Conditions: Sickle Cell Disease
Keywords: sickle cell disease
Allocation: NON_RANDOMIZED | Intervention model: SINGLE_GROUP
Enrollment: 43
Healthy volunteers: yes

Brief summary:
RATIONALE: Giving low doses of chemotherapy, such as fludarabine and cyclophosphamide, and total-body irradiation before a donor bone marrow transplant helps stop the growth of abnormal cells. It also helps stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving sirolimus and mycophenolate mofetil after transplant may stop this from happening.

PURPOSE: This phase II trial is studying how well giving fludarabine and cyclophosphamide together with total-body irradiation followed by a donor bone marrow transplant works in treating patients with sickle cell anemia and other blood disorders.

Detailed description:
OBJECTIVES:

* Determine the transplant-related mortality and progression-free survival of patients with severe hemoglobinopathies receiving nonmyeloablative conditioning comprising fludarabine phosphate, cyclophosphamide, and total-body irradiation followed by partially HLA-mismatched bone marrow transplantation from first-degree relatives or HLA-matched donors.
* Characterize donor hematopoietic chimerism at 30, 60, and 180 days after transplantation in these patients.
* Determine the hematologic and non-hematologic toxicity of this regimen in these patients.

OUTLINE:

* Preparative regimen: Patients receive fludarabine phosphate IV over 30 minutes on days -6 to -2 and cyclophosphamide IV over 1-2 hours on days -6 and -5. Patients also undergo total-body irradiation on day -1.
* Bone marrow transplantation: Patients undergo allogeneic bone marrow transplantation on day 0. Patients then receive cyclophosphamide IV over 1-2 hours on days 3 and 4.
* Graft-versus-host disease prophylaxis: Patients receive sirolimus orally daily on days 5-365 and oral mycophenolate mofetil 3 times a day on days 5-35.

After completion of study treatment, patients are followed periodically.

PROJECTED ACCRUAL: A total of 50 patients will be accrued for this study.

Arms:
arm 1: Conditioning regimen with anti-thymocyte globulin, fludarabine, cyclophosphamide, and total body irradiation - 200. Seizure prophylaxis with levetiracetam. Allogeneic bone marrow transplant infusion on Day 0. Graft-vs-host-disease (GVHD) prophylaxis with cyclophosphamide, mycophenolate mofetil, and sirolimus. arm 2: Conditioning regimen with anti-thymocyte globulin, fludarabine, cyclophosphamide, and total body irradiation - 400. Seizure prophylaxis with levetiracetam. Allogeneic bone marrow transplant infusion on Day 0. Graft-vs-host-disease (GVHD) prophylaxis with cyclophosphamide, mycophenolate mofetil, and sirolimus.

Interventions: intervention 1: Cyclophosphamide intervention 2: Fludarabine intervention 3: Mycophenolate mofetil intervention 4: Sirolimus intervention 5: Allogeneic bone marrow transplant intervention 6: Total body irradiation - 200 intervention 7: Levetiracetam intervention 8: Anti-thymocyte globulin intervention 9: Total body irradiation - 400
Intervention descriptions: intervention 1: Cyclophosphamide (Cy) 14.5 mg/kg/day intravenously (IV) on Days -6 and -5 and 50 mg/kg/day IV on Days +3 and +4. intervention 2: Fludarabine 30 mg/m\^2/day IV on Days -6, -5, -4, -3, and -2. intervention 3: Mycophenolate mofetil 15 mg/kg by mouth (PO) three times a day from Day +5 to Day +35. intervention 4: The first dose of Sirolimus is 6 mg PO on Day +5. Further dosing is adjusted according to drug levels. Sirolimus is continued through Day +365. intervention 5: An allogeneic bone marrow transplant is a procedure that involves taking bone marrow from a donor and giving it to a recipient. intervention 6: 200 centigray (cGy) in one fraction on Day -1. intervention 7: Given at 500 mg PO twice daily from Day -6 to Day +365. intervention 8: Test dose of 0.5 mg/kg IV given on Day -9, then 2 mg/kg/day IV on Day -8 and -7. intervention 9: 400 centigray (cGy) in one fraction on Day -1.

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
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Page 1 of 38 
A Phase II Trial of Non-Myeloablative Conditioning and Transplantation of 
Partially HLA-Mismatched and HLA-Matched Bone Marrow for Patients with 
Sickle Cell Anemia and Other Hemoglobinopathies 
 
Protocol Number: J0676 
 
 
 
IRB Application#: NA_00002479 
 
Principal Investigator: 
Javier Bolaños Meade, MD 
 
Office: 410-614-6398 
 
Pager:  410-283-8683 
 
Email: fbolano2@jhmi.edu 
 
 
Co-Principal Investigator: Sophie Lanzkron, MD 
 
Office:  410- 502-7770 
 
Email:  slanzkr@jhmi.edu  
 
 
Co-Investigators: 
Ephraim Fuchs, MD  
      Lode Swinnen, M.D. 
 
Leo Luznik, M.D.  
 
 
Richard J. Jones, M.D. 
Richard Ambinder, M.D., Ph.D.
 
Mark Levis, MD 
 
Carol Ann Huff, MD 
Allen Chen, MD, PhD 
 
Stephanie Terezakis, MD 
Robert Brodsky, M.D. 
 
Kenneth Cooke, MD 
Ivan M. Borrello, M.D. 
 
William Matsui, M.D. 
Chtistopher Gamper, MD, PhD 
 
David Loeb, M.D. 
Gary Rosner, ScD 
 
Marianna Zahurak, MS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
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Page 2 of 38 
 
TABLE OF CONTENTS 
 
 
SCHEMA………………………………………………………. 
3 
 
1.0 
OBJECTIVES…………………………………………………. 
4 
 
2.0 
BACKGROUND AND RATIONALE……………………….. 
4-7 
 
3.0 
DRUG INFORMATION……………………………………… 
7-12 
 
4.0 
PATIENT SELECTION……………………………………… 
12-15 
 
5.0 
TREATMENT PLAN………………………………………… 
15-20 
 
6.0 
PATIENT MONITORING………………………………….. 
20-24 
 
7.0 
TOXICITIES TO BE MONITORED……………………….. 
24-26 
 
8.0 
STUDY PARAMETERS…………………………………….. 
26-27 
 
9.0 
DATA MANAGEMENT…………………………………….. 
27-29 
 
10.0 
STATISTICAL CONSIDERATIONS……………………… 
29 
 
11.0 
RISKS AND BENEFITS…………………………………….. 
30 
 
12.0 
INFORMED CONSENT…………………………………….. 
30-31 
 
13.0 
ON-STUDY DATE…………………………………………… 
31 
 
14.0 
OFF-STUDY DATE…………………………………………. 
31 
 
 
REFERENCES………………………………………………. 
32-33 
 
 
APPENDICES………………………………………………. 
34-35 


 
 
 
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Page 3 of 38 
TREATMENT SCHEMA 
Days -9                        Thymoglobulin 0.5 mg/kg IV with pre-meds 
Start steroid taper 
 
Days -8,-7 
Thymoglobulin 2 mg/kg IV qd with pre-meds 
 
Days -6, -5 
Fludarabine 30 mg/M2 iv qd 
 
Cyclophosphamide (CTX) 14.5 mg/kg IV qd* 
 
  
 
 
Days –4 -2 
Fludarabine 30 mg/M2 iv qd 
 
 
Day –1 
TBI 400 cGy 
 
Day 0 
Infuse bone marrow and start penicillin 
 
 
Days 3, 4 
CTX 50 mg/kg iv q d 
 
Mesna 40 mg/kg iv q d** 
(First dose of CTX must be administered 48-72 hr after infusion of marrow) 
 
 
Day 5    
Begin sirolimus (section 6.6)** and  
                
MMF 15 mg/kg po tid with maximum daily dose 3 gm/d 
 
  
 
 
Day 30 
Assess Chimerism in peripheral blood 
 
 
Day 35 
 
 
 
Discontinue MMF 
 
 
Day 60 
Assess Chimerism in peripheral blood 
 
 
Day 180 
Evaluate disease 
 
 
 
     Assess Chimerism in peripheral blood 
 
 
Day 365 
Discontinue sirolimus 
 
Evaluate disease 
 
 
 
     Assess Chimerism in peripheral blood 
 
 
1 yr, 2 yrs 
Evaluate disease 
 
 
 
     Assess Chimerism in peripheral blood 
 
* Refer to Section 5.3 for complete dosing instructions. 
** Or as per institutional standards. 
 


 
 
 
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Page 4 of 38 
1.0 OBJECTIVES 
1.1 Obtain estimates of transplant-related mortality (TRM) and progression-free 
survival in patients with severe hemoglobinopathies receiving non-
myeloablative conditioning and transplantation of partially human leukocyte 
antigen (HLA)-mismatched bone marrow (haploidentical) from relatives 
(“mini-haploBMT”) as well as HLA-matched donors. 
1.2 Characterize donor hematopoietic chimerism in peripheral blood at days 
~30, ~60, and ~180 after mini-haploBMT. 
1.3 Characterize hematologic and non-hematologic toxicities of mini-
haploBMT. 
 
2.0 BACKGROUND 
 
Allogeneic blood or marrow transplantation (alloBMT) is a curative therapy for a 
variety of hematologic disorders, including sickle cell disease and other 
hemoglobinopathies such as thalassemia. Even when it is clear that alloBMT can give to 
these patients an improvement in their disease1, myeloablative transplants have important 
toxicities and mortalities associated. Substantial progress has been made recently in the 
development of reduced intensity conditioning regimens that facilitate the sustained 
engraftment of donor marrow with reduced toxicity.  Most of these regimens incorporate 
highly immunosuppressive purine analogues, such as fludarabine, which allow the 
reduction or elimination of myeloablative agents such as busulfan or total body 
irradiation without endangering the sustained engraftment of HLA-identical allogeneic 
stem cells.  Preliminary results of non-myeloablative allogeneic stem cell transplantation, 
or NST, suggest that the procedure can be performed in patients who are ineligible for 
myeloablative alloBMT, and that sustained remissions of several hematologic 
malignancies can be obtained. 
Despite the encouraging results in hematologic malignancies, the results of 
nonmyeloablative alloBMT in patients with hemoglobinopathies are less encouraging. 
Recently, Jacobsohn et al reported on 13 patients with non-malignant conditions 
undergoing nonmyeloablative alloBMT2.  Engraftment was poor in patients with 
hemoglobinopathies as only one patient engrafted out of 4 patients. These findings have 
been duplicated in other small studies3,4.  Also, the lack of suitable donors continues to be 
a limit to access to transplantation. Therefore, developing novel strategies that address the 
issue of expanding donor pool and have different immune suppression are of paramount 
relevance for the therapy of sickle cell disease. 
In the past five years, we have been developing non-myeloablative conditioning 
regimens for transplantation of marrow from partially HLA-mismatched, or 
haploidentical, bone marrow from first-degree relatives.  The main goal of J9966 (RPN 
99-11-05-01) was to titrate the dose of pre- and post-transplantation cyclophosphamide 
(CTX), a potent immunosuppressive drug, given in conjunction with pre-transplantation 
fludarabine and total body irradiation (TBI), to achieve a regimen that had an acceptably 
low risk of graft rejection and GVHD, the two major complications of haploidentical 
BMT.  All patients received mycophenolate mofetil and tacrolimus, beginning on day 4 
or 5 and terminating on days 35 and 50-180, respectively, to reduce the incidence and 
severity of GVHD.  The first cohort of three patients received no pre-transplantation CTX 


 
 
 
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Page 5 of 38 
and 50 mg/kg CTX IV on day 3, and two of the patients rejected their grafts.  A second 
cohort of 20 patients received 14.5 mg/kg CTX IV on days –6 and –5 in addition to 50 
mg/kg IV on day 3.  Of 18 evaluable patients, 13 patients had donor engraftment on day 
60, but accrual of patients to this dose level was stopped because 8/13 patients developed 
severe GVHD, an incidence convincingly in excess of the stopping criterion of 20%.  To 
reduce the incidence of GVHD, a third cohort of patients received an additional dose of 
CTX 50 mg/kg IV on day 4, and MMF dosing was increased from bid to tid, based upon 
pharmacokinetic data suggesting the need for more frequent dosing.  Of seventeen 
evaluable patients so far, two patients have had non-fatal graft rejection, and only one 
patient treated according to the protocol has had severe GVHD (an additional patient 
developed severe GVHD after withdrawal of immunosuppression to treat relapse).  Two 
patients have died of causes other than relapse: one from GVHD, and the other from 
disseminated fungal infection.  Of the sixteen patients who have been followed up to 100 
days for relapse, eight have relapsed at a median of 64 days (range 24-~100) after 
transplantation, and six patients are alive and disease free at a median of 206 days (range, 
100-429 days [as of Feb 8, 2004]) following BMT. 
In order to better judge the safety and efficacy of our non-myeloablative BMT 
protocol, the tables below compare the results of J9966, dose level 3, to the results of the 
four largest published trials of HLA-identical sibling peripheral blood versus bone 
marrow transplantation for early stage leukemia. 
 
Engraftment Data 
Author N (PB/BM) 
Median age 
ANC 500/mm3† 
Plt 20K† 
Plt 50K† 
Blaise5 
48/52* 
37/36 
15/21 
13/21 
15/26 
Bensing
er6 
81/91 
42/42 
16/21 
13/19 
NA 
Schmitz
7 
163/166 
39/37 
12/15 
15/20 
20/26 
Couban
8 
109/118 
45/44 
19/23 
16/22 
NA 
J9966 
17 
31 
16 
24 
31 
*Numbers represent: recipients of peripheral blood/recipients of bone marrow 
†Time from transplantation to designated count, sustained without transfusion 
 
 
 
 
 
 
 
 
 
 


 
 
 
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Page 6 of 38 
Outcomes data 
Author 
aGVHD II-IV 
(%) 
aGVHD III-IV 
(%) 
cGVHD (%) 
TRM (%) 
Relapse (%) 
Blaise 
45/42* 
17/28 
55/30 
23/21† 
6/11 
Bensinger 
64/57 
15/12 
46/35 
21/30† 
14/25 
Schmitz 
52/39 
28/16 
66/50 
24/24* 
12/7 
Couban 
44/44 
26/18 
40/30 
7/16† 
15/20 
J9966 
47 
13 
NA 
13 
50 
*Numbers represent: recipients of peripheral blood/recipients of bone marrow 
†Transplant-related mortality (TRM) or relapse over entire study (median f/u ~ 2 years) 
†100 day mortality 
 
Compared to the patients receiving HLA-identical sibling bone marrow following 
myeloablative conditioning, patients on J9966 were younger, took longer to engraft 
platelets, and had a substantially higher rate of relapse, but were similar in the time to 
neutrophil recovery, the incidence of GVHD, and transplant-related mortality (TRM).  
The higher rate of relapse for patients on J9966 may be attributable to a benefit of 
myeloablative conditioning in reducing the risk of relapse, or that patients on J9966 had 
advanced, poor prognosis hematologic malignancies, which relapse more frequently than 
early leukemias after alloBMT. 
Since the toxicities of non-myeloablative haploidentical BMT were not known 
when the trial was written, eligibility for J9966 was restricted to patients with advanced, 
poor-risk hematologic malignancies, such as chronic myeloid leukemia in 2nd chronic 
phase, advanced myelodysplasia, acute leukemia in 2nd remission, and lymphoma in 
relapse after autologous BMT.  We have now expanded eligibility to ‘standard risk’ 
hematologic malignancies in trial J0457, which is still on going. 
 
Between J9966 and J0457, 56 patients with hematologic malignancies received 
cyclophosphamide 50 mg/kg IV, either once (on day 3) or twice (on days 3 and 4) after 
non-myeloablative conditioning and haploidentical bone marrow transplant. Most of 
these patients had advanced disease or failed a previous autologous transplant. All were 
conditioned as outpatients with fludarabine, cyclophosphamide, and total body 
irradiation, transplanted with non-T cell-depleted marrow, and treated with tacrolimus 
and mycophenolate mofetil beginning the day after the last dose of cyclophosphamide. 
The most interesting finding was that compared to patients receiving a single dose of 
post-transplant cyclophosphamide, those receiving two doses had significantly less grade 
II-IV aGVHD (43% vs. 78%; p=.01) and grade III-IV aGVHD (20% vs. 53%; p=.006) by 
day 200 after transplant. Death from GVHD occurred in 5/13 assessable patients 
receiving one dose versus 2/28 assessable patients receiving 2 doses of 
cyclophosphamide.  
Since the data to date suggest that our treatment regimen may be as safe as HLA-
identical sibling BMT after myeloablative conditioning, non-myeloablative 
haploidentical BMT may be considered a reasonable treatment option for patients who 
have hemoglobinopathies. Also, the novel use of post-transplant cyclophosphamide on 
top of the nonmyeloablative conditioning, emerges as an interesting option of 
immunotherapy to prevent graft rejection. Moreover, as cancer relapse is not a concern in 
the setting of sickle cell disease, engraftment with NST should be curative. 


 
 
 
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Page 7 of 38 
 
In clinical transplantation, antithymocyte globulin (ATG) has been used 
extensively in conventional myeloablative and non-myeloablative conditioning regimens 
to facilitate engraftment in patients with sickle cell disease14. This effect is largely 
mediated by in vivo T-cell depletion produced by the ATG, similar to the effect of 
monoclonal T-cell antibodies in the murine model. 
 
Given that sirolimus (as opposed to calcineurin inhibitors) has not been 
commonly associated with the posterior reversible encephalopathy syndrome (PRES), we 
decided to change the immunosupression, switching sirolimus for tacrolimus. Also, given 
the very encouraging results obtained after 10 patients, and given that few patients may 
have a suitable HLA-matched donor, we have decided to expand the protocol to include 
these patients. 
 
As of June 2011 we have transplanted 11 patients on study and of these, 6 have engrafted 
(54%) with no transplant related mortality, only 1 case of mild acute GvHD and no cases 
of chronic GvHD. While these results are actually very good considering the fact that all 
these patients have been haploidentical, there is a clear need for improvement. 
Experimental data using high dose cyclophosphamide has clearly shown that in order to 
increase engraftment efficiency there are 2 clear strategies to follow: increase the 
intensity of the conditioning (such as increasing the dose of TBI) or increase the cell dose 
of the graft9, 10. Increasing the intensity of the conditioning can translate into increasing 
toxicities, therefore, we are interested on increasing the cell count in the graft. As with 
standard bone marrow harvest there may be a limit on the number of cells that can be 
harvested, “priming the marrow” with filgrastim comes as an attractive option11-13.Studies 
using bone marrow priming with filgrastin show that it is possible to double the number 
of nucleated cells from the marrow, and interestingly, high cell doses have not been 
associated with increased risk of GvHD or severe toxicities to the donor12, 13.  
 
Recently published data have shown that on patients at high risk of graft failure receiving 
non-myeloablative bone marrow transplants, the use of slightly higher doses of total body 
irradiation improve the probabilities of engraftment17,18. Given that we still facing graft 
failures in the order of 30% in our clinical trial, we decided to increase the dose of TBI to 
400cGy after discussions within the protocol team and with Radiation Oncology19. The 
higher dose may be associated with a higher incidence of sterility in men, and the patient 
has performed sperm banking and will be informed about this increased risk. However, 
we do not think will increase graft-versus-host disease rates given that our graft-versus-
host disease rates using high-dose cyclophosphamide are similar between myeloablative 
and non-myeloablative transplants20,21. Moreover. Published data showed that TBI at 
400cGy can be safely done in transplants using low intensity conditioning without 
increasing toxicities even on patients receiving mis-matched unrelated transplants22,23. 
 
 
3.0   DRUG INFORMATION 
 
3.1 
Fludarabine 
 
Fludarabine phosphate is commercially available. 


 
 
 
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Page 8 of 38 
 
Fludarabine phosphate is purine antimetabolite.that, after administration, 
undergoes rapid conversion in plasma to the nucleoside 2-fluoro ara-A (F-araA). 
F-araA subsequently enters cells where it is phosphorylated to F-araATP and the 
monophosphate F-araAMP.  Once activated, F-araATP inhibits DNA polymerase 
and ribonucleotide reductase. The monophosphate F-araAMP, once incorporated 
into DNA, is an effective DNA chain terminator. 
 
Fludarabine monophosphate, 50 mg/vial, is reconstituted with 2 ml of sterile 
water, resulting in a 25mg/ml solution. The desired dose is further diluted to 
concentrations of 0.04-1 mg/ml in normal saline or 5% dextrose (50-100ml) for 
injection and will be administered by IV infusion over 30 minutes or longer. 
 
Following IV administration, the drug is metabolized to 2-F-araA and widely 
distributed in tissues.  2-F-araA is excreted primarily in urine and has a terminal 
elimination half-life of 7 to 12 hours. 
 
Clinical toxicities of fludarabine monophosphate include: myelosuppression, 
primarily lymphopenia and granulocytopenia, alopecia, rash, dermatitis, nausea, 
vomiting, anorexia, stomatitis, diarrhea, somnolence, fatigue, peripheral 
neuropathy, mental status changes, cortical blindness, hepatocellular toxicity with 
elevation in serum transaminases, and interstitial pneumonitis. These effects are 
reversible when the drug is discontinued. 
 
Fludarabine will be administered by IV infusion over 30 minutes in a dose of 30 
mg/m2/day on days -6 to -2. 
 
Fludara® will be dispensed by the Oncology Pharmacy and is produced by Berlex 
Pharmaceuticals. 
 
3.2 
Cyclophosphamide (Cytoxan®) 
 
 
Cyclophosphamide is commercially available. 
 
Cyclophosphamide is an alkylating agent which prevents cell division primarily 
by cross-linking DNA strands.  Cyclophosphamide is cell cycle non-specific. 
 
Cyclophosphamide for injection is available in 2000 mg vials which are 
reconstituted with 100 ml sterile water for injection.  The concentration of the 
reconstituted product is 20 mg/ml.  The calculated dose will be diluted further in 
250-500 ml of Dextrose 5% in water.  Each dose will be infused over 1-2 hr 
(depending on the total volume). 
 
Clinical toxicities of cyclophosphamide include alopecia, nausea and vomiting, 
headache and dizziness, hemorrhagic cystitis, cardiotoxicity, immunosuppression, 


 
 
 
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Page 9 of 38 
myelosuppression, pulmonary fibrosis, increased hepatic enzymes and syndrome 
of inappropriate anti-diuretic hormone (SIADH). 
 
Cyclophosphamide will be dispensed by the Oncology Pharmacy and is produced 
by Mead Johnson Pharmaceuticals. 
 
 
3.3 
Mesna (sodium-2-mercapto ethane sulphonate) 
 
Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced by the  
oxasophosphorines (cyclophosphamide and ifosphamide).  It has no intrinsic 
cytotoxicity and no antagonistic effects on chemotherapy.  Mesna binds with 
acrolein, the urotoxic metabolite produced by the oxasophosphorines, to produce 
a non-toxic thioether and slows the rate of acrolein formation by combining with 
4-hydroxy metabolites of oxasophosphorines. 
 
Mesna is available in 200 mg, 400 mg and 1000 mg vials containing a 100 mg/ml 
solution.  Each dose of mesna will be diluted further in 50 ml of normal saline to 
be infused over 15 minutes (or as per institutional standards). Mesna dose will be 
based on the cyclophosphamide dose being given.  The total daily dose of mesna 
is equal to 80% of the total daily dose of cyclophosphamide. 
 
At the doses used for uroprotection mesna is virtually non-toxic.  However, 
adverse effects which may be attributable to mesna include nausea and vomiting, 
diarrhea, abdominal pain, altered taste, rash, urticaria, headache, joint or limb 
pain, hypotension and fatigue. 
 
Mesna will be dispensed by the Oncology Pharmacy and is produced by Mead 
Johnson Pharmaceuticals. 
 
3.4 
Sirolimus (rapamycin, Rapamune®) 
 
Sirolimus is an immunosuppressant that inhibits cytokine-stimulated T-cell 
activation and proliferation, and also inhibits antibody formation.   
The mean bioavailability of sirolimus after administration of the tablet is ~27% 
higher than the oral solution. Sirolimus oral tablets are not bioequivalent to the 
oral solution. Clinical equivalence has been demonstrated at the 2-mg dose level; 
however, it is not known if higher doses are clinically equivalent on a mg to mg 
basis. 
a) Sirolimus oral solution: Sirolimus oral solution (1 mg/mL) should be stored 
protected from light and refrigerated at 2°C to 8°C (36°F to 46°F). For dilution, 
the appropriate dose should be measured using an amber oral syringe, then added 
to a glass or plastic container that holds at least 60 mL.  Before taking the dose, it 
should be diluted with water or orange juice then taken immediately; it should not 
be diluted with grapefruit juice.  The syringe should be discarded after one use.  
Sirolimus oral solution provided in bottles may develop a slight haze when 


 
 
 
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Page 10 of 38 
refrigerated, which does not affect product quality; allow the product to stand at 
room temperature and shake gently until the haze disappears.  
 
b) Sirolimus tablets: Sirolimus tablets are available in 1 mg and 2 mg tablets that 
cannot be crushed or broken. Sirolimus tablets should be stored at 20° to 25° C 
(68°–77°F), protected from light. 
 
The most common adverse reactions of sirolimus are: peripheral edema, 
hypertriglyceridemia, hypercholesterolemia, hypertension, increased creatinine, 
constipation, abdominal pain, nausea, diarrhea, headache, fever, urinary tract 
infection, anemia, thrombocytopenia, arthralgia, pain. Adverse reactions that have 
resulted in rates of sirolimus discontinuation >5% were increased creatinine, 
hypertriglyceridemia, and thrombotic thrombocytopenic purpura (TTP) / 
thrombotic microangiopathy (TMA).  Sirolimus toxicities are summarized: 
 


 
 
 
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Page 11 of 38 
  
 
Common (>20%) 
Occasional (5-20%) 
Rare (<5%) 
Immediate (within 
1-2 days) 
Headache (L), 
hypertension (L), 
immunosuppression 
(L), fever, nausea, 
diarrhea, constipation 
Chest pain, insomnia, 
dyspepsia, vomiting, 
dyspnea 
Hypotension, asthma, 
cough, flu-like 
syndrome, tachycardia, 
anorexia, 
hypersensitivity 
reactions 
Prompt (within 2-
3 weeks) 
Tremor (L), renal 
dysfunction, pain 
(abdominal, back, 
arthralgias), 
hyperlipidemia c 
(hypercholesterolemia, 
hypertriglyceridemia), 
hyperglycemia, edema 
including peripheral 
edema, anemia 
Elevated LFT’s (with 
elevated sirolimus 
levels) a, stomatitis, 
infections (including 
UTI, URI), mild 
thrombocytopenia, 
leukopenia, electrolyte 
disturbances 
(hyper/hypokalemia 
[L], 
hypophosphatemia, 
hypomagnesemia [L]), 
rash, hives, pruritus, 
delayed wound 
healing or dehiscence 
(L), proteinuria, 
TTP/HUS/TMA b 
especially with 
concurrent CNI 
Pleural and pericardial 
effusions, pulmonary 
toxicity (non-infectious 
pneumonitis, BOOP, 
pulmonary fibrosis),  
thombosis, myalgias 
Delayed (any time 
later during 
therapy, excluding 
above conditions) 
Acne 
 
Kidney disease, CHF, 
ascites, arthrosis, bone 
necrosis, osteoporosis 
Late (any time 
after completion of 
treatment) 
 
 
Lymphoproliferative 
disorders, skin 
malignancies 
Unknown 
frequency and 
timing 
Embryo/fetotoxic; unknown whether excreted in human milk 
 
 
(L): Toxicity may also occur later. 
a Significant transaminitis, generally without sequellae, may occur. Sirolimus has been 
associated with higher rates of venoocclusive disease after myeloablative conditioning. 
b Incidence 3% to < 20% in a trial of kidney transplantation.  In allogeneic BMT, increase 
in TMA from 4.2% with tacrolimus or cyclosporine alone, versus 10.8% with 
tacrolimus/sirolimus combination was noted.66  
c Lipid-lowering agent may be required; consider if fasting serum triglycerides are > 2.5 x 
ULN, and recommend starting if > 800 mg/dL. 
 
 


 
 
 
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Page 12 of 38 
Drug interactions: Sirolimus is known to be a substrate for both cytochrome 
CYP3A4 and P-glycoprotein.  Agents that may increase sirolimus levels include 
tri-azole drugs (especially voriconazole and posaconazole*), amiodarone, calcium 
channel blockers, macrolide antibiotics (but not azithromycin), micafungin, 
gastrointestinal prokinetic agents (cisapride, metoclopramide), cimetidine, 
cyclosporine, grapefruit juice, and HIV protease inhibitors. Agents that may 
decrease sirolimus levels include anticonvulsants (carbamezepine, phenobarbital, 
phenytoin), rifamycins, St. John’s Wort.  
 
Dose adjustments: The sirolimus dose is adjusted to maintain a serum trough level 
of 5-15 ng/mL.  Changes in levels due to altered bioavailability should be 
apparent within 24-48 hours.  For sirolimus without CNI as in this study, a 20-
25% reduction of sirolimus dose is recommended for trough levels >12 – 18 
ng/mL, and a 20-25% increase is recommended for trough levels < 3 ng/mL. 
Renal failure does not affect the excretion of sirolimus. Excretion is reduced in 
liver failure; impaired hepatic function should prompt consideration of reduction 
in sirolimus maintenance doses but no dose adjustment of the loading dose is 
necessary. 
 
Due to extreme interactions with voriconazole and posaconazole, these drugs 
are relatively contraindicated during sirolimus therapy. Sirolimus dose is to 
be reduced by 90% when voriconazole is initiated and should also be 
significantly reduced with posaconazole.  
 
 
3.5 
Mycophenolic Acid Mofetil (Cellcept®) 
 
Mycophenolate Mofetil is an ester prodrug of the active immunosuppressant 
mycophenolic acid (MPA). This active metabolite is a noncompetitive, reversible 
inhibitor of inosine monophosphate dehydrogenase (IMPDH). There are no 
pharmacokinetic interactions with ganciclovir, cotrimoxazole, oral contraceptives 
and cyclosporine.  
 
Side effect profiles include diarrhea, leukopenia, sepsis, allergic reactions, and 
vomiting. There is also an increase in certain types of infection mainly from the 
herpes virus family (CMV, HSV & VZV) and Candida.  
 
3.6  
Rabbit antithymocyte globulin (ATG) 
 
Thymoglobulin® [Anti-thymocyte Globulin (Rabbit)] is a purified, pasteurized, 
gamma immune globulin, obtained by immunization of rabbits with human 
thymocytes. This immunosuppressive product contains cytotoxic antibodies 
directed against antigens expressed on human T-lymphocytes. This drug is 
commonly used to treat graft rejection in kidney transplantation. It is also 
commonly used in bone marrow transplantation as part of the conditioning 
regimen to avoid graft failure and to prevent graft-versus-host disease. 
 


 
 
 
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Page 13 of 38 
Thymoglobulin is a sterile, freeze-dried product for intravenous administration 
after reconstitution with Sterile Water for Injection, USP (SWFI). Each 10 mL 
vial contains 25 mg anti-thymocyte globulin (rabbit) as well as 50 mg glycine, 50 
mg mannitol, and 10 mg sodium chloride. After reconstitution with 5 mL SWFI, 
each vial of reconstituted product contains approximately 5 mg/mL of 
Thymoglobulin, of which >90% is rabbit gamma immune globulin (IgG). The 
reconstituted solution has a pH of 7.0 ± 0.4. Human red blood cells are used in the 
manufacturing process to deplete cross-reactive antibodies to non-T-cell antigens. 
The manufacturing process is validated to remove or inactivate potential 
exogenous viruses. All human red blood cells are from US registered or FDA 
licensed blood banks. A viral inactivation step (pasteurization, i.e., heat treatment 
of active ingredient at 60°C/10 hr) is performed for each lot. Each Thymoglobulin 
lot is released following potency testing (lymphocytotoxicity and E-rosette 
inhibition assays), and cross-reactive antibody testing (hemagglutination, platelet 
agglutination, anti-human serum protein antibody, antiglomerular 
 
Adverse side effects include immunodeficiency, infusion related toxicities such as 
hypertension, chills, rigors, tachycardia, capillary leak syndrome, hyperglycemia, 
cytopenias, transient hepatitis, anaphylaxis, serum sickness, myalgias, sensory 
changes including hearing loss, headaches, renal toxicity, dyspnea and bronchial 
spasm, fevers. The drug is potentially teratogenic and is unknown if it can be 
passed to children in breastfeeding. 
 
Thymoglobulin will be dispensed by the Oncology Pharmacy and is produced by 
Genzyme. ATG–rabbit must be infused through a 0.22 micro filter with 
premedications: acetaminophen 650 mg orally and diphenhydramine 25mg orally 
as well as a steroid taper (see Section 6.3). The dose to be used is 0.5 mg/kg on 
day -9 and 2 mg/kg/day on days -8 and -7. Note: Keep anaphylaxis kit at bedside 
during ATG administration. ATG should not be administered during the weekend. 
 
 
 
4.0 
PATIENT SELECTION 
 
4.1 Criteria for recipient eligibility 
 
4.1.1  Patients who are ineligible for  BMT from an HLA-   
matched, sibling donor can proceed to a haplo-BMT. Patients with an HLA-
matched related donor will proceed to a matched BMT. 
 
4.1.2   Age 2-70 years 
 
4.1.3 Good performance status (ECOG 0 or 1; Karnofsky and Lansky 70-100) 
 
4.1.4  Patients and donors must be able to sign consent forms. Donors should 
be willing to donate. 


 
 
 
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Page 14 of 38 
 
 
4.1.5 Patients must be geographically accessible and willing to  
           participate in all stages of treatment.   
 
4.1.6  Eligible diagnoses: Patients with sickle cell anemia such as sickle  
           cell anemia (Hb SS), Hb S/ β° thalassemia, Hb S/ β+ thalassemia,     
           Hb SC disease, Hb SE disease, Hb SD disease, Hemoglobn SO- 
          Arab disease Hb S/hereditary persistence of fetal hemoglobin. Other       
 
    significant hemoglobinopathies that also fulfills a criterion from  4.1.7.  
 
Plus one of the following: 
4.1.7:    
 
a. Stroke or central nervous system event lasting more than 24  
                  hours. 
 
 b. MRI changes indicative of brain parenchymal damage. 
 
 c. MRA evidence of cerebrovascular disease. 
 
 d. Acute chest syndrome requiring exchange transfusion or  
                 hospitalization. 
 
 e. Recurrent vaso-occlusive pain crisis (more than 2/year for the  
                 last 2 years). 
 
 f. Stage I or II sickle lung disease. 
 
 g. Sickle retinopathy. 
 
 h. Osteonecrosis. 
 
 i. Red cell alloimmunization (>2 antibodies) during long-term  
                transfusion. 
 
 j. Constellation of dactylitis in the first year of life and a baseline  
                haemoglobin <7 g/dL and leukocytosis (>13.4 x 103/mm3) in the  
                absence of infection during the second year of life. 
 
k. History of invasive pneumococcal disease. 
 
l. Pitted RBC count >3.5% during the first year of life. 
 
m. Abnormal transcranial Doppler. 
 
n. Transfusion dependence. 
 
o. β thalassemia major. 
 
4.2   Criteria for recipient ineligibility 
 
4.2.1 Patients will not be excluded on the basis of sex, racial or ethnic 
background. 
 
4.2.2  Poor performance status (ECOG>1). 
 
4.2.3  Poor cardiac function: left ventricular ejection fraction <35%. 
 
4.2.4   Poor pulmonary function: FEV1 and FVC<40% predicted. 


 
 
 
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Page 15 of 38 
 
 
4.2.5  Pulmonary hypertension moderate to severe by echocardiographic     
 
standards. 
 
4.2.6   Poor liver function: direct bilirubin >3.1 mg/dl 
 
  
4.2.7   HIV-positive 
 
4.2.8  Minor (donor anti-recipient) ABO incompatibility if   
           an ABO compatible donor is available. 
 
4.2.9  Prior transfusions from donor or recipient if caused alloimmunization 
vs. donor cells. 
 
4.2.10  Women of childbearing potential who currently are pregnant (- 
           HCG+) or who are not practicing adequate contraception. 
 
4.2.11  Patients who have any debilitating medical or psychiatric illness  
           that would preclude their giving informed consent or their   
           receiving optimal treatment and follow-up.   
 
4.3 Criteria for donor eligibility 
 
4.3.1   
Weight ≥ 20kg.. For donors < 18 years, the maximum recipient weight 
(actual body weight) should not 
 
exceed 1.25 times the donor weight (actual body weight). 
 
4.3.2 Donors must meet the selection criteria as defined by the Foundation 
for the Accreditation of Hematopoietic Cell Therapy (FAHCT) and 
will be screened per the American Association of Blood Banks 
(AABB).  (AABB guidelines and the recipients will be informed of 
any deviations.) 
 
4.3.3 When more than one donor is available, the donor with the lowest 
number of HLA allele mismatches will be chosen, unless there is HLA 
cross-match incompatibility or a medical reason to select otherwise, in 
which case donor selection is the responsibility of the PI, in 
consultation with the immunogenetics laboratory.  In cases where there 
is more than one donor with the least degree of mismatch, donors will 
be selected based on the most favorable combination of (i) HLA 
compatibility in cross-match testing and (ii) ABO compatibility: 
 
 
 
HLA crossmatching (in order of priority) 
 
1.Mutually compatible (no cross-matching antibodies) 


 
 
 
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2.Recipient non-cross-reactive with donor, donor cross-reactive with 
recipient 
3.Mutually cross-reactive 
 
 
ABO compatibility (in order of priority) 
 
Compatible 
Major incompatibility 
Minor incompatibility 
Major and minor incompatibility 
 
4.3.4 Donors will be selected to minimize HLA mismatch in the host-
versus-graft direction. 
 
4.3.5 Donor must have a hemoglobin S =/< ~50%. 
 
 
5.0        TREATMENT PLAN 
 
5.1  
Indwelling central venous catheter 
 
Placement of a double lumen central venous catheter will be required for 
administration of IV medications and transfusion of blood products. 
 
5.2  
Pre-treatment Evaluation 
 
All patients will require documentation of a detailed history and physical 
examination and standard evaluation of cardiac, pulmonary, liver and 
renal function.  
 
Baseline disease evaluation will be performed by collecting the following 
laboratory tests:  hemoglobin S, hemoglobin electrophoresis, hemoglobin 
F (fetal), free hemoglobin, reticulocyte count. 
 
5.3  
Preparative regimen 
 
 
Thymoglobulin will be infused through a 0.22 micro filter with 
premedications: acetaminophen 650 mg orally and diphenhydramine 
25mg orally. Keep anaphylaxis kit at bedside during ATG administration. 
ATG should not be administered during the weekend. The dose will be 0.5 
mg/kg IV on day -9 over 6 hours and 2mg/kg IV on days -8 and -7 over 4 
hours. A steroid taper will be  given to prevent reactions to ATG as 
follows: Solumedrol 1mg/kg IV 1 hour prior ATG on days -9 to -7. This 
dose may be repeated once 3 hours after the first dose. On day -6 and -5, 
solumedrol 0.75 mg/kg/ IV as a single dose; on days -4 and -3, solumedrol 


 
 
 
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Page 17 of 38 
0.5 mg/kg/ IV as a single dose; on day -2 solumedrol 0.25  mg/kg/ IV as a 
single dose. 
 
Fludarabine will be administered by intravenous infusion over 30 min. on 
D-6 to D-2.  The dose will be 30 mg/m2. 
 
For decreased creatinine clearance (< 61 ml/min) determined by  
the Cockcroft Formula: 
 
 
 
CCr = (140 – age) x weight (kg)   x   0.85 (for women) 
 
 
                       PCr x 72 
 
When calculating CrCl: if  Actual Body Weight is less than Ideal Body 
Weight, Actual Body Weight will be used; if Actual Body Weight is 
between 100-120% of Ideal Body Weight, Ideal Body Weight will be 
used; and if Actual Body Weight is > 120% of Ideal Body Weight, 
25% Adjusted Body Weight  
 
In pediatric patients (<18 years of age) the creatinine clearance must be 
measured. 
 
For decreased creatinine clearance (CrCl), fludarabine dosage should be 
reduced as follows: 
 
 
  
CrCl ≥ 70 ml/min – fludarabine 30 mg/m2 
CrCl 40-69 ml/min - fludarabine 24 mg/m2 
CrCl 20-39 ml/min – fludarabine 20 mg/m2 
CrCl < 20 ml/min – fludarabine 15 mg/m2  
 
Cyclophosphamide will be administered as an iv infusion over 1- 2 hr, 
(depending on volume) on D-6 and D-5. The dose of pre-transplantation 
cyclophosphamide is 14.5 mg/kg/day.  Dose is calculated based on the 
adjusted ideal body weight or actual body weight whichever is less. (Refer 
to Appendix 2.)  Body weight and height are measured directly.  An 
approximate weight for height would be calculated from a standard table 
or equations that reflect ideal “values”. 
 
Note:  Mesna will be utilized for the Day 3 and Day 4 post BMT 
cyclophosphamide doses, not for the pre-BMT cyclophosphamide doses. 
 
Total body irradiation: 400 cGy AP/PA with 4MV or 6MV photons at 
8-12 cGy/min at the point of prescription (average separation of 
measurements at mediastinum, abdomen, hips) will be administered in a 
single fraction on day -1. 
 
5.4  
Bone marrow transplantation and graft information 
 


 
 
 
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Bone Marrow will be harvested and infused on day 0.   
Donor bone marrow will be harvested with a target yield of 4 x 108 nucleated 
cells/kg recipient IBW.  Major incompatible ABO graft will have red blood 
cell depleted by buffy coat preparation. Minor ABO incompatible graft will 
have plasma removed.  Guidelines for the infusion of bone marrow have been 
established and are outlined in the ABO compatible/minor mismatched allo 
BMT or the ABO incompatible allo BMT standing orders.   
 
 
Major incompatible ABO graft will have red blood cell depleted by buffy 
coat preparation. Minor ABO incompatible graft will have plasma 
removed.  Guidelines for the infusion of bone marrow have been 
established and are outlined in the ABO compatible/minor mismatched 
allo BMT or the ABO incompatible allo BMT standing orders.   
 
5.5 
Post-transplantation cyclophosphamide 
 
Cyclophosphamide [50mg/kg (IBW)] will be given on D+3 post-
transplant (within 48-72 hr of marrow infusion) and on D+4 post-
transplant. Cyclophosphamide will be given as an iv infusion over 1- 2 hr 
(depending on volume).  
 
Mesna will be given in divided doses iv 30 min pre- and at 3, 6, and 8 hr 
post-cyclophosphamide or administered per institutional standards. Mesna 
dose will be based on the cyclophosphamide dose being given.  The total 
daily dose of mesna is equal to 80% of the total daily dose of 
cyclophosphamide.  
 
It is crucial that no immuno suppressive agents are given from the 
time of the transplant until 24 hours after the completion of the post-
transplant Cy.  This includes steroids as anti-emetics. 
 
5.6 
GVHD prophylaxis 
 
On day 5, patients will begin prophylaxis with Sirolimus and 
Mycophenolic Acid Mofetil (MMF).   
 
Sirolimus for patients > 18 years old: A one-time sirolimus loading dose, 6 
mg PO, is given on Day 5, at least 24 hours after Cy completion.  
Sirolimus is then continued at a maintenance dose (start 2 mg PO QD), 
with dose adjustments to maintain a trough of 5 – 15 ng/mL as measured 
by HPLC or immunoassay.  There is no planned taper.  Sirolimus 
prophylaxis is discontinued after the last dose on Day 365, or may be 
continued if there is GVHD or other indication such as mixed chimerism.  
Sirolimus troughs should be checked at minimum weekly. For patients < 
18 years old: Sirolimus dosing is based on actual body weight; however an 


 
 
 
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Page 19 of 38 
adjusted body weight may be used if the actual weight is > 50% greater 
than IBW. A one-time sirolimus loading dose, 3 mg/m2 PO with the dose 
not to exceed 6 mg, is given on Day 5, at least 24 hours after Cy 
completion.  Sirolimus is then continued at a maintenance dose (start 1 
mg/m2 PO QD, maximum 2 mg PO QD), with dose adjustments to 
maintain a trough similar to the one described for adults.  There is no 
planned taper.  Sirolimus prophylaxis is discontinued after the last dose on 
Day 365, or may be continued if there is GVHD or other indication such 
as mixed chimerism.  Sirolimus troughs should be checked at minimum 
weekly. 
 
Mycophenolic acid mofetil will be given at a dose of 15 mg/kg po TID 
(based upon actual body weight) with the maximum total daily dose not to 
exceed 3 grams (1 g po TID). 
 
MMF prophylaxis will be discontinued after the last dose on D35 and 
Sirolimus prophylaxis will be discontinued after the last dose around day 
365. 
 
5.7 
Infection prophylaxis and therapy 
 
During pre-transplant evaluation patients will be screened for respiratory 
syncitial virus, influenza A, B and parainfluenza viruses if symptomatic.  
Assays of these viruses must be negative for symptomatic patients to be 
admitted for transplant.  Strong consideration should be given to 
institution of ribavirin therapy if positive for adenovirus or nalidixic acid 
if positive for BK virus. 
 
Oral hygiene will be maintained according to institutional standards. 
 
Prophylactic anti-microbial therapy will be given per the BMT unit 
standards. 
 
An oral antibiotic for gastrointestinal decomination will be administered 
according to institutional preference until the ANC is >1000 for 3 
consecutive days following BMT. 
 
Empiric therapy with broad-spectrum antibiotics will be instituted for the 
first neutropenic fever (specific agents as per current practice). 
 
Antifungal prophylaxis will be administered according to institutional 
preference. It is important to follow sirolimus levels on patients receiving 
azoles as the combination of both drugs can raise the levels of the 
immunesuppressant to toxic levels. If the patient on sirolimis is started on 
azoles, a dose reduction of sirolimus is required and levels should be 
obtained to be sure the levels are not in the toxic range.  


 
 
 
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Page 20 of 38 
 
Pneumocystis jiroveci pneumonia (PCP) prophylaxis will be administered 
according to institutional preference starting at Day 21 and should 
continue for at least the first year following BMT and while on 
immunosuppression.  If the patient cannot tolerate po then a comparable 
dose of Bactrim will be given iv.  Patients intolerant of Bactrim will 
receive either dapsone, atovaquone, or pentamidine as PCP prophylaxis. 
 
On Day 0, all patients should start pneumococcal prophylaxis with 
Penicillin-V 250 mg PO BID, or if less than 5-years old, 125 mg PO BID 
and should continue indefinitely.  If patient has a Penicillin-V allergy, 
Bactrim SS every day should be utilized.  
 
Viral prophylaxis for HSV will be administered according to institutional 
preference.   
 
Although not required, CMV viremia (by PCR) or antigenemia (by 
ELISA) should be documented weekly or every other week beginning 
once the WBC>1000 and until discharge Monitoring of CMV viremia or 
antigenemia is recommended to continue on a weekly or every other week 
basis until day 100, then bi-weekly until day 180. Patients who are viremic 
or antigenemic will be treated pre-emptively with ganciclovir (5 mg/kg iv 
q12 hr) for 14 d and then with maintenance ganciclovir (5 mg/kg iv qd) 
until CMV testing is negative for at least 2 wk.  Consideration should be 
given to administration of CMV hyperimmune globulin (Cytogam), 
concomitant with ganciclovir at a dose of 150 mg/kg iv qod times 4 doses 
and then weekly thereafter if the patient continues to be treated with 
ganciclovir for persistent viremia or antigenemia.  If the patient is 
diagnosed with CMV disease, more frequent Cytogam administration may 
be considered. 
 
Unless the patient is being treated for CMV infection or CMV disease, 
ganciclovir should be discontinued for development of neutropenia 
(ANC<500).  If neutropenic, G-CSF may be used if clinically indicated. 
Ganciclovir should then be restarted, if appropriate.  Ganciclovir will be 
dose-adjusted appropriately for renal failure. 
 
5.8  
Growth factor support 
 
Patients will receive G-CSF (Filgrastim®) only if clinically required (i. e. 
sepsis) but will not routinely be given after transplant to speed recovery 
given the high incidence of musculoskeletal pain that may aggravate a 
pain crisis in these patients. 
 
5.9 
Transfusion support 
 
 


 
 
 
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Packed red cell transfusions will be given per current institutional 
recommendations. Platelets will be kept at all times over 50,000/mm3 (see 
below). If the patient becomes alloimmunized, the blood bank service will 
select the best blood products to transfuse and will coordinate with the 
medical floor the transfusion needs. 
 
5.10  Antiseizure prophylaxis 
 
Prophylaxis against seizures is mandatory in all recipients and should be 
commenced at the start of conditioning with fludarabine (day -6).  
Levetiracetam (Keppra) will be administered at a dose of 500 mg p.o. 
b.i.d.  Seizure prophylaxis should be continued until sirolimus is 
discontinued. 
 
Platelets should be kept at all times over 50,000/ml. Serum magnesium 
level should be maintained > 1.5 mg/dL during the period of treatment 
with calcineurin inhibitors to reduce the risk of seizures. 
 
5.11 
Anti-ovulatory treatment  
 
Menstruating females should be started on an anti-ovulatory agent prior to 
the initiation of the preparative regimen. 
 
 
6.0  
PATIENT MONITORING 
 
The following parameters will be obtained according to this schedule: (for details 
of these evaluations, see text sections 6.1-6.3) 
 
 
 
 
 
 
 
 
 
 
 
Initial 
Allowable time 
frame from 
date of 
consent**  
Day  
< 60 
Day 
30  7 
Day 
60  7 
Suspected 
GVHD 
History and Physical 
X 
within 30 days 
 
X 
X 
 
Performance status 
X 
within 30 days 
 
 
 
 
Disease staging 
X 
within 30 days 
 
X 
X 
 
CBC & Diff. 
X 
within 7 days 
*weekly 
X 
X 
 
Comprehensive 
Metabolic Panel 
X 
within 7 days 
  weekly 
X 
X 
 


 
 
 
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Page 22 of 38 
Hemoglobin S, 
hemoglobin 
electrophoresis, 
hemoglobin F (fetal), 
free hemoglobin,  
reticulocyte count 
X 
 
 
X 
X 
 
CXR 
X 
within 30 days 
 
 
 
 
Pregnancy test (women, 
childbearing age) 
X 
within 30 days 
 
 
 
 
Chimerism analysis 
Including unsorted and 
CD3 
X 
 
 
X 
X 
 
PT, PTT 
X 
within 30 days 
 
 
 
 
EKG 
X 
within 60 days 
 
 
 
 
ECHO 
X 
within 60 days 
 
 
 
 
HepB Ag, HBC Ab, 
HCV Ab, HSV IgG, 
CMV IgG, RPR, HIV, 
VZV IgG (if possible) 
X 
within 30 days 
 
 
 
 
Toxicity assessment 
X 
 
 
X 
X 
 
HLA 
typing/lymphocytotoxic 
screen 
X 
Must be done 
at JHH 
 
 
 
 
PFTs (Spirometry and 
DLCO) 
X 
within 30 days 
 
 
 
 
Sinus CT 
X 
within 30 days 
 
 
 
 
Fasting lipid profile 
X 
 
 
 
X 
 
Skin Biopsy  
 
 
 
 
 
X 
 
* Once ANC >100, this will be obtained daily until ANC >500 for three days or two 
consecutive measurements over a three day period, then weekly. 
**Baseline laboratory tests and radiology studies time frame will follow BMT standards.  
 
6.1  
Pre-transplant Evaluation 
These represent the basic baseline studies required on all patients prior to 
starting their preparative regimen. Additional investigations may be 
clinically indicated in certain individuals.  
 
6.1.1. Complete medical history which should include particular attention 
to the following details: 
a) previous treatment and response 
b) previous transfusions and transfusion reactions 
c) previous serious infections 
d) allergies 
e) current medications 
f) assessment of performance status 
 
6.1.2. Thorough general medical evaluation which should include: 
a) a careful physical examination 
b) evaluation for placement of a central venous access device, if the 
patient does not already have such a catheter. 


 
 
 
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Page 23 of 38 
 
6.1.3. Baseline investigations including: 
a) Hematologic 
i.   CBC with platelets, differential, reticulocyte count 
ii.  PT, PTT 
iii. ABO and Rh typing 
 
b) Chemistries 
i.  Comprehensive chemistry panel 
ii. Routine and microscopic urinalysis with C&S 
iii. Fasting lipid profile. 
 
c) Cardiac 
i.  EKG 
ii. Echocardiogram or MUGA scan with Left Ventricular Ejection 
Fraction (LVEF) + Right Ventricular Systolic Pressure and 
evaluation for pulmonary hypertension 
 
d) Pulmonary 
i.   Chest X-ray 
ii.  Sinus CT scan 
iii. Pulmonary function tests including at least FEV1 and FVC 
(pediatric patients under the age of 8 are excluded from this test) 
 
e) Immunologic / Infections 
i.   HBsAg, anti-HBC, anti-HCV 
ii.  RPR 
iii. HIV antibody 
iv. Serology for CMV and HSV (plus VZV – blood samples 
permitting) 
v. HLA typing/lymphocytotoxic antibody screen 
 
 
f) RFLP studies will be drawn as a baseline for subsequent engraftment 
studies including myeloid (unsorted) and CD3 chimerism. 
 
g) Disease specific studies: The following are minimal recommended 
studies. 
 
i. Sickle Cell Anemia:  Hemoglobin S, hemoglobin 
electrophoresis, hemoglobin F (fetal), free hemoglobin, 
reticulocyte count 
 
6.2  
Post-transplant Evaluation 
 


 
 
 
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6.2.1. Day 0 through Day 60 (+ 7 days) evaluation. These represent the 
minimum required. More frequent determinations and additional 
investigations may be indicated by the clinical condition of the patient. 
1. CBC daily with a WBC differential once the total WBC is greater than 
100 until ANC > 500 for three days or two consecutive measurements 
over a three day period; then CBC weekly with differential. 
2. Comprehensive metabolic panel once a week. 
3. Patients will have evaluations for infectious complications as clinically 
indicated. Surveillance cultures according to JHOC BMT program 
standards are recommended. 
4. Evaluations by history and physical examination for GVHD will be 
performed as per BMT unit standards.  (see also section 6.2).  For study 
purposes, weekly GVHD summaries will be taken from these standard 
examinations from day 14 through day 60. 
 
6.2.2 Evaluations on day ~ 30 (+7 days) 
1. History and physical examination. 
2. RFLP donor chimerism on peripheral blood (including myeloid 
(unsorted) and CD3 chimerism). 
3. Disease evaluation. 
4. CBC and differential, comprehensive panel. 
 
 
6.2.3 Evaluations on day ~60 (+7 days) 
1. History and physical examination. 
2. Disease evaluation. 
3. Studies for donor cell chimerism on peripheral blood. 
4. CBC and white blood cell differential, reticulocyte count, 
comprehensive panel. 
 
6. Fasting lipid profile. 
 
 
6.2.4  Evaluations for suspected GVHD: 
 
1. Comprehensive panel 
 
2. Biopsies if needed.  
 
 
In the event that the patient is unable to return to Johns Hopkins for these visits, every 
attempt will be made to obtain data from the patient and referring physician. After 
completion of the trial at Day 60  7, patient will be followed in accordance with the 
JHOC BMT Policy and Procedure Manual.  
 
 
7.0 
POST-BMT EVALUATION 
 


 
 
 
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Patients will be followed during (i) the initial post-BMT period (ii) IPOP care and 
(iii) after discharge to the referring physician as per standard practice.  
 
7.1      Chemotherapy toxicities  
 
The agents being used in the study are FDA approved.  These agents are used 
extensively in the Bone Marrow Transplant setting and have well defined toxicity 
profiles.  In addition, there are many expected toxicities related to a bone marrow 
transplant.  For these reasons, toxicities will be captured and recorded/graded if 
the adverse event interferes with the subject’s daily function and are considered 
clinically significant.  We will capture and grade all these events structured 
around the categories of the Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 for the first 60 days post BMT.  
 
Since this trial is an out-patient trial, the definition of an adverse event ‘interfering 
with daily function’ and ‘clinically significant’ will be events that require 
hospitalization.  For example, if a patient has a neutropenic fever that requires 
hospitalization, then ‘neutropenic fever’ will be captured and graded as an adverse 
event.  An example of a non-captured event is if a patient has hypotension that is 
corrected by fluid administration in the outpatient setting.  This will not be 
captured as an adverse event unless the patient requires a hospital admission for 
further treatment of the hypotension. 
 
Once the patient becomes hospitalized, the above definition of ‘requiring 
hospitalization’ cannot be used to capture adverse events.  For these already 
hospitalized patients, events will only be recorded once the event is greater than a 
grade 3 or 4 as stated below. 
 
The following is a list of categories that will not be recorded unless the event 
becomes a grade 4 or meets the criteria of a SAE, as stated in section 8.1.1.  
 
 
 
 
 
Allergy/Immunology 
 
Auditory/Hearing 
 
Cardiovascular (Arrhythia) 
 
Cardiovascular (General) 
 
Coagulation 
 
Constitutional symptoms 
 
Dermatology/Skin 
 
Endocrine 
 
Hemorrhage 
 
Hepatic 
 
Infection/Febrile neutropenia 
 
Lymphatics 


 
 
 
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 
Metabolic/Laboratory 
 
Secondary Malignancy 
 
Sexual/Reproductive Function 
 
The following categories will be recorded only if the event becomes a grade 3 or 
grade 4 or meets the criteria of a SAE. 
 
 
Gastrointestinal 
 
Musculoskeletal 
 
Neurology 
 
Ocular/Visual 
 
Pain 
 
Pulmonary 
 
Renal/Genitourinary 
 
The Blood/Bone Marrow category is captured as endpoints to the study.  Thus for 
this category, we will not record data according to the NCI Common Toxicity 
Criteria. 
 
7.2 
GVHD 
 
A major toxicity of allogeneic BMT from an unrelated or mismatched donor is 
GVHD.  Acute graft-versus-host disease (GVHD) shall be graded clinically 
according to the criteria developed by the consensus conference on acute GVHD14 
(Appendix 1).  All suspected cases of acute GVHD must be confirmed 
histologically by biopsy of an affected organ (skin, liver, or gastrointestinal tract).  
For purposes of reporting, a pathologist at SKCCC will be ultimately responsible 
for determining whether a patient does or does not have histologic evidence of 
GVHD. Diarrhea and/or hyperbilirubinemia in a patient with histologically 
documented skin GVHD may be assumed to be a manifestation of visceral GVHD 
and will be graded as such.  All patients with histologically documented, clinical 
grade >2 acute GVHD should receive initial treatment with corticosteroids (or a 
corticosteroid containing regimen if a protocol is available) according to 
institutional preference.  If skin GVHD resolves with treatment but suspected 
visceral GVHD does not, biopsy of the affected organ (liver or gastrointestinal 
tract) should be obtained to rule out other causes of hyperbilirubinemia and/or 
diarrhea.  Steroid refractory acute GVHD will be treated according to institutional 
preferences. 
 
The following information shall be collected on all patients with acute GVHD: 
 
Date of onset (defined as the date of first biopsy confirming GVHD) 
GVHD evaluation form at the time of onset, weekly until GVHD resolves, and 
Day 60 
Initial overall clinical grade 
Maximum overall clinical grade 


 
 
 
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Page 27 of 38 
Date of onset of grade III-IV acute GVHD, if any 
 
The occurrence and severity of acute and chronic GVHD after Day 60 will be 
captured at the patients six month and annual evaluations. 
 
 
 
7.3 
Transplant-related mortality (TRM) 
 
Causes of TRM, i.e., death in the absence of relapse, will be documented as 
important indicators of procedure-associated toxicity, particularly as these causes 
relate directly or indirectly to GVHD.  Analysis will stratify mortality with 
respect to the peri-transplant period (<100 d post-BMT) or later times post-BMT. 
 
7.4 
Disease Evaluation 
 
Disease evaluations will be performed at ~Day 30, ~Day 60, ~Day 180, ~Day 
365, and then yearly per Johns Hopkins standards.  Disease evaluations will be 
performed by collecting the following laboratory tests:  hemoglobin S, 
hemoglobin electrophoresis, hemoglobin F (fetal), free hemoglobin, reticulocyte 
count. 
 
8.0    STUDY PARAMETERS 
 
8.1 
Transplant-related mortality 
 
Transplant-related mortality, which is defined as death in the absence of relapse 
or progression, will be characterized at 100 days and at one year after BMT. 
 
8.2 
Hematologic toxicity 
 
A secondary endpoint of this Phase II trial is time to recovery of circulating 
neutrophils and platelets (following chemotherapy).  Neutrophil recovery is defined 
as the first day of three consecutive laboratory values on different days, after the 
conditioning regimen-induced nadir of blood counts, that the absolute neutrophil 
count is > 500/uL.  Platelet recovery is defined as the first day of three consecutive 
laboratory values on different days, after the conditioning regimen-induced nadir of 
blood counts, that the platelet count is  20,000 L without platelet transfusion 
support in the seven days prior. 
 
 
8.3 
Donor Chimerism 
 
Donor chimerism will be measured in the peripheral blood around day 30 and day 
60.  Patients with any amount of donor chimerism around day 60 will be 
considered as having engrafted.  


 
 
 
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Chimerism determinations will be made on peripheral blood by a number of 
different methods depending on the specific patient.  Methods may include (i) the 
usual standard of restriction fragment length polymorphism (RFLP) if the donor 
and recipient RFLPs are informative, (ii) fluorescence in-situ hybridization 
(FISH) for Y-chromosome markers on PBMC if the donor is male, (iii) 
cytogenetic analysis, (iv) flow cytometric analysis of HLA-A, B or DR on 
lymphocytes in the peripheral blood if haploidentical and suitable reagents exist 
or (v) PCR analysis of variable nucleotide tandem repeats (VNTR) in PBMC if 
informative. Mixed donor chimerism will be defined as >0%, but <95%.  
Complete donor chimerism will be defined as >95%.  
 
8.4 
Disease Status 
 
Disease status will be evaluated through the following laboratory tests:  
hemoglobin S, hemoglobin electrophoresis, hemoglobin F (fetal), free 
hemoglobin, reticulocyte count.  These disease evaluations will be performed at 
~Day 30, ~Day 60, ~Day 180, ~Day 365, and then yearly per Johns Hopkins 
standards. Relapse will be defined as the loss of donor chimerism. 
 
 
8.5 
GVHD 
 
Patients will be followed for development of acute and chronic GVHD using 
standard criteria.  Chronic GVHD is assessed according to standard criteria. 
Treatment of GVHD is outlined in Section 6.2. 
 
To allow for flexibility in patient scheduling, all time points may be 
approximated.  
 
 
9.0 
DATA MANAGEMENT 
 
Data will be maintained on case report forms and appropriate Graft Engineering 
Laboratory spreadsheets.  The research team will make assessments of GVHD. 
GVHD assessment will be evaluated and scored by the GVHD team, the Research 
Nurse, the attending BMT physician and PI.  Hematopoietic engraftment will be 
assessed by the BMT attending and the PI.  The PI will be responsible for 
evaluation of chimerism data and weekly overall toxicities.  
  
9.1 
Data and Safety Monitoring  
 
At the Sidney Kimmel Comprehensive Cancer Center (SKCCC) at Johns 
Hopkins, the Associate Director for Clinical Research, Clinical Research Review 
Committee (CRC), SKCCC Safety Monitoring Committee (SMC), CRO Quality 
Assurance Group, and the PI share monitoring responsibilities.    
 
9.1.1  
Internal Data Monitoring  


 
 
 
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Page 29 of 38 
 
The PI will review data to assure the validity of data, as well as, the safety of 
the subjects. The PI will also monitor the progress of the trial.  The PI will 
review safety reports and clinical trial efficacy endpoints and to confirm that 
the safety outcomes favor continuation of the study. 
 
The PI will be responsible for maintaining the clinical protocol, reporting 
adverse events, assuring that consent is obtained and documented, reporting of 
unexpected outcomes, and reporting the status of the trial in the continuing 
renewal report submitted to the IRB and to the trial monitoring review group. 
Content of the continuing renewal report at a minimum should include year-
to-date and full trial data on: accrual and eligibility, protocol compliance, 
treatment administration, toxicity and ADR reports, response, survival, 
regulatory compliance, compliance with prearranged statistical goals.  The 
report should be submitted in a timely manner according to the schedule 
defined by Johns Hopkins Medicine Institutional Review Board.  
 
Adverse Event reporting – Serious Adverse Events that will be reported 
should include: any death within the first 100 days post BMT, any graft 
failures associated with failure of neutrophil recovery to >500/mm³ by day 
~60 after transplantation, and any unexpected events as deemed significant by 
the PI.  The PI will be responsible for reporting events to the CRO/IRB and to 
other investigators. 
 
An external Data Safety and Monitoring Board (DSMB), comprised of three 
independent external experts, will convene as requested by the PI to review 
serious toxicities and adverse events for the purpose of determining whether 
the trial should be modified or stopped. Triggers for referral to the DSMB are 
described in the Stopping Rules Criteria of section 10.0. 
 
9.1.2  
External Data Monitoring and Auditing  
 
This is a Level I study under the SKCCC Data and Safety Monitoring Plan.  
The SKCCC Clinical Research Office, Quality Assurance Group will perform 
periodic study audits.  All trial monitoring and reporting will also be reviewed 
annually by the SKCCC Safety Monitoring Committee. 
 
9.1.3  
Safety Monitoring  
 
The SKCCC Safety Monitoring Committee (SMC) performs an annual review 
of this Level I study. 
 
The SMC is charged with ensuring the safety of participants and the validity 
and integrity of the data and the appropriate closure of studies for which 
significant benefits or risks have been uncovered.  The Committee is 
responsible for continuous, ongoing review of the conduct of the trial, 


 
 
 
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Page 30 of 38 
including adherence to study design, documentation of appropriate 
monitoring, and proper reporting of protocol problems and events.  Inherent in 
this process is the goal of enhancing the quality of the research by providing 
the investigator with constructive criticism.  The SMC membership includes 
physicians and other representatives from various Center Programs, 
biostatistics, data management, nursing, and quality assurance.   
 
 
10.0 
STATISTICAL CONSIDERATIONS 
 
The primary objective of this phase II clinical trial is to obtain risk-stratified 
estimates of two-year progression-free survival with a precision of +/- 20% (95% 
confidence bound).  To obtain this precision, it will be necessary to accrue at least 
50 patients. We expect the accrual to take 10 years based on a recruitment of 6-7 
patients per year once the study reaches a steady accrual of patients. 
 
The hypothesis of this study is that non-myeloablative conditioning with high-dose post-
transplant cyclophosphamide will increase the number of sickle cell disease (SCD) 
patients eligible for allogeneic BMT by allowing the safe and effective use of related 
haploidentical donors. 
 
The purpose of expanding the sample size in this study is to obtain a better estimate of 
the proportion of patients who achieve stable mixed donor-host hematopoietic chimerism 
following transplant.  In transplanted patients with these diseases, 10-15% chimerism can 
constitute cure where patients are symptom-free as long as they continue with 
immunosuppression treatment to maintain the graft.   
 
Sirolimus immunosuppression replaced tacrolimus by protocol amendment in August 
2011 to reduce the incidence of posterior reversible encephalopathy syndrome.  A second 
amendment included G-CSF-primed bone marrow grafts to improve engraftment.  Since 
these two protocol amendments, 16 patients have been treated with Sirolimus and G-
CSF-primed marrow.  Fourteen patients have follow-up and T cell counts through day 60.  
Engraftment has been achieved in 10 of 14 patients (71.4%).  Of the patients that have 
engrafted, 6 of 10 patients (60%) have achieved full-donor chimerism and 2 of the 4 
patients without full chimerism (50%) have achieved at least 15% chimerism.  The 
follow-up of patients with full chimerism is 2 years for 3 patients, 1 year for 4 patients, 6 
months for 2 patients, and 1 month for 1 patient.     
 
Two of the three patients accrued since January of 2014 with follow-up through day 60 
have failed to engraft and therefore this protocol amendment will remove GCSF and 
increase the TBI.  With additional follow-up, the 16 patients receiving the Sirolimus plus 
G-CSF modified treatment plan will allow us to estimate the proportion of patients with 
mixed chimerism and the proportion of patients with full chimerism with exact 95% 
binomial confidence intervals of ± 25%.   
 


 
 
 
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Page 31 of 38 
There are an additional 19 patients to be accrued to the study under the new treatment 
plan.  The proportions of patients with full and mixed chimerism in this group will be 
estimated with exact 95% confidence intervals of ±25%.   
 
The total sample size of 50 patients will allow us to estimate these proportions with exact 
95% binomial confidence intervals of ± 14.5%.   
 
Safety stopping guidelines:  The safety stopping criterion for this study is currently 
based on monitoring the combined incidence of grade III-IV acute GVHD and TRM, and 
the study design called for stopping if it appeared that this combined incidence was 
convincingly greater than 20%.  This combined incidence will continue to be monitored 
after every patient in this expansion cohort.  Although acute GVHD and TRM are not 
mutually exclusive, the mortality from acute GVHD is expected to be low.  Therefore, a 
patient who experiences grade III-IV acute GVHD then TRM will be counted once as 
having the GVHD adverse event.  The stopping rule for toxicity will halt enrollment to 
the study if the posterior probability of risk being larger than 0.2 is 70% or higher.  If the 
original prior for the first patients enrolled on the study was Beta(1,1) and we use a 
conservative assumption of one acute GVHD event in the cohort of 26 patients treated so 
far, Beta(1,25), the new prior for this toxicity monitoring rule is Beta(2, 26).  This means 
that after the first 26 patients on trial our posterior estimate of a patient’s risk of toxicity 
is 7.1%, and there is 90% probability that this risk is between 1.3% and 16.4%.  As we 
treat more patients and observe whether or not each experiences an adverse event (i.e., 
severe acute GVHD or TRM), we update the estimate of the risk and apply the stopping 
rule.  If the posterior probability is at least 70% that the risk of toxicity is 20% or higher, 
computed using Bayes rule and these assumptions, we will consider stopping the study.  
The following table shows the stopping boundary.  For example, the rule will call for 
stopping the study if 7 toxicity events are observed before the 10th patient is enrolled in 
the expansion cohort.   
Conclude 
regimen 
too toxic* 
7 
8 
9 
10 
11 
12 
out of N 
patients 
7-9 
10-14 
15-18 
19-23 
24-28 
29-30 
 
 
 
*Study will stop early if evidence suggests the regimen is too toxic. 
The next table shows the simulated operating characteristics of the stopping boundary 
applied to further enrollment of 30 patients under different hypothetical risks of toxicity.  
Based on 5,000 simulated studies, if the underlying risk of toxicity is 40%, the stopping 
rule would call for the study to be stopped 63% of the time with an average sample size 
of 24. 
Hypothetical toxicity 
0.10 
0.15 
0.20 
0.25 
0.30 
0.35 
0.40 
0.45 
% of Time Study Stops 
0.0% 
0.4% 
1.5% 
8.5% 
22.0
% 
43.0
% 
63.2
% 
82.0
% 
Expected Sample Size 
30.0 
30.0 
29.9 
29.4 
28.3 
26.3 
23.7 
20.8 
 
 


 
 
 
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Page 32 of 38 
 
 
 
 
 
11.0 
RISKS AND BENEFITS 
 
11.1 
Risks and toxicity 
 
The major toxicity of using bone marrow from HLA-mismatched, related donors 
is GVHD.  Using nonmyeloablative conditioning regimens and stem cell products 
from peripheral blood, two different studies with a total of 61 patients have shown 
an incidence of clinically significant GVHD (>Grade I) of 15-20%15, 16.  There are 
no reports of mini-BMT from PMRD to estimate the incidence of GVHD but two 
small studies presented in abstract form from European and Israeli transplant 
centers show approximately a doubling of GVHD incidence with mini-BMT from 
MUDs.  Therefore, we would expect the incidence of GVHD in this study to be in 
the 40-50% range using unmanipulated bone marrow as the source of stem cells.   
 
Another significant risk is failure-to-engraft due to rejection by host lymphocytes.  
However, because of the nonmyeloablative nature of the conditioning regimen we 
would expect patients to have full autologous, hematologic recovery.   
 
Infection is a major cause of morbidity and mortality in the peri-transplant period 
(<100d post-BMT).  However, given current supportive care and the intensive 
infection prophylaxis of this protocol, we expect the risk to be acceptable.  
Prolonged neutropenia may increase this risk in the case of graft rejection, 
however. 
 
Other risks that may be associated with fludarabine chemotherapy include 
prolonged immunosuppression of T-lymphocytes increasing the incidence of PCP 
and viral infections.  The extent of this risk is unclear at present.  Patients will 
receive appropriate PCP prophylaxis and will be monitored carefully for evidence 
of infection by viruses such as CMV, BK and adenovirus.  Major risks associated 
with cyclophosphamide chemotherapy include hemorrhagic cystitis and 
congestive heart failure.  
 
Relapse of the underlying disease also may occur.   
 
11.2 
Benefits 
 
The potential benefits of this trial are prolongation of overall survival, or 
palliation of disease-related symptoms. 
 
12.0 
INFORMED CONSENT 
 


 
 
 
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Page 33 of 38 
Patients eligible for marrow grafting are completely evaluated and then presented 
 
and approved for transplant at the Bone Marrow Transplant group conference.  
 
The group's recommendations are discussed with the patient.  If the patient is 
 
approved for BMT, the marrow processing procedure itself, the risks of the 
 
preparative regimen, risks of BMT complications including infection and GVHD 
 
and alternate forms of therapy are presented as objectively as possible.  For 
 
pediatric patients (<18 yr of age) assent is obtained from the patient and informed 
 
consent is obtained from all parents.  Informed consent is obtained  from the 
 
recipient using the forms approved by the IRB.          
 
13.0 
ON-STUDY DATE:  
 
 
Date of consent signing.  
 
 
14.0     OFF-STUDY DATE: 
 
Upon completion of “Day 60” evaluations, patients have completed their 
treatment except for sirolimus, which continues until day 365. Patient follow-up 
beyond day 60 will consist of collecting information regarding ongoing 
engraftment, disease status, late effects of this protocol, acute and chronic graft-
vs-host disease, immune reconstitution, additional therapies, and survival. Patients 
will go off study early in the event of:  
 
1. Death  
2. Patient decision (or decision by a parent or guardian on behalf of a minor) 
3. Unacceptable toxicity associated with protocol therapy, as determined by the 
treating physicians in consultation with the investigators.  
 
 
An eligibility form must be completed for every subject 
and must be kept in the research chart. 
 
 
 


 
 
 
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Page 34 of 38 
Reference List 
 
 1.  Walters MC, Patience M, Leisenring W et al. Bone marrow transplantation for 
sickle cell disease. N Engl J Med 1996; 335(6):369-376. 
 2.  Jacobsohn DA, Duerst R, Tse W, Kletzel M. Reduced intensity haemopoietic 
stem-cell transplantation for treatment of non-malignant diseases in children. 
Lancet 2004; 364(9429):156-162. 
 3.  Horan JT, Liesveld JL, Fenton P, Blumberg N, Walters MC. Hematopoietic 
stem cell transplantation for multiply transfused patients with sickle cell 
disease and thalassemia after low-dose total body irradiation, fludarabine, and 
rabbit anti-thymocyte globulin. Bone Marrow Transplant 2005; 35(2):171-177. 
 4.  Iannone R, Casella JF, Fuchs EJ et al. Results of minimally toxic 
nonmyeloablative transplantation in patients with sickle cell anemia and beta-
thalassemia. Biol Blood Marrow Transplant 2003; 9(8):519-528. 
 5.  Blaise D, Kuentz M, Fortanier C et al. Randomized Trial of Bone Marrow 
Versus Lenograstim-Primed Blood Cell Allogeneic Transplantation in Patients 
With Early-Stage Leukemia: A Report From the Societe Francaise de Greffe 
de Moelle. Journal of Clinical Oncology 2000; 18(3):537. 
 6.  Bensinger WI, Martin PJ, Storer B et al. Transplantation of bone marrow as 
compared with peripheral-blood cells from HLA-identical relatives in patients 
with hematologic cancers. N Engl J Med 2001; 344(3):175-181. 
 7.  Schmitz N, Beksac M, Hasenclever D et al. Transplantation of mobilized 
peripheral blood cells to HLA-identical siblings with standard-risk leukemia. 
Blood 2002; 100(3):761-767. 
 8.  Couban S, Simpson DR, Barnett MJ et al. A randomized multicenter 
comparison of bone marrow and peripheral blood in recipients of matched 
sibling allogeneic transplants for myeloid malignancies. Blood 2002; 
100(5):1525-1531. 
 9.  Luznik L, Jalla S, Engstrom LW, Iannone R, Fuchs EJ. Durable engraftment 
of major histocompatibility complex-incompatible cells after nonmyeloablative 
conditioning with fludarabine, low-dose total body irradiation, and 
posttransplantation cyclophosphamide. Blood 2001; 98(12):3456-3464. 
 10.  Luznik L, Engstrom LW, Iannone R, Fuchs EJ. Posttransplantation 
cyclophosphamide facilitates engraftment of major histocompatibility 
complex-identical allogeneic marrow in mice conditioned with low-dose total 
body irradiation. Biol Blood Marrow Transplant 2002; 8(3):131-138. 


 
 
 
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 11.  Chang YJ, Huang XJ. Use of G-CSF-stimulated marrow in allogeneic 
hematopoietic stem cell transplantation settings: a comprehensive review. Clin 
Transplant 2011; 25(1):13-23. 
 12.  Frangoul H, Nemecek ER, Billheimer D et al. A prospective study of G-CSF 
primed bone marrow as a stem-cell source for allogeneic bone marrow 
transplantation in children: a Pediatric Blood and Marrow Transplant 
Consortium (PBMTC) study. Blood 2007; 110(13):4584-4587. 
 13.  Morton J, Hutchins C, Durrant S. Granulocyte-colony-stimulating factor (G-
CSF)-primed allogeneic bone marrow: significantly less graft-versus-host 
disease and comparable engraftment to G-CSF-mobilized peripheral blood 
stem cells. Blood 2001; 98(12):3186-3191. 
 14.  Przepiorka D, Weisdorf D, Martin P et al. 1994 Consensus Conference on 
Acute GVHD Grading. Bone Marrow Transplant 1995; 15(6):825-828. 
 15.  Giralt S, Estey E, Albitar M et al. Engraftment of allogeneic hematopoietic 
progenitor cells with purine analog-containing chemotherapy: harnessing 
graft-versus- leukemia without myeloablative therapy. Blood 1997; 
89(12):4531-4536. 
 16.  Slavin S, Nagler A, Naparstek E et al. Allogeneic nonmyeloablative stem cell 
transplantation (NST) as an emerging new modality for immunotherapy of 
hematologic malignancies and non-malignant disorders. Blood 92, 519a. 1998.  
Ref Type: Abstract 
 
17.   Salit RB, Milano F, Gutman JA, Maris MB, Chauncey TR, Petersen F, et al. 
Umbilical Cord Blood Transplant Patients At High Risk Of Graft Rejection 
Achieve Early Full Donor Chimerism When 300cGy Is Used In The Reduced 
Intensity Conditioning Regimen. Blood 2013 Dec 6;122(21):697. 
 
18.  Ostronoff F, Milano F, Gooley T, Gutman JA, McSweeney P, Petersen FB, et 
al. Double umbilical cord blood transplantation in patients with hematologic 
malignancies using a reduced-intensity preparative regimen without 
antithymocyte globulin. Bone Marrow Transplant 2013 Jun;48(6):782-6. 
 
19.  Bolaños-Meade J, Fuchs EJ, Luznik L, Lanzkron SM, Gamper CJ, Jones RJ, 
et al. HLA-haploidentical bone marrow transplantation with posttransplant 
cyclophosphamide expands the donor pool for patients with sickle cell disease. 
Blood 2012 Nov 22;120(22):4285-91. 
 
20.  Luznik L, O'Donnell PV, Symons HJ, Chen AR, Leffell MS, Zahurak M, et al. 
HLA-haploidentical bone marrow transplantation for hematologic 
malignancies using nonmyeloablative conditioning and high-dose, 
posttransplantation cyclophosphamide. Biol Blood Marrow Transplant 2008 
Jun;14(6):641-50. 


 
 
 
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 21.  Luznik L, Bolaños-Meade J, Zahurak M, Chen AR, Smith BD, Brodsky R, et 
al. High-dose cyclophosphamide as single-agent, short-course prophylaxis of 
graft-versus-host disease. Blood 2010 Apr 22;115(16):3224-30. 
 22.  Sobecks RM, Dean R, Rybicki LA, Chan J, Theil KS, Macklis R, et al. 400 cGy 
TBI with fludarabine for reduced-intensity conditioning allogeneic 
hematopoietic stem cell transplantation. Bone Marrow Transplant 2008 
Dec;42(11):715-22. 
 23.  Lee SE, Kim HJ, Min WS, Cho BS, Eom KS, Kim YJ, et al. Favorable 
outcomes of intravenous busulfan, fludarabine, and 400 cGy total body 
irradiation-based reduced-intensity conditioning allogeneic stem cell 
transplantation for acute myelogenous leukemia with old age and/or co-
morbidities. Int J Hematol 2010 Sep;92(2):342-50. 
 
 
 


 
 
 
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Appendix 1.  Consensus conference clinical grading of acute GVHD 
 
Clinical Staging 
Stage 
Skin 
Liver: Total 
Bilirubin 
Intestinal Tract: Diarrhea 
0 
No rash 
<2.0 mg/dL 
<500 ml/day 
1 
<25% of skin surface 
2.0-3.0 
500-1000 ml/day 
2 
25-50% 
3.1-6.0 
1001-1500 ml/day 
3 
Erythroderma 
6.1-15.0 
>1500 ml/day 
4 
Erythroderma with bullae 
and desquamation 
>15.0 
Severe abdominal pain with or 
without ileus 
 
Clinical Grading 
Grade 
Skin* 
Liver 
GI 
I 
1-2 
0 
0 
II 
3 
1 
1 
III 
- 
2-3 
2-4 
IV 
4 
4 
- 
*Each column identifies minimum stage for organ grade 
 
 


 
 
 
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Appendix 2.  Ideal Body Weight and Adjusted Ideal Body Weight Calculations 
 
 
Ideal Body Weight Formula 
 
Males: 50 kg + (2.3 x the number of inches > 5 feet) 
Females: 45 kg + (2.3 x the number of inches > 5 feet) 
 
 
Adjusted Ideal Body Weight Formula 
 
[(actual weight – ideal weight) x 25%] + ideal weight 
 
Note:  If actual weight < ideal, use actual weight. 
 
If actual weight > ideal, use corrected ideal.