Conditions: Multiple Myeloma and Plasma Cell Neoplasm
Keywords: stage I multiple myeloma stage II multiple myeloma stage III multiple myeloma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 77
Healthy volunteers: no

Brief summary:
RATIONALE: Drugs used in chemotherapy work in different ways to stop cancer cells from dividing so they stop growing or die. Peripheral stem cell transplantation may allow doctors to give higher doses of chemotherapy drugs and kill more cancer cells. Biological therapies, such as interferon alfa, use different ways to stimulate the immune system and stop cancer cells from growing. Thalidomide may stop the growth of cancer cells by stopping blood flow to the tumor. Pamidronate may help to reduce the side effects of treatment for multiple myeloma.

PURPOSE: This phase II trial is studying combination chemotherapy, peripheral stem cell transplantation, biological therapy, pamidronate, and thalidomide to see how well they work in treating patients with stage I, stage II, or stage III multiple myeloma.

Detailed description:
OBJECTIVES:

* Determine the feasibility and toxic effects of high-dose melphalan, busulfan, and cyclophosphamide followed by autologous peripheral blood stem cell rescue, interferon alfa, and pamidronate in patients with responsive or stable, low-bulk multiple myeloma.
* Determine the response rate and progression-free and overall survival of patients treated with this regimen.
* Determine the feasibility of adding thalidomide to interferon alfa and pamidronate in patients who are not in complete remission (CR) 6 months after the second course of high-dose chemotherapy.
* Determine whether administration of thalidomide can increase the CR rate in patients who are not in CR 6 months after the second course of high-dose chemotherapy and determine its effect on progression-free and overall survival of these patients.
* Determine the pharmacokinetics of busulfan and cyclophosphamide and correlate the pharmacokinetics with the toxic effects of these drugs and outcome in these patients.
* Determine the effect of thalidomide on microvascular density of bone marrow and correlate these possible effects with outcome in these patients.
* Determine the cytogenetics, gene rearrangement, and fluorescence in situ hybridization in baseline and post treatment bone marrow and blood specimens and correlate the presence/persistence of these features with treatment outcome in these patients.

OUTLINE: Patients receive cyclophosphamide IV over 2 hours on day 1 and filgrastim (G-CSF) subcutaneously (SC) or IV twice a day beginning on day 2 and continuing until peripheral blood stem cells (PBSCs) are collected. PBSCs are collected beginning on day 10.

Patients receive high-dose melphalan IV on day -1. PBSCs are reinfused on day 0. G-CSF is administered IV or SC daily beginning on day 1 and continuing until blood counts recover. Between 8 and 14 weeks later, patients receive high-dose busulfan IV every 6 hours on days -7 to -4 and cyclophosphamide IV over 2 hours on days -3 and -2. PBSCs are reinfused on day 0 and G-CSF is administered IV or SC daily until blood counts recover.

Patients with responding or stable disease after chemotherapy receive maintenance therapy with interferon alfa beginning 14-20 weeks after day 0 of the second course of chemotherapy. Interferon alfa is administered SC 3 times a week for 3 years. Patients also receive pamidronate IV every 4 weeks until disease progression. Patients who are not in complete remission (CR) 6 months after completing the second course of chemotherapy receive oral thalidomide daily for a maximum of 1 year or for 3 months after achieving CR.

Patients are followed monthly for 1 year, every 3 months for 1 year, and then periodically thereafter.

PROJECTED ACCRUAL: A total of 70 patients will be accrued for this study within approximately 2.5 years.

Arms:
arm 1: Patients receive high-dose (HD) melphalan intra-venously (IV) on day -1. Peripheral blood progenitor cells (PBPCs) are reinfused on day 0. Filgrastim (G-CSF) is administered IV or SC daily beginning on day 1 and continuing until blood counts recover. Between 8 and 14 weeks later, patients receive IV high-dose busulfan every 6 hours on days -7 to -4 and cyclophosphamide IV over 2 hours on days -3 and -2. PBPCs are reinfused on day 0 and G-CSF is administered IV or subcutaneously (SC) daily until blood counts recover.

Interventions: intervention 1: filgrastim intervention 2: recombinant interferon alfa intervention 3: busulfan intervention 4: cyclophosphamide intervention 5: melphalan intervention 6: pamidronate disodium intervention 7: thalidomide intervention 8: peripheral blood stem cell transplantation
Intervention descriptions: intervention 1: None intervention 2: None intervention 3: None intervention 4: None intervention 5: None intervention 6: None intervention 7: None intervention 8: None

Protocol document:
Prot_SAP_000.pdf: 
 
IRB #99021 
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CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
DEPARTMENT OF MEDICAL ONCOLOGY AND THERAPEUTICS RESEARCH 
TITLE:  
Sequential High-Dose Melphalan and Busulfan/Cyclophosphamide Followed by 
Peripheral Blood Progenitor Cell Rescue, Interferon, Pamidronate, With or Without 
Thalidomide, for Patients With Multiple Myeloma 
CITY OF HOPE PROTOCOL NUMBER/VERSION: 
IRB #  99021 
VERSION: 09  
DATE(S)/ OF AMENDMENT(S)/REVISION(S): 
 
Version: 
 
C.O.H. Amendment #1 
06/14/99 
01 
 
C.O.H. Amendment #2 
08/12/99 
02 
 
C.O.H. Amendment #3 
09/27/99 
03 
 
C.O.H. Amendment #4 
01/07/00 
04 
 
C.O.H. Amendment #5 
03/08/00 
05 
 
C.O.H. Amendment (consent only) 
11/17/00 
00 
 
C.O.H. Amendment #6 
02/22/01 
06 
 
C.O.H. Amendment #7 
03/13/02 
         07 
       C.O.H. Amendment #8 
10/09/02 
         08 
       C.O.H. Amendment #9 
02/03/04 
09 
SITE: 
Bone Marrow 
HISTOLOGY: 
Myeloma 
STAGE (If applicable): 
I-III 
MODALITY: 
High-Dose Chemotherapy and Stem Cell Support / 
Immunotherapy 
TYPE: 
Phase II 
PRINCIPAL INVESTIGATOR: 
George Somlo, M.D. 
COLLABORATING INVESTIGATOR(S): Stephen Forman, M.D., Joseph Alvarnas, M.D., Daniel 
Arber, M.D., Firoozeh Sahebi, M.D. 
 
Biostatistician:  Joyce Niland, Ph.D. 
PARTICIPATING CLINICIANS: 
Medical Oncology:  Kim Margolin, M.D., Warren Chow, 
M.D., Timothy Synold, Pharm.D., Yun Yen, M.D. 
 
Hematology: Jeffrey Schriber, M.D., Karen Chang, M.D., 
Peter Falk, M.D., Henry Fung, M.D., Neil Kogut, M.D., 
Amrita Krishnan, M.D., Arturo Molina, M.D., Auayaporn 
Nademanee, M.D., Margaret O’Donnel, M.D., Pablo 
Parker, M.D., Roberto Rodriguez, M.D., Irena Sniecinski, 
M.D., David Snyder, M.D., Ricardo Spielberger, M.D., 
Anthony Stein, M.D., Sandra Cohen, M.D., Leslie 
Popplewell, M.D., Zaid Al-Kadhimi, M.D. 


 
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Cytogenetics:  Marilyn Slovak, Ph.D. 
PARTICIPATING INSTITUTIONS: 
City of Hope National Medical Center 
 
City of Hope Samaritan, Phoenix, AZ 


 
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TABLE OF CONTENTS 
 
 
SCHEMA 
 
1.0  
OBJECTIVES 
 
2.0  
BACKGROUND AND RATIONALE 
 
3.0  
THERAPEUTIC AGENTS 
 
4.0 
STAGING CRITERIA  
 
5.0 
PATIENT ELIGIBILITY 
 
6.0 
TREATMENT PLAN 
 
7.0 
EVALUATION AND TOXICITIES 
 
8.0 
STUDY PARAMETERS 
 
9.0 
EVALUATION AND RESPONSE 
 
10.0 
REPORTING DATA 
 
11.0 
STATISTICAL CONSIDERATIONS 
 
12.0 
MINORITIES AND WOMEN STATEMENT 
 
13.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
14.0 
BIBLIOGRAPHY 
 
APPENDICES 
 
A  
KPS SCALE 
B 
INFORMED CONSENT FORM 
C  
IDEAL BODY WEIGHT CHART 
D  
NCI MODIFIED AUTOLOGOUS TRANSPLANT TOXICITY SCALE 
E  
SPECIAL INSTRUCTIONS FOR SPECIMEN COLLECTION 
 


 
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01/07/00 
SCHEMA 
 
 
PRIMING   
 
CYCLOPHOSPHAMIDE 1.5 GM/M2 and FILGRASTIM 10 μg/kg/Day 
and APHERESIS 
 
 
 
CYCLE 1                                       
 
DAY -1              MELPHALAN 150 MG/M2 IV 
 
DAY  0              REINFUSION OF COLLECTED STEM CELLS 
    
DAY  1              START FILGRASTIM 5 MICROGRAMS/KG, DAILY, IV 
 
 
 
CYCLE 2 
TO START AT LEAST 12 WEEKS FROM DAY 1 and 
NOT BEYOND 18 WEEKS           
 
DAY -8             START DILANTIN 
DAY -7             BUSULFAN 0.8 MG/KG EVERY 6 HR x 4  IV 
          -6             BUSULFAN 0.8 MG/KG EVERY 6 HR x 4  IV 
          -5             BUSULFAN 0.8 MG/KG EVERY 6 HR x 4  IV 
          -4             BUSULFAN 0.8 MG/KG EVERY 6 HR x 4 IV 
 
DAY -3              CYCLOPHOSPHAMIDE 60 MG/KG; START MESNA IV 
          -2             CYCLOPHOSPHAMIDE 60 MG/KG; CONTINUE WITH MESNA IV 
 
03/08/00 DAY  0 
REINFUSION OF COLLECTED STEM CELLS  (PBPC) - START 
FILGRASTIM 5 MICROGRAM/KG, DAILY 
 
STARTING WITHIN 12-18 WEEKS OF DAY ZERO OF CYCLE 2,  ALPHA INTERFERON 
3 x 106 UNIT/M2 TIW FOR 3 YEARS AND AREDIA 90 MG IV. Q 4 WEEKS 
 
AT 6 MONTHS FOLLOWING DAY ZERO  OF CYCLE 2, THALIDOMIDE 400 MG/M2 
WILL BE ADMINISTERED ORALLY TO PATIENTS WHO WILL NOT HAVE ACHIEVED 
COMPLETE REMISSION BY THAT TIME 
10/10/02 


 
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1.0 
OBJECTIVES 
 
01/07/00  
1.1 
PRIMARY OBJECTIVES 
 
1.1.1  To assess the feasibility and toxicities of tandem cycle high-dose melphalan and 
busulfan/cyclophosphamide followed by autologous peripheral blood progenitor cell rescue 
(PBPC), alpha-interferon and pamidronate in patients with responsive, or stable “low bulk” 
multiple myeloma. 
 
1.1.2  To assess response rate, progression-free and overall survival following treatment with 
tandem cycle, high-dose melphalan,  busulfan/cyclophos-phamide, PBPC and maintenance 
therapy with alpha-interferon and pamidronate in patients  with responsive, or stable “low bulk” 
multiple myeloma. 
 
1.1.3  To assess the feasibility of adding thalidomide to alpha-interferon and pamidronate in 
patients not in complete remission by 6 months following the second cycle of  high-dose therapy. 
 
1.1.4 To assess whether administration of thalidomide can increase the complete remission rate 
(CR) in patients not in CR at 6 months after the second cycle of high-dose therapy and evaluate 
its effect on progression-free and overall survival in this subset of patients. 
 
1.2 
SECONDARY OBJECTIVES 
 
1.2.1 To perform cytogenetic, gene rearrangement and fluorescence in situ hybridization 
(FISH) studies on baseline and post-treatment bone marrow and blood specimens and correlate 
the presence/persistence of these features with treatment outcome. 
 
02/22/01   
 
1.2.2 To monitor the pharmacokinetics of busulfan and assess any 
correlation with toxicities and outcome in the subject population. 
 
1.2.3 To assess the effect of thalidomide on microvascular density of bone marrow and 
correlation of such possible effect on outcome. 
 
01/07/00 2.0 
BACKGROUND AND RATIONALE 
 
2.1 
The incidence of multiple myeloma (MM) has been on the rise accounting for 
approximately 10% of all hematological malignancies.  Five in 100,000 Americans suffer from 
MM; the entire spectrum of plasma cell dyscrasias affects an even greater percentage of the 
population.  These diseases include benign gammopathy, macroglobulinemia, solitary 
plasmacytoma and, within the category of MM,  smoldering and indolent forms as well as 
immunoblastic lymphoma and plasma cell leukemia1.  Adverse prognostic factors such as high 
plasma cell labeling index, elevated beta-2 microglobulin and C-reactive protein, the presence of 
specific chromosomal abnormalities, plasmablastic morphology and abnormal renal function, 
poor performance status at diagnosis and elevated serum levels of interleukin-6 are of grave 
clinical significance.2-4 Chemotherapy with melphalan and prednisone, a combination of 
alkylating agents, or vincristine, doxorubicin is effective in 50-70% of patients with newly 
diagnosed MM; however, less than 10% of patients will achieve complete remission5,6.  


 
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Unfortunately, the effects of chemotherapy are usually short-lasting. The median survival of 
patients with MM is 30-36 months.  The lack of long-term effectiveness is due to either primary, 
or acquired resistance.  Attempts to improve overall response and response duration have been 
focusing on overcoming drug resistance due to overexpression of the MDR-1 gene product7, or 
utilizing myeloablative therapy followed by allogeneic, or autologous bone marrow, or 
peripheral blood progenitor cell rescue (PBPC).8 
 
2.2 
High-dose chemo-/radiotherapy in the treatment of MM. 
 
Single agent high-dose melphalan therapy results in  response rates of > 80% with complete 
response rates of > 30% as described in earlier studies without the use of stem cell support. In a 
recent update, 1/3 of the patients from the original cohort treated with high-dose melphalan were 
reported to be alive at 9 years9,10. Thousands of patients with multiple myeloma have received 
dose-intense bone marrow ablative therapy followed by autologous bone marrow, or peripheral 
stem cell rescue, worldwide.  Complete remission rates of up to 50% have been reported in 
selected cohorts of patients with good performance status and limited tumor burden resulting 
from a response to conventional doses of chemotherapy.8  Induction regimens consisting of total 
body radiation with cyclophosphamide or melphalan, or combination chemotherapy with and 
cyclophosphamide have resulted in similar outcome in a variety of phase II trials.11-16 A 
prospective randomized study comparing high-dose consolidation therapy and stem cell rescue 
following induction therapy vs. conventional chemotherapy alone, revealed complete response 
rates (22% versus 5%) and improved favorable progression-free and overall survivals following 
high-dose therapy; projected 5 year event-free and overall survivals were 28% and 52% versus 
10% and 12%.17 Comparison of early vs. late (at the time of progression) autologous transplants 
favor early high-dose therapy resulting in prolonged progression-free survival and quality of life 
while in response.18 Tandem cycle high-dose chemo/radiotherapy in the setting of “total therapy” 
in the largest series by a single institution suggested additional benefit associated with the second 
transplant in a series of 231 patients, independent of the presence of unfavorable cytogenetics 
and elevated beta 2 microglobulin; with a median follow-up of 4.2 years among surviving 
patients actuarial 5-year event-free and overall survivals were 58% and 42%, respectively.19  The 
benefits of double dose intense therapy need further confirmation in ongoing randomized 
prospective trials.  Preliminary data from one such French study suggests a possible benefit 
favoring double transplant; similarly, EBMT data and preliminary analysis of an Italian 
randomized study comparing single versus tandem autologous transplant favors tandem 
therapy.20-22  
 


 
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Allogeneic bone marrow transplantation has been associated with a disappointing median overall 
survival of 13 months in a registry review by the European Group for Blood and Bone Marrow 
Transplantation, with  approximately 40% early, treatment-related mortality caused by regimen-
related toxicities, infections, and acute or chronic graft versus host disease.16  More recent data 
suggest diminished early mortality rates possible due to incorpotation of PBPC reinfusions in 
addition to ongoing assessment of the role of the so called mini transplants.23,24, 25,  
 
Early utilization of myeloablative therapy is recommended both with autologous and allogeneic 
bone marrow transplantation in order to consolidate complete or partial response to conventional 
treatment.  In addition, even patients with previously untreated or refractory disease may respond 
to high-dose therapy, with the possibility of long-term disease control.8 
 
2.3 
Autologous CD34+ selected PBPC support following high-dose therapy in MM. 
 
Occult tumor involvement is one of the potential risks associated with the use of a autologous 
stem cell products.  The percentage of myeloma cells contaminating the PBPC product and bone 
marrow were 0.0024% versus 0.74% using patient-specific oligonucleotide primers synthesized 
to identify patient specific Ig gene rearrangements and than amplified by PCR; these data suggest 
a potential benefit when using PBPC.26  Methods of CD34+ selection for tumor purging might 
benefit patients without significant delay in hematopoietic recovery. However, the clonogenic 
potential and contribution to disease progression of MM cells residing in  the PBPC products in 
relation to the body’s total tumor burden is unknown. Indeed, more mature data comparing 
outcome in patients supported by CD34+ selected versus standard PBPC following high-dose 
therapy for MM was not supporting the use of such technology in patients with advanced 
disease.27  In this study only in vivo “purging” with cyclophosphamide followed by Filgrastim 
will be utilized in the setting of  PBPC mobilization and processing. 
 
2.4 
Interferon maintenance 
 
Alpha interferon has been found to exhibit antitumor activity in the therapy of multiple 
myeloma. Maintenance therapy following both chemotherapy and after bone marrow 
transplantation seems to contribute toward prolonged disease-free and overall survival.28 
 
2.5 
Pamidronate in the therapy of MM 
 
Bisphosphonates –presumably by interfering with osteoclast-mediated bone resorption- are 
useful in reducing the incidence/complications of lytic metastases.  The bisphosphonate 
pamidronate, in a randomized, prospective study  had been found effective in reducing the 
number skeletal complications; pamidronate may also alter the natural history of MM by directly 
interfering with the degree of plasmocytosis.29,30  
 
2.6 
Thalidomide in the therapy of MM 
 
In bone marrow samples of patients with active MM  there is ample evidence for active 
angiogenesis;31 expression of certain adhesion molecules is also increased on the surface of such 
plasma cells in comparison to those from patients with MGUS.32 In at least one study diminished 
vascularity following high-dose therapy and PBPC seemed to be associated with better outcome.  


 
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Both interferon alpha-2 and pamidronate have the potential to inhibit angiogenesis through 
interfering with the effects of IL-6, TGF beta and other, so far undefined pathways, leading to 
prolonged survival.28,34  More recently, thalidomide, and agent with possibly antiangiogenesis 
potential had been reported to induce tumor response-including short-lasting complete 
remissions- in heavily treated, relapsed patients with MM.35  
 
2.7 
Chromosomal  abnormalities as prognostic indicators in MM 
 
Cytogenetic abnormalities can  be detected in significant numbers of  MM cases; the presence of 
11q, -13 and deletion 13q have been associated with worse survival;19  frequent abnormalities 
observed in MM include t(4;14) (p16;q32), t(11;14) (q13;q32), t(8;14) (q24;32), t(14;18) 9 
q32;q21), 13q14 (Rb loss) and others. 36 One of these translocations, t(4;14) may lead to 
dysregulations of two separate oncogenes providing one of many potential targets for specific 
interventions in the future.37 
 
Autologous stem cell transplantation following high-dose chemo-/radiotherapy may contribute to 
the development of  clonal hematopoietic evolution (or unmask/accelerate previously existing 
clonal abnormalities).  Hence,  we will apply  a unique assay (specific only in female patients) to 
detect the presence of clonal hematopoiesis prior to high-dose therapy as well as to monitor for 
the development of such clones following treatment, in female participants. 
 
2.8 
Cytogenetic and fluorescence in situ hybridization (fish) studies in multiple myeloma 
 
Classic cytogenetics and FISH analyses will be used to detect clonal aberrations in multiple 
myeloma.  Clonal aberrations will be used to monitor therapy and detect minimal residual 
disease levels at specified time intervals.   Classic cytogenetics will be performed on the baseline 
(pretreatment) bone marrow study using standard methods.  In addition, a unique system, which 
utilizes FISH for the simultaneous detection of multiple chromosome aberrations on a single 
slide with labeled chromosome probes, will be used at five-scheduled time points.  The 
Multiprobe is a disposable glass device consisting of a 3 x 8 array of raised bosses; each with 
different chromosome specific probes reversibly bound to them.38 
 
In this study, two slides will be used per scheduled time point. One slide will be use the 
Chromoprobe Multiprobe I System for the rapid evaluation of cell ploidy and to determine the 
chromosomal origin of small marker chromosomes. The probes used are pericentromeric repeat 
sequences and satellite probes; this is often the only portion of the original chromosome 
constituting the marker. Using this technique, we will test for gains or losses of whole 
chromosomes with 8 to 10 different chromosome specific probes (1, 3, 6, 7, 9, 11, 17, and 18) to 
identify and further characterize aneuploidy in patients with multiple myeloma.  The second slide 
has been customized to identify myeloma-specific cytogenetic aberrations.  Four translocations 
affecting 14q32 and two locus-specific deletions will be studied.  These non-random aberrations 
have been determined to be the most common in multiple myeloma, namely, t(4;14)(p16;q32), 
t(11;14)(q13;q32), t(8;14)(q24;q32), t(14;18)9q32;q21), 13q14 (Rb loss) with 13q telomere 
probe and TP53 loss with a chromosome 17 telomere probe.37  Multiprobe FISH complements 
conventional cytogenetics and can be used to screen normal, failed and poorly described cases of 
multiple myeloma.  Use of this approach will increase the identification of patients with multiple 


 
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myeloma tumor markers and enable them to be assigned to prognostically important subgroups, 
as reported for acute lymphoblastic leukemia.39 
 
2.9 
Humara assay methodology 
 
To determine whether dose-intensive adjuvant regimens for multiple myeloma induce genetic 
damage to hematopoietic stem cells, defined by the emergence of clonal hematopoiesis, female 
patients will be monitored for clonality by the HUMARA.  The HUMARA assay is a PCR-based 
test for detecting clonality utilizing the human androgen receptor locus on the X chromosome.  
The assay takes advantage of dosage compensation in humans achieved through random 
inactivation of one of the two X chromosomes in the cells of normal females. This inactivation 
occurs early in development and thus females are essentially cellular mosaics for the genes on 
the X chromosome, that is, some cells have either the maternal or paternal X chromosome 
inactivated.  This genetic concept is also known as the Lyon hypothesis.  In theory, all normal 
female tissue would be randomly methylated with 50% of cells having the paternal (pat) allele 
inactivated and 50% of the cells having the maternal (mat) allele inactivated; the ratio of relative 
methylation would be 50:50, or a ratio of 1. This pattern of inactivation is maintained faithfully 
in all progeny.40 
 
Clonality at the HUMARA locus is assessed by nested PCR amplification, according to Mach-
Pascual et al.41 and quantitated by the method of Delabesse et al.42 The HUMARA assay is 
designed to amplify a ~250 to 300 base pair (bp) region of the first exon of the human androgen 
receptor. Two Hpa II methylation sensitive sites reside within 100 bp 5’ to the polymorphic 
CAG repeat. Primers flank the methylation sensitive restriction enzyme sites and the CAG repeat 
simultaneously.  Methylated enzyme (Hpa II) sites correlate with X inactivation.  Unmethylated 
alleles (active X) are digested by Hpa II and eliminated from PCR amplification. The methylated 
or inactive allele will remain intact after the Hpa II digestion and is the only allele amplified.  
After amplification, the maternal and paternal alleles are resolved using a sequencing gel.  
Random inactivation will show both maternal and paternal alleles, signifying a polyclonal state; 
whereas a clonal population will be identified by the presence of one allele or a shift of greater 
than 3-fold, to control for skewed X-inactivation over the other allele.   
The allele ratio is defined as the ratio between the two chromosome X-linked alleles in a given 
sample. The corrected ratio is determined by dividing Rsa I-Hpa II by Rsa I alone. This corrects 
for preferential amplification of one of the two alleles. Those samples with a corrected ratio of 
less than 3 are considered within normal limits.  Those with a corrected ratio greater than 3 are 
consistent with either skewed X inactivation or clonal hematopoiesis.  Although criteria for 
nonrandom X-inactivation are arbitrary, an allele ratio > 3:1, which corresponds to the 
expression of 75% of one allele, has been widely accepted in the literature.42, 43  To normalize for 
excessive skewing, which occurs in ~20% of the female population and appears to increase with 
aging,44 the ratio of the two alleles in the experimental tissue (polymorphonuclear cells) must be 
divided by the ratio of the same two alleles in normal somatic control tissue (T-cells).  If the ratio 
remains greater than 3, the results are consistent with clonal hematopoiesis. 
 
 
 
 
 


 
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2.10 
COHNMC experience with tandem cycle high-dose therapy in MM 
 
Between 12/94 and 1/99,  44 patients with multiple myeloma have been enrolled on our prior 
tandem cycle high-dose chemotherapy trial.  Patients < 65 years, with a performance status of  
>70%, creatinine clearance of >70 cc/min, and with < 10% bone marrow  involvement in 
response, or with stable disease were eligible. The median age was 51 (range,38-65), 23 (52%), 
16 (37%), and 5 (11%) patients received 1, 2, and 3 prior chemotherapy regimens;  Forty three 
percent of patients received prior radiation therapy; median time from diagnosis to high-dose 
therapy (HDCT) was 9.1 months (range,4.8-73.4).  Three of forty four patients were in complete 
remission pre-high-dose threapy.  All patients underwent PBPC priming  with Filgrastim 5 μg/kg 
bid, sc to procure > 4 x 106 CD34+ cells/kg and /or > 14 x 106 mononuclear cells /kg.  HDCT 
consisted of melphalan 150 mg/m2 (C1)  followed by  busulfan 4 mg/kg/day x 4 and  
cyclophosphamide 60 mg/kg/day x 2 days (C2); each cycle was followed by PBPC. Alpha 
interferon 3 x 106 units /m2 three times a week, sc was then started for 2 years.  Four of 31 
patients (9%) did not receive C2 due to progression (n=1) deterioration in renal  function (n=1), 
dental abscess delaying admission (n=1) or psychosocial problems ( n=1).  C2 followed C1 in 
2.1 months (range, 0.9-3.9). Two patients died of hepato-renal failure (VOD), 4 pts with VOD 
recovered but one of them subsequently died of systemic candidiasis. Busulfan pharmacokinetics 
were measured in 23 of the first 27 pts treated with both C-s (85%); the median area under the 
curve (AUC) of busulfan in patients  developing VOD  (1150 uM*min, range, 788-1323) was 
not higher then in pts  without VOD (1128 uM*min, range, 622-1537). The number of days to 
absolute granulocyte recovery after C1 was 11.5 and after C 2 was 10, respectively.  Patients 
became platelet independent by day 11.5  following C 1 and day 12 (7-380+) after C2;  1 patient, 
whose myeloid lineage recovered but never reached platelet independence suffered secondary 
graft failure and subsequently became transfusion-independent 11 months post C2.  Forty five 
percent of patients in partial response pre-HDCT converted into complete remission post-HDCT. 
Complete remissions post-high-dose therapy were documented in ~ half of patients within 2 
months  following C2 and in the majority of them by 6 months.  The 3 year progression-free 
survival is 0.54 and  overall survival is 0.84  at a median post HDCT follow-up for live patients 
of 24.0 months (manuscript in preparation).45 
 
Based on the feasibility and possibly better CR rate and progression-free survival of tandem 
cycles of melphalan and busulfan/cyclophosphamide followed by alpha interferon and in view of 
the encouraging, survival data in this relatively “low tumor bulk” population with responding, or 
stable multiple myeloma we propose to treat a larger cohort of patients with exposure to < 3 prior 
treatment regimens with the same tandem regimen but with some modifications:  
 
Patients will be eligible with up to < 40% marrow involvement provided that they are either 
responding to induction therapy or have stable disease. 
 
We will incorporate cyclophosphamide both as a priming agent and to provide  in vivo purging 
prior to Filgrastim priming.  
 
Tandem cycles of high-dose melphalan and then busulfan/cyclophosphamide will be 
administered but  the dose of busulfan will be replaced with the IV preparation at 0.8 mg/kg x 16 
doses in an attempt to reduce the incidence of VOD which may be caused not just due to 


 
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exposure to busulfan but possibly due to interaction between busulfan and cyclophosphamide 
metabolism/metabolites.  
 
02/22/01  
 
Pharmacokinetic measurements of busulfan will be carried out to correlate 
toxicities and outcome with drug kinetics. 
 
We will prolong administration of alpha interferon  for 3 years in view of preliminary data in our 
current cohort suggesting a “suppressive” effect of interferon on the degree of myeloma protein 
production (manuscript in preparation). 
 
 
Pamidronate will be administered until progression at a dose of   90 mg every 4 weeks to all 
patients. 
 
For patients not in complete remission by 6 months (the majority of our patients in the previous 
trial achieved a CR by this landmark on, or off interferon and pamidronate) thalidomide 400 
mg/day will be prescribed for a period of 3-6 months in order to convert their disease into 
complete remission. 
 
Cytogenetic abnormalities by standard and FISH analysis to assess their role as predictors of 
response, monitors of residual disease and predictors of survival will be assessed.  In female 
patients the presence/evolution of clonal hematopoiesis will be monitored. 
 
3.0 
THERAPEUTIC AGENTS  
 
3.1. 
Busulfan 
 
3.1.1. Therapeutic classification – Alkylating agent 
 
3.1.2 Mechanism of action – Interfere with DNA replication and transcription of RNA and 
ultimately results in the disruption of nucleic acid function. 
 
3.1.3 Animal tumor data – Busulfan has been shown to be active against a variety of animal 
neoplasm in vivo, including mouse sarcoma 180 and Ehrlich mouse ascites tumor. 
 
3.1.4 Animal toxicology – Busulfan fed to rats in an amount equivalent to about 0.5 mg/kg of 
final body weight per day slowed weight gain and produced bone marrow depression, 
pancytopenia and cataracts after about 10 weeks.  In rats, LD50 was found to be 34 mg/kg 
intraperitoneally.  When the drug was administered on day 13, 14, or 15 of gestation at a dose of 
10 mg/kg to rats, the progeny were prematurely sterile. 
 
3.1.5 Human pharmacology – limited pharmacology data are available for the parenteral 
formulation to be used in this study and is given in above.  The pharmacokinetic data  suggests 
that the plasma decay of the formulation fits a two compartment model.  Busulfan is reported to 
be extensively metabolized, 12 metabolites have been isolated, but most have been identified.  
The drug is slowly excreted in the urine, chiefly as methanesulfonic acid.  Ten to 50% of a dose 
is excreted as metabolites within 24 hours. 


 
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3.1.5.1 Example: a 70 kg patient who is to receive a dose of 0.8 mg/kg of busulfan (6 mg/mL) 
would receive (70 kg) x (0.8 mg/kg) / ( 6 mg/mL) = 9.33 mL of busulfan injection. 
 
Calculate the amount of drug to be administered based on the dosage and the patient’s body 
weight.  
 
Prepare a solution of 0.09% Sodium Chloride Injection USP (normal saline) or 5% Dextrose 
Injection USP (D5W) that is 10 times the volume of the calculated busulfan dose in mL from the 
step above.  For example, if the dose of busulfan for injection is 9.33 mL, prepare an appropriate 
container with (9.33 mL dose) (10) = 93.3 mL of normal saline or D5W. 
 
Break off the top of the ampule and remove the calculated volume of busulfan from the container 
by using a syringe fitted with a filter needle or equivalent.  Transfer the contents of the syringe 
into the calculated amount of either normal saline or D5W making sure that drug flows into and 
through the solution.  Mix by inverting the bag.  DO NOT use if this solution contains visible 
particulates. 
 
Place a suitable intravenous administration set into the outflow port of the bag containing the 
infusion solution. 
 
3.1.6 Route of Administration:  The drug will be given by slow intravenous infusion over two 
hours.  CAUTION: DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS.  
Peristaltic pumps or syringe pumps may be used with the busulfan solutions as prepared above.  
Prior to and following each infusion, clear the catheter line with normal saline (approximately 6 
mL).  DO NOT infuse concomitantly with another intravenous solution of unknown 
compatibility. 
 
3.1.7 Pharmaceutical data: Busulfan injection is a sterile, pyrogen-free solution provided in a 
mixture of dimethylacetamide (DMA) and polyethylengegycol 400 (PEG400).  It is supplied in 
10 mL single use ampules at a concentration of 6 mg Busulfan per mL.  Each ampule 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 solutions must be administered within eight 
(8) hours of  preparation including the 2 hour infusion of the drug. 
 
3.1.8 Stability and storage – stable at 4C for at least twelve months.  Additional stability 
studies are in progress.  Ampules should be stored refrigerated at 2-8C.  DO NOT FREEZE.  
Ampules may be stored for up to 7 days at room temperature.  
 
3.1.9 Solution preparation: prepare the busulfan solution as follows: 
 
3.1.9.1 Use sterile, non-pyrogenic, disposable containers, syringes, needles, stopcocks, and 
transfer tubing, etc. 
 
3.1.10 Human toxicology: Toxicology from busulfan includes: 
 
3.1.10.1 
Severe bone marrow hypoplasia which would be fatal without administration of 


 
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bone marrow stem cells. 
 
3.1.10.2 
Nausea and vomiting which can be decreased by the use of sedation and 
antiemetic. 
 
3.1.10.3 
Stomatitis and diarrhea which can be treated symptomatically with fluid 
replacement and atropine or diphenoxylate H C1. 
3.1.10.4 
Pulmonary fibrosis  characterized by delayed onset of cough, shortness of breath 
and low grade fever. 
 
3.1.10.5 
Hepatic damage which can occur in combination with cytoxan or as a single agent 
and can result in significant hepatic toxicity which can be fatal. 
 
3.1.10.6 
Temporary hyperpigmentation of the skin and nail be changes. 
 
3.1.10.7 
Grand mal seizures which can be prevented by the prophylactic administration of 
dilantin. 
 
3.1.10.8 
Edema: Seventy-nine percent (79%) of patients exhibited some form of edema, 
hypervolemia, or weight increase: all events were reported as mild or moderate. 
 
3.1.11 Supplier: This drug is commercially available. 
 
3.2. 
Cyclophosphamide 
 
3.2.1 Mechanisms of Action: This drug is biotransformed principally in the liver to active 
alkylating metabolites which prevent cell division by cross linking strands of DNA and it also 
inhibits DNA synthesis. 
 
3.2.2 Human Toxicity:  Toxicity from cyclophosphamide includes bone marrow suppression 
which usually occurs ten to twelve days after administration, nausea and vomiting, reversible 
alopecia, hemorrhagic cystitis which can frequently be prevented with increased hydration and 
co-administration of MESNA, and sterility and decreased gonadal function.  There are isolated 
reports of hemorrhagic colitis, oral mucosal ulceration, and jaundice. 
 
3.2.3 Pharmaceutical Data:  Formulation; Cyclophosphamide is supplied in 100 mg, 200 mg, 
and 500 mg vials as a white powder.  The drug can re reconstituted in either normal saline or 
D5W. 
 
6/14/99  
 
3.2.4 Administration:  The drug should be dissolved in about 500 cc of 
D5W and it is infused IV over 2 hours.  An added dose of IV fluids may help prevent bladder 
toxicity.  Cyclophosphamide 1.5 gm/m2 (based on actual body weight) will be administered for 
mobilization, prior to apheresis.  During cycle 2 of the treatment  phase the drug will be 
administered on Days -3 and -2 at a dose of 60 mg/kg/day IBW.  There will be no correction for 
extremely obese patients.  It will be dosed by IBW.  In order to prevent hemorrhagic cystitis, 
vigorous hydration and diuresis together with MESNA will be employed.   
 


 
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3.2.5 Supplier:  This drug is commercially available for purchase by the third party. 
 
3.3 
Melphalan (L-phenylalanine mustard, L-PAM, Alkeran) 
 
3.3.1 Mode of Action:  In common with other nitrogen mustards, melphalan reacts with DNA 
to produce either DNA-DNA or DNA-proteins cross-linked products probably by binding at the 
N-7 position of guanine. 
 
3.3.2 Supply, Reconstitution and Administration:  Melphalan is commercially available by 
Burroughs Wellcome Company in sterile vials containing 50 mg lyophilized drug as the 
hydrochloride salt.  It is formulated with 20 mg povidone per 50 mg vial.  Sterile diluent is 
supplied which contains per 10 ml: sodium citrate 0.20 g, propylene glycol 6 ml, ethanol (95%) 
0.526 ml, sterile water q.s. 10 ml. Reconstituted vials (undiluted solutions) are stable for 90 
minutes.  Melphalan diluted in NS to 0.1-0.45mg/ml is stable for only 60 minutes.  Melphalan is 
unstable when diluted with NS to 2mg/ml.  The rate of infusion should be 30 minutes or less.   
 
3.3.3 Toxicity:  The dose-limiting toxicity of melphalan is myelosuppression.  Other toxicities 
after IV melphalan include mucositis, nausea, vomiting, and diarrhea.  Alopecia is generally seen 
only with high doses associated with bone marrow transplant settings.  Rarely reported reactions 
include pulmonary fibrosis, skin rash, vasculitis, and allergic reactions.  With high dose 
chemotherapy, gastrointestinal toxicity becomes dose-limiting.  At such high doses, elevated 
transaminases, syndrome of inappropriate antidiuretic hormone secretion, depression, interstitial 
pneumonitis, and hepatic veno-occlusive disease have been reported.  Acute nonlymphocytic 
leukemia and myeloproliferative syndromes may occur as secondary cancers from any alkylating 
agent such as melphalan.  Amenorrhea, permanent in many cases, have been noted when 
melphalan was used in premenopausal women undergoing adjuvant therapy for breast cancer.  
Azoospermia would be expected, but is not well documented in the literature. 
 
3.4 
Filgrastim (r-metHuG-CSF) 
 
3.4.1 Description 
 
Filgrastim is a human granulocyte colony stimulating factor (G-CSF), produced by recombinant 
DNA technology.  NEUPOGEN® is the Amgen Inc. trademark for Filgrastim, recombinant 
methionyl human granulocyte colony stimulating factor (r-metHuG-CSF).  
 
Approximately 6,400 patients in U.S. and international based trials have participated in clinical 
trials of Filgrastim to date, and the worldwide commercial populations receiving Filgrastim 
totaled approximately 190,000.  The drug has been found to be well tolerated at dosages up to 60 
μg/kg/day given IV or SC, with no toxic effects attributable to Filgrastim. A maximum tolerated 
dose has not yet been determined. 
 
3.4.2 Contraindications 
 
NEUPOGEN® is contraindicated in patients with known hypersensitivity to E. coli-derived 
proteins, Filgrastim, or any component of the product. 
 
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3.4.3 Adverse Reactions 
 
The only consistently observed clinical toxicity described with Neupogen® is medullary bone 
pain. Other clinical toxicities that have been described include skin rash, and cutaneous 
vasculitis.  Since commercial introduction of Neupogen®, there have been rare reports of 
allergic-type reactions.  Biochemical abnormalities that may occur include increases in alkaline 
phosphatase, uric acid, and lactate deydrogenase. 
 
3.4.4 Dilution and Storage 
 
If required, NEUPOGEN® may be diluted in 5% dextrose.  NEUPOGEN® diluted to 
concentrations between 5 and 15 mcg/mL should be protected from adsorption to plastic 
materials by addition of Albumin (Human) to a final concentration of 2 mg/mL.  Do not dilute 
with saline at any time; product may precipitate. 
 
NEUPOGEN® should be stored in the refrigerator at 2-8 degrees Centigrade (36-46 degrees 
Fahrenheit).  Do not freeze.  Avoid shaking.  Prior to injection, NEUPOGEN® may be allowed 
to reach room temperature for a maximum of 24 hours.  Any vial left at room temperature for 
greater than 24 hours should be discarded.   
 
3.4.5 Supplier 
 
Commercial NEUPOGEN® is available in 1 mL and 1.6 mL vials at a concentration of 300 
mcg/mL.  Discard unused portions.  Use only one dose per vial; do not reenter the vial.  Do not 
save unused drug for later administration. 
 
3.5 
MESNA (NSC-113891) 
 
3.5.1 Mode of Action 
 
Sodium-2-mercapto-ethanesulfonate (Mesna) is a urothelial protectant.  It binds to acrolein, the 
urotoxic metabolite of ifosfamide, and also inhibits the breakdown of its 4-hydroxy metabolites.  
It is excreted exclusively in the urine. 
 
Supply, Reconstitution and Administration 
 
Mesna is available from Bristol-Meyer Squibb as a 100 mg/ml solution (400 mg/4 ml ampule).  
It may be administered intravenously by bolus and/or continuous infusion. 
 
Toxicity 
 
Nausea and vomiting are the only side effects observed with Mesna. 
 
3.6 
Interferon-Alpha-2b 
 
3.6.1 Mechanism of action:  Alpha-2b interferon has a wide variety of antiproliferative, 
antiviral and immunomodulatory effects.  The major mechanism of effect in multiple myeloma is 


 
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probably an antiproliferative one directly against the myeloma cells - an effect which has been 
documented by in vitro studies.  However, both immunomodulatory and antiviral effects cannot 
be excluded in the clinical setting. 
 
3.6.2 Human toxicity:  The major toxicity of alpha-2b interferon is a "flu-like" syndrome, 
which occurs in a dose dependent fashion and consists primarily of fever, chills, myalgias, 
arthralgias and headache.  At the three million unit dosage schedule the syndrome is minor or 
non-existent.  Fatigue with decrease in performance status is also usually mild at this dosage as is 
the objective toxicity such as neutropenia, anemia and reversible liver transaminase elevations.  
Autoimmune thyroid disease has been observed in patients receiving alpha-interferon. 
 
3.6.3 Pharmaceutical data:  Alpha-2b interferon will be supplied in vials containing a sterile 
lyophilized powder.  The 5 million and 10 million IU vials are for use by intramuscular or 
subcutaneous injection and will provide 5 x 106 IU of interferon activity when reconstituted. 
 
3.6.4 Storage:  Lyophilized Powder - Vials must be stored in a secured refrigerator at 2º - 8ºC 
(36º - 46ºF). 
 
3.6.4.1 Reconstituted Solution 
 
The reconstituted solution should be refrigerated at 2º - 8ºC (36º - 46ºF) and used within 24 
hours or frozen at –20ºC. 
 
3.6.4.2 Reconstitution 
 
Each 5 x 106 IU vial requires 1.0 ml of preservative-free sterile water for reconstituting the 
lyophilized powder into solution for injection.  Each 10 x 106 IU vial requires 2.0 mls of diluent.  
It is the responsibility of the investigator to supply the sterile water.  Each vial may be used once 
only; any unused material will be discarded. 
 
3.6.5 Supplier:  Alpha-2b interferon is commercially available for purchase by a third party. 
 
 
01/07/00  
3.7 
Thalidomide (NSC #66847) 
 
3.7.1 Other Name: Thalomid 
 
3.7.2 Molecular Formula: C13O4N2H9 (M.W. 243) 
 
3.7.3 Description: Thalidomide is a racemate. 
 
3.7.4 How Supplied: Supplied by Celgene as 50 mg hard gelatin capsules 
 
3.7.5 Storage: Thalidomide should be stored at room temperature. 
 
3.7.6 Route of Administration: Oral 
 


 
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3.7.7 Toxicities: Drowsiness and sedation, headache, constipation, nausea, dryness of mucosa, 
erythematous skin eruptions, peripheral neuropathy, increased appetite, weight gain, loss of 
libido, edema of face and extremities, galactorrhea, dry skin, leukopenia, menstrual 
abnormalities, pruritis, alopecia, eosinophillia, somnolence, depression and of course, teratogenic 
effects. 
 
3.7.8 WARNING: There is an extremely high risk that a deformed infant will result if 
pregnancy occurs while taking thalidomide even for short periods.  Therefore, this teratogenic 
action of thalidomide necessitates: 
 
3.7.8.1 Female patients having any chance of becoming pregnant must have a pregnancy test 
performed within 24 hours of beginning thalidomide, weekly for the first 4 weeks of treatment, 
and then evry 4 weeks if the patients periods are regular or every 2 weeks if they are not. 
 
3.7.8.2 Female patients mus either abstain from all reproductive sexual intercourse or use 2 
methods of birth control at least 1 highly active method (e.g. intrauterine device [IUD], 
hormonal [birth control pills, injections, or implants], tubal ligation, or partner’s vasectomy) 
and 1 additional effective method (e.g. latex, condom, diaphragm, or cervical cap) at 4 weeks 
before starting thalidomide therapy, during therapy, and for 4 weeks after discontinuing 
thalidomide therapy even when there has been a history of infertility, unless due to hysterectomy 
or because the patients has been postmenopausal or has had no menses for at least 24 consecutive 
months. 
 
3.7.8.3 Male patients must be counseled about the possibility that thalidomide may be present in 
semen.  Men must use a latex condom every time they have sexual intercourse with a woman 
during therapy and for 4 weeks after discontinuing thalidomide, even if they have had a 
successful vasectomy. 
3.7.8.4 The bottle label will bear:“Warning: This product is contraindicated in men and women 
of childbearing age.  Thalidomide is an investigational new drug that can only be prescribed by a 
physician.” 
 
3.7.8.5 If secondary re-packaging is necessary then all bottles should bear a warning similar to 
the following:  “Thalidomide must not be used by males and females who are sexually active.” 
 
   
 
 
3.7.8.6 In addition, all bottles should have affixed a warning label similar 
to the following:  “This medication may cause drowsiness, alcohol may intensify this effect.  Use 
caution when driving or operating machinery.” 
 
3.8 
Pamidronate 
 
3.8.1 Mechanism of Action:  Pamidronate is an inhibitor of bone resorption and, in addition 
may interfere with the release, deposition of metastatic tumor deposits. 
 
3.8.2 Toxicity:  Fatigue, fever, diaarhea, nausea, arthralgias, and rarely hypocalcemia, phlebitis 
at the site of injection have been observed. In patients with multiple myeloma, the risk of renal 
dysfunction may be increased when a bisphosphonate is used in combination with thalidomide 
 
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3.8.3 Pharmaceutical Data:  Pamidronate is supplied  in 30, 60, and 90 mg vials as a freeze-
dried powder.  Reconstitution can be done in 10 mL of sterile water, then the appropriate volume 
of pamidronate will be mixed with normal (0.9 %) saline to a total volume of 250 mL.  
Pamidronate will be infused over 2 hours.  If the reconstituted solution is not used immediately, 
it can be stored at temperatures between 36-460F and can be used for up to 24 hours.  
 
Pamidronate is commercially available. 
 
4.0 
STAGING CRITERIA  
 
4.1 
Criteria for Diagnosis of Multiple Myeloma42 
 
4.1.1 Major Criteria 
 
Plasmacytomas on tissue biopsy. 
 
Bone marrow plasmacytosis with > 30% plasma cells. 
 
Monoclonal globulin spike on serum electrophoresis exceeding 3.5 gm% for G peaks or 2.0 gms 
for A peaks.  > 1.0 gm/24 hours of kappa or lambda light chain excretion on urine 
electrophoresis in the absence of amyloidosis. 
 
4.1.2 Minor Criteria 
 
Bone marrow plasmacytosis 10% - 30%. 
 
4.1.3 Monoclonal globulin spike present, but less than the levels defined above. 
 
4.1.4 Lytic bone lesions. 
 
4.1.5 Normal lgM less than 50 mg%, lgA less than 100%, or lgG less than 600 mg%. 
 
4.1.6 Diagnosis will be confirmed when any of the following features are documented in 
symptomatic patients with clearly progressive disease.  The diagnosis of myeloma requires a 
minimum of 1 MAJOR + 1 MINOR CRITERION or 3 MINOR CRITERIA which must include 
a+b, i.e.: 
 
4.1.6.1 l+b, l+c, l+d (l+a not sufficient) 
 
4.1.6.2 ll+b, ll+c, ll+d 
 
4.1.6.3 lll+a, lll+c, lll+d 
 
4.1.6.4 a+b+c, a+b+d 
 
4.1.7 The presence of certain nonspecific disease features will support the diagnosis, 
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4.1.7.1 Anemia 
 
4.1.7.2 Hypercalcemia 
 
4.1.7.3 Azotemia 
 
4.1.7.4 Demineralization and compression fractures 
 
4.1.7.5 Hypoalbuminemia 
 
4.1.8 Great care must be taken to distinguish between active myeloma as defined above and 
MGUS or indolent/smoldering myeloma (see Section 4.2). 
 
 
4.2 
Criteria for Monoclonal Gammopathy of Undetermined Significance (MGUS), Indolent 
Myeloma and Smoldering Myeloma (Stage I or IIA)40 
 
4.2.1 MGUS 
 
4.2.1.1 Monoclonal gammopathy 
4.2.1.2 M-Component level 
 
4.2.1.2.1 
IgG < 3.5 gm% 
 
4.2.1.2.2 
IgA < 2.0 gm% 
 
4.2.1.2.3 
BJ  < 1.0 gm/24 hours 
 
4.2.1.3 Bone marrow plasma cells < 10% 
 
4.2.1.4 No bone lesions 
 
4.2.1.5 No symptoms 
 
4.2.2 Indolent Myeloma  Criteria as for myeloma (see Section 4.2) except (all of the 
following): 
 
4.2.2.1 No or only limited bone lesions (< 3 lytic lesions); no compression fractures. 
 
4.2.2.2 M-component levels 
 
4.2.2.2.1 
IgG < 7 gm% 
 
4.2.2.2.2 
IgA < 5 gm% 
 
4.2.2.3 No symptoms or associated disease features, i.e.: 


 
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4.2.2.4 Performance status > 50% 
 
4.2.2.4.1 
Hemoglobin > 10 gm% 
 
4.2.2.4.2 
Serum calcium normal 
 
4.2.2.4.3 
Serum creatinine < 2.0 mg% 
 
4.2.2.4.4 
No infections 
 
4.2.3 Smoldering Myeloma  Criteria as for indolent myeloma except: 
 
4.2.3.1 NO bone lesions 
 
4.2.3.2 Bone marrow plasma cells < 30% 
 
4.3 
Assessment of Tumor Mass 
 
4.3.1 High Tumor Mass (Stage III)  One of the following abnormalities must be present: 
4.3.1.1 Hemoglobin < 8.5 gm%, hematocrit < 25 vol.%, or 
 
4.3.1.2 Serum calcium > 12 mg%, or 
 
4.3.1.3 Very high serum or urine myeloma protein production rates: 
 
4.3.1.3.1 
IgG peak > 7 gm% 
 
4.3.1.3.2 
IgA peak > 5 gm% 
 
4.3.1.3.3 
Bence Jones protein > 12 gm/day (24 hours), or 
 
4.3.1.3.4 
> 3 lytic bone lesions on bone survey (bone scan not acceptable) 
 
4.3.2 Low Tumor Mass (Stage I)  ALL of the following must be present: 
 
4.3.2.1 Hemoglobin > 10.5 gm% or hematocrit > 32 vol.% 
 
4.3.2.2 Serum calcium normal 
 
4.3.2.3 Low serum myeloma protein production rates: 
 
4.3.2.3.1 
IgG peak < 5 mg% 
 
4.3.2.3.2 
IgA peak < 3 gm% 
 
4.3.2.3.3 
Bence Jones protein < 4 gm/day (24 hours) 


 
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4.3.2.3.4 
Bone lesions scaled 0 (none) or 1 (osteoporosis) 
 
4.3.3 Intermediate Tumor Mass (Stage II) 
 
All other patients who do not qualify specifically for high or low tumor mass categories are 
considered to have intermediate tumor mass. 
 
4.4 
Assessment of Renal Status 
 
4.4.1 A = Good Renal Function (creatinine < 2.0 mg%) 
 
4.4.2 B = Poor Renal Function (creatinine > 2.0 mg%) 
 
4.5 
Assessment of Myeloma Cell Mass 
 
 
 
 
STAGE III 
 
 
STAGE I 
 
 
STAGE II 
 
 
Cell Mass Category 
 
High 
 
Low 
 
Intermediate 
 
# of myeloma cells 
 
> 1.2 x 1012/m2 
 
< 0.6 x 1012/m2 
 
0.6-1.2 x 102/m2 
 
Requirements 
 
One of: A,B,C,D 
 
All of: A,B,C,D 
 
Neither High or 
Low 
 
Hemoglobin (gm%)       A  
(pretransfusion) 
 
< 8.5 
 
> 10.5 
 
> 8.5 
 
 
Serum calcium (mg%)   B 
 
> 12 
 
Normal 
 
< 12 
 
M-Component                C 
 
IgG > 7 gm% 
IgA > 5 gm% 
BJ  > 12 gm/day 
 
< 5 
< 3 
< 4 
 
< 7 
< 5 
< 12 
 
Bone lesions (on     D skeletal 
survey  
only; bone scan not 
acceptable) 
 
Scaled 3 
(> 3 lytic lesions) 
 
scaled 0 or 1 (no 
lesions or 
osteoporosis only) 
 
Scaled 0, 1, or 2 
NOTE: The staging of patients with IgD or IgE monoclonal spikes is based upon other (non M-
component) criteria. 
 
5.0 
PATIENT ELIGIBILITY 
 
5.1 
Patients with multiple myeloma will be eligible. 
 
5.2 
Patients with smoldering myeloma are eligible if there is evidence of progressive  disease 
requiring therapy ( > 25% increase in M protein levels or Bence Jones  excretion; Hgb < 10.5 
g/dl; frequent infections; hypercalcemia; rise in serum creatinine above normal on two separate 
occasion) 
 
5.3 
Patients with non-quantifiable monoclonal proteins are eligible provided they meet other 


 
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criteria for multiple myeloma, or smoldering myeloma. 
 
5.4 
Patients with the following reponse/status after induction therapy and after no more than 
3 prior chemotherapy regimens (other then Decadron) are eligible: 
 
5.5 
Responding, or stable MM , and less or equal to 40%  myelomatous involvement in the 
bone marrow  biopsy specimen. 
 
5.6 
Patients with Waldenstrom’s macroglobulinemia are not eligible. 
 
5.7 
Less than 18 months since diagnosis. 
 
5.8 
Patients must be < 65 years old at the time of enrollment. 
 
5.9 
A KPS of > 70 % is required. 
 
5.10 
No contraindication to the collection of a minimum of 4 x 106 CD34+ cells/kg  by  
apheresis. 
 
5.11 
All patients must have signed a voluntary, informed consent in accordance with 
institutional and federal guidelines. 
 
5.12 
Adequate hepatic function as demonstrated by bilirubin, < 1.5 mg/dl, and SGOT and 
SGPT < 2.5 x upper limits of normal. 
 
5.13 
Adequate renal function as demonstrated by: creatinine of < 1.4 mg/dl and measured 
creatinine clearance of > 60 cc/min. 
 
5.14 
Absolute neutrophil count of > 1000/μl, platelet count of > 100,000/μl. 
 
5.15 
Cardiac ejection fraction > 50% by MUGA scan  and/or  by echocardiogram. 
 
5.16 
Adequate pulmonary function as demonstrated by FEV1 > 60% and DLCO > 50% of 
predicted lower limit.  
 
5.17 
Hepatitis B antigen, Hepatitis C RNA and HIV antibody tests negative. 
 
5.18 
No other medical, or psychosocial problems which in the opinion of the primary  
physician or principal investigator would place the patient at unacceptably high risk from this 
treatment regimen. 
 
5.19 
Females of reproductive age not using adequate birth control measures/ or who are 
pregnant are not eligible. 
 
5.20 
History of other malignancies within the last 5 years, except for non-melanoma skin 
cancer and in situ carcinoma of the cervix. 
 


 
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5.21 
Patients should have finished their prior chemotherapy, or radiation treatment at least 4 
weeks before cyclophosphamide priming. 
 
5.22 
Pre-treatment tests must have been performed within 6 weeks prior to initiation of  
cyclophosphamide. 
 
6/14/99  
5.23 
Known hypersensitivity to Filgrastim or to E. coli derived proteins is an 
exclusion. 
 
6.0 
TREATMENT PLAN 
 
6.1 
Pre-treatment Evaluation 
 
6.1.1 History and physical examination. 
 
6.1.2 Radiographic evaluation: MRI of the entire spine and pelvis and skeletal survey will be 
performed. 
 
6.1.3 Chest X-ray. 
 
6/14/99  
 
6.1.4 Pulmonary function tests 
 
6.1.5 MUGA scan or echocardiogram. 
 
6.1.6 CBC, differential count, platelet count, PT, PTT, SMA 18, Mg. 
 
6.1.7 Urine analysis. 
 
6/14/99  
 
6.1.8 24 urine collection for total protein, protein electrophoresis, 
immune  electrophoresis, and creatinine clearance. 
 
6/14/99  
 
6.1.9 Hepatitis panel, HIV antibody, HSV and CMV antibody. 
 
6.1.10 Unilateral bone marrow biopsy and aspirate for morphology, cytogenetics/FISH.  
Aspirate for HUMARA (females only). 
 
6/14/99  
 
6.1.11 Peripheral blood for FISH (including clonal hematopoiesis 
markers), gene rearrangement, and for lymphocyte subset analysis. 
 
6/14/99  
 
6.1.12 Serum protein electrophoresis, quantitative serum 
immunoglobulins, serum immunofixation electrophoresis 
 
6.1.13 Beta-2 Microglobulin level. 
 
6.1.14 Urine pregnancy test. 
 
6.1.15 HLA, ABO and Rh typing. 


 
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6.1.16 Double lumen Hickman catheter will be placed (> 12 French catheter). 
 
6.2 
Patient Registration 
 
After all pre-treatment evaluations have been performed patients can be entered on study.  
Eligibility requirements must be reviewed by a member of the department of Biostatistics and the 
principal investigator.  Patients may be screened for eligibility by calling the Department of 
Biostatistics at extension 2468. 
 
6.3 
Harvesting and Cryopreservation of Stem Cells  
 
6/14/99  
 
Cyclophosphamide 1.5 gm/m2 (based on actual body weight) will be 
administered with 500 cc D5/W over 2 hours. Filgrastim 5 μg/kg (based on actual body weight)  
bid, sq or iv will be administered starting 24 hours after cyclophosphamide and continue through 
the completion of apheresis (total daily Filgrastim dose equals 10 μg/kg/day). 
 
Beginning day 10, provided that the peripheral blood white cell count is > 1000/μL and rising, 
apheresis will commence and continue until a minimum of 4 x 106 CD34+ cells/kg are collected.  
For patients with good  CD34+ cells yields during apheresis (once the minimum CD34+ 
requirements are secured) a target of > 10 x 106 will be set and no more than 10 aphereses are 
recommended. 
 
Filgrastim will continue to be given daily; Filgrastim dose will be held if the total white cell 
count is > 80,000/μl.  If the yield from the first 3 days of apheresis is < 1 x 106/kg, the dose of 
Filgrastim will be increased to 10 μg/kg, bid. 
 
The collections will last 4 hours, or until a volume of 12 liters has been processed.  Peripheral 
stem cells will be processed and cryopreserved following standard methods at the City of Hope 
National Medical Center. 
 
6.4 
High-Dose Chemotherapy 
 
6.4.1 Cycle 1: Melphalan 
 
6.4.1.1 DAY -1 
 
 
Admission, history and physical, SMA 18, Mg, CBC, differential and PLT count, urine analysis.  
Review of required laboratory, screening and radiographic data, signing of consent form.   
 
Prophylactic IV, or p.o. fluconazole at 200 mg daily will be given to patients with AGC < 
1000/μl. 
 
Intravenous hydration with normal saline at 200 cc/hr and KCL 15 MeQ/1 will be started.  After 
6 hours of hydration melphalan 150 mg/m2 will be infused in  30min. IV hydration will 
continue with normal saline at a rate of 200 cc/hr and KCL 15 MeQ/l for a total of at least 24 
hours. 
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Appropriate intravenous antiemetics will be given. 
 
When calculating chemotherapeutic dose, ideal body weight will be used (See appendix C). 
 
6.4.1.2 DAY  0 
 
 
Half of the previously collected CD34+ cells will be reinfused. 
 
6.4.1.3 Day +1 
 
Filgrastim 5 μg/kg daily, IV, or SQ will be started.  Continue with Filgrastim until AGC > 
1000/μl for 3 consecutive days 
 
Patients will be supported through iv hydration and TPN, red cell and platelet transfusions as 
needed. CBC, PLT and SMA7, SMA 12, and Mg and weekly chest x-ray as well as the necessary 
fever workup will be done.  Patients can be followed in the outpatient unit unless they develop 
neutropenic fever, uncontrollable diarrhea or other problems requiring inpatient care.  Inpatient 
care will be provided in rooms equipped with HEPA filter and they will be in protective 
isolation.  All blood products will be filtered and  
08/99 
 
 
 
 
radiated. 
 
6.4.2 Cycle 2: 
 
6.4.2.1 Busulfan and Cyclophosphamide will start a minimum of 12 weeks and a maximum 18 
weeks from cycle number 1. 
 
6.4.2.2 DAY -8 
 
 
Admission, history and physical, SMA18, Mg, CBC, differential and PLT count, urine analysis.  
Review of required laboratory, screening and radiographic data, check for signing of consent 
form. On day -8 dilantin loading dose at 1000 mg iv will be given. 
 
Prophylactic IV, or p.o. fluconazole at 200 mg daily will be given to patients with AGC < 
1000/μl. 
 
6.4.2.3 DAY -7 through -3 
 
 
Continue with dilantin 300 mg iv, daily x five days. 
 
6/14/99  
 
 
6.4.2.4 DAY -7 through –4 
 
IV busulfan at 0.8 mg/kg Q 6 hr will be given for a total of 16 doses with each dose infused over 
2 hours. A total of 7 blood draws, approximately 2 tablespoons of blood in total will be drawn 
with the first dose of busulfan.  Five (5) milliliters of peripheral blood will be collected in green-
top (sodium heparin) tubes at the following times; pre-dose, just prior to the end of the infusion, 
then 15 minutes, 30 minutes, 1, 2, and 4 hours after the end of the dose.  The last sample will be 
10/10/02 
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obtained just prior to the start of dose 2. 
 
When calculating chemotherapeutic dose (including mesna) , ideal body weight will be used (See 
appendix C). 
 
6.4.2.5 DAY -3 
 
 
Cyclophosphamide at 60 mg/kg iv in 500 cc D5W will be given over 2 hours. MESNA 25 mg/kg 
as bolus is given prior to cyclophosphamide and then MESNA 120 mg/kg over 48 hours as 
continuous infusion is administered.  
 
When calculating chemotherapeutic dose, ideal body weight will be used. 
 
02/22/01  
 
 
6.4.2.6 DAY -2 
 
 
Processing of samples consists of adding 1 ml of whole blood to specially prepared tubes 
containing a trapping agent, which prevents the degradation of 4-hydroxycyclophosphamide 
(4HC) ex vivo. Due to the rapid breakdown of 4HC ex vivo, samples must be processed within 2 
minutes.  Therefore, a protocol nurse must be present prior to drawing blood. The remainder of 
the blood not used for 4HC measurement will be collected in green-top (sodium heparin) tubes 
and centrifuged at 1500xg to separate plasma from whole blood.  Plasma will be stored frozen at 
 -20C until later batch analysis for cyclophosphamide. 
 
6.4.2.7 DAY 0 
 
Half of the previously collected CD34+ cells will be reinfused. and Filgrastim 5 μg/kg  daily, IV, 
or SQ will be started.  Continue with hydration as needed.  Continue with Filgrastim until AGC 
> 1000/μl for 3 consecutive days. 
 
Patients will be supported through iv hydration and TPN, red cell and platelet transfusions as 
needed.  Daily CBC, PLT and SMA7, every Monday, Wednesday, Friday SMA 18, and Mg and   
weekly chest x-ray, biweekly PT, PTT as well as the necessary fever workup will be done.  
Patients can be followed in the outpatient unit unless they develop neutropenic fever, 
uncontrollable diarrhea or other problems requiring inpatient care.  The inpatient care will be 
provided in rooms equipped with HEPA filter and they will be in protective isolation.  All blood 
products will be filtered and radiated according to standards at the COH. 
 
6.4.4 Maintenance Therapy  
 
02/22/01  
 
 
6.4.4.1 Phase I: 
Patients with responding, or stable disease 
following sequential high-dose chemotherapy will receive maintenance therapy with alpha 
interferon.  Treatment with interferon will begin at least 6 weeks and no later then 20 weeks from 
day 0 of the second cycle of high-dose chemotherapy provided that an AGC of > 1000/μl and a 
platelet count of > 100,000/μl has been reached.   
 
Interferon will be given at 3.0 million units/m2 on Mondays, Wednesdays and Fridays, SQ.  
Interferon will be administered for 3 years. 


 
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6/14/99 
 
 
 
 
 
 
Aredia 90 mg  iv every 4 weeks and will be 
continued till progression. 
 
01/07/00  
 
 
6.4.4.2 Phase II: 
Patients not in complete remission by 6 
months from day 0 of the second high-dose therapy cycle will be started on Thalidomide 200 mg 
for 1 week, 300 mg for the next week, and then will be 04-01/07/00  
 
 
 
 
 
 
receiving a target dose of 400 mg.  Patients will be receiving Thalidomide for a 
maximum of 1 year, or for 3 months after a documented concersion to complete remission 
(whichever is sooner), unless they progress, or cannot tolerate Thalidomide in spite of dose 
adjustments required due to toxicities. 
 
6.5 
Dose Adjustments 
 
6.5.1 Melphalan 
 
There will be no dose adjustments for melphalan  
 
6.5.2 Busulfan and cyclophosphamide 
 
Busulfan and cyclophosphamide will be given at the earliest 12 weeks and at the latest 18 weeks 
from day 1 of the melphalan cycle.  Patients requiring further delaying of treatment will be taken 
off study. 
 
There will be no dose adjustments for Busulfan and Cyclophosphamide. 
 
Pre-cycle 2 requirements should be met prior to initiating the second cycle. 
 
01/07/00  
 
6.5.3 Thalidomide will be started at 200 mg given orally, daily for one 
week and the dose will be escalated to 300 mg for the following week, and to 400 mg from the 
third week on.  For grade >2 neurotoxicity, or > grade 2 hematologic toxicity, or other > grade 2 
toxicities the dose of Thalidomide will be held for one week and then restarted at a dose which is 
100 mg/dose lower than the dose causing > grade 2 toxicities.  Re-escalation to a higher dose 
(maximum 400 mg/day) is allowed.  Any patients who cannot tolerate the lowest 200 mg/day 
dose after being off therapy for 4 weeks due to persistent > grade 2 toxicities will not receive any 
further dose of Thalidomide. 
 
6.5.4 Interferon 
 
Patients experiencing weight loss, fatigue, flue like symptoms or any other > grade 2 toxicity 
will have their interferon dose reduced by 50%.  If after 2 weeks symptoms persist a 2 week 
break will commence. Then, interferon will be restarted at the 50% dose for two weeks and 
subsequently will be re-escalated to full dose.  A second adjustment to 50% dose is permissible 
(to 25 % of the starting dose) and patients could continue on the reduced dose of interferon for 
the duration of study.  However, should a patient require a third reduction of interferon he/she 
should be taken off therapy. 
01/07/00 
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6.5.5 General Side Effects 
 
The side effects associated with the use of individual drugs:  cyclophosphamide, MESNA, 
Filgrastim, melphalan, busulfan, alpha  interferon, and Thalidomide are listed under section 3. 
 
6.5.6 Pamidronate 
 
There will be no dose adjustments for pamidronate.  
 
7.0 
EVALUATION AND TOXICITIES 
 
Physical evaluation, laboratory and radiographic evaluation will be performed as outlined in the 
treatment regimen.  When evaluating toxicity a modified NCI autologous bone marrow toxicity 
scale will be used. 


 
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06/14/99 8.0 
STUDY PARAMETERS 
09/27/99 
01/07/00 
02/22/01 
 
 
 
Within 6 Wks 
Pre-Cytoxan 
 
Pre-
Cycle 1 
 
Cycle 1 
 
Pre-
Cycle 2 
 
Cycle 2 
 
Q30 
days** 
 
Q 6 mos# 
 
Q yr+ 
 
History and Physical 
 
 
X 
 
 
X 
 
 
 
 
X 
 
 
X 
 
 
X 
 
 
 
 X 
 
CBC, DIFF, PLT/SMA7 
 
X 
 
X 
 
Daily  
 
X 
 
 Daily  
 
X 
 
 
 
X 
 
SMA 18, MG++ 
 
X 
 
X 
 
M,W,F  
 
X 
 
M,W,F  
 
X 
 
 
 
X 
 
PT, PTT 
 
X 
 
X 
 
 
 
X 
 
QO Week 
 
 
 
 
 
X 
 
Urinalysis Creat Clearance 
 
X 
 
 
 
 
 
X 
 
 
 
X& 
 
 
 
 
 
Chest X-ray 
 
X 
 
 
 
Q Week 
 
X 
 
Q Week 
 
 
 
 
 
 
 
MRI of bones, bone x-rays 
 
X 
 
 
 
 
 
 
 
 
 
 
 
X ** 
 
X 
 
SPEP, QSIEP, Beta-2 
Microglobulin 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
24 hr urine for PEP, IEP, total 
protein, creatinine clearance 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
MUGA Scan/ or echo 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X ** 
 
EKG 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X ** 
 
PFT 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AB, RH, HLA Typing 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BM, ASP, BX, for 
morphology, cytogenetics 
FISH, gene 
rearrangements/clonal 
hematopoiesis, vascular 
density 
 
X 
 
 
 
 
 
 
 
 
 
X‡ 
 
X# 
 
X 
 
Blood for Cytogenetics/FISH 
and clonal hematopoiesis 
 
X 
 
X++ 
 
 
 
 
 
 
 
 
 
X# 
 
X 
 
PBPC product for 
cytogenetics, FISH clonal 
hematopoiesis 
 
X 
 
X++ 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Pregnancy Test  
(For female patients) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV, Hepatitis Panel to 
include A,B,C; Herpes and 
CMV Titer 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T cell subsets by flow 
cytometry NK cell activity 
 
X 
 
 
 
 
 
 
 
 
 
X * 
 
 
 
X ** 
 
#Counting from day 0 of cycle 2;  
*Pre-interferon, at 6 months from day 0 of cycle 2 (pre-Thalidomoide) and 12 months from day 0 of cycle 1; 
**During the first year; 
+  For the first 3 years; 
++ First day of apheresis 
‡ At 30 days from day 0 of cycle 2 
& If receiving thalidomide 
02/03/04 
02/03/04 
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9.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS 
 
The following definitions will be used for this study.  Response can be defined as a 50% or better 
reduction in serum myeloma protein production and further categorized as completed and partial.  
(Adopted from the ongoing Intergroup Study) 
 
9.1 
Response Gradations: 
 
9.1.1 Complete response: Defined as the absence of bone marrow or blood findings of multiple 
myeloma on at least 2 measurements at a  minimum of a 6 week interval.  Thus all evidence of 
serum and urinary M-components must disappear on electrophoresis as well as by 
immunofixation studies.  The follow-up bone marrow may not contain more than 3% plasma 
cells on aspiration or core biopsy and no evidence of increasing anemia.  Skeletal X-rays must 
either show recalcification or no change in osteolytic lesions. 
 
9.1.2 Partial Response:  Sustained decrease of the monoclonal serum protein by > 50% 
reduction) on at least two measurements of at least 6 week interval.  A response is clear-cut for 
patients who achieve a 75% or greater reduction in the serum myeloma protein concentration 
without evidence of increasing anemia.  Responding patients must also have a sustained decrease 
in 24-hour urine M-component to less of the initial prestudy value, and to less than 0.2 gm/day 
on at least two measurements at three-week intervals.  For a response to be confirmed, a marked 
reduction in both serum myeloma protein and in Bence-Jones protein excretion must be present.  
Bone marrow plasma cells should be reduced by at least 50% from the pretreatment level. 
 
9.1.3 In all complete,  and responding patients, the size and number of lytic skeletal lesions 
must not increase, and the serum calcium must remain normal.  Any of the following ancillary 
data will support the conclusion that an objective response has occurred, but are not required to 
confirm response:  1) recalcification of lytic skull or pelvis lesions (occurs in about 20% of 
responding patients with lytic lesions); 2) significant increase in depressed normal 
immunoglobulins, as in lgM increments exceeding 20 mg%, lgA exceeding 40 mg%, and lgG 
exceeding 400 mg% (occurs in about 15% of responding patients); 3) fall in the level of the 
serum beta-2 microglobulin to the normal range (less than 1.0 mg/dl).  However, it is well 
established that IFN can increase the B2M levels, which does not signify relapse. 
 
9.2 
Stable:  Patients with 25 - 49% tumor mass regression without new symptoms or signs of 
myeloma with declines in the serum myeloma protein production of less than 25% of the 
pretreatment level will be considered to have no response. 
 
9.3 
Plateau State:  Is defined as a lack of progression (change of < 25% myeloma protein) for 
a minimum duration of 3 months. 
 
9.4 
Progression:  Patients with a > 25% increase in myeloma protein production or other 
signs of disease such as hypercalcemia, etc. 
 
9.5 
Relapse:  This is defined by the unequivocal objective evidence and constitutes the 
earliest of any of the following:  1) an increase by more than 100% from the lowest level of the 
serum myeloma protein production; 2) an increase above the response level of the myeloma peak 
(i.e., relapse to more than 25% of the baseline myeloma protein production); 3) reappearance of 


 
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the myeloma peaks that had disappeared with the treatment; 4) definite increase in the size and 
number of lytic bone lesions recognized on radiographs.  Compression fractures per se do not 
constitute a relapse.   
 
9.6 
Performance Status:  Karnofsky Performance status will be recorded. 
 
10.0 
REPORTING DATA 
 
All primary data will be maintained by the Department of Biostatistics, City of Hope National 
Medical Center. This includes on study flow sheets, consent forms and off-study forms. 
 
01/07/00 11.0 
STATISTICAL CONSIDERATIONS 
 
11.1 
Sample Size  
 
The primary goal of this phase II study is to assess the feasibility and toxicities of administering 
two cycles of sequential high-dose chemotherapy consisting of melphalan and subsequent 
busulfan and cyclophosphamide followed by autologous stem cell support, alpha interferon, and 
thalidomide in patients with multiple myeloma.  Feasibility will be defined as the ability to 
receive all IL-2 
01/07/00  
 
 treatments.  The secondary objectives are to analyze response rate, 
progression-free and overall survival following receipt of this treatment regimen; and to assess 
the feasibility of adding Thalidomide for patients not yet in complete response (CR) at 6 months 
and the subsequent CR rate received. 
 
03/13/02  
 
An accrual goal of 70 patients will be set, allowing us to estimate the rate 
of feasiblely administering this treatment regimen with a maximum standard error of 
01/07/00  
 
 7%.  Based on our past experience, it is estimated that approximately 18 
patients (35%) will have achieved a CR by 6 months, so that approximately 32 patients will go 
on to receive Thalidomide. 
 
Based on the current referral patterns to the Department of Hematology and Bone Marrow 
Transplantation, it is expected that approximately 20 patients per year 
03/13/02  
 
will be eligible for this study.  With a goal of 70 patients, approximately 3 
½ years of accrual will be required.  As the majority of relapses are expected to occur within 3 
years or less, the study will continue for 3-4 years to allow sufficient follow-up for the secondary 
goal of analyzing disease progression and survival as well. 
 
11.2 
Toxicity Grading 
Hematologic suppression has traditionally been accepted as a primary endpoint for analysis of 
toxicity in investigational agents and novel drug combinations in oncology.  Nevertheless, 
autologous peripheral stem cell transplantation has ameliorated this toxicity significantly, 
allowing for high-dose chemotherapy.  We will utilize the Division of Cancer Treatment 
(DCT)/National Cancer Institute (NCI) Common Toxicity Criteria for evaluating toxicity of all 
organ systems, with the exception of the hematologic and gastrointestinal system, where we will 
follow the modified guidelines for studies involving bone marrow transplantation as 
recommended by the Cancer Therapy Evaluation Program (CTEP)  (Appendix D). 
 


 
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11.3 
Early Stopping Rules 
 
We have monitored the rate of treatment related death and so far, such death rate is 1.8% after 
treating 54 patients.  The study statistics call for a total of 70 patients for accrual.  Hence, if there 
is more then one additional VOD related treatment associated mortality in the next 10 patients, or 
if there are more then two cases within the next 20 patients who’s demise is related to VOD 
associated treatment related side effects, this study will be stopped. 
 
At the same time we will monitor the study for early stopping due to inability to receive the 
proposed treatment scheme.  Historically the overall feasibility rate with IL-2 treatment has been 
estimated to be 65%.  Inability to receive the full treatment regimen may be due to any of the 
following causes:  grade 3 or greater toxicities, intolerance, or disease progression within one 
year.  If at any point in the monitoring process there is a 95% or greater probability that the true 
feasibility rate is less than 65%, then the trial will be stopped early.  This would occur if the 
following numbers of inability to tolerate treatment regimen were observed: 
 
11.4 
Criteria for Success 
 
03/13/02  
 
If the study accrues to the full 70 patients, the trial will be considered a 
success on the primary endpoint if an overall feasibility rate of 65% or greater is observed.  If the 
estimated feasibility rate in the study group is equal to 65% then the 95% confidence interval 
would range from 52% to 78%, so that a minimum feasibility rate of 52% is ensured with 95% 
confidence.  
  
01/07/00  
 
Historically we have observed that approximately 10% of those patients 
who are not in CR at 6 months reach a CR after 6 months without administration of Thalidomide.  
If 10 out of the 32 patients (31%) receiving Thalidomide on the current study can be converted to 
CR after 6 months, then this approach will be considered a success, with the 95% confidence 
interval for late CR conversion ranging from 15% to 47%. 
 
03/13/02  
 
After treating the first 50 patients, the actual number requiring thalidomide 
is only 46%.  In order to achieve the initial targeted number of 32 patients, not in CR, and 
requiring thalidomide (thereby being able to assess the feasibility of tolerating thalidomide 
together with alpha-interferon as well as the ability of thalidomide to induce complete response 
conversion).  We request that the targeted accrual be increased to 20, hence, an additional 9 
patients, not in CR, can be treated with thalidomide for a total of 32 patients. 
 
11.5 
Analytic Plan 
 
The primary endpoint of feasibility will be estimated as a proportion along with the 95% 
confidence interval for the binomial.  If our accrual goal is met with no premature termination 
due to significant toxicity, a secondary goal of assessing response, progression-free survival 
(PFS), and overall survival (OS) will be carried out.  Survival estimates will be made using the 
product-limit method of Kaplan and Meier, with 95% confidence limits calculated using the logit 
transformation.  These estimates will be contrasted with the historical rates of 81% PFS and 85% 
OS at two years, although formal hypothesis testing will not 
01/07/00  
 
be conducted.  It is hoped that PFS and OS will be further improved with 
the addition of Thalidomide. 
10/10/02 


 
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While the primary estimates will be for the entire study group, survival estimates will also be 
carried out for subgroups stratified by bone marrow involvement (<=10% versus >10%), by 
remission status (CR/PR versus Stable Disease), and by cytogenetic abnormality (yes versus no), 
as these are known to be important prognostic factors.  Additional descriptive analyses assessing 
the incidence of hepatic and other toxicities was a correlate of busulfan and( if feasible) 
cyclophosphamide pharmacokinetics will also be carried out. 
 
01/07/00 12.0 
GENDER AND ETHNICITY STATEMENT 
 
The City of Hope has a plan in place to increase minority recruitment to our studies in 
compliance with the National Institute of Health policy for recruitment of women and minorities. 
 
The table below shows the distribution by sex and race of the patients accrued to therapeutic 
clinical studies at City of Hope for the past five years with the same primary site of disease 
targeted for this protocol (breast).  Our goal is to maintain our high accrual of women while 
continuing to increase the accrual of minority subjects. 
 
01/07/00 
 
Accrual Goal by Sex and Ethnicity  
 
 
 
 
 
By Sex 
 
By Ethnicity 
 
Site 
 
Accrual 
Goal 
 
Female 
 
Male 
 
White 
 
Hispanic 
 
Black 
 
Asian/ 
Other 
 
Unknown 
 
Multiple 
Myeloma 
 
 
367 
 
172 
(47%) 
 
195 
(53%) 
 
213 
(58%) 
 
66 
(18%) 
 
70 
(19%) 
 
14 
(4%) 
 
4 
(1%) 
 
13.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
This study is to be approved by the Institutional Review Board of the City of Hope.  All patients 
will have signed an informed consent for participation in research activities, and will have been 
given a copy of the Experimental Subject's Bill of Rights. 
 
When results of this study are reported in medical journals or at meetings, identification of those 
taking part will be withheld.  Medical records of patients will be maintained in strictest 
confidence, according to current legal requirements.  However, they will be made available for 
review, as required by the Food and Drug Administration (FDA) or to other authorized users 
such as the National Cancer Institute (NCI) under the guidelines established by the Federal 
Privacy Act. 
 
01/07/00  14.0 
BIBLIOGRAPHY 
 
1.  
Riedel DA.  In:  Epidemiology and biology of multiple myeloma.  GI Obrams and M 
Potter (eds.), Springer-Verlag, New York, 1991, pp. 13-16 
 
2.  
Kyle RA.  Epidemiology and biology of multiple myeloma.  GI Obrams and M Potter 
(eds.), Springer-Verlag, New York, 1991, pp. 75-81 
 
3.  
Barlogie B, Smallwood L, Smith T, Alexanian R.  High serum levels of lactic 


 
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dehydrogenase identify a high-grade lymphoma-like myeloma.  Annals Int Med 110:521-25, 
1989 
 
4.  
Barlogie B, Epstein J, Selvanayagam P, Alexanian R.  Plasma cell myeloma -New 
biological insights and advances in therapy.  Blood 73:865-79, 1989 
 
5.  
Boccadoro M, Marmont F, Tribalto M, et al.  Multiple myeloma:  Alternating 
combination chemotherapy (VCMP/VBAP) is not superior to melphalan and prednisone (MP) 
even in high risk patients.  J Clin Oncol 9:444-448, 1991 
 
6.  
Barlogie B, Smith L, Alexanian R.  Effective treatment of advanced multiple myeloma 
refractor to alkylating agents.  N Engl J Med 310:1353-1356, 1984. 
 
7.  
Sonneveld P, Durie BGM, Lokhorst HM, et al.  Modulation of multidrug-resistant 
multiple myeloma by cyclosporin.  Lancet 340:255-59, 1992. 
 
8. 
Barlogie B. Hematopoietic cell transplantation for multiple myeloma. in Thomas ED, 
Blume GG and Forman SJ. eds, Hematopoietic Cell Transplantation, Boston, Blackwell 
Scientific Publishers, 1998:1003-1013 
 
9.  
Cunningham D, Paz-Ares L, Gore ME, et al.  High-dose melphalan for multiple 
myeloma:  Long-term follow-up data.  J Clin Oncol 12:764-768, 1994 
 
10.  
Cunningham D, Paz-Ares L, Milan S, et al.  High-dose melphalan and autologous bone 
marrow transplantation as consolidation in previously untreated myeloma.  J Clin Oncol 12:759-
763, 1994 
 
11.  
Jagannath S, Barlogie B, Dicke K, et al.  Autologous bone marrow transplantation in 
multiple myeloma:  Identification of prognostic factors.  Blood 76:1860-1866, 1990 
 
12.  
Gore ME, Selby PJ, Viner C.  Intensive treatment of multiple myeloma and criteria for 
complete remission.  Lancet 2:879-855, 1990 
 
13.  
Barlogie B, Alexanian R, Dicke K, et al.  High-dose chemoradiotherapy and autologous 
bone marrow transplantation for resistant multiple myeloma.  Blood 70:869-72, 1987 
 
14.  
Bensinger WE, Buckner CD, Clift RA, et al.  A phase I study of busulfan and 
cyclophosphamide in preparation for allogeneic marrow transplant for patients with multiple 
myeloma.  J Clin Oncol 10:1492, 1992. 
 
15. 
Barlogie B, Gahrton G.  Bone marrow transplantation in multiple myeloma.  Bone 
Marrow Transplant 7:71-79, 1991. 
 
16. 
Bjorkstrand B, Ljungman P, Svensson H, et al.  Allogeneic bone marrow transplantation 
versus autologous stem cell transplantation in multiple myeloma: a retrospective case-matched 
study from the Europian Group for Blood and Marrow Transplantation.  Blood  88 : 4711-18, 
1996 
 


 
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17. 
Attal M, Harousseau J, Stoppa A, et al. A prospective, randomized trial of autologous 
bone marrow transplantation and chemotherapy in multiple myeloma.  Intergroupe Francais du 
Myelome.  N Engl J Med 355:1844, 1996 
 
18. 
Fermand J, Ravaud P, Chevret S, et al.  High-dose therapy and autologous peripheral 
blood stem cell transplantation in multiple myeloma: Up-front or rescue treatment? Results of a 
multicenter sequential randomized trial.  Blood  92:3131-36, 1998 
 
19. 
Barlogie B, Jagannath S, Desikan KR  et al.  Total therapy with tandem transplants for 
newly diagnosed multiple myeloma.  Blood 93:55-65, 1999 
 
20. 
Bjorkstrand B, Svennson H, Goldschmidt H, et. al.  Autotransplants in 
multiple myeloma-A registry study from the European Group for Bone Marrow 
Transplantation.  Blood 94: S3154a, 1999 
 
21. 
Attal M, Harosseau L, Facon T, et. al.  Single versus double transplant in 
myeloma: A randomized trial of the “Intergroup Francais Du Myelome.”  Blood 
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APPENDIX E.  
 
 
IMMUNOLOGIC CHARACTERISTICS, PHARMACOKINETIC STUDIES 
 
FISH AND HUMARA STUDIES 
 
Samples of 7.5  mL of blood in green top tubes will be submitted for flow cytometric analysis 
with special emphasis for CD3, CD8, CD4, CD16,  CD56 and CD57 marking.  Samples will be 
obtained pre-interferon, at 6 months from day 0 of cycle 2 (pre-thalidomide) , and 12 months 
from day 0 of cycle 1.  Details of NK cell functional analysis are still being worked out, and will 
be incorporated once the logistics (technician becomes available) are in place. 
 
2. 
A total of 7 blood draws, approximately 2 tablespoons of blood in total will be drawn 
during the administration of the first dose of busulfan.  Five (5) milliliters of peripheral blood 
will be collected in green-top (sodium heparin) tubes at the following times; pre-dose, just prior 
to the end of the infusion, then 15 minutes, 30 minutes, 1, 2, and 4 hours after the end of the 
dose.  The last sample will be obtained just prior to the start of dose 2. 
 
2.1 
Processing of samples for busulfan determination will consist of  centrifugation at 500xg 
to separate plasma from whole blood. Plasma will be stored frozen at  
 -20C until later batch analysis. 
 
2.2 
Busulfan concentrations in plasma will be determined using gas chromatography-mass 
spectrometry following derivatization with tetrafluorothiophenol.47 
 
3. 
Samples for cytogenetics/FISH/Humara assays will be obtained as follows: 
 
6.1 
Fluorescence in situ hybridization and HUMARA studies 
 
6.2 
Pretreatment samples: Applies to all patients registered to this study. 
 
6.2.1 Forty ml of peripheral blood (five sodium heparin or green top tubes) must be collected 
from each patient. 
 
6.2.2 Pretreatment bone marrow: 6-8 ml of a pretreatment bone marrow aspiratefrom each 
patient collected into standard cytogenetic tubes (tubes supplemented with tissue culture 
medium) is requested.  
2/22/01 
4. 
Apheresis sample: Two to four ml of apheresis specimen will be collected and placed in 
standard cytogenetic tubes with tissue culture medium. This sample may be obtained from any of 
the apheresis collections. 
 
6/14/99 5. 
Post-treatment samples: 
 
5.1 
Blood samples (forty ml of peripheral blood [five sodium heparin or green top tubes]) 
will be collected pre-interferon and at 12 months from day 0 of cycle 1 (melphalan) therapy from 
each patient. 
 
5.2 
Post-treatment bone marrow: 6-8 ml of a pretreatment bone marrow aspirate from each patient 


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collected into standard cytogenetic tubes (tubes supplemented with tissue culture medium) is requested.  
 
5.3 
The samples should be marked for same day delivery (room temperature) to Cytogenetics Research, 
Northwest Building, Room 2265.  Vicki Bedell (ext. 2025) or Dr. Slovak (ext. 2313, also same extension for  
additional distribution for Dr. Yen) may be contacted regarding questions concerning specimen collection 
and processing. 
 
5.4 
To reduce the cost of this study, the assays will be performed in batches.  Storage of the DNA 
(HUMARA) and fixed cell pellets (FISH) will follow the standard procedures for the cytogenetics 
laboratory, that is, samples will be stored in a  
-80oC locked freezer until ready for use.