Conditions: DS Stage I Plasma Cell Myeloma DS Stage II Plasma Cell Myeloma DS Stage III Plasma Cell Myeloma Refractory Plasma Cell Myeloma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 19
Healthy volunteers: no

Brief summary:
This phase II trial studies how well busulfan, melphalan, and bortezomib before first-line stem cell transplant works in treating patients with multiple myeloma. Giving chemotherapy before a peripheral blood stem cell transplant may stop the growth of cancer cells by stopping them from dividing or killing them. After treatment, stem cells are collected from the patient's blood and stored. The stem cells are then returned to the patient to replace the blood-forming cells that were destroyed by the chemotherapy.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the complete response rate as defined by the International Myeloma Working Group (IMWG) criteria for patients with multiple myeloma treated with high dose chemotherapy with pharmacokinetic (PK) directed intravenous (IV) busulfan, bortezomib and melphalan (Bu/BTZ/Mel140) followed by autologous hematopoietic stem cell transplantation (ASCT) as first line therapy.

SECONDARY OBJECTIVES:

I. To determine the overall response rate of the regimen Bu/BTZ/Mel140. II. To determine the treatment related toxicity and mortality of the regimen, including 100-day mortality rates.

III. To determine the duration of response, time to progression, progression-free survival, event-free survival and overall survival for this conditioning regimen.

IV. To determine whether there is a gender or race difference in the pharmacokinetic profile of IV busulfan.

V. To determine methylation and gene expression signatures of pre-treatment bone marrow plasma cells and explore associations of these signatures with outcome.

OUTLINE:

CONDITIONING: Patients receive busulfan IV over 3 hours on days -6 to -3, melphalan IV over 20 minutes on day -2, and bortezomib IV over 3-5 seconds on days -6, -3, 1, and 4.

TRANSPLANT: Patients undergo autologous peripheral blood stem cell transplant (PBSCT) on day 0.

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

Arms:
arm 1: CONDITIONING: Patients receive busulfan IV over 3 hours on days -6 to -3, melphalan IV over 20 minutes on day -2, and bortezomib IV over 3-5 seconds on days -6, -3, 1, and 4.

TRANSPLANT: Patients undergo autologous PBSCT on day 0.

Interventions: intervention 1: Busulfan intervention 2: Melphalan intervention 3: Bortezomib intervention 4: Autologous Hematopoietic Stem Cell Transplantation intervention 5: Peripheral Blood Stem Cell Transplantation
Intervention descriptions: intervention 1: Given IV intervention 2: Given IV intervention 3: Given IV intervention 4: Undergo autologous PBSCT intervention 5: Undergo autologous PBSCT

Protocol document:
Prot_SAP_000.pdf: 
 i 
Local Protocol #: 11-12-434 
 
TITLE:  “A Phase II study Assessing the Efficacy and Toxicity of PK-directed Intravenous Busulfan in 
Combination with High-Dose Melphalan and Bortezomib as Conditioning Regimen for First-line 
Autologous Hematopoietic Stem Cell Transplantation in Patients with Multiple Myeloma” 
 
 
Coordinating Center  
Montefiore-Einstein Cancer Center 
 
 
 
 
 
Montefiore Medical Center-Moses Division 
 
 
 
 
 
Clinical Trials Office 
 
 
 
 
Department of Oncology, Hofheimer Pavilion 100 
 
 
 
 
111 East 210th Street 
 
 
 
 
Bronx, New York 10467 
 
 
 
 
Phone 718-920-2006 
 
 
 
 
Fax 718-405-4712 
 
National 
 
 
Ira Braunschweig, MD 
Principal Investigator:  
Montefiore-Einstein Cancer Center  
 
 
 
 
Montefiore Medical Center-Moses Division 
 
 
 
 
Department of Oncology, Hofheimer Pavilion, Room 407 
 
 
 
 
111 East 210th Street 
 
 
 
 
Bronx, New York 10467 
 
 
 
 
Phone 718-920-4826/Fax 718-798-7474 
 
 
 
 
Email : IBRAUNSC@montefiore.org 
 
National  
Co-Principal Investigator :     Stefan Barta, MD  
 
 
 
 
Fox Chase Cancer Center  
 
 
 
 
333 Cottman Avenue  
 
 
 
 
Philadelphia, PA 19111 
 
 
 
 
 
Phone: 215-728-2674 
 
 
 
 
 
Fax: 215-728-3639 
 
 
 
 
 
Email: Stefan.Barta@fccc.edu 
 
 
Sub-Investigators: 
 
 
 
Amit K. Verma, M.B.B.S. 
 
 
 
Ramakirshna Battini, MD     
Albert Einstein College of Medicine  
 
Montefiore-Einstein Cancer Center 
Jack and Pearl Resnick Campus,  
 
 
Montefiore Medical Center-Moses Division 
Chanin Building, Room 302B  
 
 
Department of Oncology, Hofheimer Pavilion 
1300 Morris Park Avenue 
 
 
 
111 East 210th Street 
Bronx, New York 10461 
 
 
 
Bronx, New York 10467 
Phone 718-930-8761  
 
 
 
Phone 718-920-4826/Fax 718-798-7474 
Email: amit.verma@einstein.yu.edu 
 
 
Email : RABATTIN@montefiore.org 
 
 
 
 
  
IRB NUMBER: 11-12-434
IRB APPROVAL DATE: 12/01/2015


 ii 
 
Olga Derman, MD 
 
 
 
 
Noah Kornblum, MD 
 
Montefiore-Einstein Cancer Center  
 
Montefiore-Einstein Cancer Center 
 
Montefiore Medical Center-Moses Division  
Albert Einstein Cancer Center 
 
Department of Oncology, Hofheimer Pavilion 
at the Montefiore Medical Park 
 
111 East 210th Street  
 
 
 
1695 Eastchester Road 
 
Bronx, New York 10467 
 
 
 
Bronx, New York 10467 
 
Phone 718-920-4826/Fax 718-798-7474 
 
Phone 718-405-8404/Fax 718-405-8433 
 
Email : ODERMAN@montefiore.org   
 
Email : NKORNBLU@montefiore.org 
 
 
 
 
 
  
 
Jason Carter, PA-C  
 
 
 
 
Dale Wyville, PA-C  
 
Montefiore-Einstein Cancer Center  
 
Montefiore-Einstein Cancer Center 
 
Montefiore Medical Center-Moses Division  
Albert Einstein Cancer Center 
 
Department of Oncology, Hofheimer Pavilion 
at the Montefiore Medical Park 
 
111 East 210th Street  
 
 
 
1695 Eastchester Road 
 
Bronx, New York 10467 
 
 
 
Bronx, New York 10467 
 
Phone 718-920-8401/Fax 718-563-2572 
 
Phone 718-405-8404/Fax 718-405-8433 
 
Email : JASOCART@montefiore.org   
 
Email : DWYVILLE@montefiore.org  
 
Amitabha Mazumder, MD 
 
 
 
Sergio A. Giralt, MD  
Professor of Medicine 
 
 
 
Chair, Adult BMT Service  
Director, Multiple Myeloma Program 
 
Memorial Sloan-Kettering Cancer Center  
NYU Cancer Center 
 
 
 
 
1275 York Avenue  
160 East 34th St 
 
 
 
 
New York, NY 10021 
New York, NY 10016  
 
 
 
Phone: 212-639-3859 
Phone: 212-731-5757  
 
 
 
Fax: 212-639-3861 
Fax:  212-731-5646 
 
 
 
 
Email: giralts@mskcc.org  
Email:   amitabha.mazumder@nyumc.org 
 
Mecide M Gharibo, MD 
Associate Professor of Medicine 
Hematologic Malignancies and Stem Cell Transplant 
Cancer Institute of New Jersey 
UMDNJ-Robert Wood Johnson Medical School 
195 Little Albany Street 
New Brunswick, NJ 08903 
Phone: 732-235-7006 
Fax: 732-235-8681 
 
Email: gharibmm@umdnj.edu 
 
 
 
            Statistician: 
 
 
 
Study Coordinator/Data Management: 
            Nan Xue, PhD 
 
 
 
Clinical Trials Office 
 
           Albert Einstein College of Medicine                      
Montefiore Medical Center 
           Jack and Pearl Resnick Campus 
 
       
Depart. of Oncology, Hofheimer Pavilion 
           1300 Morris Park Avenue         
 
       
Bronx, NY 10467 
IRB NUMBER: 11-12-434
IRB APPROVAL DATE: 12/01/2015


 iii 
           Belfer Building, Room 1303C  
                    
Phone 718- 920-2006 
           Bronx, NY 10461    
      
      
  
       
Fax 718-405-7412 
           Phone: 718-430-2431                                                
          Email: Xiaonan.xue@einstein.yu.edu         
        
 
 
Protocol Type / Version # / Version Date: Version 4.0/ 25 February 2014  
 
SYNOPSIS 
 
BACKGROUND: High dose therapy followed by autologous hematopoietic stem cell transplantation 
(ASCT) has an established role in the treatment of patients with multiple myeloma. The most 
commonly used conditioning (or preparative) regimen in this setting is high-dose melphalan 
(200mg/m2; Mel200), which has been shown to result in improved progression free and overall 
survival. Achievement of a complete response following ASCT is a powerful indicator for freedom 
from relapse, as well as progression free and overall survival. The complete response (CR) rate 
observed after Mel200 followed by ASCT is between 10-35% depending on the induction regimen 
used. There is evidence that the combination of busulfan (Bu) and melphalan (Mel) results in longer 
progression free and overall survival compared to melphalan alone. Additionally, the use of 
bortezomib (Btz) during conditioning with either high dose melphalan alone or the combination of 
melphalan and IV busulfan has shown to be both safe and to have very promising efficacy. We 
hypothesize that the combination of Bu/Btz/Mel140 will lead to a 20% improved complete response 
rate compared with historical controls. 
 
The primary objective is to determine the complete response rate of PK directed iv Busulfan, 
Bortezomib and Melphalan (Bu/BTZ/Mel140) conditioning followed by autologous hematopoietic 
stem cell transplantation (ASCT) 
Secondary Objectives are to determine the overall response rate of the regimen Bu/BTZ/Mel140, to 
determine the treatment related toxicity and mortality of the regimen, including 100-day mortality 
rates, to determine the duration of response, time to progression, event-free and overall survival, 
and to determine whether there is a gender or race difference in the pharmacokinetic profile of IV 
busulfan. 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 iv 
TREATMENT SCHEMA 
* The baseline period can be extended to -21 to -9 days  
Abbreviations: Bu, busulfan – PK directed; Mel140; melphalan at 140mg/m2; BTZ, bortezomib at 
1mg/m2 
Eligibility Criteria: Patients must have active multiple myeloma (MM) requiring treatment, 
measurable disease, be age 18-72, have adequate heart, lung, and renal function, ECOG performance 
status  2, and a life expectancy of > 12 months. Patients will be excluded if they have received more 
than 12 months of prior chemotherapy for this disease, >Grade 2 peripheral neuropathy, 
hypersensitivity to bortezomib, boron, or mannitol, unresolved grade >2 non-hematologic toxicity 
from previous therapy, previous autologous or allogeneic stem cell transplant, uncontrolled 
infection, significant co-morbid medical conditions or uncontrolled life threatening infection, prior 
malignancy other than adequately treated non-melanoma skin cancer. 
 
Statistical Considerations: The primary endpoint of the trial will be the complete response rate 100 
days after the ASCT as defined by the International Myeloma Working Group uniform response 
criteria. We aim to demonstrate that the complete response rate (CRR) 100 Days after the ASCT is at 
least 35%. This would demonstrate at least the same complete response rate as the reported 
complete response rates of the Mel200 conditioning regimen. If the true response rate for the new 
regimen (Bu/Mel/Btz) is 55%, with 28 patients in the study, we will be able to construct a 95% 
confidence interval for the true response rate with the lower bound no less than 35%.  
The secondary endpoints to be explored will be the overall response (very good partial & partial 
response, stable disease and progression), toxicity as assessed by the Common Terminology Criteria 
for Adverse Events (CTCAE) v4.0,2 mortality at days 30, 100 and 360 post transplant, time to 
progression, median progression, event free and overall survival, and possibly associations of the 
pharmacokinetic profile of iv busulfan as determined by the test dose and the variables gender and 
race. Methylation and gene expression signatures of bone marrow pre-treatment plasma cells will be 
correlated with outcome.  
Day -14 to -11*   -6          -5           -4           -3           -2          -1          0 
        +1             +4 
  +60  
Busulfan 
Test Dose 
Bu 
Bu 
Bu 
Bu 
Mel140 
Stem Cell 
Infusion 
BTZ 
BTZ 
BTZ 
BTZ 
Response 
Assessment 
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TABLE OF CONTENTS 
Page 
 
SYNOPSIS .......................................................................................................................................... i 
 
1. OBJECTIVES ............................................................................................................................... 1 
1.1 
Primary Objectives .........................................................................................................  
1.2 
Secondary Objectives .....................................................................................................  
 
2. BACKGROUND ........................................................................................................................... 1 
2.1 
High Dose Therapy in Multiple Myeloma............................................................... 1 
2.2 
IV Busulfan (Busulfex™) ........................................................................................ 2 
2.3 
Melphalan ..................................................................................................................... 4 
2.4 
Bortezomib .................................................................................................................... 4 
2.5 
Rationale ....................................................................................................................... 5 
2.6 
Correlative Studies ........................................................................................................ 6 
 
3. PATIENT SELECTION .................................................................................................................. 6 
3.1 
Eligibility Criteria  .......................................................................................................... 6 
3.2 
Exclusion Criteria .......................................................................................................... 8 
3.3 
Inclusion of Women and Minorities ............................................................................ 9 
 
4. REGISTRATION PROCEDURES ................................................................................................. 10 
4.1  
General Guidelines ..................................................................................................... 10 
4.2  
Registration Process ................................................................................................... 10 
 
5. TREATMENT PLAN ................................................................................................................... 11 
5.1  
Agent Administration ................................................................................................. 12 
 
5.1.1 PK directed Busulfan Dosing and Administration ......................................... 12 
 
5.1.2 Melphalan ....................................................................................................... 14 
 
5.1.3    Bortezomib ...................................................................................................... 14 
 
5.1.4    Peripheral Blood Stem Cell Reinfusion .......................................................... 14
 
 
5.2  
General Concomitant Medication and Supportive Care Guidelines......................... 15 
5.3 
Restricted Medication ................................................................................................. 16 
5.4 
Duration of Follow Up ................................................................................................. 17 
5.5 
Criteria for Removal from Study ................................................................................ 17 
5.6 
Consolidation/Maintenance therapy post-transplant .............................................. 18 
 
6. SCHEDULE OF EVENTS ............................................................................................................. 19 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS .................................................. 25 
7.1  
Adverse Events and Potential Risks Lists ................................................................... 25 
7.1.1 Adverse Event List for IV Busulfan (Busulfex™) ........................................................ 25 
7.1.2 Adverse Event List for Bortezomib ............................................................................. 28 
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7.1.3 Adverse Event List for Melphalan .............................................................................. 31 
7.2  
Adverse Event Characteristics .................................................................................... 32 
7.3  
Expedited Adverse Event Reporting .......................................................................... 32 
7.4  
Data Safety and Monitoring Plan ............................................................................... 37 
7.5 
Routine Adverse Event Reporting .............................................................................. 37 
 
8. PHARMACEUTICAL INFORMATION ........................................................................................ 38 
8.1  
IV Busulfan (Busulfex™) .............................................................................................. 38 
8.2  
Melphalan ................................................................................................................... 38 
8.3  
Bortezomib .................................................................................................................. 40 
 
9. CORRELATIVE/SPECIAL STUDIES ............................................................................................ 41
 
 
 
10. STUDY CALENDAR ................................................................................................................... 42 
 
11. MEASUREMENT OF EFFECT .................................................................................................... 43 
11.1 
Response Assessment ................................................................................................ 43 
 
 
12. DATA REPORTING / REGULATORY CONSIDERATIONS .......................................................... 46 
12.1 
Data Management ...................................................................................................... 47 
12.2 
Patient Protection ....................................................................................................... 47 
12.3 
Recruitment and Informed Consent .......................................................................... 47 
 
13. STATISTICAL CONSIDERATIONS .............................................................................................. 47 
13.1 
Study Design/Endpoints ............................................................................................. 47 
13.2 
Sample Size/Accrual ................................................................................................... 48 
13.3 
Analysis of Secondary Endpoints ............................................................................... 48 
13.4 
Reporting and Exclusions ........................................................................................... 49 
13.5 
Interim Analysis Decision Rules ................................................................................. 49 
 
APPENDICES 
APPENDIX A 
Performance Status Criteria .............................................................................................. 51 
 
APPENDIX B 
Busulfan PK Testing ........................................................................................................... 52 
 
APPENDIX C 
 
Baltimore Criteria for diagnosis of VOD and severity determination ............................... 54 
 
APPENDIX D 
 
Form 1 – Eligibility and Registration Form ........................................................................ 55 
 
 
APPENDIX E 
 
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Handling and Shipping of Bone Marrow Specimens ......................................................... 57 
 
REFERENCES .................................................................................................................................. 58
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1
1. OBJECTIVES 
 
1.1. 
Primary Objectives 
 
To determine the complete response rate as defined by the International Myeloma Working 
Group (IMWG) criteria3 for patients with Multiple Myeloma treated with high dose 
chemotherapy with PK directed iv Busulfan, Bortezomib and Melphalan (Bu/BTZ/Mel140) 
followed by autologous hematopoietic stem cell transplantation (ASCT) as first line therapy 
 
1.2. 
Secondary Objectives 
 
1.2.1 To determine the overall response rate of the regimen Bu/BTZ/Mel140 
 
1.2.2 To determine the treatment related toxicity and mortality of the regimen, including 
100-day mortality rates 
 
1.2.3 To determine the duration of response, time to progression, progression-free survival, 
event-free survival and overall survival for this conditioning regimen 
 
1.2.4. To determine whether there is a gender or race difference in the pharmacokinetic 
profile of IV busulfan 
 
1.2.5 To determine methylation and gene expression signatures of pre-treatment bone 
marrow plasma cells and explore associations of these signatures with outcome 
 
 
2. BACKGROUND 
 
2.1  
High Dose Therapy in Multiple Myeloma 
 
High dose therapy followed by autologous hematopoietic stem cell transplantation (ASCT) has 
an established role in the treatment of patients with multiple myeloma. Since the early 1990s, 
several studies have compared first-line treatment including ASCT versus standard combination 
chemotherapy. Most trials have comprised patients of a younger age category, essentially up 
to the age of 65 years.4 The first randomized study to demonstrate the superiority of ASCT was 
the French IFM90 study on 200 patients, published in 1996: median OS and event-free survival 
(EFS) were 57 and 44 months, respectively, for patients who underwent ASCT, compared with 
44 and 18 months in the chemotherapy group,5 and the difference was most strongly 
pronounced in patients under the age of 60 years. However, other controlled randomized 
studies only showed improvement in EFS but not in OS, or no benefit in outcomes was 
observed. Still, high-dose treatment with ASCT is considered as the gold standard for myeloma 
patients at least up to 60 to 65 years of age, based on its demonstrated efficacy, and the 
benefits in quality of life, with long treatment-free periods of good disease control.4  
 
The most commonly used conditioning (or preparative) regimen in this setting is high-dose 
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melphalan (200mg/m2; Mel200). This intensive therapy has been shown to result in improved 
progression free and overall survival compared to other treatment strategies not involving 
high-dose chemotherapy.6-8 However, multiple myeloma remains an incurable disease and 
even after achieving a complete response patients will eventually relapse unless other 
competing events occur first. Better therapies, that prevent relapse for a longer time, are 
needed. There is convincing evidence that achievement of a complete response following 
autologous hematopoietic stem cell transplantation (ASCT) is a powerful indicator for freedom 
from relapse, as well as progression free and overall survival.9 Improved conditioning regimens 
associated with better therapeutic indexes that result in higher response rates, less morbidity 
and mortality are needed. 
 
 
2.2  
IV Busulfan (Busulfex™) 
 
Introduction 
Busulfan, a potent, cytotoxic, bifunctional alkylating agent that causes myeloablation, has been 
used clinically since the 1950s to treat hematological malignancies and myeloproliferative 
syndromes. Busulfan produces deoxyribonucleic acid (DNA) cross-linking and chromosomal 
damage that can be lethal to rapidly dividing cells. At the low end of the active dose range, 
busulfan causes a selective depression of granulocytopoiesis. Increasing doses lead to 
progressive general myelotoxicity culminating in marrow ablation due to cell death. High doses 
cause significant DNA damage and are myeloablative.10  The selectivity of busulfan for marrow 
cells has several explanations. One is based on the susceptibility of relatively undifferentiated 
stem cells during the G-phase of the cell mitotic cycle to alkylation by busulfan. Busulfan 
treatment during the G-phase halts further differentiation and progression of the cell through 
the cell cycle. Microscopic examination of stem cell populations indicates arrested cell division 
with polyploidy and cell death.10 
Busulfan was used initially at low oral doses for palliative care, then at high oral doses in 
combination with other alkylating agents having immunosuppressive properties to promote 
the engraftment of bone marrow following allogeneic or autologous transplantation. In more 
recent years, busulfan has been used as one component of a chemo- plus radiotherapy or 
chemotherapeutic-based conditioning regimen prior to transplant. Busulfan’s narrow 
therapeutic window as well as unpredictable intestinal absorption and erratic bioavailability led 
to the development of a parenteral formulation.11 Subsequently, intravenous (IV) busulfan 
(under the name of Busulfex™) was approved in 1999 in the US and Canada as a pretransplant 
conditioning agent.12 
 
Pharmacokinetics and Clinical Data  
Following doses as 3-hour infusions, daily for 4 days, drug clearance and systemic exposure 
(area under the concentration-time curve, AUC) were reported to be linear and dose 
proportional over a dose rate range of 0.4 to 1.2 mg/kg/h. The maximum concentration (Cmax) 
of busulfan increased in proportion with dose. Dose proportional kinetics were also observed 
for 3-hour infusions compared to 2-hour infusions. A dose of 130 mg/m2 infused over 3 hours 
produced a mean Cmax of 3.6 μg/ml. The mean Cmax observed for a 0.8-mg/kg/dose (~32 mg/m2) 
infused over 2 hours was 1.2 μg/ml. Similarly, the median AUC for the 130 mg/m2 dose, 3-hour 
infusion was 4873 μMxmin (CV 21.8%) and the median AUC for the ~32 mg/m2 dose, 2-hour 
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infusion was 1292 μM.min (CV 25%). Intrapatient variability in day-to-day estimated clearance 
was <20%. No drug accumulation was observed over the 4-day course of administration. 
Clearance values were similar for both dose regimens.13 
Busulfan exposure (AUC) has been shown to be correlated with clinical outcome and 
manifestation of adverse events. Andersson et al14 compared outcomes in subjects with 
busulfan exposure in the optimal range (AUC between 950 and 1520 μMxmin) to those with 
lower (AUC < 950 μMxmin) or higher (AUC >1520 μMxmin) exposures in allogeneic HSCT for 
chronic myelogenous leukemia. The optimally-dosed group had a significantly better survival 
rate than those with lower or higher exposures. A retrospective study comparing the fixed-
dose oral busulfan-based regimen and PK-directed IV busulfan-based regimen showed the 
improvement in clinical outcomes of NHL: non-relapsed mortality, IV 3% vs. oral 28%; 
progression free survival, IV 50% vs. oral 17%.15  
 
Therefore, PK-directed dose optimization of busulfan in autologous HSCT is relevant in order to 
achieve the optimal therapeutic AUC window, to eliminate unnecessary underexposure to the 
drug caused by variability in busulfan metabolism, and to potentially improve the survival in 
the patient population who undergo autologous HSCT in lymphoma. Instead of adjusting later 
busulfan doses based on the exposure (AUC) observed on the first day of dosing in a 
conditioning regimen, it was proposed to administer a test dose of busulfan to obtain busulfan 
PK parameters prior to implementation of the conditioning regimen. Kletzel et al16 
implemented a test dose method in 30 pediatric patients with malignant and nonmalignant 
conditions. A 0.8 mg/kg test dose of IV busulfan (target AUC range of 800 to 1200 μMxmin) 
was followed one to two weeks later by two daily doses of a PK-directed dose to target an AUC 
range of 3200 to 4800 μMxmin. Twenty-six of the patients had evaluable results; two of the 
sample sets showed sampling errors and two were corrupted by shipping problems. The 
conditioning regimen dose was adjusted in 20 patients based on the test dose PK; eight 
patients received lower doses (2.5 to 3.1 mg/kg) and twelve patients received higher doses (3.3 
to 7.2 kg/mg). The median dose administered was 3.2 mg/kg (2.5 to 7.2 mg/kg) and the target 
AUC was achieved in 23 of 30 patients, six of the seven patients failing to meet the target were 
less than two years old. Test dose and first PK-directed dose clearance were the same with the 
exception of two patients; one with higher clearance and one with lower clearance relative to 
the first dose. The reason for the discrepancy is not known. The authors concluded that the 
test dose provided information for subsequent dosing and the method was feasible, safe, and 
convenient for administration of IV busulfan to children. 
 
The pharmacodynamics of non-cell-cycle specific agents, including alkylating agents such as 
busulfan, tend to be associated with total exposure rather than dosing schedule. As a 
consequence, a number of investigators have evaluated the pharmacokinetics, safety, and 
efficacy of a dose of 3.2 mg/kg (or the equivalent of roughly130 mg/m2) QD administered as a 
3-hour infusion as an alternative to the labeled 0.8 mg/kg 2-hour infusions four times per day. 
Clinical outcomes were similar for a higher dose given QD and a lower dose given four-times a 
day.17-19 
 
Busulfan, as an alkylating agent, has been shown to be an effective reagent for lymphoma in 
the autograft setting as well as in allogeneic HSCT. The clinical data using busulfan and 
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cyclophosphamide with or without etoposide have yielded clinical results that are comparable 
to the other preparative regimens for autologous HSCT both in NHL and HL.15,20,21 
 
In patients with multiple myeloma, the use of intravenous busulfan in combination with 
melphalan as high dose chemotherapy has also demonstrated promising efficacy. The studies 
showed safety and indicated improved outcomes compared to historical controls that were 
treated with melphalan alone both in the upfront and relapsed setting.22,23 In a retrospective 
case-control study the combination of busulfan and melphalan resulted in longer progression 
free and overall survival compared to melphalan alone.24 This has as yet not been studied 
prospectively. 
 
 
2.3. Melphalan 
 
Melphalan, also known as L-phenylalanine mustard, phenylalanine mustard, L-PAM, or L-
sarcolysin, is a phenylalanine derivative of nitrogen mustard. Melphalan is a bifunctional 
alkylating agent that is active against selected human neoplastic diseases. It is known 
chemically as 4-[bis(2-chloroethyl)amino]-L-phenylalanine. As a result, its cytotoxicity appears 
to be related to the extent of its interstrand cross-linking with DNA, probably by binding at the 
N7 position of guanine. Like other bifunctional alkylating agents, it is active against both resting 
and rapidly dividing tumor cells. 
 
While in its first trials high-dose melphalan was administered orally, the current use of 
melphalan is largely currently restricted to the intravenous (i.v.) route, which avoids the 
problem of its inconsistent oral absorption. Melphalan does not require metabolic activation. It 
undergoes spontaneous hydrolysis in the plasma, with inactive monohydroxy and dihydroxy 
metabolites appearing within minutes of the drug administration. About 15% of the drug is 
excreted intact in the urine. It is highly bound to proteins, mainly albumin. Melphalan is 
actively transported into cells, mostly by the high-affinity L-amino-acid transport system, which 
also carries glutamine and leucine. 
Melphalan PKs remain linear when delivered at high doses, in a range from 140 to 220 mg/m2. 
Its distribution fits a two-compartment model, with an elimination half-life (t1/2 ) of 45–
60 min, which allows the infusion of stem cells within 8–24 h of melphalan administration. 
After high-dose therapy, mean peak cerebrospinal fluid concentrations may reach 10% of the 
corresponding plasma concentrations. The dose-limiting toxicity (DLT) of high-dose melphalan 
is gastrointestinal mucositis and myelosuppression.25  
 
Melphalan at a dose of 200mg/m2 intravenously (Mel200) is the most commonly used 
conditioning for multiple myeloma. Traditionally, the complete response (CR) rate observed 
after Mel200 followed by ASCT is between 10-35% depending on the induction regimen used.6-
8 
 
 
 
2.4. Bortezomib 
 
Bortezomib (Velcade, PS-341), the prototypical clinically relevant proteasome inhibitor, is a 
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5
dipeptidyl boronic acid derivative that has recently been approved for use in myeloma and 
mantle cell lymphoma and has also shown activity in other hematologic malignancies.26-28 
Bortezomib inhibits the chymotryptic activity of the 20S proteasome, and in so doing, disrupts 
the proteasome mediated degradation of diverse cellular proteins.29 Bortezomib activity has 
been postulated to reflect interference with NF-κB signaling secondary to inhibition of 
degradation of the NF-κB inhibitory protein IκBα..30 However, multiple other mechanisms of 
lethality have been proposed, including increased generation of reactive oxygen species (ROS), 
which has been demonstrated in lung cancer and leukemia cells.31 Moreover, proteasome 
inhibitors have been shown to kill cells in association with induction of ER stress, presumably 
by interfering with the disposition of unfolded proteins. For reasons that are incompletely 
understood, proteasome inhibitors selectively induce apoptosis in tumor as compared with 
normal cells. 32,33 
For patients, who are not transplant candidates, bortezomib is considered at present one of 
the most active agents, either by itself or when combined with other agents.27,34,35 
 
Additionally, the combination of bortezomib with either high dose melphalan alone or high 
dose melphalan and IV busulfan as part of a preparative regimen for autologous stem cell 
transplantation in multiple myeloma has been shown to be both safe and to have very 
promising efficacy in early trials.8,36 
 
 
2.5 Rationale 
 
High dose therapy followed by autologous hematopoietic stem cell transplantation (ASCT) has 
an established role in the treatment of patients with multiple myeloma. The most commonly 
used conditioning (or preparative) regimen in this setting is high-dose melphalan (200mg/m2; 
Mel200). This intensive therapy has been shown to result in improved progression free and 
overall survival compared to other treatment strategies not involving high-dose chemotherapy. 
Traditionally, the complete response (CR) rate observed after Mel200 followed by ASCT is 
between 10-35% depending on the induction regimen used.6-8 
 
However, multiple myeloma remains an incurable disease and even after achieving a complete 
response patients will eventually relapse unless other competing events occur first. Better 
therapies, that prevent relapse for a longer time, are needed. There is convincing evidence that 
achievement of a complete response following autologous hematopoietic stem cell 
transplantation (ASCT) is a powerful indicator for freedom from relapse, as well as progression 
free and overall survival.9 Better conditioning regimens associated with improved therapeutic 
indexes that result in higher response rates, less morbidity and mortality are needed. 
 
Oral preparations of busulfan have traditionally been used as preparation for hematopoietic 
stem cell transplantation. Its use has been limited by unreliable and erratic bioavailability that 
resulted in severe toxicity. The intravenous formulation of busulfan (Busulfex™) has a much 
more favorable safety profile secondary to its more reliable pharmacokinetic properties and 
bioavailability. Dosing based on a pharmacokinetic (PK) profile following a test dose results in 
very reliable and reproducible serum levels.13 This has not only led to less toxicity, but also 
resulted in improved outcomes.14,37 
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The use of intravenous busulfan in combination with melphalan as high dose chemotherapy 
has been explored in patients with multiple myeloma. The studies demonstrated safety and 
indicated improved outcomes compared to historical controls that were treated with 
Melphalan alone both in the upfront and relapsed setting.22,23 In a retrospective case-control 
study the combination of busulfan and melphalan resulted in longer progression free and 
overall survival compared to melphalan alone.24 
The addition of bortezomib to a preparative regimen with either high dose melphalan alone or 
the combination of melphalan and IV busulfan has shown to be both safe and to have very 
promising efficacy in early trials.8,36  
 
While high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is an 
established treatment modality for multiple myeloma, the superiority of one regimen over 
another has not been established. Based on these observations we hypothesize that a 
conditioning regimen consisting of intravenous PK-directed busulfan in addition to melphalan 
and bortezomib will be safe and result in a high response rate. The proposed regimen differs 
from a similar study by Rodriguez et al36 by using a) PK-directed dosing of iv busulfan based on 
a test dose before the first treatment dose is administered and b) bortezomib with a different 
dose-intensity (different dose and more frequent in the proposed regimen). 
 
We therefore propose a two-stage phase II single arm study1 evaluating the safety and efficacy 
of a combination of PK-directed intravenous Busulfan with Bortezomib and Melphalan 
(Bu/BTZ/Mel140) in the setting of a first transplant in patients with multiple myeloma. Our 
hypothesis is that this combination will lead to a 20% improved complete response rate 
compared with historical controls. It is routine practice in clinical research in oncology to 
perform a feasibility study of a new untested regimen to better assess safety and efficacy in a 
smaller number of patients via a phase 2 trial prior to subjecting many more patients to a much 
larger randomized phase 3 trial. We have reliable historical data on the efficacy of melphalan 
alone, and the presented study utilizes an interim efficacy analysis after 22 patients have been 
enrolled (part of the Simon 2 stage design (“minimax”), see statistical section 13.1) to explore 
whether the efficacy is promising enough to proceed to the total of 42 patients. Only once the 
efficacy and safety of the proposed regimen has been sufficiently established in 42 patients will 
we propose to proceed to a larger phase 3 trial involving more patients. Randomized phase 2 
trials are not statistically powered to declare superiority of one regimen over the other. 
 
 
2.6 Correlative Studies 
 
Gene expression studies have revealed signatures that are predictive of prognosis in myeloma and 
can identify patients with high risk disease38-41. Gene expression studies have also revealed sets of 
genes whose expression can predict response to agents such as lenalidomide and bortezomib in 
myeloma.42-44  
Gene expression is a tightly regulated process and is influenced by aberrant epigenetic changes 
that can lead to carcinogenesis. We have used the HELP (HpaII tiny fragment Enrichment by 
Ligation-mediated PCR) assay45,46 to perform an unbiased genome-wide analysis of DNA 
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methylation and shown that extensive DNA methylation changes can be seen in myeloma. 47,48 We 
observed that DNA methylation profiles are able to distinguish between subsets of myeloma with 
adverse prognosis. Additionally, important drug resistance genes are aberrantly hypomethylated in 
myeloma and can be predictive of chemoresistance. Thus it would be informative to perform 
methylome analysis on pretreatment samples and correlate it with response. 
 
 
3. PATIENT SELECTION 
 
3.1  
Eligibility Criteria 
 
3.1.1 Patients must have histologically or cytologically confirmed Multiple 
Myeloma 
 
3.1.2 Measurable disease must be present at diagnosis as defined by Protein 
criteria (quantifiable M-component in serum, urine or Serum Free Light 
Chains) in order to evaluate response as per IMWG3. Non-secretory patients 
are eligible provided the patient has > 20% plasmacytosis OR multiple (>3) 
focal plasmacytomas or focal lesions on MRI 
 
3.1.3 Age 18 to 72 years.  Because no dosing or adverse event data are currently 
available on the use of Busulfan in combination with Melphalan and 
Bortezomib in patients <18 years of age, children are excluded from this 
study but will be eligible for future pediatric phase 2 combination trials. 
 
3.1.4 Patients must have received induction chemotherapy for myeloma, but no 
more than 12 months of prior chemotherapy for this disease, and must be 
eligible for the first planned autologous transplant. Lenalidomide or 
bortezomib maintenance do not count towards the 12 months of prior 
chemotherapy. In cases of uncertainty, please discuss with the PI, who will 
be the final arbiter.  
 
3.1.5 A minimum stem cell dose of 2.0 x 106 CD34+ cells/kg has been collected.  
 
3.1.6 Life expectancy of greater than 12 months 
 
3.1.7 ECOG performance status <2 (Karnofsky >60%; see Appendix A). 
 
3.1.8 Patients must have normal organ and marrow function as defined below: 
 
- 
leukocytes  
 
 
 
 
>3,000/mcL (unless myeloma related) 
- 
absolute neutrophil count 
>1,500/mcL (unless myeloma related) 
- 
platelets  
 
 
 
 
>50,000/mcL (unless myeloma related) 
- 
total bilirubin  
 
 
 
<2 X institutional upper limit of normal 
unless 2nd to Gilbert’s disease 
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- 
AST(SGOT)/ALT(SGPT) 
 
<3 X institutional upper limit of normal 
- 
creatinine  
 
 
 
 
<1.5 X institutional upper limit of normal 
OR 
- 
creatinine clearance  
 
>60 mL/min/1.73 m2 for patients with 
creatinine levels above institutional normal 
 
 
 
 
3.1.9 Ejection fraction by ECHO or MUGA ≥ 40% performed within 90 days prior to 
registration 
 
 
 
 
3.1.10 Patients must have adequate pulmonary function studies: > 50% of predicted 
on mechanical aspects (FEV1, FVC) and diffusion capacity (DLCO) > 50% of 
predicted, within 120 days of registration. If the patient is unable to 
complete pulmonary function tests due to MM related pain or condition, 
exception may be granted if the principal investigator (PI) documents that 
the patient is a candidate for high dose therapy. 
 
 
 
 
3.1.11 The effects of Busulfan, Melphalan and Bortezomib on the developing 
human fetus at the recommended therapeutic dose are unknown.  For this 
reason and because alkylating agents as well as other therapeutic agents 
used in this trial are known to be teratogenic, women of child-bearing 
potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for at 
least six months following the stem cell transplantation.  Should a woman 
become pregnant or suspect she is pregnant while participating in this study, 
she should inform her treating physician immediately. 
 
3.1.12 Ability to understand and the willingness to sign a written informed consent 
document. 
 
 
3.2  
Exclusion Criteria 
 
3.2.1 Patients who have had chemotherapy or pelvic radiotherapy within 4 weeks 
prior to entering the study or those who have not recovered from adverse 
events due to agents administered more than 4 weeks earlier.  Palliative 
radiation to for example the extremities or the vertebrae are allowed. In 
cases of uncertainty, please discuss with the PI who will make the final 
arbitration. 
 
3.2.2 Prior treatment history of autologous HSCT or high-dose chemotherapy with 
stem cell rescue for any medical reason, not limited to myeloma treatment 
 
3.2.3 Patients may not be receiving any other investigational agents. 
 
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3.2.4 Patients with known brain metastases should be excluded from this clinical 
trial because of their poor prognosis and because they often develop 
progressive neurological dysfunction that would confound the evaluation of 
neurological and other adverse events. 
 
3.2.5 History of allergic reactions attributed to compounds of similar chemical or 
biologic composition to or other agents used in the study, such as busulfan, 
melphalan, bortezomib, boron, or mannitol 
 
3.2.6 Grade 2 or greater peripheral neuropathy within 14 days prior to enrollment 
 
3.2.7 Unresolved grade >/= 3 non-hematologic toxicity from previous therapy. 
Patients with grade 2 toxicity will be eligible at the discretion of the PI. 
 
3.2.8 Prior malignancies except resected basal cell carcinoma or treated cervical 
carcinoma in situ. Cancer treated with curative intent < 5 years will not be 
allowed unless approved by the principal investigator (PI). Cancer treated 
with curative intent > 5 years will be allowed. 
 
3.2.9 Patients must not have significant co-morbid medical condition 
 
3.2.10 Uncontrolled intercurrent illness including, but not limited to, ongoing or 
active infection, symptomatic congestive heart failure, unstable angina 
pectoris, cardiac arrhythmia, or psychiatric illness/social situations that 
would limit compliance with study requirements. Patients must not have 
suffered recent (< 6 months) myocardial infarction, unstable angina, difficult 
to control congestive heart failure, uncontrolled hypertension, or difficult to 
control cardiac arrhythmias. 
 
3.2.11 Pregnant women are excluded from this study because Busulfan, melphalan 
and bortezomib Class D agents with the potential for teratogenic or 
abortifacient effects.  Because there is an unknown but potential risk for 
adverse events in nursing infants secondary to treatment of the mother with 
the study agent breastfeeding should be discontinued if the mother is 
treated with Busulfan.  
 
3.2.12 HIV-positive patients on combination antiretroviral therapy are ineligible 
because of the potential for pharmacokinetic interactions with Busulfan.  In 
addition, these patients are at increased risk of lethal infections when 
treated with marrow-suppressive therapy.  Appropriate studies will be 
undertaken in patients receiving combination antiretroviral therapy when 
indicated. 
 
3.2.13 Patients found to have an active hepatitis B infection (hepatitis B surface 
antigen +) are not eligible unless they meet ONE of the following criteria:  
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10 
 
 Patient is able to start dual anti-Hep B therapy prior to enrollment 
with adefovir and telbivudine  
 Patient is already on dual anti-hepatitis B therapy 
 Consultation and co-management with a hepatitis expert regarding 
hepatitis B treatment is strongly encouraged before and during the 
trial.  
 
3.2.14     Patients, who are positive for Hepatits B core antibody, but negative for 
the Hepatitis B surface antigen, should be started on lamivudine 100mg daily 
until at least 3 months post stem cell transplant 
 
 
3.3  
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for 
this trial.  
 
 
 
4. 
REGISTRATION PROCEDURES 
 
4.1 
General Guidelines 
 
The coordinating center is: Montefiore-Einstein Cancer Center 
 
 
 
 
 
Montefiore Medical Center-Moses Division 
 
 
 
 
 
Clinical Trials Office 
 
 
 
 
Department of Oncology, Hofheimer100 
 
 
 
 
111 East 210th Street 
 
 
 
 
Bronx, New York 10467 
 
 
 
 
Phone 718-920-2006 
 
 
 
 
Fax 718-405-4712 
 
The eligible patients will be entered on study centrally at the Montefiore-Einstein 
Cancer Center Coordinating Center by the Study Coordinator.  All sites should call the 
Clinical Trials Office, phone 718- 920-2006 to verify eligibility.  The required forms 
(eligibility and registration form; form 1) can be found in the Appendix (Appendix D). 
 
Following registration, patients should begin protocol treatment within 5 business days. 
 Issues that would cause treatment delays should be discussed with the Principal 
Investigator (PI).  If a patient does not receive protocol therapy following registration, 
the patient’s registration on the study may be canceled.  The Study Coordinator should 
be notified of cancellations as soon as possible. 
 
4.2 
Registration Process 
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To register a patient, the following documents should be completed by the research 
nurse or data manager and faxed or e-mailed to the Study Coordinator at the 
Montefiore-Einstein Cancer Center Clinical Trials Office, phone 718- 920-2006, fax 718-
405-7412 (see also cover page): 
 
 Form 1 (Appendix D) 
 Copy of required laboratory tests 
 Copies of other supporting documents to determine eligibility (e.g. Echo report, 
PFT report) 
 Signed patient consent form 
 HIPAA authorization form 
 
The research nurse or data manager at the participating site will then call the Study 
Coordinator at the Montefiore-Einstein Cancer Center Clinical Trials Office, phone 718- 
920-2006, fax 718-405-7412 (see also cover page) to verify eligibility.  To complete the 
registration process, the Coordinator will - after discussion with the PI Ira Braunschweig:  
 assign a patient study number 
 register the patient on the study 
 fax or e-mail the patient study number to the participating site 
 call the research nurse or data manager at the participating site and verbally 
confirm registration. 
 
Once patients are found eligible for the study, they will be registered with the 
Montefiore-Einstein Cancer Center Coordinating Center.  A patient number will be 
assigned, and a copy of appendix D including the patient number will be faxed back to 
the participating center/investigator.  
 
 
5. TREATMENT PLAN 
 
Treatment will be administered on an inpatient basis.  Reported adverse events and potential 
risks for busulfan, melphalan and bortezomib are described in Section 7.  Appropriate dose 
modifications are described in Section 6.  No investigational or commercial agents or therapies 
other than those described below may be administered with the intent to treat the patient's 
malignancy. 
 
Treatment Schema: 
 
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* The baseline period can be extended to -21 to -9 days  
Abbreviations: Bu, busulfan – PK directed; Mel140; melphalan at 140mg/m2; BTZ, bortezomib 
at 1mg/m2 
 
Patients will receive an initial test dose of iv busulfan of 0.8 mg/kg IV busulfan as a continuous 
infusion over 2 hours at any time between Day −14 to −11. Results of the pharmacokinetic (PK) 
profile following this test dose will inform the dosing for the subsequent administrations of IV 
busulfan. On Days -6 to -3 patients will be receiving consecutive once daily PK-directed dosing 
for 4 days of IV busulfan administered as a single daily 3-hour infusion. The overall target 
integrated AUC (area under the curve) exposure is 20,000 μM-min including the test dose or 
approximately 5,000μMol-min daily for 4 days (see 5.1.1). This will be followed by IV Melphalan 
140mg/m2 on Day -2 (section 5.1.2). IV Bortezomib will be given at a dose of 1mg/m2 on Days -
6, -3, +1 and +4 (section 5.1.3) Peripheral blood stem cells (≥2x106CD34+ cells/kg) will be 
infused on day 0 (section 5.1.4). 
 
5.1  
Agent Administration 
 
5.1.1 PK directed Busulfan Dosing and Administration 
 
In general busulfan should be administered intravenously via a central venous catheter. DO 
NOT infuse concomitantly with another intravenous solution of unknown compatibility. 
Busulfan will be diluted in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP 
and is stable at room temperature (25°C) for up to 8 hours but the infusion must be completed 
within that time. Busulfan diluted in 0.9% Sodium Chloride Injection, USP is stable at 
refrigerated conditions (2°-8°C) for up to 12 hours but the infusion must be completed within 
that time. 
Busulfan is predominantly metabolized by conjugation with glutathione. Co-administration of 
busulfan with certain agents can influence clearance and the AUC. A list of restricted 
Day -14 to -11*   -6          -5           -4           -3           -2          -1          0 
        +1             +4 
  +60  
Busulfan 
Test Dose 
Bu 
Bu 
Bu 
Bu 
Mel140 
Stem Cell 
Infusion 
BTZ 
BTZ 
BTZ 
BTZ 
Response 
Assessment 
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medications is provided in section 5.3.  
High dose busulfan can cause seizures and prophylactic use of seizure prophylaxis is mandated 
(see section 5.2). Antiemetics for a moderately high emetogenic agent (emetogenic score 4) 
should be used prior as per institutional guidelines (see also section 5.2.3) or as outlined for 
example by the NATIONAL COMPREHENSIVE CANCER NETWORK®  (NCCN) or American 
Society for Oncology (ASCO) guidelines for supportive care.  
 
Busulfan will be administered with PK directed dosing as outlined below. It is preferred that the 
Seattle Cancer Care Alliance laboratory is used for the PK measurements. Other centers may 
use other laboratories for the PK measurements and follow different guidelines for test dose 
administration, PK assessment and final dose determination. This is allowed as long as the total 
integrated AUC target for busulfan will be 20,000 μM⋅min, including the test dose AUC. 
 
5.1.1.1 Test Dose Administration and PK Assessment 
 
A test dose of 0.8 mg/kg of IV busulfan will be administered as a 2-hour continuous infusion 
(110 minute busulfan infusion + 10 minute flush) in an outpatient setting between Days 
−21and −9 for PK analysis to inform subsequent PK-directed dosing. The test dose 
administration day will be chosen to allow for the time required to complete the PK evaluation 
before the start of the daily consecutive QD IV busulfan dosing on Day −6. For the baseline test 
dose (recommended Day -14 to Day -11, but can be given between day -21 to -9), a total of six 
PK samples will be drawn at the following time points: the end of infusion (EOI, upon 
completion of the 120 minute infusion [110 minute busulfan infusion + 10 minute flush]) 
(+5minutes), EOI + 15 minutes (± 2 minutes), EOI + 30 minutes (± 2 minutes), and 240, 300 and 
360 minutes (±10 minutes) after the start of the infusion. In exceptional circumstances where 
the is delay from the time from test dose administration to start of the conditioning regimen 
(e.g. secondary to intercurrent infection, line complication etc.) the window between test dose 
administration and start of the conditioning regimen can be longer than 1 week. This will need 
to be discussed on a case-to-case basis with the PI Dr. Braunschweig, who will make the final 
arbitration after deliberation with the treating physician. 
 
The test dose method assumes the PK of busulfan will be the same on the test dose 
administration day and the consecutive daily dosing days; as a consequence, medication 
changes will be restricted from the screening period (or adequate wash-out period for 
medications discontinued with treatment) through the end of IV busulfan dosing. One 
exception will be prophylactic anti-seizure treatment; anti-seizure medication is not expected 
to be initiated until Day −7 as discussed in section 5.2. Refer to section 5.3 for prohibited 
medications and section 5.2 for supportive care information. 
 
The PK samples will be shipped to the busulfan clinical laboratory in Seattle (shipping 
information see Appendix B) or - if unable to use Seattle Cancer Care Alliance because of 
institutional guidelines - any other CLIA accredited laboratory that is certified to perform the 
busulfan PK testing. If another laboratory than Seattle Cancer Care Alliance  is used, please 
send samples also to Seattle Cancer Care Alliance  under the Montefiore account in order to 
ensure concordance of the results between the labs. The PK report including busulfan dosing 
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time and concentration data, estimated PK parameters, and dosing recommendations will be 
sent to the site after review by the busulfan PK clinical laboratory director or designee. The 
investigator may contact the Medical Monitor for consultation. In case of discrepancies of the 
laboratory results and recommendations, the results of the laboratory required by 
institutional policy will be used to make the final dose determination after discussion with 
the study PI (Ira Braunschweig, MD; email: IBRAUNSC@montefiore.org) or one of his 
designees. 
The total integrated AUC target for busulfan is 20,000 μM⋅min, including the test dose AUC. 
The remaining doses will be equally distributed into four doses from Day −6 to Day −3 
administered as a continuous 3-hour daily infusion. For subjects whose pharmacokinetic 
samples were not assayed or missing, the dose of IV busulfan will be 3.2 mg/kg (total daily 
dose). This dose is consistent with the total daily dose recommended in the US label (0.8 mg/kg 
x 4 doses per day for 4 days). 
 
5.1.1.2 First PK-Directed Dose Administration and Confirmatory PK 
 
5.1.1.2.1 First PK-Directed Dose Administration 
 
The PK-directed dose recommendation based on the test dose will be provided by the clinical 
laboratory, available at the start of the consecutive daily dosing regimen (Day -6). The dose will 
be administered as a single daily 3-hour continuous infusion (170 minute busulfan infusion + 10 
minute flush). 
 
5.1.1.2.2 Confirmatory PK 
 
For confirmatory PK assessment on Day -6, a total of six PK samples will be drawn at the 
following time points: the end of infusion (EOI, upon completion of the 180 minute infusion 
[170 minute busulfan infusion + 10 minute flush]) (+5 minutes), EOI + 15 minutes (± 2 minutes), 
EOI + 30 minutes (± 2 minutes), and 270, 360, and 480 minutes (± 10 minutes) after the start of 
the infusion. The PK report should be available before the third and fourth dose 
administrations (Days −4 and −3) to confirm the test dose accuracy. 
 
5.1.1.2.3 Further PK-Directed Dose Administration 
 
Results from the confirmatory PK assessment taken on Day −6 will be provided to the 
investigator. On Day −5 IV busulfan will be administered as a single daily 3-hour continuous 
infusion (170 minute infusion + 10 minute flush) based on the PK-directed dose 
recommendation from the test dose as the confirmatory PK results will not yet be available. 
The investigator may modify subsequent IV busulfan doses according to results from the 
confirmatory PK sample. Daily exposure to busulfan should be targeted not to exceed 6000 
μM/min. 
 
 
 
 
5.1.2 Melphalan 
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Melphalan will be given as a single dose of 140mg/m² given intravenously once on day -2 over 
at least 20 minutes. Local oncology pharmacy protocols for the administration of melphalan 
will be followed. 
It is recommended that IV administration of melphalan diluted in 0.9% solutions be completed 
within one hour of preparation due to the instability of the diluted melphalan.  
Care should be taken to avoid possible extravasation of melphalan and it should ONLY be given 
via a central venous line. 
Hypersensitivity reactions including anaphylaxis have occurred in approximately 2% of patients 
who received the IV formulation. These reactions usually occur after multiple courses of 
treatment. Treatment is symptomatic. 
High dose Melphalan has moderately high emetogenic potential. Therefore antiemetic 
regimens recommended for agents with emetogenic score 4 should be used as outlined for 
example by the NATIONAL COMPREHENSIVE CANCER NETWORK®  (NCCN) or American 
Society for Oncology (ASCO) guidelines for supportive care.  
 
 
5.1.3 Bortezomib 
 
Bortezomib will be administered at a dose of 1mg/m2 as IV push over 3 to 5 seconds followed 
by a standard saline flush or through a running IV line on Days -6, -3, +1 and +4. On Days -6 and 
-3 it should be given 120 minutes AFTER the busulfan infusion was completed..  
Premedication with antiemetics (e.g. ondansetron* 16 mg PO or IV and dexamethasone 10 mg 
PO or IV) should be given 60 minutes prior to all Bortezomib doses.  
Bortezomib is cytotoxic. As with all cytotoxic drugs, caution is required when preparing and 
handling bortezomib solutions. Reconstituted Bortezomib should be administered promptly 
and in no case more than 8 hours after reconstitution. 
 
 
  
5.1.4  Peripheral Blood Stem Cell Reinfusion 
 
Peripheral blood stem cell reinfusion may be done according to institutional guidelines. 
However, the following procedure is suggested: 
 
• On Day 0, the frozen cells are thawed at the bedside (in close proximity to the patient 
room to minimize transit time) in a 37 - 40°C water bath and reinfused without 
additional filtering or washing steps. Only one bag of stem cells should be thawed at a 
time, and not until the preceding bag has been completely infused. The osmolality of 
the cell suspension requires the use of a flowing central venous catheter. Twelve hours 
before reinfusion of autologous stem cells, hydration must be initiated with 0.9% NS to 
ensure urine output of at least 3 ml/kg/hr. Emergency drugs (benadryl, epinephrine and 
solumedrol) in appropriate doses must be at the bedside. Baseline vital signs are 
recorded. 
 
• The patient is closely monitored during the infusion. These will be infused IV over 3 - 
10 minutes each. If the patient develops chest tightness or other symptoms, a short rest 
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period may be required. Usually a 30 - 60 minute rest may be required. 
 
• Generally, no additional premedication is needed after the short rest period. It is 
recommended that a physician be present during the stem cell infusion and for one 
hour afterwards. A nurse familiar with the adverse signs of blood transfusion should 
monitor signs between each stem cell infusion and every 15 minutes until one hour 
after the stem cell infusion is completed. The patient’s urine may be red for 12 hours 
after the infusion because of red cell hemolysis and the pH indicator in the tissue 
culture media. Orange scent may help mask the DMSO odor which will be present for 
about 24 hours after the stem cell reinfusion. 
 
5.2  
General Concomitant Medication and Supportive Care Guidelines 
 
In general, institutional guidelines can be followed for the following provided the medications 
show little potential to affect the metabolism of busulfan (see section 5.3). 
 Infection prophylaxis 
 Prophylactic drugs for blood product infusion 
 Antiemetics 
 Post-Auto HSCT growth factors.  
 Given the high risk for mucositis, the use of Palifermin, a human recombinant 
keratinocyte growth factor, is encouraged as per institutional guidelines 
 
5.2.1 Seizure prophylaxis 
 
Seizure prophylaxis should start on the evening prior to busulfan infusion (Day -7). 
Benzodiazepines are the recommended seizure prophylaxis method in this study because they 
are not eliminated by the same metabolic pathways as busulfan. 
Lorazepam can be given in a per os (PO) dose of 0.5 mg every 6 hours beginning the evening on 
Day −7 before the conditioning regimen of busulfan until the morning of Day −2, one day after 
the last day of busulfan administration. Lorazepam 0.05 mg/kg IV (maximum 2 mg per dose) 
may be used as an alternative prophylaxis method. Intravenous lorazepam is given 30 min 
before each dose of busulfan and continued every 6 h for four additional doses after the last 
dose of busulfan. The dose may be reduced by 25 to 50% (rounded to the nearest 0.1 mg) if 
excessive sedation occurs. 
 
Levetiracetam is also an acceptable choice and should be administered as 500 mg PO BID 
beginning the evening on Day −7 before the conditioning regimen of busulfan until the 
morning of Day −2, one day after the last day of busulfan administration. 
 
Phenytoin is discouraged for use as prophylaxis for busulfan-induced seizures as phenytoin is 
known as a potent inducer of hepatic drug-metabolizing enzymes causing increased clearance 
of busulfan. Subjects with seizures being stable on phenytoin should continue taking it with no 
change in dosing during the test-dose and conditioning phase of the study. 
 
5.2.2 Infection Prophylaxis 
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Prophylaxis against Herpes Simplex Virus, Varicellus Zoster Virus, Pneumocystis 
Jirovecchii Pneumonia, and Candida should be administered to all patients. Institutional 
guidelines for post-transplant infection prophylaxis should be followed. For example 
ciprofloxacin 500 mg twice daily (bid) for bacterial prophylaxis, acyclovir 400mg bid or 
valacyclovir 500mg daily for VZV prophylaxis, fluconazole 400mg daily as fungal prophylaxis, 
and Bactrim DS 1 tablet three times per week for Pneumocystis Jirovecchii prophylaxis. 
Fluconazole or other moderate to strong CYP3A4 inhibitors, except as allowed elsewhere in the 
protocol, may not be given within 3 days of busulfan and bortezomib to prevent interfering 
with busulfan and bortezomib metabolism (see also list of restricted medications section 5.3) 
 
5.2.3 Antiemetics 
 
Antiemetics can be used as per institutional protocol. 
As both busulfan and melphalan at high doses have moderately high emetogenic potential 
(emetogenic score 4) the use of, a 5-HT3 antagonist, corticosteroids, and aprepitant or 
fosaprepitant is recommended. 
For details please follow published recommendations by professional societies, such as the 
NATIONAL COMPREHENSIVE CANCER NETWORK®  (NCCN) or American Society for 
Oncology (ASCO) guidelines for supportive care. 
 
5.2.4 Growth Factors 
 
Post-Auto HSCT growth factors can be used as per institutional guidelines. Use of GCSF 
(filgrastim) at a dose of 5mcg/kg daily starting by Day +5 is recommended. 
 
 
5.3 Restricted Medication 
 
The following medications listed below are restricted 72 hours prior to IV busulfan treatment 
through 48 hours post treatment: 
 
1. Filgrastim, G-CSF 
2. Sargramostim, GM-CSF 
3. Vaccines 
4. Alkylating Agents (except for protocol specified regimen) 
5. Digoxin 
6. Herbal supplements 
7. Acetaminophen 
8. Voriconazole 
9. Metronidazole 
10. Itraconazole 
 
The following medications listed below are discouraged 72 hours prior to IV busulfan 
treatment through 48 hours post treatment:. 
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18 
 
1. Nonsteroidal antiinflammatory drugs 
2 Salicylates 
3. Thioguanine, 6-TG 
4. Anticoagulants 
5. Ethotoin 
6. Fosphenytoin 
7. Immunosuppressives (except for protocol specified regimen) 
8. Phenytoin 
9. Platelet Inhibitors 
10. Strontium-89 Chloride 
11. Thrombolytic Agents 
 
Because there is a potential for interaction of busulfan and bortezomib with other 
concomitantly administered drugs through the cytochrome P450 system, the case report form 
must capture the concurrent use of all other drugs, over-the-counter medications, or 
alternative therapies.  The Principal Investigator (PI) should be alerted if the patient is taking 
any agent known to affect or with the potential to affect selected CYP450 isoenzymes. 
 
 
5.4 
Duration of Follow Up 
 
Patients will be followed for up to 5 years, until removal from study or until death, whichever 
occurs first.  Patients removed from study for unacceptable adverse events will be followed 
until resolution or stabilization of the adverse event. 
 
 
5.5 
Criteria for removal from Study 
 
The following are criteria for removal from the study: 
 
 
Disease progression, 
 
 
Intercurrent illness that prevents further administration of treatment, 
 
 
occurrence of any adverse event (AE), intercurrent illness or abnormality in 
laboratory assessment results which, in the opinion of the investigator, warrants the 
subject’s permanent withdrawal from the trial  
 
 
treatment with a prohibited concomitant medication other than the use of 
appropriate medications for the treatment of AEs under direction of the 
investigator 
 
 
Participant becomes pregnant 
 
 
Participant is lost to follow-up 
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19 
 
 
Patient decides to withdraw from the study, or 
 
 
General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator. 
 
If a participant discontinues the trial prematurely, the reason given must be fully evaluated and 
recorded appropriately in source documents and the CRF. If the subject is being withdrawn 
because of an adverse event (AE), that AE should be indicated as the reason for withdrawal. 
Participants who receive radiation therapy or chemotherapy after transplantation are 
considered to have treatment failure, unless the radiation was pre-planned consolidation and 
that decision was made before transplantation. All participants have the right to withdraw at 
any time during treatment without prejudice. The investigator can discontinue a subject’s 
participation in the trial at any time if medically necessary.  
 
The Principal Investigator should be notified promptly when a subject is withdrawn. 
 
 
5.6 Consolidation/Maintenance therapy post-transplant 
 
Prospective studies have demonstrated at least a progression-free survival benefit of post-
transplant consolidation and/or maintenance therapy.49-51 More mature results are needed 
though at present to recommend a unified approach.52 Therefore the risks and benefits of 
consolidation and/or maintenance therapy post ASCT need to be discussed with the patient 
individually and a decision regarding post-transplant consolidation and/or maintenance 
therapy will be made by the treating physician at their discretion.  
NO CONSOLIDATION/MAINTENANCE THERAPY though should be started BEFORE the DAY 
+100 response evaluation.  
 
 
 
 
 
 
 
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6. 
SCHEDULE OF EVENTS 
 
6.1. Screening Period (Day −30 to Day −15) 
Subjects will be screened within 30 to 15 days prior to stem cell transplant. Study procedures 
and information regarding the nature of the study will be reviewed with potential subjects and 
written informed consent will be obtained prior to any study related procedures. After signing 
the informed consent, subjects will be assigned a screening number. Screening procedures will 
consist of the following: 
1) Informed consent will be obtained. 
2) Inclusion and exclusion criteria will be reviewed. 
3) Demographic information will be collected. 
4) Medical history, including previous treatment history (disease characteristics), will be 
collected. 
5) A physical examination, including weight and height, will be performed. 
6) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
7) Hematology and serum chemistry laboratory samples will be collected. 
8) INR will be measured. 
9) Pulmonary function tests will be performed to determine FEV1, FVC, or DLCO. If performed 
within 120 days of the planned IV busulfan test dose, those test results can be used. These 
data will be reported in the site progress notes only. 
10) ECOG and Karnofsky performance status will be assessed. Data from ECOG and Karnofsky 
status at initial diagnosis will also be collected if available. 
11) Myeloma staging and prognostic factors will be performed; this includes at least SPEP, 
serum IFE, 24h urine UPEP (unless prior urine IFE shows no monoclonal protein), bone marrow 
biopsy (only if needed to determine complete remission) and serum free light chain assay. 
Additional tests, such as, skeletal survey, imaging for plasmacytomas might be added if 
indicated by the individual patient’s disease manifestation (see International Myeloma working 
Group (IMWG) recommendations3) 
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 International Staging System (ISS) score53 
 Cytogenetics at last bone marrow biopsy 
 Protein criteria will be determined (quantifiable M‐component of IgG, IgA, IgD, or IgE 
and/or Urinary kappa or lambda Light chain, Bence‐Jones protein, or Free Kappa Light 
Chain or Free Lambda Light Chain) 
12) An echocardiogram (ECHO) or MUGA scan will be performed (if done within 90 days of the 
planned IV busulfan test dose, that result can be used). If cyclophosphamide was used in stem 
cell harvesting, the ECHO or MUGA must be after the harvest date. 
13) A urine or serum pregnancy test will be performed on all women of child bearing potential. 
If the urine pregnancy test is positive, a serum test to confirm the result should be performed. 
In the event of a confirmed positive result, the subject will be discontinued from the study. 
14) Concomitant medications will be recorded. 
15) Adverse events will be assessed 
16) Subjects will be instructed to avoid any restricted medications 
17) 10ml of Bone marrow Aspirate (taken at time of myeloma staging exam – see 11.) will be 
sent to Amit Verma’s laboratory (for shipping and handling instruction see Appendix E). The 
patient can refuse participating in this correlative study, but participation is strongly 
encouraged to maintain scientific validity of the study. 
18) At the same time and in the same shipment as the bone marrow aspirate, 10ml of 
peripheral blood in a green top (sodium heparin) tube with the bone marrow sample clearly 
labeled “Peripheral Blood pretreatment” as well as patient initials, medical record number and 
study ID will be sent to Amit Verma’s lab. For shipping and handling instructions see Appendix 
E. The patient can refuse participating in this correlative study, but participation is strongly 
encouraged to maintain scientific validity of the study. 
 
6.2. Baseline (Day −14  to −11)* 
* The baseline period can be extended from Day -21 to -9 
Prior to IV busulfan test dose administration: 
1) Inclusion/exclusion criteria will be re-reviewed to confirm that the subject is still eligible for 
participation in the study. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) A physical examination, including weight, will be performed. If a physical exam was 
performed within 72 hours of this visit, the exam does not need to be repeated. 
4) A urine or serum pregnancy test will be performed on all women of childbearing potential 
(WOCBP). If the urine pregnancy test is positive, a serum test to confirm the result should be 
performed. In the event of a confirmed positive result, the subject will be discontinued from 
the study. 
5) Hematology and serum chemistry laboratory samples will be collected. 
6) IV Busulfan test-dose 0.8 mg/kg will be administered as a 2-hour continuous infusion (110 
minute busulfan infusion + 10 minute flush). 
 7) Peripheral blood will be collected at baseline and stored for possible future correlative 
studies.  
 
 
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Following IV busulfan test dose administration: 
8) PK blood samples will be drawn at EOI (upon completion of the 120 minute infusion [110 
minute busulfan infusion + 10 minute flush]) (+5 minutes), EOI + 15 minutes (±2 minutes), EOI + 
30 minutes (±2 minutes), and 240, 300, and 360 minutes (±10 minutes) after the start of the 
infusion. 
9) Concomitant medications will be recorded. 
10) Adverse events will be assessed. 
11) Subjects will be instructed to avoid any restricted medications. 
 
6.3. Conditioning Phase 
 
6.3.1. Day −7 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Anti-seizure prophylaxis will be administered. 
4) Concomitant medications will be recorded. 
5) Adverse events will be assessed. 
6) Subjects will be instructed to avoid any restricted medications. 
7) Physical exam 
 
6.3.2. Day −6 
Prior to IV busulfan PK-directed dose administration: 
1) Body weight will be measured. 
2) Review IV busulfan dosing recommendation based on PK results following test dose 
administration. For subjects whose pharmacokinetic samples were not assayed or were 
missing, the dose of IV busulfan will be 3.2 mg/kg (total daily dose). 
3) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
4) Anti-seizure prophylaxis will be administered. 
5) Administration of the first IV busulfan dose per the PK-directed dosing adjustment. 
6) Physical exam 
 
Following IV busulfan PK-directed dose administration: 
7) PK blood samples will be drawn at EOI (upon completion of the 180 minute infusion [170 
minute busulfan infusion + 10 minute flush]) (+5 minutes), EOI + 15 minutes (±2 minutes), EOI + 
30 minutes (±2 minutes), and 270, 360, and 480 minutes (±10 minutes) after the start of the 
infusion 
8) Concomitant medications will be recorded. 
9) Adverse events will be assessed. 
10) Subjects will be instructed to avoid any restricted medications. 
11) Bortezomib 1mg/m2 will be given intravenously starting 120 minutes after the Busulfan 
infusion has been completed 
 
6.3.3. Day −5 
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Prior to IV busulfan PK-directed dose administration: 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Anti-seizure prophylaxis will be administered. 
4) Administration of the second IV busulfan dose as a 3-hour continuous infusion per the PK-
directed dosing recommendation. For subjects whose pharmacokinetic samples were not 
assayed or were missing, the dose of IV busulfan will be 3.2 mg/kg (total daily dose). 
 
Following IV busulfan PK-directed dose administration: 
5) Concomitant medications will be recorded. 
6) Adverse events will be assessed. 
7) Subjects will be instructed to avoid any restricted medications.  
8) Physical exam 
 
 
6.3.4 Day −4 
Prior to IV busulfan PK-directed dose administration: 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Anti-seizure prophylaxis will be administered. 
4) Review IV busulfan dosing recommendation based on confirmatory PK report and adjust 
dosing appropriately, if available. 
5) Administration of the third IV busulfan dose per the PK-directed dosing recommendation. 
For subjects whose pharmacokinetic samples were not assayed or were missing, the dose of IV 
busulfan will be 3.2 mg/kg (total daily dose). 
6) Physical exam 
 
Following IV busulfan PK-directed dose administration: 
7) Concomitant medications will be recorded 
8) Adverse events will be assessed. 
9) Subjects will be instructed to avoid any restricted medications 
10) PK blood samples might be drawn at EOI (upon completion of the 180 minute infusion [170 
minute busulfan infusion + 10 minute flush]) (+5 minutes), EOI + 15 minutes (±2 minutes), EOI + 
30 minutes (±2 minutes), and 270, 360, and 480 minutes (±10 minutes) after the start of the 
infusion 
 
 
6.3.5. Day −3 
Prior to IV busulfan PK-directed dose administration: 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Anti-seizure prophylaxis will be administered. 
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4) If the confirmatory PK report is received after the Day −4 IV busulfan dose, review IV 
busulfan dosing recommendation based on confirmatory PK report and adjust dosing 
appropriately. 
5) Administration of the fourth IV busulfan dose per the PK-directed dosing adjustment. For 
subjects whose pharmacokinetic samples were not assayed or were missing, the dose of IV 
busulfan will be 3.2 mg/kg (total daily dose). 
6) Physical exam 
7) Blood work as per calendar 
 
Following IV busulfan PK-directed dose administration: 
8) Concomitant medications will be recorded. 
9) Adverse events will be assessed. 
10) Subjects will be instructed to avoid any restricted medications. 
11) Bortezomib 1mg/m2 will be given intravenously starting 120 minutes after the Busulfan 
infusion has been completed 
12) PK blood samples might be drawn at EOI (upon completion of the 180 minute infusion [170 
minute busulfan infusion + 10 minute flush]) (+5 minutes), EOI + 15 minutes (±2 minutes), EOI + 
30 minutes (±2 minutes), and 270, 360, and 480 minutes (±10 minutes) after the start of the 
infusion 
 
 
6.3.6. Day −2 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Anti-seizure prophylaxis will be administered. 
4) Administration of Melphalan 140mg/m2 as a per institutional protocol 
5) Concomitant medications will be recorded. 
6) Adverse events will be assessed. 
7) Subjects will be instructed to avoid any restricted medications. 
8) Physical exam 
 
 
6.3.7. Day -1 (Rest Day) 
No study procedures are scheduled for Day −1. Concomitant medications will be recorded and 
adverse events will be assessed.  
 
6.3.8. Day 0 (Stem cell re-infusion) 
1) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
2) A physical examination, including weight, will be performed before HSCT. 
3) ANC and platelet count recovery information will be collected from Day 0 until day of 
discharge 
4) Stem cell re-infusion will occur according to institutional standard. 
5) Concomitant medications will be recorded. 
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6) Adverse events will be assessed. 
 
6.4. Post-transplant Phase 
6.4.1. Day +1 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Concomitant medications will be recorded. 
4) Adverse events will be assessed. 
5) Bortezomib 1mg/m2 will be given intravenously 
6) Physical exam 
 
6.4.2. Day +4 
1) Body weight will be measured. 
2) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
3) Concomitant medications will be recorded. 
4) Adverse events will be assessed. 
5) Bortezomib 1mg/m2 will be given intravenously 
6) Physical exam 
 
6.5 Follow-Up 
6.5.1. Discharge or Day 30 (whichever is earlier) 
1) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
2) Karnofsky performance status will be assessed. 
3) A physical examination, including weight, will be performed. 
4) ANC and platelet count recovery information will be collected. 
5) Full hematology and full clinical chemistry laboratory samples will be collected. 
6) Concomitant medications will be recorded. 
7) Adverse events will be assessed. 
 
6.5.2. Day 100 Follow-up 
1) Vital signs (blood pressure, heart rate and temperature) will be assessed after the subject 
has been supine for at least 3 minutes. 
2) Karnofsky performance status will be assessed. 
3) A physical examination, including weight, will be performed. 
4) Full hematology and full clinical chemistry laboratory samples will be collected 
5) Concomitant medications will be recorded. 
6) Adverse events will be assessed. 
7) Veno-occlusive disease (VOD) and pulmonary toxicities information will be collected. 
8) Disease progression and survival status will be determined (myeloma re-staging – see 
section 11) 
9) Should  bone marrow be collected as part of the routine disease restaging at this time,  10ml 
of bone marrow aspirate and 10ml of peripheral blood in a green top (sodium heparin) tube 
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will also be sent to Amit Verma’s lab. For shipping and handling instructions see Appendix E. 
10) Should  bone marrow be collected as part of the routine disease restaging at this time,  
10ml of bone marrow aspirate will also be sent to Amit Verma’s lab. For shipping and handling 
instructions see Appendix E. The peripheral blood will be sent for storage and possible future 
research.  
 
6.5.3. Day 180 Follow-up 
1) VOD and pulmonary toxicities information will be collected. 
2) Disease progression and survival status will be determined (myeloma re-staging – see 
section 11) 
3) Concomitant medications will be recorded. 
4) Adverse events will be assessed. 
 
6.5.4. Day 360 Follow-up and every 12 Months thereafter until year 5 post-transplant 
(if applicable – can be done via telephone interview) 
Follow up visits will be performed every 12 months following transplant  
1) VOD and pulmonary toxicities information will be collected. 
2) Disease progression and survival status will be determined (myeloma re-staging – see 
section 11) 
3) Adverse events will be assessed. 
4) Concomitant medications will be recorded. 
 
6.5.5. End of Study/Early Termination 
The End of Study or Early Termination visit will be done via telephone unless the visit occurs 
prior to Day 100, when it should be done in clinic/inpatient 
1) Concomitant medications will be recorded if prior to Discharge. 
2) Adverse events will be assessed. 
3) Disease progression and survival status will be determined (myeloma re-staging – see 
section  
 
 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will 
determine whether the event requires expedited (via AdEERS) reporting in addition to 
routine reporting. 
 
7.1 
Adverse Events and Potential Risks Lists  
 
7.1.1 Adverse Events List for iv Busulfan (Busulfex™) 
 
Busulfan is a marketed drug with a well known safety profile which is described in the 
Investigator’s Brochure.10 The adverse events are below. Adverse events 
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that are of particular interest are of VOD and pulmonary toxicity. The diagnosis of 
hepatic veno-occlusive disease (VOD) will be according to the Baltimore criteria54. (See Appendix 
C). 
 
 
 
Adverse Events of Busulfan 1/2 
  
Common (greater than 30%)  Less common (5%~30%)  
Rare (less than 5%)  
BLOOD & LYMPHATIC DISORDERS 
 
 
Neutropenia 
Bruising or bleeding 
 
Anemia  
Thrombosis 
 
Thrombocytopenia 
Neutropenic fever 
 
 
Epistaxis 
 
EYE DISORDERS 
 
 
 
 
 
GASTROINTESTINAL DISORDERS 
 
 
Nausea  
Rectal discomfort 
Hematemesis 
Vomiting 
Ileus 
Gastrointestinal bleeding 
Constipation 
Ascites 
Pancreatitis 
Diarrhea 
Hepatomegaly 
 
Abdominal pain 
Abnormal liver function  
 
Sores on mucous membranes and 
mouth 
Jaundice 
 
Decrease in liver function indicated 
by abnormal liver function tests 
Hepatic Veno-Occlusive Disease 
(VOD) 
 
Poor digestion  
Hiccups 
 
Hyperbilirubinemia 
 
 
GENERAL DISORDERS & 
ADMINISTRATIONS SITE 
CONDITIONS 
 
 
Loss of appetite 
Inflammation at injection site 
Drowsiness 
Fever/Chills 
Dry Mouth 
Secondary Malignancies 
Runny nose 
Chest pain 
 
Pain 
Pain at injection site 
 
Allergic reaction 
Dizziness 
 
 
Hot flushes 
 
 
Back pain  
 
INFECTIONS 
 
 
Infections 
Pharyngitis 
Sinusitis 
INVESTIGATIONS 
 
 
 
 
 
METABOLISM 7 NUTRITION 
DISORDERS 
 
 
Hyperglycemia 
Hypohosphosphatemia 
Hyponatremia 
Low blood level of electrolytes 
(potassium/calcium/magnesium) 
 
 
MUSKULOSKELETAL & 
CONNECTIVE TISSUE DISORDERS 
 
 
 
Joint pain 
Panniculitis 
 
Muscle pain 
 
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Adverse Events of Busulfan 2/2 
  
Common (greater than 30%)  Less common (5%~30%)  
Rare (less than 5%)  
Headaches 
 
Tinnitus 
 
 
Drowsiness 
 
 
Coma  
 
 
Cerebral hemorrhage 
 
 
Seizure 
PSYCHIATRIC DISORDERS 
 
 
Anxiety 
Depression 
Mental disturbances such as 
severe nervousness, confusion, 
delusion, agitation, 
hallucination. 
Fatigue 
 
 
Insomnia 
 
 
RENAL & URINARY DISORDERS 
 
 
 
Abnormal kidney function tests  
 
 
Decreased urine production  
 
  
Hematuria 
 
 
Dysuria 
 
RESPIRATORY, THORACIC & 
MEDIASTINAL DISORDERS 
 
 
 
Shortness of breath 
Pleural effusion  
Abnormal breath sounds 
Inflammation of the lung 
Scar tissue formation in the 
lungs 
Cough 
Asthma 
Hypoxia  
 
 
Respiratory failure  
 
 
Collapse of the lung tissue 
 
 
Hemoptysis 
 
 
Bleeding in the lung  
SKIN & SUBCUTANEOUS TISSUE 
DISORDERS 
 
 
Rash 
Acne 
Redness & scaling of the entire 
skin 
 
Itch  
 
 
Change in skin color 
 
 
Alopecia  
 
VASCULAR DISORDERS 
 
 
Arrhthmias 
Cardiomegaly 
Bradycardia 
Tachycardia 
Hypotension 
Pericarditis/pericardial effusion 
Edema 
Hypertension 
Cardiogenic shock 
 
 
Heart failure 
 
 
 
 
 
 
 
 
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7.1.2 Adverse Events List  for Bortezomib 
 
 
Adverse Events with Possible  Relationship to Bortezomib  
(CTCAE v4.0 Term) – 1/2 
  
EXPECTED AEs FOR 
ADEERS REPORTING 
For  Bortezomib 
Likely (>20%)  
 
Less Likely (<=20%)  
Rare but Serious 
(<3%)  
Expected  
BLOOD AND LYMPHATIC 
SYSTEM DISORDERS  
  
  
 
Anemia  
  
  
Anemia  
  
Febrile neutropenia  
  
  
EYE DISORDERS  
  
  
 
  
Blurred vision  
  
  
GASTROINTESTINAL 
DISORDERS  
  
  
 
  
Abdominal pain  
  
Abdominal pain  
Constipation  
  
  
Constipation  
Diarrhea  
  
  
Diarrhea  
  
Dyspepsia  
  
Dyspepsia  
  
Gastrointestinal 
hemorrhage 
  
  
  
  
 Gastrointestinal 
perforation 
  
  
Ileus  
  
Ileus  
Nausea  
  
  
Nausea  
Vomiting  
  
  
Vomiting  
GENERAL DISORDERS & 
ADMINISTRATION SITE 
CONDITIONS  
  
  
 
  
Chills  
  
Chills  
Edema limbs  
  
  
Edema limbs  
INFECTIONS & 
INFESTATIONS  
  
  
 
Infection 
  
  
Infection 
  
Infections and 
infestations - Other 
(Opportunistic infection 
associated with >= 
Grade 2 Lymphopenia))  
  
  
INVESTIGATIONS  
  
  
 
 Platelet count 
decreased 
 
  
 Platelet count 
decreased 
 
 Neutrophil count 
decreased 
  
Neutrophil count 
decreased 
  
Lymphocyte count 
decreased 
  
 
METABOLISM & 
NUTRITION DISORDERS  
  
  
 
Anorexia  
  
  
Anorexia  
  
Dehydration  
  
  
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Adverse Events with Possible  Relationship to Bortezomib  
(CTCAE v4.0 Term) – 2/2 
  
EXPECTED AEs FOR 
ADEERS REPORTING 
For  Bortezomib 
Likely (>20%)  
 
Less Likely (<=20%)  
Rare but Serious 
(<3%)  
Expected  
MUSCULOSKELETAL & 
CONNECTIVE TISSUE 
DISORDERS  
  
  
 
  
Arthralgia  
  
Arthralgia  
  
Back pain  
  
Back pain  
  
Bone pain  
  
Bone pain  
  
Generalized muscle 
weakness  
  
  
  
Myalgia  
  
Myalgia  
  
Pain in extremity  
  
Pain in extremity  
NERVOUS SYSTEM 
DISORDERS  
  
  
 
  
Dizziness  
  
Dizziness  
  
Headache  
  
Headache  
  
  
Leukoencephalopathy  
  
  
Neuralgia  
  
Neuralgia  
Peripheral motor 
neuropathy  
  
  
Peripheral motor 
neuropathy  
Peripheral sensory 
neuropathy  
  
  
Peripheral sensory 
neuropathy  
  
  
Reversible posterior 
leukoencephalopathy 
syndrome  
  
  
Syncope  
  
  
PSYCHIATRIC 
DISORDERS  
  
  
 
  
Anxiety  
  
  
  
Insomnia  
  
Insomnia  
RENAL & URINARY 
DISORDERS  
  
  
 
  
  
Acute kidney injury  
  
RESPIRATORY, 
THORACIC & 
MEDIASTINAL 
DISORDERS  
  
  
 
  
Cough  
  
Cough  
  
Dyspnea  
  
  
  
Epistaxis  
  
  
  
Pharyngeal mucositis  
  
Pharyngeal mucositis  
  
Pleural effusion  
  
  
SKIN & SUBCUTANEOUS 
TISSUE DISORDERS  
  
  
 
  
Rash maculo-papular  
  
Rash maculo-papular  
VASCULAR DISORDERS  
  
  
 
  
Hypotension  
  
Hypotension  
 
 
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Also reported on bortezomib trials but with the relationship to bortezomib still undetermined:  
 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(lymphadenopathy); Disseminated intravascular coagulation  
 
CARDIAC DISORDERS - Asystole; Atrial fibrillation; Atrial flutter; Cardiac disorders - Other 
(cardiac amyloidosis); Heart failure; Left ventricular systolic dysfunction; Myocardial infarction; 
Pericardial effusion; Right ventricular dysfunction; Sinus bradycardia; Ventricular tachycardia  
 
EAR AND LABYRINTH DISORDERS – Hearing impaired  
 
EYE DISORDERS - Conjunctivitis; Dry eye; Extraocular muscle paresis; Eye disorders - Other 
(conjunctival hemorrhage); Watering eyes  
 
GASTROINTESTINAL DISORDERS - Abdominal distension; Ascites; Dry mouth; Dysphagia; 
Esophagitis; Flatulence; Gastritis; Gastrointestinal disorders - Other (ischemic bowel); 
Gastrointestinal disorders - Other (eructation); Mucositis oral; Oral pain; Pancreatitis; Small 
intestinal obstruction  
 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Gait 
disturbance; General disorders and administration site conditions - Other (hepato-renal 
syndrome); Injection site reaction; Non-cardiac chest pain; Sudden death NOS  
 
HEPATOBILIARY DISORDERS - Hepatobiliary disorders - Other (portal vein thrombosis)  
 
IMMUNE SYSTEM DISORDERS - Allergic reaction  
 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Bruising; Fracture  
 
INVESTIGATIONS - Activated partial thromboplastin time prolonged; Alanine aminotransferase 
increased; Alkaline phosphatase increased; Aspartate aminotransferase increased; Blood 
bilirubin increased; CPK increased; Creatinine increased; GGT increased; INR increased; Serum 
amylase increased; Weight gain; Weight loss  
 
METABOLISM AND NUTRITION DISORDERS - Hypercalcemia; Hyperglycemia; Hyperkalemia; 
Hyperuricemia; Hypocalcemia; Hypoglycemia; Hypokalemia; Hypomagnesemia; Hyponatremia; 
Hypophosphatemia; Metabolism and nutrition disorders - Other (hypoproteinemia); 
Metabolism and nutrition disorders - Other (failure to thrive); Tumor lysis syndrome  
 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Buttock pain  
 
NERVOUS SYSTEM DISORDERS - Ataxia; Cognitive disturbance; Depressed level of 
consciousness; Dysgeusia; Dysphasia; Intracranial hemorrhage; Ischemia cerebrovascular; 
Memory impairment; Nervous system disorders - Other (spinal cord compression); Nervous 
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32 
system disorders - Other (cranial palsy); Nervous system disorders - Other (dysautonomia); 
Seizure  
 
PSYCHIATRIC DISORDERS - Agitation; Confusion; Depression; Psychosis  
 
RENAL AND URINARY DISORDERS - Bladder spasm; Hematuria; Proteinuria; Renal and urinary 
disorders - Other (calculus renal); Renal and urinary disorders - Other (bilateral 
hydronephrosis); Renal and urinary disorders - Other (glomerular nephritis proliferative); 
Urinary frequency; Urinary incontinence; Urinary retention; Urinary tract pain  
 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress 
syndrome; Allergic rhinitis; Atelectasis; Bronchopulmonary hemorrhage; Bronchospasm; 
Hiccups; Hypoxia; Pharyngolaryngeal pain; Pneumonitis; Pulmonary hypertension; Respiratory, 
thoracic and mediastinal disorders - Other (obstructive airways disease); Voice alteration  
 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin; Hyperhidrosis; Pruritus; 
Purpura; Skin and subcutaneous tissue disorders - Other (leukoclastic vasculitis); Urticaria  
 
VASCULAR DISORDERS - Capillary leak syndrome; Flushing; Hematoma; Thromboembolic event  
 
Note: Bortezomib (PS-341) in combination with other agents could cause an exacerbation of 
any adverse event currently known to be caused by the other agent, or the combination may 
result in events never previously associated with either agent. 
 
 
7.1.3 Adverse Event List for Melphalan 
 
Likely (>10%):  
Gastrointestinal: Nausea, vomiting, oral ulceration diarrhea 
Hematologic: Myelosuppression, leucopenia, thrombocytopenia, anemia, neutropenia, febrile 
neutropenia, bleeding 
Miscellaneous: Secondary malignancy (<2% to 20%; cumulative dose and duration dependent, 
includes acute myeloid leukemia, myeloproliferative syndrome, carcinoma), oral ulceration 
 
Less Likely (< 10%):  
Miscellaneous: Hypersensitivity, dyspnea, edema, hypotension, pruritus, rash, tachycardia, 
urticaria), alopecia, amenorrhea, BUN increased, , injection site reactions (ulceration, necrosis), 
interstitial pneumonitis, jaundice, ovarian suppression, pruritus, pulmonary fibrosis, rash 
(maculopapular), seizure, SIADH, skin hypersensitivity, skin vesiculation, sterility, stomatitis, 
testicular suppression, tingling sensation, transaminases increased, vasculitis, warmth 
sensation, hepatitis, infection, acute renal failure 
 
Rare, but Serious (<1%): 
Agranulocytosis, anaphylaxis (rare), bladder irritation, bone marrow failure (irreversible), 
cardiac arrest, diarrhea, encephalopathy, hemolytic anemia, hemorrhagic cystitis, hemorrhagic 
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33 
necrotic enterocolitis, hepatic veno-occlusive disease, death 
 
Please refer to the package insert for a complete list of adverse effects. 
 
7.2 
Adverse Event Characteristics  
 
 CTCAE term (AE description) and grade:  The descriptions and grading scales found in 
the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 
will be utilized for AE reporting.  All appropriate treatment areas should have access to 
a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be downloaded 
from the CTEP web site (http://ctep.cancer.gov). 
 
 
‘Expectedness’: AEs can be ‘Unexpected’ or ‘Expected’ (see Section 7.1 above) for 
expedited reporting purposes only. 
 
 
Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
7.3 
Expedited Adverse Event Reporting 
 
7.3.1. Purpose of Adverse Event Reporting and Definition of Serious Adverse Events 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents. Adverse events are reported in a routine manner at scheduled 
times during a trial (please refer to the case report forms). Additionally, certain adverse events 
must be reported in an expedited manner for timelier monitoring of patient safety and care. The 
following sections provide information about expedited reporting. 
 
In studies involving human subjects, serious adverse experience means any experience that 
suggest a significant hazard, contraindication, side effect or precaution.  A serious adverse 
experience includes any experience that is fatal or immediately life threatening, results in a 
persistent or significant disability/incapacity, requires or prolongs in-patient hospitalization, or 
is a congenital anomaly, cancer, or overdose. Other important medical events that may not 
result in death, not be life-threatening, or not require hospitalization may be considered a 
serious adverse experience when, based upon appropriate medical judgment, the event may 
jeopardize the subject/patient and may require medical or surgical intervention to prevent one 
of the outcomes listed previously.  
 
 
 
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34 
 
7.3.2. Determination of reporting requirements 
 
Reporting requirements may include the following considerations: 1) whether the patient has 
received busulfan, melphalan or bortezomib; 2) the characteristics of the adverse event including 
the grade (severity), the relationship to the study therapy (attribution), and the prior experience 
(expectedness) of the adverse event; and 3) whether or not hospitalization or prolongation of 
hospitalization was associated with the event.  
 
Given that high dose chemotherapy by itself is associated with numerous adverse events and an 
expected prolonged hospitalization of 21-28 days, only certain adverse events of particular 
concern need to be reported in an expedited manner (see below sections 7.3.6, 7.3.7. and 7.3.8.). 
 
7.3.3. Steps to determine if an adverse event is to be reported in an expedited manner: 
 
Step 1: Identify the type of event using the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) Version 4.0. The CTCAE provides descriptive terminology and a grading scale for each 
adverse event listed. A copy of the CTCAE can be downloaded from the CTEP home page 
(http://ctep.cancer.gov). Additionally, if assistance is needed, the NCl has an Index to the CTCAE 
that provides help for classifying and locating terms. All appropriate treatment locations should 
have access to a copy of the CTCAE. 
 
Step 2: Grade the event using the NCI CTCAE v4.0. 
 
Step 3: Determine whether the adverse event is related to the protocol therapy. Attribution 
categories are as follows: Unrelated, Unlikely, Possible, Probable, and Definite. 
 
Step 4: Determine the prior experience of the adverse event. Expected events are those that 
have been previously identified as resulting from administration of the agent. An adverse event 
is considered unexpected, for expedited reporting purposes only, when either the type of event 
or the severity of the event is NOT listed in section 7.1.1, 7.1.2 and 7.1.3.  
 
Step 5: Review the Protocol-Specific Expedited Adverse Event Reporting Exclusions (section 7.3.8). 
 
Step 6: Determine if the protocol treatment given prior to the adverse event included busulfan, 
melphalan or bortezomib, or a combination of these agents. 
 
7.3.4. Reporting methods 
 
An FDA Medwatch form (available online: http://www.fda.gov/downloads/Safety/MedWatch/ 
HowToReport/DownloadForms/ucm082725.pdf) should be faxed to the Montefiore-Einstein 
Cancer Center Coordinating Center and to the local institutional IRB, according to the 
guidelines outlined in section 7.3.5-7.3.7.  
 
7.3.5. When to report an event in an expedited manner 
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35 
 
This trial will be monitored by the Albert Einstein Cancer Center Data Safety Monitoring 
Committee (AECC DSMC). Follow guidelines in section 7.3.7 regarding criteria that required 
reporting of adverse events that required require 24-hour notification.  A copy of the adverse 
event report using MEDWATCH form should be faxed the Albert-Einstein Cancer Center 
Coordinating Center (see cover page for contact information).  
For any adverse events that occur more than 30 days after the last dose of treatment, only 
those that have an attribution of possibly, probably, or definitely AND meet the reporting 
requirements in Sections 7.3.6 must be reported on an expedited adverse event report form as 
per guidelines in section 7.3.7. 
 
7.3.6. Expedited reporting for the conditioning regimen Bu/Btz/Mel140 
 
Adverse events that require expedited reporting are outlined below in Table 1. 
 
NOTE: All deaths on study require both routine and expedited reporting regardless of causality. 
Attribution to treatment or other cause should be provided. All grade 3 and 4 pulmonary 
toxicity and neuropathy as well as moderate to severe VOD (see below, section 7.3.7 and 
Appendix C) require expedited adverse events reporting. 
 
Any medical event equivalent to CTCAE v4.02 grade 3, 4, or 5 that precipitates hospitalization 
(hospitalizations are defined as lasting 24 hours or longer) or prolongation of existing 
hospitalization (>28 days from admission) must be reported regardless of attribution and 
designation as expected or unexpected with the exception of any events identified as protocol-
specific expedited adverse event reporting exclusions. 
Any event that results in persistent or significant disability/incapacity, congenital anomaly, or 
birth defect must be reported via an expedited AE mechanism.  
 
Expedited AE reporting timelines: 
 
 24 Hours; 5 calendar days – The investigator must initially report the AE within 24 hours of 
learning of the event followed by a complete the AE report within 5 calendar days of the initial 
24-hour report. 
 10 calendar days – A complete AE report on the AE must be submitted within ten calendar 
days of the investigator learning of the event. 
 
Additional instructions, requirements and exceptions for this protocol:  
 
With respect to determining the specific day by which the event must be reported, the day the 
reporter learns of the adverse event constitutes “Day 0” 
 
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36 
Table 1: Expedited Reporting Requirements for Adverse Events that occur within 30 days of the 
stem cell infusion 
CTCAE  v4.0 
grade 
1 
 
2 
2 
3 
 
3 
4 & 5 
4 & 5 ¶ 
Expected-
ness 
Unexpected 
and  
Expected 
Unexpected Expected Unexpected 
Expected 
Unexpected Expected 
with  
Hospitalization 
Without 
Hospitalization 
With 
Hospitalization 
without 
Hospitalization 
 
Unrelated 
Unlikely 
Not  
Required 
Not  
Required 
Not  
Required 
Not  
Required 
Not  
Required 
10 
Calendar 
Days 
Not  
Required 
10 Calendar 
Days 
10 
Calendar
Days 
Possible 
Probable 
Definite 
Not  
Required 
10 Calendar 
Days 
Not  
Required 
Not  
Required 
Not  
Required 
Not  
Required* 
Not  
Required* 
24-Hour;  
5 Calendar 
Days 
10 
Calendar
Days** 
Adverse events with attribution of possible, probable, or definite that occur greater than 30 days after the last 
dose of treatment  require reporting as follows:  
 
24-hour notification followed by complete report within 5 calendar days for:  
o Grade 4 and Grade 5 unexpected events 
 
Complete SAE report within 10 calendar days: 
o Grade 3 unexpected events with hospitalization or prolongation of hospitalization 
o Grade 5 expected events 
¶Although 24-hour notification is not required for death clearly related to progressive disease, a full report is 
required as outlined in the table. 
*except grade 3 pulmonary toxicities and neuropathy 
** except grade 4 hematological toxicities 
 
 
7.3.7. Protocol Specific expedited reporting requirements: 
 
Contact Ira Braunschweig by telephone (718-920-4826) or email (IBRAUNSC@montefiore.org) 
to report the occurrence of an unexpected grade II or higher adverse drug reaction, any 
adverse event that requires hospitalizations or toxic death (see section 7.3.6).  
Of particular concern are grade 3 and 4 pulmonary toxicity, neuropathy, and moderate to 
severe VOD (see below, section 7.3.7 and Appendix C). These require expedited adverse events 
reporting as per the Expedited Reporting Guidelines and immediate contact of the PI Ira 
Braunschweig. 
 
For grade 2 and 3 unexpected events, reporting is only required if the event is related to the 
investigational conditioning regimen. It is not required if the event is related only to other 
agents used in the post-transplant period. 
 
NOTE: For grade 3 unexpected events with hospitalization lasting ≥24 hours following 
discharge (or prolonged hospitalization of>28 days), an AE report is required even if the event 
is unrelated to the investigational conditioning regimen (Bu/Mel140/Btz). Specifically, the 
following should be reported within 24 to 48 hours: 
 
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37 
 All life threatening events (grade 3 or 4) which may be due to drug administration. 
 All fatal events. 
 The first occurrence of any previously unknown clinical event (regardless of grade). 
 A permanently or severely disabling event 
 Prolonged or unexpected inpatient hospitalization (>28 days) 
 Overdose of drug 
 Discontinuation of dosing due to an adverse experience 
 Hospitalizations: Any grade 1 or 2 adverse event which precipitates a 
hospitalization lasting > 24 hours (or prolongs hospitalization) must be reported via 
AE report within 10 calendar days of learning of the event regardless of the 
attribution and designation as expected or unexpected 
 Grade 3 or 4 pulmonary toxicities 
 Grade 3 or 4 neuropathy 
 Veno-occlusive Disease (VOD): Any grade VOD must be submitted via expedited AE 
within 10 calendar days of learning of the event, regardless of the attribution. 
 For VOD, severity will be graded according to the following:55 
• MILD DISEASE: If patients showed no apparent adverse effect from liver 
disease; required no medications for diuresis of excessive fluid or for hepatic 
pain; and had completely reversible signs, symptoms, and laboratory 
abnormalities. 
• MODERATE DISEASE: If patients had an adverse effect from liver disease; 
required sodium restriction and diuretics to minimize signs of fluid excess 
(edema, ascites, cardiopulmonary congestion) or medication to alleviate pain 
from hepatomegaly; and eventually showed a complete resolution of all signs of 
liver damage (a return of weight to baseline, a decrease in liver size, and a 
decrease in total serum bilirubin to < 34.2 μmol/L [2 mg/dL]). 
• SEVERE DISEASE: If patients showed an effect from liver disease, and signs, 
symptoms, and laboratory values did not resolve before day 100 or the patient 
died, whichever occurred first. 
 
An Adverse Reaction Form (Form 1639) will be completed by Dr. Braunschweig, or his staff for 
timely submission to the FDA, and the other investigators.  
  
The Adverse Drug Reaction needs to be reported to the institutional IRBs of all participating 
institutions and to the FDA by the IND holder. Dr. Braunschweig or his staff will report any 
adverse drug reaction or toxic death to all investigators within 48 hours of notification, or 
sooner should there be another patient being considered for enrollment. 
 
 
7.3.8. Protocol-Specific Expedited Adverse Event Reporting Exclusions 
 
For this protocol only, certain AEs/grades are exceptions to the Expedited Reporting Guidelines 
and do not require reporting in an expedited manner (i.e., AdEERS).  Grade 3-4 hematological 
toxicities and Grade 3 non-hematological toxicities are expected with high dose 
chemotherapy and do not need to be reported in an expedited manner except grade 3 and 4 
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38 
pulmonary toxicity, neuropathy, and moderate to severe VOD (see above, section 7.3.7.).  
 
 
7.4 
Data Safety and Monitoring Plan 
 
During the recruitment and follow up phases of the trial, the Albert Einstein Cancer Center 
Data and Safety Monitoring Board (DSMB) will monitor data and oversee patient safety. The 
principal investigator will participate in the meetings as a non-voting member. The DSMB will 
meet every 6 months, or after enrollment of every 5 patients whichever comes first.  They will 
review adverse affects, adherence to protocol and study progress. All adverse events will be 
reported, as per policy, to the CCI/IRB. The DSMB will make recommendations regarding study 
performance and continuation. Ira Braunschweig will provide requested data to the DSMB to 
assess progress toward resolving research questions. 
 
In addition, Dr Ira Bruanschweig (PI) will review case report forms (CRFs) and any other toxicity 
data from all patients enrolled in this trial at regular frequent intervals. Biweekly 
conference calls will be conducted between the participating institutions to discuss trial patient 
enrolment, adverse events and protocol adherence.  
Each participating investigator will have primary responsibility for the safety of individual 
participants under his/her care and will review the data and safety on an ongoing basis. In 
addition, the independent DSMB will have primary responsibility for monitoring the 
accumulating study data for sign of adverse trends in morbidity / mortality and drug toxicity. 
 
7.5 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported through 
AdEERS must also be reported in routine study data submissions. 
 
 
 
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8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational or 
commercial agents administered in this study can be found in Section 7.1. 
 
8.1.1 IV Busulfan (Busulfex™) 
 
Supplied Form 
 
BUSULFEX™ is commercially available and is distributed as a unit carton of eight vials. 
BUSULFEX™ is packaged as a sterile solution in 10 ml single-use clear glass vials each containing 
60 mg of busulfan at a concentration of 6 mg/ml for intravenous use, Unopened vials of 
BUSULFEX™ must be stored under refrigerated conditions between 2°-8°C (36°-46°F). 
 
Storage and Stability 
 
BUSULFEX™ diluted in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP is 
stable at room temperature (25°C) for up to 8 hours but the infusion must be completed 
within that time. BUSULFEX™ diluted in 0.9% Sodium Chloride Injection, USP is stable at 
refrigerated conditions (2°-8°C) for up to 12 hours but the infusion must be completed within 
that time 
 
Guidelines for Administration 
 
BUSULFEX™  must be diluted prior to use with either 0.9% Sodium Chloride Injection, USP 
(normal saline) or 5% Dextrose Injection, USP (D5W). The diluent quantity should be 10 times 
the volume of BUSULFEX™ , so that the final concentration of busulfan is approximately 0.5 
mg/ml.. Parenteral drug products should be visually inspected for particulate matter and 
discoloration prior to administration whenever the solution and container permit. If particulate 
matter is seen in the BUSULFEX™  vial the drug should not be used.  
An administration set with minimal residual hold-up volume (2-5 cc) should be used for 
product administration. BUSULFEX™  should be administered intravenously via a central 
venous catheter. 
DO NOT infuse concomitantly with another intravenous solution of unknown compatibility.  
 
As with other cytotoxic compounds, caution should be exercised in handling and preparing the 
solution of BUSULFEX™ . Skin reactions may occur with accidental exposure. The use of gloves 
is recommended. Procedures for proper handling and disposal of anticancer drugs should be 
considered. 
 
8.1.2 Melphalan 
 
Supplied Form 
 
Melphalan for Injection is commercially available in a carton containing one single-use clear 
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glass vial of a sterile, non-pyrogenic, freeze-dried powder. Each single-use vial contains 
melphalan hydrochloride equivalent to 50 mg melphalan and 20 mg povidone. Melphalan for 
Injection is reconstituted using the sterile diluent provided. Each vial of sterile diluent contains 
sodium citrate 0.2 g, propylene glycol 6.0 ml, ethanol (96%) 0.52 ml, and Water for Injection to 
a total of 10 ml.  
 
Storage and Stability 
 
Store at controlled room temperature 15° to 30°C (59° to 86°F) and protect from light. 
Melphalan solution, diluted to final concentration in normal saline, should be administered 
within 1 hour. Nearly 1% of melphalan hydrolyzes every 10 minutes. The reconstituted solution 
should not be refrigerated, since a precipitate forms. 
 
Guidelines for Administration 
 
Melphalan is practically insoluble in water and has a pKa1 of ~2.5. Reconstitute the 50 mg vial 
with 10 ml of the provided diluent to yield a 5 mg/ml solution. Further dilute the solution to a 
concentration no greater than 0.45 mg/ml in normal saline. Inject 10 ml of the supplied diluent 
directly into the vial of lyophilized powder using a 20-gauge or larger needle and syringe. 
Immediately shake vigorously until a clear solution is obtained. This provides 5 mg/ml of 
melphalan. Immediately dilute dose to be administered in sodium chloride 0.9% injection to a 
concentration of no more than 0.45 mg/ml.. 
Complete administration within 60 min of reconstitution. Administer by injecting slowly into a 
fast-running IV infusion via an injection port of central venous line over at least 15 minutes. Do 
not administer by direct injection into a peripheral vein.  
 
The time between reconstitution/dilution and administration of Melphalan should be kept to a 
minimum because reconstituted and diluted solutions are unstable. Over as short a time as 30 
minutes, a citrate derivative of melphalan has been detected in reconstituted material from 
the reaction of melphalan with Sterile Diluent for melphalan. Upon further dilution with saline, 
nearly 1% label strength of melphalan hydrolyzes every 10 minutes. In order to ensure the 
administration of IV melphalan doses within one hour, the preparation of the dose on an “on 
call” basis is a reasonable consideration. 
 
A precipitate forms if the reconstituted solution is stored at 5°C. DO NOT REFRIGERATE THE 
RECONSTITUTED PRODUCT. 
 
As with other toxic compounds, caution should be exercised in handling and preparing the 
solution of ALKERAN. Skin reactions associated with accidental exposure may occur. The use of 
gloves is recommended. If the solution of melphalan contacts the skin or mucosa, immediately 
wash the skin or mucosa thoroughly with soap and water. Procedures for proper handling and 
disposal of anticancer drugs should be considered.  
 
Parenteral drug products should be visually inspected for particulate matter and discoloration 
prior to administration whenever solution and container permit. If either occurs, do not use 
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this product. 
 
Hypersensitivity reactions including anaphylaxis have occurred in approximately 2% of patients 
who received the IV formulation. These reactions usually occur after multiple courses of 
treatment. Treatment is symptomatic. The infusion should be terminated immediately, 
followed by the administration of volume expanders, pressor agents, corticosteroids, or 
antihistamines at the discretion of the physician. If a hypersensitivity reaction occurs, IV or oral 
melphalan should not be re-administered since hypersensitivity reactions have also been 
reported with oral melphalan. 
 
8.1.3 Bortezomib 
 
Supplied Form  
Bortezomib for Injection is a sterile, lyophilized powder for reconstitution and is supplied in 
vials containing Bortezomib and mannitol at a 1:10 ratio. Drug is available in sterile, single-use 
vials containing 3.5 mg of bortezomib. Vials containing 3.5 mg of bortezomib contain 35 mg of 
mannitol.  
 
Storage and Stability  
Vials containing lyophilized Bortezomib for Injection should be stored according to the label 
requirements. For the United States, store at USP Controlled Room Temperature which is 25ºC 
(77ºF); excursions permitted from 15 to 30ºC (59 to 86ºF). For Europe, do not store above 30ºC 
(86ºF). To date, stability data indicate that the lyophilized drug product is stable for at least 18 
months when stored under the recommended conditions.  
 
Guidelines for Administration  
The appropriate amount of Bortezomib will be drawn from the injection vial and administered 
as IV push over 3 to 5 seconds followed by a standard saline flush or through a running IV line. 
Vials are for single-use administration. 
On days Bortezomib is given with Busulfan, bortezomib should be given 120 minutes AFTER the 
busulfan infusion has finished. 
 
Bortezomib is cytotoxic. As with all cytotoxic drugs, caution is required when preparing and 
handling bortezomib solutions. The use of gloves and other appropriate protective clothing is 
recommended. In case of skin contact, wash the affected area immediately and thoroughly 
with soap and water for at least 15 minutes. If product contacts eye, immediately flush eye 
thoroughly with water for at least 15 minutes. Always contact a physician after any form of 
body contact. All materials that have been used for preparation should be disposed of 
according to standard practices. A log must be kept of all disposed materials.  
 
Each vial of bortezomib for Injection should be reconstituted under a laminar flow biological 
cabinet (hood) within 8 hours before dosing with 3.5 ml of NS (0.9%), Sodium Chloride Injection 
USP, so that the reconstituted solution contains bortezomib at a concentration of 1 mg/ml. 
Prior to reconstitution the vials should remain in the cartons to protect them from light. 
Dissolution is completed in approximately 10 seconds. The reconstituted solution is clear and 
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colorless, with a final pH of 5 to 6. Reconstituted bortezomib should be administered promptly 
and in no case more than 8 hours after reconstitution. All materials that have been used for 
preparation should be disposed of according to standard practices.  
 
 
9. CORRELATIVE/SPECIAL STUDIES 
 
A bone marrow (BM) aspirate will be performed within the framework of the routine staging 
bone marrow punctures for each patient 1 to 28 days prior to the start of therapy. An extra 
tube of 10cc will be sent within 24 hours to the Albert-Einstein College of Medicine 
Department of Molecular Biology Laboratory where they will be processed and centrally 
analyzed. We will use a multi-parameter high-speed FACS for analysis and sorting of CD138 
positive plasma cells. A detailed description of specimen collection, handling and shipping can 
be found in Appendix E. 
 
Methylation  studies of myeloma cells from pretreatment samples on CD138+ sorted plasma 
cells will be performed in Amit Verma’s laboratory. The MyPRS Plus™ commercially available 
gene expression profile will be used as gene expression study. 
 
Gene expression signatures will be correlated with response to therapy in order to develop 
biomarkers of response and prognosis.  
Aberrant epigenetic changes will be determined with a HELP (HpaII tiny fragment Enrichment 
by Ligation-mediated PCR) assay to perform an unbiased genome-wide analysis of DNA 
methylation. Methylome analysis on pretreatment samples will be correlated with response. 
 
Peripheral blood will be collected at baseline and at the Day 100 assessment. The blood will be 
stored for possible future correlative studies, such as SNP arrays or plasma cell enriched FISH 
studies. 
 
 
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10. STUDY CALENDAR 
 
STUDY CALENDAR  
Procedures 
 
Screening 
Base 
line 
Conditioning Phase 
Stem 
Cell 
Trans- 
plant  
Post- 
Transplan
t 
Follow-up 
End 
of 
Study 
Day 
-30  
to -15 
-14  
to -11^ 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
+1 
+4 
+30* or 
Discharge 
+100 
** 
+180 
** 
+360 
** 
 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographic 
Information 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical & Previous 
Treatment History 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam (incl. 
Height & Weight) 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
 
 
 
 
Vital Signs 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
 
 
 
 
Hematology, Serum 
Chemistry 
x 
x 
 
 
 
 
x 
 
 
 
 
 
x 
x 
 
 
 
Peripheral blood for 
correlative studies 
x 
X 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
INR 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary Function 
Tests 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance Status 
(ECOG/KPS) 
x 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
Myeloma 
Staging,*** 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
x 
Echo/MUGA 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti-seizure 
Prophylaxis 
 
 
x 
x 
x 
x 
x 
x^
^ 
 
 
 
 
 
 
 
 
 
Test Dose Busulfan 
(IV 0.8mg/kg) 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PK Sampling 
 
x 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Review Busulfan 
Dosing 
 
 
 
x 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
PK directed 
Busulfan dose 
 
 
 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
Bortezomib 
 
 
 
x 
 
 
x 
 
 
 
x 
x 
 
 
 
 
 
Melphalan 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
Rest Day 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
Stem Cell Re-
infusion 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
Assess disease 
progression/ 
survival status**** 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
x 
ANC & Platelet 
recovery 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant 
medications 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
x 
x 
x 
x 
Adverse Events 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
x 
x 
x 
x 
x 
 
^ The baseline period can be extended from day -21 to day -9 if required. Day -14 to -9 is the recommended time period 
^^ dose only in the morning 
*  Plus/Minus 5 days around Day +30 is permissible 
** Plus/Minus 14 days around Day +100, Day +180 and Day +360 is permissible 
*** Myeloma Staging includes at least SPEP, Serum IFE, 24 hour Urine UPEP, Urine IFE, Serum free light chain measurements 
(SFLC), bone marrow biopsy and aspirate (see 11.1) 
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**** Disease response determination based on measurable disease at study entry as per the IMWG citeria3 
 
Baseline evaluations are to be conducted within 2 weeks prior to start of protocol therapy.  
Myeloma staging must be done within 4 weeks prior to the start of therapy.  In the event that 
the patient's condition is deteriorating, laboratory evaluations should be repeated within 48 
hours prior to initiation of therapy. 
 
 
11. MEASUREMENT OF EFFECT 
 
11.1 
Response Assessment 
 
For the purposes of this study, patients should be reevaluated for response on Day +100, Day 
+180 and Day +360 post autologous stem cell transplantation. Additionally, patients should be 
evaluated earlier at any time that there is a clinical indication for disease progression. 
 
Response and progression will be evaluated in this study using the criteria recommended by 
the International Myeloma Working Group (IMWG).3 
 
11.1.1. Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of 
their first treatment with BUSULFEX™ . 
 
Evaluable for objective response.  Only those patients who have measurable 
disease present at baseline, have received therapy, and have had their disease 
re-evaluated will be considered evaluable for response.  These patients will have 
their response classified according to the definitions stated below.   
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable disease is defined by Protein criteria 
(quantifiable M-component in serum or Serum Free Light Chain Assay) in order 
to evaluate response as per IMWG3. Non-secretory patients are eligible provided 
the patient has > 20% plasmacytosis OR multiple (>3) focal plasmacytomas or 
focal lesions on MRI 
 
11.1.3 Methods for Evaluation of Measurable Disease 
 
All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks before the beginning of 
the treatment. 
 
The same method of assessment and the same technique should be used to 
characterize each identified and reported measurement at baseline and during 
follow-up. If a measure was negative during baseline it does not need to be 
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45 
repeated at the time of follow up (e.g. UPEP) 
 
 
11.1.4 Response Criteria 
 
11.1.4.1 
Definitions of Response3 
 
All response categories require two consecutive assessments made at anytime before the 
institution of any new therapy; all categories also require no known evidence of progressive or 
new bone lesions if radiographic studies were performed. Radiographic studies are not 
required to satisfy these response requirements. 
 
Stringent Complete Response (sCR):  
 
 
CR as defined below plus 
 Normal FLC ratio and 
 Absence of clonal cells in bone marrowa by immunohistochemistry or 
immunofluorescenceb 
 
Complete Response (CR): 
 Negative immunofixation on the serum and urine and 
 Disappearance of any soft tissue plasmacytomas and 
 ≤5% plasma cells in bone marrowa 
 
Very Good Partial Response (VGPR):  
 Serum and urine M-protein detectable by immunofixation but not on electrophoresis or  
 90% or greater reduction in serum M-protein  
 plus urine M-protein level <100mg per 24 h  
 
Partial Response (PR): 
 
 ≥50% reduction of serum M-protein and 
 reduction in 24-h urinary M-protein by ≥90% or to <200mg per 24 h 
 
 If the serum and urine M-protein are unmeasurable,d a ≥50% decrease in the difference 
between involved and uninvolved FLC levels is required in place of the M-protein 
criteria 
 
 If serum and urine M-protein are unmeasurable, and serum free light assay is also 
unmeasurable, ≥50% reduction in plasma cells is required in place of M-protein, 
provided baseline bone marrow plasma cell percentage was ≥30% 
 
 In addition to the above listed criteria, if present at baseline, a ≥50% reduction in the 
size of soft tissue plasmacytomas is also required 
 
Stable Disease (SD): 
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46 
 Not meeting criteria for CR, VGPR, PR or progressive disease 
 
 
Abbreviations: CR, complete response; FLC, free light chain; PR, partial response; SD, stable 
disease; sCR, stringent complete response; VGPR, very good partial response. 
 
a Confirmation with repeat bone marrow biopsy not needed. 
b Presence/absence of clonal cells is based upon the kappa/lambda (k/l) ratio. An abnormal k/l 
ratio by immunohistochemistry and/or immunofluorescencec requires a minimum of 100 
plasma cells for analysis. An abnormal ratio reflecting presence of an abnormal clone is k/l of 
>4:1 or <1:2. 
 
The rate of Overall Response (OR) is defined as the percentage of participants that achieve 
either sCR, CR, VGPR and PR. 
 
 
11.1.4.2 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence. The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria 
 
11.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented. 
 
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that recurrent disease is objectively documented. 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until 
the criteria for progression are me. 
 
11.1.6 Survival End Points 
 
Progression-Free Survival 
 
Progression free survival (PFS) is defined as the duration of time from transplant (Day 0) to 
time of progression. 
 
Progressive diseasea is defined by any one or more of the following: 
Increase of ≥25% from baseline in 
 Serum M-component and/or (the absolute increase must be ≥0.5 g/dl) b 
 Urine M-component and/or (the absolute increase must be ≥200 mg/24 h) 
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47 
 Only in patients without measurable serum and urine M-protein levels: the difference 
between involved and uninvolved FLC levels. The absolute increase must be >10 mg/dl. 
 Bone marrow plasma cell percentage: the absolute % must be ≥10% c 
 Definite development of new bone lesions or soft tissue plasmacytomas or 
 Definite increase in the size of existing bone lesions or soft tissue plasmacytomas 
 Development of hypercalcemia (corrected serum calcium >11.5 mg/dl or 2.65 mmol/l) 
that can be attributed solely to the plasma cell proliferative disorder 
 
Clinical relapse: a  
Clinical relapse requires one or more of: 
Direct indicators of increasing disease and/or end organ dysfunction (CRAB features).b It is not 
used in calculation of time to progression or progression-free survival but is listed here as 
something that can be reported optionally or for use in clinical practice 
 Development of new soft tissue plasmacytomas or bone lesions 
 Definite increase in the size of existing plasmacytomas or bone lesions. A definite 
increase is defined as a 50% (and at least 1 cm) increase as measured serially by the 
sum of the products of the cross-diameters of the measurable lesion 
 Hypercalcemia (>11.5 mg/dl) [2.65 mmol/l] 
 Decrease in hemoglobin of ≥2 g/dl [1.25 mmol/l]  
 Rise in serum creatinine by 2 mg/dl or more [177 mmol/l or more] 
 
Abbreviations: CR, complete response; DFS, disease-free survival. 
a All relapse categories require two consecutive assessments made at anytime before 
classification as relapse or disease progression and/or the institution of any new therapy. 
b For progressive disease, serum M-component increases of >1 gm/dl are sufficient to define 
relapse if starting M-component is ≥5 g/dl. 
c Relapse from CR has the 5% cutoff versus 10% for other categories of relapse. 
d For purposes of calculating time to progression and progression-free survival, CR patients 
should also be evaluated using criteria listed above for progressive disease. 
 
Event-free survival (EFS): The definition of an event is 1) disease progression or 2) death from 
any cause. EFS is the time from stem cell transplant until an event as defined above has 
occurred. 
 
TTP (Time to Progression): This is the time from start of treatment to disease progression with 
deaths owing to causes other than progression not counted, but censored. This is a helpful 
method to assess the durability of treatment benefit. 
 
Overall survival (OS) is defined as the time from transplant until death of any cause. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements).  
 
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48 
12.1 
Data Management 
 
Data on toxicities and patient outcomes will be collected at the individual participating 
institution treating the patient on protocol. Every 4 weeks the collected data will be submitted 
to the Montefiore-Einstein Cancer Center Research Study Coordinator at the Clinical Trials 
Office. Data submitted as Case Report Forms (CRF) will be submitted by participating 
institutions for central data management to the Montefiore-Einstein Cancer Center Research 
Study Coordination Center on a monthly basis, where they will be merged with the other data 
available for each study participant into one master data set. 
 
12.2 
Patient Protection 
 
This study will be conducted in compliance with the protocol, Good Clinical Practice and the 
applicable regulatory requirements. All research personnel will receive the required education 
and training needed for conducting clinical research related to the protection of human 
subjects and personal health information according to the Institutional Review board and the 
Health Insurance Portability and Accountability Act of 1996 Public Law 104-191. As mentioned 
above, each patient will be assigned a study identification number at the time of recruitment. 
Records will be kept confidential. As this research involves a drug, the U.S. Food and Drug 
Administration (FDA) may inspect the research records and medical records as may the Office 
for Human Research Protections (OHRP) and employees from Otsuka Pharmaceutical Co, Ltd. 
The research study doctors and research staff will review medical records and will keep the 
information private. No patient will be identified in any written or verbal report with the 
following exception: the local human research committees of the participating institutions may 
inspect the patient records. All hard copies of information will be stored in locked cabinets, to 
which only senior research personnel has access. The study data files will be stored on 
password protected computers.  
 
12.3 
Recruitment and Informed Consent  
 
Patients who are identified by clinicians at the participating sites as being eligible for the study 
will be approached by the local PI or co-PI about their potential participation. An informed 
consent document in English and Spanish will be provided to the patient. The investigational 
nature of the study, its objectives, the procedures and the potential risks and benefits involved 
will be explained to the patient in simple and direct lay language avoiding medical terms. The 
patient and the person taking the consent will sign the consent form and a copy of it will be 
given to the patient. A copy of the consent and the protocol will be left in the patient’s chart. 
 
 
13. STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
The study is a multi-center phase II study. 
 
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49 
The primary endpoint will be the rate of complete response (CR) at Day +100 after ASCT as 
determined by the IMWG criteria.3 We aim to demonstrate that the complete response rate 
(CRR) 100 Days after the ASCT is at least 35%. This would demonstrate at least the same 
complete response rate as the reported complete response rates of the Mel200 conditioning 
regimen.  
 
Our null hypothesis states that we will have achieved a complete response of less than 35% 
100 days after the ASCT. This CR rate is estimated based on a conditioning regimen using 
melphalan alone at a dose of 200mg/m2 intravenously in this setting. Traditionally, the 
complete response (CR) rate observed after Mel200 followed by ASCT is between 10-35% 
depending on the induction regimen used.6-8 
Our alternative hypothesis is that use of our regimen will have at least the same complete 
response rate of 35% or higher than melphalan alone (Mel200) by intention-to-treat analysis.  
 
Secondary endpoints will be the overall response rate (sCR, CR, VGPR plus PR, see section 
11.1.4), as well as toxicity assessment using CTCAE v4.02 and the Baltimore criteria for VOD54, 
time-to-progression and survival (progression-free survival, event-free survival and overall 
survival). 
The association between gender, race and pharmacokinetic data will be explored as another 
secondary endpoint. Methylation and gene expression profiles will be associated with 
outcome. 
 
13.2 
Sample Size/Accrual Rate 
 
If the true response rate for the new regimen (Bu/Mel/Btz) is 55%, with 28 patients in the 
study, we will be able to construct a 95% confidence interval for the true response rate with 
the lower bound no less than 35%. In other words, with 28 patients in the study, if the true 
response rate is 55%, we will be able to conclude with 95% confidence that the response rate 
for the new regimen is at least 35%. 
 
The primary and coordinating site will be the Montefiore-Einstein Cancer Center (MECC). The 
Bone Marrow Transplantation team at MECC sees on average 40 to 50 patients per year that 
would meet the eligibility criteria for the study.  
 
We anticipate an annual accrual of ≥20 patients. The projected time for completion of the 
study is 24 months. Should the accrual be less than 8 patients per six month period from the 
start of activation of the protocol, we will be actively approaching other sites to participate in 
the study. 
The New York Cancer Consortium mechanisms® will be utilized to conduct and coordinate the 
study and sites. 
 
13.3 
Analysis of Secondary Endpoints 
 
The analysis of the secondary endpoints is exploratory. 
The secondary endpoints to be explored will be the overall response (stringent complete response, 
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50 
complete response, very good partial & partial response, stable disease and progression), toxicity 
as assessed by the Common Terminology Criteria for Adverse Events (CTCAE) v4.0,2 mortality at 
days 30, 100 and 360 post transplant, time to progression, median progression, event free and 
overall survival, and possibly associations of the pharmacokinetic profile of iv busulfan as 
determined by the test dose and the variables gender and race. 
We will use descriptive statistics and tabular representations to describe and evaluate response 
rates and toxicities.  
Time-to-event analysis for PFS, EFS, and OS (defined in section 11.1.6) will be performed using 
Kaplan-Meier methods. The log-rank test will be used to compare survival among patients 
based on their response (as defined in section 11.1.4.1). Bivariate analysis will be used to asses 
the association of variables such as gender and age with response as the outcome. Categorical 
variables will be analyzed using the chi-square test or the non-parametric Fisher’s exact test; 
continuous variables will be analyzed using the t-test if normally distributed, or the Wilcoxon 
rank sum test. We will use logistic regression to analyze association of variables with response 
if they are biologically significant or were found on bivariate analysis to be significantly 
associated with the outcome.  
Epigenetic and genomic data (methylation and gene expression profiles of CD138 positive bone 
marrow plasma cells) will be examined in an exploratory manner to assess association with the 
clinical outcomes response rate and survival.  
 
13.4 
Reporting and Exclusions 
 
13.4.1 Evaluation of toxicity.   
 
All patients will be evaluable for toxicity from the time of their first treatment with Busulfex™ 
 
13.4.2 Evaluation of response.   
 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible.  Each patient will be assigned one 
of the following categories:  1) stringent complete response, 2) complete response, 3) very 
good partial response, 4) partial response, 5) stable disease, 6) progressive disease, 7) early 
death from malignant disease, 8) early death from toxicity, 9) early death because of other 
cause, or 10) unknown (not assessable, insufficient data).  
 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate.  
Patients in response categories 5-10 should be considered to have a treatment failure (disease 
progression).  Thus, an incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate. 
 
13.5 
Interim Analysis Decision Rules 
 
An interim analysis will be performed after the first 20 patients have enrolled to asses the 
safety of the proposed treatment. Stopping rules will be based on the 30-day mortality. 
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The anticipated treatment-related mortality with the proposed regimen is less than 5% based 
on previous studies using high dose chemotherapy followed by autologous stem cell 
transplantation in patients with multiple myeloma (ranging from 0 to 5%).5,6,36,56,57  We will 
consider a 30-day mortality of more than 5% as unacceptable. The 30-day mortality will be 
evaluated after the first 20 patients have been enrolled. If no more than 1 patient suffers a 
mortality within 30 days that is attributable to the therapy and not the underlying disease or 
unrelated to therapy, we will continue to accrue until the accrual goal is met. If 2 or more 
patients suffer a mortality that is directly attributable to therapy within 30 days of transplant, 
we will suspend accrual and investigate the causes of the higher mortality.  
 
Once the root of the high mortality has been determined, the study team will confer with the 
DSMC and the IRB to make a determination whether accrual can be resumed. 
 
 
 
 
 
 
 
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 APPENDIX A 
 
Performance Status Criteria 
 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
 
 
 
 
 
 
 
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APPENDIX B - Busulfan PK Testing information 
 
Laboratory Hours and Contact Information: 
Tuesday to Saturday: 8:00am to 5:00pm 
Sundays, Mondays, and holidays: On call  
Phone: (206) 288-7389    
Fax: (206) 288-7397 
Email: pklab@seattlecca.org 
Please send samples to:  
Pharmacokinetics Laboratory  
Seattle Cancer Care Alliance  
825 Eastlake Ave E., Room G7-405   
Seattle, WA 98109-1023 
http://www.seattlecca.org/busulfan-lab-samples.cfm 
 
Sending Samples to the Busulfan Laboratory 
If the institution has already an account with Seattle Cancer Care Alliance, please download the 
Busulfan Electronic Order Form (http://www.seattlecca.org/client/documents/doctors-
providers/Busulfan%20E-order%20Form_8582_0.pdf) to your computer and follow its 
instructions to order busulfan testing. (You need Adobe Acrobat Reader 7.0 or above; go to 
http://www.adobe.com for a free download.) If the institution is a new client, please contact 
pklab@seattlecca.org for account set-up. 
This information is also available on the company’s website: 
http://www.seattlecca.org/busulfan-lab-samples.cfm 
 
Shipment: 
Advance notice is required for all sample shipments: 
Tuesday to Saturday arrival: At least 48 hours in advance. 
Sunday, Monday, or holiday arrival: At least 72 hours in advance (Sample acceptance is only on 
pre-arranged basis).  
Please call or email us to provide package tracking information. 
 
Sample Collection and Processing: 
Draw minimum 4 ml of blood into 4-mL Sodium Heparin green top blood tubes.   
Busulfan degrades quickly at room temperature. Each sample should be kept in wet ice slurry 
or refrigerated at all time. Centrifuge them as soon as possible at 4 °C. Separate the plasma 
from each sample and transfer it to individual 4mL plastic tubes. Immediately freeze these 
plasma samples at -20 °C. 
All samples have to be labeled with patient name, Medical Record #, date and actual clock time 
of the blood draw. Two unique identifiers and clock times are REQUIRED or samples can be 
rejected.  
Samples must be shipped on a minimum of 3 kg of dry ice using an overnight carrier. Samples 
that arrived thawed will not be analyzed.  
 
A REQUISITION SHEET for regimen of Q24hr is required to be sent with the samples 
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54 
(http://www.seattlecca.org/client/documents/Req_Q6-IV_Q24-IV_Busulfex_v2.pdf). Patient 
identifiers must be matched with those on the collected samples mentioned above. Also, our 
requisition serves as physician’s order and must be signed by the attending physician or 
designee/caregiver according to the College American Pathologists (CAP) requirement.  
Results 
 
We usually release pharmacokinetics results on the same day as receipt of the samples. 
Average sample run-time is approximately 3 hours.  
Sample processing is prioritized by time zone differences or next dose due time to maximize 
the advantage of dose adjustments. 
All results must be verbally delivered to attending physician, pharmacist, or caregiver who is a 
certified MD or PharmD. No exceptions.  
After the verbal report, a hardcopy can be faxed to designated number(s). CPT Code and Cost 
of the Services 
The CPT code for our GC-MS analysis of busulfan is 82542.  
The cost of the analysis for each sample is USD $224.25. This includes the analysis and dose 
recommendations.  
 
 
 
 
 
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APPENDIX C 
 
Baltimore Criteria54 for diagnosis of VOD 
 
Development of hyperbilirubinemia with serum bilirubin > 2 mg/dl within 21 days after 
transplantation and at least 2 of the following clinical signs and symptoms: 
 
• Hepatomegaly, usually painful,  
 
• > 5% weight gain,  
 
• Ascites. 
 
Source: Jones RJ, Lee KS, Beschorner WE, et al. Venoocclusive disease of the liver following 
bone marrow transplantation. Transplantation. 1987;44:778-783 
 
 
For VOD, severity will be graded according to the following:55 
 
• MILD DISEASE: If patients showed no apparent adverse effect from liver disease; required no 
medications for diuresis of excessive fluid or for hepatic pain; and had completely reversible 
signs, symptoms, and laboratory abnormalities. 
 
• MODERATE DISEASE: If patients had an adverse effect from liver disease; 
required sodium restriction and diuretics to minimize signs of fluid excess (edema, ascites, 
cardiopulmonary congestion) or medication to alleviate pain from hepatomegaly; and 
eventually showed a complete resolution of all signs of liver damage (a return of weight to 
baseline, a decrease in liver size, and a decrease in total serum bilirubin to < 34.2 μmol/L [2 
mg/dL]). 
 
• SEVERE DISEASE: If patients showed an effect from liver disease, and signs, symptoms, and 
laboratory values did not resolve before day 100 or the patientdied, whichever occurred first. 
 
 
 
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APPENDIX D – FORM 1 (REGISTRATION AND ELIGIBLITY) 
 
Initials: _____ MR# ________________ DOB: _________ Center:___________Date: ______________ 
Treating Physician: ______________________________  
 
“A Phase II study Assessing the Efficacy and Toxicity of PK-directed Intravenous Busulfan in 
Combination with High-Dose Melphalan and Bortezomib as Conditioning Regimen for First-
line Autologous Hematopoietic Stem Cell Transplantation in Patients with Multiple 
Myeloma” 
 
Inclusion Criteria:  
The answers to the following questions must be YES in order for the patient to be eligible.  
YES NO 
3.1.1. Histologically or cytologically confirmed Multiple Myeloma 
 
 
3.1.2. Measurable disease must be present at diagnosis as defined by Protein criteria 
(quantifiable M-component in serum, urine or Serum Free Light Chains) in order to evaluate 
response as per IMWG. Non-secretory patients are eligible provided the patient has > 20% 
plasmacytosis OR multiple (>3) focal plasmacytomas or focal lesions on MRI 
 
 
3.1.3. Age >18 years and ≤72 years 
 
 
3.1.4. Must have received induction chemotherapy for myeloma, but no more than a total of 
12 months of chemotherapy, and must be eligible for the first planned autologous transplant 
 
 
3.1.5. A minimum stem cell dose of 2.0 x 106 CD34+ cells/kg has been collected.  
 
 
3.1.6. Life expectancy of greater than 12 months 
 
 
3.1.7. ECOG performance status <2 (Karnofsky >60%; see Appendix A 
 
 
3.1.8. Patients must have normal organ and marrow function as defined below: 
- 
leukocytes  
 
 
>3,000/mcL (unless myeloma related) 
- 
absolute neutrophil count 
>1,500/mcL (unless myeloma related) 
- 
platelets  
 
 
>50,000/mcL (unless myeloma related) 
- 
total bilirubin 
 
 
<2 X institutional upper limit of normal unless 2nd to 
Gilbert’s disease 
- 
AST(SGOT)/ALT(SGPT) 
 
<3 X institutional upper limit of normal 
- 
creatinine  
 
 
<1.5 X institutional upper limit of normal 
OR 
- 
creatinine clearance  
 
>60 mL/min/1.73 m2 for patients with creatinine levels 
above institutional normal 
 
 
 
3.1.9.  Ejection fraction by ECHO or MUGA ≥ 40% performed within 90 days prior to registration  
 
3.1.10. Adequate pulmonary function studies: > 50% of predicted on mechanical aspects 
(FEV1, FVC) and diffusion capacity (DLCO) > 50% of predicted, within 120 days of registration. If 
the patient is unable to complete pulmonary function tests due to MM related pain or 
condition, exception may be granted if the principal investigator (PI) documents that the 
patient is a candidate for high dose therapy. 
 
 
3.1.11. Women of child-bearing potential and men must agree to use adequate contraception 
(hormonal or barrier method of birth control; abstinence) prior to study entry and for at least six  
month following  the stem cell transplantation 
 
 
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3.1.12. Ability to understand and the willingness to sign a written informed consent document. 
 
 
 
Exclusion Criteria:  
The answers to the following questions must be NO in order for the patient to be eligible.  
 
YES 
 
NO 
3.2.1. Patient received chemotherapy or pelvic radiotherapy within 4 weeks prior to entering 
the study or has not recovered from adverse events due to agents administered more than 4 
weeks earlier. 
 
 
3.2.2 Prior treatment history of autologous HSCT or high-dose chemotherapy with stem cell 
rescue for any medical reason 
 
 
3.2.3 Patient is receiving another investigational agent. 
 
 
3.2.4   Patient has brain metastases 
 
 
3.2.5  History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to or other agents used in the study, such as busulfan, melphalan, bortezomib, 
boron, or mannitol 
 
 
3.2.6 Grade 2 or greater peripheral neuropathy within 14 days prior to enrollment 
 
 
3.2.7 Unresolved grade >/= 3 non-hematologic toxicity from previous therapy.  
 
 
3.2.8 Prior malignancies except resected basal cell carcinoma or treated cervical carcinoma in 
situ. Cancer treated with curative intent < 5 years  
 
 
3.2.9 Significant co-morbid medical condition 
 
 
3.2.10 Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, 
or psychiatric illness/social situations that would limit compliance with study requirements. 
Patients must not have suffered recent (< 6 months) myocardial infarction, unstable angina, 
difficult to control congestive heart failure, uncontrolled hypertension, or difficult to control 
cardiac arrhythmias 
 
 
3.2.11 Positive pregnancy test if woman of child bearing potential 
 
 
3.2.12 Patient is HIV positive  
 
 
3.2.13 Active Hepatitis B as defined by Hepatitis B surface antigen positivity, unless able to start 
dual anti-HepB therapy, or already on dual anti-HepB therapy 
 
 
 
Fax Registration Form to: Montefiore-Einstein Coordinating Center (see cover page) 
To be completed by the Montefiore-Einstein Cancer Center Clinical Trials Office and faxed back to Site: 
Patient Eligible:  
 
Yes                    No  
 
  
 
Patient ID :  
 
 
 
 
 (this should be used as patient identifier) 
 
 
___ ___________________________ 
 
 
____________  
 
 
 
 
 
 
 
 
Coordinating Center Staff Signature 
 
 
Date 
 
 
IRB NUMBER: 11-12-434
IRB APPROVAL DATE: 12/01/2015


 
58 
APPENDIX E 
 
HANDLING AND SHIPPING OF BONE MARROW SPECIMENS: 
 
1. Collect (3) Green top tubes of marrow aspirate that contain sodium heparin 
2. Invert the tubes thoroughly to prevent clotting 
 
SPECIMEN TRANSPORT AND DELIVERY TO DEPARTMENT OF MOLECULAR BIOLOGY 
LABORATORY: 
 
1. Identify all tubes with the patient name, medical record number, and laboratory 
I.D. number, then seal in a biohazard bag for transportation. 
2. YOU MUST NOTIFY EITHER DR. IRA BRAUNSCHWEIG* OR DR. AMIT VERMA 
PRIOR TO SENDING A SAMPLE 
3. Place sealed specimens onto wet ice, and ship container to the following 
address overnight via FEDEX: 
 
 
 
 
 
Amit K. Verma, M.B.B.S. 
 
 
 
 
Albert Einstein College of Medicine 
 
 
 
 
Jack and Pearl Resnick Campus,  
 
 
 
 
Chanin Building, Room 302B 
 
 
 
 
1300 Morris Park Avenue 
 
 
 
 
Bronx, New York 10461 
 
 
 
 
Phone 718-930-8761 
 
                        Email: amit.verma@einstein.yu.edu 
  
3. It is absolutely imperative that all specimens arrive in this laboratory within 24 
hr of collection; overnight rush delivery is therefore required. 
 
4. Any specimen demonstrating presence of clots cannot be processed. 
 
* Please call Dr. Ira Braunschweig (phone: 718-920-4826) or Amit Verma to notify that a 
shipment has been sent and for any questions. 
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59 
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ICF_001.pdf: