Conditions: Myeloablative Conditioning HLA-mismatched Bone Marrow Transplantation Graft Survival Transplantation, Bone Marrow
Keywords: Acute lymphoblastic leukemia Acute myeloid leukemia Juvenile myelomonocytic leukemia Treatment related leukemia Biphenotypic leukemia
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 35
Healthy volunteers: no

Brief summary:
This is a multi-institutional phase II haploidentical T cell replete bone marrow transplant (BMT) study in children with high-risk leukemia. The myeloablative conditioning regimen prescribed will be Total body irradiation (TBI)-based for lymphoid leukemia and busulfan-based for myeloid leukemia. Our goal is to establish an easily exportable, inexpensive platform for haplotransplantation that has a safety profile equivalent to matched related and unrelated BMTs. The primary objective will be to estimate the incidence of 6-month non-relapse mortality (NRM), hypothesizing that NRM is \< 18%.

Detailed description:
This is a phase II prospective study designed to evaluate the incidence of 6 month non- relapse mortality, safety, and feasibility of haploidentical bone marrow transplantation (BMT) after myeloablative conditioning with post-transplant Cy. Conditioning regimens include a total body irradiation (TBI)-based prep for lymphoid leukemias and a chemotherapy based prep for myeloid leukemias.

To estimate the incidence of non-relapse mortality at 180 days following myeloablative haploidentical BMT for children and young adults with high risk hematologic malignancies.

Arms:
arm 1: Patients with AML and MDS:

Days -6 through -3: Busulfan q 5-6h IV q24h x 4 days

Days -2 and -1: Cyclophosphamide 50mg/kg/day IV x 2 days+ Mesna 40 mg/kg/day IV

For patients with ALL and lymphoblastic lymphoma:

Days -5 through -4: Cyclophosphamide 50mg/kg/day IV q24h x 2 days+Mesna 40 mg/kg/day IV

Days -3 through -1: TBI 200 Centigray (cGy) twice a day for 3 days

All patients Day 0: Infuse unmanipulated bone marrow

Day +3 and +4: Cyclophosphamide 50 mg/kg/day IV + Mesna 40 mg/kg IBW/day IV

Day +5: Begin tacrolimus 0.015mg/kg IBW/dose IV over 4 hours q 12h and mycophenolate mofetil (MMF)15mg/kg po/IV tid with maximum daily dose 3 gm/day

Day +30: Assess chimerism and disease status in bone marrow

Day +35: Discontinue MMF

Day +60: Assess chimerism and disease status in bone marrow

Day 180: Discontinue tacrolimus

Interventions: intervention 1: Cyclophosphamide intervention 2: TBI intervention 3: Busulfan intervention 4: Unmanipulated Bone Marrow intervention 5: Tacrolimus intervention 6: Mycophenolate mofetil
Intervention descriptions: intervention 1: Chemotherapy administration intervention 2: Radiation Therapy intervention 3: Chemotherapy Administered intervention 4: Bone Marrow Transplant intervention 5: Immunosuppressive Drug Administered intervention 6: Immunosuppressive Drug Administered

Protocol document:
Prot_SAP_001.pdf: 
 
J13161 Protocol Version 5.1                 April 20, 2017 
1
 
 
A Pediatric Blood and Marrow Transplant Consortium (PBMTC) multi-center Phase II 
Pilot Trial of Myeloablative Conditioning and Transplantation of Partially HLA-
mismatched T cell replete Bone Marrow with post-transplantation cyclophosphamide for 
Children and Young Adults with Hematologic Malignancies 
 
 
 
Protocol Chair/Principal Investigator:  
Heather Symons, MD, MHS 
The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University 
1650 Orleans St. 
CRB1 2M52 
Baltimore, MD 21287 
Phone: 410-502-4997 
Email: hsymons2@jhmi.edu 
 
Lead Co-Investigator:   
Terry J. Fry, MD, Pediatric Oncology Branch, NCI 
 
Co-Investigators: 
Jignesh Dalal, MD, Rainbow Babies Hospital/ University Hospitals of Cleveland  
Benjamin Watkins, MD, Children’s Healthcare of Altanta/ Emory 
Joerg Kruger, MD, Toronto Sick Kids 
Amy Keating, MD, Children’s Hospital Colorado 
Benjamin Oshrine, MD, All Children’s Hospital 
Rabi Hanna, MD, Cleveland Clinic 
Michelle Hudspeth, MD, MUSC 
Leslie Lehmann, MD, Dana Farber Cancer Institute/Boston Children’s 
Jeffrey Huo, Levine Children’s Hospital 
Jeffrey Auletta, MD, Nationwide Children’s Hospital 
Emi Caywood, MD, Nemours Alfred DuPont Hospital for Children 
Michael Joyce, MD, Nemours Children’s Clinic 
Andrew Cluster, MD, Washington University in St. Louis 
Jeffrey Davis, MD, British Columbia Children’s Hospital 
Paul Martin, MD, PhD, Duke University 
Stephanie Terezakis, MD, Johns Hopkins University 
 
Research Nurse: Megan Petrycki, MSN, RN 
 
Pharmacist: Alix Dabb, PharmD 
 
Statisticians: Amanda Blackford and Hua-Ling Tsai 
 
COORDINATING CENTER: JOHNS HOPKINS UNIVERSITY 


 
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Terry Fry, MD 
National Institutes of Health 
Head, Blood and Marrow Transplant 
Pediatric Oncology Branch, Building 10 
Room 1W-3750 10 Center Drive 
Bethesda, MD 20892 
fryt@mail.nih.gov 
Phone: 301-402-0215 
 
Rabi Hanna 
Cleveland Clinic 
Mail Code S20 
9500 Euclid Avenue 
Cleveland, OH 44195 
HANNAR2@ccf.org 
Phone: 216-444-6479 
 
Jignesh Dalal, MD 
Rainbow Babies Hospital 
Dept of Pediatric Hematology Oncology and 
BMT 
11100 Euclid Ave 
Mail Stop RBC 6054 
Cleveland, Ohio 44106 
jdalal2002@gmail.com 
Phone: 216-844-8938 
 
Benjamin Watkins, MD 
Children’s Healthcare of Atlanta/ Emory 
1760 Haygood Drive 
Atlanta, GA 30322 
Benjamin.Watkins@choa.org 
Phone: 404-785-1272 
 
Joerg Kruger, MD, PhD 
The Hospital for Sick Children 
555 University Ave 
Black Wing, Room 10419A 
Toronto, ON M5G 1X8 
Joerg.Krueger@sickkids.ca 
Phone: 416-813-7654 x 208227 
 
 
 
 
 
Amy Keating, MD 
Children’s Hospital Colorado 
13123 East 16th Avenue 
Box 115 
Aurora, CO 80045 
amy.keating@childrenscolorado.org 
Phone: 720-777-0166 
 
Benjamin Oshrine, MD 
All Childrens’ Hospital 
601 5th Street South 
Ste. 302 
Dept. 70-7485 
St. Petersburg, FL 33701 
boshrin1@jhmi.edu 
Phone: 727-767-4176 
 
Jeffrey Huo, MD 
Levine Children’s Hospital 
1001 Blythe Blvd 
Medical Center Plaza, Suite 601 
Charlotte, NC 28203 
Jeffrey.Huo@carolinas.org 
Phone: 704-381-9965 
 
Michelle Hudspeth, MD 
Medical University of South Carolina 
135 Rutledge Ave, MSC588 
Charleston, SC 29425 
hudspeth@musc.edu 
Phone: 943-408-6775 
 
Micheal Joyce, MD 
Nemours Children’s Clinic 
807 Children's Way 
Jacksonville, FL 32207 
mjoyce@nemours.org 
Phone: 904-697-3793  
 
Leslie Lehmann, MD 
Dana-Farber Cancer Institute 
Pediatric Oncology 
44 Binney Street- OP5 
Boston, MA 02114 
lelehmann@bics.bwh.harvard.edu 
Phone: 617-632-2095 


 
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Jeffery Auletta, MD 
Nationwide Children’s Hospital 
700 Children's Drive 
WA4023 
Columbus, OH 43205 
Jeffery.Auletta@nationwidechildrens.org 
Phone: 614-355-2670 
 
Emi Caywood, MD 
Nemours Alfred DuPont Hospital for Children 
1600 Rockland Rd 
Wilmington, DE 19803 
Emi.Caywood@nemours.org 
Phone: 302-651-4000 
 
Andrew Cluster, MD 
Washington University School of Medicine 
Division of Pediatric Hematology-Oncology 
1 Children’s Place 
St. Louis, MO 63110 
Cluster_A@kids.wustl.edu 
Phone: 314-454-6018 
 
Jeffrey Davis, MD 
B315, Division of Pediatric Hematology/ 
Oncology/ BMT 
British Columbia Children’s Hospital 
4480 Oak Street 
Vancouver, BC V6H 3V4 
jdavis@cw.bc.ca 
Phone: 604-875-2316 
 
Paul Martin, MD, PhD 
Duke University 
2301 Erwin Road 
Durham, NC 27710 
Paul.Martin@duke.edu 
Phone: 919-668-1124 
 
Stephanie Terezakis, MD 
Johns Hopkins University 
Department of Radiation 
401 N. Broadway, Suite 1440 
Baltimore, MD 21231 
stereza@jhmi.edu 
Phone: 443-287-7889 
Genevieve Courpas, RN, BSN 
Johns Hopkins University 
Division of Pediatric Oncology 
600 N. Wolfe Street, CMSC 800 
Baltimore, MD 21287 
gcourpa1@jhmi.edu 
Phone: 410-955-8515 
 
Alix Dabb, PharmD 
Clinical Pharmacy Specialist 
Pediatric Oncology 
Johns Hopkins University 
600 N. Wolfe Street, Carnegie 180 
Baltimore, MD 21287 
abutler8@jhmi.edu 
Phone: 443-287-0559 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
4
LIST OF ABBREVIATIONS 
 
ABBREVIATION 
DEFINITION
ABW 
Actual body weight 
AE 
Adverse event 
aGVHD 
Acute graft versus host disease 
ALL 
Acute lymphoblastic leukemia 
alloHSCT 
Allogeneic hematopoietic stem cell tranplant 
ALT 
Alanine aminotransferase 
AML 
Acute myeloid leukemia 
ANC 
Absolute neutrophil count 
AP 
Anterior-posterior 
AST 
Aspartate transaminase 
AUC 
Area under the curve 
BID 
Twice a day 
BM 
Bone marrow 
BMT 
Bone marrow transplant 
BMT CTN 
Bone Marrow Transplant Clinical Trials Network 
Bu 
Busulfan 
BUN 
Blood urea nitrogen 
CBC 
Complete blood count 
cGVHD 
Chronic graft versus host disease 
cGy 
Centigray 
CI 
Confidence interval 
CML 
Chronic myeloid leukemia 
CMV 
Cytomegalovirus 
CNI 
Calcineurin inhibitors 
CNS 
Central nervous system 
COG 
Children’s Oncology Group 
CR 
Complete remission 
CrCl 
Creatinine clearance  
CRF 
Case report forms 
CSA 
Cyclosporine 
CSF 
Cerebrospinal fluid 
Css 
Steady state concentration 
CTCAE 
Common Toxicity Criteria for Adverse Events 
Cy 
Cyclophosphamide 
DLCO 
Diffusing capacity for carbon monoxide 
DFS 
Disease free survival 
DSMB 
Data Safety Monitoring Board 
dUCB 
Double umbilical cord blood 
ECHO 
Echocardiogram 
EFS 
Event free survival 
EKG 
Echocardiogram 
FACT 
Foundation for the Accreditation of Hematopoietic Cell Therapy 


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FEV1 
Forced expiratory volume 
FISH 
Fluorescence in situ hybridization 
FMT 
Fludarabine, melpahlan, thiotepa 
FVC 
Forced vital capacity 
FWA 
Federalwide Assurance 
GCP 
Good clinical practice 
GFR 
Glomerular filtration rate 
GSCF 
Granulocyte colony stimulating factor 
GU 
Genitourinary  
GVHD 
Graft versus host disease 
IRB 
Institutional Review Board 
IT 
Intrathecal therapy 
haploHSCT 
Haploidentical hematopoietic stem cell transplant 
HCT 
Hematopoietic cell transplantation 
Hgb 
hemoglobin 
HIPAA 
Health Insurance Portability and Accountability Act 
HLA 
Human leukocyte antigen 
HSCT 
Hematopoietic stem cell transplantation 
HR 
Hazard ratio 
IBW 
Ideal body weight 
JHH 
Johns Hopkins Hospital 
JHM-IRB 
Johns Hopkins Medicine Institutional Review Board 
JHU 
Johns Hopkins University 
JMML 
Juvenile myelomonocytic leukemia 
LVEF 
Left ventricular ejection fraction 
MDS 
Myelodysplastic syndrome 
MFI 
Mean fluorescence intensity 
MMF 
Mycophenolate mofetil 
MRD 
Minimal residual disease 
MUGA 
Multigated acquisition scan 
NCI 
National Cancer Institute 
NK 
Natural killer 
NRM 
Non relapse mortality 
NS 
Normal saline 
OS 
Overall survival 
PA 
Posterior-anterior 
PB 
Peripheral blood 
PBMTC 
Pediatric Blood and Marrow Transplant Consortium 
PBSC 
Peripheral blood stem cells 
PCR 
Polymerase chain reaction 
PI 
Principal investigator 
PFS 
Progression-free survival 
PFT 
Pulmonary function test 
Ph+/- 
Philadephia positive/negative 
PK 
Pharmacokinetics 


J13161 Protocol Version 5.1         April 20, 2017 
 
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PO 
Oral 
PT/Cy 
Post transplantation cyclophosphamide 
RA 
Room air 
RFLP 
Restriction fragment length polymorphism 
RSV 
Respiratory syncytial virus 
SAE 
Serious adverse event 
SIADH 
Syndrome of inappropriate antidiuretic hormone secretion 
SKCCC 
Sidney Kimmel Comprehensive Cancer Center 
TBI 
Total body irradiation 
TCD 
T cell depleted 
TCR 
T cell replete 
Tid 
Three times a day 
TKI 
Tyrosine kinase inhibitor 
TNC 
Total nucleated cells 
TRM 
Transplant related mortality 
TTP 
Thrombotic thrombocytopenic purpura 
URD 
Unrelated donor 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
7
TABLE OF CONTENTS 
 
 
 
LIST OF ABBREVIATIONS……………………………..…...     4 
SCHEMA………………………………………………………. 
8 
 
 
1.0 
OBJECTIVES…………………………………………………. 
10 
 
2.0 
BACKGROUND AND RATIONALE……………………….. 
11 
 
3.0 
SELECTION OF PATIENTS AND DONORS…………… 
19 
 
4.0 
TREATMENT PLAN………………………………………… 
22 
 
5.0 
DATA MONITORING AND MANAGEMENT……………… 28 
 
6.0 
PATIENT MONITORING…………………………………….. 37 
 
7.0 
RISKS AND TOXICITIES…………………………………….. 42 
 
8.0 
STUDY PARAMETERS…………..……………………… 
45 
 
9.0 
STATISTICAL CONSIDERATIONS………………………… 49 
 
10.0 
INFORMED CONSENT……………………………………..       52 
 
11.0     APPENDICES ………………………………………………. 
54 
 
12.0 
REFERENCES………………………………………………. 
62 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
8
Treatment Schema 1 (All patients except those with acute lymphoblastic leukemias) 
 
Days -6 through -3         Busulfan q6h IV for four days (total 16 doses)* 
     
        (Dose adjusted based on PKs) 
          
               Seizure prophylaxis** 
    ↓ 
Days -2 and -1  
       Cyclophosphamide 50mg/kg/day IV x 2 days+ 
     Mesna 40 mg/kg/day IV+ 
       
      (One day of rest may be added between Days-1 and  
        bone marrow  infusion on Day 0; see section 4.3) 
 
 
     ↓ 
Day 0   
 
        
 
Infuse unmanipulated bone marrow 
                                           (at least 24 hrs after second pre-transplant Cy infusion) 
     ↓ 
Day +3 and +4                   
 
Cyclophosphamide 50 mg/kg/day IV# 
 
 
 
       (begin 60-72 hours after the start of bone marrow infusion) 
Mesna 40 mg/kg IBW/day IV# 
     ↓   
Day +5                         Begin tacrolimus 0.015mg/kg/dose IBW dose IV over 4 hours q 12h   
 and mycophenolate mofetil (MMF)15mg/kg/dose po/IV tid  
 
 
 
 
 
 
      ↓ 
Day +30                                Assess peripheral blood donor chimerism 
 
 
 
 
 
 
      ↓ 
Day +35 
 
 
 
      Discontinue MMF 
 
 
 
 
 
 
      ↓ 
Day +60                           Assess chimerism and disease status in bone marrow 
 
 
 
 
      ↓ 
Day 180 
 
 
                 Discontinue tacrolimus 
                                                                    Evaluate disease 
 
 
 
  
 
 
      ↓ 
1 yr, 2 yrs 
 
 
 
       Evaluate disease 
 
*See section 4.3 for busulfan dosing  
** See section 4.3 for guidelines 
+ See section 4.3 for complete dosing instructions; use lesser of ideal body weight and actual body weight 
for Cy dosing 
# See section 4.5 for complete dosing guidelines; use lesser of ideal body weight and actual body weight 
for Cy dosing 
 
 
 
 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
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Treatment Schema 2 (Only patients with acute lymphocytic leukemias or patients who have 
had a prior non-TBI based transplant; can also consider for mixed phenotype leukemia) 
 
Days -5 through -4    
Cyclophosphamide 50mg/kg/day IV q24h x 2 days+ 
                Mesna 40 mg/kg/day IV+ 
             ↓ 
Days -3 through -1  
           TBI 200 cGy twice a day for 3 days + 
 
(One day of rest may be added between Days-1 and bone marrow 
infusion on Day 0; see section 4.3)  
             ↓ 
Day 0   
 
 
 Infuse unmanipulated bone marrow 
(at least 24 hrs after second pre-transplant Cy infusion) 
             ↓ 
Day +3 and +4  
 
 
Cyclophosphamide 50 mg/kg/day IV** 
 
 
 
 
 (begin 60-72 hours after the start of bone marrow infusion) 
       
 
 
 
 
Mesna 40 mg/kg IBW/day IV**  
              ↓ 
Day +5                                   Begin tacrolimus 0.015mg/kg/dose IBW/dose IV over 4 hours q 
12h  and mycophenolate mofetil (MMF)15mg/kg/dose po/IV tid 
 
 
                            ↓ 
Day +30 
                      Assess chimerism in peripheral blood  
 
 
                
↓ 
Day +35 
 
 
 
              Discontinue MMF 
 
 
 
 
 
 
                ↓ 
Day +60 
 
             Assess chimerism and disease status in bone marrow 
 
 
 
 
 
 
                ↓ 
Day 180 
 
 
                      Discontinue tacrolimus# 
                         
 
 
               Evaluate disease 
 
 
 
 
 
 
                ↓ 
1 yr, 2 yrs 
 
 
 
               Evaluate disease 
 
 
+ See section 4.3 for complete dosing instructions; use lesser of ideal body weight and actual body weight 
for Cy dosing 
** See section 4.5 for complete dosing guidelines; use lesser of ideal body weight and actual body weight 
for Cy dosing 
# Tacrolimus may be discontinued and/or weaned as early as Day +90. See section 4.6 for complete 
guidelines. 
 
 
 
 
 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
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1.0 OBJECTIVES 
 
Primary Objective: 
 
1.1  To estimate the incidence of non-relapse mortality at 180 days following 
myeloablative haploidentical BMT for children and young adults with high risk 
hematologic malignancies 
 
 
Secondary Objectives: 
 
1.2 
To estimate the incidence of donor cell engraftment (donor chimerism) at Day 60 
following myeloablative, haploidentical BMT 
 
1.3       To estimate the time to neutrophil and platelet recovery following myeloablative 
haploidentical BMT 
 
1.4   To estimate the incidence of primary and secondary graft failure following 
myeloablative haploidentical BMT 
 
1.5      To estimate the cumulative incidence of acute graft versus host disease grades 2-4 
and grades 3-4 using competing risk analysis following myeloablative 
haploidentical BMT 
 
1.6    To estimate the cumulative incidence of chronic GVHD using competing risk 
analysis following myeloablative haploidentical BMT 
 
1.7   Characterize the duration of use, number, and type of steroid and non-steroid 
immunosuppressants used to treat GVHD following myeloablative haploidentical 
BMT 
 
1.8    To estimate overall survival (OS), relapse, progression-free survival (PFS), disease-    
free survival (DFS), event-free survival (EFS), and relapse-free GVHD-free 
survival in patients receiving myeloablative haploidentical BMT for patients with 
high risk hematologic malignancies at 1 year and 2 years 
 
1.9  
To assess additional hematologic and non-hematologic toxicities of myeloablative 
haploidentical BMT 
 
1.10     Characterize immune reconstitution following myeloablative haploidentical BMT 
 
 
 
 


J13161 Protocol Version 5.1         April 20, 2017 
 
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2.0 BACKGROUND 
 
Background 
 
The need for alternative donor options in hematopoietic stem cell transplantation 
 
Hematopoietic stem cell transplantation (HSCT) is a curative treatment for a variety of 
malignant and non-malignant hematologic disorders1-3. HSCT from a human leukocyte antigen 
(HLA)-matched sibling has produced the best outcomes as measured by overall and progression-
free survival4. Unfortunately, only about a third of candidates for HSCT have HLA-matched 
siblings5;6.  For patients who lack HLA-matched siblings, there are two alternative sources of 
unrelated HLA-matched stem cells for HSCT: 1) volunteer matched unrelated donors and 2) 
umbilical cord blood7.  However, outcomes following transplants using these sources are inferior 
compared to those performed using HLA-matched related donors, largely due to the increased 
incidence of post-transplant complications such as GVHD, infections and graft failure. 
Furthermore, the frequency with which an URD can be identified may be around 50% for 
Caucasians, but the likelihood falls to ≤10% for those of certain ethnic or mixed race 
backgrounds6. Worldwide, one million HSCT had been performed by the end of 2012, as 
treatment for over 70 different diseases8.  Despite this success, over 1,000 patients are estimated 
to die each year in the U.S. because a suitable matched donor cannot be identified.  Thus, the 
development of suitable approaches for alternative mismatched donors represents an important 
issue in the field of HSCT. 
 
Cost is also a consideration for alternative donor strategies, as overall transplant costs, 
duration of hospitalization, and donor acquisition fees vary by graft source and are greatly 
increased in unrelated transplants.  A recently published single-institution report of pediatric 
allogeneic HSCT demonstrated the increased costs of unrelated donor and umbilical cord blood 
transplants compared to matched related donor transplants.  For 2004-2006, the mean costs per 
day survived were $3,446 for matched related donors (median duration of hospitalization 36 
days), $4,050 for matched unrelated donors (median duration of hospitalization 47 days), and 
$4,522 for umbilical cord blood recipients (median duration of hospitalization 57 
days).  Additionally, costs of graft acquisition varied by donor source.  The mean costs of graft 
acquisition were $8,891 for matched related donors, $57,134 for matched unrelated donors, and 
$58,910 for umbilical cord blood9.  Thus, an unrelated donor source adds approximately 
$100,000 to the cost of the first 3 months of HSCT medical care. 
 
Historical Haploidentical HSCT 
 
Since individuals share exactly one HLA haplotype with each biological parent or child 
and with half of one’s siblings, haploidentical relatives can be identified quickly as a readily 
available source of stem cells for virtually all patients.  Historically, haploHSCT has been 
associated with significant risks of graft rejection and severe GVHD10-12 , which are 
manifestations of excessive alloreactivity by host13 and donor T cells14, respectively.  The risk of 
severe GVHD may be reduced in intensively conditioned recipients of grafts that have been 
rigorously depleted of mature T cells or selectively depleted of alloreactive T cells, so called T 
cell depleted (TCD) grafts, but the risks of serious infection and death from prolonged immune 
compromise in these patients remains high15-20. Mortality from CMV disease alone was 14% in a 


J13161 Protocol Version 5.1         April 20, 2017 
 
12
recent 
study 
of 
nonmyeloablative 
transplantation 
using 
HLA-
haploidentical donors21 and as high as 
35% in other reports from all causes16-18 
 
TCD haploidentical grafts with 
“megadoses” of CD34+ cells have 
achieved 
acceptable 
engraftment 
rates22. This approach was tested in a 
phase II clinical trial at MD Anderson 
Cancer Center (MDACC) using a 
reduced-intensity conditioning regimen 
with 
fludarabine, 
melphalan 
and 
thiotepa (FMT) for patients with 
hematologic malignancies23. A high 
rate of disease relapse and serious 
infectious 
complications 
occurred, 
similar to previous reports19-21;24-27. 
Patients with AML/MDS and high 
disease burden at the time of transplant 
(>10% blasts) had a particularly poor outcome (Figure 1) 23.  These results were confirmed in a 
large retrospective study summarizing the experience of haploHSCT with T-cell depletion in 
Europe28. Thus, the use of a T-cell depleted (TCD) graft, even with increased CD34+ stem cells, 
decreases the rate of GVHD at the expense of a higher risk of rejection, reduced graft-versus-
leukemia effect, and severe infections29. Thus, to reduce toxicity and improve the efficacy of 
haploidentical HSCT, methods to selectively inhibit alloreactivity while preserving immunity to 
infection and the malignancy are needed30. 
 
The use of cyclophosphamide as a post-transplant immunosuppressant 
Cyclophosphamide (Cy) is a highly immunosuppressive antineoplastic agent that has an 
established role in conditioning for HSCT. Typically, the drug is administered prior to 
transplantation to prevent graft rejection by suppressing the host immune system.  However, pre-
transplantation conditioning with Cy also increases the risk of GVHD following allogeneic T 
cell infusion in mouse models31.  In contrast, administration of a properly timed, high dose of Cy 
after HSCT inhibits both graft rejection and GVHD32-35 .    
 
Initial results of haploHSCT with post-transplant cyclophosphamide at JHU  
In light of these observations, a non-myeloablative conditioning regimen was developed at 
Johns Hopkins University (JHU) for transplantation of T cell replete, unmanipulated marrow 
from haploidentical first-degree relatives 36.  The main goal of this study was to titrate the dose 
of post-transplantation Cy (PT/Cy) given in conjunction with pre-transplantation fludarabine and 
total body irradiation (TBI).  All patients received mycophenolate mofetil and tacrolimus, 
beginning on day 4 or 5 and terminating on days 35 and 50-180, respectively, to reduce the 
incidence and severity of GVHD (see Figure 2).  At the same time, a trial was being conducted in 
Seattle utilizing Cy 50mg/kg IV on day 3 only and MMF three times a day. All study subjects 
had poor risk hematologic malignancies. A total of 68 patients were consecutively enrolled on 
these two protocols. The median times to neutrophil and platelet recovery for all patients were 15 
Figure 1. Cumulative survival in patients with AML/MDS 
receiving a T-cell depleted haploidentical stem cell transplant 
with FMT conditioning regimen, in remission (solid line) or 
not (dotted line) at the time of transplant, based on percent 
bone marrow blasts. 


J13161 Protocol Version 5.1         April 20, 2017 
 
13
 
and 24 days, respectively. Graft failure occurred in a total of 15/84 patients (18%): 6 of 19 (32%) 
in the Hopkins group that received only one dose of PT/Cy, 3 of 26 (12%) in the Seattle group 
that received one dose of PT/Cy, and 6 of 39 (15%) in the Hopkins group that received 2 doses 
of PT/Cy, indicating that 2 doses of post-transplant cyclophosphamide was more efficacious at 
preventing engraftment failure. All but two of the patients with graft failure experienced 
recovery of autologous hematopoiesis, with median times to neutrophil and platelet engraftment 
of 15 days (range 11-48 days) and 24 days (range 15-395 days), respectively. Graft rejection 
occurred in 9 of 66 evaluable patients (13%). All but 1 patient with graft failure experienced 
recovery of autologous hematopoiesis with median times to neutrophil and platelet engraftment 
of 15 days (range: 11-42 days) and 28 days (range: 0-395 days), respectively. 
For the entire population of patients transplanted in these two studies, the probabilities of 
grades II-IV and III-IV aGVHD by day 200 were 34% and 6%, 
respectively. 
There 
was 
no 
statistically significant difference 
in the probability of aGVHD 
between patients who received 1 
versus 
2 
doses 
of 
post 
transplantation Cy. However, the 
incidence of extensive cGVHD at 
1 year in the group of patients who 
received 
2 
doses 
of 
post 
transplantation 
Cy 
(5%) 
was 
suggestively 
lower 
than 
the 
incidence of extensive cGVHD in the group of patients who received 1 dose of post 
transplantation Cy (25%; hazard ratio [HR] 0.21; 95% confidence interval [CI] 0.04-1.01; P = 
.05). The probabilities of NRM at 100 days and at 1 year after transplantation were 4% and 15%, 
respectively, and the probabilities of relapse at 1 and 2 years after transplantation were 51% and 
58%, respectively. At a median follow-up among survivors of 745 days (range: 112-1483 days), 
the actuarial OS at 1 and at 2 years was 46% and 36%, respectively. The actuarial EFS at 1 and 
at 2 years was 34% and 26%, respectively. OS and EFS were not statistically significantly 
different between groups (data not shown).  
Furthermore, CMV reactivation was observed in 17 of 45 (38%) high-risk patients with a 
median time to reactivation of 34 days. Proved or probable invasive mold infections post 
transplant, all caused by Aspergillus sp, were observed in 5 of 68 (7%) patients. Two patients 
died from Aspergillus infection: 1 while persistently neutropenic following graft failure, and 1 
with fungal sinusitis. There was no CMV-associated mortality36.  
 
Results of haploHSCT with post-transplant cyclophosphamide in the BMT-CTN 
 
Based on the promising results using post-transplant Cy in the two pilot studies, two 
Phase 2 trials (Protocols 0603, 0604) were conducted by Blood and Marrow Transplant Clinical 
Trials Network for adults with leukemia or lymphoma and no suitable related donor were 
conducted and published recently37. Either double umbilical cord blood (dUCB) or 
haploidentical bone marrow was utilized as stem cell source with RIC using cyclophosphamide, 
fludarabine, and 200 cGy of total body irradiation. 
Figure 2. Schema 


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14
 
              Figure 3. Results of BMT-CTN dUCBT and haploBMT trials 
 
The 1-year probabilities of 
overall and progression-free 
survival were 54% and 46%, 
respectively, after dUCB 
transplantation (n = 50) and 
62% and 48%, respectively, 
after haploBMT (n = 50). The 
cumulative incidence of 
neutrophil recovery was 94% 
after dUCB and 96% after 
haploBMT. The 100-day 
cumulative incidence of grade 
II-IV acute GVHD was 40% 
after dUCB and 32% after 
haploBMT. The 1-year 
cumulative incidences of 
nonrelapse mortality and 
relapse after dUCB 
transplantation were 24% and 
31%, respectively, with 
corresponding results of 7% and 
45%, respectively, after 
haploBMT (Figure 3). In 
summary trend towards reduced NRM for haploBMT was balanced by increased relapse as 
compared to dUCB to yield almost equivalent 1 yr overall and progression free survival (Figure 
3). 
 
Post-transplant Cy in matched HSCT with full-intensity conditioning 
 
Relapse was the major source of treatment failure for patients in each of the haploHSCT 
studies described above. Potential explanations are that the transplantation conditioning intensity 
was not sufficient to achieve adequate tumor cytoreduction or to augment a graft-versus-host 
reaction through epithelial tissue damage.  
Post-transplant Cy in combination with Bu Cy myeloablative conditioning was used for 
HLA-matched HSCT at JHU in study J0373, which enrolled 117 patients (median age 50, range 
21-66) with advanced hematologic malignancies38. These patients received HLA-matched related 
(n=78) or unrelated (n=39) bone marrow transplants after conditioning with busulfan on days -7 
to -3 and Cy (50 mg/kg/day) on days -2 and -1, +3, and +4 and no additional GVHD prophylaxis. 
The incidences of acute grades II through IV and grades III through IV GVHD for all patients 
were 43% and 10%, respectively. The nonrelapse mortality at day 100 and 2 years after 
transplantation were 9% and 17%, respectively. The actuarial overall survival and event-free 
survivals at 2 years after transplantation were 55% and 39%, respectively, for all patients and 
63% and 54%, respectively, for patients who underwent transplantation while in remission. With 
a median follow-up of 26.3 months among surviving patients, the cumulative incidence of 
chronic GVHD is 10%. Seven pediatric patients with high risk hematologic malignancies were 
treated in the same way and all patients engrafted, none of the patients had aGVHD or cGVHD 


J13161 Protocol Version 5.1         April 20, 2017 
 
15
and there were no TRMs. Two out of the eight patients relapsed. One patient with early ALL 
relapse who was transplanted without evidence of disease but with aplasia after reinduction 
chemotherapy relapsed early post transplant and one patient with AML relapsed two years post 
BMT. These results suggest that high-dose post transplantation cyclophosphamide is an effective 
single-agent prophylaxis of acute and chronic GVHD after BuCy conditioning and HLA-
matched BMT39. 
 
Myeloablative conditioning with post-transplant Cy for haploHSCT 
The combination of myeloablative conditioning with a haploidentical graft source and post 
transplant Cy was studied at JHU.  This trial combined the Bu/Cy myeloablative preparative 
regimen utilized in the matched setting (J0373) with the post transplantation immunosuppression 
utilized in the nonmyeloablative setting (J9966 and J0457: tid MMF and FK506), along with 
post- 
Figure 4. Schema 
 
 
transplantation Cy on days +3 and +4 utilized in both trials in an effort to achieve the same low 
toxicity profile while augmenting disease response and decreasing relapse rates39.  All patients 
with high risk hematologic malignancies received a busulfan and cyclophosphamide preparative 
regimen except those with ALL or lymphoblastic lymphoma who received a TBI based 
preparative regimen (Figure 4). The primary objective was to establish feasibility (day 60 
engraftment). Ninety-six patients were evaluated on this protocol. Median age of the patients is 
42y (1y-65y). Median total nucleated cell (TNC)/kg cells infused 4.8x108. Disease breakdown 
included 42 patients with AML, 21 patients with ALL, 2 patients with bilineage leukemia, 12 
patients with MDS, 4 patients with CML, 11 patients with lymphoma and 4 patients with other 
diagnosis. Donor engraftment at Day 60 was observed in 91% of patients (80/88 evaluable 
patients). The median time to neutrophil recovery is 24 days and platelet recovery is 29 days. 
The cumulative incidence of TRM at 100 days was 6%, and at 1 year 11%. The cumulative 
incidence of acute GVHD grades 2-4 was 17% at 100 days and severe acute GVHD grades 3-4 
was 7% at 100 days, and chronic GVHD (cGVHD) at one year was 15%, with 5% moderate-
severe cGVHD. The one-year cumulative incidence of relapse in this group of patients with 
high-risk malignancy is 36%. Overall survival at 1 year is 72% and EFS is 56%. CMV 


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16
reactivation was seen in 22% at risk, and 
hemorrhagic cystitis was seen in 24% of 
patients (all BK+ and 70% grades 1-2). 
In a recent report from Italy, 50 
patients received unmanipulated haploHSCT 
following myeloablative conditioning with 
busulfan, fludarabine, and thiotepa followed 
by post transplant Cy, CSA, and MMF40.  
This was a high-risk population of patients 
with lymphoid and myeloid malignancies, 
54% of whom were not in remission at the 
time of transplant and 20% of whom had 
received a prior alloHSCT.  Engraftment was 
90%; grade 2-4 acute GvHD 12%, and 
moderate chronic GvHD 10%.  The 2-year 
DFS was 68% for those transplanted in CR 
and 37% for those not in remission at 
transplant, with overall TRM of 18% and a 
relapse rate of 26%.  Bashey 
et 
al 
from 
Atlanta treated 20 patients who did not have 
suitable matched related or unrelated donors 
with a myeloablative preparative regimen 
consisting 
of 
fludarabine, 
busulfan, 
pretransplant cyclophosphamide (14.5mg/kg) 
and 
post 
transplant 
cyclophosphamide 
(50mg/kg/dx2) 
with 
haploidentical 
unmanipulated peripheral blood stem cells for 
adults 
with 
hematological 
malignancies. 
Donor engraftment occurred in all 20 patients 
with full donor T cell and myeloid chimerism 
by day 130. The cumulative incidence of 
grades II-IV and III-IV acute graft-versus-
host disease (aGVHD) was 30% and 10%, 
respectively. The cumulative incidence of chronic GVHD (cGVHD) was 35%. Nonrelapse 
mortality (NRM) at 100 days and 1 year was 10% for all patients and 0% for standard-risk 
patients. With a median follow-up of 20 months, the estimated 1-year overall survival (OS) and 
disease-free survival (DFS) was 69% and 50%, respectively, for all patients, and 88% and 67% 
for standard-risk patients41. 
MDACC recently published their results of a myeloablative haploBMT with fludarabine, 
melphalan, and thiotepa (FMT), in order to compare the outcomes with concurrent TCD 
aploHSCT that received the same FMT conditioning regimen42.  They analyzed 65 consecutive 
adult patients with hematologic malignancies who received T-cell replete (N = 32) or TCD (N = 
33) haploHSCT. The TCR group received post-transplantation treatment with Cy, tacrolimus, 
and MMF. Patients with TCD received antithymocyte globulin followed by infusion of 
CD34+selected cells with no post-transplantation immunosuppression. The majority of patients 
in each group had active disease at the time of transplantation.  Engraftment was achieved in 
Figure 5.  Comparison of progression-free 
survival in haploSCT patients receiving FMT 
condition and either T-cell replete (TCR) or T-cell 
depleted (TCD grafts.  A) PFS for all patients.  B) 
PFS for patients in remission at the time of 
transplant.


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17
94% of TCD versus 81% of TCR (NS). The TCR transplants were superior, however, in NRM at 
1 year (16% versus 42%, P = .02), overall survival (64% versus 30%, P = 0.02) and progression-
free survival (50% versus 21%, P = 0.02) whether or not the patients were in remission at the 
time of transplant (Figure 5). The TCR cohort had a non-significant trend toward reduced grade 
II-IV aGVHD (20% versus 11%, P = 0.20), and a significant decrease in cGVHD (7% versus 
18%, P = 0.03).  Improved reconstitution of T cell subsets, NK cells, and a lower rate of 
infection were observed in the TCR post-transplant Cy group.  
 
Experience in pediatric patients receiving haploHSCT with post-transplant Cy 
Twenty-nine pediatric patients <24 years of age have been treated at JHU using a myeloablative 
haploHSCT with the post-transplant Cy platform depicted in Figure 4.  Median age for this group 
of patients was 14y (range 1y-24y). Median time to neutrophil recovery was 24 days and platelet 
recovery was 29 days. Donor engraftment at Day 60 was 96%. The three year overall survival is 
75%. Acute GvHD grades 2-4 occurred in 16%, and aGvHD grades 3-4 in 7%.  The cumulative 
incidence of chronic GvHD is 25%, 12% moderate-severe. The cumulative incidence of TRM is 
11% and relapse at 3 years 25%43.  
 
Stem cell source- bone marrow vs. mobilized peripheral blood 
Some studies have demonstrated that peripheral blood grafts have a higher sustained 
engraftment rate than marrow grafts in the matched unrelated setting after nonmyeloablative 
conditioning. (85% vs. 56%, p=.007)44. In one trial, a multivariate statistical analysis identified 
significantly increased risks of graft rejection for patients who received marrow instead of 
peripheral blood (PB) grafts (p=.003) and those without preceding chemotherapy (p=.003). 
However, the same study also showed the probability of severe GVHD grades III-IV was higher 
among PB recipients (11% vs. 0%, p=.05).  Additionally, Anasetti et al conducted a phase III 
multicenter trial randomizing patients to receive PBSC versus bone marrow from unrelated 
donors that enrolled 551 patients. There was no significant survival difference between PBSC 
and BMT from unrelated donors. There was a slightly higher rate of graft failure with bone 
marrow (9% vs. 3%, p=0.002) but a higher rate of cGVHD with PBSC versus BM (53% vs. 
41%, p=0.01)45. Given our successful engraftment rates with BM on the nonmyeloablative and 
myeloablative haploidentical HSCT protocols and the myeloablative matched related or 
unrelated protocols as well as the increased risk for severe GVHD using haploidentical donors, 
this trial will be restricted to BM as the stem cell source. 
 
Use of a Cy/TBI prep in ALL patients 
Preparative regimens utilizing busulfan and Cy versus Cy and TBI have been compared 
in children receiving bone marrow transplants for hematologic malignancies. It has been shown 
that for pediatric patients (age < 20 years) with acute lymphoblastic leukemia, a TBI based prep 
regimen resulted in superior overall survival (55% v 40%, p=0.003) and three-year leukemia free 
survival (50% v 35%, p=0.005). In addition, treatment related mortality was higher in the Bu/Cy 
group (RR, 1.68, p=0.012), as were death and treatment failure (p=0.017 for death and p=0.006 
for relapse)46. Thus, patients with acute lymphocytic leukemia will receive a Cy/TBI based 
preparative regimen on this trial. 
 
Shortened Duration Tacrolimus 


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18
Kasamon et al presented the JHH data using shortened duration tacrolimus at the American 
Society of Hematology 2016 annual meeting. In this trial, tacrolimus was discontinued at Day 60 
or Day 90 after nonmyeloblative haploBMT instead of the historical Day +180. Of the 47 pts in 
the Day 90 cohort (median follow-up 44 months), 23 (49%) stopped tacro early as planned. 
Safety stopping criteria were not met. Of these 23 patients, 16 (70%) had no safety events before 
Day 180, 5 (22%) developed grade 2 acute GVHD (1 complicated by severe chronic GVHD) and 
2 (9%) developed grade 3-4 acute GVHD. Of the 55 patients in the Day 60 cohort (median 
follow-up 14 months), 38 (69%) stopped tacro early as planned, and safety stopping criteria were 
likewise not met. Of these 38 patients, 25 (66%) had no safety events before Day 180, 1 
developed graft failure, 9 (24%) developed grade 2 acute GVHD and 3 (8%) developed grade 3-
4 acute GVHD. In both cohorts, the D 180 cumulative incidence (CuI) of grade 2-4 acute GVHD 
was < 40% and was < 10% for grade 3-4 acute GVHD and NRM. The 1-year CuI of any chronic 
GVHD was 11% for the Day 90 arm and 13% for the Day 60 arm (12% historically). Risks of 
acute GVHD, chronic GVHD, graft failure and NRM appear similar to historical outcomes with 
tacro until Day 180. These data show that many pts (60% in this trial) can discontinue tacro 
without taper well before Day 180. The favorable toxicity profile of the PTCy platform, coupled 
with the feasibility and safety of early tacro cessation, provides an ideal setting to incorporate 
posttransplantation approaches for relapse reduction (Kasamon, ASH abstracts, Blood 2016 
128:831). JHH has since adopted Day +90 as its timepoint to stop and/or wean tacro (over 4 
weeks) after myeloablative and/or nonmyeloablative haploBMT.  
 
Second Transplants for Relapsed Disease 
Relapse of the primary malignancy after hematopoietic stem cell transplantation is a 
common cause of transplant failure. In the pediatric population one in three children will likely 
relapse following HSCT. In a retrospective study of 77 consecutive patients aged 2 to 51 years 
who relapsed after allogeneic HSCT, pediatric patients fared much better than the adults47. 
Disease Free Survival (DFS) in the 19 pediatric patients in this study was 44%. In a subsequent 
dedicated pediatric study of 25 patients, the 10 year survival was 48%48. Second allogeneic 
HSCT has been considered as a potential treatment option for patients who relapse following a 
first transplant. A recent retrospective multi-center pediatric study including 532 patients49  
evaluated the outcome of the 160 patients (30%) who relapsed.  The treatment options after 
relapse included: (a) Palliative therapy with non-curative intent (n = 43); (b) Salvage 
chemotherapy without a second HSCT (n = 55), and (c) Salvage chemotherapy followed by 
second HSCT (n = 62). The one-year DFS of the patients who underwent a second transplant 
was 50%, and this dropped to 35% at year two. In comparison, those who did not undergo 
second transplant had a 9% and 2% one and two year DFS, respectively (P=<0.0001).  After the 
second transplant, 43 (69%) of the patients died; 24% from non-relapse causes and the 
remaining from relapse of primary disease. Patients with NRM died at a median of 2 months. A 
multivariate analysis of this cohort showed that the outcome of the second transplant improved in 
proportion to the length of time to relapse following the first transplant. Furthermore, a time to 
relapse of more than twelve months from the first transplant, and receiving a second transplant 
were the only significant factors influencing overall outcome.  In a second retrospective analysis 
at a single institution, 40 of 93 (43%) patients experienced relapse after a first alloHCT. Eleven 
patients underwent a second alloHCT. The three-year overall survival probability in patients who 
underwent a second transplant was 27% (95% CI 6.5-54%) versus 5.4% (95% CI 0-20%,) for 
those who did not receive a second transplant. Eight (72%) died from post-HCT complications 


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19
including infection, multisystem organ failure, and sinusoidal obstructive syndrome. (N. Shah; 
personal communication, manuscript submitted) 
In this protocol, we plan to include patients who have relapsed after a 1st HSCT as 
separate cohort, based on the experience with second transplant in the pediatric setting and the 
low rates of TRM and infectious complications thus far in the myeloablative haploidentical 
setting. Indeed, two pediatric second transplant recipients on the JHH protocol are long-term 
survivors. Outcome in second transplant recipients has historically been considerably worse 
because of both TRM and relapse compared with patients who undergo their first HSCT. Thus, 
this small cohort of patients would be considered separately from patients receiving a first 
transplant, and providing descriptive outcome results with appropriate stopping rules for 
excessive TRM as described in the statistical section. 
Summary 
Multiple institutions have demonstrated the safety and feasibility of haploidentical HSCT 
after myeloablative conditioning with post-transplant Cy, and JHH has preliminary data 
demonstrating promising results in children.  We propose a multi-institutional phase II study in 
children with high-risk leukemias in 1st CR, acute leukemias in 2nd CR, MDS, and JMML.  The 
myeloablative conditioning regimen prescribed will be TBI-based for lymphoid leukemias and 
busulfan-based for myeloid leukemias, or for lymphoid leukemias in which a TBI-based regimen 
was used for the first transplant.  Our goal is to establish an easily exportable, inexpensive 
platform for haplotransplantation that has a safety profile equivalent to matched related and 
unrelated BMTs.  The primary objective will be to estimate the incidence of 6-month non-relapse 
mortality, hypothesizing that NRM is < 18%. This is slightly higher than the 15%  Johns 
Hopkins has seen in the combined adult and pediatric data on the myeloablative haploidentical 
BMT protocol with PT/Cy, and within the range of published TRM data for myeloablative 
haploBMT within PT/Cy as mentioned above (10-18%). 
3.0 SELECTION OF PATIENTS AND DONORS  
 
3.1 Recipient eligibility  
 
3.1.1 Patient age 0.5-25years  
 
3.1.2  Lack of a suitable HLA-matched related donor  
 
3.1.3 Patients must have a first-degree related donor or half-sibling who is at minimum 
HLA haploidentical to be enrolled. The donor and recipient must be identical at at least 
one allele of each of the following genetic loci: HLA-A, HLA-B, HLA-Cw, HLA-DRB1, 
and HLA-DQB1. A minimum match of 5/10 is therefore required, and will be considered 
sufficient evidence that the donor and recipient share one HLA haplotype.  
 
3.1.4 An unrelated donor search is not required for a patient to be eligible for this protocol, or a 
donor search and donor mobilization may be abandoned if the clinical situation dictates an 
urgent transplant.  Clinical urgency is defined as high likelihood that greater 6-8 weeks will 
be required to proceed to transplant or a low-likelihood of finding a matched, unrelated 
donor. 
 


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20
3.1.5 Patients must have at least one of the following high-risk conditions listed below (criteria 
are consistent with existing criteria within COG protocols): 
 
a) 
Acute lymphocytic leukemia (ALL) in CR1* as defined by at least one of the 
following: 
     i. hypodiploidy 
     ii. induction failure 
     viii. MRD after consolidation 
 
b) 
Acute myeloid leukemia (AML) in CR1* with high risk features defined as: 
i. 
     High allelic ratio FLT3/ITD+ 
ii. 
Monosomy 7 
iii. Del (5q) 
iv. Standard risk cytogenetics with positive minimal residual disease at the end of 
Induction I chemotherapy (for patients being treated on or according to COG 
AAML1031 who have had MRD studies sent to Seattle or performed at their local 
institution where the flow assay is sensitive enough to detect > 0.1% blasts) 
 
  
c) 
Acute Leukemias in 2nd or subsequent CR (CR>2) 
 
d) 
Mixed phenotype/Undifferentiated Leukemias in 1st or subsequent CR* 
 
e) 
Secondary or therapy related leukemias in CR  > 1 
 
f) 
NK cell leukemia or NK cell lymphoblastic leukemia/lymphoma CR > 1 
 
g) 
 Myelodysplastic syndrome (MDS)  
h)     JMML 
 
  
  
i) 
Prior transplant eligible if  < 18yo, >1 year has elapsed since BMT, and patient is off 
immunosuppression for > 3 months with no GVHD. Patients who have had a prior 
chemotherapy based preparative regimen are allowed to receive a TBI based prep, 
regardless of their disease.  
 
j) 
No known active CNS involvement or extramedullary involvement by malignancy. 
Such disease treated into remission is permitted. 
 
* Remission is defined as morphology with < 5% blasts with no morphological characteristics of 
acute leukemia (e.g., Auer Rods) in a bone marrow with > 20% cellularity. 
 
3.2 Criteria for recipient ineligibility 
 
3.2.1 Patients will not be excluded on the basis of sex, racial or ethnic background.  
 
3.2.2 Poor cardiac function: left ventricular ejection fraction <50% as determined by MUGA or 
ECHO or a shortening fraction below 27%. 
 
3.2.3 Poor pulmonary function:  


J13161 Protocol Version 5.1         April 20, 2017 
 
21
 
a) For patients receiving a TBI based preparative regimen: FEV1, FVC, and DLCO 
(corrected for Hgb) < 60% by pulmonary function tests (PFTs). 
 
b) For patients receiving a non-TBI based preparative regimen: FEV1, FVC, and DLCO <50% 
predicted (corrected for hemoglobin) for patients who have not received thoracic or 
mantle irradiation. 
  
c) For patients who have received thoracic or mantle irradiation, FEV1 and FVC <70% 
predicted or DLCO < 50 of predicted. For children unable to perform PFTs because of 
developmental stage pulse oximetry < 92% on RA,: no evidence of dyspnea at rest, no 
exercise intolerance. 
 
d) For children who are unable to cooperate for PFTs, required criteria are: no evidence of 
dyspnea at rest, no exercise intolerance, and not requiring supplemental oxygen therapy. 
 
3.2.4 Poor liver function defined as bilirubin >2 mg/dl (not due to hemolysis, Gilbert’s or 
primary malignancy) or ALT or AST > 3 x laboratory upper normal limits. 
 
3.2.5 Poor renal function: Creatinine clearance (calculated creatinine clearance is permitted) < 60 
mL/min based on Traditional Cockcroft-Gault formula:  
 
(140 - age (yrs) x Body Weight (kg) (Smaller of Actual Weight and IBW))  / 
72 x Serum creatinine (mg/dl) 
 
Multiply by 0.85 if female  
 
Intended for ages >18,y serum creatinine 0.6-7 mg/dl  
For patients <18 years: CrCl will be estimated by the Schwartz formula. A measured CrCl 
or a GFR may be substituted to determine the subject’s CrCl. 
 
Schwartz equation: CrCl (ml/min/1.73m2)=[length (cm) x k] /serum creatinine
 
K 
= 
0.45 
for 
infants 
1 
to 
52 
weeks 
old
k 
= 
0.55 
for 
children 
1 
to 
13 
years 
old
k 
= 
0.55 
for 
adolescent 
females 
13-18 
years 
old
k = 0.7 for adolescent males 13-18 years old
    
3.2.6  HIV-positive 
 
3.2.7  Positive leukocytotoxic crossmatch.  Specifically, complement dependent cytotoxicity 
and flow cytometric crossmatch assays must be negative, and the mean (or median) 
fluorescence intensity (MFI) of any anti-donor HLA antibody by solid phase 
immunoassay should be <2000.  If a screening assay against pooled HLA antigens is 
used, positive results must be followed with specificity testing using a single antigen 
assay. The MFI must be <2000 unless the laboratory has validated higher threshold 
values for reactivity for HLA antigens, such as HLA-C, DQ, and DP, that may be 
enhanced in concentration on the single antigen assays.  Consult with PI for the clinical 


J13161 Protocol Version 5.1         April 20, 2017 
 
22
significance of any anti-donor antibody.  If centers are unable to perform this type of 
testing, please contact the PI to make arrangements testing.   
 
3.2.8  Women of childbearing potential who currently are pregnant (-HCG+) or who are not 
practicing adequate contraception or who are breastfeeding 
 
3.2.9  Uncontrolled viral, bacterial, or fungal infections (currently taking medication and with 
progression of clinical symptoms or findings).  Patients with symptoms consistent with 
RSV, influenza A, B, or parainfluenza at the time of enrollment will be assayed for the 
above viruses and if positive are not eligible for the trial until they are no longer 
symptomatic (patients may have continued assay positivity for a period of time post 
resolution of symptoms secondary to the nature of the assay. 
 
3.3 Criteria for donor eligibility 
 
3.3.1  Age >0.5 years 
 
3.3.2  Donors must meet the selection criteria as defined by the Foundation for the 
Accreditation of Hematopoietic Cell Therapy (FACT). 
 
3.3.3    The following criteria, in order of importance, should also be used for donor selection: 
 
a) Medically and psychologically fit and willing to donate 
 
b) The patient must lack antibodies against donor HLA molecules potentially clinically 
significant (see section 6.1.3j) 
c) ABO compatibility (in order of priority) 
 
i. Compatible or minor ABO incompatibility 
ii. Major ABO incompatibility 
 
d) CMV status 
 
          i.   For a CMV seronegative recipient, use a CMV seronegative donor 
ii. For a CMV seropositive recipient, use a CMV seropositive donor 
 
3.3.4  If there is more than one donor option based on the above criteria, additional suggested 
criteria to consider (in no order of priority as none of these characteristics have been 
shown to make a difference in the setting of haploBMT with PT/Cy) include: 
 
a) Younger adults age >18 years and non-obese donors should be preferred. 
  
         b) If all else is equal, male donors may be preferred over nulliparous female donors who 
may be preferred over multiparous female donors. 
 
 


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23
c) If all other criteria equal and if the patient and family express a strong preference for a 
particular donor, that donor should be selected. 
 
3.3.5 Please contact Dr. Heather Symons at the Coordinating Center 
 Institution with any donor selection questions. Dr. Symons can help with donor selection upon 
request. 
 
4.0 Treatment Plan 
4.1  
Indwelling central venous catheter 
Placement of a double lumen central venous catheter will be required for administration 
of IV medications and transfusion of blood products, as per standard BMT requirements.  
This catheter may be removed and replaced as clinically indicated. However, the graft 
MUST be infused through a central line. 
 
4.2  
Pre-treatment Evaluation 
All patients will require documentation of a detailed history and physical examination 
and standard BMT evaluation of cardiac, pulmonary, liver and renal function. All patients 
with leukemia will undergo a bone marrow aspirate and biopsy for morphological, 
cytogenetic and flow cytometric evaluation.  
 
4.3  
Preparative regimen administration: 
 
4.3.1 Appropriate seizure prophylaxis (Keppra preferred) for patients above 10 years of age who 
are receiving busulfan will be administered. If institutional practice is to provide seizure 
prophylaxis for patients <10years of age, that is not a protocol violation. 
4.3.2 IV Busulfan will be administered at a starting dosage of: 
<12 kg: 1.1mg/kg/dose Q 6 hours IV (each dose over 2 hours) for 4 days (16 doses) 
>12 kg: 0.8mg/kg/dose Q 6 hours IV (each dose over 2 hours) for 4 days (16 doses) 
 
OR 
<12 kg: 1.1mg/kg/dose Q 6 hours IV (each dose over 2 hours) for 4 days (16 doses) 
< 6 years of age and >/= 12 kg: 32mg/m2/dose Q 6 hours IV (each dose over 2 hours) for 4 days 
(16 doses) 
6 years of age and older: 0.8mg/kg/dose Q 6 hours IV (each dose over 2 hours) for 4 days (16 
doses) 
 
It is recommended that the dose be based on the lesser of ideal body weight and actual body 
weight, however, dosing per institutional standards is allowed. 
 
For q 6 hour dosing, IV Busulfan is diluted in 5% Dextrose or NS for IV infusion over 2 hours. 
For accurate pharmacokinetics, it is recommended that the IV tubing be primed with drug, and 
connected as close as possible to the patient’s central venous catheter. At the conclusion of the 2 
hour infusion, it is recommended that the tubing must be disconnected so that no additional drug 
is given. With IV administration, blood samples will be drawn according to institutional 
protocol. The first dose should be administered in the evening. Busulfan kinetics should be 
drawn with the first dose. Samples will be sent to a reference laboratory to quantify each 


J13161 Protocol Version 5.1         April 20, 2017 
 
24
individual patient’s busulfan concentrations and subsequently undergo pharmacokinetic 
modeling to determine the individual’s AUC and clearance. Target AUC is 800-1400, target Css 
is 600-900.  
 
IV Busulfan may be given once daily as a 3 hour infusion as per institutional standards as long as 
pharmacokinetics are drawn around a test dose or the first dose. For 24 hr dosing, target AUC is 
3600-6000 uMol*min per day based on the dose being infused over 3 hours.  
 
If dose adjustments are made, repeat kinetics should be performed if at all possible to 
demonstrate the target AUC or Css was obtained.  
 
4.3.3 Cyclophosphamide will be given at a dose of 50 mg/kg/day IV over 1-2 hours x 2 days on 
day -2 and day -1. Dosing of cyclophosphamide is based on the LESSER of ideal body weight 
and actual body weight (ABW). Hyperhydration and maintenance of significant urine output 
after administration is required. Recommendations include starting intravenous fluids at least 2 
hours prior to cyclophosphamide and continuing for at least 8 hr post-cyclophosphamide. Fluids 
may be tailored to the individual patient and this will not result in any protocol violations. 
Recommended hydration: Hydration with ½ NS at 2x maintenance IV will be started 2 hours 
prior to cyclophosphamide and continued for 8 hours post-cyclophosphamide. 
 
Ideal Body Weight (IBW) Children (1-18 years) 
        IBW (kg) =((height in cm)2 x 1.65) / 1000 Children (5 feet and taller) 
        IBW (male) = 39 + (2.27 x height in inches >60) 
        IBW (female) = 42.2 + (2.27 x height in inches >60) Adults (18 years and older) 
        IBW (male) = 50 + (2.3 x height in inches >60) 
        IBW (female) = 45.5 + (2.3 x height in inches >60) 
 
 
 
Mesna will be given to prevent hemorrhagic cystitis at >80% of cyclophosphamide dosing per 
institutional standards.  
Recommended but not mandatory MESNA administration:  
Mesna 10 mg/kg lesser of IBW or ABW/dose IV mixed with cyclophosphamide over 1 hour, 
followed immediately by Mesna 40mg/kg lesser of IBW or ABW IV continuous infusion 
between hours 1-13 once daily.   
 
It is recommended that patients achieve and maintain a urine output over > 3ml/kg/hr before 
administering cyclophosphamide and throughout administration. Urinalysis will be performed to 
detect evidence of hemorrhagic cystitis, a known complication of high-dose Cy therapy. 
 
4.3.4 TBI will be given to those patients with acute lymphocytic leukemia, or for patients who 
have had a prior non-TBI-based BMT. Individual institutions can also choose to give a TBI 
based regimen for patients with mixed phenotype leukemia. All patients will receive 1200 cGy 
of total body irradiation (either 200 cGy bid x 3 days beginning on Day -3 or 150 cGy bid x 4 
days beginning on Day -4.). If TBI is over 4 days, then cyclophosphamide will be given on Days 
-6 and -5). Patients will be simulated for radiation prior to the start of their transplant preparative 


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25
regimen and the final TBI dose rate, field arrangements, treatment distance, field size, and beam 
energy will follow the recommendations of radiation oncology in adherence to institutional 
guidelines. TBI will be given at low-dose rate.  
Important considerations for TBI: 
- Effort should be made to avoid interruptions in TBI administration 
- The inter-fraction interval shall be no less than 5 hours between treatments (start to start) 
- A mid-plane dose rate of between 6 and 15cGy per minute is required 
 
Restricting the lung dose to < 800 cGy is required on this protocol. This requirement applies to 
both AP/PA and lateral treatments. To limit overall total lung dose to < 800 cGy, partial 
transmission lung blocks can be used. For AP/PA treatments the lung blocks may be placed in 
both AP and PA fields or alternatively in just the AP or PA field alone. Partial transmission lung 
blocks can be used to limit the overall total lung dose. 
Institutions are allowed to use their preferred method of beam attenuation to achieve the dose 
reduction to lungs.  
 
Any patient who is felt to warrant additional cranio or craniospinal irradiation based on CNS 
disease risk or testicular radiation will be addressed on a case by case basis by the oncology and 
radiation oncology teams and should be discussed with the PI. TBI may be given before Cy (TBI 
Days -5 through -3 or -6 through -3 and Cy Days -2 and -1 for scheduling issues. TBI may also 
be given once a day in the pm on Day -3 (200 cgY), twice a day on Days -2 and -1 (200 cGy 
twice a day) and once a day on Day 0 in the am (200cGy) for scheduling issues. 
 
4.3.5 Unmanipulated bone marrow on Day 0 must be infused at least 24 hours after the last dose 
of Cy. Graft may be infused on the same day as TBI administration as long as there is 4-6 hours 
between administration of TBI and infusion of bone marrow. 
 
One day of rest may be added between Days -1 and Day 0 prior to bone marrow infusion, 
depending on donor availability, operating room schedules, and as clinically indicated. 
 
4.4  
Marrow processing and infusion 
 
On Day 0, patients will receive unprocessed marrow unless there is a major ABO 
incompatibility, in which case red blood cells will be depleted from the donor marrow 
using institutional practices.  Minor ABO incompatible grafts will have plasma removed. 
Institutional practices will determine if there will be processing for minor ABO 
incompatibilities. Donor bone marrow will be harvested with a target yield of 4 x 108 
nucleated cells/kg recipient IBW, and a recommended minimum yield of 2.5 x 108 
nucleated cells/kg of recipient IBW. We recommend taking no more than 10 mL per 
aspirate. In addition to calculating the total nucleated cell dose /kg, a sample of the 
product to be infused will be sent for flow cytometry to determine the content of 
CD34+cells. The use of cryopreserved marrow is not permitted.  
 
4.5  
Post-transplantation cyclophosphamide 
 


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Cyclophosphamide will be given at a dose of 50 mg/kg/day IV over 1 hour x 2 days on 
day +3 and day +4 post-transplant. Begin Day +3 cyclophosphamide 60-72 hours after 
the start of bone marrow infusion. Dosing of cyclophosphamide is based on the LESSER 
of ideal body weight and actual body weight (ABW). Hyperhydration and maintenance of 
significant urine output after administration is required. Recommendations include 
starting intravenous fluids at least 2 hours prior to cyclophosphamide and continuing for 
at least 8 hr post-cyclophosphamide. Fluids may be tailored to the individual patient and 
this will not result in any protocol violations. Recommended hydration: Hydration with ½ 
NS at 2x maintenance IV will be started 2 hours prior to cyclophosphamide and 
continued for 8 hours post-cyclophosphamide. 
 
Mesna will be given to prevent hemorrhagic cystitis at >80% of cyclophosphamide 
dosing per institutional standards.  
Recommended but not mandatory MESNA administration:  
Mesna 10 mg/kg lesser of IBW or ABW/dose IV mixed with cyclophosphamide over 1 
hour, followed immediately by Mesna 40mg/kg lesser of IBW or ABW IV continuous 
infusion between hours 1-13 once daily.   
 
It is recommended that patients achieve and maintain a urine output over > 3ml/kg/hr 
before administering cyclophosphamide and throughout administration. Urinalysis will 
be performed to detect evidence of hemorrhagic cystitis, a known complication of high-
dose Cy therapy. 
 
It is crucial that no immunosuppressive agents are given until 24 hours after the 
completion of the post-transplant Cy. This includes corticosteroids as antiemetics. 
Corticosteroids used for adrenal support or during a medical emergency (e.g. treatment of 
anaphylaxis) will not be a violation of the protocol. 
 
4.6  
GVHD prophylaxis 
On day +5, patients will begin prophylaxis with Tacrolimus and Mycophenolate Mofetil 
(MMF).  Begin these at least 24 hours after the last PT/Cy infusion.  
 
The recommended starting dose of tacrolimus is 0.015mg/kg IBW/dose IV over 4 hours 
every 12 hours. Serum trough levels of tacrolimus should be measured around D+7 and 
the dose should be adjusted based on this level to maintain a level of 5-15 ng/ml (or 
institutional equivalent). Institutional standards (i.e. continuous infusion, etc.) of 
administering tacrolimus is allowed as long as tacrolimus is started on Day +5 and trough 
levels are maintained between 5-15 ng/ml (or institutional equivalent).  Tacrolimus 
should be converted to oral dosing when patient has a stable, therapeutic level and is able 
to tolerate food or other oral medications. For pediatric patients, the oral dosing is 
approximately two to four times the IV dosing. It is recommended that serum trough 
levels should be checked at steady state after any dose modification and when switching 
from IV to oral to ensure therapeutic trough concentrations. Serum trough concentrations 
should be checked at a minimum weekly thereafter and the dose adjusted accordingly to 
maintain a level of 5-15 ng/ml. Tacrolimus can be discontinued or weaned as early as 
Day +90 if the patient has full engraftment and no evidence of GVHD. If weaning, please 


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27
wean by approximately 25% per week such that tacro is discontinued after 4 weeks. At 
the latest, tacrolimus will be discontinued after the last dose around Day 180, or may be 
continued if active GVHD is present. This should be discussed with the PI. Tacrolimus 
may also be discontinued early if patients relapse. This should also be discussed with the 
PI. 
 
Mycophenolic acid mofetil (MMF) will be given at a dose of 15mg/kg/dose po or IV TID 
(based upon actual body weight) with the maximum total daily dose not to exceed 3 
g/day (1 g po/IV TID). MMF prophylaxis will be discontinued after the last dose on D35 
unless there is concern about engraftment and/or GVHD. Concerns should be discussed 
directly with the PI.  
 
4.7  
Supportive care  
Patients will receive transfusions, nutritional support, infection prophylaxis and 
treatment, and other supportive care according to standard of care and institutional 
guidelines. Infection prophylaxis should include, but is not limited to, agents or strategies 
(e.g. PCR screening and preemptive therapy) to reduce the risk of bacterial, herpes 
simplex, CMV, Pneumocystis jiroveci, and fungal infections. GCSF is not routinely 
given prior to engraftment on this protocol. Reasons to give GCSF prior to engraftment 
can include circumstances such as neutropenia with severe infection.  The PI should be 
notified. If GSCF will be given, the dose should be 5 mcg/kg daily. After engraftment, 
filgrastim may be given for severe neutropenia (ANC < 500/μL), without discussion with 
the PI. Other reasons for neutropenia should be considered such as bactrim or other 
myelosuppressive drugs.  Other growth factors (GM-CSF, erythropoietin) should be 
given only if clinically indicated. 
 
4.8  
Anti-ovulatory treatment  
Menstruating females must begin an anti-ovulatory agent per institutional guidelines 
before starting the preparative regimen.  
 
4.10 Post-BMT intrathecal chemotherapy 
Post-BMT intrathecal chemotherapy may be given or not given as per institutional practice.  
Intrathecal chemotherapy (IT) may not be started before Day +30 and, ideally, should begin 
when platelets are > 50,000 without supportive transfusions. IT chemo may be started with 
platelet transfusion support if platelets have not recovered by Day +60.  
 
4.11 Correlative Laboratory Studies (Recommended, Not Required; consent required) 
 
a. NK cell reconstitution studies:  
10cc peripheral blood will be collected in a sodium heparin tube and kept at room temperature at 
the following time points: Day 30+/-3, 60+/-7, 100+/-15, 180+/-30, and 365+/-60 after 
transplantation.  
 
Specimens should be sent via Fed Ex overnight Mon-Thurs to: 
Lee Lab 
Attn: Robin Nakkula 


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28
Research Institute of Nationwide Children’s Hospital 
700 Children’s Drive, WA4112 
Columbus, OH  43205 
Email: Robin.Nakkula@nationwidechildrens.org 
Phone: 614-355-1538 
 
Please email both Robin.Nakkula@nationwidechildrens.org and Dean.Lee@nationwidechildrens.org 
in advance to let them know when samples will be arriving. 
FedExAcct #2169-7339-9. Include in the note section “NCH Fund No 18951016” 
 
b. Immune reconstitution of T cells, B cells.  
When possible, 1 cc/kg of peripheral blood to max of 50mls EACH will be collected from the 
recipient in sodium heparin tube and kept at room temperature. Because of this, if samples for 
Johns Hopkins need to be drawn on a different day than the sample for Nationwide (10cc), that is 
ok. Time points: Prior to preparative regimen, days 30+/-3, 60+/-7, 180+/-30, and 365+/-60 after 
transplantation. When possible, 1cc/kg of peripheral blood to max of 50mls from the donor 
should also be collected prior to BMT. 
1. Flow cytometry for B, T cells  
2. Complete blood count with differential  
3. Additional relevant immunologic/biologic testing   
 
Specimens should be sent via Fedex overnight, Mon-Thurs (please also avoid holiday arrival) to:  
Leo Luznik, MD 
Cancer Research Bldg., (CRB-I) Rm. 290 
1650 Orleans St. 
Baltimore, MD. 21287 
Phone: (410) 502-7732 
Lab: (410) 955-8567 
E-mail: luznile@jhmi.edu 
Please email luznile@jhmi.edu at least several days prior to shipping so they know to expect the 
sample. 
FedExAcct #5403-2938-9 
4.12 Relapse prevention therapies post-BMT: Relapse prevention therapies, i.e TKIs for Ph+ 
leukemias, sorafenib for FLT-3 –ITD leukemias, etc are allowed on this trial.  
5.0 DATA MONITORING AND MANAGEMENT 
This study will be conducted in compliance with the JHM-IRB approved SKCCC Coordinating 
Center Operations Manual. The protocol chair, Dr. Heather Symons, will serve as liaison and 
will coordinate protocol development, submission, approval, amendments, results reporting and 
publications.  
 
5.1 General Guidelines 
 


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Eligible patients will be registered on study centrally at the Sidney Kimmel Comprehensive 
Cancer Center.  
 
Patients should be registered by two weeks before the start of prep regimen. Following 
registration, patients should begin protocol treatment within two weeks. Issues that would cause 
treatment delays should be discussed with the Principal Investigator. The Study Coordinator 
should be notified of cancellations as soon as possible. 
 
5.2 Registration Process 
 
A centralized, 3-part registration procedure will be used. After eligibility screening, patients who 
are selected to participate will be registered with the Coordinating Center (SKCCC) and with 
their study site/institution. A record of patients who fail to meet entry criteria (i.e., screen 
failures) will be maintained by each individual site. Patient registration must be complete before 
beginning any treatment or study activities.  
 
5.2.1 Coordinating Center (SKCCC) registration  
Prior to protocol enrollment and initiation of treatment, subjects must sign and date an IRB-
approved consent form.  To initiate registration, study sites/institutions should forward copies of 
the signed informed consent form, the research authorization/HIPAA form, the institutional 
registration form, plus any required laboratory tests to the coordinating center or sponsor by fax 
or email. Upon receipt of these forms, research personnel at the coordinating center will confirm 
patient eligibility with study personnel, assign a unique patient study identification number, and 
complete patient registration. Treatment must not commence until the site has received their 
patient’s identification number. All patients must be registered centrally at SKCCC.  
 
To register a patient, participating sites must send the documents by email (crocc@jhmi.edu)  
and CC the Lead Study Coordinator to the Coordinating Center. The Coordinating Center fax 
(410-502-9933) may be used if email is not available.  
 Signed patient consent form  
 Registration Form 
 Eligibility Checklist  
 Copies of all source documentation of all clinical studies confirming eligibility and HLA 
typing results 
 
The Coordinating Center will review the documents to confirm eligibility. To complete the 
registration process the Coordinating Center will:  
• Assign a patient study number  
• Register the patient on the study with SKCCC’s CRO Coordinating Center  
• Fax or e-mail the patient study number to the participating site  
 
The Johns Hopkins Pediatric Oncology Research Team will not register their patients through 
the SKCCC’s CRO Coordinating Center.  Eligibility for Hopkins subjects will be reviewed and 
confirmed internally by the Pediatric Oncology Research Team and verified by the Study PI.  A 
subject number, however, must be requested upon consent and prior to enrollment from the 


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30
SKCCC’s CRO Coordinating Center via email or telephone.  The SKCCC CRO Coordinating 
Center Lead Study Coordinator will provide this number to the study team. 
 
5.2.2 Institutional registration  
Patient registration at each study site/institution will be conducted according to the institution’s 
established policies. Before registration, patients will be asked to sign and date an Institutional 
Review Board (IRB)-approved consent form and a research authorization/HIPAA form. Patients 
must be registered with their local site/institution and also with the sponsor before beginning any 
treatment or study activities. 
 
5.3 Data Reporting and Regulatory Requirements 
 
5.3.1 Multicenter Guidelines 
 
Principal Investigator/Protocol Chair is responsible for performing the following tasks: 
      •    Coordinating development of the protocol as well as its subsequent  
      amendments.  
 
Taking responsibility for the overall conduct of the study at all participating  
institutions and for monitoring the progress of the study.  
 
Reviewing and ensuring reporting of Serious Adverse Events (SAE)  
 
Reviewing data from all sites.  
 
Coordinating Center  
The Coordinating Center (SKCCC) is responsible for performing the following tasks:  
 
Ensuring that IRB approval has been obtained at each participating site prior to the first 
patient registration at that site, and maintaining copies of IRB  
approvals from each site.  
 
Managing central patient registration.  
 
Collecting and compiling data from each site  
 
Establishing procedures for documentation, reporting, and submitting of AE’s  
and SAE’s to the Protocol Chair, and all applicable parties.  
 
Facilitating audits by securing selected source documents and research records  
from participating sites, or by auditing at participating sites.  
 
Ensuring that all participating institutions are using the correct version of the  
protocol.  
 
Ensuring that each participating institution has a FWA number 
 
Ensuring that participating sites are accruing a representative sample consistent with the 
estimated population of the site 
 
Preparing all submitted data for review by the protocol chair 
  
Participating Sites  
 Participating sites are responsible for performing the following tasks: 
 Securing IRB approval of the protocol and all subsequent amendments. 
 Implementing and adhering to the guidelines of Good Clinical Practice (GCP). • 
 Submitting data to the Coordinating Center. 
 Registering all patients with the Coordinating Center by promptly submitting  


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31
the patient registration form, eligibility checklist, and signed informed consent. 
 Providing sufficient experienced clinical and administrative staff and adequate  
facilities and equipment to conduct a collaborative trial according to the  
protocol. 
 Maintaining regulatory binders on site and providing copies of all required documents to 
the Coordinating Center. 
 Collecting and submitting data, including the reporting of all adverse events  
and serious adverse events, in accordance with the schedule specified in the protocol.  
 
Following the protocol as written 
 
Verifying the current active version of the protocol with the Coordinating Center. 
 
5.4 Data Entry 
Data collected during this study will be entered into a secure database. 
 
5.4.1 Case Report Forms 
Case report forms will be generated by the Coordinating Center for the collection of all study 
data. Investigators will be responsible for ensuring that the CRFs are kept up-to-date. 
 
5.4.2 Source Documents 
Study personnel will record clinical data in each patient’s source documents (i.e., the patient’s 
medical record). Source documentation will be made available to support the patient research 
record. Study monitors will review entries on the CRFs at regular intervals, comparing the 
content with source documents. 
 
5.4.3 Data Submission 
All data will be collected on case report forms. Case report forms will be provided to 
participating sites by the Coordinating Center. A primary research data file (research chart) will 
be maintained at each site, and must include completed case report forms and copies of required 
source documentation. Copies of the completed case report forms and source documents should 
be submitted to the Coordinating Center according to the following recommended schedule via 
email (crocc@jhmi.edu).  
 
Baseline/ On Study Forms 
Submit within one week of screening 
Treatment Forms  
 
Submit within 4 weeks post BMT 
Follow-up Forms  
 
Submit within 4 weeks of contact/visit date 
Off Study Form 
 
 
Submit within 4 weeks of discontinuing study 
 
5.4.4 Record Retention 
The investigator will maintain adequate and accurate records to enable the conduct of the study 
to be fully documented and the study data to be subsequently verified. After study closure, the 
investigator will maintain all source documents, study-related documents, and the CRFs. 
Because the length of time required for retaining records depends upon a number of regulatory 
and legal factors, documents should be stored until the investigator is notified that the documents 
may be destroyed. In this study, records are to be retained and securely stored for a minimum of 
7 years after the completion of all study activities. 
 


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5.5 Data Management 
 
5.5.1 Research Program Coordinators 
A Lead Research Program Coordinator at the Coordinating Center will be assigned to the study 
and will manage the study activities at each of the participating sites. The responsibilities of the 
Research Program Coordinator include project compliance, data collection, data entry, data 
reporting, regulatory monitoring, problem resolution and prioritization, and coordination of the 
activities of the protocol team. 
 
5.6 Study Monitoring and Quality Assurance 
 
Regularly scheduled registration reports will be generated to monitor patient accruals and the 
completeness of registration data. Routine data quality reports will be generated to assess 
missing data and inconsistencies. Accrual rates and the extent and accuracy of evaluations and 
follow-up will be monitored periodically throughout the study period, and potential problems 
will be brought to the attention of the Principal Investigator for discussion and action. 
 
Random-sample data quality monitoring will be conducted by the Coordinating Center at least 
every 6 months; and protocol compliance audits will be conducted by the Coordinating Center at 
least once a year and more frequently if indicated. Audits by the Coordinating Center may entail 
(1) faxing source documents and research records for selected patients from participating sites to 
the coordinating center for audit, or (2) on-site auditing of selected patient records at 
participating sites.  
 
All clinical work conducted under this protocol is subject to Good Clinical Practice (GCP) 
guidelines. This includes inspection of study-related records by the Coordinating Center, 
sponsor, its designee, or health authority representatives at any time. 
 
5.7 Data Safety Monitoring Board (DSMB)  
 
5.7.1 Role of the DSMB 
 
This study will be monitored by a DSMB. The primary role of the DSMB will be to monitor the 
conduct of the study as it pertains to TRM based on the protocol statistical guidelines and 
stopping rules (Section 13.0). A secondary role will be to monitor protocol specific adverse 
events and all SAEs.  
 
5.7.2 DSMB Membership 
The PBMTC will be providing DSMB oversight. 
 
5.7.3 Operations and responsibilities of the DSMB 
The DSMB will meet after the first 5 patients have reached day 100 after HCT. Future meetings 
will be held at 6-month intervals. At each meeting the DSMB will review the data related to 
patient safety. The safety report to the DSMB will include a summary of all protocol-specific 
adverse events as defined in Section 5.9.1, all SAEs and all unanticipated problems.  
 


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Based on the information available at each of these meetings, the DSMB is charged with 
deciding whether a) no action is required, b) the protocol should be modified, c) further 
enrollment should be suspended pending additional review, or d) the protocol should be closed.  
The DSMB will keep minutes of its meetings and provide its findings in a letter to the 
Coordinating Center within 10 working days. An exception to this time requirement will occur if 
the DSMB recommends study termination, suspension of enrollment or a protocol modification 
that significantly affects patient safety. In these cases, the DSMB will be expected to provide 
their recommendations to the Protocol Chair/Principal Investigator within 24 hours. Copies of 
the letter will be also distributed to the local PI at the participating institutions. An ad hoc 
meeting or discussion with the DSMB will be arranged as deemed necessary by the protocol PIs. 
Each institution will forward the minutes to their IRB per local institutional practice.  
 
5.7.4 Reporting data to the DSMB 
 
The Coordinating Center will be responsible for providing the DSMB with a summary of acute 
GVHD and safety data sufficient to meet their responsibilities. The participating centers are 
required to provide the Coordinating Center with completed case report forms and SAE reports 
in a timely manner to meet their obligations to the DSMB.  
 
This is a DSMP Level I study under the SKCCC Data Safety Monitoring Plan (12/6/2012). The 
Clinical Research Office will perform an audit after the first subject has been treated and then 
periodically depending on the rate of accrual and prior audit results. All trial monitoring and 
reporting will be reviewed annually by the SKCCC Safety Monitoring Committee.  The PI is 
responsible for internally monitoring the study. Data must be reviewed to assure the validity of 
data, as well as, the safety of the subjects. The PI will also monitor the progress of the trial, 
review safety reports, and clinical trial efficacy endpoints and to confirm that the safety 
outcomes favor continuation of the study. 
 
5.8 Adverse Event Reporting  
Allogeneic hematopoietic cell transplantation (HCT) is an intrinsically complex procedure 
associated with a variety of previously well-described adverse events, most of which are non-
serious without long-term sequelae. Therefore, for this study, adverse events (AEs) requiring 
reporting will be limited to post transplant Cy-related events, Serious AEs and 
Unanticipated Problems as defined in the sections below.  Only Adverse Events in any way 
realted to Cy-infusion and not related to the BMT will be captured on the Adverse Event 
Log.  Additionally, only clinically significant laboratory results considered in any way 
related to the Cy-infusion, and not at all related to the BMT are also to be captured on the 
Adverse Events Log.  Serious Adverse Events (SAEs) must be individually assessed by the 
PI on the Adverse Event Log. 
 
5.8.1 Definition and Documentation of Adverse Event (AE) 
An adverse event is the development of an undesirable medical condition or the deterioration of 
a pre-existing medical condition following or during treatment, whether or not considered 
causally related to the treatment. There are many expected toxicities of allogeneic BMT. The 
following are examples of toxicities that are serious but not unexpected: Grade 4 cytopenias; 


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neutropenic fever and sepsis; bacterial, fungal, or viral (including CMV, BK virus) infection; 
severe mucositis; pulmonary toxicities; bleeding without hemodynamic compromise. 
 
Toxicities should be described according to the National Cancer Institute (NCI) Common 
Toxicity Criteria for Adverse Events (CTCAE), version 4.0, which can be accessed and 
downloaded via the website: 
http://ctep.cancer.gov/reporting/ctc.html.  
 
As the primary research intervention in this study is the administration of cyclophosphamide 
after transplantation, adverse event reporting will focus on Cy related events. Patients will be 
assessed for the following events:  
 
 Failure to engraft neutrophils (>500/mcl) by day 60 after transplantation  
 
Other unexpected grade 3-5 events (per CTCAE, v. 4.0 possibly, probably, and 
definitely related to the cyclophosphamide  
 
Grades 3-4 aGVHD 
 Failure to detect donor chimerism >5%, as defined by the BMT-CTN and as per 
section 8.1.4 in whole blood at Day 60 
 Grade 3-5 infections (per CTCAE, v4.0)  
 
Cardiac: (per CTCAE, v. 4.0)  
Clinical Heart Failure or Cardiomyopathy:  
Left Ventricular dysfunction: Grade 3- 5 
 Gastrointestinal: (per CTCAE, v. 4.0) 
Mucositis/stomatitis (clinical exam): Grade 3- 5 
 Hemorrhage/Bleeding; (per CTCAE, v. 4.0) 
Hemorrhage, GU, - Bladder, Grade 2 – 5 (and not related to infection) 
 
Attribution of the event to the investigational product may be characterized as follows:  
 definitely related, clearly associated with study drug/treatment  
 probably related, likely associated with study drug/treatment  
 possibly related, may be associated with study drug or other treatment  
 unlikely to be related, or  
 definitely not related to the study drug/treatment 
 
For reporting purposes, an AE should be regarded as possibly, probably, or definitely related to 
the regimen if the investigator believes that at least one of following criteria are met:  
a) There is a clinically plausible time sequence between onset of the AE and the administration 
of the study drug or treatment;  
b) There is a biologically plausible mechanism for the study drug or treatment causing or 
contributing to the AE;  
c) The AE cannot be attributed solely to concurrent/underlying illness, other drugs, or   
procedures 
 
In those cases where the NCI criteria do not apply, intensity will be defined as: 
• Mild: awareness of symptom or sign, but easily tolerated 
• Moderate: discomfort is enough to cause interference with normal activities 


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 • Severe: inability to perform normal daily activities 
• Life threatening: immediate risk of death from the reaction as it occurred  
 
Adverse events will be documented on AE logs and submitted to the Coordinating Center on a 
monthly basis. Adverse events will be collected through the time of discharge from the transplant 
center, but no longer than 100 days after transplantation.  
 
5.8.2 Definition and reporting of Serious Adverse Event (SAE) 
A serious adverse event is an AE that fulfills one or more of the following criteria:  
 Results in death 
 Is immediately life-threatening 
 Requires or prolongs a hospital stay** 
Results in persistent or significant disability or incapacity  
 Is a congenital abnormality or birth defect 
 Represents a significant medical condition which, without urgent medical 
intervention, would lead to one of the above outcomes.  
 
Life-threatening means that the AE represented an immediate threat of death without 
medical intervention.  
 
All events that meet the definition of an SAE in section 5.8.2, regardless of whether they 
are related or unrelated to the protocol intervention will be reported to the Coordinating 
Center. SAEs will be reported to the Coordinating Center through the time of discharge 
from the transplant center, but no longer than 100 days after transplantation, with the 
exception of any deaths, which will be reported throughout the duration of the study. 
SAE reports also must be submitted to the local IRB per the institutional requirements.  
 
**The following hospitalizations are NOT considered SAEs: 
 Admissions as per protocol for a planned medical/surgical procedure 
 Routine health assessment requiring admission for baseline/trending of health 
status (e.g., routine colonoscopy) 
 Medical/surgical admission for the purpose other than remedying ill heath state 
and was planned prior to entry into the study [Documentation is required in these 
cases]. 
 Admissions encountered from another life circumstance that carries no bearing on 
health status and requires no medical/surgical intervention (e.g. lack of housing, 
economic inadequacy, care-giver respite, family circumstances, administrative) 
 Admission directly related to the BMT but not to the PTCy 
 
5.8.3. Role of Protocol Chair/Principal Investigator in adverse event reporting 
The Protocol Chair/Principal Investigator is ultimately responsible for the required reporting of 
all adverse events.  
 
5.8.4 Role of Coordinating Center in adverse event reporting  


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The Coordinating Center is the central location for the collection and maintenance of 
documentation of adverse events and is responsible for submitting adverse event reports to the 
Protocol Chair promptly. The Coordinating Center will maintain documentation of all adverse 
events for each participating site. Adverse event reports submitted to the Coordinating Center 
must be signed and dated by the participating site’s Principal Investigator. The Coordinating 
Center will provide appropriate forms to be used by all participating sites for reporting adverse 
events.  
 
Documentation of all SAEs must include: 
 •Subject ID number, and initials 
• Date of the event 
• Description of the event  
• Description of site's response to the event 
• Assessment of the subject's condition 
• Subject's status on the study (on study, in follow-up, off study )  
• Attribution of event to study drug  
 
5.8.5. Role of Participating Sites in adverse event reporting 
Participating sites are responsible for reporting adverse events to the local IRB,  
per local institutional requirements, and to the Coordinating Center as follows:  
 
Fatal Events whether anticipated or unanticipated, and whether or not related to the study must 
be reported to the Coordinating Center within 24 hours of the participating site Principal 
Investigator's learning of the event.  
 
Other Serious Adverse Events must be reported to the Coordinating Center within 72 business 
hours of the participating site Principal Investigator’s learning of the event.  
 
Serious Adverse Event reports are to be emailed (crocc@jhmi.edu) or faxed (410-502-9933) to 
the Coordinating Center. Follow-up reports are faxed, mailed, or sent electronically to the 
Coordinating Center as necessary. 
 
The investigator must also report follow-up information about SAEs within the same time 
frames. Investigators must follow patients with SAEs until the event has resolved or the 
condition has stabilized. If the patient is lost to follow-up with an ongoing SAE, this should be 
captured accordingly on a follow-up SAE report. 
 
If a non-serious AE becomes serious, this and other relevant follow-up information must also be 
provided within the same time frames described above. 
 
All SAEs must be collected whether or not they are considered causally related to the 
investigational product.  Investigators and other site personnel also are responsible for reporting 
all casually related SAEs to their IRB and the Protocol Chair. Site PIs and other investigators 
must provide expedited reports of all SAEs to the protocol chair.  It is the responsibility of the 
protocol chair to determine whether the SAE is related to the study and whether it is unexpected 


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37
by virtue of greater severity or higher frequency when evaluated in the context of prior 
expectations and experience in the study to date. 
 
5.9 GVHD 
 
A major toxicity of allogeneic BMT from an unrelated or mismatched donor is GVHD. Acute 
graft-versus-host disease (GVHD) shall be graded clinically according to the criteria developed 
by the consensus conference on acute GVHD5 (Appendix 3). All suspected cases of acute GVHD 
should be confirmed histologically by biopsy of an affected organ (skin, liver, or gastrointestinal 
tract). Diarrhea and/or hyperbilirubinemia in a patient with histologically documented skin 
GVHD may be assumed to be a manifestation of visceral GVHD and will be graded as such. All 
patients with histologically documented, clinical grade >2 acute GVHD should receive initial 
treatment according to institutional preference. If skin GVHD resolves with treatment but 
suspected visceral GVHD does not, biopsy of the affected organ (liver or gastrointestinal tract) 
should be obtained to rule out other causes of hyperbilirubinemia and/or diarrhea. Steroid 
refractory acute GVHD will be treated according to institutional preferences. In patients who 
develop GVHD, the GVHD assessment questionnaire must be completed at the time of onset, 
weekly until GVHD resolves, and at Day 60+/-7 days, regardless of whether or not the patient 
has GVHD. The following information shall be collected on all patients with acute GVHD:   
      
 Date of onset (defined as the date of first biopsy confirming GVHD) 
 Initial overall clinical grade  
 Maximum overall clinical grade 
 Date of onset of grade III-IV acute GVHD, if any 
 
Chronic graft-versus-host disease (cGVHD) shall be graded clinically according to the criteria 
developed by the NIH consensus conference on chronic GVHD48 (Appendix 4). All suspected 
cases of chronic GVHD should be confirmed histologically by biopsy of an affected organ 
whenever possible. Mild chronic GVHD involves only 1 or 2 organs or sites (except the lung), 
with no clinically significant functional impairment (maximum of score 1 in all affected organs 
or sites). Moderate chronic GVHD involves (1) at least 1 organ or site with clinically significant 
but no major disability (maximum score of 2 in any affected organ or site) or (2) 3 or more 
organs or sites with no clinically significant functional impairment (maximum score of 1 in all 
affected organs or sites). A lung score of 1 will also be considered moderate chronic GVHD. 
Severe chronic GVHD indicates major disability caused by chronic GVHD (score of 3 in any 
organ or site). A lung score of 2 or greater will also be considered severe chronic GVHD. 
 
The following information shall be collected on all patients with chronic GVHD: 
 
 Date of onset (defined as the date of first biopsy confirming GVHD, if possible or the 
first day of onset of clinical symptoms if no biopsy is performed) 
 Initial overall clinical score 
 Maximum overall clinical score 
 
5.10  Non-relapse mortality (NRM) 
 


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38
Causes of NRM, i.e., death in the absence of relapse or disease progression, will be documented 
as important indicators of procedure-associated toxicity, particularly as these causes relate 
directly or indirectly to GVHD. Analysis will stratify mortality with respect to the peri-transplant 
period (<100 d post-BMT) or later times post-BMT. 
 
5.11 Protocol Deviations 
 
When an emergency occurs that requires a deviation from the protocol for patient safety, a 
decision will be made as soon as possible to determine whether or not the subject (for whom the 
deviation from protocol was effected) is to continue in the study. The subject’s medical records 
will completely describe the deviation from the protocol and state the reasons for such deviation. 
In addition, the Investigator will notify their local IRB as required in writing of the deviation 
from protocol. The Transplant Center Local Principal Investigator is responsible for notifying the 
Protocol Coordinator as soon as possible of the deviation. Major deviations in this protocol 
consist of modifications of the preparative regimen or a last minute change of stem cell source or 
significant delay in stem cell source infusion.  
Non-emergency minor deviations from the protocol will be permitted with approval of the 
Protocol Coordinator. Modifications of GVHD prophylaxis/immune suppression necessary for 
good patient care are not considered protocol deviations. 
 
6.0  
PATIENT MONITORING 
The following parameters will be obtained according to this schedule: (for details of these 
evaluations, see text sections 6.1-6.2, or additional sections when indicated). 
 
Initial 
Allowable 
time 
frame 
from date of 
consent1 
Day 
30 +/-
3 
Day 60 
+/-7 
Day 
100 +/-
15 
Day 180 
+/- 30 
Day 365 
+/- 60  
History and Physical 
X 
Within 30 days 
  
 
 
 
 
Performance status 
X 
Within 30 days 
 
X 
X 
X 
X 
Disease Staging2 
X 
Within 30 days 
 
X8 
X 
 
 
RFLP 
or 
FISH 
studies3 
X 
Within 30 days 
 
 
 
 
 
CBC & Diff 
X 
Within 7 days 
X 
X 
X 
X 
X 
Reticulocyte count 
X 
Within 7 days 
 
 
 
 
 
Comprehensive 
Metabolic Panel 
X 
Within 7 days 
X 
X 
X 
X 
X 
Chimerism analysis4 
 
 
X 
X  
X  
X  
X  
MRD testing5 
X 
Within 30 days 
 
X 
 
 
 
EKG 
X 
Within 30 days 
 
 
 
 
 
 ECHO 
X 
Within 30 days 
 
 
 
 
 
HepB Ag, HBC Ab, 
HCV Ab, HSV IgG, 
CMV 
IgG, 
RPR, 
HIV, VZV IgG (if 
possible) 
X 
Within 30 days 
 
 
 
 
 
Anti-Donor 
HLA 
antibody/ 
lymphocyto-toxic 
screen 
X 
Within 30 days 
 
 
 
 
 
PFTs 
(Spirometry 
X 
Within 30 days 
 
 
 
 
 


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39
 
 
1Baseline 
laboratory 
tests and 
radiology 
studies 
time frame will follow BMT standards. 
2 See section 6.1.3 h 
3  RFLP or FISH studies will be drawn as a baseline for subsequent engraftment studies. May also be done via 
microsatellite technique or str analysis.  
4 Donor chimerism as per institutional standards on bone marrow when disease restaging is being done and on 
peripheral blood if bone marrow not being done. If bone marrow chimerism is performed, peripheral blood 
chimerism does not need to be performed. We recommend T cell engraftment (whole blood and CD3+) if possible, 
but this is not required. 
5Recommended, but not required.  See section 6.1.3 h 
6 Please see section 4.10 for details 
7 GVHD assessment should be completed at time of onset and weekly until GVHD resolves. Assessment should also 
be completed at Day 60 regardless of whether the patient has GVHD or not.  
8 Day 60 disease staging may be done as early as Day 30 +/-3 days 
 
 
6.1  
Pre-transplant Evaluation 
 
Potential subjects must meet all of the eligibility criteria.  These represent the basic baseline 
studies required on all patients prior to starting their preparative regimen. Additional 
investigations may be clinically indicated in certain individuals. Other baseline studies may be 
required for the purposes of non-preparative regimen protocols on which the patient is enrolled. 
In this case, such requirements will be stipulated in the pertinent protocols. 
 
6.1.1.  Thorough general medical evaluation which should include: 
 
a) Physical examination 
 
6.1.2.  Baseline investigations including: 
a)  Hematologic 
 
i. CBC with platelets, differential, reticulocyte count 
 
ii. ABO and Rh typing 
 
b)  Chemistries 
 
i. Comprehensive chemistry panel including electrolytes, BUN,          
creatinine, AST, ALT, alkaline phosphatase, total bilirubin, total protein, 
albumin, calcium 
 
c)  Cardiac 
 
i. EKG 
ii. Echocardiogram or MUGA scan with Left Ventricular Ejection     Fraction 
(LVEF) 
 
d) Pulmonary 
and DLCO) 
GVHD assessment7 
 
 
 
X 
 
 
 
Immune 
Reconstitution 
Studies (with consent)6 
X 
Within 30 days 
for patient and 
donor 
X 
X 
 
X 
X 
NK Reconstitution 
(with consent)6 
 
 
X 
X 
X 
X 
X 


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40
i. Pulmonary function tests including at least FEV1, FVC, and DLCO 
(pediatric patients under the age of 7-8 are excluded from this test) 
 
e)  Immunologic / Infections 
 
i. HBsAg, anti-HBC, anti-HCV 
 
ii. RPR 
 
iii. HIV antibody 
 
iv. Serology for CMV, HSV, and VZV  
 
v. HLA typing/lymphocytotoxic antibody screen 
 
f)  Donor chimerism studies will be drawn as a baseline for subsequent 
engraftment studies when the donor and patient are the same gender. 
 
 
h)  Disease specific staging studies:  
 
i.  Acute myeloid leukemia 
 
 
- Bone marrow aspirate 
 
 
- Flow cytometry 
 
 
- Comprehensive cytogenetics 
 
 
- FISH of a preexisting known chromosomal abnormality 
 
 
- CSF cytology, if previously involved 
            - MRD testing* 
 
 
 
ii.  Acute lymphocytic leukemia 
 
 
- Bone marrow aspirate 
 
 
- CSF cytology 
 
 
- Flow cytometry 
 
 
- Comprehensive cytogenetics 
 
 
- FISH of a preexisting known chromosomal abnormality 
 
 
- MRD testing* 
 
 
iii. Myelodysplasia 
 
 
- Bone marrow aspirate and biopsy 
 
 
- Cytogenetics 
 
 
- Flow cytometry 
 
 
- FISH of a preexisting known chromosomal abnormality 
 
*MRD is strongly recommended but not required. Testing should be done at 
Institutions capable of detecting MRD at a level of 0.01% for ALL and 0.1% for 
AML. If this is not possible at the home Institution, 2cc BM can be sent for MRD 
testing to an Institution with this capability.  
 
Preferably (but not mandatory), ALL specimens can be sent to: 
 
Michael Borowitz, MD, PhD 


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41
Johns Hopkins Medical Institution 
Flow Cytometry Lab 
Weinberg Building - Room 2300 
401 N Broadway 
Baltimore, MD 21231-2410 
Phone: (410) 614-2968 
Fax: (410) 502-1493 
 
 
Email: mborowit@jhmi.edu 
 
 
and AML specimens can be sent to: 
 
Michael Lokin, PhD 
Hematologics, Inc. 
3161 Elliott Avenue, Suite 200 
Seattle, WA 98121 
 
 
i.) Immune Reconstitution Study blood (with consent) 
-50ml of blood in a preservative free heparinized sterile syringe from adult 
recipients and 1cc/kg to a maximum of 50mls of blood from pediatric 
recipients and donors. 
 
 
j) Anti-donor HLA Antibody Testing: Positive anti-donor antibody is defined 
as a positive crossmatch test of any titer (by complement dependent 
cytotoxicity or flow cytometric testing) or the mean fluorescence intensity 
(MFI) of any anti-donor HLA antibody by solid phase immunoassay >3000.  
Consult with Dr. Heather Symons at the Coordinating Center for the clinical 
significance of any anti-donor antibody. 
 
6.2  
Post-transplant Evaluation 
 
6.2.1.  Day 0 through Day 60 evaluation. These represent the minimum required. More frequent 
determinations and additional investigations may be indicated by the clinical condition of 
the patient. 
1. CBC daily with a WBC differential once the total WBC is greater than 
100 until ANC > 500 for three days or two consecutive measurements over a three 
day period. Then, CBC weekly with differential. 
2.  Comprehensive metabolic panel (electrolytes, BUN, creatinine, AST, ALT, alkaline 
phosphatase, total bilirubin, total protein, albumin, calcium) once a week. 
3.   Patients will have evaluations for infectious complications as clinically indicated. 
Surveillance cultures according to institutional protocol. 
4.  Evaluations by history and physical examination for GVHD will be performed as per 
BMT unit standards.  
 
6.2.2 Evaluations on day 30 (+/-3 days) 
1. CBC and differential and comprehensive panel (electrolytes, BUN, creatinine, AST, 
ALT, alkaline phosphatase, total bilirubin, total protein, albumin, calcium). 


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42
2.  GVHD assessment/ History and Physical for GVHD 
3.  Immune Reconstitution and NK Studies: see section 4.10  
            4.  Donor chimerism evaluation on bone marrow and peripheral blood [T cell engraftment 
               (whole blood and CD3+) if possible]. 
 
6.2.3 Evaluations on day 60 (+/-7 days) 
            1. Donor chimerism evaluation on bone marrow and peripheral blood [T cell engraftment 
               (whole blood and CD3+) if possible]. 
2.   Disease staging (may be done as early as Day 30 +/- 3 days). (see section 6.1.3 h). 
MRD testing recommended but not required. 
3.  CBC and white blood cell differential, comprehensive panel (electrolytes, BUN, 
creatinine, AST, ALT, alkaline phosphatase, total bilirubin, total protein, albumin, 
calcium) 
4.  GVHD assessment/ History and Physical for GVHD 
5.  Performance status 
6.  Immune Reconstitution and NK Studies: see section 4.10 
 
  6.2.4 Evaluations on day 100 (+/- 15 days) 
1. Donor chimerism evaluation on bone marrow and peripheral blood [T cell engraftment 
(whole blood and CD3+) if possible] 
 
2.  Disease staging. (see section 6.1.3 h). MRD testing recommended but not required. 
3. CBC and white blood cell differential, comprehensive panel (electrolytes, BUN, 
creatinine, AST, ALT, alkaline phosphatase, total bilirubin, total protein, albumin, 
calcium) 
4. GVHD assessment/ History and Physical for GVHD 
5. Performance status 
6.  NK Studies: see section 4.10 
 
6.2.5 Evaluations on day 180 (+/-30 days) 
1. History and physical examination. 
 
2. Donor chimerism on bone marrow (if performed) and T cell engraftment f/u on 
peripheral blood [T cell engraftment (whole blood and CD3+) if possible]. Only 
peripheral blood is required at this time point. 
3. CBC and white blood cell differential, comprehensive panel (electrolytes, BUN, 
creatinine, AST, ALT, alkaline phosphatase, total bilirubin, total protein, albumin, 
calcium) 
4. GVHD assessment/ History and Physical for GVHD 
5.  Performance status 
6.  Immune Reconstitution and NK Studies: see section 4.10 
             
6.2.6 Evaluations on Day 365 (+/- 60 days) 
1. RFLP or FISH for donor chimerism on bone marrow (if performed) and T cell 
engraftment f/u on peripheral blood [T cell engraftment (whole blood and CD3+) if 
possible]. Only peripheral blood is required at this time point. 


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43
2. CBC and white blood cell differential, comprehensive panel (electrolytes, BUN, 
creatinine, AST, ALT, alkaline phosphatase, total bilirubin, total protein, albumin, 
calcium) 
3. GVHD assessment/ History and Physical for GVHD 
4. Performance status 
5. Immune Reconstitution and NK Studies: see section 4.10 
 
7.0 RISKS AND TOXICITIES 
 
7.1  
Busulfan (Bu) 
Busulfan Toxicities: 
a)  Nausea and vomiting - this occurs in some patients. It is usually mild but antiemetics 
may be required. 
b)  Hematologic - the doses of busulfan are expected to produce marrow ablation from 
which the patient would not be expected to recover without marrow rescue. 
c)  Pulmonary complications - diffuse interstitial pneumonitis with fibrosis has been 
reported as a complication of busulfan therapy when the drug is given in small doses 
over long periods of time. Changes in pulmonary function tests may occur following 
bone marrow transplantation. To date, no specific pulmonary complications have 
been attributed to busulfan as used in the transplant setting at this institution. 
d)  Seizures - preliminary studies suggest that significant levels of Busulfan are attained 
in the cerebrospinal fluid. In the past about 10% of our patients have experienced 
grand mal seizures during Busulfan administration. This toxicity is avoided by the use 
of keppra as outlined in the treatment plan. 
e)  Other toxic effects which may be produced by Busulfan include erythematous skin 
rash, hyperpigmentation, hepatic dysfunction, amenorrhea, testicular atrophy, 
gynecomastia, myasthenia symptoms, cataract and atrophic bronchitis associated with 
 
cytologic dysplasia. 
 
  7.2  
Cyclophosphamide (Cytoxan) 
Cyclophosphamide is an alkylating agent whose metabolites form cross-links with 
DNA resulting in cell cycle-nonspecific inhibition of DNA synthesis and function. 
Commercial supply of cyclophosphamide will be used. 
Cyclophosphamide Toxicities: 
a)  Hematologic: Leukopenia, anemia 
b)  Dermatologic: Alopecia 
c)  Gastrointestinal: Nausea, vomiting, increased AST, ALT, mucositis, diarrhea 
d)  Neurologic: Headache, dizziness 
e)  Cardiovascular: Cardiac necrosis rarely with high dose cyclophosphamide 
f)  Renal: Hemorrhagic cystitis, SIADH 
g)  Other: teratogenic, may cause secondary neoplasms, anaphylaxis (rare) 
h)  Fluid retention. Cy has anti-diuretic effect usually counteracted by furosemide  
administration. Careful physical examination should be made and accurate weights 
should be determined to detect fluid overload early. 


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44
i)  Cardiomyopathy. At doses greater than 200mg/kg, Cy can cause fatal myocardial 
necrosis with clinical heart failure. Non-specific ST changes on EKG are not unusual 
but a decrease in voltage is significant. 
j)  Hemorrhagic cystitis. Hematuria is not uncommon at this dose level, but is usually 
not symptomatic or severe unless there is inadequate diuresis. An occasional patient 
will get severe cystitis despite prophylactic measures. 
 
 7.3 TBI 
Early side effects (< 1 month): Most patients experience some degree of nausea, 
vomiting, and diarrhea either during or immediately after treatment. Fever that develops 
soon after TBI is not uncommon. Other side effects include skin erythema, parotid gland 
swelling, diminished salivary gland function, stomatitis, mouth ulcers, sore throat, 
generalized weakness and fatigue and alopecia. Myelosuppression occurs promptly 
following TBI and doses of 1000cGy or more are assumed to cause permanent bone 
marrow aplasia and would be lethal without BMT. 
Intermediate side effects (1-4 months): Interstitial pneumonia can be seen with a fatal 
incidence of up to 5-10%. Other side effects may include graft versus host disease and 
infection from prolonged immunoincompetence.  
Late effects (>4months): An increased risk of sterility and cataracts is known; the risk of 
developing a second malignancy may be increased. Additional complications for long 
term survivors may include cardiac, pulmonary, liver, and kidney damage as well as 
hearing loss. Changes in hormone levels may also occur. 
 
7.4  
Mesna (sodium-2-mercapto ethane sulphonate)  
Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced by the 
oxasophosphorines (cyclophosphamide and ifosphamide). It has no intrinsic cytotoxicity and no 
antagonistic effects on chemotherapy. Mesna binds with acrolein, the urotoxic metabolite 
produced by the oxasophosphorines, to produce a non-toxic thioether and slows the rate of 
acrolein formation by combining with 4-hydroxy metabolites of oxasophosphorines.  
 
The total daily dose of mesna is equal to at least 80% of the total daily dose of 
cyclophosphamide. At the doses used for uroprotection, mesna is virtually non-toxic. However, 
potential adverse effects include nausea and vomiting, diarrhea, abdominal pain, altered taste, 
rash, urticaria, headache, joint or limb pain, hypotension, and fatigue. 
 
7.5  
Tacrolimus (FK-506, Prograf®) 
Tacrolimus is a macrolide immunosuppressant that inhibits lymphocytes through calcineurin 
inhibition.  
 
Toxicities: There is a spectrum of well-described toxicities of tacrolimus. Toxicities include 
renal insufficiency, hypertension, hyperglycemia, hypomagnesemia, hypokalemia, nausea, 
diarrhea, headache, neurologic toxicity including tremor and leukoencephalopathy, infection, and 
rarely thrombotic thrombocytopenic purpura (TTP).  
 
Drug interactions: Tacrolimus is well absorbed orally. Tacrolimus is extensively metabolized by 
the cytochrome P-450 (CYP3A4) system and metabolized products are excreted in the urine. 


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45
Drugs that may increase tacrolimus levels include tri-azole drugs (especially voriconazole and 
posaconazole), nephrotoxic drugs, calcium channel blockers, cimetidine and omeprazole, 
metoclopramide, macrolide antibiotics, quinupristin/dalfopristin, danazol, ethinyl estradiol, 
methylprednisolone, and HIV protease inhibitors. Drugs that may decrease tacrolimus levels 
include some anticonvulsants (phenobarbital, phenytoin, carbamezepine), caspofungin, 
rifamycins, and St. John’s Wort.  
 
Dose adjustments: The tacrolimus dose is adjusted to maintain a serum trough level of 5-15 
ng/mL. Patients with hepatic or renal insufficiency should receive doses at the lower end of 
therapeutic concentrations. No dose adjustments are required in patients undergoing 
hemodialysis.  
 
Due to extreme interactions with voriconazole and posaconazole, the tacrolimus dose 
should be empirically lowered when these azoles are initiated at steady state levels of 
tacrolimus. Guidelines are provided in the table below. Dose adjustments for therapy with other 
azoles may be indicated. However, the initial tacrolimus dose (on Day 5) remains fixed.  
 
Dosing considerations with concurrent azole therapy: Triazole antifungal medications are 
expected to increase serum CNI levels; therefore dosages of CNI’s should be adjusted 
accordingly. Guidelines are provided in the table below. Of note, reversal of azole-mediated 
inhibition of CYP3A4 (and others) and P-glycoprotein is gradual when azoles are stopped. 
Therefore, immediate significant dose increases in tacrolimus are not advised when azoles are 
stopped. Rather, tacrolimus dose increases should be cautious and based on more frequent 
monitoring of levels as appropriate.  
Table: Suggested preemptive dose reduction of tacrolimus when azoles are initiated at 
steady state levels of tacrolimus 
Antifungal  
         Tacrolimus 
Dose ↓  
           Comment 
Voriconazole  
67%  
Strongly 
advised  
Posaconazole  
67%  
Advised  
Itraconazole  
50%  
Advised  
Fluconazole  
25%  
Consider  
 
7.6  
Mycophenolate Mofetil (MMF, Cellcept®)  
MMF is an ester prodrug of the active immunosuppressant mycophenolic acid (MPA).  
Side effects include: pancytopenia, infection (including sepsis, CMV, HSV, VZV, and Candida), 
nausea, vomiting, diarrhea, allergic reactions, hypertension, headache, dizziness, insomnia, 
hyperglycemia, electrolyte imbalances, rash, and leg cramps/bone pain.  
 
Drug interactions: MMF activity is decreased with oral antacids and cholestyramine. There are 
no pharmacokinetic interactions with cotrimoxazole, oral contraceptives, or cyclosporine. 
Acyclovir or ganciclovir blood levels may increase due to competition for tubular secretion. 
High doses of salicylates or other highly protein-bound drugs may increase the free fraction of 
MPA and exaggerate the potential for myelosuppression.  
 


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46
Dose adjustments: No dose adjustments are required for liver dysfunction. For renal 
insufficiency, MMF dosing should not be modified unless dialysis is needed, in which case 
MMF can be reduced to 25-50% of the starting dose. 
 
8.0 STUDY PARAMETERS 
 
8.1  
Hematologic parameters  
 
8.11 Neutrophil recovery: The cumulative incidence of neutrophil engraftment from the time of 
transplant will be estimated using the cumulative incidence function with death and relapse prior 
to engraftment as the competing risk. The definition of neutrophil engraftment is a post-nadir 
ANC > 500/mm3 for three consecutive measurements on different days. The first of the three 
days will be designated as the day of neutrophil recovery.  
 
8.12 Platelet recovery: The cumulative incidence of platelet engraftment from the time of 
transplant will be estimated using the cumulative incidence function with death and relapse prior 
to engraftment as the competing risk.  The definition of platelet engraftment is sustained platelet 
count > 20,000/mm3 and > 50,000/mm3 with no platelet transfusions in the preceding seven days. 
The first of three consecutive measurements on different days will be designated as the day of 
initial platelet recovery.  
 
8.13 Donor chimerism: Mixed donor chimerism is defined as > 5%, but < 95%, donor. Full 
donor chimerism is defined as > 95% donor. Prior to transplantation, a sample of peripheral 
blood from the patient, and either harvested bone marrow or blood from the donor, are collected 
for genetic studies to establish a baseline for subsequent chimerism assays.  
 
It is recommended (not required) that chimerism determinations from T cells (CD3+ sorted) and 
whole blood (total nucleated cells) will be made from peripheral blood per Section 6.2, and more 
frequently as indicated. Methods may include (i) PCR analysis of variable number of tandem 
repeats (VNTR) in PBMC if informative, (ii) restriction fragment length polymorphism (RFLP) 
if the donor and recipient RFLPs are informative, (iii) fluorescence in-situ hybridization (FISH) 
for Y-chromosome markers on PBMC if the donor is male and patient is female, (iv) cytogenetic 
analysis, (v) flow cytometric analysis of HLA-A, B or DR on lymphocytes in the peripheral 
blood if haploidentical and suitable reagents exist, (v) other institutional standards. Chimerism 
should also be determined from the bone marrow at required timepoints.  
 
8.14 Graft failure: < 5% donor chimerism in blood and/or bone marrow by ~Day 60 and on all 
subsequent measurements. This time point was chosen based on the median and range of donor 
engraftment seen on the Hopkins and other single institutional published studies of 
myeloablative haploBMT with PT/Cy. 
 
Primary graft failure: < 5% donor chimerism in blood and/or bone marrow by ~ Day 60  
 
Secondary graft failure: achievement of > 5% donor chimerism, followed by sustained <5% 
donor chimerism in blood and/or bone marrow.  
 


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47
< 5% donor T cell chimerism, but with > 5 % donor chimerism in total leukocytes, is not 
considered graft failure. 
 
Patients who have relapsed or died prior to day 60 will not be evaluable for full donor 
chimerism, as these are competing risk factors. 
 
8.2 Graft-versus-host Disease  
 
8.21 Acute GVHD: The cumulative incidence of acute GVHD Grades 2-4 and 3-4 will be 
assessed according to the BMT-CTN Manual of Procedures (MOP): 
https://web.emmes.com/study/bmt2/public/MOP/BMTCTNTechnicalMOPv3.pdf. Standard 
assessment criteria is also listed in Appendix 4.(Appendix 4). It is strongly recommended, when 
possible (not required), that biopsies be taken for histological confirmation of GVHD of an 
affected organ (e.g., skin, liver, or gastrointestinal tract). Date of symptom onset, date of biopsy 
confirmation of GVHD, maximum clinical grade, sites affected, and dates and types of treatment 
will be recorded. Dates of symptom onset of grade II or higher GVHD and grade III-IV GVHD 
will be recorded.  
 
The cumulative incidences of acute grade II-IV and grade III-IV GVHD will be determined 
through competing risk analysis. Relapse/progression, graft failure, or death without aGVHD are 
considered competing risks for aGVHD. . In addition, aGVHD will be reported with only graft 
failure and death regarded as competing risks.  
 
Recommended primary systemic treatment for acute GVHD will be corticosteroids. However, 
initiation of calcineurin inhibitors or other systemic immunosuppressants will be per discretion 
of the treating physician. All efforts should be made to record the systemic immunosuppressants 
used, timing of their administration and duration of treatment administered beyond the originally 
planned prophylaxis regimen We will characterize the duration, number, and type of steroid and 
non-steroid immunosuppressants used to treat aGVHD.  
 
8.22 Chronic GVHD: The cumulative incidence and severity of  chronic GVHD will be 
assessed according to the BMT-CTN Manual of Procedures (MOP): 
https://web.emmes.com/study/bmt2/public/MOP/BMTCTNTechnicalMOPv3.pdf using the  NIH 
consensus criteria.51 Date of onset, date of biopsy confirmation (if any), dates and types of 
treatment, and extent will be recorded. The cumulative incidence of chronic GVHD (overall and 
according to extent) will be determined through competing risk analysis.  Relapse/progression, 
graft failure, or death without cGVHD are considered competing risks for cGVHD. The 
cumulative incidence of cGVHD will be described at 6 months and 1 year post transplant. 
 
Use of systemic immunosuppressive therapy for treatment of chronic GVHD is at the discretion 
of the treating physicians. The event of interest is the development of any chronic GVHD severe 
enough to warrant systemic therapy, which includes corticosteroids (prednisone dose 
≥0.5mg/kg/day or equivalent), any systemic immunosuppressive agent or extracorporeal 
photopheresis. Use of topical immunosuppressive agents is not necessary for triggering this 
endpoint. Patients who continue on immunosuppressive therapy beyond day 180 due to 
manifestation of chronic GVHD will also be considered an event for the primary endpoint. 


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48
 
We will characterize the duration, number, and type of steroid and non-steroid 
immunosuppressants used to treat cGVHD.  
 
8.3 Disease and survival endpoints  
 
8.3.1 Progression-free survival: Interval from Day 0 to date of first objective disease progression 
or relapse, death from any cause, or last patient evaluation. Patients who have not progressed or 
died will be censored at the last date they were assessed and deemed free of relapse or 
progression. Disease persistence in the absence of progression is not included in this analysis.  
 
8.3.2 Event-free survival: Interval from Day 0 to date of first objective disease progression or 
relapse, an unplanned therapeutic maneuver for disease persistence, death from any cause, or last 
patient evaluation. Patients without events will be censored at the last date they were assessed 
and deemed event-free. EFS will be estimated using the Kaplan-Meier method and EFS at one 
and two years after transplantation will be estimated along with 90% confidence intervals. 
 
8.3.3  Disease-Free Survival (DFS): Disease free survival is the time from date of transplant to 
death or relapse/progression, whichever comes first.  The event for this endpoint is 
relapse/progression or death.  Patients alive and disease free will be censored at last follow-up 
 
8.3.4 Overall survival: Interval from Day 0 to date of death from any cause or last patient 
contact. Overall Survival (OS) will be estimated using the Kaplan-Meier method.  OS at one and 
two years after transplantation will be estimated along with 90% confidence intervals. 
 
8.3.5  GVHD/relapse or progression-free survival (GRFS): An event for this time to event 
outcome is defined as grade III-IV acute GVHD, chronic GVHD requiring systemic 
immunosuppressive treatment, disease relapse or progression, or death by any cause.  Patients 
will be followed up for at least one year for this endpoint. 
 
8.3.6 Nonrelapse mortality: The cumulative incidence of death without evidence of disease 
progression or relapse will be characterized at days 100, 180, and 1 year post-transplant.  An 
event for this endpoint is death without evidence of disease progression or recurrence 
Relapse/progression is a competing risk for NRM.  
 
8.3.7 Relapse or progression: Relapse is defined by either morphological or cytogenetic evidence 
of acute leukemia or MDS consistent with pretransplant features. High clinical suspicion of 
relapse will most likely lead to a disease-specific evaluation, for example a bone marrow aspirate 
for patients with leukemia or myelodysplasia. Cytogenetic studies or decreasing donor 
chimerism also increase the suspicion of relapse as well and can sometimes detect asymptomatic 
relapse in routine protocol-related marrow samples. If there is evidence of early relapse and no 
evidence of GVHD following BMT, immunosuppressive therapy may be discontinued earlier 
than indicated in Section 4.6, after discussion with PI. If there is evidence of donor chimerism 
and no evidence of GVHD, patients may be eligible for subsequent donor lymphocyte infusions. 


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49
 
Acute leukemia and MDS – Relapse will be diagnosed when there is: 
- 
Reappearance of leukemia blast cells in the peripheral blood; or, 
- 
>5% blasts in the bone marrow, not attributable to another cause (e.g. bone marrow 
regeneration) 
- 
The appearance of previous or new dysplastic changes (MDS specific) within the bone 
marrow with or without falling donor chimerism; or  
- 
The development of extramedullary leukemia or leukemic cells in the cerebral spinal 
fluid or 
- 
The reappearance of cytogenetic abnormalities present prior to transplantation 
 
Designation of disease status in other histologies will also follow standard criteria. NRM is a 
competing risk for relapse/progression.  
 
Institution of any therapy to treat persistent, progressive or relapsed disease, including the 
withdrawal of immunosuppressive therapy or donor lymphocyte infusion, will be considered 
evidence of relapse/progression regardless of whether the criteria described above were met. 
 
8.3.8 Minimal residual disease (MRD): MRD is defined by the sole evidence of malignant cells 
by flow cytometry, FISH, PCR or other techniques, in absence of morphological or cytogenetic 
evidence of disease in blood or marrow. Since the frequency and sensitivity of testing for MRD 
are variable, evidence of MRD will not be sufficient to meet the definition of relapse or 
progression in this study, but will be captured in the case report forms along with data on 
changing management in response to MRD detection.  
 
8.3.9 Primary cause of death. Primary cause of death will be classified as follows: 
- Relapse/Primary disease: If the patient relapsed/progressed after day 0 prior to death, 
the primary cause of death is relapse/progression, even if they subsequently developed 
GVHD, organ toxicities or infections that may have contributed to subsequent death.  
- GVHD: Death from acute or chronic GVHD, in the absence of relapse or AML/MDS 
disease progression.  
- Infection: Death from documented viral, bacterial or fungal infections in the absence of 
GVHD or relapse/disease progression. 
- Organ toxicity: Death from major organ toxicities not attributable to AML/MDS, 
infection or GVHD. 
- Other: Any other causes of death than those listed above. 
  
 
9.0 STATISTICAL CONSIDERATIONS 
 
Overall Study Design 
 
This study is a single-arm Phase II trial with the primary objective being to assess nonrelapse 
mortality at 180 days (NRM180) of a myeloablative preparative regimen and post transplantation 
cyclophosphamide with a partially HLA-mismatched donor in patients with hematologic 


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50
malignancies who have not had a bone marrow transplant before (cohort 1). NRM180 is defined 
from transplant date to date of death without evidence of disease progression or relapse at 180 
days. Patients who relapse or progress will be counted as competing risks events.  Patients with 
acute lymphoblastic leukemia will receive a Cy/TBI preparative regimen. All other patients will 
receive a busulfan/cytoxan preparative regimen. In the Johns Hopkins Hospital Phase 2 single 
institutional study (n=85), there was no difference in transplant toxicities including engraftment, 
NRM, or GVHD in patients treated with Cy/TBI versus Bu/Cy therefore all patients will be 
analyzed together.  
 
We will enroll a second cohort of patients who have relapsed after bone marrow transplant and 
will be receiving this regimen as their second or greater transplant.  Given these patients are 
expected to have a significantly higher NRM based on reports in the literature, their NRM will 
be descriptive only.   
 
 
9.1 Accrual 
 
We plan to accrue 31 patients over approximately one-two years in cohort 1.  Cohort 2 
(descriptive only) expects to accrue 5-7 patients. Subjects will be followed for the primary 
endpoint of NRM180, which will be described at 180 days.  
 
9.2 Sample Size Considerations 
Cohort 1 will accrue all eligible patients who are receiving their first bone marrow transplant.  
Previous literature using haploidentical bone marrow transplant without post-transplant Cy 
suggests that NRM180 is 35% or higher in this patient population. Literature using post-transplant 
Cy in the myeloablative setting suggests a NRM of 6-20%. At our institution, NRM is around 
13%.  In this multicenter study, we are interested in showing that NRM180 will be no higher than 
17%. NRM will be estimated through a cumulative incidence function, but for sample size 
considerations we performed a calculation using an exact binomial test to determine what 
difference we could detect with our projected sample size.  A sample size of 28 patients who 
meet the inclusion criteria of cohort 1 and a one-sided type 1 error rate of 10%, would yield 80% 
power to test if NRM is significantly improved from 35% (historical rates of TRM in haploBMT 
without PT/Cy as in background section) to 17%, based on an exact binomial test.  Because we 
expect approximately 10% of patients to experience a competing event (relapse), and these 
patients will not contribute in the risk set of NRM, thus we are inflating the sample size to 31.   
 
Due to the small number of patients expected to enroll on this protocol who have already 
relapsed after their first BMT, we are not providing formal sample size estimates for cohort 2. 
We anticipate enrolling 5-7 patients who meet the inclusion criteria of cohort 2, and will examine 
their outcomes in an exploratory manner. As described in the background section, NRM for these 
patients has been 25-75%. We would like to see if this regimen seems feasible for those in need 
of a second BMT such that it would be explored further on a future clinical trial 
 
9.3 Analysis of Primary Endpoint 
Cumulative incidence of NRM will be estimated using Gray’s method 50 with disease relapse or 
progression considered as competing events.  The cumulative incidence of NRM for cohort 2 


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51
will be estimated using the same approach, though we expect the confidence intervals to be fairly 
wide. Cumulative incidence of NRM at 100 days, 180 days and one year will be calculated and 
reported with 90% confidence intervals for each cohort. 
 
9.4 Analysis of Secondary Endpoints 
Secondary endpoints such as donor engraftment, platelet and neutrophil engraftment, aGVHD, 
cGVHD, survival endpoints, and relapse will be analyzed, as per section 8.1. 
9.4.1 Additional hematologic and non-hematologic toxicities: These will be recorded using 
NCI’s Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 at 
regular intervals as defined in the patient monitoring section (section 5.0). Toxicities will 
be tabulated by type and appropriate confidence intervals will be estimated. 
9.4.2  Statistical Methodology:  When appropriate, we will apply Gray’s method50 to examine 
differences in cumulative incidence functions with respect to the two cohorts of patients (BMT 
#1 vs. BMT >1) and also by regimen within cohort 1. The differences in overall survival and 
event-free survival will be explored as well using standard methods.  Thus, we will report the 
cumulative incidence of NRM at 100 days, 180 days and one year with respect to patients based 
on received regimens. In addition, we will compare these groups with respect to overall survival 
and event free survival in an exploratory manner using standard methods. 
 
9.5  Stopping Rules 
 
Because patients with severe GVHD and engraftment failures who die will be captured in NRM, 
we will apply a stopping rule based on incidence of NRM.  As outlined in Section 2.0 
(Background), the overall NRM on the mini-haplo BMT BMT-CTN trial was 7%. Our 
institutional experience with myeloablative haploBMT has shown an overall NRM of 15% and a 
pediatric NRM of 6%. Other groups using PT/Cy after myeloablative haploBMT have shown 
NRM’s in the range of 10-15%. Other haploidentical BMT trials without PT/Cy, both 
nonmyeloablative and ablative have shown NRM in the range of 30-40%, mostly from infectious 
causes. The working hypothesis of this trial is that the overall toxicity of fully ablative 
haploBMT in a national, multicenter trial is not significantly greater than the single institution 
experience with haploidentical BMT after myeloablative conditioning utilizing post-
transplantation Cy, and less then what has been seen with other nonmyeloablative and ablative 
haploidentical BMT trials that do not utilize post-transplantation Cy. NRM will capture patients 
that have transplant related mortality including, but not limited to death from severe GVHD or 
engraftment failure.  
Both cohorts will be monitored separately based on the observed NRM rate by day 100 
(NRM100). Within cohort 1, because we do not know how many patients will be accrued to each 
regimen at any one time and the NRM rate will be expected to be similar, we will separately 
monitor the NRM results of patients treated with Cy/TBI versus Bu/Cy but with the same 
stopping rule. We will monitor for NRM100 after every 2 patients enrolled at each treated 
regimen in cohort 1, and every patient in cohort 2. The stopping rule for NRM100 will hold 
enrollment if the posterior probability of NRM100 exceeding 25% within treated regimen in 
cohort 1 or 50% in cohort 2 is 0.75 or higher. The prior for this monitoring rule is a beta(1,3) for 
each regimen in cohort 1, and a beta(3,3) for cohort 2. This means that our prior guess at the 
proportion of NRM100 is 25% for each regimen in cohort 1 and 50% for cohort 2, and there is a 


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52
90% probability that these proportions are between 1.7-63.2% for each regimen in cohort 1 and 
18.9-81.1% for cohort 2. In cohort 1, if both regimens trigger a review, then consideration would 
be given to stopping the trial; otherwise if only one regimen triggers a review, then accrual to 
this regimen will be temporarily halted and consideration will be given to trial modification. We 
expect approximately 1/3 of patients to be treated with Cy/TBI and the remaining 2/3 to be 
treated with Bu/Cy, but we have included stopping rules up to the full sample size for 
completeness in Table 1 for the stopping rules. Table 2 shows the operating characteristics based 
5000 simulations. The probability of stopping in cohort 1 was estimated from the simulation 
results in two regimens, assuming the independent NRM100 event between two regimens, the 
same true toxicity rate in two regimens’ groups, and under 10 and 21 patients in Cy/TBI amd 
Bu/Cy, respectively.   
      
Table 1. Stopping rules for NRM100 for each cohort 
Cohort 1 
Cohort 2 
N patients 
who die 
due to 
transplant 
Out of N 
patients 
Probability 
of high 
NRM100* 
N patients 
who die 
due to 
transplant 
Out of N 
patients 
Probability 
of high 
NRM100* 
2 
2 
3 
4 
4 
5 
5 
6 
7 
7 
8 
8 
9 
9 
10 
2 
4 
6 
8 
10 
12 
14 
16 
18 
20 
22 
24 
26 
28 
31 
0.90 
0.76 
0.83 
0.89 
0.79 
0.85 
0.77 
0.83 
0.87 
0.80 
0.85 
0.79 
0.83 
0.77 
0.79 
2 
3 
4 
4 
5 
5 
 
 
 
 
2 
3 
4 
5 
6 
7 
 
 
0.77 
0.86 
0.91 
0.83 
0.89 
0.81 
* The probability of high NRM100 is the posterior probability of NRM100  being larger than 
25% for Cohort 1 and 50% for Cohort 2 exceed 0.75 
 
Table 2. The operating characteristics of the stopping rule are shown below and are based on 
5000 simulations.  
Cohort 1 
Cohort 2 
Cy/TBI  
(assume n=10) 
Bu/Cy 
(assume n=21) 
 
True 
NRM 
rate 
Probability 
of stopping  
Average 
sample 
size  
Probability 
of stopping
Average 
sample 
size  
Probability 
of 
Stopping 
Cohort 1 
True 
NRM 
rate 
Probability 
of stopping 
Average 
sample 
size 
10% 
0.06 
10 
0.06 
19 
0.004 
30% 
0.11 
7 


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53
15% 
0.13 
9 
0.15 
18 
0.02 
35% 
0.15 
6 
20% 
0.23 
9 
0.28 
16 
0.06 
40% 
0.22 
6 
25% 
0.36 
8 
0.45 
14 
0.16 
45% 
0.29 
6 
30% 
0.48 
8 
0.61 
12 
0.29 
50% 
0.37 
6 
35% 
0.60 
7 
0.75 
10 
0.45 
55% 
0.45 
5 
40% 
0.72 
6 
0.86 
8 
0.62 
60% 
0.56 
5 
 
 
 
 
 
 
65% 
0.65 
5 
 
 
 
 
 
70% 
0.74 
4 
 
 
 
 
10.0 INFORMED CONSENT/ASSENT 
 
Patients eligible for marrow grafting are completely evaluated and presented at group 
conference. The group's recommendations are discussed with the patient. If the patient is 
approved for BMT, the marrow processing procedure itself, the risks of the preparative regimen, 
risks of BMT complications including infection and GVHD and alternate forms of therapy are 
presented as objectively as possible. For pediatric patients (<18 yr of age) assent is obtained from 
the patient and informed consent is obtained from all parents. Informed consent is obtained from 
the recipient using the forms approved by the JCCI IRB. 
 
The requirement and process for assent will be at the discretion of the IRB at each site. 
 
10.1  On-study date: 
Date of consent signing. 
  
10.2  Off-study date: 
Upon completion of “Day 365” evaluations, patients have completed their treatment 
except for patient follow-up beyond day 365 which will consist of collecting information 
regarding ongoing engraftment, disease status, late effects of this protocol, acute and 
chronic graft vs.- host disease, immune reconstitution, additional therapies, and survival 
as per standard BMT long-term follow-up. Patients will go off study early in the event of: 
1.  Death 
2.  Disease progression and/or graft failure prior to day 100. In the event that a patient 
comes off study prior to day 60-100 due to disease progression, efforts will be made 
to obtain blood and bone marrow at the time of study discontinuation to assess 
chimerism, and to assess for the presence of GVHD. We will continue to update 
survival information on these patients. 
3.  Patient decision (or decision by a parent or guardian on behalf of a minor) 
4.  Unacceptable toxicity associated with protocol therapy, as determined by the treating 
physicians in consultation with the investigators. 
 


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APPENDIX 1 
 
 
ECOG PERFORMANCE STATUS SCALE GRADE DESCRIPTION 
 
0  
Fully active, able to carry on all pre-disease activities without 
restriction. 
 
1  
 
 
Restricted in physically strenuous activities and able to carry out 
work of a light or sedentary nature, e.g. light housework, office 
work. 
 
2  
 
 
Ambulatory and capable of all self-care but unable to carry out 
any work activities. Up and about more than 50% of waking 
hours. 
 
3  
 
 
Capable of only limited self-care; confined to bed or chair more 
than 50% of waking hours. 
 
4  
 
 
Completely disabled. Cannot carry on any self-care. Totally 
confined to bed or chair. 
 
5  
 
 
Dead. 
 
 
 
 
LANSKY PERFORMANCE STATUS SCALE 
 
100 - fully active, normal  
 
90 - minor restrictions in strenuous physical activity  
 
80 - active, but tired more quickly  
 
70 - greater restriction of play and less time spent in play activity  
 
60 - up and around, but active play minimal; keeps busy by being involved in quieter 
activities  
 
50 - lying around much of the day, but gets dressed; no active playing participates in all 
quiet play and activities  
 
40 - mainly in bed; participates in quiet activities  
 
30 - bedbound; needing assistance even for quiet play  
 
20 - sleeping often; play entirely limited to very passive activities  
 
10 - doesn't play; does not get out of bed  
 
0 - unresponsive  
 
 


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KARNOFSKY PERFORMANCE STATUS SCALE  
Able to carry on normal activity and to work; no 
special care needed. 
  100  Normal no complaints; no evidence of 
disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
80 
Normal activity with effort; some 
signs or symptoms of disease.  
Unable to work; able to live at home and care for 
most 
personal 
needs; 
varying 
amount 
of 
assistance needed. 
70 
Cares for self; unable to carry on 
normal activity or to do active work. 
60 
Requires occasional assistance, but is 
able to care for most of his personal 
needs. 
50 
Requires considerable assistance and 
frequent medical care.  
Unable to care for self; requires equivalent of 
institutional or hospital care; disease may be 
progressing rapidly. 
40 
Disabled; requires special care and 
assistance. 
30 
Severely disabled; hospital admission 
is 
indicated 
although 
death 
not 
imminent. 
20 
Very 
sick; 
hospital 
admission 
necessary; active supportive treatment 
necessary. 
10 
Moribund; fatal processes progressing 
rapidly. 
0 
Dead 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 2 
 
 
NCI COMMON TOXICITY CRITERIA 
 
 
 
The NCI common toxicity criteria can be accessed and downloaded via the website: 
http://ctep.cancer.gov/reporting 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 3 
aGVHD STAGING 
STAGE 
Skin 
GI 
Liver 
1 
 
< 25% rash 
 
Diarrhea    500-1000 mL/day or 
                  280-555 mL/m2 
 
or persistent nausea 
 
Bilirubin 2 - 3 mg/dl 
2 
 
25-50 % 
 
Diarrhea    1000-1499 ml/day or 
                  556-833 mL/m2 
 
Bilirubin 3 - 6 mg/dl 
3 
 
> 50 % 
 
Diarrhea    > 1500 ml/day or 
                  > 833 mL/m2 
 
Bilirubin 6 - 15 mg/dl 
 
4 
 
Generalized erythroderma 
with bullae 
Large volume diarrhea and severe 
abdominal pain  ileus 
Bilirubin > 15 mg/dl 
 
* For children with BSA < 1.5 m2, diarrhea volume should be recorded using mL/m2 scale.  
For skin GVHD: 
Use “Rule of Nines” or burn chart to determine extent of rash. 
For liver GVHD: 
Range of bilirubin given as total bilirubin. Downgrade one stage if an additional cause of hyperbilirubinemia is 
documented. 
For gut GVHD: 
Downgrade one stage if an additional cause of diarrhea is documented. Stage 1 is persistent nausea, vomiting and 
anorexia in the absence of other known cause unless histology is negative. 
aGVHD GRADING 
GRADE 
Skin 
Liver 
Gut 
0 
None 
None 
None 
I 
Stage 1-2 
None 
None 
II 
Stage 3 and/or 
Stage 1 and/or 
Stage 1 
III 
None or Stage 3 
Stage 2-3 or 
Stage 2-4 
IV 
Stage 4 or 
Stage 4 
NA 
Criteria for grading given as minimum degree of organ involvement required to confer that grade. 
 
 
 
 


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APPENDIX 4: NIH Consensus Scoring/Evaluation Forms for Chronic GVHD 
 
 


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59
 
Organ scoring of chronic GVHD. *AP may be elevated in growing children, and not reflective of liver dysfunction. 
†Pulmonary scoring should be performed using both the symptom and pulmonary function testing (PFT) scale 
whenever possible. When discrepancy exists between pulmonary symptom or PFT scores the higher value should be 
used for final scoring. Scoring using the Lung Function Score (LFS) is preferred, but if DLCO is not available, 
grading using FEV1 should be used. The LFS is a global assessment of lung function after the diagnosis of 
bronchiolitis obliterans has already been established [29]. The percent predicted FEV1 and DLCO (adjusted for 
hematocrit but not alveolar volume) should be converted to a numeric score as follows: >80% = 1; 70-79% = 2; 60-
69% = 3; 50-59% = 4; 40-49% = 5; <40% = 6. The LFS = FEV1 score + DLCO score, with a possible range of 2-12. 


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GVHD indicates graft versus host disease; ECOG, Eastern Cooperative Oncology Group; KPS, Karnofsky 
Performance Status; LPS, Lansky Performance Status; BSA, body surface area; ADL, activities of daily living; 
LFTs, liver function tests; AP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate 
aminotransferase; ULN, upper limit of normal. 
Mild chronic GVHD involves only 1 or 2 organs or sites (except the lung: see below), with no clinically significant 
functional impairment (maximum of score 1 in all affected organs or sites). Moderate chronic GVHD involves (1) at 
least 1 organ or site with clinically significant but no major disability (maximum score of 2 in any affected organ or 
site) or (2) 3 or more organs or sites with no clinically significant functional impairment (maximum score of 1 in all 
affected organs or sites). A lung score of 1 will also be considered moderate chronic GVHD. Severe chronic GVHD 
indicates major disability caused by chronic GVHD (score of 3 in any organ or site). A lung score of 2 or greater 
will also be considered severe chronic GVHD. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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 Appendix 5: 
 
Nomenclature for ABO Mismatching Observed and Theoretical Adverse Outcomes in 
Allogeneic BMT Reported in Previous Studies. 
 
ABO 
Mismatch 
 
Donor 
 
Recipient 
 
Know and Postulated Consequences 
Minor 
O 
A, B or AB 
Recipient hemolysis 
 
A, B 
AB 
Reports of increased GVHD 
Major 
A, B or AB 
O 
Post transplantation pure red blood cell aplasia 
 
AB 
A, B 
Reports of impaired engraftment and increased GVHD 
Bidirectional 
A 
B 
Recipient hemolysis and red blood cell aplasia 
 
B 
A 
Reports of reduced overall survival 
 
 
 
Reports of impaired engraftment and increased GVHD 
 
 
© 2005 American Society for Blood and Marrow Transplantation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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62
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