Conditions: Hematologic Malignancies
Keywords: Cyclophosphamide Hematopoietic Stem Cell Mobilization Hematologic Malignancy
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 58
Healthy volunteers: no

Brief summary:
No prospective randomized trials have evaluated the most efficacious dose of cyclophosphamide to mobilize autologous stem cells. We previously demonstrated that the time to collection of autologous hematopoietic stem cells is 10-12 days following the one dose of cyclophosphamide and daily G-CSF (granulocyte-colony stimulating factor).9 This prospective randomized trial is designed to determine if a lower dose of cyclophosphamide (1.5 gm/m2) will be as efficacious as the intermediate dose (3 gm/m2), based on cell number collected, number of apheresis required and resource utilization.

Detailed description:
This prospective randomized trial is designed to determine if a lower dose of cyclophosphamide (1.5 gm/m2) will be as efficacious as the intermediate dose (3 gm/m2), based on cell number collected, number of apheresis required and resource utilization.

The time to collection of autologous hematopoietic stem cells was ten to twelve days following cyclophosphamide and daily filgrastim. Peripheral blood CD34+ cell numbers were examined beginning ten days after cyclophosphamide administration. Leukapheresis began once the blood CD34+ number reached 10 cells/mcl. Patients received consecutive days of leukapheresis, with the goal of collecting \> 5 x 106 CD34+cells/kg. The collection process, concentration and storage of PBSC were similar for all patients. Briefly, a 4-blood volume leukapheresis PBSC collection was performed daily using a COBE Spectra cell separator (COBE BCT, Lakewood, CO). Collected cells were concentrated and cryopreserved. Cells were frozen in Cryocyte freezing bags (Nexell Therapeutics Inc.) in a controlled rate freezer (Custom BioGenic Systems, Shelby Township, MI). At the conclusion of this freezing, the cells were transferred to the vapor phase of a monitored liquid nitrogen freezer (CryoPlus III, Forma Scientific, Marietta, OH) at a temperature of -120 0C or below.

Arms:
arm 1: Patients will receive intravenous mesna 15 minutes prior to cyclophosphamide and again at 4 and 8 hours afterwards. Each infusion will be given over 15 minutes. Oral mesna can be substituted for the two post-cyclophosphamide doses. Oral mesna will be administered at 2 and 6 hours after the start of cyclophosphamide. Cyclophosphamide will be administered intravenously over one hour at the dose of 3 gms/m(2). arm 2: Patients will receive intravenous mesna 15 minutes prior to cyclophosphamide and again at 4 and 8 hours afterwards. Each infusion will be given over 15 minutes. Oral mesna can be substituted for the two post-cyclophosphamide doses. Oral mesna will be administered at 2 and 6 hours after the start of cyclophosphamide. Cyclophosphamide will be administered intravenously over one hour at the dose of 1.5 gms/m(2).

Interventions: intervention 1: Cyclophosphamide
Intervention descriptions: intervention 1: Mechanism of action: Cyclophosphamide is a pro drug that requires activation. Following hepatic and cellular activation, phosphoramide mustard and acrolein are formed. Phosphoramide mustard is the alkylating agent that demonstrates cytotoxic effects. Acrolein binds to proteins but does not contribute to the anti-tumor effects.

Protocol document:
Prot_SAP_000.pdf: 
 
 
Official Title: 
A Prospective Randomized Trial Examining Low- or 
Intermediate-Dose Cyclophosphamide for Hematopoietic 
Stem Cell Mobilization in Patients with a Hematologic 
Malignancy 
NCT number: 
02139280 
Document Type:  
Study Protocol and Statistical Analysis Plan 
Date of the 
Document: 
10/23/2020 
 
 


 
 
Mobilization Trial 05/16/2017 
 
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DMS 13179:  A Prospective Randomized Trial Examining Low- or 
Intermediate-Dose Cyclophosphamide for Hematopoietic Stem Cell 
Mobilization in Patients with a Hematologic Malignancy 
 
 
 
Principal Investigator: 
Kenneth R. Meehan, M.D. 
 
Co-Investigators: 
Lionel Lewis, M.D. 
John Hill, M.D. 
Christopher H. Lowrey, M.D. 
Nancy Dunbar M.D. 
Zbigniew Szczepiorkowski M.D., Ph.D. 
 
Division of Biostatistics 
Dr. Jiang Gui 
 
 
 
Clinical Research Associate  
and Data Management 
Dorie McKenna M.S. 
 
 
Clinical Research Associate  
Bridget Labrie 
 
 
 
Blood and Marrow Transplantation Program 
Dartmouth-Hitchcock Medical Center 
Norris Cotton Cancer Center 
1 Medical Center Drive 
Lebanon, NH 03755 
Phone 603-650-4628 
Fax 603-650-2334 


 
 
Mobilization Trial 05/16/2017 
 
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TABLE OF CONTENTS 
 
PRE-TREATMENT EVALUATION  ...................................................................................................... 3 
TREATMENT SCHEMA FOR IMMUNE MOBILIZATION ................................................................ 3 
1.0 
INTRODUCTION ........................................................................................................................ 4 
2.0 
OBJECTIVES ............................................................................................................................... 6 
3.0 
ELIGIBILITY CRITERIA............................................................................................................ 7 
4.0  
REGISTRATION AND DATA SUBMISSION .......................................................................... 7 
5.0 
GENERAL WORKUP AND DIAGNOSTIC PROCEDURES ................................................... 7 
6.0 
TREATMENT PLAN ................................................................................................................... 8 
7.0  
POTENTIAL TOXICITIES AND MANAGEMENT ................................................................ 11 
8.0 
DRUG FORMULATION, AVAILABILITY AND TOXICITY ............................................... 10 
9.0  
REQUIRED DATA AND CORRELATIVE LABORATORY STUDIES ................................ 13 
10.0  CRITERIA FOR RESPONSE AND TREATMENT ENDPOINTS .......................................... 16 
11.0  REMOVAL OF PATIENTS FROM PROTOCOL AND STOPPING RULES ......................... 14 
12.0  ADVERSE DRUG REACTION (ADR) REPORTING ............................................................. 14 
13.0 
STATISTICAL CONSIDERATIONS........................................................................................ 19 
14.0 
STUDY MONITORING, AUDITING AND INSPECTION ..................................................... 16 
15.0 
HUMAN SUBJECTS ................................................................................................................. 17 
16.0 
BIBLIOGRAPHY ....................................................................................................................... 19 
 
 
APPENDIX A - BMT SOP 0025: Stem Cell Mobilization Protocol 
 
APPENDIX B - BMT SOP 0023: Selection of Patients and Preparative High-Dose Chemotherapy 
Regimens 
 


 
 
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PRE-TREATMENT EVALUATION 
For a patient to be approved for this mobilization trial, the patient must be cleared for 
transplantation by the Transplant Attending, using the standard required results (“Pre-Transplant SOP 
Evaluation – BMT SOP 0023”). The following are the eligibility criteria for this trial: 
 
 Pretreatment Leukapheresis 
Transplant 
Course 
Patient approved for transplant (see 
above) 
X 
 
 
Laboratory analysis – to include  
blood sample pre-mobilization, one 
sample from the mobilized cell 
product and one sample around Day 
15 following transplant 
 
 
 
X 
X 
First day of 
collection 
X 
Engraftment (neutrophils and 
platelets) 
 
 
X 
TREATMENT SCHEMA FOR MOBILIZATION 
For the additional 13 non-randomized subjects, each patient will be placed on cyclophosphamide 1.5 
gms/m2. 
 
 
 
 
 
 
 
 
1.) Samples will be obtained at baseline/pre-treatment (blood), on the first day of collection (mobilized 
progenitor cells) and a final blood sample at the time of bone marrow recovery (engraftment) following 
transplant, approximately day 15 following transplant. 
2.) G-CSF dose will be based on National Marrow Donor Program guidelines 
 
 
 
 
Registration 
SAMPLES 
Cyclophosphamide 
1.5 gms/m2 
Filgrastim 
10 mcg/kg* 
Leukapheresis 
Stem Cell Collection 


 
 
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1. 1.0  
INTRODUCTION 
 
1.1. Current treatment for patients with myeloma  
1.1.1. 
  
The current treatment for myeloma patients includes 3 to 4 cycles of 
therapy to achieve cytoreduction and then proceed onto autologous stem cell 
collection and a stem cell transplant (1). Prior to an autologous stem cell transplant, 
patients must have their peripheral blood stem cells collected, so the cells can be re-
administered following high dose chemotherapy. The process of stimulating and 
releasing bone marrow cells into the blood for collection is called mobilization. 
1.1.2. 
           The optimal method to mobilize autologous stem cells for patients with 
myeloma is not known (2). Autologous stem cells can be “mobilized” using a growth 
factor alone or a combination of a growth factor with a chemotherapy medication. 
Numerous trials have demonstrated that the administration of chemotherapy with a 
growth factor, called granulocyte-colony stimulating factor or filgrastim, yields more 
cells than using filgrastim alone (3,4). Cyclophosphamide is the most common 
chemotherapy agent used for mobilization, in combination with filgrastim (5) 
Cyclophosphamide is an appealing agent since it demonstrates clinical activity against 
myeloma cells and it may provide in vivo purging of residual myeloma cells (6). In 
addition, the combination of cyclophosphamide and filgrastim work synergistically to 
mobilize autologous stem cells (2,7). A multi - center analysis of transplant centers 
using the Center for International Blood and Marrow Transplant (CIBMTR) database 
indicates that the combination of cyclophosphamide with filgrastim resulted in an 
increased number of cells collected, a fewer number of apheresis required and a fewer 
number of patients failing to mobilize, when compared to filgrastim alone (5). 
Unfortunately, when cyclophosphamide is added to filgrastim in a mobilization 
regimen, there is increased risk for febrile neutropenia and an increased incidence of 
side effects (8, 9). 
1.1.3. 
          In addition to the mobilization regimen, patient characteristics and a 
patient's clinical course may also determine a patient’s ability to mobilize autologous 
stem cells. In particular, collections of a low number of CD34+ cells can be due to the 
patient’s age, prior radiation therapy, prior use of thalidomide or lenalidomide or the 
use of single-agent filgrastim for mobilization. The standard international minimal 
number of CD 34+ cells/kg of body weight recommended for an autologous stem cell 
transplant is 2 x 106 CD34+ cells/kg (1-4). The term “mobilization failure” refers to 
an inadequate collection of CD34+ cells needed for an autologous stem cell 
transplant. This definition is based on the absolute number of CD34+ cells collected 
or the inability to collect a specified number of cells in a certain number of 
leukapheresis. Mobilization failure can also be predicted by the number of CD34+ 
cells mobilized into the peripheral blood following the mobilization treatment 
regimen. If the number of CD34+ cells in the blood is low, the apheresis process will 
not collect enough cells.” (10-14). Mobilization failure rates for myeloma patients 
vary, based on how “failure” is defined. For example, the Transplant Team at 
Memorial Sloane Kettering Cancer Center noted that 13% of myeloma patients failed 
to mobilize cells. This group defined “failure” as the inability to collect 5 x 106 
CD34+cells/kg, a number that is much higher than the international standard number 


 
 
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of CD34+ cells required (2 x 106 CD34+ cells/kg). The general consensus is a 
mobilization failure rate of 5% to 13% in myeloma patients (1-4, 10).  
 
1.2.Defining the optimal cyclophosphamide dose for mobilization - Review of the literature on 
mobilization in multiple myeloma 
1.2.1. 
         No prospective randomized trials have evaluated the optimal dose of 
cyclophosphamide to mobilize autologous stem cells (1,2,15). Published reports 
include retrospective analyses, with the doses of cyclophosphamide ranging from 1.5 
gms/m2 to 7 gms/m2 (1-5,14,16). Historically, higher doses of cyclophosphamide (5 
gms/m2 to 7 gms/m2) were used in the early 2000’s (9). The literature indicates that 
the higher the cyclophosphamide dose, the greater the toxicities, but the greater the 
number of cells mobilized and collected. Weighing these two conflicting issues, over 
the past 5 years, transplant centers have been administering lower doses of 
cyclophosphamide (doses between 1.5 to 5 gms/m2) for mobilization, in an attempt to 
achieve maximal cell yield with fewer side effects (17-19).  
1.2.2. 
         A single center retrospective analysis of two mobilization regimens 
compared low dose (1 to 2 gms/m2) with intermediate dose (3 to 4 gms/m2) 
cyclophosphamide in combination with filgrastim. Both groups of patients mobilized 
an adequate number of cells for transplantation (89% of patients in the low dose arm 
compared with 92% of patients in the intermediate dose arm), but the incidence of 
febrile neutropenia was three times higher in the intermediate dose arm (38% versus 
13%) (17). Another retrospective analysis compared two doses of cyclophosphamide, 
either 2 gms/m2 or 4 gms/m2, with filgrastim. There was a significant increase in the 
number of hospital admissions for febrile neutropenia in the patients receiving the 
higher dose of cyclophosphamide, when compared to the lower dose (p = 0.0005). 
Mobilization failure occurred in 6% of patients in the higher dose as compared with 
11% of patients in the lower dose arm. Of the five patients that did not mobilize in the 
lower dose arm, four patients mobilized with a subsequent attempt (19). Finally, a 
recent trial compared mobilizing myeloma patients using low dose cyclophosphamide 
(1.5 gms/m2) and filgrastim with a new mobilizing CXCR4 antagonist, called 
Plerixafor. Six patients (8.1%) in the cyclophosphamide group failed to mobilize cells 
(20).  
1.2.3. 
          In summary, doses of cyclophosphamide have been used ranging from 1.5 
gms/m2 to 7 gms/m2. The mobilization failure rate in myeloma patients ranges 
between 5% and 13%.When used in combination with filgrastim, higher doses of 
cyclophosphamide mobilize a larger number of CD34+ cells, at the expense of 
increased toxicity, side effects and hospital admissions for febrile neutropenia. (15-
20). 
1.2.4. 
          The International Myeloma Working Group recently reviewed various 
mobilization regimens used for myeloma patients. (1,3,4). The Committee concluded 
that the combination of cyclophosphamide and filgrastim mobilized more cells when 
compared to filgrastim alone, but the optimal dose of cyclophosphamide was not 
known. The Committee recommended exploring lower doses of cyclophosphamide, 
and not exceeding doses of 4 gms/m2. In addition, the group recommended pursuing 
novel manners to mobilize cells, including ways to improve efficacy and decreasing 
costs. (3) 


 
 
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1.2.5. 
The trial is designed as a non-inferiority trial. If the lower dose arm is shown to be 
non inferior, this will be a major new finding that will change clinical practice here at 
Dartmouth and other transplant centers. As a result, if the lower dose is shown to be 
non-inferior, additional patients will be accrued to this arm to confirm the findings 
and to address possible superiority of the lower dose arm. The number of patients 
needed will be based on the preliminary results. 
1.2.6. Since the results of the trial demonstrated no difference between the two doses of 
cyclophosphamide in terms of number of CD34+cells/kg collected, 13 additional 
patients will be accrued to the lower dose arm (1.5 gms/m2). These additional patients 
will be combined with the results from the other participants previously treated on the 
low dose arm and compared as a group with the high dose arm. (Please refer to 
Statistical Considerations – Section 13, for details).   
 
2.0 OBJECTIVES 
2.1 Primary Objective 
2.1.2 The primary objective of this clinical trial is to determine if a lower dose of 
cyclophosphamide combined with filgrastim can mobilize an adequate number of CD34+ 
progenitor cells with less toxicity.  
We postulate that low dose cyclophosphamide mobilization (1.5 gms/m2) will be as 
efficacious as the intermediate dose (3 gms/m2). 
2.1.3 To define the primary objective, we will identify the number and types of cells 
collected within the apheresis products and characterize the details of the apheresis 
process. In particular, we will define the following: 
• The number of peripheral blood CD34+ cells identified on Day 1 of collection 
• The number of apheresis required to collect >/= 5 x 106 CD34+cells/kg for 
myeloma patients and >/= 3 x 106 CD34+cells/kg for NHL patients. (These 
numbers represent a “goal” and not a stopping criteria). 
• The number of cells collected (MNC/kg and CD34+cells/kg) 
• Failure to mobilize will be defined as:  
o < 1x106 CD34+cells/kg collected after 2 days of apheresis OR 
o Failure to mobilize an adequate number of CD34+ progenitor cells 
 Blood CD34+ cell number < 5 cells/mcl if weight < 75kg 
 Blood CD34+ cell number < 10 cells/mcl if weight > 75kg 
• Toxicities during the mobilization and apheresis processes 
2.1.3 If the lower dose arm demonstrates non-inferiority at completion of patient accrual, then 
additional patients will be added to the lower dose arm to confirm non-inferiority or 
superiority. The number of patients needed to answer this will be based on statistical 
evaluation of the preliminary results (see Statistical Analysis). 
 
2.2 Secondary Objectives 
2.2.1 Define resource utilization during the mobilization and apheresis processes: 
• Transfusions of red blood cells  
• Transfusion of platelets 
• Hospitalizations 
• Incidence of febrile neutropenia 


 
 
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2.3 Exploratory Objectives 
2.3.1   Determine the post-transplant engraftment of neutrophils and platelets. 
2.3.2 Qualitative and quantitative analyses of mobilized lymphocytes (Elective-pending 
funding). 
 
3.0 ELIGIBILITY CRITERIA 
3.1 Inclusion Criteria 
3.1.1 All patients must have a pathologic diagnosis of one of the following 
malignancies: 
• Non-Hodgkin’s Lymphoma, including B- and T-cell lymphoma 
• Multiple Myeloma or another plasma cell dyscrasia (Waldenstrom, 
Amyloidosis) 
3.1.2 The patient must be approved for transplant by the treating Transplant 
physician. This includes completion of their pre-transplant workup, as 
directed by standard DHMC SOPs (BMT SOPs 0023 and 0025 - Appendix).  
3.1.3 This must be the patient’s FIRST mobilization attempt. 
3.1.4 Patients are eligible if an autologous transplant is planned within 
approximately 12 months from the time of collection of cells. 
3.1.5 Prior Treatment: No previous cytotoxic chemotherapy within 4 weeks prior 
to initiation of therapy. (This does not include IMIDs, proteasome inhibitors, 
monoclonal antibodies or steroids.) 
3.1.6 No radiation within 4 weeks of mobilization attempt. 
3.1.7 Age >18, and < 75 years  
3.1.8 No significant co-morbid medical or psychiatric illness that would 
significantly compromise the patient’s clinical care and chances of survival. 
3.1.9 Informed consent must be signed prior to the treatment. Patients must 
willingly consent after being informed of the procedure to be followed, the 
nature of the therapy, alternatives, potential benefits, side effects, risks and 
discomforts. (Human protection committee approval of this protocol and a 
consent form is required.) 
 
3.2 Exclusion Criteria  
3.2.1 Medical, social, or psychological factors that would prevent the patient from 
receiving or cooperating with the full course of therapy.  
3.2.2 Documented hypersensitivity to any of the drugs used in the protocol. 
 
4.0 REGISTRATION AND DATA SUBMISSION 
This is a randomized trial using two standard doses of cyclophosphamide, with a standard dose 
of filgrastim.  To enter eligible patients or to discuss a patient’s eligibility, please contact Dr. 
Kenneth R. Meehan (or any of the Transplant physicians) at 603-650-4628 or the Clinical Research 
Associate (Bridget Labrie at 603-650-6227). Informed consent must be signed prior to the initiation 
of treatment.  
 
 
5.0 GENERAL WORKUP AND DIAGNOSTIC PROCEDURES 


 
 
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Since this treatment regimen offers standard of care therapy, no additional workup or evaluation 
is needed besides the tests required as a standard part of the pre-transplant evaluation, as listed in 
SOPs (BMT SOPs 0023 and 0025 - Appendix). 
5.1 Informed Consent: Patients must willingly consent after being informed of the procedure 
to be followed, the nature of the therapy, alternatives, potential benefits, side effects, 
risks and discomforts. (Human protection committee approval of this protocol and a 
consent form is required.) 
 
 
 
 
 
5.2 TREATMENT SCHEMA FOR MOBILIZATION (Table 1) 
 
 
 
 
 
 
 
 
1.) Samples will be obtained at baseline/pre-treatment (blood), on the first day of collection (mobilized 
progenitor cells) and a final blood sample at the time of bone marrow recovery (engraftment) following 
transplant, approximately day 15 following transplant. 
2.) G-CSF dose will be based on National Marrow Donor Program guidelines 
 
****For the remaining patients, each patient will be placed on cyclophosphamide 1.5 gms/m2 arm and 
will NOT be randomized. 
 
 
 
6.0 RANDOMIZATION and TREATMENT PLAN  
6.1 Patients will be randomized based on age (> 60 years, <60 years) and duration of 
lenalidomide use (> 4 months, < 4 months) using a randomization process within 
Micorsoft Excel, developed by Dr. Jiang, the study statistician. Patients will be 
randomized to either 1.5 gms/m2 or 3 gms/m2 after signing an informed consent.  
Randomization will be based on: 
• Diagnosis (NHL vs. Myeloma) 
Registration 
SAMPLES 
Cyclophosphamide 
1.5 gms/m2 
Filgrastim 
10 mcg/kg* 
Leukapheresis 
Stem Cell Collection 


 
 
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• Age ( < or > 60 years) 
• Prior radiation (yes or no) 
• Prior therapy ( < or > 2 prior treatments) 
• For myeloma patients, < or > 4 months of prior lenalidomide or thalidomide 
therapy 
• Platelet count ( < or > 100,000/mcl) 
• As noted previously, randomization will not be used once the preliminary data 
have been analyzed and if the lower dose arm demonstrated non-inferiority.  
Subsequent 
patients 
will 
be 
treated 
on 
the 
lower 
dose 
arm. 
 
6.2 Cyclophosphamide 
After randomization, patients will receive either 1.5 gms/m2 or 3 gms/m2 (based on actual 
BSA). The schedule and the administration of cyclophosphamide and filgrastim will follow the 
DHMC SOP (BMT SOP 0025: Stem Cell Mobilization Protocol- Appendix). The administration 
of cyclophosphamide is outlined in the SOP. If clinically indicated, patients may receive 
intravenous mesna (600 mg/m2) 15 minutes prior to cyclophosphamide and again at 4 and 8 
hours afterwards. Each infusion will be given over 15 minutes. Oral mesna can be substituted for 
the two post-cyclophosphamide doses. Oral mesna (1200 mg/m2) will be administered at 2 and 6 
hours after the start of cyclophosphamide. Cyclophosphamide will be administered intravenously 
over one hour. 
 
For the convenience of participant, the infusion of cyclophosphamide may be administered 
locally by their primary hematologist.  The completed orders will be provided by DHMC-
Lebanon to the study participant’s local facility (including local pharmacy) for the single 
treatment dose of cyclophosphamide and subsequent doses of filgrastim.  The evaluation of each 
study participant, data supervision and management, toxicity management, and adverse event 
reporting will all occur at DHMC – Lebanon.   Any significant impediments to treatment on a 
clinic day should immediately be reported by the local facility to the DHMC – Lebanon research 
team.   
 
 
6.3 Zarxio - (filgrastim-sndz), 
Zarxio (Sandoz, Inc.) is biosimilar to Amgen Inc.’s Neupogen (filgrastim). Zarxio is an FDA-
approved biosimilar product. A biosimilar product is a compound that is approved based on 
clinical data demonstrating efficacy to a similar to an already-approved product, known as a 
reference product. The biosimilar shows no clinically meaningful differences in toxicity, safety 
or effectiveness from the reference product. Only minor differences are allowable in biosimilar 
products. Zarxio is approved for the same indications as Neupogen (filgrastim), and can be 
prescribed for patients undergoing autologous peripheral blood progenitor cell collection. The 
dosing of Zarxio is the same as Filgrastim (outlined below). 
 
 
6.4 Filgrastim 
A standard dose and schedule of filgrastim will be used.  Approximately 48 hours after 
cyclophosphamide, filgrastim (using NMDP guidelines below) will be administered as a daily 
subcutaneous injection until completion of collection (BMT SOP 0025).  Complete blood counts 
(CBC) will be monitored approximately 3x/week and the dose of filgrastim adjusted, according 


 
 
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to the CBC results. Filgrastim will continue until completion of leukapheresis.  The following 
NMDP guidelines will be used for dosing filgrastim, based on patient’s weight and vial size. 
 
Donor weight (Kg) 
Vial size:300 mcg 
Vial size : 480 mcg 
Daily dose (mcg/day) 
45 to 60 
2 
0 
600 
61 to 78 
1 
1 
780 
79 to 90 
3 
0 
900 
91 to 96 
0 
2 
960 
97 to 108 
2 
1 
1080 
109 and greater 
4 
0 
1200 
 
 
6.5  Leukapheresis  
We previously demonstrated that the time to collection of autologous hematopoietic stem 
cells is 10-12 days following cyclophosphamide and daily filgrastim (21).  Patients will undergo 
peripheral blood stem cell harvesting via leukapheresis, depending upon the peripheral blood 
WBC and CD34+ cell count, generally between Days 10 and 12, following cyclophosphamide. 
After the combination of cyclophosphamide and G-CSF are administered, there is a typical 
clinical course marked by a decrease in blood counts within 3 days and a sudden rise in CBC, 
most strikingly in the WBC, between days 10 to 12 following cyclophosphamide administration. 
Based on this clinical course, peripheral blood CD34+ cell numbers will be examined (as a 
marker of circulating stem cells), beginning Day 10, based on a patient’s CBC recovery. 
Apheresis will begin once the blood CD34+ number reaches approximately 10 cells/mcl.  
The collection process will be standard for each patient on trial. This will be accomplished 
by determining the number of cells collected each day (CD34+ cells and MNC) per volume of 
blood processed. 
 
The goal for collection will be the following: 
Patients will receive consecutive days of leukapheresis until > 5 x 106 CD34+cells/kg for 
myeloma patients and > 3 x 106 CD34+cells/kg for NHL patients have been collected.  (See 
Section “How to handle poor mobilizers” below.) 
 
Peripheral blood stem cells will be cryopreserved in the usual manner, per the Cell 
Processing Laboratory protocol.    
If < 1 x 106 CD34+cell/kg has been obtained after 2 days of leukaphereses, leukapheresis 
will be discontinued and this patient will be removed from protocol, since this is one endpoint of 
the trial. In addition, failure to mobilize cells will be defined as a peripheral blood CD34+ cell 
number < 5 cells/mcl if patient’s weight < 75kg or a blood CD34+ cell number < 10 cells/mcl if 
patient’s weight > 75kg. 
 
6.5 How to handle “Poor Mobilizers”  
Poor mobilizers are defined as patients who sluggishly mobilize autologous blood stem cells 
but do not meet criteria for “removal from trial”. Typically, these patients mobilize enough cells 
for transplant but do not meet the target CD34+ cell number. These patients will NOT be 
removed from trial. Apheresis can be discontinued in these patients before reaching the target 
CD34+ cell number if, at the discretion of the treating physician or the PI, it is not clinically 


 
 
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indicated to continue collection of cells, since this may be putting the patient at increased risk 
and enough cells have been obtained for transplantation. The patient will remain on protocol and 
will be considered evaluable on an “intent to treat” analysis. These patients will be defined as 
“poor mobilizers’’ within the database. 
 
In contrast, if a patient does not meet these end point collection criteria or if another day of 
collection is not clinically indicated but a patient has not met the CD34+ cell collection criteria, 
the collection process can be terminated at the discretion of the PI and treating physician.  For 
example, a myeloma patient mobilizes 4.8 x 106 CD34+cells/kg on the first day).  The patient 
will remain on protocol and will be considered evaluable on an “intent to treat” analysis. 
 
6.6 Supportive Medications  
Following cyclophosphamide administration, once the patient’s absolute neutrophil count 
drops to < 500 cells/mcl, oral prophylactic fluconazole (400 mg/day), acyclovir (800 mg BID) 
and levaquin (750 mg/d) will be started, if the patient is not already taking these medications. 
 
6.7 Peripheral Blood Stem Cell (PBSC) Collection and Storage 
The collection, concentration and storage of PBSC will be standard for all patients. 
Briefly, a 4-blood volume leukaphereses PBSC collection will be performed daily using a COBE 
Spectra cell separator (COBE BCT, Lakewood, CO). Collected cells will be concentrated to 50 – 
100 ml in a refrigerated centrifuge. PBSC concentrates will be cryopreserved in a medium 
consisting of 6% low molecular weight hydroxyethyl starch  (Normosol-R pH 7.4, Abbott 
Laboratories, North Chicago, IL.), 10% dimethyl sulfoxide (DMSO) (Cryoserv, Research 
Industries, Salt Lake City, UT), and autologous serum albumin, 20% concentration. Cells will be 
frozen in Cryocyte freezing bags (Nexell Therapeutics Inc) in a controlled rate freezer (Custom 
BioGenic Systems, Shelby Township, MI).  At the conclusion of this freezing, the cells will be 
transferred to the vapor phase of a monitored liquid nitrogen freezer (CryoPlus III, Forma 
Scientific, Marietta, OH) at a temperature of –120 0C or below. 
 
Pregnancy Risks: The risks of the drugs and procedures used in this study to a pregnancy are 
unknown. Pregnant women may not take part in this research study.  All women who could 
become pregnant will have a pregnancy test.  Men taking part should not father a baby while on 
this study.  All men and women who could become pregnant will be required to use a medically 
approved method of birth control in order to take part in this research study.   
 
7.0 POTENTIAL TOXICITIESAND MANAGEMENT 
7.1 Evaluation of toxicities (other than Hematologic) will be graded using NCI Common 
Toxicity Criteria, specifically CTC AE 4.0.  Life-threatening toxicities must be reported 
to the principal investigator, the clinical research assistant and the IRB.  The following 
laboratory test result abnormalities and adverse events should be captured on the non-
serious AE CRF page or SAE Report Form (paper or electronic) as appropriate: 
• Any laboratory test result/adverse reaction that is ≥ Grade 4 or meets the definition of an SAE 
• Any laboratory test result/adverse reaction abnormality that required the subject to have study 
drug discontinued or interrupted 


 
 
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• Any laboratory test result/adverse reaction deemed related to the treatment that required medical 
intervention, either by requiring an office/infusion room visit, treatment (ranging from 
medication administration, hydration or transfusion). 
Monitoring of toxicities will terminate on the last day of collection, since treatment-related 
toxicities occur during this time period.  Patients who complete mobilization will be considered 
“off treatment” on the date of the last mobilization.  There will be no specified follow up beyond 
the off treatment period other than following for engraftment.  However, should any life 
threatening event directly linked to the study take place within 2 weeks post-mobilization, the 
investigator shall use his/her discretion in reporting the event to the appropriate committees. 
7.2 Leukapheresis will be initiated approximately 11 - 12 days following cyclophosphamide 
administration.  Patients will be monitored clinically for toxicities during the 
mobilization process until completion of collection of stem cells.  In particular, the 
following will be monitored:  
• Transfusions of red blood cells  
• Transfusion of platelets  
• Hospitalizations  
• Incidence of febrile neutropenia 
 
7.3 Engraftment of neutrophils and platelets will be determined following transplant. 
Standard definitions of engraftment will be used.  Engraftment of each cell line will be 
defined as an absolute neutrophil count (ANC) of > 500/mm3 for three days (defined as first 
day) and a platelet count of 20,000/mm3 un transfused (defined as first day).  Standard 
definitions of engraftment are being used to allow comparisons to results within the 
literature.  
 
 
8.0 DRUG FORMULATION, AVAILABILITY AND TOXICITY 
8.1 Cyclophosphamide   
8.2 Mechanism of action: Cyclophosphamide is a pro drug that requires activation. 
Following hepatic and cellular activation, phosphoramide mustard and acrolein are 
formed.  Phosphoramide mustard is the alkylating agent that demonstrates cytotoxic 
effects.  Acrolein binds to proteins but does not contribute to the anti-tumor effects.  
8.3 Toxicities: Potential toxicities include: fever and/or chills, nausea and vomiting, anemia, 
oliguria/anuria, diarrhea, mental status changes, sinus tachycardia, elevated bilirubin, 
thrombocytopenia, BUN elevation, serum creatinine elevation, elevated transaminase, 
elevated alkaline phosphatase, pulmonary congestion, fatigue/weakness/malaise, 
dyspnea, pruritus, edema, erythema leukopenia, stomatitis, anorexia, rash, infection, 
weight gain  (>10%), 
arrhythmias, 
hypomagnesemia, 
acidosis, 
hypocalcemia, 
dizziness, dry skin, exfoliative dermatitis, GI bleeding, sensory dysfunction, jaundice, 
pulmonary edema, proteinuria, hypophosphatemia, headache, coagulation disorders. 
Acrolein is toxic to the bladder and is associated with the development of hemorrhagic 
cystitis. 
8.4 How supplied: cyclophosphamide is commercially available   
 
8.5 Zarxio (filgrastim-sndz; Sandoz, Inc.) 


 
 
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8.6 Zarxio (Sandoz, Inc.) is biosimilar to Amgen Inc.’s Neupogen (filgrastim). Zarxio is an 
FDA-approved biosimilar product. The dosing of Zarxio is the same as Filgrastim 
(outlined below). 
8.7 Mechanism of action: The colony stimulating factors (CSFs) are a family of 
glycoprotein hormones that support survival, clonal expansion, and differentiation of 
hematopoietic progenitor cells.  CSFs induce partially committed progenitor cells to 
divide and to differentiate in the granulocyte-macrophage pathways. 
8.8 Toxicities: Nausea/vomiting, skeletal pain, alopecia, diarrhea, neutropenic fever, 
mucositis, fever, fatigue, anorexia, dyspnea, headache, cough, skin rash, chest pain, 
generalized weakness, sore throat, stomatitis, constipation, pain. 
8.9 How Supplied: Zarxio is commercially available. 
 
8.10 
Filgrastim (Recombinant Human Granulocyte Colony Stimulating Factor; 
Amgen) 
8.11 
Mechanism of action: The colony stimulating factors (CSFs) are a family of 
glycoprotein hormones that support survival, clonal expansion, and differentiation of 
hematopoietic progenitor cells.  CSFs induce partially committed progenitor cells to 
divide and to differentiate in the granulocyte-macrophage pathways. 
8.12 
Toxicities: Nausea/vomiting, skeletal pain, alopecia, diarrhea, neutropenic fever, 
mucositis, fever, fatigue, anorexia, dyspnea, headache, cough, skin rash, chest pain, 
generalized weakness, sore throat, stomatitis, constipation, pain. 
8.13 
How Supplied: Filgrastim is commercially available. 
 
 
9.0 REQUIRED DATA and CORRELATIVE LABORATORY STUDIES 
9.1 The required data is divided into four sections: 1) Pre-Treatment Evaluation; 2) 
Mobilization/Collection; 3) Post-transplant engraftment and 4) Evaluation of the 
Laboratory Correlates.  The “Pre-Treatment Evaluation”, the “Mobilization and 
Collection Evaluation” and “Post-transplant engraftment” will be monitored by the 
treating Transplant Team and the Clinical Research Assistant.  
9.2 Pre-Treatment Evaluation: The “Treatment Evaluation” required for this trial is listed in 
Section 5.0, “General Workup and Diagnostic Procedures”. 
9.3 During the mobilization and collection processed, toxicity will be monitored (Section 
7.0, “Potential Toxicities, Dose Modifications and Management”). 
9.4 We will identify the number and types of cells collected with the apheresis process, a 
process that is performed regularly for each transplant patient.  The following data will 
be collected at the time of stem cell collection:   
• The number of peripheral blood CD34+ cells on Day 1 of collection 
• The number of apheresis required to collect > 6 x 106 CD34+cells/kg of 
body weight 
• The number of cells collected (MNC/kg and CD34+cells/kg) 
• The number of patients who failed mobilization, defined as: 
o < 1x106 CD34+cells/kg collected after 2 days of apheresis 
o Failure to mobilize an adequate number of CD34+ progenitor cells 
 Blood CD34+ cell number < 5 cells/mcl if weight < 75kg 
 Blood CD34+ cell number < 10 cells/mcl if weight > 75kg 


 
 
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9.5 Post-transplant engraftment of neutrophils and platelets.  
Engraftment of each cell line will be defined as an absolute neutrophil count 
(ANC) of > 500/mm3 for three days (count first day)and a platelet count of 20,000/mm3 
un transfused (count first day).  Standard definitions of engraftment are being used.  
 
9.6 Evaluation of the Mobilized Cells 
Pending budget issues, the following translational studies may be performed, comparing the 
results between the two cohorts:  
• Phenotypic analyses of early progenitor cells 
• Cytotoxicity of the mobilized effector cells 
• CD3+ CD8+ NKG2D+ T cell cytotoxicity; Isolation of the cytotoxic 
effector cells 
• Intracellular cytokine analysis of the mobilized effector cells 
 
9.7 Patient Samples – pending funding, patient blood samples will be analyzed in the 
laboratory.  Patient samples will be processed by the Immune Monitoring Laboratory. 
Each sample will be labeled with the trial number and provided with a unique patient 
number (UPN).  No individual patient samples will be identifiable.  The laboratory tests 
will be conducted by the Immune Monitoring Lab and a copy of the results will remain 
in the laboratory and with the PI.  The PI will be the only individual with access to the 
UPN and patient identity so that lab results can be correlated with clinical outcomes.  
9.7.1 Phenotypic analysis of early progenitor cells: The mobilized mononuclear 
cells will be analyzed to determine the presence of early progenitor cells. 
Patients’ samples will include a baseline pre-leukapheresis blood sample and 
one sample from the leukapheresis product.  Cell surface phenotype of the 
mononuclear cell (MNC) fraction of the peripheral blood and peripheral 
blood stem cells will be determined using appropriate fluorescein 
isothocyanate (FITC)- or phycoerythrin (PE)-conjugated monoclonal 
antibodies and three-color flow cytometry.  “Early” hematopoietic stem cells 
may 
demonstrate 
the 
following 
expression 
of 
surface 
antigens: 
CD34+/CD33-, CD34+/CD38-, and CD34+/HLA-DR-.  Samples of the 
collected mononuclear cells (MNC) cells will be labeled with conjugated 
monoclonal antibodies directed against the following antigens: CD34, CD33, 
CD38, HLA-DR, CD133, and CD90.  
9.7.1.1 Significance of CD133 and CD90: CD133 is a recently recognized 
stem cell antigen that identifies earlier progenitor cells then those 
identified with CD34 antigen expression alone. CD133 is found on 
50% of CD34-negative cells that contribute to long-term 
hematopoiesis, indicating that CD133 is likely an early marker of 
hematopoiesis.  The presence of CD90 (also known as Thy-1) on 
progenitor cells is an excellent predictor of prolonged engraftment. 
9.7.1.2 All flow cytometry data acquisition and automated analyses will be 
performed using two or three color staining on a FACSCalibur™ 
multipurpose flow cytometer and application-specific software 
(BDIS, San Jose, CA). 


 
 
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9.8 Phenotypic analysis of mobilized effector cells: Patients’ samples will include a baseline 
pre-leukapheresis blood sample and one apheresis sample.  Since we will be focusing on 
the mobilized effector cells with emphasis on the T cell population, the panel will 
contain antibodies directed against T cells (CD3), Helper T cells (CD3+/CD4+), 
cytotoxic T cells (CD3+/CD8), B cells (CD19+), NK cells (CD56+), and cytokine-
induced killer cells (CD3+/CD56+).  Cytokine-induced killer (CIK) cells show surface 
markers of T cells (CD3+) and NK cells (CD56+).  The CIK cell is thought to be of T 
cell origin, yet CIK cells possess the NK marker yielding the phenotype of 
CD3+CD56+. T regs and T suppressor cells will also be identified. 
9.8.1 Peripheral blood monocytes/macrophages will be mobilized.  These cells 
express various surface receptors, representing various biological functions 
such as adhesion, phagocytosis (CD11b/CD18, CD11c/CD18, CD16), 
antigen-presentation 
(HLA-DR, 
ICAM-1), 
differentiation 
(transferrin 
receptor, CD71), receptor for LPS (CD14) and initiation of the coagulation 
cascade (Tissue factor, CD142).  To test for the presence of 
monocytes/macrophages, 
we 
will 
use 
antibodies 
directed 
against 
CD64/CD16/CD45/CD14.  
 
9.9 Cytotoxicity of the mobilized effector cell population: Standard 4-hour 51C release 
cytotoxicity assays will be used to determine cytotoxic potential of the mobilized 
effector cells against NK-sensitive and LAK-sensitive K562  (CML) and NK-resistant, 
LAK-sensitive Daudi  (lymphoma) human tumor cell lines.  Three effector to target 
ratios will be evaluated (10:1, 50:1, 100:1).  The percent lysis will be calculated using 
the standard formula with data presented as mean +/- SEM.  Controls will be patient's 
own lymphocytes prior to stem cell mobilization.  The change in cytotoxicity comparing 
baseline sample and a sample from the apheresis product will be presented.  Internal 
controls consisting of media only will be used. 
 
9.10 
CD3+ CD8+ CTL Cytotoxicity; Isolation of the cytotoxic effector cells: This 
functional assay evaluates CD3 + T cell re-directed lysis of target cells.  Briefly, 
mononuclear cells will be isolated from blood or PBSC and cultured overnight in 
medium with or without IL-2 (10 U/ml).  Cells will be assayed the next day for their 
ability to lyse chromium-labeled Fc Receptor (FcR)-bearing P815 target cells (Myeloid 
cells).  A 6-hr antigen-independent redirected lysis assay is employed using anti-CD3 
MAb (OKT3) for CTL lytic activity and a control (no antibody- to measure background 
levels of lysis).  The use of an isotype control MAb W6/32 (directed against a 
monomorphic HLA-A, HLA-B, and HLA-C determinant) has demonstrated that this 
assay is specific.  The benefits of this assay over a standard Cr51 assay is that the 
addition of OKT3 “recruits” all CD3+ T cells and is specific to CD3+ T cells.  This 
recruitment allows the Fc receptor of the OKT3 to be directed against the FcR of the 
target cells (P815 cells).  Employing a method we previously developed for T cell subset 
depletion using antibodies conjugated to magnetic beads (Dynal, Oslo Norway), the 
immune-mobilized mononuclear cells will be depleted of various T cell subsets and the 
CD3 Re-Directed Lysis Test repeated.  Murine anti-human CD3, CD4, CD8 and CD56 
antibodies conjugated to goat anti-mouse magnetic beads (Dynal, Oslo Norway) will be 


 
 
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used.  After depletion and prior to performing the cytotoxicity assay, the efficacy of cell 
subset depletion will be assessed by flow cytometry using FITC-labeled antibodies 
directed against CD3, CD4, CD8 and CD56 and analyzed using a lymphocyte gate.   
 
9.11 
Intracellular cytokine analysis: We will determine if the T cells within the 
mobilized product are of T helper lymphocyte type 1 (Th1) or T helper lymphocyte type 
2 (Th2) origin. CD4+  helper T cells differentiate into two effector T cell populations, 
called Th1 cells  or Th2 cells. Th1 cells promote cell-mediated immunity and secrete 
IFN-γ, IL-2, IL-10, and TNF-α.  These cytokines promote cytotoxic T lymphocyte 
proliferation and macrophage activation resulting in destruction of tumor cells.  Th2 
cells are required for humoral immunity and secrete IL-4, IL-5, IL-9, and IL-13.  We 
have previously published our experience using either flow cytometry or ELISA to 
examine intracellular cytokines (22). 
 
10.0 
CRITERIA FOR RESPONSE AND TREATMENT ENDPOINTS 
10.1 
Primary Objective 
The primary objective of this clinical trial is to determine if a lower dose of 
cyclophosphamide combined with filgrastim can mobilize an adequate number of 
CD34+ progenitor cells with less toxicity. 
Details of this objective, as well as the Secondary and Exploratory objectives are 
listed within the “Objectives”.  
If the lower dose arm demonstrates non-inferiority at completion of patient 
accrual, then additional patients will be added to the lower dose arm to confirm 
non-inferiority or superiority. The number of patients needed to answer this will 
be based on statistical evaluation of the preliminary results (see Statistical 
Analysis). 
 
10.2 
Secondary Objectives:  
10.2.1 Define resource utilization during the mobilization and apheresis processes: 
• Transfusions of red blood cells  
• Transfusion of platelets 
• Hospitalizations 
• Incidence of febrile neutropenia 
10.3 
Exploratory Objectives 
10.3.1 Determine the post-transplant engraftment of neutrophils and platelets. 
10.3.2 Qualitative and quantitative analyses of mobilized lymphocytes. 
10.3.3 Translational studies examining the mobilized stem cell product and 
characterizing their functional abilities. This will be performed by 
determining the following: 
• Phenotypic analyses of early progenitor cells 
• Cytotoxicity of the mobilized effector cells 
• CD3+ CD8+ CTL Cytotoxicity; Isolation of the cytotoxic effector cells 
• Intracellular cytokine analysis of the mobilized effector cells 
 
 


 
 
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11.0 
REMOVAL OF PATIENTS FROM PROTOCOL and STOPPING RULES 
11.1 
Any patient may request removal from the trial at any time.  In addition, the 
treating physician may remove a patient from the trial at any time during treatment.  If a 
patient requests withdrawal, the patient’s samples will not be used for analyses.  
11.2 
Monitoring of toxicities will terminate on the last day of collection, since 
treatment-related toxicities occur during this time period.  Patients who complete 
mobilization will be considered “off treatment” on the last day of collection.  Patients 
will be considered “off protocol” after engraftment.  There will be no specified follow 
up beyond the off treatment period.  However, should any life threatening event directly 
linked to the study take place within 2 weeks post-mobilization, the investigator shall 
use his/her discretion is reporting the event to the appropriate committees. 
11.3 
Mobilization Failures: Any patient who “fails” to mobilize will be removed from 
the trial.  The term “mobilization failure” refers to an inadequate collection of CD34+ 
cells needed for an autologous stem cell transplant.  This definition is based on the 
absolute number of CD34+ cells collected or the inability to collect a specified number 
of cells in a certain number of leukapheresis.  Mobilization failure can also be predicted 
by the number of CD34+ cells mobilized into the peripheral blood following the 
mobilization treatment.  If the number of CD34+ cells in the blood is low, the apheresis 
process will not collect enough cells.  
11.4 
Based on a review of the literature, 8% to 13% of myeloma patients will not 
mobilize cells (1-4).  Using an estimated 10% of patients failing to mobilize in each 
group, we will need to accrue 44 patients to have 40 eligible patients.  Due to the 
complicated clinical course of these patients and factors known to make collection of 
autologous cells difficult, including patients’ age, previous therapy, previous radiation, 
the trial will be stopped if 20% of patients (n = 4) receiving the intermediate dose of 
cyclophosphamide (3 gms/m2) do not mobilize or 30 % of patients (n = 6) receiving the 
low dose cyclophosphamide (1.5 gms/m2) fail to mobilize.  
 
12.0 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED 
PROBLEMS 
12.1 
Since this trial represents standard of care treatment, we do not anticipate severe 
or life threatening toxicities.  In fact, many centers use a much higher dose of 
cyclophosphamide (5 gms/m2) for mobilization, then commonly used at DHMC.  We 
will closely monitor for any side effects or toxicities. 
12.2 
 Patients will be instructed to report the occurrence of any adverse event.  An 
adverse event is any undesirable event occurring from the time of consent until the last 
leukapheresis.  Adverse events will be graded according to the NCI Common Toxicity 
Criteria Version 4.0.  A copy of the CTC version 4.0 can be downloaded from the CTEP 
home page (http://ctep.info.nih.gov).  All appropriate treatment areas should have access 
to a copy of the CTC version 4.0.  Adverse events and unanticipated problems will be 
reported to The Dartmouth Committee for the Protection of Human Subjects (CPHS) as 
per their statement found at http://www.dartmouth.edu/~cphs/docs/aedsmmemo.pdf 
using their Serious Adverse Event (SAE) Reporting Form or their Reporting Form for 
An Unanticipated Problem Involving Risks to Subjects or Others (UPR)for Clinical 
Trials found at http://www.dartmouth.edu/~cphs/tosubmit/forms/.  


 
 
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Adverse events to be reported to the CPHS are: any adverse experience, defined as any 
untoward or unfavorable medical occurrence in a human subject, including any 
abnormal sign (for example, abnormal physical exam or laboratory finding), symptom, 
or disease, temporally associated with the subject’s participation in research, whether or 
not considered related to the subject’s participation in the research), that is considered: 
– 
Serious: 
Death; 
a 
life-threatening 
adverse 
drug 
experience; 
inpatient 
hospitalization or prolongation of existing hospitalization; a persistent or significant 
disability or incapacity; or a congenital anomaly or birth defect; and 
– 
Unexpected:  Any adverse experience, the specificity or severity of which is not 
consistent with the current investigator brochure or consent form; and 
– 
Possibly related:  There is a reasonable possibility that the incident, experience, or 
outcome may have been associated with the procedures involved in the research; and is 
experienced by a participant in a trial open at a site subject to review by the CPHS.  
 
 The following definitions will be used to assess causality: 
No: 
The clinical adverse event is definitely unrelated to study procedures (e.g., does 
not follow a reasonable temporal sequence from study procedure, present prior to 
procedure, etc.) 
Unlikely: 
The study procedures do not have any reasonable association with the 
observed experience; however, relationship cannot be definitely excluded. 
Possibly: 
The connection with study procedures appears feasible, but cannot be 
excluded with certainty (e.g., follows a reasonable temporal sequence from procedure, 
but may also be related to other known factors). 
Probably: 
The clinical experience appears related to the study procedures with a high 
degree of certainty (e.g., follows a reasonable temporal sequence from procedure  and 
abates upon termination of the procedure, cannot be reasonably explained by known 
characteristics of the patient’s clinical state or other modes of therapy administered to 
the patient, etc.) 
 
An unanticipated problem involving risks to subjects or others is defined as any incident, 
experience, or outcome that meets each of the following criteria: 
• 
Unanticipated in terms of nature, severity, or frequency given: (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and consent document; and (b) the characteristics of the 
subject population being studied; and 
• 
Possibly related to participation in the research means there is a reasonable 
possibility that the incident, experience, or outcome may have been associated with 
research participation; and 
• 
The problem suggests that the research places subjects or others at a greater risk 
of harm (including physical, psychological, emotional, economic, legal, or social harms) 
than was previously known or recognized. 
• 
Copies of each report and documentation of IRB notification and receipt will be 
kept in the Clinical Investigator’s study file. 
 
We will monitor and record unexpected toxicities related to the treatment and all 
> Grade 4 toxicities. 


 
 
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13.0 
STATISTICAL CONSIDERATIONS  
13.1 
Doses of cyclophosphamide commonly used for mobilization will be examined 
with a standard a dose of filgrastim.  The primary objective of this clinical trial is to 
determine if a lower dose of cyclophosphamide combined with filgrastim can mobilize 
an adequate number of CD34+ progenitor cells with less toxicity.  We postulate that the 
low dose cyclophosphamide (1.5 gms/m2) mobilization regimen will be as efficacious as 
the intermediate dose (3 gms/m2).  In the event that a patient is not evaluable, that 
patient will be replaced by enrolling another patient.  Toxicity will be tabulated 
according to type and grade, both overall and according to dose group.  Toxicity will be 
evaluated during mobilization and collection.   
13.2 
The trial is designed as a non-inferiority trial, meaning we will be examining if 
the lower dose of cyclophosphamide will mobilize a similar number of cells with fewer 
toxicities, when compared with a higher dose of cyclophosphamide.  Based on this 
assessment, 40 patients will be treated.  With 20 patients in each arm, we can achieve 
80% power to detect non-inferiority using a one-sided, two-sample t-test.  If the 
difference between the average number of apheresis required to collect cells for lower 
dose arm and higher dose arm is no greater than 0.5.  The true difference between the 
means is assumed to be 0.  The significance level (alpha) of the test is 0.025 and 
standard deviations are 0.55 for both arms.  
13.3 
Based on a review of the literature, 8% to 13% of myeloma patients will not 
mobilize cells (3).  Using an estimated 10% of patients failing to mobilize in each group, 
we will need to accrue 44 patients to have 40 eligible patients.  Due to the complicated 
clinical course of these patients and factors known to make collection of autologous 
cells difficult, including patients’ age, previous therapy, previous radiation, the trial will 
be stopped if 20% of patients (n = 4) receiving the intermediate dose of 
cyclophosphamide (3 gms/m2) do not mobilize or 30 % of patients (n = 6) receiving the 
low dose cyclophosphamide (1.5 gms/m2) fail to mobilize.  
13.4 
For other clinical outcomes, such as number of apheresis required to collect an 
adequate number of cells and the number of cells collected, we will use two sample t-
test to evaluate if there is any statistical significance between the two arms.  Where 
necessary, we will use transformations (e.g., logarithm and square root) to adjust for 
skewed distributions.  We will use 2-dimensional scatterplots to visualize the 
associations and to ensure the assumptions of t-test are not violated.  All statistical tests 
will be one-sided, and the overall type I error will be 0.025.  Engraftment rates will be 
estimated for the overall sample as well as for each dose group.  Confidence intervals 
will be constructed using exact binomial methods.  Laboratory analysis of the 
parameters related to mobilized cells will include overall summaries and graphical 
displays.  We will attempt to fit linear and non-linear models as appropriate based on the 
data summaries. 
13.5 
We do not anticipate any long-term toxicities.  As a result, after collection of the 
cells, patient follow-up will be stopped except for collection of engraftment data, if 
available. 
13.6 
SUMMARY of PRELIMINARY RESULTS: We have analyzed the preliminary 
data and some of the results are presented below.  In particular, the specific aim of the 


 
 
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trial was to show that the number of CD34+ cells and the number of mononuclear cells 
collected were similar in each arm (Table 3).  
 
Table 3 Summary of Progenitor Cell Collection 
 
Variables 
COHORT 1 
Cyclophosphamide 
1500 mg/m2 
n = 19 patients 
COHORT 2 
Cyclophosphamide  
3000 mg/m2 
n = 20 patients 
P value 
Total # of MNC (1010) 
 
5.2 (2.9 – 20.7) 
 
 
3.8 (1.9 – 7.1) 
 
 
0.03 
Total # of CD34+ cells (108) 
 
 
7.2 (2.2-49.9) 
 
 
10.5 (1.9 – 29.4) 
 
0.6 
MNC = mononuclear cells 
 
The results indicate that patients receiving the lower dose of cyclophosphamide collected more 
total mononuclear cells when compared with the higher dose of cyclophosphamide (p = 0.03).  The 
number of CD34+ cells collected is lower in the lower dose arm (7.2 x 108) compared with the 
higher dose arm (10.5 x 108), although this is not statistically significant (p = 0.6).  Although the 
lower number of CD34+ cells collected in the lower dose arm is not statistically significant, this is 
still a critical finding since the difference between the two arms might be clinically significant.  
Since the number of CD34+ cells is a more important clinical parameter used to determine 
optimal cell collection and to determine the optimal number of cells to infuse, more patients should 
be accrued to the lower dose arm to verify the number of CD34 + cells that are collected does not 
decrease.  Based on preliminary analyses of 19 patients who were treated in the lower dose arm, 
approximately 13 more patients would need to be accrued to the lower dose to confirm that the 
number of CD34+ cells collected remains within the current range and does not decrease.  The 
results from these additional 13 patients will be combined with the results from the other 
participants previously treated on the lower dose arm and compared as a group with the high dose 
arm.  The addition of 13 patients (32 patients total in the lower dose arm) would achieve 80% 
power to confirm a difference in the number of CD34+ cells collected between the two cohorts, 
with a p value (alpha) of 0.05, using a two-sided two-sample t-test.  We recognize that this new 
addition may interfere with the previous randomization.  We will use T test and Chi-square to 
determine if there is any significant difference between the two arms on all potential confounders.  
If one or more variables are identified, we will use linear regression model to include them as 
confounders.   
 
14.0 
STUDY MONITORING, AUDITING AND INSPECTION 
14.1 
Safety and Data Monitoring 


 
 
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This study will be monitored by the Data Safety Monitoring and Accrual Committee 
(DSMAC) of the Norris Cotton Cancer Center. The Committee meets quarterly to review 
accrual rates and information of all studies that have accrued participants. The Clinical 
Cancer Review Committee (CCRC) determines the frequency of DSMAC review. The 
DSMAC has the authority to suspend or to recommend termination to the CCRC of all 
research activities that fall within its jurisdiction.  In the event that a study is suspended or 
terminated by the DSMAC, that information will be forwarded to the CPHS (Dartmouth 
IRB) office. 
The DSMAC will monitor this trial. In particular, areas that will be monitored include 
accrual to the trial, toxicity associated with the treatment and patient outcomes (the 
“Objectives”). Since this trial represents standard of care treatment, we do not anticipate 
severe or life threatening toxicities. In fact, many centers use a much higher dose of 
cyclophosphamide (5 gms/m2) for mobilization, then commonly used at DHMC. We will 
closely monitor for any side effects or toxicities.  Stopping rules will be followed, as 
outlined in Section 11.  Briefly, the trial will be stopped if 20% of patients (n = 4) receiving 
the intermediate dose of cyclophosphamide (3 gms/m2) do not mobilize or 30 % of patients 
(n = 6) receiving the low dose cyclophosphamide (1.5 gms/m2) fail to mobilize.  
 
14.2 
On-site monitoring 
Clinical research monitoring for regulatory compliance and data integrity will be 
conducted according to the NCI-approved NCCC Data and Safety Monitoring Plan. 
Internal monitoring is conducted by appropriately trained staff of the NCCC Office of 
Clinical Research and Dartmouth-Hitchcock Medical Center Clinical Trials Office who 
are not involved in the study.  This monitoring will include periodic assessment of the 
regulatory compliance, data quality, pharmacy records and study integrity.  Study records 
will be reviewed and directly compared to source documents and the conduct of the study 
will be discussed with the investigator.  Monitors may request access to all regulatory 
documents, source documents, CRFs, and other study documentation for on-site 
inspection.  Direct access to these documents is guaranteed by the investigator, who must 
provide support at all times for these activities. 
 
14.3 
Auditing and Inspection 
Participation as an investigator in this study implies acceptance of potential 
inspection by government regulatory authorities and applicable Dartmouth research 
compliance and quality assurance offices.  The investigator will permit study protocol 
related audits and inspections by the Dartmouth CPHS, government regulatory bodies, 
and the Dartmouth compliance and quality assurance groups of all study related 
documents (e.g., source documents, regulatory documents, data collection instruments, 
study data etc.). The investigator will ensure the capability for inspections of applicable 
study-related facilities (e.g., pharmacy, diagnostic laboratory, etc.). 
 
  14.4  
Record Retention 
 
Following closure of the study, the investigator will maintain all site study records 
in a safe and secure location.  The records are maintained to allow easy and timely 
retrieval when needed (e.g., audit or inspection) and, whenever feasible, to allow any 
subsequent review of data in conjunction with assessment of the facility, supporting 


 
 
Mobilization Trial 05/16/2017 
 
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systems, and staff.  Upon completion of study analysis, research information is stored in 
Dartmouth College Records Management off-site storage located at 6218 Etna Road, 
Hanover, NH  03755.  Documents are shredded on site after 50 years of storage. 
 
 
 
Electronic case report forms, participant, and study information will be kept in the 
Velos eResearch password-protected database (or equivalent) indefinitely. 
 
15.0 
HUMAN SUBJECTS 
15.1 
This is a randomized study.  To enter eligible patients or discuss a patient’s 
eligibility, please contact Dr. Kenneth R. Meehan or the Clinical Research Associate 
(Bridget Labrie at 603-650-6227).  No patients shall be entered on study without 
consultation with the Principal Investigator or CRA. 
15.2 
Patient care and status will be monitored by a Transplant/Hematology Physician 
and a designated Data Manager.  All data will be maintained on a closed database with 
each subject identified by a unique patient number (UPN) with access to patient names 
only for those involved in clinical care.  All patients will provide informed consent prior 
to study entry.  Necessary information will be forwarded to the Center for International 
Blood and Marrow Transplant Registry (CIBMTR).  Each patient will be fully informed 
concerning this study, including pertinent adverse reactions.  All institutional or other 
Federal regulations and guidelines concerning informed consent will be fulfilled. 
15.3 
Gender and Minority Inclusion for Research Involving Human Subjects: The 
clinical trial is open to all patients with the hematologic malignancies as outlined within 
the “Eligibility Criteria” of the trial.  All races and both genders are eligible.  Given the 
geographic location of Dartmouth-Hitchcock Medical Center and the Norris Cotton 
Cancer Center, we anticipate the majority of patients will be Caucasian with an equal 
distribution of males and females. 
15.4 
Participation of Children: Stem cell transplants in pediatric patients are not 
performed at Dartmouth. 
 
 
 


 
 
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16.0   BIBLIOGRAPHY  
 
1. Cavo M, Rajkumar SV, Palumbo A et al. International Myeloma Working Group consensus approach 
to the treatment of multiple myeloma patients who are candidates for autologous stem cell 
transplantation. Blood 2011, 117:6063-6073. 
2. To LB, Levesque JP, Herbert KE. How I treat patients who mobilize hematopoietic stem cells poorly. 
Blood 2011, 118(17) 4530-40. 
3. Giralt S, Stadtmauer EA, Harousseau JL et al. International Myeloma Working Group (IMWG) 
consensus statement and guidelines regarding the current status of stem cell collection and high-dose 
therapy for multiple myeloma and the role of plerixafor (AMD 3100). Leukemia 2009 23, 1904–1912. 
4.  Kumar S, Giralt S, Stadtmauer EA et al. Mobilization in myeloma revisited: IMWG consensus 
perspectives on stem cell collection initial therapy with thalidomide-, lenalidomide-, or bortezomib-
containing regimens. Blood 2009, 114(9), 1729-1735. 
5. Chao NJ, Grima DT, Carrum G et al. Chemo-mobilization provides superior mobilization and 
collection in autologous stem cell transplants but with less predictability and at a higher cost.  Blood 
2011, 118: Abstract 4048. 
6. Kumar S, Flinn I, Richardson PG et al. Randomized, multicenter, phase 2 study (EVOLUTION) of 
combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously 
untreated multiple myeloma. Blood 2012, 119:4375–4382. 
7. Tanimura A, Takeshita M, Sato A et al. High-dose cyclophosphamide + filgrastim mobilization 
regimen have higher anti-myeloma effects than filgrastim alone regimen – A single institutional study in 
147 myeloma patients from Japan. Blood 2011 118:2007 abstract 731. 
 
8. Dingli D, Nowakowski GS, Dispenzieri A et al. Cyclophosphamide mobilization does not improve 
outcome in patients receiving stem cell transplantation for multiple myeloma. Clin. Lymphoma Myeloma 
2006,  6(5): 384 -388 
 
9. Narayanasami U, Kanteti R, Morelli J et al. Randomized trial of filgrastim versus chemotherapy and 
filgrastim mobilization of hematopoietic progenitor cells. Blood 2001, 98:2059-2064. 
10. Pozotrigo M, Adel N, Landau H et al. Factors impacting stem cell mobilization failure rate and 
efficiency in multiple myeloma in the era of novel therapies: Experience at Memorial Sloan Kettering 
Cancer Center. Bone Marrow Transplantation 2013, 48:1033–1039 
11.  Boccadoro M, Palumbo A, Bringhen S, Merletti F, Ciccone G, Richiardi L et al. Oral melphalan at 
diagnosis hampers adequate collection of peripheral blood progenitor cells in multiple myeloma. 
Haematologica 2002; 87: 846–850. 
 


 
 
Mobilization Trial 05/16/2017 
 
Page 24 
 
12.  Ghobrial IM, Dispenzieri A, Bundy KL, Gastineau DA, Rajkumar SV, Therneau TM et al. Effect of 
thalidomide on stem cell collection and engraftment in patients with multiple myeloma. Bone Marrow 
Transplant 2003; 32: 587–592. 
 
13. Kumar S, Dispenzieri A, Lacy MQ, Hayman SR, Buadi FK, Gastineau DA et al. Impact 
of lenalidomide therapy on stem cell mobilization and engraftment post-peripheral blood stem cell 
transplantation. Leukemia 2007; 21(9):2035-42. 
 
14. Fietz T, Rieger K, Dimeo F, Blau IW, Thiel E, Knauf WU. Stem cell mobilization in multiple 
myeloma patients: do we need an age-adjusted regimen for the elderly? J Clin Apher 2004; 19: 202–207. 
15.Hamadani M, Kochuparambil ST, Osman S, Cumpston A, Leadmon S, Bunner P, Watkins K, 
Morrison D, Speir E, DeRemer D, Kota V, Jillella A, Craig M, Awan F. Intermediate-dose versus low-
dose cyclophosphamide and granulocyte colony-stimulating factor for peripheral blood stem cell 
mobilization in patients with multiple myeloma treated with novel induction therapies. Biology of Blood 
and Marrow Transplantation. 2012; 18(7): 1128-1135. 
16. Gertz MA. Current status of stem cell mobilization. Br J Haematol 2010; 150:647–662. 
 
17. Sizemore CA, LaPorte J, Sanacore M, Holland HK, Mccollum J, Weswterman J, Morris LE, Bashey 
A, Solomon SR. A comparison of toxicity and mobilization efficacy following two different doses of 
cyclophosphamide for mobilization of hematopoietic stem cells in multiple myeloma patients. Blood 
2009; 114: Abstract 4229. 
18. Gertz MA, Kumar SK, Lacy MQ, Dispenzieri A, Hayman SR, Buadi FK, Dingli D, Gastineau DA, 
Winters JL, Litzow MR. Comparison of high-dose cyclophosphamide and growth factor with growth 
factor alone for mobilization of stem cells for transplantation in patients with multiple myeloma. Bone 
Marrow Transplantation 2009, 43: 619-625. 
19. Hiwase DK, Bollard G, Hiwase S, Bailey M, Muirhead J, Schwarer AP. Intermediate-dose 
cyclophosphamide and filgrastim more efficiently mobilize adequate numbers of stem cells for tandem 
autologous transplantation compared with low-dose cyclophosphamide in patients with multiple 
myeloma. Chemotherapy 2007; 9(6): 539 – 547. 
20- Karanes C, DAgis S, Wang A et al. Is Low dose cyclophosphamide plus filgrastim mobilization as 
effective as plerixafor plus filgrastim in myeloma patients who are candidates for tandem autologous 
transplant ? J Clin Onc 28:15s, 2010, Abstract 8142. 
21. Meehan KR, Hill JM, Patchett L, Webber SM, Wu J, Ely P, Szczepiorkowski ZM. Implementation 
of peripheral blood CD34 analyses to initiate leukapheresis: marked reduction in resource utilization. 
Transfusion, 46:523-529, 2006 


 
 
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22.  Barber A, Meehan KR, Sentman C. Treatment of multiple myeloma with adoptively transferred 
chimeric NKG2D receptor-expressing T cells.  Gene Therapy, 2011; 18(5): 509–516 


 
 
Mobilization Trial 05/16/2017 
 
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Appendix A 
 
Job Aid 
Stem Cell Mobilization Job Aid - Blood 
and Marrow Transplant 
ID: 
9624 
Keywords 
Not Set 
Department 
Blood and Marrow Transplant Program 
 
I. Purpose 
 
The purpose of this Job Aid is information on Hematopoietic Progenitor Cells, Apheresis (HPC-
A) mobilization for healthy allogeneic donors and patients undergoing autologous stem cell 
transplantation. 
 
Patients enrolled in a clinical trial, refer to the specific trial protocol, as it may utilize 
Sargramostim or Pegfilgrastim for mobilization and it may stipulate alternative specifications for 
colony stimulating factor (CSF) dose schedule. 
 
A. CSF Medication List: 
 
1. Filgrastim (granulocyte colony stimulating factor, G-CSF, Neupogen®) 
*the primary colony stimulating factor utilized at D-H for PBSC mobilization 
2. Sargramostim (granulocyte-macrophage colony stimulating factor, GM-CSF, Leukine®) 
3. PEG-filgrastim (Neulasta®) 
4. Plerixafor (Mozobil) 
 
B. Pre-Mobilization 
 
a. All candidates for peripheral blood stem cell (PBSC) collection have peripheral venous 
access of the upper extremities assessed in the Apheresis area prior to initiation of the 
stem cell mobilization regimen. 
a. Once the donor has been assessed: 
1) Apheresis nurse notifies the Blood and Marrow Transplant Nurse 
Coordinator if placement of a central venous access device is 
required. 
b. Donors with inadequate venous access require placement of a temporary or 
a 3-lumen pheresis catheter. 
 


 
 
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C. Mobilization 
 
1. Standard G-CSF Mobilization 
 
a. Growth factor is initiated by Provider five days prior to the onset of stem cell 
collection. 
 
b. Subcutaneous G-CSF is used to mobilize peripheral blood stem cells. 
2. Routinely, collection begins on the fifth day if the peripheral blood CD34+ count is greater 
than 5-10 cells/mcL. 
 
3. Collection continues until the requested CD34+/kg recipient number has been reached, 
generally greater than 2-3 x 10e6 cells/kg recipient. 
 
4. Patients that fail to mobilize, consideration is given for further attempt at PBSC collection 
or to proceed with a bone marrow harvest. 
 
D. CSF Medication List 
 
1. Filgrastim -Granulocyte colony stimulating factor, G-CSF, Neupogen® 
*The primary colony stimulating factor utilized at D-H for PBSC mobilization 
 
a. Filgrastim is generally considered to be the CSF of choice for PBSC mobilization. 
b. Filgrastim may be administered as a single agent to allogeneic donors; as a single 
agent or following chemotherapy for autologous stem cell collection. 
c. Filgrastim may be administered as a single agent to allogeneic donors; as a single 
agent or following chemotherapy for autologous stem cell collection. 
d. If post chemotherapy, begin at least 24 hours after the last dose of chemotherapy. 
e. Administration continues until optimal stem cell collection is completed. 
 
2. Sargramostim -Granulocyte-macrophage colony stimulating factor, GM-CSF, Leukine® 
 
3. PEG-filgrastim (Neulasta®) 
 
4. Plerixafor (Mozobil 


 
 
Mobilization Trial 05/16/2017 
 
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5. Cyclophosphamide (Cytoxan) GCSF Mobilization 
 
a. Cyclophosphamide is given in conjunction with IV fluid hydration 
 
b. Mesna is given with Provider order 15 minutes prior to Cyclophosphamide then at dose 
four and 8 hours following Cyclophosphamide with provider order.. 
 
c. Filgrastim is given on day 3 of mobilization with provider order 
 
d. CBC/differential checks on days 4, 6, 8 locally, then on day 11-12 at D-H with 
associated peripheral blood CD34 cell count with provider order. 
 
e. Routinely, collection of cells will begin on day 11 or 12 and the peripheral blood CD34+ 
count is greater than 5-10 cells/ mcL. 
 
f. Collection of cells continues until the requested CD34+/kg recipient number has been 
reached, generally greater than 2-5x10e6 cells/kg recipient depending on disease. 
g. For patients that fail to mobilize, consideration is given for further attempt at HPC-A 
collection with provider order of G-CSF & Plerixiflor (Mozobil) or patient proceeds 
with a bone marrow harvest. 
 
6. Chemotherapy / G-CSF Mobilization 
 
a. The majority of the lymphoma patients have been treated with different chemotherapy 
regimens ie. RICE, ESHAP, EPOOCH, and IVAC. 
b. The BMT program utilizes those cycles of chemotherapy and has added G-CSF to 
the regimen starting 24hours after last dose of chemotherapy is given. 
1) Filgrastim is recommended as first line with provider order. 
2) CBC/diff laboratory checks 2-3x week locally, then on day 12-14 at D-H with 
associated peripheral blood CD34 cell count with provider order. 
3) Routinely, collection of cells begins between day 12-14 with the peripheral 
blood CD34+ count is greater than 3-10 cells/mcL. 
4) Collection continues until the requested CD34+/kg recipient number has 
been reached generally greater than 2-5 x 10e6 cells/kg recipient depending 
on disease. 
 


 
 
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7. Adverse Effect Management 
a. CSFs are generally well-tolerated. 
b. Constitutional symptoms are common. 
c. The majority of patients receiving CSFs experience: 
1) Bone pain 
2) Fevers have also been associated with CSF use, particularly with sargramostim. 
 
Responsible Owner: 
Blood and Marrow Transplant 
Program 
Contact(s): email 
Joshua Hickman 
Approved By: 
Office of Policy Support Job Aid 
George Routzhan, Kenneth Meehan 
Version # 
1 
Current Approval Date: 
12/09/2014 
Old Document ID: 
BMT.0025 
Date Policy to go into Effect: 
12/09/2014 
Related Polices & 
Procedures: 
Related Job Aids: 
 
 
 


 
 
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Appendix B 
 
Job Aid 
Pre-Transplant Allogeneic and Autologous 
Recipient Evaluation and Selection Job Aid - 
Blood and Marrow Transplant 
ID: 
10052 
Keywords 
Not Set 
Department 
Hematology/Oncology 
 
I. Purpose 
The purpose of this procedure is to formalize guidelines pertaining to patient suitability and 
eligibility for allogeneic and autologous hematopoietic stem cell transplantation and to 
standardize the process of evaluating and selecting prospective hematopoietic stem cell 
recipients (peripheral blood and bone marrow) to achieve optimal assessment and 
minimization of potential risks during transplant. 
 
The recipient of conditioning therapy followed by allogeneic or autologous bone marrow or 
peripheral blood stem cell infusion must be evaluated for all potential risks from this 
procedure, including the stem cell mobilization and collection process (autologous 
recipient), chemotherapy regimen (high-dose or reduced intensity or non-myeloablative), 
stem cell infusion, infectious complications, organ compromise, and graft-versus-host 
disease (allogeneic recipient). These issues require early thoughtful discussion with the 
prospective hematopoietic recipient and referring physician, along with consideration of 
relative risk in the context of the specific medical history and overall state of health of this 
individual. 
 
Established requirements for high-dose chemotherapy followed by allogeneic or 
autologous stem cell transplantation are outlined below, subject to interpretation and 
potential modification, depending on the overall status of the patient in question and 
circumstances surrounding the transplant. 
The patient eligibility is discussed in the weekly transplant clinical meetings and a consensus 
decision is made to proceed or not by the BMT team. 
 
 
a) General considerations for eligibility 
• Recipient has chemotherapy-sensitive disease & attainment of minimal residual 
disease and no second active malignancy. Disease status will be evaluated using 
accepted means based on the patient’s diagnosis 


 
 
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Page 31 
 
. 
• Potential Malignancy 
o Female – pap smear, mammogram 
o Male – prostate exam and/or PSA 
o Colonoscopy – pending age and risk factors. 
 
• Adequate organ function. 
o Echo/Muga – cardiac ejection fraction greater than or equal to 45%. 
o EKG – no evidence of potentially life-threatening cardiac dysrhythmia. 
o Pulmonary function tests – FVC / FEV1 greater than or equal to 50%, and DLCO 
greater than or equal to 50% predicted. 
o Chest x-ray – R/O lung infection or process that would indicate recipient @ high 
risk of developing lung issues/complications. 
o 24 hr urine clearance or Glomerular Filtration Rate (GFR) greater than 50 ml/min. 
o Liver function: total bilirubin less than or equal to 2.0 and transaminases. 
o No pregnancy 
 
• No life-threatening viral exposures. 
o Hepatitis B Core Antibody 
o Hepatitis B Surface Antigen 
o Hepatitis C Virus 
o HIV 1/2 Antibody 
o HTLV I/II Antibody  
o Nat Multiplex 
o Syphillis Serology 
o West Nile Virus NAT 
o Chagas Antibody 
o CMV Antibody 
o Herpes simplex virus IgG 
o Toxoplasmosis antibody 
o Varicella zoster virus IgG 
o EBV (Epstein Bar Virus) nuclear IgG 
 
• No life-threatening co-morbidities that would likely compromise the patient’s clinical care 
and chance for optimal post-transplant survival. 
 
• Eradication of any active pre-transplant infection. A dental assessment must be done 
prior to transplant. 
 
• Age, auto/reduced intensity conditioning and non-myeloablative less than or equal to 75 years 
and myeloablative conditioning less than or equal to 60 years. 
 


 
 
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Page 32 
 
• Karnofsky performance score greater than or equal to 70% 
 
• Psychosocial assessment addressing barriers to transplant (financial, lack of caregivers, and 
compliance issues). If a barrier is identified, team will discuss and determine if patient can 
proceed to transplant. 
 
• Allogeneic transplant patients must have an available HLA-matched related or unrelated 
donor. (10/10 match; 9/10 match feasible, depending on locus of mismatch) 
 
• Pre-transplant stem cell goal of 2-3x106 CD34 positive cells per kilogram recipient weight. 
 
• Patients registered on specific protocols will clearly meet the requirements of that protocol. 
 
b) Other points to consider: 
• Venous access assessment 
o All patients will have a 3 lumen tunneled CVC line placed at time of transplant. 
 
• Radiation Oncology Consultation 
o When total body irradiation (TBI) is intended as part of the pre-transplant conditioning 
regimen, a formal request for Radiation Oncology consultation will be initiated by the 
BMT nurse coordinator. 
 
• Biological product deviations (case-specific basis) 
o A transplant physician will document in the recipient’s medical record the prospective 
donor’s suitability for stem cell donation prior to initiation of the recipient’s 
conditioning therapy. In the event of circumstances where a deviation from the 
standard donor criteria for transplant is noted, including biological product deviations, 
appropriate rationale for donor selection will be required in writing, along with the 
informed consent of both the donor and the recipient. If indicated, this will also reflect 
consensus from a weekly BMT Team Meeting discussion, documented in writing. In 
the event of a biological product deviation (stem cell contamination, damage during 
storage, or suboptimal stem cell yield), written documentation of discussion with and 
approval for use (including the rationale) by the Director of the Dartmouth Hitchcock 
Transfusion Medicine Service will be required. 
 
• On a case by case basis, patients will be considered for their appropriateness for outpatient stem 
cell transplant (autologous or non-myeloablative allogeneic), depending on several factors, 
including but not necessarily limited to the following: 
o Personal patient and caregiver desire for and commitment to outpatient transplant 


 
 
Mobilization Trial 05/16/2017 
 
Page 33 
 
o Patient compliance and caregiver competency/reliability 
o Appropriate home and/or local environment availability (e.g., hotel, VNA services) 
o Suitability of conditioning regimen for outpatient therapy 
o No other medical condition that may complicate outpatient therapy. 
 
• Re-evaluation of transplant assessment will occur in these two instances: 
o If more than 12 weeks has elapsed between harvest or peripheral blood stem cell 
(PBSC) collection and transplant, the need for reconfirmation of eligibility will 
be assessed. 
o Patients who do not meet the transplant criteria upon their initial assessment will be 
re- evaluated when deemed appropriate by the transplant physician. The patient’s 
treatment plan will take into consideration the individual issue(s) which have 
precluded the patient from transplant, determinations of whether they are 
modifiable, and the appropriate time frames for re-evaluation. 
 
FOR ALLOGENEIC TRANSPLANT PATIENTS ONLY 
• As allogeneic patients are evaluated, the EBMTR and Hematopoietic Stem Cell Transplant Co-
morbidity Index (HCT-CI) scores will be assessed in an effort to select those patients that will 
optionally do best with an allogeneic stem cell transplant. These results will be documented 
in the patient’s medical record. 
 
EBMT Risk Score 
• It is sometimes difficult to determine a patient’s risk when deciding if a patient is a candidate 
for transplant. The European Blood and Marrow transplant (EBMT) Group developed a risk 
score to assess potential allogeneic recipients before transplant. The EBMTR group identified 
5 patient and donor characteristic, including: 
o Patient age 
o Disease stage 
o Time from diagnosis to transplant, 
o Donor type 
o Donor-recipient gender 
• These 5 traits were examined in 56,505 allogeneic transplant patients (myeloablative and non-
ablative regimens), with various hematologic malignancies and were predicative of survival 
and treatment- related mortality. 
 
 
 
 
 
 
 


 
 
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Page 34 
 
Table 1. European Group for Blood and Marrow Transplantation Risk Score Definition 
                                Risk Factor  
 
 
 
 
Score Point 
Age of the patient, y 
Less than 20 
0 
20-40 
1 
Greater than 40 
2 
Disease stage 
Early 
0 
 
Late 
2 
Time interval from diagnosis to transplant, 
months* 
Less than 12 
0 
Greater than 12 
1 
 
 
 
Donor type 
 
Unrelated donor 
1 
 
 
 
*Does not apply for patients transplanted in first complete remission (score 0).
Intermediate 
1 
HLA-identical sibling donor 
0 
Donor-recipient sex combination 
All other 
0 
Donor female, male recipient 
1 


 
 
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Page 35 
 
Figure 1: Risk score for outcome after allogeneic hematopoietic stem cell transplantation 
 
 
 
 
 
Survival (Top) and transplant‐related mortality 
(TRM) (Bottom) of 56,605 patients with an 
allogeneic hematopoietic stem cell transplantation 
(HSCT) for an acquired hematological disorder is 
shown by risk score. Graphs reflect probability of 
survival (Top) and transplant‐related mortality 
(Bottom) over the first 5 years after HSCT. 
 
 
 
 
HCT-CI 
• The Hematopoietic Stem Cell Transplant Co-morbidity Index was developed by Sorror, 
et. al. and addresses a patient’s survival and non-relapsed mortality based on specific 
patient characteristics.


 
 
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Table 2. Definitions of comorbidities included in the HCT-CI 
 
 
Comorbidity 
Definitions of comorbidities included in the HCT-CI                   HCT-CI 
weighted scores 
 
Arrhythmia 
Atrial fibrillation or flutter, sick sinus syndrome, or ventricular 
arrhythmias 
1 
Cardiac 
Coronary artery disease*, congestive heart failure, myocardial 
1 
infarction, or EF less than or equal to 50% 
Diabetes 
Requiring treatment with insulin or oral hypoglycemics but not diet 
1 
alone 
Cerebrovascular disease 
Transient ischemic attack or cerebrovascular accident 
1 
Psychiatric disturbance 
Depression or anxiety requiring psychiatric consult or treatment 
1 
Obesity 
Patients with a body mass index greater than 35 kg/m2 
1 
Rheumatologic 
SLE, RA, polymyositis, mixed CTD, or polymyalgia rheumatica 
2 
Moderate/severe renal 
Serum creatinine greater than 2 mg/dL, on dialysis, or prior renal 
2 
transplantation 
Prior solid tumor 
Treated at any time point in the patient's past history, excluding 
3 
nonmelanoma skin cancer 
Severe pulmonary 
DLco and/or FEV1 less than or equal to 65% or dyspnea at rest or 
3 
requiring oxygen 
*One or more vessel-coronary artery stenosis requiring medical treatment, stent, or bypass graft. 
Inflammatory bowel 
disease 
Crohns disease or ulcerative colitis 
1 
Hepatic, mild 
Chronic hepatitis, bilirubin greater than ULN to 1.5 x ULN, or 
AST/ALT greater than ULN to 2.5 x ULN 
1 
Infection 
Requiring continuation of antimicrobial treatment after day 0 
1 
Peptic ulcer 
Requiring treatment 
2 
Moderate pulmonary 
DLco and/or FEV1 66%-80% or dyspnea on slight activity 
2 
Heart valve disease 
Except mitral valve prolapse 
3 
Moderate/severe hepatic 
Liver cirrhosis, bilirubin greater than 1.5 x ULN, or AST/ALT greater 
than 2.5 x ULN 
3 


 
 
Mobilization Trial 05/16/2017 
 
Page 37 
 
Table 3: HCT-CI scores, 2 year survival and hazard ratios for NRM (Non-Relapse 
Mortality) 
 
HCT-CI 
NRM 
Survival 
Score 
N 
HR*(95% CI) 
2-year, % 
HR*(95% CI) 
2-year, % 
0 
38 
1.0 
14 
1.0 
71 
1 to 2 
34 
1.42 (0.8-2.7) 
21 
1.31 (0.8-2.0) 
60 
3 or more 
28 
3.54 (2.0-6.3) 
41 
2.69 (1.8-4.1) 
34 
* Adjusted for age, disease risk, and conditioning. 
 
References 
 
1. FACT–JACIE International Standards for Cellular Therapy Product Collection, 
Processing, and Administration, Fifth Edition, March 2012, Foundation for the 
Accreditation of Cellular Therapy (FACT), Omaha Nebraska. 
2. Gratwohl, A, et. al. Hematopoietic stem cell transplantation A Global Perspective 
JAMA. Apr 28, 2010; 303(16): 1617-1624.  
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219875/pdf/nihms308448.pdf 
3. Ezzone, Susan. Hematopoietic Stem Cell Transplantation. A Manual for Nursing 
Practice. ONS, Pittsburgh, PA; 2013 
4. Recommended Timing for Transplant Consultation, Published jointly by the National 
Marrow Donor Program®/Be The Match® and the American Society for Blood and 
Marrow Transplantation  
https://bethematchclinical.org/WorkArea/DownloadAsset.aspx?id=3545 
5. Gratwohl A, Stern M, Brand R, et al. Risk score for outcome after allogeneic 
hematopoietic stem cell transplantation: a retrospective analysis.  Cancer. 
2009;115(20):4715-26. 
6. Sorror ML, Maris MB, Storb R, Baron F, Sandmaier BM, Maloney DG, et al. 
Hematopoietic cell transplantation (HCT)-specific comorbidity index: a new tool for risk 
assessment before allogeneic HCT. Blood. 2005; 106 (8): 2912-19. 
 
Barba P, Martino R, Perez-Simon JA, et al. Combination of the Hematopoietic Cell Transplantation Comorbidity 
Index and the European Group for Blood and Marrow Transplantation score allows a better stratification of high-
risk patients undergoing reduced-toxicity allogeneic hematopoietic cell transplantation.  Biol Blood Marrow 
Transplant. 2014;20(1):66-72. 
 
 
 
 


 
 
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Page 38 
 
Responsible Owner: 
Blood and Marrow Transplant 
Contact(s): email 
Joshua Hickman 
Approved By: 
Office of Policy Support Job Aid 
George Routzhan, Kenneth Meehan 
Version # 
1 
Current Approval Date: 
02/10/2015 
Old Document ID: 
BMT0020 
Date Policy to go into Effect: 
02/10/2015 
Related Polices & 
Procedures: 
Second Transplant Guidelines – Blood and Marrow Transplant 
Selection of Preparative High-Dose Chemotherapy Regimens Job Aid- Blood  
and Marrow Transplant 
Management of Non-Conforming Products Procedure - CTC - Laboratory  
Donor Lymphocyte Infusions (DLI) Following Allogeneic Stem Cell Transplant  
Guidelines – Blood and Marrow Transplant 
Related Job Aids: 
Pre-Transplant Patient-Recipient Evaluation Allogeneic Stem Cell Transplant  
Job Aid - Blood and Marrow Transplant 
Pre-Transplant Donor/Patient Autologous Evaluation Job Aid - Blood and  
Marrow Transplant 
 
 
 


 
 
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Page 39 
 
 
Job Aid 
Selection of Preparative High-Dose Chemotherapy 
Regimens Job Aid- Blood and Marrow Transplant 
ID: 
8412 
Keywords 
Not Set 
Department 
Blood and Marrow Transplant Program 
 
I. Purpose 
The purpose of this Job Aid is educational information surrounding the selecting of 
conditioning therapy prior to hematopoietic stem cell transplantation (HSCT). 
 
A. Selection of Appropriate Patients for Hematopoietic Stem Cell Transplant 
 
• The recipient of conditioning therapy followed by allogeneic or autologous bone 
marrow or peripheral blood stem cell infusion must be evaluated for all potential risks 
from this procedure, including the stem cell mobilization and collection process 
(autologous recipient), high-dose chemotherapy, stem cell infusion, infectious 
complications, organ compromise, and graft-versus- host disease (allogeneic 
recipient). 
 
• These issues require early thoughtful discussion with the prospective hematopoietic 
recipient, along with consideration of relative risk in the context of the specific medical 
history and overall state of health of this individual. 
 
• Established eligibility for high-dose chemotherapy followed by allogeneic or autologous 
stem cell transplantation and is subject to interpretation and potential modification, 
depending on the overall status of the patient in question and circumstances surrounding 
the transplant. 
 
B. Selection of High-Dose Chemotherapy Regimens Prior to Hematopoietic Transplant 
 
• The conditioning (preparative) regimen is a critical factor in the hematopoietic stem 
cell process, with objectives that differ between the allogeneic and autologous 
settings: 
 
• Conditioning Regimen Objectives 
 


 
 
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Page 40 
 
a. Allogeneic 
 Ablation of host immunity (to prevent rejection of the transplanted donor 
graft) 
 Tumoricidal activity (when malignant disease is present) 
 
b. Autologous 
 Tumoricidal activity 
 Steep dose-response curve 
 Lack of cross resistance with other drugs 
 Low extra-medullary dose-limiting toxicity 
• More specific factors in the selection of the pre-transplant preparative agents relate to potential 
toxicities of a potential conditioning regimen in the context of the patient’s pre-transplant status, 
the relative toxicity of prior therapies and existing comorbidities. For example, a patient with a 
history of Hodgkin’s disease including a prior mediastinal mass that required radiation would 
not be an optimal candidate for a BCNU-containing conditioning regimen, given the combined 
risks for interstitial pneumonitis. 
 
• Alternately, older patients with a characteristically lower threshold for neurologic toxicity are 
less optimal candidates for high-dose cytarabine, given that cerebellar toxicity is a primary 
extra- medullary side effect of this agent. 
 
• The extra-medullary dose limiting toxicities of several common conditioning agents are listed 
below: 
 
Extra-medullary Dose Limiting Toxicities 
Therapy 
Possible Toxicities 
Carmustine (BCNU) 
lung (interstitial pneumonitis) 
Etoposide (VP-16) 
mucositis; liver 
Cytarabine (Ara-C) 
CNS ataxia; mucositis 
Busulfan 
veno-occlusive disease (VOD); seizures; lung; mucositis 
Cyclophosphamide 
hemorrhagic cystitis; heart failure 
Total body irradiation (TBI) 
lung; heart 
 
• Commonly Used Conditioning Regimens for HSCT 
a. Autologous 
• Melphalan 
• Melphalan & Velcade 
• CBV – Cyclophosphamide, Carmustine & Etoposide 


 
 
Mobilization Trial 05/16/2017 
 
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• BEAM – Carmustine, Etoposide, Cytarabine & Melphalan 
 
b. Allogeneic 
• Non-Myeloablative 
 Fludarabine/Total Body Irradation (Flu/TBI) 
 Fludarabine/Busulfan (Dosing for Busulfan 9.6 mg/kg) 
• Reduced Intensity 
 Fludarabine/Cyclophosphamide (Dosing for Cytoxan 120 mg/kg) 
 Fludarabine/Melphalan 
 Flurabine/Bulsulfan (Dosing for Busulfan 6.4 mg/kg) 
• Myeloablative 
 Bulsulfan/Cyclophosphamide (BuCy) 
 Cyclophosphamide/Total Body Irradiation (Cy/TBI) 
 Fludarabine/Cyclophosphamide (Dosing for Cytoxan 3 mg/m2) 
 
 
• Ultimately, the final decision regarding the choice of pre-transplant conditioning 
regimens is made on the basis of a combination of factors, including patient-related 
issues (as discussed above), the disease in question (e.g., CBV being used typically for 
the transplant of patients with lymphoma), and personal experience and preference on 
the part of the transplant center and its BMT team. 
 
• Each potential transplant patient is discussed 2-3 times at the BMT team meetings 
(Tuesday or Thursday), with representation from Transfusion Medicine, Cellular 
Therapy, and Pharmacy. The patient’s medical history is reviewed, and selection of a 
treatment regimen is finalized. 
 
• As a double-check, the BMT Coordinators will confirm the preparative regimen with the 
Attending when the orders are being written. 
 
 
 
References 
Gyurkocza B, Sandmaier B. Conditioning regimens for hematopoietic cell transplantation: one 


 
 
Mobilization Trial 05/16/2017 
 
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size does not fit all. Blood Jan 2014, DOI: 10.1182/blood-2014-02-514778 
 
Responsible Owner: 
Blood and Marrow Transplant 
Program 
Contact(s): email 
Joshua Hickman 
Approved By: 
Office of Policy Support - 
Organizational Policies Only 
Version # 
2 
Current Approval Date: 
10/29/2014 
Old Document ID: 
BMT.0023 
Date Policy to go into Effect: 
10/29/2014 
Related Polices & 
Procedures: 
Pre-Transplant Allogeneic and Autologous Recipient Evaluation and Selection 
Procedure -  Blood and Marrow Transplant 
Related Job Aids: