Conditions: Stem Cell Transplantation Leukemia Lymphoma
Keywords: Cancer Blood And Marrow Transplantation Stem Cell Leukemia Lymphoma Pediatrics Bone marrow Lymph node system Allogeneic Stem Cell Transplant ASCT Busulfan Busulfex Myleran Clofarabine Clofarex Clolar Thiotepa Antithymocyte globulin ATG Thymoglobulin G-CSF Filgrastim Neupogen Cyclophosphamide Cytoxan Neosar Mesna Mesnex Tacrolimus Prograf Methotrexate
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 60
Healthy volunteers: no

Brief summary:
Any time the words "you," "your," "I," or "me" appear, it is meant to apply to the potential participant.

The goal of this clinical research study is to learn if thiotepa, busulfan, and clofarabine, when given before an allogeneic (bone marrow , blood, or cord blood cells) or haploidentical (bone marrow) stem cell transplantation can help to control cancers of the bone marrow and lymph node system. The safety of this treatment will also be studied.

This is an investigational study. Thiotepa and clofarabine are FDA approved and commercially available for the treatment of leukemia. Busulfan is FDA approved and commercially available for use in stem cell transplantation. The combination of thiotepa, clofarabine, and busulfan together with a stem cell transplant is investigational.

Up to 60 participants will take part in this study. All will be enrolled at M. D. Anderson.

Detailed description:
The Study Drugs:

Thiotepa and busulfan are designed to bind to DNA (genetic material of cells), which may cause cancer cells to die. They are commonly used in stem cell transplants.

Clofarabine is designed to interfere with the growth and development of cancer cells.

Study Drug Administration:

If you are found to be eligible to take part in this study, you will begin receiving the study drugs before you receive the stem cell transplant.

The days before you receive your stem cells are called minus days, such as Day -2 and Day -1. The day you receive the stem cells is called Day 0. The days after you receive the stem cells are called plus days, such as Day +1 and Day +2.

On Day -8 (8 days before you receive the stem cell transplant), you will receive thiotepa through a central venous catheter (CVC) over 2 hours. A CVC is a sterile, flexible tube that will be placed into a large vein while you are under local anesthesia. Your doctor will explain this procedure to you in more detail, and you will be required to sign a separate consent form for this procedure.

On Day -7, you will receive busulfan through a CVC. This dose of busulfan is a low level "test" dose to check how your blood levels change over time. This information will be used to decide the next dose level of busulfan.

Blood (about 1 teaspoon each time) will be drawn 6-11 times total over Days -7 and -5 for pharmacokinetic (PK) testing. PK testing measures the amount of busulfan in the body at different time points. This PK testing will be done to find the dose of busulfan needed for your body size on the other days that you receive busulfan. A heparin lock line will be placed in a vein to lower the number of needed sticks performed for draws. If you cannot have the blood level tests performed for any reason, you will receive the standard busulfan dose.

On Days -6, -5, -4, and -3, you will receive clofarabine through a CVC over 1 hour.

On Days -5, -4, and -3, you will receive busulfan through a CVC over 3 hours.

If you will receive stem cells from a donor whose cells do not match your own cells closely, on Days -4 and -3 you will also receive antithymocyte globulin (ATG) by vein over 4 hours. This will help to reduce the risk of your body rejecting the transplant. If your transplant will involve haploidentical stem cells, you will not receive ATG on Days -4 and -3.

On Days -2 and -1, you will "rest," which means you will not be given any drugs, but your CVC will remain in place.

If thiotepa is not available:

If thiotepa is not available, or if you doctor thinks it is in your best interest, you will receive the following study drugs and total body irradiation (TBI) before you receive the stem cell transplant. TBI involves the delivery of high doses of radiation designed to destroy cancer cells and/or lower the immune system in order to lower the risk of the body rejecting the new stem cells.

Between Days -16 and -7, you will receive a low-level "test" dose of busulfan by vein over about 45 minutes to 1 hour. Test doses are used to study how your body breaks down busulfan and decide the dose of busulfan that you will receive. You may receive the test dose before Day -6 as an outpatient in the clinic, or on Day -6 as an inpatient in the hospital.

Blood (about 1 teaspoon each time) will then be drawn for PK testing up to 11 times over the 11 hours after the busulfan test dose and on Day -4. PK testing measures the amount of study drug in the body at different time points. The study staff will tell you more about the PK testing schedule.

A heparin lock line will be placed in your vein before the PK testing to lower the number of needle sticks needed for these draws. If for any reason it is not possible for the PK tests to be performed, you will receive the standard dose of busulfan.

On Day -7 or Day -6, you will be admitted to the hospital and given fluids through a CVC to hydrate you.

On Days -5, -4, -3, and -2, you will receive clofarabine through a CVC over 1 hour.

On Days -4, -3, and -2, you will receive busulfan through a CVC over 3 hours.

If you will receive stem cells from a donor whose cells do not match your own cells closely, on Days -3 and -2 you will also receive antithymocyte globulin (ATG) by vein over 4 hours. This will help to reduce the risk of your body rejecting the transplant. If your transplant will involve haploidentical stem cells, you will not receive ATG on Days -3 and -2.

On Day -1, you will receive TBI one time.

Stem Cell Transplant:

On Day 0, you will have an allogeneic or haploidentical stem cell transplant through the CVC. Allogeneic stem cells come from a donor whose cells closely match your own cells. Haploidentical stem cells come from a donor whose cells do not match your own cells as closely, but they are specially processed to help prevent graft versus host disease (GVHD).

Receiving stem cells is similar to receiving a blood transfusion. The time required to receive the stem cells will depend on the type of cells you are receiving. Receiving cord blood stem cells can take several minutes. Receiving bone marrow and blood stem cells may take several hours.

You will receive G-CSF (filgrastim) (which helps to produce white blood cells) as an injection under the skin once a day, starting 1 week after the transplant, until your blood cell levels return to normal.

You will receive drugs (mycophenolate mofetil (MMF), tacrolimus and/or methotrexate) to help prevent side effects, such as GVHD. You will receive methylprednisolone if you develop GVHD.

You will stay in the hospital for about 4 weeks after the stem cell transplantation.

If you had a haploidentical stem cell transplant, on Days 3 and 4 after your stem cell transplant, you will receive cyclophosphamide through a CVC over 3 hours. Mesna will be given by vein at the same time you are given each dose of cyclophosphamide, to help protect your bladder from bleeding.

Study Visits:

Beginning on Day -9, once a day while you are in the hospital:

* You will have a physical exam, including measurements of your vital signs.
* You will be asked if you have had any side effects.
* Blood (about 4 tablespoons) will be drawn to test your blood cell counts. Two (2) times a week, this blood will be also be used for routine tests.

After you are out of the hospital, 2 times a month until it has been 100 days after the transplant:

* You will have a physical exam, including measurements of your vital signs and weight.
* You will be asked if you have had any side effects.
* Blood (about 4 tablespoons) will be drawn for routine tests.

About 1, 3, 6, and 12 months after the transplant, blood (about 4 tablespoons) will be drawn to check the status of the disease. You will also have bone marrow aspirations to check the status of the disease. You will also have a physical exam.

If the doctor thinks it is necessary, you may have extra tests and procedures.

Length of Study:

You will be on study for about 1 year. You will be taken off study if the disease gets worse or needs further treatment.

Follow-Up:

If you live close to M. D. Anderson, you will return to the clinical once every several months for a physical exam. At these visits, blood (about 3 teaspoons) will be drawn for routine tests.

You and/or your local doctor will be called every several months and asked about your health status and if the leukemia or MDS has come back.

Arms:
arm 1: Pre-transplant conditioning regimen:

Thiotepa (Thio) + Clofarabine (Clo) + Busulfan (Blu) + Allogeneic Stem Cell Transplantation (Allo SCT) + ATG + G-CSF

Post haploidentical stem cell transplant participants:

Cyclophosphamide 50 mg/kg by vein on Days + 3 and + 4. Mesna 10 mg/kg by vein just prior to the first dose of cyclophosphamide, repeated every 4 hours for a total of ten (10) doses.

Interventions: intervention 1: Thiotepa intervention 2: Clofarabine intervention 3: Busulfan intervention 4: Allogeneic Stem Cell Transplantation intervention 5: Thymoglobulin (ATG) intervention 6: G-CSF (Filgrastim) intervention 7: Tacrolimus intervention 8: Methotrexate intervention 9: Cyclophosphamide intervention 10: Mesna
Intervention descriptions: intervention 1: 5 mg/kg through a central venous catheter (CVC) over 2 hours on Day -8. intervention 2: 40 mg/m\^2 through a central venous catheter (CVC) over 1 hour daily on 4 consecutive days (Days -6 through -3). intervention 3: Test dose of 0.5 mg/kg through a central venous catheter (CVC)over 30 minutes on Day -7.

High dose 5,000 µMol-min through a central venous catheter (CVC) over 3 hours on Days -5, -4, and -3. intervention 4: Infusion of stem cells through through a central venous catheter (CVC) On Day 0. intervention 5: 1.25 mg/kg by vein on Day -4 and 1.75 mg/kg on Day -3. intervention 6: 5 µg/kg Injection under the skin once a day, starting 1 week after transplant, until blood cell levels return to normal. intervention 7: Starting dose of 0.015 mg/kg (ideal body weight) as a 24 hour continuous infusion daily, to be changed to oral dosing when tolerated. Tacrolimus is to be tapered as indicated after transplant day 90, if no GVHD is present. Tacrolimus is adjusted trough level of 5-15 ng/mL. intervention 8: 5 mg/m2 by vein on Days 1, 3 and 6 and Day +11 post transplant. The Day 11 methotrexate dose may be held as indicated if mucositis is present. intervention 9: Post haploidentical stem cell transplant participants: 50 mg/kg by vein on Days + 3 and + 4. intervention 10: Post haploidentical stem cell transplant participants: 10 mg/kg by vein just prior to the first dose of cyclophosphamide, repeated every 4 hours for a total of ten (10) doses.

Protocol document:
Prot_SAP_000.pdf: 
2008-0363 
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Page 1 of 27
 
 
 
 
 
 
 
 
 
 
Thiotepa-Clofarabine-Busulfan with Allogeneic Stem Cell 
Transplant for High Risk Malignancies 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol No.: 
 
2008-0363 
Principal Investigator: 
Laura L. Worth, M.D., Ph.D. 
Phase: 
 
 
II 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Table of Contents 
 
 
 
1.0 
Objectives .................................................................................................. 3 
2.0 
Background ............................................................................................... 3 
3.0 
Background Drug Information ................................................................. 6 
4.0 
Patient Eligibility ..................................................................................... 12 
5.0     Pretreatment evaluation ......................................................................... 14 
6.0    Treatment Plan ......................................................................................... 14 
7.0    Evaluation During Study ......................................................................... 19 
8.0    Criteria for Study Evaluation .................................................................. 21 
9.0    Statistical Consideration ......................................................................... 22 
10.0  Adverse Events ........................................................................................ 23 
11.0  Criteria for Removal from the Study ...................................................... 26 
12.0  References ............................................................................................... 26 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1.0 
Objectives 
 
1.1 
The primary objective is to determine the safety and efficacy of a pre-
transplant conditioning regimen consisting of thiotepa, busulfan, and 
clofarabine followed by allogeneic hematopoietic stem cell transplant for 
high risk malignancies. 
1.2 
The secondary objectives are to evaluate the engraftment, toxicity, relapse 
rate, rate and severity of graft-vs-host disease, disease-free and overall 
survival. 
2.0 
Background 
 
High dose chemoradiotherapy supported by allogeneic bone marrow, umbilical 
stem cells, or peripheral blood stem cell transplantation (SCT) is a potentially 
curative therapy for patients with hematological malignancies.   Many preparative 
regimens for allogeneic stem cell transplant use high-dose chemotherapy with or 
without total body irradiation (TBI).  Comparative studies of TBI and non-TBI 
based regimens have not shown significant differences in efficacy (1).  Because 
of the known side effects associated with TBI (cataract formation, second 
malignancies, hormonal deficiencies), chemotherapy only regimens have a 
potential for major advantages, especially in children.   
 
Thiotepa-Busulfan-Cyclophosphamide 
We have extensive experience with the chemotherapy-only regimen consisting of 
Thiotepa, Busulfan (Bu), and Cyclophosphamide (Cy) with advanced 
malignancies (2, 3).  Bu-Cy is a well established preparative regimen for 
allogeneic stem cell transplantation for patients with hematological malignancies 
(4).  Thiotepa was added to this regimen because of its ability to cross the blood-
brain barrier (5), its in vitro activity against hematological malignancies (6), and 
its non-overlapping toxicities with BU-CY.  More than 50 children were treated 
with thiotepa (250 mg/m2 x 3 days), adjusted-dose busulfan x 3 days (AUC 
1200-1800/micromol/min/L) and cyclophosphamide (60 mg/kg x 2 days).  All 
stem cell sources were used including related and unrelated peripheral blood 
stem cells and bone marrow as well as unrelated cord blood (CB) stem cells.  
Two of the 23 patients receiving CB as a stem cell source failed to engraft and 
went on to receive a second transplant. Infection was a frequent cause of death 
in the early years of this study.  With the improvement in HLA typing, diagnostic 
techniques, new antibiotics, and overall supportive care, the morbidity and 
mortality from all causes declined. Regimen related toxicities (grade 3-4) were 
predominantly esophagitis, mucositis, emesis, and hepatic dysfunction.  Three 
patients developed veno-occlusive disease (VOD).  All three were transplanted 
prior to the availability of the IV formulation of busulfan.  The erratic absorption of 
BU orally may have contributed to hepatotoxicity since no patients receiving the 
IV formulation of BU developed VOD. Of the 16 patients treated with active 


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disease at the time of transplantation, only the patients with AML did well.  See 
survival curve below. 
 
 
Survival
0
1000
2000
3000
4000
5000
6000
5
15
25
35
45
55
65
75
85
95
105
ALL
AML
ALL+AML
Days
 
 
 
Clofarabine as an antileukemic agent 
Clofarabine is a second-generation deoxyadenosine analog designed to 
improve efficacy and minimize the toxicity of other analogs.  It has a cytotoxic 
activity against a wide variety of leukemias and solid tumors.  Although phase I 
studies are dose finding studies, the pediatric phase I study performed at M D 
Anderson Cancer Center showed definitive responses (7). Of the 25 patients 
with multiple relapsed or refractory leukemias, five patients obtained a 
complete response and an additional 3 patients obtained a partial response for 
an overall response rate of 32%.  The phase II study (8) that enrolled 61 
pediatric patients served as the basis of the FDA approval of clofarabine in 
2004.   
 
Clofarabine in stem cell transplant 
Protocol 2006-0200 (Busulfan-Fludarabine-Clofarabine with allogeneic stem 
cell transplant for advanced refractory acute myeloid leukemia, 
myelodysplastic syndrome and advanced, Gleevec refractory chronic myeloid 
leukemia. A randomized phase II study) is investigating the efficacy of 
fludarabine and clofarabine in combination with busulfan.   
 
The study is designed to determine which of the following combinations is 
optimal.  Patients are being treated on one of the following 4 treatment arms: 
1) Busulfan-fludarabine (30mg/m2/day) clofarabine (10mg/m2/day) 
2) Busulfan-fludarabine (20mg/m2/day) clofarabine (20mg/m2/day) 
3) Busulfan-fludarabine (10mg/m2/day) clofarabine (30mg/m2/day) 


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4) Busulfan- clofarabine (40mg/m2/day) 
 
The busulfan dose is adjusted based on pharmacokinetic data to ensure a 
constant AUC daily dose of 6,000 microMol-min (+ 5%). 
 
To date more than four patients have been enrolled on each treatment arm.  
All patients treated on this protocol have engrafted.  The regimen related 
toxicities are tolerable (no grade III or IV non-hematological toxicities).  
Although it is too early to analyze some of secondary endpoints, relapse rate, 
long-term and overall and disease-free survival, only two patients have had 
progressive disease. 
 
Preliminary results of 2008-0363 
We recently presented a poster at ASBMT/IBMTR detailing preliminary results 
of Protocol 2008-0363.  We have 15 patients that are more than 100 days after 
transplant.  All 15 patients have engrafted at a median of 16 days.  As 
expected cord blood recipients engrafted more slowly and peripheral blood 
stem cell recipients more quickly.  Several patients had active disease at the 
time of transplant.  One patient shortly after engraftment had disease 
progression. 
 
Stem Cell 
Source 
ANC >500/mL
Median (range) 
Platelets >20,000/mL
Median (range) 
All Sources (15)
16 (11-29)
28 (12-69)
Double Cord (7)
18 (13-29)
41 (28-61) (n=6)
Single Cord (2)
16 (16)
27 (21-37)
Bone Marrow (3)
14 (11-16)
28 (21-51)
PBSC (n=3)
11 (11)
12 (11-12)
 
Results 
Fifteen patients with advanced malignancies were treated with a preparative 
regimen containing thiotepa, busulfan and clofarabine prior to allogeneic stem 
cell transplant.  
 
 All patients engrafted rapidly (median 16 days).  
 
 All evaluable patients had 100% donor chimerism by day +30.  
 
 Regimen related toxicities were as expected or lower for a myeloablative 
regimen (nausea, vomiting, diarrhea, mucositis).  
 
 Two patients met Jones criteria for VOD (1  mild, 1  severe).  
 
The mild case resolved with supportive care.   
 
The severe case received defibrotide therapy. Despite transient 
pulmonary and acute renal failure, the patient recovered 
completely.  
 
Acute GVHD was seen in 53% of patients.  
 
Grade III-IV acute GVHD was seen in 20% of patients.  


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5/15 patients had skin GVHD II that resolved with topical treatment  
 
2/15 patients developed grade III GI GVHD  
 
1/15 patients developed fatal grade IV skin and liver GVHD  
 
Two non-relapse deaths were secondary to GVHD and aspiration 
pneumonia.  
 
Day 30 survival was 100%.  
 
Day 100 survival was 78%.  
 
3.0 
Background Drug Information 
 
3.1. Thiotepa: 
CHEMISTRY 
Thiotepa, an ethylenimine derivative, is a polyfunctional alkylating agent. The 
drug is supplied as a sterile lyophilized powder, containing 15 mg of thiotepa. 
The drug is reconstituted with sterile water for injection resulting in a drug 
concentration of approximately 10 mg/ml. the reconstituted solution has a pH of 
approximately 5.5-7.5. The solution should be further diluted with Sodium 
Chloride Injection before use. 
 
STABILITY 
Both thiotepa powder for injection and reconstituted solutions of the drug should 
be stored at 2-8ºC, protected from light at all times. Reconstituted solutions are 
stable for 8 hours and solutions further diluted with Sodium Chloride Injection 
should be used immediately. In order to eliminate haze, solutions should be 
filtered through a 0.22 micron filter prior to administration. 
Reconstituted solutions should be clear. Solutions that remain opaque or 
precipitate should not be used. 
 
PHARMACOLOGY 
Thiotepa, as an alkylating agent, interferes with DNA replication and transcription 
of RNA, and ultimately results in the disruption of nucleic acid function. Thiotepa 
also possesses some immunosuppressive activity. 
 
PHARMACOKINETICS 
Absorption - Thiotepa is incompletely absorbed from the GI tract. Variable 
absorption also occurs through serous membranes, such as the pleura and 
bladder, and from IV injection sites. 
Absorption through the bladder mucosa may range from 10% to almost 100% of 
the instilled dose and is enhanced by extensive tumor infiltration or inflammation. 
Following IV administration of thiotepa C14, serum concentrations of radioactivity 
reportedly begin to decline within 10 minutes, but detectable concentrations 
persist for 72 hours. 
 
 


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KNOWN SIDE EFFECTS AND TOXICITIES 
Myelosuppression, nausea, vomiting, dermatitis, and alopecia 
 
3.2 Clofarabine: 
CHEMISTRY 
Clofarabine purine nucleoside analog. It is formulated as a concentration of 
1mg/mL in United States Pharamacopeia (USP) sodium chloride (9mg/mL), and 
USP water for injection (qs to 1mL). Clofarabine is supplied in 2 vial sizes: a 
10mL flint vial and 20mL flint vial. The 10 mL flint vials contain 5mL (5mg) of 
solution and the 20mL flint vials contain 20mL (20mg). For both vial types, the pH 
range of the solution is 4.0 to 7.0. The solution is clear with color ranging from 
colorless to yellow and is free from visible particulate matter. 
Expected toxicities: myelosuppression, nausea/vomiting, diarrhea, mucositis, 
skin rash (particularly hand-foot syndrome), fatigue, mental status 
changes/coma, allergic reactions (including fever, muscle aches, edema, 
dyspnea), congestive heart failure, conjunctivitis, anorexia, febrile neutropenia, 
pruritus, headache, flushing and pyrexia, liver failure. 
 
STABILITY 
Clofarabine vials containing undiluted clofarabine for injection should be stored at 
25°C or 77°F with temperature excursion permitted to 15 to 30°C or 59 to 86°F. 
Ongoing self-life stability indicate that clofarabine is stable for 36 months at 25°C 
(±2°C) and 60% (±5%) relative humidity and for 6 months at 40°C (±2°C) and 
75% (±5%) relative humidity. 
 
PHARMACOLOGY 
Clofarabine is a purine nucleoside analog. When phosphorylated intra cellularly, 
it inhibits DNA polymerase a, inhibits ribonucleotide reductase, and activates 
apoptosis. 
 
KNOWN SIDE EFFECTS AND TOXICITIES 
Hepatotoxicity veno-occlusive liver disease, nausea, vomiting, diarrhea, 
proctalgia, mucositis. 
Esophagitis, gastritis. Colitis. Cholestasis. Pancreatitis. Insomnia, coma, and/or 
changes in mental status (confusion, somnolence). Dysarthria. Skin rashes 
including hand-foot-syndrome. 
Allergic reaction. Hypotension. Renal insufficiency. Congestive heart failure. 
Myocardial infarction. Atrial fibrillation. Fatigue, flushing, itching, chills, weakness, 
muscle aches, loss of appetite, peeling hands/feet, pneumonia, constipation, 
nosebleed, anxiety, pain in arms and legs, shaking, cough, shortness of breath, 
respiratory failure, palpitations and arrhythmias, arthralgias, dizziness, bone pain. 
Tingling in hands and feet, back pain, chest pain, changes in taste. 
Alopecia. Amnesia. Febrile neutropenia, pyrexia, sepsis. Pneumonia. 
Bacteremia. Neutropenia. Thrombocytopenia. Myelosuppression. Tumor lysis 
syndrome. Capillary leak syndrome. Multi-system organ failure. Disseminated 
intravascular coagulation. 


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3.3 Busulfan (IV BusulfexTM): 
CHEMISTRY 
Busulfan is an antineoplastic alkylating agent. It is a sterile, pyrogen-free solution 
provided in a mixture of dimethylacetamide (DMA) and polyethyleneglycol 400 
(PEG400). It is supplied in 10 ml single use ampoules at a concentration of six 
(6) mg busulfan per ml. Each ampoule contains 60 mg of busulfan in 3.3 ml of 
DMA and 6.7 ml of PEG400. When diluted in normal saline or D5W to a 
concentration of 0.5 mg/ml, the resulting solution must be administered within 
eight (8) hours of preparation including the three (3) hour infusion of the drug. 
 
STABILITY 
Ampoules should be stored refrigerated at 2-8°C (35-46°F). Stable at 4°C for at 
least twelve (12) months. Additional stability studies are in progress. DO NOT 
use beyond the expiration date. 
DO NOT use if the solution is cloudy or if particulates are present. 
Solution Preparation: Prepare the busulfan solution as follows (The patient is to 
receive a dose of 130 mg/m2 of busulfan): mix into normal saline to a final 
concentration of 0.5 mg/mL. In each bag 6.0 mg busulfan (1.0 ml at 6 mg/ml and 
11 ml saline) should be added to compensate for drug lost in the tubing with each 
infusion (approximately 12 ml at 0.5 mg/ml is lost in the tubing when using the 
controlled rate infusion pump). 
CAUTION: DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS. 
 
PHARMACOLOGY 
Busulfan interferes with DNA replication and transcription of RNA through DNA 
alkylation, and ultimately results in the disruption of nucleic acid function. 
 
PHARMACOKINETICS 
The pharmacokinetic data suggests that the plasma decay of the formulation fits 
an open one-compartment model with linear pharmacokinetics in the dose range 
of 12 mg-130 mg/m2. 
The drug is slowly excreted in the urine, chiefly as methanesulfonic acid. Ten to 
fifty percent (10-50%) of a dose is excreted as metabolites within twenty-four (24) 
hours. 
 
KNOWN SIDE EFFECTS AND TOXICITIES 
Dose limiting toxicity is expected to be hematological when used without stem 
cell support. Other toxicities seen frequently following high-dose busulfan in 
preparative regimens for bone marrow transplantation include: VOD, nausea, 
vomiting, pulmonary fibrosis, seizures, rash, and an 
-like syndrome. 
 
3.4 Thymoglobulin: 
Thymoglobulin® (Rabbit antithymocyte globulin, Genzyme Corporation) will be 
used as an in vivo immunosuppression. 
 


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CHEMISTRY 
Thymoglobulin is a polyclonal anti-lymphocyte preparation. The drug is supplied 
as a sterile lyophilized powder, containing 25 mg of antithymocyte globulin. It is 
reconstituted 50  500 mL of saline or dextrose solution. 
 
STABILITY: 
The lyophilized powder should be stored in a refrigerator at 2 to 8°C (36 to 46°F). 
Thymoglobulin should be used within 4 hours after reconstitution if kept at room 
temperature. For vials containing the unreconstituted lyophilized powder, the 
product is stable for 36 months at 5-3°C (41 4°F), and 12 months at 37°C (98.6° 
F). Reconstituted product is stable for 72 hours at room temperature 20 to 25°C 
(68 to 77°F). 
Immediately before intravenous administration, dilute reconstituted 
Thymoglobulin in isotonic saline or dextrose solution to a total infusion volume of 
50 to 500 mL (usually 50 mL of IV admixture solution per 25 mg vial). The 
recommended route of administration is intravenous infusion through an in-line 
0.22 micron filter into a high-flow vein.  
 
PHARMACOLOGY 
Mechanism of action: Possible mechanisms by which Thymoglobulin may induce 
immunosuppression in vivo include: T-cell clearance from the circulation and 
modulation of T-cell activation, homing, and cytotoxic activities. Thymoglobulin is 
thought to induce T-cell depletion and modulation by a variety of methods, 
including Fc receptor-mediated complement-dependent lysis, opsonization and 
phagocytosis by macrophages, and immunomodulation leading to long 
term depletion via antibody dependent cell-mediated cytotoxicity and activation of 
apoptosis. 
 
KNOWN SIDE EFFECTS AND TOXICITIES: 
The most common adverse reactions are fever, chills, leukopenia, 
thrombocytopenia, rashes, systemic infections, abnormal renal function tests, 
and serum sickness-like symptoms. Other reported side effects are arthralgia, 
chest and/or back pain, diarrhea, dyspnea/apnea, nausea and vomiting. 
 
3.5 Mycophenolate Mofetil (MMF): 
THERAPEUTIC CLASSIFICATION 
Immunosuppressant for GVHD prophylaxis and treatment. 
 
 
CHEMISTRY 
Oral: 250-mg and 500-mg capsules, and as 200 mg/mL oral suspension. It may 
also be prepared extemporaneously as an oral suspension (100 mg /mL; in 
cherry syrup; pH = 6.0 - 6.7; Injectable: 500 mg vial to be reconstituted in 14 mL 
of D5W to yield about 15 mL containing 33.33 mg/mL of MMF. 
 
 


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PHARMACOLOGY 
Oral: stable for at least four months at room temperature. Injectable: Each 500-
mg vial should be reconstituted with 14 mL D5W to yield about 15 mL of MMF 
solution (33.33 mg/mL) as above. 
 
The dose should be further diluted in D5W to a final concentration of about 6 
mg/mL. The solution should not be refrigerated and should be administered 
within 4 hrs of preparation. The dose should be infused over at least two hrs. The 
manufacturer does not specify the type of container to use for parenteral. 
 
MECHANISM OF ACTION 
MMF inhibits T and B cell proliferation by blocking the production of guanosine 
nucleotides required for DNA synthesis. 
 
SIDE EFFECTS 
Constipation, diarrhea, nausea, vomiting, headache, confusion, tremor, 
gastrointestinal bleeding, hypertension, peripheral edema, cough exacerbation, 
infection, sepsis and bone marrow suppression including severe neutropenia. 
 
3.6 Filgrastim: 
MODE OF ACTION 
Filgrastim is a human granulocyte-stimulating factor that acts on hematopoietic 
cells to stimulate proliferation, differentiation, and some end-cell functional 
activity. 
 
STORAGE AND STABILITY 
Filgrastim should be stored at 2° to 8° C. Prior to injection, Filgrastim may be 
allowed to reach room temperature, however, any vials left at room temperature 
for greater than 24 hours should be discarded. Vials should not be shaken. Vials 
should be inspected for sedimentation or discoloration prior to administration. If 
sedimentation or discoloration is observed, the vials should not be used. 
 
ROUTE OF ADMINISTRATION 
SC Injection-IV Infusion. 
 
INCOMPATIBILITY 
No definite incompatibilities are known. However, drugs that may potentiate the 
release of neutrophils should be used with caution. 
 
 
AVAILABILITY 
Commercially available in single-dose, preservative-free vials containing 300 
mcg (l mL) and 480 mcg (1.6 mL) of Filgrastim. Used portions should be 
discarded. 
 
 


2008-0363 
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SIDE EFFECTS 
Mild to moderate bone pain is possible in patients receiving myelosuppressive 
therapy. General skin rash, alopecia, fevers, thrombocytopenia, osteoporosis, 
nausea, vomiting, diarrhea, mucositis, anorexia, inflammation of the blood 
vessels, and/or cardiac dysrhythmia can occur. 
Splenomegaly may result at high doses of Filgrastim. Headaches, wheezing, 
dyspnea, swelling, and/or increased enzyme levels. May accelerate the growth of 
tumors or cancers. 
 
3.7 Tacrolimus: 
THERAPEUTIC CLASSIFICATION 
Cyclic polypeptide immunosuppressive agent 
 
MECHANISM OF ACTION 
Macrolide antibiotic produced by Streptomyces tsukubaensis that inhibits T and B 
cell proliferation. 
 
PHARMACOLOGY 
Available in 5 mg/mL vials. Anhydrous is diluted in alcohol dehydrated 80% v/v 
and polyoxyl 60 hydrogenated castor oil 200 mg/mL. For IV infusion, solution is 
diluted with 0.9% NaCl or 5% dextrose to a concentration of 4-20 mcg/mL. Also 
available in tablets of 0.5, 1, and 5 mg. 
Disposition is biphasic with a terminal half-life of 10-30 hours. Elimination is 
mainly by hepatic metabolism and biliary excretion. 
 
STABILITY 
The oral from is stable at room temperature protected from light for at least 2 
months. The IV preparation is diluted in D5W or NS and is stable for 24 hours. 
 
KNOWN SIDE EFFECTS 
Tacrolimus may cause kidney and/or liver damage, high blood pressure, high 
blood sugar, and/or diabetes. It may cause low levels of potassium, magnesium, 
and/or phosphate in the blood, which can lead to weakness or other neurological 
symptoms such as shaking of hands. 
The drug may cause nausea, vomiting, constipation, burning feeling in the hands 
and/or feet, seizures, coma, and/or confusion. An allergic reaction may occur. 
The drug may cause headache, difficulty sleeping, diarrhea, high blood pressure, 
blurred vision, chest pain, higher sensitivity to pain, ringing in the ears, sweating, 
enlarged heart, and/or weakening of the immune system, which may result in the 
development of infections. It may cause rapid growth of body hair, loss of 
appetite, weight loss, wheezing, facial flushing, yellowing and/or darkening of the 
skin due to bile in the blood, and/or abdominal pain. It may cause an increased 
risk of cancer of the lymph glands. It may also cause rashes, itching, changes in 
hearing, fluid in the lungs, and/or back pain. 
 
 
 


2008-0363 
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3.8   
 
 
CHEMISTRY 
The Distribution (Vd) is 0.48-0.71 L/kg; crosses placenta; crosses into CSF.  
Protein binding is 10-60%. Hepatically metabolized to active metabolites acrolein, 
4-aldophosphamide, 4-hydroperoxycyclophosphamide, and nor-nitrogen 
mustard.  Bioavailability is >75%.  Half-life elimination is 3-12 hours.  Excretion in 
urine (<30% as unchanged drug, 85% to 90% as metabolite). 
 
PHARMACOLOGY 
Cyclophosphamide is an alkylating agent that prevents cell division by cross-
linking DNA strands and decreasing DNA synthesis. It is cell cycle phase non-
specific. Cyclophosphamide also possesses potent immunosuppressive 
properties.  It is a pro-drug metabolized by the liver to active metabolites 
 
KNOWN SIDE EFFECTS: 
 Leukopenia, anemia, alopecia, nausea, vomiting, increased AST, ALT, 
mucositis, diarrhea, headache, dizziness. Cardiomyopathy, non-specific ST 
changes on EKG. At doses greater than 200mg/kg, Cy can cause fatal 
myocardial necrosis with clinical heart failure.  Hemorrhagic cystitis, SIADH, fluid 
retention, hemorrhagic cystitis are possible. Teratogenic, may cause secondary 
neoplasms, anaphylaxis (rare). 
 
3.9 Mesna (sodium -2-mercapto ethane sulphonate): 
 
Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced by 
the oxazophosphorines (cyclophosphamide and ifosfamide).  It has no intrinsic 
cytotoxicity and no antagonistic effects on chemotherapy.  Mesna binds with 
acrolein, the urotoxic metabolite produced by the oxazophosphorines, to produce 
a non-toxic thioether and slows the rate of acrolein formation by combining with 
4-hydroxy metabolites of oxazophosphorines. At the doses used for 
uroprotection, mesna is virtually non-toxic.  However, adverse effects which may 
be attributable to mesna include nausea and vomiting, diarrhea, abdominal pain, 
altered taste, rash, urticaria, headache, joint or limb pain, hypotension and 
fatigue. 
 
 
4.0 
Patient Eligibility 
 
4.1 
Inclusion Criteria 
4.1.1  Diagnosed with one of the following: 
a.  Acute myelogenous leukemia (AML) in induction failure, relapse, past first 
remission, or CR1 considered at risk for relapse. 


2008-0363 
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b.  Myelodysplastic syndromes with International Prognostic Scoring System 
score {IPSS score (9)} >/= 2 or myelodysplasia that has not responded to 
chemotherapy. 
c.  Biphenotypic leukemia 
d.  Acute lymphocytic leukemia with induction failure, first complete remission 
with high risk cytogenetics (e.g. Philadelphia positive chromosome, t(4:11) 
Remission requiring more than 2 cycles of chemotherapy to achieve 
remission, or any stage beyond CR1. 
e.  Chronic Myelogenous Leukemia (CML): second chronic phase, 
accelerated phase or blast crises with less than 10% blasts in the bone 
marrow, or CR1 and resistance to Gleevec or other tyrosine kinase 
inhibitors. 
f.  Non-Hodgkin's Lymphoma (NHL) with induction failures, second or third 
complete remission, or relapse (including relapse post autologous 
hematopoietic stem cell transplant). 
g.  Hodgkin's disease - induction failure, second or later complete remission, 
or relapse (including relapse post autologous hematopoietic stem cell 
transplant). 
h. Chronic Lymphocytic Leukemia (CLL) that has failed induction therapy or 
Rai Stages 2-4 
4.1.2 A related or unrelated donor which is HLA-matched or mismatched in 1 
HLA A, B, C, DR, or DQ locus is acceptable (i.e. at least a 9/10 matched 
related or unrelated donor, matched with molecular high-resolution 
technique per current standard for the BMT program). Cord blood units 
must match the patient at 4, 5, or 6/6 HLA class 1 serological and II 
molecular antigens with a minimum of 2 x 10e7 total nucleated cells/kg 
recipient weight in the pre-thawed fraction.  For patient lacking a matched 
related or unrelated volunteer donor or acceptable cord blood unit(s), a 
related haploidentical donor (</= 7/8 allele matched at the A, B, C, Dr loci) 
may be used. 
4.1.3 Age </= 60 years. 
4.1.4 Lansky performance score >/= 50% for patients </= 16 years of age, or    
         Zubrod performance status score of 0-2 for patients > 16 years of age. 
(Refer to Appendices H and I) 
4.1.5 Cardiac function - left ventricular ejection fraction >/= 40%. 
4.1.6 Pulmonary function - diffusion capacity of 50% predicted. Children unable 
to perform pulmonary function tests (e.g. less than 7 y.o.) pulse oximetry of 
>/= 92% on room air. 
4.1.7 Serum creatinine < 1.6 mg/dL or creatinine clearance >/= 50 ml/min. 
4.1.8 SGPT </= 200 IU/mL, serum bilirubin < 1.5 x normal. 
4.1.9 Written informed consent and assent as is age appropriate. 
4.1.10  No active infection. 
 
4.2 Exclusion Criteria 
4.2.1 Pregnancy in women of childbearing potential (pregnancy test performed 
within 2 weeks of study entry) 


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4.2.2 HIV positive (highly immunosuppressive treatment) 
4.2.3 Active CNS leukemia 
4.2.4 Chronic or active Hepatitis B or Hepatitis C. If questions about liver health, 
discuss with PI and strongly consider liver biopsy. 
5.0  Pretreatment evaluation 
 
The following standard evaluations will be conducted within the last 4 weeks prior 
to admission unless otherwise indicated below: 
 
5.1  
EKG and Echocardiogram (or other measure of LVEF) 
5.2  
CT of sinuses 
5.3  
Dental consult within 3 months of transplant as clinically indicated 
5.4  
Infectious disease panel 
5.5  
Serum HCG in all female patients of childbearing potential 
5.6  
CBC, platelets, differential, SGPT, Calcium, glucose, uric acid, 
magnesium, serum bilirubin, BUN, creatinine, serum protein, albumin, 
alkaline phosphatase, electrolytes, PT, PTT 
5.7  
Chest X-ray 
5.8  
Pulmonary function test with diffusional lung capacity (pulse oximetry in 
children too young to perform pulmonary function tests) 
5.9  
Urinalysis 
5.10  Patients with leukemia  bone marrow aspirate and cytogenetics (only if 
never done before) within 2 weeks of admission 
5.11  
: CT chest, abdomen, 
and pelvis; bilateral bone aspirates and biopsies or PET-CT as indicated if 
active disease at time of admission. 
 
6.0  Treatment Plan 
 
6.1  
Preparative Regimen 
Thio = Thiotepa 
Bu = Busulfan 
Clo = clofarabine 
*ATG = Rabbit ATG 
 
 
 
 
 
Treatment Plan for recipients with HLA non-identical or unrelated donors 
 
Day 
Treatment 
-9 
Hydration therapy  


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-8 
Thiotepa 5 mg/kg 
-7 
IV Bu 0.5 mg/kg test dose for patients 12 and younger  (adult test dose 32 mg/m2 for 
patients 13 and older) 
-6 
Clofarabine 40 mg/m2  
-5 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  
-4 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  +*rabbit ATG 1.25 mg/Kg 
-3 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  +*rabbit ATG 1.75 mg/Kg 
-2 
Rest 
-1 
Rest 
0 
Stem cell 
 
alt = alternatively 
*Patients with HLA nonidentical or unrelated donors will receive Thymoglobulin®. 
 
Adjusted dose: the Busulfan dose determined to achieve an average daily AUC 
-min ± 10% for the entire 3-day treatment period is administered to 
all patients. If it is not possible to perform pharmacokinetic testing, busulfan 130 
mg/m2 should be administered. 
 
Treatment Plan for haploidentical marrow recipients only 
 
Day 
Treatment  
-9 
Hydration therapy  
-8 
Thiotepa 5 mg/kg  
-7 
IV Bu 0.5 mg/kg test dose for patients 12 and younger (adult test dose 32 mg/m2 for 
patients 13 and older)  
-6 
Clofarabine 40 mg/m2  
-5 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  
-4 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  
-3 
IV Bu to AUC 5,000 mcMol-min (or 130 mg/m2 / alt 3.2 mg/kg BW) +Clofarabine 40 
mg/m2  
-2 
Rest  
-1 
Rest  
0 
Unmanipulated bone marrow infusion 
+3 
Cyclophosphamide 50 mg/kg 
+4 
Cyclophosphamide 50 mg/kg 
 
alt = alternatively 
Patients with HLA-haploidentical related donors will not receive rabbit ATG 
(Thymoglobulin®). 
 
 


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6.2.1 Thiotepa administration: Thiotepa will be dosed at 5 mg/kg for patients 
who are within 20% of their ideal body weight.  Patients greater that 20% of 
their ideal body weight will be dosed using adjusted body weight. Thiotepa 
will be administered on Day -8 by controlled-rate pump, 
 
6.2.2 Clofarabine administration: Clofarabine will be dosed per actual body 
weight/actual body surface area. No arbitrary dose adjustment(s) based on 
a perceived need for such modifications of a chemotherapeutic agent in 
high-dose chemotherapy is allowed for clofarabine, since insufficient data 
regarding the impact of such modification(s) on engraftment and 
toxicity/disease-control are available. 
 
Clofarabine is administered at a dose of 40 mg/m2 diluted in NS to produce 
a final concentration of 0.15mg/mL to 0.4mg/mL on each of four (4) 
consecutive days (Days -6 through -3). The doses of Clofarabine are to be 
given immediately preceding busulfan. Intravenous fluids should be 
administered at a rate of approximately 1.5 L/m2/days (125 cc/hr in adults) 
starting the evening before the start of this chemotherapy, after the last 
dose of Busulfan. 
 
6.2.3 Busulfan administration: Pharmacokinetic-guided (PK-guided) treatment: 
 
 
for pediatric patients 12 years of age and younger, no dose adjustment(s) 
based on a perceived need for modification is allowed for busulfan. For 
children 13 years of age and older and for 
2. This busulfan dose will be administered on Day 7, 
it will be will be given by controlled-rate infusion pump. The 
pharmacokinetic-guided daily high-dose busulfan dose(s) will be started 
immediately upon completion of the daily Clofarabine doses (on the day 
clofarabine is given). The busulfan doses will be diluted in normal saline 
and administered daily by controlled rate infusion pump. 
 
Busulfan is administered at the dose calculated to achieve a systemic 
exposure dose of 5,000 Mol-min in normal saline for three (3) consecutive 
days (Days -5 to -3), starting immediately after the completion of 
Clofarabine, see below. The Busulfan dose on Day -5 to Day -3 will be 
based on the pharmacokinetic studies to target an AUC of 5,000 
-min 
± 10% in this program. This PK-guided, adjusted dose, will be administered 
in an identical fashion to the previously used 130 mg/m2 dose. 
 
The PK adjusted dose of busulfan = Target AUC x busulfan mol. wt 
(0.2463) x busulfan gross clearance normalized to body surface area 
(L/min)+ the dose uninfused in the IV line. 
 


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If it is not feasible to perform pharmacokinetic monitoring, patients  13 will 
receive a fixed Busulfan dose of 130 mg/m2/day for 3 days. PKs are 
required for children <13 y.o. 
 
Please see special precautions for administration of IV Busulfan. IT IS 
MANDATORY, THAT ACETAMINOPHEN NOT BE USED, BETWEEN 
DAY 9 AND DAY 0, SINCE IT INTERFERES WITH THE METABOLISM 
OF BUSULFAN AND MAY CONTRIBUTE TO SERIOUS LIVER 
DAMAGE. 
 
Other drugs known to interfere with the metabolism of clofarabine and/or 
busulfan should not to be concomitantly used during the chemotherapy 
administration up to and including the day of transplantation. In particular, 
drugs that are known to affect the hepatic cytochrome P450-systems (such 
as the azoles) and tyrosine kinase inhibitors should be omitted for at least 
5 days prior to the busulfan test dose. It is also recommended that  
t
least three weeks prior to admission, since these agents have either a well 
described interference, or a high propensity for an adverse interaction with 
busulfan disposition in the human body. As needed these agents can be 
resumed starting one day following the stem cell transplant SCT day +1. 
 
6.2.4 Anti-thymocyte globulin: Patients with HLA-haploidentical related donors 
will not receive Thymoglobulin.  Patients receiving a graft from a matched 
unrelated donor or 1-antigen mismatched donor will receive Thymoglobulin; 
1.25 mg/kg on Day 4 and 1.75 mg/kg on Day 3. Thymoglobulin will be 
administered as per regular departmental routines, and will be infused in 
the afternoon of respective days so not to interfere with the chemotherapy 
administration. 
 
6.3 PBSC/Marrow Processing and Infusion 
NOTE: Section 6.4.1 represents recommended guidelines regarding stem cell 
products, bone marrow, peripheral blood progenitor cell, or cord blood 
processing and infusion procedures. The Investigator may follow procedures 
described in current departmental protocols and guidelines see standard 
operating procedures for department of Blood and Marrow Transplantation. 
 
Patients may receive bone marrow, peripheral blood progenitor, or CB cells 
as sources of stem cells for allogeneic transplantation. The products are not 
T-cell depleted, but may be manipulated as per standard procedures for ABO 
incompatibility. The cells may be infused fresh or after cryopreservation. 
 
 
ALLOGENEIC MARROW OR HLA-MATCHED RELATED DONOR STEM 
CELL TRANSPLANTATION: PBPC or marrow cells may be collected and 
infused on the day of the transplant or infused after cryopreservation. The 


2008-0363 
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goal is to infuse >3.0 X 108 marrow mononuclear cells/kg, 5 X 106 CD34+ 
cells/kg from peripheral blood progenitor cells (PBPC), or a CB with a 
minimum of 2 x 107 total nucleated cells/kg. 
 
For infusion of fresh or cryopreserved hematopoietic stem cells, the patient 
should be premedicated with IV steroid(s) and IV diphenhydramine per 
departmental guidelines. A normal saline intravenous drip will be established. 
 
6.4 Supportive Care 
NOTE: This section indicates recommended guidelines regarding supportive 
care. The Investigator may elect to follow other procedures as per 
departmental routines and guidelines. All concomitant medications (i.e. 
supportive care) administered to the patient during the study will be 
documented in the 
 
 
6.4.1 Antiemetics should be administered per institutional guidelines prior to the 
first dose of Bu and continued on a fixed schedule through 12-24 hours 
after the last dose of Bu. 
 
6.4.2 Antiseizure prophylaxis is to be given to all patients according to 
department guidelines.  
 
6.4.3 All patients should receive supportive care (allopurinol, menstrual 
suppression, prophylactic antibiotics, empiric antibiotics, IV Ig, transfusions 
of blood products, hyperalimentation, etc.) as clinically indicated, according 
to departmental guidelines. 
 
6.4.4 Patients may receive G-
size) s.c. starting on Day +1 CB recipients and Day +7 for bone marrow 
and peripheral blood recipients until ANC exceeds 0.5 per microliter for 3 
days. 
 
6.4.5 GVHD prophylaxis for peripheral blood and bone marrow recipients will be 
tacrolimus and methotrexate. Tacrolimus administered at starting dose of 
0.015 mg/kg (ideal body weight) as a 24 hour continuous infusion daily, to 
be changed to oral dosing when tolerated. Tacrolimus is to be tapered as 
indicated after transplant day 90, if no GVHD is present. Tacrolimus is 
adjusted trough level of 5-15 ng/mL. Methotrexate 5 mg/m2 will be 
administered intravenously on days 1, 3 and 6 and Day +11 post transplant. 
The Day 11 methotrexate dose may be held as indicated if mucositis is 
present. 
 
CB recipients will receive tacrolimus as outlined above. Instead of 
methotrexate, patients with CB receive MMF from Days -3 to +30 (stop at 
day +30 if GVHD is not present). If the patient has acute GVHD requiring 
systemic therapy, MMF therapy may be prolonged. MMF is dosed 15 mg/kg 


2008-0363 
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orally twice daily, with a maximum dose of 1 gram twice daily. IV route can 
be used if PO is not tolerated (same dosing).  Patients receiving 
haploidentical stem cell products will receive tacrolimus at doses described 
above and MMF will be dosed TID.  These agents will start on day +5. 
 
 
6.4.6   Post transplant cyclophosphamide administration with Mesna:  
Premedication:  Patients will receive a dose of Mesna 10 mg/kg IVPB just 
prior to the first dose of cyclophosphamide (Cy), that will be repeated 
every 4 hours for a total of ten (10) doses.  Patients will also receive 
ondansetron (or a comparable anti-emetic) and dexamethasone prior to 
each dose of Cy.  
 
Patients will receive Cy on days + 3 and + 4 at a dose of 50 mg/kg per 
dose. Patients weighing within 20% above their ideal body weight will be 
dosed according to actual body weight. Patients weighing more than 20% 
above their ideal body weight will be dosed according to the adjusted body 
weight. Formula to calculate adjusted body weight: Adjusted BW (Kg) = 
IBW + 0.5 (Actual body weight-IBW). The first dose of cyclophosphamide 
must be administered 60 to 72 hours following the start of marrow 
infusion.  
 
Cy will be mixed in D5W to a maximum concentration of 20mg/ml and 
given by controlled-rate infusion pump.  Patients should be well hydrated.  
It is recommended to receive IV Fluids at a rate of 150 ml/hour starting the 
evening (Day +2) before the first dose of Cy (minimum of 8 hours before 
first dose) and continued for a minimum of 24 hours after the last dose. 
For pediatric patients, it is recommended to receive IV Fluids at a rate of 
125 ml/m2/hr starting the evening (Day +2) before the first dose of Cy 
(minimum of 8 hours before first dose) and continued for a minimum of 24 
hours after the last dose.   
 
7.0  Evaluation During Study 
7.1 STUDY PERIOD: EVALUATION DURING THE INITIAL HOSPITALIZATION 
(BMT Day -9 THROUGH DISCHARGE) 
a) Daily physical examinations. 
b) Toxicity grading and evaluation for adverse experiences. 
c) Vital signs (VS), intake/output (I/O) per daily routine. 
d) Bone marrow biopsy and aspirate (with cytogenetics and/or chimeric 
studies) at approximately (1) one month (Day 28) (+/-3 days), or as 
clinically indicated. 
e) CBC and platelet counts daily and as clinically indicated. 
f)  Chemistry profile twice per week 


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g) Peripheral blood T-cell and myeloid cell chimerism at approximately Day 
28 (+/-3 days) 
 
7.2 POST-STUDY SURVEILLANCE: EVALUATION FROM BMT DISCHARGE 
THROUGH BMT DAY +100. 
Note: For this study, post-study surveillance from initial hospital discharge to 
BMT Day +100 will include data collection of serious adverse experiences 
and survival. The data as listed below will continue to be collected per 
institutional transplant guidelines. The following will be performed at least 
twice monthly: 
a) Physical examination. 
b) Toxicity grading. 
c) Vital signs (VS), and weights 
d) CBC and platelet count. 
e) Chemistry profile. 
Bone marrow aspirate with cytogenetics if indicated and Peripheral blood T-
cell and myeloid cell chimerism will be performed between 2 and 3 months 
post transplant. 
 
7.3 POST-STUDY SURVEILLANCE: EVALUATION AFTER BMT DAY +100 
POSTTRANSPLANT 
NOTE: For this study, post-study surveillance after BMT Day +100 will 
include quarterly data collection of patient status and survival. The data as 
listed below will continue to be collected per departmental transplant 
guidelines. 
 
a) Physical Examination, screening labs and bone marrow aspirate with 
cytogenetics and chimerism studies at approximately three (3) months, six 
(6) months, and twelve (12) months for all patients, or at other time points 
if clinically indicated. 
 
7.4 Busulfan Pharmacokinetic Studies 
ulfan, at 0.5 mg/kg administered IV on 
Day 7 for measurement of pharmacokinetic parameters to determine the 
dose that will give a 
-min (± 
10%) on Days 5 till 3. Blood samples (5ml each) will be drawn on Day 7 
and Day -5 at time points per SCTCT Department standards as determined 
by the Department of Laboratory Medicine.  For the full therapeutic (3 hr) 
busulfan infusion the 15 minute time point will be replaced with a 90 minute 
time point. 
 
Pharmacokinetic analysis and individualized IV busulfan dose will be 
calculated and ordered on Day 7. This complete sampling schedule will later 
be replaced with a limited sampling schedule when a validated limited 
sampling assay becomes available. All PK samples will be drawn from a 
peripheral line to minimize the number of venipunctures for each patient, 


2008-0363 
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since 
to yield a high incidence of erratically high busulfan concentrations, likely due 
to local turbulence around the tip of the CVC catheter. Plasma concentrations 
of busulfan will be determined in duplicate for each time point by a sensitive 
and specific HPLC assay following derivatization, or alternatively by GC-MS 
when a high-through-put validated busulfan assay becomes available. 
 
8.0  Criteria for Study Evaluation 
 
8.1 Engraftment 
Will be recorded as the first day of 3 consecutive days that the ANC exceeds 
0.5 X 109/L and will be displayed for the group in a life-table format in the 
manner of Kaplan-Meier and compared with historical controls. treated with 
our standard conditioning regimen of IV Busulfan-Fludarabine (29). 
 
8.2 Graft Failure 
Is defined for the purpose of this trial as the failure to reach an ANC >0.5 X 
109/L within 30 days after transplantation. Patients who engraft within the first 
100 days after transplantation but who develop a sustained ANC <0.5 x 109/L 
(three consecutive days) will be classified as secondary graft failure, unless 
this is correlated with progression / recurrence of the underlying malignancy. 
 
8.3 Relapse 
Will be recorded by the day of detection of histologic diagnosis of recurrent 
disease. Per standard transplant practices, relapsed patients eligible for and 
electing to participate in alternative treatment protocols will be withdrawn from 
participation in this protocol and data beyond that of survival will not be 
collected. 
 
8.4 Survival 
Will be recorded by the day of death and the cause of death will be assessed. 
 
8.5 Response: 
8.5.1 Leukemias - 
Complete Response will be defined as bone marrow with <5% blasts 
 
 
 
 
8.5.2 Lymphomas - 
Complete Response will be defined as disappearance of all evidence of 
active tumor for a minimum of 8 wks, without symptoms 
 


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Partial Response: 50% or greater decrease in the sum of the products of 
measured lesions persisting for 8 wks or more. No new lesions. 
 
No change: results inferior "partial response," and/or no progression for a 
minimum of 8 weeks. 
 
Progressive disease: appearance of new lesions or increase in the size of 
measurable disease. 
 
9.0  Statistical Consideration 
 
Statistical Considerations 
We will monitor the data for safety/toxicity following the methods of Thall and 
Simon (10). The primary outcome of this study will be the survival rate at 100 
days post-transplant. We will enroll at most 60 patients. 
 
The toxicities will be monitored and scored on a daily basis. All regimen related 
toxicities for unexpected non-hematological toxicities will be reviewed with the 
Chair of the Clinical Research Committee (CRC) after the first three patients and 
after six patients. If two or more patients out of the first three patients experience 
a grade IV regimen related toxicity, accrual will be halted for review. 
 
A Bayesian stopping rule will be used to stop the trial if there is a 90% chance 
that the true toxicity rate exceeds the target toxicity rate of 0.25. We will employ 
the following monitoring rule for grade 3 and 4 severe adverse events.  (See 
section 10.2.1). 
 
We will stop the trial if P(toxicity > 25% | data) > 0.90. That is, given the 
outcomes from the patients who have already been evaluated, if we determine 
that there is more than a 90% chance that the toxicity rate is more than 25% we 
will stop the trial. This decision rule gives the following stopping rule. We assume 
a beta (0.5, 1.5) prior distribution for the toxicity rate. This prior distribution has a 
mean of 0.25 and a standard deviation of 0.25. Stop the trial if 
 
[ # of pts with toxicity / # of pts evaluated ] 
 
>/= 5/10, 6/12, 7/15, 8/18, 9/21, 10/24, 11/28, 12/31, 13/34, 14/38, 15/41, 16/44, 
17/48, 18/51, 19/55, 20/58. 
 
The operating characteristics of this study design are shown in Table 1. 
 
 
 
Table 1.  Operating Characteristics of Safety Monitoring Rule 


2008-0363 
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Rate of  
Toxicity 
 
Probability of
Stopping 
Sample Size 
 
P25 
 
P50 
 
P75 
0.15 
0.024 
40 
40 
40 
0.20 
0.102 
40 
40 
40 
0.25 
0.285 
39 
40 
40 
0.30 
0.553 
14 
40 
40 
0.35 
0.806 
11 
20 
40 
0.40 
0.938 
10 
13 
26 
 
 
 
Formal continuous interim monitoring for safety will be conducted using the 
above stopping rule.  
 
Once we have completed the study we will estimate the toxicity rate with a 90% 
credible interval. For example, if we complete the study with 10 of 60 patients 
with toxicity, then the 90% credible interval for the toxicity rate will be 0.09 to 
0.25. We will also report the posterior probability that the toxicity rate is 
greater than 25%. We will use the Kaplan-Meier (11) product limit method to 
estimate overall survival and relapse-free survival rates with 95% confidence 
intervals at the conclusion of the study. 
 
10.0  Adverse Events 
 
10.1 Definitions 
An Adverse Event (AE) is defined as any untoward medical event, including 
worsening of increased frequency of an event present at baseline, in a subject 
registered in this study and receiving either of the preparative regimens in 
combination with stem cell transplantation. 
 
Transplant related adverse events:  
For the purpose of this study, common transplant related AE are those known to 
be related to the preparative regimen and stem cell infusion occurring up to 30 
days post transplant. The most common are listed below. 
 
Neutropenic Fever without infection, Non-Neutropenic Fever, Infections 
associated with grade 3 or 4 neutropenia, Nausea and vomiting, readmission 
during the active treatment period, transfusions of platelets and RBCs, Low blood 
pressure due to dehydration requiring fluid replacement, Mucositis, cytokine 
storm. These events will be monitored and captured in the database during the 
first 30 days post transplant. 
 
The following common transplant related events will be captured in the database 
any time when observed: cytopenias post-transplant, including secondary graft 


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failure whether or not leading to death, hemorrhagic cystitis, liver function test 
abnormalities associated with VOD, TTP, significant infections and graft vs. host 
disease. 
 
Serious Adverse Event: any adverse event occurring that results in any of the 
following outcomes: 
· Death 
· Life-threatening 
· Persistent or significant disability/incapacity 
· In patient hospitalization or prolongation of existing hospitalization 
· Congenital anomaly/birth defect 
health and may require medical or surgical intervention to prevent one of 
the other outcomes listed in this definition. 
 
Attribution 
The Investigator will determine if an adverse event is in some way related to the 
use of the study drugs or procedures and/or participation in this study. This 
relationship will be described as follows: 
Definite: The event is clearly related. 
Probable: The event is likely related. 
Possible: The event may be related. 
Unlikely: The event is doubtfully related. 
Unrelated: The event is clearly NOT related. 
 
10.2 Assessment of Adverse Event 
Ad
Terminology Criteria for Adverse Events (CTCAE) v3.0. 
 
10.2.1 Adverse Events Not Considered Serious (regardless of the grade, these 
events are expected to be reversible): 
1. Related to myelosuppression: thrombocytopenia, bleeding, platelets 
and RBCs transfusions. 
2. Fever: Non Neutropenic or Neutropenic without infection 
3. Infections in the presence or absence of neutropenia 
4. Readmissions (lasting <10 days) 
5. Cytopenias post transplant including secondary graft failure 
6. Low blood pressure due to dehydration requiring fluid replacement 
7. Fluid overload leading to cardiac dysfunction 
8. Mucositis 
9. GI related: nausea, vomiting, diarrhea 
10. Organ dysfunction: cardiac, pulmonary, hepatic, CNS and/ or renal. 
11. Fatigue 
12. Neurologic: seizures, neuropathies 


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13. Stem Cell Transplant Syndromes: Cytokine Storm, VOD, TTP, 
hemorrhagic cystitis, interstitial pneumonitis (including pulmonary 
hemorrhage), GVHD (acute and chronic). 
 
10.2.2 Adverse Events Considered Serious: 
1. Prolonged hospitalization due to infections and/or organ failure requiring 
extensive supportive care (i.e. dialysis, mechanical ventilation). 
2. Readmissions from any cause resulting in a prolonged hospitalization 
(>10 days). 
3. Graft Failure/ rejection. 
4. Any expected or unexpected event resulting in an irreversible condition 
and/or leading to death. 
 
10.2.3 Abnormal Lab Findings Due to Underlying Disease 
In this study, patients are expected to experience changes in laboratory 
parameters such as electrolyte imbalances, uric acid changes, liver 
function abnormalities, including elevations of GPT, GOT, LDH and 
alkaline phosphatase. These changes are due to the underlying disease 
and the nature of the treatment including transplantation and 
chemotherapy. These expected changes will not be considered Adverse 
Events and will not be recorded in the eCRF unless in the view of the 
investigator they are judged clinically significant 
 
10.2.4 Study specific AE relationship: Based on the objectives of this study 
incidence of GVHD and graft failure will be considered as adverse events 
definitive related to the study. 
 
10.3 AE Recording 
The onset date, resolution date, and maximum grade of adverse events will 
be collected. Intermittent events should be labeled as such and followed 
until resolution. If a subject is taken off study while an event is unresolved, 
this will be followed until resolution unless another therapy is initiated. 
Pre-existing medical conditions will be recorded only if the condition 
worsens during active treatment. 
 
The Investigator or Designee will complete and maintain adequate source 
documentation which may include progress notes, laboratory reports, 
discharge summaries, and other original records. The information will be 
stored in a secured location. 
 
10.4 AE Reporting 
Upon the Investigator's awareness of adverse events occurring during 
subject participation, these events will be reported to the Institutional 
Review Board (IRB) according to institutional guidelines and the BMT AE 
Reporting Policy (refer to Appendix E). 
 


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This study will be conducted as described in this protocol, except for an 
emergency situation in which the protection, safety, and well-being of the 
patient requires immediate intervention, based on the judgment of the 
Investigator or designee. 
11.0  Criteria for Removal from the Study 
 
Subjects may be withdrawn from the study for the following reasons: 
· Parent, guardian, or patient withdraws consent 
· Subject's noncompliance 
· Disease progression 
· Death 
· Discretion of the Principal Investigator 
· Termination of study. 
12.0  References 
 
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with less T cell mixed chimerism but increased risk of relapsed compared to 
busulfan in patients with haematological malignancies after allogeneic stem 
cell transplantation. Bone Marrow Transpl. 32:477-83, 2003. 
 
2. Worth LL, Tran H, Petropoulos D, Culbert SC, Mullen CA, Roberts WM, 
Przepiorka D, Chan KW. Hematopoietic stem cell transplantation for 
childhood myeloid malignancies after high-dose thiotepa, busulfan and 
cyclophosphamide. Bone Marrow Transplant. 24:9:947-52, 1999. 
 
3. Worth LL, Koontz SE, Petropoulos D, Tran HT, Choroszy MS, Chan K. High-
dose thiotepa busulfan, and cyclophosphamide for allogeneic stem cell 
transplantation in risk pediatric patients with high-risk leukemias. 
IBMTR/ASBMT Tandem Meeting, Abst. #150063, 2007. 
 
4. Santos GW. The development of busulfan/cyclosphamide preparative 
regimens. Semin Oncol. 20:4:12-16, 1993. 
 
5. Heideman RL, Cole DE, Balis F, et al. Phase I and pharmacokinetic evaluation 
of thiotepa in the cerebrospinal fluid and plasma of pediatric patients: 
evidence for dose-dependent plasma clearance of thiotepa. Cancer Res. 
49:736-741, 1989. 
 
6. Emanuel NM, Konovalove NP, Djachkovskaya RF. Toxicity, antitumor activity 
and pharmacokinetics of spin-labelled thioTEPA analogs. Cancer Treat Rep. 
60:1605-1609, 1976. 
 


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7. Jeha S, Gandhi V, Chan K, et al: Clofarabine, a novel nucleoside analog, is 
active in pediatric patients with advanced leukemia. Blood 103:784-789, 2004. 
 
8. Jeha S, Gaynon PS, Razzouk BI, Franklin J, Kadota R, Shen V, Luchtman-
Jones L, Rytting M, Borngaars LR, Rheingold S, Richtey K, Alabno E, Arceci 
RJ, Goldman S, Griffin T, Altman A, Gordon B, Steinherz L, Weitman S, 
Steinherz P. Phase II Study of Clofarabine in Pediatric Patients with Refractory 
or Relapsed Acute Lymphoblastic Leukemia. Journal of Clin. Oncol. 24:12, 
2006. 
 
9. Greenberg P, Cox C, LeBeau MM, et al. International Scoring System for 
evaluating prognosis in myelodysplastic syndromes. Blood 89:2079-2088, 
1997. 
 
10. Thall PF, Simon R. Practical Bayesian Guideline for Phase IIB Clinical Trials. 
Biometrics 50:2 337-49, 1994. 
 
11. Kaplan EL, Meier P. Non-parametric estimation from incomplete 
observations. Journal of the Amer. Statist. Assoc. 53:457-481, 1958. 
 
12. Worth LL, Andersson BS., Kazerooni R, Petropoulos D, Kelly SS, Lee DA, Du 
M, Madden TL, deLima MJ, Champlin RE., Cooper LJN.  Thiotepa (TT), 
Busulfan (Bu), And Clofarabine (Clo) as a conditioning therapy for allogeneic 
Hematopoietic stem cell transplant for patients with high risk malignancies: 
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16: page S292, 2010.