Conditions: Leukemia
Keywords: adult acute myeloid leukemia in remission adult acute myeloid leukemia with inv(16)(p13;q22) adult acute myeloid leukemia with t(15;17)(q22;q12) adult acute myeloid leukemia with t(8;21)(q22;q22) adult acute myeloid leukemia with 11q23 (MLL) abnormalities adult acute myeloid leukemia with t(16;16)(p13;q22) childhood acute myeloid leukemia in remission
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 12
Healthy volunteers: no

Brief summary:
RATIONALE: Giving chemotherapy and colony-stimulating factors, such as G-CSF, may increase the number of stem cells in the blood. The stem cells are collected from the patient's blood and stored. Chemotherapy or radiation therapy is given to prepare the bone marrow for the stem cell transplant. The stem cells are then returned to the patient to replace the blood-forming cells that were destroyed by the chemotherapy and radiation therapy.

PURPOSE: This clinical trial is studying how well an autologous stem cell transplant works in treating patients with acute myeloid leukemia.

Detailed description:
OBJECTIVES:

* To assess whether sufficient peripheral blood stem cells (PBSC) can be collected from patients with acute myeloid leukemia (AML) using cyclophosphamide, etoposide, and granulocyte-colony stimulating factor (G-CSF) mobilization.
* To assess the rate of myeloid, platelet, and erythroid recovery following autologous PBSC transplant.
* To assess the disease-free survival rate of patients with AML receiving PBSC auto grafts.

OUTLINE:

* Chemotherapy and filgrastim (G-CSF) priming for PBSC collection: Patients receive cyclophosphamide IV on day 0; etoposide IV over 3 hours on days 0 and 1; and oral dexamethasone twice daily on days 0 and 1. Patients also receive G-CSF subcutaneously (SC) beginning on day 3 and continuing until apheresis is complete. After blood counts recover, apheresis is performed in 4-6 daily planned collections until the minimum CD34+ cell dose of \> 2.5 x 10\^6 cells/kg is achieved. If the minimum CD34+ cell dose is not achieved after 6 apheresis collections, patients undergo bone marrow examination including a bone marrow biopsy and aspiration, at the termination of the PBSC collection to confirm remission. If remission is confirmed, and if peripheral counts and marrow cellularity are sufficient, the patient remains off G-CSF for 7 days and receives sargramostim (GM-CSF) for 5 days to increase the marrow cellularity, after which a bone marrow harvest is performed.
* Bone marrow harvest without prior PBSC collection: Children will undergo primed bone marrow harvest comprising GM-CSF IV or SC for 5 days prior to harvest to increase cellularity and then marrow is harvested. Marrow and blood specimens are also obtained with the initial bone marrow evaluation and at the time of harvest if a cytogenetic abnormality was previously described. Other patients who are unable to undergo PBSC collection may proceed with a bone harvest at the discretion of the protocol chairperson.
* Cytoreductive regimen:

  * Patients over 2 years old: Patients undergo total body irradiation (TBI) twice daily on days -7 to -4 (total of 8 fractions), cyclophosphamide IV over 2 hours on days -3 and -2, followed by a 1-day rest period on day -1.
  * Patients under 2 years old and patients who cannot undergo TBI: Patients receive busulfan IV or orally every 6 hours on days -7 to -4, cyclophosphamide IV over 2 hours on days -3 to -2, followed by a 1-day rest period on day -1.
* Stem cell transplantation: All patients undergo autologous PBSC and/or bone marrow infusion on day 0. Patients also receive G-CSF IV or SC beginning on day 1 and continuing until blood counts recover.

After completion of study treatment, patients are followed periodically for 5 years.

Arms:
arm 1: Patients over the age of two will receive a cytoreductive regimen of total-body irradiation and cyclophosphamide (TBI/CY) as well as sargramostim, dexamethasone, etoposide, transplantation (bone marrow transplantation/hematopoietic stem cell transplantation/peripheral blood stem cell transplantation). arm 2: Patients under the age of two, and patients who cannot receive total body irradiation (TBI), will receive a cytoreductive regimen of Busulfan and cyclophosphamide (BU/CY) as per the Johns Hopkins University Hospital regimen as well as sargramostim, dexamethasone, etoposide, transplantation (bone marrow transplantation/hematopoietic stem cell transplantation/peripheral blood stem cell transplantation).

Interventions: intervention 1: sargramostim intervention 2: busulfan intervention 3: cyclophosphamide intervention 4: dexamethasone intervention 5: etoposide intervention 6: bone marrow transplantation intervention 7: hematopoietic stem cell transplantation intervention 8: peripheral blood stem cell transplantation intervention 9: total-body irradiation
Intervention descriptions: intervention 1: Given subcutaneously (SC) 10 μg/kg/day from day +3 until apheresis is completed intervention 2: 4 mg/kg po in 4 divided doses (.8 mg/kg/dose orally every 6 hours) on days -7 through -4. intervention 3: 4 gm/m\^2 x 1 (day 0) and 60 mg/kg intravenous (IV) over 2 hours on days -3 and -2. intervention 4: 20 mg/m\^2 x 4 doses every 12 hours given intravenously (IV) push before cytoxan on day 0 and then every 12 hours intervention 5: 300 mg/m\^2/day x 2 days (day 0-1) over 3 hours intravenously (IV) intervention 6: Day 0 infusion of bone marrow cells intervention 7: Stem cell infusion (\>48 hours after the last dose of cyclophosphamide) intervention 8: Day 0 infusion of peripheral blood stem cells intervention 9: 165 cGy/dose given twice a day on days -7 through -4.

Protocol document:
ICF_001.pdf: 































Prot_000.pdf: 
 
 
UNIVERSITY OF MINNESOTA BONE MARROW TRANSPLANTATION PROGRAM 
 
AUTOLOGOUS PERIPHERAL BLOOD STEM CELL TRANSPLANT FOR  
ACUTE NON-LYMPHOCYTIC LEUKEMIA (AML)  
 
MT2006-13 
 
 
 
 
 
October 31, 2018 
 
Study Committee 
Daniel Weisdorf, M.D.,Chair 
Paul J. Orchard, M.D., Co-Chair 
John Wagner, M.D. 
Claudio Brunstein, M.D. 
Jeffrey Miller, M.D. 
Kathryn Dusenbery, M.D. 
Todd DeFor, M.S. 
 
 
 
 
 
This document contains confidential information that is the property of the Blood and Marrow Transplant 
Program.  Do not copy, disclose, or circulate without written authorization from the Fairview-University 
Blood and Marrow Transplant Services Medical Director. 
 


 
October 31, 2018 
2
PROTOCOL CHANGES  
DATE 
PROTOCOL CHANGE 
IRB APPROVAL 
7/11/2008 
revised the eligiblity to exclude patients with active or 
resistant CNS leukemia; not those with prior CNS 
leukemia 
 
2/13/2009 
Corrected typo in section 4.2.2 
 
12/04/2013 
Corrected typo in section 4.3.2; adjustment to listed 
busulfan dose, section 4.3.2 
 
8/4/2016 
Updated to current standard of care guidelines: 
-follow up will be two years post BMT (subjects then 
transferred to BMT database follow up) 
-updated data and safety monitoring plan 
-updated required observations table 
-updated TBI guidelines 
 
Removed Linda Burns from study committee 
 
10/31/2018 
Removed 1.5 year visit from observations table; updated 
link to Masonic Cancer Center's Data & Safety 
Monitoring Plan 
 
 
 
 
 
 
 
 
 
 


 
October 31, 2018 
3
TABLE OF CONTENTS 
 
SECTION 
 
TITLE  
 
 
 
 
 
PAGE 
 
 
 
 
Protocol Schema 
 
 
 
 
 
4 
 
 
1.0 
 
Objectives 
 
 
 
 
 
 
5 
 
 
2.0 
 
Background and Rationale 
 
 
 
 
5 
 
 
3.0 
 
Eligibility and Exclusion Criteria 
 
 
 
7 
 
 
4.0 
 
Treatment Schema 
 
 
 
 
 
8 
 
 
5.0 
 
Required Observations 
 
 
 
 
11 
 
 
6.0 
 
Follow-up Studies 
 
 
 
 
 
12 
 
 
7.0 
 
Toxicities and Complications  
 
 
 
12 
 
 
8.0 
 
Drug Information 
 
 
 
 
 
13 
 
 
9.0 
 
Experimental Design and Statistical Considerations  
14 
 
 
10.0 
 
Data and Safety Monitoring Plan 
 
 
 
15 
 
 
11.0 
 
References 
 
 
 
 
 
 
15 
 
 
12.0 
 
Appendices 
 
 
 
 
 
 
18 
 
 
 
 
Appendix I 
BMT Priority: AML  
 
 
 
18 
 
 
Appendix II 
Apheresis 
 
 
 
 
 
19 
 
 
Appendix III Required Studies 
 
 
 
 
20 
 
 
Appendix IV  Radiation Guidelines  
 
 
 
21 
 
 
 
 


 
October 31, 2018 
4
Schema MT 2006-13 
Autologous AML  
 
 
Chemotherapy Priming : 
Cytoxan 4 Gm/m2 IV day 0 
Etoposide 300 mg/m2 day 0 
Etoposide 300 mg/m2 day +1 
Dexamethasone 20 mg/m2 bid day 0 
Dexamethasone 20 mg/m2 bid day +1 
 
G-CSF 10 ug/kg/day - Begin day +3 
 
 
Autologous Stem Cell Collection 
(when counts recover) 
 
 
 
 
BMT Admission 
2 years  to 70 years 
BMT Admission 
Patients < 2 years of age 
OR 
Any patient who cannot receive TBI 
Day -7 
TBI 165 cGy/dose BID 
Day -7 
Busulfan .8 mg/kg IV q  6 hr 
Day -6 
TBI 165 cGy/dose BID 
Day -6 
Busulfan .8 mg/kg IV q  6 hr 
Day -5 
TBI 165 cGy/dose BID 
Day -5 
Busulfan .8 mg/kg IV q  6 hr 
Day -4 
TBI 165 cGy/dose BID 
Day -4 
Busulfan .8 mg/kg IV q  6 hr 
Day -3 
Cytoxan 60 mg/kg IV 
Day -3 
Cytoxan 60 mg/kg IV 
Day -2 
Cytoxan 60 mg/kg IV 
Day -2 
Cytoxan 60 mg/kg IV 
Day -1 
 
Day -1 
 
Day 0 
Stem Cell Infusion 
Day 0 
Stem Cell Infusion 
Day +1 
G-CSF 
Day +1 
G-CSF 
 
 
 


 
October 31, 2018 
5
1.0 
OBJECTIVES 
 
In order to improve clinical outcomes and reduce the morbidity of bone marrow transplantation for 
patients with acute non-lymphocytic leukemia (AML), this study is designed to assess:   
 
1.1 
Can sufficient peripheral blood stem cells (PBSC) be collected from subjects with AML using 
cyclophosphamide (Cy), etoposide (VP-16) and granulocyte-colony stimulating factor (G-
CSF) mobilization?   
 
1.2 
What is the rate of myeloid, platelet and erythroid recovery following autologous PBSC 
transplant?   
 
1.3 
What is the disease free survival (DFS) rate of patients with AML receiving PBSC auto 
grafts? 
 
2.0 
BACKGROUND AND RATIONALE 
 
2.1 
Chemotherapy and Allogeneic BMT for AML:   
With current induction regimens using combinations of cytosine arabinoside (Ara-C) and 
daunorubicin the majority of patients with acute non-lymphocytic leukemia will achieve 
remission; however, the majority of these patients relapse.  The 5 year disease free survival 
(DFS) with chemotherapy is approximately 30% in adults, but may be somewhat higher in 
children treated on current very aggressive chemotherapy regimens (1,2).  Patients who 
receive intensive cytoreductive therapy followed by allogeneic bone marrow transplantation 
(BMT) using matched related donors have 5 year DFS rates of approximately 50-60% (3-6).   
 
2.2 
Autologous BMT for AML:   
Autologous marrow transplantation has been an accepted form of treatment for AML when a 
matched related donor is not available, or for certain ANLL subgroups.  While the rate of 
relapse is higher with autologous BMT for AML than allogeneic transplant, in several 
comparative reports due to the increased transplant related mortality of allogeneic BMT the 
long term disease free survival rates are comparable (1,7).  Studies have consistently 
documented 5 year disease-free survival (DFS) rates of 40-50% for patients in first remission 
(1,8).  The survival of patients in second remission or in those transplanted in relapse are 
lower (9-11).  The difficulties related to achieving long term DFS with autologous BMT 
include:   
 
2.2.1 BMT Related Toxicity:   
There is a 10-15% peri-BMT mortality observed with autologous transplantation for AML 
(6,12).  Modfications that would decrease the period of neutropenia would be beneficial.  In 
this context, the use of peripheral blood stem cells as a source of CD34+ cells has been 
explored to obtain more rapid engraftment (13-15).   
 
2.2.2 Relapse:  
The largest obstacle to prolonged DFS following autologous BMT for AML is relapse, 
occurring in 30-40% of patients.  Relapse may result from residual disease in the marrow, as 


 
October 31, 2018 
6
has been documented by molecular techniques (13), or from incomplete eradication of disease 
in vivo.  While purging with agents such as 4-hydroxycyclophosphamide (4-HC) has been 
used to decrease the rate of relapse (16,17), currently this agent is not available for clinical 
trials.  In addition, engraftment may be delayed following purging, and may therefore lead to 
increased morbidity and mortality (18).  It is possible that the chemotherapy used in this study 
prior to the collection of peripheral blood stem cells will improve disease free survival.    
 
2.3 
Autologous Transplant in "Good Risk" AML Patients: 
Recent studies relating to the prognosis of patients with AML based on chromosomal findings 
have suggested that it may be possible to identify a patient population where this is likely to 
have an improved outcome (24,25).  Specifically, patients with t8:21 and inv16 have been 
reported to have a 5 year DFS rate of approximately 60% or higher, especially if high dose 
cytosine arabinoside is used in the consolidation regimen (24).  Based on this information, it 
is important to address the issue of whether these patients should be offered autologous 
transplantation in first remission.  A randomized study of autologous transplantation or no 
further therapy in patients with AML in first remission was recently reported (26), suggesting 
that autologous transplantation was superior on an intent to treat analysis for providing DFS at 
7 years (53 vs. 40%; p=0.04).  In addition, when patients in a "good risk" category were 
identified, those that underwent autologous transplantation had a decreased risk of relapse 
(25% vs. 49%, p=0.02) as well as improved DFS (70% vs. 48%, p=0.04).   
 
2.4 
The Use of Peripheral Stem Cells (PBSC) in BMT:   
It has been well documented that CD34+ cells can be identified in the peripheral blood, and 
that the proportion of these early progenitors can be increased using cytokines such as 
granulocyte-colony stimulating factor (G-CSF) and/or chemotherapy (14,18).  In autologous 
BMT using PBSC as a source of CD34+ cells rapid hematopoietic recovery has been 
observed, making this approach attractive as an alternative to harvesting autologous marrow 
(31).  Unfortunately, in patients heavily pre-treated with chemotherapy it may prove more 
difficult to obtain adequate numbers of peripheral blood CD34+ cells.  For AML patients 
receiving autologous peripheral blood stem cell transplants, it has been shown that increasing 
the cell dose decreases the mortality observed by day 100 (14,32).  The recovery of the 
platelet count following autologous BMT for AML has also been of concern (14,33).  For 
these reasons, we will administer >2.5 x 106 CD34+ cells/kg to patients on this study.   
 
2.5 
Chemotherapy and G-CSF Priming of PBMC for AML.   
The administration of G-CSF increases the number of circulating CD34+ cells that can be 
obtained from the peripheral blood.  Alternatively, chemotherapeutic agents have been used in 
this capacity, with or without G-CSF.  Due to concerns regarding the potential stimulation of 
myeloid leukemia by priming with G-CSF (14,21), in this investigation we will combine G-
CSF with chemotherapeutic agents in an attempt to decrease concern regarding possible risk 
of leukemic stimulation.  An agent commonly used in this role is Cy, which has often been 
administered in a single dose of 4 gm/M2.  It has been suggested that the combination of Cy (4 
gm/M2 IV x 1) and VP-16 (200 mg/M2 IV x 3) may increase the CD34+ cell yield compared 
to Cy alone (34).  As VP-16 has substantial activity against AML, Cy and VP-16 followed by 
G-CSF (10 µg/kg/day subcutaneously [SC]) will be used prior to PBSC harvest for 
mobilization.  This dose of G-CSF was chosen as it appears that the combination of Cy, VP-


 
October 31, 2018 
7
16 and doses of G-CSF of at least 10 µg/kg/day were associated with increased yield of 
CD34+ cells and faster hematopoietic recovery (35).   
 
3.0 ELIGIBILITY AND EXCLUSION CRITERIA 
Children under the age of two are eligible for this protocol, but will not receive total body irradiation.  
Instead, children under the age of two will receive Bu/Cy conditioning as the preparative regimen in 
order to obviate deleterious effects of radiation at this age.  Patients who cannot receive TBI (for 
example those with prior radiation therapy) will also receive the Bu/CY conditioning. 
 
3.1 
AML 
All children and adults less than the age of 70 with AML who have achieved a first or second 
bone marrow remission are eligible for this protocol.  Patients must undergo peripheral blood 
stem cell collection or marrow harvest while in remission and must not be expected to have 
better outcomes with allogeneic transplantation.   
 
Patients with cytogenetic abnormalities suggesting an improved prognosis [t(8:21), t(15;17) 
and inv(16)] will be eligible for transplantation in first remission. 
 
3.2 
Allogeneic transplant with an HLA-identical sibling will be recommended for patients <55 
years.  If the patient refuses allogeneic transplant, they may still be eligible for this protocol. 
 
3.3 
Patients can also be deemed not eligible for transplant because of specific organ toxicity.  
Specifically, patients with pre-existing compromise to the heart, lungs, kidney, CNS or liver 
may be excluded: 
 
3.3.1 ECOG (See Appendix II). 
Performance status: 
0 or 1  
 
3.3.2 Heart 
The patient must be free of symptoms of uncontrolled cardiac disease, and must not have 
compromised cardiac function detected by ECHO or by gated cardiac blood flow scan 
(MUGA)  LVEF >45%).   
 
3.3.3 Kidney 
The patient must have a corrected creatinine clearance >50% of normal. 
 
3.3.4 Liver 
The total serum bilirubin < 2.5 mg/dL; ALT <2 x upper limit of normal. 
 
3.3.5 Lung 
Patients must have no significant obstructive airways disease or resting hypoxemia (PO2 <80), 
and must have acceptable diffusion capacity (DLCO > 50% of predicted). 
 
3.3.6 Central Nervous System: 
Patients must be free of active or ongoing ischemic or degenerative CNS disease and no 
active or resistant CNS leukemia. 


 
October 31, 2018 
8
 
4.0 
TREATMENT SCHEMA 
 
4.1 
Peripheral Blood Stem Cell Mobilization, Collection:   
 
4.1.1 Criteria to Begin Priming for PBSC:   
Prior to proceeding with an autologous stem cell collection, a remission must be achieved (M1 
marrow; less than 5% blasts in a marrow which is slightly hypocellular, normocellular or 
hypercellular), and the patient must have recovered blood counts (absolute neutrophil count >1500 
cells/mL, Hgb (untransfused) >9 gm/dL, platelet count (untransfused) >100,000 cells/mL); all 
unsupported by hematopoietic growth factors for >14 days.  Patients should be at least 4 weeks from 
previous myelosuppressive chemotherapy.  Cytogenetic complete remission is necessary to be 
eligible for peripheral stem cell or marrow harvest.   
 
4.1.2 Priming for PBSC Collection 
Patients will receive chemotherapy and G-CSF priming as follows:   
 
Admit to hospital: 
 
After > 4 hours of hydration (rate of 3000 mL/M2/day) 
 
1. Cyclophosphamide (Cy)  4 gm/M2 x 1 (day 0)  
Mesna 800 mg/M2 x 5 doses;  (to begin 10-15 min. before   
Cy, at 1 hr, 3, 6 and 12 hrs.) 
 
2. Dexamethasone 20mg/m2 x 4 doses q 12 hr given IV push pre cytoxan on day 0 and 
then q 12h. 
 
3. Etoposide (VP-16)   300 mg/M2/day x 2 days (day 0-1)  
VP-16 is to be given over 3 hours IV. 
 
4. G-CSF (subcutaneously; SC 10 μg/kg/day* from day +3 until apheresis is completed 
*Round dose to G-CSF vial size;  
 
4.1.3 Apheresis will be performed when the ANC achieves 1000 cells/mL, and will continue 
for a minimum of 4 daily planned collections. 
 
4.1.4 The minimum CD34+ cell dose is >2.5 x 106 cells/kg.  If this cell dose is not achieved 
at the end of 4 collections, 2 additional collections can be performed; (total of 6 
collections).   
 
4.1.5 Should the total number of CD34+ cells from 6 collections be inadequate to obtain the 
minimum cell dose (2.5 x 106 CD34+ cells/kg), a bone marrow harvest will be 
planned.  A bone marrow examination will be performed, including a biopsy and 
aspirate, at the termination of the PBSC collection to confirm remission.  If remission 
is confirmed, and if the peripheral counts and marrow cellularity are sufficient (see 


 
October 31, 2018 
9
Section 4.1.1), the patient will remain off G-CSF for 7 days.  GM-CSF (250 
ug/M2/day) will then be started for 5 days to increase the marrow cellularity, after 
which a bone marrow harvest will be performed on day 6.  A total of 1.5 liters of 
marrow will be drawn from adult patients, or if the patient is >60 kg.  For children and 
those <60 kg, 20 mL/kg of marrow will be obtained during a harvest. 
 
4.2 
Bone Marrow Harvest Without Prior PBSC Collections:   
 
4.2.1 Children <10 kg will not be eligible for PBSC collection, and will undergo a primed 
bone marrow harvest using GM-CSF.  Other patients that are unable to have PBSC 
collections performed may proceed with a bone marrow harvest at the discretion of the 
protocol chairperson.   
 
4.2.2 Patients to undergo a marrow harvest without prior PBSC collections will receive 5 
days of GM-CSF (250 mcg/M2/day) IV or SC prior to harvest to increase cellularity 
and marrow will be harvested on day 6.  Marrow and blood specimens will still be 
obtained with the initial bone marrow evaluation and at the time of harvest if a 
cytogenetic abnormality was previously described.  A dose of 20 mL/kg of marrow 
will be obtained during the harvest. 
 
4.3 
Transplant Schema 
 
4.3.1 Patients over the age of two will receive a cytoreductive regimen of "TBI/CY".  A 
fluid flush of 3000 mL/M2 is to begin 10 hours prior to the infusion of Cy (Section 
4.6.3), with administration of MESNA to total 120 mg/kg according to current 
guidelines.   
Day 
Agents 
-7 
TBI 165 cGy /dose given twice a day* 
-6 
TBI 165 cGy /dose given twice a day 
-5 
TBI 165 cGy /dose given twice a day 
-4 
TBI 165 cGy /dose given twice a day 
-3 
Cyclophosphamide 60 mg/kg IV over 2 hrs (10 AM) 
-2 
Cyclophosphamide 60 mg/kg IV over 2 hrs (10 AM) 
-1 
Rest 
0 
Peripheral blood stem cell (and/or marrow) infusion 
 
*Radiation therapy and the attending BMT physician may decide that patients may begin their 
TBI as an outpatient, and will then be admitted on day -4 to begin the Cy fluid flush.   
 
1320 cGy will be administered in 8 fractions of 165 cGy each with 2 fractions being given 
each day. 
 
 
4.3.2 Patients under the age of two, and patients who cannot receive TBI, will receive a 
cytoreductive regimen of "BU/CY" as per the Johns Hopkins University Hospital 
regimen. 


 
October 31, 2018 
10 
Day 
Agents 
-7 
*Busulfan 3.2 mg/kg in 4 divided doses (.8 mg/kg/dose IV q 6 hrs) 
-6 
Busulfan 3.2  mg/kg in 4 divided doses (.8 mg/kg/dose IV q 6 hrs) 
-5 
Busulfan 3.2  mg/kg in 4 divided doses (.8 mg/kg/dose IV q 6 hrs) 
-4 
Busulfan 3.2  mg/kg in 4 divided doses (.8 mg/kg/dose  IV q 6 hrs) 
-3 
Cyclophosphamide 60 mg/kg/day IV over 2 hours 
-2 
Cyclophosphamide 60 mg/kg/day IV over 2 hours 
-1 
Rest 
0 
Stem cell infusion (>48 hours after the last dose of 
cyclophosphamide) 
* Busulfan (intravenous BUSULFEX) dose, administration and 
phamacokinetic monitoring to be administered as described in MT2003-19S. 
 
4.4 
Infusion of Cryopreserved Autologous Stem Cells and/or Marrow 
 
4.4.1 Stem cells are preserved using dimethyl sulfoxide (DMSO) as a cryoprotectant.  
DMSO may cause nausea during infusion.  Patients should be premedicated with an 
anti-emetic one half hour prior to anticipated infusion.  Autologous stem cells will be 
thawed on the transplant ward and infused intravenously. 
 
4.4.2 The stem cells should be infused rapidly through a central venous catheter. 
 
4.4.3 The entire line through which the stem cells are to be infused must be flushed with 
normal saline both pre and post-infusion. The remainder of the fluids administered to 
the patient may be of any composition deemed appropriate by the clinical physicians. 
 
4.5 
Supportive Care 
 
4.5.1 Infectious Disease Prophylaxis:  
Pneumocystis prophylaxis, CMV, fungal and bacterial prophylaxis will be performed 
according to current University of Minnesota guidelines.   
 
4.5.2 Fluids 
Adequate diuresis must be maintained before and after Cy administration to help 
prevent hemorrhagic cystitis.  The recommended maintenance fluid is 3000-4000 
mL/M2/24o.  This rate should be started at least 10 hours before the first Cy dose and 
24 hours after the last Cy dose.  Cyclophosphamide has been associated with bladder 
cystitis and SIADH; therefore, serum electrolytes will be followed frequently, along 
with b.i.d. weights and strict intake and output.  If patient develops any sign of fluid 
overload, appropriate measures will be taken to reduce fluid retention, such as use of 
diuretics.  (See cytoxan fluid guidelines) 
 
4.5.3 G-CSF Administration Post Transplant: 
All patients will receive G-CSF (5 mcg/kg/day) subcutaneously or IV from day +1 
until the ANC is >2,500 for 2 days.   
 


 
October 31, 2018 
11 
4.5.4 All blood products administered after the initiation of primary chemotherapy will be 
irradiated (> 1500 rad).  To prevent transfusion associated graft vs host disease. 
 
4.5.5 Phenytoin:   
Although patients receiving busulfan may on a rare occasion develop seizures, patients 
on this protocol will not receive anti-convulsants prophylactically as it is unknown 
whether anti-convulsants significantly change metabolism of busulfan in vivo.  If 
seizures do develop, it is recommended that they be treated with phenytoin.   
 
5.0 
REQUIRED OBSERVATIONS 
 
5.1 
History:  A complete medical history with full details of the patient's previous treatment and 
response including particularly: 
 
5.1.1 Drugs (including previous chemotherapy regimens and total dose of 
 
anthracyclines). 
 
5.1.2 Presenting WBC, FAB morphology and cytogenetics.   
 
5.1.3 Cell surface markers on malignant cells. 
 
5.1.4 Previous radiation (including dose and field size). 
 
5.1.5 Previous CNS disease and treatment. 
 
5.1.6 Previous other extramedullary relapses (e.g. chloromas). 
 
5.1.7 Previous infections (specific organisms if known and antibiotic therapy). 
 
5.1.8 Transfusions, including significant reactions. 
 
5.1.9 Hemorrhage. 
 
 
5.2 
Physical examination of recipient; To include: 
 
5.2.1 Height, weight, head circumference for patients < 4 years. 
 
5.2.2 Tanner stage (breast, pubic) for patients <21 years. 
 
5.3 
Disease Status:   
 
5.3.1 
• If sufficient CD34+ cells are achieved in the PBSC harvest, the patient will proceed to 
transplant. 
 


 
October 31, 2018 
12 
• If sufficient numbers of CD34+ are not achieved in the PBSC collection, and the 
marrow remains in remission, the patient will progress to bone marrow harvest.  If 
disease progression is observed, either in the marrow or if extramedullary disease 
develops, the patient will be ineligible for transplant until further therapy is received 
and remission achieved.   
 
 
5.4 
Cytogenetic Studies: 
5.4.1 Initial Testing:   
All patients with previously documented cytogenetic abnormalities will have samples 
of blood (10 cc in sodium heparin tube) and 3-5 mL of heparinized marrow sent to the 
cytogenetics laboratory as part of their initial evaluation pre-BMT for metaphase 
and/or FISH analysis as indicated.   
 
6.0 
FOLLOW-UP STUDIES/RESPONSE EVALUATION 
6.1 
CBC, differential count, and platelets should be performed daily until ANC >500, then as 
needed until discharge.  Thereafter, CBC's should be done every 1-2 months for the first two 
years after transplantation. 
 
6.2 
ALT, bilirubin, alkaline phosphatase, and electrolytes should be performed at least twice 
weekly during transplantation hospitalization.   
 
6.3 
Bone marrow aspiration and biopsy will be done as follows: day 28, at day 100, at 6 months 
at one year and 2 years from the date of transplantation, and then whenever clinically 
indicated.  If a particular patient had a clonal cytogenetic abnormality pre-transplantation in 
the leukemia cells, then bone marrow cytogenetic studies should be obtained with each 
marrow aspirate. 
 
6.4 
Long-term follow-up studies to determine late effects of treatment: 
 
6.4.1 Thyroid function studies (T4, TSH) will be performed yearly for two years. 
 
6.5 
Response Evaluation; Definition of outcomes : 
 
6.5.1 Disease evaluation will be completed approximately 100 days after stem cell infusion 
and 6 months, 1 year, and until 2 years after infusion. 
 
 
6.5.2 Time to treatment failure - from date of stem cell infusion to date of recurrence. 
 
7.0 
TOXICITIES AND COMPLICATIONS 
 
7.1 
Cyclophosphamide: 
Bone marrow suppression, nausea, vomiting, diarrhea, mouth sores, alopecia, hemorrhagic cystitis, 
acute cardiac decompensation, and hyponatremia (usually responsive to limiting free water intake). 
 
7.2 
Busulfan: 


 
October 31, 2018 
13 
Myelosuppression, mucositis, diarrhea, alopecia, pulmonary fibrosis, sterility, amenorrhea, and rarely 
seizures. 
 
7.3. 
Etoposide (VP-16) 
• Nausea, vomiting and diarrhea are common. 
• Mucositis.  Oropharyngeal mucosal inflammation may be severe with high-dose etoposide.  
This may require parenteral analgesia as the mucositis may be severe enough to prevent 
talking, swallowing or eating without pain. 
• Secondary malignancy 
 
7.4 
Total Body Irradiation: 
Nausea and vomiting, diarrhea, parotitis (rapid onset within 24-48 hours, usually self limiting), skin 
(generalized mild erythema), late effects (possible growth retardation, vertebral abnormalities, 
cataracts, probable increased risk of second malignant neoplasms, sterility). 
 
7.5 
G-CSF: 
The administration of G-CSF can be associated with bone pain, headaches, body aches, fatigue, 
nausea, vomiting, insomnia, dyspnea and fever.  Symptoms are usually minor and can usually be 
controlled with acetaminophen. 
 
8.0 
DRUG INFORMATION 
 
8.1 
Cyclophosphamide (Cytoxan (R), CPM)  NSC - 6271.  Commercially available. 
 
8.1.1 Formulation 
100.0 mg, 200.0 mg and 500.0 mg vials for IV use. 
 
8.1.2 Storage 
Room temperature. 
 
8.1.3 Mixing 
IV drug should be mixed with sterile water for IV use.  Dissolves very slowly with cold 
water; it helps to warm water or warm vial after adding water. 
 
8.1.4 Stability 
IV solution should be used within 12 hours of mixing.  May be stored at room temperature for 
24 hours and 6 days when refrigerated. 
 
8.1.5 Administration 
By IV drip over 30-120 minutes. 
 
8.1.6 Toxicity 
Nausea and vomiting, alopecia, bone marrow depression, immunosuppression, hemorrhagic 
cystitis, SIADH, and rarely acute cardiac decompensation. 
 
8.2 
Busulfan (Myleran) 


 
October 31, 2018 
14 
 
8.2.1 Formulation 
IV solution. 
 
8.2.2 Storage 
Room temperature. 
 
8.2.3 Stability 
Note manufacturer's date. 
 
8.2.4 Toxicity 
Myelosuppression, mucositis, diarrhea, alopecia, pulmonary fibrosis, amenorrhea, 
azoospermia.   
 
8.3 
 Etoposide (VP-16) 
Commercially available 
 
8.3.1 Formulation 
300 mg/m2 IV given on day 0 and day +1 
 
8.3.2 Storage 
Room Temperature 
 
8.3.3 Administration 
By IV infusion over 3 hours 
 
8.3.4 Toxicity 
Nausea, vomiting, diarrhea, myelosuppression, mucositis and secondary malignancy. 
 
9.0 
STUDY DESIGN  
 
9.1 
Objectives And Primary Outcome Variables:   
 
1. Can sufficient PBMC be collected with the Cy/VP-16/G-CSF priming regimen? (from 1.1)  
The proportion of primed patients with adequate number of cells collected will be calculated. 
2. What is rate of myeloid, platelet, and erythroid recovery (engraftment) (from 1.2).  median 
days from BMT engraftment to cell recovery.   
3. What is the rate of relapse? (from 1.3)  will be delivered by Kaplan-Meier estimate.  
 
9.2 
Statistical Analysis: 
 
This study defines a treatment plan for patients in whom transplantation is determined to be 
the preferred therapy.  As a defined treatment plan, no statistical comparisons are planned. 
 
9.3 
Outcomes and Follow-up. 
 


 
October 31, 2018 
15 
Patients will be followed for a minimum of 2 years post transplant and data will collected for 
a descriptive analysis of late effects of therapy.  The percentage of individuals with various 
late effects will be examined, including thyroid function abnormalities, gonadal abnormalities, 
cataracts, pulmonary dysfunction, growth and development abnormalities, and second 
malignant neoplasms.  Parameters will be observed for at least two years in individuals 
surviving post-transplantation.  
 
After two years of follow up, patients will be monitored for survival data on through the BMT 
database.  
 
10.0   DATA AND SAFETY MONITORING PLAN 
 
This study will be in compliance with the Masonic Cancer Center's Data & Safety Monitoring 
Plan, which can be accessed at http://z.umn.edu/dmsp  
 
For the purposes of data and safety monitoring, this study is classified as moderate risk.  
Therefore the following requirements will be fulfilled: 
 The Masonic Cancer Center Data and Safety Monitoring Council (DSMC) will review the 
study’s progress at least every 6 months with the understanding the Cancer Protocol 
Review Committee (CPRC) may require more frequent reporting. 
 The PI will comply with at least twice yearly monitoring of the project by the Masonic 
Cancer Center monitoring services. 
 The PI will oversee the submission of any event meeting the definition of reportable to the 
University of Minnesota IRB 
(http://www.research.umn.edu/irb/guidance/ae.html#.VC7xraI0-sh) with a copy to the 
MCC SAE Coordinator (mcc-saes@umn.edu) .   
In addition, at the time of the continuing review with the University of Minnesota IRB, a copy 
of the report with any attachments will be submitted to the Cancer Protocol Review 
Committee (CPRC). 
 
 
 
 
11.0 
REFERENCES 
 
1.  Zittoun, R. A., Mandelli, F., Willemze, R., de Witte, T., Labar, B., et al. Autologous or allogeneic 
bone marrow transplantation compared with intensive chemotherapy in acute myelogenous leukemia. 
European Organization for Research and Treatment of Cancer (EORTC) and the Gruppo Italiano 
Malattie Ematologiche Maligne dell'Adulto (GIMEMA) Leukemia Cooperative Groups [see 
comments], N. Engl. J. Med. 332: 217-23, 1995. 
2.  Woods, W. G., Kobrinsky, N., Buckley, J. D., Lee, J. W., Sanders, J., et al. Timed-sequential 
induction therapy improves postremission outcome in acute myeloid leukemia: a report from the 
Children's Cancer Group, Blood. 87: 4979-89, 1996. 
3.  Dinndorf, P. and Bunin, N. Bone marrow transplantation for children with acute myelogenous 
leukemia. [Review] [161 refs], Journal of Pediatric Hematology/Oncology. 17: 211-24, 1995. 


 
October 31, 2018 
16 
4.  Christiansen, N. P. Allogeneic bone marrow transplantation for the treatment of adult acute 
leukemias. [Review] [145 refs], Hematology   Oncology Clinics of North America. 7: 177-200, 1993. 
5.  Mehta, J., Powles, R., Treleaven, J., Horton, C., Tait, D., et al. Long-term follow-up of patients 
undergoing allogeneic bone marrow transplantation for acute myeloid leukemia in first complete 
remission after cyclophosphamide-total body irradiation and cyclosporine, Bone Marrow Transplant. 
18: 741-6, 1996. 
6.  Gorin, N. C., Labopin, M., Fouillard, L., Meloni, G., Frassoni, F., et al. Retrospective evaluation 
of autologous bone marrow transplantation vs allogeneic bone marrow transplantation from an HLA 
identical related donor in acute myelocytic leukemia. A study of the European Cooperative Group for 
Blood and Marrow Transplantation (EBMT), Bone Marrow Transplant. 18: 111-7, 1996. 
7.  Vowels, M. R., Lam-Po-Tang, R., Ford, D., Trickett, A., and Mameghan, H. Allogeneic and 
autologous bone marrow transplantation for acute non-lymphoblastic leukaemia, Journal of 
Paediatrics & Child Health. 30: 319-23, 1994. 
8.  Dusenbery, K. E., Steinbuch, M., McGlave, P. B., Ramsay, N. K., Blazar, B. R., et al. Autologous 
bone marrow transplantation in acute myeloid leukemia: the University of Minnesota experience, 
International Journal of Radiation Oncology, Biology, Physics. 36: 335-43, 1996. 
9.  Dusenbery, K. E., Daniels, K. A., McClure, J. S., McGlave, P. B., Ramsay, N. K., et al. 
Randomized comparison of cyclophosphamide-total body irradiation versus busulfan-
cyclophosphamide conditioning in autologous bone marrow transplantation for acute myeloid 
leukemia [see comments], International Journal of Radiation Oncology, Biology, Physics. 31: 119-
28, 1995. 
10.  Ball, E. D. and Rybka, W. B. Autologous bone marrow transplantation for adult acute leukemia. 
[Review], Hematology   Oncology Clinics of North America. 7: 201-31, 1993. 
11.  Petersen, F. B., Lynch, M. H., Clift, R. A., Appelbaum, F. R., Sanders, J. E., et al. Autologous 
marrow transplantation for patients with acute myeloid leukemia in untreated first relapse or in 
second complete remission, Journal of Clinical Oncology. 11: 1353-60, 1993. 
12.  Cahn, J. Y., Labopin, M., Mandelli, F., Goldstone, A. H., Eberhardt, K., et al. Autologous bone 
marrow transplantation for first remission acute myeloblastic leukemia in patients older than 50 years 
- a retrospective analysis of the european bone marrow transplant group, Blood. 85: 575-579, 1995. 
13.  Brenner, M. K., Rill, D. R., Moen, R. C., Krance, R. A., Heslop, H. E., et al. Gene marking and 
autologous bone marrow transplantation. [Review], Ann N Y Acad Sci. 716: 204-14, 1994. 
14.  Demirer, T., Buckner, C. D., Appelbaum, F. R., Petersen, F. B., Rowley, S., et al. Rapid 
engraftment after autologous transplantation utilizing marrow and recombinant granulocyte colony-
stimulating factor-mobilized peripheral blood stem cells in patients with acute myelogenous 
leukemia, Bone Marrow Transplant. 15: 915-22, 1995. 
15.  Henon, P. R. Peripheral blood stem cell transplantations: past, present and future. [Review] [119 
refs], Stem Cells. 11: 154-72, 1993. 
16.  Cassileth, P. A., Andersen, J., Lazarus, H. M., Colvin, O. M., Bennett, J. M., et al. Autologous 
bone marrow transplant in acute myeloid leukemia in first remission, Journal of Clinical Oncology. 
11: 314-9, 1993. 
17.  Woods, W. G., Kobrinsky, N., Buckley, J., Neudorf, S., Sanders, J., et al. Intensively timed 
induction therapy followed by autologous or allogeneic bone marrow transplantation for children 
with acute myeloid leukemia or myelodysplastic syndrome: a Childrens Cancer Group pilot study 
[see comments], Journal of Clinical Oncology. 11: 1448-57, 1993. 
18.  Imrie, K., Dicke, K. A., and Keating, A. Autologous bone marrow transplantation for acute 
myeloid leukemia. [Review] [80 refs], Stem Cells. 14: 69-78, 1996. 


 
October 31, 2018 
17 
20.  Bloomfield, C., Lawrence, D., Arthur, D., Berg, D., Schiffer, C., et al. Curative Impact of 
Intensification with High-Dose Cytarabine (HiDAC) in Acute Myeloid Leukemia (AML) Varies by 
Cytogenetic Group, Blood. 84: suppl 1, 1994. 
21.  Mrozek, K., Heinonen, K., de la Chapelle, A., and Bloomfield, C. D. Clinical significance of 
cytogenetics in acute myeloid leukemia. [Review] [93 refs], Seminars in Oncology. 24: 17-31, 1997. 
22.  Burnett, A. K., Goldstone, A. H., Stevens, R. M., Hann, I. M., Rees, J. K., et al. Randomised 
comparison of addition of autologous bone-marrow transplantation to intensive chemotherapy for 
acute myeloid leukaemia in first remission: results of MRC AML 10 trial. UK Medical Research 
Council Adult and Children's Leukaemia Working Parties, Lancet. 351: 700-8, 1998. 
23.  To, L., Roberts, M., Haylock, D., Dyson, P., Branford, A., et al. Comparison of recovery times 
and supportive care requirements of autologous recovery phase peripheral blood stem cell transplants, 
autologous bone marrow transplants and allogeneic transplants, Bone Marrow Transplant. 9: 277-
284, 1992. 
24.  Demirer, T., Gooley, T., Buckner, C. D., Petersen, F. B., Lilleby, K., et al. Influence of total 
nucleated cell dose from marrow harvests on outcome in patients with acute myelogenous leukemia 
undergoing autologous transplantation, Bone Marrow Transplant. 15: 907-13, 1995. 
25.  Roberts, M. M., Dyson, P. G., Willson, K., Juttner, C. A., and To, L. B. Peripheral blood stem 
cells mobilized from patients with acute myeloid leukaemia have different platelet repopulating 
abilities compared with those mobilized from patients with other diseases, Bone Marrow Transplant. 
18: 41-5, 1996. 
26.  Demirer, T., Buckner, C. D., Storer, B., Lilleby, K., Rowley, S., et al. Effect of different 
chemotherapy regimens on peripheral-blood stem-cell collections in patients with breast cancer 
receiving granulocyte colony-stimulating factor, Journal of Clinical Oncology. 15: 684-90, 1997. 
27.  Demirer, T., Buckner, C. D., and Bensinger, W. I. Optimization of peripheral blood stem cell 
mobilization. [Review] [77 refs], Stem Cells. 14: 106-16, 1996. 
28.  Meloni, G., Diverio, D., Vignetti, M., Avvisati, G., Capria, S., et al. Autologous Bone Marrow 
Tranplantation for Acute Promyelocytic Leukemia in Second Remission: Prognostic Relevance of 
Pretransplant Minimal Residual Disease Assessment by Reverse-Transcriptase Polymerase Chain 
Reaction of the PML/ARA฀ Fusion Gene, Blood. 90: 1321-1325, 1997. 
 
APPENDIX I 
 
Suggested Priorities for BMT:  AML  
 
Because of the differences in the treatment of subjects with these diseases based on age, active 
multicenter studies and U of Minnesota BMT Program scientific priorities, the following are 
suggested guidelines that should be considered in determining what type of BMT is considered. 
 
AML 
 
1. First remission:  Autologous BMT for PBSC transplant for AML will be considered for adults  
with standard risk AML in CR1 with favorable cytogenetics t(8;21) 
 
• Second (or greater) remission:  Subjects in >2nd CR are eligible for this autologous 
transplantation protocol, allogeneic transplantation is generally a proposed option.  


 
October 31, 2018 
18 
Subjects with no donor available, or APL (M3) in molecular CR2 or those for whom 
allografting is unavailable or refused can be treated on this study. 


 
October 31, 2018 
19 
APPENDIX II 
 
 
Cell Collection, Storage and Use/Vascular Access for Apheresis 
 
Peripheral blood stem cells will be collected using available apheresis machines.  Currently apheresis 
will be performed using either antecubital veins or 13.5 Fr Quinton/Davol catheters if antecubital 
veins are not appropriate for apheresis collection.  A minimum of >2.5 x 106 CD34+ cells/kg in the 3-
6 apheresis collections will be required to proceed.  If <2.5 x 106 CD34+ cells/kg are collected, the 
patient will proceed to bone marrow harvest to obtain additional nucleated cells.  All collected 
cryopreserved cells are to be infused on day 0. 
 
 
 
 
 
 
 


 
October 31, 2018 
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APPENDIX III 
Required Studies (within 30 days of scheduled date) 
 
 
Pre 
D 
21 
D 
28 
 
D 
100 
6 
mo 
1 yr 
 
2 
yr 
Bone Marrow: 
 
 
 
 
 
 
 
 
 
 
Trephine  
X 
 
X 
 
 
X 
X 
 
X 
 
Aspirate 
X 
 
X 
 
 
X 
X 
 
X 
 
Chromosomes 
 
 
X 
 
 
X 
X 
 
X 
Spinal Tap : 
X 
 
 
 
 
 
 
 
 
 
Prot., gluc., cell ct, cytospin 
 
 
 
 
 
 
 
 
 
MUGA 
X 
 
 
 
 
 
 
 
 
PFT 
X 
 
 
 
 
 
 
 
 
EKG 
X 
 
 
 
 
 
 
 
 
Chest x-ray 
X 
 
 
 
X 
 
 
 
 
UA 
X 
 
 
 
X 
 
X 
 
 
Blood Work : 
 
 
 
 
 
 
 
 
 
 
CBC, Plt, Diff 
X 
X 
X 
 
X 
X 
X 
 
X 
 
BUN/Creat, GNE 
X 
 
 
 
X 
 
X 
 
 
 
ALT, Bili, Alk Phos 
X 
 
 
 
X 
 
X 
 
 
 
HBSAG, HBCAB, Hep. C 
X 
 
 
 
 
 
  
 
 
 
Anti HTLVI, HIV I/II 
X 
 
 
 
 
 
 
 
 
 
HIV Antigen 
X 
 
 
 
 
 
 
 
 
 
RPR 
X 
 
 
 
 
 
 
 
 
 
CMV, HSV Antibody 
X 
 
 
 
 
 
 
 
 
 
PT, PTT, TT, INR 
X 
 
 
 
 
 
 
 
 
 
Uric Acid 
X 
 
 
 
 
 
 
 
 
 
T4, TSH 
 
 
 
 
 
 
X 
 
X 
 
ABO, Rh 
X 
 
 
 
 
 
 
 
 
 


 
October 31, 2018 
21 
APPENDIX IV: TBI GUIDELINES 
  
Fractionated Total Body Irradiation (In Lateral Position) 
  
1320 cGy administered in an 8 fractions of 165 cGy each with 2 fractions being given each day. The 
interval between fractions should be at least 4 hours. 
  
Total body irradiation is given at a dose rate of 10-19 cGy/minute prescribed to the midplane of the 
patient at the level of the umbilicus. 
  
The total body irradiation will be delivered with right and left lateral fields, with the patient supine on 
a specially designed couch. 
  
Based on measurements of transverse thickness, aluminum compensators will be used as necessary to 
deliver a uniform dose within ±10% of the prescribed dose .  Usually head/neck, leg and lung 
compensators are used (although based on calculated mid-mediastinal doses, lung compensators are 
often not needed). 
  
TBI will be given by 6, 10, or 18 MV x-ray beams.  The energy used will be based on the calculated 
dose to the midline at points up and down the patient’s torso.  The lowest energy that gives 90-100% 
of the prescription point dose will be used. 
 
 
A beam spoiler will be used for skin sparing.   
  
  
Half value layer lung and kidney blocks will not be utilized.