Conditions: Acute Myeloid Leukemia Acute Myeloid Leukemia in Remission Aplastic Anemia Chronic Myelomonocytic Leukemia Hodgkin Lymphoma Indolent Non-Hodgkin Lymphoma Malignant Neoplasm Myelodysplastic Syndrome Myeloproliferative Neoplasm Plasma Cell Myeloma Refractory Anemia Refractory Anemia With Excess Blasts Refractory Anemia With Ring Sideroblasts Refractory Cytopenia With Multilineage Dysplasia Refractory Cytopenia With Multilineage Dysplasia and Ring Sideroblasts
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 35
Healthy volunteers: no

Brief summary:
This clinical trial studies the use of reduced intensity chemotherapy and radiation therapy before donor stem cell transplant in treating patients with hematologic malignancies. Giving low doses of chemotherapy, such as cyclophosphamide and fludarabine phosphate, before a donor stem cell transplant may help stop the growth of cancer cells. It may also stop the patient's immune system from rejecting the donor's stem cells. The donated stem cells may replace the patient's immune cells and help destroy any remaining cancer cells (graft-versus-tumor effect). Reducing the intensity of the chemotherapy and radiation may also reduce the side effects of the donor stem cell transplant.

Detailed description:
PRIMARY OBJECTIVES:

I. To demonstrate efficacy of this approach over the historical 2 step reduced intensity conditioning (RIC) approaches in the "vulnerable" population defined as: patients with hematopoietic cell transplant (HCT)-co-morbidity index (CI)/age scores \>= 2, but no more than a score of 5 as based on the Sorror et al. data.

SECONDARY OBJECTIVES:

I. To compare the non-relapse mortality (NRM) and relapse related mortality (RRM) rates at 1 year for patients treated on this study to the that of patients undergoing haploidentical RIC hematopoietic stem cell transplantation (HSCT) as reported in the literature and as observed in the 2 step RIC trials.

II. To determine the incidence and severity of graft-versus-host disease (GVHD) in patients undergoing treated on the Thomas Jefferson University (TJU) RIC 2 step approach.

III. To evaluate engraftment rates and lymphoid reconstitution in patients treated on the TJU RIC 2 step approach.

OUTLINE:

RIC: Patients receive fludarabine phosphate intravenously (IV) over 60 minutes on days -10 to -8 and cyclophosphamide IV over 2 hours on days -3 and -2. Patients also undergo total body irradiation (TBI) followed by a donor lymphocyte infusion (DLI) on day -6.

TRANSPLANT: Patients undergo cluster of differentiation (CD)34+ peripheral blood stem cell transplant on day 0.

GVHD PROPHYLAXIS: Patients receive tacrolimus orally (PO) beginning day -1 with a taper initiated on day 42 and mycophenolate mofetil IV twice daily (BID) on days -1 to 28 in the absence of GVHD.

After completion of study treatment, patients are followed up for 1 year.

Arms:
arm 1: RIC: Patients receive fludarabine phosphate IV on days -10 to -8 and cyclophosphamide IV on days -3 and -2. Patients also undergo TBI followed by a DLI on day -6.

TRANSPLANT: Patients undergo CD34+ peripheral blood stem cell transplant on day 0.

GVHD PROPHYLAXIS: Patients receive tacrolimus PO beginning day -1 with a taper initiated on day 42 and mycophenolate mofetil IV BID on days -1 to 28 in the absence of GVHD.

Interventions: intervention 1: Fludarabine intervention 2: Total-Body Irradiation intervention 3: T Cell-Depleted Donor Lymphocyte Infusion intervention 4: Cyclophosphamide intervention 5: Peripheral Blood Stem Cell Transplantation intervention 6: Allogeneic Hematopoietic Stem Cell Transplantation intervention 7: Tacrolimus intervention 8: Mycophenolate mofetil intervention 9: Laboratory Biomarker Analysis
Intervention descriptions: intervention 1: Given IV intervention 2: Undergo TBI intervention 3: Undergo DLI intervention 4: Given IV intervention 5: Undergo PBSC transplant intervention 6: Undergo PBSC transplant intervention 7: Given PO intervention 8: Given IV intervention 9: Correlative studies

Protocol document:
Prot_SAP_000.pdf: 
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15D.323 Protocol version 7.0 dated 11Oct2022 
A Two Step Approach to Non-Myeloablative Allogeneic Hematopoietic Stem Cell 
Transplantation for Patients with Hematologic Malignancies 
Principal Investigator 
Usama Gergis, MD 
Co-Investigators 
S. Onder Alpdogan, MD
Adam Binder, MD
Joanne Filicko-O’Hara, MD 
Margaret Kasner, MD 
Thomas Klumpp, MD 
William O’Hara, PharmD 
Ubaldo Outschoorn Martinez, MD 
Pierluigi Porcu, MD 
Lindsay Wagner, MD 
Biostatistics 
Inna Chervoneva, PhD 
Radiation Oncologists 
Wenyin Shi, MD, PhD 
Maria Werner-Wasik, MD 
Thomas Jefferson University (TJU) 
Blood and Marrow Transplantation Program 
Department of Medical Oncology 
Suite 320, 834 Chestnut Street 
Philadelphia, PA 19107 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
 
Table of Contents 
Abbreviations ____________________________________________________________ 4 
1.0 Introduction and Background ___________________________________________ 6 
1.1 Development of Less Intensive Conditioning Regimens ________________________ 6 
1.2 Ablative versus Non-Myeloablivative HSCT _________________________________ 7 
1.3 The TJU 2 Step Approach _______________________________________________ 7 
1.4 Addressing the Needs of a Growing Population _______________________________ 10 
1.5 Purpose of the Clinical Trial 
11 
2.0 Hypothesis and Objectives ______________________________________________ 12 
2.1 Primary Objective _____________________________________________________ 12 
2.2 Secondary Objective ____________________________________________________ 12 
3.0 Patient and Donor Selection _____________________________________________ 12 
3.1 Patient Selection _______________________________________________________ 12 
3.2 Inclusion Criteria ______________________________________________________ 13 
3.3 Exclusion Criteria ______________________________________________________ 13 
3.4 Donor Selection _______________________________________________________ 14 
4.0 Informed Consent _____________________________________________________ 15 
5.0 Treatment Plan _______________________________________________________ 15 
5.1 Administration of Fludarabine ____________________________________________ 16 
5.2 TBI _________________________________________________________________ 16 
5.3 Donor Lymphocyte Infusion _____________________________________________ 16 
5.4 Cyclophosphamide _____________________________________________________ 18 
5.5 Collection and Infusion of Progenitor Cells (PBSCs) __________________________ 18 
5.6 GVHD Prophylaxis _____________________________________________________ 19 
6.0 Study Measurements ___________________________________________________ 20 
6.1 Hematologic Engraftment: Defined as ______________________________________ 22 
6.2 Toxicity Criteria _______________________________________________________ 22 
6.3 Disease Response ______________________________________________________ 22 
6.4 GVHD Scoring ________________________________________________________ 22 
6.5 Adverse Event Reporting ________________________________________________ 22 
6.6 Reports to the Federal Drug Administration (FDA) ____________________________ 22 
6.7 Study Endpoints _______________________________________________________ 23 
7.0 Supportive Care _______________________________________________________ 23 
7.1 Avoidance of Infection __________________________________________________ 23 
7.2 Infectious Prophylaxis: General Guidelines __________________________________ 23 
7.3 Growth Factor and Transfusion Support _________________________________ 24 
8.0 Drug Information and Administration __________________________________________ 24 
8.1 Cyclophosphamide _____________________________________________________ 24 
8.2 Donor Lymphocyte Infusion (DLI) ________________________________________ 25 
8.3 Fludarabine ___________________________________________________________ 25 
8.4 G-CSF ______________________________________________________________ 26 
8.5 GM-CSF _____________________________________________________________ 26 
8.6 Mycophenolate Mofetil (MMF) ___________________________________________ 27 
8.7 Plerixafor ____________________________________________________________ 28 
8.8 Tacrolimus ___________________________________________________________ 28 
9.0 Patient Safety _________________________________________________________ 28 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
9.1 FDA Reports _________________________________________________________ 30 
10.0 Statistical Analysis ____________________________________________________ 30 
10.1 Study Design ________________________________________________________ 30 
10.2 Accrual and Study Duration _____________________________________________ 30 
10.3 Analysis of the Primary Endpoint _________________________________________ 31 
10.4 Sample Size _________________________________________________________ 31 
10.5 Assessment of the Secondary Endpoint ____________________________________ 31 
10.6 Analysis of Safety _____________________________________________________ 31 
11.0 Reference ___________________________________________________________ 31 
12.0 Appendices __________________________________________________________ 39 
Appendix A: Guidelines for Total Body Irradiation _______________________________ 41 
Appendix B: GVHD Grading System Grade ____________________________________ 43 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
 
 
 
Abbreviations 
AABB 
American Associate if Blood Banks 
AE 
Adverse Event/Experience 
ALL 
Acute Lymphocytic Leukemia 
ALT 
Alanine Aminotransferase 
AML 
Acute Myeloid Leukemia 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase 
BID 
Twice daily 
BMT 
Blood and Marrow Transplant 
C&S 
Culture and Sensitivity 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
CLL 
Chronic Lymphocytic Leukemia 
CML 
Chronic Myeloid Leukemia 
CMML 
Chronic Myelomonocytic Leukemia 
CR 
Complete remission 
CRO 
Clinical Research Office 
CY/CTX 
Cyclophosphamide 
CX 
Culture 
DLCL 
Diffuse Large Cell Lymphoma 
DLCO 
Diffusing Capacity of the Lung for Carbon Monoxide 
DLI 
Donor Lymphocytes Infusion 
DS 
Double strength 
DSMC 
Data and Safety Monitoring Committee 
DSMP 
Data and Safety Monitoring Plan 
DNA 
Deoxyribonucleic acid 
EF 
Ejection Function 
FACT 
Foundation of Accreditation for Cell Therapy 
FDA 
Food and Drug Administration 
FEV 
Forced expiratory volume 
G-CSF 
Granulocyte colony stimulating factor 
GM-CSF 
Granulocyte macrophage colony-stimulating factor 
GVHD 
Graft Versus Host Disease 
GVT 
Graft versus Tumor 
Gy 
Gray 
HCT-CI 
Hematopoietic Cell Transplantation-Comorbidity Index 
HBV 
Hepatitis B Virus 
HCV 
Hepatitis C Virus 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
HPC 
Hematopoietic Progenitor Cell 
HSCT 
Hematopoietic Stem Cell Transplantation 
IRB 
Institutional Review Board 
IV 
Intravenous 
SKCC 
Sidney Kimmel Cancer Center 
KM 
Kaplan-Meier 
KPS 
Karnofsky Performance Status 
LVEF 
Left Ventricular End Diastolic Function 
MA 
Myeloablative 
MDS 
Myelodysplastic Syndromes 
MDS NOS 
Myelodysplastic Syndrome Unclassified 
MLE 
Maximum Likelihood Estimation 
MMF 
Mycophenolate mofetil 
MPA 
Mycophenolic acid 
MPD 
Myeloproliferative disease 
MV 
Megavolts 
NHL 
Non-Hodgkin’s Lymphoma 
NRM 
Non-Relapsed mortality 
NM HSCT 
Non-Myeloablative hematopoietic stem cell transplantation 
OS 
Overall Survival 
PBSC 
Peripheral Blood stem cell 
PCP 
Pneumocystispneumonia 
PCR 
Polymerase chain reaction 
PI 
Principal Investigator 
PRC 
Protocol Review Committee 
RAEB 
Refractory Anemia with Excess Blasts 
RCMD-RS 
Refractory cytopenia with multilineage dysplasia and ringed sideroblasts 
RIC 
Reduced Intensity 
RRM 
Relapse related mortality 
SAE 
Serious Adverse Event/Experience 
SIADH 
Secretion of anti-diuretic hormone 
SPO2 
Peripheral Capillary Oxygen saturation 
TBI 
Total Body Irradiation 
TJU 
Thomas Jefferson University 
TJUH 
Thomas Jefferson University Hospital 
TMP-SMZ 
Trimethoprim/Sulfamethoxazole 
TRM 
Transplant Related Mortality 
WBC 
White Blood Count 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
1.0 Introduction and Background 
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative therapy for many 
disorders of lymphohematopoiesis. (Armitage, 1994; Blume, 1993; Bortin & Rimm, 1986; 
Thomas, 1992; Thomas, 1995) While allogeneic transplants are often associated with lowerrates 
of relapse than autografts or conventional dose treatment, this advantage is partially offset by 
higher regimen related mortality. (Archimbaud et al., 1994; Attal et al., 1996; Ballester, 1993; 
Barlogie et al., 1997; Bensinger et al., 1996; Björkstrand et al., 1996; Cassileth et al., 1992; Cavo, 
Benni, Cirio, Gozzetti, & Tura, 1995; Couban, Stewart, Loach, Panzarella, & Meharchand, 1997; 
Gahrton, Tura, Ljungman, Blade, Cavo et al., 1995; Gahrton, Tura, Ljungman, Blade, Brandt 
et al., 1995; Mehta et al., 1998; Reece et al., 1995; Samson, 1992; Samson, 1996; Varterasian 
et al., 1997; Vesole et al., 1996; Zittoun et al., 1995) Much of this increase can be traced to 
the toxicities of the conditioning regimen, GVHD and the immunosuppressive measures required 
for the prevention and/or treatment of GVHD. (Antin & Ferrara, 1992; Brent, 1995; Champlin, 
1991; Ferrara & Deeg, 1991; Irschick et al., 1992; Vogelsang & Hess, 1994) Nowhereis this more 
apparent than in published outcomes after HSCT for multiple myeloma. In many of these trials, 
there is a survival benefit with autologous HSCT over allogeneic HSCT, despitea graft versus 
myeloma effect, on the basis of the toxicity associated with the latter procedure. (Armeson, Hill, 
& Costa, 2013) 
 
For more than a decade, it has been recognized that long-term disease control after allogeneic 
HSCT is mediated through the anti-tumor effects of the transplanted immune system and less so 
by the intensity of the conditioning regimen. This GVT effect can occur even inthe absence 
of overt graft versus host disease (GVHD). (Horowitz et al., 1990) In acute myeloid leukemia 
(AML) and chronic myeloid leukemia (CML), for example, relapse ratesare higher in 
recipients of twin transplants than in GVHD-free recipients of matched sibling grafts. (Gale et 
al., 1994) Moreover, in CML, many patients who relapse after BMT can be rendered disease free 
through the infusion of additional lymphocytes from the marrow donor without any additional 
chemoradiotherapy. (Collins Jr. et al., 1997; Drobyski et al., 1993; Kolb et al., 1995; Mackinnon 
et al., 1995; Porter, Roth, McGarigle, Ferrara, & Antin, 1994) 
 
1.1 Development of Less Intensive Conditioning Regimens 
Based on this recognition that long term disease control is mediated through the transplanted 
immune system, HSCT regimens that are not lethally myeloablative (NM HSCT) have been 
developed over the last decade. These approaches do not use dose intensity to eradicate 
malignancy. Rather they use immunosuppressive agents, irrespective of their anti-neoplastic 
properties, to facilitate donor lymphoid and stem cell engraftment. The donor lymphoid elements 
then destroy the residual normal and in some cases malignant lymphohematopoietic elements 
allowing the transition to donor chimerism. These regimens rely less heavily on the conditioning 
regimen for disease control by exploiting the GVT effects of the donor immune system. They are 
associated with less treatment-related mortality (Hamadani, Awan, & Copelan, 2008) and have 
allowed older and heavily pretreated patients who otherwise would not tolerate the rigors of a 
fully myeloablative HSCT, to undergo transplant successfully. (Kroger & Mesa, 2008) 
Nonmyeloablative HSCT has been dramatically effective in CML, chronic lymphocytic 
leukemia (CLL), and follicular lymphoma in its original application and may have utility in other 
diseases as well. (Giralt et al., 1996; Giralt et al., 1997; Khouri et al., 1998; Slavin et al., 1996) 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
1.2 Ablative versus Non-Myeloablative HSCT 
Despite the demonstration of successful outcomes after NM HSCT, this type of therapy is not 
universally successful. This is because in order to optimize the graft versus tumor (GVT) effects 
of the transplanted donor immune system, malignant cells should be controlled to a degree that 
they do not outgrow the graft. The “permissible” disease burden at the time of HSCT varies by 
the kinetics of the specific malignancy and to some extent, the dose intensity of the conditioning 
regimen which reduces the malignant burden. Many studies contrasting the outcomes between 
ablative and non-ablative conditioning show that the superior results for NM HSCT in terms of 
treatment related mortality are offset by higher rates of relapse. (Aoudjhane et al., 2005; Martino 
et al., 2006; Vela-Ojeda et al., 2004) This issue becomes particularly important in diseases not 
known to have a strong GVT effect such as acute lymphocytic leukemia (ALL) (Fielding & 
Goldstone, 2008; Stein & Forman, 2008) and certain lymphoma subtypes, (Armand et al., 2008; 
Corradini et al., 2007; Smith, 2006) where dose intensity may be just as important as a GVT 
effect in terms of overall survival. Many of the non-myeloablative regimens are minimally 
myelosuppressive, while others are more immunosuppressive and are associated with prompter 
engraftment of donor cells than their less intensive counterparts. The former approach has been 
associated with less TRM but with incomplete initial chimerism and increased rates of relapse. 
(Couriel et al., 2004; Martino et al., 2006; Slavin et al., 1998) The latter approach, alternately 
referred to as “reduced intensity” (RIC) HSCT, has been associated with more TRM but less 
relapse. (Anderlini et al., 2005; de Lima et al., 2004) A NM HSCT approach that is not an 
“either/or” proposition has not been clearly identified. 
 
Based on the typically more aggressive diagnoses of the population presenting for treatment to 
the Thomas Jefferson University (TJU) Blood and Marrow Transplant, RIC as opposed to NM 
approaches have been developed in recent years at our institution. 
 
1.3 The TJU 2-Step Approach 
Since 2006, investigators in the TJU Blood and Marrow Transplant Program have opened three 
(IRB # 06U.328, 11D.247, and 12D.501) 2-step haploidentical RIC HSCT clinical trials using 
cyclophosphamide (CY) as a tolerization agent. The initial trial completed accrual in 2010; the 
later trials are still accruing patients. The basic 2-step approach for both myeloablative (MA) and 
RIC HSCT is comprised of a chemoradiotherapy conditioning backbone which is followed by an 
infusion of donor lymphocytes (DLI) containing 2 x 108/kg T cells. The DLI results in a 
haploimmunostorm characterized by high fevers and in some cases, rash and diarrhea. During 
this time period, it is theorized that the activation of the donor lymphocytes results in GVT 
effects. This is based on literature documenting disease responses in the non-HSCT setting using 
a comparable dose of lymphocytes. (Colvin et al., 2009; Guo et al., 2012) The 
haploimmunostorm also results in the activation of the most alloreactive donor and host T cells. 
Two days after the DLI, CY is administered to eradicate these most reactive T cells establishing 
bidirectional tolerance and leaving behind a subset of less alloreactive T cells to form the basis of 
post HSCT lymphoid immunity. One day after the completion of CY, a CD 34 selected stem cell 
product is infused to restore hematopoiesis. In patients with controlled disease at the time of 
HSCT, overall survival rates (2-8 years of follow-up) have been 75% in the MA setting. (Grosso, 
Carabasi et al., 2011; Grosso et al., 2014) In terms of the 2 step RIC approaches, OS to date has 
also been high in fit patients with controlled disease at HSCT. However, in subgroups of patients 
who are older, are less physically fit, or who have multiple associated comorbidities, rates of 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
non-relapse mortality (NRM) have been greater than acceptable, resulting in decreased overall 
survival (OS). (Gaballa, Alpdogan, Carabasi, Filicko-O'Hara, Kasner, Martinez et al., 2014a; 
Grosso et al., 2010; Palmisiano et al., 2014) 
 
Thirty-four patients were treated on the completed initial 2 step RIC trial (IRB # 06U.328). 
Diagnoses were AML (17), MPD (1), MDS (3), B cell ALL (3), CLL (3), Myeloma (2), Aplastic 
Anemia (1), DLCL (1), NHL (2), and CMML (1). Median age was 67 years old at the time of 
treatment. The patients are now a median of 76 (range 51 to 89 months) post HSCT with an OS 
of almost 50% at 12 months and 35% at the median follow-up time. Of the patients that died 
after being treated on the initial RIC trial, 50% died of relapse causes and 50% died of non- 
relapse causes. This is profoundly different from the MA 2 step trials in which relapsed disease 
is the primary cause of mortality and death from non-relapse causes is low. 
 
Analysis of this initial trial revealed that multiple comorbidities were associated with decreased 
OS. While organ function guidelines were part of the eligibility criteria for this trial (as was 
typical for transplant protocols at the time of the initiation almost 10 years ago), the sum of all of 
all of the comorbidities that each patient may have possessed were not accounted for. For 
example, patients could minimally meet organ criteria across 2-3 systems and still be eligible for 
HSCT despite having cumulative comorbidities which would have predicted increased risk of 
toxicity. Conversely, gentler NM approaches to haploidentical HSCT have not been associated 
with high OS rates either. For example, the Hopkins group, with one of the largest experiences 
with haploidentical HSCT in the United States, reported a 1 year OS in younger patients (median 
age 46 years) undergoing NM haploidentical HSCT using post transplantation CY of 46% (event 
free survival at 1 year was only 34%) (Luznik et al., 2008) with mortality from recurrent disease 
the primary cause of treatment failure. Therefore, OS after RIC and NM haploidentical HSCT 
has been low, with causes of mortality varying with the intensity of the conditioning regimen. 
 
To help increase the safety of HSCT at TJUH, a widely tested comorbidity index developed by 
Mohamed Sorror, the HCT-CI, (Sorror et al., 2005) was used in subsequent trials for risk 
assessment. Outcomes stratified by comorbidity points using this tool were first published in 
2005, with further testing and widespread use occurring a few years after the initial publication. 
 
We retrospectively analyzed the outcomes of the 34 patients treated on the initial RIC 2 step trial 
and as seen below, the number of comorbidity points is also correlated with outcomes in this 
older population treated at our institution. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
 
 
The other primary predictor of outcomes after HSCT is age at the time of the procedure. 
Accounting for age in association with the HCT-CI strengthens the predictability of OS 
probability of the HCT-CI. This has been demonstrated by Dr. Sorror and colleagues in a 
multivariate analysis of over 3000 patients undergoing HLA matched donor HSCT. (Sorror et al., 
2014) In this analysis, 1 comorbidity point for age ≥ 40 was added to the HCT-CI scores for the 
patients analyzed. OS at 1 year for patients undergoing intensive regimens with HCT-CI scores 
of 3 and 4 (2 or 3 points plus age >40 years) resulted in an OS of approximately 60% and 50% at 
12 and 24 months respectively, and for scores of 5 (4 points plus age >40 years) of OS of 40% 
and 30% at 12 and 24 months respectively. 
 
Dr. Neil Palmisiano, as part of his graduate work in the Jefferson School of Pharmacology, 
performed a survival analysis based on the combination of age and HSCT of patients undergoing 
HSCT on the TJU 2 step trials to date. All of the trials use intensive conditioning regimens. The 
patients analyzed included those treated on both the first and 2nd generation 2-step RIC trials. 
Consistent with the Sorror et al. findings, Dr. Palmisiano found that patients with HCT-CI scores 
of 0-2 did well in terms of OS regardless of age, but comorbidity scores of >2 were not as well 
tolerated in older patients (> 40 years-Sorror; > 60 years Palmisiano) with increasing detriment 
correlating with increasing comorbidity score. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
From Palmisiano: 
 
 
As shown in the table above, patients greater than age 60 years with HCT-CI scores of > 2 have 
a 1 year OS of approximately 45%, decreasing to about 30% at 2 years. While these outcomes 
are similar to Dr. Sorror’s data based on HCT-CI score alone, we note that 87% of patients in the 
Sorror et al. analysis were < age 60, while the median age of the population in the initial 2 step 
RIC trial was 67 years. This highlights the fact that at TJUH, the cut-off age for the same 
outcomes based on the HCT-CI is higher. Other analyses support the age of 60 years or greater 
as a point of increasing vulnerability in the 2 step population. Dr. Sameh Gaballa et al.(Gaballa, 
Alpdogan, Carabasi, Filicko-O'Hara, Kasner, Martinez et al., 2014b) performed a multivariate 
analysis of factors influencing outcomes after the TJUH 2 step approach in older patients. 
In addition, an internal analysis of all patients treated to date on the 2 step trials (n=163), show 
the beginning of a decreasing probability of OS at age 60 years, further supporting that 
demarcation as significant in the 2 step trials (Grosso, institutional data). 
 
1.4 Addressing the Needs of a Growing Population 
In 2011, a second generation 2-step RIC trial for patients with good risk disease was opened 
at TJUH. Good risk was defined as having leukemia in remission or an indolent lymphoma such 
as CLL or follicular lymphoma in which GVT effects were stronger and the incidence of post 
HSCT relapse was lower based on these more indolent diagnoses. The twenty-three patients 
treated on this trial to date have a median age of 56 (range 20- 74 years) with a median follow- 
up of 25.5 (range 2-40 months). In part based on the more stringent entry criteria that have been 
adopted in the TJUH Blood and Marrow Transplant Program for the second generation 
2 step trials, all of the patients were discharged from the HSCT stay and lived at least 12 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
months after HSCT. Furthermore, of the 4 patients that died, 3 succumbed to relapsed disease and 
only one patient died of complications of GVHD. The KM estimate of OS at 2 years is 81%. These 
excellent outcomes are based on the types of diseases transplanted (ie more indolent with less 
aggressive pretreatment history), the lower ages of the cohort, and the more stringent 
prescreening process based on comorbidity analyses added to the 2 step protocols. The majority 
of these patients were accrued by 2012 however, and only 1 patient wastreated on this trial in 
2013. The primary reason for this precipitous drop in accrual is the development of targeted drugs 
in B cell malignancies which have dramatically changed the landscape of lymphoma treatment, 
with less patients requiring allogeneic HSCT to achieve disease control. This change in the field 
has shifted the cohort of patients requiring HSCT to those with acute leukemia, MDS, or highly 
resistant lymphoma, all more aggressive diseases requiring aggressive approaches. In addition, 
the median age of patients with AML and MDS atpresentation is > 60 years, resulting in a growing 
cohort of patients who are not only older, but often have multiple comorbidities related to their 
age and aggressive pre-HSCT treatment of their disease. Based on our own in-house analyses and 
the Sorror et al. data, much of this emerging population of older patient is unlikely to withstand 
the rigors of an RIC approach. This point was demonstrated above in the KM figure of the initial 
2 step RIC trial in which the 34 patients (median age of 67 years), had significant decreases in 
OS when the analysis was broken down by HCT-CI points. 
 
Of note in the Sorror study, (Sorror et al., 2014) patients undergoing NM HSCT as opposed 
to RIC and MA HSCT tolerated a HCT-CI/age score (=HCT-CI score plus 1 if > than 40 years), 
of 3-4 points better in terms of NRM. Patients undergoing NM HSCT with an adjusted HCT- 
CI/age score of 3-4 had a NRM rate of 17% at 2 years as opposed to 36% and 37% for RIC and 
MA HSCT respectively. Therefore, it is possible to decrease NRM in vulnerable patients (i.e. 
advanced age/increased comorbidities), with the use of a NM HSCT regimen. There is currently 
no 2 step regimen that is NM. Two year OS rates for patients with an HCT-CI/age score of ≥ 5 
were less than 35% at 2 years in all categories of conditioning regimens. 
 
1.5 Purpose of the Clinical Trial 
This clinical trial is aimed at reducing NRM in the expanding population of high-risk patients 
with higher comorbidity scores and/or who are older, undergoing HSCT with the use of a gentler 
NM 2 step approach. To compensate for the higher risk of post HSCT relapse with this type of 
gentler approach, strategies to immunologically increase GVT effects will be employed. First, 
patients will undergo HSCT using the TJU 2 step approach, developed at Jefferson in 2006,which 
has been an associated with low rates of relapse in patients with controlled disease at 
HSCT.(Grosso et al., 2011; Grosso et al., 2014) The GVT effects associated with the 2 step 
approach are thought to be due to the use of a haploidentical donor, the administration of high 
doses of tolerized T cells, the selection of the most predicted alloreactive donor, and the avoidance 
of T cell polarization to a Th2 type by G-CSF. A second strategy to increase GVT effects will be 
the infusion of higher doses of donor stem cells, which can now be reliably obtained with the 
drug plerixifor. The administration of a high dose of CD34 cells has been associated with 
decreased relapsed rates in Jefferson 2 step patients (Gaballa et al., 2014a)and at other HSCT 
centers. (Gõmez-Almaguer et al., 2013; Klingebiel et al., 2010; Törlén et al.,2014) 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
2.0 Hypothesis and Objective 
The hypothesis of this research study is that haploidentical HSCT using a NM 2 step approach 
will decrease NRM as compared to the historical 2 step RIC approaches. Immunological 
strategies to increase GVT effects will compensate for the gentler conditioning regimen such that 
relapse related mortality (RRM) will remain acceptable. Therefore, OS rates (impacted by NRM 
+ RRM) will be higher at 1 year using a NM HSCT versus historical TJU 2 step RIC outcomes. 
Examples of vulnerable patients who will be treated on this protocol include but are not limited 
to patients with higher comorbidity scores, and/or who are older, or have had previous histories 
that predispose to higher toxicity. An example of patients who are predisposedto higher toxicities 
are patients who have received autologous HSCT in the past, who are heavilypretreated, or those 
who received agents such as bleomycin which can affect the lungs. Patients who do not require 
intensive conditioning may also be treated on this protocol. 
 
Patients who are younger and fit, will continue to be treated on the 2 step RIC or MAregimens. 
 
2.1 Primary Objective 
Our primary objective is to demonstrate efficacy of this approach over the historical 2 step 
RIC approaches in the “vulnerable” population as defined above. To prove efficacy, 1 year OS 
of the patient population should be 60%, increased from 45% based on the Palmisiano analysis, 
and equal to the patients with HSCT-CI scores of >2 in the Sorror et al. analysis (87% of which 
were < 60 years old) undergoing HLA matched HSCT. If an OS of 60% were reached at 1 year, 
we would conclude that we have been able to improve OS in patients with a higher number of 
comorbid conditions and/or are older, undergoing HSCT at our institution, and that haploidentical 
HSCT using the 2 step approach is a safe alternative to HLA matched HSCT in this patient subset. 
 
2.2 Secondary Objective 
1. To compare the NRM and RRM rates at 1 year for patients treated on this study to the 
that of patients undergoing haploidentical RIC HSCT as reported in the literature and as 
observed in the 2 step RIC trials (06U.327 and 12D.501). 
2. To determine the incidence and severity of graft-versus-host disease (GVHD) in patients 
undergoing treated on the TJU RIC 2 step approach. 
3. To evaluate engraftment rates and lymphoid reconstitution in patients treated in the TJU 
RIC 2 step approach. 
 
3.0 Patient and Donor Selection 
3.1 Patient Selection 
The majority of patients treated on this protocol will have have a history of heavy pretreatment, 
or an age or comorbidity score which is higher than allowable on the current TJUH 2 step trials. 
Because of the NM conditioning regimen, patients must not have rapidly evolving disease as 
described below: 
 
3.2 Inclusion Criteria 
1. Patients treated on this study will have: 
a. Acute myeloid leukemia in morphologic CR not requiring treatment for their 
disease for 4 weeks 


13 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
b. A history of AML with ≤10% residual blasts (use highest count on staging 
studies) after induction therapy and persisting with <10% blasts for at least 8 
weeks without reinduction and at the time of HSCT. 
c. RA or RARS or isolated 5q- 
d. RAEB-1, RCMD+/-RS, or MDS NOS with stable disease for at least 3 months. 
e. RAEB-2 must demonstrate chemo-responsiveness. Chemo-responsiveness is 
defined as a persistent blast percentage decrease by at least 5 percentage points to 
therapy and there must be ≤ 10% blasts (use highest count on staging studies) 
after treatment and at the time of transplant. 
f. Hodgkin or indolent Non-Hodgkin’s lymphoma 
g. Myeloma with <5% plasma cells in the marrow 
h. Myeloproliferative disorders (excludes CMML) 
i. Aplastic Anemia 
j. A hematological or oncological disease (not listed) in which allogeneic HSCT is 
thought to be beneficial, and the disease is chemoresponsive 
k. Patients without clear manifestations of their disease status in terms of stage 
and/or responsiveness should be discussed with the PI and enrollment analysis 
should be documented in the study records. 
2. Patients must have related donor who is HLA mismatched at 2, 3, or 4 antigens at the 
HLA-A; B; C; DR loci in the GVHD direction. (Patients with related donors who are 
HLA identical or are a 1-antigen mismatch may be treated on this therapeutic approach, 
but their outcomes will not be part of the statistical aims of the study (see Statistical 
Section). The HLA matched related category includes patients with a syngeneic donor. 
3. Patients must have had front line therapy for their disease. 
4. Patients must have adequate organ function: 
a. LVEF (Left Ventricular End Diastolic Function) of ≥45%. 
b. DLCO (Diffusing Capacity of the Lung for Carbon Monoxide) ≥45% of predicted 
corrected for hemoglobin FEV-1 (forced expiratory volume at 1 second ≥50% of 
predicted 
c. Adequate liver function as defined by a serum bilirubin ≤1.8, AST or ALT ≤2.5 x 
upper limit of normal 
d. Creatinine Clearance of ≥60 mL/min 
5. HCT-CI/Age Score ≤5 points (Patients with greater than 5 points will be allowed for trial 
with approval of the PI and the Co-PI or his designee. This is an adjustment to account 
for healthy patients who meet the spirit of this protocol but have histories that result in 
higher than HCT-CI 5 points. An example is a patient with a solid tumor malignancy in 
their remote history (adds 3 points to HCT-CI total) where the treatment for the 
malignancy occurred years to decades before and there has been complete recovery of 
toxicities. 
6. KPS ≥90% patients older than 70 years, KPS ≥80% patients younger than 70 years 
7. Patients must be willing to use contraception if they have childbearing potential. 
 
3.3 Exclusion Criteria 
1. Performance status <90% in patients 70 years or greater, <80% in patients less than age 
70 years 
2. HCT-CI/age score >5 points (Patients with greater than 5 points will be allowed for trial 


14 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
with approval of the Principal Investigator and the Co-Principal Investigator or his 
designee. This is an adjustment to account for healthy patients who meet the spirit of this 
protocol but have histories that result in higher than HCT-CI 5 points. An example is a 
patient with a solid tumor malignancy in their remote history (adds 3 points to HCT-CI 
total) where the treatment for the malignancy occurred years to decades before and there 
has been complete recovery of toxicities. 
3. A diagnosis of CMML, unless in morphologic CR 
4. HIV positive 
5. Active involvement of the central nervous system with malignancy 
6. Inability to obtain informed consent from patient or surrogate 
7. Pregnancy 
8. Patients with life expectancy of ≤6 months for reasons other than their underlying 
hematologic/oncologic disorder 
9. Patients who have received alemtuzumab or antithymocyte globulin within 8 weeks of 
the transplant admission. The absence of these therapies in the medical record will serve 
as documentation that they were not given. 
10. Patients with evidence of another malignancy, exclusive of a skin cancer that requires 
only local treatment, should not be enrolled on this protocol 
 
3.4 Donor Selection 
All donors are selected and screened for their ability to provide adequate infection-free apheresis 
products for the patient in a manner that does not put the donor at risk for negative consequences. 
Donor selection, evaluation, and treatment will be in compliance with 21 CFR 1271 and all TJU 
BMT Program SOPs relating to the use of the allogeneic donor for HSCT. 
 
Specifically, donors will be tested, using the appropriate FDA-licensed and designated screening 
tests, for 
1. HIV, type 1 
2. HIV, type 2 
3. HBV (HBsAg, anti0HBc IgC and IgM) 
4. HCV 
5. Treponema pallidum 
6. Human T-lymphotropic virus, types I and II 
7. Cytomegalovirus 
8. West Nile Virus 
9. Trypanosoma cruzi 
 
As per the Jefferson Blood Donor Center Quality Plan, all allogeneic donor testing samples 
(including HPC donors) will be sent to a laboratory that is FDA and CLIA licensed. 
Agreements/contracts for these services will be developed according to TJUH policies and all 
pertinent regulatory requirements will be retained by the Blood Bank. 
 
 
Infectious disease testing must be completed by the time of the recipient’s transplant admission 
date. 


15 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
Per FACT guidelines, pregnancy will be assessed during the initial donor evaluation and just 
prior to the start of the recipient’s conditioning regimen in female donors of childbearing age. 
 
4.0 Informed Consent 
Patients referred for the trial will have their eligibility criteria verified. On meeting the eligibility 
for the trial as outlined, informed consent will be obtained using forms approved by the Thomas 
Jefferson University Hospital Institutional Review Board and following guidelines related to the 
use of human subjects in research. The risks and hazards of the procedure, as well as alternative 
forms of therapy will be presented to the patient in detail. Patients will receive a signed copy if 
the consent form after the consent interview. In addition, donors will be asked to sign consent 
after they have been fully informed about the procedures and risk of donating. 
 
5.0 Treatment Plan 
While the days of radiation and drug administration are fixed, the exact timing of these 
treatments on the day they are due is not specified because of expected variations in clinical 
care. 
Treatment Schema 
 
Patient Schedule: 
-11 
-10 
-9 
-8 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
AM 
 
Fludara 
30 
mg/m2 
Fludara 
30 
mg/m2 
Fludara 
30 
mg/m2 
TBI 
2Gy 
Rest 
Rest 
CY 60 
mg/kg 
CY 60 
mg/kg 
Rest 
Start FK 
506 & 
MMF 
CD-34+ 
PBSC 
Infusion 
PM 
TBI 
2 Gy 
DLI 
May not use voriconazole until Day -1 
Table Definitions: CY = cyclophosphamide, DLI = Donor Lymphocyte Infusion, 
FK 506 = tacrolimus; Fludara = fludarabine, Gy = gray, MMF = mycophenolate mofetil, 
PBSC = peripheral blood stem cell, TBI = total body irradiation 
 
Donor Schedule 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
AM 
Lymphocyte 
Collection 
Lymphocyte 
Collection 
G-CSF 
G-CSF 
G-CSF 
G-CSF 
PBSC 
Collection 
G-CSF 
PBSC 
Collection 
PM 
G-CSF 
G-CSF 
G-CSF 
Plerixafor 
G-CSF 
Plerixafor 
Table Definitions: G-CSF = granulocyte colony stimulating factor, PBSC = peripheral blood stem cell 
 
There should be no administration of agents that suppress lymphocyte reactivity from 
admission until Day-1 in this protocol. This includes steroids, calcineurin inhibitors, MMF, or 
monoclonal antibodies that affect lymphocyte number or function. If patients have previously 
required steroids as a premedication for transfusion, they may receive a dose of steroids 
equivalent to 5 mg of prednisone through day -10. After day -10, a significant portion of the 
conditioning regimen is completed. At this time, the immune system response to alloantigens 
should be somewhat attenuated. Diphenhydramine and meperidine may be used if necessary. 
Any use of steroids from day -10 through day 0 should not be administered without approval 


16 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
from the PI. 
 
Voriconazole is prohibited until day -1 due to its interaction with cyclophosphamide. 
 
The absence of agents that suppress lymphocyte reactivity and voriconazole in the medical 
record serves as documentation that they were not given. 
 
All chemotherapy and HPC doses in this protocol are to be based on adjusted dosing weight 
(40% of the difference between actual and ideal weight). 
 
5.1 Administration of Fludarabine 
Fludarabine is administered for 3 days on (days -10 through – 8) at a dose of 30 mg/m2 IV. 
Creatinine should be checked prior to each dose of fludarabine. If renal insufficiency develops, 
the attending physician must be notified in cases where a dose adjustment needs to be made. 
 
 
5.2 TBI 
4 Gy of TBI will be administered in two divided doses of 2 Gy each on day -7. At this low dose, 
there is almost no clinical scenario in which this small dose of radiation would be associated with 
added toxicity from prior radiation. However, because of the heterogeneous past histories of the 
patients to be treated on this protocol, all patients will be evaluated by the radiation oncologist 
for assessment of radiation toxicity in the context of previous treatment. In addition there may be 
technical or patient related factors which will require some minor modification in the TBI 
technique utilized. Selected patients may require local boosting of certain organ sites prior to 
conditioning therapy. See Appendix A for radiation guidelines. 
 
5.3 Donor Lymphocyte Infusion 
Hematopoietic cell doses and cyclophosphamide dosing will be based on adjusted dosing weight 
(40% the difference between actual and ideal body weight + the actual body weight). The dose of 
the donor lymphocyte infusion (DLI) will be based on CD3+ T cells per kilogram of recipient 
adjusted body weight. Donor lymphocytes will be collected prior to the use of white cell growth 
factor for progenitor cell collection. 
 
The goal of the first day of donor lymphocyte collection is to process a blood volume that is both 
safe for the donor as well as to obtain the prescribed dose of CD3+ T cells/recipient kg. 
Approximately 18-27 liters will be processed the first day of donor lymphocyte collection. If a 
second day of collection is needed, the volume processed will be based on the amount of T cells 
required to meet the T cell target. 
 
DLI specimen handling and labeling conventions will be performed in accord with the relevant 
AABB (American Association of Blood Banks) and/or FACT (Foundation for Accreditation for 
Cell Therapy) regulations and guidelines. All DLI specimens must be appropriately labeled in 
accord with these standards to be accepted by the Processing Laboratory. A valid prescription 
and request form must be submitted by the requesting physician. 
 
Determination of the targeted T cell dose from the apheresis product is as follows: 


17 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
Total T-cells required for the initial infusion = (2x108 T-cells/kg) * (Weight in kg) 
Panel: 
 
 
 
 
 
CD3 count is calculated directly with single-platform flow cytometry. Reported CD3 absolute 
count is the mean from 3-tube counts. 
 
All donors will be apheresed for lymphocytes on day -7. If the target number of CD3+ T cell 
lymphocytes, 2 x 108/recipient kg is not obtained, apheresis will be repeated on day -6. 
 
Lymphocyte apheresis will be performed at Thomas Jefferson University Hospital or the 
American Red Cross, by trained apheresis personnel using standard techniques and equipment. 
 
Patients will receive 2 x 108/kg T cells on day -6. During the infusion, the patient will be 
monitored for any untoward reactions. Donor lymphocyte infusions will be administered by 
nursing staff experienced in the administration of blood products. 
 
DLI must NOT be irradiated. DLI should NEVER be administered through a leukocyte 
depletion (PALL) filter. If blood filtration is necessary, the filter should be a standard blood 
product filter with pore size of at least 170 microns. 
 
5.4 Cyclophosphamide 
CTX 60 mg/kg IV will be administered on days –3 and –2 of the conditioning regimen. Mesna 
60 mg/kg continuous IV infusion over 24 hours X 2 doses will be infused on days –3 through –2. 
Day –1 is a day of rest. 
 
5.5 Collection and Infusion of Progenitor Cells (PBSCs) 
Donors will begin G-CSF, 5μg/kg bid on days -5 to -1. They may additionally receive Plerixafor 
administered at a dose of 0.24 mg/kg/day in the evening on day -3 or -2. The donor will return 
for a primed progenitor cell collection on days -2 and -1. 18 to 27 liters will be processed per 
day. Collection days and Plerixafor dosing may be adjusted by one day less or one day more 
based on initial progenitor cell collection numbers. It is anticipated that with the use of 
Plerixafor, only one day of PBSC collection may be needed to achieve the desired CD-34 cell/kg 
dose. CD34+ cell enrichment will be performed via the closed system method using the 
CliniMACS® CD34 Reagent System (Miltenyi Biotec Inc., Auburn, CA). The CliniMACS 
system utilizes super-paramagnetic particles composed of iron oxide and dextran conjugated to 
monoclonal antibodies. These antibodies bind to target cells with the corresponding cell surface 
antigen (in this case, CD34). After magnetic labeling, the cells are separated using a high- 
gradient magnetic separation column. The magnetically labeled cells are retained in the column 
FITC 
PE 
PE-Cy7 
APC 
APC- 
H7 
Tube1 
CD19 
CD16+56 
CD3 
CD45 
Tube2 
CD8 
CD4 
CD3 
CD45 
Tube3 
TCR-ab 
TCR-gd 
CD3 


18 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
and separated from the unlabeled cells. Removing the magnetic field from the separation column 
elutes the retained cells. Eluted cells will be characterized using fluorescent-activated cell sorting 
(FACS) analysis. All procedures will be performed in a sterile environment with strict adherence 
to all applicable regulations regarding the processing and use of human stem cells. The use of 
this device will conform to TJU BMT Laboratory standard operating procedures. 
 
The target dose of donor PBSCs to be infused into the recipient is 15 x 106 CD34 cells/kg of 
recipient dosing body weight. The acceptable minimum infusion target of PBSCs will be 1 x 106 
CD34 cells/kg. Recipients will receive no more than 2.0 x 107 CD34 cells/kg, the maximum 
dose. 
 
In our experience, the ideal amount of T-cells left in the PBSC product is no greater than 
5x104/kg, so that every effort will be made to keep T-cell amounts to below this threshold. 
 
Progenitor cell apheresis will be performed at Thomas Jefferson University Hospital or the 
American Red Cross, by trained apheresis personnel using standard techniques and equipment. 
 
Handling and labeling of the progenitor cell product will be performed in accord with the 
relevant AABB (American Association of Blood Banks) and/or FACT (Foundation for 
Accreditation for Cell Therapy) regulations and guidelines. All donor specimens must be 
appropriately labeled in accord with these standards to be accepted by the Processing Laboratory. 
A valid prescription and request form must be submitted by the requesting physician. 
 
The donor PBSC product is infused UNFILTERED or through a filter of at least 170 micron size 
intravenously through a central catheter. PBSCs should only be piggybacked through normal 
saline and not other intravenous solutions. Contingency plans for an inadequate collection of 
progenitor cells via apheresis or non-viable donor cells will be made according to institutional 
policies. 
 
During the infusion, the patient will be monitored for any untoward reactions. PBSC infusions 
will be administered by nursing staff experienced in the administration of blood products. PBSC 
products must NOT be irradiated. PBSC products should NEVER be administered through a 
leukocyte depletion (PALL) filter. If blood filtration is necessary, the filter should be a standard 
blood product filter with pore size of at least 170 microns. 
 
Significant red cell incompatibility between donor and recipient will be managed according to 
standard operating procedure, CL: Ppp033, of the Thomas Jefferson University Hospital Blood 
and Marrow Transplant Processing Lab. Pre-medications (if any) prior to PBSC infusion will be 
at the discretion of the physician. 
 
Benadryl, epinephrine, and hydrocortisone should be available for emergency use if necessary. 
Oxygen with nasal cannula should be immediately available. 
 
5.6 GVHD Prophylaxis 
Tacrolimus will be started on day -1. Tacrolimus dose titration will occur to target a goal 
level of 7 ng/ml +/- 2. It is recognized that there may be values beyond this target range 


19 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
due to interpatient variability. 
 
If grades II-IV GVHD develop at any time after transplant (inpatient or outpatient), any GVHD 
treatment deemed necessary by the covering attending physician may be utilized. 
 
The tacrolimus taper can be initiated by day + 42 in the absence of concern for GVHD or 
interference with a GVHD plan of care that was developed prior to day +42. Because of the 
variability in patient outpatient office visit times and the need for GVHD assessment, it is not 
mandatory that the taper begins exactly day on +42. 
 
MMF will be discontinued beginning at day +28 +/- 3 days in the absence of GVHD. 
 
Tacrolimus and MMF may be discontinued earlier if there is count suppression from the 
drugs or other unforeseen circumstances in which the drug is felt to be deleterious to the 
plan of care, such as infection, count suppression, drug side effects, or a need for 
alternate GVHD treatment. 
The BMTU attending physician may change these GVHD prophylaxis guidelines if 
clinically indicated. 
 
6.0 Study Measurements 
The table below outlines the measurements and time points specific to this study. Only the 
day +28 studies are mandatory. The other elements are recommended. The attending 
physician may perform assessments/labs more or less frequently based on the patient’s 
unique course. 
Baseline 
Assessment 
During 
Conditioning 
After 
Conditioning 
through 
Day +28 
Days 
28-90 
Days 
90-180 
Day 
180 
Days 180- 
365 
History and 
physical with 
vital signs, 
including SPO2. 
Assessment of 
infectious signs, 
pregnancy test 
for females of 
childbearing 
potential done 
on baseline 
assessment 
X 
Every 1-2 
days 
Daily if in 
hospital 
weekly until 
day 28 after 
discharge 
Twice 
Monthly 
Monthly 
Every other 
Month 
Laboratory 
Studies* 
X 
Every 1-2 
days 
Daily if in 
hospital 
weekly until 
day 28 after 
discharge 
Twice 
monthly or 
as 
clinically 
indicated 
Twice 
monthly 
or as 
clinically 
indicated 
Every other 
Month 
Quantitative 
cytomegalovirus 
by polymerase 
chain reaction 
PCR 
Weekly or as 
clinically 
indicated 
Weekly until 
discharge or 
as clinically 
indicated 
Twice 
monthly or 
as 
clinically 
indicated 
As 
clinically 
indicated 
Monthly or 
as clinically 
indicated 


20 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
GVHD 
Assessment: 
Presence and 
degree of skin 
rash, presence 
and amount of 
diarrhea, LFTs 
N/A 
Daily after 
engraftment 
until 
discharge and 
then weekly 
if indicated 
X 
Twice 
Monthly 
Monthly 
Every other 
Month 
Chimerism/ 
Disease 
Assessment 
Peripheral 
blood for CD3+ 
chimerism & 
Total 
chimerism 
At d +28 
Twice 
Monthly 
until >95% 
donor 
chimerism 
Once 
d+90 
Once 
d+180 
As 
clinically 
indicated 
Bone marrow 
exam 
(morphology, 
flow cytometry. 
Cytogenetics, 
buffy coat 
chimerism) 
At d+28 
As 
clinically 
indicated 
Immune 
Reconstitution 
Studies 
Flow cytometry 
for lymphocyte 
subsets 
At d+28 
Once 
d+90 
Once 
d+180 
Once d 
+365 
Radiographic 
Studies: In 
applicable 
situations for 
disease staging 
X 
Day +90 
or as 
clinically 
indicated 
Day +365 
or as 
clinically 
indicated 
Study measurements are minimum requirement 
* Laboratory studies include a complete blood count with differential comprehensive 
metabolic panel, and GVHD prophylaxis drug levels where applicable. 
 
The day +28 peripheral blood, marrow studies, and IRP can be obtained within 1 week before 
day 28 (i.e. day +21 through day +28) and within 2 weeks after day +28 (i.e. day 28 through day 
+42) to account for scheduling factors and failed testing. 
 
The formal endpoint of this study for efficacy is 1 year post HSCT. Therefore patients will not be 
followed for this study after this time. However, outcomes for patients undergoing HSCT at 
TJUH are followed programmatically beyond this study indefinitely 
 
6.1 Hematopoietic Engraftment: Defined as 
Hematopoietic engraftment will be defined as: 
• ANC ≥ 0.5 x10e9/L for at least 3 days 
• Platelet engraftment > 20,000 with no transfusion x7 days 


21 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
6.2 Toxicity Criteria 
Regimen-related toxicity will be graded according to the NCI Common Toxicity Criteria version 
4.0. 
 
6.3 Disease Response 
Disease response will be measured according to the National Comprehensive Cancer Network 
Guidelines (NCCN). The guidelines are disease specific and the guidelines for each disease can 
be found at: 
 
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site 
 
6.4 GVHD Scoring 
GVHD will be graded according to standard criteria contained in Appendix B. 
 
6.5 Adverse Event Reporting 
All patients will be followed for adverse experiences (AEs) (serious and non-serious), regardless 
of relationships to study treatment, from the time of enrollment until d+100 after transplant. The 
following events are expected side effects of high-dose chemotherapy and transplant and will be 
recorded but not reported: 
• Alopecia, headache, dry skin 
• Emesis from chemotherapy or other agents unless refractory to standard supportive care, 
nausea, anorexia 
• Weight loss, cough, dry mouth 
• Grades 1-3 fever 
• Grades 1-3 infectious sequellae 
• Grades 1-3 electrolyte imbalances 
• Grades I-III abnormalities in alkaline phosphatase, AST and ALT 
• Neutropenia/uncomplicated neutropenic fever 
• Thrombocytopenia, petechiae, ecchymoses, minor vaginal bleeding, epistaxis, 
hemorrhoidal bleeding, or other similar bleeding events will not be reported. (Bleeding 
events requiring intervention such as endoscopy or radiologic evaluation will be reported) 
• Anemia 
• Grades 1-3 rash 
• Grades 1-3 fatigue 
• Grades 1-3 mucositis 
• Grades 1-3 diarrhea 
• Allergic or other reactions to drugs used for supportive care or GVHD prophylaxis unless 
grade 4-5 
 
Serious adverse events reporting to the TJU Institutional Review Board will occur for grade 4 
and grade 5 events and/or for an event that results in hospitalization or permanent disability 
regardless to the relationship to the study treatment. 
 
After d+100, only AEs that are considered by the investigator to be possibly or probably 
associated with the treatment regimen will be reported. 


22 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
6.6 Reporting to SKCC DSMC 
All AEs and SAEs except those listed in section 6.5, safety and toxicity data, and any corrective 
actions will be submitted to the DSMC per the frequency described in the SKCC DSMP. The 
report to the SKCC DSMC will also include any unanticipated problems that in the opinion of 
the PI should be reported to the DSMC. 
For expedited reporting requirements, see table below: 
 
DSMC AE/SAE Reporting Requirements 
 
 
6.7 Reports to the Federal Drug Administration (FDA) 
All grade 3-5 hematopoietic cell infusion reactions and all unexpected SAEs as defined in 21 
CFR 312.32 will be reported to the FDA in an expedited fashion. 
 
All Unanticipated Adverse Device Effects will also be reported to the FDA within 10 working 


23 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
days as defined in 21 CFR 812.150. 
 
An annual report will be sent to the FDA regarding the progress to date of patients on the trial. In 
the report, a separate listing of infusion toxicities and all biological product deviations will be 
included in addition to the other required elements. 
 
6.8 Study Endpoint 
The endpoint of this study is OS at 1 year. 
 
7.0 Supportive Care 
7.1 Avoidance of Infection 
 
It is recommended that IVIG 0.5 g/kg IV is administered every 4 weeks post-transplant to 
support immune function, until the IgG level is ≥ 500 mg/dL on 2 consecutive monthly 
measurements. The first dose will be administered on day +7 if the patient is clinically stable 
enough to receive it. If not, IVIG should be administered as soon as feasibly possible after d +7. . 
 
The infusion of IVIG to patients undergoing matched sibling transplant is at the discretion of the 
attending physician. 
 
7.2 Infectious Prophylaxis: General Guidelines 
Patients post partially-matched related donor transplantation will be maintained on antifungal 
prophylaxis, usually voriconazole 200 mg BID. It is at the discretion of the treating attending 
physician to change agents as clinically indicated. 
 
Patients post partially-matched related donor transplantation will be maintained on HSV 
prophylaxis, usually valacyclovir 500 mg daily. It is at the discretion of the treating attending 
physician to change agents based on culture results and sensitivities. 
 
Patients post partially-matched related donor transplantation will be maintained on PCP 
prophylaxis, usually TMP-SMZ DS 1 tablet daily weekly. It is at the discretion of the treating 
attending physician to change agents based on culture results, drug intolerance. 
 
Prophylactic medications may be discontinued at the discretion of the attending physician. Their 
absence in the medical record serves as documentation that they were discontinued. 
 
7.3 Growth Factor and Transfusion Support 
To prevent inadvertent lymphoid engraftment, all blood cell products must be irradiated. 
 
All red cell and platelet products will be leukodepleted to prevent alloimmunization and decrease 
infectious sequela. 
 
Packed red blood cell transfusions will be given as necessary to target a hemoglobin ≥ 7-8g/L. 
 
Platelet transfusions will be used as needed to keep the morning count ≥ 10-20x10e9/L, with 
10x10e9/L used for situations without an excessive bleeding risk. 


24 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
It is recognized that values for hemoglobin and platelet count may go below targets as these labs 
are not continuously checked and a time delay need to order blood products. 
 
GM-CSF (granulocyte-macrophage colony-stimulating factor) 250μg/m2 will be administered 
daily beginning on day +1. GM-CSF will be weaned/discontinued at the discretion of the 
attending physician. Every effort should be made to keep the ANC ≥ 1000 for all patients post 
partially-matched related donor transplantation. GCSF 5μg/m2 can be substituted for GM-CSF in 
the event of a GM-CSF shortage or if a patient has a deleterious reaction to GM-CSF as 
determined by the BMTU attending physician. 
 
Red cell growth factors are permissible after transplantation. 
 
8.0 Drug Information and Administration 
8.1 Cyclophosphamide 
Mechanism: A multistep process activates it by conversion to 4-hydroxycyclophosphamide by 
the liver microsomal oxidase system and to aldophosohamide by tautomerization in the 
peripheral tissues. Aldophosphamide spontaneously degrades into acrolein and phosporamide 
mustard, which cause cellular glutathione depletion and DNA alkylation. This results in 
inhibition of DNA replication and transcription. Cells expressing high levels of aldehyde 
dehydrogenase (e.g. stem cells, L1210 leukemia cells) resist cyclophosphamide-mediated 
cytotoxicity as aldophosphamide is inactivated by this enzyme. The drug also does not affect 
quiescent cells and therefore stem cells are generally protected, an important factor if autologous 
hematopoietic recovery is relied on in the event of graft failure. 
 
Metabolism: Cyclophosphamide is broken down as described above and the break down 
products are excreted by the kidneys. 
 
Incompatibilties: Phenobarbital or rifampin may increase the toxicity of cyclophosphamide. 
Concurrent allopurinol or thiazide diuretics may exaggerate bone marrow depression May 
prolong neuromuscular blockade from succinylcholine Cardiotoxicity may be additive with other 
cardiotoxic agents (cytarabine, daunorubicin, doxorubicin). May decrease serum digoxin levels. 
Additive bone marrow depression with other antineoplastics or radiation therapy. May potentiate 
the effects of warfarin. May decrease antibody response to live-virus vaccines and increase the 
risk of adverse reactions. Prolongs the effects of cocaine. 
 
Toxicity: Nausea, vomiting, water retention due to inappropriate secretion of anti-diuretic 
hormone (SIADH), cardiomyopathy with myocardial necrosis and congestive heart failure, 
hemorrhagic cystitis, alopecia, skin rash, pulmonary fibrosis, sterility and secondary 
malignancies. 
 
Administration: Patients will receive a dose of cyclophosphamide 60 mg/kg IV, on days –3 and - 
2. The dose of cyclophosphamide will be calculated according to the dosing body weight. 
MESNA (sodium-2-mercaptoethane sulfonate) will be administered as a 60 mg/kg/continuous IV 
infusion over 24 hours starting 30 minutes prior to cyclophosphamide infusion and ending 
approximately 24 hours after the last dose of cyclophosphamide. The dose of MESNA will also 


25 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
be calculated based on dosing body weight. 
 
Reference: Skeel R & Lachant N. Handbook of Cancer Chemotherapy, 4th Ed. Little, Brown & 
Co.: Boston. 
 
8.2 Donor Leukocyte Infusion (DLI) 
Administration: All patients will receive a dose of donor CD3+ T cells per kilogram of dosing 
body weight as outlined in the treatment design. Details of the apheresis procedure to obtain 
white blood cells, quantification of CD3+ T cells by flow cytometry, and administration of the 
white cell product to the recipient are provided in the treatment section. All drugs that may cause 
lymphocyte suppression are starting on the day of admission through day 0 as detailed in the 
treatment section. 
 
Toxicity: Infusion reactions, GVHD. 
 
8.3 Fludarabine 
Mechanism: Fludarabine phosphate is fluorinated nucleotide and analog of antiviral agent 
vidarabine, that is relatively resistant to adenosine deaminase deamination. It is actively 
dephosphorylated to 2-fluoro-ara-A and phosphorylated further by deoxycytidine kinase to 2- 
fluoro-ara-ATP, then acts by inhibiting DNA polymerase alpha, ribonucleotide reductase and 
DNA primase resulting in DNA synthesis inhibition. 
 
Metabolism: Renal Excretion 
In a pharmacokinetic study of patients treated with fludarabine for rheumatoid arthritis, the mean 
total clearance was 14.01 L/hr following a dose of 20 mg/m2/day, and 13.4 L following a dose of 
30 mg/m2/day (Knebel et al, 1998). The median total body clearance was 9.6 L/hr after 
intravenous or subcutaneous fludarabine 30 mg/m2 for 3 days in 5 patients with lupus nephritis 
(Kuo et al, 2001). 
 
Incompatibilities: Fludarabine has drug interactions with several vaccines and its simultaneous 
use with Rotavirus vaccine is contraindicated. 
 
Toxicities: Common: Endocrine/Metabolic: Shivering, Gastrointestinal: Loss of Appetite, 
Nausea, Vomiting, Neurologic: Asthenia, Other: Fatigue, Malaise, Serious: Cardiovascular: 
Edema (frequent), Dermatologic: Aplasia of skin (rare), Hematologic: Autoimmune Hemolytic 
Anemia, Graft versus host disease, Transfusion-associated, with non-irradiated blood (rare), 
Myelosuppression (frequent), Neurologic: Neurotoxicity, Respiratory: Pneumonia (frequent), 
Other: Fever (frequent), Infectious disease. 
 
Administration: In this protocol, Fludarabine is administered for 3 days on (days -10 through – 8) 
at a dose of 30 mg/m2 IV. Creatinine should be checked prior to each dose of fludarabine. If 
renal insufficiency develops, the attending physician must be notified in cases where a dose 
adjustment needs to be made. 
 
Reference: MicroMedex Health Care Series, Thomson 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
8.4 G-CSF 
Mechanism: G-CSF is a human granulocyte colony-stimulating factor produced by recombinant 
DNA technology. It is a glycoprotein which acts on hematopoietic cells by binding to specific 
cell surface receptors and stimulating proliferation, differentiation, commitment, and some end- 
cell functions. 
 
Metabolism: Absorption and clearance of G-CSF follows first-order pharmacokinetic modeling 
without apparent concentration dependence. The elimination half-life in both normal and cancer 
patients is 3.5 hours. 
 
Incompatibilties: Safety and efficacy of G-CSF when used simultaneously with chemotherapy or 
radiotherapy has not been evaluated. Donors receiving either of these 2 modalities will not be 
permitted on study. 
 
Toxicities: Allergic reactions consisting of rash, wheezing and tachycardia. Splenic rupture, 
ARDS, and exacerbation of sickle cell disease have been reported rarely. 
Administration: In this protocol, G-CSF will be administered to healthy donors at a dose of 10 
μg/kg (actual weight) subcutaneously on days -5 through day -1. 
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 
 
8.5 GM-CSF 
Mechanism: GM-CSF is a recombinant human granulocyte-colony stimulating factor produced 
by recombinant DNA technology in a yeast expression system. It supports survival, clonal 
expansion, and differentiation of hematopoietic cells. GM-CSF is also capable of activating 
mature granulocytes and macrophages, and is a multilineage factor with effects on the 
myelomonocytic, erythroid, and megarkaryocytic lines. 
 
Metabolism: GM-CSF is detected in the serum at 15 minutes after injection. Peak levels occur 
about 1 to 3 hours after injection, and it is detectable in the serum for up to 6 hours after 
injection. 
 
Incompatibilities: Interactions between GM-CSF and other drugs have not been fully evaluated. 
Drugs which may potentiate the myeloproliferative effects of GM-CSF, such as lithium and 
corticosteroids, should be used with caution. 
 
Toxicities: Allergic and anaphylactic reactions have been reported. A syndrome characterized by 
respiratory distress, hypoxia, flushing, hypotension, syncope and or tachycardia has been 
associated with the first administration of GM-CSF in a cycle. These signs have resolved with 
treatment. 
 
Administration: In this protocol, GM-CSF will be given to the patients beginning on Day +1 in 
the PM. 
 
Reference: Physician’s Desk Reference, Edition 58, 2004. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
8.6 Mycophenolate Mofetil (MMF) 
Mechanism: Inhibits the enzyme inosine monophosphate dehydrogenase, which is involved in 
purine synthesis. This inhibition results in suppression of T- and B-lymphocyte proliferation. 
 
Metabolism: Following oral and IV administration, mycophenolate is rapidly hydrolyzed to 
mycophenolic acid (MPA), its active metabolite. Distribution is unknown. MPA is extensively 
metabolized; <1% excreted unchanged in urine. Some enterohepatic recirculation of MPA 
occurs. Half Life: MPA¾17.9 hr. 
 
Incompatibilities: Combined use with azathioprine is not recommended (effects unknown) · 
Acyclovir and ganciclovir compete with MPA for renal excretion and, in patients with renal 
failure, may increase each other's toxicity. Magnesium and aluminum hydroxide antacids 
decrease the absorption of MPA (avoid simultaneous administration). Cholestyramine and 
colestipol decrease the absorption of MPA (avoid concurrent use). Toxicity may be increased by 
salicylates. May interfere with the action of oral contraceptives (additional contraceptive method 
should be used). May decrease the antibody response to and increase risk of adverse reactions 
from live-virus vaccines, although influenza vaccine may be useful. When administered with 
food, peak blood levels of MPA are significantly decreased. 
 
Toxicities: GI: Bleeding, Diarrhea, Vomiting, Hematopoietic: Leukopenia Miscellaneous: 
Sepsis, Increased Risk of Malignancy 
 
Administration: In this protocol, MMF will be administered at a dose of 1 gram IV BID 
beginning on day -1. MMF will be discontinued on day +28 in the absence of GVHD. MMF may 
be stopped earlier if there is count suppression from the drug or other unforeseen circumstances 
in which the drug is felt to be deleterious to the plan of care. 
 
8.7 Plerixafor 
Mechanism: Reversibly inhibits binding of stromal cell-derived factor-1-alpha (SDF-1α), 
expressed on bone marrow stromal cells, to the CXC chemokine receptor 4 (CXCR4), resulting 
in mobilization of hematopoietic stem and progenitor cells from bone marrow into peripheral 
blood. Plerixafor used in combination with filgrastim results in synergistic increase in CD34+ 
cell mobilization. Mobilized CD34+ cells are capable of engrafting with extended repopulating 
capacity. 
 
Metabolism: Plerixafor is absorbed rapidly after subcutaneous administration and is distributed 
primarily in the extravascular fluid space. The terminal half-life elimination is 3-6 hours and the 
drug is excreted in the urine, about 70% as parent drug. 
 
Incompatibilities: There are no known significant incompatibilities. 
 
Toxicities: Adverse reactions include fatigue, headache, dizziness, local injection site reaction, 
and arthralgia 
 
Administration: Allogeneic donors may receive a dose of 0.24 mg/kg daily x 2 days in the PM of 
days -3 and day -2 as needed. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
8.8 Tacrolimus 
Mechanism: Tacrolimus, it is a macrolide immunosuppressant. It inhibits lymphocytes by 
forming a complex with FKBP-12, calcium, calmodulin leading to the decrease in the 
phosphatase activity of calcineurin. This in turn prevents generation of NF-AT, a nuclear factor 
for initiating gene transcription for lymphokines like interleukin-2 and interferon-γ99. This drug 
is used with corticosteroids for prophylaxis of organ rejection in patients receiving allogeneic 
liver transplants. Its use is also currently being investigated in kidney, bone marrow, cardiac, 
pancreas, pancreatic island cell and small bowel transplantation. 
 
Metabolism: This drug is well absorbed orally. It is metabolized in the liver by unknown 
mechanisms and demethylation and hydroxylation has been proposed based on in vitro studies. 
The metabolized products are excreted in the urine. 
 
Incompatibilities: Nephrotoxic drugs, antifungals (azoles), calcium-channel blockers, cimetidine, 
danazol, erythromycin, methylprednisone and metoclopramide increase the bioavailabilty of 
tacrolimus. On the other hand phenobarbital, phenytoin, rifamycins and carbamazepine decrease 
tacrolimus levels. 
 
Toxicities: Adverse reactions include: tremor, headache, neurotoxicity; diarrhea, nausea; 
hypertension; TTP and renal dysfunction. 
 
Administration: Tacrolimus will be started on day -1. The drug dose will be titrated to a goal 
level of 7 ng/ml +/- 2, although it is recognized that there may be variations beyond the target 
range due to interpatient variability. 
9.0 Patient Safety 
To ensure patient safety, a number of steps will be taken. 
 
The study will be monitored on an ongoing fashion by the Principal Investigator (PI) and the 
study medical monitor. Monitoring reports will be submitted to the Clinical Research t Office 
(CRO) for review by the DSMC during their quarterly review. Adverse events and a report 
summarizing their impact on the conduct of the trial are submitted to the Data Monitoring and 
Safety Committee (DMSC) quarterly, and the DSMC reports are then submitted to the PRC and 
IRB annually. The PI will submit serious adverse events (SAE) to the TJU IRB utilizing the 
electronic Kimmel Cancer Center Clinical Trials Adverse Event Reporting system. Due to the 
nature of the study treatment as outlined in this protocol, expected grade 3 AE/SAEs that occur 
while receiving standard inpatient protocol treatment may be included on the patient’s AE log for 
quarterly review by the DSMC rather than be reported via the eSAEy System per the DSM Plan. 
It is the responsibility of the study Principal Investigator (PI) to report any grade 3 AE/SAE to 
the DSMC per the DSM Plan should the length of standard protocol treatment hospitalization be 
extended and/or the grade 3 AE/SAE is more acute than expected as outlined in the informed 
consent form. Unexpected deaths related to this protocol will be reported within 24 hours. 
 
The medical monitor will be a TJU physician who is not a collaborator in this trial. The medical 
monitor will review all adverse events (in addition to unexpected adverse events), safety data and 
activity data observed when this trial is ongoing. The medical monitor may recommend reporting 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
adverse events and relevant safety data not previously reported, and may recommend suspension 
or termination of the trial. The summary of all discussions of adverse events will be submitted to 
the DSMC after completion and included in the PI's reports to the PRC and the TJU IRB as part 
of the study progress report. The PRC, DMSC, and/or the TJU IRB may, based on the monitor's 
recommendation suspend or terminate of the trial. The quarterly safety and monitoring reports 
will include a statement as to whether this data has invoked any stopping criteria (dose-limiting 
toxicities) in the clinical protocol. 
 
In addition to the Cancer Center's DMSC, the TJU BMT program members meet weekly to 
discuss the status of patients on trial and generate discussion regarding the progress of the 
patients on the trial. 
 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, the 
funding sponsor, government regulatory bodies, and University compliance and quality 
assurance groups of all study related documents (e.g. source documents, regulatory documents, 
data collection instruments, study data etc.). The investigator will ensure the capability for 
inspections of applicable study-related facilities. 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality assurance 
offices. 
 
In addition to review by the DSMC, all studies initiated by SKCC investigators are audited by an 
independent auditor once they have achieved 10% of target accrual. However, a study can be 
audited at any time based on recommendations by the IRB, DSMC, PRC and/or the Director of 
Clinical Investigations, SKCC. Studies are re-audited once they have achieved 50% of target 
accrual. Special audits may be recommended by the IRB, DSMC or PRC based on prior findings, 
allegations of scientific misconduct and where significant irregularities are found through quality 
control procedures. Any irregularities identified as part of this process would result in a full audit 
of that study. 
 
In addition to the audits at 10 and 50%, the CRO randomly audits at least 10 percent of all 
patients entered into therapeutic SKCC trials and other trials as necessary, on at least a bi-annual 
basis, to verify that there is a signed and dated patient consent form, the patient has met the 
eligibility criteria, and that SAEs are documented and reported to the TJU IRB. 
 
All audit reports are submitted to the DSMC for review and action (when appropriate). A copy of 
this report and recommended DSMC action is sent to the PRC and TJU IRB. The committee 
regards the scientific review process as dynamic and constructive rather than punitive. The 
review process is designed to assist Principal Investigators in ensuring the safety of study 
subjects and the adequacy and accuracy of any data generated. The TJU IRB may, based on the 
DSMC and auditor’s recommendation, suspend or terminate the trial. 
 
9.1 FDA Reports 
All grade 3-5 hematopoietic cell infusion reactions and all unexpected SAEs as defined in 21 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
CFR 312.32 will be reported to the FDA in an expedited fashion. 
 
All Unanticipated Adverse Device Effects will also be reported to the FDA within 10 working 
days as defined in 21 CFR 812.150 
 
An annual report will be sent to the FDA regarding the progress to date of patients on the trial. In 
the report, a separate listing of infusion toxicities and all biological product deviations will be 
included in addition to the other required elements. 
 
Lastly, a current list of investigators, including the names and addresses of all investigators 
participating in this trial, will be provided to the FDA every six months. 
 
10.0 Statistical Analysis 
10.1 Study Design 
This is a one arm interventional study in which patients with hematological malignancies are 
treated with haploidentical HSCT using a NMA conditioning regimen. 
 
10.2 Accrual and Study Duration 
The total of 35 patients will be accrued in about 6 years and 6 months and then followed for at 
least 1 more year. The total study duration is approximately 7 years 6 months. 
 
10.3 Analysis of the Primary Endpoint 
The primary endpoint for this study is OS at 1 year post HSCT. 
 
The primary null hypothesis is that 1 year OS rate is at most 45%. 45% is the figure representing 
the OS at 1 year of patients treated on the initial TJU 2 Step RIC HSCT trial and would represent 
a failure to improve OS in patients undergoing haploidentical HSCT at our institution and others 
reported in the literature. Alternative hypothesis is OS at 1 year of 60%. OS will be estimated 
using Kaplan-Meier curves. The 1-year OS rate and corresponding 95% confidence interval will 
be estimated from the Kaplan-Meier curve for the OS. The null hypothesis will be rejected if the 
lower bound of the 95% confidence interval for the 1-year OS rate is above 0.45. 
 
10.4 Sample Size 
Assuming that 35 patients will be accrued in 6 years and 6 months and then followed for 1 
more year there is 74% power to show that 1-year OS is greater than 45% if the true 1-year 
survival is 60% or higher (calculations are based on the assumptions of uniform accrual over 
time, no loss to follow-up, exponentially distributed death times, and use of the exponential 
MLE one-sided testwith alpha=0.05). 
 
10.5 Assessment of the Secondary Endpoint 
The secondary endpoints include (1) relapse-related mortality (RRM) rate at 1 year; (2) NRM at 
1 year; (3) the incidence and severity of graft-versus-host disease (GVHD); (4) engraftment 
rates; and (5) the evaluation of lymphoid reconstitution monthly to every other month during the 
first year post HSCT. These secondary endpoints will be reported descriptively. RRM and NRM 
may also be estimated using Kaplan Meier curves and/or cumulative incidence analyses. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
10.6 Analysis of Safety 
The safety data analysis will be descriptive. The estimates of the incidence rates will be 
presented with corresponding confidence intervals using the exact method. 
 
Patient outcomes are routinely monitored in an ongoing fashion for all patients on investigational 
trials, beyond their formal endpoints. Based on prior experience using a two-step approach 
similar to that described in this trial, we anticipate that the incidence of graft failure should be 
less than 20%, the incidence of severe GVHD should be less than 20%, and the non-relapse 
mortality should be less than 30% at 100 days. If at any point incidences higher than these 
thresholds are seen, that would trigger a protocol review to assess whether there are any obvious 
reasons for the inferior outcomes observed. Depending on the results of the review, enrollment 
may continue on a limited basis with careful further observation, the protocol may be revised, or 
the protocol may be terminated. 
 
In addition, it is estimated that up to 5 patients with matched sibling donors will undergo HSCT 
on this approach during the time that the research study is open. The small number of patients 
undergoing matched sibling RIC HSCT in our transplant program precludes a separate research 
protocol for that group. To prevent withholding of transplant therapy, these patients will be 
treated on this protocol. Only the outcomes of the patient group undergoing HSCT from 
haploidentical donors (2, 3, or 4 antigen mismatches in the GVH direction) will be used in the 
analysis of outcomes for the statistical ends of the trial. Outcomes for patients with matched 
sibling donors will be reported descriptively. 
 
11.0 References 
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Antin, J. H., & Ferrara, J. L. M. (1992). Cytokine dysregulation and acute graft-versus-host 
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Aoudjhane, M., Labopin, M., Gorin, N. C., Shimoni, A., Ruutu, T., Kolb, H. -., . . . Lauria, F. 
(2005). Comparative outcome of reduced intensity and myeloablative conditioning regimen in 
HLA identical sibling allogeneic haematopoietic stem cell transplantation for patients older than 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
50 years of age with acute myeloblastic leukaemia: A retrospective survey from the acute 
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Archimbaud, E., Thomas, X., Michallet, M., Jaubert, J., Troncy, J., Guyotat, D., & Fiere, D. 
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Barlogie, B., Jagannath, S., Vesole, D. H., Naucke, S., Cheson, B., Mattox, S., Tricot, G. (1997). 
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Bortin, M. M., & Rimm, A. A. (1986). Increasing utilization of bone marrow transplantation. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
Transplantation, 42(3), 229-234. 
 
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histotype heavily influence outcome. Leukemia, 21(11), 2316-2323. 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
Couban, S., Stewart, A. K., Loach, D., Panzarella, T., & Meharchand, J. (1997). Autologous and 
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de Lima, M., Anagnostopoulos, A., Munsell, M., Shahjahan, M., Ueno, N., Ippoliti, C., Giralt, S. 
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disease control after allogeneic hematopoietic stem cell transplantation. Blood, 104(3), 865-872. 
 
De Lima, M., Couriel, D., Thall, P. F., Wang, X., Madden, T., Jones, R., . . . Andersson, B. S. 
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in AML and MDS. Blood, 104(3), 857-864. 
 
Drobyski, W. R., Keever, C. A., Roth, M. S., Koethe, S., Hanson, G., McFadden, P., 
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Gaballa, S., Alpdogan, S., Carabasi, M., Filicko-O'Hara, J., Kasner, M., Martinez, U., Grosso, D. 
(2014a). Outcomes of older patients undergoing a 2-step approach to haploidentical and matched 
related peripheral blood hematopoietic stem cell transplantation (HSCT): A single institution 
experience [Abstract]. European Blood and Marrow Transplantation 40th Annual Meeting, 
Milan, Italy, 
 
Gaballa, S., Alpdogan, S., Carabasi, M., Filicko-O'Hara, J., Kasner, M., Martinez, U., Grosso, D. 
(2014b). Outcomes of older patients undergoing a 2-step approach to haploidentical and matched 
related peripheral blood hematopoietic stem cell transplantation (HSCT): A single institution 
experience. Presented in Poster and Abstract Form at the European Society of Bone Marrow 
Transplantation Meetings, Milan, Italy, 


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15D.323 Protocol version 7.0 dated 11Oct2022 
 
Gahrton, G., Tura, S., Ljungman, P., Blade, J., Brandt, L., Cavo, M., Volin, L. (1995). Prognostic 
factors in allogeneic bone marrow transplantation for multiple myeloma. Journal of Clinical 
Oncology, 13(6), 1312-1322. 
 
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15D.323 Protocol version 7.0 dated 11Oct2022 
 
and Marrow Transplantation 
 
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15D.323 Protocol version 7.0 dated 11Oct2022 
 
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12.0 Appendices 
Appendix A: Guidelines for Total Body Irradiation 
Modality: 
Photon irradiation is to be used for the TBI in all patients. 
 
Energy: 
A linear accelerator with energy ≥ 4 MV may be used. Dose to superficial tissues near skin 
surface will be increased by using a beam “spoiler” lucite plate close to the patient. 
Since neoplastic infiltrates may be found in the skin, it is necessary for the superficial dose to 
satisfy the same total dose requirements as other locations. 
 
Geometry: 
The treatment configuration shall be such that the patient is entirely included within the 
treatment beam. It is essential that the correlation between the light field and the radiation field 
be established and verified for extended TBI distances. 
 
Dose Rate: 
A dose rate of 0.05 to 0.25 Gy/minute at the prescription point shall be utilized. The physicist of 
record, involved with TBI treatments, shall be consulted to achieve correct range of treatment 
dose rate. 
 
Calibration & Beam Data Verification: 
The calibration of the output of the machine, used for this protocol, shall be verified on a daily 
basis prior to start TBI treatments. All dosimetric parameters, necessary for the calculation of 
dose delivered during TBI treatments, shall be measured at the appropriate treatment distance. 
They shall be documented and made available for calculation of every patient treatment. 
 
Treatment Volume: 
The patient shall be entirely included within the treatment beam. Care should be taken to 
guarantee that all of the patient is within the 90% decrement line at each depth. The 90% 
decrement line is defined as the line in each plane perpendicular to the central axis connecting 
the points which are 90% of the central axis dose, in that plane. 
 
Treatment Dose: 
Prescription Point: 
The prescription point is defined as the midplane point along the longitudinal axis at the level of 


40 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
the umbilicus. 
 
Dose Unit 
All doses shall be specified in Gray (Gy) to muscle tissue. 
 
Tissue Inhomogeneity Considerations: 
No inhomogeneity corrections shall be made in the calculation of the dose to the prescription 
point. 
 
Prescription Point Dose: 
The total dose shall be 4 Gy delivered administered in two divided doses of 2 Gy each on day -7. 
 
Time-Dose Considerations: 
Dose Homogeneity: 
The total absorbed dose along the patient's head to toe axis (in the midplane of the patient) shall 
not deviate more than 10% from the prescribed dose. 
 
Treatment Technique: 
Treatment Fields: 
Equally weighted parallel opposed portals shall be used. AP/PA fields shall be used. 
 
Field Size: 
The collimation and treatment distance shall be such that the patient will be entirely included 
within the treatment beam and that no part of the patient extends beyond that region. The 
agreement of the light field and the radiation field should be checked periodically for the 
extended TBI treatment distance. 
 
Treatment Position: 
The patient shall be treated in any position that is compatible with the homogeneity requirement, 
allowing for the reproducibility of the patient setup and dosimetry. 
 
Field Shaping: 
Patients will be treated with open fields. 
 
Calculations: 
Central Axis Dose: 
It is recommended that the dose calculation method be based upon measurements that are made 
in a unit density phantom with the following minimum dimensions: 
• Length equal to top of shoulder to the bottom of the pelvis. 
• Width equal to the patient width at the level of the umbilicus. 
• Thickness equal to the typical patient thickness at the umbilicus. 
• All measurements should be made at the appropriate extended SSD. 
 
Superficial Dose: 
For the radiation beam with the Plexiglas plate in place, data should be available demonstrating 
that the skin dose is within 5% of the prescribed dose. 


41 
15D.323 Protocol version 7.0 dated 11Oct2022 
 
Quality Assurance Documentation: 
For purposes of quality assurance the following must be performed on every patient undergoing 
TBI: 
• A check of the monitor unit calculation by a second physicist and a radiation oncologist 
prior to first treatment. 
 
Appendix B: GVHD Grading System Grade 
Clinical Staging of Acute Graft-Versus-Host Disease 
 
Stage 
Skin 
Liver 
Gut 
+ 
Maculopapular 
rash < 25% body 
surface 
Bilirubin, 2-3 
mg/dl 
Diarrhea, 500- 
1,000 ml/day or 
persistent nausea 
++ 
Maculopapular 
rash 25-50% body 
surface 
Bilirubin, 3-6 
mg/dl 
Diarrhea, 1,000- 
1,500 ml/day 
+++ 
Generalized 
erythroderma 
Bilirubin, 6-15 
mg/dl 
Diarrhea, > 1,500 
ml/day 
++++ 
Desquamation and 
bullae 
Bilirubin, > 15 
mg/dl 
Pain +/- ileus 
 
Clinical Grading of Acute Graft-Versus-Host DiseaseStage 
Overall 
Grade 
Skin 
Liver 
Gut 
Functional 
Impairment 
0 (none) 
0 
0 
0 
0 
I (mild) 
+ to ++ 
0 
0 
0 
II (moderate) 
+ to +++ 
+ 
+ 
+ 
III (severe) 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV (life- 
threatening) 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++ 
Tables from Glucksberg H, Storb R, Fefer A, et al. Clinical manifestations of graft-versus-host 
disease in human recipients of marrow from HL-A-matched sibling donors. Transplantation, 18: 
295-304, 1974. 
 
RefWorks: New Mini Haplo File