Conditions: Hematopoietic/Lymphoid Cancer
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 41
Healthy volunteers: no

Brief summary:
This phase II trial studies how well total-body irradiation, donor lymphocyte infusion, and cyclophosphamide before donor stem cell transplant works in treating patients with high-risk hematologic malignancies. Giving total-body irradiation, donor lymphocyte infusion, and chemotherapy before a donor stem cell transplant helps stop the growth of cancer and abnormal cells and helps stop the patient's immune system from rejecting the donor's stem cells. When certain 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. Removing the T cells from the donor cells before transplant and giving tacrolimus and mycophenolate mofetil may stop this from happening.

Detailed description:
PRIMARY OBJECTIVES:

1\) To assess 1 year relapse free survival in high risk patients undergoing hematopoietic stem cell transplant (HSCT) using the Thomas Jefferson University (TJU) 2 step approach with 2 days inserted between the last fraction of total-body irradiation (TBI) and the infusion of donor T cells (donor lymphocyte infusion \[DLI\]).

SECONDARY OBJECTIVES:

1. To assess regimen related toxicity in this updated conditioning regimen, graft-versus-host disease (GVHD) incidence and severity, and overall survival in patients undergoing treatment on this protocol.
2. To assess the consistency and pace of engraftment.
3. To assess the pace of T cell and B cell immune recovery.

OUTLINE:

CONDITIONING REGIMEN: Patients undergo TBI twice daily (BID) on days -10 to -8, undergo DLI on day -6, and receive cyclophosphamide intravenously (IV) over 2 hours on days -3 and -2.

TRANSPLANT: Patients undergo cluster of differentiation (CD) 34+ selected allogeneic HSCT on day 0.

GVHD PROPHYLAXIS: Patients receive tacrolimus IV or orally (PO) beginning on day -1 with taper beginning by day 42, and mycophenolate mofetil IV BID on days -1 to 28.

After completion of study treatment, patients are followed up for 1 year.

Arms:
arm 1: CONDITIONING REGIMEN: Patients undergo TBI BID on days -10 to -8, undergo DLI on day -6, and receive cyclophosphamide IV over 2 hours on days -3 and -2.

TRANSPLANT: Patients undergo CD34+ (cluster of differentiation 34+) selected allogeneic HSCT on day 0.

GVHD PROPHYLAXIS: Patients receive tacrolimus IV or PO beginning on day -1 with taper beginning by day 42, and mycophenolate mofetil IV BID on days -1 to 28.

Interventions: intervention 1: Total-Body Irradiation (TBI) intervention 2: Donor Lymphocyte Infusion (DLI) intervention 3: Cyclophosphamide intervention 4: Allogeneic hematopoietic stem cell transplantation (HSCT) intervention 5: Mycophenolate mofetil
Intervention descriptions: intervention 1: Undergo TBI intervention 2: Undergo DLI intervention 3: Given IV intervention 4: Undergo CD34+ selected allogeneic HSCT intervention 5: Given IV

Protocol document:
Prot_SAP_000.pdf: 
Thomas Jefferson University 
 Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
1 
December 22, 2015 
Version 2.3 
A Two Step Approach to Allogeneic Hematopoietic Stem Cell Transplantation for 
High-Risk Hematologic Malignancies Using One Haploidentical Donor 
IRB # 13D.352 
Principal Investigator: 
Dolores Grosso, DNP, CRNP 
Co-PI: 
Neal Flomenberg, MD 
Co-Investigators: 
Seyfettin Onder Alpdogan, MD 
Matthew Carabasi, MD 
Joanne Filicko-O’Hara, MD 
Margaret Kasner, MD 
Ubaldo Martinez, MD 
John L. Wagner, MD 
Sameh Gaballa, MD 
Neil Palmisiano, MD 
Radiation Oncologist: 
Wenyin Shi, MD, PhD 
Maria Werner-Wasik, MD 
Biostatistics: 
Inna Chernovena, PhD 
Protocol Written by: Dolores Grosso, DNP, CRNP 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
Version 2.3 
 
Table of Contents 
 
1.0 
Introduction ……………………………………………………………………………...3 
 
2.0 
Objectives ………………….…………………………………………………………..15 
 
3.0 
Patient and Donor Selection …………………………………………………………15 
 
4.0 
Informed Consent ……………………………………………………………………..17 
 
5.0 
Treatment Plan ………………………………………………………………………..18 
 
6.0 
Laboratory Studies/Outcome Assessments ………………………………………..24 
 
7.0 
Supportive Care ……………………………………………………………………….26 
 
8.0 
Drug Information and Administration ………………………………………………..27 
 
9.0 
Patient Safety ………………………………………………………………………….31 
 
10.0  Statistical Analysis …………………………………………………………………….33 
 
11.0 References …………………………………………………………………………….34 
 
12.0 Appendices …………………………………………………………………………….38 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Kimmel Cancer Center 
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December 22, 2015 
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1.0 
Introduction 
Allogeneic hematopoietic stem cell transplant (HSCT) is a life saving therapy for 
patients with hematopoietic malignancies. The ability of HSCT to control an underlying 
hematologic malignancy is based on three variables, the intrinsic sensitivity/resistance 
of the malignancy, treatment regimen intensity, and graft versus tumor effects.  
Transplantation was initially developed as a treatment in patients with resistant 
leukemia. While the approach achieved short term control in many patients, relapse 
remained a problem in this patient group such that only 10-20% of patients became long 
term disease free survivors using matched sibling donors. Even today, long term 
disease free survival in patients with active leukemia at the time of transplant as 
reported by the CIBMTR is less than 20%. In contrast, patients transplanted in 
remission for similar diseases with identical conditioning regimens may achieve long 
term survivals of greater than 60%. Treatment intensity is near maximal in most 
transplant regimens. Higher doses of TBI or chemotherapy are associated with lower 
incidences of relapse, but usually at the price of more regimen related toxicity which 
limits overall gains in outcome. Disease sensitivity/resistance is not something that can 
be changed when patients present for treatment, and transplant regimen intensity can 
be further increased only over a narrow additional range. Consequently, it is difficult to 
manipulate these variables to effect substantial improvements in this group of high risk 
HSCT candidates. Graft versus tumor (GVT) effects may thus be the only variable 
which can be manipulated to address this problem.   
 
It is now understood that, in some diseases, a GVT effect, not regimen intensity, is the 
primary mechanism for long-term disease control after allogeneic transplantation. In 
other diseases, both treatment intensity and GVT effects contribute to disease 
eradication. This principle has been firmly established by analysis of transplant 
outcomes from identical twins, the success of reduced intensity HSCT1 and disease 
eradication after donor lymphocyte infusions.2 Unfortunately, despite the potent GVT 
effects associated with HSCT, death due to relapsed disease remains the greatest 
barrier to long-term survival for patients with resistant disease undergoing matched 
donor HSCT. As demonstrated in Table 1, the outcomes reported in several trials for 
patients in this category are dismal with overall survival (OS) rates consistently less 
than 30% for all the trials, and below 25% in many.   
 
 
 
 
 
 
 
 
 
 
 
 
 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
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Table 1    Outcome in Patients with Refractory Disease at the Time of Allo HSCT 
 
One strategy to increase GVT effects for patients with resistant disease is with the use 
of a mismatched donor. Graft versus tumor effects in man have been elegantly 
Disease 
Trial 
Overall Survival 
AML 
Kim et al., 2013, n=478, median age 38.5, primarily 
myeloablative, matched related and URD, minority mismatched 
URD3 
28% at 5 years for 
patients not in CR 
at HSCT. ↑relapse 
cause of death 
 
Oyekunle et al., 2006, n= 25, median age 28, myeloablative, 
related & URD4 
28% @ 5 years 
Relapse primary 
cause of death 
 
Kebriaei et al., 2005, n=68, median age 42, primarily 
myeloablative & matched sib donors5 
28% @ 10 years 
Relapse most 
frequent  cause of 
death 
 
Wong et al., 2005, n= 93, median age 49.5, myeloablative (41%) 
and non-myeloablative (59%) related & URD6 
28% @ ½ year 
Relapse primary 
cause of death 
 
Michallet et al., 2000, n=379, majority adult patients, 
myeloablative, majority matched related donors7 
22% @ 5 years 
AML arising 
from MDS 
Alessandrino et al., 2008, n=127, median age 48,  myeloablative 
(67%) and non-myeloablative (33%) matched sib & URD8 
25% @ 5 years 
MDS 
Lim et al., 2010, n=1,333, median age 56, 62% RIC, 38% 
myeloablative, matched URD 39%, matched sib 61%9 
At 4 years: 
Age >60 27% 
Age 50-60 34% 
Relapse main 
cause of death 
ALL 
Garderet et al., 2003, n=102, median age 17-18 years, 
myeloablative, all matched unrelated donors, 2 groups BM v 
PBSC10 
21-32% leukemia 
free survival  
 
Ringden et al. , 2009,  n=4099 (ALL, AML, CML) 324 with 
intermediate or advanced ALL, matched related and unrelated 
donors, median age of whole cohort 37-38 years11 
5-27% @ 5 years 
 
Terwey et al., 2008, n=60, median age 29.1 years, primarily 
myeloablative, matched sib or unrelated donor12 
28% @ 5 years 
Lymphoma 
Bertz et al., 2002, n=25, mostly aggressive NHL & Hodgkin, 
median age 37, myeloablative and non-myeloablative, majority 
matched related & MUD 13 
23% in patient with 
chemo resistant 
disease 
 
Hamadani et al., 2009, n=46, aggressive NHL, median age 46, 
myeloablative, majority matched related 14 
38% @ 5 years 
 
Rigacci et al., 2012, n=165 patients relapsed after auto BMT for 
DLCL. Median age 43, 50% chemorefractory. 65% matched sib, 
35% MUD15 
Progression-free 
survival (PFS) at 
median 21 months 
was 32% 
CLL 
Dreger et al., 2008, n=90, age <65. 47% Fludarabine refractory. 
39% matched related, 61% matched URD, NM HSCT.16 
3 year OS 42% 
whole cohort, 
chemorefractory 
lower 
 
Khouri et al., 2002, N=28, myeloablative, majority matched 
related donors17 
PFS 26% for those 
with refractory CLL 
@ 5 years 
Myeloma 
Kröger et al., 2009, N=32, multiple myeloma achieving partial 
remission after HSCT given DLI, median age 50, majority non-
myeloablative, related donor and URD 18 
Progression-free 
survival 35% in 
those not achieving 
CR @ 56 months 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
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demonstrated in studies of transplants from identical twins which have shown much 
higher relapse rates than transplants from HLA identical siblings. The twin is 
presumably unable to mount a stronger GVT response than the patient him/herself. 
Conversely, unrelated donor (URD) transplants tend to have lower relapse rates than 
transplants from matched sibling donors because of the greater mismatching of non-
inherited antigens. While HLA antigens and alleles can be matched for in URD HSCT, 
there is a much greater probability of minor histocompatibility (mHAg) and killer 
inhibitory receptor (KIR) mismatching resulting in greater recognition of non-self19 by the 
donor cells. Unfortunately, only about one in three patients will have an available well-
matched unrelated donor and for many non Caucasians, the odds of finding a well-
matched unrelated donor are considerably worse.   
 
HLA mismatching associated with haploidentical HSCT has been shown to potentiate 
graft versus tumor (GVT) effects because of the high degree of mismatch involved in 
this type of transplant. It has been demonstrated that the graft versus tumor effects 
associated with haploidentical HSCT are more potent than those from matched sibling 
HSCT.20-22 The use of haploidentical donors also broadens the application of HSCT 
because it is not limited by racial/ethnic HLA diversity. Thus haploidentical HSCT 
enfranchises segments of the population such as individuals of mixed racial ancestry as 
well as African Americans who, because of a higher degree of HLA diversity, are often 
without a well matched donor. Unfortunately, haploidentical HSCT has traditionally been 
associated with higher mortality rates as compared to transplants from well matched 
donors, limiting its application. The primary approach to haploidentical BMT has been to 
rigorously T cell deplete the graft to avoid severe GVHD. T-cell depletion techniques 
have been successful in decreasing GVHD, but higher rates of relapse, graft rejection 
and opportunistic infection (OI) due to the lack of T cells in the donor inoculum have 
resulted in increased mortality.23,24 Outstanding clinical results have been achieved with 
large doses of rigorously CD34 selected HSC by Ruggeri and associates,25 but their 
approach has not lent itself to widespread adoption at other centers. Additionally, 
relapse rates and treatment related mortality in patients entering transplant with active 
malignancy remain high using this approach.   
 
In recent years, administration of cyclophosphamide (CY) after a T replete (ie non T cell 
depleted) marrow graft in order to preferentially eliminate proliferating alloreactive T 
cells has been successfully utilized in non-myeloablative haploidentical HSCT.26, 27 With 
this approach, patients avoid profound immunoincompetence due to the remaining 
donor T cells which, because they are not alloreactive and proliferating early after 
transplant, are less affected by CY. While promising, this approach does not allow one 
to separately control the T cell and stem cell content of the transplant, as the T cells 
represent a varying number of passenger cells in the graft. In addition, depending on 
the patient’s age or disease at the time of transplant, a reduced intensity regimen is not 
always an optimal treatment strategy. An approach to myeloablative haploidentical BMT 
with low non relapse mortality serves as an ideal platform to explore the GVT effects 
associated with haploidentical HSCT.  
 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
Version 2.3 
1.1 
2-Step Myeloablative Haploidentical Transplantation  
To address this issue, we developed a 2-step myeloablative approach to HSCT from 
haploidentical donors which we have successfully applied to patients with hematologic 
malignancies.  We refer to this as a 2-step approach because the lymphoid and stem 
cell portions of the graft are collected and administered at different time points during 
the conditioning regimen. Our approach does not involve ex vivo T cell depletion, but 
uses CY to tolerize donor lymphocytes. The separation of the myeloid and lymphoid 
portions of the graft allows us to use a fixed dose of donor T cells creating a consistent 
platform from which to compare outcomes. We believe this approach fulfills the need for 
an approach to explore GVT effects in a setting where regimen-related mortality is 
acceptable. 
 
In the initial 2 step trial (IRB #06U.20, 2006-2009), we used TBI (1.5 Gray x 8) and CY 
(60 mg/kg x 2) for conditioning. Tacrolimus and Mycophenolate Mofetil (MMF) were 
used as post transplant immunosuppression in a relatively standard fashion. The 
treatment schema is below.   
 
Patient Treatment Schema for Myeloablative Haploidentical BMT 
Day 
-9 
Tues 
-8 
Wed 
-7 
Thu 
-6 
Fri 
-5 
Sat 
-4 
Sun 
-3 
Mon 
-2 
Tues 
-1 
Wed 
0 
Thu 
AM 
TBI 
TBI 
TBI 
TBI 
Rest Rest 
CY 
CY 
Tacrolimus 
 & MMF** 
 
CD 34+ 
selected 
HSCT 
 
 
HSCT 
Step 2 
PM 
TBI 
TBI 
TBI 
TBI 
Donor T 
cell 
Infusion 
HSCT 
Step 1 
 
 
 
 
 
TBI=Total 
Body 
Irradiation, 
DLI=Donor 
Lymphocyte 
Infusion, 
MMF=Mycophenolate 
Mofetil, 
HSCT=Hematopoietic Stem Cell Transplant 
 
As illustrated in the treatment schema above, donor lymphocytes infusions (DLI) 
containing a fixed dose of donor T cells, were given after the final fraction of TBI on day 
-6. In the phase I portion of the trial, the dose of T cells which resulted in consistent 
engraftment and the avoidance of severe GVHD was 2 x 108/kg. This dose given to all 
patients in the trial as well as all of the subsequent patients treated on 2 step trials. CY 
was infused on days -3 and -2 with the intention of leaving at least 60 hours between 
administration of the DLI and the first dose of CY. This was to allow the alloreactive 
lymphocytes to become activated and thus more susceptible to elimination by CY but 
also to enable them to eliminate the remaining vestiges of host immunity and further 
debulk the malignancy. The HSC portion of the graft was administered 48 hours after 
the second dose of CY. In total, the regimen was two days longer than it would be if we 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
7 
December 22, 2015 
Version 2.3 
were administering a conventional, one step transplant. For this trial, donors underwent 
2 leukophereses for the DLI and then two additional leukophereses the following week 
for HSC collection. G-CSF was initiated the day after DLI collections were completed to 
avoid polarization of the T-cells in the DLI product to a TH2 phenotype. We found that 
donors tolerated the aphereses without appreciable toxicity.   
 
In this approach, T cells in the HSC portion of the graft are not exposed to CY and thus 
are potentially alloreactive.  Our goal was to administer a CD34+ cell dose of  2-
10x10e6/kg and a CD3+ cell dose of <5x10e4/kg. To minimize T cell content, the HSC 
portion of the graft was CD34 selected, using the Isolex device (Baxter). After CD34 
selection, we incubated the CD34 cells in OKT3 and then washed out any unbound 
antibody. The goal was to coat any residual T cells with OKT3 which would lead to their 
lysis in vivo after infusion, but to avoid infusing free OKT3 which would compromise the 
T cells which had been rendered tolerant by CY.   
 
1.1.1  Results of Our Initial Trial 
Patient Population: Between 2006 and 2009 twenty-seven patients, median age of 52 
years (range 19-67), with high risk hematological malignancies were transplanted from 
haploidentical donors that were mismatched for HLA-A, B, C, and DR in the GVHD 
direction at 4 antigens (13), 3 antigens (11), and 2 antigens (2). One patient had no 
mismatches in the GVHD direction but was a 3 antigen mismatch in the rejection 
direction due to HLA homozygocity. It was subsequently decided that patients with 
mismatches only in the HVG direction should be treated on our matched related rather 
than haploidentical trial (ie that we would consider matching status from the GVH, not 
HVG perspective). Consequently, the study was amended to add one additional patient 
to the study group such that 27 patients were treated, rather than the initially planned 
26. Diagnoses included MDS (n=2), AML (n=16), ALL (n=4), Biphenotypic Leukemia 
(n=1), CLL/Richter’s (n=1), NHL (n=2), and Aplastic Anemia (n=1). Fifteen of 27 patients 
(56%) had evidence of persistent disease at the time of transplant. All 27 had some high 
risk feature including high risk cytogenetics, secondary leukemia, progressive disease, 
or second or greater remission.   
 
Results: All patients are currently at least 4 years post HSCT and there have been no 
changes in DFS or OS since 2009. In this group, there were no deaths from GVHD and 
the cumulative incidence of grade III-IV GVHD was only 7.4%. Only 16% of patients 
developed chronic GVHD, and in all cases it was mild (NIH consensus criteria score of 
1).   
 
Cumulative incidence of non-relapse mortality (NRM) was 22.6% with 3 deaths from 
infection and 3 deaths from regimen-related toxicity. Engraftment was consistent with 
this approach. Two patients experienced graft failure and died from complications of 
undergoing two condition regimens in close succession in a second engraftment 
attempt. These patients account for 2 of the 3 patients that died of regimen-related 
toxicity. The graft failures occurred in maternal recipients with HLA antibodies to their 
children/donors’ HLA antigens. The risk of rejection based on HLA antibodies in the 
myeloablative setting was not widely recognized at the time of this trial. In patients 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
8 
December 22, 2015 
Version 2.3 
CD4 Recovery
(Patients with 6 Months Follow Up)
0
50
100
150
200
250
300
350
400
450
1
3
6
9
12
15
Months After Transplant
CD4 Count (cells/ul)
treated after this study closed, there have been no graft rejections using the 2 step 
approach.  
 
The use of CY to tolerize T cells as opposed to depleting T cells from the graft resulted 
in robust immune reconstitution. The median CD3/CD4 counts of 16 patients treated on 
this trial were 33.6 cells/µl at 28 days and 104.6 cells/µl at 90 days post HSCT. These 
values are far greater than those observed post T cell depleted HSCT at our institution 
and others, and we believe account for the low rate of infectious mortality. Figure 1 
represents the CD 4 recovery of patients who lived at least 6 months after HSCT.  
 
The primary cause of 
treatment failure was 
recurrent disease. 
Cumulative incidence of 
relapse related mortality 
was 29.6%. Eight of 25 
evaluable patients 
experienced a relapse of 
their malignancy 49-327 
days after HSCT. Six of 
the 8 relapses occurred 
in patients who had 
active AML or MDS at 
the time of HSCT.  
 
Overall survival (as shown in Figure 2) was 48% at 3 years post-transplant, which is 
impressive in high risk patients receiving haploidentical grafts. Twenty one of 27 
patients treated on the protocol survived through discharge and only 6 of 27 patients 
died of infection or regimen related toxicities. Relapse free survival (RFS) was 27% for 
patients not in CR at the time of transplant and 75% for patients without disease at 
HSCT. The results of this initial trial 
were published in 2011.28 
 
Summary 
Based on the above summary of the 
trial, we concluded that the 2 step 
approach was a well-tolerated 
therapy with similar incidences of 
GVHD, toxicity, and infection when 
compared to matched sibling 
regimens. This approach met the 
criteria for being a safe platform for 
which to exploit the GVT effects of 
haploidentical transplant.  We 
considered all of the patients on this 
trial to be high risk based on disease 
Figure 1 
0.0 
10.0 
20.0 
30.0 
40.0 
50.0 
60.0 
0.0 
0.2 
0.4 
0.6 
0.8 
1.0 
Cum
Disease at  
HSCT 
No 
Yes 
 Overall Survival 
27% 
75% 
48% 
Whole 
Group 
 Figure 2 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
Version 2.3 
at HSCT, chromosomal abnormalities, the presence of secondary disease or chemo-
resistance. The patients without disease at the time of HSCT, despite being high risk in 
other respects, have done very well in terms of relapse free survival which may relate to 
the degree of mismatch between donor and recipient. A second generation 2 step trial 
for patients without disease at the time of HSCT (IRB #10D.219) is currently completing 
accrual. With 26 of 28 patients accrued, the probability of OS is 80% with a median 
follow-up of 12.5 months (range 1-28 months). This second generation trial confirms the 
findings of the initial trial. Patients with controlled disease at HSCT have high OS rates 
after haploidentical HSCT using the 2 Step approach due to the low incidence of NRM. 
Figure 3 displays the current probability of OS for this second generation trial. 
 
1.2 
Relapse in Patients with Disease at the Time of HSCT  
 
Relapse is the primary cause of treatment 
failure in patients with disease at the time 
of HSCT. This is a consistent finding in 
matched related and unrelated HSCT (as 
reviewed 
in 
Table 
1) 
as 
well 
as 
haploidentical HSCT,29-31 including the 
initial 2 Step trial. In developing strategies 
to 
better 
treat 
this 
population 
we 
recognized that the ability to intensify the 
conditioning regimen further is very limited, 
and for patients presenting with resistant 
disease, there are little to no options to 
achieve remission prior to transplant.  
Therefore, new paradigms in treatment 
which further exploit an immunological 
basis for treatment, the only variable which 
can be further manipulated, were clearly 
needed.  
 
1.2.1 2nd Generation 2-Step Approach for Patients with Active Disease at HSCT 
(IRB# 10D.06) 
 
To address this issue, we developed a 2nd generation 2 Step approach for patients with 
resistant disease at HSCT in which the timing of the T cell infusion within the context of 
the 2 Step platform was modified with the goal of immunologically increasing anti-tumor 
effects. 
 
 
 
 
 
 
 
5.0 
10.0 
15.0 
20.0 
25.0 
Months after HSCT 
0.0
0.2
0.4
0.6
0.8
1.0 
 
Figure 3- 2nd Generation 2 Step 
Patients in Remission at HSCT 
      Probability of Survival-#10D.219 
 
80% 
% Surviving  


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
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December 22, 2015 
Version 2.3 
Fever Post DLI
96
97
98
99
100
101
102
103
104
105
106
0
24
48
72
96
120
144
Hours Post DLI
Temperature (F)
CY 
#1
CY 
#2
The infusion of 2 x 108/kg haploidentical donor T cells in the 2 Step approach results in 
their rapid alloactivation demonstrated by the relatively consistent emergence of high 
fever, diarrhea, and to a lesser extent skin rash within 24 hours of administration of the 
DLI. For all intents 
and purposes, this 
appears to be a 
hyperacute GVHD 
which disappears 
after CY 
administration as 
the alloactivated 
haploidentical 
lymphocytes die 
off. A graph of the 
fever response in 
25 patients is 
shown in Figure 4.  
This has not been 
observed in studies 
using post-transplant CY where smaller doses of T cells were administered.26, 27 
However, a similar phenomenon was observed in studies by Colvin and associates 
where similar doses of haploidentical DLI were administered.32 It is important to note 
that in the Colvin study, clinical remissions were seen despite the fact that all grafts 
were ultimately rejected which illustrates the potential of large doses of haploidentical 
DLI to target normal and malignant lympho-hematopoiesis. As cytotoxic lymphocytes 
can kill a target cell every 20 minutes, the ability to extend the period of time prior to CY 
administration by even another 24 hours has the potential to allow for tremendous 
additional immunologic cytoreduction. This extension may be the most beneficial to 
patients who because of their lower precursor frequency, experience peak donor T cell 
effector functions later than others. Therefore, extension of the allogeneic reaction has 
the potential to regularize and increase the immunological GVT effects of this regimen 
and provide a second mechanism of enhancing immunological treatment for resistant 
malignancy.    
 
In 2010, the 2nd generation 2 Step trial (IRB #10D.06) for patients with resistant disease 
at the time of HSCT was opened in which the interval between DLI and CY was 
increased by 24 hours from the initial Step trial. In previous work with CY tolerization in 
murine33 and human studies,27 CY was given 72 hours after transplant. Three days 
appears to be the optimal timeframe for CY administration in mice. In the 2nd generation 
trial, CY was given approximately 84 hours after HSCT with the rationale that there is a 
longer time required for cycling of human versus murine lymphocytes. The hypothesis of 
this trial is that the extra time of alloreactivity would result in greater tumor kill resulting 
in improved disease-free survival rates in patients with resistant disease. The 2nd 
generation 2 Step treatment schema for patients with resistant disease at the time of 
HSCT is shown below: 
 
Figure 4 


Thomas Jefferson University                           Haploidentical HSCT for Patients with High Risk Disease 
Kimmel Cancer Center 
11 
December 22, 2015 
Version 2.3 
TBI=Total Body Irradiation, CY-Cyclophosphamide, MMF=Mycophenolate Mofetil, HSCT=Hematopoietic 
Stem cell Transplant 
 
To date, 19 of 25 planned patients have been treated on this clinical trial. We have 
observed a 37% NRM rate (7/19) consisting of 4 deaths from infection, 1 death from 
GVHD, 1 death from veno-occlusive disease, and 1 death from cardiotoxicity related to 
heavy pretreatment and CY. Death from relapsed disease (RRM) occurred in 5/19 
patients (26%), leaving 7/19 patients (37%) alive. All of the patients who are alive are 
disease free, 4-29 months after HSCT. In addition to the one death from GVHD, there 
have been two incidences of grade III GVHD (both hepatic), although a large 
percentage of patients have developed no acute GVHD at all. 
 
1.2.2 Comparison of Outcomes of Patients with Disease at HSCT Initial versus 
2nd Generation 2-Step Trial 
Fifteen patients on the initial trial had evidence of their disease at the time of HSCT. The 
NRM rate in this group was 33% (5/15), the RRM was 40% (6/15), with 27% (4/15 
patients, 2 with lymphoma 2 with AML, alive and well all at least 4 years post HSCT. 
See below for a tabular comparison of the outcomes of these 2 trials (Table 2).  
 
Because 6 more patients are needed to accrue to the current 2nd generation trial, and 
because the data from this trial is not mature, comparison to the outcomes from the 
initial trial are somewhat premature. However, because our investigator group is 
committed to the performance of HSCT on clinical trials, new clinical trials must be 
written prior to the existing ones closing. With this philosophy, no patient is treated off 
study and patient outcomes are universally reported.  
 
Therefore, based on the time constraints required for the writing and approval of a new 
trial, we have performed this interim analysis to guide us in the development of future 
therapy for this high-risk patient group. While RRM is mildly lower with the new trial, 
there is not a major difference in overall survival between the two trials. Our conclusion 
therefore is that a graft versus tumor (GVT) benefit may have been derived from adding 
 
-10 
 
-9 
 
-8 
 
-7 
 
-6 
 
-5 
 
-4 
-3 
 
-2 
 
-1 
 
0 
 
AM 
TBI 
TBI 
TBI 
TBI 
Rest 
Rest 
Rest 
CY 60 
mg/kg 
CY 60 
mg/kg 
Tacrolimus 
&MMF 
 
 
CD 34+ 
selecte
d HSCT 
PM 
TBI 
TBI 
TBI 
TBI 
DLI 
 
 
 
 
 
 
Table 2 
Initial 2 Step Trial  
(TJU IRB #06U.20) 
(Patients with Disease at 
HSCT only n=15) 
F/U 4-6.5 Years 
2nd Generation 2 Step 
Trial 
(TJU IRB # 10D.06) 
All Patients with Disease at 
HSCT, n=19 Accrued to Date 
F/U 4-29 Months 
Non-relapse Mortality 
33% 
37% 
Relapse-Related Mortality 
40% 
26% 
Disease Free Survival 
27% 
37% 


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the extra day of alloreactivity between the DLI and the CY in the 2 step platform, but 
there is not sufficient evidence that the 2nd generation trial for patients with disease at 
HSCT has resulted in significant progress in terms of increasing OS rates for this 
population. Therefore, alternate strategies are required to increase OS in patients with 
resistant disease at HSCT.  
 
1.3 
Rationale and Hypothesis for the Current Trial 
A potentially important difference between remission and relapsed patients undergoing 
transplant is the percentage of GVT versus GVH reactive T cells that are likely to be 
rapidly activated in vivo and, as a result of this activation, subsequently eliminated by 
CY. In both remission and relapsed patients, the majority of GVH reactive T cells are 
likely to encounter an antigen presenting cell capable of activating them, thus rendering 
them more susceptible to CY.  In the remission patient, with a small tumor burden, many 
GVT reactive T cells may not encounter a tumor cell or an antigen presenting cell 
capable of presenting tumor antigens during the first few days after infusion. As a result, 
a smaller percentage of GVT T cells will be activated early on, and, consequently, fewer 
GVT T cells are likely to be eliminated by CY than their more consistently activated 
GVH counterparts (Figure 5). As the tumor burden progressively increases, more and 
more GVT reactive T cells will encounter tumor cells during the first few days after 
infusion, thus becoming activated and subsequently eliminated by CY as well. The 
larger the tumor burden at the time of lymphocyte administration, the more the potential 
of CY to blunt the 
GVT 
effect, 
ultimately 
eliminating 
any 
differential 
impact 
compared to GVHD 
which may occur in 
remission 
patients. 
One 
simple solution to this 
problem would be to 
administer 
the 
T 
Cells closer to the 
true 
tumor nadir following 
the 
conditioning 
chemoradiotherapy.  
 
Currently, the DLI, 
containing 2 x 108/kg 
T 
cells, is administered immediately after the last fraction of radiation. In this proposed 
trial, we will administer the T cells two days after radiation ends. This will allow a longer 
time period for tumor cells and antigen presenting cells capable of presenting tumor 
antigens to die off prior to the infusion of the DLI. Our hypothesis is that after the 
infusion, less donor GVT reactive T cells will become activated due to the reduction of 
these recipient stimulator tumor and antigen presenting cells, and by extension, less 
GVT reactive donor T cells will be vulnerable to subsequent eradication by CY. 
According to the original work done by Matsuzaki et al.,34 the induction of peripheral 
Figure 5 


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tolerance by CY of activated donor T cells results in intrathymic clonal deletion of the 
activated donor T cell population. While this deletion is favorable in the case of 
eradication of GVH reactive T cells,33 we wish to avoid the deletion of GVT reactive 
donor T cells in this trial.  
 
In order to estimate when tumor cells were likely to be at nadir, we determined when the 
maximal effects of TBI could be expected in the 2 Step regimen. Using white blood cell 
counts as surrogate markers for post HSCT nadir of hematopoietic cells, we examined 
the historical CBCs of patients with active AML at HSCT undergoing a 2 step HSCT on 
the current approach. See Table 3.  
 
Table 3-Historical WBCs During Conditioning in the Current 2 Step Approach 
AM 
TBI 
1.5 Gy  
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy  
Rest 
Rest 
Rest 
CY 1 
PM 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy 
TBI 
1.5 Gy  
 
DLI 
 
 
 
 
Median WBC 
 (x 103)  
Early AM 
COUNTS 
Patients 
Treated on 
10D.06 
n=15 
2.2 
 
(Range 
0.6-
10.3) 
1.15 
 
(Range 
0.2-
10.7) 
1.0 
 
(Range 
0.1-
8.1) 
0.7 
 
(Range 
0.1-
4.2) 
0.6 
 
(Range 
0.1-
3.4) 
0.6 
 
(Range 
0.0-2.8) 
0.2 
 
(Range 
0.0-0.8) 
0.1 
 
(Range 
0.0-
0.9) 
Median WBC 
(x 103) 
Early AM 
COUNTS 
Patients 
Treated on 
06U.20 
n=8 
0.95 
 
(Range 
0.3-
1.7) 
0.75 
 
(Range 
0.1-
2.9) 
0.35 
 
(Range 
0.1-
1.2) 
0.25 
 
(Range 
0.1-
1.8) 
0.15 
 
(Range  
0.1-
2.3) 
0.05 
 
(Range 
0.0-4.2) 
X 
0.1 
 
(Range 
0.0-
0.5) 
 
We found that patients treated on both trials had measurable hematopoiesis at the time 
of DLI infusion, with some patients having normal white counts at the time of the DLI, 
and all patients with evidence of normal hematopoiesis 2-3 days after DLI. This 
indicates that the DLI was infused well ahead of the post-TBI immune system nadir and 
by extension; the T cells were exposed to a potentially significant disease burden.  
 
Furthermore, ten of the 23 patients had peripheral blood AML blasts detectable after 
two days of radiation (6 Gy), and in many cases, the blasts persisted to the day of the 
DLI or after. All 10 of these patients died of relapsed disease. Conversely, of the 
remaining 13 patients who had no peripheral blood blasts or who had blasts that 
disappeared after 2 days of radiation, only 1 patient died of relapsed disease. The 
decreased relapse rates occurred despite the fact that this latter group had 


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demonstrable AML in the marrow just prior to HSCT and all of these patients were at 
high risk for relapse. As peripheral blood blasts are a reflection of marrow 
hematopoiesis, the absence of or lack of detectable blasts early in the conditioning 
regimen for the patients who achieved sustained remission is a reflection of a lower 
disease burden in these patients. Therefore, the data suggests that even a small 
decrease in tumor burden at the time of the DLI can improve DFS, possibly due to a 
parallel decrease in the amount of GVT T cells that become activated by tumor and then 
later eliminated by CY.  
 
1.4 
Summary 
The goal of this clinical trial is to increase DFS rates in patients with resistant disease at 
the time of HSCT. In order to do so, a delay period will be inserted into the 2 step 
platform between the last dose of TBI and the infusion of donor T cells, to allow more of 
the tumor cells and antigen presenting cells capable of presenting tumor antigens to 
undergo TBI mediated elimination prior the infusion of donor T cells. This will 
hypothetically result in less activation of donor GVT reactive T cells and by extension, 
less vulnerability of these cells to elimination by CY. In the previous 2 Step platforms, 12 
Gy of radiation was delivered in 1.5 Gy fractions twice daily over 4 days. In this new 
protocol, 12 Gy of TBI will be given in 2.0 Gy fractions twice daily over 3 days. This 
shorter TBI schedule is an alternate, standard TBI regimen for HSCT patients.35-38 The 
shorter radiation schedule will allow the radiation therapy to be completed in 3 days 
(Monday-Wednesday). Instead of administering the DLI immediately after the last 
fraction of radiation as is currently done, the DLI will be administered on Friday 
afternoon, approximately 48 hours after the last fraction of TBI. Comparison of historical 
white cell counts of patients treated on the standard 2 step approach (Table 3) to the 
historical white counts inserted into the proposed 2 step approach (Table 4) shows that 
the median immune system nadir will occur approximately 12 hours after the DLI in this 
proposed trial as compared to 60 hours in the historical 2 step approach. 
 
Table 4- Historical WBCs During Conditioning as Applied to the Proposed 2 Step 
Approach 
AM 
TBI 
2 Gy  
TBI 
2 Gy 
TBI 
2 Gy 
Rest 
Rest 
 
 
 
PM 
TBI 
2 Gy 
TBI 
2 Gy 
TBI 
2 Gy 
 
DLI 
 
 
 
Median WBC 
 (x 103)  
Early AM 
COUNTS 
Patients 
Treated on 
10D.06 
n=15 
2.2 
 
(Range 
0.6-
10.3) 
1.15 
 
(Range 
0.2-
10.7) 
1.0 
 
(Range 
0.1-
8.1) 
0.7 
 
(Range 
0.1-
4.2) 
0.6 
 
(Range 
0.1-
3.4) 
0.6 
 
(Range 
0.0-2.8) 
0.2 
 
(Range 
0.0-0.8) 
0.1 
 
(Range 
0.0-
0.9) 


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Median WBC 
(x 103) 
Early AM 
COUNTS 
Patients 
Treated on 
06U.20 
n=8 
0.95 
 
(Range 
0.3-
1.7) 
0.75 
 
(Range 
0.1-
2.9) 
0.35 
 
(Range 
0.1-
1.2) 
0.25 
 
(Range 
0.1-
1.8) 
0.15 
 
(Range  
0.1-
2.3) 
0.05 
 
(Range 
0.0-4.2) 
X 
0.1 
 
(Range 
0.0-
0.5) 
 
We also note that patients with lymphoma will be treated on this protocol. While most of 
these patients do not have marrow based involvement of their malignancy, the 
additional time between the radiation and the donor GVT reactive T cell infusion will 
allow tumor cells in the lymph nodes as well as antigen presenting cells capable of 
presenting tumor antigens, to die off. As with marrow based disease scenarios, the 
activation and subsequent elimination by CY of donor GVT reactive T cells will also be 
avoided. The only difference is that the primary location of the malignant disease is 
different.  
 
2.0 
Objectives 
The objective of this phase II study is to decrease post HSCT relapse rates in patients 
with high risk hematological malignancies. 
 
Primary Objective: 
1. To assess 1 year relapse free survival in high risk patients undergoing HSCT 
using the TJU 2-step approach with 2 days inserted between the last fraction of 
TBI and the infusion of donor T cells (DLI) 
 
Secondary Objectives: 
1. To assess regimen related toxicity in this updated conditioning regimen, GVHD 
incidence and severity, and overall survival in patients undergoing treatment on 
this protocol. 
2. To assess the consistency and pace of engraftment 
3. To assess the pace of T cell and B cell immune recovery 
  
3.0 
Patient and Donor Selection 
3.1 
Patient Selection 
Patient Inclusion Criteria: 
1. This treatment is for patients with high risk hematologic malignancies, High risk is 
defined as: 
 Any patient with a hematologic malignancy with residual disease after 
treatment with 1 or more chemotherapy regimens in whom achievement of 
remission with additional chemotherapy is felt to be unlikely. 
 Patient without morphologic evidence of disease but when high risk 
features which would predict for relapse despite remission at HCST such 
as adverse cytogenetics, 3rd or greater CR, or failure to recover peripheral 
blood counts  to normal ranges. While these patients do not have 


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detectable disease by current methods, like all patients they have non-
detectable disease which in their case is highly aggressive. 
2. Patients must have one related donor who is HLA mismatched in the GVHD 
direction at two or more HLA loci. 
3. Patient must have adequate organ function: 
 LVEF of ≥ 50% 
 DLCO (adjusted for hemoglobin) ≥ 50% of predicted and FEV-1 ≥ 50% 
 Adequate liver function as defined by a serum bilirubin ≤ 1.8, AST or ALT 
≤ 2.5 x upper limit of normal 
 Creatinine clearance of ≥60 ml/min 
4. Karnofsky Performance status of ≥ 80% on the modified KPS tool (see Appendix 
A) 
5. Patients must be willing to use contraception if they have childbearing potential 
6. Able to give informed consent 
 
Patient Exclusion Criteria: 
1. Modified KPA of < 80% 
2. > 5 Comorbidity Points on the HCT-CI Index (See Appendix B) 
3. Class I or II antibodies against donor HLA antigens 
4. HIV positive 
5. Active involvement of the central nervous system with malignancy 
6. Psychiatric disorder that would preclude patients from signing an informed 
consent 
7. Pregnancy, or unwillingness to use contraception if they have childbearing 
potential 
8. Patients with life expectancy of ≤ 6 months for reasons other than their 
underlying hematologic/oncologic disorder 
9. Alemtuzumab treatment within 8 weeks of HSCT admission 
10. ATG level of ≥ 2 ugm/ml 
11. Patients with active inflammatory processes including T max > 101 or active 
tissue inflammation are excluded 
12. Inability to tolerate cyclophosphamide or undergo total body irradiation at the 
doses specified in the treatment plan. 
 
The time of the required evaluations for transplant is reviewed in the Jefferson Blood 
and Marrow Transplant SOP CP:P043. 
 
3.2 
Donors 
Donors will be selected based on which donor in the donor pool is expected to be the 
most alloreactive. The current version of the donor selection tool will be utilized for the 
selection. The study binder for each patient will contain the alloreactivity point 
worksheets for each donor or donor pool, as well as documentation of haplotype 
analysis. 
 
All donors are selected and screened for their ability to provide adequate infection-free 
apheresis products for the patient in a manner that does not put the donor at risk for 


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negative consequences. Donor selection will be in compliance with 21 CFR 1271 and 
TJU BMT Program SOP CP: P009.03. 
 
Specifically, donors will be tested, using the appropriate FDA-licensed and designated 
screening tests, for: 
1. HIV, type 1 
2. HIV, type 2 
3. HBV (HBsAg, anti-HBc IgC and IgM) 
4. HCV 
5. Treponema pallidum 
6. Human T-lymphotropic virus, types I and II 
7. Cytomegalovirus 
8. West Nile Virus 
9. Trypanosoma cruzi 
 
As per the Jefferson Blood Donor Center Quality Plan, all allogeneic donor testing 
samples (including HPC donors) will be sent to a laboratory that is FDA and CLIA 
licensed. Agreements/contracts for these services will be developed according to TJUH 
policies and all pertinent regulatory requirements will be retained by the Blood Bank. 
 
Additional donor testing may be performed as required to assess the possibility of 
transmission of other infectious and non-infectious diseases. 
 
TJUH HPC transplant personnel will discuss the potential for disease transmission from 
donor to recipient (i.e. the purpose of infectious disease testing) during the donor 
evaluation. 
 
Infectious disease testing must be completed by the time of the recipient’s transplant 
admission date. 
 
As per FACT guidelines, pregnancy will be assessed during the initial donor evaluation 
and just prior to the initiation of the recipient’s conditioning regiment in female donors of 
childbearing age. 
 
4.0 
Informed Consent 
Patients referred for the trial will have their eligibility criteria verified. On meeting the 
eligibility for the trial as outlined, informed consent will be obtained using forms 
approved by the Thomas Jefferson University Hospital Institutional Review Board and 
following guidelines related to the use of human subjects in research. The risks and 
hazards of the procedure, as well as alternative forms of therapy will be presented to 
the patient in detail. Patients will receive a signed copy of the consent form after the 
consent interview.   
 
 
 


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December 22, 2015 
Version 2.3 
5.0 
Treatment Plan 
Proposed Schema for Partially-Matched Related HSCT - Patient 
 
-10 
-9 
-8 
-7 
-6 
-5 
 
-4 
 
-3 
 
-2 
 
-1 
 
0 
 
AM 
2 Gy 
TBI 
2 Gy 
TBI 
2 Gy 
TBI 
Rest 
Rest 
Rest 
Rest 
CY 60 
mg/kg 
CY 60 
mg/kg 
Tacrolimus 
&MMF 
 
 
CD 34+ 
selected 
HSCT 
PM 
2 Gy 
TBI 
2 Gy 
TBI 
2 Gy 
TBI 
 
DLI 
 
 
 
 
 
TBI=Total Body Irradiation, CY-Cyclophosphamide, MMF=Mycophenolate Mofetil, HSCT=Hematopoietic 
Stem Cell Transplant 
 
Proposed Schema for Partially-Matched Related HSCT - Donor  
 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
AM 
Lymphocyte 
Collection 
Lymphocyte 
Collection 
 
G-CSF 
G-CSF 
G-CSF 
G-CSF 
 
PBSC 
Collection 
G-CSF 
 
PBSC 
Collection 
PM 
 
 
G-CSF 
 
G-CSF 
G-CSF 
G-CSF 
 
G-CSF=Granulocyte Colony Stimulating Factor, PBSC=Peripheral Blood Stem Cell Collection 
 
5.1 
Administration of Immunosuppressive Agents during Conditioning 
There should be no administration of agents that suppress lymphocyte reactivity 
from admission until day -1 in this protocol. This includes steroids, calcineurin 
inhibitors, MMF, or monoclonal antibodies that affect lymphocyte number or function. 
Patients must be off steroids (aside from premedication for transfusion) for at least 7 
days prior to admission. If patients have previously required steroids as a premedication 
for transfusion, they may receive a dose of steroid equivalent to 5 mg of prednisone on 
the first day of TBI. After this, no steroids at all should be given through day -1 of the 
transplant regimen. Diphenhydramine and meperidine may be used if necessary. Any 
use of steroids after the first day of TBI through day -1 should not be administered 
without approval from the PI. 
 
5.2 
TBI 
2 Gy TBI will be administered twice daily for 3 days (6 fractions) on days -10 through -8. 
The daily fractions of TBI will be minimally separated by 7 hours, but ideally by 8 hours 
to reduce toxicity.  
 
TBI will be utilized for all patients eligible for this protocol. Prior irradiation will be 
evaluated by the radiation oncologist to define eligibility for this TBI schedule. In 
additional there may be technical or patient related factors which will require some 
minor modification in the TBI technique utitlized. Selected patient may require local 
boosting of certain organ sites prior to conditioning therapy. Deviations from the 
guidelines described here may only be performed with the approval of the radiation 
oncologists and the PI. See Appendix C for radiation guidelines. 
 


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December 22, 2015 
Version 2.3 
5.3 
Donor Lymphocyte Infusions 
The dose of the donor lymphocyte infusion (DLI) will be based on CD3+ T cells per 
kilogram 
of 
recipient 
body 
weight. 
T-cell 
and 
progenitor 
cell 
doses 
and 
cyclophosphamide dosing will be based on adjusted dosing weight (40% the difference 
between actual and ideal body weight + the actual body weight). The donor T-cells will 
be collected prior to the use of G-CSF for progenitor cell collection.   
 
DLI specimen handling and labeling conventions will be performed in accord with the 
relevant AABB (American Association of Blood Banks) and/or FACT (Foundation for 
Accreditation for Cell Therapy) regulations and guidelines. All DLI specimens must be 
appropriately labeled in accord with these standards to be accepted by the Processing 
Laboratory. A valid prescription and request form must be submitted by the requesting 
physician.  
 
The following guidelines should be used to calculate the correct volume of blood to be 
obtained from the donor to achieve the target T-cell dose.  
 
An aliquot of the apheresis product will be assessed for CD3 content by flow cytometry. 
The following cell panel will be used:  
FITC  
PE  
IgG1  
IgG1  
IgG1  
IgG2a  
CD45  
CD14 + CD13  
CD3  
CD4  
CD3  
CD8  
CD3  
CD16 + CD56  
CD3  
CD19  
CD4  
CD8  
CD4 
CD25+ FoxP3+ 
 
A gate is drawn around the entire CD45+ population. %WBC/total events = the 
percentage of CD45+ cells within this gate corrected for the isotype control. CD3 
percentages are calculated, corrected for the isotype control, based on the total white 
cell (CD45+) gate, not based on a “lymphocyte gate”. There are 4 CD3 counts 
performed in the panel. The two median values are averaged to determine the final raw 
CD3 count. The raw CD3 count is then corrected for any counted events which are not 
WBC (i.e. CD45-), as follows:  
 
Corrected %CD3 = (raw CD3 count)/(%WBC/total events). 
Total T-cells required for the initial infusion = (2x108 T-cells/kg) * (Weight in kg) 
T-cells/ml of product 


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T-cells/ml of product = (WBC) * (Corrected %CD3) 
Volume to be infused = (Total T-cells required for the initial infusion)/(T-cells/ml of 
product) 
 
All donors will report for apheresis of lymphocytes the day before the planned DLI. If the 
targeted amount of lymphocytes is not collected on the first day, the donor will return for 
a second day of lymphocyte collection on the day of the DLI. 
 
Lymphocyte apheresis will be performed at Thomas Jefferson University Hospital or the 
American Red Cross, by trained apheresis personnel using standard techniques. No 
hematopoietic growth factors will be administered to apheresis donors prior to 
lymphocyte collection. The donor will have venous catheters placed in each arm for the 
purposes of undergoing leukopheresis. Leukocyte collections will be performed using a 
standard apheresis machine such as the Cobe Spectra apheresis instrument (Cobe 
Laboratories Inc., Lakewood, CO).  
 
For the donor lymphocyte apheresis, total blood volumes to be processed will be 
determined using the following calculation: 
 
Recipient weight in kg:                    __________kg 
Multiply by desired CD3+ cells/kg:  x __________x10(7)/kg 
Total CD3+ cells requested:          = __________x10(7) 
Multiply by 2                              x 2 
TOTAL mononuclear cells (TMC)     = __________x10(7) 
Divided by 100 x 10(&) TMC/L        = _____ Liters processed 
 
During the infusion of the DLI, the patient will be monitored for any untoward reactions. 
Each infusion will take place in the Bone Marrow Transplant Unit. Donor lymphocyte 
infusions will be administered by nursing staff experienced in the administration of blood 
products.  
 
5.3.1 DLI Dosing 
2 x 10e8/kg donor T cells will be collected from a single donor and infused 
approximately 48 hours after the last TBI fraction. Based on minor variations in donor 
collection and laboratory processing times, an exact time for the DLI infusion will not be 
prescribed by this protocol. The DLI will be infused in the afternoon on day -6. Because 
it is anticipated that the last fraction of TBI will be delivered 48 hours before the day of 
the DLI at approximately 4 PM, the optimal time for DLI infusion on day -6 is 4 PM. 
Infusion of the DLI prior to 3 PM on day -6, is prohibited. The DLI must be infused 
before day -5.  
 
DLI must NOT be irradiated. DLI should NEVER be administered through a leukocyte 
depletion filter. If blood filtration is necessary, the filter should be a standard blood 
product filter with pore size of at least 170 microns.  
 


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December 22, 2015 
Version 2.3 
5.4 
Cyclophosphamide 
CY 60 mg/kg IV over 2 hours will be administered on days –3 and –2 of the conditioning 
regimen. Mesna 60 mg/kg continuous IV infusion over 24 hours X 2 doses will be 
administered on days –3 and -2. Day –1 is a day of rest. 
 
Voriconazole can block the conversion of CY to its active metabolite, 4-
hydroxycyclophosphamide. For this reason, no voriconazole will be administered 
to any patient from admission (or the beginning of conditioning) until day -1.  
Voriconazole may be started on day -1.  
 
The data39 regarding Posaconazole, a newer drug is unclear in this regard. 
Therefore, like voriconazole, no posaconazole will be administered to any patient 
from admission (or the beginning of conditioning) until day -1.  Posaconazole 
may be started on day -1. 
 
There are no restrictions on the use of liposomal amphotericin.  
 
5.5 
Collection and Infusion of Progenitor Cells 
Donors will begin G-CSF, 5µg/kg bid, on day -5, and will return for neupogen-primed 
progenitor cell collection on days -2 and -1. Each day, 18-27 liters will be processed. 
 
5.5.1 CD 34+ Cell Doses 
The target dose of donor PBSCs to be infused into the recipient is between 3 –5 x 106 
CD34 cells/kg of recipient dosing body weight. The acceptable minimum infusion target 
of PBSCs will be 1 x 106 CD34 cells/kg. Recipients will receive no more than 10 x 106 
CD34 cells/kg, the maximum dose. If less than 50% of the minimum acceptable CD34 
cells/kg target dose is obtained after the first collection, one dose of Plerixafor, 0.24 
mg/kg (donor actual body weight), may be administered subcutaneously the evening 
prior to the second collection. Because the meaningful dose of T cells has already been 
collected and infused by this time, Plerixafor would not have polarization effects on T 
helper cells. A third day of collection may be performed to meet the minimum cell 
requirements.  
 
Progenitor cell apheresis will be performed at Thomas Jefferson University Hospital or 
the American Red Cross, by trained apheresis personnel using standard techniques. 
The donor will have venous catheters placed in each arm or an apheresis catheter for 
the purposes of undergoing leukopheresis. Leukocyte collections will be performed 
using a standard apheresis machine such as the Cobe Spectra apheresis instrument 
(Cobe Laboratories Inc., Lakewood, CO).  
 
Handling and labeling of the progenitor cell product will be performed in accord with the 
relevant AABB (American Association of Blood Banks) and/or FACT (Foundation for 
Accreditation for Cell Therapy) regulations and guidelines. All donor specimens must be 
appropriately labeled in accord with these standards to be accepted by the Processing 
Laboratory. A valid prescription and request form must be submitted by the requesting 
physician.  


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December 22, 2015 
Version 2.3 
 
CD34+ cell enrichment will be performed via the closed system method using the 
CliniMACS® CD34 Reagent System (Miltenyi Biotec Inc., Auburn, CA). The CliniMACS 
system utilizes super-paramagnetic particles composed of iron oxide and dextran 
conjugated to monoclonal antibodies. These antibodies bind to target cells with the 
corresponding cell surface antigen (in this case, CD34). After magnetic labeling, the 
cells are separated using a high-gradient magnetic separation column. The magnetically 
labeled cells are retained in the column and separated from the unlabeled cells. 
Removing the magnetic field from the separation column elutes the retained cells. 
Eluted cells will be characterized using fluorescent-activated cell sorting (FACS) 
analysis. All procedures will be performed in a sterile environment with strict adherence 
to all applicable regulations regarding the processing and use of human stem cells. The 
use of this device will conform to TJU BMT Laboratory standard operating procedures. 
 
In our experience, the ideal amount of T-cells left in the PBSC product is no greater 
than 5x104/kg, so that every effort will be made to keep T-cell amounts to below this 
threshold. It is recognized that because of donor heterogeneity, every product will have 
varying percentages of cells. Thus, patients will be advised during the informed consent 
process that an excess amount of residual T-lymphocytes in the PBSC product may 
increase the risk of GVHD.  
 
The donor product is infused UNFILTERED or through a filter of at least 170 micron size 
intravenously through a central catheter. Marrow should only be piggybacked through 
normal saline and not other intravenous solutions.  
 
During the infusion, the patient will be monitored for any untoward reactions. Each 
infusion will take place in the Bone Marrow Transplant Unit. PBSC infusions will be 
administered by nursing staff experienced in the administration of blood products.  
Progenitor cell products must NOT be irradiated.  Progenitor cell products should 
NEVER be administered through a leukocyte depletion filter. If blood filtration is 
necessary, the filter should be a standard blood product filter with pore size of at least 
170 microns.  
 
Significant red cell incompatibility between donor and recipient will be managed 
according to standard operating procedure, CL: Ppp040.05, of the Thomas Jefferson 
University Hospital Blood and Marrow Transplant Processing Lab.  Pre-medications (if 
any) prior to marrow infusion will be at the discretion of the physician.  
 
5.6 
GVHD Prophylaxis 
Tacrolimus and MMF will be started on day -1. The day -1 tacrolimus dose is a loading 
dose and will be 0.03 mg/kg IV in a divided dose whether the patient is on voriconazole 
or posaconazole. Starting on day 0, tacrolimus will be maintained at a dose of 0.015 
mg/kg in divided doses IV if given simultaneously with voriconazole or posaconazole.  If 
the patient is not receiving voriconazole or posaconazole, the dose of tacrolimus will 
remain at 0.03 mg/kg in divided doses IV. Tacrolimus levels will be checked daily 


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starting on day 0. Tacrolimus dosing should be titrated to maintain a target level of 
8ng/ml +/- 2.  
 
MMF will be dosed at 1 gram IV BID beginning on day -1. 
 
Tacrolimus oral dosing will be initiated at least 2 to 3 days prior to discharge. This is to 
assure that stable, therapeutic levels are reached on oral drug prior to discharge.   
 
MMF will be discontinued beginning at day +28 +/- 3 days in the absence of GVHD.  
MMF may be discontinued earlier if there is count suppression thought to be due to the 
drug. Do not wean MMF. MMF is not tapered. 
 
The tacrolimus taper should be initiated by day + 42 in the absence of GVHD. The taper 
will take place at roughly 15% per week (range 10 to 20% per week). Once tacrolimus 
levels are less that 5 ng/ml levels, they no longer have to be checked unless there is a 
clinical concern to do so. Because of the variability in patient outpatient office visit times 
and the need for GVHD assessment, it is not mandatory that the taper begins exactly 
day +42, but should begin within 2 weeks of day 42. 
 
5.6.1 Treatment of Patients with Acute GVHD 
The following steps will be taken if GVHD is suspected: 
 Begin prednisone at a dose of 2 mg/kg/day (1mg/kg q12h).  As soon as 
manifestations show clear cut evidence of improvement usually 2-3 days after 
initiation of therapy (and not to be interpreted as complete resolution of all 
manifestations) reduce the prednisone dose to 1 mg/kg/day (0.5 mg/kg q12h).  
Thereafter, taper by 20 mg/dose every 2 to 3 days if an inpatient or at least 
weekly as an outpatient until a 20 mg daily dose is reached. 
 If patients were on Tacrolimus and/or MMF, they may remain on these 
mediations to facilitate weaning the steroids. If these medications had been 
discontinued, they should be restarted only if the patient fails to respond to 
steroids.   
 Once prednisone is at 20 mg per day or lower, it may be preferable to taper 
tacrolimus or discontinue MMF while holding prednisone at the current dose as 
these other medications may represent a more substantial burden of 
immunosuppression for the patient at these low prednisone doses. Alternatively, 
one can complete the steroid wean over another 2-4 weeks. 
 In the absence of GVHD flare, begin weaning Tacrolimus or discontinue MMF 
two weeks after the prior medication has been stopped (or immediately after the 
steroid taper has been paused at a dose of 20 mg/day of prednisone or less.   
 If patients flare on this sort of taper, medications should be increased to at least 
the prior dose which achieved control and photopheresis should be initiated 2-3 
times per week for patients with skin disease. Efforts should be made to begin a 
taper again after 2 weeks of photopheresis.   
 This taper reflects a guide as to the slowest, not the fastest, that immune 
suppression should be tapered.  The pace should be accelerated in patients with 
significant bacterial, viral, fungal, or other infections. The goal is to find which 


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patients will not tolerate a prompt taper of immune suppression and move them 
to photopheresis rapidly so as to facilitate tapering systemic immunosuppressive 
medications.   
 For situations that are not covered by these criteria, discuss the case with the PI. 
 
6.0 
Laboratory Studies/Outcome Assessment 
6.1 
Analyses of Leukemia MHC Gene Content and Expression 
Since the majority of these patients will be transplanted in relapse, it is permissible, but 
not mandatory, to obtain and cryopreserve buccal swabs, blood and/or marrow 
specimens prior to transplant and at the time of relapse if relapse occurs. Specimens 
will be analyzed using pan-HLA class I and pan-HLA class II antibodies to assess 
whether overall levels of MHC molecules have declined on the cells surface. Genetic 
analysis including sequencing of these paired specimens will allow us to assess 
whether asymmetric loss of one haplotype, such as from uniparental disomy, occurs 
after transplant on this regimen.  
 
In addition to the above studies, SNP or other genetic analyses can be performed in the 
matched pair samples as hypotheses are generated to test for other mechanisms 
through which leukemia cells escape GVT.   
 
6.2 
Study Measurements 
All post-allogeneic transplant patients have physical assessments, laboratory studies 
and pathology studies performed as per the TJUH BMT Guidelines for Post-Transplant 
Allogeneic Assessments (CP: P035.02) found on the TJUH BMT intranet. 
 
Table 5 outlines the mandatory measurements and time points specific to this study. 
Table 5 
 
 
Day + 28 
 
 
Days 28-90 
 
 
Days 91 -180 
 
 
Days 180- 270 
 
 
1 Year 
GVHD Assessment 
Presence and degree 
of skin rash, presence 
and amount of 
diarrhea, LFT’s 
 
 
 
 
On day 
+28 
 
 
 
 
Twice 
Monthly 
 
 
 
 
Monthly 
 
 
 
 
Every 3 Months 
 
 
 
 
At 1 year 
Chimerism/ 
Disease Assessment 
 
 
 
 
 
 
Peripheral blood for 
Total, MNC & CD3+ 
chimerism   
 
On day 
+28 
 
Monthly 
 
Monthly 
 
Every 3 Months 
 
At 1 year 
Bone marrow exam 
(morphology, flow 
cytometry, 
cytogenetics, 
chimerism) 
 
 
 
On day 
+28 
 
 
 
At day +90 
 
 
 
At day +180 
 
 
 
At day  +270 
 
 
 
At 1 Year 
Flow cytometry for 
lymphocyte subsets 
(IRP) 
 
On day 
+28 
 
Monthly  
 
Monthly 
 
Every 2 Months 
 
At 1 year 


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The day +28 peripheral blood, marrow studies and the day 28 assessment can be 
obtained within 1 week of day 28 (i.e. +/- 7 days) to account for scheduling factors. 
Patient assessments, peripheral blood chimerism and IRP studies, as well as the day 
+90, +180, +270, and 1 year marrows can be obtained within the time period of 1 month 
before or 1 month after the targeted time to account for patient scheduling factors. This 
table represents a minimum recommended sampling and visit strategy.  
 
6.3 
Hematopoietic Engraftment 
Will be defined as: 
 ANC ≥ 0.5x109/L for at least 30 days 
 Platelet engraftment > 20,000 with no transfusion x 7 days 
 
6.4 
Toxicity Criteria 
Regimen-related toxicity will be graded according to the NCI Common Toxicity Criteria, 
version 3.0.   
 
The NCI Common Toxicity Criteria can also be found at the following WEB address:     
http://ctep.cancer.gov/reporting/ctc.html 
 
6.5 
Disease Response 
Disease response will be measured according to the National Comprehensive Cancer 
Network Guidelines (NCCN).  The guidelines are disease specific and the guidelines for 
each disease can be found at: 
 
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site  
 
6.6 
GVHD Scoring 
GVHD will be graded according to the standard criteria contained in Appendix B. 
 
6.7 
Adverse Event Reporting 
All patients will be followed for adverse experiences (AEs) (serious and non-serious), 
regardless of relationships to study treatment, from the time of enrollment until day +100 
post-transplant. The following events are expected side effects of high-dose 
chemotherapy and transplant and will not be reported except as noted:  
 Alopecia, dry skin 
 Emesis from chemotherapy or other agents unless refractory to standard 
supportive care, nausea, and anorexia 
 Weight loss, cough, dry mouth, headache 
 Neutropenia/uncomplicated neutropenic fever, grades 1-3 infectious sequellae 
 Thrombocytopenia, petechiae, ecchymoses, minor vaginal bleeding, epistaxis, 
hemorrhoidal bleeding, or other similar bleeding events will not be reported.  
(Bleeding events requiring transfusion and/or intervention such as endoscopy or 
radiologic evaluation will be reported.) 
 Anemia 
 Grade I - III Mucositis  


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 Grade I - III Diarrhea  
 Grades 1-3 allergic or other common reactions to drugs used for supportive care 
 Fluid and electrolyte disturbances not associated with instability 
 
After d + 100, only events that are considered by the investigator to be possibly or 
probably associated with the treatment regimen will be reported.   
 
6.8 
Reports to the Federal Drug Administration (FDA) 
All grade 3-5 infusion reactions and all unexpected SAEs as defined in 21 CFR 312.32 
will be reported to the FDA in an expedited fashion. 
 
An annual report will be sent to the FDA regarding the progress to date of patients on 
the trial. In the report, a separate listing of infusion toxicities and all biological product 
deviations will be included in addition to the other required elements. 
 
6.9 
Study Endpoint 
The formal endpoint of this study is 1 year post HSCT. Therefore patients will not be 
followed for the purposes of this clinical trial after this time. However, outcomes for 
patients undergoing HSCT at TJUH are followed programmatically beyond this study 
indefinitely. These outcomes include survival, relapse, and GVHD. The study will be 
eligible for closure when the last patient treated is 1 year post HSCT.  
 
7.0 
Supportive Care 
7.1 
Avoidance of Infection 
Patients who are post haploidentical transplantation will follow the same 
guidelines as patients who are neutropenic until advised differently by their 
attending physician.  Infectious prophylaxis and treatment of infection will be as per 
the “TJUH Guidelines for Infectious Prophylaxis and Management of Febrile 
Neutropenia”.  These guidelines can be found on the TJUH intranet. 
 
Central venous catheters will be removed as soon as clinical manageable.  
 
IVIG 0.5 g/kg IV will be administered every 4 weeks post transplant to support immune 
function, until the IgG level is > 500 mg/dL on 2 consecutive monthly measurements. 
Because there are qualitative defects in humoral immunity for years after HSCT, it is 
suggested, but not mandated, that IVIG be given monthly for at least 1 year after HSCT, 
even if there is evidence of quantitative recovery as described above. The first dose will 
be administered approximately on day +7. It may be given earlier or later if the patient 
cannot tolerate the large volume on day +7. 
 
7.2 
Infectious Prophylaxis-General Guidelines 
Patients post haploidentical transplantation will be maintained on antifungal (including 
mold coverage) prophylaxis, usually voriconazole 200 mg BID. It is at the discretion of 
the treating attending physician to change agents as clinically indicated.   
 


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Patients post haploidentical transplantation will be maintained on HSV prophylaxis, 
usually Acyclovir 400 mg BID or Valacyclovir 500 mg BID. It is at the discretion of the 
treating attending physician to change agents based on culture results and sensitivities.  
 
Patients post partially-matched related donor transplantation will be maintained on PCP 
prophylaxis, usually Bactrim DS 1 daily. It is at the discretion of the treating attending 
physician to change agents based on culture results, drug intolerance.   
 
Prophylactic medications may be discontinued when the patient is off 
immunosuppressive medications for at least 1 month, and/or the CD4 count is > 100/µl.  
 
7.3 
Growth Factor and Transfusion Support 
To prevent inadvertent lymphoid engraftment, all blood cell products must be irradiated 
to ≥2500cGy. 
 
All red cell and platelet products will be leukodepleted to prevent alloimmunization and 
decrease infectious sequela.   
 
Packed red blood cell transfusions will be given as necessary with a goal of keeping the 
hemoglobin ≥ 8 g/L. 
 
Platelet transfusions will be given as necessary with a goal of keeping the morning 
count ≥ 20x10e9/L, with 10x10e9/L used for situations without an excessive bleeding 
risk.  
 
GM-CSF 250µg/m2 will be administered daily beginning on day +1. GM-CSF will be 
weaned/discontinued at the discretion of the attending physician. Every effort should be 
made to keep the ANC > 1000 for all patients post haploidentical transplantation.  
G-CSF 5µg/m2 can be substituted for GM-CSF in the event of a GM-CSF shortage or 
withdrawal from market. 
 
Red cell growth factors are permissible after transplantation. 
 
8.0 
Drug Information and Administration 
8.1 
Cyclophosphamide 
Mechanism: A multistep process activates it by conversion to 4-
hydroxycyclophosphamide by the liver microsomal oxidase system and to 
aldophosohamide by tautomerization in the peripheral tissues.  Aldophosphamide 
spontaneously degrades into acrolein and phosporamide mustard, which cause cellular 
glutathione depletion and DNA alkylation. This results in inhibition of DNA replication 
and transcription. Cells expressing high levels of aldehyde dehydrogenase (e.g. stem 
cells, L1210 leukemia cells) resist cyclophosphamide-mediated cytotoxicity as 
aldophosphamide is inactivated by this enzyme. The drug also does not affect quiescent 
cells and therefore stem cells are generally protected, an important factor if autologous 
hematopoietic recovery is relied on in the event of graft failure.  
 


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Metabolism: Cyclophosphamide is broken down as described above and the break 
down products are excreted by the kidneys. It is a substrate of CYP2A6 (minor), 
CYP2B6 (major), CYP2C19 (minor), CYP2C9 (minor), CYP3A4 (minor); Note: 
Assignment of Major/Minor substrate status based on clinically relevant drug interaction 
potential; Inhibits CYP3A4 (weak); Induces CYP2B6 (weak/moderate), CYP2C9 
(weak/moderate). 
 
Incompatibilities: Phenobarbital or rifampin may increase the toxicity of 
cyclophosphamide. Concurrent allopurinol or thiazide diuretics may exaggerate bone 
marrow depression may prolong neuromuscular blockade from succinylcholine 
Cardiotoxicity may be additive with other cardiotoxic agents (cytarabine, daunorubicin, 
doxorubicin). May decrease serum digoxin levels. Additive bone marrow depression 
with other antineoplastics or radiation therapy. May potentiate the effects of warfarin. 
May decrease antibody response to live-virus vaccines and increase the risk of adverse 
reactions. Prolongs the effects of cocaine. 
 
Toxicity: Nausea, vomiting, water retention due to inappropriate secretion of anti-diuretic 
hormone (SIADH), cardiomyopathy with myocardial necrosis and congestive heart 
failure, hemorrhagic cystitis, alopecia, skin rash, pulmonary fibrosis, sterility and 
secondary malignancies. 
 
Administration: Patients will receive a dose of cyclophosphamide 60 mg/kg IV, on days 
–3 and -2. The dose of cyclophosphamide will be calculated according to the dosing 
body weight. The cyclophosphamide dose is dissolved in saline and administered as a 2 
hour IV infusion. Patients shall receive hydration consisting of normal saline solution at 
3 ml/kg/hour (actual weight) for 2 hours before and 8 hours after the cyclophosphamide 
infusion. MESNA (sodium-2-mercaptoethane sulfonate) will be administered as a 60 
mg/kg/continuous IV infusion over 24 hours starting 30 minutes prior to 
cyclophosphamide infusion and ending 24 hours after the last dose of 
cyclophosphamide. The dose of MESNA will also be calculated based on dosing body 
weight.  
 
References: Skeel R & Lachant N.  Handbook of Cancer Chemotherapy, 4th Ed. Little, 
Brown & Co.: Boston.  
 
Information from LexiComp on line reviewed on 7/4/12 at 
http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6674#f_inte
ractions 
 
8.2 
Donor Leukocyte Infusion (DLI) 
Administration: All patients will receive a dose of CD3+ T cells per kilogram of dosing 
body weight as outlined in the treatment design. Details of the apheresis procedure to 
obtain white blood cells, quantification of T cells by flow cytometry, and administration of 
the white cell product to the recipient are provided in the treatment section. All drugs 
that may cause lymphocyte suppression are held prior to lymphocyte infusion (day -6), 
through day 0 as detailed in the treatment section. Every effort will be made to 


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administer the donor lymphocytes 48 hours after the last fraction of TBI as described in 
section 5.0. Moreover the viability of the lymphocytes will be tested by flow cytometry 
and the number of viable CD3+ T cells will be used to dose the DLI.  
 
Toxicity: GVHD, delayed myelosuppression, infusion reactions. 
 
8.3 
G-CSF 
Mechanism: G-CSF is a human granulocyte colony-stimulating factor produced by 
recombinant DNA technology. It is a glycoprotein which acts on hematopoietic cells by 
binding to specific cell surface receptors and stimulating proliferation, differentiation, 
commitment, and some end-cell functions. Activates neutrophils to increase migration 
andtoxicity. 
 
Metabolism: Absorption and clearance of G-CSF follows first-order pharmacokinetic 
modeling without apparent concentration dependence. The elimination half-life in both 
normal and cancer patients is 3.5 hours.   
 
Incompatibilities: Safety and efficacy of G-CSF when used simultaneously with 
chemotherapy or radiotherapy has not been evaluated. Donors receiving either of these 
2 modalities will not be permitted on study. 
 
Toxicities: Allergic reactions consisting of rash, wheezing and tachycardia.  Splenic 
rupture, ARDS, and exacerbation of sickle cell disease have been reported rarely. 
 
Adminstration: In this protocol, G-CSF will be administered to healthy donors at a dose 
of 10 µg/kg (actual weight) subcutaneously on days -5 through day -1. 
 
References: Physician’s Desk Reference, Edition 58, 2004.  
 
In addition, information from LexiComp on line reviewed on 7/4/12 at 
http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6674#f_inte
ractions 
 
8.4 
GM-CSF (Sargramostim, Leukine) 
Mechanism: GM-CSF is a recombinant human granulocyte-colony stimulating factor 
produced by recombinant DNA technology in a yeast expression system. It supports 
survival, clonal expansion, and differentiation of hematopoietic cells. GM-CSF is also 
capable of activating mature granulocytes and macrophages, and is a multilineage 
factor with effects on the myelomonocytic, erythroid, and megarkaryocytic lines.  
 
Metabolism: GM-CSF is detected in the serum at 15 minutes after injection. Peak levels 
occur about 1 to 3 hours after injection, and it is detectable in the serum for up to 6 
hours after injection.  
 


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Incompatibilities: Interactions between GM-CSF and other drugs have not been fully 
evaluated. Drugs which may potentiate the myeloproliferative effects of GM-CSF, such 
as lithium and corticosteroids, should be used with caution.  
 
Toxicities: Allergic and anaphylactic reactions have been reported. A syndrome 
characterized by respiratory distress, hypoxia, flushing, hypotension, syncope and or 
tachycardia has been associated with the first administration of GM-CSF in a cycle.  
These signs have resolved with treatment.  
 
Administration: In this protocol, GM-CSF will be given to the patients beginning on Day 
+1. The drug should continue until the patient has a self-sustaining ANC of ≥ 1000. 
 
References: Physician’s Desk Reference, Edition 58, 2004.  
 
In addition, information from LexiComp on line reviewed on 7/4/12 at 
http://online.lexi.com.prox 
 
8.5 
Mycophenolate Mofetil (MMF) 
Mechanism: Inhibits the enzyme inosine monophosphate dehydrogenase, which is 
involved in purine synthesis. This inhibition results in suppression of T- and B-
lymphocyte proliferation.  
 
Metabolism: Following oral and IV administration, mycophenolate is rapidly hydrolyzed 
to mycophenolic acid (MPA), its active metabolite. Distribution is unknown. MPA is 
extensively metabolized; <1% excreted unchanged in urine. Some enterohepatic 
recirculation of MPA occurs. Half Life: MPA¾17.9 hr. 
 
Incompatibilities: Combined use with azathioprine is not recommended (effects 
unknown).  Acyclovir and ganciclovir compete with MPA for renal excretion and, in 
patients with renal failure, may increase each other's toxicity. Magnesium and aluminum 
hydroxide antacids decrease the absorption of MPA (avoid simultaneous 
administration). Cholestyramine and colestipol decrease the absorption of MPA (avoid 
concurrent use). Toxicity may be increased by salicylates. May interfere with the action 
of oral contraceptives (additional contraceptive method should be used). May decrease 
the antibody response to and increase risk of adverse reactions from live-virus 
vaccines, although influenza vaccine may be useful. When administered with food, peak 
blood levels of MPA are significantly decreased. 
 
Toxicities: GI: Bleeding, Diarrhea, Vomiting, Hematopoietic: Leukopenia Miscellaneous: 
Sepsis, Increased Risk of Malignancy  
 
Administration: In this protocol, MMF will be administered at a dose of 1 gram IV BID 
beginning on day -1. MMF will be discontinued on day +28 in the absence of GVHD. 
MMF may be stopped earlier if there is count suppression from the drug.  
 


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Reference: Information from LexiComp on line reviewed on 7/4/12 at 
http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6674#f_inte
ractions 
 
8.6 
Tacrolimus 
Mechanism: Tacrolimus, it is a macrolide immunosuppressant. It inhibits lymphocytes 
by forming a complex with FKBP-12, calcium, calmodulin leading to the decrease in the 
phosphatase activity of calcineurin. This in turn prevents generation of NF-AT, a nuclear 
factor for initiating gene transcription for lymphokines like interleukin-2 and interferon 
gamma. This drug is used with corticosteroids for prophylaxis of organ rejection in 
patients receiving allogeneic liver transplants. Its use is also currently being investigated 
in kidney, bone marrow, cardiac, pancreas, pancreatic island cell and small bowel 
transplantation.  
 
Metabolism: This drug is well absorbed orally. It is metabolized in the liver by unknown 
mechanisms and demethylation and hydroxylation has been proposed based on in vitro 
studies. The metabolized products are excreted in the urine. Tacrolimus is a substrate 
of CYP3A4 (major), P-glycoprotein; Note: Assignment of Major/Minor substrate status 
based on clinically relevant drug interaction potential; Inhibits CYP3A4 (weak), P-
glycoprotein.  
 
Imcopabilities: Nephrotoxic drugs, antifungals (azoles), calcium-channel blockers, 
cimetidine, danazol, erythromycin, methylprednisone and metoclopramide increase the 
bioavailabilty of tacrolimus. On the other hand phenobarbital, phenytoin, rifamycins and 
carbamazepine decrease tacrolimus levels.  
 
Toxicities: Adverse reactions include: tremor, headache, neurotoxicity; diarrhea, 
nausea; hypertension; TTP and renal dysfunction.     
 
Administration: Tacrolimus will be started on day -1. The day -1 tacrolimus dose is a 
loading dose and will be 0.03 mg/kg IV in a divided dose whether the patient is on 
voriconazole or posaconazole. Starting on day 0, tacrolimus will be maintained at a 
dose of 0.015 mg/kg in divided doses IV if given simultaneously with voriconazole or 
posaconazole. If the patient is not receiving voriconazole or posaconazole, the dose of 
tacrolimus will remain at 0.03 mg/kg in divided doses IV. Tacrolimus dosing should be 
based on levels due to numerous drug interactions such as with antidepressants 
(Serotonin Reuptake Inhibitor/Antagonist). Tacrolimus levels will be checked daily 
starting on day 0. Tacrolimus dosing should be titrated to maintain a target level of 
7ng/ml +/- 2. The tacrolimus wean will be initiated by day +42 in the absence of GVHD. 
 
Reference: Information from LexiComp on line reviewed on 7/4/12 at 
http://online.lexi.com.proxy1.lib.tju.edu/lco/action/doc/retrieve/docid/patch_f/6674#f_inte
ractions 
 
9.0 
Patient Safety 
To ensure patient safety, a number of steps will be taken. 


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The study will be monitored on an ongoing fashion by the Principal Investigator (PI) and 
the study medical monitor.  Monitoring reports will be submitted to the Clinical Research 
Management Office (CRMO) for review by the DSMC during their quarterly review.  
Adverse events and a report summarizing their impact on the conduct of the trial are 
submitted to the Data Monitoring and Safety Committee (DMSC) quarterly, and the 
DSMC reports are then submitted to the CCRRC and IRB annually. The PI will submit 
serious adverse events (SAE) to the TJU IRB utilizing the electronic Kimmel Cancer 
Center Clinical Trials Adverse Event Reporting system. Due to the nature of the study 
treatment as outlined in this protocol, expected grade 3 AE/SAEs that occur while 
receiving standard inpatient protocol treatment may be included on the patient’s AE log 
for quarterly review by the DSMC rather than be reported via the eSAEy System per the 
DSM Plan.  It is the responsibility of the study Principal Investigator (PI) to report any 
grade 3 AE/SAE to the DSMC per the DSM Plan should the length of standard protocol 
treatment hospitalization be extended and/or the grade 3 AE/SAE is more acute than 
expected as outlined in the informed consent form. Unexpected deaths related to this 
protocol will be reported within 24 hours. 
 
The medical monitor will be a TJU physician who is not a collaborator in this trial. The 
medical monitor will review all adverse events (in addition to unexpected adverse 
events), safety data and activity data observed when this trial is ongoing. The medical 
monitor may recommend reporting adverse events and relevant safety data not 
previously reported, and may recommend suspension or termination of the trial. The 
summary of all discussions of adverse events will be submitted to the DSMC after 
completion and included in the PI's reports to the CCRRC and the TJU IRB as part of 
the study progress report. The CCRRC, DMSC, and/or the TJU IRB may, based on the 
monitor's recommendation suspend or terminate of the trial. The quarterly safety and 
monitoring reports will include a statement as to whether this data has invoked any 
stopping criteria (dose-limiting toxicities) in the clinical protocol.  
 
In addition to the Cancer Center's DMSC, the TJU BMT program members meet weekly 
to discuss the status of patients on trial and generate discussion regarding the progress 
of the patients on the trial. 
 
Auditing and Inspecting: 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, 
the funding sponsor, government regulatory bodies, and University compliance and 
quality assurance groups of all study related documents (e.g. source documents, 
regulatory documents, data collection instruments, study data etc.). The investigator will 
ensure the capability for inspections of applicable study-related facilities. 
 
Participation as an investigator in this study implies acceptance of potential inspection 
by government regulatory authorities and applicable University compliance and quality 
assurance offices. 
 


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In addition to review by the DSMC, all studies initiated by KCC investigators are audited 
by an independent auditor once they have achieved 10% of target accrual. However, a 
study can be audited at any time based on recommendations by the IRB, DSMC, 
CCRRC and/or the Director of Clinical Investigations, KCC. Studies are re-audited once 
they have achieved 50% of target accrual. Special audits may be recommended by the 
IRB, DSMC or CCRRC based on prior findings, allegations of scientific misconduct and 
where significant irregularities are found through quality control procedures. Any 
irregularities identified as part of this process would result in a full audit of that study.  
 
In addition to the audits at 10 and 50%, the CRMO randomly audits at least 10 percent 
of all patients entered into therapeutic KCC trials and other trials as necessary, on at 
least a bi-annual basis, to verify that there is a signed and dated patient consent form, 
the patient has met the eligibility criteria, and that SAEs are documented and reported 
to the TJU IRB.  
 
All reports are submitted to the DSMC for review and action (when appropriate). A copy 
of this report and recommended DSMC action is sent to the CCRRC and TJU IRB. The 
committee regards the scientific review process as dynamic and constructive rather 
than punitive. The review process is designed to assist Principal Investigators in 
ensuring the safety of study subjects and the adequacy and accuracy of any data 
generated. The TJU IRB may, based on the DSMC and auditor’s recommendation, 
suspend or terminate the trial. 
 
10.0  Statistical Analysis 
Statistical Analysis Plan: 
The main objective of this trial is to demonstrate that the disease free survival (DFS) at 
one year for patients treated on this clinical trial is significantly higher than 25% (the 
average 1-year DFS in historic controls). The primary hypothesis will be tested using an 
exact one-sided binomial test with alpha 0.05. The trial will be considered successful if 
the null hypothesis of 25% 1-year disease free survival (DFS) is rejected. In addition, 
the exact binomial 95% confidence interval for 1-year DFS will be computed. 
 
Sample Size: 
Sample size computations are based on expectation of ~45% disease free survival 
(DFS) at one year for patients treated on this clinical trial. This figure is based on the 
historical literature reviewed in Section 1.0, as well as our current experience with the 
outcomes of patients with similar disease states treated on the 2 Step 
approach. Assuming that the true 1 year DFS rate is 45%, we need 36 evaluable 
patients for an 80% power using a one-sided binomial test with alpha 0.05. Assuming a 
10% dropout/incompletion rate, we will need to enroll up to 40 people in order to 
achieve 36 evaluable subjects. Subject are considered evaluable if…We estimate that it 
will take 7 years to complete this trial; 6 years to treat 36 patients plus 1 year follow-up. 
 
Assessment of Secondary Objectives 


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Assessments for the secondary objectives will be reported descriptively. Data pertaining 
to the secondary objectives will be collected and placed in each patient’s study binder 
for analysis.  
 
Analysis for Safety 
Patient outcomes are routinely monitored in an ongoing fashion for all patients on 
investigational trials, beyond their formal endpoints. Based on prior experience using a 
two step approach similar to that described in this trial, we anticipate that the incidence 
of graft failure should be less than 10%, the incidence of severe GVHD (grade 3 or 4) 
should be less than 20%, and the non-relapse mortality should be less than 20% at 100 
days. If at any point incidences higher than these thresholds are seen, that would trigger 
a protocol review to assess whether there are any obvious reasons for the inferior 
outcomes observed. Depending on the results of the review, enrollment may continue 
on a limited basis with careful further observation, the protocol may be revised, or the 
protocol may be terminated. Incidences will be calculated starting after 10 patients are 
treated on this trial in order to have a sufficient denominator in which to examine 
outcomes based on percentages. 
 
11.0 References 
1. Giralt S, Estey E, Albitar M, et al. Engraftment of allogeneic hematopoietic progenitor 
cells with purine analog-containing chemotherapy: harnessing graft-versus-leukemia 
without myeloablative therapy. Blood. 1997;89(12):4531-4536.  
 
2. Bacigalupo A, Soracco M, Vassallo F, et al. Donor lymphocyte infusions (DLI) in 
patients with chronic myeloid leukemia following allogeneic bone marrow 
transplantation. Bone Marrow Transplant. 1997;19(9):927-932.  
 
3. Lee S-, Yoon J-, Shin S-, et al. Impact of pre-transplant marrow blasts on survival of 
allogeneic stem cell transplantation in adult acute myeloid leukemia. Int J Hematol. 
2013:1-10.  
 
4. Oyekunle AA, Kroger N, Zabelina T, et al. Allogeneic stem-cell transplantation in 
patients with refractory acute leukemia: a long-term follow-up. Bone Marrow Transplant. 
2006;37(1):45-50.  
 
5. Kebriaei P, Kline J, Stock W, et al. Impact of disease burden at time of allogeneic 
stem cell transplantation in adults with acute myeloid leukemia and myelodysplastic 
syndromes. Bone Marrow Transplant. 2005;35(10):965-970.  
 
6. Wong R, Shahjahan M, Wang X, et al. Prognostic factors for outcomes of patients 
with refractory or relapsed acute myelogenous leukemia or myelodysplastic syndromes 
undergoing allogeneic progenitor cell transplantation. Biology of Blood & Marrow 
Transplantation. 2005;11(2):108-114.  
 
7. Michallet M, Thomas X, Vernant JP, et al. Long-term outcome after allogeneic 
hematopoietic stem cell transplantation for advanced stage acute myeloblastic 


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leukemia: a retrospective study of 379 patients reported to the Societe Francaise de 
Greffe de Moelle (SFGM). Bone Marrow Transplant. 2000;26(11):1157-1163.  
 
8. Alessandrino E, Della Porta M, Bacigalupo A, et al. WHO classification and WPSS 
predict posttransplantation outcome in patients with myelodysplastic syndrome: a study 
from the Gruppo Italiano Trapianto di Midollo Osseo (GITMO). Blood. 2008;112(3):895-
902.  
 
9. Lim Z, Brand R, Martino R, et al. Allogeneic hematopoietic stem-cell transplantation 
for patients 50 years or older with myelodysplastic syndromes or secondary acute 
myeloid leukemia. Journal of Clinical Oncology. 2010;28(3):405-411.  
 
10. Garderet L, Labopin M, Gorin NC, et al. Patients with acute lymphoblastic leukaemia 
allografted with a matched unrelated donor may have a lower survival with a peripheral 
blood stem cell graft compared to bone marrow. Bone Marrow Transplant. 
2003;31(1):23-29.  
 
11. Ringden O, Pavletic SZ, Anasetti C, et al. The graft-versus-leukemia effect using 
matched unrelated donors is not superior to HLA-identical siblings for hematopoietic 
stem cell transplantation. Blood. 2009;113(13):3110-3118.  
 
12. Terwey TH, Massenkeil G, Tamm I, et al. Allogeneic SCT in refractory or relapsed 
adult ALL is effective without prior reinduction chemotherapy. Bone Marrow Transplant. 
2008;42(12):791-798.  
 
13. Bertz H, Illerhaus G, Veelken H, Finke J. Allogeneic hematopoetic stem-cell 
transplantation for patients with relapsed or refractory lymphomas: comparison of high-
dose conventional conditioning versus fludarabine-based reduced-intensity regimens. 
Annals of Oncology. 2002;13(1):135-139.  
 
14. Hamadani M, Benson Jr. DM, Hofmeister CC, et al. Allogeneic Stem Cell 
Transplantation for Patients with Relapsed Chemorefractory Aggressive Non-Hodgkin 
Lymphomas. Biology of Blood and Marrow Transplantation. 2009;15(5):547-553.  
 
15. Rigacci L, Puccini B, Dodero A, et al. Allogeneic hematopoietic stem cell 
transplantation in patients with diffuse large B cell lymphoma relapsed after autologous 
stem cell transplantation: A GITMO study. Ann Hematol. 2012;91(6):931-939.  
 
16. Dreger P, Stilgenbauer S, Boettcher S, et al. Prognostic Factors for Outcome of 
Nonmyeloablative Allogeneic Stem Cell Transplantation (NST) in Poor-Risk Chronic 
Lymphocytic Leukemia (CLL): Final Results from a Prospective Multicenter Trial 
(GCLLSG CLL3X study). ASH Annual Meeting Abstracts. 2008;112(11):565.  
 
17. Khouri IF, Keating MJ, Saliba RM, Champlin RE. Long-term follow-up of patients 
with CLL treated with allogeneic hematopoietic transplantation. Cytotherapy. 
2002;4(3):217-221.  


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18. Kröger N, Badbaran A, Lioznov M, et al. Post-transplant immunotherapy with donor-
lymphocyte infusion and novel agents to upgrade partial into complete and molecular 
remission in allografted patients with multiple myeloma. Exp Hematol. 2009;37(7):791-
798.  
 
19. Farag SS, Bacigalupo A, Eapen M, et al. The Effect of KIR Ligand Incompatibility on 
the Outcome of Unrelated Donor Transplantation: A Report from the Center for 
International Blood and Marrow Transplant Research, the European Blood and Marrow 
Transplant Registry, and the Dutch Registry. Biology of Blood and Marrow 
Transplantation. 2006;12(8):876-884.  
 
20. Ogawa H, Ikegame K, Kawakami M, et al. Powerful graft-versus-leukemia effects 
exerted by HLA-haploidentical grafts engrafted with a reduced-intensity regimen for 
relapse following myeloablative HLA-matched transplantation. Transplantation. 
2004;78(3):488-489.  
 
21. Burroughs LM, O'Donnell PV, Sandmaier BM, et al. Comparison of outcomes of 
HLA-matched related, unrelated, or HLA-haploidentical related hematopoietic cell 
transplantation following nonmyeloablative conditioning for relapsed or refractory 
Hodgkin lymphoma. Biology of Blood & Marrow Transplantation. 2008;14(11):1279-
1287.  
 
22. Hauer J, Tosi S, Schuster FR, Harbott J, Kolb HJ, Borkhardt A. Graft versus 
leukemia effect after haploidentical HSCT in a MLL-negative infant AML with 
HLXB9/ETV6 rearrangement. Pediatric Blood & Cancer. 2008;50(4):921-923.  
 
23. Koh LP, Rizzieri DA, Chao NJ. Allogeneic hematopoietic stem cell transplant using 
mismatched/haploidentical donors. Biology of Blood & Marrow Transplantation. 
2007;13(11):1249-1267.  
 
24. Gill S, Olson JA, Negrin RS. Natural Killer Cells in Allogeneic Transplantation: Effect 
on Engraftment, Graft- versus-Tumor, and Graft-versus-Host Responses. Biology of 
Blood and Marrow Transplantation. ;In Press, Corrected Proof.  
 
25. Ruggeri L, Mancusi A, Capanni M, et al. Donor natural killer cell allorecognition of 
missing self in haploidentical hematopoietic transplantation for acute myeloid leukemia: 
challenging its predictive value. Blood. 2007;110(1):433-440.  
 
26. Luznik L, O'Donnell PV, Symons HJ, et al. HLA-haploidentical bone marrow 
transplantation for hematologic malignancies using nonmyeloablative conditioning and 
high-dose, posttransplantation cyclophosphamide. Biology of Blood & Marrow 
Transplantation. 2008;14(6):641-650.  
 


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27. O'Donnell PV, Luznik L, Jones RJ, et al. Nonmyeloablative bone marrow 
transplantation from partially HLA-mismatched related donors using posttransplantation 
cyclophosphamide. Biology of Blood & Marrow Transplantation. 2002;8(7):377-386.  
 
28. Grosso D, Carabasi M, Filicko-O'Hara J, et al. A2-step approach to myeloablative 
haploidentical stem cell transplantation: A phase 1/2 trial performed with optimized T-
cell dosing. Blood. 2011;118(17):4732-4739.  
 
29. Ruggeri L, Capanni M, Urbani E, et al. Effectiveness of donor natural killer cell 
alloreactivity in mismatched hematopoietic transplants. Science. 2002;295(5562):2097-
2100.  
 
30. Huang X, Liu D, Liu K, et al. Treatment of Acute Leukemia with Unmanipulated 
HLA-Mismatched/Haploidentical Blood and Bone Marrow Transplantation. Biology of 
Blood and Marrow Transplantation. 2009;15(2):257-265.  
 
31. Bartolomeo PD, Santarone S, De Angelis G, et al. Haploidentical, unmanipulated, 
G-CSF-primed bone marrow transplantation for patients with high-risk hematologic 
malignancies. Blood. 2013;121(5):849-857.  
 
32. Colvin GA, Berz D, Ramanathan M, et al. Nonengraftment Haploidentical Cellular 
Immunotherapy for Refractory Malignancies: Tumor Responses without Chimerism. 
Biology of Blood and Marrow Transplantation. 2009;15(4):421-431.  
 
33. Luznik L, Engstrom LW, Iannone R, Fuchs EJ. Posttransplantation 
cyclophosphamide facilitates engraftment of major histocompatibility complex-identical 
allogeneic marrow in mice conditioned with low-dose total body irradiation. Biology of 
Blood and Marrow Transplantation. 2002;8(3):131-138.  
 
34. Matsuzaki G, Yoshikai Y, Ogimoto M, Kishihara K, Nomoto K. Clonal deletion of 
self-reactive T cells at the early stage of T cell development in thymus of radiation bone 
marrow chimeras. Journal of Immunology. 1990;145(1):46-51.  
 
35. Kröger N, Zabelina T, Krüger W, et al. Comparison of total body irradiation vs 
busulfan in combination with cyclophosphamide as conditioning for unrelated stem cell 
transplantation in CML patients. Bone Marrow Transplant. 2001;27(4):349-354.  
 
36. Mori T, Aisa Y, Kato J, et al. Safety and efficacy of total body irradiation, 
cyclophosphamide, and cytarabine as a conditioning regimen for allogeneic 
hematopoietic stem cell transplantation in patients with acute lymphoblastic leukemia. 
Am J Hematol. 2012;87(4):349-353.  
 
37. Watanabe N, Takahashi Y, Matsumoto K, et al. Total body irradiation and melphalan 
as a conditioning regimen for children with hematological malignancies undergoing 
transplantation with stem cells from HLA-identical related donors. Pediatr Transplant. 
2011;15(6):642-649.  


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38. Zohren F, Czibere A, Bruns I, et al. Fludarabine, amsacrine, high-dose cytarabine 
and 12Gy total body irradiation followed by allogeneic hematopoietic stem cell 
transplantation is effective in patients with relapsed or high-risk acute lymphoblastic 
leukemia. Bone Marrow Transplant. 2009;44(12):785-792.  
 
39. Worth, L. J. et al. Optimizing antifungal drug dosing and monitoring to avoid toxicity 
and improve outcomes in patients with haematological disorders. Intern. Med. J. 38, 
521-537 (2008). 
 
12.0 Appendices 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix A: Modified Karnofsky Performance Scale – Web Based Tool 
The modified KPS is a Web-based tool developed in our program that builds upon the 
original KPS.64 The tool was developed to characterize each patient’s performance 
status in more depth than what was possible with the original KPS. The tool is intended 
to assist with the assessment and counseling of patients regarding their ability to 
withstanding the rigors of HSCT.  
 
On the tool, the item that most closely reflects the patient’s performance status is 
selected and the “submit” button is chosen. A performance score is then calculated. 
 
The categories “Not on immune suppression” and “At home, not self sufficient” are not 
further subdivided. The other three categories subdivide into additional questions. An 
example this further characterization is given below for the “Self sufficient at home” 
category. 
 
 
 


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Appendix B: The Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) 
Comorbidity 
Definitions of  the 
Comorbidity 
HCT-CI 
Weighted       
Scores 
Arrhythmia 
Atrial Fibrillation/Flutter, Sick Sinus 
Syndrome, 
Or Ventricular Arrhythmias 
1 
Cardiac 
Coronary Artery Disease, CHF, MI 
Or EF < 50% 
1 
Inflammatory 
Bowel Disease 
Crohn Disease or  
Ulcerative Colitis 
1 
Diabetes 
Requiring Treatment with Insulin 
or Oral Agent but not Diet Alone 
1 
Cerebral Vascular 
Disease 
Transient Ischemic Attack or 
Cerebral Vascular Accident 
1 
Psychiatric 
Disturbance 
Depression or Anxiety Requiring 
Psychiatric Consult or Treatment 
1 
Hepatic-Mild 
Chronic Hepatitis, Bilirubin > ULN to 1.5 X 
ULN 
Or AST/ALT > ULN to 2.5 X ULN 
1 
Obesity 
Patients with Body Mass Index > 35 kg/m2 
1 
Infection 
Requiring Continuation of Antimicrobial  
Treatment after Day 0 
1 
Rheumatologic 
SLE, RA, Polymyositis, Mixed CTD 
Or Polymyalgia Rheumatica 
2 
Peptic Ulcer 
Requiring Treatment 
2 
Moderate/Severe 
Renal 
Serum Creatinine > 2 mg/dL, on Dialysis, 
Or Prior Renal Transplantation 
2 
Moderate 
Pulmonary 
DLco and/or FEV1 66%-80%,  
Or Dyspnea on Slight Activity 
2 
Prior Solid Tumor 
Treated at any Time Point in the Patient’s 
Past 
History, Excluding Nonmelanoma Skin 
Cancer 
3 
Heart Valve 
Disease 
Except Mitral Valve Prolapse 
3 
Severe Pulmonary 
DLco and/or FEV1 < 65%, or Dyspnea 
At rest or Requiring Oxygen 
3 
Moderate/Severe 
Hepatic 
Liver Cirrhosis, Bilirubin > 1.5 X ULN, 
Or AST /ALT > 2.5 X ULN 
3 
Sorror, M. 65 
 
 
 
 
 


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Appendix C: Radiation Guidelines 
 
Modality: 
Photon irradiation is to be used for the TBI in all patients. Areas beneath lung blocks will 
be supplemented with electrons to maintain the homogeneity criteria.  
 
Energy:  
A linear accelerator with energy ≥ 4 MV. Dose to superficial tissues near skin 
surface will be increased by using a beam “spoiler” lucite plate close to the 
patient. 
 
Since neoplastic infiltrates may be found in the skin, it is necessary for the superficial 
dose to satisfy the same total dose requirements as other locations. 
 
Geometry  
The treatment configuration shall be such that the patient is entirely included within the 
treatment beam. It is essential that the correlation between the light field and the 
radiation field be established and verified for extended TBI distances. 
 
Dose Rate 
A dose rate of 0.05 to 0.25 Gy/minute at the prescription point shall be utilized. The 
physicist of record, involved with TBI treatments, shall be consulted to achieve correct 
range of treatment dose rate. 
 
Calibration & Beam Data Verification 
The calibration of the output of the machine, used for this protocol, shall be verified on a 
daily basis prior to start TBI treatments. All dosimetric parameters, necessary for the 
calculation of dose delivered during TBI treatments, shall be measured at the 
appropriate treatment distance. They shall be documented and made available for 
calculation of every patient treatment. 
 
Treatment Volume 
The patient shall be entirely included within the treatment beam. Care should be taken 
to guarantee that the entire patient is within the 90% decrement line at each depth. The 
90% decrement line is defined as the line in each plane perpendicular to the central axis 
connecting the points which are 90% of the central axis dose, in that plane.  
 
Diagnostic Determination  
CT scans through the chest and abdomen will be done prior to initiating irradiation. An 
average chest wall thickness (both anteriorly and posteriorly) will be calculated and 
used in determination of electron energy for supplementing the chest wall beneath the 
lung blocks. The abdominal scan, renal ultrasound, or intravenous pyelogram will be 
used to localize the kidneys for proper placement of renal shielding.  
 
Treatment Dose  
Prescription Point  


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The prescription point is defined as the midplane point along the longitudinal axis at the 
level of the umbilicus.  
 
Dose Units  
All doses shall be specified in Gray (Gy) to muscle tissue.  
 
Tissue Inhomogeneity Considerations  
No inhomogeneity corrections shall be made in the calculation of the dose to the 
prescription point.  
 
Prescription Point Dose  
The total dose shall be 12.0 Gy.  A hyperfractionated regimen over 3 consecutive days 
shall be used.  
 
Time-Dose Considerations  
Hyperfractionation  
For patients receiving 2 fractions per day, there is a required minimum time interval of 7 
hours between the fractions. 
 
Chest Wall Supplement  
Supplementing the chest wall dose with electrons (both anteriorly and posteriorly) shall 
be done once a day on 2 treatment days, immediately preceding or following treatment 
to the entire body. The area beneath the lung blocks shall receive an additional 6.0 Gy 
to dmax in a total of 2 fractions.  
 
Total Number of Treatment Days  
There shall be a total 3 consecutive treatment days.  
 
Treatment Interruptions  
An interruption in the radiotherapy regimen shall not be allowed.  
 
Dose Homogeneity  
The total absorbed dose along the patient's head to toe axis(in the midplane of the 
patient) shall not deviate more than 10% from the prescribed dose.  
 
Treatment Technique 
Treatment Fields  
Equally weighted parallel opposed portals shall be used. AP/PA fields shall be used. 
 
Field Size  
The collimation and treatment distance shall be such that the patient will be entirely 
included within the treatment beam and that no part of the patient extends beyond that 
region. The agreement of the light field and the radiation field should be checked 
periodically for the extended TBI treatment distance.  
 


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Treatment Position  
The patient shall be treated in any position that is compatible with the homogeneity 
requirement, allowing for the reproducibility of the patient setup and dosimetry.  
 
Field Shaping  
Customized blocking to the lungs is required. Customized blocking to the liver and/or 
kidneys is optional, at the discretion of each participating center with the approval of the 
coordinating center radiation oncologist.  
 
Patient specific, individually fabricated shielding blocks are required for the lung from 
both the anterior and posterior directions. A partial transmission block corresponding to 
a total dose of 8.0 Gy at midplane of the patient under the blocks shall be used. No 
corrections for inhomogeneity shall be used.  
 
Patient specific, individually fabricated shielding blocks are optional for the liver from 
both the anterior and posterior directions. A partial transmission block corresponding to 
a dose reduction to 90% of the central axis dose shall be utilized.  
 
Patient specific, individually fabricated shielding blocks are optional for the kidneys from 
the posterior direction only. A partial transmission block yielding a total dose of 10.8 Gy 
+/- 10% to the midplane of the kidney shall be used.  
 
Customized electron cut-outs shall also be constructed corresponding to the size of the 
lung block plus appropriate margins in all directions.  
 
Superficial Tissue Supplement Technique  
The portion of the chest wall shielded by the partial transmission lung blocks will be 
supplemented with customized (or shaped) low energy electron fields. A total of 6.0 Gy 
to dmax in 2 fractions will be given to the anterior and posterior chest wall. Electron 
energy will be determined by chest wall thickness as determined by a chest CT scan, 
with the depth of the 90% dose relative to dmax used to determine the electron energy. 
The dose prescription point will be at dmax.  
 
Calculations  
Central Axis Dose  
It is recommended that the dose calculation method be based upon measurements that 
are made in a unit density phantom with the following minimum dimensions:  
Length equal to top of shoulder to the bottom of the pelvis. 
Width equal to the patient width at the level of the umbilicus. 
Thickness equal to the typical patient thickness at the umbilicus. 
All measurements should be made at the appropriate extended SSD. 
 
Superficial Dose  
For the radiation beam with the Plexiglas plate in place, data should be available 
demonstrating that the skin dose is within 5% of the prescribed dose.  


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Normal Tissue Sparing-Lung Dose  
Lung Dose  
Each patient must have a calculation performed which shows that with the lung 
shielding and chest wall supplement, the TBI delivers between 8.0 Gy +/- 10% (defined 
at midplane at level of carina). 
 
Quality Assurance Documentation  
For purposes of quality assurance the following must be performed on every patient 
undergoing TBI:  
 A check of the monitor unit calculation by a second physicist and a radiation 
oncologist prior to first treatment.  
 Simulation films documenting lung, liver and kidney blocks in both the anterior 
and/or posterior projections shall be taken.  
 Portal films (both AP & PA) verifying the position of the lung, liver and kidney 
blocks shall be taken and must be approved by the supervising radiation 
oncologist prior to delivery of the first TBI treatment.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix D: GVHD Scoring 
 
Clinical Staging of Acute Graft-Versus-Host Disease 
Stage 
Skin 
Liver 
Gut 
+ 
Maculopapular 
rash < 25% body 
surface 
Bilirubin, 2-3 mg/dl Diarrhea, 500-
1,000 ml/day or 
persistent nausea 
++ 
Maculopapular 
rash 25-50% body 
surface 
Bilirubin, 3-6 mg/dl Diarrhea, 1,000-
1,500 ml/day 
+++ 
Generalized 
erythroderma 
Bilirubin, 
6-15 
mg/dl 
Diarrhea, > 1,500 
ml/day 
++++ 
Desquamation 
and bullae 
Bilirubin, 
> 
15 
mg/dl 
Pain +/- ileus 
 
Clinical Grading of Acute Graft-Versus-Host Disease 
 
Overall Grade 
Skin 
Liver 
Gut  
Functional 
Impairment 
0 (none) 
0 
0 
0 
0 
I (mild) 
+ to ++ 
0 
0 
0 
II (moderate) 
+ to +++ 
+ 
+ 
+ 
III (severe) 
++ to +++ 
++ to +++ 
++ to +++ 
++ 
IV (life-
threatening) 
++ to ++++ 
++ to ++++ 
++ to ++++ 
+++ 
 
Tables from Glucksberg H, Storb R, Fefer A, et al. Clinical manifestations of graft-
versus-host disease in human recipients of marrow from HL-A-matched sibling donors. 
Transplantation, 18: 295-304, 1974. 
 
 

ICF_001.pdf: