Conditions: Acute Myeloid Leukemia With Multilineage Dysplasia Following Myelodysplastic Syndrome Adult Acute Myeloid Leukemia in Remission Adult Acute Myeloid Leukemia With 11q23 (MLL) Abnormalities Adult Acute Myeloid Leukemia With Del(5q) Adult Acute Myeloid Leukemia With Inv(16)(p13;q22) Adult Acute Myeloid Leukemia With t(15;17)(q22;q12) Adult Acute Myeloid Leukemia With t(16;16)(p13;q22) Adult Acute Myeloid Leukemia With t(8;21)(q22;q22) de Novo Myelodysplastic Syndromes Previously Treated Myelodysplastic Syndromes Recurrent Adult Acute Myeloid Leukemia Secondary Acute Myeloid Leukemia
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
This phase II trial studies how well decitabine and total-body irradiation followed by donor bone marrow transplant and cyclophosphamide works in treating patients with relapsed or refractory acute myeloid leukemia. Giving decitabine and total-body irradiation before a donor bone marrow transplant helps stop the growth of cancer cells. It may also 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 decitabine and total-body irradiation before the transplant together with high-dose cyclophosphamide, tacrolimus, and mycophenolate mofetil after the transplant may stop this from happening.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine overall survival at 100 days after transplantation following decitabine and a bone marrow transplant using a donor that is at least partially-matched and a myeloablative preparative regimen with post-transplantation cyclophosphamide for graft-versus-host disease (GVHD) prophylaxis.

SECONDARY OBJECTIVES:

I. Patients enrolled in this study will also be followed for the following endpoints: neutrophil and platelet recovery, graft failure, acute graft-versus-host disease (GVHD), chronic GVHD, incidence of infection, treatment-related mortality, time to relapse/progression, overall survival, and progression-free survival.

OUTLINE:

Beginning between days -29 and -22, patients receive decitabine intravenously (IV) over 1 hour daily for 10 days, fludarabine phosphate IV over 30 minutes on days -5 to -2, and busulfan IV over 3 hours on days -5 to -2.

PREPARATIVE REGIMEN: Patients undergo total-body irradiation twice daily (BID) on day -1.

TRANSPLANT: Patients undergo allogeneic bone marrow transplant on day 0.

GVHD PROPHYLAXIS: Patients receive cyclophosphamide IV over 2 hours on days 3 and 4, tacrolimus orally (PO) BID or IV continuously on days 5-180, mycophenolate mofetil PO three times daily (TID) on days 5-35 and filgrastim subcutaneously (SC) beginning day 5 until absolute neutrophil count (ANC) \>= 1,000/mm\^3 for 3 consecutive days.

After completion of study treatment, patients are followed up at 6 months and 1 year.

Arms:
arm 1: Beginning between days -29 and -22, patients receive decitabine IV over 1 hour daily for 10 days, fludarabine phosphate IV over 30 minutes on days -5 to -2, and busulfan IV over 3 hours on days -5 to -2.

PREPARATIVE REGIMEN: Patients undergo total-body irradiation BID on day -1.

TRANSPLANT: Patients undergo allogeneic bone marrow transplant on day 0.

GVHD PROPHYLAXIS: Patients receive cyclophosphamide IV over 2 hours on days 3 and 4, tacrolimus PO BID or IV continuously on days 5-180, mycophenolate mofetil PO TID on days 5-35, and filgrastim SC beginning day 5 until ANC \>= 1,000/mm\^3 for 3 consecutive days.

Interventions: intervention 1: decitabine intervention 2: fludarabine phosphate intervention 3: busulfan intervention 4: cyclophosphamide intervention 5: tacrolimus intervention 6: mycophenolate mofetil intervention 7: filgrastim intervention 8: total-body irradiation intervention 9: allogeneic bone marrow transplantation intervention 10: laboratory biomarker analysis
Intervention descriptions: intervention 1: Given IV intervention 2: Given IV intervention 3: Given IV intervention 4: Given IV intervention 5: Given PO or IV intervention 6: Given PO intervention 7: Given SC intervention 8: Undergo total-body irradiation intervention 9: Undergo allogeneic bone marrow transplantation intervention 10: Correlative studies

Protocol document:
Prot_SAP_000.pdf: 
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HO11421 
 
 
Decitabine Followed by Bone Marrow Transplant and High-Dose 
Cyclophosphamide for the Treatment of Relapsed and Refractory Acute 
Myeloid Neoplasms 
 
 
Principal Investigator:  
 
Mark B. Juckett, MD 
 
 
Blood and Marrow Transplant Program 
 
 
Division of Hematology & Medical Oncology 
 
 
University of Wisconsin 
 
 
Protocol Version Date: 
 
 October 13, 2015 
 
 
Co-Investigators: 
 
Walter Longo, MD 
 
 
Natalie Callander, MD 
 
 
Peiman Hematti, MD 
 
 
Vaishalee Kenkre, MD 
 
 
Ryan Mattison, MD 
 
 
Statistician: 
 
KyungMann Kim, PhD 
 
 
Funding Sponsor: 
 
University of Wisconsin Carbone Cancer 
Center 
 
 


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PROTOCOL SYNOPSIS 
 
Decitabine Followed by Bone Marrow Transplant and High-Dose 
Cyclophosphamide for the Treatment of Relapsed and Refractory Acute 
Myeloid Neoplasms 
 
Principal Investigator: 
Mark B. Juckett, MD  
 
Study Design:  
This study is a Phase II study of decitabine followed 
by myeloablative conditioning and transplantation of 
bone marrow from HLA-matched or HLA-mismatched, 
related donors. 
 
Primary Objective:  
The primary objective is to determine overall survival 
at 100 days following decitabine and a bone marrow 
transplant using a myeloablative preparative regimen 
and post-transplantation cyclophosphamide.  
 
Secondary Objectives: 
Patients enrolled in this study will also be followed for 
the following endpoints: neutrophil and platelet 
recovery, graft failure, acute graft-versus-host disease 
(GVHD), chronic GVHD, incidence of infection, 
treatment-related mortality, time to 
relapse/progression, overall survival, and 
progression-free survival.  
 
Study Design:  
This study is a Phase II study of decitabine followed 
by myeloablative conditioning, transplantation of bone 
marrow and post-transplantation cyclophosphamide in 
patients with acute myelogenous leukemia, and high-
risk myelodysplastic syndrome.   
 
Accrual Objective:  
The target sample size is 20 patients. 
 
Accrual Period: 
The estimated accrual period is two years. 
 
Eligibility Criteria: 
Patients 18 - 75 years of age and with at least a 
partially (≥ 5 of 10) HLA-matched donor.   
 
Treatment Description: The preparative regimen will consist of:  
- Decitabine 20 mg/m2 IV daily for 10 days to begin 
no sooner than 24 days and no later than 17 days 
prior to the beginning of the preparative regimen for 
transplant 
- Fludarabine 50 mg/m2 IV daily over 30 minutes on 
Days -5 to -2 
- Busulfan 3.2 mg/kg IV daily over 3 hours on Days -5 
to -2 with dosing modified based on 
pharmacokinetic modeling to achieve steady state 
concentration of 800 ng/mL for patients age 18 to 60 


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or Busulfan 2.4 mg/kg IV daily over 3 hours on Days 
-5 to -2 with dosing modified based on 
pharmacokinetic modeling to achieve steady state 
concentration of 600 ng/mL for patients 61 to 75. 
- Total body irradiation (TBI) 4 Gy will be given Day -1 
followed by infusion of a bone marrow transplant on 
Day 0. 
- G-CSF 5 mcg/kg/day beginning Day 5 until ANC  
1,000/mm3. 
 
 
 
 
 
  
The GVHD prophylaxis regimen will consist of: 
- Cyclophosphamide 50 mg/kg IV Days 3, 4 for all 
patients. 
- Patients with an HLA-mismatched donor (at one or 
more HLA loci) will also receive: 
o Tacrolimus 0.12 mg/kg/day oral in two 
divided doses (or 0.04 mg/kg/day IV if 
unable to tolerate oral) with dose adjusted 
to maintain a level of 5-15 ng/mL beginning 
Day 5 until Day 180 and Mycophenolate 
mofetil (MMF) 15 mg/kg oral TID beginning 
Day 5 until Day 35  
 
Study Duration: 
Patients will be followed for one year after 
transplantation.  
 
 


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TABLE OF CONTENTS  
 
 
Protocol Synopsis 
 
 
 
 
 
 
 
  2 
  
Introduction 
 
 
 
 
 
 
 
 
 6 
 
Study Aims/ Study Objectives 
 
 
 
 
 
 
12 
 
Selection of Study Patients 
 
 
 
 
 
 
13 
 
 
Research Design and Methods 
 
 
 
 
 
 
16 
 
Registration Procedures 
 
 
 
 
 
 
16 
 
Treatment / Intervention Plan 
 
 
 
 
 
 
17 
 
Adverse Event Reporting Requirements  
 
 
 
 
20 
 
Study Endpoints 
 
 
 
 
 
 
 
30 
 
Schedule of Evaluations 
 
 
 
 
 
 
32 
 
Statistical Considerations 
 
 
 
 
 
 
33 
 
Records to be Kept  
 
 
 
 
 
 
34 
 
Patient Consent and Peer Judgment 
 
 
 
 
 
35 
 
Data and Safety Monitoring 
 
 
 
 
 
 
35 
 
References 
 
 
 
 
 
 
 
 
36 
 


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1.0 
INTRODUCTION 
 
In Wisconsin, there were approximately 194 patients with a new diagnosis 
of acute myelogenous leukemia (AML), and 244 patients diagnosed with 
myelodysplastic syndromes (MDS) in 2010 
(http://statecancerprofiles.cancer.gov/).   The majority of these patients will die 
from their disease within two years primarily because of ineffective treatment.  
Patients with high-risk AML or MDS can only be cured with hematopoietic stem 
cell transplantation (HSCT), but the relapse rate remains high following HSCT, 
particularly in those patients who are not in a remission or who have overtly 
chemotherapy refractory disease prior to transplantation.  In fact, most HSCT 
centers do not offer HSCT to patients with AML that is not in remission because 
of the high relapse rate and regimen-related mortality among these patients.  A 
recent retrospective registry study examined in detail the outcome of 2,255 
patients with relapsed or refractory AML who underwent HSCT (1).  With a 
median 61 month follow-up, 3-year overall survival rates were 19% with a 
mortality rate at 100 days after HSCT of 39%.  A multivariate analysis identified 5 
adverse prognostic variables that influenced survival: length of first CR duration, 
circulating blasts at the time of HSCT, disease-associated cytogenetics, donor 
source, and performance status.  Patients with no risk factors had OS at 3 years 
of 42% while those with 3 or more risk factors had OS rate of 6%.  The primary 
cause of failure was relapse, which was present in 42% of deaths, often within 
the first 3 months after HSCT.  Infection and organ failure were the second and 
third most common reason for early demise, which are likely reflections of 
prolonged neutropenia and toxicity from repeated attempts at AML control prior 
to transplantation.  The relapses occurred early after HSCT despite the use of so 
called “myeloablative” preparative regimens. 
 
We hypothesize that we can improve the outcome of patients with relapsed 
& refractory AML and high-risk MDS by using a novel strategy with the following 
features: 
• Administering a 10 day course of decitabine immediately prior to 
transplantation, which as a single agent, is associated with minimal non-
hematologic toxicity, and is an effective leukemia agent via a mechanism 
that does not depend on direct cytotoxicity 
• Selecting a donor based on optimal natural-killer (NK) cell receptor 
expression to maximize the chance for NK-directed leukemia cell 
reactivity.  This includes selecting partially HLA-matched related donors 
that may allow for KIR mismatching between donor and patient. 
• Using high-dose cyclophosphamide for prophylaxis against GVHD 
• Using myeloablative doses of total body irradiation (12 Gy over 8 
fractions) 
 
 


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Pretreatment with decitabine 
Decitabine is a methyltransferase inhibitor that appears to exert a 
therapeutic effect by epigenetic modification of suppressed genes associated 
with oncogenic potential.   It is FDA approved to treat MDS using a cumbersome 
inpatient schedule that was associated with a 17% overall response rate (2).  A 
5-day outpatient regimen was later developed, which resulted in an overall 
response rate of 73%, a complete remission rate of 39% (3), and with minimal 
non-hematologic toxicity.  A retrospective comparison suggested that older 
patients receiving decitabine experience a significant survival advantage 
compared to intensive chemotherapy (4), primarily because of the reduced 
toxicity associated with decitabine treatment.  The overlap of clinical and 
pathologic features between high-risk MDS and AML favored studies of 
decitabine in AML, which to date, suggest that decitabine is an important new 
agent.  In a similar 5-day schedule, Cashen, et al. demonstrated that decitabine 
is associated with a 24% CR rate with minimal non-hematologic toxicity in 
patients with AML (5).  The improvement in response previously observed after a 
longer treatment schedule led Blum, et al. to study a 10-day schedule in patients 
with AML that resulted in a CR rate of 47% (6,7) (figure 1 below).  The excellent 
activity in AML, unique mechanism of action, and minimal non-hematologic 
toxicity has led to our interest in studying its use prior to HSCT in patients who 
are not in remission prior to transplantation.   
 
Figure 1. 
 


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Selecting donors based on NK receptor expression 
The recurrence of AML shortly after transplantation using myeloablative 
chemotherapy and whole-body irradiation is a common occurrence when patients 
are not in remission at the start of the process, and this fact is consistent with the 
notion that treatment of relapsed and refractory AML is unlikely to be improved 
by dose intensity.  In fact, it appears that successful treatment of AML by HSCT 
is more dependent on factors other than dose-intensity.  Several studies have 
shown that myeloablative regimens perform no better than reduced-intensity 
regimens in terms of overall survival following HSCT(8,8–10).  Furthermore, 
other studies have supported the concept that successful HSCT is related to 
immunological factors that help support a graft-vs-leukemia reaction, and it is this 
process that is most responsible for long-term control of AML.  One of the first 
examples of this phenomenon is a study demonstrating improved outcome 
among patients receiving allogeneic stem cells from a matched-sibling compared 
to an identical-twin, and improved outcome among those patients with mild 
chronic GVHD compared to those who had none after allogeneic HSCT(11) 
(below).   
 
The immune cell responsible for a so-called “graft-vs-leukemia” (GvL) 
effect is not well delineated.  NK cells are a subset of peripheral blood 
lymphocytes that are characterized by the expression of CD56 and CD16 and the 
absence of the T-cell receptor and CD3 (12).  NK cells are cytotoxic lymphocytes 
that are known to lyse various tumor- and virus-infected cells without prior 
stimulation or immunization (13).  There is an array of inhibitory and activating 
receptors on the surface of the NK cell and it is the complex interplay between 
activating and inhibitory receptors that ultimately can lead to NK cell activation or 


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inhibition.  Perhaps the best understood NK cell receptors are the killer 
immunoglobulin receptors (KIRs). KIRs can be activating or inhibiting and the 
best characterized are those that are inhibitory in nature.  KIRs recognize the 
MHC class I molecule on somatic cells, and this interaction inhibits the activation 
of the NK cell, but down regulation of MHC I that occurs, for example, after a viral 
infection, can lead to loss of NK inhibition and NK directed lysis of the infected 
cell.  The absence of the cognate ligand for KIR on a target cell (e.g., tumor cell) 
is permissive for activation of NK cells by tumor specific antigens, which may 
lead to subsequent lysis of the target cell. 
HLA genes are encoded on chromosome 6. The genes for KIR expression 
are encoded on chromosome 19 and segregate independently from HLA genes. 
Recently, several investigators have shown that allogeneic NK cells may play an 
important role in reducing relapse risk among patients with AML and may play an 
important role in a GvL response(14,15).  Ruggeri et al (16). has shown, for 
example, that patients who received an HSCT from a donor mismatched at 
certain HLA-C or B loci so that a “KIR-mismatch” occurred had a reduced chance 
of relapse consistent with the hypothesis that NK KIR ligands may be important 
mediators in a NK directed anti-leukemia response.  In fact, these investigators 
found that transplantation from NK-alloreactive donors was associated with a 
significantly lower relapse rate in patients transplanted in CR (3% vs. 47%, 
p>0.003), better event-free survival in patients transplanted in relapse (34% vs. 
6%, p=0.04), and in remission (67% vs. 18%, p=0.02) for 112 patients with high-
risk AML with and without NK-alloreactive donors respectively (16).  In this study, 
the NK-alloreactivity results from missing KIR ligands that occur in a HLA-
mismatched donor setting.  This observation has been replicated in other centers 
within studies of HLA-mismatched HSCT (17), but more recently, it appears that 
NK-alloreactivity may occur within the context of an HLA-matched HSCT when a 
patient receives a transplant from a donor that possesses certain KIR genes that 
can be broadly defined as a “B”-haplotype (14,15).  Taken together, it appears 
that donors may be selected for optimal KIR expression in a manner that will 
optimize the occurrence of GvL and a web-site has been created to optimize this 
strategy(http://www.ebi.ac.uk/ipd/kir/) (17)(18).  
 
It is our hypothesis that certain KIR-HLA combinations between a donor 
and a recipient of a transplant will allow donor derived NK cells to eradicate 
residual leukemia and improve outcome in patients with AML.  We further 
hypothesize that this form of NK cell based immunotherapy may be 
accomplished within the setting of HSCT.  An additional advantage of NK cell 
therapy is that while NK cells have similar cytotoxic properties as T cells, they do 
not seem to cause GVHD.   
  
High-dose cyclophosphamide for GVHD prophylaxis 
After HSCT, infused lymphocytes of donor origin recognize tissue antigens 
of recipient origin and these so-called “alloreactive” lymphocytes have the 
potential to proliferate and initiate a cytotoxic response against recipient tissues.  
This process, if left unchecked can lead to a potentially life-threatening condition 


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called Graft-Vs-Host Disease (GVHD).  The risk of GVHD can be reduced by 
eradicating the most alloreactive lymphocytes early after transplantation – a 
process referred to as “GVHD prophylaxis”. GVHD prophylaxis strategies usually 
include a calcineurin inhibitor (i.e. tacrolimus) to moderate cytokine signaling and 
a cytotoxic agent intended to cause cell death of stimulated and rapidly 
proliferating lymphocytes (i.e. methotrexate).  Investigators from Johns Hopkins 
have pursued a more aggressive approach to eliminating alloreactive 
lymphocytes by using high-dose cyclophosphamide 50 mg/kg given days 3 and 4 
after HSCT, and found this to be sufficient for matched-related HSCT alone and 
for partially-matched HSCT when combined with tacrolimus and 
mycophenolate(19–21).  The rationale for the strategy depends on the sensitivity 
of alloreactive and therefore, proliferating T-cells to cyclophosphamide, whereas 
non-reactive lymphocytes will be unaffected (as depicted below). 
 
 
 
 
A table summarizing three reported studies is listed below.  In these 
studies, performed at Johns Hopkins University and the Fred Hutchison Cancer 
Research Center, patients did not have HLA-identical donors and had a variety of 
myeloid malignancies. 
 
 
Hopkins A 
Hopkins B 
Fred Hutch 
Patients (N) 
20 
40 
28 
Treatment 
 
 
 
Preparative 
regimen 
Cy 29 mg/kg 
Flu 150 mg/m2 
TBI 200 cGy 
Same 
Same 
Cy dosing 
Cy 50 mg/kg  
day +3 
Cy 50 mg/kg  
day +3 & 4 
Cy 50 mg/kg  
day +3 
GVHD proph 
Tac until day 50 
MMF BID day 35 
Tac until day 180 
MMF TID day 35 
Tac until day 90 
MMF TID day 35 


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Results 
 
 
 
ANC > 500 
Day 15 
Day 16 
Day 12 
Plt > 20,000 
Day 30 
Day 26 
Day 18 
Graft Failure 
6/19 
6/39 
3/26 
Acute GVHD (III – 
IV) 
10% 
10% 
10% 
Chronic GVHD 
15% 
8% 
46% 
 
The consensus drawn from these studies is that partially-HLA-matched 
HSCT can be performed with relatively little GVHD, with reasonable safety and 
with excellent overall survival that rivals HLA-matched HSCT.   These studies 
formed the basis for a multi-center clinical trial opened within the NCI-supported 
Blood and Marrow Transplant Clinical Trial Network (BMTCTN).  In the BMTCTN 
0603 trial, cyclophosphamide was given 50 mg/kg days 3 & 4, tacrolimus was 
given for 180 days and MMF was given TID for 35 days (all denoted in bold in the 
table above).  This study was conducted in parallel with a separate BMTCTN 
0604 trial using a similar preparative regimen and umbilical cord blood.  In a 
report that included both studies, the outcome was similar between the two graft 
sources with OS at one year of 54% vs. 46% for cord units vs. partially matched 
family donors respectively (22).  The follow-up randomized study comparing cord 
units to partially matched family donors is ongoing (BMTCTN 1101).  Although 
there have not been direct comparisons between multiple graft sources, evidence 
exists supporting the possibility that outcome following the use of a partially-
matched donor graft with cyclophosphamide for GVHD prophylaxis will be 
equivalent or possibly better than using HLA-matched donors.  For example, a 
study examining the relationship between outcome and HLA-disparity showed 
that patients receiving a graft HLA mismatched at 3 – 4 loci had equivalent 
survival compared to those receiving grafts with 0 – 2 mismatches (23) if treated 
with cyclophosphamide.  A single institution study of 271 patients receiving 
transplants from matched-related, matched-unrelated or partially-matched family 
donors (treated with cyclophosphamide for GVHD prophylaxis) demonstrated no 
difference in two year survival (76%, 67%, and 64% respectively) (24).  A second 
study presented in abstract form demonstrated among 611 patients with 8-year 
follow-up that there was no difference in overall survival between patients 
receiving partially-matched family, matched-related or matched-unrelated donors 
(although a different method of GVHD prophylaxis was used) (25). In our study, 
relapse is the expected reason for failure in the majority of patients and given the 
evidence of similar outcome between partially-matched family donors, umbilical 
cord units, and matched-unrelated donors combined with the possibility of 
reducing relapse by using pretransplant decitabine and selecting donors where 
possible based on optimal NK-KIR interactions, we plan to offer the protocol to all 
patients eligible regardless of the possibility of finding a matched-unrelated donor 
through the National Marrow Donor Program.  
 
 


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Purpose of this proposal:  Our BMT program at UW does not currently offer 
HSCT to patients with relapsed or refractory AML or those with high-risk myeloid 
malignancies who do not have an HLA-matched adult donor.  In addition, we do 
not offer HSCT from mismatched donors other than from umbilical cord blood, 
which is generally an unsuitable option for patients NOT in remission.  We wish 
to conduct a phase II study that will provide a potentially curative option for 
patients who do not otherwise have a viable transplant option with high-risk 
myeloid malignancies, based on the hypotheses mentioned above.  If the 
protocol is successful at meeting the specific objectives mentioned below, we 
envision using the regimen as a platform to pursue further immunotherapy 
options such as NK cell infusion after transplantation to improve immune 
reconstitution and graft-vs-malignancy effects.   
 
2.0 
STUDY AIMS/STUDY OBJECTIVES 
 
2.1 
Patients with AML that is not in remission at the time of 
transplantation have a high relapse rate, and high-transplant 
related mortality following standard transplant protocols.  We hope 
to improve on the outcome of these patients by using decitabine to 
better control disease prior to transplantation, using a novel donor 
selection process to optimize a “graft-vs-malignancy” effect, and 
using a novel GVHD prevention strategy.  If this approach improves 
outcome, we will expect to see improved overall survival after 
transplantation. 
 
 
Primary Hypothesis 
• The overall survival at day 100 after transplantation is over 
70% 
 
 
Secondary Hypotheses 
• The acute GVHD grade III and IV by day 100 is below 20% 
• The graft failure rate by day 30 is below 10% (defined by 
ANC < 500/uL AND platelets < 20,000/uL in the absence of 
relapse).  
 
 
To study these hypotheses, we propose to conduct a clinical trial 
with the following objectives: 
 
 
Primary Objective:  The primary objective is to determine overall 
survival at 100 days after transplantation following decitabine and a 
bone marrow transplant using a donor that is at least partially-
matched and a myeloablative preparative regimen with post-
transplantation cyclophosphamide for GVHD prophylaxis.  
 
Secondary Objectives: Patients enrolled in this study will also be 
followed for the following endpoints: neutrophil and platelet 


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recovery, graft failure, acute graft-versus-host disease (GVHD), 
chronic GVHD, incidence of infection, treatment-related mortality, 
time to relapse/progression, overall survival, and progression-free 
survival.  
 
3.0  
SELECTION OF STUDY PATIENTS 
 
3.1  
Study entry is open to adult patients regardless of gender, race or 
ethnic background. Every effort will be made to include women and 
minority patients, but the patient population is expected to be similar to the 
advanced AML and high-risk MDS population seen at the UWCCC.  
 
3.2  
Inclusion Criteria 
3.2.1 Age 18 to 75 years  
3.2.2 Patients must meet one of two disease criteria listed in 3.2.3 
or 3.2.4. 
3.2.3 Acute myelogenous leukemia within one of the following 
categories: 
• Primary induction failure (PIF): Patients who have not 
achieved a complete remission following initial diagnosis 
and after at least two induction cycles of chemotherapy 
consisting of cytarabine and an anthracycline or high-dose 
cytarabine.   
• Relapsed AML:  Patients are defined as having relapsed 
disease if they entered a complete remission confirmed 
with a bone marrow biopsy following initial treatment, and 
then were found to have morphological or cytogenetic 
evidence of recurrent disease on a subsequent bone 
marrow exam.  
• Any CR2 or greater: CR must be defined using a bone 
marrow exam taken at least 21 days since the last 
chemotherapy (including a methyltransferase inhibitor), 
and may include CRp (morphologic CR without peripheral 
platelet recovery).   
• CR1 with high-risk features. Includes patients with 
treatment-related AML, secondary AML (following MDS or 
MPN), high-risk cytogenetic or molecular phenotype (by 
NCCN criteria).   
• Untreated AML (> 20% blasts on a bone marrow) arising 
from a previous confirmed diagnosis of MDS or MPN 
(excluding BCR-ABL positive diseases).  


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3.2.4 Myelodysplastic syndromes within one of the following 
categories: 
• High-risk MDS at diagnosis as defined by the IPSS or 
WPSS. 
• Transfusion dependent MDS (either RBC or platelet 
dependent) without a hematologic response to at least 4 
months of MTI therapy.  Hematologic response is defined 
as transfusion independence for two or more months. 
• Progressive MDS following at least 4 months of MTI 
therapy.  Progression is defined as resumption of 
transfusion dependence after at least two months of 
transfusion independence OR increase of marrow blasts 
by 50% from pretreatment OR overall blasts over 10% of 
marrow cells at any time after treatment. 
3.2.5 Available related donor that is at least an allele level 
haplotype-match at HLA- A, B, C, DRB1 and DPB1 loci 
(DPB1 matching according to the “permissive – non-
permissive” dichotomy as stated by UW Histocompatibility 
Laboratory).  A minimum match of 5/10 loci is required.  An 
unrelated donor search is not required for a patient to be 
eligible for this protocol.   
3.2.6 Karnofsky score of 60% or better (“Requires occasional 
assistance, but is able to care for most of his/her needs”). 
3.2.7 Pulmonary: DLCO (corrected for hemoglobin) > 40%; and 
FEV1 > 50% 
3.2.8 Cardiac: EF ≥ 50% and no uncontrolled angina, symptomatic 
ventricular arrhythmias, or ECG evidence of active ischemia. 
3.2.9 Renal: serum creatinine within normal range for age, or if 
serum creatinine outside normal range, then renal function 
(estimated GFR by MDRD formula)  > 40 mL/min/1.73m2 
3.2.10 Women of child bearing potential must have a negative 
pregnancy test within 14 days prior to study registration and 
agree to use adequate birth control during study treatment. 
3.2.11 Voluntary written consent 
3.2.12 Patients must be 28 days from the end of the last induction 
course or at least 14 days from completion of previous 
methyltransferase inhibitor therapy (azacitidine or 
decitabine) at the time of registration. 
 
3.3  
Exclusion Criteria 
3.3.1 Active CNS leukemia within two weeks of registration.  
Patients with a history of CNS leukemia must have adequate 
treatment as defined by at least two negative spinal fluid 
assessments separated by at least one week. Patients who 


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have received cranial XRT must still be eligible to receive 
total body irradiation to 4 Gy.  
3.3.2 New or active infection as determined by fever, unexplained 
pulmonary infiltrate or sinusitis on radiographic assessment.  
Infections diagnosed within 4 weeks of registration must be 
determined to be controlled or resolving prior to treatment.   
3.3.3 Active HIV, hepatitis A, B or C infection 
3.3.4 Allergy or hypersensitivity to agents used within the 
treatment protocol. 
 
3.4  
Donor selection 
3.4.1 Inclusion criteria   
• 
Donors must be at least HLA-haploidentical first 
degree relatives of the patients.  Eligible donors 
include biological parents, siblings, half-siblings or 
children.   
• 
Age ≥ 18 and ≤ 60 years. 
• 
Donors must meet the selection criteria prior to the 
start of the recipient’s pre-transplant conditioning 
regimen as defined by the Foundation for the 
Accreditation of Cell Therapy (FACT) and will be 
screened according to the American Association of 
Blood Banks (AABB) guidelines and UW BMT 
program SOP.   
3.4.2 Exclusion criteria 
3.4.2.1 
Recipient derived anti-donor high-titer (> 3000 
MFI) HLA antibody as determined by Luminex 
assay.  
3.4.2.2 
Not suitable for donation according to UW BMT 
program donor selection SOP.   
 
3.5 
Donor prioritization schema 
While an objective of this trial is to optimize donor selection with 
respect to KIR genotype, the single most important determinant in 
predicting outcome following allogeneic transplantation is the HLA 
match between the donor and recipient (26).  To assure the 
greatest likelihood of favorable outcome following transplantation, 
we will prioritize HLA match over KIR selection in choosing donors.  
All potential donors will undergo HLA typing.  Among two or more of 
the best HLA-matched donors, KIR typing will also be performed. 
The selection of donors will occur with the following priorities: 
 
1. HLA-genotypic match 
2. KIR mismatch based on the “receptor-ligand” model (see 
appendix A) 
3. KIR genotype according to “B” content (see appendix A) 
 
 
 


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When the donor search is initiated, all available potential donors will 
undergo HLA typing according to the current UW SOP.  The best 
available donors based on HLA match with the recipient will then be 
chosen for further genotypic KIR typing.  If there is more than one 
possible donor of a given HLA match, narrowing the selection will 
be performed according to the priorities listed above.  If there is 
more than one donor available after working through the selection 
priorities above, then the donor will be selected based on CMV 
serology, ABO matching and age (in that order) according to our 
standard UW guidelines.   
 
4.0 
RESEARCH DESIGN AND METHODS: 
 
The study is a phase II study intended to study outcome and toxicity of a 
novel transplant approach for patients with high-risk myeloid malignancies.  
Research subjects will be identified among patients referred to the 
UWCCC for treatment of advanced myeloid malignancies.  The patients 
will be treated and followed within the UW BMT program according to our 
approved standard-operating-procedures for clinical management of 
patients undergoing HSCT.  All clinical care will be provided by the UW 
BMT program and follow-up thereafter according to the clinical needs of 
the patients and what is considered standard of care.  There will be no 
scheduled visits or evaluation on dates that do not correspond to those 
indicated by best practice.  Scheduled evaluations may be performed 
within 3 days from the targeted date prior to day 28 and within 7 days 
thereafter.   
 
Study Data Collection and Monitoring 
The study will report clinical data using the OnCore database using 
electronic case report forms.  Key study personnel are trained on the use 
of OnCore and will comply with protocol specific instructions and all 
measures to maintain confidentiality.  In addition, specific transplant 
related information will be collected and recorded in the UW BMT program 
database according to the program standard operating procedures, which 
will assure confidentiality according to HIPAA regulations.   
 
5.0 
REGISTRATION PROCEDURES  
 
Patients cannot begin protocol treatment prior to registration. 
Registration will occur after the patient has signed the subject consent and 
eligibility is confirmed, but before any treatment has been administered.  
Any patient signing consent, but not enrolled in the study, will be recorded 
as a screen failure.  To be eligible for registration to this study, the patient 
must meet each criteria listed on the eligibility checklist based on the 
eligibility assessment documented in the patient’s medical record.   
 
 


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6.0 
TREATMENT / INTERVENTION PLAN 
 
 
Day -29 to -22 
Start decitabine 20 mg/m2 IV daily for 10 days 
Day -5 to -2 
Fludarabine 50 mg/m2 IV daily over 30 minutes 
Day -5 to -2 
Busulfan 3.2 mg/kg (or 2.4 mg/kg) IV daily over three 
hours following fludarabine 
Day -1 (or Day 0) 
Total Body Irradiation (TBI) 4 Gy in 2 fractions 
Day 0 
Bone marrow transplant 
Day 3, 4 
Cyclophosphamide 50 mg/kg IV, Mesna 40 mg/kg IV 
Day 5 
Begin tacrolimus, MMF (for partially matched donors 
only) 
Day 5 
Begin G-CSF 
 
The protocol is intended for patients with active AML or high-risk MDS at 
the time of registration.  We expect that decitabine will succeed in 
controlling AML prior to transplantation in most but not all patients, and a 
subset will experience progressive disease during and after the 10 day 
period of decitabine treatment. Patients who have evidence of rapidly 
progressing AML while on treatment are felt to be at particularly high-risk 
for early death during the transplant process and are unlikely to derive any 
long-term benefit from transplantation.  Accordingly, patients with a 
peripheral blast count that is rising during decitabine treatment and 
the week following to over 150% of pre-treatment count AND have a 
absolute blast count that exceeds 10,000 blasts per microliter of 
blood within 7 days of the completion of decitabine will be ineligible 
to proceed. While there are no restrictions on the use of growth-factors, 
these are discouraged as they may influence the blast count and render a 
patient ineligible for transplantation.   
 
6.1 
Weight Calculations  
 
For all medications, actual body weight will be used for patients 
when actual body weight is less than ideal body weight.  Unless 
otherwise stated, if the actual body weight is above ideal body 
weight, then adjusted ideal body weight will be used.   
 
 
 
Ideal Body Weight (IBW) Formulas: 
 
 
 
Males IBW = 50 kg + 2.3 kg/inch over 5 feet 
 
 
Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet 
 
 
Adjusted Ideal Body Weight Formula: 
 
 
 
AIBW = IBW + [(0.25) x (ABW - IBW)] 
 
 


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6.2 
Decitabine  
Actual body weight is used to calculate decitabine dose. Patients 
will receive decitabine 20 mg/m2 IV over one hour daily for 10 
consecutive days according to current UW chemotherapy council 
approved treatment plan that is available in Beacon.  The 
decitabine must start by 29 days but no later than 22 days prior to 
transplant (be completed within 14 days but not sooner than 7 days 
from the start of the preparative regimen).   
 
 
6.3 
Preparative Regimen 
 
Fludarabine 50 mg/m2/day will be administered over 30 minutes 
intravenous infusion on Days -5 through -2 for a total dose of 200 
mg/m2. For patients who have an estimated or measured GFR < 70 
mL/min/1.73 m2, the fludarabine dose should be reduced by 20%. 
Fludarabine dosing is based on the last calculated GFR prior to the 
start of conditioning. The fludarabine dose should be the same on 
Days -5 to -2, even if the patient’s creatinine changes.  Fludarabine 
must be administered before busulfan on each day. 
 
Busulfan 3.2 mg/kg/day given intravenously over 3 hours on Days 
-5 to -2 following fludarabine for patients up to the age of 60.  For 
patients 61 to 75, the busulfan dose is 2.4 mg/kg/day.  Following 
the first busulfan infusion, the IV administration line will be flushed 
with normal saline and blood samples (3 mL/sample) will be 
collected in sodium heparin tubes.  The samples will be 
immediately placed on ice, centrifuged at 4°C and the plasma 
collected and frozen in a labeled plastic tube.  Samples will be 
collected at the end of the infusion (180 min), and 195 min, 4, 5, 6 
and 8 hours after the infusion began.  The frozen plasma samples 
will be sent to the Seattle Cancer Care Alliance Pharmacokinetics 
Laboratory, Seattle Washington, for the analysis of busulfan 
pharmacokinetics.   
 
After quantitation of busulfan samples, the individual patient’s 
concentration-time data are fit using WinNonlin (version 5.2). The 
AUC is estimated and the steady state concentration calculated.  
After calculation of the patient’s clearance, the target dose for 
subsequent doses is calculated linearly to achieve the target Css 
(27).   


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Drug Interactions:  Busulfan is metabolized in the liver primarily 
through a reaction with glutathione-S-transferase, but clearance 
also depends on the CYP3A4 enzyme system, although the 
mechanism is not well described.  It is important to avoid 
administering drugs that compete with busulfan for clearance via 
the glutathione pathway or interact with the CYP3A4 enzyme 
system.  The most important interactions include those with 
phenytoin, acetaminophen, metronidazole and extended-spectrum 
antifungal azoles.  It is recommended that the patient not take 
these medications within one weeks of the first dose of busulfan 
and until 3 days following the completion of busulfan.   
 
Total-body irradiation will be administered at a dose of 4 Gy in 2 
fractions on Day -1 according to the current UW standard operating 
procedure.  If needed because of scheduling requirements, TBI 
may be given on Day 0 but Day -1 is the preferred day of treatment. 
 
 
6.4 
Bone marrow transplant 
 
 
 
On Day 0, patients will receive unprocessed marrow unless there is 
a major ABO incompatibility, in which case red blood cells will be 
depleted from the donor marrow using the current UW SOP.  Donor 
bone marrow will be harvested with a target yield of 4 x 108 
nucleated cells/kg recipient ideal body weight (IBW).  A sample of 
the product to be infused will be sent for flow cytometry to 
determine the content of CD34+, CD3+, CD4+ and CD8+ cells.  
 
 
6.5 
Graft-vs-Host Disease Prophylaxis 
 
 
 
6.5.1 Post-transplantation cyclophosphamide with mesna – 
hydration with normal saline at 2 mL/kg/hr IV will be started 2 hours 
prior to cyclophosphamide and continued at 2 mL/kg/hr for 8 hours 
post-cyclophosphamide.   
 
Mesna will be given in divided doses IV over 15 - 30 min at the 
following time points:  Prior to the start of cyclophosphamide and at 
Target Concentration of busulfan at steady state 
(Css) 
 
Age 18 to 60: 800 ng/mL 
 
Age 61 to 75: 600 ng/mL 
 


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3, 6, and 8 hours post-cyclophosphamide.  Mesna dose will be 80% 
of the total daily dose of cyclophosphamide. 
 
 
Cyclophosphamide (50 mg/kg if the actual body weight is above 
ideal body weight, then ideal body weight will be used) 
will be given on Day +3 (between 60 and 72 hours after marrow 
infusion) and on Day +4 (approximately 24 hours after Day +3 
dose) post-transplant.  Cyclophosphamide will be given as an IV 
infusion over 2 hours.  No corticosteroids may be given as anti-
emetics with the cyclophosphamide.   
 
6.5.2 Tacrolimus and Mycophenolate For those patients 
receiving a transplant from a partially matched donor (including one 
or more mismatches at HLA A, B, C, DR or non-permissive DP) 
tacrolimus and mycophenolate will be started on Day +5.   
 
Tacrolimus – will be started no earlier than 24 hours after the 
completion of cyclophosphamide.  The management of tacrolimus 
will reflect standard operating procedures for the UW BMT 
Program.  Tacrolimus 0.12 mg/kg/day oral in two divided doses with 
each dose rounded to the nearest 0.5 mg (or 0.04 mg/kg/day IV if 
unable to tolerate oral) beginning Day 5 with dose adjusted to 
maintain a level of 5-15 ng/mL beginning Day 5 until Day 180 and 
Mycophenolate mofetil (MMF) 15 mg/kg oral PO TID beginning Day 
5 until Day 35.  Tacrolimus dosing is calculated using actual body 
weight unless the patient is >25% above ideal body weight in which 
case adjusted actual body weight should be used to calculate the 
dose.  Serum levels will be measured no later than Day +7 and 
should be checked biweekly to maintain a level between 5-15 
ng/mL.  Patients will remain on tacrolimus until day 180, when, in 
the absence of GVHD, tacrolimus will be discontinued.   
 
Mycophenolate Mofetil (MMF) – will be given at a dose of 15 
mg/kg PO TID (based upon actual body weight and rounded up to 
the nearest pill size) with the maximum total daily dose not to 
exceed 3 grams (1g PO TID).  MMF prophylaxis will be 
discontinued after the last dose on day 35, or may be continued if 
there is active GVHD present.   
 
 
6.6 
Indwelling Central Venous Catheter – patients must have a 
peripherally inserted central catheter (PICC) for the administration 
of IV medications and transfusion of blood products.  
 
 
6.7 
Growth Factor Support –  
 
 


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21 
 
 
 
 
 will be given according to UW standard for engraftment following 
BMT.  Specifically, G-CSF 
 
 
will be given subcutaneously beginning Day +5 and daily until the 
ANC is > 1,000 for one day.  The dose will be based on actual body 
weight as follows: for weight ≤ 80 kg give 300 mcg and for weight > 
80 kg, give 480 mcg.   
 
6.8 
Supportive Care 
Patients will receive the standard supportive care provided to HSCT 
patients according to the UW BMT SOPs. 
 
7.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
 
Purpose 
An adverse event (AE) is any untoward medical occurrence in a clinical 
investigation subject that is enrolled in a clinical trial.  An AE may be any 
unfavorable or unintended sign, symptom, or disease temporally 
associated with participation in a clinical trial. While some events may not 
initially appear to be associated with the use of the study treatment, a 
relationship may not emerge until sufficient numbers of reports 
accumulate over the course of the study. 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. 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.  
 
General AE reporting requirements 
The study period during which all AEs and SAEs must be reported begins 
upon initiation of study treatment and ends at the 12 month post-transplant 
follow-up visit, or at the time of initiation of non-protocol treatment for the 
underlying primary malignancy or death, whichever comes first.  After this 
period, investigators should only report SAEs that are attributed to prior 
study treatment.  Both AEs and SAEs will be reported using NCI’s 
Common Terminology Criteria for Adverse Events (CTCAE Version 4.0).  
In general, HSCT is performed by first administrating myelotoxic and 
immunosuppressive medications followed by infusion of allogeneic stem 
cells.  There is a predictable and expected period of severe hematologic 
toxicity followed by recovery as the allogeneic stem cells engraft (grow) 
and produce blood cells.  This early post-transplant toxicity is predictable, 
expected and typically resolved by one month after transplantation.  
Consequently, reporting requirements for expected AEs and SAEs until 


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22 
day 30 will follow the guidelines outlined in Table 1.  Beyond day 30, 
patients are followed as outpatients in the clinic and the AE and SAE 
reporting will be determined according to Table 2below.   
 
 
Serious Adverse Events (SAE) 
 
Defining an SAE and Reporting Responsibilities: 
 
Adverse events that qualify as serious are defined in the list below (see 
Serious Adverse Event Definition). Using the list, first determine 
whether the adverse event is considered an SAE. Depending on the 
nature and severity of the serious adverse event, an SAE report will be 
submitted according to the reporting timeline specified in Table I and 
Table 2 (below).  All serious adverse events must be reported to the 
UWCCC Data and Safety Monitoring Committee Chair.  SAEs will be 
submitted to the UW-IRB per institutional guidance.  SAEs will be reported 
to the FDA if deemed appropriate by the UWCCC Sponsor-Investigator 
Determination of FDA Reporting for Institutional Trials. 
 
The UWCCC Principal Investigator assumes responsibilities of the study 
sponsor in accordance with FDA 21 CFR 312.32. In this capacity, the 
UWCCC PI reviews all reports of SAE occurring on this study at the 
UWCCC and makes a determination of 1) suspectedness (i.e., whether 
there is a reasonable possibility that the AE is caused by transplantation 
process); and 2) whether the event is unexpected (the event is not listed in 
the list of expected transplant associated AEs) in the context of this study. 
SAEs will be submitted to the DSMC, IRB, and FDA as appropriate. 
 
 
Serious Adverse Event Definition 
 
Following FDA guidance, Serious Adverse Events are events that have 
any of the following outcomes: 
1. 
Death 
2. 
A life-threatening adverse event. 
3. 
An adverse event that results in inpatient hospitalization or 
prolongation of existing hospitalization for ≥ 24 hours. 
4. 
A persistent or significant incapacity or substantial disruption 
of the ability to conduct normal life functions. 
5. 
A congenital anomaly/birth defect. 
6. 
Important Medical Events (IME) that may not result in death, 
be life threatening, or require hospitalization may be 
considered serious when, based on medical judgment, they 
may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the 
outcomes listed in this definition (FDA, 21 CFR 312.32; ICH 
E2A and ICH E6).   


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TABLE 1 – Serious Adverse Event Reporting Requirements for Events That 
Occur Within 30 days after HSCT 
 
Grade 1 – 
3 
Grade 4 
Grade 4 
Grade 5 
Grade 5 
 
 
Unexpected 
Expected 
Unexpected 
Expected 
Unrelated 
Unlikely 
Not 
required 
Not required 
Not 
required 
10 
Calendar 
days 
10 
Calendar 
days 
Possible 
Probable 
Definite 
Not 
required 
10 
Calendar 
days 
Not 
required 
24-Hrs;  
5 
Calendar 
Days 
10 
Calendar 
days 
 
 
TABLE 2 – Serious Adverse Event Reporting Requirements for Events That 
Occur 31 to 365 days after HSCT 
Hospitalization 
Grade 1 and Grade 2 
Timeframes 
Grade 3 Timeframes 
Grade 4 & 5 
Timeframes 
Resulting in 
hospitalization ≥ 24 hrs 
10 Calendar Days 
24-Hour; 5 Calendar 
Days 
Not resulting in 
hospitalization ≥ 24 hrs 
Not Required 
10 Calendar Days 
NOTE: Expedited AE reporting timelines are defined as: 
 
• 
24-Hour; 5 Calendar Days – The AE must initially be reported via MedWatch within 24 hours of 
learning of the AE, followed by a complete expedited report within 5 calendar days of the initial 
24-hour report.  Note:  MedWatch form only required to be completed and submitted as 
indicated by the UWCCC Sponsor-Investigator Determination of FDA Reporting for Institutional 
Trials form. 
• 
10 Calendar Days – A complete expedited report on the AE must be submitted within 10 calendar 
days of learning of the AE.  Note:  MedWatch form only required to be completed and submitted 
as indicated by the UWCCC Sponsor-Investigator Determination of FDA Reporting for Institutional 
Trials form. 
 
Exceptions to SAE Reporting 
Specific protocol exceptions to expedited reporting (SPEER) are listed in the 
CAEPR Table below.   
 
Risks and Toxicities 
 
Total Body Irradiation – nausea and vomiting, diarrhea, parotitis, generalized 
mild erythema, hyperpigmentation, fever, mucositis, alopecia, infertility, 
amenorrhea, late secondary malignancies. Late effects may include cataract 
formation, growth retardation, pulmonary damage, carcinogenesis, and 
sterilization. 
 
Busulfan – Severe myelosuppression with marrow ablation, alopecia, and mild 
nausea/vomiting are expected. Alopecia may not be completely reversible. Liver 
toxicity including severe or fatal veno-occlusive disease (<5%) may occur. 


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24 
Pulmonary toxicity is rare in this schedule. It is expected that patients will require 
mouth care including narcotic analgesia, and may require parenteral nutrition. 
Busulfan may cause skin toxicity including painful desquamation, and this may 
require local care and narcotic analgesia. Darkening of the skin may occur and 
may last several months. Seizures may occur (<5%).  Busulfan causes 
immunosuppression and risk of opportunistic infection even after resolution of 
neutropenia. Busulfan is expected to cause nearly universal infertility in the 
doses used, although men may occasionally father children. 
 
Fludarabine – Myelosuppression (dose limiting toxicity), fever, nausea, vomiting, 
stomatitis, diarrhea, gastrointestinal bleeding, anorexia, edema, skin rashes, 
myalgia, headache, agitation, hearing loss, transient episodes of somnolence 
and fatigue, autoimmune hemolytic anemia, autoimmune thrombocytopenia, 
paresthesias, peripheral neuropathy, renal and pulmonary toxicity (interstitial 
pneumonitis). Severe fatal CNS toxicity presenting with loss of vision and 
progressive deterioration of mental status were encountered almost exclusively 
after very high doses of fludarabine monophosphate. Such toxicity has only been 
rarely demonstrated at the 25-30 mg dosage of fludarabine monophosphate used 
in this regimen. Tumor lysis syndrome, complicating fludarabine monophosphate 
therapy has been observed, especially in patients with advanced bulky disease. 
Opportunistic infections (protozoan, viral, fungal, and bacterial) have been 
observed in both pre-treated patients receiving fludarabine and in individuals 
receiving fludarabine combined with other agents.  
 
Tacrolimus – In patients receiving tacrolimus, 5% to 47% experienced anemia, 
8% to 32% experienced leukocytosis, and 14% to 24% experienced 
thrombocytopenia. Rare cases of microangiopathic hemolytic anemia have been 
reported. Mild to moderate hypertension was reported in 38% to 50% of patients 
receiving tacrolimus. Mild to moderate hypertension is a common adverse effect 
associated with tacrolimus therapy. Chest pain was reported in 19%. 
Antihypertensive therapy may be required. The most common adverse effects of 
tacrolimus have involved the central nervous system, and include headache 
(37% to 64%), tremors (48% to 56%), insomnia (32% to 64%), paresthesia (17% 
to 40%); and dizziness (19%). Tremor and headache may respond to a dosage 
reduction. Agitation, anxiety, confusion, seizures, depression, hallucinations, 
myoclonus, neuropathy, psychosis, incoordination, and abnormal dreams have 
been reported in 3% to 15% of tacrolimus-treated patients. Hyperkalemia (13% to 
45%), 
hypokalemia 
(13% 
to 
29%), 
hypophosphatemia 
(49%), 
and 
hypomagnesemia (16% to 48%) have been associated with tacrolimus therapy. 
In addition, hirsutism occurs only rarely with tacrolimus. Hyperuricemia has been 
reported in greater than 3% of tacrolimus-treated patients. Gastrointestinal 
adverse effects of tacrolimus have included nausea (32% to 46%), vomiting (14% 
to 29%), anorexia (7% to 34%), constipation (23% to 35%) and diarrhea (37% to 
72%). Nephrotoxicity was reported in 36% to 40% and 52% of liver and kidney 
transplant patients receiving tacrolimus. Overt nephrotoxicity is usually seen 
early after transplantation and is characterized by an increased serum creatinine 


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25 
and a decrease in urine output. Hematuria has been reported in greater than 3% 
of tacrolimus-treated patients (Prod Info Prograf®, 1997). Abnormal liver function 
tests have been reported in 6% to 36% of patients receiving tacrolimus; ascites 
was reported in 7% to 27% of these patients.  Other miscellaneous effects that 
have occurred in clinical trials include pain (24% to 63%), fever (19% to 48%), 
asthenia (11% to 52%), back pain (17% to 30%), and peripheral edema (12% to 
36%). The incidence of hyperglycemia is 17% and may require therapy with 
insulin. Other less frequently occurring effects (greater than 3%) include abscess, 
chills, peritonitis, and photosensitivity reactions. Anaphylaxis has been reported 
in a few patients receiving intravenous tacrolimus. Tacrolimus contains castor oil 
which has been associated with anaphylaxis in other drugs containing castor oil 
derivatives.  The incidence of bloodstream infection is 22%. Most infections are 
due to bacteria (81%), followed by candidemia (14%), and cryptococcemia (5%). 
The source of bloodstream infection was primarily intravascular catheter, 
accounting for 39% of cases. 
 
Cyclophosphamide – cardiomyopathy, skin rash, mucositis, sterility, fluid weight 
gain/edema, alopecia and hemolytic/anemia. Hematologic including leukopenia, 
thrombocytopenia, anemia, pancytopenia; gingivitis, glossitis, pharyngitis, 
stomatitis, enteritis; nausea/vomiting, anorexia, diarrhea; hematemesis, melena; 
photosensitivity; 
nephropathy: 
hemorrhagic 
cystitis, 
dysuria, 
azotemia, 
hematuria, renal failure.  
 
Mycophenolate 
Mofetil 
– 
pancytopenia, 
nausea, 
vomiting, 
diarrhea, 
hypertension, headache, dizziness, 
insomnia, hyperglycemia, electrolyte 
imbalances, rash, and leg cramps/bone pain, reversible renal insufficiency, 
hypertension, hyperglycemia, hypomagnesemia, hypokalemia, and neurologic 
toxicity. 
 
Comprehensive Adverse Events and Potential Risks (CAEPR) List for BMT. 
 
Adverse Events with at least possible relationship to 
allogeneic stem cell transplantation 
 
Specific Protocol 
Exceptions to 
Expedited 
Reporting (SPEER) 
Likely (> 20%) 
Less Likely 
(<20%) 
Rare but Serious 
(<3%) 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
 
Pancytopenia 
 
 
Anemia, 
thrombocytopenia, 
neutropenia (gr.3)  
Febrile 
neutropenia 
 
 
Febrile 
neutropenia 
(gr. 3,4 before day 
30) 
 
Immune 
 
 


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26 
Hemolytic anemia 
 
 
Microangiopathic 
hemolytic anemia 
 
CARDIAC DISORDERS 
 
 
Atrial fibrillation 
 
 
GASTROINTESTINAL DISORDERS 
 
 
Abdominal pain 
 
Diarrhea (gr. 3) 
 
Constipation 
 
Nausea/vomiting 
(gr.3) 
Diarrhea 
 
 
 
Oral mucositis 
 
 
 
Nausea 
and 
vomiting 
 
 
 
Anorexia 
 
 
Anorexia 
(gr. 
4 
before day 30) 
Colitis 
 
 
 
GENERAL DISORDERS  
 
Edema 
 
 
 
Fever 
 
 
 
 
 
Multi-organ failure  
Pain 
 
 
 
 
Non-cardiac 
chest pain 
 
 
HEPATOBILIARY DISORDERS 
 
 
 
Hepatic failure 
 
 
 
Veno-occlusive 
disease 
 
IMMUNE SYSTEM DISORDERS 
 
Graft-vs-host 
disease 
 
 
 
 
 
Cytokine release 
syndrome 
 
INFECTIONS AND INFESTTIONS 
 
 
Bladder infection 
 
 
 
Catheter 
related 
infection 
 
 
 
Bacteremia 
 
 
 
 
Sepsis 
 
 
Lung infection 
 
 
 
Pustular rash 
 
 
 
Sinusitis 
 
 
INVESTIGATIONS 
 
 
AST, ALT, bili, 
Alkaline 
 
 


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27 
phosphatase 
increased 
 
Creatinine 
increased 
 
 
 
Lymphocytes 
decreased 
 
Lymphocytosis 
(gr. 
3) 
 
Weight gain/loss 
 
 
 
WBC, HGB, PLTs 
decreased 
 
Anemia, 
thrombocytopenia, 
neutropenia (gr.3) 
METABOLISM AND NUTRITIONAL DISORDERS 
 
 
Multiple 
electrolyte 
abnormalities 
 
Dehydration (gr.3), 
Hyponatremia (gr.3), 
hypokalemia (gr.3) 
 
Iron overload 
 
 
MUSCULOSKELETAL 
AND 
CONNECTIVE 
TISSUE 
DISORDERS 
 
 
 
Avascular 
necrosis 
 
 
 
Fibrosis 
deep 
connective tissue 
 
 
Muscle weakness  
 
 
Osteoporosis 
 
 
RENAL AND URINARY DISORDERS 
 
 
 
Acute 
kidney 
injury 
 
 
Proteinuria 
 
 
REPRODUCTIVE SYSTEM 
 
Azoospermia 
 
 
 
Dysmenorrhea 
 
 
 
Infertility 
 
 
 
RESPIRATORY 
DISORDERS 
 
 
 
 
 
ARDS 
 
 
 
Bronchiolitis 
obliterans 
(bronchial 
obstruction) 
 
 
 
Pneumonitis 
 
 
 
Pulmonary 
edema 
 
 
 
Pulmonary 
fibrosis 
 
 
 
Respiratory 
failure 
 


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SKIN AND SUBCUTANEOUS DISORDERS 
 
 
Erythroderma 
 
 
 
Skin induration 
 
 
 
Rash 
maculo-
papular 
 
 
VASCULAR DISORDERS 
 
 
Capillary 
leak 
syndrome 
 
 
 
Hypertension 
 
 
 
Thromboembolic 
event 
 
 
 
Investigator Reporting to the FDA 
The FDA does not need to be automatically notified of every SAE that occurs 
during the clinical trial.  For every SAE, the PI (or Sub-I in absence of the PI) 
must complete the UWCCC Sponsor-Investigator Determination of FDA 
Reporting for Institutional Trials.  The PI or Sub-I will evaluate the SAE against 
certain criteria and determine if reporting to the FDA is necessary. 
 
Adverse drug reactions that are Serious, Unlisted/Unexpected, and at least 
possibly associated to the drug and that have not previously been reported in 
the Investigators brochure, or reference safety information document should be 
reported promptly to the Food and Drug Administration (FDA) in writing by each 
investigator/physician engaged in clinical research.  A clear description of the 
suspected reaction should be provided along with an assessment as to whether 
the event is drug or disease related. 
 
The investigator/physician shall notify the FDA by telephone or by fax of any 
unexpected fatal or life threatening experience associated with the use of the 
drug as soon as possible, but no later than 7 calendar days after the sponsor’s 
initial receipt of the information.  All other events can be reported within 15 days. 
 
Reporting a 24 SAE : A Summary 
 
Serious Adverse Events requiring expedited reporting within 24 hours will be 
reported to the Data and Safety Monitoring Committee (DSMC) Chair via an 
email to saenotify@uwcarbone.wisc.edu within one business day. 
 
A 24 hr initial “SAE Details” Report, generated in the UWCCC database, OnCore, 
must be attached to the email along with the UWCCC Sponsor-Investigator 
Determination of FDA Reporting for Institutional Trials and any additional 
pertinent information available at the time of initial reporting. The DSMC Chair 
will review the information and determine if immediate action is required. 
 


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29 
Within 10 working days, all subsequent SAE documentation must be submitted 
electronically along with a 24 hour follow-up or final “SAE Details” Report to 
saenotify@uwcarbone.wisc.edu.  Final reports will also be submitted to 
appropriate individuals listed on the UWCCC SAE Routing Form, however, the 
Routing Form itself should not be sent with the final SAE.   All information is 
entered and tracked in the UWCCC database. 
 
Procedures for Reporting a 24 Hour SAE that Occurs at the UWCCC 
 
a. To the FDA: 
Consult the UWCCC Sponsor-Investigator Determination of FDA 
Reporting for Institutional Trials to determine if the event requires reporting 
to the FDA.  If so, report the SAE using the FDA MedWatch form available 
at 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/defa
ult.htm 
 
b. To the UW HS-IRB:  
Consult the UW-IRB website for reporting guidelines. 
 
c.  To the UWCCC: 
Reference the SAE SOP (Standard Operating Procedure) and the SAE 
Reporting Workflow for DOWGs on the UWCCC website 
(http://www.uwccc.wisc.edu) for specific instructions on how and what to 
report to the UWCCC for 24 hour initial and follow-up reports. Include the 
UWCCC Sponsor-Investigator Determination of FDA Reporting for 
Institutional Trials and the FDA MedWatch form with this submission if 
applicable.  A follow-up report is required to be submitted to the 
UWCCC within 10 business days of the initial 24 hour report.   The 
“SAE Details” Report and related supporting documents should be e-
mailed to the DSMC at saenotify@uwcarbone.wisc.edu.  Final reports will 
also be submitted to appropriate individuals listed on the UWCCC SAE 
Routing Form, however, the Routing Form itself should not be sent with 
the final SAE.    
 
Reporting a 10 Day SAE : A Summary 
 
Serious Adverse Events requiring reporting within 10 working days (as described 
in the protocol) will also be sent to the UWCCC DSMC Chair via email to 
saenotify@uwcarbone.wisc.edu. A 10 day “SAE Details” report, generated in the 
UWCCC database, OnCore, must be attached to the email along with the 
UWCCC Sponsor-Investigator Determination of FDA Reporting for Institutional 
Trials and any additional pertinent information regarding the SAE. Final reports 
will also be submitted to appropriate individuals listed on the UWCCC SAE 


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30 
Routing Form, however, the Routing Form itself should not be sent with the final 
SAE.  The DSMC Chair will review the information and determine if further action 
is required. This information is entered and tracked in the UWCCC database. 
 
Procedures for Reporting a 10 Day SAE that Occurs at the UWCCC 
a. To the FDA: 
Consult the UWCCC Sponsor-Investigator Determination of FDA 
Reporting for Institutional Trials to determine if the event requires reporting 
to the FDA.  If so, report the SAE using the FDA MedWatch form available 
at 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/defa
ult.htm 
 
b. To the UW HS-IRB: 
Consult the UW-IRB website for reporting guidelines. 
 
c. To the UWCCC: 
Reference the SAE SOP (Standard Operating Procedure) and the SAE 
Reporting Workflow for DOWGs on the UWCCC website 
(http://www.uwccc.wisc.edu) for specific instructions on how and what to 
report to the UWCCC for 10 day initial and follow-up reports. Include the 
UWCCC Sponsor-Investigator Determination of FDA Reporting for 
Institutional Trials and the FDA MedWatch form with this submission if 
applicable.  The “SAE Details” Report and related supporting documents 
should be e-mailed to the DSMC at saenotify@uwcarbone.wisc.edu.  Final 
reports will also be submitted to appropriate individuals listed on the 
UWCCC SAE Routing Form, however, the Routing Form itself should not 
be sent with the final SAE.    
 
Study Progress Review 
 
Cumulative reports of serious adverse events requiring expedited reporting and 
any new serious adverse event requiring expedited reporting are also reviewed 
at the DSMC bimonthly meetings. 
 
An overall assessment of accrual, toxicities as described in the protocol, and 
responses will enable the committee members to assess whether significant 
benefits or risks are occurring that would warrant study closure. This information 
is provided by Disease Group meeting minutes, internal audit and/or response 
review reports. The committee may request external DSMB reports or further 
information from the Disease Groups, or Study Chair. 
 


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The Data and Safety Monitoring Committee recommendations for modifications 
to the trial are forwarded to the Clinical Research Committee (CRC), composed 
of Cancer Center senior leaders that oversee all aspects of clinical research 
conducted at the UWCCC and makes final decisions on all issues related to 
clinical trials. The Study Chair is notified of this recommendation in order that 
he/she may alert all investigators, at the UWCCC and at external sites involved in 
the trial, about the potential action. At this time the Study Chair may submit to the 
CRC additional information that could affect the Committee’s decision. The CRC 
will notify the Study Chair if they concur with the Data and Safety Monitoring 
Committee recommendations, including suspension or closure. The Study Chair 
will notify all investigators involved with the study at UWCCC and external sites, 
the IRB, the sponsor and the funding source. 
 
8.0 
STUDY ENDPOINTS 
 
8.1  
Primary Endpoint 
The primary endpoint is overall survival at 100 days from the time 
of transplantation. 
 
8.2 
Secondary Endpoints 
8.2.1 Neutrophil recovery – is defined as achieving an ANC ≥ 
500/uL for three consecutive measurements on different 
days.  The first of the three days will be designated the day 
of recovery.  The only competing event for neutrophil 
recovery is death without neutrophil recovery. 
8.2.2 Platelet recovery – is defined as the first day of a platelet 
count > 20,000/mm3 with no platelet transfusions in the 
preceding 7 days.  The first day of the sustained platelet 
count will be the designated day of platelet engraftment.  
8.2.3 Primary graft failure – is defined as < 5% donor chimerism in 
the CD3 and CD33 selected cell populations at any time 
after transplantation.   
8.2.4 Acute GVHD – The cumulative incidence of grade II – IV 
GVHD will be determined.  The GVHD grade will be 
determined by the standard BMT Clinical Trials Network 
(BMTCTN) criteria (Appendix B).  The time to onset of grade 
II-IV and III-IV aGVHD will be recorded and maximum grade 
achieved.  
8.2.5 Chronic GVHD – The cumulative incidence of chronic GVHD 
will be recorded and defined according to the BMTCTN 
criteria (Appendix C).   
8.2.6 Complete remission after transplantation – is determined 
when there is neutrophil and platelet engraftment, a bone 
marrow with < 5% blasts (and no morphologically abnormal 


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32 
blasts seen on aspirate), and resolution of any disease 
related cytogenetic marker of the original disease.  
8.2.7 Relapse will be diagnosed when there is any of the following: 
• 
Reappearance of leukemia blasts in the peripheral 
blood 
• 
5% blasts in the marrow, not attributable to another 
cause (e.g. bone marrow regeneration) 
• 
The reappearance of dysplastic changes in the bone 
marrow aspirate accompanied by cytogenetic findings 
or chimerism testing to confirm disease. 
• 
The finding of extramedullary leukemia including in 
the cerebral spinal fluid.  
 
 
 
 


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9.0  
SCHEDULE OF EVALUATIONS  
 
All evaluations are considered part of the standard of care evaluation of a 
patient prior to allogeneic stem cell transplantation.  The pretransplant 
evaluations must be completed within 28 days of registration unless otherwise 
stated below.  
 
Pre-study 
Evaluation7 
Pre-BMT 
Evaluation 
Day 1 to 
neutrophil 
engraftment 
Day 28 
Weekly day 
28 to 100 
6, 9, 12 
months 
Informed Consent 
X 
 
 
 
 
 
Medical History 
X 
X 
 
X 
X 
X 
Toxicity 
Assessment 
X 
X 
weekly 
 
X 
X 
Physical Exam 
X 
X 
 
X 
X 
X 
Performance 
Status 
X 
X 
 
X 
Every 4 
weeks 
X 
GVHD evaluation1 
 
 
Twice weekly 
X 
X 
X 
CMV PCR2 
 
 
X  
X 
X 
X 
EBV PCR 
 
 
 
 
Every two 
weeks 
X 
CBC   
X5 
X5 
Twice weekly 
 
X 
X 
LFT’s Total 
bilirubin, Alkaline 
Phosphatase, 
AST, ALT 
X 
X 
weekly 
 
X 
X 
Electrolytes, Mag, 
Creatinine, BUN,  
X 
X 
Twice weekly 
 
X 
X 
Uric acid, INR, 
Vitamin D, ferritin, 
calcium, 
phosphate 
X 
 
 
 
 
 
Total cholesterol, 
triglycerides 
X 
 
 
 
 
 
Tacrolimus 
 
 
Twice weekly 
 
X 
 
Pre-transplant viral 
panel3 
X 
 
 
 
 
 
Urinalysis with 
microscopy and 
culture if indicated 
X 
X 
 
 
 
 
Pregnancy test4 
X 
X 
 
 
 
 
Luminex screen6 
X 
X 
 
 
 
 
BM aspirate and 
biopsy 
X5 
X5 
 
X 
X (day 100 
only) 
X 
CD3, CD33 STR 
(PB) 
X 
 
 
X 
Every 4 
weeks 
X 
ECG 
X 
 
 
 
 
 
Cardiac ECHO 
X 
 
 
 
 
 
CT scans – sinus 
plus C/A/P, 
panorex 
X 
 
 
 
 
 
CXR8 
 
X 
 
 
 
 
PFT’s 
X 
 
 
 
 
 
CD4/8 
 
 
 
X 
X (day 100 
only) 
X 
Quant 
immunoglobulins 
X 
 
 
 
X (day 100 
only) 
X 
 
1. Refer to appendix B for acute GVHD grading scales 
2. Weekly CMV PCR starting day 14 for those at risk for CMV infection (CMV positive donor 
or recipient) until day 100 and then 6, 9 and 12 months 
3. Viral panel according to the UW standard operating procedure for pre-HSCT evaluation 
4. Urine or serum within 14 days of registration 
5. A bone marrow and CBC with differential must be performed within 14 days of beginning 
decitabine and again within 14 days before beginning the preparative regimen.    


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34 
6. Recipients will be screened for anti-donor HLA antibodies prior to final selection of 
donors. Testing will be repeated if more than 30 days have elapsed between the results 
and the start of decitabine.  
7. Unless otherwise specified, pre-study evaluation assessments to be done within 28days 
of registration. 
8. CXR will be performed one the day of or within one week of admission to begin the 
preparative regimen. 
 
10.0 STATISTICAL CONSIDERATIONS 
 
10.1 Objectives: 
 
 
As a phase II trial, the objective is to generate preliminary data on clinical 
outcome such as overall survival, acute GvHD (aGvHD), and graft failure 
(GF) after transplant, non-hematologic toxicity, and blast content of the 
bone marrow before and after decitabine from the use of decitabine prior 
to HSCT, the use of a partially-matched but KIR-HLA selected donor, and 
the incorporation of high-dose cyclophosphamide for GVHD prophylaxis. 
 
10.2 Endpoints: 
 
 
The primary endpoint of the study is overall survival at day 100 after 
transplant.  Any patient who is enrolled will be accounted for in the final 
assessment. Secondary endpoints include aGvHD grade III-IV by day 100, 
graft failure by day 30 after transplant, and grade 3 or worse non-
hematologic toxicity.  These analyses will include only those patients who 
survive to Day 0 (the day of transplantation).  Lastly, the blast content of 
the bone marrow before and after decitabine will be analyzed among 
those patients who have completed the decitabine treatment and the bone 
marrow analyses before and after decitabine treatment. 
 
10.3 Analysis plan: 
 
Overall survival and other times to event data such as aGvHD and GF will 
be analyzed using Kaplan-Meier (KM) method, and day 100 OS and 
aGVHD grade III-IV and 30 day GF rates will be obtained from the KM 
estimates along with 95% confidence intervals.  Binary outcome variables 
such as grade 3 or worse non-hematologic toxicity, will be summarized 
with a proportion and a 95% confidence interval.  The blast content of the 
bone marrow before and after decitabine and its change will be 
summarized with mean and standard deviation or median and interquartile 
range, and the change will be tested using a one-sample paired t-test at a 
two-tailed significance level of 0.05. 
 
 
 
 


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35 
10.4 Sample size justification: 
 
The sample size is limited by the feasibility over 2 years.  Twenty subjects 
will be enrolled into the trial.  With 20 subjects, the trial will have 0.71 
(0.93) power to detect the 100 day OS ≥ 0.7 according to a one-tailed test 
of the null hypothesis that it is ≤ 0.5 (0.4) at a significance level of 0.1.  
The trial will have 0.76 (0.94) power to detect the 100 day aGvHD grade 
III-IV ≤ 0.2 according to a one-tailed test of the null hypothesis that is is ≥ 
0.4 (0.5) at a significance level of 0.1.  Also the trial will have 0.85 (0.98) 
power to detect the 30 day GF ≤ 0.1 according to a one-tailed test of the 
null hypothesis that is is ≥ 0.3 (0.4) at a significance level of 0.1. 
 
10.5 Sequential safety monitoring: 
 
Because of safety concern, OS, aGvHD grade III-IV, and GF will be 
monitored continuously using a sequential probability ratio test (SPRT).  
For example, each time death is observed before day 100 or patient 
survives beyond day 100, a sequential probability ratio test will be 
performed to test the null hypothesis that the 100 day OS is less than or 
equal to 0.5 against the alternative hypothesis that it is at least 0.7.  
Likewise each time grade III or IV aGvHD is observed before day 100 or 
patient does not experience grade III or IV aGvHD by day 100, a 
sequential probability ratio test will be performed to test the null hypothesis 
that the 100 day aGvHD grade III-IV is greater than or equal to 0.4 against 
the alternative hypothesis that it is no more than 0.2.  Also each time GF is 
observed before day 30 or patient is free of GF by day 30, a sequential 
probability ratio test will be performed to test the null hypothesis that the 
30 day GF is greater than or equal to 0.3 against the alternative 
hypothesis that it is no more than 0.1.  The trial will be suspended if the 
SPRT boundary for the null hypothesis is crossed for any of the three 
outcome measures and the UWCCC DSMC will be notified.  After 
investigation of the clinical outcomes as of the SPRT boundary crossing, 
the PI in consultation with other investigators and study statistician and the 
UWCCC DSMC will make the decision whether to continue the trial or to 
terminate for patient safety concern. 
 
11.0 RECORDS TO BE KEPT 
 
The UW BMT Program maintains a HIPAA compliant clinical database 
that is used to comply with FACT and Center for International Blood and 
Marrow Transplant Research (CIBMTR) reporting requirements.  Patient, 
disease, treatment and outcome data are collected and reported as 
required by regulatory and quality reporting requirements.  Patients will 
also be registered in the OnCore database within the UWCCC. 
 
 


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36 
12.0 PATIENT CONSENT AND PEER JUDGMENT 
 
Current FDA, NCI, state, federal and institutional regulations concerning 
informed consent will be followed. 
 
13.0 DATA AND SAFETY MONITORING  
 
The UWCCC Data and Safety Monitoring Committee (DSMC) is 
responsible for monitoring data quality and subject safety for all UWCCC 
clinical studies.  A summary of DSMC activities follows: 
• 
Review of all clinical trials conducted at the UWCCC for data integrity 
and safety 
• 
Review of all serious adverse events requiring expedited reporting as 
defined in the protocol (see section 7) 
• 
Review of reports generated by the UWCCC data quality control 
review process  
• 
Submit recommendations for corrective action to the CRC 
• 
Notify the Study Chair of the DSMC’s recommendation to the CRC 
• 
Work in conjunction with the Health Sciences IRB in the review of 
protocol deviations, violations and unanticipated problems reported by 
the UWCCC DOWGs.  
• 
The committee ensures that notification is provided to all external sites 
participating in multiple-institutional clinical trials coordinated by the 
UWCCC of serious adverse events requiring expedited reporting. 
 
 
Monitoring And Reporting Guidelines 
 
Data related to these trials are discussed at regularly scheduled Disease 
Oriented Working Group meetings where the result of each subject’s 
treatment is discussed. The discussion will include for each treatment 
arm/dose level, the number of subjects, significant toxicities as described in 
the protocol, dose adjustments, and responses observed.  Twice yearly, 
Protocol Summary Reports are required for submission to the Data and 
Safety Monitoring Committee for review.  Any unanticipated problems, 
complications, and adverse events will be reported to the investigator upon 
occurrence, and reported to the IRB in accordance with posted guidance. 


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37 
14.0  REFERENCES 
 
1.  
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Hematopoietic Stem-Cell Transplantation for Acute Leukemia in Relapse or 
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2.  
Kantarjian H, Issa J-PJ, Rosenfeld CS, Bennett JM, Albitar M, DiPersio J, 
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Cashen AF, Schiller GJ, O’Donnell MR, DiPersio JF. Multicenter, Phase II 
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Blum W, Garzon R, Klisovic RB, Schwind S, Walker A, Geyer S, et al. 
Clinical response and miR-29b predictive significance in older AML patients 
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Blum W, Klisovic RB, Hackanson B, Liu Z, Liu S, Devine H, et al. Phase I 
Study of Decitabine Alone or in Combination With Valproic Acid in Acute Myeloid 
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Lim Z, Brand R, Martino R, van Biezen A, Finke J, Bacigalupo A, et al. 
Allogeneic Hematopoietic Stem-Cell Transplantation for Patients 50 Years or 
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9.  
Alyea EP, Kim HT, Ho V, Cutler C, Gribben J, DeAngelo DJ, et al. 
Comparative outcome of nonmyeloablative and myeloablative allogeneic 
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2005 Feb 15;105(4):1810–4.  
10.  
Martino R, Iacobelli S, Brand R, Jansen T, van Biezen A, Finke J, et al. 
Retrospective comparison of reduced-intensity conditioning and conventional 
high-dose conditioning for allogeneic hematopoietic stem cell transplantation 
using HLA-identical sibling donors in myelodysplastic syndromes. Blood. 2006 
Aug 1;108(3):836–46.  
11.  
Horowitz MM, Gale RP, Sondel PM, Goldman JM, Kersey J, Kolb HJ, et 
al. Graft-versus-leukemia reactions after bone marrow transplantation. Blood. 
1990 Feb 1;75(3):555–62.  
12.  
Miller JS. The biology of natural killer cells in cancer, infection, and 
pregnancy. Exp Hematol. 2001 Oct;29(10):1157–68.  
13.  
Kiessling R, Klein E, Pross H, Wigzell H. “Natural” killer cells in the mouse. 
II. Cytotoxic cells with specificity for mouse Moloney leukemia cells. 


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Characteristics of the killer cell. Eur J Immunol. 1975 Feb;5(2):117–21.  
14.  
Cooley S, Weisdorf DJ, Guethlein LA, Klein JP, Wang T, Le CT, et al. 
Donor selection for natural killer cell receptor genes leads to superior survival 
after unrelated transplantation for acute myelogenous leukemia. Blood. 2010 Oct 
7;116(14):2411–9.  
15.  
Cooley S, Trachtenberg E, Bergemann TL, Saeteurn K, Klein J, Le CT, et 
al. Donors with group B KIR haplotypes improve relapse-free survival after 
unrelated hematopoietic cell transplantation for acute myelogenous leukemia. 
Blood. 2009 Jan 15;113(3):726–32.  
16.  
Ruggeri L, Mancusi A, Capanni M, Urbani E, Carotti A, Aloisi T, et al. 
Donor natural killer cell allorecognition of missing self in haploidentical 
hematopoietic transplantation for acute myeloid leukemia: challenging its 
predictive value. Blood. 2007 Jul 1;110(1):433–40.  
17.  
Symons HJ, Leffell MS, Rossiter ND, Zahurak M, Jones RJ, Fuchs EJ. 
Improved Survival with Inhibitory Killer Immunoglobulin Receptor (KIR) Gene 
Mismatches and KIR Haplotype B Donors after Nonmyeloablative, HLA-
Haploidentical Bone Marrow Transplantation. Biology of Blood and Marrow 
Transplantation. 2010 Apr;16(4):533–42.  
18.  
Main Page - NKcells [Internet]. [cited 2010 Oct 16]. Available from: 
http://www.nkcells.info/mw/index.php/Main_Page 
19.  
Luznik L, Bolanos-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.  
20.  
Luznik L, Jones RJ, Fuchs EJ. High-dose cyclophosphamide for graft-
versus-host disease prevention. Current Opinion in Hematology. 2010 
Nov;17(6):493–9.  
21.  
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.  
22.  
Brunstein CG, Fuchs EJ, Carter SL, Karanes C, Costa LJ, Wu J, et al. 
Alternative donor transplantation after reduced intensity conditioning: results of 
parallel phase 2 trials using partially HLA-mismatched related bone marrow or 
unrelated double umbilical cord blood grafts. Blood. 2011 Jul 14;118(2):282–8.  
23.  
Kasamon YL, Luznik L, Leffell MS, Kowalski J, Tsai H-L, Bolaños-Meade 
J, et al. Nonmyeloablative HLA-haploidentical bone marrow transplantation with 
high-dose posttransplantation cyclophosphamide: effect of HLA disparity on 
outcome. Biol Blood Marrow Transplant. 2010 Apr;16(4):482–9.  
24.  
Bashey A, Zhang X, Sizemore CA, Manion K, Brown S, Holland HK, et al. 
T-cell-replete HLA-haploidentical hematopoietic transplantation for hematologic 
malignancies using post-transplantation cyclophosphamide results in outcomes 
equivalent to those of contemporaneous HLA-matched related and unrelated 
donor transplantation. J Clin Oncol. 2013 Apr 1;31(10):1310–6.  
25.  
Stanghellini L, Teresa M, Mastaglio S, Carrabba M, Sala E, Marcatti M, et 
al. Haploidentical Transplantation Outcome is Not Inferior to Standard Matched 
Related - Unrelated Donor Transplantation: An Intention-to-Treat Analysis of 611 


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Patients in 8-Years Experience at San Raffaele Scientific Institute. Biology of 
Blood and Marrow Transplantation. 2013 Feb;19(2):S122–S123.  
26.  
Lee SJ, Klein J, Haagenson M, Baxter-Lowe LA, Confer DL, Eapen M, et 
al. High-resolution donor-recipient HLA matching contributes to the success of 
unrelated donor marrow transplantation. Blood. 2007 Dec 15;110(13):4576–83.  
27.  
Yeh RF, Pawlikowski MA, Blough DK, McDonald GB, O’Donnell PV, 
Rezvani A, et al. Accurate Targeting of Daily Intravenous Busulfan with 8-Hour 
Blood Sampling in Hospitalized Adult Hematopoietic Cell Transplant Recipients. 
Biology of Blood and Marrow Transplantation. 2012 Feb;18(2):265–72.  
 


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Appendix A 
I. Donor Selection 
 
Related donors that are at least haploidentical with respect to HLA class I and II 
antigens defined genotypically will be used as donors.  The first priority in 
choosing donors will be based on HLA match.  If there are multiple donors of the 
same degree of HLA-match, then further selection will be based on KIR-HLA 
ligand mismatching as described below.  Using the table below, for each donor, 
the KIR expressed by the donor will be indicated across the top of the table.  The 
HLA type of the patient will be indicated along the first column and a point will be 
given for each “match” that occurs within a shaded area on the table.   
 
 
 
HLA type of Patient 
 
 
KIR genotype of Donor 
KIR 2DL1 
(“A”) 
KIR 2DL2 
(“B”) 
KIR 2DL3 
(“A”) 
KIR 3DL1 
(“A”) 
 
HLA-C2 
 
 
 
 
 
 
HLA-C1 
 
 
 
 
 
 
HLA-Bw4 
 
 
 
 
 
 
Donor with lowest score (number of shaded boxes checked) is preferred. If there 
are more than one donor with the same KIR-HLA ligand score, then a further 
determination will be made based on the “B” haplotype content as determine by 
the calculator on this site: http://www.ebi.ac.uk/ipd/kir/donor_b_content.html.  The 
donor with the most “B” haplotype content with be chosen.  If there remain 
options between donors, then usual selection criteria will apply that is based on 
age, CMV status and ABO blood type.   
 
Donor selection priority: 
1. 
HLA-match 
2. 
KIR-ligand mismatch 
3. 
KIR B haplotype content 
 
 
 


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41 
TABLE of KIR Genotypes 
 
Group C1 
Ser77 Asn80 
Cw*01 
Cw*03 
Cw*07 
Cw*08 
Cw*12 
Cw*13 
Cw*14 
Cw*16 
2DL2 
2DL3 
 
 
 
Group C2 
Asn77 Lys80 
Cw*02 
Cw*04 
Cw*05 
Cw*06 
Cw*15 
Cw*17 
Cw*18 
2DL1 
 
 
 
Bw4 
B5 
B13 
B17 
B27 
B37 
B38 
B44 
B47 
B49 
B51 
B52 
B53 
B57 
B58 
B59 
B63 
B77 
B*1513 
B*1516 
B*1517 
B*1523 
B*1524 
3DL1 
 
 
 
 
 
 


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42 
APPENDIX B 
ACUTE GRAFT-VS-HOST DISEASE (GVHD) 
Introduction 
Investigators should document on a weekly basis (beginning with the day of 
transplant) the raw data for the GVHD target organs either in the medical record 
directly or on a trial-specific worksheet.  This should include the extent of skin 
rash, if any; the bilirubin; the daily stool output; or number of stools per day for an 
outpatient.  The weekly record should reflect the worst representative days of the 
preceding week for each target organ involvement.  Biopsy confirmation of target 
organs is recommended in most circumstances to confirm the diagnosis acute 
GVHD. 
 
In addition to the raw data record to verify acute GVHD organs staging, the 
relevant differential diagnoses should be recorded (e.g., drug rash, GI infection 
such as C. difficile, veno-occlusive disease (VOD), total parenteral nutrition 
(TPN), etc.) each week for target organ involvement.  The record should indicate 
whether a biopsy was diagnostic, not diagnostic, or not done of each organ 
involved and should indicate when systemic GVHD therapy was initiated. 
 
Grading 
Acute GVHD grading should be performed by the consensus conference criteria 
(Przepiorka, et. al., 1994).  See  Acute GVHD Staging and Grading TablesFigure 
1.3.1 – Sample Data Sheet 
 
Clinical Acute GVHD Assessment 
 
Date  ___________ Patient ID  ____________________________________         Karnofsky/Lansky _______ 
 
   Code 
 
 
 
 
 Differential Diagnosis 
 
0 
1 
2 
3 
4 
5 
 
 GVHD 
Drug 
 Rxn 
 Cond 
  Reg 
TPN 
Infect 
VOD 
Other 
Skin 
     
 % body rash:____ 
      
   
 
 
Lower GI *       Vol: ___________ 
          
 
 
Upper GI   
 
 
 
 
 
          
 
 
Liver 
     
 Max bili: ________             
 
 
Treatment:  CSA 
 Tacrolimus 
 Pred 
 Methylpred 
 Ontak 
 
 Pentostatin 
 MMF 
 Etanercept 
 Other _______________________ 
 
Code Definitions: 
 
Skin: 
0  No rash 
1  Maculopapular rash,  
<25% of body surface 
2  Maculopapular rash,  
25-50% of body surface 
3  Generalized erythroderma 
4  Generalized erythroderma 
with bullous formation and 
desquamation 
Lower GI * (Diarrhea): (* GUT) 
0  None 
1  ≤500 mL/day or <280 mL/m2 
2  501-1000 mL/day or 280- 555 mL/m2 
3  1001-1500 mL/day or 556- 833 mL/m2 
4  >1500 mL/day or >833 mL/m2 
5  Severe abdominal pain with or without 
ileus, or stool with frank blood or melena 
Upper GI: 
0  No protracted 
nausea and 
vomiting 
1  Persistent 
nausea, 
vomiting or 
anorexia 
Liver (Bilirubin): 
0  <2.0 mg/dl 
1  2.1-3.0 mg/dl 
2  3.1-6.0 mg/dl  
3  6.1-15.0 mg/dl 
4  >15.1 mg/dl 
 
 
 
 
 


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Acute GVHD STAGING and GRADING 
Tables 
 
 
 
 
 
Data Collection 
Weekly GVHD raw data, staging, and grading should be collected until 60-70 
days post-transplant for all patients and, if feasible, to Day +100.  Subsequently, 
monthly data involving acute GVHD symptomatology should be collected for all 
patients remaining on immunosuppressive therapy until two months after 
discontinuation of immunosuppressive treatment for acute GVHD.  If acute 
GVHD develops later or flares, the data collection should be continued frequently 
(every 1, 2, or 4 weeks as feasible) in sufficient detail to monitor the progress of 
the disease. 
 
 
 


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APPENDIX C 
Definitions of Chronic GVHD 
The diagnosis of chronic GVHD is based on both clinical and histopathologic 
findings for each organ system.  Pathognomonic and possible manifestations of 
chronic GVHD are outlined below; possible manifestations should be further 
evaluated to rule out other potential non-chronic GVHD etiologies.  For example, 
pancreatic enzyme insufficiency may cause malabsorption and weight loss 
independent of chronic GVHD.  
 
Time since transplant will not be used to distinguish acute from chronic GVHD 
(e.g., chronic GVHD may occur before Day 100, and acute GVHD may occur 
after Day 100).  If acute GVHD is suspected after Day 60 or chronic GVHD is 
suspected before Day 100, biopsies are strongly encouraged to confirm the 
diagnosis.  Additionally, biopsies are encouraged to confirm the diagnosis of 
chronic GVHD in patients with “possible” manifestations (see Table 2.3.1). 
 
Table 2.3.1 – Definite and Possible Manifestations of Chronic GVHD 
Organ System 
Definite manifestations of chronic 
GVHD 
Possible manifestations of chronic 
GVHD 
Skin 
Scleroderma (superficial or fasciitis), 
lichen planus, vitiligo, scarring alopecia, 
hyperkeratosis pilaris, contractures from 
skin immobility, nail bed dysplasia 
Eczematoid rash, dry skin, 
maculopapular rash, 
hyperpigmentation, hair loss 
Mucous 
membranes 
Lichen planus, non-infectious ulcers, 
corneal erosions/non-infectious 
conjunctivitis 
Xerostomia, keratoconjunctivitis sicca  
GI tract 
Esophageal strictures, steatorrhea 
Anorexia, malabsorption, weight loss, 
diarrhea, abdominal pain 
Liver 
None 
Elevation of alkaline phosphatase, 
transaminitis, cholangitis, 
hyperbilirubinemia 
GU 
Vaginal stricture, lichen planus 
Non-infectious vaginitis, vaginal atrophy 
Musculoskeleta
l/ Serosa 
Non-septic arthritis, myositis,  
myasthenia, polyserositis, contractures 
from joint immobilization 
Arthralgia 
Hematologic 
None 
Thrombocytopenia, eosinophilia, 
autoimmune cytopenias 
Lung 
Bronchiolitis obliterans  
Bronchiolitis obliterans with organizing 
pneumonia, interstitial pneumonitis 
 
Standards of Care 
The severity of chronic GVHD reporting and the treatment algorithm will be 
according to the UW BMT program SOP regarding chronic GVHD. 
 
 


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45 
 
ADDENDUM 
 
Study Summary 02/17/2017 
 
 
Study design, primary and secondary objectives remain the same 
throughout the study.  Patient enrollment was completed on December 
31, 2016,  at which time the study was closed to enrollment.   
 
 
Twenty patients enrolled on study.   Eighteen patients are off study and 
two remain on study, on treatment.  Ongoing treatment is proceeding 
according to the schedule of evaluations (Section 9.0) for both 
patients.  Pre-study and pre-transplant evaluations are completed for 
both patients.  The remaining schedule of evaluations include post- 
transplant weekly follow-up to Day 100 and again at 6, 9 and 12 
months.  Follow up procedures include physical exam, bone marrow 
aspirate and biopsy, medical history, blood sample collection for 
routine panel and toxicity assessment.   
 
 
There is no new information at this time that would impact study 
rationale and all subject data collected under protocol 2012-0217, 
including any on-going follow-up or previously enrolled patients will be 
maintained and analyzed under the auspices of protocol application 
2017-0116. 
 
 
AML remains a rare disease with limited treatment options.  Treatment 
options include: 
 
 - Induction therapy with chemotherapy drug with the goal of achieving 
remission 
 
 - Stem cell transplantation (hematopoietic cell transplant (HCT) or 
bone marrow transplant (BMT))   
 
- Participation in clinical trials.  Clinicaltrials.gov lists 144 clinical trials 
for patients with AML, including those listed below.   Trials are listed as 
completed, active, recruiting, results pending, etc.  Four trial titles are 
listed below. 
 
 
• 10-day Decitabine, Fludarabine and 2 Gray TBI as Conditioning Strategy 
for Poor and Very Poor Risk AML in CR1(NCT02252107) 
 


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• Decitabine, Donor Natural Killer Cells, and Aldesleukin in Treating 
Patients With Relapsed or Refractory Acute Myeloid Leukemia 
(NCT02316964) 
 
• Leukemia SPORE Phase II Randomized Study of Decitabine Versus 
Decitabine and Carboplatin Versus Decitabine and Arsenic in Relapsed, 
Refractory, and Elderly AML and MDS(NCT02190695) 
 
• Decitabine, Filgrastim, Cladribine, Cytarabine, and Mitoxantrone 
Hydrochloride in Treating Patients With Newly Diagnosed, Relapsed, or 
Refractory Acute Myeloid Leukemia or High-Risk Myelodysplastic 
Syndrome(NCT02921061)