Conditions: Acute Myeloid Leukemia Arising From Previous Myelodysplastic Syndrome Adult Acute Lymphoblastic Leukemia in Remission Adult Acute Myeloid Leukemia in Remission CD45-Positive Neoplastic Cells Present Chronic Myelomonocytic Leukemia Previously Treated Myelodysplastic Syndrome Refractory Anemia With Excess Blasts Refractory Anemia With Ring Sideroblasts Refractory Cytopenia With Multilineage Dysplasia Refractory Cytopenia With Multilineage Dysplasia and Ring Sideroblasts
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 26
Healthy volunteers: no

Brief summary:
This phase I trial studies the side effects and best dose of iodine I 131monoclonal antibody BC8 when given together with fludarabine phosphate, cyclophosphamide, total-body irradiation, and donor bone marrow transplant, and to see how well they work in treating patients with acute myeloid leukemia or acute lymphoblastic leukemia that has spread to nearby or other places in the body (advanced), or high-risk myelodysplastic syndrome. Giving chemotherapy drugs, such as fludarabine phosphate and cyclophosphamide, and total-body irradiation before a donor bone marrow transplant helps stop the growth of cancer or abnormal cells and helps stop the patient's immune system from rejecting the donor's stem cells. Also, radiolabeled monoclonal antibodies, such as iodine I 131 monoclonal antibody BC8, can find cancer cells and carry cancer-killing substances to them without harming normal cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclophosphamide together with mycophenolate mofetil and tacrolimus after the transplant may stop this from happening. Giving a radiolabeled monoclonal antibody together with donor stem cell transplant, fludarabine phosphate, cyclophosphamide, mycophenolate mofetil, and tacrolimus may be an effective treatment for advanced acute myeloid leukemia, acute lymphoblastic leukemia, or myelodysplastic syndromes.

Detailed description:
PRIMARY OBJECTIVES:

I. To estimate the maximum tolerated dose of radiation delivered via 131 I-BC8 antibody (iodine I 131 monoclonal antibody BC8) when combined with pre- and post-transplant cyclophosphamide (CY), fludarabine phosphate (FLU), 2 Gy total-body irradiation (TBI), tacrolimus, mycophenolate mofetil (MMF), and a haploidentical allogeneic hematopoietic marrow transplant in patients who have advanced acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), or high risk myelodysplastic syndromes (MDS).

II. To estimate rates of immune reconstitution, engraftment, and donor chimerism resulting from this combined preparative regimen.

III. To determine rates of disease relapse, acute graft-versus-host disease (GVHD), and day 100 disease-free survival in patients receiving 131 I-BC8 antibody (Ab) combined with CY, FLU, 2 Gy TBI, tacrolimus, MMF, and human leukocyte antigen (HLA)-haploidentical allogeneic hematopoietic cell transplant (HCT).

OUTLINE: This is a dose-escalation study of iodine I 131 monoclonal antibody BC8.

RADIOIMMUNOTHERAPY: Patients receive therapeutic iodine I 131 monoclonal antibody BC8 via central line on day -14.

NONMYELOABLATIVE CONDITIONING: Patients receive FLU intravenously (IV) over 30 minutes on days -6 to -2 and CY IV over 1 hour on days -6 and -5. Patients undergo TBI on day -1.

TRANSPLANTATION: Patients undergo allogeneic bone marrow transplantation on day 0.

POST-TRANSPLATATION IMMUNOSUPPRESSION: Patients receive CY IV over 1-2 hours on day 3, MMF IV or orally (PO) thrice daily (TID) on days 4 to 35, and tacrolimus IV over 1-2 hours or PO on days 4 to 180 with taper on day 84.

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

After completion of study treatment, patients are followed up at 6, 9, 12, 18, and 24 months, and then annually thereafter.

Arms:
arm 1: RADIOIMMUNOTHERAPY: Patients receive therapeutic iodine I 131 monoclonal antibody BC8 via central line on day -14.

NONMYELOABLATIVE CONDITIONING: Patients receive FLU IV over 30 minutes on days -6 to -2 and CY IV over 1 hour on days -6 and -5. Patients undergo TBI on day -1.

TRANSPLANTATION: Patients undergo allogeneic bone marrow transplantation on day 0.

POST-TRANSPLATATION IMMUNOSUPPRESSION: Patients receive CY IV over 1-2 hours on day 3, MMF IV or PO TID on days 4 to 35, and tacrolimus IV over 1-2 hours or PO on days 4 to 180 with taper on day 84.

Interventions: intervention 1: Allogeneic Bone Marrow Transplantation intervention 2: Cyclophosphamide intervention 3: Fludarabine Phosphate intervention 4: Iodine I 131 Monoclonal Antibody BC8 intervention 5: Laboratory Biomarker Analysis intervention 6: Mycophenolate Mofetil intervention 7: Tacrolimus intervention 8: Total-Body Irradiation
Intervention descriptions: intervention 1: Given via central line intervention 2: Given IV intervention 3: Given IV intervention 4: Given IV (dosimetry dose) or via central line (therapeutic dose) intervention 5: Correlative studies intervention 6: Given IV or PO intervention 7: Given IV or PO intervention 8: Undergo TBI

Protocol document:
Prot_000.pdf: 
FHCC Protocol 2186 Cover Page 
 
 
FHCC Protocol 2186: 
Title: Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid 
Leukemia (AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using 
Related HLA‐Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with 
Immunosuppression Before and After Transplantation 
Version: 10/12/2016 
NCT#:  NCT00589316 


Protocol 2186.00  
FRED HUTCHINSON CANCER RESEARCH CENTER 
 
Title:  
Hematopoietic Bone Marrow Transplantation for Patients with High-Risk Acute 
Myeloid Leukemia (AML), Acute Lymphoblastic Leukemia (ALL), or 
Myelodysplastic Syndrome (MDS) using Related HLA-Mismatched Donors: A Trial 
Using Radiolabeled Anti-CD45 Antibody Combined with Immunosuppression 
Before and After Transplantation 
 
Protocol Number:  
2186 
Current Version: 
10/12/2016 
Prior Version(s):  
06/16/2015   
 
IND Number: 
BB-IND 3771 
Investigational Agent: 
Iodine (I-125, I-131) Conjugated Murine Monoclonal Antibody (BC8) to CD45 
Study Regimen: 
Radiolabeled 131I BC8 Antibody Combined with CY, Fludarabine, 2 Gy TBI, 
Tacrolimus, MMF and Haploidentical Allogenic Hematopoietic Marrow Transplant 
Principal Investigator: 
Johnnie J Orozco, MD, PhD, Research Associate, Fred Hutchinson Cancer Research 
Center 
Sponsor:  
Fred Hutchinson Cancer Research Center 
 
1100 Fairview Ave N, M/S LM-200 
 
Seattle, WA 98109-1024 
 
(O): 206-667-2731 
 
(F):  206-667-6068 
 
ISIOC@fredhutch.org 
 
Medical Monitor:  
Brian Till, MD 
 
Assistant Member, Fred Hutch Clinical Research Division 
 
(O): 206-667- 7269 
 
tillb@fredhutch.org 
 
Authorized Sponsor Representative: 
Name (typed or printed):_Brian Till, MD_____________________________________ ______________ 
Institutional Title:    
_Assistant Member, ISIOC Medical Monitor  _____________________  ______ 
Institution: 
 
_Fred Hutchinson Cancer Research Center ___  _______ __________________ 
Signature:  ______________________________________________ Date: _____   _________________ 


Protocol 2186.00  
Signature Page: 
Investigator Statement: 
I have carefully read Protocol 2186 entitled “Hematopoietic Bone Marrow Transplantation for Patients 
with High-Risk Acute Myeloid Leukemia (AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic 
Syndrome (MDS) using Related HLA-Mismatched Donors: A Trial Using Radiolabeled Anti-CD45 Antibody 
Combined with Immunosuppression Before and After Transplantation” (“Protocol”) version date 
10/12/2016.   
I agree to carry out my responsibilities in accordance with the Protocol, applicable laws and regulations 
(including 21 CFR Part 312), Good Clinical Practice: Consolidated Guidance (ICH-E6), and applicable 
policies of Fred Hutch. 
Principal Investigator: 
Name (typed or printed):_Johnnie J Orozco, MD, PhD__________________________________________ 
Institution and Address: _Fred Hutchinson Cancer Research Center_______________________________ 
 
 
 
_1100 Fairview Avenue N, M/S D3-190    _______ __________________ ______ 
 
 
 
_ Seattle, WA 98109-1024_______  ____________ ________________________ 
Phone Number:  
_206-667-4102_______ ________________________ _____________________ 
Signature:_______________________________________________ Date: ____________________   ___   


Protocol 2186.00 
Page 3 of 50 
TABLE OF CONTENTS 
1.0 INTRODUCTION AND BACKGROUND .................................................................................................................. 5 
2.0 OBJECTIVES ......................................................................................................................................................... 17 
3.0  SUBJECT SELECTION ........................................................................................................................................... 18 
4.0  DONOR SELECTION ............................................................................................................................................ 19 
5.0  INFORMED CONSENT OF SUBJECTS AND DONOR ............................................................................................. 19 
6.0  SUBJECT REGISTRATION ..................................................................................................................................... 19 
7.0  PLAN OF TREATMENT ........................................................................................................................................ 20 
8.0  PATIENT AND DONOR EVALUATION .................................................................................................................. 28 
9.0  TOXICITIES AND COMPLICATIONS ..................................................................................................................... 29 
10.0 ADVERSE EVENT REPORTING ............................................................................................................................ 33 
11.0  DEFINITIONS .................................................................................................................................................... 37 
12.0 STATISTICAL CONSIDERATIONS ........................................................................................................................ 37 
13.0 DATA AND SAFETY MONITORING PLAN ........................................................................................................... 37 
14.0 
DATA MANAGEMENT/CONFIDENTIALITY ................................................................................................... 38 
15.0 
TARGETED/PLANNED ENROLLMENT .......................................................................................................... 39 
16.0  REFERENCES ..................................................................................................................................................... 39 
APPENDIX A:  BEARMAN CRITERIA FOR REGIMEN-RELATED TOXICITY .................................................................... 41 


Protocol 2186.00 
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APPENDIX B: METHODS USED TO ESTIMATE RADIATION ABSORBED DOSES TO PATIENTS .................................... 44 
APPENDIX C: POTENTIAL ADVERSE EVENTS ASSOCIATED OR EXPECTED WITH HEMATOPOIETIC CELL 
TRANSPLANTATION .................................................................................................................................... 49 
 


Protocol 2186.00 
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1.0  INTRODUCTION AND BACKGROUND  
 
1.1 
Introduction 
 
 
It is important to extend the option of hematopoietic cell transplantation (HCT) for potential 
therapy of hematologic malignancies to patients who do not have a readily available HLA-matched 
donor.  This problem is especially acute for patients in ethnic minority groups. Almost all patients would 
have a related donor identical for one HLA haplotype (haploidentical) and mismatched at HLA-A, B or DR 
of the unshared haplotype.  Moreover, it is important to improve disease control for advanced acute 
myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and high-risk MDS patients without 
substantially increasing the toxicity of the transplant regimen.  In this protocol, we will combine targeted 
hematopoietic radiation delivered by 
131I-BC8 (anti-CD45) antibody with a combination of 
immunosuppressive agents including cyclophosphamide (CY) administered before and after HCT to 
facilitate engraftment and to delete highly alloreactive T-cell clones presumably involved in graft versus 
host disease (GvHD).  Specifically, this study will assess the feasibility and safety for patients with 
advanced AML, ALL or high risk MDS of treatment with 131I-BC8 antibody at a starting dose of 12 Gy 
delivered to the normal organ receiving the highest dose, combined with CY, fludarabine and 2 Gy total 
body irradiation (TBI), followed by transplantation with non-T-cell depleted bone marrow from 
haploidentical donors.  On day +3, patients will be given a single dose of high-dose CY.  On day +4, 
patients will begin prophylaxis for GvHD with tacrolimus and mycophenolate mofetil (MMF).  Growth 
factor support with G-CSF will begin on day +4 and continue until recovery of neutrophils (>500 per µL).  
The primary endpoint is determination of the maximum tolerated dose (MTD) of targeted radiation.  
The study will also estimate rates of non-relapse mortality (NRM), disease response and disease-free 
survival, and determine rates of donor chimerism and acute graft-versus-host disease (GvHD) through 
day 100 post-transplantation. 
 
1.2 Background   
 
The combination of high-dose chemotherapy and allogeneic HCT is potentially curative therapy 
for a number of hematologic malignancies but is not an option for many patients who lack a readily 
available HLA-matched donor, either related or unrelated.  The ability to use related, HLA-haploidentical 
donors for allogeneic HCT can expand this option to almost all patients, but stem cell transplants after 
myeloablative conditioning have been complicated by high rates of morbidity and mortality.1-5 In the 
non-myeloablative setting, studies of HLA-haploidentical transplants for hematologic malignancies have 
been reported from two other transplant centers.6, 7  In both studies, depletion of host and donor T-cells 
in vivo was accomplished using polyclonal or monoclonal antibodies specific for lymphocytes.  Relatively 
high rates of relapse, severe GvHD, non-relapse mortality, and low rates of donor chimerism were 
observed by Spitzer et al.6  Improved engraftment and reduced rates of acute and chronic GvHD were 
observed in the study by Rizzieri et al.,7 but non-relapse mortality (NRM) was 31%, mostly due to 
infection including 14% of patients who developed CMV disease.  Infection has continued to be a major 
cause of morbidity and mortality in studies of HLA-haploidentical transplants using myeloablative or 
non-myeloablative conditioning. In a recent study of nonmyeloablative HCT for hematologic 
malignancies using related, HLA-haploidentical donors carried out at the Hutchinson Center and Johns 
Hopkins Sidney Kimmel Cancer Center, mortality secondary to infection was <5%, suggesting that 
induction of tolerance by post-transplant CY may spare T-cell immunity to infection (submitted for 
publication).   Developing a safe and effective approach to HCT from related, HLA-haploidentical donors 


Protocol 2186.00 
Page 6 of 50 
is an important goal since the graft-versus-leukemia (GVL) effect is expected to be augmented in this 
setting.3, 4  
 
The central problem of HCT from related, HLA-haploidentical donors is controlling the potent 
alloreactivity of host T-cells that can lead to rejection of the graft or severe GvHD.  Using the strategy of 
non-myeloablative HCT pioneered by Storb and colleagues at the FHCRC,8 a protocol was developed 
with the goal of achieving complete donor T-cell engraftment, low rates of rejection and GvHD of 
acceptable severity by increasing the amount of immunosuppressive therapy before and after 
transplantation of HLA-haploidentical bone marrow.  The key to the success of this protocol was the 
incorporation of the highly immunosuppressive alkylating agent, CY, before and after transplantation. 
The protocol was based on pre-clinical data from a mouse model of non-myeloablative HCT using 
haploidentical donors.9  In this model, pre-transplant immunosuppression consisted of fludarabine and 
low-dose total body irradiation (TBI, 200 cGy) .  High-dose CY was then given on day +3 post-BMT to 
delete highly alloreactive T-cells of the donor [for a review, see Mayumi, H., et al.10].  CY causes DNA 
damage and subsequent death of activated, proliferating T-cells.10  Luznik, et al. showed that successful 
induction of stable, mixed chimerism could be achieved across total MHC disparity in congenic mice (6/6 
H-2 mismatch, no minor histocompatibility differences) and in haploidentical strain combinations (3/6 H-
2 mismatch, minor histocompatibilty differences) with a decreased incidence of GVHD compared to a 
set of control mice which were not given CY after HCT.9  Another set of control mice not given a marrow 
graft recovered autologous hematopoiesis.  Furthermore, it was found that addition of CY before HSCT 
was synergistic with fludarabine in preventing graft rejection and increasing the degree of donor 
chimerism, a finding also reported recently by Petrus et al.11 
 
Using this approach, an initial clinical trial was initiated at Johns Hopkins in patients with high-
risk hematologic malignancies.  This dose-finding trial was designed to determine whether 
administration of CY as additional immunosuppression before HSCT might be required for 
engraftment.12  In the first 13 patients it was found that CY at a dose of 14.5 mg/kg administered on 
days –6 and –5 improved the rate of donor engraftment.  Eight of 10 patients receiving pre- and post-
transplant CY achieved >90% donor T-cell engraftment by day +28.  The two patients who rejected their 
grafts and recovered autologous hematopoiesis were patients with MDS who nonetheless remained in 
complete remission of their disease for at least one year post-transplant.   
 
The Johns Hopkins trial has continued and a second clinical trial was opened at this Center in 
2002 (FHCRC Protocol 1667). A joint report of these two studies has been submitted for publication.  
Patients with advanced hematologic malignancies (n=88) were studied in three cohorts as shown in the 
Table 1.1 and Schema below (Fig. 3.1).   Cohorts differed by the total dose of post-transplantation CY (50 
mg/kg versus 50 mg/kg x 2) and the dosing frequency of MMF (two versus three times daily).   
 
Table 1.1:  Cohorts of patients separated by dose of post-transplantation CY and the dosing frequency 
of MMF 
Cohort 
N 
Doses of CY MMF Dosing interval 
Hopkins-A 20 
1 
Twice daily 
FHCRC 
28 
1 
Three times daily 
Hopkins-B 40 
2 
Three times daily 
 
  Fig. 1.1: Schema 
 


Protocol 2186.00 
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As shown in Table 1.2 below, the cohorts were not significantly different with respect to age, gender, 
ethnicity, sensitivity to last therapy given, or prior autologous transplantation.   
 


Protocol 2186.00 
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Table 1.2: Patient Characteristics 
Treatment cohort 
1 (Hopkins A) 
2 (Seattle) 
3 (Hopkins B) 
Number of patients 
20 
28 
40 
Treatment location 
Baltimore 
Seattle 
Baltimore 
Post-transplantation 
Cy 
50 mg/kg 
50 mg/kg 
100 mg/kg 
MMF frequency 
bid 
tid 
tid 
Tacrolimus given on 
days: 
4-50 (n=10) 
4-180 (n=10) 
4-90 
5-180 
Median Age (years) 
49.5 (23-62) 
40.5 (20-67) 
47.5 (1-71y) 
Sex 
Male 
Female 
 
13/20 (65%) 
7/20  (35%) 
 
16/28 (57%) 
12/28 (43%) 
 
26/40 (65%) 
14/40 (35%) 
Ethnicity 
White 
African-American 
Asian 
Hispanic 
Native American 
 
16/20 (80%) 
4/20 (20%) 
0 
0 
0 
 
18/28 (64%) 
5/28 (18%) 
1/28 (4%) 
2/28 (7%) 
2/28 (7%) 
 
32/40 (80%) 
7/40 (17.5%) 
1/40 (2.5%) 
0 
0 
Diagnosis 
AML 
ALL 
MDS 
CML/CMML 
CLL 
HD 
NHL 
MM/Plasmacytoma 
PNH 
 
7 (35%) 
2 (10%) 
5 (25%) 
3 (15%) 
0 
0 
1 (5%) 
  2 (10%) 
0 
 
13 (46%) 
2 (7%) 
0 
2 (7%) 
0 
8 (29%) 
2 (7%) 
1 (4%) 
0 
 
14 (35%) 
2 (5%) 
1 (2.5%) 
4 (10%) 
3 (7.5%) 
5 (12.5%) 
8 (20%) 
2 (5%) 
1 (2.5%) 
Prior Treatment 
regimens (#) 
2 (0-8) 
5 (1-10) 
3 (0-6) 
Sensitive to prior 
treatment 
14/15(93%) 
33/37 (89%) 
21/28 (75%) 
Prior autologous 
transplant 
4/20 (20%) 
11/28 (39%) 
10/40 (25%) 
Abbreviations: Cy, cyclophosphamide; MMF, mycophenolate mofetil; AML, acute myeloid leukemia; ALL, acute lymphocytic 
leukemia; MDS, myelodysplastic syndrome; CML, chronic myeloid leukemia; CLL, chronic lymphocytic leukemia; HD, Hodgkin’s 
disease; NHL, non-Hodgkin’s lymphoma; MM, multiple myeloma; PNH, paroxysmal nocturnal hemoglobinuria 
 
The three cohorts also did not differ with respect to the age of the donor or the relationship of the 
donor to the patient. Diagnoses were similarly distributed over the three cohorts with the exception 
that Hodgkin’s lymphoma was not present in the Hopkins A cohort.  Patients in the Seattle cohort did 
receive a significantly greater number of prior regimens compared to either Hopkins cohort.  The 
median number of prior regimens in this group was 5, compared to 2 in Hopkins A and 3 in Hopkins B.   
 
As shown in Table 1.3 below for the entire group, half (44/88) of the donors were siblings of the patient, 
and a quarter each (22/88) of the donors were either parents or children of the patient.  Donors differed 


Protocol 2186.00 
Page 9 of 50 
from their recipients by a median of 3 HLA antigens in both the host-versus-graft (HVG) and graft-versus-
host (GVH) directions.  About one-third of patients had at least four HLA antigens mismatched (71% in 
the FHCRC cohort).   
 
Table 1.3: Donor and Graft Characteristics 
 
Cohort 
1 (Hopkins A) 
2 (Seattle) 
3 (Hopkins B) 
Median Age in years 
(range) 
39 (20-63) 
45 (21-66) 
43.5 (22-69) 
Sex 
Male 
Female 
 
11 (55%) 
9 (45%) 
 
18 (64%) 
10 (36%) 
 
20 (50%) 
20 (50%) 
Relationship 
Parent 
Sibling 
Child 
 
3 (15%) 
11 (55%) 
6 (30%) 
 
10 (36%) 
10 (36%) 
8 (28%) 
 
  9  (23%) 
23  (58%) 
  8  (20%) 
CD3+ cells/kg x 107 
Mean (SD) 
3.26 (0.85) 
4.49 (1.48) 
4.07 (1.49) 
CD34+ cells/kg x 106 
Mean (SD) 
4.21 (2.05) 
5.64 (2.71) 
4.21 (1.54) 
Infused MNC/kg x 108 
Mean (SD) 
1.18 (0.25) 
1.68 (0.53) 
1.48 (0.51) 
# HLA mismatches in 
GVH direction 
            Mean 
0→ 
1→ 
2→ 
3→ 
4→ 
 
Antigen      Allele 
    2.85         3.15 
      1               0 
      2               3 
      3               2 
      7               4 
      7              11 
 
Antigen    Allele 
   2.89        3.21  
      1             0 
      2             3 
      4             2 
     13            9 
      8            14 
 
Antigen     Allele* 
   2.78         3.31 
      1              1 
      1              0 
     12             4 
     18            15 
      8             19 
# HLA mismatches in 
HVG direction 
Mean 
0→ 
1→ 
2→ 
3→ 
4→ 
 
Antigen      Allele 
    2.75         3.05  
      1               0 
      4               4 
      1               1 
      7               5 
      7              10 
 
Antigen    Allele 
   2.96        3.21 
      2             1 
      1             2 
      4             3 
     10            6 
     11           16 
 
Antigen      Allele* 
    2.88         3.28 
      1               1 
      1               0 
      8               5 
     22             14 
      8              19 
*Not done for one patient 
 
 


Protocol 2186.00 
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Engraftment and chimerism 
For the entire group of patients, the median times to hematopoietic recovery of neutrophils and 
platelets were 15 and 29 days, respectively as shown below in Figure 1.2.   
 
 
 
 
 
 
Fig. 1.2. Engraftment and chimerism.  Cumulative incidence of (A) neutrophil and (B) platelet engraftment by cohort.  
(C) Percentage of donor chimerism at days 28-30 and 56-60 by cohort.  Open circles represent the day 56-60 donor chimerism 
values for the 20 patients who are alive and event-free at the time of last follow-up.  When two chimerism values are available 
for these patients, the open circle is shown for the marrow sample for the Hopkins cohorts and CD33+ cells for the Seattle 
cohort. 
 
By cohort the median times to neutrophil recovery were 15, 12, and 16 days and the median 
times to platelet recovery were 31, 20, and 30 in the Hopkins A, Seattle, and Hopkins B cohorts, 
respectively.  In a multivariate analysis, a higher dose of CD34+ cells in the graft was associated with 
faster recovery of both neutrophils and platelets, which may explain in part the faster engraftment 
times of the Seattle cohort.  Graft failure occurred in a total of 15 out of 84 evaluable patients (18%): six 
out of nineteen (32%) in the Hopkins A cohort, three out of twenty-six (11%) in the Seattle cohort, and 
six out of thirty-nine (13%) in the Hopkins B cohort.  All but two patients with graft failure experienced 
recovery of autologous hematopoiesis with a median time to neutrophil and platelet engraftment of 24 
days (range 11-48 days) and 44 days (range 15-395 days), respectively.  Adjusting for cohort, 
transplantation of female donor marrow into a male recipient increased the probability of graft failure 
(OR=6.23, 95% CI: 1.4-32.9; p=0.014), while increasing numbers of prior regimens decreased the risk of 
failure (OR=0.61, 95% CI: 0.36-0.90; p=0.007).  Achievement of full donor chimerism was rapid after 
transplantation from an HLA-haploidentical donor (Fig. 1.2).  Analysis of peripheral blood that was 
either: a) unfractionated (Hopkins cohorts) or b) separated by cell sorting into T-cell (CD3-positive) or 
granulocyte (CD33-positive) fractions (Seattle cohort) showed that with few exceptions, donor 
chimerism was virtually complete (>95%) by 2 months post-transplant.    
 
Hospitalizations and transfusions 


Protocol 2186.00 
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All patients received their treatment in the outpatient department and were discharged to their 
referring oncologist between 60 and 90 days after transplantation, unless complications requiring 
admission to the hospital supervened.  The median number of hospitalizations prior to day 60 was 1 
(range 0-4) for each patient cohort.  The reason for admission was neutropenic fever in 56% of patients, 
non-neutropenic infection in 33%, and other causes, including acute GVHD, for the remaining 11%.  A 
total of 36 patients (41%) did not require hospitalization within the first 60 days of transplantation.  The 
median total number of hospital days prior to day 60 was 3, 6 and 2 for the Hopkins A, Seattle and 
Hopkins B, respectively.  The median number of units of packed red blood cells transfused per patient 
was 8, 4, and 10 for the Hopkins A, Seattle, and Hopkins B cohorts.  Three patients in the entire study did 
not require red blood cell transfusions. 
Patients who are seropositive for cytomegalovirus (CMV) are known to be at high-risk for 
reactivating CMV after transplantation, regardless of the serologic status of the donor.  In this study, 
CMV reactivation was observed in 20/60 (33%) high-risk patients (Table 1.4).  The incidence of 
reactivation in high-risk patients differed across the cohorts but the median time to onset did not differ 
by cohort.  Acute GVHD was diagnosed in 10/20 (50%) patients on or about the time of CMV 
reactivation.  Despite the varying rates of CMV reactivation among the cohorts, with preemptive 
therapy the incidence of CMV disease was low.  CMV pneumonia developed in only one patient in the 
Hopkins A cohort for an overall incidence of 5%.  There was no CMV-associated mortality. 
In the current era of anti-fungal prophylaxis, the incidence of invasive mold infections after 
transplantation, especially Aspergillus, has been an increasing problem.  However, with the advent of 
anti-mold agents such as voriconazole, survival of patients with invasive mold infections has improved 
significantly.  As shown in Table 1.4, proven or probable invasive mold infections post-transplant, all 
caused by Aspergillus sp, were observed in only 6 out of 88 patients, an incidence of 6.8%.  Two patients 
in the Hopkins B cohort died from invasive Aspergillus infection, one while persistently neutropenic 
following graft failure. 
 
Table 1.4. CMV Reactivation and Invasive Mold Infection 
 
Hopkins A 
(n=20) 
Seattle 
(n=28) 
Hopkins B 
(n=40) 
No. patients at high-risk 
for CMV reactivation 
10 (50%) 
24 (86%) 
25 (63%) 
No. high-risk patients 
with CMV reactivation 
3 (30%) 
15 (62.5%) 
2 (8%) 
No. high-risk patients 
with CMV disease 
1 (10%) 
0 
0 
Median days to onset of 
CMV reactivation 
(range) 
47 (42-48) 
30 (17-80) 
47 (38-48) 
No. patients with 
invasive mold infection 
1 (10%) 
3 (11%) 
2 (5%) 
 
Acute and chronic graft-versus-host disease 
For the entire patient population, the cumulative incidences (CI) of grades II-IV and III-IV acute 
GVHD by day 200 were 35% and 10%, respectively (Fig. 1.3A).   
 
 


Protocol 2186.00 
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Fig. 1.3. Cumulative incidence of acute and chronic GVHD. (A) Cumulative incidence of acute GVHD grades II-IV 
and III-IV. (B) Combined cumulative incidence of severe (grades III-IV) acute GVHD and graft failure. (C) Cumulative incidence of 
total chronic and extensive chronic GVHD. (D) Cumulative incidence of total chronic GVHD by cohort.   
 
There were no significant differences between cohorts in the incidence of acute grades II-IV and 
III-IV GVHD.  Since graft failure and severe (grades III-IV) acute GVHD can both be manifestations of 
inadequate post-transplantation pharmacologic immunosuppression, the summed cumulative 
incidences of these events is shown in Figure 1.3B. The combined incidence of graft failure and severe 
acute GVHD in the Hopkins A cohort was 55% by 1 year, which motivated the addition of the second 
dose of post-transplantation Cy on day 4 and the change to thrice daily MMF in the Hopkins B cohort. 
The cumulative incidences of total chronic and extensive chronic GVHD in the first year after 
transplantation for the entire population were 20% and 11%, respectively (Fig. 1.3C).  For the Hopkins A, 
Seattle, and Hopkins B cohorts, the cumulative incidences  of chronic GVHD at 1 year after 
transplantation were 25%, 43%, and 10%, respectively (Fig. 1.3D).  The incidence of chronic GVHD in the 
Seattle cohort was significantly higher than in the Hopkins B cohort (p = .004) and marginally higher than 
in the Hopkins A cohort (p = .08).  There was no significant difference between cohorts in the incidence 
of extensive chronic GVHD. 
 
Non-relapse mortality (NRM) and relapse 
Overall, the cumulative incidences of NRM at 180 days and 1 year after transplantation were 
13% and 19%, respectively, and the cumulative incidences of relapse at 1 and 2 years after 
transplantation were 50% and 57%, respectively (Fig. 1.4A).   
 


Protocol 2186.00 
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Fig. 1.4. Outcomes among nonmyeloablative haploidentical BMT recipients. (A) Cumulative incidence of non-
relapse mortality and relapse. (B) Overall survival. (C) Event-free survival (D) Event-Free Survival by Disease Category (lymphoid 
versus myeloid).   
 
There were no significant differences in the cumulative incidences of either NRM or relapse 
between cohorts.  In a stratified multivariate analysis, patients with lymphoid malignancies had a 
significantly lower risk of relapse (HR  0.50, 95% CI .25-.99, p < .046) than patients with myeloid 
malignancies.  In the same analysis, increasing age, graft CD3+ cell dose, or number of prior regimens 
was not associated with a significantly increased incidence of relapse. 
 
Overall and event-free survival (EFS) 
With a median follow-up of 817 d (range: 112-1808 d) the actuarial overall survivals of the entire 
group at 1 and 2 years, respectively, were 50% and 37%, respectively (Fig, 1.4B)  The actuarial event-free 
survivals (EFS) at 1 and 2 years was 33% and 24%, respectively (Fig. 1.4C).  Overall and EFS survivals did 
not differ significantly between cohorts.  However, compared to patients with myeloid malignancies, 
patients with lymphoid malignancies had a superior EFS at 1 year (42% versus 24%) and at 2 years after 
transplantation (36% versus 15%; p = .04, Fig. 1.4D).   
A multivariate analysis of risk factors for event-free survival is presented in Table 1.5. Compared 
to patients with AML, patients with non-Hodgkin’s lymphoma and Hodgkin’s lymphoma had an 
improved event-free survival.  Interestingly, an increasing number of HLA-antigen mismatches in the 
host-versus-graft direction was associated with a marginally improved EFS, whereas an increasing graft 
dose of CD3+ cells was associated with a marginally worse EFS. 
 
 


Protocol 2186.00 
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Table 1.5.  Multivariate hazard ratios for event-free survival, stratified by cohort 
 
 
HR Confidence Limits 
 
Variable 
Hazard Ratio 
Lower 
Upper 
p 
NHL 
0.34 
0.12 
0.91 
.03 
HD 
0.28 
0.11 
0.75 
.01 
ALL 
0.46 
0.13 
1.57 
.21 
MDS 
0.55 
0.22 
1.35 
.19 
CML 
0.78 
0.30 
2.01 
.60 
Other dx 
1.27 
0.59 
2.73 
.54 
# mismatches in HVG direction 
0.77 
0.59 
1.01 
.06 
Graft CD3+ cell dose 
2.54 
0.97 
6.62 
.06 
 
Of 57 deaths, 41 occurred in patients with relapsed or progressive disease (Table 1.6).  GVHD 
accounted for five of the sixteen deaths in the Hopkins A cohort but for only one out of 41 deaths in the 
other two treatment cohorts.  Only 4 patients died of infection without GVHD. 
 
Table 1.6 Causes of death among transplanted patients.   
 
 
 
 
 
 
 
 
 
 
 
Targeted hematopoietic irradiation delivered by 131I-anti-CD45 antibody 
 
The anti-leukemic effects of radioimmunoconjugates that selectively deliver irradiation to 
targeted leukemic blasts, with less toxicity inflicted on normal tissues, have been investigated as therapy 
for myeloid and lymphoid malignancies in the hope that cure rates could be significantly improved.  The 
CD45 antigen is an attractive target for immunotherapy since the vast majority of hematologic 
malignancies express CD45, including 85-90% of acute myeloid and lymphoid leukemias.  The CD45 
antigen is not found on tissues of non-hematopoietic origin, and thus an antibody (Ab) reactive with the 
CD45 antigen targets the primary sites of leukemic cell involvement (the marrow and spleen), as well as 
lymphoid tissue.  By selecting an Ab reactive with normal leukemic precursors and all mature leukocytes, 
most malignant blasts, including blasts scattered in normal myeloid and lymphoid tissue, should receive 
relatively high doses of radiation given that the surrounding normal hematopoietic cells will be targeted 
as well.  For this reason, 131I-anti-CD45 Ab (BC8) may offer clinical benefit both to patients with active 
disease and to those in remission. 
 
Prior studies have shown that escalating the dose of systemic therapy decreases the risk of 
relapse for patients with advanced AML, but also increases non-relapse mortality, resulting in no 
improvement in overall survival.13  Early encouraging phase I results have demonstrated the feasibility of 
using 131I-BC8 Ab combined with a transplant regimen employing 120 mg/kg CY and 12 Gy TBI for 
therapy of acute leukemias.14  Biodistribution of trace-labeled Ab was initially determined in 41 patients 
with advanced AML or acute lymphocytic leukemia (ALL), and 3 patients with advanced myelodysplastic 
Cause of death 
Hopkins A 
(n=20) 
Seattle 
(n=28) 
Hopkins B 
(n=40) 
Relapse 
10 
12 
19 
Graft-versus-host disease 
5 
 
1 
Infection 
 
2 
2 
CNS hemorrhage 
 
 
2 
Unknown 
 
1 
1 
Hepatorenal syndrome 
1 
 
 
Secondary AML 
 
1 
 


Protocol 2186.00 
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syndrome (MDS).  The dose of 131I delivered to each patient was determined from dosimetry studies, 
and was escalated in cohorts of 3-7 patients to deliver estimated radiation doses of 3.5 Gy to 12.25 Gy 
to the normal organ receiving the highest dose.  Most (84%) patients had favorable biodistribution of 
Ab, with improved therapeutic ratios of radiation delivered to marrow and spleen as compared to liver 
(average 2.3 and 4.8 times higher than liver, respectively).  Thirty-four patients were treated with the 
amount of 131I estimated to deliver from 3.5 Gy to 12.25 Gy to the normal organ receiving the highest 
dose.  At the time of initiation of this protocol, eight patients  remained disease-free since treatment, 
surviving at 8.9 to 15 years (median 13.2 years) post-transplant; one additional surviving patient 
relapsed 6.4 years post transplant.  Sixteen patients died following relapse at 3.8 to 141.9 months 
(median 16.6 months) post-transplant.  Nine patients died from non-relapse related causes, from 8 days 
to 10.9 years (median 41 days) post transplant.  At the maximum tolerated dose (MTD) of 10.5 Gy, it was 
determined that 131I-BC8 Ab in combination with CY and TBI could deliver up to an additional dose of 24 
Gy to marrow and 50 Gy to spleen.  Therefore, this study demonstrated that ratios of at least 2 to 1 of 
radiation delivered to the target organs of marrow and spleen, as compared to the normal organ 
receiving the highest dose, can be reliably achieved in patients who are either in remission or acute 
leukemic relapse. 
 
Based on these results, we used the same preparative regimen in a Phase II study for patients 2-
55 years old with AML beyond CR1, or with relapsed/primary refractory disease.  Twenty-six patients, 10 
to 55 (median 39) years old, with AML (5 CR2, 18 relapsed or refractory) or MDS (1 RAEB, 2 RAEBT) 
received a test infusion of BC8 Ab trace-labeled with 131I. Favorable biodistribution, with estimated 
radiation absorbed dose to bone marrow and spleen > to liver (normal organ receiving the highest 
dose), was observed in 24 (92%) patients.  Eighteen patients received a therapy infusion of 0.5 mg/kg of 
Ab labeled with 127-389 (median 252) mCi of 131I to deliver a planned dose of 8 Gy to the liver, in 
addition to 120 mg/kg CY over 2 days and 12 Gy TBI over 3 days, followed by matched related (MRD, 
n=9) or unrelated donor (URD, n=9) HCT.  The initial target radiation absorbed dose delivered to liver 
from radiolabeled Ab was set lower (8 Gy) than that for HLA-MRD recipients (10 Gy) since regimen-
related toxicity (RRT) with conventional transplant regimens was typically higher for patients receiving 
URD stem cells.  Mean estimated radiation absorbed doses from radiolabeled Ab were 21 + 8 Gy to 
marrow and 45 + 18 Gy to spleen, with a median of 2 (1-9.1) times greater radiation delivered to 
marrow than to liver. All patients engrafted (ANC > 500 cells/mm3) at a median of 18 (15-30) days post-
HCT.  All patients experienced at least grade II (moderate) mucositis.  Survival and morbidity outcomes 
on this study are similar to that of historical controls treated with conventional CY/TBI regimens at the 
center during the same period.  At the time of initiation of this protocol, seven of 18 patients (39%) were 
alive and disease-free at a median of 3.5 (2 to 5.5) years after transplant. Seven patients relapsed 44 - 
266 
days 
post-HCT. 
The 
estimated 
probability of relapse at 2 years is 38.9%.  
Nine patients received a dose to BM < 7 
cGy/mCi and 9 other patients received > 7 
cGy/mCi to BM.  Only 1 relapse occurred in 
the higher dose group while 6 relapses were 
seen in the lower dose cohort.  The hazard 
of relapse in the group that received < 7 
cGy/mCi to BM is higher than that in the 
higher dose (> 7 cGy/mCi) group (HR=6.30, 
95% CI 0.76-52.60, p=0.05 by log-rank test).  
These results suggest that a greater 
radiation absorbed delivered to BM may 
lead to lower post-transplant relapse rates 
Fig. 1.5:  Probability of relapse for patients with advanced AML 
who received a therapy dose of I-131-anti-CD45 Ab combined with 
CY/TBI on FHCRC Protocols #1297.  Thick solid line = absorbed 
radiation dose to BM > 7 cGy/mCi; thick dashed line = absorbed 
radiation dose to BM < 7 cGy/mCi. 
Dose to BM > 7 cGy/mCi 
Dose to BM < 7 cGy/mCi 


Protocol 2186.00 
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for patients with high-risk AML/MDS (Fig. 1.5). 
Based on our demonstration that, in the majority of patients, greater estimated radiation doses 
could be delivered to marrow and spleen compared to liver, lung, and kidney, and that significant 
supplemental doses of hematopoietic radiation could be safely combined with a conventional transplant 
preparative regimen, a trial for patients with AML in first remission receiving HLA-matched related 
marrow was then initiated.  Radiolabeled antibody was combined with BU/CY because a prospective 
randomized study in chronic phase CML had demonstrated lower toxicity with BU/CY15 while 
retrospective comparisons of BU/CY and CY/TBI for transplant of AML in first remission have shown 
similar incidences of long-term disease-free 
survival.16  In this Phase I/II study first 
remission AML patients received targeted 
irradiation delivered by 131I-BC8 Ab combined 
with targeted BU (area-under-curve, 600-900 
ng/ml) and CY (120 mg/kg).  Fifty-two of 59 
patients (88%) receiving a trace 131I-labeled 
dose of 0.5 mg/kg BC8 murine Ab had higher 
estimated absorbed radiation in bone 
marrow and spleen than in any other organ.  
Forty-six patients were treated with 102-298 
mCi 131I delivering an estimated 5.3-19 (mean 
11.3) Gy to marrow, 17-72 (mean 29.7) Gy to 
spleen, and 3.5 Gy (n=4) to 5.25 Gy (n=42) to 
the liver.  The estimated 3-year non-relapse 
mortality and disease-free survival (DFS) 
were 21% and 61%, respectively (Fig. 1.6).  These results were compared to those from 509 similar 
International Bone Marrow Transplant Registry patients transplanted using BU/CY alone.  After adjusting 
for differences in age and cytogenetics-risk, the hazard of mortality among all antibody-treated patients 
was 0.65 times that of the Registry patients (95% CI 0.39-1.08; p=.09).   
 
The encouraging results achieved with 131I-BC8 Ab and BU/CY in younger patients led us to ask 
how this approach might be applied to older AML patients, since the outcome for AML patients over 55 
is poor using standard chemotherapy, with a 5-year survival rate of <10%.17-19  As noted above, recent 
success achieving stable donor chimerism following infusion of allogeneic peripheral blood stem cells 
(PBSC) after reduced intensity conditioning regimens affords an opportunity to safely induce a graft-vs-
leukemia (GvL) effect with minimal acute morbidity.  GvL effects, however, appear to be most potent in 
patients with low tumor burdens at the time of transplantation.  Given the minimal RRT of this non-
ablative approach, we hypothesized that the anti-leukemic effect in advanced disease patients may be 
improved by the addition of targeted hematopoietic irradiation delivered by 131I-BC8 Ab to the low-
intensity conditioning regimen.  The MTD of radiation delivered via 131I-BC8 Ab combined with the non-
myeloablative regimen for older patients, however, was unknown.  We have therefore conducted a 
Phase I clinical trial of targeted hematopoietic irradiation delivered by an 131I-labeled anti-CD45 Ab (BC8) 
to determine the feasibility, safety and efficacy of this approach toward reducing the burden of disease 
before an established non-myeloablative regimen.  This dose escalation study was designed to estimate 
the MTD of 131I-BC8 Ab that can be combined with fludarabine (FLU) and low dose TBI followed by 
allogeneic transplantation.  At the time of initiation of this protocol, 51 patients aged 50 to 74 (median 
62) years old received a test infusion of BC8 Ab trace labeled with I-131.  Six patients who received a test 
dose did not go on to be treated on this study.  Two patients became positive for Human Anti-Mouse Ab 
(HAMA), two patients had reactions to the Ab and did not continue on study, one patient did not have 
Fig. 1.6: Estimates of the probability of DFS, NRM, and relapse 
among all patients who received a therapeutic dose of 131I-BC8 
antibody, followed by BU/CY. 


Protocol 2186.00 
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good uptake of the Ab with the dosimetry infusion, and one patient was hospitalized for fevers and 
pulmonary events approximately one week following the dosimetry infusion and did not recover 
sufficiently to proceed with the study. 
 
Forty five patients over 50 years of 
age with advanced AML or high-risk MDS 
(> 5% blasts), with no other treatment 
options at our Center, received a therapy 
infusion of 0.5 mg/kg of Ab labeled with 
246 to 932 mCi 131I delivering an estimated 
5.2 to 45.9 (mean 27.5) Gy to bone 
marrow, 39.6 to 155 (mean 86.1) Gy to 
spleen, and 12-24 Gy to the liver (dose-
limiting organ).  In 44 patients, this was 
followed by FLU (30 mg/m2 daily for 3 
days), 2 Gy TBI and matched related (14) 
or unrelated (30) PBSC infusion combined 
with cyclosporine and mycophenolate 
mofetil.  The first patient entered on this 
protocol had a matched related donor and 
was treated with I-131 Ab combined with 
2 Gy TBI and matched related PBSC.  At 
that time, FLU was to be added for 
patients with unrelated donors only.  The protocol was then modified to add FLU to the treatment 
regimen for all patients on this protocol.  At the time of initiation of this protocol, of the 45 patients 
treated, 11 patients were alive and disease free with the longest being 33 months post-transplant.  Two 
additional patients were alive following relapse.  Eighteen patients have died following relapse, and 14 
patients have died of other causes: 7 from infections, 5 from pulmonary causes, and 1 each from 
refractory GVHD and cerebral bleed.  The pulmonary events include 2 instances of bronchiolitis 
obliterans organizing pneumonia (BOOP), 1 alveolar hemorrhage, 1 aspiration pneumonitis leading to 
respiratory failure, and 1 resistant pneumonia that occurred approximately 2 years post treatment.  
These events represent the majority of the Grade III/IV (Bearman) toxicities that have impacted dose 
escalation/de-escalation on this study. 
 
While it remains to be determined whether this approach will reduce post-transplant relapse 
rates for older patients with high-risk AML/MDS, the results are sufficiently encouraging such that we 
now propose to combine targeted hematopoietic radiation delivered by 131I-BC8 Ab with the 
transplantation approach using haploidentical donors in an effort to improve disease control for 
advanced acute leukemia and high-risk MDS patients. Specifically, this study will assess the feasibility 
and safety for patients with advanced AML/ALL/MDS treated with a starting dose of 12 Gy 131I-BC8 Ab 
delivered to the normal organ receiving the highest dose, combined with FLU and 2 Gy TBI, plus CSP, 
followed by haploidentical allogeneic HCT and immunosuppression using tacrolimus and MMF.  
Nonrelapse-related mortality (NRM) will be the major study endpoint to determine the maximum 
tolerated dose of radiation when used as part of this regimen.  The study will also estimate the rates of 
disease response and disease-free survival, and determine rates of donor chimerism and GvHD. 
   
2.0  OBJECTIVES 
1. To estimate the maximum tolerated dose of radiation delivered via 131I-BC8 antibody when 
combined with pre- and post-transplant CY, FLU, 2 Gy TBI, tacrolimus, MMF, and a 
 
PFS 
NRM 
Relapse 
OS 
Fig. 1.7: Estimates of the probability of PFS, NRM, and relapse 
among all patients who received a therapeutic dose of 131I-BC8 Ab, 
followed by FLU/TBI. 
 


Protocol 2186.00 
Page 18 of 50 
haploidentical allogeneic hematopoietic marrow transplant in patients who have advanced AML. 
ALL, or high risk MDS.  
2. To estimate rates of immune reconstitution, engraftment, and donor chimerism resulting from 
this combined preparative regimen. 
3. To determine rates of disease relapse, acute GvHD, and day 100 disease-free survival in patients 
receiving 131I-BC8 Ab combined with CY, FLU, 2 Gy TBI, tacrolimus, MMF, and HLA-haploidentical 
allogeneic HCT. 
 
3.0  SUBJECT SELECTION  
 
A.  Inclusions 
1. Patients with advanced AML or ALL defined as beyond first remission, primary refractory 
disease, or evolved from myelodysplastic or myeloproliferative syndromes; or patients with 
MDS expressed as refractory anemia with excess blasts (RAEB), refractory cytopenia with 
multilineage dysplasia (RCMD), RCMD with ringed sideroblasts (RCMD-RS), or chronic 
myelomonocytic leukemia (CMML). 
2. Patients not in remission must have CD45-expressing leukemic blasts.  Patients in remission do 
not require phenotyping and may have leukemia previously documented to be CD45 negative 
(because in remission patients, virtually all antibody binding is to non-malignant cells which 
make up > 95% of nucleated cells in the marrow).  
3. Patients must be > 18 years of age. 
4. Patients should have a circulating blast count of less than 10,000/mm3 (control with 
hydroxyurea or similar agent is allowed). 
5. Patients must have a creatinine clearance greater than 50/ml per minute by the following 
formula (test must be performed within 28 days prior to registration):    
 
CrCl= (140-age) (Wt in Kg) x 0.85 (female) OR 1.0 (male) 
72 x serum Cr* 
 
6. Patients must have normal hepatic function (bilirubin, AST and ALT < 2 times the upper limit of 
normal).   
7. Karnofsky score > 70 or ECOG < 2. 
8. Patients must have an expected survival of >60 days and must be free of active infection. 
9. Patients must have a related donor who is identical for one HLA haplotype and mismatched at 
the HLA-A, -B or DRB1 loci of the unshared haplotype with the exception of single HLA-A, -B or 
DRB1 mismatches.   
 
B.  Exclusions   
1. Circulating antibody against mouse immunoglobulin (HAMA). 
2. Prior radiation to maximally tolerated levels to any critical normal organ. 
3. Cross-match positive with donor 
4. Patients may not have symptomatic coronary artery disease and may not be on cardiac 
medications for anti-arrhythmic or inotropic effects. 
5. Patients with the following organ dysfunction: 
a. Left ventricular ejection fraction <35% 
b. Corrected DLCO <35% and/or receiving supplemental continuous oxygen  


Protocol 2186.00 
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c.   Liver abnormalities: fulminant liver failure, cirrhosis of the liver with evidence of portal 
hypertension, alcoholic hepatitis, esophageal varices, hepatic encephalopathy, 
uncorrectable hepatic synthetic dysfunction as evidenced by prolongation of the 
prothrombin time, ascites related to portal hypertension, bacterial or fungal liver 
abscess, biliary obstruction, chronic viral hepatitis, or symptomatic biliary disease. 
6. Patients who are known seropositive for HIV. 
7. Perceived inability to tolerate diagnostic or therapeutic procedures, particularly treatment in 
radiation isolation. 
8. CNS involvement with disease refractory to intrathecal chemotherapy and/or standard cranial-
spinal radiotherapy. 
9. Women of childbearing potential who are pregnant (β-HCG+) or breast feeding 
10. Fertile men and women unwilling to use contraceptives during and for 12 months post-
transplant.  
11. Inability to understand or give an informed consent. 
 
4.0  DONOR SELECTION 
 
 
 
Donors must meet HLA matching criteria as outlined under section 5.A.9 as well as standard Seattle 
Cancer Care Alliance (SCCA) criteria for Allogeneic bone marrow donation.  Preference should be 
given to donors who are mismatched at the HLA-A, -B and –DRB1 loci.  
 
 
For the very few occasions where we identify a donor HPC-A from a non-NMDP source, we have 
procedures in place through our unrelated donor office to collect the information necessary to 
comply with donor testing, screening, and declaration of donor eligibility according to 21 CFR 1271.  
We require that the donor testing be performed by a U.S. CLIA approved laboratory.  In the very rare 
case where the donor testing is not able to be performed in a CLIA approved laboratory, or there is 
confirmatory testing that needs to be performed, or for any donor identified from Europe and at risk 
for CJD, we note this on the donor screening form and require that the unrelated donor Medical 
Director or the attending physician approves the use of the donor HPC-A product under Urgent 
Medical Need. 
 
5.0  INFORMED CONSENT OF SUBJECTS AND DONOR 
 
 
Subjects will be referred to University of Washington/Seattle Cancer Care Alliance for consideration 
of HCT and will be completely evaluated. The protocol should be discussed thoroughly with subject 
and family, and all known risks will be described. The procedure and alternative forms of therapy 
will be presented objectively and the risks and hazards of the procedure explained. Consent will be 
obtained using forms approved by the Institutional Review Board of the Fred Hutchinson Cancer 
Research Center. A summary of the conference should be dictated for the medical record detailing 
what was covered. 
Donors will be consented according to clinical consenting practices at SCCA (related donors) or 
NMDP or at other donor centers (unrelated donors). 
 
6.0  SUBJECT REGISTRATION 
 
 


Protocol 2186.00 
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Patients will be assigned to a protocol by the Clinical Coordinator who will register the patient with 
the Registration Office, (206) 667-4728, between 8:30 am and 4:00 pm, Monday through Friday.  
After hours, the Registration Office can be reached by paging (206) 995-7437.   
 
7.0  PLAN OF TREATMENT 
 
Treatment will be initiated in the outpatient department for the dosimetric dose of 131I-BC8 antibody 
and subsequent gamma scans.  All patients will be admitted to lead-lined radiation isolation rooms 
at the University of Washington Medical Center (UWMC) for the therapeutic dose of 131BC8 antibody 
and will remain in isolation for approximately 5-10 days, as described under section 7.C.1.d.  
Patients will then continue transplant regimen on an outpatient basis unless clinically indicated. 
 
A. Outline of treatment plan (see Table 7.1) 
The day of treatment is listed only to give a loose time-frame.  An individual study calendar is 
created for each patient, with modifications permitted in consideration of clinical and logistical 
needs.  It is anticipated that stem cells will be infused approximately 14 days after delivery of the 
131I-BC8 therapy dose. 
 
~Day -23 
Dosimetric Dose 131I-BC8 Antibody Rx 
 
~Day -22 to -20 
Gamma scans  
 
~Day -14 
Therapeutic Dose 131I-BC8 Antibody Rx 
 
Days -6, -5 
FLU 30 mg/M2 iv qd 
CY 14.5 mg/kg iv qd 
Mesna (dosed at 100% CY dose) 
 
Days –4 to –2 
FLU 30 mg/M2 iv qd 
 
Day –1 
200 cGy TBI at 6-7 cGy/min   
 
Day 0 
Infuse processed marrow allograft 
 
Day +3 
CY 50 mg/kg 
(Must be administered 60-72 hr post-BMT) 
Mesna (dosed at 100% CY dose) 


Protocol 2186.00 
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Day +4 
Begin Tacrolimus 1 mg IV and MMF 15 mg/kg po tid 
Begin G-CSF (5 µg/kg/d) IV or SC, continue until ANC>500/mm2 x 3d 
 
Day +28 
Assess chimerism in peripheral blood  
 
Day +35** 
Discontinue MMF 
 
Day +56 
Assess chimerism in peripheral blood 
If day +28  <50 % donor 
 
Day +84 
Assess disease status; assess chimerism in peripheral blood 
Immune reconstitution studies 
If no GVHD, start Tacrolimus taper 
 
Day +180 
Discontinue Tacrolimus (under care of primary hematologist/oncologist) 
 
**MMF may be discontinued earlier than day+35 at the discretion of the study doctor in patients  
    who have no GVHD 
 
 
Table 7.1:  Outline of treatment plan 
 
Days before transplant 
 
~23 ~14 
Radiation Isolation 
−6 −5 −4 −3 −2 −1 
Antibody test dose ● 
 
 
 
 
 
 
 
Antibody therapy dose 
 
● 
 
 
 
 
 
 
Fludarabine 
 
 
● 
● 
● 
● 
●  
Cyclophosphamide and 
Mesna 
 
 
● 
●  
 
 
 
Total body irradiation  
 
 
 
 
 
 
● 
Bone Marrow Transplant: Day 0 
 
Days after transplant 
3 
4 
35 
84 
180 
**Cyclophosphamide and Mesna 
● 
 
 
 
 
G-CSF  
Start* 
 
 
 
MMF#  
Start 
Stop# 
 
 
Tacrolimus  
Start 
→ 
Taper 
Stop 
*G-CSF will continue until absolute neutrophil count (ANC) is greater than 500/mm2 for three 
consecutive days. 
** Corticosteroids may not be used as an anti-emetic agent and should not be administered until 24 
hours after the completion of post-transplantation cyclophosphamide, unless used for adrenal support 
or during a medical emergency (e.g. treatment of anaphylaxis). 


Protocol 2186.00 
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# MMF may be discontinued earlier than day +35 at the discretion of the study doctor if patient has no 
GVHD 
 
B. 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. 
 
C.  Radiolabeled Antibody Evaluation (Biodistribution Dose) 
1. Biodistribution study 
 
 
The radiation absorbed doses for each organ delivered by 131I-labeled Ab will be estimated for 
each patient prior to administration of therapeutic amounts of 131I-labeled Ab.  For this purpose 
1 to 10 mg of Ab will be labeled with 4-10 mCi 131I.  The 131I-labeled Ab will be mixed with 
unlabeled Ab to achieve a total dose of 0.5 mg/kg ideal body weight for patients at or above 
ideal body weight, or actual body weight for patients below ideal body weight. Estimates of 
radiation absorbed doses for each organ will be calculated after the infusion.  These estimates 
will be used to determine the amount of 131I with which the therapeutic dose of isotope-Ab 
conjugate will be labeled. The therapy dose is labeled with larger amounts of 131I, as determined 
by the cGy/mCi 131I estimates calculated from the biodistribution Ab infusion for the normal 
organ receiving the highest dose, the dose level at which the patient is to be treated, and the 
current limit of radiation dose delivered to marrow.   
 
a) Iodination and Characterization of Labeled Antibody 
Abs will be labeled in the radiochemical facilities of the Division of Nuclear Medicine at 
the University of Washington, using established techniques (Chloramine-T) for the 
radioiodination of antibodies for human use.  Following the labeling procedure, the 
antibody will be sterilized by filtration through a 0.1 μm filter and tested for endotoxin 
content.  Since antibody labeled with therapeutic amounts of 131I must be infused within 
several hours of labeling to avoid radiolysis, the results of sterility testing will not be 
available at the time of antibody infusion.  131I-labeled antibody immunoreactivity will be 
determined following each labeling procedure. 
 
b) Non-radioactive Iodine Solution 
The thyroid will be blocked with Lugol’s Strong Iodine Solution, 5 drops three times daily 
PO (depending on patient weight), or saturated solution of potassium iodide (SSKI) 4 drops 
three times daily PO, starting two days prior to the morning of the biodistribution dose of 
labeled antibody and continuing for three weeks following the last infusion (unless limited 
by other medical conditions). 
 
c) Vital signs 
Vital signs will be obtained prior to infusion and monitored every 30 minutes for the first 
2 hours and then hourly until the infusion is complete or more often if clinically indicated. 
 
d) Antibody administration 
 
Radiolabeled Ab will be administered through a central venous catheter. Premedications 
will include: 
i. 
acetaminophen 650 mg PO 


Protocol 2186.00 
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ii. diphenhydramine 25-50 mg IV or ranitidine 50mg IV over 20-30 minutes for 
patients who do not tolerate diphenhydramine 
iii. ondansetron 8 mg IV 
iv. hydrocortisone 100 mg IV.   
v. D51/2NS to start with the Ab infusion and to continue until the antibody 
infusion is complete.   
vi. Hydrocortisone 100 mg IV will be repeated every 2 hours until the 
completion of the infusion.   
 
The mixture of 131I-labeled BC8 Ab (4-10 mCi) will be diluted to approximately 25 ml and 
infused intravenously at 7.5 mg/hour.  Infusion of the biodistribution dose will occur at the 
UW Medical Center. 
 
Specifics of Radiolabeled Antibody Administration - Therapeutic Dose: The therapeutic dose 
of 131I-BC8 Ab will be according to the same schedule as the trace-labeled (biodistribution) 
dose.  The patient will continue taking non-radioactive iodine drops following the 
biodistribution dose until a minimum of three weeks after the therapeutic infusion (unless 
limited by other medical conditions).  The patient, when able, will be instructed in drawing 
his or her blood samples from a central venous catheter and in taking his or her own vital 
signs using an automated blood pressure machine.  The patient will be admitted to a special 
lead-lined isolation room with appropriate shielding to minimize exposure of health care 
personnel and to prevent contamination of the room with radioisotope at UWMC on the 
morning of the therapeutic infusion (generally day –12) and will remain there until total 
body activity is less than 30 mCi 131I, as estimated by a measurement of < 7 mR/hour one 
meter from the patient or as directed by the UWMC Radiation Safety Officer based on the 
public dose calculation from Nuclear Regulatory Commission Regulatory Guide 8.39.  All 
blood, urine, and tissue samples containing radioisotopes will be clearly identified as such. 
Samples containing high levels of activity (>50 uCi) will be transported in shielded 
containers. All samples will be processed by personnel trained in the use of radioisotopes. 
The patient can then be discharged, and can remain an outpatient to complete treatment 
unless admission is medically indicated. 
 
e) Antibody and blood samples 
Aliquots of the infusion mix will be taken prior to infusion, to be used as quantitative 
standards for assessment of counts in blood and marrow.  A blood sample (2-5ml) will be 
obtained at the time of marrow biopsy (see section 7.C.1.g below).  This sample will be 
obtained at the SCCA.  These samples will be used for analysis of Ab clearance. 
 
f) 
Gamma scanning 
Serial gamma camera images will be obtained at 0 hours (i.e. end of infusion) on day 0, 
and on at least two of the following days: day 1, 2, and 3 post infusion of antibody, to be 
stored on removable soft disks and magnetic tape.  Images will include anterior and 
posterior head/neck, anterior and posterior chest with upper humeri, abdomen, and pelvis  
with upper femurs.  At each imaging time a source of 131I will be counted and imaged on the 
gamma camera in a fixed geometry to account for radioactive decay and changes in camera 
sensitivity during the study so that body tissue activity curves and areas of interest, etc. can 
be temporally compared more accurately.  Whole body counts will be measured at each 
time point by a gamma probe. 


Protocol 2186.00 
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Images will be inspected for general body distribution of activity, especially liver, kidney, 
bone marrow and spleen, and relative counts at various times over the organs for any organ 
with activity above background will be recorded and compared to the fixed 131I source. 
For all patients, reporting of dosimetry will include the MIRD/OLINDA-EXM calculations 
for all 25 organs included in the program.  These calculations will include the use of 
quantitative data from serial gamma camera images performed after the biodistribution 
dose of trace I-131-BC8 antibody for all organs with activity above background.  Specifically, 
we will include estimated dosimetry for thyroid and bladder, although neither will be 
considered a dose-limiting organ.   
 
g) Marrow biopsies 
A unilateral bone marrow biopsy (no aspirate) will be performed at least one time on 
the day after antibody infusion (i.e. ~ 24 hours).  If that sample is judged to be inadequate, a 
second sample may be obtained within 48 hours of the infusion.  This will be performed in 
the SCCA Procedure Suite.  Small sections will be weighed and counted via gamma counter 
for 131I content, with comparison to a quantitative standard of the infusion mix, allowing 
calculation of % injected dose/gram marrow of labeled BC8 Ab. The biopsy section will be 
collected using NO FIXATIVE agents.  A research technician from the Press Laboratory will 
prepare the research portion for the Press Lab and send the remaining portion to SCCA 
Pathology for morphology.  A portion of the biopsy may be analyzed using flow cytometry 
(for detection of bound antibody). 
 
h) Laboratory samples 
A blood sample for HAMA will be obtained the day prior to planned therapy infusion.  
Blood samples (CMP and CBC/CBD) will be obtained pre-infusion, at the end of infusion and 
on day 1 for CBC, BUN, creatinine, AST, ALT, and bilirubin.   
 
2. Requirements for Therapy 
Patients must be HAMA negative on a blood sample obtained the day prior to therapy.  All 
patients will be eligible to receive a therapy dose of 131I-BC8 Ab unless they are positive for 
HAMA prior to the planned dose, even if their estimated radiation dose to marrow is less than 
liver.  In previous patients receiving biodistribution doses on our other studies, the estimated 
doses to marrow and spleen were greater than doses to lung, kidney and total body even in 
those few patients whose marrow dose was slightly lower than liver dose.  Therefore, for this 
group of patients who would not tolerate a conventional preparative regimen, we will proceed 
with a therapy dose of 131I-BC8 Ab regardless of the ratio of radiation delivered to marrow as 
compared to liver. 
 
D. Selection and Timing of 131I-Labeled Antibody Dose for Therapy 
 
131I-labeled Ab for therapy will be administered to each patient in a protein dose and infusion 
schedule identical to that used for dosimetry studies in the patient.  This dose will be administered 
following the patient’s inpatient admission to radiation isolation at the University of Washington 
Medical Center.  The therapeutic dose will be generally infused 6 to 14 days after the trace-labeled 
biodistribution dose, but can be delayed further if necessary because of clinical circumstances (as 
long as the patient has not developed HAMA).  In our previous patients, serum Ab concentrations 
after the dosimetry infusion have declined to much less than 10% of their initial level by this time.  
At least 6 days is required to allow calculation of radiation absorbed dose and ordering of the 


Protocol 2186.00 
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therapeutic dose of isotope.  The day of administration of the therapy dose will generally be day –
14. 
 
1. Selection of Isotope Dose 
 
The total amount of 131I administered will be individualized based on the biodistribution of the 
trace-labeled dose in each patient.  The dose of 131I will be calculated to deliver the 
predetermined radiation dose to the normal critical organ (almost always liver) predicted to 
receive the highest estimated dose of radiation.  For each patient, the dose level at which the 
patient will be treated will be discussed by the P.I. (or his designee) and Dr. Rajendran (or his 
designee).  In some patients with a high bone marrow: liver radiation dose ratio, there may be 
the possibility of adversely affecting engraftment by damage to the bone marrow supportive 
stroma resulting from delivering too much radiation to the marrow.  These patients may have 
the 131I dose limited to that which would deliver the currently stipulated maximum dose to 
marrow (see further discussion under section 12.2.B). 
 
2. Timing of Marrow Infusion 
For patients with estimated marrow biologic half-times of less than 96 hours as estimated 
by the biodistribution dose, donor marrow will be infused ~14 days after the therapy dose of 
131I-BC8 Ab.  In the unlikely event that a patient has an estimated marrow biologic half-time 
longer than 96 hours, marrow infusion will be delayed until the estimated radiation dose rate in 
marrow is < 2 mR/hour, and the actual number of days prior to marrow infusion that the 
therapy dose of Ab is administered will be adjusted accordingly. 
 
E. Conditioning regimen 
1. Fludarabine:  
a. Description:  Fludarabine monophosphate is a purine antimetabolite that, after 
administration, undergoes rapid conversion in plasma to the nucleoside 2-fluoro ara-A 
(F-araA). F-araA subsequently enters cells where it is phosphorylated to F-araATP and 
the monophosphate F-araAMP.  Once activated, F-araATP inhibits DNA polymerase and 
ribonucleotide reductase. The monophosphate F-araAMP, once incorporated into DNA, 
is an effective DNA chain terminator. Following IV administration, the drug is 
metabolized to 2-F-araA and widely distributed in tissues. 2-F-araA is excreted primarily 
in urine and has a terminal elimination half-life of 7-12 hr. 
b. Storage and Administration:  Fludarabine monophosphate is commercially available as a 
50 mg/vial which is reconstituted with 2 ml of sterile water, resulting in a 25mg/ml 
solution. The desired dose is further diluted to concentrations of 0.04-1 mg/ml in 
normal saline or 5% dextrose (50-100ml) for injection and administered by IV infusion. 
Fludarabine will be administered by IV infusion over 30 minutes in a dose of 30 
mg/M2/day on days -6 to -2.        
 
2. Cyclophosphamide (14.5 mg/kg Adjusted BW*, unless IBW>ABW, then ABW per Standard 
Practice Guidelines)  
a. Description: CY is an alkylating agent which prevents cell division primarily by cross-
linking DNA strands. CY is cell cycle non-specific. CY is not stem cell toxic. 
b. Storage and administration: CY for injection is commercially available in 2000mg vials 
which are reconstituted with 100 ml sterile water. The concentration of the 
reconstituted product is 20mg/ml. The calculated dose will be diluted further in 250-500 


Protocol 2186.00 
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ml of Dextrose 5% in water. Each dose of CY will be administered as an IV infusion over 1 
hr on day -6 and day -5. Cyclophosphamide pre- and post hydration with normal saline 
will be administered outpatient for 2 hours pre- and 8 hours post cyclophosphamide, or 
inpatient for 4 hours pre- and 8 hours post cyclophosphamide.   
*Adjusted BW = [(ABW – IBW) 0.25] + IBW 
 
3. Mesna:  
a. Description: Mesna is a prophylactic agent used to prevent hemorrhagic cystitis induced 
by the oxasophosphorines (CY 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. Administration and patient monitoring will be per standard 
practice.  
b. Storage and Administration:  Mesna is commercially available in 200 mg, 400 mg and 
1000 mg vials containing a 100 mg/ml solution. Each dose of mesna will be diluted 
further in 50 ml of normal saline to be infused over 15 min.  Mesna dose will be based 
on the cyclophosphamide dose being given.  The total daily dose of mesna will be equal 
to 100% of the total daily dose of CY. 
 
4. Total body irradiation (200 cGy) will be given on day –1 at a rate of 6-7 cGy/min per Standard 
Practice Guidelines. Dosimetry calculations are performed by the radiation therapist. Refer to 
Standard Practice Manual for information about administration, toxicity, and complications. 
 
5. As the testes may serve as a sanctuary for ALL, male patients with ALL will receive 1600 cGy of 
testicular radiation per Radiation Oncology. The testicular radiation can be given concurrently 
with conditioning.  
 
F. Bone marrow infusion 
The donor marrow harvest will occur on Day 0 per standard procedures.  The total nucleated cell 
(TNC) goal will be based on the recipient’s ideal body weight per standard practice protocol. In the 
absence of ABO or other red cell incompatibility, the marrow product will be directly infused into 
the recipient without manipulation.  If major or minor ABO incompatibility exists with significant 
donor or recipient antibody titers, the product will be manipulated according to standard practice 
procedures. 
 
G. Post-transplant immunosuppression 
1. Cyclophosphamide:  A single dose of CY (50mg/kg Adjusted BW*, unless IBW>ABW, then ABW 
per Standard Practice Guidelines) will be given on day +3 after transplant (within 60-72 hr of 
marrow infusion). CY will be given as an IV infusion over 1-2 hr (depending on total dose) with 
Mesna and appropriate hydration as described above in Section 7.E.2.  Monitoring of urine 
output and for hematuria will be performed similarly. 
a. Corticosteroids may not be used as an anti-emetic agent and should not be administered 
until 24 hours after the completion of post-transplantation cyclophosphamide, unless used 
for adrenal support or during a medical emergency (e.g. treatment of anaphylaxis). 


Protocol 2186.00 
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2.   Tacrolimus and MMF: 
a. Description: Tacrolimus, also known as FK-506, is a macrolide immunosuppressive agent. 
Tacrolimus inhibits lymphocytes by forming a complex with FKBP-12, calcium, and 
calmodulin, leading to the decrease in the phosphatase activity of calcineurin. Calcineurin 
mediates the first intracellular signal required for T-cell activation after antigen recognition 
by the T-cell receptor. This drug is used with corticosteroids for prophylaxis of organ 
rejection in patients receiving allogeneic liver transplants and for prophylaxis of GvHD in the 
setting of HCT. It is also used for immunosuppression after kidney, cardiac, pancreas, 
pancreatic islet cell and small bowel transplantation. This drug is well-absorbed orally. It is 
metabolized in the liver by unknown mechanisms, but demethylation and hydroxylation 
have been proposed based on in vitro studies. The metabolized products are excreted in the 
urine.  
b. Storage and administration: Tacrolimus is commercially available in capsule form (0.5, 1.0 
and 5.0 mg) and as a sterile solution in 1mL ampules (5mg/mL) for IV administration. 
Starting on day +4, tacrolimus will be given at a dose of 0.03 mg/kg/d (for patients <30 kg) 
and 1mg/d (for patients >30kg) IV over 1-2 hr and should be changed to a PO dosing 
schedule as tolerated once a therapeutic level (5-15 ng/ml) is achieved.  Serum levels of 
tacrolimus should be measured on day +8 or as frequently as needed to establish a 
therapeutic level and then weekly thereafter with the dose adjusted accordingly to maintain 
a level of 5-15 ng/ml.  Tacrolimus will be tapered after day +86 (adapted dose-reduction to 
be discontinued by day +180) if there is no evidence of GVHD. 
  
3. Mycophenolic Acid Mofetil (MMF): 
a. Description: MMF is the morpholinylethylester prodrug of the active immunosuppressant 
mycophenolic acid (MPA). This active metabolite is a noncompetitive, reversible inhibitor of 
inosine monophosphate dehydrogenase, particularly the type II isoform that is more 
prominent in activated lymphocytes. As a result of the inhibition of de novo purine 
synthesis, proliferation of T- and B-lymphocytes is blocked and antibody production is 
inhibited.  There are no pharmacokinetic interactions with ganciclovir, cotrimoxazole, oral 
contraceptives or cyclosporine. 
b. Storage and administration: MMF is commercially available in an oral and an intravenous 
formulation. The oral formulation is supplied in 250 mg hard gelatin capsules and can be 
stored at room temperature. MMF for iv administration is supplied as a lyophilized powder 
in a glass vial containing the equivalent of 500 mg. Starting on day +4, MMF will be given 
orally or intravenously at a dose of 15 mg/kg tid.  If orally, doses will be rounded to the 
nearest 250 mg (capsules are 250 mg).  
 
H. Modification of immunosuppression for early disease progression or relapse 
 
Guidelines provided in this section are for patients who demonstrate either: i) progression of 
stable disease present at the time of transplant or ii) relapse of their underlying disease before 
discontinuation of immunosuppression has been completed. Patients fulfilling the criteria for relapse or 
progression should undergo a reduction in immunosuppression after careful evaluation for GvHD. In the 
event that patients with early disease progression or relapse do not have GvHD, immunosuppression 
should be discontinued. Persistence of stable, underlying disease itself does not mandate accelerated 
reduction of immunosuppression. 
 


Protocol 2186.00 
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I. 
Growth Factor Support 
 
Patients will receive G-CSF at 5 µg/kg/d [rounded to the nearest vial size (300 µg or 480 µg )] SC 
starting at day +4 and continuing until the ANC >500/mm2 for 3 consecutive days. 
 
J. 
Infection prophylaxis and therapy 
 
Patients will receive prophylaxis and therapy for bacterial, fungal and viral infections according 
to Standard Practice Guidelines.  Standard CMV monitoring and prophylaxis should commence at the 
time of transplant and should continue as appropriate. 
 
K. Intrathecal Therapy and Treatment of CNS Disease 
 
All patients will have a diagnostic lumbar puncture performed during the initial pre-transplant 
workup in the outpatient department.  Patients with history of CNS disease or evidence of current CNS 
leukemic involvement will not be excluded, and may be considered for instillation of methotrexate as 
per the Standard Practice Manual.  This regimen may be modified by the Attending Physician as clinically 
indicated.  Patients with evidence of CNS leukemic involvement will also be considered by the Attending 
Physician to receive up to 18 Gy (10 fractions of 1.8 Gy) cranial or cranial-spinal irradiation as 
consolidation if indicated, beginning approximately day 32 post transplant or as soon as engrafted, 
whichever comes later.   
 
8.0  PATIENT AND DONOR EVALUATION 
 
A. HLA-typing of patient and potential donors (pre-transplant evaluation and secondary endpoint) 
As broad a range of potential donors as possible should be considered.  Included would be parents, 
siblings, and eligible children.  HLA-typing should be at least intermediate resolution for HLA-A, HLA-
B and HLA-DRB1.    
Blood samples should be sent to the Clinical Immunogenetics Lab (CIL) for HLA-typing (green top 
tube, 10 cc). 
 
B. Donor 
Donors will be evaluated according to Standard Practice Guidelines, including blood sample storage 
by CIL for subsequent determination of donor chimerism.  
 
C. Patient - Pre-transplant Baseline Evaluation  
Patient work-up will be in accordance with Standard Practice Policy Manual Evaluation Guidelines 
for Marrow Transplant Patients, with the following additional requirements: 
 
a. 10 cc blood in red top tube labeled “Protocol 2186” to Press Lab (D3-395, Thomas Building) 
for analysis of HAMA (Human Anti-Mouse Antibody). 
b. Thyroid function (TSH) test. 
c. CT scan of chest and abdomen for calculation of organ volumes (lungs, liver, spleen, 
kidneys).  Other imaging studies as clinically indicated. 
d. Unilateral bone marrow biopsy and aspirate for pathology, flow cytometry, and cytogenetics 
within 30 days prior to consent signing/enrollment. 
e. Heparinized blood sample (green top tube, 10 cc) as a pre-transplant reference for 
subsequent determination of donor chimerism sent to the CIL.   
 


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D. Patient Evaluation During Conditioning and for First 100 Days Post-Transplant 
 
See Standard Practice Policy Manual for standard "Evaluation Guidelines for Marrow Transplant 
Patients." Data from these standard laboratory studies, other clinically indicated studies, and clinical 
assessments by the primary care team will be reviewed regularly to assess for regimen-related toxicity, 
occurrence of Serious Adverse Events, and other potential post-transplant complications such as GvHD 
and infections. 
 
The following additional studies and tests will be performed (within ±7 days of target days listed below): 
1. Heparinized blood 10 cc to hematopathology for quantitation of T cell, NK cell and granulocyte 
chimerism on days +28, +56 (only if day +28  <50 % donor), and +84. 
2. Bone marrow aspirate to chimerism lab for chimerism studies on approximately days +28 and 
+84. 
3. Bone marrow aspirate (and biopsy if unable to obtain adequate aspirate sample) to pathology 
on approximately days +28 and +84.  Aspirate to flow cytometry at each time point and to 
cytogenetics, if patient’s disease has a known cytogenetic abnormality.  
4. Thyroid function test (TSH) at approximately day +84 workup. 
5. Chronic GvHD screening between days 80 and 100 post-transplant. 
 
 
Following day +100 or discharge from the SCCA, patients will return to their primary care 
physicians under the guidance of the FHCRC/SCCA Long-Term Follow-Up After Hematopoietic Stem Cell 
Transplant General Guidelines for Referring Physicians, with additional recommendations for thyroid 
testing (and initiation of treatment if clinically indicated) at 6, 9, 12, 18 and 24 months after 
transplant, and then annually if still normal.  Patient follow-up will be performed primarily by the FHCRC 
Long-Term Follow-Up Department under the FHCRC/SCCA Master Protocol for Collection of Clinical Data 
and Storage of Leftover Specimens from Patients Treated According to FHCRC Protocols (Protocol 
#0999.209).  The following data collected through this mechanism will be recorded for purposes 
of this study at 6, 9, 12, 18 and 24 months post transplant: 
 
1. Survival. 
2. Disease status. 
3. Hypothyroidism. 
4. Selected blood counts (WBC, hemoglobin, hematocrit, platelets). 
5. Renal (creatinine, BUN) and hepatic (Bilirubin, AST, ALT) laboratory values. 
6. Presence/treatment of chronic GVHD. 
7. Serious adverse events. 
8. Secondary malignancies. 
 
Any of these data that are unavailable through standard long-term follow-up will be requested directly 
from the patient or local physician.  After the two-year follow-up time point, we will continue to monitor 
any changes to survival and disease status reported under the standard long-term follow-up protocol, 
and will record this data for long-term analysis and reporting. 
 
9.0  TOXICITIES AND COMPLICATIONS 
 
A. 
131I-BC8 Antibody  
 
131I-BC8 Ab will be given at a dose of 0.5 mg/kg ideal body weight, or actual body weight for 
patients below ideal body weight.  The Ab itself can cause side effects including fever, chills, nausea, 


Protocol 2186.00 
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vomiting, diarrhea, hypotension, dyspnea, joint pain, rash, and anaphylaxis.  The biodistribution dose is 
labeled with 4-10 mCi 131I, which by itself does not cause symptoms.  This dose is usually administered as 
an outpatient in the UWMC General Clinical Research Center (GCRC) or current treating location.  
Patients who are not stable at the end of infusion are admitted for overnight observation at University 
Hospital.  The therapy dose of 131I can cause nausea and vomiting, in addition to myelosuppression and 
other organ toxicities seen with high dose radiation. 
 
Two separate sorts of toxicities are anticipated, those due to antibody infusions and those due 
to the radiation delivery and combined preparative regimen.  
 
1. Toxicity Attributable to Monoclonal Antibody Infusions: Allergic reactions to administration of 
foreign mouse protein may include fever, urticaria, bronchospasm, anaphylaxis, Arthus reaction, 
vasculitis and serum sickness.  In addition, rapid infusion of Ab may produce pulmonary, renal or 
hepatic toxicity as a result of lysis or agglutination of circulating cells.  Table 9.1 describes the 
grading of the most common acute toxicities due to Ab infusion.   
 
Table 9.1: Grading of Acute Toxicities due to Antibody Infusion (from NCI CTCAE version 3.0): 
 
 
Modifications for Acute Toxicity: Patients experiencing acute allergic type toxicity during Ab 
infusion will have the infusion slowed or terminated.  If grade 2 allergic toxicity is encountered, 
the infusion should be paused, the patient treated as indicated below, and the infusion not 
restarted until symptoms have subsided.  If grade 3 allergic toxicity is encountered and does not 
resolve using measures described above, the infusion must be terminated and not-restarted, 
and the patient will be off protocol. Other grade 2 or 3 acute toxicity may be treated and the 
infusion restarted.  If toxicity persists or progresses, the infusion will be terminated.  Patients 
with grade 4 acute toxicity will have the infusion stopped and further participation in the study 
will be terminated.   
 
Potential acute side effects and their planned management are as follows: 
Fever: 
acetaminophen 650 mg (or 15 mg/kg) PO every 4 hours PRN 
Rigors: 
meperidine 25-50 mg IV (or 0.5 – 1 mg/kg) every 2-4 hours PRN 
Pruritus: diphenhydramine 25-50 mg (or 1 mg/kg) PO or IV every 2-4 hours PRN or 
ranitidine 50mg IV over 20-30 minutes for patients who do not tolerate 
diphenhydramine 


Protocol 2186.00 
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Nausea: lorazepam 0.5-2 mg (0.05 mg/kg) IV every 4 hours PRN 
diphenhydramine 25-50mg (1 mg/kg) IV every 4 hours PRN or  
ranitidine 50mg IV over 20-30 minutes for patients who do not tolerate 
diphenhydramine 
 
ondansetron 8mg IV every 8 hours for first 24 hours from start of infusion, 
then every 8 hours PRN for nausea. 
Cough, chest or throat tightness, wheezing: 
 
diphenhydramine and hydrocortisone may be repeated 
 
albuterol nebulizer 2.5–5 mg up to every 1-2 hours PRN 
Anaphylaxis:  Cessation of antibody infusion and treat per institution standards 
 
Hepatic and/or renal toxicity will not be evident during the antibody infusion but instead will be 
determined by laboratory samples obtained at the end of infusion and the following day.  If a 
patient experiences grade 3 hepatic or renal toxicity after the biodistribution dose, 
determination of whether or not the patient can proceed to the therapy dose will be made by 
the P.I. or his designee in consultation with the attending physician, and will depend in part 
upon the rate of recovery from the laboratory abnormalities.  A patient experiencing grade 4 
hepatic or renal toxicity after the biodistribution dose will not receive the therapy dose and will 
be treated on an alternate protocol. 
 
2. Long-Term Toxicities: Hypothyroidism is the most common long-term effect of radiation 
exposure resulting from the 131I therapy dose and has been seen in approximately 70% of 
patients receiving this treatment.  Some incidence of avascular necrosis (AVN) has been seen in 
patients following treatment with 131I-BC8; however, it is not clear whether this represents any 
increase from AVN rates typically seen following transplant and use of prednisone for treatment 
of GVHD. 
 
B. Fludarabine  
 
Clinical toxicities of fludarabine monophosphate include: myelosuppression, primarily 
lymphopenia and granulocytopenia, alopecia, rash, dermatitis, nausea, vomiting, anorexia, 
stomatitis, diarrhea, somnolence, fatigue, peripheral neuropathy, mental status changes, 
cortical blindness, hepatocellular toxicity with elevation in serum transaminases, and interstitial 
pneumonitis. These effects are reversible when the drug is discontinued.  Immunosuppression 
observed with the use of fludarabine increases the risk of infection which can be life-
threatening. 
 
C. Cyclophosphamide 
Clinical toxicities of CY include alopecia, nausea and vomiting, headache and dizziness, 
hemorrhagic cystitis, cardiotoxicity, immunosuppression, myelosuppression, pulmonary fibrosis, 
increased hepatic enzymes and syndrome of inappropriate anti-diuretic hormone (SIADH). 
 
D. Mesna 
At the doses used for uroprotection, mesna is virtually non-toxic.  However, adverse effects 
which may be attributable to mesna include nausea and vomiting, diarrhea, abdominal pain, 
altered taste, rash, urticaria, headache, joint or limb pain, hypotension and fatigue. 
 


Protocol 2186.00 
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E. Tacrolimus  
 
Adverse reactions include tremor, headache, insomnia, nausea, diarrhea, hypertension, and 
renal dysfunction (hyperkalemia, increased BUN and creatinine). 
 
 
Drugs that may increase blood levels of tacrolimus include: macrolide antibiotics, antifungals 
(fluconazole and itraconazole), calcium channel blockers, cimetidine, danazol, methylprednisone 
and metoclopramide.  Drugs that may decrease blood levels of tacrolimus include: 
phenobarbital, phenytoin, carbamazepine, rifamycins and the anti-fungal agent caspofungin. 
 
F. Mycophenolic Acid Mofetil  (MMF) 
 
Side effects and toxicity: Side effect profiles include diarrhea, leukopenia, sepsis, allergic 
reactions, and vomiting. MMF use during pregnancy carries a significant risk of miscarriage or 
birth defects.  An increase in certain types of infection mainly from the herpes virus family 
(CMV, HSV & VZV) and candida has been reported. There have been reports of progressive 
multifocal leukoencephalopathy (PML), sometimes fatal, and of Pure Red Cell Aplasia (PRCA) in 
patients receiving MMF as part of an immunosuppressive regimen. MMF has not been studied 
extensively in patients after HCT. Most common side effects known from studies in patients with 
solid organ transplants are hematologic (decline in WBC and hematocrit) and gastrointestinal 
(nausea, vomiting, diarrhea, G.I. bleeding). Experience has shown that nausea can be 
successfully treated with anti-emetics, and that side effects often respond to a decrease in dose. 
Several etiologic factors may cause alterations in G.I. and hematologic parameters in the setting 
of HCT. MMF dose adjustments will therefore be made when clinically indicated if the 
responsible physician ruled out other possible causes. Dose adjustments should be discussed 
with the principal investigator. With the exception of hypophosphatemia there seems to be no 
difference in side effects between i.v. and oral MMF administration and efficacy is the same 
with both administration routes.  
1. If an observed toxicity related to MMF administration occurs in the clinical judgement of 
the investigator, the MMF dose will be adjusted.  Based on previous observations in 
patients after nonmyeloablative HCT, the side effect most likely to occur will be 
neutropenia due to myelosuppression. Severe gastrointestinal toxicity such as 
gastrointestinal hemorrhage has been very rare after nonmyeloablative HCT. A 
thorough evaluation of neutropenia should occur including peripheral blood chimerism 
studies, marrow aspiration and review of marrow suppressive medications (e.g. co-
trimoxazole or ganciclovir). Dose adjustments will not be made for neutropenia unless it 
is severe or persists after day +21. In the rare event of gastrointestinal toxicity that 
requires medical intervention including medication for control of persistent vomiting or 
diarrhea that is considered to be due to MMF, a 20% dose reduction will be made or the 
drug may be given IV at the same dose. For severe toxicity related to MMF (grade 4 
neutropenia refractory to G-CSF, severe refractory diarrhea, or overt gastrointestinal 
bleeding), the MMF may be temporarily stopped. MMF should be restarted at 20% 
reduced dose when the underlying toxicity subsides. The discontinuation of MMF at any 
point should be discussed with the Study PI and should be documented in the 
permanent medical record and Case Report Forms (CRF). MMF will be discontinued on 
day +35. However, MMF may be discontinued earlier than day +35 at the discretion of 
the study doctor in patients with no GVHD. 
  
G. Marrow infusion 
 
As per Standard Practice Guidelines. 


Protocol 2186.00 
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10.0  ADVERSE EVENT REPORTING 
10.1 
Adverse Event Definitions 
• 
Adverse Event 
An Adverse Event (AE) is any untoward medical occurrence in a clinical investigation subject 
administered a medicinal product; the event does not necessarily have a causal relationship with 
study drug administration or usage. An adverse event can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not considered related to the medicinal 
product. 
• 
Serious Adverse Event  
A serious adverse event (SAE) is defined as an untoward medical occurrence that results in any of 
the following outcomes: 
1. Death. 
2. Life-threatening situation (i.e., with an immediate risk of death from the event as it occurred 
but not including an event that, had it occurred in a more serious form, might have caused 
death). 
3. In-patient hospitalization or prolongation of existing hospitalization. Inpatient 
hospitalization comprises formal admission to a hospital for medical reasons, for any length 
of time, whether or not hospitalization extends overnight. However, hospital admissions for 
administration of the study drug, procedures required by the study protocol, or tumor-
related diagnostic procedures are not considered serious. 
4. Persistent or significant disability/incapacity or substantial disruption of the ability to 
conduct normal life functions. 
5. Congenital anomaly/birth defect. 
6. An important medical event that requires intervention to prevent one of the above 
outcomes. 
• 
Unexpected Adverse Event 
An unexpected adverse event is defined as an event that has a nature or severity, or frequency that 
is not consistent with the applicable investigator brochure.  “Unexpected,” as used in this definition, 
refers to an adverse drug experience that has not been previously observed and reported rather 
than an experience that has not been anticipated based on the pharmacological properties of the 
study drug. 
 
10.2 
Monitoring and Recording AEs 
Adverse events will be assessed by the investigator or qualified designee and recorded in the CRFs. The 
investigator should attempt to establish a diagnosis of the event on the basis of signs, symptoms and/or 
other clinical information. In such cases, the diagnosis should be documented as the adverse event 
and/or serious adverse event and not described as the individual signs or symptoms. The following 
information should be recorded: 
• 
Description of the adverse event using concise medical terminology 


Protocol 2186.00 
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• 
Description as to whether or not the adverse event is serious  
• 
The start date (date of adverse event onset) 
• 
The stop date (date of adverse event resolution) 
• 
The severity (grade) of the adverse event  
• 
A description of the potential relatedness of the adverse event to study drug or a study procedure  
• 
The action taken due to the adverse event 
• 
The outcome of the adverse event 
 
10.3  Grading of the Severity of an Adverse Event 
AEs will be graded in severity according to the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf). If a CTCAE 
criterion does not exist, the investigator should use the grade or adjectives: Grade 1 (mild), Grade 2 
(moderate), Grade 3 (severe), Grade 4 (life-threatening), or Grade 5 (fatal) to describe the maximum 
intensity of the adverse event. However, the Bearman Scale of Regimen-Related Toxicity will be used for 
decisions regarding dose escalation/ de-escalation and invocation of stopping rules.   
 
10.4 Attribution of Adverse Event 
Association or relatedness to the study agent will be assessed by the investigator as follows: 
• 
Definite:  The event follows a reasonable temporal sequence from exposure to the investigational 
agent, has been previously described in association with the investigational agent, and cannot 
reasonably be attributed to other factors such as the patient’s clinical state, other therapeutic 
interventions or concomitant medications; AND the event disappears or improves with withdrawal 
of the investigational agent and/or re-appears on re-exposure (e.g., in the event of an infusion 
reaction). 
• 
Probable:  The event follows a reasonable temporal sequence from exposure to the investigational 
agent and has been previously been described in association with the investigational agent OR 
cannot reasonably be attributed to other factors such as the patient’s clinical state, other 
therapeutic interventions or concomitant medications. 
• 
Possible:  The event follows a reasonable temporal sequence from exposure to the investigational 
agent, but could be attributable to other factors such as the patient’s clinical state, other 
therapeutic interventions or concomitant medications. 
• 
Unlikely:  Toxicity is doubtfully related to the investigational agent(s).  The event may be attributable 
to other factors such as the patient’s clinical state, other therapeutic interventions or concomitant 
medications. 
• 
Unrelated:  The event is clearly related to other factors such as the patient’s clinical state, other 
therapeutic interventions or concomitant medications. 
 
For general AE assessment, an AE is considered related if it is assessed as definitely, probably, or 
possibly related; unrelated if it is assessed as unlikely related or unrelated. For determination of IND 
safety reporting, AE attribution will be assessed according to the suspected adverse reaction definition 


Protocol 2186.00 
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described in 21 CRF 312.32 as an AE for which there is a reasonable possibility that the drug caused the 
adverse event where “reasonable possibility” means there is evidence to suggest a causal relationship 
between the drug and the AE. Suspected adverse reactions that are both serious and unrelated will be 
reported to the FDA as an IND safety report, in accordance with regulations under 21 CFR 312.32. 
 
10.5 Adverse Event Reporting Period 
 
AEs will be monitored and recorded in study-specific case report forms (CRFs). From the time of first 
exposure to an investigational agent (i.e., the start of the biodistribution dose) through day +100 post-
transplant (or discharge prior to that date from the SCCA system to care of the patient’s primary 
physician), all adverse events and all serious adverse events will be captured in protocol-specific case 
report forms.  Beyond day +100, serious adverse events,  development of secondary malignancies, 
disease progression and survival will be collected through 24 months post-transplant. AEs with an onset 
date prior to the first exposure to an investigational product will not be recorded, except in the case of 
clinically significant worsening of the AE during the specified monitoring time frame. A subject 
withdrawn from the study because of an adverse event must be followed until the clinical outcome from 
the adverse event is determined.  
All deaths except those from relapse of malignancy, but otherwise regardless of attribution, that occur 
within the first 100 days following transplant will undergo expedited reporting. If the patient has 
returned to the care of the referring physician prior to day 100 post-transplant, the death will be subject 
to expedited reporting based on the time we learn of the death. Deaths occurring after 100 days will not 
undergo expedited reporting although they will be included in Annual Reports and publications of the 
study. 
 
The following events are not identified as AEs in this study: 
• 
Disease progression or relapse.  However, clinical events associated with progression/relapse may 
be reportable as AEs. 
• 
Hospitalization for the purpose of facilitating conditioning and/or stem cell infusion is not 
considered an AE.  Any AE requiring prolongation of this hospitalization will be recorded and subject 
to applicable SAE reporting. 
• 
Medical or surgical procedures in and of themselves, including those that require hospitalization 
(e.g., surgery, endoscopy, biopsy procedures) are not considered AEs.  However, an event or 
condition requiring such procedures may be an AE. 
 
10.6 Adverse Event Reporting Requirements 
10.6.1 Research Site Reporting Requirements 
Classification of an event as serious or non-serious (see Section 10.1) determines the reporting 
procedures to be followed by the site for reporting the event to the IND Sponsor. The investigator must 
report events to the Fred Hutch IRB in accordance with the policies of the IRB. 
TABLE 10.1: PI to IND Sponsor Reporting Requirements for Adverse Events 
Classification 
Reporting Time 
Reporting Action 
Contact Information 


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Serious 
Adverse 
Event (SAE) 
Fatal or life-
threatening 
Within 24 hours of research 
team awareness 
Email notification to IND 
Sponsor’s Medical Monitor & 
ISIOC Administrator 
Medical Monitor email: 
tillb@fredhutch.org 
ISIOC email: 
ISIOC@fredhutch.org 
All SAEs 
Within 2 business days of 
research team awareness 
Submit completed 
Institution-Sponsored IND 
SAE Reporting Form signed 
by PI or designated sub-
Investigator 
ISIOC Fax: 
206-667-6068 
ISIOC email: 
ISIOC@fredhutch.org 
Non-serious Adverse Event 
Per CRF completion 
guidelines 
Record information on 
appropriate CRFs 
N/A 
*Research team is defined as the individuals listed on the delegation of authority log. Physicians listed on the study’s delegation 
of authority log as transplant service attending physicians delegated authority to administer informed consent will not be 
considered part of the research team unless additional responsibilities related to the conduct of the study have been delegated 
to them by the Principal Investigator.  
The information in the Institution-Sponsored IND SAE Reporting Form must match or be reconciled with 
the information recorded in the adverse events section of the CRF and study database. For example, the 
same adverse event term should be used on both forms. 
The investigator must report events to the Fred Hutch IRB in accordance with the policies of the IRB. The 
IND sponsor assumes responsibility for IND safety reporting to the FDA and participating investigators, in 
accordance with regulations under 21 CFR 312.32.  
10.6.2 Fred Hutch IND Sponsor Reporting Requirements 
The sponsor assumes responsibility for IND safety reporting to the FDA and participating investigators, in 
accordance with regulations under 21 CFR 312.32. 
Each serious adverse event report received from the investigator will be evaluated by the Medical 
Monitor who will assess the seriousness of the event (see Section 10.1), the expectedness of the event 
(see Section 10.1), and the relationship to participation in the study (see Section 10.4). For regulatory 
reporting purposes, the IND Sponsor will determine expectedness relating to the investigational product 
using safety information specified in the Investigator Brochure. An event will be classified as related if 
either the investigator or the IND Sponsor determines that the event may be related to the study drug. 
 
The IND Sponsor or its designee will provide all investigators with a safety letter notifying them of an 
event that meets FDA IND Safety Reporting criteria. Investigators will be requested to provide written 
notification of safety report to the Fred Hutch IRB as soon as is practical, consistent with IRB 
requirements. 
10.7 
SAES Associated with Hematopoietic Cell Transplantation (HCT) 
Certain events that are commonly observed as SAEs following HCT are described in Appendix C in order 
to facilitate assessments of attribution.  SAEs that are identified as routinely experienced in the 
allogeneic transplant setting would typically be assessed as unrelated to elements of the investigational 
regimen used in this protocol.   
 


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11.0  DEFINITIONS 
 
A. Complete remission: complete resolution of all signs of myelodysplasia or leukemia for at least four 
weeks with all of the following: 
1. Normal bone marrow with blasts <5% with normal cellularity, normal megakarypoiesis, more 
than 15% erythropoiesis and more than 25% granulocytopoiesis. 
2. Normalization of blood counts (no blasts, platelets > 100000/mm3 , granulocytes >1500/mm3)  
3. No extramedullary disease. 
B. Partial remission: 
1) Improvement of hematological parameters in the peripheral blood 
2) 50% decline in marrow blasts from pre-transplant level with >10% erythropoiesis and 25% 
granulocytopoiesis. 
C. Non responder: 
 
1) All patients not qualifying for complete or partial remission. 
D. Relapse: 
1) After CR: >5% blasts in the bone marrow and/or peripheral blood. Confirmation of relapse by 
bone marrow analysis with more than 10% blasts. 
2) After PR: increase of blasts cells in the marrow to >50% of those during PR. 
3) Extramedullary disease confirmed cytologically or histologically. 
E. Persistent Disease:  
1) >5% blasts in the bone marrow by histology 
2) presence of a clonal population of myeloid cells by flow 
3) persistence/recurrence of a previously documented cytogenetic abnormality 
F. Full Chimerism: >95% donor CD3+ T cells.  
G. Mixed Chimerism: the detection of peripheral blood donor T cells (CD3+) and granulocytes (CD33+) 
as a proportion of the total peripheral blood T cell and granulocyte population, respectively.   
H. Increasing Donor Chimerism: an absolute increase of 20% of CD3+ T cells over the chimerism 
evaluation of the previous month.   
I. 
Decreasing Donor Chimerism: decreasing donor chimerism is defined as an absolute decrease of at 
least 20% of CD3+ T cell chimerism over the previous month.   
J. 
Low Donor Chimerism: low donor chimerism is defined as <40% CD3+ T cells after HSCT.  Low donor 
chimerism should always be confirmed with repeat peripheral blood T cell and granulocyte 
chimerism analysis. 
K.   Graft Failure: Primary graft failure is defined as failure to achieve neutrophil engraftment (ANC 
>500/µL) in patients surviving at least 28 d; secondary graft failure as neutrophil recovery followed 
by a decline in ANC to <500/µL unresponsive to growth factor stimulation.     
 
12.0  STATISTICAL CONSIDERATIONS (submitted as a separate document) 
 
13.0  DATA AND SAFETY MONITORING PLAN 
This is a single institution trial where all patients are followed closely by the investigators.  Additionally, 
the trial design provides rules for dose escalation depending upon the rate of development of Grade 
III/IV RRT (Bearman Scale).  This design mandates ongoing review of the outcome of previous patients 
treated on study so that the appropriate Dose Level for the current patient can be assigned. The 
principal investigator, primary research nurse, and study data coordinator communicate routinely 
(typically weekly) to review recently acquired data, stopping rules, and adverse events.  The data 


Protocol 2186.00 
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recorded within the research charts and protocol database is compared with the actual data that is 
available from the medical record and/or clinical histories.  Data detailed in the research case report 
forms includes the nature and severity of all significant toxicities, which are also reported as described 
above.  All investigators on the protocol have received formal training in the ethical conduct of human 
research.  
Institutional support of trial monitoring will be in accordance with the FHCRC/University of Washington 
Cancer Consortium Institutional Data and Safety Monitoring Plan (DSMP).  Under the provisions of this 
plan, FHCRC Clinical Research Support coordinates data and compliance monitoring conducted by 
consultants, contract research organizations, or FHCRC employees unaffiliated with the conduct of the 
study.  Independent monitoring visits occur at specified intervals determined by the assessed risk level 
of the study and the findings of previous visits per the institutional DSMP.  
 
In addition, protocols are reviewed at least annually and as needed by the Consortium Data and Safety 
Monitoring Committee (DSMC), FHCRC Scientific Review Committee (SRC) and the FHCRC/University of 
Washington Cancer Consortium Institutional Review Board (IRB).  The review committees evaluate 
accrual, adverse events, stopping rules, and adherence to the applicable data and safety monitoring plan 
for studies actively enrolling or treating patients.  The IRB reviews the study progress and safety 
information to assess continued acceptability of the risk-benefit ratio for human subjects.  Approval of 
committees as applicable is necessary to continue the study. 
The trial will comply with the standard guidelines set forth by these regulatory committees and other 
institutional, state and federal guidelines. 
14.0  DATA MANAGEMENT/CONFIDENTIALITY 
The investigator will ensure that data collected conform to all established guidelines. Each subject is 
assigned a unique subject number to assure subject confidentiality. Subjects will not be referred to by 
this number, by name, or by any other individual identifier in any publication or external presentation. 
The licensed medical records department, affiliated with the institution where the subject receives 
medical care, maintains all original inpatient and outpatient chart documents. Additional clinical data 
may be made available from the Fred Hutch core database (Gateway), which is managed and verified 
independent of the research group.   
The research team will maintain Case Report Forms (CRF) and associated research documentation for 
each patient treated under the protocol.  This documentation includes both clinical data and study-
specific documents for each patient.  Additional study-specific documents and radiologic data are 
maintained by the UW Division of Nuclear Medicine.  The Principal Investigator or a designee will verify 
completed CRFs against source documentation on an ongoing basis as they are completed for individual 
patients.  CRFs should be complete and data entered into the study database within 120 days of 
transplant. Data required for analysis of patients treated on this protocol will be maintained in a 
password-protected study-specific database. Data from the CRFs are keyed directly into the database by 
authorized research staff and verified on an ongoing basis.   


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15.0  TARGETED/PLANNED ENROLLMENT 
 
 
TARGETED/PLANNED ENROLLMENT:   
Number of Subjects (must provide actual numbers. i.e. no range) 
 
Ethnic Category 
 
 
 
Sex/Gender 
 
Females 
Males 
Total 
Hispanic or Latino 
2 
2 
4 
Not Hispanic or Latino 
19 
27 
46 
Ethnic Category Total of All Subjects* 
21 
29 
50 
 
                  Racial Categories 
American Indian/Alaska Native 
1 
2 
3 
Asian 
1 
1 
2 
Native Hawaiian or Other Pacific Islander 
1 
1 
2 
Black or African American 
3 
3 
6 
White 
15 
22 
37 
Racial Categories: Total of All Subjects * 
21 
29 
50 
 
16. Termination of Study Participation by Individual Patients 
 
A. Patient request. 
B. Unacceptable toxicity during dosimetry antibody infusion (see section 11.A.1 for complete toxicity 
descriptions and stopping rules). 
C. Development of anti-mouse antibodies. 
 
16.0  REFERENCES 
 
1. 
Henslee-Downey, P.J., S.H. Abhyankar, R.S. Parrish, et al., Use of partially mismatched related donors 
extends access to allogeneic marrow transplant. Blood, 1997. 89(10): p. 3864-72. 
2. 
Anasetti, C., D. Amos, P.G. Beatty, et al., Effect of HLA compatibility on engraftment of bone marrow 
transplants in patients with leukemia or lymphoma. N Engl J Med, 1989. 320(4): p. 197-204. 
3. 
Anasetti, C., P.G. Beatty, R. Storb, et al., Effect of HLA incompatibility on graft-versus-host disease, 
relapse, and survival after marrow transplantation for patients with leukemia or lymphoma. Hum 
Immunol, 1990. 29(2): p. 79-91. 
4. 
Beatty, P.G., R.A. Clift, E.M. Mickelson, et al., Marrow transplantation from related donors other than 
HLA-identical siblings. N Engl J Med, 1985. 313(13): p. 765-71. 
5. 
Aversa, F., A. Terenzi, A. Carotti, et al., Improved outcome with T-cell-depleted bone marrow 
transplantation for acute leukemia. J Clin Oncol, 1999. 17(5): p. 1545-50. 
6. 
Spitzer, T.R., S.L. McAfee, B.R. Dey, et al., Nonmyeloablative haploidentical stem-cell transplantation using 
anti-CD2 monoclonal antibody (MEDI-507)-based conditioning for refractory hematologic malignancies. 
Transplantation, 2003. 75(10): p. 1748-51. 
7. 
Rizzieri, D.A., L.P. Koh, G.D. Long, et al., Partially matched, nonmyeloablative allogeneic transplantation: 
clinical outcomes and immune reconstitution. J Clin Oncol, 2007. 25(6): p. 690-7. 
8. 
McSweeney, P.A., D. Niederwieser, J.A. Shizuru, et al., Hematopoietic cell transplantation in older patients 
with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. 
Blood, 2001. 97(11): p. 3390-400. 


Protocol 2186.00 
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9. 
Luznik, L., S. Jalla, L.W. Engstrom, R. Iannone, and E.J. Fuchs, Durable engraftment of major 
histocompatibility complex-incompatible cells after nonmyeloablative conditioning with fludarabine, low-
dose total body irradiation, and posttransplantation cyclophosphamide. Blood, 2001. 98(12): p. 3456-64. 
10. 
Mayumi, H., M. Umesue, and K. Nomoto, Cyclophosphamide-induced immunological tolerance: an 
overview. Immunobiology, 1996. 195(2): p. 129-39. 
11. 
Petrus, M.J., J.F. Williams, M.A. Eckhaus, R.E. Gress, and D.H. Fowler, An immunoablative regimen of 
fludarabine and cyclophosphamide prevents fully MHC-mismatched murine marrow graft rejection 
independent of GVHD. Biol Blood Marrow Transplant, 2000. 6(2A): p. 182-9. 
12. 
O'Donnell, P.V., L. Luznik, R.J. Jones, et al., Nonmyeloablative bone marrow transplantation from partially 
HLA-mismatched related donors using posttransplantation cyclophosphamide. Biol Blood Marrow 
Transplant, 2002. 8(7): p. 377-86. 
13. 
Clift, R.A., C.D. Buckner, F.R. Appelbaum, et al., Allogeneic marrow transplantation in patients with acute 
myeloid leukemia in first remission: a randomized trial of two irradiation regimens. Blood, 1990. 76(9): p. 
1867-71. 
14. 
Matthews, D.C., F.R. Appelbaum, J.F. Eary, et al., Phase I study of (131)I-anti-CD45 antibody plus 
cyclophosphamide and total body irradiation for advanced acute leukemia and myelodysplastic 
syndrome. Blood, 1999. 94(4): p. 1237-47. 
15. 
Clift, R.A., C.D. Buckner, E.D. Thomas, et al., Marrow transplantation for chronic myeloid leukemia: a 
randomized study comparing cyclophosphamide and total body irradiation with busulfan and 
cyclophosphamide. Blood, 1994. 84(6): p. 2036-43. 
16. 
Ringden, O., M. Labopin, S. Tura, et al., A comparison of busulphan versus total body irradiation combined 
with cyclophosphamide as conditioning for autograft or allograft bone marrow transplantation in patients 
with acute leukaemia. Acute Leukaemia Working Party of the European Group for Blood and Marrow 
Transplantation (EBMT). Br J Haematol, 1996. 93(3): p. 637-45. 
17. 
Ruutu, T., A. Hanninen, G. Jarventie, et al., Intensive chemotherapy of poor prognosis myelodysplastic 
syndromes (MDS) and acute myeloid leukemia following MDS with idarubicin and cytarabine. Leuk Res, 
1997. 21(2): p. 133-8. 
18. 
Lowenberg, B., S. Suciu, E. Archimbaud, et al., Mitoxantrone versus daunorubicin in induction-
consolidation chemotherapy--the value of low-dose cytarabine for maintenance of remission, and an 
assessment of prognostic factors in acute myeloid leukemia in the elderly: final report. European 
Organization for the Research and Treatment of Cancer and the Dutch-Belgian Hemato-Oncology 
Cooperative Hovon Group. J Clin Oncol, 1998. 16(3): p. 872-81. 
19. 
Bennett, J.M., M.L. Young, J.W. Andersen, et al., Long-term survival in acute myeloid leukemia: the 
Eastern Cooperative Oncology Group experience. Cancer, 1997. 80(11 Suppl): p. 2205-9. 
20. 
Storer, B.E., Small-sample confidence sets for the MTD in a phase I clinical trial. Biometrics, 1993. 49(4): p. 
1117-25. 
 


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APPENDIX A:  BEARMAN CRITERIA FOR REGIMEN-RELATED TOXICITY 
 
The criteria for toxicity were developed to convey the following considerations about the toxicity of the 
preparative regimen.  It is the responsibility of the principal investigator to try and distinguish toxicities 
due to the preparative regimen from these due to other features of transplantation. 
 
Grade 1 
Development of transient chemical abnormalities which are not of major clinical 
consequence and which reverse without requiring major medical interventions.  In 
general, the intent of this toxicity scale is to observe transient target organ toxicity 
which is reversible. 
Grade 2 
Development of chemical or laboratory abnormalities which are persistent and 
which may represent target organ damage which may not be readily reversed.  It is 
anticipated that at this dose of drug, the toxicity obtained would be manageable by 
clinical methods but may interfere with other therapies. 
Grade 3 
Development of major clinical, chemical or laboratory abnormalities which 
represent maximum toxicities without being fatal.  This grade of toxicity is designed 
to be the dose limiting toxicity.  Further, the development of this degree of toxicity 
cannot be considered to be a regular acceptable but rather an occasional toxicity 
(<20%), acceptable given the severity of the disease.  Included in this would be the 
need for life support techniques such as renal dialysis and ventilation therapy. 
Grade 4 
Fatal. 
 
A. Cardiac 
Grade 1 
EKG voltage decrease by 25% or less, resting tachycardia with weight gain but 
responsive to diuretic therapy. 
Grade 2 
EKG voltage decrease by 25-50%, congestive heart failure responsive to diuretic 
therapy, arrhythmias manageable with medical therapy. 
Grade 3 
Symptomatic CHF unresponsive to diuretic therapy, decrease in EKG voltage by 
more than 50%, life-threatening arrhythmia. 
Grade 4 
Fatal toxicity. 
 
B. Bladder 
Grade 1 
Microscopic hematuria for more than 7 days. 
Grade 2 
Macroscopic hematuria. 
Grade 3 
Hemorrhagic cystitis requiring transfusion and placement of an indwelling catheter 
to remove clots, or cystoscopy with or without installation of sclerosing agents. 
Grade 4 
Fatal toxicity. 
 
C. Renal 
Grade 1 
Increase in creatinine up to twice baseline value. 
Grade 2 
Increase in creatinine above twice baseline value but not requiring dialysis. 


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Grade 3 
Requirement of dialysis. 
Grade 4 
Fatal toxicity. 
 
D. Pulmonary 
Grade 1 
Decrease in pO2 or dyspnea without an infiltrate or, at most, a transient patchy 
infiltrate. 
Grade 2 
Transient interstitial pneumonia (either idiopathic or unbiopsied) that does not 
require ventilatory support). 
Grade 3 
Interstitial pneumonia requiring ventilatory support. 
Grade 4 
Fatal toxicity. 
 
E. Hepatic 
Grade 1 
Transient elevations in liver function tests less than those listed as Grade 2 toxicity. 
Grade 2 
Hepatic dysfunction with bilirubin elevation greater than 5, SGOT increase greater 
than five-fold or ascites.  
Grade 3 
Hepatic failure including hepato-renal syndrome, hepatic encephalopathy, bilirubin 
elevation greater than 20, or Grade 3 VOD as defined by Shulman et al. 
Grade 4 
Fatal toxicity. 
 
F. Central Nervous System 
Grade 1 
Transient somnolence. 
Grade 2 
Somnolence more than 36 hours or other signs of CNS toxicity. 
Grade 3 
Seizures or coma. 
Grade 4 
Fatal. 
 
G. Stomatitis 
Grade 1 
Ulceration or pain but not prohibiting oral intake. 
Grade 2 
Painful ulceration prohibiting oral intake. 
Grade 3 
Severe ulceration requiring intubation. 
Grade 4 
Fatal. 
 
H. Gastrointestinal 
Grade 1 
Watery stools, but less than 6 stools/day. 
Grade 2 
Watery stools more than 6-12 stools/day, or hemorrhagic enterocolitis not requiring 
transfusion, or transient ileus. 


Protocol 2186.00 
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Grade 3 
Hemorrhagic enterocolitis requiring transfusion, or ileus requiring nasogastric 
suction. 
Grade 4 
Fatal. 


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APPENDIX B: METHODS USED TO ESTIMATE RADIATION ABSORBED DOSES TO 
PATIENTS 
 
Absorbed radiation doses are calculated for each patient’s normal organs and tissues, the whole 
body, and for tumor masses.  Doses are calculated using the formal methods that are recommended by 
the Medical Internal Radiation Dose (MIRD) Committee of The Society of Nuclear Medicine (a, b, c).  
These methods account for both the penetrating gamma and the non-penetrating beta radiation 
emitted by radioactivity distributed throughout the body.  Dosimetry calculations are based on a set of 
direct measurements in individual patients.  These include, based on gamma-camera measurements of 
iodine-131 activity in the major source organs, tumor tissue (the red marrow) and the total body at 
various time-points post-infusion of the radiolabeled antibody.  Red marrow biopsies indicate the 
activity concentration in marrow at specific time points.  Organs for which measurement data are 
obtained are called “source organs.”  Organs, tissues, and the whole body for which radiation absorbed 
doses are estimated, are called “target organs.”   
 
Direct Measurements in Patients 
Conjugate-view quantitative planar imaging with anterior and posterior measurements is the most 
widely used method for assessing source-organ activity in patients (d, e).   The conjugate view method 
does not require knowing the depth of the source region and does not depend on assumptions inherent 
in single-view phantom simulations. 
After a tracer level of iodine-131 (usually about 5 to 8 mCi) on the monoclonal antibody is 
administered, the patient is imaged using collimated anterior and posterior planar gamma-camera 
imaging.  Images are acquired over the source organs using a large-field-of-view camera.  Anterior plus 
posterior conjugate view are obtained using a collimated system with the photon energy window set 
over the relevant energy peak at about ± 15-20% (full width at half-maximum).  Images will include 
head/neck, chest with upper humeri, abdomen, and pelvis with upper femurs. 
Regions of interest are selected for the major source organs, such as the liver, spleen, red marrow 
space, and occasionally for the lungs and kidneys (when suitable images can be obtained), and for any 
other tissue with activity above background, including thyroid and bladder.  Measurements are also 
made of representative background tissue (such as the thigh muscle), and a counting standard with and 
without the patient in the camera field-of-view.  The outlines for the regions of interest are drawn by a 
technician from the acquired image, and counts are obtained from the selected regions.  The counts are 
appropriately decay-corrected to a radionuclide standard.  Patient thickness and the distance from the 
gamma camera to the source organ are determined.  The geometric mean of the anterior and poster 
counts is obtained for each region of interest.  Counts are then corrected for attenuation, geometry, and 
background. 
 
Total body measurements will be obtained using an external, non-imaging gamma probe at a 
distance of 4 meters from the patient to quantify the absolute I-131 activity in the patient, over time, as 
a fraction of the total administered activity.  
 
Sampling Times 
Selecting an appropriate number of counting times requires a trade-off between the desire for 
sufficient data, while economizing the overall costs and minimizing patient inconvenience.   Our 
objective is to select the fewest time points that will provide a reasonable description of the time-
activity curve.  The minimum number of data measurement points is typically four.  These include one 
measurement at or near the zero time point (time of radionuclide infusion), plus additional 
measurements at about 18, 44, and 66 hours post-infusion.  These analyses provide an estimate of the 


Protocol 2186.00 
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fraction of the administered activity that resides in each source organ (and in the total body) at each 
measurement time post-infusion. 
 
Time-Activity Curves 
 
The sequential measurement data are plotted to determine the cumulated activity and residence 
time for each source organ.  Plotted are the fractions of the total administered activity that are present 
at each measurement time point.  Time-activity curves are constructed from the measurement data and 
are integrated out to infinite time to determine the residence times (τ, hours) for each source organ, the 
red marrow, and for the whole body.  The points are fitted to an exponential or sum of exponentials.   
An estimate of the long-term tail of the time activity curve may be made by fitting an exponential 
function to the last two points. 
We plot the effective fractions present (as measured), rather than the values that were decay-
corrected from a radionuclide standard, because internal doses are approximately proportional to the 
integral areas under the effective time-activity curves.   
 
Residence Time Calculations: Integrating the Time-activity Curves 
The residence time for a source organ is the fraction of the administered activity in a source organ 
over time to complete decay, obtained by integrating the time-activity curve. Thus, the residence time is 
the area under the fractional time-activity curve.  The residence times are the basic input value to the 
software packages MIRDOSE2 and MIRDOSE3 computer programs (f) (Oak Ridge Associated Universities, 
Oak Ridge, Tennessee) and OLINDA-EXM (Vanderbilt University, Nashville, Tennessee) that implement 
the MIRD dosimetry schema.   
The cumulated activity, Ã h, and residence time, τ h, are determined by integrating the area under 
the time-activity curves for the clinical measurement data for each source organ and the remainder 
tissues.  The integrations are carried to infinity for accuracy and simplicity.   
Residence times for red marrow are determined from a set of gamma camera measurements of 
iodine-131 activity in marrow spaces (usually the right and left acetabula), and from a bone marrow 
biopsy that is weighed and then counted in a standard well-type counter.  The time-activity curve is 
developed from the marrow counts, and then the curves are adjusted to exactly cross through the data 
point for the marrow activity concentration.  The long-term tail of the exponential may be estimated by 
curve-fitting.   
 
According to the MIRD schema, the cumulated activity, Ã h, is proportional to the sum of all nuclear 
transformations during the time of interest in a source organ, h.  The cumulated activity is also called 
the time integral of Ah(t), or  
 
Ã h  =  ∫ Ah(t) dt,  
(1) 
 
where the units of cumulated activity are given in µCi-hr or Bq-sec.  If a single exponential is fit to the 
data points representing simple clearance, then the activity in the source organ at any point in time, t, 
may be estimated by the equation: 
 
Ah(t)  =   Ah(0) exp(-λt), 
(2) 
 
where Ah(0) is the y-axis intercept of the exponential equation, and where λ is the long-term effective 
(not corrected for radioactive decay) constant.  The effective clearance constant λ is:   
 
λ. =  (ln 2)/(T1/2eff),  
(3) 


Protocol 2186.00 
Page 46 of 50 
 
and therefore the effective clearance halftime, T1/2eff, is: 
 
T1/2eff  =  (ln 2)/λ  =  1.443 / λ. 
(4) 
 
The integral of the single exponential for the cumulated activity, or area under the curve is:  
 
∫ Ah(t) dt    =   Ah(0) (1/ln 2) (T1/2eff), and 
(5) 
 
∫ Ah(t) dt    =   Ah(0) (1.443) (T1/2eff), 
(6) 
 
where Ah(0) is the y-axis intercept.  It follows that the residence time, τ h , is: 
 
τ h   =   [Ah(0)/Ao] (1.443) (T1/2eff). 
(7) 
 
If a multi-exponential function is needed to describe the pharmacologic uptake, retention, clearance, 
and physical decay processes, the time-activity curves are described using multiple exponential 
functions of the form: 
 
y  =  A exp(-λ1t)  + B  exp(-λ2t) . . . 
(8) 
 
where λ1 and λ2 are the effective retention constants.  If a multi-exponential function is fit to the 
measurement data, then the integral of the function (or area under the curve) is simply 
 
∫ y  dt   =   A/λ1 + B/λ2   . . . .  
(9) 
 
Patient-specific Dosimetry 
The residence times for each source organ are corrected for actual patient mass (if known from CT-
imaging volumetrics) using a method described by Fisher et al. (g, h).  Methods for this correction for 
patient-specific dosimetry are described in the following paragraphs.  
 
It has been well documented by this and other studies that the actual patient weights and organ 
sizes may vary considerably from those used in the standard MIRD dosimetric models.  Since organ dose 
is approximately proportional to the inverse of target mass, a correction may be made for patient 
weight and organ mass when actual organ weights are known from CT-imaging.  The correction involves 
recalculating the S values for each of the source-target combinations where patient-specific organ 
volumes are known.  The recalculated S values will account for both the gamma component specific 
absorbed fraction of energy and the mass over which the beta component is averaged.  For most 
radionuclides, the beta self-irradiation dose in a source organ is the greater contributor to total organ 
dose (usually more than 90 percent of the total). 
 
A less-accurate, but more convenient “short-cut” method for correcting for known organ mass is 
given below.  This short-cut method corrects the beta component but does not correct for the lesser-
important gamma component.  For individual organs and for the whole-body, the correction may be 
made by multiplying the calculated source-organ residence time, τ h, by the ratio of the defined 
reference man or reference woman organ mass to the known organ mass: 
 
τ new  ≈   ( τh ) (mMIRD/mactual). 
(10) 
 


Protocol 2186.00 
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This correction may be appropriate when most of the organ dose is due to non-penetrating radiation. 
The new residence time for each source organ and for the remainder tissues may then be entered into 
MIRDOSE or OLINDA-EXM to estimate normal organ and whole-body doses (in rad/mCi or mGy/MBq 
administered) for the patient.   
 
Dose Calculations 
In the MIRD schema, the absorbed dose, D, to target organs or tissues (rk), and the whole body, is 
calculated from the sum of the products of the cumulated activity Ã (µCi-hours) in each source organ (rh) 
and the S value (the absorbed dose per unit cumulated activity in rads per µCi-hour, or gray per 
becquerel-second) for each source-target organ pair, according to the MIRD equation 
 
D(rk←rh)  =  Σ Ã S(rk←rh),  
(11) 
 
                                 h 
 
where the cumulated activity Ã in a source organ is also the product of the residence time τ and the 
administered activity A0.  Thus,  
 
 Ã  = τ A0,       and  τ = Ã/A0 
(12) 
 
The dose calculations are implemented by the MIRDOSE2 and MIRDOSE3 computer software for medical 
internal dose assessment (Oak Ridge Associated Universities, Oak Ridge, Tennessee) or OLINDA-EXM 
(Vanderbilt University, Nashville, Tennessee).   
Relevant to the use of MIRDOSE2 and MIRDOSE3 software, S values used for the calculations 
MIRDOSE2 computer software are the same as those that were previously implemented in ICRP 
Publication 30 (i).  Revised S values for marrow and the skeleton are implemented in MIRDOSE3 (f).  S 
values for solid tumors are estimated by extrapolation using normal organs of similar size and location in 
the body.  In this leukemia trial, we assume that the cancer cells are in the red marrow, and therefore 
the dose to red marrow and the dose to leukemia cells are assumed to be the same.  MIRDOSE2 S values 
for red marrow are used when appropriate, since a new evaluation of the S values at the University of 
Florida has shown that MIRDOSE3 S values may underestimate the mean dose per unit cumulated 
activity to red marrow. 
 
Therapy Doses 
The radiation absorbed doses that are estimated for the tracer infusion of iodine-131-labeled 
monoclonal antibody are extrapolated linearly to higher levels of activity that are later administered for 
the therapeutic infusion. 
 
REFERENCES:  APPENDIX B 
 
a. International Commission on Radiation Units and Measurements (ICRU).  Methods of assessment of 
absorbed dose in clinical use of radionuclides.  ICRU Report No. 32.  Washington, DC: International 
Commission on Radiation Units and Measurements, 1979. 
b. National Council on Radiation Protection and Measurements (NCRP).  The experimental basis for 
absorbed dose calculations in medical uses of radionuclides.  NCRP Report No. 83.  Bethesda, 
Maryland: National Council on Radiation Protection and Measurements, 1985. 


Protocol 2186.00 
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c. Loevinger, R., Budinger, T. F., and Watson, E. E.  MIRD primer for absorbed dose calculations.  New 
York: The Society of Nuclear Medicine, Inc., 1988. 
d. Leichner PK, Koral KF, Jaszczak RJ, Green AJ, Chen GTY, Roeske JC: An overview of imaging 
techniques and physical aspects of treatment planning in radioimmunotherapy.  Med Phys 1993, 
20:569-577. 
e. Thomas SR, Maxon HR, Kereiakes JG:  In vivo quantitation of lesion radioactivity using external 
counting methods.  Med Phys 1976, 3:253-255. 
f. 
Stabin MG:  MIRDOSE: Personal computer software for internal dose assessment in nuclear 
medicine.  J Nucl Med 37:538-546, 1996. 
g. Fisher, D. R., Badger, C. C., Breitz, H, Eary, J. F., Durham, J. S., Hui, T. E., Hill, R. L., and Nelp, W. B.  
Internal radiation dosimetry for clinical testing of radiolabeled monoclonal antibodies.   Antibody 
Immunocon. Radiopharm 4:655-664, 1991.  See equation (7) on p. 658. 
h. Fisher, D. R. 2000.  “Internal Dosimetry for Systemic Radiation Therapy.”  Sem. in Rad. Oncol. 
10(2):123-132. 
i. 
International Commission on Radiological Protection.  Limits for intakes of radionuclides by workers.  
ICRP Publication 30.  Oxford: Pergamon Press, 1979. 


Protocol 2186.00 
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APPENDIX C: POTENTIAL ADVERSE EVENTS ASSOCIATED OR EXPECTED WITH 
HEMATOPOIETIC CELL TRANSPLANTATION 
 
1. Graft versus host disease:  GVHD is a major toxicity associated with the infusion of allogeneic donor 
stem cells.  GVHD may be acute or chronic and may affect multiple organ systems, including the skin, 
liver, and GI tract. 
 
2. Opportunistic infections, including viral and fungal infections, can result in severe pulmonary, 
neurologic, hepatic and other organ dysfunction, and possible death. 
 
3. Gastrointestinal toxicity. Nausea and vomiting can be anticipated during the entire course of ablative 
therapy. Mucositis and diarrhea should be expected. Prednisone can cause GI bleeding. 
 
4. Cardiac toxicity. Cardiotoxicity (congestive heart failure, pericardial effusion, EKG changes) is 
uncommonly associated with the chemotherapy agents and TBI used in the regimen and these sequelae 
may prove lethal. 
 
5. Pulmonary toxicity. Diffuse interstitial pneumonitis of unknown etiology and diffuse alveolar 
hemorrhage occurs with some regularity after BMT and interstitial fibrosis occurs much more rarely. 
Both are well-described complications of intensive chemotherapy and TBI regimens and may prove 
lethal. 
 
6. Hepatic toxicity. Veno-occlusive disease of the liver is a common toxicity of high-dose 
chemoradiotherapy and may result in death. Calcineurin inhibitors may cause elevation of ALT/AST. 
 
7. Renal dysfunction. Chemoradiotherapy may uncommonly cause renal dysfunction. More commonly, 
nephrotoxicity results from calcineurin inhibitors and generally responds to dose reduction. Rarely, 
idiopathic or calcineurin inhibitor-associated hemolytic-uremic syndrome may occur and may be 
progressive and fatal. A syndrome of moderate renal insufficiency and hemolysis has been seen 5-7 
months post HSCT after intensive multi-agent conditioning plus TBI. 
 
8. Hemorrhagic cystitis, manifested either as gross or microscopic hematuria, is a common toxicity after 
high-dose chemoradiotherapy, but usually associated with regimens that include cyclophosphamide. 
Hemorrhagic cystitis may predispose to a long-term increased risk of bladder cancer. 
 
9. Central nervous system toxicity. Radiation and chemotherapy can cause CNS toxicity, including 
seizures, depressed mental status, or leukoencephalopathy. Calcineurin inhibitors can cause seizures or 
other CNS toxicity. 
 
10. Marrow aplasia. Severe neutropenia, thrombocytopenia, and anemia, is expected to occur for a 
period of 7 to 42 days after the pretransplant conditioning regimen. Transfusion of platelets and red 


Protocol 2186.00 
Page 50 of 50 
blood cells is expected as supportive care. Transfusion of blood products may be associated with 
acquisition of HIV or a hepatitis virus. Neutropenia may increase the risk for acquiring serious infection. 
Thrombocytopenia may increase the risk of life-threatening hemorrhage. Hemorrhagic or infectious 
complications during the expected period of aplasia may result in death. 
 
11. Miscellaneous. Alopecia and sterility are expected complications of the program as a whole. Cataract 
development is possible after TBI and/or steroids. Deficiencies of growth hormone, thyroid hormone, 
and sex hormones are possible after TBI. Calcineurin inhibitors can cause transient gingival hyperplasia, 
tremor, seizure, hypertension, headache, dysesthesia and hirsutism. Steroid therapy can also contribute 
to fluid retention, easy bruising, hypertension, aseptic necrosis of bone and increased susceptibility to 
infection. MMF can cause spontaneous abortions and birth defects. Hospitalization during conditioning 
and recovery period is expected to be 5-9 weeks in duration. 
 

SAP_001.pdf: 
FHCC Protocol 2186 Statistical Analysis Plan 
Cover Page 
 
 
FHCC Protocol 2186: 
Title: Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid 
Leukemia (AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using 
Related HLA‐Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with 
Immunosuppression Before and After Transplantation 
Version: 10/12/2016 
NCT#:  NCT00589316 


FHCC Protocol#: 2186.00 
Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid Leukemia 
(AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using Related HLA‐
Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with Immunosuppression 
Before and After Transplantation 
 
 
12.0  STATISTICAL CONSIDERATIONS 
12.1 Dose‐Finding and Suspension Rules 
This is a Phase I dose‐escalation study whose primary objective is the estimation of the MTD of radiation 
delivered to normal organs by 131I‐BC8 Ab when combined with FLU/CY, and 2 Gy TBI followed by HCT 
from related, HLA‐haploidentical donors.  For this group of patients at extremely high risk of relapse 
after marrow transplantation, it is reasonable to accept a rate of grade III/IV regimen‐related toxicity as 
high as 25% if anti‐leukemic efficacy is improved by the therapy.  Thus in this study we will define the 
MTD as the dose that is associated with a true Grade III/IV RRT rate of 25%, and the dose escalation/de‐
escalation schema is based upon this target toxicity rate.  We anticipate treating 25 to 50 patients, with 
the final number treated dependent upon the extent of dose escalation and the number of patients 
treated at each dose level to achieve a minimum of 20 patients evaluable for RRT in the second phase of 
the trial.  If a patient(s) is available for study enrollment prior to all 4 patients in a cohort being fully 
evaluated for DLT, such a patient will be treated at the current dose level.  The outcome of this patient 
with respect to DLT will not impact the decision of what dose to treat the next cohort.  However, such 
patients will be used in the estimation of the MTD at the conclusion of the second stage (as detailed in 
section 12.2). 
 
A secondary objective of this study is to examine whether engraftment can be achieved safely 
among patients with high‐risk hematologic malignancies who undergo non‐myeloablative HCT from 
related, HLA‐haploidentical donors.   In a recent study by Luznik, et al. (submitted for publication and 
see Background section of protocol), 15/84 (18%) haploidentical patients with at least 2 mismatched 
antigens experienced graft rejection.  Based on these data, a rule for trial suspension will be put in place 
such that if sufficient evidence exists suggesting that the true rate of graft rejection exceeds 20%, the 
protocol will be suspended and reviewed by the investigators and other experts/committees as 
appropriate to determine whether the trial should be terminated, continued without change, or 
continued with revisions.  Sufficient evidence will be taken to be a lower limit of the appropriate 80% 
one‐sided confidence interval associated with the estimated proportion of rejections in excess of .20.  
These proportions and associated confidence intervals will be calculated after every 5th patient enrolled 
is evaluable.  Operationally, graft rejection at any of the following observed proportions would trigger a 
suspension: 3/5, 4/10, 5/15, 6/20, 8/25, 9/30, 10/35, or 11/40 patients. 
 
 
In addition to graft rejection, the study will be suspended if there is sufficient evidence to 
suggest that the true rate of grades III‐IV acute GvHD at day +100 is excessive (graded according to the 
established criteria at the FHCRC).  Sufficient evidence for grades III‐IV GvHD will be taken to be an 
observed proportion of GvHD whose lower limit to the associated one‐sided 80% confidence interval 
exceeds 35%.  As with rejection, these proportions will be evaluated after every 5th enrolled patient 
becomes evaluable.  Operationally, any of the following observed proportions of GvHD would lead to 
study suspension: 4/5, 6/10, 8/15, 10/20, 12/25, 14/30, 16/35, or 18/40. 


FHCC Protocol#: 2186.00 
Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid Leukemia 
(AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using Related HLA‐
Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with Immunosuppression 
Before and After Transplantation 
 
Each suspension rule will be evaluated among all patients enrolled, regardless of the dose of antibody 
administered. 
The following table summarizes the operating characteristics of each of these rules, each rule 
considered independent of the other. 
Table 12.1  Characteristics of Suspension Rules 
 
Number of Patients 
True Rate of 
Graft Rejection 
Probability of 
Suspension1 
True Rate of 
GVHD  
Probability of 
Suspension2 
20 
.15 
.12 
.25 
.04 
35 
.15 
.13 
.25 
.05 
20 
.35 
.80 
.50 
.66 
35 
.35 
.90 
.50 
.83 
1Represents estimate of the probability of study suspension by associated number of 
patients due to excess graft rejection.   
2Represents estimate of the probability of study suspension by associated number of 
patients due to excess GvHD. 
Each estimated from 5,000 Monte Carlo simulations. 
 
Activation of any stopping/suspension rule will be reported within 7 days of determination to the FHCRC 
IRB, study investigators, and FDA. 
Because the anti‐leukemic effect of 131I‐BC8 Ab combined with this non‐myeloablative regimen is 
unknown, but likely to increase at higher dose levels, we will follow disease response and duration of 
remission, but rates of relapse post‐transplant, or failure to enter remission, will not halt the study. 
12.2 
Dose‐Escalation/De‐Escalation 
 
A.  Dose to Normal Organ 
Dose escalation/de‐escalation will be conducted by the “two‐stage” approach introduced by Storer.20  
The maximum tolerated dose (MTD) will be defined as the dose that is associated with a true dose‐limiting 
toxicity (DLT) rate of 25%.  A DLT will be defined as a Grade III/IV (Bearman scale) toxicity that occurs 
within 30 days following transplant.  The starting dose level will be a total isotope dose estimated to 
deliver Dose  Level 6, 12  Gy to the normal organ receiving the  highest dose.  The estimated MTD of 
radiation delivered to the normal organ receiving the highest dose by I‐131‐BC8 Ab on our Phase I study 
(Protocol #1432) will be at least 24 Gy delivered to the liver.  The primary objective of our Phase I study 
(Protocol #1432) has been to estimate the MTD of Iodine‐131‐labeled BC8 (anti‐CD45) Ab, followed by 
FLU, TBI conditioning.  The original version of this protocol stated that the two‐stage design of Storer 
would be used to estimate the MTD, with 20 patients to be enrolled on the second stage.  The only DLTs 
(i.e., toxicities that dictate the dose modifications) thus far observed have occurred at the highest dose 
level (26 Gy) visited in the second stage.  However, Protocol #1432 combined I‐131‐BC8 Ab with FLU, TBI 
conditioning followed by matched related or unrelated peripheral blood stem HCT, whereas this protocol 
combines I‐131‐BC8 Ab with FLU, CY, and TBI followed by HCT using haploidentical allografting.  Given the 


FHCC Protocol#: 2186.00 
Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid Leukemia 
(AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using Related HLA‐
Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with Immunosuppression 
Before and After Transplantation 
 
differences in conditioning and stem cell donors utilized between the protocols, a conservative starting 
dose of radiation from Ab of 12 Gy will be employed in this study.  We anticipate that the combined 
toxicity of this starting dose of 12 Gy delivered by I‐131‐BC8 Ab combined with FLU, CY, and 2 Gy TBI will 
be less than that of 24 Gy delivered by I‐131‐BC8 Ab combined with FLU and 2 Gy TBI.     
Single patients will be entered on the first stage, and escalation by 2 Gy increments (in the radiation 
dose delivered to the normal organ receiving the highest dose – Table 12.2) will occur until a patient 
experiences a DLT, at which point the second stage will begin at the next lower dose level.  If the first 
patient (i.e., at the starting dose level) has DLT, de‐escalation will occur by 2 Gy increments (Table 12.2) 
until the first dose at which a patient does not have DLT, at which point the second stage will begin at that 
dose level.   
 
In the second stage, patients will be entered in cohorts of 4 evaluable patients (i.e., patients surviving 
at least 30 days following transplant, or patients who clearly have Grade III/IV RRT during that time frame).  
If the current cohort is treated at dose level k, the next cohort will be treated according to the following: 
level k‐1 if 2 or more DLTs are encountered in the cohort; level k if 1 DLT is observed within the current 
cohort; level k+1 if 0 DLTs are seen in the current cohort.  These rules are followed until a minimum of 20 
evaluable patients have been treated at the second stage and have been evaluated for DLTs.  The dose 
level will be capped at 26 Gy, however, so that if zero DLTs are observed within a cohort of 4 patients 
treated at 26 Gy, the next cohort of patients will be treated at 26 Gy.  At the highest dose level, de‐
escalation rules will continue to apply to cohorts of 4, such that the next cohort of patients will be treated 
at 24Gy if 2 or more DLTs are observed.  It is possible that a patient will be entered on the protocol before 
a patient currently enrolled on Stage 1 or all 4 patients in a cohort in Stage 2 have been followed long 
enough (30 days post‐transplant) to evaluate toxicity.  Such patients will be treated at the current dose 
level and will be used for purposes of fitting the dose‐response curve upon completion of the second 
stage.  However, these patients will not be used for purposes of dose modification unless required in the 
interests of patient safety based on the clinical judgment of the principal investigator, nor will they be 
counted towards the required number of patients for completion of the second stage. 
Following the completed observation of the final patient, a two‐parameter logistic model will be fit to 
the data, thereby generating a dose‐response curve based on the observed toxicity rate at the various 
dose levels visited.  Based on this fitted model, the MTD is estimated to be the dose that is associated 
with a toxicity rate of 25%.   
 


FHCC Protocol#: 2186.00 
Hematopoietic Bone Marrow Transplantation for Patients with High‐Risk Acute Myeloid Leukemia 
(AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) using Related HLA‐
Mismatched Donors: A Trial Using Radiolabeled Anti‐CD45 Antibody Combined with Immunosuppression 
Before and After Transplantation 
 
Table 12.2:  Dose Levels for Escalation/De‐Escalation 
 
Dose Level 
Gray delivered by 131I‐BC8 Ab to normal organ receiving 
the highest dose (liver) 
1 
2 Gy 
2 
4 Gy 
3 
6 Gy 
4 
8 Gy 
5 
10 Gy 
6 
12 Gy (starting dose level) 
7 
14 Gy 
8 
16 Gy 
9 
18 Gy 
10 
20 Gy 
11 
22 Gy 
12 
24 Gy 
13 
26 Gy 
 
B.  Dose to Bone Marrow and Graft Failure  
Initially no patient will receive a dose of 131I estimated to deliver more than 43 Gy to the marrow (5 
Gy less than the 48 Gy from 131I‐BC8 Ab tolerated on Protocol #1432).  Patients for whom the amount of 
131I required to deliver the stipulated dose to liver would result in the delivery of more than 43 Gy to 
marrow will have the 131I dose limited to the amount which would deliver 43 Gy to marrow.  If 0 of 3, or 
no more than 1 of 6 patients treated at this estimated dose to marrow experiences graft failure, we will 
then escalate in increments of 5 Gy to marrow in those patients as allowed by the marrow:  liver radiation 
absorbed dose ratio (i.e., without exceeding intended estimated radiation absorbed dose to liver).  The 
MTD of radiation dose to marrow will be estimated to be the dose below any dose where > 2 patients of 
up to 6 treated experience graft failure.