimus/ mini-
methotrexate at MD Anderson Cancer Center (MDACC).18 There were no significant differences 
in the rate of relapse at 3 years between TCD and unmodified graft recipients (18% vs. 25%, p= 
0.3).  
 
1.2.3. Immune Reconstitution after CD34 Selection 
 
Allogeneic HCT is associated with deficiencies in the recovery of T and B cells that are associated 
with increased rates of infections,30, 31, 32, 33 disease relapse,34 and the development of secondary 
malignancies.35 While several factors contribute to these immune defects, the use of either in vivo 
(with alemtuzumab or ATG) or ex vivo T-cell depletion has marked effects on immune recovery.6, 
7, 8, 9, 30, 36, 37, 38, 39, 40, 41 Studies of thymic output have shown lower T-cell receptor rearrangement 
excision circles (TRECs) in recipients of TCD allografts compared to unmodified allograft 
recipients.41 These differences, however, abated beyond 9 months. Delayed thymic output 
translates into delayed recovery of total and naïve CD4+ T-cells, prolonged inversion of the 
CD4/CD8 ratio, and delayed recovery of T-cell mitogen responses, which is associated with an 
increase in Epstein-Barr Virus-Associated Lymphoproliferative disorders and opportunistic 
infections in the first year post-transplant.30, 40 Studies of T-cell receptor (TCR) diversity in allo-
HCT patients using 5’-RACE PCR with deep sequencing have shown more rapid recovery in 
diversity in recipients of conventional grafts compared to TCD grafts. 42 It should be noted, 
however, that GVHD also has a significant impact on immune recovery through direct effects on 
the thymus, 43, 44 and particularly because of the immunosuppressive drugs required to treat 
GVHD.45, 46, 47, 48, 49 In the MSKCC/MDACC retrospective study, 6 (5%) and 2 (1%) patients died 
of infections within 100 days post-transplant, in the TCD and unmodified groups (p=0.04), 
respectively.18 Despite these differences in infectious deaths, there were no significant differences 
in three-year relapse-free (RFS) and overall survival (OS) rates. 
 
 
 


 
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1.2.4. Advantages of CD34- Selection 
 
The main advantage of the use of a CD34-selected graft is the significant reduction in acute and 
chronic GVHD. This is particularly relevant in patients who do not have a fully matched donor. 
Another advantage of CD34-selected grafts is the fact that no post-transplant GVHD prophylaxis 
is required. The ability to avoid CNI eliminates the renal toxicity associated with their use in allo-
HCT therefore allows inclusion of patients with underlying renal dysfunction, including older 
patients. The lack of CNI increases the ability to use ablative regimens in older patients where the 
combined toxicity of an ablative regimen and post-transplant GVHD prophylaxis that includes a 
CNI and methotrexate represents a dose limiting toxicity. As a result, older patients receiving 
conventional grafts are typically treated with reduced intensity or non-ablative conditioning 
regimens, which are associated with higher rates of relapse in acute leukemias. Finally, the use of 
a CD34-selected graft also represents the ideal platform for post-transplant immunotherapy with 
adoptive cell therapy targeting minimal residual disease. This approach has the potential advantage 
of overcoming any loss of GVL without affecting the benefit of reduced GVHD. 
 
T-cell depletion has now been under investigation for over 3 decades with few studies comparing 
outcomes with patients receiving unmodified grafts. As noted above, results from the 
MSKCC/MDACC comparative study demonstrated similar RFS and OS after TCD and 
conventional transplants from related/unrelated donors in patients with AML in CR1, but a 
significant reduction in GVHD in the TCD cohort.18 A prior retrospective study of 146 patients 
with hematological malignancies did not show significant differences in survival, GVHD rates, 
and quality of life between patients who received TCD and unmodified grafts, although the method 
of T-cell depletion used only achieved a 1-2 log reduction in T-cells.50 In the only prospective 
randomized phase II-III trial, the 
incidence of acute GVHD was 
lower after TCD-HCT, but there 
was no difference in survival. 51 
This study 
also 
used 
older 
methods of T-cell depletion that 
only achieved 1 - 2 logs of 
depletion. A recent analysis of the 
BMT 
CTN 
0303 
patients 
compared to a subset of patients 
on BMT CTN 0101 who received 
a conventional transplant for 
AML in CR1/CR2 showed no 
differences in rates of graft 
rejection, 
leukemia 
relapse, 
transplant-related 
mortality 
(TRM), and disease-free and overall survival rates.10 Two-year rates of chronic GVHD were lower 
with TCD grafts than conventional grafts (19% v 50%, respectively; P < .001) and TCD was 
associated with a higher GVHD-free survival at 2 years (41% v 19%; P = .006).  
 
Figure 1.2: Chronic GVHD comparing recipients of T-cell depleted 
graphs (TCD) to recipients of unmanipulated grafts with chronic 
immunosuppression (IST) (Pasquini MC et al, 2012 JCO) 


 
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1.3. 
Post-Transplant Cyclophosphamide 
 
1.3.1. Rationale of Post-Transplant Cyclophosphamide 
 
High-dose cyclophosphamide is a potent immunomodulatory agent that has been successfully used 
to prevent GVHD in HLA-matched and –mismatched setting in several single-center as well as in 
multi-center studies. Preclinical studies have shown that cyclophosphamide administered early 
post HSCT preferentially kills activated, cycling allo-reactive T-cells while sparing resting, non 
allo-reactive T-cells leading to suppression of GVHD as well as graft rejection.52, 53 Furthermore, 
a recent study showed that human regulatory T cells are resistant to post-transplant 
cyclophosphamide (PTCy) and contribute to its GVHD preventive effects.54  
 
1.3.2. Post-Transplant Cyclophosphamide in Haploidentical Donor Transplants 
 
Based on promising pre-clinical results at Johns Hopkins, a Phase I/II clinical trial of 
haploidentical HCT to treat high-risk hematologic malignancies was initiated in 1999.52, 53 
Following a non-myeloablative regimen of fludarabine, cyclophosphamide, and low-dose TBI, 
GVHD prophylaxis consisted of cyclophosphamide (Cy) given on Days +3 and +4 post-transplant, 
tacrolimus, and mycophenolate mofetil (MMF).41 Primary graft failure occurred in 13% of 
patients, and was fatal due to infection in one patient in whom autologous hematopoiesis failed to 
occur. In general, complete T-cell engraftment was observed by Day +28 or the grafts were 
rejected. Cumulative incidences of grades II-IV and grades III-IV acute GVHD by Day 200 were 
34% and 6%, respectively. There was lower incidence of extensive chronic GVHD among 
recipients of two versus one dose of post-transplantation Cy (5% versus 25%; p=0.05). There was 
no difference in the incidence of severe acute GVHD with one or two doses of post-transplant Cy. 
The cumulative incidences of non-relapse mortality and relapse at 1 year were 15% and 51%, 
respectively. Actuarial overall and event-free survivals (EFS) at two years after transplantation 
were 36% and 26%, respectively. Patients with lymphoid malignancies appeared to have an 
improved EFS compared to those with myeloid malignancies (p=0.02). 
 
The BMT CTN sponsored a multi-center Phase II trial of haploidentical BMT (BMT CTN 0603) 
for high-risk hematologic malignancies modeled after the Hopkins approach. This was published 
along with a similar study using double umbilical cord blood (dUCB) grafts without post-
transplant Cy (BMT CTN 0604).39 The 1-year probabilities of overall and progression-free 
survival were 54% and 
46% 
after 
dUCB 
transplantation 
and 
62% and 48% after 
haploidentical 
bone 
marrow HCT. The Day 
+56 
cumulative 
incidence of neutrophil 
recovery was 94% after 
dUCB and 96% after 
haploidentical marrow. 
Figure 1.3.2: Treatment schema of patients undergoing haploidentical  
donor transplants in the BMT CTN 0603 clinical trial. 
Figure 1.3.2: Treatment schema of patients undergoing haploidentical  
donor transplants in the BMT CTN 0603 clinical trial. 


 
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The 100-day cumulative incidence of grade II-IV acute GVHD was 40% with dUCB and 32% 
with haploidentical bone marrow. The 1-year cumulative incidences of non-relapse mortality and 
relapse after cord transplantation were 24% and 31%, respectively; corresponding rates after 
haploidentical bone marrow transplantation were 7% and 45%. 
 
Several other centers have reported studies using PTCy to facilitate haploidentical transplantation 
in the myeloablative conditioning setting.55 56 57 58 The outcomes reported with these studies are 
consistent with the low NRM seen in studies of non-myeloablative T-cell replete haploidentical 
donor transplantation performed using PTCy as well as consistently low rates of severe acute and 
chronic GVHD. 
 
To date, haploidentical non-myeloablative transplantation with post-transplant Cy has used bone 
marrow as the graft source. Use of PBSC instead of marrow may allow wider applicability of this 
approach but there is concern about higher risks of acute and chronic GVHD due to the 5-10-fold 
higher number of T-cells in the allograft. Recently, groups in Atlanta and Seattle/London reported 
small studies in which PBSC were substituted for bone marrow with post-transplant Cy in the 
haploidentical donor setting.59 60 In both studies, PBSC was used for HLA-haploidentical HCT 
with PTCy with overall outcomes of severe acute GVHD, chronic GVHD, and non-relapse 
mortality at 1 year with HLA-matched related or unrelated HCT. 
 
A number of studies accompanying clinical trials of haploidentical HCT with post-transplant Cy 
have been performed. Kasamon et al. looked at the effect of HLA disparity on transplant outcomes 
in a retrospective analysis of 185 patients transplanted in Baltimore.61 No association was found 
between the degree of mismatching at 5 HLA loci and the risk of acute GvHD or NRM. A 
retrospective study by Burroughs, et al., 62 compared the outcomes of patients with relapsed 
Hodgkin lymphoma (92% of whom had failed autologous transplants) who had undergone 
nonablative conditioning and transplantation with either haploidentical donors or HLA-matched 
related or unrelated donors in Baltimore or Seattle. GvHD prophylaxis after transplantation with 
matched donors was a calcineurin inhibitor plus MMF. Although the number of patients in each 
group was relatively small, it appeared that outcomes after haploidentical transplantation were no 
worse and possibly better than those after transplantation from matched donors. Two year NRM 
was similar for haploidentical and unrelated donors (9% and 8%, respectively) compared to 21% 
for related donors. EFS at 2 years was 51% for haploidentical donors compared to 23% and 29% 
for related and unrelated donors, respectively. The finding of similar outcomes after haploidentical 
HCT using PTCy compared with matched related or unrelated donors for a variety of hematologic 
malignancies was also recently reported.63  
 
1.3.3. PTCy in HLA Matched Donor 
 
Given the success of PTCy in the prevention of GVHD in the setting of haploidentical 
transplantation, Luznik et al.64 reported a large study of patients who underwent allogeneic HCT 
from HLA-matched donors after myeloablative conditioning using busulfan-cyclophosphamide 
(BuCy) and PTCy as a single agent for prophylaxis of GvHD. A total of 117 patients with high-
risk hematologic malignancies were transplanted from 78 related or 39 unrelated donors. Half of 
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patients. The incidence of GVHD was remarkably low (43% grades II-IV acute, 10% grades III/IV 
acute, 10% chronic) showing the effectiveness of the approach (Figure 1.3.2). There was no 
difference in the incidence of acute or chronic GVHD between related or unrelated donors. Almost 
two-thirds of the patients did not require any additional immunosuppressive therapy after post-
transplant Cy. Patients who did develop GVHD responded to steroids alone in 20% of cases or 
steroids plus a second agent (calcineurin or non-calcineurin) in 75% of cases. Rates of grade II-IV 
acute and chronic GVHD were both 10% (Figure 1.3.2). Observed rates of non-relapse mortality 
and disease relapse were 20% and 44%, respectively. This study showed that post-transplant Cy 
was effective as a single-agent to prevent severe acute or chronic GVHD in the vast majority of 
patients undergoing myeloablative transplantation from matched donors. Only 3% of deaths were 
due to infection suggesting that immune reconstitution is robust in such patients. Obviating the 
need for ongoing immunosuppression post-transplant provides an optimal platform for cellular 
therapy to prevent or treat relapsed disease.   
 
These encouraging outcomes with PTCy in prevention of GVHD were recently reproduced in a 
multi-institutional study that effectively combined this novel single-agent short-course GVHD 
prevention strategy in combination with IV Bu/Flu myeloablative conditioning. In this study, 92 
adult patients (median age 49, range 21-65) with high-risk hematologic malignancies were enrolled 
at three centers. Forty-five (49%) patients received related allografts, and 47 (51%) received 
unrelated allografts. GVHD prophylaxis was solely with PTCy at 50 mg/kg/day on post-transplant 
days +3 and +4 after bone marrow allografting. The cumulative incidences of grade II-IV acute, 
grade III-IV acute, and chronic GVHD were 51%, 15%, and 14%, respectively. Non-relapse 
mortality (NRM) at 100 days and 1 year were 9% and 16%, respectively. With a 2.2 year median 
follow-up, the two-year event-free survival (EFS) and overall survival (OS) were 62% and 67%, 
respectively. Donor type did not impact on NRM, EFS, or OS. Patients in complete remission (CR) 
without evidence of minimal residual disease had remarkably high rates of EFS (80%) and OS 
(79%). The results obtained in these two studies serve as the basis for the PTCy CNI-free strategy 
in this clinical trial. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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1.3.4. Immune Reconstitution after PTCy 
 
The ability to shorten the duration of post-grafting immunosuppression after HLA-matched allo-
HSCT with PTCy was marked by prompt immune reconstitution and a low incidence of 
opportunistic infections. Among 47 patients studied immunophenotypically after HLA-matched 
HCT the mean CD4+ T cell count on day 30 was 98 cells μl and on day 60 was 124 cells/μl.54 At 
both days 30 and 60 after HCT, the CD8+ T cell counts were already within the normal range. 
Effector regulatory T cells rapidly recovered to donor levels by 30 days after HCT, and there was 
favorable memory CD4+ T cell recovery compared with naïve CD4+ T cells. 
 
In both studies detailed in section 1.3.3. above, no patients died of CMV or invasive fungal 
infection. Reactivation of CMV occurred in 29% of patients, and there were only two documented 
cases of CMV disease. The rapid recovery of CMV-specific immunity correlated with the results 
of in vitro ELISPOT assays. The frequency of cells secreting interferon gamma in response to 
stimulation with pentadecapeptides of the immunodominant CMV protein, pp65, at day 30–60 
after allo-HSCT did not differ from pre-transplantation specimens from CMV-seropositive 
donor/recipient pairs. The absence of post-transplantation Epstein–Barr virus-associated 
lymphoproliferative disease is another indicator of the prompt immunologic recovery seen with 
post-transplant Cy. 65 
 
1.4. 
Benchmark Analysis and Composite Endpoint 
 
In order to better evaluate the efficacy of novel approaches for GVHD prophylaxis, a benchmark 
analysis was performed using data from the Center for International Blood and Marrow Transplant 
Research (CIBMTR) for patients who received standard CNI based GVHD prophylaxis with 
tacrolimus and MTX.  
 
The CIBMTR maintains an outcomes registry that prospectively collects data from all centers 
performing allogeneic HCTs and almost all centers performing autologous HCTs in the United 
States in addition to about 100 non-US centers. Centers must report all consecutive patients and 
provide longitudinal follow-up on those patients according to set timelines that include a pre-
transplant report, a 100 day report, a 6 month report and an annual report through 6 years post-
transplant followed by a biannual report in perpetuity. Data are reported on two tracks: a 
“Transplant Essential Data” track and a “Comprehensive Report Form” track. Centers provide a 
pre-transplant Transplant Essential Data form for all patients. Data from this form are used to select 
patients for the Comprehensive Report Form track using a weighted random selection that over 
selects patients with rare diseases or procedures or for the purposes of specific studies. For 
example, most patients on BMT CTN trials are selected for the Comprehensive Report Form track 
so that data collected by the CIBMTR can supplement clinical trial data collected through 
AdvantageEDCSM and can allow for long-term follow-up of trial patients for specific late effects 
of treatment. Longitudinal data are collected for patients on both the Transplant Essential Data and 
Comprehensive Report Form Track; the data differ in quantity and granularity. Data quality is 
ensured by computerized error checks and on-site audits. 
 


 
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The objective of the benchmark analysis was to select promising approaches to be further studied 
and to explore novel endpoints that could not only assess GVHD, but also the complex 
relationships between relapse and GVHD as well as prolonged use of immune suppression. The 
control population selected from the CIBMTR database was comprised of patients who received 
HSCT in a US center from 2006 to 2009 and who received tacrolimus and methotrexate as their 
sole GVHD prophylaxis. Data from single institution studies of the three agents to be tested in this 
protocol were also studied. Populations differed according to disease, donor, conditioning 
intensity, disease risk and patient age. Six investigational approaches were evaluated: 
tacrolimus/MTX+etanercept, 
tacrolimus/MTX+pentostatin/ATG, 
PTCy, 
CD34-selection, 
tacrolimus/MTX+bortezomib and tacrolimus/MTX+maraviroc and compared to CIBMTR 
controls. Each investigational cohort differed in respect to size, disease status, graft source, 
conditioning regimen intensity and donor type. These differences between the investigational and 
control cohorts were adjusted using a Cox Regression models analyzing GVHD and survival 
outcomes (Table 1.4). CD34-selection showed promising results in GVHD and survival outcomes, 
and PTCy showed superiority in chronic GVHD outcomes compared to controls.  
 
 
Table 1.4: RESULTS FROM THE CIBMTR BENCHMARK ANALYSIS OF GVHD 
PROPHYLAXIS REGIMENS 
 
 
Outcome 
Time1/ HR2 
Tacro/MTX 
N=5,048 
Etanercept 
N=74 
Pentostatin/ATG 
N=66 
PTCy 
N=117 
CD34-sel 
N=291 
Bortezomib 
N=44 
Maraviroc 
N=33 
Acute Grade  
3-4 GVHD 
100d (%) 
95% CI 
23 
(22-24) 
21 
(14-31) 
14 
(7-23) 
21 
(13-30) 
4 
(2-8) 
10 
(4-20) 
4 
(0-18) 
HR 
95% CI 
1.00 
 
0.86 
(0.5-1.3) 
0.50* 
(0.3-0.9) 
0.90 
(0.6-1.4) 
0.31* 
(0.2-0.5) 
0.48* 
(0.2-1.0) 
0.91* 
(0.4-2.0) 
Chronic  
GVHD 
12 m (%) 
95% CI 
45 
43-46 
59 
(47-69) 
39 
(27-51) 
13 
(7-20) 
8 
(5-11) 
43 
(28-58) 
19 
(7-35) 
HR 
95% CI 
1.00 
 
1.50* 
(1.1-2) 
0.60* 
(0.4-0.9) 
0.24* 
(0.1-0.4) 
0.10* 
(0.1-0.2) 
0.73 
(0.5-1.1) 
0.29 
(0.1-0.7) 
Overall  
Survival 
12 m (%) 
95% CI 
60 
58-61 
66 
(55-75) 
63 
(52-73) 
57 
(47-66) 
73 
(67-78) 
79 
(66-88) 
64 
(47-77) 
HR 
95% CI 
1.00 
 
0.85 
(0.6-1.2) 
0.69* 
(0.5-0.9) 
1.07 
(0.8-1.4) 
0.68* 
(0.5-0.8) 
0.53* 
(0.3-0.8) 
0.80 
(0.5-1.4) 


 
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In addition to the standard variables of GVHD 
and survival, we studied a composite outcome that 
combined three important outcomes with median 
times of occurrence >90 days after HCT: chronic 
GVHD, relapse and all-cause mortality (CRFS). 
The proportion of patients not achieving this 
composite outcome within the CIBMTR controls 
was 20% by one year post-transplant (Figure 
1.4). Thus, with current standard transplant 
approaches, only one fifth of patients are alive, 
disease- and GVHD-free at one year postHCT. 
The BMT CTN Steering Committee felt that 
improvement on this dismal result should be the 
focus of the next generation of transplant trials 
and a goal for improvement in the field.  
 
1.5. 
Rationale 
 
This multicenter Phase III clinical trial will evaluate two CNI-free approaches for their efficacy in 
improving the proportion of patients who do not develop moderate to severe chronic GVHD, 
disease progression or relapse or death compared to recipients of CNI-based GVHD prophylaxis. 
The results of this study will inform whether these CNI-free approaches offer advantage over CNI 
based according to this novel CRFS without the need for chronic immunosuppression.  
 
 
Figure 1.4: Chronic GVHD/Relapse-free survival 
(CRFS) after bone marrow transplantation using 
calcineurin inhibitor based GVHD prophylaxis 
Figure 1.4: Chronic GVHD/Relapse-free survival 
(CRFS) after bone marrow transplantation using 
calcineurin inhibitor based GVHD prophylaxis. 


 
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CHAPTER 2 
 
 
2. 
STUDY DESIGN 
 
2.1. 
Study Overview 
 
This is a Phase III randomized, open label, multicenter trial comparing two CNI-free strategies: 
CD34 selection in PBSC grafts and infusion of BM grafts followed by high dose 
cyclophosphamide (PTCy) to unmanipulated BM transplants with standard CNI (tacrolimus) and 
methotrexate (Tac/MTX) GVHD prophylaxis in patients with hematologic malignancies 
undergoing myeloablative conditioning hematopoietic cell transplantation. The primary endpoint 
of chronic GVHD/relapse-free survival (CRFS) as a time to event endpoint will be compared 
between the two CNI-free strategies as well as between each CNI-free strategy and the CNI-based 
controls.  
 
2.2. 
Hypothesis and Specific Objectives 
 
2.2.1. Hypothesis 
 
CNI-free approaches result in lower rates of chronic GVHD and relapse and improved survival 
compared to standard CNI-based GVHD prophylaxis.   
 
2.2.2. Study Objectives  
 
The primary objective of the randomized trial is to compare CRFS after hematopoietic stem cell 
transplant (HSCT) across the three arms of this trial. Secondary objectives are to compare rates of 
grade II-IV and III-IV acute GVHD and chronic GVHD; chronic GVHD-free survival; 
immunosuppression-free survival; neutrophil and platelet engraftment; disease relapse; transplant-
related mortality; rates of Grade ≥ 3 toxicity according to the Common Terminology Criteria for 
Adverse Events (CTCAE) Version 4.0; specifically rates of hepatic sinusoidal obstructive 
syndrome (SOS) and idiopathic pneumonia syndrome (IPS), incidence of infections; specifically 
infections by CMV and EBV, quality of life and overall survival across the three arms of this trial.  
 
2.3. 
Patient Eligibility  
 
2.3.1. Inclusion Criteria 
1. Males and females aged ≥ 1.0 year and < 66.0 years 
2. Patients with acute leukemia in morphologic complete remission with or without 
hematologic recovery or with myelodysplasia (MDS) with no circulating blasts and with 
less than 5% blasts in the bone marrow. Patients with CMML must have a WBC count ≤ 
10,000 cells/µL and < 5% blasts in the marrow. Patients with ≥ 5% blasts due to a 
regenerating marrow must contact the protocol chairs for review. 
3. Planned myeloablative conditioning regimen (see eligible regimens in Table 2.4) 


 
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4. Patients must have a related or unrelated donor as follows: 
a. Related donor must be an 8/8 match for HLA-A, -B, and -C at intermediate (or 
higher) resolution, and -DRB1 at high resolution using DNA-based typing. 
Pediatric related donors must weigh ≥ 25.0 kg., must have adequate peripheral 
venous catheter access for leukapheresis or must agree to placement of a central 
catheter, must be willing to (1) donate bone marrow and (2) receive G-CSF 
followed by donation of peripheral blood stem cells (product to be determined by 
randomization post enrollment) and must meet institutional criteria for donation1.  
b. Unrelated donor must be an 8/8 match at HLA-A, -B, -C and –DRB1 at high 
resolution using DNA-based typing. Unrelated donor must be medically eligible to 
donate according to NMDP (or equivalent donor search organization) criteria. At 
time of enrollment, the donor should not have any known preferences or 
contraindications to donate bone marrow or peripheral blood stem cells1. 
i. Selection of unrelated donors is to be performed according to institutional 
practice. It is recommended that the time from collection to initiation of the 
cell processing be considered when prioritizing donors, as data shows better 
results for CD34 selection when cell processing begins within 36 hours of 
the end of collection as indicated in section 2.5.1.2. 
5. Cardiac function: Ejection fraction at rest ≥ 45.0% or shortening fraction of ≥ 27.0% by 
echocardiogram or radionuclide scan (MUGA). 
6. Estimated creatinine clearance (for patients > 12 years) greater than 50.0 mL/minute 
(using the Cockcroft-Gault formula and actual body weight); for pediatric patients (≥ 1 
year to 12 years), GFR estimated by the updated Schwartz formula ≥ 90.0 mL/min/1.73 
m2. If the estimated creatinine clearance is < 90 mL/min/1.73 m2, then renal function 
must be measured by 24-hour creatinine clearance or nuclear GFR, and must be > 70.0 
mL/min/1.73 m2. 
7. Pulmonary function: DLCO ≥ 50% (adjusted for hemoglobin), and FVC and FEV1 ≥ 
50%; for children who are unable to perform for PFTs due to age or developmental 
ability, there must be no evidence of dyspnea and no need for supplemental oxygen, as 
evidenced by O2 saturation ≥ 92% on room air. 
8. Liver function: total bilirubin < 2x the upper limit of normal (unless elevated bilirubin is 
attributed to Gilbert’s Syndrome) and ALT/AST < 2.5x the upper limit of normal. 
9. Signed informed consent.  
 
2.3.2. Exclusion Criteria 
1. Prior autologous or allogeneic hematopoietic stem cell transplant 
                                                 
1  For unrelated donors, during the period of confirmatory typing, some donors may have preferences or 
contraindications to donate a certain stem cell graft source. Similar information would apply to related donors during 
the donor work up procedures. If a patient has only one potential donor and the donor has restrictions on which product 
he/she will donate, then the patient would not be eligible for this study. 


 
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2. Karnofsky or Lansky Performance Score < 70% 
3. Active CNS involvement by malignant cells 
4. Patients with uncontrolled bacterial, viral or fungal infections (currently taking medication 
and with progression or no clinical improvement) at time of enrollment 
5. Presence of fluid collection (ascites, pleural or pericardial effusion) that interferes with 
methotrexate clearance or makes methotrexate use contraindicated 
6. Patients seropositive for HIV-1 or -2 
7. Patients seropositive for HTLV-I or -II 
8. Patients with active Hepatitis B or C viral replication by PCR  
9. Documented allergy to iron dextran or murine proteins 
10. Women who are pregnant (positive serum or urine βHCG) or breastfeeding 
11. Females of childbearing potential (FCBP)2 or men who have sexual contact with FCBP 
unwilling to use 2 effective forms of birth control or abstinence for one year after 
transplantation 
12. History of uncontrolled autoimmune disease or on active treatment 
13. Patients with prior malignancies, except resected non-melanoma or treated cervical 
carcinoma in situ. Cancer treated with curative intent ≥ 5 years previously will be allowed. 
Cancer treated with curative intent < 5 years previously will not be allowed unless 
approved by the Protocol Officer or one of the Protocol Chairs.  
14. Patient unable to comply with the treatment protocol including appropriate supportive care, 
follow-up and research tests  
15. Planned post-transplant maintenance therapy except for FLT3 inhibitors or TKIs 
a. Must be declared prior to randomization. 
16. If it is known prior to enrollment that the hematopoietic stem cell product will need to be 
cryopreserved, the patient should not be enrolled.   
17. German centers only: Treatment with any known non-marketed drug substance or 
experimental therapy within 5 terminal half lives or 4 weeks prior to enrollment, whichever 
is longer, or participation in any other interventional clinical study. 
 
 
                                                 
2 A female of childbearing potential is a sexually mature female who: 1) has not undergone a hysterectomy or bilateral 
oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses 
at any time in the preceding 24 consecutive months). 


 
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2.4. 
 Conditioning Regimens 
 
Minor modifications to the myeloablative regimens that involve start day or days of rest in the 
Control Arm are allowed but must be approved by the protocol chairs. Only minor modifications 
will be considered for approval. Modifications to the myeloablative regimens in the intervention 
arms (CD34 Cell Selection Arm and Post-Transplant Cy Arm) are not allowed. An additional 
day of rest may be added to conditioning regimens of any arm when transportation and/or 
delivery of the patient’s graft is delayed. 
 
For patients who weigh less than 125% of their ideal body weight (IBW), dosing should be based 
on actual body weight. These dosing rules apply to all chemotherapy drugs listed in section 2.4. 
including cyclophosphamide, thiotepa, rATG, busulfan, fludarabine, melphalan and etoposide. 
Ideal and actual body weight units are in kg. 
 
Patients ≥ 18.0 Years of Age 
Males IBW = 50 kg + 2.3 kg/inch over 5 feet (60 in) 
Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet (60 in) 
For patients less than 5 feet, subtract 2.3 kg/inch 
 
Metric Conversion 
Males IBW = 50 kg + 2.3 kg ([height in meters -1.52] /0.025)  
Females IBW = 45.5 kg + 2.3 kg ([height in meters -1.52] /0.025) 
For patients shorter than 1.52 m, subtract 2.3 kg/ for each 2.5 cm below 1.52m 
 
 
Patients ≥ 1.0 Year and < 18.0 Years of Age 
 
Height Less than 60 inches (5 feet or 1.52m) 
IBW = (ht2 x 1.65)/1000 where ht = cm, IBW = kg 
 
Height More than 60 inches (5 feet or 1.52m) 
Males IBW = 39.0 + [2.27 x (ht - 60)] where ht = inches, IBW = kg 
Females IBW = 42.2 + [2.27 x (ht - 60)] where ht = inches, IBW = kg 
 
Metric Conversion  
Males IBW = 39.0 + [2.27 x (height in meters – 1.52/0.025)] 
Females IBW = 42.2 + [2.27 x (height in meters– 1.52/0.025)]  
 
For patients who weigh greater than or equal to 125% of their IBW, dosing should be based on the 
adjusted ideal body weight (AIBW). 
Adjusted Ideal Body Weight (AIBW) Formula: 
     AIBW = IBW + [(0.25) x (actual body weight – IBW)] 
 
 


 
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TABLE 2.4: ALLOWABLE MYELOABLATIVE REGIMENS BY TREATMENT ARM 
CD34 Selection Arm (PBSC) 
§ 2.4.1. 
Total Body Irradiation/ 
Cyclophosphamide/Thiotepa/rATG 
• TBI (1320 – 1400 cGy) 
• Cyclophosphamide (120 mg/kg) 
• Thiotepa (10 mg/kg) 
• rATG (5mg/kg) 
§ 2.4.2. 
Busulfan/Melphalan/Fludarabine/rATG 
• 
Busulfan (9.6 mg/kg IV) 
• 
Fludarabine (125 mg/m2) 
• 
Melphalan (140 mg/m2) 
• 
rATG (5mg/kg) 
 
Post-Transplant Cy Arm (BM) 
 
Control Arm (BM) 
§ 2.4.3.1. 
Busulfana/Cyclophosphamide 
(Bu/Cy) 
• 
Busulfan (16 mg/kg PO or 12.8 
mg/kg IV) 
• 
Cyclophosphamide (100 mg/kg) 
§ 2.4.3.2. 
Busulfana/Cyclophosphamide 
(Bu/Cy) 
• 
Busulfan (16 mg/kg PO or 12.8 
mg/kg IV) 
• 
Cyclophosphamide (120 mg/kg) 
§ 2.4.4. 
Busulfana /Fludarabine (Bu/Flu) 
• 
Busulfan (16 mg/kg PO or 12.8 
mg/kg IV) 
• 
Fludarabine (160 mg/m2) 
§ 2.4.4. 
Busulfana /Fludarabine (Bu/Flu) 
• 
Busulfan (16 mg/kg PO or 12.8 
mg/kg IV) 
• 
Fludarabine (160 mg/m2) 
§ 2.4.5.1. 
Cyclophosphamide/Total Body 
Irradiation (Cy/TBI) 
• 
Cyclophosphamide (100 mg/kg) 
• 
TBI (1200-1420 cGy) 
§ 2.4.5.2. 
Cyclophosphamide/Total Body 
Irradiation (Cy/TBI) 
• 
Cyclophosphamide (120 mg/kg) 
• 
TBI (1200-1420 cGy) 
 
 
§ 2.4.6. 
Total Body Irradiation/Etoposide 
(TBI/Etoposide) 
• 
 TBI (1200-1320 cGy) 
• 
Etoposide (60 mg/kg) 
a Bu = PO doses will be adjusted to maintain BU Css at 900±100 ng/ml. 
 
 


 
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2.4.1. TBI, Cyclophosphamide, Thiotepa, and rATG (Cy/TBI/Thio/rATG) 
 
Table 2.4.1. - CD34 Cell Selection Arm: Total Body Irradiation/ Cyclophosphamide/ Thiotepa/ 
rATG Regimen 
 
 
Days -9 to -6 
TBI (1375cGy): Administered at a dose rate of < 20 cGy/minute. 
Doses of 125 cGy/fraction are administered at a minimum interval 
of 4 hours between fractions, three times/day for a total of 11 doses 
(1375 cGy) over 4 days 
Days -5 to -4 
Thiotepa 5 mg/kg/day: IV for two consecutive days 
Days -4 to -3 
rATG 2.5 mg/kg/day: Given as a single intravenous dose on Day -4 
and Day -3 using rabbit antithymocyte globulin (Genzyme) 
Days -3 to -2 
Cyclophosphamide 60 mg/kg/day: IV for two consecutive days 
 
Hyperfractionated TBI is administered at a dose rate of < 20 cGy/minute. Doses of 125 
cGy/fraction are administered at a minimum interval of 4 hours between fractions, three times/day 
for a total of 11 doses (1375 cGy) over 4 days (Day -9, -8, -7 and -6). Sequential doses are 
administered in an anterior/posterior or lateral orientation. The orientation of TBI chosen will be 
left to the discretion of the radiation oncology specialist at each center but should remain consistent 
at each institution throughout the duration of the trial. Full value lung blocks are not allowed. 
Compensators and lung blocks yielding a minimum of 800 cGy lung dose are allowed based on 
institutional practice. Depending on the method of lung shielding employed and institutional 
practice, the blocked areas should be boosted with high-energy electrons or be otherwise radiated 
so that the cumulative chest wall dose is approximately 1300 cGy, so as to insure that marrow sites 
in the ribs are adequately treated. Palifermin may be given to patients receiving TBI per 
institutional practices.  
 
In addition, male patients receiving transplants for ALL or AML, use of boost to testes is allowed 
according to institutional practices.  
 
If general anesthesia is required for TBI administration (e.g., young children), a dose of 200cGy 
q12h x 7 doses to a total dose of 1400 cGy may be given. Alternatively, a dose of 165 cGy q12h x 
8 doses to a total dose of 1320 cGy may be given to patients < 18 years according to institutional 
guidelines.  
 
Thiotepa will be administered at a dose of 5mg/kg/day IV for two consecutive days (Day -5 and 
-4). 
 
Rabbit anti-thymocyte globulin (Thymoglobulin®) will be given as a single intravenous dose 
on Day -4 and Day -3 using rabbit antithymocyte globulin (Genzyme) at a dose of 2.5 mg/kg/day. 
If the patient has a history of allergy or intolerance to rabbit ATG, equine antithymocyte globulin 
at a dose of 30 mg/kg may be used. The dose of ATG will be administered over 6-8 hours. 
Methylprednisolone 1 mg/kg will be given as premedication x 2 days with the ATG administration 


 
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and will be discontinued thereafter. Additional medications to prevent or treat reactions will be 
administered as indicated according to institutional guidelines. If severe reaction is encountered 
after the first dose of ATG, the second dose can be delayed until Day +5.  
 
Cyclophosphamide will be administered at a dose of 60 mg/kg/day IV for two consecutive days 
(Day -3 and -2). The Day –2 dose should be given in the morning, preferably before 10AM. Use 
of Mesna and dosing will be done according to institutional standards. A recommended approach 
is as follows: Mesna dose of ≥ 80% of the total daily dose of Cy and given in divided doses 30 
minutes before and at 3, 6, and 8-9 hours after completion of Cy intravenously. 
 
2.4.2. Busulfan, Melphalan, Fludarabine, and rATG 
 
Table 2.4.2. – CD34 Cell Selection Arm: Busulfan, Melphalan, Fludarabine, and rATG 
Regimen 
 
 
Days -9 to -7 
Busulfan:  
if >4 years old: 0.8 mg/kg/dose Q6h IV 
 
 
if ≤ 4 years old:1 mg/kg/dose Q6h IV   
 
Infused over two hours. 
Days -6 to -5 
Melphalan:  
if weight > 12 kg: 70 mg/m2/day 
 
 
if weight ≤ 12 kg: 2.3 mg/kg/day 
 
Infused once daily intravenously over 30 minutes 
Days -6 to -2 
Fludarabine 25 mg/m2/day: Administered intravenously over 30 
minutes at a total dose of 125 mg/m2 divided into 5 daily doses of 
25 mg/m2/day 
Days -3 to -2 
rATG 2.5 mg/kg/day: Will be given at 2.5 mg/Kg/day x 2 days on 
Days -3 and -2 
 
Busulfan will be infused over 2 hours. Phamacokinetics on busulfan based on test dose or the first 
dose can be done according to institutional practices. Busulfan pharmacokinetics studies are 
strongly encouraged with first AUC of 800-1400 μMol-min or Bu Css 900 ± 100 ng/mL/, but are 
not mandated by this protocol. 
 
Melphalan will be infused once daily intravenously over 30 minutes. 
 
 
Fludarabine will be administered intravenously over 30 minutes at a total dose of 125 mg/m2 
divided into 5 daily doses of 25mg/m2/day. 
 
Rabbit anti-thymocyte globulin (Thymoglobulin®) will be given at 2.5 mg/Kg/day x 2 days on 
Days -3 and -2. If the patient has a history of allergy or intolerance to rabbit ATG, equine 
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ATG will be administered over 6-8 hours. Methylprednisolone 1 mg/kg will be given as 
premedication x 2 days with the ATG administration and will be discontinued thereafter. 
Additional medications to prevent or treat reactions will be administered as indicated according to 
institutional guidelines. If severe reaction is encountered after the first dose of ATG, the second 
dose can be delayed until Day +5. 
 
2.4.3. Busulfan and cyclophosphamide (Bu/Cy) 
 
2.4.3.1. 
The allowable Bu/Cy regimen for the Post-Transplant Cy Arm is the following: 
 
Table 2.4.3.1.  – Post-Transplant Cy Arm: Busulfan and Cyclophosphamide Regimen 
 
 
Days -7 to -4 
Busulfan*:  
4 mg/kg/day PO, total dose of 16 mg/kg PO 
 
 
3.2 mg/kg/day IV total dose of 12.8 mg/kg 
Days -3 to -2 
Cyclophosphamide: 50 mg/kg/day, total dose of 100 mg/kg 
*Busulfan should be administered per institutional guidelines but dosing divided in q6h 
administration x 4 days is recommended for patients randomized to the PTCy treatment arm.  
 
2.4.3.2. 
The allowable Bu/Cy regimen for the Control Arm is the following: 
 
Table 2.4.3.2.  – Control Arm: Busulfan and Cyclophosphamide Regimen 
 
 
Days -7 to -4 
Busulfan:  
4 mg/kg/day PO, total dose of 16mg/kg PO 
 
 
3.2 mg/kg/day IV total dose of 12.8 mg/kg 
Days -3 to -2 
Cyclophosphamide: 60 mg/kg/day, total dose of 120 mg/kg 
 
Participating centers will have the option of using oral or intravenous Busulfan (Bu). Oral Bu will 
be administered at 4 mg/kg/day on Days -7, -6, -5 and -4 (1mg/kg every 6 hours). If the center is 
administering busulfan orally, pharmacokinetics analysis and targeting the dose to  
900+100 ng/mL must be performed or first AUC of 800-1400 Bu Css 900 ± 100 ng/mL/or AUC 
of 800-1400 μMol-min. 
 
Intravenous Bu is administered at a dose of 3.2 mg/kg/day or 130 mg/m2/day on Days -7, -6, -5 
and -4 either in four divided doses (0.8 mg/kg) or once daily (3.2 mg/kg or 130 mg/m2). Patients 
randomized to the PTCy arm, it is recommended that Bu dosing be divided in a Q6h schedule for 
four days. Busulfan pharmacokinetics studies are strongly encouraged with Bu Css 900 ± 100 
ng/mL/ or first AUC of 800-1400 μMol-min, but are not mandated by this protocol. 
 
Cyclophosphamide (Cy) will be administered on Day -3 and Day -2 at a dose of 50 mg/kg per 
day intravenously (IV) if the patient is randomized to the PTCy arm, or at a dose of 60 mg/kg per 
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2 hours. Lower doses may be administered over one hour.  
 
Hydration prior to Cy may be given according to institutional standards. A recommended 
approach is as follows: Patients are instructed to increase fluids overnight before Cy 
administration. Hydration with normal saline at 3 ml/kg/hr IV will be started 2 hours prior to Cy, 
then the rate will be reduced to 2 ml/kg/hr for 1 hour pre-cyclophosphamide and continued at 2 
ml/kg/hr for 8 hours post-Cy. 
 
Mesna is required in patients on the post-transplant Cy arm. Mesna dose must be ≥ 80% of the 
total daily dose of Cy and given in divided doses 30 minutes before and at 3, 6, and 8-9 hours after 
completion of Cy intravenously. 
 
For patients in the Control Arm, use of Mesna and dosing will be done according to institutional 
standards. A recommended approach is as follows: Mesna dose of ≥ 80% of the total daily dose of 
Cy and given in divided doses 30 minutes before and at 3, 6, and 8-9 hours after completion of Cy 
intravenously. 
 
2.4.4. Busulfan and fludarabine (Bu/Flu) 
 
Table 2.4.4.  – Post-Transplant Cy and Control Arms: Busulfan and Fludarabine Regimen 
 
 
Days -5 to -2 
Busulfan:  4 mg/kg/day PO dose with Bu Css 900±100 ng/mL, total dose of 16mg/kg PO 
 
3.2mg/kg/day IV total dose of 12.8mg/kg 
 
130 mg/m2/day 520 mg/m2 
Days -5 to -2 Fludarabine: 40 mg/m2/day, total dose of 160 mg/m2 
 
The sequence of busulfan and fludarabine administration will be done according to institutional 
standards as long as the prescribed doses are the same as the allowable regimen above. 
 
Fludarabine will be administered intravenously at a total dose of 160 mg/m2 divided into four 
daily doses according to institutional practices. 
 
2.4.5. Cyclophosphamide and total body irradiation (Cy/TBI) 
 
2.4.5.1. 
The allowable Cy/ TBI regimen for the Post-Transplant Cy Arm is the following: 
 


 
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Table 2.4.5.1.  – Post-Transplant Cy Arm: Cyclophosphamide and Total Body Irradiation 
Regimen 
 
 
Days -7 to -4 
TBI 1200–1420 cGy: Administered according to the schedules 
utilized by the participating clinical centers.  
Days -3 to -2 
Cyclophosphamide: 50 mg/kg/day, total dose of 100 mg/kg 
 
2.4.5.2. 
The allowable Cy/ TBI regimen for the Control Arm is the following: 
 
Table 2.4.5.2.  – Control Arm: Cyclophosphamide and Total Body Irradiation Regimen 
 
 
Days -7 to -4 
TBI 1200–1420 cGy: Administered according to the schedules 
utilized by the participating clinical centers.   
Days -3 to -2 
Cyclophosphamide: 60 mg/kg/day, total dose of 120 mg/kg 
 
The sequence of cyclophosphamide, TBI and TBI administration practices will be in accordance 
with institutional standards as long as the prescribed doses are the same as the allowable regimen 
above. 
 
Fractionated TBI will be administered according to the schedules utilized by the participating 
clinical centers.  Radiation sources, dose rates, details of lung shielding, and sites receiving boost 
radiation will also be defined by the institution. TBI may be delivered from either linear accelerator 
or Cobalt sources. Palifermin may be given to patients receiving TBI per institutional practices.  
 
Mesna is required in patients on the post-transplant Cy arm. Mesna dose must be ≥ 80% of the 
total daily dose of Cy and given in divided doses 30 minutes before and at 3, 6, and 8-9 hours after 
Cy intravenously.  
 
For patients in the Control Arm, use of Mesna and dosing will be done according to institutional 
standards. A recommended approach is as follows: Mesna dose of ≥ 80% of the total daily dose of 
Cy and given in divided doses 30 minutes before and at 3, 6, and 8-9 hours after completion of Cy 
intravenously. 
 
2.4.6. Total body irradiation and etoposide (TBI/Etoposide) – for the Control Arm only 
 
The allowable TBI/Etoposide regimen is the following: 
 
Table 2.4.6.  – Control Arm: Total Body Irradiation and Etoposide Regimen 
 
 
Days -7 to -4 
TBI 1200–1320 cGy: Administered according to the schedules 
utilized by the participating clinical centers.  


 
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Day -3 
Etoposide 60 mg/kg: Administered at a single dose of 60 mg/kg 
 
Fractionated TBI will be administered according to the schedules utilized by the participating 
clinical centers. Radiation sources, dose rates, details of lung shielding, and sites receiving boost 
radiation will also be defined by the institution. TBI may be delivered from either linear accelerator 
or Cobalt sources. Palifermin may be given to patients receiving TBI per institutional practices.  
 
Etoposide will be administered at a single dose of 60 mg/kg on Day -3.   
 
2.5. 
Hematopoietic Stem Cell Graft Collection 
 
2.5.1. CD34 Selection Arm 
 
Donors of patients randomized to the CD34 selection arm are considered research subjects 
according to the FDA regulations regarding human subjects (21 CFR Part 812.3). Unrelated donors 
will be consented after recipients are randomized. For unrelated donors, the National Marrow 
Donor Program (NMDP) will oversee the donor consent procedures by distributing the donor 
consent document to Donor Centers and maintaining IRB oversight of the consent procedures. For 
related donors, the consent process will be done at the transplant center along with routine donor 
consent procedures according to institutional guidelines. The donor informed consent document 
for related donors, including assent for minors, will be reviewed by each transplant center’s IRB. 
 
2.5.1.1. 
Mobilization of Donor 
 
Following screening and enrollment, the donor of patients randomized to the CD34-selection arm 
will receive mobilization therapy with once daily G-CSF. Mobilization will begin on Day -5 of the 
conditioning regimen at a G-CSF dose of 10 µg/kg/day actual body weight subcutaneously 
(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. 
  
2.5.1.2. 
Progenitor Cell Collection and Processing 
 
Leukapheresis 
Leukapheresis will be performed on a continuous flow cell separator according to institutional 
standards and will commence on the morning of the fifth 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 three to four times 
total blood volume as tolerated by the donor. Concurrent plasma (200-300 mL) should be collected 
for products to be stored overnight after receipt into the processing facility. A unique identification 
and labeling system shall be used to track the leukapheresis product from collection to infusion 
according to FACT/JACIE guidelines.  
 


 
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2-12 
For the purpose of cell infusion, the actual body weight will be used to calculate cell dose. A target 
dose ≥ 5.0 x 106 CD34+ cells/kg after selection containing ≤ 1.0 x 105  CD3+ cells/kg is desired.  
Up to two leukapheresis products containing a total of 10.0 x 106 CD34+ cells per kg may be 
needed to achieve this dose, assuming a 50% recovery of CD34+ cells after processing.  A 
minimum of 4.0 x 106 CD34+ cells/kg must be collected to achieve an expected infusion dose of 
2.0 x 106 CD34+ cells/kg.   
 
For related donors - Decisions concerning the need for further product collection will be based 
on the known or projected enriched CD34+ cell content of the previously collected products. Data 
from the BMT CTN 0303 trial indicates a median recovery of CD34+ cells of 65% with more than 
90% of selection procedures having a recovery ≥ 50%.66 As a conservative estimate ≥10.0 x 106 
CD34+ cells/kg recipient body weight at collection should result in the desired target infusion dose 
of 5.0 x 106 CD34+ cells/kg. The majority of patients will achieve this dose in a single apheresis 
collection and nearly all will achieve this dose with two collections. T-cell depletion was excellent 
in the BMT CTN 0303 study and it is not expected that T-cell content will exceed 1.0 x 105/kg 
with two collections. If after two collections the CD34+ cell dose is ≥ 2.0 x 106 per kg (the 
minimum required dose for infusion), no more collections will be performed. If the CD34+ cell 
dose is less than 4.0 X 106 cells/kg per kg CD34+ selection will not be performed. 
 
 
A third collection to be infused without CD34-enrichment may be considered only if < 2.0 x 106 
CD34+ cells/kg are expected to be available for infusion after two collections. If subsequent 
apheresis collection is not possible, or if minimum CD34 dose cannot be achieved without 
exceeding the maximum CD3 content, the patient will receive sufficient cells from the CD34-
reduced fraction to reach the minimum CD34 dose. 
 
If some or all of a third unmanipulated collection is infused or if cells from the CD34-reduced 
fraction are infused, the patient will be treated as if on the Control arm, receiving Tac/Mtx, but 
will be analyzed on the CD34+ selection arm, in accordance with the intent to treat principle. 
 
For unrelated donors - The work up request to the donor center will include the CD34+ cell dose 
required of 10.0 x 106 CD34+ cells per kg, which falls within routine specifications from NMDP. 
The peripheral stem cell collection procedures will be according to NMDP procedures.  
  
Transport and storage of product prior to processing 
Analysis of processing data has indicated better results when processing is started within 36 hours 
of the end of collection. Therefore transport or storage times before the beginning of processing 
should target this upper limit. Products that will start processing within 24 hours of collection 
should be transported or stored at room temperature (19-25oC). Products that require ≥24 hours of 
transport or storage should be maintained from the time of collection at refrigerator temperatures 
(1-8oC) but must be warmed to room temperature prior to the start of processing. 
 
CD34+ selection with CliniMACS device 
Cell processing personnel will receive training by Miltenyi on the CliniMACS System prior to 
activation of this protocol at their clinical site. The site will provide documentation to Miltenyi on 


 
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2-13 
competency in the processing procedures, including the results of validation runs on the 
CliniMACS System. 
 
CD34+ cell selection will be performed according to procedures given in the CliniMACS Users 
Manual for the CliniMACS® CD34 Reagent System and the BMT CTN 1301 Standard Operating 
Procedures (SOPs) for CD34 Selection, in place and validated at the study sites. The CliniMACS 
Users 
Manual 
can 
be 
found 
on 
the 
manufactures 
website 
(http://www.miltenyibiotec.com/en/clinical-applications/clinimacs-cd34-reagent-system-fda-
approved/health-care-professionals/downloads-and-references.aspx). 
 
Analysis of allograft 
Samples will be taken from each leukapheresis product after collection and before processing and 
on each fraction of cells after processing on a single CliniMACS tubing set. Pre- and post-CD34+ 
selected cells shall be characterized as follows:  
• Graft Evaluation (tests are performed as part of graft processing) 
- Gram stain (done locally) post-selection  
- Total nucleated cell count (done locally) pre- and post-processing  
- Endotoxin testing post-processing, done locally or sent to an authorized lab 
- Flow cytometric analysis for CD34+ cells and for CD3+ cells pre- and post-processing 
done locally using validated SOPs 
- Flow cytometric analysis of monocytes, B cells, NK cells in the CD34-enriched 
products 
- Viability testing (7-AAD method or other fluorescent vital dye) pre- and post-
processing 
- 14 day sterility cultures post-processing done locally using validated SOPs. 
• Criteria for release of graft product for infusion. Note more than one CD34-enriched 
fraction may constitute a single graft product. 
- Viability ≥ 70% after selection 
- Negative gram stain 
- Cumulative CD34+ cell content ≥2.0 x 106 per kg  
- Cumulative CD3+ cell content ≤1.0 x 105 per kg 
 
As noted above, the target optimal allograft cell doses following processing on the CliniMACS 
device include both a CD34+ cell count of > 5.0 x 106/kg recipient weight and a CD3+ cell dose of 
< 1.0 x 105/kg actual recipient weight. The targeted minimum CD34+ cell dose following CD34+ 
selection is 2.0 x 106/kg while the absolute minimum CD34+ cell dose is ≥1.0 x 106/kg.  
 
It is also possible that doses of CD34+ cells far exceeding 5 x 106/kg can be given without 
exceeding the maximum T-cell dose of 1.0 x 105 CD3+ cells/kg. High doses of CD34+ cells in 


 
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2-14 
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 1.0 x 105/kg.  
 
Cryopreservation: If it is determined after randomization that cryopreservation may be needed, it 
must be approved by the protocol chairs. 
 
2.5.1.3. 
Bone Marrow Collection and Processing 
 
Bone marrow grafts will be used in patients who are randomized to either the PTCy or the Control 
arms. Bone marrow donors should undergo harvest in a time frame that will allow fastest delivery 
on Day 0. Either general or regional (epidural, spinal) anesthesia may be used. Donor bone marrow 
will be harvested with a target yield of 4 x 108 nucleated cells/kg recipient actual body weight. The 
CD 34+ and T-cell count in the marrow will be quantified by flow cytometry according to 
institutional guidelines. Prior to the initiation of the transplant conditioning regimen, the estimated 
cell dose and a planned donor marrow volume shall be agreed upon by the donor and transplant 
center for unrelated donors; and between the transplant physician and cell processing laboratory 
for related donors.  
 
Bone marrow processing, other than anticoagulation, filtration, packaging, and labeling in 
preparation for transportation, should not be performed by the collection center. The bone marrow 
graft will not be manipulated to deplete T cells. Patients will receive unprocessed marrow unless there 
is a major ABO incompatibility, in which case red blood cells will be depleted from the donor marrow 
using institutional practices. Institutional practices will determine if there will be processing for minor 
ABO incompatibilities. Processing for reduction of volume, plasma or fat may be performed by the 
transplant center according to institutional guidelines. 
 
Cryopreservation: If it is determined after randomization that cryopreservation may be needed, it 
must be approved by the protocol chairs. 
2.6. 
GVHD Prophylaxis 
 
For patients who weigh less than 125% of their ideal body weight (IBW), dosing should be based 
on actual body weight. For patients who weigh greater than or equal to 125% of their IBW, dosing 
should be based on the adjusted ideal body weight (AIBW). These dosing rules do not apply to 
cyclosporine or tacrolimus, which should be dosed based on actual body weight. 
 
2.6.1. Post-Transplant Cyclophosphamide 
 
Hydration prior to cyclophosphamide may be given according to institutional standards. A 
recommended approach is as follows: Patients are instructed to increase fluids overnight before 
cyclophosphamide administration. Hydration with normal saline at 3 ml/kg/hr IV will be started 2 
hours prior to cyclophosphamide, then the rate will be reduced to 2 ml/kg/hr for 1 hour pre-
cyclophosphamide and continued at 2 ml/kg/hr for 8 hours post-cyclophosphamide. 
 


 
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Mesna is required in patients on the post-transplant Cy arm. Mesna dose must be ≥ 80% of the 
total daily dose of Cy and given in divided doses 30 minutes before and at 3, 6, and 8-9 hours after 
completion of Cy intravenously.  
 
Cyclophosphamide [50 mg/kg] will be given on Day 3 post-transplant (between 60 and 72 hours 
after marrow infusion) and on Day 4 post-transplant (approximately 24 hours after Day 3 
cyclophosphamide). Cyclophosphamide will be given as an IV infusion over 1-2 hours (depending 
on volume).  
 
Systemic corticosteroids may not be used as an anti-emetic agent and should not be 
administered until 24 hours after the completion of post-transplantation cyclophosphamide, 
unless clinically indicated.   
 
If patient develops GVHD on one of the CNI-free arms (PTCy or CD34 selection), the following 
treatment approach is recommended: 
 
a. Skin disease only (< 50%BSA) – the recommended treatment is topical steroids. 
 
b. Skin disease only (>50%BSA) – the recommended treatment is topical steroids 
with low threshold to escalate to systemic steroids. For systemic steroids, 
prednisone (1 to 2 mg/kg/day or IV equivalent) can be used. If no response after 72 
hours or need for prolonged systemic steroids, the recommendation is to add 
tacrolimus (level 5-10 ng/mL). 
 
c. Grade 2 GI (upper or lower) - the recommended treatment is a trial of 
budesonide (9 mg total daily). If no response within 7 days or progression within 
72h, prednisone (2 mg/kg/day or IV equivalent) can be used, in addition to 
beclomethasone and/or budesonide for GI GVHD, and tacrolimus (level 5-10 
ng/ml).  
d. Grade 3-4 GI (upper or lower) or hepatic GVHD: the recommended treatment 
is prednisone (2 mg/kg/day or IV equivalent), in addition to beclomethasone 
and/or budesonide for GI GVHD, and tacrolimus (level 5-10 ng/ml). 
 
2.6.2. CNI/Methotrexate Control Arm 
 
2.6.2.1. 
Tacrolimus 
 
Tacrolimus will be given orally or intravenously per institutional standards starting Day –3. The 
dose of tacrolimus may be rounded to the nearest 0.5 mg for oral formulations. Subsequent dosing 
will be based on blood levels, with a target of 5-15 ng/ml. If patients are on medications which 
alter the metabolism of tacrolimus (e.g. azoles), the initial starting dose and subsequent doses 
should be altered as per institutional practices. Tacrolimus taper can be initiated at a minimum of 
90 days post HSCT if there is no evidence of active GVHD. The rate of tapering will be done 
according institutional practices but patients should be off tacrolimus by Day 180 post HSCT if 
there is no evidence of active GVHD.  


 
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Cyclosporine may be substituted for tacrolimus if the patient is intolerant of tacrolimus or per 
institutional practice. Cyclosporine will be administered IV beginning on Day -3 and doses will be 
adjusted to maintain a trough level of 200-400 ng/mL by HPLC or 250-500 ng/mL by TDX method 
(or 100-250 ng/mL by Tandem MS or equivalent level for other CSA testing methods) or within 
therapeutic level per institutional standard testing. If patients are on medications which alter the 
metabolism of cyclosporine (e.g. azoles), the initial starting dose and subsequent doses should be 
altered as per institutional practices. Cyclosporine taper can be initiated at a minimum of 90 days 
post HSCT if there is no evidence of active GVHD. The rate of tapering will be done according 
institutional practices but patients should be off cyclosporine by Day 180 post HSCT if there is no 
evidence of active GVHD. 
 
2.6.2.2. 
 Methotrexate 
 
Methotrexate will be administered at the doses of 15 mg/m2 IV bolus on Day +1, and 10 mg/m2 
IV bolus on Days +3, +6 and +11 after hematopoietic stem cell infusion. The Day +1 dose of 
methotrexate should be given at least 24 hours after the hematopoietic stem cell infusion ends. 
Dose reduction of MTX due to worsening creatinine clearance after initiation of conditioning 
regimen, high serum levels or development of oral mucositis is allowed according to institutional 
practices. Leucovorin rescue is allowed according to institutional practices. 
 
2.7. 
Transplant Procedures 
 
Unmanipulated BM or mobilized CD34-selected PBSC grafts will be administered on Day 0 to all 
patients according to individual institutional guidelines after appropriate processing and 
quantification has been performed by the local laboratory. Stem cells are administered through an 
indwelling central venous catheter. If infusion occurs over two days, Day 0 is the first day the 
infusion is initiated. 
 
2.8. 
Supportive Care 
 
All supportive care will be given in keeping with the BMT CTN Manual of Procedures and local 
institutional practice. Supportive care should be administered in a similar fashion to subjects 
randomized to all three arms of the study. 
 
2.8.1. Growth Factors 
 
G-CSF may be given per institutional guidelines.  
 
2.8.2. Seizure Prophylaxis 
 
Keppra (Levetiracetam) will be administered for the prevention of busulfan-associated seizures to 
all research participants receiving busulfan, starting Day –10 or 12 hours prior to starting busulfan. 
Dosing of Levetiracetam will be administered as per the BMT guidelines. Alternatively, Phenytoin 
or another similar seizure prophylaxis agents may be administered starting day –10 or 12 hours 


 
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prior to starting busulfan for the prevention of busulfan-associated seizures, according to 
institutional practices.  
 
2.8.3. Blood Products 
 
Transfusion thresholds for blood product support will be consistent with the BMT CTN MOP and 
standard institutional guidelines. All blood products will be irradiated. 
 
2.8.4. Prophylaxis Against Infections 
 
Patients will receive infection prophylaxis according to institutional guidelines. Infection 
prophylaxis should include, but is not limited to, agents or strategies (e.g., PCR screening and 
preemptive therapy) to reduce the risk of bacterial, herpes simplex, CMV, EBV, Pneumocystis 
jiroveci, toxoplasmosis, and fungal infections: 
• Antifungal therapy: Prophylaxis with fluconazole or other antifungal agents can be given 
as per local institutional guidelines. Fluconazole, voriconazole and other azoles are 
expected to increase serum cyclosporine or tacrolimus levels, therefore, dosages of 
cyclosporine or tacrolimus should be adjusted accordingly.  
• Cytomegalovirus (CMV): For patients on the CD34-selection arm, CMV monitoring 
through nucleic acid amplified testing (NAAT) will be done weekly through Day 100 and 
then at each clinical assessment until Day 180 post-transplant. For patients on the other 2 
arms, CMV monitoring will be done according to institutional guidelines. It is 
recommended that weekly assessment for CMV be done through Day 63 post-transplant, 
and then at each clinical assessment until day 180 post-transplant. Any reactivation and/or 
CMV disease will be captured in this study. Preemptive treatment (early treatment of CMV 
viremia detected by PCR) is the preferred strategy for the majority of patients. It is 
recommended that the threshold to initiate preemptive therapy will be according to a value 
determined by the assay being performed at the institution or a rising trend on successive 
measurements from patient’s baseline. As an example, when using an FDA-approved assay 
that has been calibrated, using WHO CMV standards, a threshold of 500 international units 
(IU)/mL may be used.  
• Epstein-Barr Virus (EBV): For patients on the CD34-selection arm, EBV monitoring 
through nucleic acid amplified testing (NAAT) will be done weekly through Day 100 and 
then at each clinical assessment until Day 180 post-transplant. For patients on the other 2 
arms, EBV monitoring will be done according to institutional guidelines. See below for 
management of patients with EBV viremia or lymphoproliferative syndrome (section 
2.9.7.).  
• Pneumocystis jiroveci: Prophylaxis with agents against Pneumocystis jiroveci can be given 
as per local institutional guidelines. In recipients of CD34-selected grafts, it is 
recommended that prophylaxis continue beyond day 180, until immune recovery, defined 
by a normal CD4 T cell count. 


 
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2-18 
• Herpes virus (HSV or VZV): Patients must receive acyclovir or valacyclovir through Day 
365 post-transplant as standard prophylaxis against HSV and VZV per institutional 
guidelines or until the CD4 T-cell count has normalized.  
• Toxoplasmosis: For patients on the CD34-selection arm that are at risk (seropositive patient 
or donor), it is required that toxoplasmosis prophylaxis, through site preferred methods, 
begin on Day 30 post-transplant. Prophylaxis with agents against toxoplasmosis can be 
given as per local institutional guidelines. In recipients of CD34-selected grafts, 
prophylaxis should be given to patients at risk and continued beyond day 180, until immune 
recovery, defined by a normal CD4 T cell count. 
 
2.8.5. Intravenous Immune Globulin (IVIG) 
 
IVIG administration will be according to local institutional standard practice. 
 
2.8.6. Sinusoidal Obstruction Syndrome (SOS)/Veno-occlusive Disease (VOD) of the Liver 
Prophylaxis 
 
Prophylaxis against SOS/VOD with heparin and/or ursodiol will be according to local institutional 
standard practice. 
 
2.8.7. Donor Lymphocyte Infusions – Viral-specific Cytotoxic T-Lymphocytes (CTLs) 
 
Donor lymphocyte infusions (DLI) should only be performed for therapeutic reasons, including 
but not limited to relapsed or persistent disease or refractory infections. DLI should not be 
administered for mixed chimerism only. 
 
Viral specific CTL (donor-derived or third-party) may be given for treatment of infections not 
responding to standard therapy (e.g. CMV, EBV, adenovirus, etc). For any investigational agent, 
the investigator will submit the research protocol to the BMT CTN 1301 protocol coordinator for 
review and approval by the protocol chairs/officer in order to co-enroll the patient on the non-
BMT CTN study.  
 
2.9. 
Participant Risks 
 
2.9.1. Potential Sensitization to Murine Proteins  
 
Mouse protein antibodies are used in the CliniMACS processing procedures in the CD34 –
selection arm. If the recipient has a pre-existing allergy, he or she may be at risk for allergic 
reactions during infusion of the processed cells, although the residual amount of murine protein in 
the final product is very low (estimated maximum dose for a 50 kg patient would be 30 µg). To 
date, no allergic reactions are reported in patients receiving cells processed with the CliniMACS 
System. Epinephrine and antihistamines will be available at the recipient's bedside during the 
PBSC infusion. 
 


 
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2.9.2. Graft Infusion 
 
Symptoms may include changes in heart rate and/or rhythm, changes in blood pressure, fever, 
chills, sweats, nausea, vomiting, diarrhea, abdominal cramping, hemoglobinuria, acute renal 
failure, allergic reactions, respiratory dysfunction, or headache. 
 
2.9.3. Infections 
 
Transplantation puts the patient at higher risk for bacterial, viral, or fungal infections, which are 
potentially life-threatening. These risks are potentially higher with CD-34 selected transplants.  
Prophylaxis will be initiated and patients will be closely monitored for signs of infections and will 
receive early and appropriate treatment. 
 
2.9.4. Graft-Versus-Host Disease 
 
Acute or chronic GVHD may develop after allogeneic transplantation that can be disabling and 
can lead to death. GVHD is thought to be initiated by T-cells contained in the graft. CD34+ 
selection and PTCy reduce the number of alloreactive T-cells but GVHD can occur after these 
transplants. 
 
2.9.5. Sinusoidal Obstruction Syndrome (SOS)/Veno-occlusive Disease (VOD) of the Liver  
 
SOS/VOD is a manifestation of damage to the liver by the conditioning regimen that usually 
develops within two weeks after allogeneic transplant and is characterized by at least two of the 
following: 
• Hyperbilirubinemia (total bilirubin > 2 mg/dL) 
• Hepatomegaly or right upper quadrant pain, or 
• Sudden weight gain (> 5% above baseline) 
Recipients developing SOS/VOD will be monitored closely and will receive appropriate 
supportive care and careful fluid management. TCD is not expected to affect the risk of SOS/VOD. 
 
2.9.6. End Organ Damage 
 
End organ damage of all or any of the major organs, including the brain, may occur as a result of 
cumulative toxicity from anti-neoplastic therapy, reactions to other drugs, and as a result of 
destructive processes (e.g., infection, GVHD, etc.) and may have a fatal outcome. Toxicities may 
occur in any individual patient due to multiple events and cumulative effects that may involve any 
and all organs, including the brain. Brain damage can result in severe loss of cognitive or 
neurologic function. Data from previous studies do not suggest that the risk of end organ damage 
is appreciably affected by TCD or the preparative regimens to be used in this study. 
 
2.9.7. Lymphoproliferative Syndrome 
 


 
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Recipients of CD34-selected allogeneic grafts have an increased risk of developing post-transplant 
lymphoproliferative disorder (PTLD) caused by EBV. Patients who develop a fever of unknown 
origin to > 39oC, lymphadenopathy, or hepatosplenomegaly, should undergo CT scanning of the 
chest and abdomen and/or PET scan to rule out or stage EBV PTLD. Tissue diagnosis that includes 
EBER and LMP-1 immunocytochemistry should be attempted. Other diagnostic or staging studies 
will be performed as clinically indicated. EBV PTLD may rapidly progress and can be fatal if not 
treated. Management of suspected EBV PTLD should be discussed with one of the Protocol 
Chairpersons. EBV PTLD can be treated with rituximab and/or infusion of 106 T-cells/kg from the 
donor. It is recommended that patients with EBV DNA levels of > 1000 copies/mL receive 375 
mg/m2 of rituximab. Those patients that continue to have levels above 1000 copies/mL on 
subsequent testing should be considered to receive three additional weekly infusions of 375 mg/m2 
of rituximab. Patients with rapidly rising EBV DNA levels or clinical symptoms are recommended 
to have imaging studies to diagnose an EBV PTLD. An accelerated schedule of days 1, 4, 8, 15 
can be used if there is a suspicion of EBV PTLD. Rituximab has been shown to induce regression 
in 50 - 70% of cases. Note: Rituximab does not enter the CNS and is not effective in treating CNS 
disease. Donor lymphocyte infusions may induce regression in > 90% of cases of EBV PTLD and 
are effective in CNS disease. 
 
2.9.8. Death 
 
There is an approximate 5-10% risk of transplant-related mortality within the first month of 
transplant due to the risk of severe regimen related toxicity, hemorrhage, opportunistic infection, 
or other complications. It is not expected that the regimens to be used in this protocol will increase 
this risk. 
 
2.9.9. Therapy Toxicities 
 
All toxicities will be graded using the Common Terminology Criteria for Adverse Events 
(CTCAE) Version 4.0. Below is a list of the most common toxicities for therapies used in this 
study. See the FDA-approved package insert for each drug for a comprehensive list of adverse 
events. 
 
2.9.10. Busulfan 
 
Busulfan (1, 4-dimethanesulfonoxybutane) is an alkylating agent. The drug is extensively 
metabolized and its metabolites are eventually excreted in the urine. The oral preparation is well 
absorbed but studies at this institution have indicated that there is a ten-fold variability area under 
the curve (AUC) of the drug among patients receiving busulfan by mouth. There is a statistical 
association between increased AUC and the development of veno occlusive disease of the liver. 
Since its FDA approval in 1999, IV Bu has been used increasingly in combination with CY or 
Flu.17, 18, 19, 20 IV Bu was initially administered every 6-hours, similar to oral Bu. However, several 
studies have used the drug with once or twice daily administration. In terms of safety, IV Bu and 
oral Bu appear to have similar toxicity profiles. It has been proposed that sinusoidal obstruction 
syndrome and mucositis may be reduced in incidence and severity with IV Bu.21 The IV 
formulation at a dose of 0.8 mg/kg IV every 6-hrs is considered equivalent to the oral formulation 


 
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at a dose of 1 mg/kg PO every 6 hrs in conditioning regimens. On this basis a regimen using 4x0.8 
= 3.2 mg/kg as a single daily dose has been developed.19, 22 
 
Toxicities associated with busulfan administration include: 
• Gastrointestinal: nausea, vomiting, constipation, diarrhea, abdominal discomfort, anorexia, 
dyspepsia and mucositis 
• Hepatobiliary: veno-occlusive disease 
• Neurologic: headache, insomnia and seizures 
• Cardiovascular: hypertension, hypotension and tachycardia 
• Pulmonary: dyspnea, lung fibrosis 
• Endocrine and metabolic: hypermagnesemia, hyperglycemia and hyperphosphatemia 
• Miscellaneous: rhinorrhea, amenorrhea, infertility, skin rashes, cataracts 
 
2.9.11. Cyclophosphamide  
 
Cyclophosphamide (CY) is an alkylating agent which prevents cell division primarily by cross-linking 
DNA strands. CY is converted to its active form in vivo by hepatic enzymes. After a single dose, 
tissue enzymes degrade most of the active metabolites. After high doses (> 40 mg/kg), the 
alkylating activity in the plasma is minimal by 24 hours. Several of the metabolites appear to have 
toxic actions. One of the metabolic products, acrolein (CH2=CH-CHO), is known to be toxic to 
the bladder urothelium and can cause hemorrhagic cystitis when CY is administered at high doses.  
 
Some of the most common toxicities associated with cyclophosphamide include: 
• 
Gastrointestinal: nausea, vomiting and anorexia 
• 
Hematologic: myelosuppression 
• 
Cardiovascular: severe chronic heart failure characterized by cardiomegaly, pericardial 
effusions, diffuse voltage decrease on ECG and decreased LVEF 
• 
Genitourinary: hemorrhagic cystitis (prevented by hydration and mesna therapy or bladder 
irrigation) and gonadal function impairment 
• 
Miscellaneous: fluid retention, alopecia and rare pulmonary toxicity 
 
2.9.12. Etoposide 
 
The most common side effects of etoposide are:  
• Hematologic: myelosuppression 
• Gastrointestinal: nausea, vomiting, anorexia, diarrhea, abdominal pain, stomatitis 
• Dermatologic: alopecia 
• Cardiovascular: hypotension 
• Neurologic: peripheral neuropathy 
• Miscellaneous: elevated liver function tests, allergic reactions, and second cancers 
including myelodysplasia 
 


 
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2.9.13. Fludarabine 
 
Fludarabine is a fluorinated nucleoside analog. After phosphorylation to fluoro-ara-ATP the drug 
appears to incorporate into DNA and inhibit DNA polymerase alpha, ribonucleotide reductase and 
DNA primase, thus inhibiting DNA synthesis. Excretion of fludarabine is impaired in patients with 
impaired renal function. 
 
Common side effects of fludarabine include: 
• Hematologic: hematopoietic suppression including neutropenia with increased risk of 
infection and immunosuppression 
• Neurologic: peripheral neuropathy and encephalopathy manifested by fatigue, weakness, 
paresthesia, visual disturbances, somnolence and coma 
• Gastrointestinal: nausea, vomiting, diarrhea and stomatitis 
• Miscellaneous: fever, skin rash, cough and idiopathic pneumonitis 
 
2.9.14. Rabbit Anti-Thymocyte Globulin  
 
The ATG to be used in this trial is a purified preparation of rabbit gamma globulin containing high 
concentrations of antibodies against human lymphocytes. The preparation may contain low levels 
of antibody that cross-react with human platelets, white cells or red cells. The potential side effects 
of ATG are: 
• Hematologic: neutropenia and thrombocytopenia 
• Dermatologic: skin rash and itching 
• Neurologic: fever, chills,  
• Miscellaneous: serum sickness (severe skin rashes, mouth and vaginal sores, pain and 
swelling of the joints, or kidney damage) and anaphylaxis (hypotension, wheezing, 
difficulty breathing and severe hives) 
 
2.9.15. Melphalan 
 
Common toxicities of melphalan include: 
• Hematologic: bone marrow suppression and hemolytic anemia 
• Gastrointestinal: severe stomatitis, esophagitis and diarrhea 
• Pulmonary: pulmonary fibrosis and interstitial pneumonitis 
• Dermatologic: skin hypersensitivity and alopecia 
• Miscellaneous: vasculitis and allergic reactions 
 
2.9.16. Total Body Irradiation 
 
Common toxicities of total body irradiation include: 
• Gastrointestinal: nausea, vomiting and diarrhea 
• Hematologic: marrow suppression 
• Dermatologic: reversible skin pigmentation and alopecia 


 
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2-23 
• Late effects: cataract formation, growth retardation, pulmonary damage, carcinogenesis 
and sterilization 
• Miscellaneous: fever and parotiditis 
 
2.9.17. Thiotepa 
 
The most common toxicities seen with thiotepa include: 
• Gastrointestinal: nausea and vomiting  
• Hematologic: myelosuppression 
• Dermatologic: transient generalized skin erythema, mainly in the axillary and inguinal 
folds  
• Neurologic: mild cognitive dysfunction, disorientation, confusion and irritability 
 
2.9.18. Tacrolimus 
 
Tacrolimus often called by its original drug code name, FK-506, is a macrolide immunosuppressant 
that inhibits calcineurin (phosphatase 2B)-mediated T-cell activation by forming a complex with 
FK506 binding protein 12 (FKBP12). Tacrolimus side effects include:  
• Cardiovascular: hypertension 
• Neurologic: confusion, dizziness, insomnia, seizures, tremors, changes in how clearly one 
can think 
• Gastrointestinal: nausea, vomiting 
• Hematologic: microangiopathic hemolytic anemia, thrombocytopenia 
• Endocrine and metabolic: hypomagnesemia, hypokalemia, hypocalcemia, hyperlipidemia 
• Miscellaneous: unwanted hair growth, changes in vision, liver problems, reversible renal 
insufficiency, infections and post-transplant lymphoproliferative disorders  
 
2.9.19. Methotrexate 
 
The most frequently reported adverse reactions associated with methotrexate use as GVHD 
prophylaxis include: 
• Neurologic: fever, dizziness, chills, undue fatigue 
• Gastrointestinal: ulcerative stomatitis, nausea, abdominal distress, diarrhea 
• Hematologic: leucopenia, anemia, and suppressed hematopoiesis (leading to infection) 
• Miscellaneous: abnormal liver tests, kidney failure, and pulmonary complications after 
transplantation  
 
2.9.20. Cyclosporine 
 
The most common side effects of cyclosporine are: 
• Cardiovascular: hypertension 
• Neurologic: paresthesias, neuropathy and seizures 


 
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• Hematologic: thrombotic microangiopathy 
• Endocrine and metabolic: electrolyte imbalances 
• Miscellaneous: hirsutism; hepatic and renal dysfunction; nephrotoxicity; gingival 
hyperplasia; transient blindness  
 
2.9.21. MESNA (Sodium -2-Mercaptoethane Sulphonate)  
 
Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced by the 
oxazophosphorines (cyclophosphamide and ifosfamide). It has no intrinsic cytotoxicity and no 
antagonistic effects on chemotherapy. Mesna binds with acrolein, the urotoxic metabolite 
produced by the oxazophosphorines, to produce a non-toxic thioether and slows the rate of acrolein 
formation by combining with 4-hydroxy metabolites of oxazophosphorines. At the doses used for 
uroprotection, mesna is virtually non-toxic. The most common side effects of MESNA are: 
• 
Cardiovascular: hypotension 
• 
Dermatologic: rash, urticarial 
• Gastrointestinal: nausea and vomiting, diarrhea, abdominal pain, altered taste 
• 
Neurologic: headache, joint or limb pain  
• 
Miscellaneous: fatigue 
 
 
2.10. Quality of Life Assessments 
 
2.10.1. Instruments 
 
FACT-BMT: The Functional Assessment of Cancer Therapy – Bone Marrow Transplant 
subscale67 version 4.0 instrument is a 37 item scale comprised of a general core questionnaire, the 
FACT-G, that evaluates the health-related quality of life (HQL) of patients receiving treatment for 
cancer, and a specific module, BMT Concerns, that addresses disease and treatment-related 
questions specific to bone marrow transplant. The FACT-G consists of four subscales developed 
and normed in cancer patients: Physical Well-being, Social/Family Well-being, Emotional Well-
being, and Functional Well-being. Each subscale is positively scored, with higher scores indicating 
better functioning. The FACT-BMT Trial Outcome Index, comprised of the physical well being 
scale, the functional well being scale and the BMT specific items, will be used as the outcome 
measure in summarizing the FACT-BMT data. The FACT-BMT takes 6 minutes to complete, and 
is routinely used in BMT CTN trials.  
 
MOS SF-36: The Medical Outcomes Study Short Form 36 is a 36 item general assessment of 
health quality of life with eight components: Physical Functioning, Role Physical, Pain Index, 
General Health Perceptions, Vitality, Social Functioning, Role Emotional, and Mental Health 
Index. Each domain is positively scored, indicating that higher scores are associated with positive 
outcome. This scale has been widely applied in a variety of outcome studies and is being used in 
this protocol as a generic measure of quality of life. To facilitate comparison of the results with 
published norms, the Physical Component Summary (PCS) and Mental Component Summary 
(MCS) will be used as the outcome measures in summarizing the SF-36 data. These summary 
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factor score coefficient and summing the products. Resulting scores are then transformed into T-
scores (mean=50; standard deviation=10). The SF-36 takes 6 minutes to complete.68, 69 
 
MDASI: The MD Anderson Symptom Inventory is a 19 item instrument that captures 13 
symptoms (0=“not present” to 10=“as bad as you can imagine”) and 6 items measuring 
interference with life from 0 (“did not interfere”) to 10 (“interfered completely”). It provides two 
summary scales: symptoms and interference.70 The MDASI takes less than 5 minutes to complete, 
and was collected in the BMT CTN 0802 trial of acute GVHD treatment.  
 
PedsQL: The PedsQL™ Stem Cell Transplant Module is a 46 item instrument that measures 
health-related quality of life in children and adolescents undergoing hematopoietic stem cell 
transplant, and is developmentally appropriate for self-report in ages 8 through 18 years.  
 
2.10.2. Administration 
 
The self report questionnaires will be completed at Baseline, then at Day 100, Day 180, 12 months 
and 24 months post-transplant or until death. Only English speaking adult and pediatric patients, 
and Spanish speaking adult patients are eligible to participate in the Health Quality of Life (HQL) 
component of this trial. Patients >18 years will complete the FACT-BMT, MOS SF-36 and 
MDASI instruments. Patients ≥ 8 years through 18 years will complete the PedsQL™ Stem Cell 
Transplant Module. Surveys are completed by participants using self-completed instruments as a 
first choice. If this method of data collection is not possible, then surveys and response options 
may be read verbatim to participants, either in person or over the phone, to collect data. The method 
of survey completion, the date, and the language will be recorded in the database. Surveys may 
not be completed by surrogates. 
 
TABLE 2.10 – REQUIRED PATIENT-REPORTED OUTCOMES  
DATA COLLECTION1 
Instrument 
Number 
of items 
Baseline 
Day 
100 
Day 
180 
12 
months 
24 
months 
FACT-BMT 
37 
X 
X 
X 
X 
X 
MOS SF-36 
36 
X 
X 
X 
X 
X 
MDASI 
19 
X 
X 
X 
X 
X 
PedsQL™ SCT Module 
46 
X 
X 
X 
X 
X 
1Surveys will be completed only by English speaking adult and pediatric patients, and Spanish speaking adult patients 


 
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3-1 
CHAPTER 3 
 
 
3. 
STUDY ENDPOINTS 
 
3.1. 
Primary Endpoint 
 
The primary endpoint is chronic GVHD/relapse-free survival (CRFS). All randomized patients 
will be analyzed for this endpoint from the date of randomization. An event for this time to event 
outcome is defined as moderate to severe chronic GVHD according to NIH consensus criteria 
global score, disease relapse, or death by any cause. Patients will be followed up for two years for 
this endpoint. 
 
3.2. 
Secondary Endpoints 
 
3.2.1. Overall Survival 
 
Overall survival is defined as the time interval between date of transplant and death from any cause 
or for surviving patients, to last follow-up. The event for this endpoint is death from any cause.  
 
3.2.2. Disease Relapse  
 
Relapse is defined by either morphological evidence of acute leukemia or MDS consistent with 
pre-transplant features, documented or not by biopsy. The event is defined as increase in size of 
prior sites of disease or evidence of new sites of disease, documented or not by biopsy.  
 
Acute leukemia and MDS – Relapse will be diagnosed when there is morphologic or clinical 
evidence of disease: 
- 
Reappearance of leukemia blast cells in the peripheral blood; or, 
- 
>5% blasts in the bone marrow, not attributable to another cause (e.g. bone marrow 
regeneration); or 
- 
The appearance of previous or new dysplastic changes (MDS specific) within the bone 
marrow with or without falling donor chimerism; or  
- 
The development of extramedullary leukemia or leukemic cells in the cerebral spinal fluid; 
or 
 
Institution of any therapy to treat persistent or relapsed disease, including donor lymphocyte 
infusion, will be considered evidence of relapse regardless of whether the criteria described above 
were met. Two exceptions are the administration of FLT3 and other tyrosine kinase inhibitors for 
post-transplant maintenance and for prevention of disease relapse in patient with or without 
minimal residual disease identified after transplant.  
 
 


 
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3.2.3. Relapse-Free Survival 
 
Relapse-free survival is the time from date of transplant to death or relapse, whichever comes first. 
The event for this endpoint is relapse or death. Patients alive and free from disease relapse will be 
censored at last follow-up.  
 
3.2.4. Transplant-related Mortality 
 
The cumulative incidence of transplant-related mortality (TRM) will be estimated at Days 100, 
180, and 1 year after HSCT. An event for this endpoint is death without evidence of disease 
recurrence. Disease recurrence will be considered a competing event. 
 
3.2.5. Immunosuppression-free Survival 
 
Patients who are alive, relapse-free, and do not need ongoing immune suppression to control 
GVHD at one year post HSCT are considered successes for this endpoint. Immune suppression is 
defined as any systemic agents used to control or suppress GVHD. Corticosteroid doses of 
prednisone >10 mg, or equivalent (0.15 mg/kg for pediatrics) will be considered active systemic 
immune suppression treatment. Patients who discontinued immune suppression ≤ 15 days prior to 
the 1-year time point will be considered to be on immune suppression for this endpoint. 
Additionally the burden of immunosuppression in one year defined as the number of agents, the 
line of therapy, dose and duration of therapy will be described for all patients.  
 
3.2.6. Hematologic Recovery 
 
Hematologic recovery will be assessed according to neutrophil and platelet counts recovery after 
HSCT. Neutrophil recovery is defined as achieving an absolute neutrophil count (ANC) ≥ 
500/mm3 for three consecutive measurements on three different days. The first of the three days 
will be designated the day of neutrophil recovery. The competing event is death without neutrophil 
recovery. For patients who never drop ANC below 500/mm3, the date of neutrophil recovery will 
be Day +1 post HSCT.  
 
Platelet recovery is defined as the first day of a sustained platelet count >20,000/mm3 with no 
platelet transfusion in the preceding seven days. The first day of sustained platelet count above 
this threshold will be designated the day of platelet engraftment. For patients who never drop their 
platelet count below 20,000/mm3, the date of platelet recovery will be Day +1 post HSCT.  


 
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3.2.7. Graft Failure 
 
Graft failure will be assessed as secondary endpoints, including primary and secondary graft 
failure.  Primary graft failure is defined as no neutrophil recovery to > 500 cells/µL by Day 28 post 
HSCT.  Secondary graft failure will be assessed according to neutrophil count after initial 
hematologic recovery. Secondary graft failure is defined as initial neutrophil engraftment followed 
by subsequent decline in absolute neutrophil counts < 500 cells/µL, unresponsive to growth factor 
therapy, but cannot be explained by disease relapse or medications. Assessment for this endpoint 
will occur up to two years post HSCT. 
 
 
 
3.2.8. Acute GVHD 
 
Cumulative incidences of grade II-IV and III-IV acute GVHD will be determined. Acute GVHD 
will be graded according to the BMT CTN MOP. The time of onset of acute grades II-IV and III-
IV acute GVHD will be recorded, as well as the maximum grade achieved. This endpoint will be 
evaluated through 180 days post HSCT.  
 
3.2.9. Chronic GVHD 
 
The cumulative incidence of chronic GVHD will be determined. Data will be collected directly 
from providers and chart review according to the recommendations of the NIH Consensus Criteria. 
Eight organs will be scored on a 0-3 scale to reflect degree of chronic GVHD involvement. Liver 
and pulmonary function test results and use of systemic therapy for treatment of chronic GVHD 
will also be recorded. These data will allow calculation of the NIH global severity scores of mild, 
moderate and severe chronic GVHD. Assessment of development of chronic GVHD will occur up 
to two years post HSCT.  
 
3.2.10. Chronic GVHD-Free Survival 
 
The event for this endpoint includes moderate to severe chronic GVHD according to NIH 
consensus criteria global score, or death by any cause. Assessment for this endpoint will occur up 
to two years post HSCT.  
 
3.2.11. Toxicity 
 
All grades ≥ 3 toxicities according to CTCAE, version 4 will be tabulated for each intervention 
arm. The proportion of patients developing grade ≥ 3 AE across intervention arms will be 
compared. Additionally incidences of hepatic sinusoidal obstruction syndrome/veno-occlusive 
disease (SOS/VOD) or idiopathic pneumonia syndrome (IPS) will also be described. SOS/VOD 
defined as the presence of at least two of the findings listed below within the first 25 days from 
transplant: 


 
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• Hyperbilirubinemia (total bilirubin > 2 mg/dL) 
• Hepatomegaly or right upper quadrant pain, or 
• Sudden weight gain (> 5% above baseline) 
 
Clinical suspicion of SOS/VOD after 25 days might require further radiologic evidence of 
compromised portal flow or biopsy to rule out other diagnosis. 
  
IPS is defined as presence of pneumonia like clinical picture with rapid decline of pulmonary 
function without evidence of infectious etiology, usually occurring within the first 100 days post-
transplant.  
 
3.2.12. Infections 
 
The incidence of definite and probable viral, fungal and bacterial infections will be tabulated for 
each intervention arm. All Grade 2 and 3 infections will be reported according to the BMT CTN 
MOP. Infections of interest, including reactivation of CMV with or without organ involvement 
will be capture and described. Reactivation is defined as the presence of >1000 copies/mL or 500 
IU/mL of CMV in the blood by NAAT. In addition, in the CD34-selected arm, reactivation of 
EBV (defined as the presence of >1000 copies in the blood by NAAT) with or without organ 
involvement will also be captured and described. Organ involvement requires assessment of 
pathologic specimens. Furthermore, for CMV and EBV, a decision to institute treatment by the 
patient’s physician will also be considered an infection. 
 
3.2.13. Immune Reconstitution 
 
It is proposed that quanitative assessments of peripheral blood CD3, CD4, CD8, CD19 and CD56 
positive lymphocytes will be performed through flow cytometric analysis at a central lab on 
optional research samples collected at Days 35, 100, 180, and 365 after transplant. Qualitative 
assessments will be tabulated according to time from transplant (see Appendix C). 
 
3.2.14. Health-Related Quality of Life 
 
HQL will be measured at Baseline and then at Days 100, 180, 365, and 730 post-transplant using 
four instruments: the SF36, FACT-BMT, and MDASI for adult patients (> 18 years), and the 
PedsQL™ Stem Cell Transplant Module for pediatric patients (≥ 8 years through 18 years). The 
instruments will be scored according to the recommendations of the developers. See section 2.10.1 
for detailed descriptions of the instruments. The FACT-BMT instrument will be summarized by 
the Trial Outcome Index, comprised of the physical, functional, and BMT-specific items. The 
SF36 will be summarized by the Physical Component Summary (PCS) and Mental Component 
Summary (MCS). HQL will be described and compared between the treatment arms over time. 
Only adult patients able to read and speak in English or Spanish, and pediatric patients able to read 
and speak in English, are eligible to participate in the HQL component of this trial. 
 
 


 
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4-1 
CHAPTER 4 
 
 
4. 
PATIENT ENROLLMENT AND EVALUATIONS 
 
4.1. 
Approaching Patients, Eligibility Screening and Obtaining Consent 
 
Subjects will be approached for this study after the decision to proceed with transplantation is 
made and a suitable HLA-matched donor is identified. Patients willing to participate in the trial 
will sign an Institutional Review Board approved consent form. For patients with unrelated donors, 
it is recommended a hold for workup request be submitted to the NMDP at this time. Transplant 
physicians will evaluate the patient eligibility for randomization onto this study (see Section 2.3). 
Eligibility criteria will be verified and ineligible patients will not be randomized and no follow-up 
will be obtained. At the time of enrollment, donors without known contraindications or preferences 
for a specific stem cell source will be selected to donate. Transplant center personnel will record 
the documentation of patient consent and eligibility criteria in Emmes AdvantageEDCSM 
(Electronic Data Capture, an Internet-based data entry system). For patients with unrelated donors, 
the transplant center staff will submit an unrelated donor work up request for the specific stem cell 
graft and dose according to randomization results.  
 
Donors of patients randomized to the CD34+ selection arm will be required to sign an additional 
donor consent prior to donation. The transplant center personnel will be responsible for consenting 
related donors to patients randomized to the CD34+ selection arm. For patients with unrelated 
donors randomized to this arm, a Request for NMDP Donor to Participate in a Research Study 
form must also be submitted to the NMDP. The NMDP will be responsible for overseeing the 
consent procedures among unrelated donors to patients randomized to the CD34+ selection arm.  
 
4.2. 
Randomization 
 
Once the patient is deemed eligible and has given written informed consent, and the transplant 
center has confirmed the donor match grade by entering the recipient and donor HLA typing in 
AdvantageEDCSM, the patient will be randomized to a treatment arm (CD34 selection, post-
transplant cyclophosphamide or control). Once the randomization has occurred, the transplant 
center will submit the unrelated donor workup request to the NMDP, or initiate their related donor 
workup process. Initiation of conditioning regimens should occur as soon as possible after 
randomization. 
 
If there is an unexpected delay in initiation of conditioning, certain pre-transplant evaluations may 
have to be repeated. Refer to section 4.4.1.1 Patient Assessments-Pre-Transplant Evaluations. 
 
After randomization, if the donor changes his or her mind or refuses to donate the requested graft, 
the patient will be treated according to the Control arm, with calcineurin inhibitor-based GVHD 
prophylaxis (Tax/Mtx). This patient will be followed for all study outcomes and will be analyzed 
according to the “intent to treat” principle in the arm to which the patient was randomized.  
 


 
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4.3. 
Treatment Scheduling 
 
Treatment should be initiated as soon as possible after randomization. This will prevent subject 
attrition prior to HSCT for reasons such as disease progression.  
 
4.4. 
Study Monitoring 
 
The follow-up schedule for scheduled study visits is outlined in Table 4.4a. A detailed description 
of each of the forms and the procedures required for forms completion and submission can be 
found in the Data Management Handbook and User’s Guide. 
 
TABLE 4.4a: FOLLOW-UP SCHEDULE 
 
Study Visit 
Target Day Post-Transplant 
Baseline 
≤ 42 days from randomization 
1 week 
7 ± 3 days 
2 week 
14 ± 3 days 
3 week 
21 ± 3 days 
4 week 
28 ± 3 days 
5 week 
35 ± 3 days 
6 week 
42 ± 3 days 
7 week 
49 ± 3 days 
8 week 
56 ± 3 days 
9 week 
63 ± 3 days 
100 day 
100 ± 7 days 
5 month 
150 ± 7 days 
6 month 
180 ± 28 days 
9 month 
270 ± 28  days 
12 month 
365 ± 28 days 
24 month 
730 ± 28 days 
 
 
4.4.1. Patient Assessments 
 
Table 4.4b summarizes patient clinical assessments over the course of the study.  
 


 
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TABLE 4.4b: PATIENT CLINICAL ASSESSMENTS 
This table is offered as a visual overview of expected assessments and their time points during the course of this study. Please 
refer to Sections 4.4.1.1. and 4.4.1.2. for details of each assessment. 
Study Assessments/  
Testing 
Baseline 
 
7 
14 
21 
28 
35 
42 
49 
56 
63 
100 
150 
180 
270 
365 
730 
History, physical exam, weight and height1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Karnofsky or Lansky performance status  
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
X 
X 
HCT-Specific Co-Morbidity Index (HCT-CI) score 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HLA typing (recipient and donor) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC2, differential, platelet count, and blood chemistries3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
 
Estimated creatinine clearance4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious disease markers 5 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac assessments6  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary function tests7 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
 
X 
X 
Disease evaluation8 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
Chest x-ray or chest CT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test9 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GVHD assessments10 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Toxicity assessments11 
 
 
 
 
X 
 
 
 
X 
 
X 
 
X 
X 
X 
X 
CMV Monitoring (Refer to Section 2.8.4.) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
EBV Monitoring (Refer to Section 2.8.4.) 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Quality of Life assessments12 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
Optional Research Samples13 
X 
 
 
 
 
X 
 
 
 
 
X 
 
X 
 
X 
 
1Height is only required at the Baseline visit. 
2CBC and manual WBC differential performed three times weekly from Day 0 until ANC > 500/mcL for three days and platelet count > 20,000/mcL after nadir, 
while hospitalized. CBC then performed weekly through Day 63 post-transplant and every other week through Day 100 post-transplant, then at Days 180, 270 
and 365 post-transplant. 


 
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3Blood chemistries include: serum creatinine, bilirubin, alkaline phosphatase, AST and ALT. Blood chemistries performed twice weekly until hospital discharge. 
Blood chemistries performed weekly after hospital discharge until Day 63 post-transplant, then every other week through Day 100 post-transplant, and then at 
Days 180, 270 and 365 post-transplant. 
4Estimated creatinine clearance for patients > 12 years is calculated using the Cockroft-Gault formula and actual body weight; the updated Schwartz formula 
should be used for pediatric patients (≥ 1 year to 12 years). See Appendix D for estimated creatinine clearance formulas). 
5Infectious disease markers include: CMV, EBV, Hepatitis panel (HepA Ab, HepB SAb, HepB SAg, HepB Core Ab, HepC Ab), herpes simplex virus, syphilis, 
HIV-1 and -2 and HTLV-I and -II antibody, varicella zoster, and toxoplasmosis (IgG and IgM). 
6Cardiac assessments include EKG and left ventricular ejection fraction (LVEF) or shortening fraction by echocardiogram or radionuclide scan (MUGA).  
7Pulmonary function tests include DLCO (Adj for Hgb), FEV1 and FVC. For children who are unable to perform for PFTs due to age or developmental ability, 
there must be no evidence of dyspnea at rest and no need for supplemental oxygen (as evidenced by O2 saturation > 92% on room air) at baseline in order to 
meet eligibility criteria. 
8Disease evaluation for acute leukemia and MDS includes a bone marrow aspirate and biopsy. Cytogenetics, molecular, or other institutional assessment to 
determine Minimal Residual Disease (MRD) will be recorded at Baseline to document patient’s pre-transplant MRD status. 
9Pregnancy test must be performed ≤ 30 days before the start of the transplant conditioning regimen. Pregnancy test is required for females of child-bearing 
potential (i.e., not postmenopausal or surgically sterile), and may be performed per institutional practices. 
10GVHD assessments performed weekly until Day 63 post-transplant, and then at Days 100, 150, 180, 270, 365, and 730. The GVHD assessment will include a 
review of all abnormalities experienced during the entire assessment period and the highest grade for each abnormality (whether attributed to GVHD or 
not) during the assessment period will be recorded on the Acute GVHD form and/or the Follow-up GVHD form in AdvantageEDC. 
11The toxicity assessment will include a review of all toxicities experienced during the entire assessment period and the highest grade for each toxicity during 
the assessment period will be recorded on the Toxicity form in AdvantageEDC. 
12QOL assessments include self-reported patient questionnaires: SF-36, FACT-BMT, and MDASI for English and Spanish speaking patients > 18 years, and 
PedsQL Stem Cell Transplant Module for English speaking pediatric patients (ages 8 through 18 years). 
13Optional Research Sample collection for the BMT CTN Repository for patients who weigh > 30.0 kg and who consent to provide samples (see Appendix C).The 
Baseline sample will be collected prior to initiation of the conditioning regimen. 
 
 


 
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4.4.1.1. 
Pre-Transplant Evaluations 
 
The following observations must be made ≤ 28 days prior to study randomization, and ≤ 56 days 
from the planned initiation of conditioning, unless otherwise indicated. If after randomization there 
is a delay in the initiation of conditioning, pre-transplant evaluations must be repeated according 
to institutional practice, unless otherwise indicated. 
• History, physical examination, height and weight. 
• Karnofsky or Lansky performance status and HCT-Specific Co-Morbidity Index (HCT-
CI) score. 
• CBC with WBC differential and platelet count, serum creatinine, bilirubin, alkaline 
phosphatase, AST and ALT. 
• Estimated creatinine clearance, using the Cockroft-Gault formula and actual body weight 
for patients > 12 years; the Schwartz formula will be used for pediatric patients (≥ 1 year 
to 12 years). 
• Infectious disease markers to include: CMV antibody, EBV antibody, Hepatitis panel 
(HepA Ab, HepB SAb, HepB SAg, HepB Core Ab, HepC Ab), herpes simplex virus, 
syphilis, HIV-1 and -2, and HTLV-I and -II antibody and varicella zoster.  For patients 
randomized to the CD34 Cell Selection Arm, toxoplasmosis (IgG and IgM) must also be 
performed < 56 days from the planned initiation of conditioning. 
• CD34+ Selection arm only: Donor toxoplasmosis serologic evaluation (IgG and IgM). For 
both related and unrelated donors, toxoplasmosis testing will be performed at the transplant 
center. The transplant center must request additional ‘day of collection’ samples from the 
NMDP for unrelated donors in order to conduct the testing at their center. Donor testing 
must be performed on or before day of transplant. 
• EKG and left ventricular ejection fraction (LVEF) or shortening fraction by 
echocardiogram or radionuclide scan (MUGA). Cardiac evaluations may be performed ≤ 
56 days prior to randomization and ≤ 84 days prior to the planned initiation of conditioning. 
• Pulmonary function tests, including DLCO (adjusted for hemoglobin), FEV1, and FVC. 
For children who are unable to perform for PFTs due to age or developmental ability, there 
must be no evidence of dyspnea at rest and no need for supplemental oxygen, as evidenced 
by O2 saturation ≥ 92% on room air. Pulmonary function assessments may be performed ≤ 
56 days prior to randomization and ≤ 84 days prior to the planned initiation of conditioning. 
• Disease evaluation: bone marrow aspirate for pathology and cytogenetics. Cytogenetics, 
molecular, or other institutional assessment to determine Minimal Residual Disease 
(MRD) will be recorded at Baseline to document patient’s pre-transplant MRD status. 
Note: Bone marrow aspirate must be performed ≤ 30 days prior to randomization 
and must be repeated if not within 30 days prior to the initiation of the transplant 
conditioning regimen. For MDS patients, Bone marrow aspirate must be performed ≤ 6 
weeks prior to randomization and must be repeated if not within 6 weeks prior to the 
initiation of the transplant conditioning regimen. 


 
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• Chest X-ray or chest CT. 
• Pregnancy test per institutional practices for females of child-bearing potential (i.e., not 
postmenopausal or surgically sterile). NOTE: pregnancy test must be performed ≤ 
30 days prior to randomization and must be repeated if not within 30 days prior 
to the initiation of the transplant conditioning regimen.  
• Quality of Life, patient ‘self-reported’ assessments to include the Functional 
Assessment of Cancer Therapy – Bone Marrow Transplant (FACT-BMT), the Medical 
Outcomes Study Short Form 36 (SF-36), and the MD Anderson Symptom Inventory 
(MDASI) for English and Spanish speaking adult patients (≥ 18 years). English 
speaking pediatric patients (ages 8 through 18 years) will complete the PedsQL™ Stem 
Cell Transplant Module. Quality of Life assessments may be completed after the patient 
has provided consent and at any time prior to the onset of conditioning. 
• Optional peripheral blood samples for future research (limited to patients who weigh 
greater than 30.0 kg.) Samples must be obtained after the patient has provided consent 
and prior to the initiation of the conditioning regimen (Appendix C). 
 
4.4.1.2. 
Post-Transplant Evaluations 
 
The following observations should be made according to Table 4.4b: 
• History and physical exam weekly through Day 63 post-transplant, then at Days 100, 150, 
180, 270, 365 and 730 post-transplant.  
• Toxicity assessments at Days 28, 56, 100, 180, 270, 365 and 730 post-transplant. 
• GVHD assessments: 
o Clinical assessments weekly from Day 7 until Day 63 post-transplant, then at Days 
100, 150, 180, 270, 365 and 730 post-transplant. GVHD should be monitored in 
accordance with BMT CTN guidelines as specified in the BMT CTN Manual of 
Procedures (BMT CTN MOP). 
o Pulmonary function tests at Days 180, 365 and 730 post-transplant. 
• Data on occurrence of infections and recorded as per the BMT CTN MOP. 
o CMV Monitoring: For patients on the CD34-selection arm, CMV monitoring 
through nucleic acid amplified testing (NAAT) will be done weekly through Day 
100 and then at each clinical assessment until Day 180 post-transplant. For patients 
on the other 2 arms, CMV monitoring will be done according to institutional 
guidelines. It is recommended that weekly assessment for CMV be done through 
Day 63 post-transplant, and then at each clinical assessment until day 180 post-
transplant. However, if both the recipient and the donor are CMV negative prior to 
transplant, CMV monitoring is not recommended unless clinically indicated.  See 
Section 2.8.4. for details. 
o EBV Monitoring: For patients on the CD34-selection arm, EBV monitoring 
through nucleic acid amplified testing (NAAT) will be done weekly through Day 


 
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100 and then at each clinical assessment until Day 180 post-transplant. For patients 
on the other 2 arms, EBV monitoring will be done according to institutional 
guidelines. See Section 2.8.4. for details. 
• CBC and WBC differential performed at least three times a week from Day 0 until ANC > 
500/µL for 3 days and platelet count > 20,000/µL for 3 days (while hospitalized only) after 
nadir is reached.  Manual WBC differential is not required if WBC < 500/µL.  Thereafter, 
CBC weekly until Day 63 post-transplant, then every other week through Day 100 post-
transplant, and then at Days 180, 270 and 365 post-transplant. 
• Serum creatinine, bilirubin, alkaline phosphatase, ALT and AST, twice a week until 
hospital discharge. Thereafter, weekly until Day 63 post-transplant, then every other week 
through Day 100 post-transplant, and then at Days 180, 270 and 365 post-transplant. 
• Disease evaluation: bone marrow aspirate for pathology and cytogenetics at Days 100, 180, 
365 and 730 post-transplant. 
• Quality of Life, patient ‘self-reported’ assessments at Days 100, 180, 365 and 730 post-
transplant to include the Functional Assessment of Cancer Therapy – Bone Marrow 
Transplant (FACT-BMT), the Medical Outcomes Study Short Form 36 (SF-36), and 
the MD Anderson Symptom Inventory (MDASI) for English and Spanish speaking 
adult patients (> 18 years). English speaking pediatric patients (ages 8 through 18 
years) will complete the PedsQL™ Stem Cell Transplant Module.  
• Optional peripheral blood samples for future research (limited to patients who weigh 
greater than 30.0 kg.) at Days 35, 100, 180 and 365 post-transplant (Appendix C).  
 
4.4.2. Criteria for Forms Submission 
 
4.4.2.1. 
Electronic Case Report Forms (eCRFs) 
 
All data for patients are recorded in the electronic Case Report Forms (eCRF) exclusively designed 
for the study. The Principal Investigator at each of the participating centers are responsible for 
complete, accurate, and timely reporting of data. 
 
Criteria for timeliness of submission for all study forms are detailed in the Data Management 
Handbook and User’s Guide. Forms that are not entered into AdvantageEDC within the specified 
time will be considered delinquent. A missing form will continue to be requested either until the 
form is entered into the AdvantageEDC and integrated into the Data and Coordinating Center’s 
(DCC) master database, or until an exception is granted and entered into the Missing Form 
Exception File, as detailed in the Data Management Handbook. 
 
Corrections in the eCRF are to be conducted only by authorized personnel and may require 
authorization prior to implementation of corrections. However, all earlier entries are retrievable 
despite corrections. All corrections are recorded automatically concerning date, time point and 
person. Plausibility and completeness of the eCRF are verified by personnel at the Data 
Coordinating Center.  


 
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At all times, the Principal Investigators at the participating centers have full responsibility for 
ensuring accuracy and authenticity of all clinical and laboratory data entered on the eCRFs. 
 
4.4.2.2. 
Reporting Patient Deaths 
 
Recipient death information must be entered into AdvantageEDC within 24 hours of knowledge 
of the patient’s death. If the cause of death is unknown at that time, it need not be recorded at that 
time. However, once the cause of death is determined, the form must be updated in 
AdvantageEDC. 
 
4.4.2.3. 
CIBMTR Data Reporting 
 
Centers participating in BMT CTN trials must register pre- and post-transplant outcomes on all 
consecutive hematopoietic stem transplants done at their institution during their time of 
participation to the Center for International Blood and Marrow Transplant Research (CIBMTR). 
Registration is done using procedures and forms of the Stem Cell Transplant Outcomes Database 
(SCTOD) (Note: Federal legislation requires submission of these forms for all US allotransplant 
recipients). Enrollment on BMT CTN 1301 must be indicated on the SCTOD pre-transplant 
registration form. Additionally, CIBMTR pre- and post-transplant Report Forms must also be 
submitted for all patients enrolled on this trial. CIBMTR forms will be submitted directly to the 
CIBMTR at the times specified on the Form Submission Schedule.  
 
4.4.3. Access to Data 
 
Participating sites and their Principal Investigators must agree to allow trial-related on-site 
monitoring, including audits and regulatory inspections by DCC personnel such that the DCC has 
direct access to source data/documents as required. 
 
4.4.4. Record Retention 
 
Responsibilities of the Sponsor: As required by law, all study documents must be stored by the 
sponsor for at least 10 years after the clinical trial was finished or stopped. 
 
Responsibilities of the Principal Investigator: The Investigator agrees to keep records, including 
the identity of all participating patients, all original signed informed consent forms, copies of all 
CRFs, source documents, detailed records of treatment disposition and other trial-related 
documents. The trial-related records should be retained by the Investigator for at least 10 years or 
as specified by contract, whichever is longer. In order to comply with the German Transfusion 
Law requirements, all participating German centers must ensure that the information and 
documents relating to the traceability for all the stages from donation of the hematopoietic cells to 
infusion into the recipient (including blood products and the graft [bone marrow or PBSC]) are 
archived in safe custody for a minimum of 30 years, even if the patient withdraws consent. 
 
4.4.5. Study Monitoring 
 


 
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Monitoring and audits will be performed during the clinical study to ensure that the study meets 
the quality criteria.  
 
The investigator agrees that the monitor will visit the study center in appropriate intervals. During 
these visits, the monitor will check the quality of the data recording and ensure that the study center 
adheres to the timeframe as set in the study protocol. The investigators agree to provide any 
relevant information and documentation whenever requested by the monitor. This includes access 
to all original study documents and source data including access to electronic source documents if 
necessary. Source data are checked and compared with entries in the data base. The participant has 
given consent to this procedure by signing the patient information and written informed consent 
form. 
 
The monitor has the responsibility to treat all information confidentially and to safeguard the 
integrity and personal privacy of the study participants. 
 
Following a monitoring visit, the Monitor will provide a report to the sponsor and the site, which 
will summarize the documents reviewed and a statement of findings, deviations, deficiencies, 
conclusions, actions taken and actions required. The Principal Investigator at each site will be 
responsible for ensuring that monitoring findings are addressed (this may be delegated to an 
appropriate member of staff). 
 
Details of monitoring activities will be included in the Site Monitoring Plan. 
 
4.4.6. Adverse Events 
 
4.4.6.1. 
Adverse Event Definitions 
 
Adverse Event - Any unfavorable and unintended sign (including an abnormal laboratory 
finding), symptom or disease temporally associated with the use of a medical treatment or 
procedure regardless of whether it is considered related to the medical treatment or procedure 
(attribution of definite, probable, possible, unlikely, or unrelated).  
 
Life-Threatening Adverse Event - Any adverse event that places the participant, in view of the 
investigator, at immediate risk of death from the reaction. 
 
Serious Adverse Event (SAE) - Any adverse event that results in any of the following outcomes: 
death, a life threatening adverse event, in-patient hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, or a congenital anomaly/birth 
defect. 
 
Unanticipated adverse device effect (UADE) - Any serious adverse effect on health or safety, 
any life-threatening problem or death caused by, or associated with a device, if that effect, 
problem, or death was not previously identified in nature, severity, or degree of incidence in the 
application; or any other unanticipated serious problem associated with a device that relates to 
the rights, safety, or welfare of subjects. 


 
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Unexpected Adverse Event - Any adverse event, the specificity or severity of which is NOT 
listed in the study protocol, product inserts or informed consent document. 
 
Attribution - The determination of whether an adverse event is related to a medical treatment or 
procedure. Attribution categories: 
Definite 
The adverse event is clearly related to the study drug/device/procedure/ 
treatment(s).  
 
Probable 
The adverse event is likely related to the study drug/device/procedure/ treatment. 
For BMT CTN studies: the adverse event is not likely to be caused by the subject’s underlying 
medical condition or other concomitant therapy, and the nature of the adverse event or the 
temporal relationship between the onset of the adverse event and study drug/device/treatment 
administration lead the investigator to believe that there is a reasonable chance of causal 
relationship.  
 
Possible 
The adverse event may be related to the study drug/device/procedure/ 
treatment(s). 
For BMT CTN studies: the adverse event could be attributed to the subject’s underlying medical 
condition or other concomitant therapy, but the nature of the adverse event or the temporal 
relationship between the onset of the adverse event and study drug/device/treatment 
administration lead the investigator to believe that there could be a causal relationship. 
 
Unlikely 
The adverse event is doubtfully related to the study drug/device/ 
procedure/treatment(s). 
 
Unrelated 
The adverse event is clearly NOT related to the study drug/device/procedure/ 
treatment(s). 
For BMT CTN studies: the adverse event is most plausibly explained by the subject’s underlying 
medical condition or other concomitant therapy, or the adverse event has no plausible biological 
relationship to study drug/device/ treatment.  
 
Common Terminology Criteria Adverse Events (CTCAE) – a descriptive terminology developed 
by the National Cancer Institute (NCI) for use in reporting adverse events. The CTCAE includes 
a grading (severity) scale for each adverse event term. Exhibits 6-1-1 and 6-1-2 provide reporting 
requirements for BMT-related complex/multi-component events. A copy of the current CTCAE 
guidelines is located at http://ctep.cancer.gov/reporting/. 
 
 


 
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Grade – Severity of the adverse event. Grades were developed using the following guidelines: 
 
 
Grade 0 – No adverse event or within normal limits 
 
 
1 – Mild adverse event 
 
 
2 – Moderate adverse event 
 
 
3 – Severe adverse event 
 
 
4 – Life-Threatening or disabling adverse event 
 
 
5 – Fatal adverse event 
 
4.4.6.2. 
Device Effect Reporting 
 
4.4.6.2.1. Adverse Device Effect Reporting 
 
Unanticipated Adverse Device Effects will be reported via a web-based adverse event (AE) 
system identical to reporting for Unexpected Grade 3-5 adverse events. Any UADE that is a direct 
result of the CliniMACS CD34 System requires reporting through an expedited AE reporting 
system within 24 hours of the investigator/clinical site becoming aware of the event. The Adverse 
Event Coordinator will review daily all submitted unanticipated adverse device effects and forward 
the information to the Medical Monitor for review. Refer to section 4.5.5.3. for the remainder of 
reporting procedures. Unanticipated adverse device effects, captured on the AE forms described 
above, require FDA notification via submission of an IDE safety report. The DCC safety group 
will submit IDE safety reports regarding all unanticipated adverse device effects within 10 days 
from initial event notification. 
 
In addition, any SAE assessed by the investigator to be a direct result of the CliniMACS CD34 
System requires reporting through an expedited AE reporting system within 24 hours of the 
investigator/clinical site becoming aware of the event.  
 
4.4.6.2.2. Reporting of Other Device Events 
 
Any device malfunction, device failure, aborted device run, or product contamination must be 
reported through the device issues form within 24 hours of the investigator/clinical site becoming 
aware of the event. Though completion of the form is not required until day 7, sites are expected 
to complete as much information as is available on the form within 24 hours in the event a device 
malfunction, device failure, aborted device run, or product contamination occurs.  
 
4.4.6.3. 
Adverse Event Reporting 
 
Unexpected Adverse Events: Unexpected adverse events will be reported via a web-based 
adverse event (AE) system. The Adverse Event Coordinator will review daily all submitted 
unexpected adverse events and forward the information to the Medical Monitor for review. 
 
Reporting of patient adverse events (AEs) will be consistent with the BMT CTN Manual of 
Procedures (MOP). Unexpected, grades 3-5 AEs, irrespective of the attribution of the event to the 
study drug/device/procedure/treatment, will be reported through an expedited AE reporting system 


 
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via the web-based electronic data capture system, AdvantageEDC, and will be graded according 
to the NCI Common Terminology Criteria for Adverse Events (CTCAE), Version 4.0. 
Unexpected, grades 4-5AEs must be reported within 24 hours of knowledge of the event. 
Unexpected, grade 3 AEs must be reported within three business days of knowledge of the event. 
The NHLBI Data and Safety Monitoring Board will receive summary reports of all adverse 
experiences at least twice yearly. 
 
All unexpected adverse events will be reviewed by the Medical Monitor within 2 business days of 
receiving the summary of the adverse event from the transplant center. If the Medical Monitor 
requires additional information to make his/her assessment, transplant centers will have 4 business 
days to respond to the request for additional information. 
 
The Medical Monitor has medical expertise relevant to the study protocol and may request the 
participant's treatment assignment when reviewing the adverse event. A designated person at the 
DCC is responsible for notifying the Project Officer (National Heart Lung and Blood Institute 
[NHLBI]) immediately of all Grade 3-5 unexpected adverse events and of any concerns regarding 
the frequency or type of adverse event(s) on a study or study treatment arm. The NHLBI Project 
Officer (or designee) is responsible for reviewing the adverse event materials to determine if the 
materials are complete. If there are any concerns regarding the type or frequency of the event, the 
NHLBI Project Officer will request that the Data Safety Monitoring Board (DSMB) Executive 
Secretary notify the DSMB Chair. The DSMB Chair will review the adverse event materials, 
determine if the information is complete, determine if additional DSMB review is required and 
make recommendations to the NHLBI concerning continuation of the study. Full documentation 
of the procedures will be available at the DCC. 
 
The Medical Monitor will review cumulative unexpected grades 3-5 SAEs on a quarterly basis 
(data will be reported in a blinded fashion). The Medical Monitor may seek additional guidance 
from one of the DCC Principal Investigators, based on the expertise required, for their assessments 
as long as the DCC Principal Investigator’s institution is not participating in the protocol under 
consideration, and the DCC Principal Investigator is not considered to be otherwise in conflict by 
the NHLBI or by the Steering Committee. If there any concerns regarding safety, the NHLBI 
Program Directors will be notified immediately. The Medical Monitor will provide a written 
summary of the safety concern. 
 
The DCC will prepare semi-annual summary reports of all unexpected adverse events for the 
NHLBI Project Officer and DSMB Chair. Semi-annual reports will be made available on a secure 
website and the NHLBI Project Officer and DSMB Chair will be notified by e-mail when the 
materials are posted.  
 
Expected Adverse Events: The DCC will prepare semi-annual summary reports of all Grade 5 
expected adverse events for the NHLBI Project Officer and the DSMB Chair. Semi-annual reports 
will be made available on a secure website and the NHLBI Project Officer and DSMB Chair will 
be notified by e-mail when the materials are posted. Grade 3-5 expected adverse events defined in 
the interim analysis plan will be reported as defined in the protocol. Any concern regarding the 
type or frequency of a Grade 3-5 expected adverse event will be reported to the NHLBI Project 


 
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4-13 
Officer who will determine if referral to the DSMB is warranted. If required, data materials will 
be provided by the DCC. The DSMB Executive Secretary will arrange for review by the DSMB 
Chair. The Chair will determine if additional DSMB review is required and make 
recommendations to the NHLBI concerning continuation of the study. The DCC will ensure that 
any additional reporting requirements defined by the NHLBI Project Officer, DSMB Chair and 
other oversight groups are identified and implemented. The DCC in collaboration with the NHLBI 
Project Officer will determine the exact content of these summary reports and the reporting 
schedule. 
 
The Protocol Coordinator and Medical Monitor will review the adverse events monitored for 
stopping guidelines at least monthly.  
 
Additionally, the Protocol Coordinator and Medical Monitor will review events reported on the 
protocol-specific toxicity form, the GVHD forms and the infection forms on a regular basis (at 
least semi-annually) to assess whether there are safety concerns that should be referred to the 
DSMB. The Medical Monitor may seek additional guidance from one of the physicians at the 
DCC in these assessments as long as this physician’s institution is not participating in the 
protocol under consideration. 
 
 


 
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TABLE 4.5a: REPORTING UNEXPECTED ADVERSE EVENTS ON A BMT CTN 
PHASE II OR PHASE III STUDY 
 
 
SEVERITY 
GRADE 
ATTRIBUTION 
TRANSPLANTCENTER REPORTING 
REQUIREMENTS 
5 - Fatal 
4 - Life-Threatening 
     or Disabling 
 
All attributions 
 
Submit the adverse event form and a summary of the event 
to the DCC within 24 hours of the event. For Grade 5, also 
submit study death form to the DCC. 
Submit all completed AE forms to the DCC within 4 
working days. For Grade 5, the summary should include 
potential contributing causes of death. 
Information reported for the adverse event must include: 
Name of adverse event, date of first onset, peak severity, 
relationship to study drug/device/procedure/treatment, 
resolution date, actions taken with respect to 
administration of study drug/device/procedure/treatment, 
and other treatment for the adverse event. 
3 – Severe 
 
 
All attributions 
 
 
 
 
Definite 
Probable 
Possible 
 
 
 
 
 
 
Unlikely 
Unrelated 
Submit the adverse event form and a summary of the event 
to the DCC within 3 working days of the adverse event.  
Submit all completed AE forms to DCC within 4 working 
days 
Information reported for the adverse event must include: 
Name of adverse event, date of first onset, peak severity, 
relationship to study drug/device/procedure/treatment, 
resolution date, actions taken with respect to 
administration of study drug/device/procedure/treatment, 
and other treatment for the adverse event.  
Multiple recurrences of the same adverse event should be 
reported separately. 
Information reported for the adverse event must include: 
name of adverse event, date of first onset, peak severity, 
and relationship to the study drug/device/treatment.  
Multiple recurrences of the same adverse event should be 
reported together.  
 
Note: Any adverse event prompting a change in the administration of study 
drug/device/procedure/treatment must include resolution date, actions taken with respect to 
administration of study drug/device/procedure/treatment, and other treatment for the adverse 
event. 
 
 


 
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TABLE 4.5b: REPORTING EXPECTED ADVERSE EVENTS ON A BMT CTN PHASE 
II OR PHASE II STUDY 
 
 
SEVERITY GRADE 
ATTRIBUTION 
TRANSPLANT 
CENTER 
REPORTING 
REQUIREMENT 
5 – Fatal  
 
All attributions 
Submit study death form to the DCC within 24 hours of 
learning of the death. 
Submit death summaries and/or autopsy reports of the 
expected adverse event to DCC quarterly or as requested. 
The summaries should include potential contributing 
causes of death. 
4 – Life-Threatening 
      or disabling 
All attributions 
Submit study form(s) capturing data on the expected 
adverse event to the DCC at the form’s scheduled due 
date.  If the event is not captured on a study from, report 
using the AE system in an expedited manner. 
 
3 – Severe 
 
All attributions 
Submit study form(s) capturing data on the expected 
adverse event to the DCC at the form’s scheduled due 
date.  
Note: Selected Grade 3-5 events will be tracked and regularly monitored by the DCC and DSMB 
as specified in protocol-specific monitoring plans. 
 


 
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5-1 
CHAPTER 5 
 
 
5. 
STATISTICAL CONSIDERATIONS 
 
5.1. 
Study Design and Objectives 
 
The study is designed as a three arm randomized Phase III, multicenter trial comparing two 
calcineurin inhibitor (CNI)-free strategies for GVHD prophylaxis to one another and to standard 
tacrolimus and methotrexate (Tac/Mtx) in patients with acute leukemia or myelodysplasia 
undergoing myeloablative conditioning hematopoietic stem cell transplantation. The target 
enrollment is 345 patients, 115 for each arm.  
 
5.1.1. Accrual 
 
It is estimated that 42 months of accrual will be necessary to enroll the targeted sample size. 
 
5.1.2. Randomization 
 
Patients will be randomized at a ratio of 1:1:1 between the treatment arms using permuted blocks 
of random sizes. Randomization will be stratified by donor type (sibling vs. unrelated) and age 
(<18 vs. 18-40 vs. >40).  
 
5.1.3. Primary Endpoint 
 
The primary endpoint is the chronic GVHD free, relapse free survival (CRFS) probability, treated 
as a time to event outcome. The primary analysis will be performed using the intent-to-treat 
principle so that all randomized patients will be included in the analysis. Development of moderate 
to severe chronic GVHD, relapse, or death will be considered failures for this endpoint, which will 
be adjudicated by a blinded endpoint review committee. 
 
5.1.4. Primary Hypothesis 
 
There are three primary null hypotheses of the study, for the pairwise comparisons of each of the 
two CNI-free strategies (CD34 selection and Post-Transplant Cy) against the Tac/Mtx control. 
Using HR to denote hazard ratios for the CRFS primary endpoint, the hypotheses are  
 
H01: 
HRCD34select vs. Tac/Mtx = 1 vs. Ha1: 
HRCD34select vs. Tac/Mtx  ≠ 1 AND 
H02: 
HRPostTxCy vs. Tac/Mtx = 1 vs. Ha2: 
HRPostTxCy vs. Tac/Mtx  ≠ 1  AND 
H03: 
HRCD34select vs. PostTxCy = 1 vs. Ha3: 
HRCD34select vs. PostTxCy ≠ 1  AND 
. 
These three hypotheses will each be tested at the 0.05 / 3 level using a Bonferroni correction to 
control the overall type I error rate.  
 
 


 
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5-2 
5.1.5. Duration of Follow-Up 
 
All patients will be followed for 2 years post-transplant for primary and secondary endpoints.  
 
5.2. 
Sample Size and Power Considerations 
 
The primary analysis will be done using log-rank tests for each pairwise comparison, with a type 
I error of 0.05/3 using a Bonferroni correction to account for multiple testing. The primary analysis 
is planned to be conducted when 155 events have been observed for each comparison to control. 
This assumes that the CRFS probabilities in the control group are 46%, 28%, and 22% at 6 months, 
1 year, and 2 years, based on CIBMTR data, uses a piecewise exponential survival function to fit 
those CRFS probabilities, and ensures approximately 85% power to detect a hazard ratio of 0.576 
(corresponding to a 20% difference in CRFS at 1 year). No stopping rules for efficacy are planned, 
because of the interest in having follow up for overall survival on all patients. However, the study 
design will incorporate interim futility analyses so that one or more of the CNI free arms may be 
dropped, if the conditional power for the comparison to control under the alternative hypothesis 
(HR=0.576) is less than 15%. If a treatment group is dropped for futility, the type I error is still 
maintained at 0.05/3 (see further discussion in section 5.5.1.). We simulated the operating 
characteristics of this design, using uniform accrual of 345 patients over 42 months, 1 year of 
follow up on the last patient enrolled (which is the expected time at which the targeted number of 
events is observed), follow-up censored at 2 years, and an interim futility analysis at 2 years, which 
is at approximately 57% of the planned accrual and approximately 45% of the expected number 
of events.  
 
Simulation results are shown in the table below, where groups A and B refer to the CNI-free 
strategies, and group C refers to the control. All tests in the study are two-sided, and the two-sided 
familywise type I error rate is shown in the overall power column of the table when both HR are 
1.0. These results indicate that the overall type I error rate is controlled at 5% conservatively, 
primarily due to the impact of the futility analysis which may result in treatment arms being 
dropped and comparisons not being performed. Note that since the significance level is not 
adjusted for the futility stopping rule, even if the futility stopping rule is not followed exactly the 
study will still control the type I error rate. We also looked at type I error for the various pairwise 
comparisons. The two-sided type I error rate is very low for the CNI-free comparison under the 
overall null hypothesis (all groups have the same CRFS). This is because frequently one or more 
of the treatment groups are dropped, preventing this comparison from occurring. The futility 
analysis also has an impact on the type I error rate for the pairwise comparisons to control, in the 
sense that the one-sided type I error rate favoring the control is essentially zero due to the futility 
analysis in place. Therefore, the two-sided type I error rate is approximately equal to the one-sided 
type I error rate favoring the CNI-free arm. As expected, the simulations also show that the power 
for each comparison to the control group is maintained at 85%. If a CNI-free approach has no 
impact on CRFS relative to the control group, there is a 48-49% chance of stopping it early for 
futility. Note that the power for the CNI-free comparison (A vs. B) is low, but this is mainly due 
to the fact that often one of the arms is closed early for lack of efficacy, precluding its subsequent 
comparison. 
 


 
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5-3 
HR relative 
to control (A 
vs. C, B vs. 
C) 
Interim analysis Decision 
Power at final analysis 
Continue with 
Stop 
A, C 
B, C 
A, B, C 
Overall 
A vs. C  
(2-sided  
≈1-sided) 
B vs. C  
(2-sided 
≈1-sided) 
A vs. B  
(2-sided) 
1.0,1.0 
29.7% 
19.6% 
19.7% 
31.0% 
1.8% 
0.9% 
0.9% 
0.2% 
0.576,1.0 
0.4% 
48.5% 
0.1% 
50.9% 
85.5% 
85.2% 
1.3% 
35.5% 
0.576,0.576 
0.0% 
0.3% 
0.4% 
99.2% 
94.2% 
84.7% 
84.6% 
1.7% 
 
5.3. 
Interim Analysis and Stopping Guidelines 
 
No formal interim analyses for efficacy will be used. Although the primary endpoint focuses on 
chronic GVHD through the CRFS endpoint, it is important to get good estimates of the impact of 
the treatments on a key secondary endpoint of overall survival. Stopping early for efficacy on the 
primary endpoint would negatively impact the precision of our estimate of the hazard ratio for 
overall mortality. We also did not include in the design an option for closure of the control group 
while keeping the two treatment arms open, in the event that at least one of the treatments 
demonstrate early efficacy. This would also negatively impact the precision of our estimate of the 
hazard ratio relative to control for a key secondary endpoint of overall mortality. Interim analyses 
for futility will be conducted at times coincident with regularly scheduled meetings of the NHLBI-
appointed Data and Safety Monitoring Board (DSMB), starting when approximately 45-50% of 
the targeted number of events have been observed. The interim analysis for futility is based on 
conditional power less than 15% under the targeted alternative hypothesis for the comparisons to 
the control group. Policies and composition of the DSMB are described in the BMT CTN’s Manual 
of Procedures. The stopping guidelines serve as a trigger for consultation with the DSMB for 
additional review and are not formal “stopping rules” that would mandate automatic closure of 
study enrollment. Toxicity, adverse events, and other safety endpoints will be monitored regularly 
and reported to the DSMB at each meeting. 
 
5.3.1. Guidelines for Safety Monitoring 
 
Monitoring of a key safety endpoint will be conducted monthly, and if rates significantly exceed 
pre-set thresholds, the NHLBI will be notified in order that the DSMB can be advised. Policies 
and composition of the DSMB are described in the BMT CTN's Manual of Procedures. The 
stopping guideline serves as trigger for consultation with the DSMB for additional review. 
 
The key safety endpoint for this study is mortality. The rate of mortality will be monitored up to 
100 days post-randomization separately in each of the three treatment arms. At least three events 
must be observed in order to trigger review. The expected probability of 100 day mortality after a 
myeloablative transplant is 15-20%, based on CIBMTR data. Each month, the null hypothesis that 
the 100-day mortality rate is less than or equal to 20% is tested. An extension of the sequential 
probability ratio test (SPRT) for censored exponential data will be used for monitoring, as 
described in greater detail below and in Appendix G. 
 


 
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This sequential testing procedure conserves type I error at 5% across all of the monthly 
examinations for a treatment arm. The SPRT can be represented graphically. At each monthly 
interim analysis, the total time on study in months (x axis) is plotted against the total number of 
endpoints (y axis) (e.g., patients experiencing death). The continuation region of the SPRT is 
defined by two parallel lines. Only the upper boundary will be used for monitoring to protect 
against excessive 100-day mortality. If the graph falls above the upper boundary, the SPRT rejects 
the null hypothesis, and concludes that there are more events than predicted by the observed time 
on study. Otherwise, the SPRT continues until enrollment reaches the maximum of 110 patients. 
 
This procedure assumes a censored exponential distribution for the time until death during the first 
100 days, and censors follow-up time after 100 days. Only deaths that occur on or before the patient 
has been followed for 100 days are counted. Total time on study is computed as time from 
registration to death, or to 100 days, whichever comes first, summed for all patients on study. 
 
The usual measures of performance of an SPRT are the error probabilities α and β of rejecting H0 
when θ = θ0 and of accepting H1 when θ = θ1, respectively, and the expected sample size E(N|θi). 
The tests to be used in this protocol were developed from the following SPRT:  
A SPRT contrasting 20% versus 35% 100-day rate of mortality results in decision boundaries 
with a common slope of 0.096 and an upper intercept of 4.03, with nominal type I and II errors 
of 6% and 15%, respectively. 
 
The actual operating characteristics of the truncated test, shown in Table 5.3, were determined in 
a simulation study that assumed uniform accrual of 115 individuals over a 42 month time period, 
and exponential time to failure after randomization.  
 
TABLE 5.3: OPERATING CHARACTERISTICS OF SEQUENTIAL TESTING 
PROCEDURE FROM A SIMULATION STUDY WITH 10,000 REPLICATIONS 
  
Day 100 MORTALITY 
 
True 100-Day Rate 
20% 
30% 
35% 
Probability Reject Null 
0.046 
0.669 
0.930 
Mean Month Stopped 
44.0 
28.2 
18.8 
Mean # Endpoints in 100 Days 
22.4 
21.7 
16.6 
Mean # Patients Enrolled 
111.8 
74.6 
50.9 
 
For example, the testing procedure rejects the null hypothesis in favor of the alternative 5% of the 
time when the true 100-day mortality rate is 20%, and 93% of the time when the rate is 35%. This 
corresponds to a type I error rate of α = 0.05 and a type II error rate of β = 0.07. When the true 
100-day mortality rate is 35%, on average, the DSMB will be consulted 19 months after opening, 
when 17 events have been observed in 51 patients. 
5.4. 
Demographic and Baseline Characteristics 
 


 
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Demographics and baseline characteristics will be summarized for all patients. Characteristics to 
be examined are: age, gender, race/ethnicity, performance status, primary disease/disease risk, 
CMV status, HCT-comorbidity index, time from diagnosis to transplantation, cytogenetic at 
diagnosis (AML and ALL), HLA matching, and number of regimens prior to transplant 
(lymphoma only). Between group comparisons will be performed for continuous variables via a 
Kruskal-Wallis test and for categorical variables, via the chi-square test. A secondary analysis of 
all outcomes will adjust for age, performance status, primary disease/disease risk, and donor type, 
in addition to any other demographic and baseline characteristics which are statistically different 
between treatment arms (p<0.1).   
 
5.5. 
Analysis Plan 
 
5.5.1. Analysis of the Primary Endpoint 
 
The primary outcome of the trial is CRFS, treated as a time to event variable. There are three 
primary pairwise comparisons between the CNI-free strategies and the Tac/Mtx control group, 
each to be tested at a Bonferroni adjusted significance level of 0.05/3. We do not use adaptive 
design strategies to modify the multiplicity adjustment if a treatment group is dropped for futility 
at an interim analysis. This allows us to directly apply gatekeeping strategies to control the 
familywise type I error rate also across a key secondary endpoint of overall survival, as described 
in 5.5.2.2. These comparisons of CRFS will be done using pairwise log-rank tests, applied to the 
primary intent-to-treat population of all randomized patients. The hazard ratio, along with 
confidence intervals, will be estimated from a Cox model with treatment as a covariate. Kaplan-
Meier estimates of CRFS will also be described for each group, along with confidence intervals at 
1 and 2 years. A secondary analysis of CRFS will be conducted using Cox regression, adjusting 
for donor type, age, performance status, and primary disease/disease risk, in addition to any other 
demographic and baseline characteristics which are statistically different between treatment arms 
(p<0.1).   
 
5.5.2. Analysis of Secondary Endpoints 
 
Overall survival will be a key secondary endpoint, with an analysis plan which ensures control of 
the overall type I error rate, as described below. All other secondary endpoints will be considered 
exploratory without explicit control of the type I error rate, and the analyses of these endpoints 
will use the transplanted populations rather than the ITT population. All time to event endpoints 
below will also have secondary analyses using Cox regression, adjusting for donor type, age, 
performance status, and primary disease/disease status, in addition to any other demographic and 
baseline characteristics which are statistically different between treatment arms (p<0.1). Details of 
the analyses are provided below. 
 
 


 
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5.5.2.1. 
Relapse-Free Survival 
 
Relapse-free survival curves will be estimated using the Kaplan-Meier estimator, and compared 
between treatment groups using the log-rank test. Hazard ratios, along with confidence intervals, 
will be estimated from a Cox model with treatment group as a covariate. 
 
5.5.2.2. 
Overall Survival 
 
Overall survival will be a key secondary endpoint, with explicit control of the type I error rate 
through a gatekeeper approach. Formal significance testing of OS between a CNI-free strategy and 
the control will be conducted if the corresponding CRFS comparison is significant. This OS 
comparison will be done using a Bonferroni adjusted significance level of 0.05/3 to account for 
three potential CNI-free comparisons to the control. Otherwise, survival analyses will be 
considered exploratory. Overall survival curves will be estimated using the Kaplan-Meier 
estimator applied to the ITT population, and compared between treatment groups using the log-
rank test. The hazard ratio, along with confidence intervals, will be estimated from a Cox model 
with treatment group as a covariate. Overall survival will also be described in each arm from the 
time of transplant. 
 
5.5.2.3. 
Transplant-Related Mortality  
 
Incidence of TRM will be estimated using the cumulative incidence function, treating 
relapse/progression as a competing risk. Incidence of TRM will be compared between the 
treatment arms using Gray’s test71.  
 
5.5.2.4. 
Immunosuppression-Free Survival  
 
Proportions of patients alive, relapse free, and off immune suppression at one year will be 
described for each group, and compared using the chi-square test. If there is censoring prior to one 
year, multistate models will be constructed to estimate these probabilities. Agreement between this 
endpoint and the primary endpoint of CRFS will be described using cross-tabulation frequencies 
and assessed using the Kappa statistic.  
 
5.5.2.5. 
Disease Relapse 
 
Incidence of relapse will be estimated using cumulative incidence function, treating death in 
remission as a competing risk. Incidence of relapse will be compared between the treatment arms 
using Gray’s test.  
 
5.5.2.6. 
Hematologic Recovery 
 
Incidence of neutrophil and platelet engraftment from the time of transplant will be estimated using 
the cumulative incidence function with death prior to engraftment as the competing risk. Incidence 
of neutrophil engraftment at 28 days and incidence of platelet engraftment at 60 days will be 


 
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compared between the treatment arms using a pointwise comparison of the cumulative incidence 
probabilities.   
 
5.5.2.7. 
Graft Failure 
 
Primary graft failure will be assessed as a secondary endpoint.  The proportion of patients who do 
not achieve neutrophil recovery to > 500 cells/µL by Day 28 post HSCT will be computed for each 
treatment arm and compared between the treatment arms using the Z test for binomial proportions.  
Secondary graft failure will be assessed as a secondary endpoint using cumulative incidence 
function.  The cumulative incidence of secondary graft failure at 2 years post-transplant will be 
computed along with 95% confidence intervals and compared between the treatment arms using 
Gray’s test.  Patients will be considered as reaching the endpoint if the initial neutrophil 
engraftment is followed by subsequent decline in absolute neutrophil counts < 500 cells/µL, is 
unresponsive to growth factor therapy, and cannot be explained by disease relapse or medications.  
Death prior to secondary graft failure will be considered as a competing risk. 
 
5.5.2.8. 
Acute GVHD of Grades II-IV and III-IV 
 
Cumulative incidence of acute GVHD will be estimated from the time of transplant using the 
cumulative incidence function, treating death prior to acute GVHD as the competing risk. 
Cumulative incidence of acute GVHD will be compared between treatment arms using Gray’s test.  
 
5.5.2.9. 
Chronic GVHD  
 
Cumulative incidence of chronic GVHD from the time of transplant will be estimated using the 
cumulative incidence function, treating death prior to chronic GVHD as the competing risk. 
Cumulative incidence of chronic GVHD will be compared between treatment arms using Gray’s 
test.  
 
5.5.2.10. 
Chronic GVHD-Free Survival 
 
Chronic GVHD-free survival curves will be estimated using the Kaplan-Meier estimator, and 
compared between treatment groups using the log-rank test. Hazard ratios, along with confidence 
intervals, will be estimated from a Cox model with treatment group as a covariate. 
 
5.5.2.11. 
Incidence of Toxicities Grade ≥ 3 per CTCAE Version 4.0 
 
All Grade ≥ 3 toxicities will be tabulated by grade for each treatment arm, by type of toxicity as 
well as the peak grade overall. Toxicity frequencies will be described for each time interval as well 
as cumulative over time.  
 
5.5.2.12. 
Incidence of Infections 
 
The number of infections and the number of patients experiencing infections will be tabulated by 
type of infection, severity, and time period after transplant. The cumulative incidence of severe, 


 
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life-threatening, or fatal infections, treating death as a competing event, will be compared between 
the treatment arms using Gray’s test.  
 
5.5.2.13. 
Immune Reconstitution 
 
It is proposed that quantitative assessment of peripheral blood CD3, CD4, CD8, CD19 and CD56 
positive lymphocytes will be performed for each randomized treatment arm at the specified time 
points assessed after transplant (days 35, 100, 180 and 365). Analysis of effector and regulatory 
T-cell subsets will also be described in the sub-cohort of adult patients sending samples to a 
centralized lab. Correlations among the lymphocyte populations will be explored using rank 
correlations. Analysis will be done separately for each immune reconstitution measurement using 
a Bonferroni adjusted significance level (0.05/7). Log transformations will be considered to induce 
normality in the lymphocyte subset counts. Partly conditional regression conditioning on being 
alive at each time point will be implemented using GEE to compare the longitudinal immune 
reconstitution measurements over time between the treatment groups72 . Interactions with time will 
be tested for and if significant, treatment effects will be estimated separately for each time point. 
The missing data pattern of the immune reconstitution lab measurements will be examined using 
graphical techniques and logistic regression models conditional on survival, and if necessary 
inverse probability of censoring weighted GEE73 will be used to account for missing data. We 
anticipate at least 50 samples per treatment arm being available at each time point, even in the 
adult sub-cohort, based on anticipated 63% overall survival at one year. This sample size will yield 
at least 85% power to detect a 2 fold increase in cell counts between treatment arms, assuming a 
0.95 SD in the log cell counts, a value consistent with our preliminary data. Additional lymphocyte 
subsets will also be analyzed in the adult sub-cohort in an exploratory fashion using similar 
methods, except that a false discovery rate controlling procedure will be used to account for 
multiple testing.74 In addition to comparing immune reconstitution among the three groups, we 
will also examine how changes in lymphocyte subpopulations are associated with subsequent 
clinical outcomes, including development of acute and chronic GVHD, survival, CRFS, relapse, 
and infection. Cox multivariate regression will be performed using landmark analysis or time 
dependent covariates to model the relationship between the most recent cell count or change in 
cell count and the development of subsequent events.  
 
5.5.2.14. 
Health-Related Quality of life 
 
HQL will be measured at Baseline and then at Days 100 180, 365, and 730 post-transplant using 
six instruments: the SF36 (both PCS and MCS), FACT-BMT, and MDASI for English and Spanish 
speaking adult patients (> 18 years), and the PedsQL™ Stem Cell Transplant Module for English 
speaking pediatric patients (≥ 8 years through 18 years). HQL at each time point will be 
summarized using simple descriptive statistics (mean, SD). Analysis will be done separately for 
each instrument using a Bonferroni adjusted significance level (0.05/4). All models will be 
adjusted for baseline HQL. Partly conditional regression conditioning on being alive at each time 
point will be used to compare the longitudinal HQL measurements over time between the treatment 
groups.72 Interactions with time will be tested for and if significant, treatment effects will be 
estimated separately for each time point. The missing data pattern of the HQL measurements will 
be examined using graphical techniques and logistic regression models conditional on survival. At 


 
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each time point, estimates of the difference in HQL between the treatments conditional on survival 
at that time point will be obtained using inverse probability of censoring weighted GEE with 
independent estimating equations73 to account for missing data.   
 
5.5.2.15. 
Subgroup Analysis 
 
Subgroup analyses will be conducted for CRFS according to disease, disease risk and age. 
Interaction tests between treatment group and subgroup will be conducted within a Cox 
proportional hazards regression model with treatment, subgroup, and a treatment*subgroup 
interaction term. A Bonferroni adjusted significance level of 0.05/3=0.0167 will be used for each 
interaction test to account for multiple testing. If a significant interaction is identified, plots of 
Kaplan-Meier estimates of CRFS by treatment will be shown separately for each level of the 
subgroup, and a forest plot will be used to show the HR’s for each subgroup.  
 
 


 
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CHAPTER 6 
 
 
6. 
ETHICS AND REGULATORY 
 
6.1. 
Good Clinical Practice Guidelines 
 
The DCC and the clinical investigators assure that the clinical study is performed in accordance 
with the protocol, the ICH Harmonized Tripartite Guidelines for Good Clinical Practice 1996, the 
Declaration of Helsinki (Recommendations guiding physicians in Biomedical Research involving 
Human Subjects, Helsinki 1964, amended Tokyo 1975, Venice 1983, Hong Kong 1989, Somerset 
West 1996, Edinburgh, 2000, Seoul 2008, Fortaleza 2013) and applicable regulatory requirements. 
 
6.1.1. Patient Consent 
 
Candidates for the study will be identified as described in Chapter 4 of the protocol. The Principal 
Investigator or his/her designee at each transplant center will contact the candidates, provide the 
patient with information about the purpose of the study and obtain consent. The BMT CTN will 
provide a template of the consent form to each center. Each center will customize the template 
according to their local requirements and submit it for review by the local Internal Review Board 
(IRB). The DCC will verify the adequacy of the consent forms prior to submission to the IRB. 
Each center must provide evidence of IRB approval. 
 
6.1.2. Patient Withdrawal 
 
6.1.2.1. 
Patient Withdrawal from Intervention 
 
Participation in the trial is voluntary. Patients will be advised that they may voluntarily withdraw 
from the study at any time and will be instructed to notify the investigator. Patients may choose to 
withdraw for any reason(s). Patients are not obligated to reveal their reason(s) for withdrawal to 
the sponsor.  
 
6.1.2.2. 
Patient Withdrawal from Data Collection 
 
If a patient explicitly states they do not wish to contribute further data to the trial their decision 
must be respected and notified to the sponsor in writing. In this event details should be recorded 
in the patient’s hospital records, no further CRFs must be completed and no further data sent to 
the sponsor. 
 
6.1.2.3. 
Patient Removal from Study 
 
The investigator has the right to terminate the participation of any subject at any time, if s/he deems 
it in the participant’s best interest. The reason and circumstances for study discontinuation will be 
documented by the site and sent to the DCC. 
Reasons for study discontinuation might be: 


 
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• Intolerable side effects of the study product. 
• Changes in medical status of the patient such that the Investigator believes that patient 
safety will be compromised or that it would be in the best interest of the patient to stop 
treatment. 
• Pregnancy. 
• Withdrawal of consent. 
• Relevant non-compliance with the protocol. 
 
6.1.3. Confidentiality 
 
Confidentiality will be maintained by individual names being masked and assigned a patient 
identifier code upon enrollment in AdvantageEDC. The code relaying the patient’s identity with 
the ID code will be kept separately at the center.  
 
6.1.4. Participation of Women and Minorities 
 
Women and ethnic minorities and other populations will be included in this study. Accrual of 
women and minorities at each center will be monitored to determine whether their rates of 
enrollment are reflective of the distribution of potentially eligible women and minorities 
expected from data reported to the CIBMTR and from published data on incidence of acute 
leukemia and myelodysplasia in these groups. Centers will be notified if their rates differ 
significantly from those expected and asked to develop appropriate recruitment reports. 
 
6.1.5. NMDP Unrelated Donors 
 
The National Marrow Donor Program (NMDP) IRB will be responsible for the review and 
continuing oversight of protocol procedures that relate only to NMDP unrelated donors.  
 
6.1.6. International Unrelated Donor Consent 
 
Donor research consent may be waived for international donors if the country of the donor 
registry does not consider such donors to be research subjects. However, the donor must meet all 
donor-eligibility criteria for the study and must consent to donation as per requirements of the 
collecting donor registry and regulations of the country of donation. 
 
6.2. 
Protocol Amendments 
 
All protocol amendments containing substantive changes must be reviewed and accepted by 
members of the DSMB before distribution to Clinical Centers. The review may take place at a 
DSMB meeting, on an arranged conference call, or by ballot.  
 
Once approved by the DSMB, participating centers (and the FDA if applicable) will be notified of 
approved protocol amendments by an e-mail announcement from the DCC. Amendment 
documents may be included with the e-mail announcement and will be posted on the BMT CTN 
website. The documents will include: 


 
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1. A summary of protocol changes 
2. A revised protocol with changes highlighted 
3. A second version with the changes fully incorporated into the document 
4. A rationale for changes may be provided 
 
Other types of amendments containing non-substantive changes may be released to Centers before 
DSMB notification or deliberation. These changes will be reviewed at the next regularly scheduled 
DSMB meeting or conference call. 
 
The DCC PIs will determine the appropriate review process in collaboration with the NHLBI 
Project Officer. 
 
Clinical Centers are responsible for implementing all amendments according to institutional 
policy. 
 
6.3. 
Protocol Deviations 
 
Clinical centers should inform the DCC of any major protocol deviations. These will be submitted 
to the DSMB on a semi-annual basis. 
 
6.4. 
Premature Termination of the Trial 
 
The sponsor has the right to discontinue the study due to relevant medical or administrative 
reasons. Participants who still receive medication during the time of discontinuation will undergo 
a final visit which has to be documented in the CRF. 
 
Possible reasons for discontinuation by the sponsor are: 
• failure in recruiting participants, 
• data quality is insufficient, 
• unforeseen circumstances at the study site that make the continuation of the study 
impossible, 
• early prove of superiority or non-inferiority of a treatment group, 
• occurrence of unjustifiable risks or toxicity, 
• new scientific knowledge that does not justify continuation of the clinical study. 
 
6.5. 
Publication Policy 
 
Manuscripts reporting the results of this trial will be prepared and submitted to a reputable peer-
reviewed medical journal in accordance with basic ethical principles, including preservation of 
the accuracy of the results and making both positive and negative results publicly available. In all 
publications the confidentiality of patients’ data will be ensured. 
 


 
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Data analysis and authorship will be conducted according to the BMT CTN MOP. No clinical 
trial results are released, presented or published without approval from the Publications 
Committee, the BMT CTN DCC, NHLBI and NCI. 
 
The study is registered in the clinical trials database (www.clinicaltrials.gov) which is accessible 
to the public. The ClinicalTrials.gov number NCT02345850 allocated to this trial will be quoted 
in any publications resulting from this trial. 
 
By signing this study protocol, the investigators accept that the results of this clinical trial can be 
presented to national and international authorities. They also accept that in this context their 
name, address, qualification and grade of involvement in this trial will be published. 
 
6.6. 
German Transfusion Law 
 
To comply with the German Transfusion Law requirements, German centers must ensure that the 
information and documents relating to the traceability for all the stages from donation of the 
HSC units to their infusion into the recipient (including information about the blood product) are 
archived in safe custody for a minimum of 30 years, even if the patient withdraws consent. 
 
 


 
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APPENDIX A 
 
LIST OF ABBREVIATIONS 


 
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LIST OF ABBREVIATIONS 
 
7-AAD – 7-amino-actinomycin D 
ACD – Acid Citrate Dextrose 
AdvantageEDCSM – Proprietary electronic 
data capture system 
AE – Adverse Event 
AIBW – Adjusted Ideal Body Weight 
ALL – Acute Lymphoblastic Leukemia 
ALT – Alanine Aminotransferase 
AML – Acute Myeloid Leukemia 
ANC – Absolute Neutrophil Count 
AST – Aspartate Aminotransferase 
ATG – Anti-Thymocyte Globulin 
ATP – Adenoside Triphosphate 
AUC – Area Under the Curve 
B-ALL – Acute B Lymphoblastic Leukemia 
BID – bis in die (two times/day) 
BM – Bone Marrow 
BMT – Bone Marrow Transplant 
BMT CTN – Blood and Marrow Transplant 
Clinical Trials Network 
BSA – Body Surface Area 
CBC – Complete Blood Count 
CCr – Creatinine Clearance Rate 
CCR7 – C-C Chemokine Receptor 7 
CD127 – Cluster of Differentiation 127 
CD16 – Cluster of Differentiation 16 
CD19 – Cluster of Differentiation 19 
CD25 – Cluster of Differentiation 25 
CD27 – Cluster of Differentiation 27 
CD3 – Cluster of Differentiation 3 
CD31 – Cluster of Differentiation 31 
CD34 – Cluster of Differentiation 34 
CD38 – Cluster of Differentiation 38 
CD4 – Cluster of Differentiation 4 
CD45RA - Cluster of Differentiation 45 
Antibody 
CD56 – Cluster of Differentiation 56 
CD8 – Cluster of Differentiation 8 
CD95 – Cluster of Differentiation 95 
CDC – Centers for Disease Control 
cGVHD – Chronic Graft Versus Host 
Disease 
cGY - Centigray 
CI – Confidence Interval 
CIBMTR – Center for International Blood 
and Marrow Transplant Research 
CMV - Cytomegalovirus 
CNI – Calcineurin Inhibitor 
CNS – Central Nervous System 
CR - Complete Remission 
CrCl – Creatinine Clearance 
CRF – Case Report Form 
CRFS – Chronic GVHD/Relapse-Free 
Survival 
CsA/CSA – Cyclosporine A 
CT – Computed Tomography 
CTD – Connective Tissue Disease 
CTL – Cytotoxic T-Lymphocyte 
CTCAE – Common Terminology Criteria 
for Adverse Events 
CY - Cyclophosphamide 
DCC – Data and Coordinating Center 
DLCO – Diffusing Capacity of the Lung for 
Carbon Monoxide 
DLI – Donor Lymphocyte Infusion 
DNA – Deoxyribonucleic Acid 
DSMB – Data Safety Monitoring Board 
dUCB – Double Umbilical Cord Blood 
EBER – Epstein-Barr virus-encoded small 
RNA 
EBV – Epstein Barr Virus 
ECG – Electrocardiogram 
eCRF – Electronic Case Report Form 
EDTA – Ethylenediaminetetraacetic Acid 
EFS – Event-Free Survival 
EKG - Electrocardiogram 
ELISPOT – Enzyme-Linked ImmunoSpot 
FACT-BMT – Functional Assessment of 
Cancer Therapy – Bone Marrow Transplant 
FACT-G – Functional Assessment of 
Cancer Therapy – General Core 
Questionnaire 
FACT-JACIE – Foundation for the 
Accreditation of Cellular Therapy - Joint 
Accreditation Committee ISCT-EBMT 
FDA – Food and Drug Administration 


 
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FEV1 – Forced Expiratory Volume 1 
FISH – Fluorescence In Situ Hybridization 
FK-506 - Tacrolimus 
FKBP12 – FK506 Binding Protein 12 
FVC – Forced Vital Capacity 
G-CSF – Granulocyte Colony Stimulating 
Factor 
GEE – Generalized Estimating Equation 
GFR – Glomerular Filtration Rate 
GI - Gastrointestinal 
GINA – Genetic Information 
Nondiscrimination Act  
GVHD – Graft versus Host Disease 
GVL – Graft Versus Leukemia 
HCG – Human Chorionic Gonadotropin 
HCT-CI – Hematopoietic Cell Transplant-
Specific Co-Morbidity Index 
HepA – Hepatitis A 
HepB – Hepatitis B 
HepC – Hepatitis C 
HHV-6 – Human Herpesvirus 6 
HIPAA – Health Insurance Portability and 
Accountability Act 
HIV – Human Immunodeficiency Virus 
HLA – Human Leukocyte Antigen 
HPLC – High Performance Liquid 
Chromatography 
HQL – Health-related Quality of Life  
HR – Hazard Ratio 
HSCT – Hematopoietic Stem Cell 
Transplant 
HSV – Herpes Simplex Virus 
HTLV – Human T-Lymphotrophic Virus 
IBW – Ideal Body Weight 
ICH – International Conference on 
Harmonisation of Tehcnical Requirements 
for Registration of Pharmaceuticals for 
Human Use 
IDE – Investigational Device Exemption 
IgA – Immunoglobulin A 
IgD – Immunoglobulin D 
IgG – Immunoglobulin G 
IgM – Immunoglobulin M 
IL-2Rα – Interleukin 2 Receptor, Alpha 
IL-7R – Interleukin 7 Receptor 
IPS – Idiopathic Pneumonia Syndrome 
IRB – Institutional Review Board 
ISCT-EBMT – International Society for 
Cellular Therapy – European Group for 
Blood and Marrow Transplantation 
ITT – Intention To Treat 
IU – International Units 
IUD – Intrauterine Device 
IV - Intravenous 
IVIG – Intravenous Immune Globulin 
LDH – Lactate Dehydrogenase 
LMP – Latent Membrane Protein 
LN – Liquid Nitrogen 
LVEF – Left Ventricular Ejection Fraction 
MAC – Myeloablative Conditioning 
MCS – Mental Component Summary 
MDACC – MD Anderson Cancer Center 
MDASI – MD Anderson Symptom 
Inventory 
MDS – Myelodysplastic Syndrome 
MESNA – Sodium-2-Mercaptoethane 
Sulphonate 
MI – Myocardial Infarction 
MMF – Mycophenolate Mofetil 
MOP – Manual of Procedures 
MOS SF-36 – Medical Outcomes Study 
Short Form 36 
MRD – Minimal Residual Disease 
MSKCC – Memorial Sloan Kettering 
Cancer Center 
MTX – Methotrexate 
MUD – Matched Unrelated Donor 
MUGA – Multi Gated Acquisition Scan 
NAAT – Nucleic Acid Amplified Testing 
NCBI – National Center for Biotechnology 
Information 
NCI – National Cancer Institute 
NHLBI – National Heart, Lung, and Blood 
Institute 
NIH – National Institutes of Health 
NK – Natural Killer 
NMDP – National Marrow Donor Program 
NRM – Non-Relapse Mortality 
OHRP – Office for Human Research 
Protections 


 
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OS – Overall Survival 
PBMTC – Pediatric Blood and Marrow 
Transplant Consortium 
PBSC – Peripheral Blood Stem Cell 
PBMC – Peripheral Blood Mononuclear 
Cell 
PCR – Polymerase Chain Reaction 
PCS – Physical Component Summary 
PECAM1 – Platelet/Endothelial Cell 
Adhesion Molecule 1 
PET – Positron Emission Tomography 
PFT – Pulmonary Function Test 
PI – Principal Investigator 
PO – Per Os (by mouth) 
PR – Partial Response  
PTCy – Post-Transplant Cyclophosphamide 
PTLD – Post-Transplant 
Lymphoproliferative Disorder 
RA – Rheumatoid Arthritis 
RACE – Rapid Amplification of cDNA 
Ends 
rATG – Rabbit Anti-thymocyte Globulin 
RBC – Red Blood Cell 
RFS – Relapse-Free Survival 
RIC – Reduced Intensity 
ConditioningSCTOD – Stem Cell 
Therapeutic Outcomes Database 
SD – Standard Deviation 
SLE – Systemic Lupus Erythematosus 
SOP – Standard Operation Procedure 
SOS – Sinusoidal Obstruction Syndrome 
SPRT – Sequential Probability Ratio Test 
T-ALL – T-cell Acute Lymphoblastic 
Leukemia 
Tandem MS – Tandem Mass Spectrometry 
TBI – Total Body Irradiation 
TCD – T-cell Depleted 
TCRαβ – T-cell Receptor Alpha Beta 
TID – ter in die (three times/day) 
TREC – T-cell Receptor Rearrangement 
Excision Circle 
TRM – Transplant-Related Mortality  
ULN – Upper Limit of Normal 
VOD – Veno-occlusive Disease 
VZV – Varicella Zoster Virus 
WBC – White Blood Cell 
WHO – World Health Organization 
 


 
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APPENDIX B-1 
 
PATIENT INFORMED CONSENT 
 
 


 
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Informed Consent to Participate in Research 
 
 
 
 
 
 
 
 
 
Your Name:  
________________________________ 
 
 
Study Title:  
A Randomized, Multi-Center, Phase III Trial of Calcineurin 
Inhibitor-Free Interventions for Prevention of Graft-versus Host-
Disease  
 
Protocol: 
 
BMT CTN # 1301 
 
Principal 
Investigator:   
Insert local PI information 
 
 
Sponsor:  
The National Institutes of Health (NIH) is sponsoring this study by 
providing financial support through the Blood and Marrow Transplant 
Clinical Trials Network (BMT CTN).  
 
 
 
 
1. Introduction 
We invite you to join this clinical trial, also known as a research study. We are doing this study 
because we want to compare three transplant procedures to see which is better at preventing 
Graft-versus-Host Disease (GVHD). You are being asked to join this study because: 
1. You have a disease that can be treated by an allogeneic blood or marrow stem cell 
transplant; and 
2. Your doctor plans on using a standard intensity conditioning regimen for your transplant. 
 
This study will take at least two (2) years and will include 345 participants – 115 participants in 
each of three (3) treatment groups.  
 
This Consent Form will tell you about the purpose of the study, the possible risks and benefits, 
other options available to you, and your rights as a participant in the study.  


 
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Everyone who takes part in research at [insert facility name] should know that: 
 Being in any research study is voluntary. 
 You may or may not benefit from being in the study. Knowledge we gain from this study 
may benefit others. 
 If you join the study, you can quit the study at any time.  
 If you decide to quit the study, it will not affect your care at [insert name of facility or 
institution]. 
 Please ask the study staff questions about anything that you do not understand, or if you 
would like to have more information. 
 You can ask questions now or any time during the study. 
 Please take the time you need to talk about the study with your doctor, study staff, and 
your family and friends. It is your decision to be in the study. If you decide to join, please 
sign and date the end of the Consent Form. 
 
You and your doctor will discuss other treatment choices if you do not want to participate in this 
study. 
 
 
2. Study Background 
The National Institutes of Health (NIH), through the Blood and Marrow Transplant Clinical 
Trials Network (BMT CTN), are providing staff support and money for this research study. The 
BMT CTN and the NIH will make decisions about how to manage the study. Miltenyi Biotec, a 
company that produces a device used to process the stem cells before administering in patients, is 
also supporting this study with supplies and money.  
 
A hematopoietic stem cell transplant (HSCT) is a standard therapy for blood cancers such as 
acute leukemias and myelodysplastic disorders. A common problem that may occur after HSCT 
is a condition known as Graft-Versus-Host Disease (GVHD). The word “graft” refers to the 
donor blood cells that you will receive during your transplant. The word “host” refers to the 
person (in this case, you) receiving the cells. GVHD is a complication where the donor graft 
attacks and damages some of your (the transplant recipient's) tissues. It has two basic forms, an 
acute form which tends to occur rapidly and is most common in the first three months after the 
transplant and a chronic form, which develops slowly and at a later time after transplant.  
• GVHD can cause skin rash, intestinal problems such as nausea, vomiting, or diarrhea,  
• It may also damage your liver and cause hepatitis or jaundice.  
• GVHD may also increase your risks of infection. 
• Chronic GVHD can affect many organs and causes significant impact on the quality of life 
of patients. 
 
 


 
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3. Study Purpose 
We are inviting you to take part in this study because you have acute leukemia or 
myelodysplasia, and a hematopoietic stem cell transplant is a treatment option. 
 
The purpose of this study is to compare three different combinations of treatment plans to see 
whether one or more of them are better than a standard transplant procedure. The procedures 
being studied have the objective to reduce the occurrence of chronic GVHD. The procedures 
included in this clinical trial are: 
Treatment Group A: CD34 Selected Peripheral Blood Stem Cell Transplant 
Treatment Group B: Bone Marrow Transplant followed by Post-Transplant 
Cyclophosphamide 
Treatment Group C: Bone Marrow Transplant with Tacrolimus and Methotrexate as 
GVHD Prevention 
 
Doctors primarily want to compare Groups A and B with Group C (control). The study will help 
doctors make choices about transplants procedures with fewer chronic GVHD complications for 
patients. 
 
 
4. Right to Ask Questions and/or Withdraw 
You have the right to ask questions about the study at any time. If you have questions about your 
rights as a participant or you want to leave the study, please contact:  
[insert contact info] 
 
Being in this study is voluntary. You can choose not to be in this study or leave this study at any 
time. If you choose not to take part or leave this study, it will not affect your regular medical care 
in any way.  
 
Your study doctor and study staff will be available to answer any questions that you may have 
about taking part in or leaving this study.  
 
 
5. Study Treatment and Tests  
We will check your health before you start treatment, while you receive treatment, and for two 
years after transplant.  
 
Before You Begin the Study 
Before you begin the study, you will need to have several exams, tests or procedures to find out 
if you can be in the study. All patients participating in this study need to have a matched donor. 
Most of these exams, tests or procedures are part of regular cancer care and may be done even if 
you do not join the study. These include: 


 
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 Medical history 
 Physical examination, including height and weight 
 Blood and urine tests 
 Heart function tests, including EKG and ejection fraction 
 Lung (pulmonary) function tests 
 Tests to evaluate your cancer, including a bone marrow aspirate/biopsy 
 Chest X-ray or chest CT 
 A pregnancy test if you are a woman able to have children. If you are pregnant, you will 
not be able to take part in this study. 
If you join the study, the study-specific assessments listed below will be done before you begin 
the conditioning regimen: 
 Health quality of life questionnaires (for English and Spanish speaking adult patients ≥ 18 
years of age and English speaking pediatric patients, ages 8 to 18 years). 
 Optional blood samples for future research (see Section 18: Blood Samples for Future 
Research)  
 
Study Participation 
If you decide to join the study, your participation will last for 2 years after your transplant. We 
will ask you to sign this Consent Form and you will get a copy of the signed form to keep.  
 
Randomization  
We will use a computer to randomly assign you to 1 of 3 treatment groups. You will have an equal 
chance of being placed in 1 of the 3 groups. Neither you nor your doctor or study investigator will 
have any control over which treatment group you will be assigned. 
 
During Your Transplant 
The treatments that are used to prevent GVHD either start before or after the infusion of stem cells. 
These treatments are a combination of immune suppressing drugs and a standard component of the 
transplant. 
 
The 3 treatment groups being included in this study are outlined below:  
Treatment Group A: CD34 Selected Peripheral Blood Stem Cell Graft 
• 
Conditioning regimen: your doctor will select one of two conditioning regimens 
that are allowed in this treatment group. One includes total body irradiation plus 
chemotherapy, and the other includes chemotherapy alone.  
• 
The donor graft will be peripheral blood stem cells. 
• 
The donor graft will be processed through a device that removes cells that are 
associated with the development of GVHD.  


 
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Treatment Group B: Post-Transplant Cyclophosphamide 
• Conditioning regimen: your doctor will choose one of three conditioning regimens 
allowed in this treatment group.  
• The donor graft will be bone marrow. 
• After your transplant:  
o Cyclophosphamide will be given by intravenous infusion (through your vein), 
over 1-2 hours, on Day 3 and Day 4 after your transplant. 
Treatment Group C: Tacrolimus and Methotrexate 
• Conditioning regimen: your doctor will choose one of four conditioning regimens 
allowed in this treatment group.  
• Before your transplant: 
o Tacrolimus will be given as a pill by mouth or by intravenous infusion (through 
your vein) twice a day, beginning three (3) days before your transplant. The 
amount of drug given will slowly be decreased and eventually stopped. This 
process occurs over several months. 
• The donor graft will be bone marrow. 
• After your transplant: 
o Methotrexate will be given by intravenous infusion (through your vein) on four 
(4) different days (1, 3, 6 and 11) after your transplant. 
 
Both Treatment Groups A and B do not require long term use of medication to suppress the 
immune system.  
 
Peripheral Blood Stem Cell or Bone Marrow Transplant 
On your transplant day, the bone marrow or peripheral blood stem cells will be given to you 
through your catheter, like a blood transfusion. The cells will travel to your bone marrow where 
they will start to make healthy, new blood cells after several weeks.  
 
Health Evaluations After the Transplant 
We will test (evaluate) your health during the study. These tests and how often they are scheduled 
are standard care for patients receiving an allogeneic transplant. Most of these would be done even 
if you were not part of this study. You will be watched closely for any signs and symptoms of 
GVHD. 
• Physical exam to assess toxicities, and infections weekly until Day 63 and then at Days 
100, 150, 180, 270, 365 and 730. 
• Physical exam to assess GVHD weekly starting Day 7 until Day 63 and then at Days 100, 
150, 180, 270, 365 and 730. 
• Routine blood tests (cell counts, liver and kidney function) weekly until Day 63 and then 
at Days 100, 180, 270, and 365. 


 
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• Blood tests to monitor for CMV and EBV weekly until Day 100 and then at each clinical 
assessment until Day 180. 
• Restaging tests to see how much cancer you have after transplant on Days 100, 180, 365 
and 730.  
• Health quality of life questionnaires after the transplant on Days 100, 180, 365 and 730 
(for English and Spanish speaking adult patients ≥ 18 years of age and English speaking 
pediatric patients, ages 8-18 years). 
• Optional blood samples for future research after transplant on Days 35, 100, 180 and 365 
(see Section 18: Blood Samples for Future Research).  
 
6. Health Quality of Life (for English and Spanish speaking adult patients, and 
English speaking pediatric patients only) 
We will ask you about your general health and how well you feel while you participate in this 
study. Even though different treatments may treat a disease equally well, there might be a 
difference in how patients feel or the side effects they have after their treatment. This is 
important information for when we evaluate the treatments in this study. 
 
We will collect information by using surveys. The surveys will ask about: 
 
How you feel 
 
What symptoms you might have and how they affect you 
 
How well can you do regular daily activities 
 
You will need to fill out the surveys and each survey should take about 30 minutes to finish. 
Your answers will help us understand how your transplant treatment affects how you feel, what 
you can do, and your general quality of life.  
 
7. Risks and Discomforts 
You will have side effects while on the study. Side effects can range from mild to serious.  
The risks and discomforts of participating in this study will be similar to what you may have 
with stem cell transplant if you do not participate in this study, but you might do better or worse 
than on standard transplant treatment. Your health care team may give you medicines to help 
lessen side effects such as feeling sick to your stomach (nausea) among other support treatments. 
In some cases, side effects can be long lasting or may never go away.  
 
Risks and Toxicities Related to Conditioning Regimens 
The table below describes all conditioning regimens that are allowed to be used in this clinical 
trial. The regimen you will receive depends on the treatment group you will be assigned and your 
doctor’s choice. Some of these regimens are used in transplants performed outside a clinical trial.  
 
 
 


 
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TABLE 1: CONDITIONING REGIMEN OPTIONS BY TREATMENT GROUP 
Treatment Group A: CD34 Selection 
Treatment Groups B &C: PTCy & Control 
1 
Total Body Irradiation / 
Cyclophosphamide/Thiotepa/AntiThymocyte 
Globulin (ATG) 
3 
Busulfan/Cyclophosphamide (Bu/Cy) 
4 
Busulfan /Fludarabine (Bu/Flu) 
2 
Busulfan/Melphalan/Fludarabine/ 
AntiThymocyte Globulin (ATG) 
5 
Cyclophosphamide/Total Body 
Irradiation (Cy/TBI) 
6 
Total Body Irradiation/Etoposide 
(TBI/Etoposide) ONLY FOR THE 
CONTROL ARM 
  
The risks associated with each medication and or radiation you will receive as part of the 
conditioning regimen are listed below. The expected frequency of each of these side effects is 
shown in Table 2. 
 
TABLE 2 - RISKS AND SIDE EFFECTS 
Likely 
What it means: This type of side effect is expected to occur in more than 20% of 
patients. This means that 21 or more patients out of 100 might get this side effect. 
Less Likely 
What it means: This type of side effect is expected to occur in 20% of patients or 
fewer. This means that 20 patients or fewer out of 100 might get this side effect. 
Rare, but Serious 
What it means: This type of side effect does not occur very often – in fewer than 
2% of patients – but is serious when it occurs. This means that 1 or 2 patients (or 
fewer) out of 100 might get this side effect. 
 
 
TABLE 3 – ADVERSE EVENTS 
Busulfan 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Abdominal discomfort 
Constipation 
Diarrhea 
Dizziness 
Fluid retention 
Headache 
Heartburn 
Insomnia 
Lack of appetite 
Mouth sores  
Nausea and vomiting 
Running nose 
Skin rashes 
Irregular or no menstrual cycles 
Tachycardia 
Cough 
Hepatic Veno-occlusive disease  
High blood pressure 
High magnesium and phosphorus 
levels in the blood 
High sugar levels in the blood 
Infertility 
Low blood pressure 
Seizures 
Shortness of breath 
Cataracts 
Lung fibrosis 
 


 
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Cyclophosphamide 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Sores in mouth or on lips 
Damage to male (tests) and female 
(ovaries) sex glands 
Diarrhea 
Fluid retention 
Hair loss 
Infertility 
Irregular or no menstrual cycles 
Loss of appetite  
Nausea, Vomiting 
Suppression of the immune system 
Decreased platelet count and 
increased risk of bleeding 
 
Bleeding in the bladder 
Anemia (low red blood cell count) 
Damage to the fetus if you become 
pregnant while taking drug 
Stomach pain 
Skin rash 
 
Allergic reaction 
Lung fibrosis (scarring of lung tissue 
with cough and shortness of breath) 
Serious skin rashes 
Severe heart muscle injury and death 
(at very high doses) 
Secondary (new) cancers 
If you are taking cyclophosphamide, your doctor may also prescribe you a medicine called Mesna. 
Mesna helps prevent bladder discomfort and bleeding that can occur from taking 
cyclophosphamide. 
Etoposide 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Diarrhea 
Hair loss 
Nausea and vomiting 
Mucositis 
Constipation  
Abdominal pain 
 
Allergic reaction 
Peripheral Neuropathy 
 
Fludarabine 
 
Melphalan 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Constipation 
Diarrhea 
Hair loss 
Mucositis 
Nausea and vomiting 
Heart rhythm abnormalities 
Hepatitis 
Kidney failure 
Allergic reaction 
Interstitial Pneumonia 
Seizure 
Lung fibrosis 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Diarrhea 
Mouth sores  
Nausea and vomiting 
Suppression of the immune system 
 
Fever 
Numbness in the extremities 
Sleepiness 
Visual changes 
Weakness 
 
Coma 
Cough 
Inflammation of the lung 
Interstitial Pneumonia 
Skin rash 


 
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Total body Irradiation (TBI) 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Diarrhea (loose stools) 
Nausea (sick to the stomach) 
Stomach cramps 
Vomiting (throwing up) 
Painful swelling of the parotid 
gland (salivary glands under the 
ears) for a few days 
Short-Term hair loss 
Anemia 
Infection 
Bleeding 
Cataracts 
Sterility (inability to have children 
Growth failure 
Endocrinopathies (such as thyroid 
disease or diabetes) 
Mouth sores 
 
Lung inflammation Pneumonia 
Redness of the skin 
Liver problems 
Risk of developing other cancers in 
the future as a consequence of having 
received the total body irradiation 
Difficulty swallowing 
Back problems 
Kidney problems 
 
 
Thiotepa 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Lower white blood cell count with 
increased risk of infection 
Diarrhea (loose stools) 
Vomiting (throwing up) 
Liver damage 
Lower sperm production in men 
Hair loss 
Nausea (feeling sick to your 
stomach) 
Loss of appetite 
Missing or stopping menstrual 
cycle in women 
Mouth/throat sores 
Sterility (inability to have 
children) 
 
Liver abnormalities 
Skin rash 
Change in skin coloring 
Risk of bleeding due to low platelet 
count 
 
Confusion 
Disorientation 
 
 


 
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Rabbit Anti-Thymocyte Globulin (rATG) 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Fever 
Shaking chills 
Low blood pressure 
Skin rash 
Itching 
Decreased platelet counts 
Decreased white blood cell counts 
Serum sickness, consisting of : 
-Severe skin rashes 
-Mouth sores 
-Vaginal sores 
-Pain/swelling of joints 
-Kidney damage 
Severe allergic reaction which may 
cause: 
-Life-Threatening drop in blood 
pressure 
-Wheezing 
-Difficulty breathing 
-Severe hives 
 
Risks and Toxicities Related to GVHD Prophylaxis 
If you were assigned to the CD34 Selection Arm and your cells are selected with the CliniMACS® 
CD34 Reagent System, you may receive low doses of iron, iron-dextran and monoclonal antibody 
when the selected cells are re-infused.  Our experience shows that these low doses are unlikely to 
cause any bad side effects, including cancer. 
 
If you were assigned to the control group (treatment group C) you will receive medications to help 
prevent the development of GVHD.  
 
Methotrexate 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Decreased white blood cell count 
with increased risk of infection. 
Fatigue 
Infections 
 
Nausea/Vomiting 
Irritation or sores in the lining of 
the throat or mouth 
Diarrhea 
Abdominal discomfort 
Fever 
Chills 
Anemia 
Abnormal liver tests 
Kidney failure 
 
Dizziness 
Scarring of the lungs 
 


 
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Tacrolimus (FK506, Prograf®)  
Likely Side Effects  
(May happen in more than 20% of patients) 
Less Likely  
(May happen in less than 
20% of patients) 
Rare  
(May happen in less than 2% of 
patients) 
 
Kidney problems 
 
Loss of magnesium, calcium, potassium 
 
High blood pressure 
 
Tremors 
 
Increases in cholesterol and triglyceride 
 
Decreased platelet count with increased 
risk of bleeding 
 
Infections 
 
Nausea 
 
Vomiting 
 
Liver problems 
 
Changes in how 
clearly one can think 
 
Insomnia 
 
Unwanted hair 
growth 
 
Confusion 
 
 
 
Seizures 
 
Changes in vision 
 
Dizziness 
 
Red blood cell destruction 
It is very important that you do not eat grapefruit or drink grapefruit juice while taking 
Tacrolimus. Grapefruit has an ingredient called bergamottin, which can affect some of the 
treatment drugs used in this study. Common soft drinks that have bergamottin are Fresca, 
Squirt, and Sunny Delight.  
 
Cyclosporine A 
Likely Side Effects  
(May happen in more than 20% of 
patients) 
Less Likely  
(May happen in less than 20% of 
patients) 
Rare  
(May happen in less than 2% of 
patients) 
Kidney problems 
Loss of magnesium, calcium, and 
potassium 
High blood pressure 
Liver problems 
Unwanted hair growth 
Growth of extra tissue on the gums 
Burning, tingling or numbness in the 
hands, arms, feet or legs 
 
Seizures 
Changes in vision 
Formation of very small blood 
clots 
 
Risks and Toxicities Related to Transplant 
The following problems may occur as a result of stem cell transplantation. These risks may occur 
whether a transplant was done as part of the study or not:  
 
Slow recovery of blood counts. The red blood cells, white blood cells, and platelets can be slow 
to recover after blood or marrow transplant. Until your blood counts recover, you will need 
blood and platelet transfusions, and will be at risk for bleeding and infections. To speed the 
recovery of the white cells as much as possible you may receive Filgrastim.  
 
Graft failure. The stem cells (the “graft”) may fail to grow inside your body. Past experience 
suggests that there can be up to a 10-15% chance of graft failure. If graft failure occurs, this may 
result in low blood counts for a long period of time. If your counts do not recover, you may need to 
receive a second transplant. Graft failure can be fatal. 
 
Graft-Versus-Host Disease (GVHD). GVHD results from cells in the graft recognizing your body 
as foreign and attacking it. In most cases, GVHD can be successfully treated. Sometimes GVHD is 
severe or difficult to treat and may lead to death. You will be watched closely for this complication 
and given drugs to prevent and/or treat it.  


 
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Acute GVHD may produce skin rash, nausea, vomiting, diarrhea, abdominal pain, abnormalities of 
liver function, and an increased risk of infection. Chronic GVHD may produce skin rashes, hair loss, 
thickened dry skin, dry eyes, dry mouth, liver disease, weight loss, diarrhea, and an increased risk of 
infection. To confirm the diagnosis of acute or chronic GVHD, you may be asked to have a biopsy (a 
small sample of your tissue to look at under the microscope) of your skin, gut, or, rarely, your liver.  
 
Other complications. Other complications may include: 
a. Damage to the vital organs in your body. The transplant could cause problems in any body 
organ such as the heart, lungs, liver, gut, kidneys and bladder, or brain. The kidneys and the 
liver are most likely to be damaged. Some patients will experience serious lung problems from 
infections or the chemotherapy and radiation.  
b. Serious infections. Full and complete recovery of your immune system may take many months. 
During this time, there is an increased risk of infections. You will be prescribed certain drugs to 
reduce the chance of those infections. However, these treatments do not always work. If you 
have an infection, you may have to stay in the hospital longer or be re-hospitalized after 
transplant. Although most infections can be successfully treated, some infections may result in 
death.  
c. Relapse of disease or a new blood cancer. Your leukemia may come back even if the 
transplant is initially successful. In rare cases, a new blood cancer may develop from the donor 
cells. Cyclophosphamide can cause damage to blood cells, which may result in a blood 
cancer such as myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). The 
blood cancer usually develops 2-10 years after treatment, or 6 years on average. The risk of 
developing a new blood cancer after allogeneic blood or marrow transplant is probably less 
than 2%. If cancer develops in your donor’s blood cells, you may require additional treatment 
with chemotherapy or another blood or marrow transplant. 
d.  Lymphoproliferative Syndrome: Patients in Treatment Group A (CD34 Selected Peripheral 
Blood Stem Cell Graft) have an increased risk of developing post-transplant lymphoproliferative 
disorder (PTLD) or lymphoma caused by a virus called EBV. They can develop symptoms like 
fevers and enlarged lymph nodes. Your doctor may use scans and biopsies to confirm the 
diagnosis. Your blood will be monitored to check if you have signs of EBV in the blood. In 
many patients EBV can be treated at that stage before it ever progresses to lymphoma. EBV in 
the blood or EBV lymphoma often responds to treatment with rituximab, a drug commonly used 
in other lymphomas. PTLD can be fatal. 
e. Risk to the unborn. The treatments in this study have not been proven to be safe at any stage of 
pregnancy. Therefore, if you are pregnant or nursing, you are not eligible for this study. Women 
who can become pregnant must use effective birth control while receiving chemotherapy, TBI, 
and drugs to prevent GVHD, and for 1 year after transplant. Effective birth control is defined as 
the following: 
1. Refraining from all acts of vaginal sex (abstinence)  
2. Consistent use of birth control pills 


 
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3. Injectable birth control methods (Depo-Provera, Norplant) 
4. Tubal sterilization or male partner who has undergone a vasectomy 
5. Placement of an IUD (intrauterine device) 
6. Use of a diaphragm with contraceptive jelly and/or condoms with contraceptive foam 
every time you have sex. 
 
Reproductive Risks  
The drugs used in this research study may damage your reproductive organs, affect your ability to 
have children or possibly cause birth defects if you take them while you are pregnant. It is 
important that a woman is not pregnant or breast-feeding and does not become pregnant during 
the course of the study.  
It is important that both women who can become pregnant and their male partners use 
birth control for 1 year after transplantation while on this study. 
 
If you are a woman and can become pregnant, you will need to take a pregnancy test before you 
start the study. You should discuss ways to prevent pregnancy while you are in the study. 
Women who have gone through puberty may find that their menstrual cycle becomes irregular or 
stops permanently. This does not mean that you cannot become pregnant. You must still use an 
effective method of birth control during your transplant and continue until you are finished with 
your GVHD prevention treatment. 
 
If you are a man, your body may not be able to produce sperm (become sterile). You should talk 
with your doctor about banking your sperm before having a transplant. 
 
Please check with your doctor to understand more about these risks. 
 
Unforeseen Risks  
New risks might appear at any time during the study. These risks might be different from what is 
listed in this Consent Form. We will promptly tell you about new information that may affect 
your decision to take part in the study. We may learn new things that might make you want to stop 
being in the study. We will let you know if this happens and you can decide if you want to continue 
in the study.  
 
Other Treatments or Medications 
Some medicines react with each other, and it is important that you tell the study doctor or staff 
about any other drugs, treatments, or medicines you are taking. This includes non-prescription 
medications, vitamins and herbal treatments.  
 
It is also important that you tell the study staff about any changes to these medications during 
your participation in the study. 
 
For more information about risks and side effects, ask your study doctor. 
 
 


 
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7. Alternative Treatments 
Participation in this study is optional. If you choose not to take part, you may still receive an 
allogeneic transplant to treat your disease. The treatment and evaluations you would receive 
could be very similar to what would receive if you join this study.  
 
Your study doctor will talk with you about your options. If you decide not to participate in this 
study, your medical care will not be affected in any way. 
 
Your other choices may include: 
 Treatment with other drugs, radiation, or a combination of drugs and radiation without a 
transplant. 
 An allogeneic blood or marrow transplant that is not part of the study, or another type of 
transplant 
 Participation in another clinical trial, if available (check with your doctor) 
 No treatment for your blood cancer at this time 
 Comfort care 
 
Every treatment option has benefits and risks. Talk with your doctor about your treatment 
choices before you decide if you will take part in this study. 
 
 
8. Possible Benefits 
Taking part in this study may or may not make your health better. The information from this 
study will help doctors learn more about medications used to prevent GVHD. 
 
 
9. New Information Available During the Study 
During this research study, the study doctors may learn about new information about the study 
drugs or the risks and benefits of the study. If this happens, they will tell you about the new 
information. The new information may mean that you can no longer participate in the study, or that 
you may not want to continue in the study.  
 
If this happens, the study doctor will stop your participation in the study and will offer you all 
available care to suit your needs and medical conditions. 
 
 
10. Privacy, Confidentiality and Use of Information  
Your confidentiality is one of our main concerns. We will do our best to make sure that the 
personal information in your medical record is kept private. However, we cannot guarantee total 
privacy. All your medical and demographic (such as race and ethnicity, gender and household 


 
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income) information will be kept private and confidential. (Name of Transplant Center) and the 
organizations listed below will not disclose your participation by any means of communication 
to any person or organization, except by your written request, or permission, or unless required 
by federal, state or local laws, or regulatory agencies.  
 
Individuals authorized by the organizations below will have access to your research and medical 
information. They may use this information for inspections or audits to study the outcomes of 
your treatment, or for required reporting to regulatory authorities (such as the FDA for serious 
adverse events). In agreeing to participate, you consent to such inspections and to the copying of 
parts of your records, if required by these organizations. 
 The National Institutes of Health (NIH), which include the National Heart, Lung, and Blood 
Institute (NHLBI) and the National Cancer Institute (NCI) 
 The Food and Drug Administration (FDA) 
 The Blood and Marrow Transplant Clinical Trials Network Data and Coordinating Center 
(BMT CTN DCC), including the Center for International Blood and Marrow Transplant 
Research (CIBMTR), the National Marrow Donor Program (NMDP), and the EMMES 
Corporation. 
 The BMT CTN Data and Safety Monitoring Board (DSMB) 
 Miltenyi Biotec, makers of the device that removes cells that are associated with the 
development of GVHD (used in Treatment Group A) 
 
We will not identify you by name in any publications or reports that come from these organizations 
or groups. 
 
Information that does not include personally identifiable information about this clinical trial has 
been or will be submitted, at the appropriate and required time, to the government-operated 
clinical trial registry data bank, which contains registration, results, and other information about 
registered clinical trials.  
 
This data bank can be accessed by you and the general public at www.ClinicalTrials.gov. Federal 
law requires clinical trial information for certain clinical trials to be submitted to the data bank. 
 
Genetic Information Nondiscrimination Act: 
A new federal law (2009), called the Genetic Information Nondiscrimination Act (GINA), 
generally makes it illegal for health insurance companies, group health plans, and employers of 15 
or more persons to discriminate against you based on your genetic information. Health insurance 
companies and group health plans may not request your genetic information that we get from this 
research. This means that they must not use your genetic information when making decisions 
regarding insurability. Be aware that this new federal law will not protect you against genetic 
discrimination by companies that sell life insurance, disability insurance, or long-term care 
insurance. 
 


 
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11. Ending Your Participation 
Being in this study is voluntary. You can choose to not be in this study, or leave this study at any 
time. If you choose not to take part or leave this study, your regular medical care will not be 
affected in any way. Tell your doctor if you are thinking about stopping or decide to stop. He or 
she will tell you how to stop safely. 
 
The study doctor or the study sponsor may stop the study at any time, and we may ask you to 
leave the study. We may ask you to leave the study if you do not follow directions or if you 
suffer from side effects of the treatment. If we ask you to leave the study, the reasons will be 
discussed with you. Possible reasons to end your participation in this study include: 
 You do not meet the study requirements.  
 You need a medical treatment not allowed in this study. 
 The study doctor decides that it would be harmful to you to stay in the study. 
 You are having serious side effects. 
 You become pregnant. 
 You cannot keep appointments or take study drugs as directed. 
 The study is stopped for any reason. 
If you decide to leave this study after taking the study treatment, or are asked to leave by your 
doctor for medical reason, you will need to come back to the doctor’s office for tests for your 
safety. Even if you leave the study, the information collected from your participation will be 
included in the study evaluation. 
 
12. Physical Injury as a Result of Participation  
It is important that you tell your doctor, __________________ [investigator's name(s)] or study 
staff if you feel that you have been injured because of taking part in this study. You can tell the 
doctor in person or call him/her at __________________ [telephone number]. 
 
You will get medical treatment if you are injured as a result of taking part in this study. You 
and/or your health plan will be charged for this treatment. The study will not pay for medical 
treatment.  
 
In case of injury resulting from this study, you do not lose any of your legal rights to seek 
payment by signing this form. 
 
13. Compensation or Payment 
You will not be paid for your participation in the research study. You will not get compensation or 
reimbursement for any extra expenses (travel, meals, etc.) you may have through your participation 
on this trial. 
 


 
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14. Costs and Reimbursements 
Most of the visits for this research study are standard medical care for patients undergoing 
allogeneic transplants and will be billed to your insurance company. You and/or your health 
plan/insurance company will need to pay for some or all of the costs of standard treatment in this 
study.  
 
You or your insurance will not be charged for optional blood samples for research on this study. 
 
For more information on clinical trials and insurance coverage, you can visit the National Cancer 
Institute’s Web site at http://cancer.gov/clinicaltrials/understanding/insurance-coverage. You can 
print a copy of the “Clinical Trials and Insurance Coverage” information from this Web site. 
Another way to get the information is to call 1-800-4-CANCER (1-800-422-6237) and ask them 
to send you a free copy. 
 
 
15. Ethical Review 
The ethical aspects of this research study have been reviewed and approved by [name of IRB]. 
 
 
16. For More Information 
If you need more information about this study, or if you have problems while you are participating 
in this study, you can contact the study doctor or his/her staff. They can be reached at the telephone 
numbers listed here: 
[Insert name and contact details] 
 
 
17. Contact Someone about Your Rights 
If you wish to speak to someone not directly involved in the study, or if you have any complaints 
about any aspect of the project, the way it is being conducted or any questions about your rights as a 
research participant, then you may contact:  
[Insert appropriate contact details] 
For questions about your rights while taking part in this study, call the __________[name of 
center] Institutional Review Board (a group of people who review the research to protect your 
rights) at __________________ (telephone number).  
 
 


 
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18. Optional Blood Samples for Future Research  
This section of the informed consent form is about optional future research studies. This 
research will be done using blood samples from patients who are taking part in the main 
study described above. You may give blood samples for these research studies if you want 
to. You can still be a part of the main study even if you say 'no' to giving blood samples for 
these research studies. You can say "yes" or "no" to giving these optional blood samples 
for research. Please mark your choice at the end of this section. 
 
We would like to have five (5) blood samples for future research studies. If you agree, these 
samples will be drawn before you begin the conditioning regimen for your transplant (2 
teaspoons or 6 mL), and at 4 different times after your transplant on Days 35, 100, 180, and 365 
(20 teaspoons or 86 mL at each time point). These samples will only be collected in patients 
who weigh more than 30.0 kg. Usually the blood can be drawn from a vein in your arm at the 
same time as other blood collections.  
 
The samples collected for future research purposes will be sent to the BMT CTN Repository. 
The samples will be labeled with unique codes that do not contain information that could identify 
you. A link to this code does exist. The link is stored at the Data and Coordinating Center for the 
Blood and Marrow Transplant Clinical Trials Network (BMT CTN DCC). The staff at the 
repository where your samples are being stored does not have a link to this code. Your research 
samples will continue to be stored at the BMT CTN Repository until they are used up for 
research. 
 
The reason for collection of these samples is to perform future studies to better understand how 
your immune system recovers after the transplant. This will help understand why patients develop 
complications after transplant, including infections and graft-versus-host disease. 
 
The research that may be done with your blood is not designed specifically to help you. It might 
help people who have cancer and other diseases in the future.  
 
Reports about research done with your blood will not be given to you or your doctor. These 
reports will not be put in your health record. The research will not have an effect on your care.  
 
Genome-Wide Association Studies: 
DNA from your stored blood samples might be used in genome-wide association (GWA) studies 
for a future project either done or supported by the National Institutes of Health (NIH). Genome-
wide association studies are a way for scientists to find genes that have a role in human disease or 
treatment. Each study can look at hundreds of thousands of genetic changes at the same time. 
 
If your coded samples are used in such a study, the researcher is required to add your test 
results and sample information into a shared, public research database. This public database is 
called the NIH Genotype and Phenotype Database and it is managed by the National Center 
for Biotechnology Information (NCBI). The NCBI will never have any information that would 


 
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identify you, or link you to your information or research samples, although the results of 
genetic studies could theoretically include identifying information about you.  
Things to Think About:  
The choice to let us have blood samples for future research is up to you. No matter what you 
decide to do, it will not affect your care.  
 
If you decide now that your blood can be kept for future research, you can change your mind at 
any time. Just contact your study doctor and let him or her know that you do not want us to use 
your blood sample. Then any blood that remains will no longer be used for research.  
 
In the future, people who do research on these blood samples may need to know more about your 
health. While the study doctor or others involved in running this study may give the researchers 
reports about your health, it will not give them your name, address, phone number, or any other 
information that will let the researchers know who you are.  
 
Your blood will be used only for research and will not be sold. The research done with your blood 
may help to develop new products in the future.  
 
 
Benefits: 
The benefits of research using blood include learning more about how your body’s immune system 
recovers after a transplant, as well as why certain complications like graft-versus-host disease or 
infections develop.  
 
Risks: 
There is a small risk of an infection or fainting from the blood draw.  
 
The greatest risk to you is the release of information from your health records. We will do our 
best to make sure that your personal information will be kept private. The chance that this 
information will be given to someone else is very small.  
 
Making Your Choice: 
Please read each sentence below and think about your choice. After reading each sentence, 
please indicate your choice below. If you have any questions, please talk to your doctor or nurse, 
or call our research review board at ___________________.  
 
No matter what you decide to do, it will not affect your care. 
 


 
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Statement of Consent 
The purpose of storing blood samples, the procedures involved, and the risks and benefits have 
been explained to me. I have asked all the questions I have at this time and I have been told 
whom to contact if I have more questions. I have been told that I will be given a signed copy of 
this consent form to keep. 
 
I understand that I do not have to allow the use of my blood for research. If I decide to not let 
you store research samples now or in the future, it will not affect my medical care in any way. 
 
I voluntarily agree that blood samples may be collected and that my blood and related 
information can be stored indefinitely by the BMT CTN Repository for research on how my 
body’s immune system recovers after the transplant. 
 
 I do agree to give optional blood samples for future research. 
 I do not agree to give optional blood samples for future research. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature 
 
 
 
 
 
 
Date 
                                               
 
 


 
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Health Insurance Portability and Accountability Act 1 (HIPAA3) Authorization to use and 
disclose individual health information for research purposes 
 
A. Purpose:  
As a research participant, I authorize the Principal Investigators and the researcher’s staff to 
use and disclose my individual health information for the purpose of conducting the research 
study:  
A Randomized, Multi-Center, Phase III Trial of Calcineurin Inhibitor-Free 
Interventions for Prevention of Graft-versus-Host Disease  
 
B. Individual Health Information to be Used or Disclosed:  
My individual health information that may be used or disclosed to do this research includes:  
 Demographic information (for example: date of birth, sex, weight).  
 Medical history (for example: diagnosis, complications with prior treatment). 
 Findings from physical exams. 
 Laboratory test results obtained at the time of work up and after transplant (for example: 
blood tests, biopsy results).  
 
C. Parties Who May Disclose My Individual Health Information:  
The researcher and the researcher’s staff may collect my individual health information from: 
[List hospitals, clinics or providers from which health care information can be requested]. 
 
D. Parties Who May Receive or Use My Individual Health Information:  
The individual health information disclosed by parties listed in item c and information 
disclosed by me during the course of the research may be received and used by the following 
parties: 
 
Study Sponsors  
 National Heart, Lung, and Blood Institute (NHLBI) and the National Cancer Institute 
(NCI), both of the National Institutes of Health (NIH) 
 Blood and Marrow Transplant Clinical Trials Network Data and Coordinating Center 
(BMT CTN DCC) , including the Center for International Blood and Marrow 
Transplant Research (CIBMTR), the National Marrow Donor Program (NMDP), and 
the EMMES Corporation. 
 BMT CTN 1301 Co-Principal Investigators: Dr. Leo Luznik, Dr. Marcelo Pasquini, 
and Dr. Miguel Angel Perales. 
 
Other Organizations 
                                                 
3 HIPAA is the Health Insurance Portability and Accountability Act of 1996, a federal law related to privacy of health 
information 


 
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 U.S. government agencies that are responsible for overseeing research such as the 
Food and Drug Administration (FDA) and the Office of Human Research Protections 
(OHRP) 
 U.S. government agencies that are responsible for overseeing public health concerns 
such as the Centers for Disease Control (CDC) and federal, state and local health 
departments 
 Miltenyi Biotec, makers of the device that removes cells that are associated with the 
development of GVHD (used in Treatment Group A) 
 
E. Right to Refuse to Sign this Authorization:  
I do not have to sign this Authorization. If I decide not to sign the Authorization, I will not be 
allowed to participate in this study or receive any treatment related to research that is 
provided through the study.  
My decision not to sign this authorization will not affect any other treatment, payment, or 
enrollment in health plans or eligibility for benefits.  
 
F. Right to Revoke:  
I can change my mind and withdraw this authorization at any time by sending a written 
notice to the Principal Investigator to inform the researcher of my decision.  
If I withdraw this authorization, the researcher may only use and disclose the protected health 
information already collected for this research study. No further health information about me 
will be collected by or disclosed to the researcher for this study. 
 
G. Potential for Re-disclosure:  
My individual health information disclosed under this authorization may be subject to re-
disclosure outside the research study and no longer protected. 
Examples include potential disclosures for law enforcement purposes, mandated reporting or 
abuse or neglect, judicial proceedings, health oversight activities and public health measures. 
 
H. This authorization does not have an expiration date. 
 
 
 


 
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I have read and understood this Consent Form. The nature and purpose of the research study has 
been explained to me. 
 I have had the chance to ask questions, and understand the answers I have been given. I 
understand that I may ask questions at any time during the study. 
 I freely agree to be a participant in the study. 
 I understand that I may not directly benefit from taking part in the study. 
 I understand that, while information gained during the study may be published, I will not 
be identified and my personal results will stay confidential. 
 I have had the chance to discuss my participation in this research study with a family 
member or friend. 
 I understand that I can leave this study at any time, and doing so will not affect my 
current care or prevent me from receiving future treatment. 
 I understand that I will be given a copy of this signed consent form. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Participant Name 
 
 
 
 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature 
 
 
 
 
 
 
Date 
 
 
 
If you are not the subject, please print your name 
 
 
 
 
 
and indicate one of the following: 
 
 
 
The subject’s parent  
 
     The subject’s guardian 
 
 
A surrogate 
 
 
 
     A durable power of attorney 
 
 
A proxy 
 
 
 
     Other, please explain: 
 
 
 
 
 
 
 
 
 
 
 
 
 
Legally Authorized Representative Signature 
 
Date 
 
 
 


 
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I certify that I have provided a verbal explanation of the details of the research study, including 
the procedures and risks. I believe the participant has understood the information provided. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Name of Counseling Physician 
 
 
 
Date 
 
 
 
 
 
 
 
 
 
                                                                
Signature of Counseling Physician 
 
    
 
Date 
 
 
 


 
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CONSENT AND ASSENT INSTRUCTIONS 
 
 
CONSENT: Subjects 18 years and older must sign on the Subject Signature line below. For 
subjects under 8 years old, consent is provided by the Legally Authorized Representative. 
 
ASSENT: 
Is required for subjects ages 7 to 17, using the Assent Section on the following 
page. 
 
I have been informed about this study’s purpose, procedures, possible benefits and risks. I have 
been given the chance to ask questions. My questions have all been answered satisfactorily. I 
understand that I can ask other questions at any time. 
 
I voluntarily agree to take part, or to allow my child to take part, in this study. 
 
By signing this consent form, I have not given up any of the legal rights that I (my child) 
otherwise would have as a subject in a research study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Subject‘s Signature 
 
 
 
 
 
Date 
 
 
 
 


 
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Pediatric Assent to Participate in Research 
 
For Children Ages 7 to 17 years old 
 
Study Title:  
A Randomized, Multi-Center, Phase III Trial of Calcineurin Inhibitor-Free 
Interventions for Prevention of Graft-versus Host-Disease  
 
Protocol: 
 
BMT CTN # 1301 
 
• Why am I here? 
 
We are inviting you to join our study because you will receive a stem cell transplant to treat your 
disease. A transplant uses blood-making cells from another person (donor) to replace your cells 
that are not healthy. A donor is the name for a person who gives some of their blood-making cells 
for a transplant. 
 
• Why are you doing the study? 
 
We are comparing three different ways (types) to do a transplant to learn if any of them are better. 
Sometimes the donor cells cause a problem called graft versus host disease (GVHD). GVHD 
happens when the donor cells attack your body. One way to avoid this problem is to give 
medications, other ways include removing the donor cells that can attack your body before 
injecting them to you or killing them after they are injecting in you. These are the three types of 
transplant that are being compared in this study.  
 
• What will happen to me? 
 
If you participate in this study you will receive one of the transplant types which will be chosen 
by chance, like a flip of a coin.  
 
Before your transplant, your will have check-ups with your doctors. Then, you will get a small 
tube put in your chest in the operating room (you will be asleep for this). The small tube makes it 
easier for you to get your medications. It will also make it easier and less painful for drawing blood 
for tests.  
 
You will receive medicines that will help the cells from your donor grow in your body. These 
medicines might make you feel sick. You might throw up, lose your hair, or get sores in your 
mouth.  
 
After you are done taking the medicines, you will get cells from your donor. This is your transplant. 
Your donor can be your sister or brother (related to you) or someone you don’t know (unrelated to 
you). You new cells will come from your donor’s bone marrow. The cells will make new and 
healthy cells in your body. 
 


 
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You will stay in the hospital for several days before your transplant and for about 4 weeks after 
your transplant. After you go home, you will need to go back to see your doctor often.  
 
It is possible that your disease will come back after the transplant. If this happens, your doctor will 
find another way to treat you.  
  
• Will it Hurt? 
 
For your transplant, we will put a small tube in your chest. It might hurt a little and you might 
bleed a little. You will need blood drawings sometimes from your arm, which also might hurt a 
little. Your doctor and nurses will make sure you feel as little pain as possible.  
 
• Will the Study help me? 
 
We don’t know if the study will help you or not. 
 
• What if I have questions? 
 
You can ask any question that you have about the study. If you forget to ask a question and think 
of it later, you can call me [insert office number]. You can also ask your question the next time 
you see me.  
  
 
• Do I have to be in the study? 
 
 
Writing your name on this page means that you agree to be in the study and know what will happen to you. 
If you decide to quit the study, all you have to do is tell your doctor.  
 
You and your parent or guardian will get a copy of this form after you sign it.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Child 
 
 
 
Date 
 
 
Age (years) 
 
 
 
 
 
 
 
 
 
 
 
          
Print Name of Child 
 
 
Certification of Counseling Healthcare Professional: I certify that the nature and purpose, the potential 
benefits, and possible risks associated with participation in this study have been explained to the above 
individual and that any questions about this information have been answered.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Counseling Healthcare Professional    
 
 
Date 


 
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APPENDIX B-2 
 
RELATED DONOR INFORMED CONSENT 
 


 
  
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Related Donor Informed Consent to Participate in Research 
 
 
 
 
 
 
 
 
 
This is an informed consent document for a research study that your family member is participating 
in. This document will inform you about the details of this study, which will involve manipulation 
of your donated cells before they are given to your family member.  
 
Your family member has a blood cancer and will be treated with a stem cell transplant under a 
research study. The goal of this study is to compare 2 different combinations of treatment plans to 
a standard transplant procedure. The objective is to see whether one or both of these treatment 
plans are better at reducing the occurrence of chronic graft versus host disease (GVHD), a life-
threatening complication of transplant. The treatment plan that your family member was 
randomized to requires manipulation of your cells through a device that removes certain types of 
cells that can cause this complication.  
 
This informed consent document will explain important information about the study. There is no 
additional requirement from you beyond the procedure of stem cell collection to which you have 
already agreed. The cells you donate will be manipulated using a cell selection system that is part 
of the research study. Therefore, you need to be informed about this process and consent that your 
cells can be manipulated according to the procedures in the study. It is important to know that: 
• You will not be paid to be in this study. 
• You, your medical insurance company, or the patient’s medical insurance company 
will pay for all medical bills for your treatment and the cell manipulation procedure. 
 
 
Before you decide on consenting and signing this document, please read the information below. 
Feel free to ask questions to understand your rights. The consent process is voluntary and will not 
interfere with your donation and the recipient’s transplant. 
 
1. Title of Research Study 
A Randomized, Multi-Center, Phase III Trial of Calcineurin Inhibitor-Free Interventions  
for Prevention of Graft-versus-Host Disease 
 
2. Principal Investigator Contact Information at your Institution 
Name/Title/Phone number/ 
 
3. Contact information for emergencies after hours or on weekends or holidays: 
Name/Phone number/ 


 
  
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B-31 
 
4. Sponsors and Source of Funding or Other Material Support 
The National Institutes of Health (NIH), through the Blood and Marrow Transplant Clinical 
Trials Network (BMT CTN), are providing staff support and money for this research study. The 
BMT CTN and the NIH will make decisions about how to manage the study. Miltenyi Biotec, 
a company that produces the cell selection system used to process the stem cells before giving 
them to patients, is also a contributor to this study and they are providing supplies and money. 
This research study is also registered with the US Food and Drug Administration (FDA) which 
is overseeing the investigational device that is part of the cell selection system that will be used 
to remove T cells from your stem cell donation, called stem cell manipulation, prior to 
transplantation.  
 
5. What will be different for you as a donor of peripheral blood stem cells if you choose to 
participate in this study? 
Participation in this study by signing this document will not change any aspect of the stem cell 
donation that you have agreed to already. By signing this document, you acknowledge that your 
family member is participating in a research study and that you consent that the cells you donate 
can be manipulated in an investigational device.  
 
6. What is the purpose of this study? 
The purpose of this study is to compare two different combinations of treatment plans to a 
standard transplant procedure in order to see whether one or both of them are better at reducing 
the occurrence and severity of chronic GVHD. The research portion of this study involves 
manipulation of your stem cell product by removing T-cells, which cause chronic GVHD. 
 
7. What will be done if you take part in this research study? 
By signing this document, you consent that, after your donation, your cells will be manipulated 
by removing certain cells that can cause chronic GVHD in the recipient. The manipulation is 
performed by the investigational device. The way that you donate stem cells will not be changed 
with your participation in the study. 
 
T-Cell Depletion (CD34+ Selection) 
The blood cells collected from you as part of the donation process will have large numbers of 
T cells, along with other cells, including your blood stem cells. The process of removing these 
T cells is called T-cell depletion and there are several ways that this can be done. In this study, 
they are being removed through a process called negative selection. The device used to do this 
is called CliniMACS and is produced by Miltenyi Biotec. The procedure involves labeling the 
stem cells, also called CD34+ cells, with an antibody attached to a magnetic substance. The 
CliniMACS tubing set has columns that will bind only the CD34+ cells allowing all the other 
cells, including the T cells, to pass through. After the selection is done, the stem cell product 
will have mainly CD34+ cells, or stem cells, and will be depleted of T cells. The CliniMACS 
device has been extensively used in transplantation and has been proven to be safe. However, 
it remains an investigational device. This means it is not yet approved by the FDA for routine 
use. The FDA has granted approval for the use of this device and the CD34 reagent in this study 
and the study investigators are required to tell the FDA all information related to what happens 
with study participants. The CliniMACS CD34 Reagent System was approved as a 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
B-32 
humanitarian device and authorized by U.S. Federal law for use in the treatment of patients with 
acute myeloid leukemia (AML) in first complete remission. The effectiveness of the device for 
this use has not been demonstrated. 
 
8. Will you provide blood samples for research? 
You will not be asked to provide extra blood samples for this research study. 
 
9. What are the possible discomforts and risks? 
T-cell Depletion: The process of manipulation occurs after your donation is completed. The 
amount of cells requested for collection from you is not larger than what is routinely requested 
for a transplant. However, the amount of cells donated needs to be above a certain number and 
some donors may need an extra day of donation in order to achieve this number of cells. Results 
from earlier studies using the same cell manipulation procedures found that 36% of the time, 
only 1 collection was needed; 45% of the time, 2 collections were needed; and 7% of the time, 
a third collection was needed. 
 
Breach of Confidentiality: Medical records are considered confidential. These records are kept 
in a secured area accessible to people involved in the conduct of the study. You will not be 
identified by name in any publication or presentation of the results of this study. All data entered 
into a computer will be coded. No data that may be linked to you will be entered on any network 
computer that could allow access to confidential information. The master list will be stored off-
line and available only to the principal investigator and his or her designee(s). Although we will 
make every effort possible to maintain confidentiality, there is however, a slight risk of loss of 
confidentiality.  
 
10. As with any treatment, there may be yet unknown and/or unexpected side effects from 
donating peripheral blood stem cells. 
Donating blood stem cells is routinely done and is not considered research. Unanticipated side 
effects may occur that have not been previously reported. If you have any unusual symptoms, 
you should report them immediately to your doctor.  
 
In an attempt to avoid side effects, your doctor will examine you and obtain laboratory tests 
(blood tests, chest x-ray, etc.) to determine the effects of the donation and alter the drug doses 
if necessary. 
 
11. What other alternatives are available if you do not want to be in this study? 
Your participation is voluntary and you may choose not to participate in this research study or 
withdraw your consent at any time. Your choice will not at any time affect the commitment of 
your health care providers to provide care to you or to your family member. There will be no 
penalty or loss of benefits to which you or your family member are otherwise entitled. 
Alternatives to participating in this research include donating your blood stem cells to your 
family member for a transplant that is not part of this research study. 
 
12. What are the possible benefits to you? 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
B-33 
You will not benefit directly from participating in this research. You may receive indirect 
benefit from knowing that you may be helping your family member or other donors and patients 
in the future. 
13. What are the possible benefits to others? 
You may be helping other patients get better treatment in the future. 
 
14. If you choose to take part in this study, will it cost you anything? 
Normally the insurance company of the patient covers the medical expenses associated with 
collecting your blood stem cells and the T-cell depletion procedure. This will be reviewed with 
the patient’s insurance company prior to collecting your stem cells. Neither you (the donor)  nor 
your insurance company will be charged for the T-cell depletion of the peripheral blood stem 
cell graft. 
 
15. Will you be paid for taking part in this research study? 
No. 
 
16. How can you withdraw from this research study? 
If you change your mind after you have provided consent, you can still decline participation in 
the study prior to the stem cell manipulation. Please contact the person who discussed this 
document with you and request to be withdrawn from the study. The stem cell manipulation 
will occur within 24 to 36 hours from your donation.  
 
17. How will your privacy and the confidentiality of your research records be protected? 
The centers and doctors in charge of this study will keep your personal information as private 
as possible. They will do their best to see that it is shared only when required by state or federal 
law or the terms of this consent. The research study that your family member is participating in 
will not be collecting any information about you as the donor. 
 
Information that does not include personally identifiable information about this clinical trial has 
been or will be submitted, at the appropriate and required time, to the government-operated 
clinical trial registry data bank, which contains registration, results, and other information about 
registered clinical trials. This data bank can be accessed by you and the general public at 
www.ClinicalTrials.gov. Federal law requires clinical trial information for certain clinical trials 
to be submitted to the data bank. 
 
18. How will the researcher(s) benefit from you being in this study? 
The researchers have no money invested in this study. But, in general, presenting research 
results helps the career of a scientist. Therefore, the Principal Investigator may benefit if the 
results of this study are presented at scientific meetings or in the scientific press. In addition, 
the Principal Investigator is being paid a small amount to cover the costs of the study. 
 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
B-34 
19. HIPAA1 authorization to use and disclose individual health information for research 
purposes 
a. Purpose: As a research participant, I authorize the Principal Investigator and the 
researcher’s staff to use and disclose my individual health information for the purpose of 
conducting the research study entitled A Randomized, Multi-Center, Phase III Trial of 
Calcineurin Inhibitor-Free Interventions for Prevention of Graft-versus-Host Disease. 
b. Individual Health Information to be Used or Disclosed: My individual health information 
that may be used or disclosed to conduct this research includes: demographic information 
(e.g., age, date of birth, sex, weight), medical history (e.g., diagnosis, complications with 
prior treatment) and physical examination findings. 
c. Parties Who May Disclose My Individual Health Information: The researcher and the 
researcher’s staff may obtain my individual health information from (list hospitals, clinics 
or providers from which health care information can be requested). 
 
 
 
d. Parties Who May Receive or Use My Individual Health Information: The individual health 
information disclosed by parties listed in item “c.” above and information disclosed by me 
during the course of the research may be received and used by the following parties: 
- Principal Investigator and the researcher’s staff 
- Dr. Marcelo Pasquini, Study Chairperson at Medical College of Wisconsin 
- Dr. Miguel Perales, Study Chairperson at Memorial Sloan-Kettering Cancer Center 
- Dr. Leo Luznik, Study Chairperson at Johns Hopkins University 
- National Heart, Lung and Blood Institute (NHLBI) and National Cancer Institute 
(NCI), both of the National Institutes of Health (NIH), study sponsors 
- Blood and Marrow Transplant Clinical Trials Network Data and Coordinating Center 
(BMT CTN DCC), including the Center for International Blood and Marrow 
Transplant Research (CIBMTR), the National Marrow Donor Program (NMDP), and 
the EMMES Corporation 
- The BMT CTN Data and Safety Monitoring Board (DSMB) 
- U.S. government agencies that are responsible for overseeing research such as the Food 
and Drug Administration (FDA) and the Office of Human Research Protections 
(OHRP) 
                                                 
1 HIPAA is the Health Insurance Portability and Accountability Act of 1996, a federal law related to privacy 
of health information. 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
B-35 
- U.S. government agencies that are responsible for overseeing public health concerns 
such as the Centers for Disease Control (CDC) and federal, state and local health 
departments 
- Miltenyi Biotec, makers of the device that removes cells that are associated with the 
development of GHVD (used in the treatment group that your family member was 
randomized to) 
e. Right to Refuse to Sign this Authorization: I do not have to sign this Authorization. If I 
decide not to sign the Authorization, I will not be allowed to participate in this study or 
receive any research-related treatment that is provided through the study. However, my 
decision not to sign this authorization will not affect any other treatment, payment, or 
enrollment in health plans or eligibility for benefits. 
f. Right to Revoke: I can change my mind and withdraw this authorization at any time by 
sending a written notice to the Principal Investigator to inform the researcher of my 
decision. If I withdraw this authorization, the researcher may only use and disclose the 
protected health information already collected for this research study. No further health 
information about me will be collected by or disclosed to the researcher for this study. 
g. Potential for Re-disclosure: My individual health information disclosed under this 
authorization may be subject to re-disclosure outside the research study and no longer 
protected. Examples include potential disclosures for law enforcement purposes, mandated 
reporting or abuse or neglect, judicial proceedings, health oversight activities and public 
health measures. 
h. This authorization does not have an expiration date. 


 
  
CNI-Free GVHD Protocol - 1301 
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B-36 
20. Donor’s Consent 
 
I have been informed of this study’s purpose, procedures, possible benefits and risks. I have 
been given a chance to ask questions and have had them answered to my satisfaction. I 
understand that I can ask more questions at any time. 
 
I voluntarily agree to participate in this study. 
 
By signing this consent form, I have not given up any of the legal rights, which I otherwise 
would have as a subject in a research study. 
 
_________________________________________ 
 
____________ 
Signature of Donor 
 
 
 
 
 
Date 
 
_________________________________________ 
Print Name of Donor 
 
 
Certification of Counseling Healthcare Professional 
 
I certify that the nature and purpose, the potential benefits, and possible risks associated with 
participation in this study have been explained to the above individual and that any questions 
about this information have been answered. 
 
_________________________________________ 
 
____________ 
Signature of Counseling Healthcare Professional 
 
Date 
 
_________________________________________ 
Print Name of Counseling Healthcare Professional 
 
 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
B-37 
Related Donor Informed Assent to Participate in Research 
 
 
 
 
 
 
 
This is a form for a research study. This form is to help you decide if you want to participate in 
this study. 
 
Purpose of the Research Study 
Your brother or sister has blood cancer and is being treated with a transplant of peripheral blood 
stem cells from a matched family member donor in a research study.  
 
The goal of this study is to compare 2 different treatment plans to a standard transplant procedure. 
The objective is to see whether one or both of these treatment plans are better at reducing the rate 
of a serious complication called chronic graft versus host disease (GVHD). The treatment plan that 
your brother or sister was assigned to requires putting your donated cells through a device that 
removes certain types of cells that cause this complication before the cells are transplanted to your 
brother or sister.  
 
You are being asked to be in the study because you are a match for your brother or sister and can 
donate peripheral blood stem cells to them. Your doctor or another person on the study team will 
explain to you what you must do if you are going to donate peripheral blood stem cells for your 
brother or sister. The team will also follow you closely to see if you are having any side effects 
while donating peripheral blood stem cells on the study. 
 
If you have any questions, ask your doctors and make sure you understand their answers. Your 
parents (or a guardian) are also asked for their permission for you to join this treatment study. 
 
I agree to donate blood stem cells in this study. 
 
_________________________________________  
____________ 
Signature of Donor 
 
 
 
 
 
Date 
 
_________________________________________  
 
Print Name of Donor  
 
 
 
 
 
 
_________________________________________  
_____________ 
Signature of Doctor 
 
 
 
 
 
Date 
 
_________________________________________ 
Print Name of Doctor 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
C-1 
APPENDIX C 
 
LABORATORY PROCEDURES 


 
  
CNI-Free GVHD Protocol - 1301 
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C-2 
APPENDIX C 
 
LABORATORY PROCEDURES 
 
 
OPTIONAL FUTURE RESEARCH: PROPOSED DETAILED IMMUNOLOGIC STUDIES 
 
Patients consenting to the optional future research will have samples collected for undefined future 
research, as well as immune reconstitution and proposed detailed immunological studies. Samples 
will be collected at Baseline (prior to the initiation of the conditioning regimen) and post-transplant 
at Days 35, 100, 180 and 365. These samples will be shipped for cryopreservation to the BMT 
CTN Repository and processed for later analysis. The BMT CTN Repository will process samples 
according to standard operating procedures (SOPs). Table 1 describes allocation of specimens for 
immunologic analysis. 
 
Patients who weigh more than 30.0 kg are eligible to provide optional research samples and will 
have 6 mL of whole blood collected at Baseline and 80 mL of whole blood collected at each post-
transplant time point.  
 
Proposed Experimental Approach 
Multi-parameter flow cytometric analysis of effector and regulatory T-cell subsets: The flow 
cytometric examination of effector and regulatory T cells will be conducted on blood samples on 
cryopreserved samples. Based on established SOPs by the NMDP repository each sample will be 
aliquoted in multiple vials with a cell viability upon freeze thaw of >95%. This “central” sample 
processing is expected to provide maximal viability and functionality of the cells. Shipment of 
specimens between NMDP repository and institutions will occur in batches and will start in year 
2 of patient accrual. The proposed studies are designed to assess the impact of GVHD prophylaxis 
strategy on reconstitution of lymphocyte subsets, particularly balance of alloreactive effector and 
regulatory T cells and the relationship between GVHD prophylaxis and thymus function. 
Lymphocyte subsets will be identified using the following panels: CD4 subsets: naïve, effector, 
effector memory and central memory subpopulations defined by CD4 CD45RA CCR7 CD38 
HLA-DR markers; recent thymic emigrants identified by the CD4+ CD45RA+ CD31+ CD95 dim 
phenotype. 75 , 76 , 77 , 78 CD8 subsets: naïve, effector, effector memory and central memory 
subpopulations defined by the CD8 CD45RA CCR7 CD38 HLA-DR markers;75, 79, 80 recent 
thymic emigrant identified by the CD8+CD45RA CD31+ CD95dim phenotype. B cell subsets: 
memory versus naïve B cell populations will be delineated by their expression of CD27, IgM and 
IgD.81 NK cell subsets: (CD56 bright, CD16 neg and CD56 moderate, CD16+). The analysis of 
regulatory T cells will be performed using multi-color flow cytometry with a pre-determined panel 
of monoclonal antibodies (mAbs) including but not limited to those specific for CD3, CD4, CD25 
(IL-2Rα), CD31 (PECAM1), CD45RA, CD127 (IL-7R), Ki-67 and intracellular Foxp3. This 
multi-color approach would allow phenotypic separation of human CD4+Foxp3+ T cells into three 
distinct subpopulations as well as assessment of their proliferative status (percentage of Ki-67 
positive cells).82, 83 In addition, we will combine these stains with Bcl-2, CD95, and Annexin V 
stains to assess the apoptotic susceptibility of donor Tregs. In all analyses the frequency and total 
number of cells will be determined.  


 
  
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
C-3 
Table 1: Allocation of Specimens for Immunologic Analysis and Future Research 
 
Optional Research Samples 
Subjects 
Research 
Sample 
Type 
Time Points 
Sample 
Quantity 
Stored 
Material 
Sample 
Processing 
& Storage 
Site 
Aliquots 
Stored 
Proposed Studies 
Patients who  
weigh > 30.0 kg. 
Peripheral  
Blood 
 
Pre-Transplant 
prior to the 
initiation of 
conditioning 
regimen 
 
6 mL 
EDTA 
Whole Blood 
BMT CTN 
Repository 
Maximum 6 
aliquots  
1.0 mL whole 
blood aliquots 
stored at -80° C 
Undefined Future 
Research 
(Genomic DNA 
Isolation) 
Post-Transplant 
Days 35, 100, 
180, and 365 
80 mL 
Heparin 
 
Viable 
PBMCs 
 
BMT CTN 
Repository 
 
Maximum 12  
1.0 mL aliquots 
containing ~5.0-
10.0 x 106 
PBMC; 
controlled-rate 
frozen and stored 
in LN 
Advanced Immune 
Reconstitution 
(MSKCC) 
Tregs assays/ multi-
color flow cytometry 
(Johns Hopkins) 
6 mL 
Clot 
Serum 
BMT CTN 
Repository 
Maximum 6  
0.5 mL plasma 
aliquots stored at 
-80° C 
Undefined Future 
Research 
(Proteomic) 
 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
D-1 
APPENDIX D 
 
ESTIMATED CREATININE CLEARANCE FORMULAS 
 
 


 
  
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
D-2 
APPENDIX D 
 
ESTIMATED CREATININE CLEARANCE FORMULAS 
 
 
 
Cockcroft-Gault (for patients > 12 years) 
 
Estimated CrCl = (140 - age) x Mass (in kilograms) x [0.85 if Female] 
                                             72 x Serum Creatinine (in mg/dL) 
 
 
 
Updated Schwartz (for patients ≥ 1 year to 12 years) 
 
Estimated GFR = k x Height (in centimeters) 
                           Serum Creatinine (in mg/dL) 
 
Where k is a constant that depends on muscle mass, which varies with a child's age:  
• In first year of life, for pre-term babies k=0.33and for full-term infants k=0.45 
• For infants and children of age 1 to 12 years, k=0.55.  
 
 
 
 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
E-1 
APPENDIX E 
 
KARNOFSKY AND LANSKY PERFORMANCE STATUS SCALES 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
E-2 
APPENDIX E 
 
KARNOFSKY AND LANSKY PERFORMANCE STATUS SCALES 
 
Karnofsky for patients ≥ 16 years 
Index 
Specific Criteria 
General 
100 
Normal, no complaints, no evidence of 
disease. 
 
Able to carry on normal activity; 
no special care needed. 
90 
Able to carry on normal activity, minor signs 
or symptoms of disease. 
80 
Normal activity with effort, some signs or 
symptoms of disease. 
70 
Care for self, unable to carry on normal 
activity or to do work. 
Unable to work, able to live at 
home and care for most personal 
needs, varying amount of 
assistance needed. 
60 
Requires occasional assistance from others but 
able to care for most needs. 
50 
Requires considerable assistance from others 
and frequent medical care 
40 
Disabled, requires special care and assistance. 
Unable to care for self, requires 
institutional or hospital care or 
equivalent, disease may be rapidly 
progressing. 
 
30 
Severely disabled, hospitalization indicated, 
but death not imminent. 
20 
Very sick, hospitalization necessary, active 
supportive treatment necessary. 
10 
Moribund 
0 
Dead 
 
Lansky for patients < 16 years 
Index 
Specific Criteria 
100 
Fully Active 
90 
Minor restriction in physically strenuous play 
80 
Restricted in strenuous play, tires more easily, otherwise active 
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 
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 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
E-2 
0 
Dead 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
F-1 
APPENDIX F 
 
HCT-SPECIFIC COMORBIDITY INDEX SCORE 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
F-2 
APPENDIX F 
 
HCT-SPECIFIC COMORBIDITY INDEX SCORE 
 
Comorbidities 
Definition 
Score 
Migraine/headache 
 
0 
Osteoporosis 
 
0 
Osteoarthritis 
 
0 
Hypertension 
 
0 
Gastrointestinal 
Including inflammatory bowel disease 
0 
Mild pulmonary 
DLCo and/or FEV1 >80% or 
Dyspnea on moderate activity 
0 
Mild renal 
Serum creatinine 1.2-2 mg/dl 
0 
Endocrine 
 
0 
Bleeding 
 
0 
Coagulopathy 
Deep venous thrombosis or pulmonary embolism 
0 
Asthma 
 
0 
Arrhythmia 
 
1 
Myocardial 
Coronary artery disease, congestive HF, history of 
medically documented MI, EF≤50% 
1 
Mild hepatic 
Chronic hepatitis, Bilirubin >ULN- 1.5 X ULN, or 
AST/ALT >ULN-2.5XULN 
1 
Cerebro-vascular 
accident 
History of transient ischemic attack or cerebro-vascular 
accident 
1 
Morbid obesity 
 
1 
Diabetes 
Requiring treatment 
1 
Depression/anxiety 
 
1 
Infection 
Requiring continuation of treatment after Day 0 
1 
Rheumatologic 
SLE, RA, polymyositis, mixed CTD, polymyalgia 
rheumatica 
 
2 
Moderate pulmonary 
DLCo and/or FEV1 66-80% or 
Dyspnea on slight activity 
2 
Peptic ulcer 
Patients who have required treatment 
2 
Moderate-severe renal 
Serum creatinine >2 mg/dl, on dialysis, or prior renal 
transplantation 
2 
Valvular heart disease 
Except mitral valve prolapse 
3 
Prior solid tumor 
Requiring treatment with chemotherapy 
3 
Moderate-severe hepatic 
Liver cirrhosis, Bilirubin >1.5 X ULN, or AST/ALT 
>2.5XULN 
3 
Severe pulmonary 
DLCo and/or FEV1 ≤65% or 
Dyspnea at rest or requiring oxygen 
3 
Total score is the sum of all comorbidities present pre-transplant. 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
G-1 
APPENDIX G 
 
DERIVATION OF A SEQUENTIAL TEST STATISTIC FOR CENSORED 
EXPONENTIAL DATA 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
G-2 
APPENDIX G 
 
DERIVATION OF A SEQUENTIAL TEST STATISTIC FOR CENSORED 
EXPONENTIAL DATA 
 
 
Background – The Sequential Probability Ratio Test 
 
Let 
)
(.,θ
f
be the density function for random variable X. According to Neyman and Pearson, the 
most powerful test of 
o
H
θ
θ =
:
0
 versus
1
1 :
θ
θ =
H
 decides in favor of 
1
H  or 
0
H if 
αc
Ln >
 or 
αc
Ln <
, respectively, where 
∏
=
n
i
i
i
n
x
f
x
f
L
)
;
(
/)
;
(
0
1
θ
θ
is the likelihood ratio, and 
αc is 
determined to have the size α . When the sample size is not fixed in advance, further improvement 
is possible by using Wald’s Sequential Probability Ratio Test (SPRT). The SPRT continues to 
sample as long as 
A
L
B
n <
<
 for some constant 
A
B
<
<1
, stops sampling and decides in favor of 
1
H as soon as 
A
Ln >
, and stops sampling and decides in favor of 
0
H as soon as 
B
Ln <
. 
 
The usual measures of performance of such a procedure are the error probabilities 
α
and β of 
rejecting 
0
H when 
0
θ
θ =
, and of accepting 
0
H when 
1
θ
θ =
, respectively, and the expected sample 
size 
)
(
)
|
(
N
E
N
E
j
j ≡
θ
. Wald and Wolfowitz showed that among all tests, sequential or not, for 
which 
α
≤
)
reject 
(
Pr
0
0
H
 and 
β
≤
)
reject 
(
Pr
0
1
H
, and for which 
)
(N
E j
 are finite, j=0,1, the 
SPRT with error probabilities 
α
 and β minimizes 
)
(
0 N
E
 and 
)
(
1 N
E
. If, in addition, the 
,...
2
,1 x
x
 are independent and identically distributed (i.i.d.) with density function 
)
,
(
θ
x
f
, with 
monotone likelihood ratio in 
)
(x
τ
, then any SPRT for testing 
0
θ against 
)
(
0
1
θ
θ >
 has non-
decreasing power function. 
 
For the SPRT with error probabilities 
α
and β , the SPRT boundaries are given approximately by 
α
β /)
1( −
=
A
 and 
)
1
/(
α
β
−
=
B
. The operating characteristics of the SPRT are given by 
)
/(
)1
(
)
,
,
,
,
(
)
(
)
(
)
(
1
0
θ
θ
θ
θ
θ
β
α
θ
h
h
h
B
A
A
O
−
−
=
 where 
)
(θ
h
is the non-trivial solution to the equation 
∫
=1
)
;
(
))
,
(
/)
;
(
(
)
(
2
1
dx
x
f
x
f
x
f
h
θ
θ
θ
θ
.  
 
The formula 
)
;
(
/]
log
)
(
log
)]
(
1
[[(
)
;
(
θ
θ
θ
θ
z
E
B
O
A
O
N
E
+
−
=
provides the average sample number 
for an arbitrary θ . The sample size distribution is very highly skewed, 
2
)]
(
[
)
(
N
E
N
Var
≈
. Thus we 
will consider a truncated test with maximum sample size of 
0
N  and simulate to obtain the 
operating characteristics of the test. 
 


 
 
CNI-Free GVHD Protocol - 1301 
Version 4.0 dated June 22, 2017 
 
 
G-3 
Derivation of the SPRT for Censored Exponential Survival Times 
 
Suppose that we wish to construct a sequential test for the composite null hypothesis that the rate 
of overall mortality at an early time point t is less than or equal to p0 versus the alternative 
hypothesis that it is greater than or equal to p0. Let us assume that the survival times, 
n
T
T
T
,...,
,
2
1
, 
are i.i.d. with exponential density function 
T
e
T
f
θ
θ
θ
−
=
)
,
(
. Although an exponential model may 
not fit well for overall mortality, it usually provides a reasonable model over a short time frame 
for modeling toxicity, so in all discussion below we assume that exponential survival times are 
censored at time point t. In the exponential parameterization, a t-day survival rate of p0 translates 
into a mean survival of µ0=-t/ln(1-p0) (rate parameter 
=
0
θ
-ln(1-p0)/t). . 
 
The SPRT is derived with reference to a simple null and alternative hypothesis for the rate 
parameter, in this case, 
0 :
o
H
θ
θ
=
 versus
1
1 :
θ
θ =
H
 . The log-likelihood ratio for the exponential 
in 
the 
presence 
of 
censoring 
is 
1
0
1
0
1
0
log
( ;
)
log
( ,
)
(log( )
log(
))
(
)
n
n
n
i
i
i
i
i
i
f x
f x
d
T
θ
θ
θ
θ
θ
θ
−
=
−
−
−
∑
∏
∏
, where d is the number of 
events. The SPRT can be represented graphically when plotting the number of deaths (d) on the y 
axis against the total time on study ∑
n
i
iT  on the x axis. The continuation region in terms of d is 
bounded by two parallel lines given by 
1
0
1
0
1
0
1
0
1
0
1
0
(
)
(
)
log( )
log( )
(log
log
)
(log
log
)
(log
log
)
(log
log
)
n
n
i
i
i
i
B
A
T
d
T
θ
θ
θ
θ
θ
θ
θ
θ
θ
θ
θ
θ








−
−
+
<
<
+








−
−
−
−








∑
∑
 
with 
common 
slope 
1
0
1
0
(
) / (log
log
)
θ
θ
θ
θ
−
−
, 
and 
intercepts 
1
0
log
/ (ln
ln
)
A
θ
θ
−
 and 
1
0
log
/ (ln
ln
)
B
θ
θ
−
, for the upper and lower bounds, respectively. For monitoring purposes, at an 
interim analysis calendar time point s, suppose that d(s) events have occurred and that the total 
time on study is 
( )
n
i
i
T s
∑
.The cumulative number of events d(s) is plotted on the y axis against the 
total time on study,
( )
n
i
i
T s
∑
. When this graph crosses the upper boundary, the null hypothesis is 
rejected. In practice, monitoring will be scheduled monthly after the start of enrollment to the 
study.  
 
A truncated version of the SPRT can be obtained by specifying a maximum sample size. We 
truncate the SPRT by declaring that if the test has failed to terminate after the maximum sample 
size, that the null hypothesis will be accepted. Since the probability that the untruncated SPRT 
would reject the null at the maximum sample size is negligible, it makes little difference how the 
final boundary value is selected, and this rule is chosen for simplicity. The operating characteristics 
of this proposed truncated SPRT for censored exponential data can be estimated by simulation. 


 
 
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H-1 
 
APPENDIX H 
 
REFERENCES 
 
 


 
 
CNI-Free GVHD Protocol - 1301 
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H-2 
APPENDIX H 
 
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3 Sorror ML, Leisenring W, Deeg HJ, Martin PJ, Storb R. Twenty-Year Follow-Up of a Controlled 
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H-3 
                                                                                                                                                             
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H-4 
                                                                                                                                                             
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H-6 
                                                                                                                                                             
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Allogeneic Hematopoietic Cell Transplantation using Nonmyeloablative Conditioning 
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Relapsed 
or 
Refractory 
Hodgkin 
Lymphoma. 
Biol 
Blood 
Marrow 
Transplant. 
2009;14(11):1279-87 
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