Conditions: Fanconi Anemia
Keywords: Fanconi anemia
Allocation: NON_RANDOMIZED | Intervention model: SINGLE_GROUP
Enrollment: 14
Healthy volunteers: no

Brief summary:
RATIONALE: A bone marrow or umbilical cord blood transplant may be able to replace blood-forming cells that were destroyed by chemotherapy. Giving combination chemotherapy before a donor stem cell transplant may make the transplant more likely to work. This may be an effective treatment for patients with high risk Fanconi's anemia.

PURPOSE: This clinical trial is studying how well combination chemotherapy works in treating high risk patients who are undergoing a donor stem cell transplant for Fanconi's anemia.

Detailed description:
OBJECTIVES:

Primary

* Determine whether the incidence of neutrophil engraftment is acceptable in high-risk patients with Fanconi's anemia treated with busulfan, cyclophosphamide, fludarabine, and antithymocyte globulin followed by allogeneic hematopoietic stem cell transplantation.

Secondary

* Determine the tolerability of mycophenolate mofetil in these patients.
* Determine the incidence of acute and chronic graft-vs-host disease in patients treated with this regimen.
* Determine the incidence of major infections in patients with a history of major infections treated with this regimen.
* Determine the incidence of relapse in patients with refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, or acute myeloid leukemia treated with this regimen
* Determine the probability of 1-year survival of patients treated with this regimen.

OUTLINE: Patients are stratified according to donor/recipient HLA type (identical vs other).

* Cytoreductive combination chemotherapy: Patients receive busulfan intravenously (IV) over 2 hours twice daily on days -7 and -6 and cyclophosphamide IV over 2 hours and fludarabine IV over 30 minutes once daily on days -5 to -2.
* Graft failure prophylaxis: Patients receive methylprednisolone IV twice daily on days -5 to 30 and anti-thymocyte globulin IV over 4-6 hours twice daily on days -5 to -1.
* Graft-vs-host disease prophylaxis: Patients receive cyclosporine IV over 2 hours twice daily on days -3 to 100 (if patient has a matched sibling donor) or days -3 to 180 (if patient has another donor type). Patients also receive mycophenolate mofetil orally or IV twice daily on days -3 to 45.
* Allogeneic hematopoietic stem cell transplantation (HSCT): Patients undergo allogeneic HSCT (using bone marrow or umbilical cord blood) on day 0. Patients receive filgrastim (G-CSF) subcutaneously beginning on day 1 and continuing until blood counts recover.

After completion of study treatment, patients are followed periodically for 3 years.

Arms:
arm 1: Bone marrow processed using Isolex300i arm 2: No processing arm 3: Bone marrow processed using CliniMACS system arm 4: Sibling donor without the use of CliniMACS system

Interventions: intervention 1: anti-thymocyte globulin intervention 2: filgrastim intervention 3: busulfan intervention 4: cyclophosphamide intervention 5: fludarabine phosphate intervention 6: methylprednisolone intervention 7: Hematopoietic stem cell transplantation
Intervention descriptions: intervention 1: Given 15 mg/kg/day intravenously every 12 hours on Days -5 through -1. intervention 2: given 5 mcg/kg/day intravenously on Day 1 (continue until absolute neutrophil count (ANC) ≥2.5 x 10\^9/L) intervention 3: Busulfan 0.8 mg/kg intravenously (IV) every 12 hours on Days -7 and -6 (1.0 mg/kg IV if \<4 years old) intervention 4: 10 mg/kg intravenously (IV) on Days -5 through -2. intervention 5: 35 mg/m\^2 intravenously (IV) on Days -5 through -2. intervention 6: 1 mg/kg intravenously (IV) every 12 hours on Days -5 through -1. intervention 7: Infused on Day 0 - Donor bone marrow or umbilical cord blood will be collected in the usual sterile manner using established parameters determined by the National Marrow Donor Program.

Protocol document:
Prot_SAP_000.pdf: 
UNIVERSITY OF MINNESOTA BLOOD AND MARROW TRANSPLANTATION 
PROGRAM 
 
 
 
 
 
 
 
Hematopoietic Stem Cell Transplantation in High Risk Patients with 
Fanconi Anemia 
 
MT2002-02 
CPRC # 2002LS014 
 
 
 
 
 
Study Committee 
Margaret L. MacMillan, MD, PI 
John E. Wagner, MD 
Todd DeFor, MS (biostatistician)  
 
Version Date 
September 4, 2019 
 
 
 
 
 
 
 
 
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 
 
 
 
DATE 
PROTOCOL CHANGE 
12/17/12 
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 
Add arm 4 for registration purposes – Sibling donor, without use of the CliniMACS 
Add section 4.5 Registration with definition of arms 
Correct donor inclusion criteria section 4.3.5 
Clarify peripheral blood will be used as a cell source only if bone marrow cannot be obtained. 
Replace Dilantin with Keppra for seizure prophylaxis per current institutional practice 
Replace Antifungal Therapy section with updated drugs per current institutional practice 
Update statistical section 
Update to current IRB and FDA event definitions and reporting requirements 
Update to current formatting 
03/02/2011 
Revised eligibility criteria to include only subjects with 1) FA and biallelic BRCA2 mutation, or 2) 
with FA and aplastic anemia, advanced MDS or acute leukemia who are ineligible for total body 
irradiation. Added documentation that protocol is conducted under IND 14536 (cover page, 
sections 9.1.2 and 9.2, 
03/24/2010 
Section 7.4 Cell Processing – replace Isolex 300i System with CliniMACS® Cell Selection System 
(Miltenyi Biotec), add protocol to current  CliniMACS IDE (D. Weisdorf sponsor); add section 
9.1.4 for reporting CliniMAC malfunction to Miltenyi; Section 8.9 Immune Reconstitution – 
replace reference to terminated protocol MT2001-12 with current protocol MT2009-22R; Section 9 
replace with current SAE reporting requirements and DSMP, update risks.  Delete appendix I and 
VII, renumber rest; Additional Minor edits; Update consents 
5/12/2008 
Updated DSMC plan 
8/11/2004 
Donor eligibility criteria added 
5/5/2004 
a) deleted the exclusion criteria 5.2.3 “Malignancy within 1 year of HSCT”, and b) added to the 
inclusion criteria 5.1.1 2) history of malignancy, currently in remission. 
Stopping rules in section 9.3 have been amended to include as treatment related mortality (TRM) as 
a stopping rule 
Added voriconazole to toxicities 
1/26/2004 
Peripheral stem cells added as source (sections 3.0, 4.3.1, 7.0, 7.1, 8.6, Appendix VII) 
Eligibility: recipients must be between 18 and 45 (section 5.1.1) 
Voriconazole added to fungal therapy (section 6.3.1) 
Double cord blood added (section 7.2.1, 8.6) 
Toxicities added for donors (Appendix VII) 
Todd DeFor, M.S. replaces Anne Goldman Ph.D. as Biostatistician 
11/01/2016 
Updated protocol to remove IND as all subjects will now be co-enrolled on the HUD protocol. 
Antifungal therapy updated to current standard of care (section 5.3) 
Removed standard of care evaluations from the trial (section 7 and Appendix 1) 
Removed day 21 bone marrow biopsy 
09/04/2019 
Revised to clarify that post transplant bone marrow aspirates and biopsies will only be performed as 
clinically indicated 
Clarified that ATG is dosed every 24 hours 
Busulfan, ATG, and supportive chemotherapy updated per current pharmacy standard of care 
Updated reporting requirements to current MCC SOP 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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Table of Contents 
 
TREATMENT PLAN ..................................................................................................................... 4 
1 
OBJECTIVES .......................................................................................................................... 5 
2 
STUDY DESIGN .................................................................................................................... 5 
3 
BACKGROUND ..................................................................................................................... 5 
4 
PATIENT/DONOR SELECTION AND REGISTRATION ................................................... 9 
5 
PREPARATIVE THERAPY/IMMUNOSUPPRESSIVE THERAPY ................................. 10 
6 
STEM CELL COLLECTION, PROCESSING AND INFUSION ........................................ 13 
7 
SCHEDULE OF STUDY ACTIVITIES ............................................................................... 14 
8 
ADVERSE EVENT MONITORING AND REPORTING  .................................................. 16 
9 
DATA AND SAFETY MONITORING PLAN .................................................................... 19 
10 
STATISTICAL CONSIDERATIONS............................................................................... 19 
11 
ETHICAL AND REGULATORY CONSIDERATIONS ................................................. 20 
12 
REFERENCES .................................................................................................................. 22 
APPENDIX I - SCHEDULE OF ACTIVITIES FOR EACH PATIENT ..................................... 24 
APPENDIX II-  GRAFT VERSUS HOST DISEASE ................................................................. 25 
APPENDIX III - PERFORMANCE STATUS SCALE ............................................................... 26 
APPENDIX IV - STUDY RELATED TOXICITIES ................................................................... 27 
 
 
 
 
 
 
 
 
 
Sponsor/Investigator Contact Information: 
Margaret L. MacMillan, MD, MSc 
University of Minnesota  
Pediatric Blood and Marrow Transplant Program  
MMC 484   
420 Delaware Street SE 
Minneapolis, MN 55455 
612 626-2961 (phone) 
612-626-2815 (fax) 
macmi002@umn.edu (email) 
 
 
 
 
 
 


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TREATMENT PLAN 
 
 
possible stem cell sources:  related donor BM, unrelated donor BM, UCB  
 
 
treatment plan: 
 
 
 
 
 
 
 
 
 
 
 
   HSCT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     -8 
-7 
-6 
     -5                -4                -3   
     -2                -1                 0       
     +45 
 
 
 
 
 
 
   CSA 
 
 
 
 
 
 
   MMF  
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
    G-CSF 
 
 
 
 
 
 
 
 
 
 
 
 
 
            Busulfan 0.8 mg/kg IV q 12 hours (1.0 mg/kg IV q 12 hours if <4 years old) day -7 and -6 
 
  
 
            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 
 
 
              Antithymocyte globulin or ATG (ATGAM)  30 mg/kg/day IV every 24 hours days -5 through day -1 
(Methylprednisolone pre-med 2 mg/kg IV) 
 
 
 
 
 


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CPRC #2002LS014 
 
1 
OBJECTIVES 
 
1.1 
Primary Objective 
To determine the incidence of neutrophil engraftment in Fanconi Anemia patients with high 
risk disease treated with busulfan (BU), cyclophosphamide (CY), fludarabine (FLU) and 
antithymocyte globulin (ATG) followed by HSCT. 
 
1.2 
Secondary Objectives 
To evaluate: 
• incidence of acute and chronic graft-versus-host disease (GVHD) 
• incidence of relapse in patients with refractory anemia with excess blasts (RAEB), 
refractory anemia with excess blasts in transformation (RAEBt) or acute myeloid 
leukemia (AML) 
• incidence of major infections (gram negative infections, probable or proven fungal 
infections) in patients with history of major infections 
• incidence of regimen-related toxicity (RRT) based on transplant outcomes 
• tolerability of mycofenolate mofetil (MMF) 
• probability of one year survival 
 
 
2 
STUDY DESIGN 
 
This is a single center study to evaluate the safety, and incidence of neutrophil engraftment in high 
risk Fanconi anemia patients transplanted with related or unrelated CD34+ selected cells after a 
cytoreductive preparative regimen consisting of busulfan, cyclophosphamide, fludarabine, and 
antithymocyte globulin (ATG). Effective with November 1, 2016 protocol, subjects receiving CD34+ 
selected cells will co enroll on MT2015-31 for T-cell depletion. 
 
 
3 
BACKGROUND 
 
3.1 
Overview 
HSCT from an allogeneic donor is the only treatment with potential to reverse the 
hematological complications of FA.  Until recently, few patients with a non-HLA identical 
sibling donors have survived HSCT.  However, as a result of a series of phase I studies, we 
have identified a safe and effective regimen that reproducibly allows for primary engraftment 
with low risk of regimen related toxicity (RRT) and graft-versus-host disease (GVHD).  New 
data suggest that the success of transplantation is dependent upon the clinical status of the 
patient at the time of HSCT.1   
 
3.2 
Results with non-HLA Identical Sibling Donor HSCT: Review of the Literature 
For the IBMTR, Gluckman et al. (1995) analyzed the outcome of 199 patients who received 
HSCT for FA from HLA-identical siblings (n=151), mismatched family member donors 
(n=29) or unrelated donors (n=19).2  Age at transplant ranged from 1 to 39 years (median 10 
years) for HLA-identical sibling recipients and 4 to 31 years (median 9 years) for non-HLA 
identical sibling donor recipients.  A variety of preparative therapies, GVHD prophylaxis and 


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supportive care strategies were utilized.  For recipients of HLA-identical sibling HSCT, two 
year probability of myeloid engraftment was 92%.  Estimated probabilities of grade II-IV 
acute GVHD at day 100 was 42% and of chronic GVHD at 2 years 44%.  Estimated 
probability of survival at 2 years was 66%.  In multivariate analysis, improved engraftment 
rates were observed with age of HSCT ≤10 years, conditioning including ATG, and higher 
platelet count before transplant.  In multivariate analysis, decreased mortality was observed 
with younger age, use of ATG in the conditioning regimen, conditioning with LFI and low-
dose CY versus ≥100 mg/kg CY and no irradiation, and the use of cyclosporin with or without 
methotrexate for GVHD prophylaxis.  Patients who received marrow from alternate donors 
(i.e. donors other than HLA-identical sibling donors) had worse outcomes.  Myeloid 
engraftment was observed in only 76% of patients and grade II-IV acute GVHD occurred in 
51%.  The probability of survival was 29% after alternative donor transplantation. 
 
More recently, the results of a retrospective multicenter study of 69 unrelated donor HSCTs 
facilitated through the European Group for Blood and Marrow Transplantation were recently 
reported by the Paris group.3  Median age at time of HSCT was 10.8 years (range 4.0 to 37.4 
years).  Eleven patients (16%) had features of MDS (n = 8) or AML (n = 3) prior to HSCT.  
Preparative therapy consisted of low dose CY, total body irradiation (TBI) ± ATG in 56% 
patients, low dose CY, thoracoabdominal irradiation (TAI) ± ATG in 41% patients and 
chemotherapy ± ATG in 3% patients.  The probability of achieving neutrophil recovery by 
day 30 was 83%.  In multivariate analysis, higher probability of achieving neutrophil recovery 
was associated with younger age (<10 years), a pretransplant elevation of serum 
alanine/aspartate transaminases (ALT/AST) >2x upper limit of normal, the use of a male 
donor, and absence of 3-lineage cytopenia before initiation of preparative therapy.  Primary 
graft failure occurred more frequently when female donors were used, mainly due to lower 
nucleated cell doses compared to grafts from male donors.   The probability of severe (grade 
III-IV) acute GVHD was 34%.  Elevated serum ALT/AST before HSCT, limb, urogenital 
tract or nephrologic malformations, and non-T cell depleted grafts were predictive or severe 
GVHD.  Three year probability of survival was 33%.   Among the 14 patients older than 15 
years at the time of HSCT, 2 were alive at last follow-up giving a 3 year estimated survival of 
14%.  In multivariate analysis, extensive congenital malformations, positive cytomegalovirus 
serology, the use of androgens before HSCT, and female donors were associated with a worse 
outcome.  
 
In 2012, arm 4 was added in section 4.5 as it was recognized not all sibling donor bone 
marrow will require cell selection using the CliniMACS.  The decision whether or not to do 
CD34 selection will be made on an individual patient basis. 
 
3.3 Results with non-HLA Identical Sibling Donor HSCT at the University of Minnesota 
3.3.1 Results with CY-TBI-ATG 
At the University of Minnesota, between June 1993 and July 1998, 29 FA patients were 
treated with cyclophosphamide 40 mg/kg, total body irradiation (TBI) 450 cGy or 600 
cGy and anti-thymocyte globulin (ATG) followed by HSCT from a non-HLA identical 
sibling donor HSCT.4  GVHD prophylaxis consisted of cyclosporine A (CSA) for 6 
months, short course methylprednisolone (2 mg/kg/d) between day +5 and +19 and TCD 
by counterflow elutriation in bone marrow recipients.  For the entire cohort, the 
probability of neutrophil recovery was 61% (95%CI 43-79%). In univariate analysis, 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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factors associated with increased graft failure in bone marrow (BM) recipients were 
presence of T cell somatic mosaicism (p = .04) and smaller cell dose (<median of 3.4 x 
107 nucleated cells/kg, p = .05).  Of 25 patients evaluable for myeloid engraftment, 3 of 13 
patients without T cell somatic mosaicism (< median of 10% DEB insensitive cells) failed 
to engraft while 7 of 12 patients with T cell somatic mosaicism (>median of 10% DEB 
insensitive cells) experienced primary graft failure.  Probabilities of neutrophil recovery 
for patients with and without somatic mosaicism were 42% (95% CI 14-70%) and 83% 
(95% CI 61-100%), respectively (p = .05).   Probability of grade III-IV acute GVHD was 
28% (95%CI 8-48%).  The probability of survival at 1 year was 34% (95% CI 17-51%).  
Kaplan-Meier estimate of 1 year survival for the entire cohort of 29 patients was 34% 
(95%CI 17-51%).  One year survival in the TBI 450 cGy, TBI 450 cGy with ATG, and 
600 cGy with ATG groups, were 43% (95%CI 17-69%), 43% (95%CI 6 - 80%), and 13% 
(95%CI 0-35%), respectively (p = NS).4   
 
3.3.2 Results with FLU-CY-TBI-ATG 
Based on all the data from here and elsewhere through 1999, the major obstacle to 
successful alternate donor HSCT for patients with FA was graft failure.  To potentially 
improve engraftment rate we chose a relatively new immunosuppressive agent, 
fludarabine (FLU)5-8 to add to the  commonly used preparative regimen of 
cyclophosphamide (CY, 40 mg/kg), total body irradiation (TBI, 450 cGy) and ATG (150 
mg/kg).  Between April 1999 and November 2001, 27 patients with FA (AA [n=17], 
RAEB [n=6], RAEBt [n=4]) underwent T cell depleted bone marrow (n=19) or umbilical 
cord blood transplantation (n=6) from alternate donors (ie. non-HLA-matched sibling 
donors).  Primary neutrophil engraftment was achieved in 25/25 evaluable patients 
including 9 patients with somatic mosaicism, a potential risk factor for GF.  This outcome 
was of particular significance since the same CY/TBI/ATG regimen but without FLU 
resulted in only a 63% (95% CI, 42-82%) incidence of engraftment (p<0.01).  Notably, 
secondary GF occurred in 2 recipients of the FLU based regimen at 5 and 7 months after 
HSCT.  OF 25 patients surviving beyond day 21 after HSCT, none developed severe 
(grade 3-4) acute GVHD.  Chronic GVHD has been observed in 2 patients thus far.  With 
a median follow up of 14 months, the probability of survival at 1 year is 46%.   
 
In a recent analysis1, we stratified the patients on the basis of disease status, a known risk 
factor that impacts survival in FA patients undergoing HCST.2, 3  Patients were considered 
high risk if they had advanced myelodysplastic syndrome (MDS, i.e. refractory anemia 
with excess blasts [RAEB] or refractory anemia with excess blasts in transformation 
[RAEBt]), acute myeloid leukemia (AML) or a history of systemic gram negative or 
Months
Probability of Survival
0.0
0.2
0.4
0.6
0.8
1.0
0
2
4
6
8
10
12
p < .01
standard risk  86%
high risk  13%


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invasive fungal infection.  Of note, systemic risk patients (n = 18) had a high probability 
of survival ((86%, 95% CI 67-100%).  In contrast, as shown in the figure below, patients 
with high risk disease (n = 9) had a significantly lower survival (13%, 95% CI 0-36%, 
p<0.01). 
 
Therefore, we elected to terminate enrollment of high risk patients onto the FLU-CY-TBI-
ATG regimen and develop a novel treatment regimen for high risk patients in an attempt 
to improve survival without compromising engraftment.  Standard risk patients which 
have done exceptionally well, will continue to receive the FLU-CY-TBI-ATG regimen as 
detailed in protocol MT 1999-05. 
 
3.3.3 Summary 
In summary, the addition of FLU to CY, TBI and ATG is associated with superior 
engraftment in patients undergoing alternate donor HSCT as compared to all prior 
regimens without FLU.  However, survival remains poor specifically in FA patients with 
advanced disease.  
 
3.4 
Rationale for Proposed Novel Treatment Regimen 
Based on the data here as shown above, a new approach is needed for patients with high risk 
FA.  Busulfan is effective chemotherapeutic agent against leukemia and myelodysplasia.9  
Furthermore, it may eliminate the need for TBI which is toxic to FA patients potentially 
increasing their risk of infection (i.e., by increased breakdown of the mucosal barrier of the 
gastrointestinal tract).  While the use of TBI is standard of care for patients with FA 
undergoing HSCT, TBI may play a role in the increased risk for the development of late 
malignancies.  If engraftment can be achieved with busulfan without increased toxicity, this 
therapy may be applicable to standard risk patients in the future in an attempt to decrease the 
risk of late effects (malignancy, sterility and endocrinopathies). 
 
3.4.1 Busulfan Mechanism of Action 
Busulfan (BU) is an alkylating agent with profound myeloablative and anti-leukemic 
properties.  It is frequently used in preparative regimens prior to HSCT as a irradiation 
sparing agent.9-11  The levels of oral busulfan have been shown to be quite variable, 
presumably due to marked differences in absorption and/or clearance.12  In addition, there 
is some suggestion that increased plasma levels may relate to enhanced toxicity, while 
inadequate levels may be associated with graft failure.13  The recent availability of an 
intravenous form of the drug may result in decreased variation of the pharmacokinetics of 
the drug.14  The drug has been tested in children using a dose of 0.8 mg/kg; however, it 
was determined that in children less than 4 years of age the clearance was more rapid and 
in this population a dose of 1.0 mg/kg will be used.15   
 
3.4.2 Busulfan Based Preparative Therapy for HSCT for FA Patients 
There have been a few case reports published in the literature using BU as preparative 
therapy in patients with FA as shown in the chart below.  The BU dose has varied 
considerably.  Nevertheless, patients have experienced durable engraftment and favorable 
outcome with tolerable amounts of regimen related toxicity. 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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Reference 
Conditioning Regimen 
Number of 
Cases 
Sustained 
Engraftment 
 
Outcome 
Flowers et al., 199216 
CY 100 mg/kg + BU 14 
mg/kg PO 
1 
1/1 
Died, day 4 
 
Ratanatharathorn et al., 
199317* 
BU 8 mg/kg PO + TLI 5Gy 
2 
2/2 
Alive >20 mos 
Died, day 45 
Maschan et al, 199718* 
BU 8mg/kg PO + CY 40 
mg/kg 
1 
1/1 
Alive >17 mos 
 
Ebell et al., 200119 
BU 2 mg/kg IV + FLU 180 
mg/m2 + ATG 
8 
8/8 
6 Alive 
Kato G. (personal 
communication) 
BU 16  mg/kg PO 
CY 200 mg/kg 
1 
1/1 
Alive 17 years 
* Advanced MDS patients 
 
3.5 
Schema for HSCT for Patients with FA 
In summary, the decision of when to transplant a patient with FA and with which preparative 
therapy depends on the patient’s age, risk status and type of available donor.   
 
 
4 
PATIENT/DONOR SELECTION AND REGISTRATION 
 
4.1 
Patient Inclusion Criteria 
 
4.1.1 Patients must be <45 years of age with a diagnosis of Fanconi anemia with 
Biallelic BRCA2 mutations or  
Aplastic anemia, or advanced MDS (MDS with ≥5% blasts), or acute leukemia who 
are ineligible for total body irradiation. Aplastic anemia is defined as having at least 
one of the following (with or without cytogenetic abnormalities): 
- 
platelet count <20 x 109/L 
- 
ANC <5 x 108/L 
- 
Hemoglobin <8 g/dL 
 
Patients must have an HLA-A, B, DRB1 identical or 1 antigen mismatched related or 
unrelated BM donor or have an HLA-A, B, DRB1 identical, 1 antigen or 2 antigen 
mismatched related or a suitable unrelated umbilical cord blood (UCB) donor.  
Patients and donors will be typed for HLA-A and B, DRB1 using high resolution 
molecular typing. Related donors will be evaluated under the University of Minnesota 
donor protocol MT2012-14C.   
 
4.1.2 Adequate major organ function including: 
• Cardiac: ejection fraction >45% 
• Hepatic: no clinical evidence of hepatic failure (e.g. coagulopathy, ascites, no 
cirrhosis) 
• Karnofsky performance status >70% (age 16 years and older) or Lansky Play Score 
>50 (16 years and younger) – appendix I 
 
4.1.3  Women of child bearing potential must be using adequate birth control and have a 
negative pregnancy test 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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4.2 
Exclusion Criteria 
 
4.2.1  Active CNS leukemia at time of HSCT 
 
4.2.2. Active uncontrolled infection within one week of HSCT 
 
4.2.3 Pregnant or lactating female 
 
4.3 
Donor Inclusion Criteria 
4.3.1 In good health based on review of systems and results of physical examination 
 
4.3.2 Normal hemoglobin, white count, platelet count and PTT, and a negative DEB test 
4.3.3 HIV-NAT negative, HTLV-1, HTLV-2 negative, Hepatitis B and C negative 
4.3.4 Female donors of childbearing potential must have a negative pregnancy test 
4.3.5 Must agree to PBSC donation in the event sufficient BM cells are not collected 
 
4.4 
Donor Exclusion Criteria 
 
 
4.4.1 Donor is a lactating female 
 
4.5 
Patient/Donor Registration 
The eligibility checklist will be completed at the time of study enrollment.  Upon completion 
of the screening evaluation and obtaining consent, the study coordinator or designee will 
enroll the patient and donor (if related) into OnCore®, the Masonic Cancer Center’s clinical 
database. 
 
The patient will be assigned to one of the following preparative arms based on cell source: 
Arm 1:  BM using the Isolex 300i System (closed September 2010) 
Arm 2:  UCB (co-enroll in MT2011-13r for unmanipulated UCB’s) 
Arm 3: BM using the CliniMACS (effective October 2010) Subjects enrolled on the 
November 1, 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:  Sibling donor without use of the CliniMACS  
 
The decision whether or not to do CD34 selection will be made on an individual patient basis. 
 
5 
PREPARATIVE THERAPY/IMMUNOSUPPRESSIVE THERAPY 
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.).    
 
 
 


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Treatment Plan: 
 
Day 
Treatment Plan 
-8 
Admit to start levetiracetam (Keppra) 
-7 
Busulfan 0.8 mg/kg IV q 12h 
(1.0 mg/kg IV q 12h if <4 years old)  
-6 
Busulfan 0.8 mg/kg IV q 12h 
(1.0 mg/kg IV q 12h if <4 years old) 
-5 
Cyclophosphamide 10 mg/kg IV 
Fludarabine 35 mg/m2 IV 
Methylprednisolone 2 mg/kg IV q 24h 
Antithymocyte globulin (ATGAM) 30 mg/kg/day 
IV q 24 hours 
-4 
Cyclophosphamide 10 mg/kg IV 
Fludarabine 35 mg/m2 IV 
Methylprednisolone 2 mg/kg IV q 24h 
Antithymocyte globulin (ATGAM) 30 mg/kg/day 
IV q 24 hours 
-3 
Cyclophosphamide 10 mg/kg IV 
Fludarabine 35 mg/m2 IV 
Methylprednisolone 2 mg/kg IV q 24h 
Antithymocyte globulin (ATGAM) 30 mg/kg/day 
IV q 24 hours 
-2 
Cyclophosphamide 10 mg/kg IV 
Fludarabine 35 mg/m2 IV 
Methylprednisolone 2 mg/kg IV q 24h 
Antithymocyte globulin (ATGAM) 30 mg/kg/day 
IV q 24 hours 
-1 
Methylprednisolone 2 mg/kg IV q 24h 
Antithymocyte globulin (ATGAM) 30 mg/kg/day 
IV q 24 hours 
0 
HSCT 
+1 
Initiate G-CSF 5mcg/kg/day IV (continue until ANC 
≥2.5 x 109/L) 
 
 
 
 
5.1 
Preparative Therapies 
The preparative cytoreductive therapy will be identical for all patients.  Treatment related 
toxicities are defined in the Appendix IV. 
 
All drugs will be prepared and administered per institutional guidelines, with the drugs, doses 
and scheduled modified as clinically indicated.   
 


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Busulfan 
As seizures have occurred following high dose busulfan, all patients will be treated with 
Keppra beginning the night before the first dose of Busulfan (day -8) and continuing until day 
-4 per institutional guidelines. 
 
Busulfan 0.8 mg/kg IV (with dose of 1.0 mg/kg IV for children <4 years of age) over 2 hours 
to be given q 12 hours for 2 days for a total dose of 3.2 mg/kg (4.0 mg/kg if <4 years of age).   
 
Busulfan administration and monitoring (including BU levels) should be performed per 
institutional guidelines.  Dosing may be based on Bayesian pharmacokinetics if available or in 
consultation with inpatient pharmacists using Long-Boy model23.   
 
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.  
 
5.2 
Immunosuppressive Therapies 
 
5.2.1 Graft Failure Prophylaxis 
Methylprednisolone 2 mg/kg/day intravenously every 24 hours will be given on days -
5, -4, -3, -2 and –1, immediately prior to the infusion of antithymocyte globulin 
(ATGAM). 
 
Antithymocyte globulin (ATGAM) 30 mg/kg every 24 hours will be administered 
after each dose of methylprednisolone on days -5, -4, -3, -2 and -1.  Antithymocyte 
globulin will be diluted in sterile normal saline or half normal saline for intravenous 
infusion to a concentration of 1-2 mg/mL and will be infused through the Hickman 
catheter over 4-6 hours.  In the event of a significant reaction to antithymocyte 
globulin (ATGAM), further doses of the agent will not be administered.   
 
If the patient does not tolerate ATGAM, they will receive the following: 
 
• Thymoglobulin 3 mg/kg IV q24h.  Patient will still receive methylpred 2 
mg/kg IV q24h as a premed. 
 


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5.2.2 GVHD Prophylaxis 
Patients will receive cyclosporine A (CSA) and mycophenylate mofetil (MMF) as 
GVHD prophylaxis. 
 
CSA 
Patients will receive CSA therapy beginning on day -3 with a taper commencing on 
day +100 for matched sibling donor (MSD) recipients and day +180 for non-MSD 
recipients.  For adults with normal baseline renal function (creatinine <1.2 mg/dL), the 
initial CSA dose will be 2.5 mg/kg IV over 2 hours every 12 hours; for children 
<45kg, the initial dose will be 2.5 mg/kg IV over 2 hours every 8 hours.  CSA dosing 
will be monitored and altered as clinically appropriate per institutional pharmacy 
guidelines.   
 
MMF 
Patients will receive MMF therapy beginning on day –3 until day +45 inclusively.  
MMF will be given at a dose of 15 mg/kg/dose (max 1000mg) IV/PO TID  adjusted to 
tablet sizes of 250 mg and 500 mg as per institutional guidelines.  MMF may be given 
IV at the same dose if PO not tolerated. 
 
5.3 
Antifungal Therapy 
Patients will receive anti-fungal prophylactic therapy with itraconazole, posaconazole, 
caspofungin or micafungin or per current standard of care 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 
 
Preference will be made for the use of bone marrow 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.   
 
6.1 
Bone Marrow 
Unrelated donor bone marrow will be collected in the usual sterile manner using established 
parameters determined by the National Marrow Donor Program. 
 
Related donors will be evaluated and collected per MT2012-14C. Related donor bone marrow 
will be collected per institutional guidelines. 
   
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 November 2016 amendment, we will be using MT2015-31 to co-enroll subjects needing 
CD34+ cell isolation. A minimum of 5.0 x 108/kg nucleated bone marrow cells will be 
collected.  CD34+ cells will be isolated from the bone marrow using the CliniMACS® Cell 
Selection System (Miltenyi Biotec) from unrelated donors and selected related donors.  


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Related BM may or may not be T-cell depleted as determined on a per patient basis according 
to current T-cell depletion guidelines.  
 
Infusion will be according to the current University of Minnesota guidelines. 
 
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.  
 
6.2 
Umbilical Cord Blood 
For those patients without an HLA identical unrelated donor or HLA identical or 1 antigen 
mismatched related donor, UCB will be the stem cell source of choice.  The UCB graft may 
be composed of 1 or 2 UCB units.  The final UCB graft must contain at least 2.5 x 107 
nucleated cells/kg recipient weight (or 1.7 x 105 CD34+ cells/kg recipient weight, if known) 
based on cell numbers at time of cryopreservation.  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. 
 
 
7 
SCHEDULE OF STUDY ACTIVITIES 
 
7.1 
Schedule of Activities – refer to appendix I 
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. 
 
7.2 
Pre Study Screening Procedures 
 
• Urinalysis and 24 hour urine creatinine clearance or GFR.  
• Pregnancy test (urine) - as clinically indicated 
• CMV titer (donor/recipient) 
• Chest radiograph, high resolution chest CT, sinus CT, and other radiographic studies 
(as clinically indicated) 
• Tumor characteristics at sites of involvement including CT scan of head, chest, 
abdomen and pelvis (if clinically indicated) 
• Bone marrow aspirate and biopsy 
• Karnofsky or Lansky performance status (Appendix I) 
• Ultrasound of liver and kidneys (within 3 months of HSCT) 


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• If history of androgens and liver US normal, CT scan of abdomen with contrast to 
assess for hepatic adenoma.  If both ultrasound and CT scan negative, MRI abdomen 
to assess for adenoma. 
• Pulmonary functions tests (children >6 years, adults) 
• ECG; echocardiography with left ventricular ejection fraction 
• Infectious disease consultation 
 
7.3 
Evaluation During Therapy Until Engraftment 
• CBC with platelet count daily until one week after ANC ≥ 5 x 108/L, PLT ≥20 x 109/L 
• Review for events per section 8 and for the BMT database  
• 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 toxicity/events per section 8 and for the BMT database  
 
7.5 
Evaluation Post Engraftment at Day 60, 100, 180, and 365 and then Once Yearly until 2 
Years after HSCT 
• CBC, differential and platelet 
• GVHD score 
• Physical exam 
• Bone marrow aspiration, biopsy at day 100, 180 and 365 days if clinically indicated 
• Donor chimerism by peripheral blood VNTR at day 60 
• Tumor characteristics and sites of involvement 
• Patient characteristics evaluated at each visit (Karnofsky or Lansky scale, weight, age) 
• Review for events/toxicity per section 8 and for the BMT database  
• Clinical Summary at close of study 2 years after BMT or, at death (obtain autopsy 
report if available) 
 
7.6 
Engraftment Evaluation  
Peripheral blood CBC counts will be monitored daily after transplantation until engraftment 
and weekly after engraftment while hospitalized.  CBC counts will be evaluated at follow-up 
visits in the outpatient clinic.  Chimerism assay of the bone marrow will be sent on day 21, 
day 60, day 100, day 180, and day 365 and once a year for 2 years.  If the patient's peripheral 
blood counts are slow to recover, (i.e. ANC <5 x 108/L by day 30) or the peripheral blood 
counts drop below 1 x 109/L after an initial recovery, the peripheral blood and bone marrow 
will be evaluated. Patients diagnosed with graft failure (ANC <5 x 108/L by day 45) must be 
reported. 
 
7.7 
Residual/Recurrent Disease Evaluation  
Patients with leukemia will be evaluated routinely for histological evidence of leukemia by 
bone marrow examination at day 21, 60, day 100, day 180, day 365 and annually thereafter 
for a maximum of 2 years.  If at any time recurrent disease is suspected, additional analyses of 


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CPRC #2002LS014 
the peripheral blood and bone marrow will be performed.  When appropriate, molecular or 
cytogenetic diagnostic tests will also be performed to detect residual or recurrent disease. 
 
7.8 
Immune Reconstitution 
Patients should be considered for the University Of Minnesota protocol MT2009-22R - 
Monitoring of Immune Function and Minimal Residual Disease in Patients and Donors After 
Hematopoietic Cell Transplantation (HCT). 
 
 
8 
ADVERSE EVENT MONITORING AND REPORTING  
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 
 
 
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 protocol-related 
documents (e.g. protocol, consent documents, investigator brochure, package insert) or is not 
listed at the specificity or severity that has been observed or given the characteristics of the 
subject population being studied  
 
Attribution: is the relationship between an adverse event or serious adverse event and the 
study dru g. Attribution is assigned as follows: 
• 
Definite – The AE is clearly related to the study drug 
• 
Probable – the AE is likely related to the study drug 
• 
Possible – the AE may be related to the study drug 
• 
Unlikely – the AE is doubtfully related to the study drug 
• 
Unrelated – the AE is clearly not related to the study drug 
Attribution must be assigned by the treating physician or the PI. 
 
The following definitions are from the Masonic Cancer Center’s Standard Operating 
Procedure (SOP) Deviation Reporting: 
 
 
Major Deviation: A deviation or violation that impacts the risks and benefits of the research; 
may impact subject safety, affect the integrity of research data and/or affect a subject’s 
willingness to participate in the research. Deviations that place a subject at risk, but do not 
result in harm are considered to be major deviations. 
 
Minor Deviation: A deviation or violation that does not impact subject safety, compromise 
the integrity of research data and/or affect a subject’s willingness to participate in the 
research. 
 
Expedited (Rapid) Reporting: Certain events may require rapid notification to entities 
providing patient safety oversight (e.g. IRB) as detailed in section 8.2.  For the IRB this is 5 
working days.   
 
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. 
 
 
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 


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• Recipient bacteremia with clinical signs and symptoms related to a contaminated UCB 
within 24 hours after infusion 
 
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   
 
The incidence of graft failure, treatment related morality, opportunistic infection, and GVHD 
will be monitored as part of the secondary objectives.  These events may not necessary 
constitute a serious adverse advent; however such events may count toward early study 
stopping rules as detailed in section 10.3.  
 
 
8.3 
Reporting Requirements 
 
 
Agency 
reporting to 
Criteria for reporting 
Timeframe 
Form to Use 
Submission 
address/email 
address 
U of MN IRB  
Unanticipated death of a locally enrolled 
subject(s); New or increased risk; Any 
adverse event  that require a change to the 
protocol or consent form – refer to the IRB 
website for complete details  
5 Business 
Days 
IRB Report Form  
 
irb@umn.edu 
Clinical deviations per current IRB reporting requirements 
OnCore Deviation 
Form  
1) Serious and unexpected suspected 
adverse reaction or 
2)  increased occurrence of serious suspected 
adverse reactions over that listed in the 
protocol or investigator 
brochure or 
3) findings from other sources (other studies, 
animal or in vitro testing) 
no later than 
15 Calendar-
Days 
 
Masonic 
Cancer Center 
SAE 
Coordinator 
Events that meet the definition of dose 
limiting toxicity or an early study stopping rule 
(see section 10.3) 
At time of 
reporting 
Event Form 
mccsaes@umn.edu 


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CPRC #2002LS014 
 
 
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.   
 
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 
 
It is anticipated that we will enroll a total of 25 patients.  Patients will be stratified on the basis of 
donor type (HLA genotypically identical versus other donor). 
 
10.1 
Objectives 
The primary objective of this study is to estimate the probability of engraftment.  The 
incidence of GVHD, relapse, major infections, transplant-related mortality (at day 100) and 
cumulative proportion surviving at 1 year will also be evaluated.  The plan is to enroll a 
maximum of 25 patients in a single arm study. 
 
10.2 
Statistical Analysis 
There will be continuous monitoring of graft failure.  The goal is that graft failure (day 30) be 
<10% with an upper limit of 25%.  Analysis of secondary objectives will consider the 
incidence of acute GVHD, chronic GVHD, opportunistic infections, relapse (to MDS or 
AML), and cumulative proportion surviving at 1 year.  These will be estimated using 
cumulative incidence20 and by the cumulative proportion event-free (by Kaplan-Meier 


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CPRC #2002LS014 
estimates) and their confidence intervals.21  Early mortality will be a competing or a censoring 
event, respectively for the two methods.  Confidence levels of 90% will be used because of 
the small number of available patients. 
 
10.3 
Toxicity Monitoring and Early Stopping Rules 
Graft failure will be monitored with a type I error rate of 10% to increase the probability of 
stopping early and because of the small sample size.  Stopping boundary for graft failure (H0 
P=0.10 vs. H1 P=0.25): stop for 2 graft failures in the first 2 patients, 4 of 8 or 5 of 25.  This 
has a type I error rate of 10% if the actual rate is 0.10 and a power of 79% to detect a rate as 
high as 0.25 at an average sample size of 17.5 patients.  If the actual graft failure rate were 
only 0.20, the power is lowered to 59%.  Because graft failure is likely to be more of a 
problem for those with unrelated donors, the same stopping boundary will be used for that 
group alone.  The smaller sample size and problems with multiple testing are ignored.22  
 
The monitoring boundary will be set up based on an overall goal of terminating the study if 
more than 38% of patients have treatment related mortality by day 100 post transplant. 
 
The monitoring boundary for this study is: 
4/4 death, 5/5, 6/7, 7/10, 8/13, 9/25 
 
This boundary has a type I error rate of .10 if the true event rate is approximately 25% and a 
power of 0.65 for a rate of 38%22 
 
10.4 Data Collection  
Data collection will include those data that are routinely recorded for related and unrelated 
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 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 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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CPRC #2002LS014 
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 
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. 
 
11.4 
Ethical Considerations 
The study will be conducted in accordance with ethical principles founded in the Declaration 
of Helsinki.  The IRB will review all appropriate study documentation in order to safeguard 
the rights, safety and well-being of the patients.  The study will only be conducted at sites 
where IRB approval has been obtained.  The protocol, informed consent, written information 
given to the patients, safety updates, annual progress reports, and any revisions to these 
documents will be provided to the IRB by the investigator. 
   
11.5 
Informed Consent 
All potential study participants will be given a copy of the IRB-approved consent document to 
review. The investigator or designee will explain all aspects of the study in lay language and 
answer all questions regarding the study. If the participant decides to participate in the study, 
he/she will be asked to sign and date the consent document. Patients who refuse to participate 
or who withdraw from the study will be treated without prejudice. 
 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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CPRC #2002LS014 
 
12 REFERENCES 
 
1.   MacMillan ML, Weisdorf DJ, DeFor TE, et al. Marked reduction in graft failure and regimen related 
toxicity after unrelated donor hematopoietic cell transplantation in patients with Fanconi anemia: 
Impact of disease stage and fludarabine. Blood. 2001;98:670a. 
2.   Gluckman E, Auerbach AD, Horowitz MM, et al. Bone marrow transplantation for Fanconi anemia. Blood. 
1995;86:2856-2862. 
3.   Guardiola P, Pasquini R, Dokal I, et al. Outcome of 69 allogeneic stem cell transplantations for Fanconi 
anemia using HLA-matched unrelated donors: a study on behalf of the European Group for Blood and 
Marrow Transplantation. Blood. 2000;95:422-429. 
4.   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. 
5.   Terenzi A, Aristei C, Aversa F, et al. Efficacy of fludarabine as an immunosuppressor for bone marrow 
transplantation conditioning: preliminary results. Transplant Proc. 1996;28:3101. 
6.   Slavin S, Nagler A, Naparstek E, et al. Nonmyeloablative stem cell transplantation and cell therapy as an 
alternative to conventional bone marrow transplantation with lethal cytoreduction for the treatment of 
malignant and nonmalignant hematologic diseases. Blood. 1998;91:756-763. 
7.   Nagler A, Or E, Naparstek G, et al. Matched unrelated bone marrow transplantation (BMT) using a non-
myeloablative  conditioning regimen. Blood. 1998;92:289a. 
8.   Spitzer T, McAfee S, Sackstein R, et al. Induction of mixed chimerism and potent anti-tumor responses 
following non-myeloablative conditioning therapy and hla-matched and mismatched donor bone 
marrow transplantation (BMT) for refractory hematologic malignancies (HM). Blood. 1998;92:519a. 
9.   Santos GW. The development of busulfan/cyclophosphamide preparative regimens. Semin Oncol. 
1993;20:12-16; quiz 17. 
10.   Santos GW, Tutschka PJ, Brookmeyer R, et al. Marrow transplantation for acute nonlymphocytic 
leukemia after treatment with busulfan and cyclophosphamide. N Engl J Med. 1983;309:1347-1353. 
11.   Tutschka PJ, Copelan EA and Klein JP. Bone marrow transplantation for leukemia following a new 
busulfan and cyclophosphamide regimen. Blood. 1987;70:1382-1388. 
12.   Vassal G. Pharmacologically-guided dose adjustment of busulfan in high-dose chemotherapy regimens: 
rationale and pitfalls (review). Anticancer Res. 1994;14:2363-2370. 
13.   Schuler US, Ehrsam M, Schneider A, et al. Pharmacokinetics of intravenous busulfan and evaluation of 
the bioavailability of the oral formulation in conditioning for haematopoietic stem cell transplantation. 
Bone Marrow Transplant. 1998;22:241-244. 
14.   Andersson BS, Gajewski J, Donato M, et al. Allogeneic stem cell transplantation (BMT) for AML and 
MDS following i.v. busulfan and cyclophosphamide (i.v. BuCy). Bone Marrow Transplant. 2000;25 
Suppl 2:S35-38. 
15.   Worth L, Tran H, Petropoulos D, et al. Hematopoietic stem cell transplantation for childhood myeloid 
malignancies after high-dose thiotepa, busulfan and cyclophosphamide. Bone Marrow Transplant. 
1999;24:947-952. 
16.   Flowers ME, Doney KC, Storb R, et al. Marrow transplantation for Fanconi anemia with or without 
leukemic transformation: an update of the Seattle experience. Bone Marrow Transplant. 1992;9:167-
173. 
17.   Ratanatharathorn V, Karanes C, Uberti J, et al. Busulfan-based regimens and allogeneic bone marrow 
transplantation in patients with myelodysplastic syndromes. Blood. 1993;81:2194-2199. 
18.   Maschan AA, Kryzanovskii OI, Yourlova MI, et al. Intermediate-dose busulfan and cyclophosphamide as 
a conditioning regimen for bone marrow transplantation in a case of Fanconi anemia in 
myelodysplastic transformation. Bone Marrow Transplant. 1997;19:385-387. 
19.   Ebell WH. Transplants in Fanconi Anemia - Improvements and Prospects. in Thirteenth Annual 
International Fanconi Anemia Scientific Symposium. 2001. Portland, Oregon. 


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20.   Lin DY. Non-parametric inference for cumulative incidence functions in competing risks studies. Stat 
Med. 1997;16:901-910. 
21.   Kalbfleisch J and Prentice R. The Statistical Analysis of Failure Time Data. 1980, New York: John 
Wiley. 
22.   Goldman AI and Hannan PJ. Optimal continuous sequential boundaries for monitoring toxicity in clinical 
trials: a restricted search algorithm. Stat Med. 2001;20:1575-1589. 
23.   Long-Boyle, Janel et al. Population Pharmacokinetics of Busulfan in Pediatric and Young Adult Patients 
Undergoing Hematopoietic Cell Transplant: A Model-Based Dosing Algorithm for Personalized 
Therapy and Implementation into Routine Clinical Use. Ther Drug Monit. 2015 Apr; 37(2): 236–245.  
 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
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APPENDIX I - SCHEDULE OF ACTIVITIES FOR EACH PATIENT 
 
 
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(admission) 
 
 
 
 
Clinical evaluation 
x(admission) 
x(1) 
x(1) 
x(2, discharge 
home) 
x(day 180, 365, 
720) 
Karnofsky/Lansky 
score 
 
x(admission) 
 
 
 
x(discharge) 
 
x (100, discharge 
home) 
 
x(day 180,365, 
720) 
Laboratory 
evaluation 
x(admission) 
 
 
 
 
CBC/differential 
x(admission) 
x(1) 
x(1) 
x(2) 
x(day 180, 365, 
720) 
Cr/Cr clearance 
x(admission) 
x(1) 
 
 
x(3) 
CXR 
x(admission) 
 
 
 
 
PFT 
x(admission) 
 
 
 
x(3) 
ECG/MUGA/ LVEF 
x(admission) 
 
 
 
x(3) 
US liver & kidneys 
x(admission) 
 
 
 
 
MRI liver 
x (3) 
 
 
 
 
CT head, chest, abd, 
pelvis 
x(3) 
 
 
 
 
Bone Marrow biopsy, 
aspirate, Chimerism 
assay 
If clinically 
indicated 
 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 
If clinically 
indicated 
GVHD evaluation 
 
x(1) 
x(1) 
x(3) 
x(3) 
x(1)=perform test daily 
 
 
x(2)=perform test weekly 
x(3)=perform test as clinically indicated 
x(day)=perform test on day indicated 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 25 of 30 
CPRC #2002LS014 
APPENDIX II-  GRAFT VERSUS HOST DISEASE STAGING 
 
Acute GVHD: 
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 
 
 
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 
 
Chronic GVHD: 
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. 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 26 of 30 
CPRC #2002LS014 
APPENDIX III - PERFORMANCE STATUS SCALE 
 
KARNOFSKY PERFORMANCE STATUS SCALE 
Percentage 
 
100 
Normal, no complaints, no evidence of disease 
90 
Able to carry on normal activity; minor signs or symptoms of disease 
80 
Normal activity with effort; some signs or symptoms of disease 
70 
Cares for self; unable to carry on normal activity or do active work 
60 
Requires occasional assistance, but is able to care for most of his/her needs 
50 
Requires considerable assistance and frequent medical care 
40 
Disabled; requires special care and assistance 
30 
Severely disabled, hospitalization indicated.  Death not imminent 
20 
Very sick, hospitalization necessary, active supportive treatment necessary 
10 
Moribund, fatal processes, progressing rapidly 
0 
Dead 
 
Reference 
Karnofsky DA.  Editorial: Meaningful clinical classification of therapeutic responses to anti-cancer drugs. Clin Pharmacol 
Ther 2:709-712, 1961. 
 
LANSKY PLAY STATUS SCALE 
Score 
 
100 
Fully active, normal 
90 
Minor restrictions in physically strenuous activity 
80 
Active, but tires more quickly 
70 
Both greater restriction of, and less time spent in, play activities 
60 
Up and around, but  minimal active play; keeps busy with quieter activities 
50 
Gets dressed but lies around much of the day, no active play; able to participate 
in all quiet play and activities 
40 
Mostly in bed; participates in quiet activities 
30 
In bed; needs assistance even for quiet play 
20 
Often sleeping; play entirely limited to very passive activities 
10 
Unresponsive 
0 
Dead 
 
REFERENCE 
Lansky SB, List MA, Lansky LL, Ritter-Sterr C, Miller DR (1987). "The measurement of performance in childhood 
cancer  patients". Cancer 60 (7): 1651–6.  
 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 27 of 30 
CPRC #2002LS014 
APPENDIX IV - STUDY RELATED TOXICITIES 
 
Toxicities associated with the preparative therapies: 
Busulfan  
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) which may cause 
tiredness, headache, dizziness  
• hair loss or thinning, including 
face and body hair (usually 
grows back after treatment)  
• long-term or short-term 
infertility (inability to have 
children) in men and women 
 
 
• tiredness  
• sores in mouth or 
on lips  
• fever  
• nausea  
• vomiting 
• rash  
• loss of appetite  
• diarrhea  
• serious infection 
due to low white 
blood cell count  
 
 
• abnormal blood tests results which suggest 
that the drug is affecting the liver (Your 
doctor will discuss the importance of this 
finding, if any.)  
• allergic reaction with hives, itching, 
headache, coughing, shortness of breath, 
or swelling of the face, tongue, or throat  
• scarring of lung tissue, with cough, 
difficulty breathing, and shortness of 
breath that may occur after prolonged use, 
or even months or years after stopping the 
drug  
• leukemia (several years after treatment)  
• darkened skin  
• heart problems with high-dose treatment, 
most often in people with thalassemia (a 
type of genetic anemia that is present at 
birth)  
• problems with the hormone system that 
cause weakness, tiredness, poor appetite, 
weight loss, and darker skin  
• death due lung damage, bone marrow 
shutdown, sepsis (severe infection) or 
other causes  
 
 
 
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  
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 28 of 30 
CPRC #2002LS014 
 
 
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  
• 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 
 
• low platelet count 
with increased 
risk of bleeding  
• darkening of nail 
beds  
• acne  
• tiredness  
• infection  
• fetal changes if 
pregnancy occurs 
during 
cyclophosphamide  
 
• 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  
• 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  
 
 
Anti-Thymocyte globulin (ATG) - 
 
Common 
Occurs in 21-100 people 
out of 100 
 
Less Frequent 
Occurs in 5-20 people out of 
every 100 
 
Uncommon 
Occurs in <5 people out of every 
100 
fever 
chills 
leukopenia 
pain 
headache 
abdominal pain 
diarrhea 
hypertension 
nausea 
thrombocytopenia 
peripheral edema 
dyspnea 
asthenia 
hyperkalemia 
tachycardia 
malaise 
dizziness 
severe allergic reaction 
(anaphylaxis) 
 
 
 
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 29 of 30 
CPRC #2002LS014 
 
Toxicities associated Immunosuppressive Therapies 
 
   Cyclosporine (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 
 
 
 
Haploidentical Hematopoietic Stem Cell Transplantation 
• 
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)  
 
UCB Infusion 
Infusion of cord blood may be associated with expected and unexpected adverse events similar to those seen 
with transfusion of fresh and cryopreserved blood products.  Expected adverse events include: 
• 
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 associated with double cord blood infusion has also been reported.   
  
 
 


MT2002-02:  HSCT in high risk Fanconi Anemia 
 
 
 
 
 
 
 
September 4, 2019 
Page 30 of 30 
CPRC #2002LS014 
G-CSF  
bone pain 
headaches 
body aches 
fatigue  
nausea/vomiting 
insomnia 
dyspnea 
rash 
edema