Conditions: Acute Biphenotypic Leukemia Acute Erythroid Leukemia in Remission Acute Leukemia in Remission Acute Lymphoblastic Leukemia in Remission Acute Myeloid Leukaemia With Prior Myelodysplastic Syndrome Acute Myeloid Leukemia in Remission Acute Myeloid Leukemia With FLT3/ITD Mutation Acute Myeloid Leukemia With Inv(3)(Q21Q26.2); RPN1-EVI1 Acute Myeloid Leukemia With Multilineage Dysplasia Acute Myeloid Leukemia With t(6;9) Acute Undifferentiated Leukemia Adult Acute Lymphoblastic Leukemia in Complete Remission B Acute Lymphoblastic Leukemia With T(1;19)(Q23;P13.3); E2A-PBX1 (TCF3-PBX1) Ph+ ALL Burkitt Lymphoma Childhood Acute Lymphoblastic Leukemia in Complete Remission DS Stage II Plasma Cell Myeloma DS Stage III Plasma Cell Myeloma Myelodysplastic Syndrome Recurrent Anaplastic Large Cell Lymphoma Blasts Under 5 Percent of Bone Marrow Nucleated Cells Recurrent Follicular Lymphoma Recurrent Hodgkin Lymphoma Recurrent Mantle Cell Lymphoma Recurrent Marginal Zone Lymphoma Recurrent Plasma Cell Myeloma Refractory Plasma Cell Myeloma Secondary Acute Myeloid Leukemia T Lymphoblastic Lymphoma Hematopoietic Cell Transplant Recipient
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 46
Healthy volunteers: no

Brief summary:
This phase II trial studies how well donor peripheral blood stem cell (PBSC) transplant works in treating patients with hematologic malignancies. Cyclophosphamide when added to tacrolimus and mycophenolate mofetil is safe and effective in preventing severe graft-versus-host disease (GVHD) in most patients with hematologic malignancies undergoing transplantation of bone marrow from half-matched (haploidentical) donors. This approach has extended the transplant option to patients who do not have matched related or unrelated donors, especially for patients from ethnic minority groups. The graft contains cells of the donor's immune system which potentially can recognize and destroy the patient's cancer cells (graft-versus-tumor effect). Rejection of the donor's cells by the patient's own immune system is prevented by giving low doses of chemotherapy (fludarabine phosphate and cyclophosphamide) and total-body irradiation before transplant. Patients can experience low blood cell counts after transplant. Using stem cells and immune cells collected from the donor's circulating blood may result in quicker recovery of blood counts and may be more effective in treating the patient's disease than using bone marrow.

Detailed description:
PRIMARY OBJECTIVES:

I. To demonstrate that use of PBSC in place of marrow as the source of lymphocytes and stem cells for nonmyeloablative transplants from related, haploidentical donors will not result in unacceptable rates of high-grade acute or chronic GVHD, non-relapse mortality or relapse compared to historical data on nonmyeloablative transplants from unrelated donors.

SECONDARY OBJECTIVES:

I. Estimates of the rates of neutrophil and platelet recovery, number of red blood cell (RBC) and platelet transfusions, incidences of graft failure, transplant-related toxicities, disease-free survival and overall survival.

OUTLINE:

Patients receive fludarabine intravenously (IV) over 30-60 minutes daily on days -6 through -2 and cyclophosphamide IV over 1-2 hours on days -6, -5, and 3-4. Patients undergo total-body irradiation on day -1. Patients undergo donor peripheral blood stem cell transplant on day 0. Patients then receive tacrolimus IV once daily or orally (PO) twice daily (BID) on days 5-180 (may be continued if active GVHD is present), mycophenolate mofetil IV or PO thrice daily (TID) on days 5-35 (may be continued if GVHD present), and filgrastim IV beginning on day 5 until the absolute neutrophil count (ANC) is \>= 1,000/mm\^3 for three consecutive days.

Treatment continues in the absence of disease progression or unacceptable toxicity.

Arms:
arm 1: Patients receive fludarabine IV over 30-60 minutes daily on days -6 through -2 and cyclophosphamide IV over 1-2 hours on days -6, -5, and 3-4. Patients undergo total-body irradiation on day -1. Patients undergo donor peripheral blood stem cell transplant on day 0. Patients then receive tacrolimus IV once daily or PO BID on days 5-180 (may be continued if active GvHD is present), mycophenolate mofetil IV or PO TID on days 5-35 (may be continued if GvHD present), and filgrastim IV beginning on day 5 until the ANC is \>= 1,000/mm\^3 for three consecutive days.

Interventions: intervention 1: Cyclophosphamide intervention 2: Filgrastim intervention 3: Fludarabine Phosphate intervention 4: Mycophenolate Mofetil intervention 5: Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation intervention 6: Peripheral Blood Stem Cell Transplantation intervention 7: Tacrolimus intervention 8: Total-Body Irradiation
Intervention descriptions: intervention 1: Given IV intervention 2: Given SQ intervention 3: Given IV intervention 4: Given PO intervention 5: Undergo PBSC intervention 6: Undergo PBSC intervention 7: Given IV or PO intervention 8: Undergo total-body irradiation (TBI)

Protocol document:
Prot_SAP_000.pdf: 
1 
2372.00 
FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, 
DEPARTMENT OF MEDICINE, DIVISION OF ONCOLOGY 
SEATTLE CHILDREN’S 
Current Version: 5/24/2019 
Previous Version: 01/03/2019 
Nonmyeloablative Hematopoietic Cell Transplantation (HCT) for Patients with 
Hematologic Malignancies using Related, HLA-Haploidentical Donors: A Phase II trial of 
Peripheral Blood Stem Cells (PBSC) as the Donor Source 
Principal Investigator: 
Rachel Salit, MD, Assistant Member, Fred Hutch; Assistant Professor, UW 
206-667-1317
Biostatistician: 
Ted Gooley, Ph.D., Full Member, FHCRC; Affiliate Full Professor of Biostatistics, UW 
206-667-6533
Clinical Research Nurse: Nancy Anderson, RN 
206-667-6264
Emergency (24 hour) Phone: (206) 598-8902 
Fax: (206)-598-4034 
IRO REC'D 9/19/2022
FHCRC IRB Approval  
OCT 13 2022 
Document Released Date


2 
1.0 
Introduction 
 
Transplantation of haploidentical bone marrow in the nonmyeloablative setting with post-
transplant cyclophosphamide prophylaxis of graft-versus-host disease (GvHD) has been 
shown to be safe therapy of hematologic malignancies. This approach has extended the 
transplant option to patients without matched related or unrelated donors, especially to ethnic 
minorities who have comprised about 20% of patients on these studies.  Over 200 such 
transplants have now been performed at this and other centers.  The incidence of graft 
rejection, nonrelapse mortality and survival is similar to that of transplants using matched 
donors.  The incidences of Grades III/IV acute GvHD and extensive chronic GvHD are similar 
and possibly lower.  In many centers, the lack of availability of operating room time and 
expertise of harvesters or bias in favor of peripheral blood stem cells (PBSC) have been 
barriers to acceptance of this approach.  
 
Therefore, we propose a phase II trial of PBSC as the donor source in nonmyeloablative HCT 
from haploidentical donors in an attempt to overcome such barriers. 
 
 
1.1    Background 
 
Allogeneic blood or marrow transplantation, following either marrow-ablative or 
nonmyeloablative conditioning, is a potentially curative treatment for a variety of hematologic 
malignancies and non-malignant hematologic disorders [1].  Of all the potential sources of 
allografts, those from human leukocyte antigen (HLA)-matched  donors have generally 
produced the best overall and progression-free survival [2]. Unfortunately, HLA- matched 
donors can be found in only about 70% of transplant candidates.  For patients who lack HLA-
matched donors alternative sources of allografts are units of umbilical cord blood or HLA-
mismatched (haploidentical) related donors [3].  Since any patient shares exactly one HLA 
haplotype with each biological parent or child and half of siblings, an eligible HLA-
haploidentical donor can be identified rapidly in nearly all cases. 
 
Cyclophosphamide (Cy) is a highly immunosuppressive anti-neoplastic agent that has an 
established role in conditioning for allogeneic transplantation.  Typically, the drug is 
administered prior to transplantation to prevent graft rejection by suppressing the host immune 
system.   In contrast, administration of a properly timed, high dose of Cy after transplantation 
can inhibit both graft rejection and GvHD.   Studies in mouse models of haploidentical bone 
marrow transplantation have shown that administration of high-dose cyclophosphamide early 
post-transplant deletes the highly alloreactive clones of T-cells, which in the absence of any 
other immunosuppressive therapy, would become activated and proliferate in the first few days 
post-transplant causing severe GvHD [4-7]. Studies at this center and at Johns Hopkins 
University over the past several years have shown that bone marrow transplanted from 
haploidentical donors as treatment of high-risk hematologic malignancies can engraft rapidly 
and stably after nonmyeloablative conditioning that includes post-transplantation Cy 
[8],[9][unpublished data].  Protocols at this center and Johns Hopkins differed in the dose of post-
transplant cyclophosphamide (Cy) administered as GvHD prophylaxis (50 mg/kg at day+3 
[FHCRC] or 50 mg/kg on days +3, +4 [JHU]).  The only difference in outcomes observed 
between the two protocols was a higher incidence of extensive chronic GvHD in the group 
receiving a single dose of post-transplant Cy (25% vs. 5%, respectively) [9].   


3 
 
To date, 48 patients have been transplanted on protocol 1667 at this center (Ref 9] included 
the first 28 patients).  Six of 45 evaluable patients (survival ≥28 d) failed to engraft.  Successful 
donor engraftment (≥95% donor T-cells) was achieved in all patients who survived to day 
+100.  Persistent mixed chimerism of donor T-cells or granulocytes was not observed in any 
patient.  The rate of primary graft rejection was 13%.   A fatal outcome secondary to persistent 
aplasia was observed in two of the 6 patients who rejected their grafts. No secondary graft 
failures were observed  
 
Other safety endpoints of the study were met by the low and acceptable rates of severe acute 
GvHD or NRM.  Comparison of outcomes after haploidentical transplants to those after related 
or unrelated donors at this or other centers is shown in Table 1.1.  The rates of Grades III/IV 
GvHD (9%) and of extensive chronic GvHD (23%) were similar to or lower than that observed 
for matched donors.  Some of the difference may be related to the donor source (bone marrow 
in protocol 1667 vs. peripheral blood stem cells in most current transplants from matched 
donors) which is known to affect the development of chronic GvHD[10].  The rate of NRM at 1 
yr was 23%, also similar to patients transplanted from matched donors.  NRM occurred almost 
exclusively in patients with lymphomas, primarily due to infection.  Many of these patients had 
extensive prior cytotoxic therapy including autologous transplantation for their recurrent 
diseases and had progressive disease at the time of transplantation.  Clearly, special attention 
to monitoring for infection and prophylaxis and treatment is warranted in such patients.  
 
Although not endpoints of this study, survival data showed that the transplant approach with 
haploidentical donors can be effective therapy for hematologic malignancies with overall and 
event-free survival of 36% and 32%, respectively at 3 yr.  For a mixed population of advanced 
hematologic malignancies, these outcomes are not different from those observed with matched 
donors.  In our study, relapse was the main cause of treatment failure.  Patients with myeloid 
or lymphoid malignancies who were long-term survivors were either those with high-risk AML 
in first complete remission or lymphoma patients who had a very good partial or complete 
response to salvage chemotherapy.  There were no survivors among the 5 patients with AML 
in second or third complete remissions or among patients with bulky lymphomas.  One 
explanation of this outcome is that the GvL effect may be diminished by post-transplant 
depletion of T-cells by cyclophosphamide making it is less effective against residual, more 
aggressive leukemia or lymphoma cells which have undergone genetic selection during 
disease progression.  Treatment failures in patients with refractory disease, particularly 
lymphomas suggest that eligibility criteria in the current trial should be revised to exclude such 
patients.   
 
 
 
 
 
 
 
 
 


4 
Table 1.1  Comparison of outcomes after nonmyeloablative transplantation for  
heterogeneous populations of high-risk hematologic malignancies using matched 
donors or related haploidentical donors 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
A number of randomized, controlled trials in the myeloablative setting have shown that the 
incidence of clinically significant acute GvHD after transplantation using PBSC does not differ 
significantly from that after BMT despite the fact that G-CSF-mobilized PBSC allografts contain 
~10-fold greater number of T-cells than marrow allografts [10].   
 
Although there are no such randomized trials in the nonmyeloablative setting, outcomes seen 
with PBSC in phase II trials are consistent with results in the myeloablative setting (see Table 
1.1).  The reason that acute GvHD is not increased markedly despite the 10-fold excess of T-
cells in the PBSC allograft is thought to be due to a skewing of the T-cell repertoire in PBSC 
caused by exogenous G-CSF from a Th1 immunophenotype which is known to play a direct 
role in acute GvHD to an anti-inflammatory Th2 immunophenotype which can suppress acute 
GvHD [14]. Use of PBSC may have several advantages over bone marrow as the allograft 
source for haploidentical transplants including (1) ease of collection, (2) more rapid time to 
platelet-independence (2 wks vs. 3 wks) and (3) decreased relapse in advanced hematologic 
malignancies, the primary cause of treatment failure in our studies using bone marrow as the 
allograft source.  Disadvantages may include (1) a higher incidence of grades III/IV acute 
GvHD and (2) a higher incidence of extensive chronic GvHD.   No differences would be 
expected in recovery of neutrophils (median of 12 d in the FHCRC/JHU protocols) or in 
nonrelapse mortality at 1 yr post-transplant. 
 
 
 


5 
 
2.0 
Study Overview 
 
This is a Phase II study to assess the safety of haploidentical peripheral blood stem cell 
transplantation using a nonmyeloablative preparative regimen and post-transplant 
cyclophosphamide.   
 
 
2.1 
Primary Endpoints 
 
 
To demonstrate that use of PBSC in place of marrow as the source of lymphocytes and 
 
stem cells for nonmyeloablative transplants from related, haploidentical donors will not 
 
result in unacceptable rates of high-grade acute or chronic GvHD, nonrelapse 
 
mortality or relapse compared to historical data on nonmyeloablative transplants  from 
 
unrelated donors.  
 
 
2.2 
Secondary Endpoints 
 
 
Estimates of the rates of neutrophil and platelet recovery, number of RBC and 
 
platelet transfusions, incidences of graft failure, transplant-related toxicities, disease-
 
free survival and overall survival. 
 
 
2.3 
Patient Inclusion Criteria 
 
 
2.3.1 No age limit.   
2.3.2 Molecular based HLA typing will be performed for the HLA-A, -B, -Cw, -
DRB1 and –DQB1 loci to the resolution adequate to establish haplo-identity. A 
minimum match of 5/10 is required.  An unrelated donor search is not required 
for a patient to be eligible for this protocol if the clinical situation dictates an 
urgent transplant.  Clinical urgency is defined as 6-8 weeks from referral or low-
likelihood of finding a matched, unrelated donor. 
 
2.3.3 Acute leukemias (includes T lymphoblastic lymphoma).  Remission is 
defined as < 5% blasts with no morphological characteristics of acute leukemia 
(e.g., Auer Rods) in a bone marrow with > 20% cellularity, peripheral blood 
counts showing ANC >1000/l, including patients in CRp.  If the marrow has < 
20% cellularity due to treatment related cytotoxicity, but still has < 5% blasts, an 
exception may be made to include this patient up to PI discretion.  
2.3.3.1  
Acute Lymphoblastic Leukemia in high risk CR1 as defined 
by at least one of the following:  


6 
2.3.3.1.1 
Adverse cytogenetics including but not limited 
tot(9;22), t(1;19), t(4;11), MLL rearrangements.  
  
 
 
2.3.3.1.2 
White blood cell counts >30,000/mcL, 
  
 
 
2.3.3.1.3 
Patients over 30 years of age 
  
 
 
2.3.3.1.4 
Time to complete remission >4 weeks 
  
 
 
2.3.3.1.5 
Presence of extramedullary disease. 
  
 
 
2.3.3.1.6 
Minimal residual disease 
  
 
 
2.3.3.1.7 
Other risk factors determined by the patient’s 
attending physician to be high risk features 
requiring transplantation.  
 
 
2.3.3.2 
Acute Myelogeneous Leukemia in high risk CR1 as defined  
 
 
 
 
by at least one of the following:  
 
 
 
2.3.3.2.1 
Greater than 1 cycle of induction therapy  
 
 
 
 
 
required to achieve remission,  
 
 
 
2.3.3.2.2 
Preceding myelodysplastic syndrome (MDS),  
 
 
 
2.3.3.2.3 
Presence of Flt3 abnormalities, 
 
 
 
2.3.3.2.4 
FAB M6 or M7 leukemia, or 
 
 
 
2.3.3.2.5 
Adverse cytogenetics for overall survival such  
 
 
 
 
 
as  
 
 
 
 
 
2.3.3.2.5.1 
those associated with MDS  
 
 
 
 
 
2.3.3.2.5.2 
Complex karyotype ( 3  
 
 
 
 
 
 
abnormalities) 
 
 
 
 
 
2.3.4.3.5.3 
Any of the following: inv(3) or  
 
 
 
 
 
t(3;3), t(6;9), t(6;11), + 8 [alone or with other  
 
 
 
 
 
abnormalities except for t(8;21), t(9;11), inv(16) 
 
 
 
 
 
or t(16;16)], t(11;19)(q23;p13.1) 
2.3.3.2.6 
Other risk factors determined by the patient’s 
attending physician to be high risk features 
requiring transplantation. 
  
 
2.3.3.3 
Acute Leukemias in 2nd or subsequent remission 
  
 
2.3.3.4 
Biphenotypic/Undifferentiated Leukemias in 1st or  
 
  
 
 
 
subsequent CR. 
  
 
2.3.3.5 
High-risk MDS status-post cytotoxic chemotherapy 
 
 2.3.4 Burkitt’s lymphoma: second or subsequent CR. 
 
 2.3.5 Lymphoma. 


7 
2.3.5.1 Chemotherapy-sensitive (at least stable disease; see response 
criteria Appendix C) large cell, Mantle Cell or Hodgkin’s lymphomas that 
have failed at least 1 prior regimen of multi-agent chemotherapy and are 
ineligible for an autologous transplant. 
 
2.3.5.2  Marginal zone B-cell lymphoma or follicular lymphoma that  has 
progressed after at least two prior therapies (excluding single agent 
Rituxan). 
 
2.3.6  MM Stage II or III patients who have progressed after an initial response to 
chemotherapy or autologous HSCT or MM patients with refractory  
disease who may benefit from tandem autologous-nonmyeloablative      
allogeneic transplant. 
 
         2.3.7 Patients with adequate physical function as measured by: 
 
 
2.3.7.1 Cardiac: left ventricular ejection fraction at rest must be   
 
 
 
35%. 
 
 
2.3.7.2 Hepatic: bilirubin ≤ 2.5 mg/dL; and ALT, AST, and Alkaline   
 
 
Phosphatase < 5 x ULN.  
 
 
2.3.7.3 Renal: serum creatinine within normal range for age, or if  
 
 
 
serum creatinine outside normal range for age, then renal  
 
 
 
 
function(creatinine clearance or GFR) > 40 mL/min/1.73m2. 
 
 
2.3.7.4 Pulmonary: FEV1, FVC, DLCO (diffusion capacity) ≥ 40%  
 
 
 
predicted (corrected for hemoglobin); if unable to perform  
 
 
 
 
pulmonary function tests, then O2 saturation > 92% on room   
 
 
 
air. 
 
           
 
2.3.7.5  Performance status: Karnofsky/Lansky score  60%. 
2.3.7.6 Patients who have received a prior allogeneic HSCT and who have 
either rejected their grafts or who have become tolerant of their grafts with 
no active GVHD requiring immunosuppressive therapy. 
 
          2.3.8 Patients will undergo standard pre-transplant work-up as dictated by 
standard practice guidelines the results of which may be used for 
screening for this study. 
 
 
2.4 
Patient Exclusion Criteria 
 
 
 
2.4.1 HLA-matched, or single allele-mismatched donor able to donate. 
 
 
2.4.2 Pregnancy or breast-feeding. 
 
 
 


8 
 
 
2.4.3 Current uncontrolled bacterial, viral or fungal infection (currently taking  
 
 
medication with evidence of progression of clinical symptoms or radiologic  
 
 
findings).  
 
 
2.4.4 Patients with primary idiopathic myelofibrosis. 
 
 
2.5 
Donor Inclusion Criteria 
 
 
 
2.5.1 Donors must be HLA-haploidentical first-degree relatives of the patient.   
 
 
Eligible donors include biological parents, siblings, or children, or half-siblings. 
 
 
 
 
 
 
2.5.2 Age ≥ 12 years 
 
 
2.5.3  Weight  40 kg 
 
 
2.5.4  Ability of donors < 18 years of age to undergo apheresis without use of a  
 
 
 
vascular access device; vein check must be performed and verified by an  
 
 
 
apheresis nurse prior to arrival at the SCCA 
 
 
2.5.5 Donors must meet the selection criteria as defined by the Foundation for  
 
 
 
the Accreditation of Cell Therapy (FACT) and will be screened per the  
 
 
 
American Association of Blood Banks (AABB) guidelines.  
 
 
2.6 
Donor Exclusion Criterion 
 
 
 
  
2.6.1 Positive anti-donor HLA antibody. 
 
 
2.7 
Donor Prioritization Schema 
 
 
 
2.7.1 In the event that two or more eligible donors are identified, the following  
 
 
order of priority: 
 
 
 
2.7.1.1 For CMV seronegative recipients, a CMV seronegative  
 
 
 
 
 
 donor 
 
 
 
2.7.1.2 Red blood cell compatibility 
 
 
 
2.7.1.2.1 RBC cross-match compatible 
 
 
 
2.7.1.2.2 Minor ABO incompatibility 
 
 
 
2.7.1.2.3 Major ABO incompatibility 
 
 
2.8 
Treatment Plan  
 
Day –6, -5 
Fludarabine 30 mg/M2 IV over 30-60 minutes 
Cyclophosphamide 14.5 mg/kg IV over 1-2 
hours* 
Mesna 14.5 mg/kg in 4 divided doses
Day –4-2 
Fludarabine 30 mg/M2 IV over 30-60 minutes 
Day –1
TBI 200 cGy, donor apheresis
Day   0
T cell replete PBSC


9 
Days 3,4 
Cyclophosphamide 50 mg/kg IV 
Mesna 50mg/kg IV in 4 divided doses
Day   5
Begin tacrolimus ,mycophenolate, and G-CSF
 
 
 
 
2.8.1 Fludarabine 
 
 
 
Fludarabine 30 mg/m2/day will be administered over 30-60 minutes   
 
 
 
intravenous infusion on Days –6 through –2.  Fludarabine will be dosed  
 
 
 
according to the recipient’s actual body weight, unless the actual body  
 
 
 
weight is greater than or equal to two times their ideal body weight, in  
 
 
 
which case the Principal Investigator must be consulted.  
 
 
 
For decreased creatinine clearance (< 61 mL/min) determined by the  
 
 
 
Cockcroft Formula: 
 
 
 
CCr = (140 – age) x ideal body weight (IBW) (kg)   x   0.85  
 
 
 
 
 
PCr x 72 
 
(for women) 
 
 
                        
 
 
Fludarabine dosage should be reduced as follows: 
 
 
 
CCr  46-60 mL/min, fludarabine = 24 mg/m2 
 
 
CCr 31-45 mL/min, fludarabine = 22.5 mg/m2 
 
 
CCr 21-30 mL/min, fludarabine = 19.5 mg/m2 
 
 
CCr < 20 mL/min, fludarabine   = 15 mg/m2 
 
 
2.8.2 Pre-transplantation Cyclophosphamide with Mesna 
 
 
 
Cy 14.5 mg/kg/day will be administered as a 1-2 hour intravenous infusion  
 
 
with a high volume fluid flush on Days –6 and –5.  Cy will be dosed   
 
 
 
according to the recipient’s actual body weight  unless the patient   
 
 
 
weighs more than 100% of IBW, in which case the drug will be dosed  
 
 
 
according to the adjusted IBW (AIBW; see below for formulas).   
 
 
 
 
 
Mesna should be given in 4 divided doses IV per standard practice. Mesna dose 
will be based on the cyclophosphamide dose being given.  The total daily dose of 
mesna is equal to 100% of the total daily dose of cyclophosphamide.   
  
 
 
2.8.2.1 
Ideal Body Weight (IBW) Formulas: 
 
 
 
 
Males IBW = 50 kg + 2.3 kg/inch over 5 feet 
 
 
 
 
Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet 
 
 
 
 
2.8.2.2 
Adjusted Ideal Body Weight Formula: 
 


10 
 
 
 
 
AIBW = IBW + [(0.25) x (ABW - IBW)] 
 
 
2.8.3 Total Body Irradiation 
 
 
 
Total body irradiation: 200 cGy will be administered in a single fraction on   
 
 
Day –1 via linear accelerator.  
 
 
2.8.4 Hematopoietic Stem Cell Infusion 
 
 
 
Donors who consent to PBSC donation will receive 5 daily doses of G- 
 
 
 
CSF, 16 μg/kg/day by subcutaneous injection commencing on day –5.   
 
 
 
PBSC’s will be collected in the afternoon of day -1, stored at 4C  
 
 
 
 
overnight, and infused as soon as possible on day 0.  If the collection on   
 
 
day –1 contains less than 5.0 X 106 CD34+ cells per kg recipient weight, a  
 
second collection will be performed the following morning and transfused   
 
 
on day 0. 
 
 
 
Quantitation of CD34 and CD3 cells will be performed by the Cellular  
 
 
 
Therapy Lab.  For all patients, the target number of CD34 cells to be  
 
 
 
infused should be 5-6 X 106 cells per kg recipient weight. PBSC in excess   
 
 
of 6.0 x 106 CD34 cells/kg recipient weight may be cryopreserved.   
 
 
2.8.5 Post-transplantation Cyclophosphamide with Mesna 
 
 
 
Hydration prior to cyclophosphamide may be given according to Standard   
 
 
Practice Guidelines.   
 
 
 
 
 
Cyclophosphamide [50mg/kg] will be given on Day 3 post-transplant  
 
 
 
(approximately 72 (+/- 12 hours) after marrow infusion) and on Day 4 post- 
 
transplant (approximately 24 ( +/- 6 hours) hours after Day 3 cyclophosphamide).   
 
 
 
 
Cyclophosphamide will be given as an IV infusion over 1-2 hours  
 
 
 
 
(depending on volume). 
 
Mesna should be given in 4 divided doses IV per standard practice  post-  
cyclophosphamide. Mesna dose will be based on the cyclophosphamide dose 
being given.  The total daily dose of mesna is equal to 100% of the total daily 
dose of cyclophosphamide.   
 
 
 
It is crucial that no immunosuppressive agents are given until 24 hours  
 
after the completion of the post-transplant Cy. This includes corticosteroids as 
anti-emetics. 
 
 
 
 
2.8.6 Tacrolimus 
 


11 
Tacrolimus will be given at a dose of 1 mg IV daily  or 1 mg po  
 
 
  
twice daily. If tacrolimus is initiated using the IV formulation it will be changed  
  
to a PO dosing schedule once a therapeutic level is achieved. Serum levels  
  
of tacrolimus will be measured around Day 7 and then should be checked   
  
at least weekly thereafter and the dose adjusted accordingly  to  
 
 
  
maintain a level of 5-10 ng/mL. Tacrolimus will be discontinued after the last  
  
dose around Day 180, or may be continued if active GVHD is present.  
 
  
Cyclosporine (target concentration 200-400 ng/ml) may be substituted for   
  
tacrolimus if the patient is intolerant of tacrolimus. 
 
 
2.8.7 Mycophenolate  
 
 
 
Either the sodium salt of mycophenolate or mycophenolate mofetil (MMF)   
 
 
may be used as prophylaxis of GvHD and will be dosed by actual body  
 
 
 
weight.  Only MMF is available as IV formulation.  Sodium mycophenolate  
 
will be given at a dose of 10mg/kg PO TID rounded to the nearest number  
 
of 180mg tablets.   MMF will be given at a dose of 15 mg/kg PO TID.  The   
 
 
maximum total daily dose should not exceed 2160 mg (sodium salt) or 3   
 
 
grams (mofetil).  Mycophenolate prophylaxis will be discontinued after the   
 
 
last dose on Day 35, or may be continued if active GVHD is present.  
 
2.8.8 Growth Factor Support 
 
G-CSF will be given beginning on Day 5 at a dose of 5 mcg/kg/day (rounding to 
the nearest vial dose is allowed), until the absolute neutrophil count (ANC) is > 
1,000/mm3  for three consecutive days. 
 
 
2.8.9 Supportive Care 
 
 
 
Patients will receive transfusions, infection prophylaxis and nutritional  
 
 
 
support according to Standard Practice Guidelines.   
 
 
2.8.10 Transfusion Support 
 
 
 
Platelet and packed red cell transfusions will be given per Standard  
 
 
 
Practice Guidelines. 
 
 
2.8.11 Anti-Ovulatory Treatment 
 
 
 
Menstruating females should be started on an anti-ovulatory agent prior to  
 
 
the initiation of the preparative regimen. 
 


12 
2.9 
Risks and Toxicities 
 
 
2.9.1 Cyclophosphamide    
 
Side effects include: nausea/vomiting, cardiomyopathy, skin rash,  mucositis, 
 
stomatitis, sterility, diarrhea, hemorrhagic cystitis, fluid weight gain/edema, 
 
alopecia and  hemolytic anemia. 
 
 
2.9.2 Fludarabine 
 
 
The most serious side effect is neurotoxicity which may include agitation   
 
 
or confusion, blurred vision, loss of hearing, peripheral neuropathy or  
 
 
 
weakness. Severe neurologic effects, including blindness, coma, and  
 
 
 
death have been observed in 36% of patients treated with doses  
 
 
 
 
approximately four times greater than specified in this protocol.  Other  
 
 
 
side effects may include anemia, VTE, fever, skin rash, nausea/vomiting,   
 
 
diarrhea , stomatitis, anorexia, chills, peripheral edema, and,  
 
 
 
 
very rarely, hemorrhagic cystitis and pulmonary toxicity. 
 
 
2.9.3 Total Body Irradiation 
 
TBI can cause: nausea and vomiting, diarrhea, parotitis (rapid onset within 
 
24-48 hours, usually self-limited), generalized mild erythema, 
 
hyperpigmentation, fever, mucositis, and alopecia. 
 
 
Late effects include: possible growth retardation, vertebral deformities, 
 
cataracts, probable increased risk of secondary malignant neoplasms, 
 
sterility, nephropathy, interstitial pneumonitis and veno-occlusive disease.  
 
 
2.9.4 Mycophenolate 
 
Side effects include: birth defects, pancytopenia, nausea, vomiting,  diarrhea, 
hypertension, headache, dizziness, insomnia, hyperglycemia,  
electrolyte 
imbalances, rash, and leg cramps/bone pain. 
 
 
2.9.5 Tacrolimus 
 
Side effects include: reversible renal insufficiency, hypertension, 
 
hyperglycemia, hypomagnesemia, hypokalemia, and neurologic toxicity.   
 
 
2.9.6 Graft Failure 
 
Based on historical data with nonmyeloablative transplants of PBSC, there could 
 
be a 15% chance of graft failure.   
 
 
 
2.9.6.1 Management of Slow Engraftment and Graft Failure 
 
 
 
 Slow engraftment or graft failure should be managed   
 
 
 
 
 
 according to Standard Practice Guidelines. 
 
 
 
 
 
 


13 
3.0 STUDY ENDPOINTS 
 
 
3.1 
Primary Endpoints 
 
 
 
3.1.1  Acute GvHD 
 
 
 
Incidence of grades III/IV acute GvHD at day +84. GvHD is scored as  
 
 
 
described in Appendix A. 
 
 
  
3.1.2  Chronic Graft-versus-Host Disease.  Scored according to the NCI criteria  
   
 
as described in Appendix B.  The time to onset of limited and extensive  
   
 
chronic GVHD will be recorded. 
 
 
  
3.1.3   Nonrelapse Mortality (NRM) 
 
 
 
The cumulative incidence of NRM should be estimated at day +100  
 
 
 
and at 1 year.  An event for this endpoint is death without  
 
 
 
 
 
evidence of disease progression. 
 
 
 
3.1.5  Relapse of Malignancy. Testing for recurrent malignancy in the blood,  
 
 
 
marrow or other sites will be used to assess relapse after transplantation.   
 
 
For the purpose of this study, relapse is defined by either morphological or  
 
 
cytogenetic evidence of acute leukemia consistent with pre-  
 
 
 
 
transplant features, or radiologic evidence of lymphoma progression.  
 
 
 
When in doubt, the diagnosis of recurrent or progressive lymphoma  
 
 
 
should be documented by tissue biopsy. 
  
Because malignant cells can sometimes evade immune attack of the GvL 
effect after haploidentical HCT by mutation to uniparental disomy of the 
HLA region, HLA-typing of tissue samples: (for example bone marrow, 
peripheral blood, or lymph node) obtained from patients who experience 
recurrent disease will be performed whenever possible to direct potential 
therapy strategies. 
 
 
 
 
3.1.5.1  
Relapse of acute leukemia will be diagnosed when there is:  
 
 
 
 
 
(i) reappearance of leukemia blast cells in the peripheral  
 
 
 
 
 
blood, (ii) > 5% blasts in the marrow not  attributable to  
 
 
 
 
 
another cause (e.g., bone marrow regeneration), (iii) the  
 
 
 
 
 
appearance of new dysplastic changes within the bone  
 
 
 
 
 
marrow, (iv) the development of extramedullary leukemia or  
 
 
 
 
 
leukemic cells in the cerebral spinal fluid, or (v) clonal  
 
 
 
 
 
cytogenetic abnormalities. 
 
 
 
 
3.1.5.2 
Relapse of lymhphoma is diagnosed when  
 
 
 
 
 
 
there is: (i) appearance of any new lesion more than  
 
 
 
 
 
1.5 cm in any axis during or at the end of therapy,  
 
 
 
 
 
even if other lesions are decreasing in size,  
 
 
 
 
 
 
(increased FDG uptake in previously unaffected site  
 
 
 
 
 
should only be considered  relapsed or progressive  
 
 
 
 
 
disease after confirmation with other modalities; in  


14 
 
 
 
 
          patients with no prior history of pulmonary lymphoma,  
 
 
 
 
          new lung nodules identified by CT are mostly benign),  
 
 
 
 
          or (ii) at least a 50% increase from nadir in the sum  
 
 
 
 
          of the product diameters (SPD) of any previously  
 
 
 
 
          involved nodes, or in a single involved node, or the  
 
 
 
 
          size of other lesions (e.g.,splenic or hepatic nodules).   
 
 
 
 
 
 
 
 
 
 
To be considered progressive disease, a lymph node  
 
 
 
 
 
with a diameter of the short axis of less than 1.0 cm  
 
 
 
 
 
must increase by  50% and to a size of 1.5 x 1.5 cm  
 
 
 
 
 
or more than 1.5 cm in the long axis, or (iii) at least a  
 
 
 
 
 
50% increase in the longest diameter of any single  
 
 
 
 
 
previously identified node more than 1 cm in its short  
 
 
 
 
 
axis. 
 
3.1.5.3  
Multiple Myeloma. Relapse or progressive disease will be  
 
 
diagnosed when there is: (i)Reappearance or increase in the 
 
 
serum M or urine globulins, or (ii)Appearance of new lytic  
 
 
lesions in bone, or (iii)Bone marrow examination contains  
 
 
>5% abnormal plasma cells 
 
 
3.2 
Secondary Endpoints 
 
 
  
3.2.1 Neutrophil Recovery  
 
 
 
Achievement of an ANC ≥ 500/mm3 for three consecutive  
 
 
 
 
 
measurements on different days.  The first of the three days will be   
 
 
 
designated the day of neutrophil recovery.   
 
 
 
3.2.2 Primary graft failure 
 
 
 
< 5% donor CD3 chimerism  as measured at day +84.   
 
 
 
3.2.3  Secondary graft failure/rejection: Decline of neutrophil count to <500/ul  
 
 
 
with loss of donor chimerism after day 55.  
 
 
 
 
 
3.2.4 Platelet recovery  
 
 
 
The first day of a sustained platelet count >20,000/mm3 with no  
 
 
 
 
platelet transfusions in the preceding seven days.   
 
 
  
3.2.5 Donor Cell Engraftment  
 
 
 
Donor chimerism in the T-cell (CD3-positive) and granulocyte  
 
 
 
 
(CD33-positive) fractions of sorted peripheral blood  50% on day   
 
 
 
84 after transplantation.  Donor engraftment also should be tested   
 
 
 
on day +28.   
 
 
  
3.2.6 Progression-free Survival 
 
 
 
Progression-free survival is the minimum time interval to  
 
 
 
 
 
relapse/recurrence, to death or to last follow-up. 
 


15 
 
 
3.2.7   Infections 
 
 
 
Infections will be reported by anatomic site, date of onset, organism  
 
 
 
and resolution, if any.   
 
 
  
4.0   PATIENT ENROLLMENT AND EVALUATION 
 
 
4.1 
Protocol Registration 
 
 
 
On the basis of diagnosis and type of transplant, the Clinical Coordinator will 
assign patients to this protocol.  Additional screening will be completed pre-
transplant to ensure the patient and donor meet the inclusion and exclusion 
criteria.  Patients will be registered between 8:00 am and 5:00 pm, Monday 
through Friday. 
 
In addition, for each patient on this study a copy of the signed informed consent 
and a completed FHCRC Research Subject Registration Form (Appendix D) 
must be sent to the FHCRC Research Coordinator via email as a PDF or by FAX 
to 206-667-2011. 
 
 
4.2 
Clinical Evaluation 
 
 
 
 
 
The follow-up schedule for scheduled study visits is outlined in Table  
 
 
 
4.4.5. 
  
 
4.3      Records 
 
 
 
The primary research record includes the medical chart and standard flow sheets 
on which clinical information and laboratory data are recorded.  The medical 
records department at each site maintains all original inpatient and outpatient 
chart documents.  Patient case report forms will be kept in a locked file cabinet in 
a secure building.  The patient database will be maintained by the study 
coordinator in a secure computer network at FHCRC. Any publication or 
presentation will refer to patients in agggregate and not by name. 
 
 
4.4 
Procedures for Data Safety and Monitoring 
 
 
 
The PI and research coordinator for this study will closely monitor all patients 
enrolled on this study.  The clinical research nurse and PI will, at a minimum, 
meet to evaluate patient data after each group of 3 patients has completed the 
“day 80” departure work-up which is typically performed between days 80 and 
100 post-transpant. 
 
The dedicated protocol Data Safety Monitoring Board (DSMB) will consist of two 
clinical investigators not associated with the study and the study biostatistician. 
The DSMB will review protocol outcomes annually; at least 2 of the 3 members 
must be present to hold the meeting.  This Committee will be responsible for 
making a recommendation regarding the continuation or discontinuation of the 


16 
current protocol based on these outcomes in comparison to other settings with 
regard to the safety and potential efficacy of the proposed regimen.   
 
 
 
4.4.1 Guidelines for Reporting Serious Adverse Events 
 
Only serious, unexpected and possibly related adverse events will be 
reported to the IRB according to  FHCRC Guidelines for Reporting 
Adverse Events  through 1 year after transplantation. The PI will review all 
SAE reports to determine if the report should be submitted to the FHCRC 
IRB prior to continuing review. 
 
Study-wide deaths will be reported to the FHCRC IRB at continuing 
review. 
 
 
4.4.2 Protocol Data and Monitoring Plan 
 
A secondary endpoint of this study is to assess toxicity related to this 
treatment regimen, specifically to evaluate regimen-related toxicity.  
Toxicities will be assessed up to the time the patient is discharged from 
the transplant clinic at the SCCA. Toxicities will be documented per 
CTCAE v3.0 (see http://ctep.cancer.gov/reporting/ctc.html). 
 
The incidence of all non-hematologic adverse events > grade 3 will be 
determined. 
   
 
 
The protocol will be reviewed annually by the Data and Safety Monitoring 
Committee DSMC of the Fred Hutchinson Cancer Research Center and 
the protocol-specific DSMB Committee.  If the PDMC or Review 
Committee should recommend discontinuation of the protocol, the IRB will 
be notified immediately. 
 
 
 
4.4.3 GVHD Monitoring 
 
GVHD should be monitored in accordance with each participating site’s 
Standard Practice Guidelines.  Assessment of acute GVHD should be 
performed as clinically necessary and reported monthly on the CRFs 
supplied by the Coordinating Center. Chronic GVHD will be assessed  at 1 
year (D365) post-transplant.  
 
 
 
 
 
4.4.4 Ethnic and Gender Distribution Chart 
 
TARGETED / PLANNED ENROLLMENT:  Number of Subjects1 
Ethnic Category 
 
Sex / Gender 
Females
Males
Total
Hispanic or Latino 
1 
1 
2 


17 
Not Hispanic or Latino 
20 
28 
48 
Ethnic Category Total of All 
21 
29 
50 
A. Racial Categories 
American Indian / Alaska 
1 
0 
1 
Asian 
1 
1 
2 
Native Hawaiian or Other 
0 
0 
0 
Black or African American 
2 
3 
5 
White 
17 
25 
42 
Racial Categories:  Total of All 
21 
29 
50 
 
                      1Based on actual data of Protocol 1667 (48/50 patients accrued as of 7/15/09) 
 
 
  
4.4.5 Patient Assessments 
 
  
TABLE 4.4.5  SUMMARY OF PATIENT CLINICAL ASSESSMENTS 
 
Study Assessments/Testing 
Baseline 
Day 
28* 
Day 
56* 
Day 
84* 
Day 
365* 
History, physical exam, weight, height, and 
Karnofsky/Lansky performance status1 
X 
X 
X 
X 
X 
Infectious disease titers2 
X 
 
 
 
 
EKG and  LVEF 
X 
 
 
 
 
DLCO, FEV1 and FEV or O2 saturation 
X 
 
 
 
 
Bone marrow aspirate for pathology and cytogenetics 
(as clinically indicated) and/or biopsy3 
X 
X 
X 
X 
X 
CT or PET/CT imaging4 
X 
 
 
X 
X 
Chest X-ray6 
X 
 
 
 
 
ß-HCG serum pregnancy test (non-menopausal 
women7)  
X 
 
 
 
 
Acute GVHD assessments 
 
X 
X 
X 
 
Chronic GVHD assessment 
 
 
 
 
X 
Chimerism5 
 
X 
 
X 
X 
Notes: 
1  History, height, weight, and Karnofsky/Lansky performance status only required at baseline 
2  Infectious disease titers include: CMV, Hepatitis panel (HepA, Ab, HepB SAb, HepB SAg, HepB Core Ab, 
HepC Ab), herpes simplex virus, syphilis, HIV and HTLV I/II antibody, and varicella zoster. 
3  LEUKEMIA and MDS PATIENTS ONLY.  Bone marrow aspirate and/or biopsy should be sent to 
pathology, cytogenetics and hematopathology for flow cytometry.  
4 LYMPHOMA AND CLL PATIENTS ONLY   
5  Chimerism will be measured by STR-PCR on peripheral blood sorted into CD3+ and CD33+ cell fractions. 
6 Chest-Xray is only required in patients not having Chest CT 
+/- 14 days from expected. Day 365 evaluations should be done +/- 60 days from expected. 
7 Menopause confirmed by gynecology note 
* Day 28 & 56 evaluations should be done +/- 7 days from expected. Day 84 evaluations should be 
completed  
 
5.0 
Statistical Considerations and Termination of the Study 
 
The primary objective of this trial is to assess the safety and potential efficacy of the use 
of haploidentical PBSC with a nonmyeloabaltive preparative regimen and post-
transplant cyclophosphamide.  The endpoints that will contribute to this assessment 
include severe acute GVHD, chronic GVHD, relapse, and NRM.  Specific benchmarks 
for each of these endpoints will not be set, but guidelines for what would be considered 


18 
acceptable rates will be drawn from the haploidentical setting where bone marrow is the 
source of stem cells in addition to data from “matched” unrelated donors.  Experience 
with the regimen proposed in the current protocol with bone marrow as the source of 
stem cells has led to severe acute GVHD in less than 10% of patients, chronic GVHD in 
roughly 25% of patients, an estimated probability of relapse by 3 years of approximately 
50%, and non-relapse mortality by one year of about 15%.  In the unrelated donor 
setting using PBSC, rates of severe GVHD range from 10-25%, chronic GVHD ranges 
from roughly 40% to 70%, non-relapse mortality at 1 year 20-30%, and relapse by 3 
years in the neighborhood of 50%.  A protocol-specific  DSMB  consisting of two clinical 
investigators who are not associated with the study and the study biostatistician will 
meet yearly, and this committee will be responsible for making a recommendation 
regarding the continuation or discontinuation of the current protocol based on these 
outcomes in comparison to other settings with regard to the safety and potential efficacy 
of the proposed regimen.   
 
 
Fifty patients will be enrolled.  This sample size was not chosen based on any statistical 
 
arguments or desire to show statistically significant differences with respect to historical 
 
benchmarks.  Rather it was chosen based on a balance between a number of patients 
 
that could be enrolled in a reasonable time frame and a number that provides a 
 
reasonably precise estimate of each of the above endpoints.  With 50 patients, the 
 
estimate of failure for each endpoint will be within at least 0.12 of the true failure rate 
 
with 90% confidence.  We believe that this level of precision will allow an informed 
 
decision as to whether PBSC is an acceptable alternative to BM in this setting. 
 
 
 
6.0 
References 
 
1.  Thomas' Hematopoietic Cell Transplantation, Third edn. Oxford, UK: Blackwell Publishing 
Ltd., 2004. 
2.  Szydlo R, Goldman JM, Klein JP et al. Results of allogeneic bone marrow transplants for 
leukemia using donors other than HLA-identical siblings. J Clin Oncol 1997; 15: 
1767-1777. 
3.  Zuckerman T, Rowe JM. Alternative donor transplantation in acute myeloid leukemia: which 
source and when? (Review). Curr Opin Hematol 2007; 14: 152-161. 
4.  Mayumi H, Umesue M & Nomoto K. Cyclophosphamide-induced immunological tolerance: 
an overview (Review). Immunobiology 1996; 195: 129-139. 
5.  Mayumi H, Himeno K, Tokuda N & Nomoto K. Drug-induced tolerance to allografts in mice. 
VII. Optimal protocol and mechanism of cyclophosphamide-induced tolerance in an 
H-2 haplotype-identical strain combination. Transplant Proc 1986; 18: 363-369. 
6.  Luznik L, Jalla S, Engstrom LW et al. Durable engraftment of major histocompatibility 
complex-incompatible cells after nonmyeloablative conditioning with fludarabine, 
low-dose total body irradiation, and posttransplantation cyclophosphamide. Blood 
2001; 98: 3456-3464. 


19 
7.  Luznik L, Engstrom LW, Iannone R & Fuchs EJ. Posttransplantation cyclophosphamide 
facilitates engraftment of major histocompatibility complex-identical allogeneic 
marrow in mice conditioned with low-dose total body irradiation. Biol Blood Marrow 
Transplant 2002; 8: 131-138. 
8.  O'Donnell PV, Luznik L, Jones RJ et al. Nonmyeloablative bone marrow transplantation 
from partially HLA-mismatched related donors using posttransplantation 
cyclophosphamide. Biol Blood Marrow Transplant 2002; 8: 377-386. 
9.  Luznik L, O'Donnell PV, Symons HJ et al. HLA-haploidentical bone marrow transplantation 
for hematologic malignancies using nonmyeloablative conditioning and high-dose, 
post-transplantation cyclophosphamide. Biol Blood Marrow Transplant 2008; 14: 
641-650. 
10. Stem Cell Trialists' Collaborative Group. Allogeneic peripheral blood stem-cell compared 
with bone marrow transplantation in the management of hematologic malignancies: 
an individual patient data meta-analysis of nine randomized trials. J Clin Oncol 2005; 
23: 5074-5087. 
11. Giralt S, Logan B, Rizzo D et al. Reduced-intensity conditioning for unrelated donor 
progenitor cell transplantation: long-term follow-up of the first 285 reported to the 
National Marrow Donor Program. Biol Blood Marrow Transplant 2007; 13: 844-852. 
12. Maris MB, Niederwieser D, Sandmaier BM et al. HLA-matched unrelated donor 
hematopoietic cell transplantation after nonmyeloablative conditioning for patients 
with hematologic malignancies. Blood 2003; 102: 2021-2030. 
13. Mielcarek M, Storer BE, Sandmaier BM et al. Comparable outcomes after 
nonmyeloablative hematopoietic cell transplantation with unrelated and related 
donors. Biol Blood Marrow Transplant 2007; 13: 1499-1507. 
14. Fowler DH. Shared biology of GVHD and GVT effects: potential methods of separation 
(Review). Critical Reviews in Oncology-Hematology 2006; 57: 225-244. 
15. Cheson BD, Pfistner B, Juweid ME et al. Revised response criteria for malignant 
lymphoma. J Clin Oncol 2007; 25: 579-586. 


20 
APPENDIX A 
 
ACUTE GRAFT-VERSUS-HOST-DISEASE STAGING AND GRADING TABLES 
 
 
Clinical Stage of Acute GVHD According to Organ System 
Stage
Skin
Liver
Intestine (1)
1 
Maculopapular rash 
<25% of body surface 
Bilirubin 2-3 mg/dl 
>500-1000 mL diarrhea 
per day or (nausea, 
anorexia or vomiting 
with biopsy (EGD) 
confirmation of upper GI 
GVHD
2 
Maculopapular rash 25-
50% of body surface
Bilirubin 3.1-6 mg/dl 
>1000 -1500 mL 
diarrhea per day
3 
Maculopapular rash 
>50% body surface area 
or Generalized 
erythroderma
Bilirubin 6.1-15 
mg/dl 
>1500 mL diarrhea per 
day 
4 
Generalized 
erythroderma with bullous 
formation and 
desquamation
Bilirubin >15 mg/dl 
 Severe abdominal pain 
with or without ileus 
 
 
Overall Clinical Grading of Severity of Acute GVHD 
Grade
Skin
Liver
GI
I
1-2
0
0
IIA
3 and/or
1 and/or
1
IIIA,B
4 and/or
2-4 and/or
2-4
IVA,C
4 and/or
2-4 and/or
2-4
 
A. 
Grade II-IV GVHD with only single organ involvement should be biopsy confirmed. 
B. 
Non-fatal GVHD 
C.       Fatal GVHD 
 
(1) For pediatric patients the following diarrhea volumes will apply:  
 
Stage 1 - > 10 ml/kg/day 
 
Stage 2 - > 20 ml/kg/day 
 
Stage 3 - > 30 ml/kg/day 
 
 
 
 
 
APPENDIX B 


21 
 
CHRONIC GRAFT-VERSUS-HOST DISEASE (GvHD) 
 
Chronic GVHD in allogeneic transplant recipients resembles autoimmune disorders such as 
scleroderma,Sjogren syndrome, primary biliary cirrhosis, lichen planus, wasting syndrome, 
bronchiolitis obliterans among other manifestations (see below). Approximately 50% of 
patients will develop this complication within 6 months after the transplant despite continued 
treatment with immunosuppressive medications.  Close monitoring is recommended during the 
first 2 years after allogeneic stem cell transplantation so that appropriate treatment can be 
instituted promptly in patients who develop chronic GVHD. Debilitation, joint contractures and 
profound immunosuppression resulting in recurrent bacterial infections are prominent 
characteristics of untreated chronic GVHD. 
 
A. Classification of Chronic GVHD 
 
The purpose of this classification is to identify patients with cGVHD who need long-term 
systemic immunosuppression according to clinical and laboratory findings and risk factors at 
the time of initial diagnosis. In addition, a morbidity scale has been developed to help grade 
the severity of manifestation of chronic GVHD (see below) at the time of diagnosis, when 
changes in treatment are made and when assessing treatment response. 
 
1. Chronic GVHD not requiring systemic treatment: mild abnormalities involving a single site, 
with platelet count >100,000 and no steroid treatment at the onset of chronic GVHD 
 
 
a)  Oral abnormalities consistent with cGVHD, a positive skin or lip biopsy, and no other 
 
manifestations of cGVHD. 
 
 
b)  Mild liver test abnormalities (alkaline phosphatase ≤2 x upper limit of normal, AST or 
 
ALT ≤3 x upper limit of normal and total bilirubin ≤1.6) with positive skin or lip biopsy, 
 
and no other manifestations of cGVHD. 
 
 
c)  Less than 6 papulosquamous plaques, macular-papular or lichenoid rash involving 
 
<20% of body surface area (BSA), dyspigmentation involving <20% BSA, or erythema 
 
involving <50% BSA, positive skin biopsy, and no other manifestations of cGVHD. 
 
 
d)  Ocular sicca (Schirmer’s test ≤5mm with no more than minimal ocular symptoms), 
 
positive skin or lip biopsy, and no other manifestations of cGVHD. 
 
 
e)  Vaginal or vulvar abnormalities with positive biopsy, and no other manifestations of 
 
cGVHD. 
 
2. Chronic GVHD requiring systemic treatment: more severe abnormalities or involvement of 
multiple sites, or platelet count <100,000, or steroid treatment at the onset of chronic GVHD 
 
 
a)  Involvement of two or more organs with symptoms or signs of cGVHD, with biopsy 
 
documentation of cGVHD in any organ. 
 


22 
 
b)  ≥15% base line body weight loss not due to other causes, with biopsy 
 
documentation of cGVHD in any  organ. 
 
 
c)  Skin involvement more extensive than defined for clinical limited cGVHD, confirmed 
 
by biopsy. 
 
 
d)  Scleroderma or morphea. 
 
 
e)  Onycholysis or onychodystrophy thought to represent cGVHD, with documentation 
 
of cGVHD in any organ. 
 
 
f)  Decreased range of motion in wrist or ankle extension due to fascitis caused by 
 
cGVHD. 
 
 
g)  Contractures thought to represent cGVHD. 
 
 
h)  Oral involvement with functional impairment, refractory to topical treatment. 
 
 
i)  Vaginal involvement with functional impairment, refractory to topical treatment. 
 
 
j)  Bronchiolitis obliterans not due to other causes. 
 
 
k)  Positive liver biopsy; or abnormal liver function tests not due to other causes with 
 
alkaline phosphatase >2 x upper limit of normal, AST or ALT >3 x upper limit of normal, 
 
or total bilirubin >1.6, and documentation of cGVHD in any organ. 
 
 
l)  Positive upper or lower GI biopsy. 
 
 
m)  Fasciitis or serositis thought to represent cGVHD and not due to other causes 
 
B. Physical manifestations of Chronic GVHD 
 
Manifestations that are distinctive for chronic GVHD can begin before day +100 after the 
transplant, and manifestations that are typical of acute GVHD can persist long after day +100. 
For this reason, the differential diagnosis between acute and chronic GVHD cannot be made 
solely according to the time interval from transplant. The diagnosis of chronic GVHD requires 
at least one manifestation that is distinctive for chronic GVHD (identified by italic print below) 
as opposed to acute GVHD. In all cases, infection and others causes must be 
ruled out in the differential diagnosis of chronic GVHD. Karnofsky or Lansky Clinical 
Performance scores <60%, ≥15% weight loss, and recurrent infections are usually signs of 
clinical extensive chronic GVHD. Abnormalities that could indicate chronic GVHD are 
categorized by organ system are listed below (italic print identifies manifestation more distinct 
of chronic GVHD): 
 
1)  Skin Erythema, dryness, pruritis, macular-papular or urticarial rash, pigmentary changes 
(i.e., hyperpigmentation, vitiligo), mottling, papulosquamous or lichenoid plaques, 
hyperkeratosis, exfoliation (ichtyosis), nodules, scleroderma, morphea (one or several 
circumscribed, indurated and shiny lesions). The extent of skin involvement and the skin 


23 
thickness score for patients with scleroderma needs to be recorded at the time of diagnosis, 
when changes in treatment are made and when assessing treatment response. Medical 
photos are also useful for assessing the extent of skin involvement and response to treatment. 
 
2)  Nails Ridging, onychodystrophy, onycholysis 
 
3)  Hair Premature graying (scalp hair, eyelashes, eyebrows), thinning scalp hair, alopecia, 
decreased body hair 
 
4)  Mouth Dryness, burning, gingivitis, mucositis, striae, dryness, atrophy, erythema, lichenoid 
changes, ulcers, labial atrophy or pigmentary changes, tightness around the mouth, sensitivity 
to acidic, strong flavors, heat or cold, tooth decay 
 
5)  Eyes Dryness, burning, blurring, gritty eyes, photophobia, pain 
Vagina/vulva Dryness, dyspareunia, stricture or stenosis, erythema, atrophy or lichenoid 
changes not induced by ovarian failure or other causes 
 
6)  Liver Jaundice and elevated liver function tests not due to other causes (see laboratory 
tests) 
 
7)  Lung Bronchiolitis obliterans (see diagnostic indicators), cough, wheezing, dyspnea on 
exertion, history of recurrent bronchitis or sinusitis 
 
8)  GI Anorexia, nausea, vomiting, diarrhea, malabsorption, dysphagia, odynophagia 
 
9)  Myofascial Stiffness and tightness with restriction of movement, occasionally with swelling, 
pain, cramping, erythema and induration, most commonly affecting the forearms, wrists and 
hands, ankles, legs and feet, inability to extend the wrists without flexing the fingers or the 
elbows, contractures 
 
10)   Muscle Proximal muscle weakness, cramping 
 
11)  Skeletal Arthralgia of large proximal girdle joints and sometimes smaller joints 
 
12)  Serosal Unexplained effusions involving the pleural, pericardial, or peritoneal cavities not 
due to venocclusive disease of the liver, cardiac insufficiency, malignancy, infection, GM-CSF 
toxicity or other causes 
 
C. Laboratory Testing and Diagnostic Indicators of Chronic GVHD 
 
1)  Eye Schirmer’s test with a mean value ≤ 5 mm at 5 minutes, or values of 6-10 mm in 
patients who have sicca symptoms, or keratitis detected by slit lamp examination 
 
2)  Liver Elevated liver function tests not due to other causes (alkaline phosphatase ≥2 x upper 
limit, of normal, AST or ALT >3 x upper limit of normal or total serum bilirubin ≥1.6) 
 
3)  Lung New obstructive lung defect defined as an FEV1 <80% of predicted with either an 
FEF 25-75 <65% of predicted or RV >120% of predicted, or a decrease of FEV1/FVC by >12% 


24 
within a period of less than 1 year, thought not to be caused by an infectious process, asthma 
or recurrent aspiration from the sinuses or from gastroesophageal reflux. In the absence of 
GVHD in any other organ, the diagnosis of bronchiolitis obliterans requires negative 
microbiological tests from bronchoalveolar lavage, evidence of air trapping by high resolution 
end-expiratory and end-inspiratory CAT scan of the lungs, or confirmation by thoracoscopic 
biopsy. 
 
4)  Esophagus Esophageal web formation, stricture or dysmotility demonstrated by barium 
swallow, endoscopy or manometry 
 
5)  Intestine Endoscopic findings of mucosal edema and erythema or focal erosions with 
histological changes of apoptotic epithelial cells and crypt cell drop out. Patients with 
unresolved acute GVHD may have more severe intestinal mucosal lesions including ulcers and 
mucosal sloughing. 
 
6)  Muscle Elevated CPK or aldolase, EMG findings consistent with myositis with biopsy 
revealing no other etiological process 
 
7)  Blood Thrombocytopenia (usually 20,000-100,000/_l), eosinophilia (> 0.4 x 103/uL), 
hypogammaglobulinemia. Hypergammaglobulinemia and autoantibodies occur in some cases. 
 
 
 


25 
Appendix C   
LYMPHOMA RESPONSE CRITERIA 
 
 
 
From Cheson, B.D. et al. [15]   


26 
Appendix D 
Research Subject Registration Form 
 
Protocol Number:_2372 __ Principal Investigator __Rachel Salit, MD___ 
 
Research Subject Name:___________________________________ 
 
Date of Birth:  ___  ___/___ ___/ ___ ___ ___ ___ 
 
 
Month     Day          Year 
 
 
 
 
 
Ethnicity: (Choose one) 
  Hispanic or Latino  (A person of Cuban, Mexican, Puerto Rican, South or Central American, or 
other Spanish culture or origin, regardless of race.  Term “Spanish Origin” can also be used in addition to 
“Hispanic” or “Latino”  
 
 
 
  Not Hispanic or Latino 
 
 
 
  Refused to Report 
 
Race: (check all that apply) 
  American Indian/Alaska Native  (A person having origins in any of the original peoples of 
North, Central, or South America, and who maintains tribal affiliations or community attachment) 
 
 
 
  Asian  (A person having origins in any of the original peoples of the Far East, Southeast, Asia, or the Indian subcontinent 
including, for example, Cambodia, China, India Japan, Korea, Malaysia, Pakistan, the Philippine Islands, 
Thailand and Vietnam) 
  Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of 
Hawaii, Guam, Samoa or other Pacific Islands) 
 
 
 
  Black/African American (A person having origins in any of the black racial groups of Africa.   
  White  (A person having origins in any of the original peoples of Europe, the Middle East or North 
Africa) 
 
 
 
 
 
  Unknown 
 
 
   Refused to Report 
 
Gender: 
 
  Male 
 
 
 
  Female 
  Unknown 
 
HIPAA  Authorization: (check one) 
 
 
 
 
 Protocol covered under general HIPAA authorization 
 
 
 
 Protocol specific HIPAA authorization required for  
 
 
 
        this protocol. (Attach and submit with this form) 
 
Name of person completing form (Please Print) 
 
 
_______________________________________________________ 
Name   
 
 
 
 
 
Phone Number 
_____________________________________________________ 
Date Submitted  
 
 
 
 
Time 
 
 


27 
FAX COVER SHEET 
 
 
DATE:______________________________ 
 
 
TO: Research Coordinator 
 
FAX (206) 667-2011 
 
RE: RESEARCH SUBJECT REGISTRATION FORM 
 
FROM:____________________________________ 
 
FAX:______________________________________ 
 
PHONE:___________________________________ 
 
 
 
 
 
 
 
 
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