Conditions: Leukemia, Myeloid, Chronic Lymphomas Multiple Myeloma Myelodysplastic Syndrome Leukemia, Lymphocytic, Acute Leukemia, Lymphocytic, Chronic AML
Keywords: donor lymphocyte infusions BMT bone marrow transplant
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 57
Healthy volunteers: no

Brief summary:
The purpose of this study is to test the hypothesis that a pre-infusion preparative regimen of cyclophosphamide and fludarabine will improve the effectiveness of DLI in patients with blood cancers.

Detailed description:
When cancer relapses after donor bone marrow transplantation, regular dose chemotherapy offers little hope of prolonged survival. However, there is evidence that lymphocytes can attack cancer cells. There is considerable evidence that this immune attack on cancer cells is associated with graft-versus-host disease. Although graft-versus-host disease can cause problems, this immune reaction may, in part, be the way that bone marrow transplantation cures cancer. In this study we hope that infusion of immune cells from the subject's bone marrow donor plus a chemotherapy regimen of cyclophosphamide and fludarabine will activate the subject's immune system to attack their cancer.

Arms:
arm 1: Patients with Chronic Myelogenous Leukemia (CML) who have failed or refused Gleevec(TM) therapy and will receive Donor Lymphocyte Infusion. arm 2: Patients with non-CML or CML who have failed Donor Lymphocyte Infusion (DLI) and will receive induction chemotherapy plus DLI.

Interventions: intervention 1: Donor Lymphocyte Infusion intervention 2: Induction Chemotherapy
Intervention descriptions: intervention 1: donor cells infused over 2 hrs at cell dose of 0.5 dx 10\^8 CD3+T-cells/kg intervention 2: Fludarabine 25 mg/m2 IV Cyclosphosphamide 60 mg/kg IV

Protocol document:
Prot_SAP_000.pdf: 
10/10/2008
Page 1 of 39
UNIVERSITY OF MINNESOTA BONE MARROW TRANSPLANT PROGRAM
USE OF CYCLOPHOSPHAMIDE/FLUDARABINE TO PROMOTE IN VIVO EXPANSION OF
DONOR LYMPHOCYTE INFUSIONS (DLI) TO ENHANCE EFFICACY AFTER RELAPSE
FROM ALLOGENEIC TRANSPLANT
MT2003-15
Original 8/4/03
Revised 2/23/04
Revised 5/18/2004
Revised 7/30/2004
Revised 12/22/2004
Updated 3/4/2005 (covering 1/4/05, 1/18/05, 2/11/05 revision letters)
Revised 3/22/2005
Revised 4/22/2006
Clarification: 10/10/2008
Study Committee
Jeffrey Miller, M.D., Principal Investigator
Daniel Weisdorf, M.D.
Linda Burns, M.D.
Bruce Blazar, M.D.
Michael Verneris, M.D.
Todd DeFor, M.S.
This document contains confidential information that is the property of the Blood and Marrow
Transplant Program. Do not copy, disclose, or circulate without written authorization from the Fairview-
University Blood and Marrow Transplant Services Medical Director


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PROTOCOL REVISION HISTORY
Version
Date
Amendment
Details of changes
Consent
change?
8/4/03
original
2/23/04
revised per CPRC review
5/18/2004
Induction chemotherapy change: moved
cyclophosphamide dose from day –7 to day
-5
Yes
7/30/2004
Section 4.1.5.2 change in LFT eligibility
No
12/22/2004
Section 6.5.2 Change in method of DLI
infusion. -- approved 1/20/2005
No
1/4/2005
Section 4.1.6 and 4.2.2, Appendix 1
changed eligibility to allow for subjects to
be off prednisone and other
immunosuppressive drugs for at least 3
days, except for subjects who are on
immunosuppressive drugs for GVHD (who
will continue to be excluded from the study
unless they have been off the medication for
2 weeks). Approved by the IRB 1/20/2005
No
1/18/2005
Section 12.4 defined Marrow aplasia,
clarified monitoring guidelines of early
death. CPRC approval 2/5/05; IRB
approval 3/10/2005
No
2/11/2005
Section 4.1.2, Appendix 1 Clarified
eligibility of CML patients. IRB approval
2/23/2005
No
3/22/2005
Section 4.1.1.2 Clarified definition of
relapse
Section 7.1.1, Appendix 2. Pre-transplant
bone marrow biopsies can be done within 30
days of starting therapy (rather than 10).
Section 7.2.2, Appendix 2. Clarified that
daily assessment of CBC will not be
necessary for outpatients.
4/22/2006
Decrease in DLI cell dose due to excess rate
and intensity of GVHD
Yes
10/10/2008
Section 4.2.3 clarified that exclusion criteria
is for known active CNS leukemia; section
13.2 revised instructions on lab draws
No


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TABLE OF CONTENTS
Schema
4
1.0
PURPOSE
5
2.0
OBJECTIVES
5
3.0
BACKGROUND
5
4.0
SELECTION OF PATIENTS
9
5.0
REGISTRATION PROCEDURES
11
6.0
TREATMENT PLAN
11
7.0
STUDY PARAMETERS
13
8.0
ADVERSE EVENT REPORTING
15
9.0
DATA AND SAFETY MONITORING PLAN
15
10.0
MEASUREMENT OF EFFECT
16
11.0
DRUG FORMULATION AND PROCUREMENT
16
12.0
EXPERIMENTAL DESIGN & STATISTICAL CONSIDERATIONS
18
13.0
CORRELATIVE STUDIES
20
14.0
RECORDS TO BE KEPT
20
15.0
REFERENCES
20
Appendix 1
ELIGIBILITY CHECKLIST
25
Appendix 2
PARAMETERS
28
Appendix 3
EXPECTED TOXICITIES, SERIOUS ADVERSE EVENTS, AND
COMPLICATIONS OF THERAPY
29
Appendix 4
ACUTE GVHD ASSESSMENT GRADING SCALES
31
Appendix 5
CHRONIC GVHD CLASSIFICATION
32
Appendix 6
UNIVERSITY OF MINNESOTA ACUTE GVHD GRADING
33
Appendix 7
RESPONSE CRITERIA
34
PI CONTACT INFORMATION:
Jeffrey S. Miller, M.D.
University of Minnesota Cancer Center, Room 560F
E-mail: mille011@tc.umn.edu
Phone: 612-625-7409 Fax: 612-626-4915
Hospital Operator: 612-273-3000 beeper # 7128


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SCHEMA
CML
(must have failed or
refused GleevecTM)
DLI Alone
Observation
If relapse, option to re-treat with
induction chemo and DLI
Non-CML
(or CML who have
failed DLI)
Induction Chemotherapy
+ DLI
Observation
INDUCTION CHEMOTHERAPY: (non-CML or CML who failed DLI alone)
Day
Drug
-6
fludarabine 25 mg/m2 IV
-5
fludarabine 25 mg/m2 IV
cyclophosphamide 60 mg/kg IV
-4
fludarabine 25 mg/m2 IV
-3
fludarabine 25 mg/m2 IV
-2
fludarabine 25 mg/m2 IV
-1
rest
0
DLI
DONOR LYMPHOCYTE INFUSION (DLI) : (all patients)
day 0: collect donor lymphocytes the morning of the infusion
donor cells will be infused over 2 hours at a cell dose of 0.5 x 108 CD3+ T-cells/kg


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1.0
PURPOSE
We have considerable experience giving donor lymphocyte infusions (DLI) to patients who relapse after
allogeneic transplantation. For patients with CML, DLI without chemotherapy has been very successful
with durable responses in approximately 75% of patients. Unfortunately, for non-CML patients (most with
acute leukemia or MDS), long-term disease free survival is significantly worse. Our conclusion from these
studies is that DLI alone in non-CML patients is inadequate therapy and further modifications are needed to
enhance the immune properties of DLI. Recently, animal studies and at least one human clinical trial show
that adoptively transferred lymphocytes will expand in vivo if given with a regimen that clears lymphoid
space (i.e. must be potent enough to induce lymphopenia). We hypothesize that the limited efficacy of DLI
in non-CML patients may be enhanced by giving DLI along with a regimen that induces lymphopenia. The
purpose of this study is to test the safety and efficacy of cyclophosphamide/fludarabine to enhance DLI.
There are no perfect measures to evaluate in vivo expansion of lymphocytes because patients at the time of
relapse often have endogenous donor lymphocytes still circulating. Patients who receive DLI +
chemotherapy will be compared to historical outcomes outlined in section 3.4.
2.0
OBJECTIVES
2.1
To test whether cyclophosphamide/fludarabine, a preparative regimen thought to allow in
vivo expansion of lymphocytes, is safe when combined with DLI in non-CML patients or
CML patients who fail DLI without chemotherapy.
2.2
To test whether cyclophosphamide/fludarabine enhances the efficacy of DLI.
2.3
We will monitor for in vivo expansion using surrogate markers of proliferation and activation
on blood lymphocytes. The validity of this analysis to detect in vivo expansion is unknown
and will NOT serve as an endpoint for this trial.
3.0
BACKGROUND
3.1
Introduction
Allogeneic bone marrow transplantation results in an approximately 40-60% disease-free survival in
patients with acute or chronic leukemias and myelodysplastic syndromes. The effectiveness of allogeneic
bone marrow transplantation depends in part on ablation of the malignant clone with a preparative regimen
and reinfusion of benign stem cells to restore normal hematopoiesis. However, it is well established that the
success of allogeneic transplantation is in part mediated by a graft-versus-leukemia effect induced by donor-
derived T lymphocytes or NK cells. This graft-versus-leukemia effect is usually associated with acute
and/or chronic graft-versus-host disease which are also mediated by donor-derived lymphocytes. In patients
with leukemia and multiple myeloma there is a statistically significant correlation between the occurrence
of acute graft-versus-host disease and freedom from relapse (1-4).
3.2
Relapse after allogeneic transplantation: Past experience.


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The effectiveness of bone marrow transplantation for diseases such as CML, AML, MDS and ALL depends
on the disease and the disease stage at the time of transplant. Relapse rates in patients undergoing
transplantation with unmodified allogeneic donor grafts vary and are approximately 15% for good risk
patients and up to 50% for advanced leukemias. Relapse rates are higher in those patients who receive
lymphocyte depleted grafts, especially for CML where relapse rates are as high as 70% at 3 years (1-3).
CLL numbers are small and often are not separated out from other miscellaneous lymphoid malignancies in
the literature, however there definite long-term survivors after allogeneic transplant. If a patient relapsed
after bone marrow transplantation, prior to lymphocyte infusions, very few effective therapies were
available.
In multiple myeloma, in a study of 17 patients with advanced stage disease, the rate of complete remission
increased to 73% after a dose-reduced allograft increase from 18% after cytoreductive autografting. (5) For
patients with AML and ALL, a second course of reinduction chemotherapy can be given with variable
results. Between 12% and 70% of patients will achieve a second complete remission. However, the median
survival of patients undergoing additional chemotherapy for relapse post-transplant in acute leukemia varies
between 5.5 and 12 months. Long-term disease-free survival is very unlikely.
Table 1: Treatment for Relapse Post-Transplant - AML/ALL: Chemotherapy
Group (reference)
Number patients
CR
Median Survival
Westminster (ALL/AML)
88
7 (12%)
7 months
Minnesota (ALL) (6)
53
29 (56%)
5.5 months
EBMTR (ALL/AML) (7)
74
32 (40%)
12 months
Seattle (AML) (8)
62
20 (30%)
6 months
Seattle (ALL) (8)
94
52 (65%)
10.5 months
A second marrow transplant can be performed for AML, ALL, CML, or MDS but with significant mortality.
Several studies demonstrate that continuous complete remission for greater than one year varies between 10
and 50%. A second bone marrow transplant is associated with very high early mortality (between 20 and
55%). IBMTR data evaluating second sibling transplants in 114 patients demonstrate that leukemia-free
survival was 7% if undergoing transplantation within 6 months of first transplantation and 28% if second
transplantation occurred greater than 6 months after the first (13). Hospitalizations for second transplants
are lengthy, complicated and costly.
Table 2: Treatment for Relapse Post-Transplant - AML/ALL/CML: Second Transplant
Group (ref.)
Number
patients
CCR (> 1 year)
Acute Mortality
(< 100 days)
Minnesota
23
38%
3%9
Seattle (14)
77
15%
30%
MD Anderson
17
12%
24%
EBMTR (15)
90
12%
48%
Hopkins (16)
23
39%
---
Sidney
9
11%
44%
Duarte
5
20%
20%
Goldman (17)
16
50%
31%


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3.3
Relapse after allogeneic transplantation: Donor Lymphocyte Infusions.
As demonstrated above, once patients relapse after allogeneic transplant, long term disease free survival is
possible but limited to few patients and associated with high morbidity and mortality. Based on the premise
that freedom from relapse is mediated by donor lymphocytes, reports of donor lymphocyte infusions first
appeared in 1990 when three CML patients were successfully treated into cytogenetic remission with buffy
coat infusions and interferon-. Since then, hundreds of patients have been treated with lymphocyte
infusions.
Table 3: Treatment for Relapse Post-Transplant - AML/ALL/CML: Donor Lymphocyte Infusions
Group (ref.)
Disease
No. patients
CR
Mortality
Goldman (18)
CML:
Molec/cytogen relapse
Hematologic relapse
9 sibs/5 URD
n=7
n=7
71%
100%
43%
7%
0%
14%
Arnold (19)
CML
8
75%
37%
Flomenburg (20)
CML
8
75%
13%
Antin (21)
CML
11
55%
27%
Roosnek (22)
CML
3
100%
0%
EBMTR (23)
CML
51
70%
~12%
Fay (25)
CML
6
50%
EBMTR (23)
AML
10
40%
~12%
Henslee-Downy (24)
AML
2
50%
Sheridan (28)
AML
4
25%
Fay (25)
AML/ALL
13
23%
EBMTR (23)
ALL
13
30%
~12%
Fay (25)
MM
3
66%
3.4
Donor Lymphocyte Infusion Experience at the University of Minnesota since 1993.
Forty-two patients received DLI at our institution between July 1993 and December 1999. Twenty-four
patients had CML, 10 had AML, 6 had MDS, 1 had ALL and 1 had juvenile myelomononcytic leukemia
(JMML). All patients received T-cell replete SCT from HLA-identical siblings, except 7 patients who
received their transplants from unrelated donors, and 1 patient from an HLA-mismatched sibling. Donor
lymphocytes from the original donor were obtained by lymphapheresis. CML and non-CML patients
received 3 lymphapheresis products, irrespective of the cell dose, but as of February 1996, all CML patients
received a fixed dose of 1 x 108 CD3+ T cells/kg (n=8). Twenty five of 42 patients (60%) achieved CR after
DLI. Eighteen of the 25 patients (72%) had CML, and seven patients (28%) had non-CML diseases (6
patients with AML and 1 patient with MDS). As previous studies have shown, patients treated for relapsed
CML had significantly higher survival rates compared with those treated for relapsed non-CML diseases.
Because of marked differences in survival, all subsequent analyses are based on the 2 groups of patients:
with CML and non-CML diseases.


10/10/2008
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Patients with CML. Eighteen of 24 CML patients (75%) achieved molecular remission after DLI,
confirmed by conversion to negative BCR/ABL status by PCR analysis. The median survival was 54
months (14-79) for patients who achieved CR, versus 6 months (2.6-35) for those who did not obtain CR
after DLI (p< 0.01). The median time to complete remission (CR) was 104 days (35-279) after DLI. Two
patients (11%) relapsed 3.5 and 65 months after CR was documented. The first patient died of respiratory
failure secondary to radiation pneumonitis 5 months after relapse, while the other was treated with another
course of DLI, and is still alive 7 months after relapse. Eighteen patients (75%) remain alive in CR after a
median follow-up of 59 months (30-79 months). CML patients had an overall probability of survival of 79%
(62-96%) at 1 year, and 75% (58-92%) at 5 years after DLI. Patients who achieved remission had a 94%
(82-100%) relapse-free survival 5 years after CR. All 7 CML patients (100%) treated for cytogenetic relapse
only achieved CR and had a median survival of 62 months (36-76 months), while 11 of 17 patients (65%)
who presented with hematological relapsed CML achieved CR and had a median survival of 38 months (14-
79 months).
Gleevec may be safer and as effective for relapsed CML. The use of DLI as the favored first-line therapy
in relapsed CML patients after allogeneic SCT has been recently challenged by the specific inhibitor of the
BCR-ABL tyrosine kinase imatinib mesylate (Gleevec). Recent reports showed encouraging results, with
overall response rates as high as 79%, and complete cytogenetic responses of 35% (29, 30). In the study of
Kantarjian et al., imatinib mesylate was used in 28 patients, of whom 13 (46%) received DLI a median of 4
months (2-39 months) prior to imatinib. While it is likely that the responses noted in those patients (11 of 13
responded to imatinib) was due to imatinib itself, a DLI influence cannot be discarded as it is well described
that responses after DLI may be protracted and occur as late as 6 to 12 months after therapy. Given the
safety profile of Gleevec compared to DLI, it will be offered as first line therapy for CML patients who
relapse after allogeneic transplant (may want to start at time immunosuppression being withdrawn).
Patients with non-CML malignancies. The overall probabilities of survival for non-CML patients were
28% (7-49%) at 1 year, and 6% (0-16%) at 5 years after DLI. Seven of 18 (39%) non-CML patients
achieved complete remission. Among them, 4 patients (57%) were in remission at the time of DLI from
prior treatment with salvage chemotherapy, and could not be evaluable for a direct DLI effect. Overall, the
non-CML patients had a median survival of 5 months (0.6-97 months). Whereas patients who attained CR
(n=7) had a median survival of 8 months (range 2.6-97 months), those who did not achieve CR had a
median survival of 2.7 months (range 0.6-24 months). Four of 11 patients (36%) pre-treated with salvage
chemotherapy achieved CR prior to DLI and survived a median of 20 months (2.6-97 months). Three of 7
patients (43%) treated with DLI without prior salvage chemotherapy attained CR and had a median survival
of 5 months (2.6-36 months). For the 3 evaluable patients who attained CR from direct DLI effect,
remission occurred a median of 29 days (27-70 days) after DLI. The median time to relapse for patients in
CR from direct DLI effect was 8 months (1-15 months) compared with 5.5 months (1.7-25 months) for
patients in CR after salvage chemotherapy. Our conclusion from these studies is that DLI is inadequate for
non-CML diseases, which is the major focus of this protocol.
3.5
Lymphoid space must be cleared for expansion of adoptively transferred lymphocytes.
Growing evidence suggests that preparative therapy must be strong enough to induce lymphopenia if
adoptively transferred lymphocytes are to expand in vivo. The hypothesis is that lymphopenia (or clearing
space) changes the competitive balance between transferred lymphocytes and endogenous lymphocytes.


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Alternatively, lymphopenia induces survival factors or depletes inhibitory effects (cells or soluble factors)
(reviewed in 31, 32). In recent murine studies, preparative regimens sufficient to induce lymphopenia allow
homoeostatic T-cell expansion in vivo and can potentiate effective antitumor immunity (33). This concept
has recently been tested in human clinical trials at the NIH by Rosenberg’s group (34). T-cell lymphopenia
was induced by cyclophosphamide (60 mg/kg/day x 2 followed by fludarabine 25 mg/m2/day x 5 days).
This therapy allowed in vivo expansion of adoptively transferred cytotoxic T-lymphocytes with specificity
for melanoma cells, resulting in subsequent clinical efficacy. This trial is the basis for the preparative
regimen to be tested here. We have elected to only give 1 dose of cyclophosphamide since patients are
already heavily pretreated and to proceed cautiously. Both drugs used in this regimen, cyclophosphamide
and fludarabine, have demonstrated activity against hematologic malignancies (35-38) and should result in
lymphopenia, and hence facilitate in vivo expansion of lymphocytes as outlined here.
4.0
SELECTION OF PATIENTS
4.1
Inclusion criteria
4.1.1
Patients (age > 1 years) with a diagnosis of relapse after related or unrelated allogeneic stem
cell transplantation for a hematological malignancy.
4.1.1.1 For CML, relapse will be defined as any cytogenetic evidence of a Philadelphia
chromosome or persistence of BCR/ABL rearrangements by molecular testing on at
least two measurements over a 6 month interval. If cytogenetics are normal and there
is PCR evidence of a BCR/ABL fusion, patients will be eligible if they have evidence
of a quantitative increase in CML measured either by quantitative PCR or by
fluorescent in situ hybridization (FISH).
4.1.1.2 For non-CML, relapse will be defined based on disease specific morphologic criteria
from a bone marrow biopsy and aspirate or recurrence of disease specific
cytogenetics. For disease specific definition of relapse, see appendix 3. Relapse can
be determined morphologically with less than 5 percent blasts if definitive relapse can
be determined. Equivocal results for relapse should result in a repeated test after an
appropriate time interval (suggested 1 month) to determine eligibility.
Post-transplant lymphoproliferative diseases (often referred to as EBV-associated
lymphomas) are NOT eligible for this protocol.
4.1.2
For Chronic Phase CML patients only
4.1.2.1 must have failed (no response in 3 months or incomplete response at 6 months) or
refused treatment with Gleevec
4.1.2.2 if no prior DLI, CML patients will first have DLI– if relapse occurs after DLI, DLI
with chemotherapy per this protocol will be offered
4.1.3
Patients must be within one year of identification of relapse or if beyond that time period,
must have at least 10% donor DNA by RFLP or cytogenetics.
4.1.4
Same allogeneic donor (sibling or URD) used for transplantation is available for lymphocyte
donation.
4.1.5
No severe organ damage (by laboratory or clinical assessment) as measured by:
4.1.5.1
blood creatinine ≤2.0 mg/dL
4.1.5.2
liver function tests < 5 x normal
4.1.5.3
left ventricular ejection fraction > 40% (testing required only if symptomatic
or prior known impairment).


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4.1.5.4
pulmonary functions > 50% (testing required only if symptomatic or prior
known impairment). Oxygen saturation (>92%) can be used in child where
PFT’s cannot be obtained.
4.1.5.5
chest x-ray without evidence of active infection
4.1.6
Off prednisone and other immunosuppressive agents (given for any reason) for at least 3
days prior to DLI infusions.
4.1.7
Performance status ≥60%
4.1.8
Women must not be pregnant or lactating. The agents used in this study may be teratogenic
to a fetus and there is no information on the excretion of agents into breast milk All females
of childbearing potential must have a blood test or urine study within 2 weeks prior to
registration to rule out pregnancy
4.1.9
Women of childbearing potential and sexually active males are strongly advised to use an
accepted and effective method of contraception
4.1.10 Patient must given written informed consent indicating understanding of the nature of the
treatment and its potential risks
4.2
Exclusion criteria
4.2.1
Concurrent signs of acute or chronic graft-versus-host disease requiring ongoing treatment at
the time of relapse will be ineligible.
4.2.2
Patients being treated for GVHD with prednisone, cyclosporine, Imuran or other
immunosuppressive medications are not eligible until these medications are discontinued for
at least 2 weeks without a flare of GVHD.
4.2.3
Known active CNS leukemia
4.2.4
Active fungal infection or pulmonary infiltrates (stable prior treated disease is allowable)
4.2.5
HIV positive
4.3
2nd step eligibility – CML patients who relapsed after DLI alone
4.3.1
diagnosis of relapse after DLI
4.3.2
meets all inclusion and exclusion criteria in sections 4.1 and 4.2
4.4
Donor Eligibility
4.4.1
Able to undergo lymphapheresis - donor's weighing less than 40 kg. (children) will need
evaluation by a pediatrician to evaluate for suitability of the lymphapheresis procedure
4.4.2
HIV-1, HIV-2 negative, HTLV-1, HTLV-2 negative, Hepatitis B and C negative, not
pregnant and good general medical condition.
4.4.3
Able to give informed written consent
5.0
REGISTRATION PROCEDURES
5.1
Registration with the Clinical Trials Office (CTO)
All patients should be registered with the CTO in addition to other registration procedures required by the
protocol.
CML patients who are treated with DLI alone on this protocol and relapse should be re-registered for this
protocol.


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To register a patient to this study, complete the Subject Registration Form and study specific eligibility
checklist (appendix 1) and fax it to the Clinical Trials Office Registrar at (612) 624-9654. To register by
phone call (612) 624-9487 with the completed Subject Registration Form available.
5.2
Patients who are registered and do not begin study treatment
If a patient is registered to the study, and is later found not able to begin the planned study treatment, for
whatever reason, the patient will be removed from study and treated at the physician’s discretion. Study
data will be collected until the time of off study. The reason for removal from study will be clearly
indicated on the case report forms.
If a patient begins treatment, and then is discontinued for whatever reason, the patient must be followed per
section 7.0.
6.0
TREATMENT PLAN
6.1
At diagnosis of relapse
At the time of relapse, patients should be tapered off immunosuppressive medications as soon as possible.
It is unknown whether Gleevec alters the response to or toxicity from DLI. Since Gleevec is active in
BCR/ABL positive malignancies and not known to be immunosuppressive, concomitant Gleevec will be the
allowed in patients who receive DLI for a BCR/ABL positive leukemia.
6.2
Before Day –6
Determine patient and donor eligibility.
Obtain donor and recipient consent.
Evaluate donor venous access, donor blood for CBC, Hepatitis B, C and HIV-1, HIV-2, HTLV-1, HTLV-2,
serologic test for syphilis, ALT, EBV and CMV serology.
Recipient Disease staging as in section 7.0
6.3
Day -6
Admit, begin allopurinol (day -6 through day 0), insert venous access device
6.4
Day –6 through day –2 - chemotherapy administration (Non-CML and CML who have
relapsed after DLI alone):
Obese patients should be dosed half way between ideal and actual weights
Days –6
Fludarabine 25 mg/m2 IV over 30 minutes
Days –5
Fludarabine 25 mg/m2
Cyclophosphamide 60mg/kg IV over 2 hours
Mesna 12mg/kg (pre and 3, 6, 9, and 12 hours after
cyclophosphamide)
Vigorous intravenous hydration (2000-3000 ml/m2/day)
should be given from 6 hours prior to the cyclophosphamide


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dose and continuing for 24 hours after the end of the
cyclophosphamide infusion.
Adequate diuretics should be given and patients urged to
urinate every 1-2 hours to ensure urinary output of at least
200 ml every 2 hours to maintain appropriate polyuria and
fluid balance.
Patients should be weighed BID during cyclophosphamide
administration to aid in managing fluid balance.
Days –4
Fludarabine 25 mg/m2
Days –3
Fludarabine 25 mg/m2
Days –2
Fludarabine 25 mg/m2
Day –1
Rest day
6.5
Day 0 – donor lymphocyte infusion (all patients)
6.5.1
Lymphapheresis
Donor lymphocytes obtained by lymphapheresis should be obtained from the same allogeneic donor
(sibling or unrelated donor) used for transplantation. For local related donors, lymphocyte
collections will be performed on the morning of the planned infusion using standard automated
mononuclear cell collection techniques by the University of Minnesota Blood Bank. For unrelated
donors or non-local related donors, the lymphocyte collects will be performed at an outside facility
according to procedures set by the National Marrow Donor Program. If the collection is non-local,
coordination for the timing of the cell collection and the ability to transport the cells to the
University of Minnesota is required.
6.5.2
Donor Lymphocyte infusion
All patients will receive a cell dose of 0.5 x 108 CD3+ T-cells/kg.
The lymphapheresis product will be infused without concurrent GVHD prophylaxis therapy. Donor
lymphocytes will be infused over 2 hours. Patients receiving infusions on an outpatient basis will
be monitored for at least 2 hours for acute transfusion related complications.
6.6
Dose Modifications
There are no dose modifications for this protocol except after discussion with the principal investigator and
based on modifications judged to be in the patient’s best interest. For example, there is some rationale for
giving a lower dose of DLI in patients who relapse after T-cell depleted transplants. Since this is unusual in
our current cohorts and dose modifications would be an unusual occurrence.
6.7
Supportive Care
6.7.1
All supportive measures consistent with optimal patient care will be given throughout the
study.
6.7.2
During infusions, patients will be monitored for occurrence of untoward effects of the
infusion of allogeneic lymphocytes such as rash, acute allergic reaction, bronchospasm,
respiratory distress, acute vascular leak syndrome, localized or systemic infections.


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6.7.3
Since G-CSF may have immunosuppressive effects on lymphocytes, it use should be avoided
if possible. However, in the setting of severe neutropenia (ANC < 500), unexplained fever or
documented infection, use of G-CSF will be at the discretion of caring physician.
6.7.4
Steroids should not be used as anti-emetics under any circumstances during this protocol.
6.8
Duration of Therapy
Patients will receive protocol therapy unless:
6.8.1
Extraordinary Medical Circumstances: If at any time the constraints of this protocol are
detrimental to the patient's health, protocol treatment should be discontinued.
6.8.2
Patient withdraws consent.
6.9
Duration of Follow-up
For this protocol, all patients, including those who discontinue protocol therapy early, will be followed for 6
months regardless of therapy. Follow-up for response and survival will continue for at least 5 years from
the date of registration.
7.0
STUDY PARAMETERS
7.1
Required observations (before starting treatment)
7.1.1
Clinical Observations

A complete pre-infusion history and physical exam as well as laboratory tests to confirm
eligibility (within 30 days of initiating therapy).

CBC, differential, platelet count
electrolytes, BUN, blood creatinine, blood glucose
AST, ALT, bilirubin, alkaline phosphatase

Chest X-ray

MUGA and/or PFT’s if clinically indicated

bone marrow aspirate and biopsy - for the presence of donor or host derived cell populations
(RFLP, chromosome studies) and leukemia by routine morphologic analysis and other
studies as indicated (i.e. BCR/ABL, Ph chromosome or other chromosome abnormalities).
7.1.2
Research samples – see section 13.1
7.2
Required observations (during and after treatment)
7.2.1
Clinical observations
An interim assessment will be performed daily until neutrophil recovery including days +14,
+21, then 1, 2, 3 and 6 months post, then as clinically indicated.
Patients will be monitored after infusion of allogeneic cells for the occurrence of acute and
chronic graft-versus-host disease, which will be staged according to the current GVHD
protocol through the University of Minnesota BMT Program.
7.2.2
Clinical labs (minimal requirements, additional tests as clinically indicated)


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CBC, differential, platelet count: daily until neutrophil recovery, including +14, +21, then 1,
2 and 3 months post. Daily assessment of neutrophil recovery is not necessary if the patient
is an outpatient. Follow up for this parameter will be performed as clinically indicated.
Typically this would be every one to four days until neutrophil recovery.
electrolytes, BUN, blood creatinine, blood glucose: QOD until neutrophil recovery, including
+14, +21, then 1, 2 and 3 months post.
AST, ALT, bilirubin, alkaline phosphatase: days 0, +7, +14, +21, then 1, 2 and 3 months
post.
A bone marrow aspirate and biopsy for the presence of donor or host derived cell populations
(RFLP, chromosome studies) and leukemia by routine morphologic analysis and other
studies as indicated (i.e. BCR/ABL, Ph chromosome or other chromosome abnormalities)
will be performed 1 and 3 months after therapy.
Each lymphocyte collection will be analyzed for cell count, as well as T-cells, T-subsets, NK
cells, and other mononuclear cells (CD3, CD4, CD8, CD16, CD56 called a TH/TS panel to
be performed by the immunophenotyping lab).
7.2.3
Research samples – see section 13.2
7.3
Follow-up after 3 months
Follow-up for response, toxicity, and survival will occur at 6 months and 1 year after the infusion and then
annually for at least 5 years from study enrollment.
Since most patients with poor-prognosis myeloid leukemia are expected to die of their disease, beyond 3
months, deaths due to additional therapy (such as transplant for example) or relapse will be reported to the
IRB and the CPRC as part of annual reporting.
8.0
ADVERSE EVENT REPORTING
All subjects will be monitored continuously for all serious unexpected and selected serious adverse
experiences during the first 3 months after the donor lymphocyte infusion. Afterward, subjects will be
monitored at 6 months and 1 year after the infusion and then annually thereafter. Serious adverse events
include: graft failure/autologous recovery, severe acute GVHD (Grades III and IV), relapse, and death.
Serious adverse events will be reported within 10 working days of the event or knowledge of the event
during the first 100 days. After day 100, only death or a serious unexpected adverse event will be reported
10 working days of knowledge of the event. All other adverse events will be reported annually.
Serious adverse events will be reported simultaneously to the Institutional Review Board and Cancer
Protocol Review Committee/Data Safety and Monitoring Council as required. Toxicities, complications of
therapy and other adverse events, which are considered expected as part of therapy in general, are listed in


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the Appendix 3: Expected Transplant Related Toxicities.
Other toxicity and adverse events will be
classified according to NCI's Common Terminology Criteria for Adverse Events V 3.0 (CTCAE)
Reporting of Other Second Primary Cancers
All cases of new primary cancers that occur on protocols monitored by the University of Minnesota Cancer
Center Clinical Trial Office during or after protocol must be reported to CTO, according to the follow-up
schedule outlined in the protocol (on the Second Primary Cancer Form) within 30 days of diagnosis,
regardless of relationship to protocol treatment.
Once data regarding survival and remission status are no longer required by the protocol, only second
primaries thought to be possibly related to protocol treatment should be reported. A copy of the pathology
report should be sent, if available.
9.0
DATA AND SAFETY MONITORING PLAN
This study will be in compliance with the University of Minnesota Cancer Center's Data & Safety
Monitoring Plan, which can be accessed at http://www.cancer.umn.edu/page/resource/dataplan.html
Regular meetings of the study's principal investigator and staff will be held to discuss matters related to the
safety of protocol participants (SAE reporting), validity and integrity of the data, enrollment rate, retention
of participants, adherence to protocol, and data completeness
The Principal Investigator will provide at least monthly monitoring of patient safety with quarterly reporting
to the Clinical Trials Office (CTO) for distribution to the Cancer Protocol Review Committee's (CPRC)
Data & Safety Monitoring Council (DSMC).
At the time of the IRB continuing review, the Principal Investigator will report to the CPRC the number of
patients entered on the trial, the number of patients, treated, a summary of all adverse events reported to date
using CTC grading, a specific list of serious adverse events requiring immediate reporting, and significant
literature reporting developments that may affect the safety of participants or the ethics of the study.
10.0
MEASUREMENT OF EFFECT
See appendix B for disease specific response criteria.
11.0
DRUG FORMULATION AND PROCUREMENT
11.1
Cyclophosphamide
11.1.1 Other names: Cytoxan, Neosar, CTX, CPM
11.1.2 Classification: alkylating agent
11.1.3 Mode of Action: Inactive in its parent form; Activated by the liver cytochrome P450
microsomal system to the cytotoxic metabolites phospharamide mustard and
acrolein;Cyclophosphamide metabolites form cross links with DNA resulting in inhibition of
DNA synthesis and function; Cell cycle-nonspecific agent, active in all phases of the cell
cycle


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11.1.4 Storage and Stability: Injectable powder is stored at room temperature. Reconstituted
solution is stable for 24 hours room temperature and for 6 days upon refrigeration.
11.1.5 Dose Specifics: In this study, cyclophosphamide will be given as a single intravenous dose.
The dose will be 60 mg/kg with obese patients dosed half way between ideal and actual
weights.
11.1.6 Preparation: Dilute vials with sterile water. It is important to shake well so that the solution
is completely dissolved.
11.1.7 Route of Administration:
Intravenously
11.1.8 Incompatibilities--drug interactions: Phenobarbial, phenytoin, and other drugs that stimulate
the liver P450 system, anticoagulants, digoxin, doxorubicin special considerations: use with
caution in patients with abnormal renal function, IV hydration required for high dose
administration, pregnancy category D
11.1.9 Availability commercially available
11.1.10
Side Effects

myelosuppression

bladder toxicity

nausea and vomiting

alopecia

amenorrhea with ovarian failure

cardiotoxicity with high doses

increased risk of secondary malignancies

immunosuppression
inappropriate secretion of antidiuretic hormone (SIADH)
hypersensitivity reaction
11.1.11
Nursing Implications

monitor CBC, platelet count

advise patient of possible alopecia

assess hydration and fluid balance

premedicate with antiemetics

observe for possible phlebitis

administer antiemetics as indicated
11.2
Fludarabine
11.2.1 Other names: 2-Fluoro-ara-AMP, Fludara
11.2.2 Classification: antimetabolite


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11.2.3 Mode of Action:

5-Monophosphate analog of arabinofuranosyladenoisine (ara-A) with high specificity for
lymphoid cells. Presence of the 2-fluoro group on adenine ring renders fludarabine resistant
to breakdown by adenosine deaminiase

Considered a prodrug

Antitumor activity against both dividing and resting cells

Tripohphate metabolite incorporates into DNA resulting in inhibition of DNA chain
extentsion

Induction of apoptosis
11.2.4 Storage and Stability: Unreconstituted drug vials are stored at room temperature.
11.2.5 Dose Specifics: In this study, fludarabine will be given at the dose of 25 mg/m2 for 5 days.
11.2.6 Preparation

Available in a 50 mg vial, lypholized cake for IV use.

Add 2 ml sterile water to vial to give a final concentration of 25 mg/mL

May be further diluted in 100 mL of 5% dextrose or 0.9% sodium chloride

Once reconstituted, the drug should be used within 8 hours
11.2.7 Availability: commercially available
11.2.8 Incompatibilities
drug interactions: cytarabine – fludarabine may enhance the anti-tumor activity of cytarabine by
inducing the expression of deoxycytidine kinase
cyclophosphamide, cisplatin, mitoxantrone – fludarabine may enhance the anti-tumor activity of
cyclophosphamide by inhibiting nucleotide excision repair mechanisms
pentostatin – increased incidence of fatal pulmonary toxicity when fludarabine is used in
combination with pentostatin. Use of this combination is absolutely contraindicated.
special considerations: use with caution in patients with abnormal renal function, use with caution
in elderly patients and in those with bone marrow impairment as they are at increased risk of
toxicity, monitor for signs of infection, monitor for signs of tumor lysis, allopurinol may be given
prior to initiation to previent hyperuricemia, use irradiated blood products in patients requiring
transfusion as transfusion associated GVD may rarely occur, pregnancy category D, breastfeeding is
not recommended.
11.2.9 Route of Administration
Intravenously
11.2.10
Side Effects

myelosuppression

immunosuppression

nausea and vomiting


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
fever

hypersensitivity reaction

tumor lysis syndrome

transient elevation in serum transaminases, clinically asymptomatic

neurotoxicity observed usually with high doses – presents as weakness, agitation, confusion,
progressive encephalopathy, cortical blindness, seizures, and/or coma. Thought to be secondary
to demyelination process
11.2.11
Nursing Implications

monitor CBC, platelet count

premedicate with antiemetics

monitor for stomatitis

observe for CNS toxicity

anticipate tumor lysis syndrome in patients with bulky disease

monitor pulmonary function
12.0
EXPERIMENTAL DESIGN AND STATISTICAL CONSIDERATIONS
12.1
Study Design and Objectives
The principal objective of this phase II study is to show efficacy and establish safety of the DLI procedure
among the non-CML and CML patients. Due to low expected enrollment among the CML patients, the non-
CML patient population is driving the study design. In order to show efficacy, the primary endpoint for this
study is one year survival. Secondary endpoints include disease-free survival at one year, complete
remission at one year, acute GVHD by day 100 and marrow aplasia.
12.2
Sample size
The sample size for this study will be based on trying to show a 20% improvement over the historical one
year survival of 28% among the non-CML patients. Based on a type I error rate of .05 and a power of .80, a
total of 47 non-CML patients will be required to show this difference.
Because the number of CML patients enrolled in this study is expected to be low, total enrollment of CML
patients at the end of five years is estimated to be approximately 10. Because of the low patient numbers, an
analysis of these patients will remain descriptive.
12.3
Statistical Analysis
The estimates of survival and disease free survival will be calculated by the Kaplan-Meier method. The
secondary endpoints of complete remission, acute GVHD and aplasia will be calculated by cumulative
incidence, treating death as a competing risk. Comparison of the endpoints will be completed by the log-
rank test.
12.4
Monitoring guidelines


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This study will be continuously monitored for aplasia and treatment related mortality prior to day 100. To
help guide the protocol committee in evaluating the safety of the protocol, the following monitoring
boundaries will be applied to the non-CML patient population.
Marrow aplasia, will be defined as an absolute neutrophil count of less than 500 with a bone marrow less
than 5% cellular in the absence of disease 42 days after donor lymphocyte infusions. The monitoring
boundary for marrow aplasia is 5 of 5, 6 of 12, 7 of 23, 8 of 40 or 9 of 45. This boundary has a type I error
rate of .05 if the true event rate is 10% and a power of .85 for a rate of 25%.
Early death is defined as treatment related mortality (e.g. aplasia in the absence of relapse, GVHD
irrespective of relapse) before day 100 after donor lymphocyte infusions. The monitoring boundary for
early death is 3 of 3, 4 of 14, or 5 of 40. This boundary has a type I error rate of .05 if the true event rate is
5% and a power of .90 for a rate of 20% (1).
Due to the low rate of enrollment among the CML patients, monthly monitoring as specified in section 9.0
will be sufficient to evaluate safety among these patients. No continuous guidelines will be used.
12.5
Data Collection
Standard data will be prospectively collected and recorded on the BMT research database, including the
adverse events. Patients will be followed for complications and death according to standard procedures.
Goldman AI, Hannan PJ. Optimal continuous sequential boundaries for monitoring toxicity in clinical trials,
a restricted search algorithm. Statistics in Medicine 20:11 (2001).
12.6
Gender and ethnicity statement
This study is open to men and women of all racial/ethnic groups. The patient enrollment pattern is expected
to be similar to that of other hematologic cancer studies. It is not anticipated that the outcome will be
affected by race. The study will not have separate accrual targets for different subgroups.
13.0
CORRELATIVE STUDIES
13.1
Pre-treatment:
A sample of bone marrow will be obtained pre-treatment at the time of clinical sampling if possible
(specimen need not be re-drawn if for research use only). Approximately 30 cc of a heparinized sample will
be requested. Pediatric patient research samples (blood or marrow) will be 20 cc or a maximum of 2 cc/kg.
For all patients: 80 ml of heparinized blood (8 green top tubes) and 10 ml of serum (red top tubes) prior to
treatment (day –6 or before) will be sent to Translational Therapy Lab for phenotype and functional
analyses (Call
612-625-6165 to pick up sample). Pediatric patient blood draws will be 20 cc of
heparinized blood (2 green top tubes) or a maximum of 2 cc/kg.
13.2
During and after treatment:
80 ml of heparinized blood (8 green top tubes) and 10ml of serum (1 red top tube) will be sent to
Translational Therapy Lab for phenotype and functional analyses on days +14, +28, and 3 months post DLI


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infusion.(Page 2316 for pick-up, if not in town – OK to mail). Pediatric patient blood draws will be 20 cc of
heparinized blood (2 green top tubes) or a maximum of 2 cc/kg.
OK to allow ± 2 days for any scheduled time point to allow for weekends and scheduling variability
The above sample will be analyzed for:
lymphocyte subsets by imunophenotyping (including Ki67 – proliferation marker)
Pediatric patient research samples (blood or marrow) will be 20 cc or a maximum of 2 cc/kg.
14.0
RECORDS TO BE KEPT
Records Retention
The investigator will retain study records, including source data, copies of CRF’s, and all study
correspondence indefinitely in a secured facility. In addition, the Clinical Trials Office (CTO) will keep a
master log of all patients participating in the study, with sufficient information to allow retrieval of the
medical records for that patient.
Please contact the CTO prior to destroying any source documents.
15.0
REFERENCES
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Leukemia. Blood 78:2120, 1991
2. Sullivan KM, Weiden PL, Storb R et al.: Influence of Acute and Chronic Graft-Versus-Host Disease
on Relapse and Survival After Bone Marrow Transplantation From HLA-Identical Siblings as
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3. Wagner JE, Zahurak M, Piantodosi S et al.: Bone Marrow Transplantation of Chronic Myelogenous
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5. Kroger N., Schwerdtfeger R., Kiehl M., et al: Autologus Stem Cell Transplantation Followed by a
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6. Bostrom B, Woods WG, Nesbit ME et al.: Successful Reinduction of Patients with Acute
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8. Mortimer J, Blinder MA, Schulman S et al.: Relapse of Acute Leukemia After Marrow
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Chronic Myelogenous Leukemia in Chronic Phase After Allogeneic Bone Marrow Transplantation.
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11. Archese W, Goldman JM, D'Arcangelo E et al.: Outcome for Patients Who Relapse After Allogeneic
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Recombinant Human Interleukin-2 and Interferon-a2a. J Hematotherapy 3:75, 1994
13. Mrsic M, Horowitz MM, Atkinson K et al.: Second HLA-Identical Sibling Transplants for Leukemia
Recurrence. Bone Marrow Transplant 9:269, 1992
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15. Barrett AJ, Locatelli F, Treleaven JG, Gratwohl A, Szydlo R, Zwaan FE: Second Transplants for
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19. Hertenstein B, Wiesneth M, Novotny J et al.: Interferon-Alpha and Donor Buffy Coat Transfusions
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20. Drobyski WR, Keever CA, Roth MS: Salvage Immunotherapy Using Donor Leukocyte Infusions as
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MT2003-15
Use of cyclophosphamide/fludarabine to promote in vivo expansion of donor lymphocyte infusions
(DLI) to enhance efficacy after relapse from allogeneic transplant
ELIGIBILITY CHECKLIST
INCLUSION CRITERIA (answers should be yes):
Circle yes or no
Disease Criteria
Yes/No
Diagnosis of relapse after related or unrelated allogeneic stem cell transplantation
for a hematological malignancy
Yes/No/NA
For CML, relapse will be defined as any cytogenetic evidence of a Philadelphia
chromosome or persistence of BCR/ABL rearrangements by molecular testing on
at least two measurements over a 6 month interval. If cytogenetics are normal and
there is PCR evidence of a BCR/ABL fusion, patients will be eligible if they have
evidence of a quantitative increase in CML measured either by quantitative PCR
or by fluorescent in situ hybridization (FISH).
Yes/No/NA
For non-CML, relapse will be defined based on disease specific
morphologic criteria from a bone marrow biopsy and aspirate or
recurrence of disease specific cytogenetics. For disease specific
definition of relapse, see appendix 3.
Yes/No/NA
For CML patients only: if no prior DLI, CML patients will first have
DLI without chemo (per MT 9524)
If relapse occurs after DLI, DLI with chemotherapy per this protocol
will be offered
Yes/No/NA
For Chronic Phase CML patients only: must have failed ( no response in 3
months or incomplete response in 6 months) or refused treatment with Gleevec
Yes/No
Must be within one year of identification of relapse or if beyond that time period,
must have at least 10% donor DNA by RFLP or cytogenetics
Patient Health Status (e.g. organ function)
Yes/No
Age > 1 years, Performance status ≥60%
Yes/No
blood creatinine ≤2.0 mg/dL
Yes/No
liver function tests < 5 x normal
Yes/No
left ventricular ejection fraction > 40% (testing required only if symptomatic or
prior known impairment).
Yes/No
pulmonary functions > 50% (testing required only if symptomatic or prior known
impairment). Oxygen saturation (>92%) can be used in child where PFT’s cannot
be obtained.
Yes/No
chest x-ray without evidence of active infection


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Other Eligibility Criteria as Necessitated per Protocol
Yes/No
Same allogeneic donor (sibling or URD) used for transplantation is available for
lymphocyte donation
Yes/No
Off prednisone and other immunosuppressive medications (given for any reason)
for at least 3 days prior to DLI infusions
EXCLUSION CRITERIA (answers should be no):
Circle yes or no
Yes/No
Post-transplant lymphoproliferative disease (often referred to as EBV-associated
lymphomas)
Yes/No
Pregnant or lactating
Yes/No
Concurrent signs of acute or chronic graft-versus-host disease requiring ongoing
treatment at the time of relapse
Yes/No
Patients being treated for GVHD with prednisone, cyclosporine, Imuran or other
immunosuppressive medications are not eligible until these medications are
discontinued for at least 2 weeks prior to DLI infusions without a flare of GVHD
Yes/No
Active CNS leukemia
Yes/No
Active fungal infection or pulmonary infiltrates (stable prior treated disease
allowed)
Yes/No
HIV positive
Donor Inclusion Criteria (answers should be yes)
Donor Name ______________________
Circle yes or no
Yes/No
Able to undergo lymphapheresis - donor's weighing less than 40 kg (children) will
need evaluation by a pediatrician to evaluate for suitability of the lymphapheresis
Yes/No
HIV-1, HIV-2 negative, HTLV-1, HTLV-2 negative, Hepatitis B and C negative
Yes/No
Good medical condition, not pregnant
Yes/No
Signed IRB approved informed consent
INFORMED CONSENT SIGNED (YES/NO) __________________ (date).
PATIENT GIVEN COPY OF CONSENT (YES/NO) __________________ (date).
______________________ Does/ Does NOT meet all eligibility criteria.
(patient name)
_________________________________________
____________
PHYSICIAN SIGNATURE
DATE


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APPENDIX 2 - PARAMETERS
Pre: w/in
10 days of
starting
therapy
Daily
QOD
Day
-1
Day
0
Day
+1
Day
+2
Day
+7
Day
+14
Day
+21
Day
+28
2
mon
.
3
mon
.
Physical
Exam and
watch for
toxicity
X
X1
X
X
X
X
Chest X-ray
X
CBC, diff, plt
X
X1
X
X
X
X
X
Lytes, BUN,
creat, glucose
X
X1
X
X
X
X
X
AST, ALT,
bili, alk phos
X
X
X
X
X
X
X
X
Bone Marrow
Biopsy and
aspirate
X (w/in
30 days of
starting
therapy)
X
X
Research
bloods: 80 ml
heparinized
blood (8 green
top tubes) and
10 ml serum
(1 red top) for
Translational
Therapy
Lab**
X
X
X
X
** Pediatric patient research samples (blood or marrow) will be 20 cc or a maximum of 2 cc/kg.
OK to allow ± 2 days for any scheduled time point to allow for weekends and scheduling variability
1 -- until neutrophil recovery; daily assessment of CBC not necessary for outpatients (should be 1-4 days as clinically indicated).
2—prior to DLI infusion


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APPENDIX 3- EXPECTED TOXICITIES, SERIOUS ADVERSE EVENTS, AND
COMPLICATIONS OF THERAPY
Cyclophosphamide –
Common
Occurs in 21-100
people out of every
100
Less Frequent
Occurs in 5-20 people out of
every 100
Uncommon
Occurs in <5 people out of every
100
Nausea/vomiting
Mucositis
Sterility
Severe suppression of
blood counts
Diarrhea
Fluid weight
gain/edema
Alopecia
Hemorrhagic cystitis
Cardiomyopathy
Skin rash
SIADH (Syndrome of Inappropriate
Anti-diuretic Hormone)
Fludarabine -
Common
Occurs in 21-100
people
out of 100
Less Frequent
Occurs in 5-20 people out of
every 100
Uncommon
Occurs in <5 people out of every 100
Severe suppression of
blood counts
Diarrhea
Anorexia
Mucositis
Nausea/vomiting
Stomatitis
Osteoporosis
Dysuria
Chills
Fever
GI bleeding
Peripheral edema
Neurotoxicity
Agitation and confusion
Blurred vision
Peripheral neuropathy
Hearing loss
Headache
Cerebellar syndrome
Blindness
Coma
Weakness
Depression
Insomnia
Hemorrhagic cystitis (except in FA)
Abnormal renal function test
Autoimmune hemolytic anemia
Deep venous thrombosis


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Aneurysms
Pruritic skin rash
Abnormal liver function/Liver failure
Constipation
Transient ischemic attack
Dysphagia
Myalgia
Arthralgia
Renal failure


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APPENDIX 4– ACUTE GVHD ASSESSMENT GRADING SCALES
Consensus Clinical Stage and Grade of Acute GVHD (Przepiorka et al, 1995)
Stage
Skin
Liver
Lower
Gastrointestinal
Tract
Upper
Gastrointestinal
Tract
1
Maculopapular rash
<25% of body
surface
Bilirubin 2.0 – 3.0
mg/dl
Diarrhea 500 – 1000
mL/day or 280 – 555
mL/m2
No protracted
nausea and vomiting
2
Maculopapular rash
25-50% body
surface
Bilirubin 3.1 – 6.0
mg/dl
Diarrhea 1000 – 1500
mL/day or 556 – 833
mL/m2
Persistent nausea,
vomiting or anorexia
3
Generalized
erythroderma
Bilirubin 6.1 – 15.0
mg/dl
Diarrhea >1500
mL/day or
>833
mL/m2
4
Generalized
erythroderma with
bullous formation
and desquamation
Bilirubin > 15
mg/dl
Severe abdominal
pain, with or without
ileus, or stool with
frank blood or melena


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APPENDIX 5– CHRONIC GVHD CLASSIFICATION
Limited CGVHD
Localized skin involvement (<50% body surface area) and/or
Limited hepatic involvement (abnormal LFTS; bilirubin < 3 mg/dl)
Extensive CGVHD
The presence of one or more of the following criteria may be used for the diagnosis of
extensive CGVHD:
o
Generalized skin involvement (50% body surface area) (see Appendix 3)
o
Liver histology consistent with involvement by CGVHD with bilirubin 3
mg/dl
Positive Schirmer’s test (< 5 mm wetting)
o
Histologically-proven involvement by CGVHD of oral mucosa or salivary
glands
- Lung dysfunction with bronchiolitis obliterans with no evidence of viral causation on
histology.
- Gastrointestinal involvement: malabsorption and/or weight loss due to anorexia without
explanation other than CGVHD


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APPENDIX 6–UNIVERSITY OF MINNESOTA ACUTE GVHD GRADING
Acute GVHD
Grade
Skin Stage
Liver Stage
Lower GI
Stage
Upper GI Stage
I
1-2
0
0
0
II
3
1
1
1
III
-
2-4
2-3
IV
4
-
4
• Each column identifies minimum criteria for organ grade.
• Each grade is based on maximum stage for each individual organ involved


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APPENDIX 7 - RESPONSE CRITERIA
CHRONIC MYELOGENOUS LEUKEMIA (CML) RESPONSE CRITERIA
Complete Remission (CR)
Peripheral Blood Counts
Neutrophil count ≥1.0 x 109/L.
Platelet count ≥100 x 109/L.
Reduced hemoglobin concentration or hematocrit has no bearing on remission status.
Leukemic blasts must not be present in the peripheral blood.
Bone Marrow Aspirate and Biopsy
Cellularity of bone marrow biopsy must be > 20% with maturation of all cell lines.
< 5% blasts
Auer rods must not be detectable.
Extramedullary leukemia, such as CNS or soft tissue involvement, must not be present.
Must continue ≥4 weeks.
Partial Remission (PR)
Requires that all of the criteria for complete remission be satisfied except that the bone marrow may
contain > 5% blasts but < 25% blasts.
If all other criteria for CR are met, then a value of ≤5% blasts with Auer rods or abnormal
morphology is considered a partial remission.
Must continue ≥4 weeks.
Cytogenetic Response
Patients will be evaluated for the presence of a cytogenetic abnormalities both before
treatment and at best response. The continued presence of abnormal clones despite
hematologic and marrow complete response will constitute a cytogenetic PR. Complete
absence of the abnormal clone on cytogenetic evaluation will constitute a cytogenetic
CR.
Hematologic Improvement (HI)
NOTE: This category will be used for the purpose of reporting outcome, but not for reporting
response rate.
This classification documents improvement in clinical features, i.e., physical findings, symptoms,
absence of transfusion requirement, without total normalization of hemogram or marrow. The criteria
used were utilized in a study published by M.D. Anderson Tumor Institute (16).
Marrow: ≥5% – ≤50% Blasts and Promyelocytes.
Hemogram: Hgb > 9.0 gm; neutrophils > 1000/mm3; platelets > 50,000/mm3 and no transfusion
necessary.
Physical Exam: At least 50% reduction in organomegaly or lymphadenopathy.
Relapse
Relapse following complete remission is defined as:
Peripheral Blood Counts
Reappearance of blasts in the blood.
Bone Marrow Aspirate and Biopsy
Presence of > 5% blasts, not attributable to another cause (e.g., bone marrow regeneration).
If there are no circulating blasts and the bone marrow contains 5% to 20% blasts, then
a repeat bone marrow performed ≥1 week later documenting more than 5% blasts is
necessary to meet the criteria for relapse.


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Stable Disease (SD)
No progression but no improvement in marrow or peripheral blood counts.
Progressive Disease (PD)
Continued increase in WBC count with increasing numbers of blasts in peripheral blood and marrow.
Distinction between hyperleukocytosis due to drug versus PD must be determined.
Progressive decline in platelet count.
Progressive enlargement of spleen and/or lymph nodes.
Continuation or development of systemic symptoms, including fever and night sweats.
Progressive deterioration in marrow with decline in degree of maturation.
ACUTE MYELOGENOUS LEUKEMIA (AML) RESPONSE CRITERIA
Complete Remission (CR)
Requires that all of the following be present for at least 4 weeks.
Peripheral Blood Counts
Neutrophil count ≥1.0 x 109 /L.
Platelet count ≥100 x 109 /L.
Reduced hemoglobin concentration or hematocrit has no bearing on remission status.
Leukemic blasts must not be present in the peripheral blood.
Bone Marrow Aspirate and Biopsy
Cellularity of bone marrow biopsy must be > 20% with maturation of all cell lines.
≤5% blasts
Auer rods must not be detectable.
Extramedullary leukemia, such as CNS or soft tissue involvement, must not be present.
Partial Remission (PR)
Requires that all of the criteria for complete remission be satisfied except that the bone marrow may
contain > 5% blasts but < 25% blasts.
If all other criteria for CR are met, then a value of ≤5% blasts with Auer rods or abnormal morphology
is considered a partial remission.
Relapse
Relapse following complete remission is defined as:
Peripheral Blood Counts
Reappearance of blasts in the blood.
Bone Marrow Aspirate and Biopsy
Presence of > 5% blasts, not attributable to another cause (e.g., bone marrow regeneration).
If there are no circulating blasts and the bone marrow contains 5% to 20% blasts, then
a repeat bone marrow performed ≥1 week later documenting more than 5% blasts is
necessary to meet the criteria for relapse.
ACUTE LYMPHOCYTIC LEUKEMIA (ALL) RESPONSE CRITERIA
Complete Remission (CR)
Requires that all of the following be present for at least 4 weeks.


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Peripheral Blood Counts
Neutrophil count ≥1.0 x 109/L.
Platelet count ≥100 x 109/L.
Reduced hemoglobin concentration or hematocrit has no bearing on remission status.
Leukemic blasts must not be present in the peripheral blood.
Bone Marrow Aspirate and Biopsy
Cellularity of bone marrow biopsy must be > 20% with maturation of all cell lines.
≤5% blasts.
Extramedullary leukemia, such as CNS or soft tissue involvement, must not be present.
Partial Remission (PR)
Requires that all of the criteria for complete remission be satisfied except that the bone
marrow may contain > 5% blasts but < 25% blasts.
Relapse
Relapse following complete remission is defined as:
Peripheral Blood Counts
Reappearance of blasts in the blood.
Bone Marrow Aspirate and Biopsy
Presence of > 5% blasts, not attributable to another cause (e.g., bone marrow regeneration).
If there are no circulating blasts and the bone marrow contains 5% to 20% blasts, then a repeat bone
marrow performed ≥1 week later documenting more than 5% blasts is necessary to meet the criteria
for relapse.
CHRONIC LYMPHOCYTIC LEUKEMIA RESPONSE CRITERIA
Assessment of Clinical Response
The major criteria for determination of the response to therapy in patients with B-CLL include physical
examination and evaluation of peripheral blood and bone marrow. It is recommended that the laboratory and
radiographic studies which are abnormal pre-study be repeated to document the degree of maximal response.
Complete remission requires all of the following for a period of at least 2 months:

Absence of lymphadenopathy by physical examination and appropriate radiographic techniques.

No hepatomegaly or splenomegaly.

Absence of constitutional symptoms.

Normal CBC as exhibited by:

Polymorphonuclear leukocytes ≥1500/μl.

Platelets > 100,000/μl.

Hemoglobin > 11.0 gm/dl (untransfused).

Peripheral blood lymphocytes ≤4000/μl.

One marrow aspirate and biopsy should be performed no sooner than 2 months after clinical and
laboratory evidence of a CR to document that a complete remission has been achieved. The marrow
sample must be at least normocellular with <30% of nucleated cells being lymphocytes. If it is
hypocellular, a repeat determination should be made in 2 weeks. Samples are to be analyzed by a
pathologist and the presence or absence of nodules noted, although not included in the current
definition of CR. A patient who is in CR, but has nodules, will be considered to have nodular PR &
recorded separately.


10/10/2008
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
Any other laboratory assays (e.g., quantitative immunoglobulins) will not be used currently as an
index for response but will be recorded for clinical correlations.
To be considered in PR, the patient must exhibit the features in sections 1,2, and, 3 (if abnormal prior to
therapy) as well as one or more of the remaining features (sections 4, 5, 6) for at least 2 months. In addition to
the parameters listed below, the presence or absence of constitutional symptoms will be recorded.

≥50% decrease in peripheral blood lymphocyte count from the pretreatment baseline value.

≥50% reduction in lymphadenopathy.

≥50% reduction in size of liver and/or spleen.

Polymorphonuclear leukocytes ≥1500/μl or 50% improvement over baseline.

Platelets > 100,000/μl or 50% improvement over baseline.

Hemoglobin > 11.0 gm/dl or 50% improvement over baseline without transfusions.
Progressive disease (PD) will be characterized by at least one of the following:

≥50% increase in the sum of the products of at least 2 lymph nodes on 2 consecutive examinations 2
weeks apart (at least 1 node must be ≥2 cm). Appearance of new palpable lymph nodes.

≥50% increase in the size of liver and/or spleen as determined by measurement below the respective
costal margin; appearance of palpable hepatomegaly or splenomegaly which was not previously
present.

≥50% increase in the absolute number of circulating lymphocytes.

In the absence of progression as defined above, the presence of a ≥2 gm/dl decrease in hemoglobin, or
≥50% decrease in platelet count and/or absolute granulocyte count will not exclude a patient from
continuing on study. Bone marrow aspirate and biopsy are strongly encouraged to better define the
cause of the suppressed counts.

Transformation to a more aggressive histology (e.g. Richter's syndrome or prolymphocytic leukemia
with >55% prolymphocytes).
Patients who have not achieved a CR or a PR, or who have not exhibited findings consistent with Progressive
Disease will be considered as having Stable Disease.
NON-HODGKIN’S LYMPHOMA RESPONSE CRITERIA
Assessment of Clinical Response
It is sufficient for patients who achieve the response parameters to proceed to the next sequential treatment
stage. It is not necessary to wait 4 weeks to confirm response before proceeding to the next sequential
treatment phase.
Complete Response (CR)
Patients achieving a complete regression for ≥4 weeks of all palpable and x-ray demonstrable disease
and bone marrow disease judged by unilateral iliac crest bone marrow biopsy (if initially positive) will
be considered to have had a complete response.
Lymph nodes remaining in areas of previous known disease will be considered to be
uninvolved if they measure ≤1.0 x 1.0 cm
Lymph nodes of larger size must be documented to be free of tumor on biopsy, or have failed to
enlarge over 3 months off-therapy, if a patient is to be considered a complete responder.


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If the liver and/or spleen are enlarged prior to onset of treatment, they must return to normal size.
Furthermore, negative liver biopsy is required to document complete remission if a positive liver
biopsy was obtained prior to initiation of induction therapy.
Partial Response (PR)
Patients who have not achieved a complete response, but have shown a response to therapy with a
50% or greater reduction in the sum of the products of the dimensions of the measurable lesions for ≥
4 weeks will be considered to have a partial response.
If the liver is an indicator lesion, the sum of the measurements below the right costal
margin, xyphoid process, and left costal margin respectively must decrease by at least
50%.
If the spleen was enlarged prior to therapy and measured < 5 cm below the costal margin, it must
return to normal size. If the spleen is measured ≥5 cm below the costal margin, it must decrease in
size by ≥50%.
Stable Disease (SD)
Disease which does not satisfy the criteria of the other sections (CR, PR or PD) will be
categorized as no change. Stable disease is also defined by at least a 4-week period that
fits this description.
Progressive Disease (PD)
Progressive disease is defined as an increase in size of 25% of the sum of the products of the
pretreatment measurements or appearance of new lesions.
If the liver and/or spleen increases in size > 2.0 cm in distance from the costal margin,
the patient will be considered a treatment failure except, if in the view of the clinician,
this finding is attributed to other causes (e.g., hematopoietic growth factors may cause
splenomegaly and hepatitis may cause liver enlargement).
Relapse
Relapse is defined as the re-appearance of any clinical evidence of lymphoma in a
patient who has had a CR. Relapse for partial responders is defined as progressive
disease relative to disease status during the partial remission.
Duration of Response
This is measured from the documented beginning of response (CR or PR) to the time of
relapse.
Engraftment Parameters
Neutrophil engraftment will be monitored as the number of days to an ANC (neutrophil and band
forms) of > 500 mm and > 1,000/mm .
Platelet engraftment will be monitored as the number of days to a platelet count of
> 20,000 and > 50,000 independent of platelet transfusions for at least 7 days.
The total number of red blood cell and platelet transfusions will be monitored.


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MULTIPLE MYELOMA RESPONSE CRITERIA
Response will be evaluated using the following Myeloma Response Criteria, which have been modified to
exclude references to non-secretory myeloma.
Objective Response
Response evaluation will be based on determination of reduction in serum and/or urine M-protein
(monoclonal or myeloma protein) and on improvement in measurable soft tissue plasmacytomas when
present. The following table presents requirements for objective response based on pretreatment
protein manifestations of disease:
Serum and Urine M-Protein Criteria for Objective Response1
Pretreatme
nt
M-protein
in:
Serum M-protein
must decrease to:
AN
D
24-hr Urine Excretion of
M-protein must
decrease to:
Serum +
≤50% pretreatment
g/dL
AN
D
≤50% of pretreatment
g/24 hr
Urine
Serum
only
< 50% pretreatment
g/dL
AN
D
< 150 mg/24 hours
Urine only
< 1.0 g/dL
AN
D
≤10% pretreatment/24
hours
1 If present, all of these parameters must be followed for response.
Protein criteria supersede other criteria in determining response or progressive disease (PD) unless there is
clear-cut, obvious progressive disease by other criteria, e.g. plasma cell leukemia, hypercalcemia,
plasmacytoma, or unequivocal bone progression. In the case of uninterpretable protein data, response data
may be determined by ancillary measures.
In general, serum and urine M-protein levels should be determined by electrophoresis in preference to
quantitative immunoglobulin levels alone. There are exceptions, however, in which the investigator may
determine the submitted M-spike value to be unreliable as in the following instances:

Small β-migrating M-proteins are contaminated by normal beta globulins that are often greater
in quantity than the M-spike itself.

Cases in which the M-spike measurement provided is difficult to interpret due to excess
scatter, small M-spike, or reflecting the addition of β plus γ plus β / γ regions rather than 
measurement of the spike itself.
In these instances, the investigator may need to rely on the quantitative serum Ig values or recalculate
the M-spike from the SPEP tracing. In sequential measures, SPEP should only be compared to SPEP
values and quantitative Ig values only to quantitative Ig values.
NOTE: Protein requirements for response must be verified on 2 consecutive determinations separated by at
least 2 weeks. Unequivocal progression of skeletal disease could constitute progression, even if
protein manifestations of disease are improving if the criteria in the relapse/progression section
(below) are met. Collapse of bony structure from previous disease will not constitute progression or


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failure to respond. For objective response criteria to be met, there must be no new bone lesions, no
increase in existing lytic lesions, no recurrence or persistence of hypercalcemia, no increase in any
existing plasmacytomas and no new plasmacytomas.
Complete Response (CR)
Patients with objective response who also have complete disappearance of an M-protein and no
evidence of myeloma in the bone marrow are considered to have complete response.
To be considered CR, patients must meet the following criteria:

Complete disappearance of myeloma protein from serum: Patients with no detectable serum M-
spike by serum protein electrophoresis and with quantitative immunoglobulins within normal
range (may vary according to lab) will have a repeatserum immunoelectrophoresis. If no serum
M-protein detected, immunofixation of serum should be performed to confirm CR.

Complete disappearance of myeloma protein from urine: Patients must have an appropriately
concentrated urine specimen. If there is no detectable urine M-protein by urine protein
electrophoresis, patients will have repeat urine immunoelectrophoresis and if negative,
immunofixation of urine should be done to confirm CR.

Bone marrow biopsy demonstrating < 3% plasma cells.

As above, there must be no evidence of progressive disease by other parameters.
Near Complete Response (NCR)
Patients with objective response meeting CR criteria except for 1 of the following are considered to
have NCR:

Lacking repeat bone marrow

3%-6% bone marrow plasma cells remaining, or

< 3% plasma cells remaining on routine bone marrow differential count but marrow aspiration or
biopsy still shows clear evidence of myeloma (sheets or clusters of malignant plasma cells).
Partial Response (PR)
Patients meeting objective response (OR) criteria but not complete response (CR) or near complete
response (NCR) criteria are considered to have a partial response (PR).
Disease Plateau
A patient in CR, NCR, or PR will be further classified as being in plateau if the following criteria are
met.
NOTE:
Plateau is not a distinct response category.
Objective response AND
Serum and urine M-protein values must be stable (< 20% variation) or must have disappeared for a
period of at least 4 weeks. For the purposes of the formula below, serum M-protein is defined as the
serum M-spike as measured by serum protein electrophoresis.
To qualify as < 20% variation, M-protein measurements over at least a 4-week period must satisfy


10/10/2008
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(MAX - MIN) ÷ MAX < 0.20,
where max = maximum M-protein value, and min = minimum M-protein value. The difference
between the maximum and minimum values observed is divided by the maximum value observed. If
the result is greater than 0.20, then there has been a greater than 20% variation in the M-protein values.
Date of plateau will be date of CONFIRMATION that patient is in plateau.
Any patient who is continuing to improve by any criteria would not be considered in plateau and
should remain on treatment until the continued improvement plateaus.
No Response (NR)
Failure to meet response criteria outlined in Section 6.1.
Relapse or Progression (PD)
Patients meeting two or more of the criteria in 1-4 OR 5 will be considered to have relapse or
progression:
1.
Increase in serum M-protein to > 50% above the lowest response level or a rise of 2.0 g/dL (this
increase must be to a level >1.0 g/dL if it is to constitute the sole protein manifestation of relapse).
(The serum M-protein should be measured by electrophoresis unless the M-spike is <1.5 g/dL.
However, when only quantitative Ig values are reported, it may be accepted as definitive even though
serum protein electrophoresis should have been done.)
2.
Increase in urine M-protein to 50% above the lowest remission value for 24-hour excretion or an
increase of 2g/24 hours of urine M-protein (this increase must also represent a 24-hour M-protein
excretion of >250 mg).
3.
Increase in soft tissue plasmacytomas by 50% as measured serially by the sum of the products of the
cross diameters of each measurable lesion.
4.
Definite appearance of new lytic bone lesions or increase in the size of the existing bone lesions by
50%. Caution must be exercised to avoid rating progression or relapse on the basis of variation of
radiologic technique alone. When progression is based on skeletal disease alone, it should be
discussed with the PI before removing the patient from study.
OR
5.
A > 50% increase in serum or urine M-protein as defined above plus one of the following will
constitute relapse or progression:

Hypercalcemia > 12 mg/dL without other cause.

Anemia (decrease in hemoglobin > 2g/dL to a level < 11g/dL in men or < 10g/dL in women).
Chemotherapy or alpha2b-IFN-induced anemia or myelodysplastic syndrome with anemia do not
constitute criteria for relapse of myeloma.

Increase in bone marrow plasma cell percentage by >50%.

Generalized bone pain.