Conditions: Fanconi Anemia
Keywords: Bone Marrow transplant stem cell transplant cord blood transplant total body irradiation thymic shielding
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 83
Healthy volunteers: no

Brief summary:
This is a single arm, total body irradiation (TBI) trial. All patients will be prescribed TBI 300 cGy with the goal of evaluating secondary endpoints.

Detailed description:
Study Treatment: Patients will receive voriconazole (antifungal therapy) by mouth beginning 1 month prior to conditioning therapy, if possible. 1) The subject is to receive total body irradiation (300 cGy) with thymic shielding; it will be given six days before the stem cells are given (day -6). 2) Day -5 through Day -2, subjects will receive a chemotherapy regimen of Fludarabine and Cyclophosphamide via central line (i.e. Hickman or Broviac). Starting Day -3, patients will receive sirolimus therapy with a taper commencing on day +180 and also mycophenolate mofetil (MMF) through day +30 or for 7 days after engraftment, whichever day is later, if no acute graft-versus-host disease (GVHD). 4) If the subject is receiving bone marrow or "peripheral" stem cells (cells collected from the donor's arm via a cell separator), on the day of transplantation, the stem cells taken from the donor will be put into a machine which will separate the lymphocytes (the cells that cause graft-versus-host disease \[GVHD\]) from the stem cells. If the subject is receiving an umbilical cord blood, the lymphocytes will not be removed because the risk of GVHD is not as high. Otherwise all patients will receive the same treatment. The stem cells are given as an infusion into the subject's existing catheter over 1-2 hours on day 0.5. On the day after transplant (day +1) subjects will be given G-CSF to stimulate the growth of the transplanted cells. 6. While receiving treatment and until the subject's blood counts recover he/she will have daily blood tests, and several bone marrow biopsies and aspirates. After recovery, subjects will be seen once a month for a health assessment and blood tests until at least 3 months after the cells have been infused. Additional blood tests or assessments may be done as medically indicated.

Arms:
arm 1: Patients treated with total body irradiation, Fludarabine, Cyclophosphamide, Bone Marrow Transplantation, Mycophenolate Mofetil, and Sirolimus.

Interventions: intervention 1: Cyclophosphamide intervention 2: Fludarabine intervention 3: Total Body Irradiation intervention 4: Bone Marrow Transplantation intervention 5: Mycophenolate Mofetil intervention 6: Sirolimus
Intervention descriptions: intervention 1: Day -5 through Day -2, subjects will receive chemotherapy of Cyclophosphamide via central line (i.e. Hickman or Broviac),10 mg/kg intravenously (IV) intervention 2: Day -5 through Day -2 prior to transplant; subjects will receive chemotherapy of Fludarabine via central line (i.e. Hickman or Broviac),35 mg/m\^2 intravenous (IV) intervention 3: total body irradiation (300 cGy) with thymic shielding will be given six days before the stem cells are given (day -6). Thymic shielding is done by placing a piece of lead on the chest during the irradiation treatment so that the irradiation beams do not go to the thymus. intervention 4: A target of 5 \* 10\^6/kg and a minimum of 4 \* 10\^6 CD34+ cell/kg recipient weight will be collected by apheresis and used for transplant. In most cases this dose will be recovered in a single apheresis; however, a second or rarely third apheresis performed on the following days may be required to achieve the minimum dose. intervention 5: Patients will receive MMF therapy beginning on day -3 through day +30 or for 7 days after engraftment, whichever day is later, if no acute graft-versus-host disease (GVHD). Engraftment is defined as 1st day of 3 consecutive days of absolute neutrophil count \[ANC\] \> 0.5 \* 10\^9/L. MMF will be given at a dose of 15 mg/kg/dose every 8 hours by mouth(to a maximum dose of 1 gram). intervention 6: Sirolimus will be administered starting at day -3 with 8mg-12mg mg oral loading dose followed by single dose 4 mg/day with a target serum concentration of 3 to 12 mg/mL by high-performance liquid chromatography (HPLC). Levels are to be monitored 3 times/week in the first 2 weeks, weekly until day +60, and as clinically indicated until day +100 post-transplantation. In the absence of acute GVHD sirolimus may be tapered starting at day +100 and eliminated by day +180 post-transplantation.

Protocol document:
Prot_SAP_000.pdf: 
UNIVERSITY OF MINNESOTA BLOOD AND MARROW TRANSPLANTATION 
PROGRAM 
 
 
 
 
 
 
 
Total Body Irradiation Dose De-Escalation Study in Patients with 
Fanconi Anemia Undergoing Alternate Donor Hematopoietic Cell 
Transplantation 
MT2006-05 
 
 
 
 
 
 
 
Study Committee 
Margaret L. MacMillan, M.D. 
John E. Wagner, M.D., Co-Investigator 
 
Biostatisticians 
Todd DeFor, M.S. 
Chap Le, Ph.D. 
 
 
Version Date 
November 16, 2018 
 
 
 
 
 
 
 
 
This document contains confidential information that is the property of the Blood and Marrow 
Transplant Program.  Do not copy, disclose, or circulate without written authorization from 
the  University of Minnesota, Fairview Blood and Marrow Transplant Services Medical Director. 
 
 


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Revision History 
 
Revision 
# 
Revision 
date 
Summary of Changes 
 
7/26/2006 
Eligibility Change: 
High risk Fanconi anemia patients will be included in this study if they have one or 
more of the following high risk features: 
History at any time of systemic fungal or gram negative infection 
Severe renal disease with a creatinine clearance <40 mL/min 
Recipient age > 18 years 
Patients with advanced MDS (.i.e. RAEB or RAEBt or acute leukemia) will be 
excluded from this study. 
1 
3/30/2007 
Section 9.2 processing, added specific CD3 dose patients will receive 
Section 11.1, stopping rules, clarified that it is primary graft failure that will 
determine de-escalation 
2 
4/14/2008 
TBI dose de-escalation trial terminated early due to secondary graft failure in 2 of 2 
patients.  Aim of study is to evaluate secondary endpoints with additional patients 
enrolled at TBI 300 cGy. 
- 
7/27/09 
Synopses corrected to match the eligibility criteria 
- 
9/8/2009 
Added additional high risk diagnoses to the eligibility 
3 
03/24/10 
Section 8.2, MMF will now be used for GVHD prophylaxis per current institutional 
standards; Section 9.1 Cell Processing – replace Isolex 300i System with 
CliniMACS® Cell Selection System (Miltenyi Biotec), add protocol to current  
CliniMACS IDE (D. Weisdorf sponsor); add section SAE reporting and DSMP 
4 
09/29/10 
Revisions in conjunction change to CliniMACS® Cell Selection System to be used 
for bone marrow and peripheral blood processing. 
Establish study arms based on cell source as follows:  
arm 1:  bone marrow and peripheral blood processed using Isolex 300i (for patients 
enrolled through April 2010), arm 2: UCB (no processing), arm 3: bone marrow 
and peripheral blood processed using CliniMACS (for patients enrolled beginning 
with this protocol version); section 7 – update to reflect change in cell processing 
device. 
Other revisions:  Section 6.2 - update MMF administration; Section 6.4 update cell 
infusion guidelines  
Revision of primary endpoint and accrual plans based on expanding TBI cohort of 
300 cGy to a total of at least 41 patients (synopsis, section 1 and 10) 
Updates:  section 5.3 add patient registration information; Section 6 add standard 
care language (delete supportive care appendix, add drug formulation and 
availability appendix); Section 9 – update to current definition of UPRITSO and 
AE reporting table; add data collection and record retention sections; add appendix 
VI – expected toxicities and appendix VII – study drug formulation; update header 
and footer; edits throughout for clarity. 
5 
1/5/2011 
• Add stopping rule for remaining (10) subjects to be treated on current TBI dose 
to monitor for primary graft failure.  
• Update section 5.2 Exclusion Criteria to be consistent with wording from 
protocol summary on pages 3-4. 
• Add language to reflect that study is conducted under IND 14536 (cover page, 
sections 9.1.1 and 9.2). 
• Clarify primary graft failure as an 2nd endpoint vs secondary graft failure 
• Updated schema 
- 
2/7/11 
• Clarification of cell doses in sections 7.2 and 7.3. 


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Revision 
# 
Revision 
date 
Summary of Changes 
6 
11/23/11 
• Add treatment Arm 4 for very high risk subjects (as defined in section 4.3). 
excluding thymic shielding and eliminating T cell depletion of donor stem cells 
regardless of their  source. 
• Update accrual goal at the accepted dose to a total of 52 patients in section 10.1 
• Include information regarding the unmanipulated CB IND 
• Update format and standard language throughout. 
- 
04/17/12 
Correct ATG scheduling inconsistency in schema to match protocol and orders – 
should read 30 mg/kg/day not 15 mg/kg/day every 12 hours, also adjust MP pre-
med to 2 mg/kg 
7 
05/09/12 
• Expand eligibility to include patients requiring a second HSCT for graft failure 
• Delete ATG and CSA, add rapamycin (sirolimus) while retaining MMF 
Resolve data collection inconsistencies: 
• Clarify the secondary objective/endpoint of regimen related toxicity is based on 
transplant outcomes through day 100 (engraftment, infections, treatment related 
mortality, etc.)  
• Patients will be monitored for reportable events through day 100 according to 
the table in section 8.3, decrease reporting to the DSMC 
8 
9/14/12 
• Correction of typographical error in schema 
• Correction of typographical error in eligibility criteria section to reflect that 
High Risk population may include patients requiring a second HSCT for graft 
failure (change was made in previous revision, but eligibility section was 
inadvertently not updated) 
• Correction of typographical error in section 5, Treatment Plan 
(methylprednisone and ATG were inadvertently not deleted from the list of 
drugs, although these treatments were removed in the previous protocol 
revision) 
9 
11/16/12 
• Restore methyl prednisone to the preparative regimen 
• Section 5.2 update sirolimus (rapamycin) administration section 
• Section 5.3 update anti-fungal medication section 
• Sections 7.1 and 7.2 add lipid panel at baseline and post-transplant to monitor 
for changes in triglyceride and cholesterol level (risks of sirolimus)  
• Appendix VII Drug Formulation and Availability – Delete – all drugs are 
commercially available and administered according to current institutional 
guidelines unless otherwise indicated in individual drug sections  
• Other minor updates and edits 
10  
1/11/13 
• Increase sample size to 100 subjects 
11 
09/29/14 
• Restore CSA and remove rapamycin as GVHD prophylaxis  
• Update to current IRB language 
12 
10/31/16 
• Remove references to IND, update to include references to HUD protocol 
MT2015-31 
• Update IRB reporting language 
• Related donor consents archived as related donors will now be enrolled on BMT 
protocol MT2012-14C 
• Antifungal therapy updated to current standard of care (section 5.3) 
• Updated required observations to remove standard of care evaluations (section 7, 
appendix II) 
• Removed Day 21 bone marrow biopsy 
• Increased accrual goal to 120 subjects 
13 
11/16/2018 
• Revised to clarify that post transplant bone marrow aspirates and biopsies will 
only be performed as clinically indicated 


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Table of Contents 
 
SYNOPSIS ...................................................................................................................................... 5 
TREATMENT PLAN ..................................................................................................................... 7 
1 
OBJECTIVES .......................................................................................................................... 8 
2 
STUDY DESIGN .................................................................................................................... 8 
3 
BACKGROUND ..................................................................................................................... 8 
4 
PATIENT SELECTION/REGISTRATION.......................................................................... 13 
5 
TREATMENT PLAN............................................................................................................ 15 
6 
STEM CELL COLLECTION, PROCESSING AND INFUSION ........................................ 17 
7 
SCHEDULE OF STUDY ACTIVITIES ............................................................................... 19 
8 
ADVERSE EVENT MONITORING AND REPORTING ................................................... 20 
9 
DATA AND SAFETY MONITORING PLAN .................................................................... 23 
10 
STATISTICAL CONSIDERATIONS............................................................................... 24 
11 
ETHICAL AND REGULATORY CONSIDERATIONS ................................................. 25 
12 
REFERENCES .................................................................................................................. 27 
APPENDIX I - TOTAL BODY IRRADIATION ........................................................................ 29 
APPENDIX II - SCHEDULE OF ACTIVITIES FOR EACH PATIENT ................................... 31 
APPENDIX III - IMMUNE RECONSTITUTION: SCHEDULE OF ACTIVITIES .................. 32 
APPENDIX IV - ACUTE GRAFT-VERSUS-HOST DISEASE ................................................. 33 
APPENDIX V CHRONIC GRAFT-VERSUS-HOST DISEASE ................................................ 34 
APPENDIX VI - EXPECTED TOXICITIES ............................................................................... 35 
 
 
 
 


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SYNOPSIS 
 
 
Title  
MT2006-05: Total Body Irradiation Dose De-Escalation Study in 
Patients with Fanconi Anemia Undergoing Alternate Donor 
Hematopoietic Cell Transplantation 
 
 
Primary Objective 
To determine the lowest dose of total body irradiation (TBI) required to 
achieve consistent neutrophil engraftment after alternate donor HSCT in 
patients with Fanconi anemia.  (TBI dose de-escalation was terminated 
in December 2007 due to secondary graft failure in 2 of 2 patients.) 
After December 2007 - To evaluate the primary graft failure rate with 
enough precision to show that it is less than 15% of evaluable patients 
transplanted with TBI 300 cGy. 
 
 
Secondary Objectives 
To assess risks of primary graft failure, regimen related toxicity, acute 
and chronic GVHD and survival. 
 
 
Study Design 
Single center, single arm, TBI dose de-escalation trial. 
 
 
Primary Endpoint and 
Secondary Endpoints 
Primary: 
Incidence of neutrophil recovery (absolute neutrophil count ≥500/µL for 
three consecutive days) by day 42. 
Secondary: 
Incidence of serious regimen related toxicity based on transplant 
outcomes at day 100. 
Incidence of secondary graft failure at 100 days. 
Incidence of acute graft-versus-host disease (GVHD) at 100 days. 
Incidence of chronic GVHD at one year. 
Probability of survival at one year. 
Incidence of infections at 100 days, 6 months, and one year. 
Immune reconstitution at 100 days, 6 months, and one year. 
 
 
Sample Size 
35 to 120 patients with at least 91 patients enrolled at the acceptable 
TBI dose level of 300 cGy 
 
 
 
 


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Eligible Diseases 
Patients must be either standard or high risk with the following: 
Standard risk patients must be <18 years of age with a diagnosis of 
Fanconi anemia with aplastic anemia (AA), myelodysplastic syndrome 
without excess blasts, or high risk genotype as defined below: 
• Aplastic anemia is defined as having at least one of the 
following when not receiving growth factors or transfusions: 
- 
platelet count <20 x 109/L 
- 
ANC <5 x 108/L 
- 
hemoglobin <8 g/dL 
• Myelodysplastic syndrome (MDS) with multilineage dysplasia 
(< 5% blasts) with or without chromosomal anomalies 
• High risk genotype (e.g. IVS-4 or exon 14 FANCC mutations, 
or BRCA1 or 2 mutations) 
High risk patients must have one or more of the following high risk 
features: 
• Advanced MDS (≥ 5% blast) or acute leukemia 
• Requiring additional HSCT for graft failure 
• History of systemic fungal or gram negative infection 
• Severe renal disease with a creatinine clearance <40 mL/min 
• Recipient age > 18 years 
Very high risk patients must have the following features advanced MDS 
(≥ 5% blast) or acute leukemia  
 


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TREATMENT PLAN 
TBI dose de-escalation trial was terminated December 2007 due to secondary graft failure in 2 of 2 
patients.  All patients transplanted after December 2007 will be prescribed TBI 300 cGy with the goal of 
evaluating the rate of primary graft failure and secondary endpoints. 
 
Revised Schema effective January 2011: 
 
 
possible stem cell sources:  related donor BM, unrelated donor BM, UCB 
 
treatment plan: 
 
 
 
 
 
 
 
 
 
 
 
   HSCT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
         
-7 
-6 
     -5                -4                -3   
     -2                -1                 0       
     +30 
 
 
 
 
 
               CSA 
 
 
 
 
 
 
   MMF  
 
 
 
 
 
 
 
 
 
 
 
G-CSF  
 
 
                        methylprednisolone 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
            Total Body Irradiation (TBI) 300 cGy 
 
 
  
 
            Cyclophosphamide 10 mg/kg IV over 2 hours days -5 through day -2 
 
            Fludarabine 35 mg/m2 IV over 30 minutes days -5 through -2 
 
 
 
 
 
 
 


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1 
OBJECTIVES 
 
1.1 
Primary Objective 
To determine the lowest possible dose of total body irradiation (TBI) required to achieve 
consistent neutrophil engraftment after alternate donor hematopoietic stem cell 
transplantation (HSCT) in patients with Fanconi anemia. (TBI dose de-escalation trial 
was terminated December 2007 due to secondary graft failure in 2 of 2 patients).  
 
After December 2007 - To evaluate the primary graft failure rate with enough precision 
to show that it is less than 15% of evaluable patients transplanted with TBI 300 cGy. 
 
1.2 
Secondary Objectives 
To determine: 
• Incidence of serious regimen related toxicity based on transplant outcomes by day 
100 
• Incidence of secondary graft failure at 100 days 
• Incidence of acute graft-versus-host disease (GVHD) at 100 days 
• Incidence of chronic GVHD at one year 
• Probability of survival at one year 
• Incidence of infections at 100 days, 6 months, and one year 
• Immune reconstitution at 100 days, 6 months, and one year 
 
 
2 
STUDY DESIGN 
 
This is a single center, single arm, TBI dose de-escalation study designed to determine the lowest 
dose of TBI required (toxicity endpoint) without impairing the hematopoietic engraftment (safety 
endpoint) in FA patients.  TBI dose de-escalation was terminated in December 2007 due to 
secondary graft failure in 2 of 2 patients.  After December 2007, all patients are to be treated 
with the fixed dose of TBI 300 cGy.  In November 2011 the treatment plan was revised to add  
“Arm 4,” which treats very high risk subjects using TBI without thymic shielding and without T-
cell depleting the cell product regardless of source. 
 
 
3 
BACKGROUND 
 
3.1 
Fanconi Anemia 
Fanconi anemia (FA) is a genetically and phenotypically heterogeneous inherited 
disorder characterized by congenital malformations, progressive bone marrow (BM) 
failure and marked predisposition to malignancy.  The FA phenotype is extremely 
variable.  Congenital malformations may range from none to many, often involving the 
major organ system, resulting in dysfunction in some patients1-3.  Hematologic 
abnormalities occur in virtually all patients with FA, at a median age of 7 years (range, 
birth to 41 years).4  Based on clinical data in the International Fanconi Anemia Registry 
(IFAR; n = 754 patients), the cumulative incidence of BM failure by age 40 was 90%.5  


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Notably, some patients presented with myelodysplastic syndrome (MDS) or acute 
myelocytic leukemia (AML) without a prior diagnosis of aplastic anemia (AA).  Of the 
754 IFAR FA patients, 120 (16%) patients developed MDS or AML with a cumulative 
incidence of MDS or AML by age 40 years of 33%.  Based on a survey of FA patients by 
Rosenberg et al, the median age of onset of leukemia was 11.3 years.6   
 
The fundamental defect in FA cells remains unknown.  Defects in DNA repair, cell cycle 
checkpoints, oxygen metabolism and induction of apoptosis have all been described in 
FA cells.  To date, 11 FA complementation groups have been described and x genes have 
been identified.7  These all encode unique proteins, which do not exhibit any functional 
domains.  The heterogenous nature of FA makes an understanding of the correlation 
between genotype and phenotype important in the clinical management of FA patients.  
For example, in FA-C patients, patients with intron 4 or exon 14 mutations have an 
earlier onset of bone marrow failure and poorer survival compared to patients with exon 1 
mutations.8  Patients with biallelic BRCA2 mutations which is the FANCD1 gene, have 
an extraordinary risk for developing acute leukemia, Wilms tumor and medulloblastoma 
at a very young age.9 
 
3.2 
Hematopoietic Stem Cell Transplantation for Fanconi Anemia 
Hematopoietic stem cell transplantation (HSCT) from an allogeneic donor is the only 
treatment with curative potential for patients with the hematological complications of 
Fanconi Anemia (FA).1,10-12  Early experiences with HSCT for the treatment of FA were 
negative.  Poor outcomes were primarily the result of excessive regimen-related toxicity 
(RRT) and severe graft-versus-host disease (GVHD).  Conditioning regimens were those 
used for acquired AA, consisting of cylophosphamide (CY) at a dose of 200 mg/kg with 
or without irradiation.  Severe RRT was noted with a high proportion of patients dying 
early after transplant with impaired cardiac function, severe mucositis, skin toxicity, 
infection, gastrointestinal hemorrhage and hemorrhagic cystitis.  
18% ± 9%
  
 Figure 1.   Overall Survival at 2 Years after Unrelated Donor HSC Transplantation in FA Patients 
 
As a result of in vitro tests demonstrating hypersensitivity to radiation and alkylating 
agents in FA patients, Gluckman et al proposed the use markedly lower doses of CY and 
lower dose unfractionated irradiation to reduce toxicity and improve survival, with 


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improved results.  Subsequently, survival markedly improved in recipients of HLA 
matched sibling donor BMT.  Incidences of RRT, GVHD and graft failure, however, 
remained particularly high after unrelated donor BMT with very poor survival (18%) at 3 
years (Figure 1).13  While RRT was less, reduced doses of conditioning were insufficient 
to achieve consistent donor cell engraftment and GVHD remained a major obstacle. 
 
3.3 
University of Minnesota Experience 
Over the past 11 years a number of systematic protocol modifications have been made at 
the University of Minnesota to address the problems of graft failure, RRT and infections 
after alternate donor HSCT in FA patients.  
 
In 1995, we started to T cell deplete bone marrow from unrelated donors in an attempt to 
further reduce RRT and overcome the obstacle of GVHD in FA patients.14  GVHD 
prophylaxis consisted of cyclosporine A (CSA) for six months, and short course 
methylprednisolone (2 mg/kg/d) between day 5 and 19.  For the entire cohort of 29 FA 
patients treated from 1995-1998, the incidence of grade 2-4 acute GVHD was 8% with no 
patient having chronic GVHD.  
 
In 1999, we added fludarabine (FLU) to the CY-TBI-ATG preparative regimen to 
overcome the high risk of graft failure, particularly in patients with somatic mosaicism.  
Between April 1999 and August 2003, 45 FA patients were treated with FLU 175 mg/m2, 
CY 40 mg/kg, TBI 450 cGy and ATG.  All recipients received T cell depleted marrow (or 
umbilical cord blood if no marrow donor could be identified).  As in the prior studies, 
GVHD prophylaxis consisted of CSA for six months and short course 
methylprednisolone.  Of 45 FA patients who underwent alternate donor HSCT in this 
manner from 1999-2003, 44 engrafted, resulting in a cumulative incidence of 97% (95% 
CI, 91-100). The incidence of acute and chronic GVHD was low being 21% (95% CI, 9-
33%) and 10% (95% CI, 1-19%).  
 
Despite the advances in engraftment and reducing the incidence of GVHD, regimen 
related toxicity (RRT) and opportunistic infections remained major obstacles to 
successful HSCT.  In this most recent cohort of patients, significant RRT occurred in all 
patients with everyone exhibiting significant mucositis requiring narcotics and 48% 
having significant hemorrhagic cystitis.  Other severe toxicities included pulmonary 
hemorrhage (n=9), interstitial pneumonitis (n=4), GI hemorrhage (n=6), renal failure 
(n=9), erythroderma (n=3), and severe hepatic veno-occlusive disease (n=2).  While RRT 
was common, RRT was a direct cause of death in 4 patients.  Infectious disease 
complications were also common, with 77 events documented by pathogen isolation in 
36 patients with a complete dataset.  Bacterial and viral pathogens accounted for most 
events (34 and 30, respectively) with fungal pathogens (n=12) and other pathogens (n=1) 
observed less frequently.   
 
In 2003, we initiated a study to determine the effect of thymic shielding as a strategy to 
improve immune reconstitution and in turn reduce the risk of opportunistic infection.  
Between October 2003 and January 2006, 15 FA patients were treated with FLU 175 
mg/m2, CY 40 mg/kg, TBI 450 cGy and ATG as previously described for the prior study 


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with the addition of thymic shielding at the time of radiation therapy.  All recipients 
received T cell depleted marrow (or umbilical cord blood if not marrow donor could be 
identified).  Thirteen of 15 patients achieved neutrophil engraftment at a median of 12 
days (range, 10-38 days), suggesting that thymic shielding has no deleterious effect on 
hematopoietic recovery.  Five of 15 patients developed severe acute GVHD and none has 
developed chronic GVHD thus far.  For this group of patients, the probability of survival 
at 1 year is 66% (95% CI 41-91%).  Significant RRT occurred in all patients with all 
patients exhibiting significant mucositis requiring narcotics and more than 50% having 
significant hemorrhagic cystitis.  Other severe toxicities included pulmonary 
hemorrhage/interstitial pneumonitis, GI hemorrhage, renal failure and severe hepatic 
veno-occlusive disease.  While RRT was common, RRT was a direct cause of death in 2 
patients.  Of the 5 patients that have died, two died from graft failure, one from ARDS, 
one from renal failure and one from fungal infection.  
 
3.4 
Non-TBI Based Regimens for Fanconi Anemia Patients 
Long-term follow-up studies of FA patients indicate that approximately 40% of FA 
patients develop a malignancy within 15 – 20 years after HSCT.15 Reported risk factors 
include exposure to irradiation and the development of chronic GVHD.6,15-19  Eliminating 
irradiation will also potentially reduce the risk of regimen related toxicity and GVHD.  In 
addition, the risks for cataracts, endocrinopathies and potentially infertility in women, 
will be reduced (the majority of FA males are infertile). 
 
In non-FA patients with aplastic anemia, a multicenter prospective trial was conducted 
from 1994-1999 to determine the minimum dose of TBI sufficient to achieve sustained 
engraftment and to determine the tolerability and toxicity of the regimen.20  All patients 
received an unrelated donor BMT after 3 cycles of 30 mg/kg ATG and 4 cycles of 50 
mg/kg cyclophosphamide (CY) and TBI.  The starting dose of TBI was 3 x 200 cGy and 
was decreased over time in the trial such that the lowest possible dose (200 cGy) in 
combination with CY/ATG was sufficient to allow engraftment without inducing 
prohibitive toxicity.  The follow up to this trial is the current Blood and Marrow 
Transplant Clinical Trials Network trial in which fludarabine has been added to CY, TBI 
200 cGy and ATG as a means to reduce the dose of CY required to achieve adequate 
engraftment.   
 
HLA-matched sibling donor HCT.  At the University of Minnesota, we developed a 
non-irradiation based preparative regimen using fludarabine (FLU), CY and anti-
thymocyte globulin (ATG) followed by infusion of T-cell depleted (TCD) bone marrow 
(BM) or unmanipulated umbilical cord blood (UCB) for FA patients with HLA-matched 
related donors.  The goals of this trial were to potentially reduce the risks of malignancy, 
GVHD and other late effects, such as endocrinopathy and infertility.  GVHD prophylaxis 
consisted of cyclosporine and short course methylprednisolone.21  Between April 2000 
and January 2006, 12 patients with FA (11 AA, 1 MDS) underwent related donor HCT 
using this regimen.  Stem cell sources were BM and UCB in 9 and 3 patients, 
respectively.  All patients demonstrated primary engraftment.  Median days to neutrophil 
and platelet engraftment were 11 days (range 9 – 13) and 38 days (range 19 – 381), 
respectively.  No patient developed GVHD after primary HCT.  The patient with MDS 


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relapsed with AML and a maternal donor recipient experienced secondary graft failure.  
The Kaplan-Meier estimate of survival at 2 years is 100% at a median follow-up of 2.5 
years (range 1.6 – 4.5).  The results of this study demonstrate that a FLU-based, non-
irradiation approach is effective for FA patients with AA undergoing genotypically HLA-
identical sibling HCT.21   
 
3.5 
Study Rationale 
Over the last decade, major advances have been made to improve survival of patients 
with FA undergoing alternate donor HSCT.  We have shown that fludarabine based 
preparative regimens have drastically improved engraftment rates from 66% to 98%.  As 
well, T cell depletion of bone marrow has decreased the rates of GVHD from 50-70% to 
20-30%.  We have also shown that thymic shielding during TBI is well tolerated with no 
deleterious effect on engraftment or other transplant outcomes.  However, is too early to 
determine if thymic shielding speeds immune recovery. 
 
We hypothesize that FA patients undergoing alternate donor HSCT can achieve 
neutrophil engraftment with the use of fludarabine, cyclophosphamide and ATG, without 
the use of irradiation in a similar fashion as was accomplished in FA patients undergoing 
HLA-matched sibling donor HSCT.  It is anticipated that rates of regimen related toxicity 
and GVHD will be lower with this non-irradiation based approach, resulting in improved 
survival.  We also anticipate that risk for late malignancies will be reduced.  All patients 
will have immune function tests performed to study the pace of immune recovery.  
 
Our plan is to build upon our sequential modifications in our approach to alternate donor 
HSCT for FA patients to improve survival without compromising engraftment after 
HSCT.  We will decrease the dose of TBI in each cohort, using FLU, CY and ATG, 
followed by T cell depleted BM or UCB.  The decision to proceed with each stepwise 
decrease in TBI (300 cGy to 150 cGy to no irradiation) will be based upon achieving 
adequate neutrophil engraftment in the current cohort of patients. 
 
TBI dose de-escalation was terminated in December 2007 due to secondary graft failure 
in 2 of 2 patients.  After December 2007, all patients are to be treated with the fixed dose 
of TBI 300 cGy.   
 
In June 2012, ATG was deleted from the preparative regimen as graft failure is no longer 
a major concern.  Patients will continue to receive methylprednisolone for 5 days prior to 
transplant.  Omitting ATG may speed immune recovery after HSCT and reduce the risk 
for opportunitistic infections.  Additionally CSA was replaced by sirolimus to test the 
effectiveness of this immunosuppressive agent.  The future plan for FA patients 
undergoing alternative HSCT is to give T regulatory cells (Tregs) at the time of HSCT to 
help promote engraftment and reduce the risk of GVHD.  CSA inhibits the growth of T 
regs whereas sirolimus promotes their growth.  Therefore sirolimus has replaced CSA in 
this trial in anticipation of the future trial with T regs. 
 


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In September 2014, the protocol was revised to restore CSA as GVHD prophylaxis as it 
is better tolerated by the patient.  Sirolimus (rapamycin) was deleted as future trials with 
T regs are on hold indefinitely (see previous paragraph). 
 
 
4 
PATIENT SELECTION/REGISTRATION 
 
4.1 Patient Inclusion Criteria 
4.1.1 
Disease Criteria 
• Standard risk patients must be <18 years of age with a diagnosis of Fanconi 
anemia with aplastic anemia (AA), myelodysplastic syndrome without excess 
blasts, or high risk genotype as defined below: 
o Aplastic anemia is defined as having at least one of the following when 
not receiving growth factors or transfusions: 
- 
platelet count <20 x 109/L 
- 
ANC <5 x 108/L 
- 
Hemoglobin <8 g/dL 
o Myelodysplastic syndrome with multilineage dysplasia with or without 
chromosomal anomalies 
o High risk genotype (e.g. IVS-4 or exon 14 FANCC mutations, or BRCA1 
or 2 mutations) 
 
• High risk patients must have one or more of the following high risk features: 
o Advanced MDS (≥ 5% blast) or acute leukemia 
o Require additional HSCT for graft failure 
o History at any time of systemic fungal or gram negative infection 
o Severe renal disease with a creatinine clearance <40 mL/min 
o Age ≥ 18 years 
 
• Very high risk patients (Arm 4, described in section 4.3) must have 
Advanced MDS (≥ 5% blast) or acute leukemia after initial HSCT 
 
4.2 Patients must have an appropriate source of stem cells (as detailed in section 
6.1).  Patients and donors will be typed for HLA-A, B, C and DRB1 using high 
resolution molecular typing. Related donors will be evaluated under the 
University of Minnesota donor protocol MT2012-14C 
4.2.1 Adequate organ function including: 
• 
Cardiac: ejection fraction >45% 
• 
Hepatic: bilirubin, AST or ALT, ALP <5 x normal 


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4.2.2 Karnofsky performance status >70% or Lansky >50 (if < 16 years of age) 
4.2.3 Women of child-bearing age must be using adequate birth control and 
have a negative pregnancy test 
4.2.4 Written consent 
 
4.3 
Patient Exclusion Criteria 
4.3.1 
Available HLA-genotypically identical related donor in standard risk 
patients. 
4.3.2 
Active CNS leukemia at time of study enrollment 
4.3.3 
History of squamous cell carcinoma of the head/neck/cervix within 
previous 2 years 
4.3.4 Prior radiation therapy that prevents further TBI 
 
 
4.4 
Patient Registration with the Clinical Trials Office 
Upon completion of the screening evaluation, eligibility confirmation and obtaining 
written consent, a designated study staff person will enroll the patient into OnCore.   
 
At the time of registration, the patient’s cell source/processing will be indicated in 
OnCore as one of the following study arms: 
Arm 1:  bone marrow or peripheral blood processed using Isolex 300i (for patients 
enrolled through April 2010) 
Arm 2: UCB – no processing. If one or both of the cord blood units used for the graft is 
unlicensed, the participant will co-enroll on University of Minnesota protocol 
MT2011-13R “Infusion of Cell Populations from Unlicensed Umbilical Cord 
Blood Units.” 
Arm 3: bone marrow or peripheral blood processed using CliniMACS (for patients 
enrolled beginning with the September 2010 protocol version). Subjects enrolled 
on the October 31, 2016 version of the protocol will co-enroll on University of 
Minnesota Protocol MT2015-31 “CliniMACS CD34 Reagent System as a HUD 
for Obtaining CD34+ Cell-Enriched Products” 
Arm 4: TBI with no thymic shielding and no T-cell depletion (processing using 
CliniMACS device) regardless of stem cell source 
 
TBI dose de-escalation was terminated December 2007 due to secondary graft failure in 2 
of 2 patients.   
 
4.5 
Patients Who Are Registered and Do Not Receive Study Treatment 
If a patient is registered to the study, and is later found not able to begin the preparative 
regimen (beginning with the first dose of fludarabine), for whatever reason, the patient 


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will be removed from study and treated at the physician’s discretion.  The patient will be 
considered a screen/baseline failure and the reason for removal from study will be clearly 
indicated in OnCore. 
 
 
5 
TREATMENT PLAN 
In order to provide optimal patient care and to account for individual medical conditions, 
investigator discretion may be used in the prescribing of all supportive care therapy (i.e. 
acetaminophen, diphenhydramine, G-CSF, antimicrobials, etc). 
 
Patients will receive antifungal prophylaxis beginning 1 month prior to conditioning 
therapy, if possible.  Refer to section 5.3. 
 
See appendices VI and VII for preparative and prophylaxis drug information including 
expected toxicities 
 
 
Day 
Treatment 
-6 
TBI 300 cGy with thymic shielding* 
 
-5 
Cyclophosphamide (CY) 10 mg/kg IV 
Fludarabine (FLU) 35 mg/m2 IV 
Methylprednisolone 1 mg/kg IV q12h 
-4 
CY 10 mg/kg IV 
FLU 35 mg/m2 IV 
Methylprednisolone 1 mg/kg IV q12h 
-3 
CY 10 mg/kg IV 
FLU 35 mg/m2 IV 
Methylprednisolone 1 mg/kg IV q12h 
-2 
CY 10 mg/kg IV 
FLU 35 mg/m2 IV 
Methylprednisolone 1 mg/kg IV q12h 
-1 
Methylprednisolone 1 mg/kg IV q12h 
 0 
HSCT 
+1 
Initiate G-CSF 5mcg/kg per day IV (continue until ANC >2.5 x 109/L) 
* Shielding of the thymus will not be required in those individuals who, in the opinion of the treating 
investigator, would be at an increased risk of graft failure or relapse due to non-irradiated marrow in the 
sternum. 
 
 
5.1 
Preparative Therapies 
The preparative cytoreductive therapy will be identical for all patients.  Treatment related 
toxicities are defined in the Appendix VI. 
 
The administration of the preparative regimen will follow the institutional and supportive 
care guidelines.  Dose and/or schedule adjustments consistent with the standard of care 
may be made on an individual patient basis as needed for safety.     
 
Total Body Irradiation 


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TBI will be given in a single fraction of 300 cGy administered on day –6 via anterior and 
posterior fields as detailed in Appendix I.   
 
The thymus will be shielded using 5 HVL anterior and posterior cerrabend thymus blocks 
designed by determining the position of the thymus by treatment planning CT scan.  
Shielding of the thymus will not be performed for subjects enrolled in Arm 4 (‘very high 
risk’ as defined in section 4.1), as these subjects would be at an increased risk of relapse 
due to unradiated marrow in the sternum.   
 
If necessary because of decreased attenuation through the lungs, lung compensators will 
be designed to keep the dose to the lungs 300 cGy (+/-5%).  The position of these lung 
compensators will be determined by treatment planning CT scan.  Dose is prescribed at 
the midplane of the patient at the midpelvis.  The dose rate will be 26 cGy/minute. 
 
Cyclophosphamide 
Cyclophosphamide 10 mg/kg is to be given as a 2 hour infusion for 4 days for a total dose 
of 40 mg/kg.  Strict attention should be made to vigorous hydration, fluid balance and 
maintenance of good urine output. Mesna (10 mg/kg/day) in divided doses will be given 
on the same days as cyclophosphamide for 4 days for a total dose of 40 mg/kg per 
institutional guidelines.   
 
Fludarabine 
Fludarabine 35 mg/m2 will be given IV over 30 minutes daily for 4 days for a total dose 
of 140 mg/m2. Preparation, administration and monitoring will be according to standard 
practice procedures. 
 
Methylprednisolone 
Methylprednisolone 1 mg/kg will be given IV over 30 minutes every 12 hours for 5 days 
on days -5 to -1.   Preparation, administration and monitoring will be according to 
standard practice procedures. 
 
5.2 
GVHD Prophylaxis 
 
Patients will receive cyclosporine A (CSA) and mycophenylate mofetil (MMF) as GVHD 
prophylaxis. 
 
 
Cyclosporine A (CSA) 
All patients (regardless of allograft source) will receive CSA therapy beginning on day –3.   
 
Dosing of CSA will be per the University of Minnesota BMT Program guidelines.  The 
target CSA trough level will be 200 mg/L to 400 mg/L.  
 
CSA taper begins at day +180 or 1 month after control of GVHD.  Taper to zero by 10% 
weekly dose reduction over approximately 10 weeks.   
 
MMF 


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Patients will receive MMF therapy beginning on day –3 until day +30 or for 7 days after 
engraftment, whichever day is later.  Engraftment is defined as 1st day of 3 consecutive 
days of absolute neutrophil count [ANC] > 0.5 x 109/L. 
 
MMF will be given at a dose of 15 mg/kg/dose every 8 hours PO (to a maximum dose of 
1 gram).  The MMF dose may be adjusted to tablet sizes of 250 mg and 500 mg or 
administered using the suspension.  MMF may be given IV at the same dose if PO not 
tolerated.  MMF dosing is to be monitored and altered as clinically appropriate based on 
Pharmacist orders.  Patients will be eligible for pharmacokinetic studies. 
  
If the patient has acute GVHD requiring systemic therapy, MMF may be stopped 7 days 
after initiation of systemic therapy for acute GVHD (e.g. resolution of skin rash, 
vomiting, and diarrhea). 
 
5.3 
Antifungal Therapy 
Patients will receive anti-fungal prophylactic therapy with itraconazole, posoconazole, 
caspofungin or micofungin beginning up to 1 month prior to conditioning therapy. 
Antifungal prophylaxis will be given until at least 100 days after HSCT. 
 
 
   
 
 
6 
STEM CELL COLLECTION, PROCESSING AND INFUSION 
 
6.1 
Stem Cell Source Selection 
 
The following will be the preferential order of stem cells to be used, provided appropriate 
cell doses are available as detailed in sections 6.2, 6.3 and 6.4: 
 
1. Related donor matched at HLA-A, B, C and DRB1. Related donors will be evaluated 
and collected per MT2012-14C. 
2. Related marrow donor mismatched at 1 HLA-A, B, C and DRB1 antigen. Related 
donors will be evaluated and collected per MT2012-14C. 
3. Unrelated marrow donor matched at HLA-A, B, DRB1. Use unrelated donor PBSC if 
marrow not available. 
4. Unrelated UCB single or double units matched or 1 locus mismatch at HLA-A, B, 
DRB1 with adequate cell doses per institutional guidelines. 
5. Unrelated marrow donor mismatched at 1 HLA-A, B, DRB1.  Use unrelated PBSC if 
marrow not available. 
 
If and when a marrow donor has been selected on the basis of HLA-A, B, C and DRB1 
typing as above, preference will be made for donors matched at the HLA-C locus. 
 
Bone marrow, peripheral stem cells, and UCB grafts will be evaluated for sterility, cell 
viability, nucleated cell count, CD34 and CD3 counts. 


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Preference will be made for the use of bone marrow BM cells as the stem cell source for 
patients from either related donors or unrelated donors.  Peripheral blood stem cells will 
only be used if a donor is unwilling or unable to undergo bone marrow cell collection. 
If a suitable donor is not available in a timely fashion, unrelated donor umbilical cord 
blood will be used as the stem cell source.   
 
6.2 
Bone Marrow Collection and Processing 
 
Unrelated donor bone marrow will be collected in the usual sterile manner using 
established parameters determined by the National Marrow Donor Program. 
 
Refer to MT2012-14C for related donor collection guidelines.  
A goal of ≥ 5.0 x 108/kg (based on patient ideal body weight) nucleated bone marrow 
cells will be collected. 
 
With the September 2010 amendment, CD34+ cells will be isolated from the bone 
marrow using the CliniMACS® Cell Selection System (Miltenyi Biotec).  Patients will 
be given all isolated CD34+ cells.  Prior to activation of the September 2010 amendment, 
cell selection was done using the Isolex®300i System (Nexell Therapeutics, Inc.). “Very 
high risk (see section 4.1)” patients who are treated on Arm 4 (see section 4.3) will 
receive cell products which are not T-cell depleted using the CliniMACS or other cell 
selection device. In August 2016, the University of Minnesota received approval to use 
the CliniMACS CD34 Reagent System as a Humanitarian Use Device (HUD) as protocol 
number MT2015-31. With the October 2016 amendment, we will be using MT2015-31 to 
co-enroll subjects needing CD34+ cell isolation. 
 
Infusion will be according to the current University of Minnesota guidelines. 
 
Each patient is to receive 1.0 x 105/kg CD3+ cells.  An add back infusion of CD3+ cells 
may be required to achieve this prescribed cell dose if an insufficient number are present 
in the CD34+ isolated cell fraction given to the patient. 
 
Peripheral blood stem cells will be used only if bone marrow cannot be collected as BM 
and UCB are the preferred stem cell source.  PBSC will be collected and processed per 
institutional guidelines.  
 
6.3 
Umbilical Cord Blood 
The UCB graft may consist of one or two UCB units to provide an adequate cell dose per 
institutional guidelines.  Cord Blood units should be selected according to current 
University of Minnesota Umbilical Cord Blood Graft Selection Algorithm.   
 
Cord blood products are thawed and filtered (170-micron) in the Molecular and Cellular 
Therapeutics (MCT) Lab. 
 
Infusion will be according to the current University of Minnesota guidelines. 


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7 
SCHEDULE OF STUDY ACTIVITIES 
 
See Appendix II and Appendix III.  Scheduled evaluations prior to engraftment (day 30) may be 
performed +/-3 days from the targeted date; assessments to be performed between engraftment 
and day 100 may be done +/-7 days of the targeted date; assessments after day 100 may be 
performed +/-30 days of the targeted date.  In addition, targeted days may be altered as clinically 
appropriate. 
 
7.1 
Schedule of Activities – refer to appendix II 
 
7.2 
Pre Study Screening Procedures 
 
• Immune function testing (30 cc [10 cc in 3 green top tubes] to Wagner lab – 
appendix III) 
• Immunoglobulin levels 
• Urinalysis and 24 hour urine creatinine clearance or GFR  
• Pregnancy test (urine) – for age appropriate females 
• Chest radiograph 
• High resolution CT chest, abdomen and pelvis 
• CT of sinuses  
• Ultrasound of liver and kidneys 
• Bone marrow aspirate and biopsy 
• Karnofsky or Lansky performance status (Appendix I) 
• Pulmonary functions tests (children >6 years, adults) 
• ECG; echocardiography with left ventricular ejection fraction 
• Other radiographic studies (as clinical indicated) 
7.3 
Evaluation During Therapy Until Engraftment 
• CBC with platelet count daily until one week after ANC ≥ 5 x 108/L for 3 
consecutive days, then weekly, platelets to be monitored daily  until the count is ≥ 
50,000 µL for 7 consecutive days without transfusion, then weekly thereafter 
• Review for events/toxicity and for the BMT database per section 8  
• After BM infusion, GVHD evaluation weekly and as clinically indicated 
 
7.4 
Evaluation Post Engraftment To Discharge 
• Physical examinations weekly until discharge 
• CBC with platelet count weekly until discharge 
• GVHD evaluations as clinically indicated 
• Test peripheral blood and/or bone marrow for chimerisms as clinically indicated 
• Review for events/toxicity and for the BMT database per section 8 
 
7.5 
Evaluation Post Engraftment at Day 60, 100 and 180, 365 and then Once 
Yearly until 2 Years after HSCT 
• CBC, differential and platelet 


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• GVHD score 
• Physical exam 
• Bone marrow aspiration and biopsy  - if clinically indicated at day 100, 180 and 
365 days.Additional biopsies performed more often as clinically indicated 
• Peripheral blood chimerism at day 60 
• Patient characteristics evaluated at each visit (Karnofsky or Lansky scale, weight, 
age) 
• Review for events/toxicity and for the BMT database per section 8 
• Clinical Summary at close of study 2 years after BMT or, at death (obtain autopsy 
report if available) 
• Lipid panel 
 
7.6 
GVHD Assessments 
 
Acute GVHD 
Acute GVHD will be evaluated daily during inpatient hospitalization, at all follow-up 
visits and at Day 100.  Evaluation will include descriptive characteristics of rash and 
estimates of body surface area involved; extent of any wet dermal/epidermal separation; 
identification of concomitant causes of rash other than GVHD; peak serum bilirubin; 
concomitant causes of increased bilirubin other than GVHD; presence or absence of 
nausea, vomiting or anorexia persistent after engraftment; peak diarrhea volume with 
annotations concerning the presence or absence of urinary mixing and estimates of the 
true diarrhea volume; presence or absence of abdominal cramps; presence or absence of 
frank stool blood or melena; concomitant causes of GI symptoms other than GVHD; 
biopsy results; identification of any agents used for treatment; and autopsy results (if 
applicable).  The diagnosis and staging of acute GVHD is detailed in Appendix IV. 
 
Chronic GVHD 
At Day 100 and at all evaluations thereafter, patients will be evaluated for chronic 
GVHD.  Symptoms to be monitored include skin disorders (rash, dermatitis, hardening), 
liver damage (ALT and total serum bilirubin), difficulty swallowing, dry eyes and mouth, 
increased susceptibility to infections, and hair loss. The diagnosis and staging of chronic 
GVHD is detailed in Appendix V. 
 
7.7 
Immune Reconstitution Evaluation 
Immune recovery will be measured as detailed in the Appendix III. All patients will have 
a systematic evaluation of 1) lymphocyte subset recovery, and 2) immunoglobulin levels.  
Patients will be studied before HSCT as baseline (before preparative therapy) and at day 
100, 6 months, and 1 year after HSCT.  
 
 
8 
ADVERSE EVENT MONITORING AND REPORTING  
 


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Toxicity and adverse events will be classified according to NCI's Common Terminology Criteria 
for Adverse Events V 4.0 (CTCAE). A copy of the CTCAE can be downloaded from the CTEP 
home page: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40 
 
FOR UNLICENSED UCB UNITS ONLY: Selected expected adverse reactions determined to be 
caused by or at least possibly caused by the UCB units based on objective evidence will be 
reported in an expedited manner to the FDA under University of Minnesota IND BB-14797 (C. 
Brunstein, MD, PhD –sponsor/investigator). 
 
FOR CD34+ SELECTED CELLS ONLY: Any clinically significant safety issues associated 
with cell processing failure or device malfunction regarding the CliniMACS® system must be 
reported to the PI (Dr. Margaret MacMillan) and Miltenyi (boston@miltenyibiotec.com) per 
institutional procedures under protocol MT2015-31. 
 
8.1 
Definitions  
The following definitions are based on the Code of Federal Regulations Title 21 Part 
312.32 (21CFR312.32(a)). 
  
 
Adverse Event:  Any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related.  
 
Suspected Adverse Reaction:  Any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event.  
 
Life-Threatening Adverse Event Or Life-Threatening Suspected Adverse Reaction: 
An adverse event or suspected adverse reaction is considered “life-threatening” if, in the 
view of either the investigator or sponsor, its occurrence places the patient or subject at 
immediate risk of death. 
   
Serious Adverse Event Or Serious Suspected Adverse Reaction:  An adverse event or 
suspected adverse reaction is considered “serious” if, in the view of either the investigator 
or sponsor, it results in any of the following outcomes:  
• 
Death 
• 
A life-threatening adverse event 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
• 
A congenital anomaly/birth defect 
• 
Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate 
medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this 
definition 
 


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Unexpected adverse event or unexpected suspected adverse reaction: An adverse 
event or suspected adverse reaction is considered “unexpected” if it is not listed in the 
investigator brochure or is not listed at the specificity or severity that has been observed; 
or, if an investigator brochure is not required or available, is not consistent with the risk 
information described in the general investigational plan or elsewhere in the current 
application, as amended.  Thus, adverse events that occur as part of the disease process or 
underlying medical conditions are considered unexpected; however, they will not be 
reportable per section 8.3. 
 
 
 
 
FOR UNLICENSED UCB UNITS ONLY:  These patients will be co-enrolled on 
University of Minnesota protocol MT2011-13R.  Selected expected adverse reactions 
determined to be caused by or probably caused by the UCB unit based on objective 
evidence will be reported in an expedited manner to the FDA under University of 
Minnesota IND BB-14797 (C. Brunstein, MD, PhD – sponsor/investigator). Included are 
the following: 
• The unit is mislabeled or failure to pass local lot release 
• Serious infusion reaction within first 24 hours after infusion 
• Recipient bacteremia with clinical signs and symptoms related to a contaminated 
UCB within 24 hours after infusion 
 
FOR CD34+ SELECTED CELLS ONLY: These patients will be co-enrolled on 
University of Minnesota protocol MT2015-31. Adverse events determined to be caused 
by or probably caused by the CD34+ enriched cell product for hematopoietic 
reconstitution based on objective evidence will be reported to the IRB and Miltenyi 
Biotech per institutional procedures under protocol MT2015-31. 
 
8.2 
Adverse Event Monitoring 
Patients will be monitored for excessive treatment related toxicity through day 100 and 
reported as applicable per section 8.3.   After day 100 and upon knowledge, only those 
events meeting the definition of expedited reporting will be submitted to the appropriate 
entity per section 8.3   
 
 


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8.3 
Reporting Requirements 
After day +100, only those events requiring expedited reporting will be reported upon 
knowledge.  
 
 
 
The SAE Coordinator will provide the Masonic Cancer Center’s Data and Safety Monitoring 
Council (DSMC) with the SAE in an appropriate format depending on the individual SAE (as 
reported or in a summary format). 
 
 
9 
DATA AND SAFETY MONITORING PLAN 
 
The study’s Data and Safety Monitoring Plan will be in compliance with the University of 
Minnesota Masonic Cancer Center's Data & Safety Monitoring Plan (DSMP), which can be 
accessed at http://z.umn.edu/dmsp. 
 
For the purposes of data and safety monitoring, this study is classified as moderate risk.  
Therefore the following requirements will be fulfilled: 
 
• The Masonic Cancer Center Data and Safety Monitoring Council (DSMC) will review 
the trial’s progress twice yearly 
• The PI will comply with at least twice yearly monitoring of the project by the Masonic 
Cancer Center monitoring services. 
• The PI will oversee the submission of all reportable adverse events per the definition of 
reportable in section 8.3 to the Masonic Cancer Center’s SAE Coordinator, the University 
of Minnesota IRB, and the FDA.   
 
Agency 
Criteria for reporting 
Timeframe 
Form to 
Use 
Submission 
address/ fax 
numbers 
Copy AE to: 
U of MN 
IRB 
UPIRTSO: any event which is unanticipated, involved new or 
increased risk to subjects, and was at least possibly related to study 
procedures 
Other Problems or Events meeting the definition of UPIRTSO in 
section 8.1 
 
5 Working 
Days 
MCC 
SAE 
University Of 
Minnesota 
IRB 
MMC 820 
Masonic 
Cancer Center 
SAE 
Coordinator 
mcc-
saes@umn.edu 
UPIRTSO 
Form 
Non-UPIRTSO:  events that do not meet the IRB’s definition 
 
:  For a complete list refer to 
http://www.research.umn.edu/irb/guidance/ae.html#.VC7xraI0-
sh 
 
Annually 
Summary 
Format 
 
Any event that counts toward a study stopping rule (see section 
10.3) 
 
 
Upon 
reporting  
 
 
Study 
stopping 
rule form  
 
 
SAE 
Coordinator 
mcc-
saes@umn.edu 
 
 
Not applicable 
 
MCC SAE 
Coordinator 
 


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In addition, at the time of the continuing review with the University of Minnesota IRB, a copy of 
the report with any attachments will be submitted to the Cancer Protocol Review Committee 
(CPRC). 
 
 
 
10 STATISTICAL CONSIDERATIONS 
 
10.1 
Study Design 
 
To date, TBI 300 cGy has shown that primary graft failure is no longer a concern.   We 
will no longer dose-escalate or de-escalate but instead try to give a precise estimate of 
donor engraftment with this preparative therapy.  
 
Approximately 91 patients will be treated at the accepted dose. 
  
The TBI dose de-escalation trial was terminated December 2007 due to secondary graft 
failure in 2 of 2 patients.  All patients transplanted after December 2007 will be 
prescribed TBI 300 cGy with the goal of evaluating the primary endpoint with more 
precision. As of January, 2013, there were 42 evaluable patients enrolled at the accepted 
dose level with one non-evaluable patient due to early death. Our goal is to reach 91 
evaluable subjects. One or two patients may be considered high risk and two patients 
considered very high risk (and treated) after October 2011; these patients will not be 
included in the evaluable population. With the addition of 49 patients at the accepted 
dose, the 3 patients in cohort 2 and the 6 potential patients in the high risk arm, our total 
enrollment on the protocol will be approximately 120. 
 
10.2 
Sample Size Considerations 
 
 
All patients transplanted after December 2007 will be prescribed TBI 300 cGy with the 
goal of evaluating the primary endpoint with more precision. Specifically we would like 
to show that with the current estimated graft failure rate of 5.0%, we can show with 95% 
confidence that the true graft failure rate is less than 10%. To do this we will need to 
enroll an additional 49 patients or more to the current 43 evaluable patients for a total of 
at least 91 patients at the accepted dose of TBI 300 cGy. 
 
10.3 
Analysis 
 
The primary endpoint of graft failure will be estimated by a simple proportion with 
confidence limits constructed from the standard errors.  Any patients dying prior to day 
28 post transplant without an evaluable bone marrow assessment will be considered un-
evaluable.  The primary objective of this study will be answered by the design of the trial.  
The secondary endpoints of engraftment, acute GVHD and chronic GVHD will be 
estimated by cumulative incidence treating early deaths as a competing risk.  Survival 


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will be estimated by Kaplan-Meier methods.  Regimen-related toxicity will be 
summarized by simple proportions. 
 
10.4 
Monitoring Guidelines 
 
Patients will be monitored for excess 100 day transplant-related mortality (>50%). With 
the change back to CSA from Rapamycin 09/29/2014, we will only be monitoring among 
the additional cohort of 20 patients. 
 
We hypothesize that the rate of TRM will be less than 25% based on current experience.  
A rate that exceeds 50% is considered unacceptable. The power for TRM is preset at 90% 
with a type-I error of 5%. Therefore, the trial will be stopped if 5 events occur in the first 
6 patients, 6 in the first 9, 7 in the first 11, 8 in the first 14, 9 in the first 17 or 10 in the 
first 19. 
 
Following completion of the TBI dose de-escalation phase of the study at the selected 
dose of TBI 300 cGy and the change in regimen on November, 2012 stopping rules will 
be monitored for the cohort of 49 patients receiving Cy/Flu/TBI (300)/Methyprednisone: 
 
This study will be monitored for primary graft failure by day 42.  The study will be 
stopped (and reviewed) if there is an excess incidence of graft failure.  Based on our prior 
experience with this therapy in this population, we expect that the rate of primary graft 
failure will be approximately 5%. Our maximum tolerated level will be 20%.  
 
The stopping rule has been developed using the sequential probability ratio test with the 
level of significance and power preset at 5% and 80% respectively.  With these 
stipulations, the trial will be stopped if there is graft failure in 2 out of 2 or 3 out of 11, 4 
out of 20, 5 out of 29, 6 out of 38 or7 at any time.   
 
10.5 
Data Collection 
 
Data collection will include those data that are routinely recorded for related donor 
transplants with special attention to neutrophil engraftment and donor chimerism.  Protocol 
summaries will be available to the protocol chair when requested and as needed for 
standard Cancer Center safety monitoring procedures. 
 
 
11 ETHICAL AND REGULATORY CONSIDERATIONS 
 
11.1 
Inclusion of Women and Minorities 
While there will be every effort to seek out and include women and minority patients, the 
patient population is dependent upon the referral pattern and the ability to locate a 
suitable unrelated marrow donor.  Women and minority patients are eligible for all 
aspects of the study and their participation will be actively encouraged.  It is recognized 
that certain minority groups are less likely to find suitably compatible unrelated BM 
donors through the NMDP registry.  Formal efforts to increase minority donor 


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Page 26 of 37 
recruitment are being made by the NMDP in order to enhance the availability of this 
treatment option to all minorities.  All minority patients with suitable unrelated BM 
donors will be actively encouraged to enroll in this pilot study. 
 
11.2 
Monitoring 
 
The sponsor-investigator will permit study-related monitoring, audits, and inspections by 
the IRB, government regulatory bodies, and University of Minnesota compliance groups 
in addition to the monitoring requirements of the Cancer Center’s Data and Safety 
Monitoring Plan (section 9).  The investigator will make available 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 (e.g. pharmacy, diagnostic laboratory, etc.) will be available for 
trial related monitoring, audits, or regulatory inspections. 
 
11.3 
Informed Consent 
 
The principles of informed consent described in FDA Regulations (21 CFR Part 50) will 
be followed to comply with Food and Drug Administration regulations.  A patient must 
give written consent prior to study participation which must be witnessed and dated.  The 
original consent will be retained by the investigator as part of the study records.  A copy 
of the consent form will be given to the patient. 
 
Once a suitable donor has been identified for an individual patient, the patient will be 
completely evaluated by a physician who subsequently outlines the course of therapy.  
Assuming the donor and patient meet the medical requirements for undergoing the stem 
cell donation and transplant procedure, respectively, the patient will then be admitted to 
the inpatient unit where the course of therapy will again be reviewed.  The risks of the 
procedures to the patient will be discussed in detail.  The plan of the pilot study, 
including the potential risks and benefits will be presented as objectively as possible. 
 
11.4 
Record Retention 
 
The investigator will retain study records including source data, copies of case report 
forms, consent forms, HIPAA authorizations, and all study correspondence in a secured 
facility for at least 6 years after the study file is closed with the IRB and FDA.   
 
In addition, the Clinical Trials Office (CTO) will keep a master log of all patients 
participating in the study with sufficient information to allow retrieval of the medical 
records for that patient. Please contact the CTO before destroying any study related 
records. 
 
 


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12 REFERENCES 
1. 
Wagner JE, MacMillan ML, Auerbach AD. Hematopoietic Cell Transplantation for Fanconi 
Anemia. In: Blume KG, Forman SJ, Appelbaum FR, eds. Hematopietic Cell Transplantation (ed 
Third). Malden: Blackwell Sciences Ltd.; 2004:1483-1504. 
2. 
Giampietro PF, Adler-Brecher B, Verlander PC, Pavlakis SG, Davis JG, Auerbach AD. The need 
for more accurate and timely diagnosis in Fanconi anemia: a report from the International 
Fanconi Anemia Registry. Pediatrics. 1993;91:1116-1120. 
3. 
Giampietro PF, Verlander PC, Davis JG, Auerbach AD. Diagnosis of Fanconi anemia in patients 
without congenital malformations: an international Fanconi Anemia Registry Study. Am J Med 
Genet. 1997;68:58-61. 
4. 
Butturini A, Gale RP, Verlander PC, Adler-Brecher B, Gillio AP, Auerbach AD. Hematologic 
abnormalities in Fanconi anemia: an International Fanconi Anemia Registry study. Blood. 
1994;84:1650-1655. 
5. 
Auerbach AD, Allen RG. Leukemia and preleukemia in Fanconi anemia patients. A review of the 
literature and report of the International Fanconi Anemia Registry. Cancer Genet Cytogenet. 
1991;51:1-12. 
6. 
Rosenberg PS, Greene MH, Alter BP. Cancer incidence in persons with Fanconi anemia. Blood. 
2003;101:822-826. 
7. 
Fanconi Anemia Mutation Database RU. http://www.rockefeller.edu/fanconi/mutate/. 
8. 
Gillio AP, Verlander PC, Batish SD, Giampietro PF, Auerbach AD. Phenotypic consequences of 
mutations in the Fanconi anemia FAC gene: an International Fanconi Anemia Registry study. 
Blood. 1997;90:105-110. 
9. 
Wagner JE, Tolar J, Levran O, et al. Germline mutations in BRCA2: shared genetic susceptibility 
to breast cancer, early onset leukemia, and Fanconi anemia. Blood. 2004;103:3226-3229. 
10. 
Gluckman E, Auerbach AD, Horowitz MM, et al. Bone marrow transplantation for Fanconi 
anemia. Blood. 1995;86:2856-2862. 
11. 
Gluckman E. Bone marrow transplantation in Fanconi's anemia. Stem Cells. 1993;11 Suppl 
2:180-183. 
12. 
Socie G, Gluckman E, Raynal B, et al. Bone marrow transplantation for Fanconi anemia using 
low-dose cyclophosphamide/thoracoabdominal irradiation as conditioning regimen: chimerism 
study by the polymerase chain reaction. Blood. 1993;82:2249-2256. 
13. 
Wagner JE, Eapen M, Harris RE, MacMillan ML, Auerbach AD. Unrelated donor transplantation 
for Fanconi anemia: Analysis of prognostic factors impacting engraftment and survival. Blood. 
2004;104:235a. 
14. 
MacMillan ML, Auerbach AD, Davies SM, et al. Haematopoietic cell transplantation in patients 
with Fanconi anaemia using alternate donors: results of a total body irradiation dose escalation 
trial. Br J Haematol. 2000;109:121-129. 
15. 
Deeg HJ, Socie G, Schoch G, et al. Malignancies after marrow transplantation for aplastic anemia 
and fanconi anemia: a joint Seattle and Paris analysis of results in 700 patients. Blood. 
1996;87:386-392. 
16. 
Socie G, Devergie A, Girinski T, et al. Transplantation for Fanconi's anaemia: long-term follow-
up of fifty patients transplanted from a sibling donor after low-dose cyclophosphamide and 
thoraco-abdominal irradiation for conditioning. Br J Haematol. 1998;103:249-255. 
17. 
Kutler DI, Auerbach AD, Satagopan J, et al. High incidence of head and neck squamous cell 
carcinoma in patients with Fanconi anemia. Arch Otolaryngol Head Neck Surg. 2003;129:106-
112. 
18. 
Socie G, Henry-Amar M, Cosset JM, Devergie A, Girinsky T, Gluckman E. Increased incidence 
of solid malignant tumors after bone marrow transplantation for severe aplastic anemia. Blood. 
1991;78:277-279. 


MT 2006-05 TBI De-Escalation Study in Alternate Donor HSCT for FA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Page 28 of 37 
19. 
Witherspoon RP, Fisher LD, Schoch G, et al. Secondary cancers after bone marrow 
transplantation for leukemia or aplastic anemia. N Engl J Med. 1989;321:784-789. 
20. 
Deeg HJ, Amylon ID, Harris RE, et al. Marrow transplants from unrelated donors for patients 
with aplastic anemia: minimum effective dose of total body irradiation. Biol Blood Marrow 
Transplant. 2001;7:208-215. 
21. 
Tan PL, Wagner JE, Auerbach AD, Defor TE, Slungaard A, Macmillan ML. Successful 
engraftment without radiation after fludarabine-based regimen in Fanconi anemia patients 
undergoing genotypically identical donor hematopoietic cell transplantation. Pediatr Blood 
Cancer. 2006;46:630-636. 
 
 


11/16/2018 
 
 
Page 29 of 37 
 
APPENDIX I - TOTAL BODY IRRADIATION 
 
Dose Calculations for the Prescription Point and Off-Axis Points 
 
The calculation of the treatment time or the meter set for the prescribed dose can be carried out 
using standard techniques.  However, TBI presents special problems relative to the routine 
treatment situation in that the field sizes are much larger and treatment distances are much 
longer.  Therefore, it is recommended that checks be performed to guarantee the correct delivery 
of the prescribed dose.  For example, the calculation method should be compared to a 
measurement using a unit density phantom with dimensions equal to the trunk size of an average 
patient.   The skin dose should be >90 % of the prescription point dose.  Beam spoilers may be 
used, if necessary, to ensure this.    
 
Provided an agreement between measurements and calculations is established, the following 
technique is used to find the meter set or treatment time.  If differences are detected, modified 
terms or additional correction factors should be introduced.  For example, modified values for 
percentage depth dose, tissue-air-ratios and tissue-phantom-ratios are necessary for some 
treatment units when the patient is positioned at a long distance from the photon source and near 
the floor or one wall of the room.  Also, some deviation from an exact inverse square decrease 
with distance has been demonstrated for certain room geometries. 
 
 
Example calculation (central axis prescription point) 
MS= 
meter set for linear accelerator 
D= 
prescribed dose per field 
PR= 
tissue-phantom ratio for area, A and depth, d 
A= 
the area of the entrance surface presented by the patient's 
trunk 
D= 
depth to midline at level of the umbilicus 
FSCF= 
field size correction factor for field length, L, and field 
width, W 
U= 
the treatment unit calibration in units of cGy/meter unit 
ISCF= 
inverse square correction factor 
 
Similar calculations can be written for time treatment machines (Co 60 units) or for fixed SSD 
set ups.  In order to obtain uniformity among centers using TBI, the Percentage Depth Dose 
(PDD), Tissue Air Ratio (TAR) must be determined for a depth equal to the half-separation at 
the level of the umbilicus and for a unit density scattering volume having dimensions equal to the 
top-of-shoulder to bottom-of-pelvis measurement in one direction and equal to the width at the 
umbilicus in the other direction.  This second dimension will be equal to the AP thickness at the 
umbilicus for lateral field irradiation, and will correspond to the lateral width at this same level 
for AP/PA treatment. 
 
Prescription Point and Dose Rate 
 
A midplane dose rate of 26 cGy per minute is required.  The prescription point is the midplane at 
the low pelvis at the level of the mid-hip.  If the patient is short, he/she will be treated with a 


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single anterior and posterior field.  If the patient is too tall to fit into the single field, the patient 
will either be treated standing on a specially designed stand or treated with 2 abutting fields lying 
prone and supine on the floor.  If abutting fields are used, they will be angled away from each 
other so as to prevent overlap.  The match point will be below in the mid femur area to avoid 
matching over the pelvis.  Total body irradiation will be delivered with a linear accelerator using 
6, 18, or 24 MV X-rays.   
 
Lung Compensators 
 
A treatment planning CT scan will be performed and a isodose computer plan generated using 
lung inhomogeneity correction factors.  If needed aluminum compensators or thin cerrubend 
blocks will be fabricated to attenuate the beam so as to keep the lung dose no higher than the 
prescription dose of 300 cGy.  Customized bolus may be necessary to compensate for the 
thickness of the breast tissue, or if there is a large variation in the chest wall thickness over the 
field.   
 
Since patients need to be supine for the treatment planning CT and are upright for the chest wall 
boost, if there is uncertainty about the chest wall thickness with the patient in an upright position, 
an ultrasound evaluation of the chest wall thickness with the patient upright may be performed.   
 
Thymus blocking 
 
The treatment planning CT scan will be used to determine the location of the thymus.  If it is 
poorly visualized, the radiation oncologist and radiologist will block the area that best 
corresponds to the usual thymus position.  A 5HVL cerrubend blocks will be fabricated and 
placed so as to block the thymus from both the anterior and posterior TBI fields.   The thymus 
blocks will be attached to the special TBI stand brackets that secure the lung compensators. 
 
At the discretion of the treating investigator(s), thymic shielding will not be done in a small 
subset of patients who, based on their disease status at study entry and/or previous treatment 
history, would be at an increased risk of relapse due to the unradiated marrow in the sternum. 
 
A beam “spoiler” or bolus will be used to ensure a full skin dose.  Testicular boosts (used for 
leukemia patients) will not be utilized.  
 


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APPENDIX II - SCHEDULE OF ACTIVITIES FOR EACH PATIENT 
Scheduled evaluations prior to engraftment (day 30) may be performed +/-3 days from the targeted date; assessments to be performed between engraftment 
and day 100 may be done +/-7 days of the targeted date; assessments after day 100 may be performed +/-30 days of the targeted date.  In addition, targeted 
days may be altered as clinically appropriate. 
Activity 
Pre-BMT 
Day +1 to 
Engraftment 
Post-engraftment to 
Discharge (days 
<30 minimum) 
Short-term Post-
engraftment Follow-up 
(days 31-100 minimum) 
Long-term Post-
engraftment Follow-up 
(>day 100) 
Informed consent 
x 
 
 
 
 
Clinical evaluation 
 
 
 
 
 
 
 
 
 
 
 
 
Karnofsky/Lansky score 
x 
x(2) 
x(2) 
x(2, discharge home) 
x(day 180,360, ,720) 
CXR 
x 
 
 
 
 
PFT 
x 
 
 
 
x(3) 
ECG/ECHO 
x 
 
 
 
 
US liver & kidneys 
x 
 
 
 
 
CT chest, abd, pelvis 
x 
 
 
 
 
CT of sinus 
x 
 
 
 
 
Urine pregnancy test (if applicable) 
x 
 
 
 
 
Cr/Cr cl or GFR 
x 
 
 
 
 
Serum chemistries 
x 
x(1) 
x(1) 
x(2) 
x(day 180,360,720) 
Lipid panel 
 
 
 
x (day 60) 
x(day 100,180,360,720) 
CBC/differential 
x 
x(1) 
x(1) 
x(2) 
x(day 180,360, 720) 
PT/INR, serum alpha fetoprotein, 
CMV titer 
x 
 
 
 
 
BM aspirate/chimerism1 
x 
 
x(3) 
x(day 90-100) 
x(day 180,360, 720) 
Toxicity Evaluation 
 
x(1) 
x(1) 
x(3) 
x(3) 
GVHD evaluation 
 
x(1) 
x(1) 
x(3) 
x(3) 
Immunoglobulin levels and 
Immune Function Evaluation 2 
x 
 
 
x (day 100)  
x (day 180, 360)   
x(1)=perform test daily 
 
 
x(2)=perform test weekly 
x(3)=perform test as clinically indicated 
x(day)=perform test on day indicated 
1 - to cell repository - PBLpatient for DNA;  BMdonor for DNA 
2 – refer to appendix III - three 10 cc green top tubes for Wagner lab per section 7.7 


 
 
  
 
 
 
 
 
 
 
 
 
 
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APPENDIX III - IMMUNE RECONSTITUTION: SCHEDULE OF ACTIVITIES 
 
Activity 
Pre-
HSCT 
Day 
100 
6 
months 
1 year 
*Cellular Immunity 
• thymopoiesis/peripheral T cell 
reconstitution 
- FACS (CD3, CD4, CD8, CD19, CD25, 
CD27, CD57, CD69, CD45RA, 
CD45RO, HLA-DR) 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
**Humoral Immunity 
• immunoglobulin levels 
 
X 
 
X 
 
X 
 
X 
 
 
*For each time point, send 30cc blood (3 green tops) to John Wagner’s lab (call 625-2966). 
Label tube ‘FA:2006-05 Immune Assays’. 
** Immunoglobulin levels to chemistry lab. 


 
 
  
 
 
 
 
 
 
 
 
 
 
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Page 33 of 37 
 
  
 
APPENDIX IV - ACUTE GRAFT-VERSUS-HOST DISEASE 
 
Patients will be considered evaluable for acute GVHD if they demonstrate donor cell 
engraftment and survive to day 42.  Organ involvement will be staged using the criteria outlined 
in the table below.  Biopsy of each organ site at diagnosis or major change in disease activity 
will be performed unless clinical circumstances make it impossible. 
Consensus Clinical Stage and Grade of Acute GVHD  
(Glucksberg et al, 1974; Thomas et al, 1975, Przepiorka et al, 1995) 
Stage 
Skin 
Liver 
Lower 
Gastrointestinal 
Tract 
Upper 
Gastrointestinal 
Tract 
1 
Maculopapular rash 
<25% of body 
surface 
Bilirubin 2.0 – 3.0 
mg/dl 
Diarrhea 500 – 1000 
mL/day or 280 – 555 
mL/m2 
No protracted 
nausea and vomiting 
2 
Maculopapular rash 
25-50% body 
surface 
Bilirubin 3.1 – 6.0 
mg/dl 
Diarrhea 1000 – 1500 
mL/day or 556 – 833 
mL/m2 
Persistent nausea, 
vomiting or anorexia 
3 
Generalized 
erythroderma 
Bilirubin 6.1 – 15.0 
mg/dl 
Diarrhea >1500 
mL/day or    >833 
mL/m2 
 
4 
Generalized 
erythroderma with 
bullous formation 
and desquamation 
Bilirubin > 15 
mg/dl 
Severe abdominal 
pain, with or without 
ileus, or stool with 
frank blood or melena 
 
 
Conversion Chart for Staging the Volume of Diarrhea in Pediatric Patients 
Stage 
Stool Volume/day 
0 
< 7 mL/kg 
1 
7 – 14 mL/kg 
2 
14 – 21 mL/kg 
3 
21 – 28 mL/kg 
4 
≥28 mL/kg 
 
University of Minnesota Acute GVHD Grading 
Acute GVHD 
Grade 
Skin Stage 
Liver Stage 
Lower GI 
Stage 
Upper GI Stage 
   I 
1-2 
0 
0 
0 
   II 
3 
1 
1 
1 
   III 
- 
2-4 
2-3 
 
   IV 
4 
- 
4 
 
•  Each column identifies minimum criteria for organ grade.   
•  Each grade is based on maximum stage for each individual organ involved 
e.g. Grade II = skin stage 3 and/or liver stage 1 and/or gut stage 1 and/or UGI stage 1 
 
 


 
 
  
 
 
 
 
 
 
 
 
 
 
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APPENDIX V CHRONIC GRAFT-VERSUS-HOST DISEASE 
 
Limited CGVHD 
Localized skin involvement (<50% body surface area) 
and/or 
Limited hepatic involvement (abnormal LFTS; bilirubin < 3 mg/dl) 
Extensive CGVHD  
The presence of one or more of the following criteria may be used for the diagnosis of extensive 
CGVHD: 
- Generalized skin involvement (≥ 50% body surface area) 
- Liver histology consistent with involvement by CGVHD with bilirubin ≥ 3 mg/dl 
- Positive Schirmer’s test (< 5 mm wetting) 
- Histologically-proven involvement by CGVHD of oral mucosa or salivary glands 
- Lung dysfunction with bronchiolitis obliterans with no evidence of viral causation on histology. 
- Gastrointestinal involvement: malabsorption and/or weight loss due to anorexia without 
explanation other than CGVHD 
 
  


 
 
  
 
 
 
 
 
 
 
 
 
 
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APPENDIX VI - EXPECTED TOXICITIES 
 
Toxicities associated with the Preparative Therapies: 
 
Total Body Irradiation (TBI) 
Common 
Less Common 
Rare 
• nausea and vomiting 
• diarrhea 
• cataracts 
• sterility 
• endocrinopathies 
• growth failure 
• intestinal cramps 
• mucositis 
• parotitis 
• interstitial 
pneumonitis 
• generalized mild 
erythema 
• veno-occlusive 
disease 
• dysphagia 
• vertebral deformities 
• nephropathy 
• risk of 2nd malignancy years later (when 
given along with chemotherapy) 
 
Fludarabine  
Common 
Less Common 
Rare 
• low white blood cell count 
with increased risk of infection  
• low platelet count with 
increased risk of bleeding  
• low red blood cell count 
(anemia) with tiredness and 
weakness  
• tiredness (fatigue)  
• nausea  
• vomiting  
• fever and chills  
• infection 
 
 
• pneumonia  
• diarrhea  
• loss of appetite  
• weakness  
• pain 
 
 
• numbness and tingling in hands and/or 
feet related to irritation of nerves  
• changes in vision  
• agitation  
• confusion  
• clumsiness  
• seizures  
• coma  
• cough  
• trouble breathing  
• intestinal bleeding  
• weakness  
• death due to effects on the brain, infection, 
bleeding, severe anemia, skin blistering, or 
other causes  
 
 
Cyclophosphamide 
Common 
Less Common 
Rare 
 
 
 
• low white blood cell count 
with increased risk of 
infection  
• hair loss or thinning, 
including face and body hair 
(usually grows back after 
treatment)  
• nausea  
• vomiting  
• loss of appetite  
• low platelet count 
with increased risk 
of bleeding  
• darkening of nail 
beds  
• acne  
• tiredness  
• infection  
• fetal changes if 
pregnancy occurs 
• heart problems with high doses, with chest 
pain, shortness of breath, or swollen feet  
• severe allergic reactions  
• skin rash  
• scarring of bladder  
• kidney damage (renal tubular necrosis) 
which can lead to kidney failure  
• heart damage, with trouble getting your 
breath, swelling of feet, rapid weight gain  


 
 
  
 
 
 
 
 
 
 
 
 
 
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Page 36 of 37 
 
  
 
Cyclophosphamide 
Common 
Less Common 
Rare 
• sores in mouth or on lips  
• bleeding from bladder, with 
blood in urine  
• diarrhea  
• long-term or short-term 
infertility (inability to have 
children) in women and men 
 
during 
cyclophosphamide  
 
• scarring of lung tissue, with cough and 
shortness of breath  
• second cancer, which can happen years 
after taking this drug  
• death from infection, bleeding, heart 
failure, allergic reaction, or other causes  
 
 
 
Toxicities Associated With Immunosuppressive Therapies 
 CSA   
 
 
 
 
Mycophenolate Mofetil (MMF) 
• nephrotoxcity 
• seizures 
• hypertension 
• hirsutism 
• increased risk of relapse 
• thrombotic thrombocytopenic purpura 
• electrolyte imbalances 
• paresthesias/neuropathy 
• gingival hyperplasia 
• increased risk of opportunistic infection 
•  
• pancytopenia 
• headache 
• insomnia 
• electrolyte imbalances 
• leg cramps/bone pain 
• hypertension 
• dizziness 
• hyperglycemia 
• rash 
• nausea/diarrhea 
 
 
Toxicities Associated With Other Therapies 
Methylprednisolone may cause nausea, vomiting, heartburn, headache, dizziness, trouble 
sleeping, appetite changes, increased sweating, acne, or pain/redness/swelling at the injection 
site.  This medication may make your blood sugar level rise, which can cause or worsen diabetes.  
Serious, but rare side effects include: unusual weight gain, menstrual period changes, bone/joint 
pain, easy bruising/bleeding, mental/mood changes (such as mood swings, depression, agitation), 
muscle weakness/pain, puffy face, slow wound healing, swelling of the ankles/feet/hands, 
thinning skin, unusual hair/skin growth, vision problems, fast/slow/irregular heartbeat.  Very 
rarely, but possibly fatal, stomach or intestinal bleeding has been reported.   
 
Toxicities associated with Voriconazole 
• diarrhea, nausea, vomiting 
• fever, headaches 
• liver abnormalities 
• swelling of extremities 
• rash 
• visual changes 
• allergic reaction 


 
 
  
 
 
 
 
 
 
 
 
 
 
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Risks Associated with T cell depletion  
The toxicities and complications that could potentially result from the removal of lymphocytes 
from the donated bone marrow are failure of bone marrow engraftment (due to loss or damage to 
hematopoietic progenitor cells), an increased risk of relapse, and an increased risk of EBV-
associated lymphoproliferative syndrome. 
Risks Associated with Hematopoietic Stem Cell Infusion/Overall Transplant Process 
• 
nausea and vomiting  
• 
possible allergic reaction (including itching, hives, flushing [red face], shortness of 
breath, wheezing, chest tightness, skin rash, fever, chills, stiff muscles, or trouble 
breathing) 
• 
graft-versus-host-disease (GVHD) 
• 
veno-occlusive disease  
• 
mucositis,  
• 
infections (sepsis)  
• 
acute hemolytic reactions 
• 
febrile nonhemolytic reactions 
• 
allergic reactions 
• 
anaphylactoid or anaphylactic reactions 
• 
transfusion-related acute lung injury (TRALI) 
• 
DMSO toxicity 
• 
transmission of bacterial, viral or protozoal infection 
• 
fat embolism (marrow) 
• 
bleeding 
• 
transfusion-associated circulatory overload (TACO) 
• 
hypothermia 
• 
non-immunologic hemolysis 
• 
granulocyte-related complications 
• 
cardiotoxicity   
 
G-CSF  
• 
bone pain 
• 
headaches 
• 
body aches 
• 
fatigue  
• 
nausea/vomiting 
• 
insomnia 
• 
dyspnea 
• 
rash 
• 
edema