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1 Not for publication or presentation A G E N D A CIBMTR WORKING COMMITTEE FOR GRAFT SOURCES & MANIPULATION Grapevine, TX Thursday, February 27, 2014, 2:45 4:45 pm Co Chair: Co Chair: Co Chair: Statisticians: Scientific Director: Daniel H. Fowler, MD, National Cancer Institute, Bethesda, MD Telephone: ; Fax: ; E mail: [email protected] Miguel Angel Perales, MD, Memorial Sloan Kettering Cancer Center, New York, NY Telephone: ; Fax: ; E mail: [email protected] Vanderson Rocha, MD, PhD; Churchill Hospital, Oxford, UK Telephone: ; Fax: ; E mail: [email protected] Mei Jie Zhang, PhD, CIBMTR Statistical Center, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] Junfang Chen, MS, CIBMTR Statistical Center, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] Mary Eapen, MD, MS, Medical College of Wisconsin, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] 1. Introduction Minutes and Overview Plan from February 2013 meeting (Attachment 1) 2. Accrual summary (Attachment 2) 3. Published or submitted papers a. GS08 02 Alousi AM, Le Rademacher J, Saliba RM, Appelbaum FR, Artz A, Benjamin J, Devine SM, Kan F, Laughlin MJ, Lazarus HM, Liesveld J, Perales MA, Maziarz RT, Sabloff M, Waller EK, Eapen M, Champlin RE. Who is the better donor for older hematopoietic transplant recipients: an older aged sibling or a young, matched unrelated volunteer? Blood 121(13): , b. GS09 02 Eapen M, Klein JP, Ruggeri A, Spellman S, Lee SJ, Anasetti C, Arcese W, Barker JN, Baxter Lowe LA, Brown M, Fernandez Vina MA, Freeman J, He W, Iori AP, Horowitz MM, Locatelli F, Marino S, Maiers M, Michel G, Sanz GF, Gluckman E, Rocha V. Impact of allele level HLA matching on outcomes after myeloablative single unit umbilical cord blood transplantation for hematologic malignancy. Blood 123(1):133 40, c. GS11 01 Marks DI, Ahn KW, Xiaobo Z, Appelbaum, Bachanova V, Barker JN, Brunstein CG, Gibson J, Kebriaei P, Lazarus HM, Olsson R, Perales, Pidala J, Savani B, Rocha V, Eapen M. Unrelated umbilical cord blood transplant for adult acute lymphoblastic leukemia in first and second complete remission: a comparison with allografts from adult unrelated donors. Haematologica 99(2): ,

2 Not for publication or presentation d. GS12 03 Weisdorf D, Eapen M, Ruggeri A, Zhang M, Zhong X, Brunstein C, Ustun C, Rocha V, Gluckman E. Alternative donor transplantation for order patients with Acute Myeloid Leukemia in first complete remission: a CIBMTR Eurocord analysis. Submitted. 4. Studies in progress (Attachment 3) a. GS05 01 CB processing and thawing techniques on MA CB HCT Manuscript Preparation outcomes (K Ballen) b. GS08 01 Reassessment of impact donor age on outcome after URD Manuscript Preparation HCT (C Kollman) c. GS12 01 Stem cell dose in RIC HCT for AML and MDS (J Törlén/T Manuscript Preparation Erkers/O Ringdén) d. GS13 01 ATG vs non ATG for CB HCT (D Ponce/ M Perales/J Barker) Analysis e. GS13 02 Matching between UCB units in double UCB Protocol Development transplantation (C Brunstein) 5. New study proposals a. PROP Comparison of clinical outcomes between T cell replete haploidentical and matched related and unrelated donor hematopoietic stem cell transplantation (S Pingali/ E Fuchs/ S Ciurea) (Attachment 4) b. PROP Haplo identical transplants as an alternative to matched unrelated donor transplants (O Ringden) (Attachment 5) c. PROP Evaluation of three alternative donor strategies for patients with hematologic malignancies: Comparison between unrelated double umbilical cord blood (ducb) and HLA haploidentical related donor using either post transplant cyclophosphamide or ex vivo T cell depletion (A Mussetti/ M Perales) (Attachment 6) d. PROP Trends in HLA haploidentical allogeneic hematopoietic stem cell transplantation for hematologic malignancies: a CIBMTR analysis (G Akpek) (Attachment 7) e. PROP Association between recipient and donor sex and clinical outcome after allogeneic hematopoietic stem cell transplantation (P Armand/ H Kim) (Attachment 8) f. PROP Peripheral stem cell graft composition of female donors and transplant outcome (J Schetelig/ A Nagler/ A Shimoni/ G Ehninger) (Attachment 9) g. PROP The impact of graft T cell subset doses on the outcomes of allogeneic peripheral blood stem cell transplants after reduced intensity conditioning in patients with hematologic malignancies (R Reshef/ D Porter) (Attachment 10) h. PROP Using landmark analysis to provide updated relapse and leukemia free survival estimates to patients after umbilical cord blood transplantation (C Brunstein/ S Lee) (Attachment 11) 2

3 Not for publication or presentation Attachment 1 MINUTES AND OVERVIEW PLAN CIBMTR WORKING COMMITTEE FOR GRAFT SOURCES AND MANIPULATION Salt Lake City, Utah Friday, February 15, 2013, 12:15 pm 2:15 pm Co Chair: Co Chair: Co Chair: Statisticians: Scientific Director: Mary Laughlin, MD, University of Virginia, Charlottesville, VA Telephone: ; Fax: ; E mail: [email protected] Daniel H. Fowler, MD, National Cancer Institute, Bethesda, MD Telephone: ; Fax: ; E mail: [email protected] Miguel Angel Perales, MD, Memorial Sloan Kettering Cancer Center, New York, NY Telephone: ; Fax: ; E mail: [email protected] Mei Jie Zhang, PhD, CIBMTR Statistical Center, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] Junfang Chen, MS, CIBMTR Statistical Center, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] Mary Eapen, MD, MS, Medical College of Wisconsin, Milwaukee, WI Telephone: ; Fax: ; E mail: [email protected] 1. Introduction Dr. Perales called the meeting to order at 12:20pm, Drs. Laughlin, Fowler, Perales and Eapen chaired the meeting. Dr. Perales thanked Dr. Mary Laughlin for her strong leadership and guidance as Co Chair of the committee, and welcomed incoming Co Chair Vanderson Rocha, MD, PhD. Dr. Perales also clarified that the voting scale is from 1 to 9, the lowest score has the highest scientific impact. The minutes of the February 2012 meeting were approved without modifications. 2. Accrual summary Due to the full agenda, the accrual summary of registration and research cases between 1989 and 2012 were not presented to the committee but included in the Working Committee documents. 3. Presentations, published or submitted papers Publications were briefly reviewed. a. GS09 03 Brunstein CG, Eapen M, Ahn KW, Appelbaum FR, Ballen KK, Champlin RE, Cutler C, Kan F, Laughlin MJ, Soiffer RJ, Weisdorf DJ, Woolfrey A, Wagner JE. Reduced intensity conditioning transplantation in acute leukemia: the effect of source of unrelated donor stem cells on outcomes. Blood 119(23): ,

4 Not for publication or presentation Attachment 1 b. GS08 05 Scaradavou A, Brunstein C, Eapen M, Le Rademacher J, Barker J, Spellman S, Kan F, Laughlin MJ, Kurtzberg J, Wagner JE, Shpall EJ. Umbilical cord blood transplantation for adults with acute leukemia: impact of single versus double cord blood units on transplantation outcomes. Blood 121(5): , c. GS08 02 Alousi AM, Le Rademacher J, Saliba RM, Appelbaum FR, Artz A, Benjamin J, Divine SM, Kan F, Laughlin MJ, Lazarus HM, Liesveld J, Perales M, Maziarz RT, Sabloff M, Waller EK, Eapen M, Champlin RE. Who is the better donor for older hematopoietic transplant recipients: an older aged sibling or a young, matched unrelated volunteer? Blood. In Press. 4. Studies in progress a. HC03 01 Prevalence of microbially contaminated hematopoietic stem cell products (R Champlin) This study examines the effect (if any) on early survival after transplantation of microbially contaminated hematopoietic stem cell products. The manuscript for this study is being prepared will require some additional analyses prior to final draft. b. GS05 01 Effect of cord blood processing and thawing techniques on transplant outcomes after single myeloablative umbilical cord blood transplantation (K Ballen) The study will study the effect of cord blood banking practice on hematopoietic recovery and early survival after myeloablative single umbilical cord blood transplants. The study population is limited to US cord blood banks and transplants in the U.S. The final analysis has been completed; a copy of the results and its interpretation submitted to the Project Officer for the SCTOD. c. GS07 01 Peripheral blood versus bone marrow for non myeloablative stem cell transplantation (R Champlin) This study is dropped was not discussed at the meeting. A larger more recent cohort includes these patients and the findings of the more recent study (funded study SC11 02). d. GS08 01 Reassessment of impact of donor age on outcome after unrelated donor hematopoietic cell transplantation (HCT) (C Kollman) This study explored the association between donor characteristics and graft versus host disease and survival in over 6000 matched or mismatched donor recipient pairs. The final draft of the manuscript is under review writing committee and will be submitted shortly. e. GS09 02 The effect of better HLA matching on survival after umbilical cord blood transplants (M Eapen /V Rocha /S Spellman) The study examined the relative importance of donor recipient allele level matching at HLA A, B, C and DRB1 on outcomes after umbilical cord blood transplantation for acute leukemia and myelodysplastic syndrome. The results suggest better HLA matching of the cord blood unit to the recipient results in significantly lower rates of non relapse mortality. Further, an isolated mismatch at HLA A, C and DRB1 led to high rates of non relapse mortality. This effect was not seen at the HLA B locus implying a mismatch at HLA B was better tolerated than a mismatch at HLA A, C or DRB1. In addition, the effect of TNC is independent of HLA mismatching; the optimal TNC is > /Kg, increasing TNC to higher doses including in excess of /Kg does not overcome the excess non relapse mortality risks associated with HLA mismatch. The manuscript is being prepared. 4

5 Not for publication or presentation Attachment 1 f. GS10 03 Outcomes using a cryopreserved donor graft in unrelated allogeneic HCT (N Frey /H Lazarus) The primary objective of this study is to compare outcomes after transplantation of cryopreserved grafts (bone marrow or peripheral blood) from adult unrelated donors. There are about such transplants facilitated by the NMDP. Given the numbers of proposals the committee received, the working committee members were asked to assign a priority score. The study received an average priority score therefore, the study was dropped. g. GS11 01 The outcome of myeloablative and reduced intensity unrelated donor cord blood transplants for ALL in CR1 and CR2 in adults. A comparison with unrelated donor marrow and peripheral blood transplantation (D Marks) This study compared outcomes after single or double cord blood transplantation for ALL in first or second complete remission in adults to that after 8/8 or 7/8 HLA matched bone marrow/peripheral blood transplants. Compared to recipients of adult donor transplantation, recipient of cord blood transplants had significantly slower and lower likelihood of neutrophil recovery at day 28 and platelet recovery at day 100. The risk of graft failure was higher after cord blood transplants. Results of multivariate analysis confirmed lower risks for 2 4 acute graft versus host disease (GVHD) but without differences in chronic GVHD, non relapse and overall mortality. However, treatment failure was higher after cord blood transplants failure rates were driven by higher relapse risks, which is contrary to other publications. Review of data at the statistical center revealed inconsistencies in the definition of leukemia relapse. The study file has been reviewed / corrected as needed. The final analysis will be undertaken shortly. The manuscript for this study is being prepared. h. GS12 01 Role of stem cell dose in reduced intensity conditioning transplants for AML/MDS and ALL (J Törlén/T Erkers/O Ringdén) The aim of this study is to evaluate the role of nucleated and CD34 cell dose in the setting of reduced intensity conditioning. The study population will include patients with acute lymphoblastic, acute myeloid leukemia or myelodysplastic syndrome and received allografts (bone marrow or peripheral blood) from HLA matched siblings or matched unrelated donors, between 1998 and Outcomes of interest include: hematopoietic recovery, graft failure, acute and chronic graft versus host disease, non relapse mortality, relapse, treatment failure and overall mortality. The study is important since it is necessary to deliver an optimal cell dose for successful transplantation and whether delivering doses in excess may in fact contribute to higher risks of acute or chronic graft versus host disease. There was extensive discussion of this study; suggestions included looking at the ratio of CD34 to nucleated cells, including pediatric patients, and a sub analysis of conditioning intensity. It was pointed out to Dr. Ringden that in the analysis, the interaction between conditioning regimen and in vivo T cell depletion reported from a paper from this working committee be considered. Another important point is the predominance of the graft, peripheral blood progenitor cells in the setting of reduced intensity conditioning. The number of bone marrow transplants available may prohibit the study of this graft. Further, Dr. Ringden made no efforts to limit the study population to current practice as it pertains to selection of adult unrelated donors. The statistical center recommends that only 8/8 and 7/8 HLA matched unrelated donor transplants be included. The statistical center will also review the number of eligible bone marrow recipient to determine whether these cases should 5

6 Not for publication or presentation Attachment 1 be included. The statistical center will review the conditioning regimens used and will likely limit the study population to transplants with alkylating agents / fludarabine with or without in vivo T cell depletion, low dose TBI (200 cgy) and commonly used graft versus host disease prophylaxis package regimens. Other suggestions included separate analyses of donor types as well as graft types (if feasible) and a careful consideration be given to patient ages included in the dataset. For example, reduced intensity conditioning is infrequent in younger patients and perhaps excluded to generate a homogeneous population. Also review carefully the diseases included particularly the number of patients with acute lymphoblastic leukemia. Given the numbers of proposals the committee received, the working committee members were asked to assign a priority score. The study received a high priority score proceed to protocol development. 5. Future/ Proposed studies a. PROP Who is the better donor for older adult hematopoietic transplant recipients: an older aged sibling or unrelated double UCB? (M Laughlin/C Brunstein/J Barker) This study will compare rates of graft versus host disease, overall and non relapse mortality in older patients who received mismatched cord blood transplants to those who received grafts from their sibling. This proposal was developed in light of the findings of GS08 02, which showed lower rates of graft versus host disease after older matched sibling donor transplants compared to HLA matched transplants from younger donors and better survival in good risk patients after HLA matched sibling transplants. As with GS08 02, the study population will include patients 50 years or older who received grafts from their HLA matched sibling or mismatched umbilical cord blood (one or two units). Approximately 1200 HLA matched sibling transplants and 400 double cord blood transplants are eligible. Discussions included the relevance of such a study often when a matched sibling is available, that donor is preferred. However graft versus host disease is lower after cord blood transplants compared to unrelated donor transplants BUT unlikely to be lower than matched sibling transplants. There was discussion about co morbidities in older sibling donors rendering them ineligible to donate. There was also some discussion as to what would determine the optimal unit, i.e., differing selection criteria between transplant centers and how would one adjust for practice variation. While there were no major concerns about feasibility or scientific merit, when ranked against the approved studies and other proposals this was assigned a lower priority score. Therefore this proposal was dropped. b. PROP Comparison of cord blood transplantation outcomes according to the inclusion of anti thymocyte globulin (ATG) in pre transplant conditioning (DM Ponce/JN Barker/ MA Perales) Dr. Juliet Barker presented the proposal. The primary aim of the study is to compare diseasefree and overall survival after cord blood transplants testing the effect of in vivo T cell depletion in the setting of myeloablative and reduced intensity conditioning. Other outcomes include: hematopoietic recovery including graft failure, acute and chronic graft versus host disease, EBVassociated PTLD, immune reconstitution, recurrent disease and non relapse mortality. The hypothesis being omission of anti thymocyte globulin will result in better disease free survival. Study population will include the following hematologic malignancies (ALL, AML, CLL, MDS, NHL and HL) and transplanted with cord blood grafts between 2007 and Suggestions included: information on ATG dose, type of ATG and if possible timing (this would require supplemental 6

7 Not for publication or presentation Attachment 1 data collection contact centers to establish the timing of administration which is likely to be uniform at centers). Received the highest priority score approved / proceed to protocol development. c. PROP Matching between UCB units in double UCB transplantation (C Brunstein) The purpose of the study is to determine whether matching between two mismatched units affect hematopoietic recovery, acute graft versus host disease and early survival. The selection of units when considering a double unit transplant varies some match the two units to each other to no more than two mismatches and others ignore matching between two units. The study population will include transplants for acute lymphoblastic and myeloid leukemia from The outcomes of interest include hematopoietic recovery, GVHD and overall survival at day 100 and 1 year. Dr. Laughlin suggested looking at whether the mismatch was at class I or class II or both, if feasible. HLA match will consider HLA match at A and B at intermediate resolution and allele level at DRB1. There were also suggestions to extend the transplant period to include 2012 transplants as outcomes are short term: day 28 neutrophil recovery, day 100 / 1 year survival and grade 2 4 acute GVHD. This proposal received a high priority score approved / proceed to protocol development. d. PROP Cord blood unit release testing criteria and the impact on transplantation outcome (D Regan) The primary aim of the study is to determine the impact of umbilical cord blood colony forming unit (CFU) testing at the time of release on transplantation outcome. The secondary aim is to determine potential CFU growth thresholds for release of cord blood units for transplantation. Study population includes recipients with first allogeneic, myeloablative single unit cord blood transplants for AML, ALL or MDS facilitated by the NMDP. The interested outcomes are: hematopoietic recovery and day 100 overall survival. In a survey undertaken by the NMDP, 19 cord blood banks in the US are eligible. A survey was undertaken to determine which of these banks have established criteria and/or criteria used to determine which of the units are released to transplant centers. Of the 19 eligible banks, 14 responded to the survey. Twelve of 14 have established criteria for release but there is no consensus as to what these criteria should be. Of interest for this proposal is CFU testing the survey suggest only 6 of the 14 banks perform CFU testing prior to release and the results reported as any growth versus no growth. The other 8 banks test either total nucleated cell dose and/or CD34 dose. Twelve of the 14 banks perform viability but the method of testing is variable between banks and the acceptable viability range also varied between banks. This proposal indicated the primary question would be: was any CFU growth present vs. none. In the ensuing discussion there were concerns about the lack of a quantitative number for CFUs, the heterogeneous approach to testing adopted by the banks, heterogeneous handling / processing methods at transplant centers and the cumulative effect of these variations on transplant outcome. Additionally, this proposal will require collection of supplemental data from cord blood banks per unit basis (to link release criteria as established by each bank to the unit used for transplantation). In addition to feasibility, there were concerns about the scientific merit / validity of any results generated from the planned analyses in particular the lack of quantification of CFU growth at the banks that routinely perform this testing and its comparison with the other banks that do 7

8 Not for publication or presentation Attachment 1 not use this method for release. The committee assigned a low priority score the proposal was dropped. 6. Other business None. Proposals and were approved. Meeting adjourned at 2:06 PM. Working Committee Overview Plan for a. HC03 01 Prevalence of microbially contaminated hematopoietic stem cell products we will update survival, re run logistic regression model for early survival (day 100) the primary endpoint. We anticipate submitting the manuscript June 2013 Dr. Laughlin will have primary responsibility for drafting the manuscript and therefore, first author. b. GS05 01 Effect of cord blood processing and thawing techniques on transplant outcomes after single myeloablative umbilical cord blood transplantation. Completed final analyses and report submitted to the Project Officer for the SCTOD. A copy of that report will be send to Dr. Ballen as soon we have approval from HRSA / Advisory Committee to the Stem Cell Therapeutics Outcomes Database. We anticipate submitting the manuscript by June c. GS08 01 Reassessment of impact of donor age on outcome after unrelated donor hematopoietic cell transplantation. The statistical center has a copy of the manuscript from the principal investigator this is the final copy pending any revisions undertaken at the statistical center. We anticipate submitting this manuscript for peer review March d. GS09 02 The effect of better HLA matching on survival after umbilical cord blood transplants. The manuscript for this study is being written, anticipated submission by April e. GS11 01 The outcome of myeloablative and reduced intensity unrelated donor cord blood transplants for ALL in CR1 and CR2 in adults. The manuscript for this study is being written, anticipated submission by April f. GS12 01 Role of stem cell dose in reduced intensity conditioning transplants for acute myeloid leukemia, myelodyspalstic syndrome and acute lymphoblastic leukemia. We anticipate beginning to work on this project March 2013, complete analysis by June 2013 and submit an abstract to the 2013 American Society of Hematology meeting. We anticipate submitting the manuscript for peer review October/November g. GS13 01 (PROP ) Comparison of cord blood transplantation outcomes according to the inclusion of anti thymocyte globulin in pre transplant conditioning. We anticipate developing the study protocol May/June 2013; prepare study file and final analyses by December We anticipate submitting the manuscript for peer review by March/April

9 Not for publication or presentation Attachment 1 h. GS13 02 (PROP ) Matching between cord blood units in double cord blood unit transplantation is there an effect on hematopoietic recovery, acute graft versus host disease and overall survival? We anticipate developing the study protocol May/June 2013; prepare study file and final analyses by December We anticipate submitting the manuscript for peer review by March/April Work Assignments for Working Committee Leadership (February 2013) Daniel Fowler Mary Eapen HC03 01: Prevalence of microbially contaminated hematopoietic stem cell products GS05 01: Effect of cord blood processing and thawing techniques on transplant outcomes after single myeloablative umbilical cord blood transplantation GS11 01: The outcome of myeloablative and reduced intensity unrelated donor cord blood transplants for ALL in CR1 and CR2 in adults GS13 02: (PROP ) Matching between cord blood units in double cord blood unit transplantation is there an effect on hematopoietic recovery, acute graftversus host disease and overall survival? Vanderson Rocha GS09 02: The effect of better HLA matching on survival after umbilical cord blood transplants GS12 01: Role of stem cell dose in reduced intensity conditioning transplants for acute myeloid leukemia, myelodyspalstic syndrome and acute lymphoblastic leukemia Miguel Perales GS13 01: (PROP ) Comparison of cord blood transplantation outcomes according to the inclusion of anti thymocyte globulin in pre transplant conditioning 9

10 Not for publication or presentation Attachment 2 Accrual Summary for Graft Sources and Manipulation Working Committee Characteristics of patients reported to the CIBMTR between 1989 and 2013 Characteristics TED N (%) Research N (%) Number of cases Donor type HLA identical sibling donor HCT Bone marrow (53) (61) Peripheral blood (46) (37) Peripheral blood + bone marrow 634 (<1) 202 (<1) Umbilical cord blood 549 ( <1) 234 (<1) Identical twin donor HCT Bone marrow 579 (41) 310 (45) Peripheral blood 834 (59) 369 (54) Peripheral blood + bone marrow 8 (<1) 2 (<1) Umbilical cord blood 4 (<1) 3 (<1) Other related donor HCT Bone marrow 8791 (60) 5709 (78) Peripheral blood 5457 (37) 1449 (20) Peripheral blood + bone marrow 228 ( 2) 66 (<1) Umbilical cord blood 113 (<1) 49 (<1) Unrelated donor HCT Bone marrow (43) (51) Peripheral blood (41) (31) Peripheral blood + bone marrow 147 (<1) 124 (<1) Umbilical cord blood (15) 6209(17) 10

11 Not for publication or presentation Attachment 3 TO: FROM: The Members, Graft Sources and Manipulation Working Committee Mary Eapen, MD, MS RE: Summary of the Committee s Activities for 02/ /2014 Completed Studies: 02/ /2014 GS05 01: Effect of cord blood processing and thawing techniques on transplant outcomes after single myeloablative umbilical cord blood transplantation (K Ballen): A variety of processing and freezing practices at the cord blood banks (CBB) and thawing techniques at transplantation centers are employed, but optimal practices have not been determined. Processing and banking practices at 16 public CBB in the United States were collected and their effect on transplant outcomes assessed. The study population included 530 single umbilical cord blood (UCB) myeloablative transplantations for hematologic malignancies. UCB banking practices were separated into four mutually exclusive groups based on whether processing was automated or manual; units were plasma / red blood cell reduced or buffy coat method or plasma reduced; and hespan or dimethyl sulfoxide (DMSO) added to the bag. Neutrophil recovery at day 28 was significantly lower after transplantation of units that were manually processed and plasma reduced with DMSO added to the bag. Day 100 survival did not differ by CBB of origin. However, day 100 survival was marginally better with units thawed with the dextranalbumin wash method at transplant centers as opposed to the no wash or a dilution only technique. These data suggest an effect of banking practices on neutrophil recovery and an early survival advantage with thawing practices at the transplant center. GS08 01: The effect of donor characteristics on survival after unrelated donor transplantation for hematologic malignancy (C Kollman): Over 6000 unrelated donor recipient transplantations between 1988 and 2006 were examined to identify donor characteristics associated with survival. All patients had a hematologic malignancy and donor recipient pairs were HLA typed at the allele level. In multivariate analysis, three donor characteristics were identified: survival was higher with donors aged 32 years or younger, HLA matched at the allele level at HLA A, B, C and DRB1 and blood group ABO matched to the recipient. Each of these donor characteristic had an independent prognostic value. Donor recipient gender match was not associated with survival. However, chronic GVHD rates were lower with transplantation of grafts from male or nulliparous female donors. Donor CMV serostatus was not associated with survival. In conclusion, donor age, donor recipient HLA match and ABO match are equally important when selecting adult unrelated donors. GS12 01: Low CD34 cell dose is associated with higher non relapse and overall mortality after reduced intensity conditioning hematopoietic cell transplantation for acute myeloid leukemia and myelodysplastic syndrome (J Thörlén/O Ringden): The effect of CD34 dose on 1057 patients aged years with AML or MDS who received RIC 11

12 Not for publication or presentation Attachment 3 regimen HCT between 2000 and 2011 were studied. Patients received grafts from HLA matched siblings (n = 370) or from volunteer adult unrelated donors matched at the allele level at HLA A, B, C and DRB1 (8/8; n = 522) or mismatched at 1 HLA locus (7/8; n = 178). All patients received peripheral blood progenitor cells (PBPC), low dose TBI regimens (200 cgy) or alkylating agent plus fludarabine containing regimens. Separate analyses were conducted for HLA matched and unrelated donor transplants. For HLA matched sibling transplants, exploratory analysis identified differences in survival for CD34 dose less than 4 x 10 6 /kg. Multivariate modeling, adjusting for performance score, disease status, cytogenetic risk and transplant period, showed transplantation of PBPC with CD34 dose < 4 x 10 6 /kg was associated with higher risks of overall mortality and non relapse mortality. The effect of CD34 dose was independent of the other factors associated with mortality. In contrast, after unrelated donor transplantation, the effect of CD34 cell dose on mortality was marginal. Exploratory analysis identified differences in survival for CD34 dose less than 6 x 10 6 /kg. After adjusting for age, performance score, disease status, interval from diagnosis to HCT, and HLA match, transplantation of PBPC with CD34 dose < 6 x 10 6 /kg was associated with marginally higher risks for overall mortality and non relapse mortality. For both donor sources, CD34 dose was not associated with acute or chronic GVHD or disease recurrence. Further, we did not identify a CD34 dose for either donor source above which acute or chronic GVHD risks were higher. In the setting of RIC transplants for AML and MDS, the data support optimizing PBPC collections such that the CD34 dose delivered is in excess of 4 x 10 6 /kg for HLA matched sibling and CD34 dose in excess of 6 x 10 6 /kg for unrelated donor transplants. GS12 03: Alternative Donor Transplantation for Older Patients with Acute Myeloid Leukemia in First Complete Remission: a CIBMTR Eurocord Analysis (D Wiesdorf): Transplant outcomes for AML in patients over age 50 years in CR1 were compared after adult unrelated donor (URD; n = 441, 8/8 and n = 94 7/8 HLA matched) and umbilical cord blood (UCB; n = 205) transplantations to determine the relative efficacy of one graft source over the other. UCB recipients less often achieved CR1 within 8 weeks, more often received reduced intensity conditioning, and cyclosporin based GVHD prophylaxis. Three year transplant related mortality was higher and leukemiafree survival lower with UCB compared to 8/8 URD transplantation. Compared to 8/8 URD transplants, transplant related mortality was higher after 7/8 URD, but leukemia free survival similar. Chronic GVHD was lowest after in UCB transplantation. Three year survival was highest after 8/8 URD 43%. Survival was lower after UCB 30% and 7/8 URD transplants. Although a fully matched URD is preferred when available, transplantation with UCB or mismatched URD extends survival for over a third of older patients. Less frequent chronic GVHD with UCB transplantation may be of particular value for older patients. Studies: Active GS13 01: Comparison of cord blood transplantation outcomes according to the inclusion of antithymocyte globulin in pre transplant conditioning (D Ponce/ M Perales/J Barker): This study compares outcomes after cord blood transplantation testing the effect of in vivo T cell depletion. Given differences in patient characteristics, in particular age, by transplant conditioning intensity, two separate analyses will be conducted. The first will focus on myeloablative transplant conditioning regimens in a pediatric population and second, on adults who received reduced intensity conditioning. GS13 02: Matching between UCB units in double UCB transplantation (C Brunstein): This study will explore whether better matching between two mismatched units in the setting of double umbilical cord blood transplantation affects early transplant outcomes. 12

13 Not for publication or presentation Attachment 4 Study Proposal Study Title: Comparison of Clinical Outcomes between T cell Replete Haploidentical and Matched Related and Unrelated Donor Hematopoietic Stem Cell Transplantation Sai R. Pingali, MD 1, Ephraim Fuchs 2, Stefan O. Ciurea, MD 1 1 The University of Texas, M. D. Anderson Cancer Center, TX 2 Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, MD Hypothesis: Outcomes of haploidentical stem cell transplantation performed with post transplantation cyclophosphamide, tacrolimus and mycophenolate for GVHD prevention are similar to matched transplantation. Specific Aims: To compare outcomes of patients with hematologic malignancies (myeloid and lymphoid) treated with haploidentical stem cell transplantation ( 2 antigen mismatch) with matched (related and unrelated) donor transplants for same disease indications. Outcomes to be evaluated include: engraftment, nonrelapse mortality (NRM), relapse rate (RR), overall survival (OS) and disease free survival (DFS). Background: Allogeneic Hematopoietic stem cell transplantation is an effective treatment for advanced hematologic myeloid and lymphoid malignancies 1. An HLA identical donor transplant is preferred; however, a matched sibling is available for less than 25% of the recipients. Using international registries, an unrelated donor is identified in the US for 50% 60% of the Caucasian population, while the chance to find an unrelated donor for non Caucasian population is less than that (approximately 30% for Hispanics, 10% for African Americans and Asians). In addition, it takes an average of 3 4 months to identify and procure the stem cells from an unrelated donor 2. These numbers are expected to be even smaller with increase in the minority population and interethnic/interracial marriages 3, 4. Mismatched relatives represent a potential donor source of stem cells for such patients, >90% will have an available haploidentical donor for transplantation 5,6. Historically, haploidentical stem cell transplantation (HaploSCT) was associated with high rates of graft rejection and acute graft versus host disease (agvhd) 7. T cell depletion decreased the rate of GVHD at the expense of a higher risk of rejection and severe infections 8. T cell replete (TCR) HaploSCT with the use of post transplant high dose cyclophosphamide(ptcy), tacrolimus and mycophenolate mofetil (MMF) for GVHD prophylaxis pioneered by the Hopkins group, was shown to have similar rates of agvhd with matched transplantation and low non relapse mortality without significantly compromising engraftment In addition, the risk of fatal infections was also lower with this strategy because of more effective immune reconstitution presumably related to maintaining the memory T cells in the graft 12. Recent studies comparing TCR HaploSCT with matched transplants, showed similar outcomes 12,13. We reviewed data from our institution for patients treated with a haploidentical, matched sibling and matched unrelated donor transplant in an uniform cohort of patients with AML/MDS in remission who received the same conditioning, melphalan based. There were no significant differences in engraftment, NRM, relapse rate and PFS between recipients of haploidentical and matched related or 13

14 Not for publication or presentation Attachment 4 unrelated donor transplantations, while T cell depleted HaploSCT recipients did significantly worse (ASH abstract #61013) (Figure 1). The objectives of this study are to compare outcomes of patients who underwent TCR HaploSCT (treated at MD Anderson Cancer Center and Johns Hopkins) with a matched cohort of HLA matched donor transplants reported to Center for International Blood and Marrow Transplant registry (CIBMTR) between years 2000 and Other patients who received a TCR HaploSCT with PTCY and reported to the CIBMTR database may be added to the investigational arm, if available. Methodology: Patients who underwent TCR HaploSCT with myeloablative, RIC and non myeloablative conditioning as previously defined 14 who received post transplant cyclophosphamide, tacrolimus and MMF for GVHD prophylaxis at The University of Texas M. D. Anderson Cancer Center (UTMDACC) and Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins (SKCCCJH) from January 2000 to December 2012 will be included in the experimental arm of the study. We estimate the TCR HaploSCT cohort would consist of approximately 400 patients. Patients who had matched donor transplantation during the same time period with similar patient and disease related characteristics from CIBMTR will be included in the control group 15. Control patients will be identified using a matched pair analysis with patient and disease characteristics. Comparison will be performed using Cox proportional hazards model. Overall survival (OS) is defined as time from SCT to last follow up. Similarly, non relapse mortality (NRM) will be computed from time of SCT to last known vital sign. Time to progression is defined time of SCT and date of disease progression. Patients who are alive and did not experience progression of disease at the last follow up date will be censored. The Kaplan Meier method will be used to estimate OS and DFS and the log rank test was used to assess differences between specific groups 16. NRM and time toprogression will be determined by the cumulative incidence function using the competing risks method. The cumulative incidence of grade II IV acute graft vs. host disease (GVHD) and chronic GVHD (cgvhd) (limited and extensive) will also be determined using the competing risks method 17. The competing risks include disease progression and death, while those patients who do not experience GVHD or progression of disease and alive at the last follow up will be censored. All statistical analyses will be performed using SAS 9.3 for Windows. Endpoints: The primary endpoints of these analyses are: Hematopoietic recovery: Time to neutrophil engraftment ANC > 0.5 x 10 9 /L for three consecutive days will be the primary measure for comparisons of hematopoietic recovery. Time to platelet engraftment platelet count 20 x 10 9 /L Time to platelet count 100 x 10 9 /L. Graft Failure: Primary graft failure defined as no evidence of transplanted marrow function after day 28 post transplant Secondary graft failure Development of inadequate marrow function (fall of granulocytes to <0.5/mcl for 3 or more consecutive days) any time after initial engraftment has been achieved. Incidence of acute and chronic GVHD: grade II IV acute GVHD and limited and extensive chronic GVHD. 14

15 Not for publication or presentation Attachment 4 Treatment related mortality: time to death without evidence of disease recurrence. Patients are censored at time of relapse or at last follow up. Disease recurrence: time to onset of disease relapse. Patients will be censored at death in continuous CR or, for patients surviving in continuous complete remission, at the last contact. Disease free survival: time to treatment failure (death or relapse). Patients are censored at time of last follow up. Overall survival: time to death. Patients are censored at time of last follow up. Variables to be analyzed: A Continuous variables B Categorical variables Patient related: Age at transplant (A) Gender (female vs male) (B) Karnofsky performance score at transplant (<90% vs 90%), when available (B) Disease related (at initial diagnosis): Cytogenetics (AML, MDS) (good/intermediate vs. poor prognosis) (B) AML: Prior hematological disorder (MDS or secondary/therapy related) (yes/no) (B) Extramedullary disease (yes/no) (B) CNS disease? (yes/no) (B) Disease related (at the time of transplant): Disease status transplant (B) Time from diagnosis to transplant (A) Ever achieved a first remission? (yes/no) (B) Time to achieve complete remission (A) Duration of complete remission (B) Number of cycles of induction therapy to achieve first complete remission (1 vs >1) for patients with acute leukemia (B) Treatment related: Donor age (A) Donor recipient gender match (F M vs M F vs M M vs F F) (B) Donor type (child/parent/sibling/other) (B) Donor recipient HLA match (# of antigen mismatches) (A) Donor recipient CMV status: ( / vs others) (B) Conditioning regimen (MA vs. RIC vs. NMA) (B) Conditioning regimen type (A) Infused number of nucleated and CD34+ cells: n/kg recipient weight (A) Infused number of CD3+ cells: n/kg recipient weight (A) Source of stem cells: (BM vs PBSC vs both) (B) Growth factors post transplant: G CSF or GM CSF: (yes/no) (B) Treatment related Second transplant (if applicable): Second transplant for graft failure? (y/n) (B) Second transplant same donor? (y/n) (B) Disease status at transplant (remission vs not) (B) Relapse after transplant? (y/n) (B) GVHD present at time of second BMT? (y/n) (B) 15

16 Not for publication or presentation Attachment 4 Time from relapse post transplant (A) Time from transplant (A) Significance: There are no large studies comparing outcomes of HaploSCT versus matched related donor transplantations. This study would allow us to effectively compare the outcomes while adjusting for the patient and disease related factors, thereby giving us a better understanding of HaploSCT outcomes. Figure 1. References: 1. Copelan, E. A. (2006). "Hematopoietic stem cell transplantation." N Engl J Med 354(17): Washington, D. C. G. A. O. (2002). Bone marrow transplant: despite recruitment successes, national programs may be underutilized. 3. J.S. Passel, W. W., P. Taylor (2011). "Marrying Out: One in Seven New U.S. Marriages is Interracial or Interethnic." Pew Research Center Publications, Washington, DC. 4. Bayraktar, U. D., et al. (2012). "Progress in haploidentical stem cell transplantation." Biol Blood Marrow Transplant 18(3): Falk, P. M., et al. (1978). "Bone marrow transplantation between a histocompatible parent and child for acute leukemia." Transplantation 25(2): Powles, R. L., et al. (1983). "Mismatched family donors for bone marrow transplantation as treatment for acute leukaemia." Lancet 1(8325): Szydlo, R., et al. (1997). "Results of allogeneic bone marrow transplants for leukemia using donors other than HLA identical siblings." J Clin Oncol 15(5):

17 Not for publication or presentation Attachment 4 8. Marmont, A. M., et al. (1991). "T cell depletion of HLA identical transplants in leukemia." Blood 78(8): Luznik, L., et al. (2008). "HLA haploidentical bone marrow transplantation for hematologic malignancies using nonmyeloablative conditioning and high dose, posttransplantation cyclophosphamide." Biol Blood Marrow Transplant 14(6): O'Donnell, P. V., et al. (2002). "Nonmyeloablative bone marrow transplantation from partially HLA mismatched related donors using posttransplantation cyclophosphamide." Biol Blood Marrow Transplant 8(7): Brunstein, C. G., et al. (2011). "Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA mismatched related bone marrow or unrelated double umbilical cord blood grafts." Blood 118(2): Ciurea, S. O., et al. (2012). "Improved early outcomes using a T cell replete graft compared with T cell depleted haploidentical hematopoietic stem cell transplantation." Biol Blood Marrow Transplant 18(12): Bashey, A., et al. (2013). "T cell replete HLA haploidentical hematopoietic transplantation for hematologic malignancies using post transplantation cyclophosphamide results in outcomes equivalent to those of contemporaneous HLA matched related and unrelated donor transplantation." J Clin Oncol 31(10): Bacigalupo A., et al.(2009). Defining the intensity of conditioning regimens: working definitions. Biol Blood Marrow Transplant 15(12): Cox DR, (1972). " Regression models and life tables [with discussion]." J R Stat Soc B. 1972(34): Kaplan EL, M. P. " Nonparametric estimation for incomplete observations." J Am Stat Assoc 1958( 53): Prentice RL, K. J., Peterson AV "The analysis of failure times in the presence of competing risks." Jr. Biometrics 1978(34(4)):

18 Not for publication or presentation Attachment 4 Characteristic of AML and ALL patients who underwent first allogeneic haploidentical or 8/8 HLA matched unrelated transplant and reported to CIBMTR, Ex vivo T cell depletion N (%) CD34 selection N (%) post Transplant Cy N (%) 8/8 HLA matched unrelated N (%) Variable Number of patients Number of centers Age at transplant, years <10 27 (22) 31 (19) 11 (4) 41 (5) (23) 30 (19) 17 (6) 46 (5) (12) 17 (11) 34 (12) 104 (12) (8) 13 (8) 38 (14) 123 (15) (10) 23 (14) 45 (16) 164 (20) (10) 23 (14) 68 (25) 199 (24) (15) 23 (14) 61 (22) 161 (19) Disease AML 74 (60) 103 (64) 216 (79) 684 (82) ALL 50 (40) 57 (36) 58 (21) 154 (18) Conditioning regimen Myeloablative 82 (66) 105 (66) 109 (40) 603 (72) Reduced intensity 42 (34) 55 (35) 161 (60) 235 (28) 18

19 Not for publication or presentation Attachment 5 Study Proposal Study Title: Haplo identical transplants as an alternative to matched unrelated donor transplants Olle Ringdén, MD, PhD, Professor of Transplantation Immunology [email protected] Karolinska Institutet Dept. of Laboratory Medicine Division of Therapeutic Immunology, F79 Karolinska University Hospital Huddinge SE Stockholm, Sweden Phone: Fax: Specific Aims: To compare haplo identical transplants using post transplant cyclophosphamide and evaluate if this can be a valid alternative to matched unrelated donor transplants. Evaluate the cumulative probability of acute and chronic GVHD and non relapse mortality (NRM) in the two groups Compare relapse probability, overall survival and disease free survival (DFS) in the two groups Scientific Justification: Haplo identical transplants are increasingly used when there is no HLA identical sibling or HLA matched unrelated donor available 1 3. These protocols used T cell depletion with or without a megadose of CD34 stem cells from the donor to modulate GVHD. In more recent years, reduced intensity conditioning (RIC) and a high dose post transplant cyclophosphamide to eliminate alloreactive T cells from the donor has emerged as a simple way to perform haplo identical bone marrow transplantation 4 6. A promising outcome with this approach has also been confirmed by others 7, 8. In MUD transplants, immunosuppression including ATG, cyclosporine or tacrolimus combined with methotrexate or mycophenolate mofetil are used with subsequent impaired immune reconstitution and with a high incidence of infectious complications. With post transplant cyclophosphamide used in haplo identical transplants, immune reconstitution and T cell immunity against virus and fungi may be preserved 9. Using haplo identical transplants, there are several HLA antigen mismatches. Recipient mismatched HLA antigens on leukemic cells may be targets for an allo reactive donor graft versus leukemia effect. If such an effect will disappear or will be preserved by allo depletion is unknown. Therefore, it is of interest to compare haplo identical transplants using post transplant cyclophosphamide with MUD transplants. Since most patients have access to an haplo identical donor, a sibling, parent or a child, such a graft may be availabe for almost all patients. The aim of the investigation is to find out if haploidentical transplants using post transplant cyclophosphamide may be an alternative to MUD transplants. Haplo identical transplants may also be a cheaper alternative. 19

20 Not for publication or presentation Attachment 5 Patient Eligibility Population: Patients with leukemia (AML, ALL, CML, CLL), MDS and lymphomas reported to CIBMTR and transplanted between 2000 and today (with a minimum follow up of three months), using various conditioning regimens, RIC or MAC. Haplo identical transplants receiving post transplant cyclophosphamide will be compared to MUD transplants (HLA match 8/8 or 7/8). Data Requirements: The CIBMTR Data Base will be used. No additional data will be requested. Sample Requirements: No samples are needed. Variables to be analyzed: Patient related: Age at transplant Gender: male vs. female Karnofsky score pre transplant; <90% vs. 90%. Disease related: AML vs. ALL vs. CML vs. MDS vs. CLL vs. Lymphoma Lymphoma: small lymphocytic, follicular, diffuse large cell, mantel cell, other Disease status at the time of transplant: 1 st CR vs. 2 nd 3 rd CR, vs. relapse AML FAB subtype ALL: immunophenotype; CML: 1 st chronic phase, accelerated phase, blast crisis MDS: RA/RARS vs. RAEB/RAEBt Lymphoma: CR, PR, relapse sensitive, relapse resistant WBC at diagnosis: <25x10 9 /L, 25 50x10 9 /L, x10 9 /L, >100x10 9 /L Duration of CR1 (for patients beyond CR1): <6 months, 6 12 months, >12months. Time from remission to transplant (for patients in CR1): <3 months, 3 6 months, >6 months Time from remission to transplant for CML: <12 months, >12 months Cytogenetics: AML: good vs. intermediate vs. poor vs. no abnormalities vs. missing data ALL: No abnormalities vs. hyperdiploid vs. hypodiploid/ t(9;22)/ t(4;11)/ t(8;14) vs. other abnormalities vs. missing data Transplant related: Source of stem cells: bone marrow vs. peripheral stem cells Donor age: group by 10 year increments Donor recipient gender match: F M vs. M F vs. M M vs. F F Donor recipient CMV status ( / vs. /+ vs. +/ vs. +/+) Conditioning regimen: myeloablative vs. RIC vs. NMC. GVHD prophylaxis: CsA + MTX ± other, CsA ± MMF, FK506 + MTX ± other, FK506 ± other, other. Year of transplant before or after the median HLA match: MUD, HLA compatible 8/8, HLA one antigen mismatched 7/8 20

21 Not for publication or presentation Attachment 5 Study Design: Depending on the number of patients, the analysis may be restricted to a more homogenous disease category leukemias or lymphomas. To characterize the data set, descriptive tables of patients, disease and transplant related variables will be included. The comparison is between haplo identical transplants and MUD. For discrete factors, the number of cases and their respective percentages will be calculated. For continuous factors, the median and the range will be calculated. The main and primary objective of the study is to compare DFS according to Kaplan Meier between the two groups. Comparison of survival curves will be done using the log rank test. Secondary objectives include comparison of cumulative incidence of acute and chronic GVHD and NRM. First, a univariate analysis will be performed and subsequently a multivariate analysis including factors which are significant or with a trend will be included (p=0.1). References: 1. Aversa F, Terenzi A, Tabilio A, Falzetti F, Carotti A, Ballanti S et al. Full haplotype mismatched hematopoietic stem cell transplantation: a phase II study in patients with acute leukemia at high risk of relapse. J Clin Oncol 2005; 23(15): Ruggeri L, Capanni M, Urbani E, Perruccio K, Shlomchik WD, Tosti A et al. Effectiveness of donor natural killer cell alloreactivity in mismatched hematopoietic transplants. Science 2002; 295(5562): Handgretinger R, Klingebiel T, Lang P, Schumm M, Neu S, Geiselhart A et al. Megadose transplantation of purified peripheral blood CD34(+) progenitor cells from HLA mismatched parental donors in children. Bone Marrow Transplant 2001; 27(8): Bolanos Meade J, Fuchs EJ, Luznik L, Lanzkron SM, Gamper CJ, Jones RJ et al. HLA haploidentical bone marrow transplantation with posttransplant cyclophosphamide expands the donor pool for patients with sickle cell disease. Blood 2012; 120(22): Luznik L, Jalla S, Engstrom LW, Iannone R, Fuchs EJ. 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): Luznik L, O'Donnell PV, Symons HJ, Chen AR, Leffell MS, Zahurak M et al. HLA haploidentical bone marrow transplantation for hematologic malignancies using nonmyeloablative conditioning and high dose, posttransplantation cyclophosphamide. Biol Blood Marrow Transplant 2008; 14(6): Tuve S, Gayoso J, Scheid C, Radke J, Kiani A, Serrano D et al. Haploidentical bone marrow transplantation with post grafting cyclophosphamide: multicenter experience with an alternative salvage strategy. Leukemia 2011; 25(5): Bacigalupo A, Dominietto A, Di Grazia C, Tamparelli T, Gualandi F, Ibatici A et al. Unmanipulated haploidentical transplants compared with other alternative donors and matched sibling grafts: a single center experience in 488 patients (abstract). Bone Marrow Transplant 2013; 48(suppl 2): S Kanakry JA, Kasamon YL, Bolanos Meade J, Borrello IM, Brodsky RA, Fuchs EJ et al. Absence of Post Transplantation Lymphoproliferative Disorder after Allogeneic Blood or Marrow Transplantation Using Post Transplantation Cyclophosphamide as Graft versus Host Disease Prophylaxis. Biol Blood Marrow Transplant 2013; 19(10):

22 Not for publication or presentation Attachment 5 Characteristic of AML and ALL patients who underwent first allogeneic haploidentical or 8/8 HLA matched unrelated transplant and reported to CIBMTR, Variable Ex vivo T cell depletion N (%) CD34 selection N (%) post Transplant Cy N (%) 8/8 HLA matched unrelated N (%) Number of patients Number of centers Age at transplant, years Disease <10 27 (22) 31 (19) 11 (4) 41 (5) (23) 30 (19) 17 (6) 46 (5) (12) 17 (11) 34 (12) 104 (12) (8) 13 (8) 38 (14) 123 (15) (10) 23 (14) 45 (16) 164 (20) (10) 23 (14) 68 (25) 199 (24) (15) 23 (14) 61 (22) 161 (19) AML 74 (60) 103 (64) 216 (79) 684 (82) ALL 50 (40) 57 (36) 58 (21) 154 (18) Conditioning regimen Myeloablative 82 (66) 105 (66) 109 (40) 603 (72) Reduced intensity 42 (34) 55 (35) 161 (60) 235 (28) 22

23 Not for publication or presentation Attachment 6 Study Proposal Study Title: Evaluation of three alternative donor strategies for patients with hematologic malignancies: Comparison between unrelated double umbilical cord blood (ducb) and HLA haploidentical related donor using either post transplant cyclophosphamide or ex vivo T cell depletion Alberto Mussetti, MD, Memorial Sloan Kettering Cancer Center, [email protected] Miguel Angel Perales, MD, Memorial Sloan Kettering Cancer Center, [email protected] Specific Aims: To compare outcomes of 3 alternative donor strategies: unrelated double umbilical cord blood (ducb), haploidentical stem cell transplantation (haplo HCT) using in vitro positive selection of CD34+ cells (TCD) or high dose post transplant cyclophosphamide (PT/Cy): 1. Engraftment (neutrophil recovery; platelet recovery, donor chimerism) 2. Acute graft versus host disease (GVHD) 3. Chronic GVHD 4. Transplant related mortality 5. Basic measures of Immune reconstitution 6. Infection rate 7. Disease relapse or progression; 8. Overall survival; 9. Progression free survival; 10. Cause of death. Scientific Justification: Patients with hematologic malignancies who are candidates for an allogeneic HCT, but do not have a matched donor, currently have two options: double umbilical cord blood HCT or haplo HCT. In recipients of haploidentical grafts, however, the higher HLA diversity degree between donor and recipient would result in a significantly increased risk of GVHD mediated by alloreactive T cells with the use of standard GVHD prophylaxis 1. To overcome this complication several T cell depleting methods have been developed for haplo HCT. The first effective technique consisted in ex vivo selection of donor CD34+ stem cells resulting in very low levels of T cells in the infused graft 2. Although this approach demonstrated a significant reduction in GVHD incidence, it was also associated with a higher rate of post transplant infections and a probable loss of graft versus leukemia/lymphoma effect due to delayed immune reconstitution. In particular the non relapse mortality rate (NRM) ranged between 35% 40%. In addition the laboratory complexity of this method has affected broader implementation of ex vivo T cell depletion in haplo HCT. Over the past few years, alternative approaches have emerged. Investigators at Johns Hopkins University have used post transplant high dose cyclophosphamide (PT/Cy) in order to eliminate only alloreactive donor T cells while preserving the majority of T memory cells. This technique allowed a faster immune reconstitution while reducing the incidence of GVHD 3. Given the relatively easy feasibility of this approach, several groups started to apply this method in small phase 2 studies with a notable degree of success 4 6. At the present time, the optimal approach to alternative donor HCT has not been clearly defined. The Blood and Transplant Clinical Trial Network (BMT CTN) performed two parallel phase 2 studies using the same reduced intensity conditioning (RIC) with either unrelated ducb or haploidentical related donor bone marrow 7.The 1 year probabilities of overall and progression free survival were 54% and 46%, respectively, after ducb transplantation (n = 50) and 62% and 48%, respectively, after Haplo marrow 23

24 Not for publication or presentation Attachment 6 transplantation (n = 50). On the basis of these results, the BMT CTN has just opened a multicenter randomized phase 3 study in order to compare haplo HCT (performed by PT/Cy technique) and ducb HCT 8. In the setting of haploidentical donors, there have been no randomized clinical trials comparing different techniques and the only retrospective study comparing ex vivo positive CD34+ cells versus PT/Cy had a small number of patients and a short follow up period (11 months) 7. Considering the increasing use of Haplo HCT followed by PT/Cy, an important unanswered question remains which is the best alternative donor: CD34+ positive selection haplohct, haplo HCT with PT/Cy or ducb HCT. A registry study would be a useful method to obtain results in a shorter period of time while awaiting the results of the ongoing multicenter randomized clinical trial. Patient Eligibility Population: This study will include adult patients of years that have received haplo HCT between 01/2005 and 12/2012 using PT/Cy or ex vivo CD34+ positive selection (Clinimacs system) or unrelated double umbilical cord blood HCT and reported to the CIBMTR. Both myeloablative and reduced intensity conditioning regimen will be included. Recipients of prior allografts, non malignant disease, leukemia in morphologic relapse or refractory disease will be excluded. Data Requirements: Utilizing data collected by CIBMTR from pre and post HCT, which includes pre transplant essential data form #2400, post transplant essential data form #2450, chimerism studies form #2451, selective posttransplant selective data form #2455 and 100 day post HCT data form #2100, Six Months to Two Years Post HCT Data #2200. The parameters to be assessed are outlined in table 1 below. Table 1 Data Requirements: Type of data Data point Specific data Patient Patient specific Age at transplant (Date of birth) Specific characteristics Gender Race Significant comorbidities Weight Infectious serologies (CMV, EBV) Primary disease type (AML, ALL, CLL, MDS, NHL, HL) Disease risk (high risk or standard) Status of disease at transplantation Remission status (CR1, CR2, etc) Transplant Transplant date Transplant date Specific Transplant information Full haploidentical or double unit cord blood Preparative regimen Myeloablative used Reduced Intensity/ non myeloablative GVHD prophylaxis TCD using CliniMacs system (Miltenyi Biotec) TCR using PT/Cy with tacrolimus and MMF Others (for cord blood) Graft characteristic Donor recipient HLA match Donor recipient class I allele match if available Stem cell source (BM or PBSC) Infused TNC cell dose Infused CD34+ cell dose 24

25 Not for publication or presentation Attachment 6 Outcome Measures Infused CD3+ cell dose Engraftment Time to absolute neutrophil count >500 cells/mm 3 for 3 consecutive laboratory readings Time to unsupported platelets >20 x 10 9 cells/l and >50 x 10 9 cells/l Donor recipient chimerism Graft failure (primary and secondary) GVHD Acute GVHD (agvhd) o Incidence of grade II IV acute GVHD (agvhd) (subset evaluating grade III IV agvhd) o Time to agvhd GVHD after day 100 o Incidence of chronic GVHD at 2 years (cgvhd) o Severity of GVHD after day 100 Mortality Time to mortality Day 100, 6 months and 2 year mortality Treatment related mortality at 6 months and 1 year Cause of mortality Infection Incidence of viral, fungal, bacterial infection Disease relapse Incidence of disease relapse Time to disease relapse Immune reconstitution Recovery of ALC, CD3+4+, CD3+8+ T lymphocytes Study Design: A retrospective multicenter study will be conducted utilizing CIBMTR data. Patients will be eligible if they satisfied the criteria detailed in the Patient eligibility population section. Patients will then be stratified according to ducb HCT, CD34+ positive selection Haplo HCT or PT/Cy Haplo HCT. The objective of this analysis is to compare these three approaches and their effects on HCT outcomes including engraftment rate, acute and chronic graft versus host disease, transplant related mortality, immune reconstitution, infection rate, relapse rate, overall survival, PFS and cause of death. Patient and transplantation characteristics will be compared between the 3 groups using ANOVA test for comparison between more than than two groups. Incidences of neutrophil and platelet engraftment, donor chimerism, acute and chronic GVHD, infections and relapse will be estimated using the cumulative incidence function. The incidence of engraftment for patients who receive ducb or Haplo HCT will be compared using a Gray s test. Similarly, we will compare incidence of both grade II IV agvhd and grade III IV agvhd, chronic GVHD, NRM, PFS relapse and OS. If one of the 3 strategies appears to be significantly associated with any outcome, multivariate models can be implemented to adjust for other known risk factors. PFS and OS will be estimated using Kaplan Meier methodology, and these curves will be stratified by the use of ducb and HaploHCT. A logrank statistics will be used to test for a difference in the survivals for the two groups. If one of the two techniques is associated with PFS and or overall survival, a Cox proportional hazards model will be implemented to adjust for other important known risk factors. To control the clinical heterogeneity of the patients propensity score models will be performed and applied to the primary outcome analyses. These models will be selected and based on the pretransplant and post transplant potential confounders. Extensive sensitivity analysis will be performed to assess the effect of missing data on the results observed with available data. 25

26 Not for publication or presentation Attachment 6 Potential Pitfalls and Solutions: It is possible that there may not be enough recipients of TCD haplo HCT in the CIBMTR dataset. If that is the case, we could consider a collaboration with EBMT since several centers in Europe are currently using this approach. In the absence of adequate data in both registries, we would confine the analysis to the comparison of ducb and PT/Cy. References: 1. Szydlo R, Goldman JM, Klein JP, et al. Results of allogeneic bone marrow transplants for leukemia using donors other than HLA identical siblings. J Clin Oncol. 1997;15(5): Aversa F, Tabilio A, Velardi A, et al. Treatment of High Risk Acute Leukemia with T Cell Depleted Stem Cells from Related Donors with One Fully Mismatched HLA Haplotype. New England Journal of Medicine. 1998;339(17): Luznik L, Jalla S, Engstrom LW, Iannone R, Fuchs EJ. 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): O'Donnell PV, Luznik L, Jones RJ, et al. Nonmyeloablative bone marrow transplantation from partially HLA mismatched related donors using posttransplantation cyclophosphamide. Biol Blood Marrow Transplant. 2002;8(7): Brunstein CG, Fuchs EJ, Carter SL, et al. Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA mismatched related bone marrow or unrelated double umbilical cord blood grafts. Blood. 2011;118(2): Solomon SR, Sizemore CA, Sanacore M, et al. Haploidentical transplantation using T cell replete peripheral blood stem cells and myeloablative conditioning in patients with high risk hematologic malignancies who lack conventional donors is well tolerated and produces excellent relapse free survival: results of a prospective phase II trial. Biol Blood Marrow Transplant. 2012;18(12): Brunstein CG, Fuchs EJ, Carter SL, et al. Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA mismatched related bone marrow or unrelated double umbilical cord blood grafts. Blood. 2011;118(2): Clinicaltrails.gov. Double Cord Versus Haploidentical (Blood and Marrow Transplant Clinical Trials Network #1101). 26

27 Not for publication or presentation Attachment 6 Characteristic of AML and ALL patients who underwent first allogeneic haploidentical or unrelated double UCB transplant and reported to CIBMTR, Variable Ex vivo T cell depletion N (%) CD34 selection N (%) post Transplant Cy N (%) Unrelated double UCB N (%) Number of patients Number of centers Age at transplant, years Disease <10 27 (22) 31 (19) 11 (4) (23) 30 (19) 17 (6) 18 (4) (12) 17 (11) 34 (12) 99 (23) (8) 13 (8) 38 (14) 68 (16) (10) 23 (14) 45 (16) 85 (20) (10) 23 (14) 68 (25) 82 (19) (15) 23 (14) 61 (22) 76 (18) AML 74 (60) 103 (64) 216 (79) 304 (71) ALL 50 (40) 57 (36) 58 (21) 124 (29) Conditioning regimen Myeloablative 82 (66) 105 (66) 109 (40) 243 (57) Reduced intensity 42 (34) 55 (35) 161 (60) 185 (43) 27

28 Not for publication or presentation Attachment 7 Study Proposal Study Title: Trends in HLA haploidentical allogeneic hematopoietic stem cell transplantation for hematologic malignancies: a CIBMTR analysis Görgün Akpek, MD, MHS, Banner MD Anderson Cancer Center, [email protected] Hypothesis: The study proposed here will analyze CIBMTR data to address the working hypothesis that there has been an increasing trend in the use of haploidentical allogeneic hematopoietic stem cell transplantation (allo HCT) for treatment of hematologic malignancies. Specific Aims: Compare trends and transplant outcomes among 5 cohort of patients who received haploidentical allo SCT for hematologic malignancies based on their year of transplantation (1980* 1989, , , , and ). *The first cohort will start with the earliest year when the first haploidentical transplant registered to CIBMTR Identify variables associated with favorable survival outcomes Primary endpoint: Transplant related mortality at day+100 and 1 year Secondary endpoints: Hematopoietic recovery (ANC and platelet) Cumulative incidence of graft failure Cumulative incidence of acute and chronic GVHD Relapse/progression free survival Event free survival Overall survival Scientific Justification: Allogeneic hematopoietic stem cell transplantation (allo HCT) from matched unrelated donor is the standard approach for eligible patients with hematologic malignancies who have no HLA identical sibling donors. Although, the number of volunteer donors for HCT is approaching 20 million, approximately two thirds of unrelated donors do not end up having their stem cells utilized 1 3. Cord blood, either single or double unit is usually the next stem cell source for those who have no 8/8 HLA match unrelated donor (MUD) transplant option 4 6. Allo HCT from a haploidentical family member donor has long been considered experimental and recommended under a clinical trial because of high rates of graft rejection, hyper acute GVHD and treatment related mortality (TRM) 7,8. The high risk of both graft failure and acute GVHD has been partially overcome by infusing mega doses (>10 x 10 6 /kg) of ex vivo T cell depleted CD34 + purified peripheral blood stem cells, a method introduced by Aversa et al As a result of these encouraging results in acute leukemia, there has been a new momentum started in haploidentical allo HCT by implementation of new methods of GVHD prophylaxis such as post transplant cyclophosphamide along with reduced intensity conditioning, introduced by Hopkins investigators 12. More recently, a combination of five pharmacologic immunosuppressive agents including ATG, 28

29 Not for publication or presentation Attachment 7 cyclosporine, methotrexate, mycophenolate and basiliximab, has been incorporated in myeloablative G CSF stimulated haploidentical bone marrow transplant in 80 patients with encouraging results 13. Although, there are other published studies with alternative approaches using a vigorous pre and posttransplantation GVHD prophylaxis, most of these reports are from small series from single institutions A recent two parallel trials have attempted to compare the cord blood unit allogeneic approach to haploidentical allo HCT in patients with leukemia and lymphoma with high risk disease 17. Prospective BMT CTN comparative trial of double cord vs. haploidentical transplant is underway. Despite the fact that there has been a growing enthusiasm among transplant programs using haploidentical donor transplant protocols, the current trends of this approach are not well known. The outcomes of patients undergoing haploidentical allo SCT reported are also not consistent. Finally, the question about what is the best approach in haploidentical transplant remains to be determined 18. Data reported to the Center for International Blood and Marrow Transplantation Research (CIBMTR) offers a unique resource to study these trends and outcomes. The cumulative data to be described here will guide transplant programs to make prioritization in developing their research protocols in the field of alternative donor HCT. We will analyze the trends in patient demographics, disease characteristics, transplant characteristics and rates of GVHD, TRM, progression free survival (PFS), and overall survival (OS) among patients undergoing allo HCT from haploidentical donor family members from 1980 to Patient Eligibility Population: Recipients of allo HCT from haploidentical family member transplants for hematologic malignancies between 1980 and 2012 reported to the CIBMTR will be included in this study. Patients who receive haploidentical stem cells from a third party in addition to another stem cell source such as cord blood unit transplant will be excluded from the analysis. Patients who had prior autologous stem cell transplantation will also be excluded. Data Requirements: This study will use data collected from CIBMTR research centers. No additional data is required. Sample Requirements: No sample is needed Study Design: Patient, disease, and transplantation related variables of haploidentical allo HCT recipients for hematologic malignancies will be analyzed in 5 cohorts (or 4 cohorts depending on data availability and completeness) based on their year of transplantation ( , , , , and ). Cohorts will be compared with the χ 2 statistic for categorical variables and the Kruskal Wallis test for continuous variables. Probability of PFS and OS will be calculated with the Kaplan Meier estimator, with the variance estimated by Greenwood formula. Values for other endpoints will be generated with the use of cumulative incidence estimates to accommodate competing risks. Comparison of survival curves will be done with the log rank test. Potential prognostic factors for survival will be evaluated in a multivariate analysis with the use of the Cox proportional hazards regression. The variables considered in the multivariate analysis will be age at transplantation (continuous), time from diagnosis to transplantation ( 12 months vs. > 12 months), 29

30 Not for publication or presentation Attachment 7 level of HLA match (5/6 match vs. 4/6 match vs. 3/6 match), donor recipient sex match, conditioning regimen (myeloablative vs. NMA/RIC), GVHD prophylaxis (post transplant cyclophosphamide vs. ATG vs. others), any form of T cell depletion (no vs. yes). Maga dose (>10 x10 6 ) of CD34 use (no vs. yes). A stepwise model selection approach at a.05 significance level will be used to identify all significant risk factors. Each step of model building will contain the main effect for year of transplantation ( , , , , and ). In the model, the assumption of proportional hazards will be tested for each variable, and factors violating the proportionality assumption will be adjusted by stratification. The potential interactions between the main effect and all other significant risk factors will be tested. Adjusted probabilities of OS will be generated from the final Cox models. All computations will be made with the statistical package SAS Version 9 (SAS Institute). All P values will be 2 sided. Outcomes: o Hematopoietic recovery: Time to ANC > 0.5 x 10 9 /L sustained for 3 consecutive days. Time to achieve platelet count >20 x 10 9 /L independent of platelet transfusion o o o o o Graft failure: No hematopoietic recovery by day+30 Transplant related mortality (TRM): Death without progression in the first 100 days post transplant or death in continuous remission. Relapse of ALL is the competing risk. Those who survive without relapse are censored at the time of last contact. Progression free survival: Survival without progression. Disease progression is event for this outcome.. Those who survive without progression are censored at the time of last contact. Event free survival: Survival without progression or death. Disease relapse and death are events for this outcome. Those who survive without progression are censored at the time of last contact. Overall survival: Time to death. Death from any cause will be considered an event. Surviving patients will be censored at the time of last contact. Variables to be described and analyzed: Patient related: Patient age at transplant, years: continuous Patient gender: male vs. female Race: Caucasian vs. African American vs. Hispanic vs. others Performance score before transplant: < 90 vs. 90 Number of transplant center Disease related: Disease type: AML, ALL, MDS, NHL, HL, Myeloma, CLL, CML, others Disease status at transplant: Early, intermediate, advance Number of lines of chemotherapy prior to transplant: 1 vs. >2 Sensitivity to chemotherapy before transplant: Sensitive vs. resistant Poor risk cytogenetic: No vs. Yes vs. not performed/reported Transplant related: Time from diagnosis to HCT: continuous/ <12 vs vs. >18 mos. Type of conditioning regimen: Myeloablative vs. Non myeloablative/ric 30

31 Not for publication or presentation Attachment 7 Conditioning regimens used: Summarize and group the ones that have similar intensities HLA match: 5/6 vs. 4/6 vs. 3/6 Graft sources: PB vs. BM Donor age: <10, 10 20, 20 40, 40 60, >60 Donor sex: male vs. female Relationship: Sibling, mother, father, son, daughter Year of transplant: 1980* 1989, , , , and GVHD prophylaxis: <2 drugs [FK506 (or CSA) + Methotrexate (or MMF)] plus ATG (or Campath) vs. <2 drugs plus post transplant cyclophosphamide vs. Multiple (>3 ) drug combination T cell depletion: no vs. yes Positive T cell depletion (CD34+ selection): no vs. yes Mega dose (>10 x 10^6 CD34+/kg) infusion: no vs. yes References: 1. Petersdorf EW. The World Marrow Donor Association: 20 years of international collaboration for the support of unrelated donor and cord blood hematopoietic cell transplantation. Bone Marrow Transplant 2010;45(5): Foeken LM, Green A, Hurley CK, et al. Monitoring the international use of unrelated donors for transplantation: the WMDA annual reports. Bone Marrow Transplant 2010;45(5): Bone Marrow Donors Worldwide. Statistics: Stem cell donor registries Ballen KK, Spitzer TR. The great debate: haploidentical or cord blood transplant. Bone Marrow Transplant 2011;46(3): Ballen KK, Koreth J, Chen Y B, Dey BR, Spitzer TR. Selection of optimal alternative graft source: mismatched unrelated donor, umbilical cord blood, or haploidentical transplant. Blood 2012;119(9): Gluckman E, Rocha V. Cord blood transplantation: state of the art. Haematologica 2009;94: Powles RL, Morgenstern GR, Kay HE, et al. Mismatched family donors for bone marrow transplantation as treatment for acute leukaemia. Lancet. 1983;1(8325): Beatty PG, Clift RA, Mickelson EM, et al. Marrow transplantation from related donors other than HLA identical siblings. N Engl J Med. 1985; 313(13): Aversa F, Tabilio A, Velardi A, et al. Treatment of high risk acute leukemia with T cell depleted stem cells from related donors with one fully mismatched HLA haplotype. N Engl J Med 1998;339(17): Aversa F, Terenzi A, Tabilio A, et al. Full haplotype mismatched hematopoietic stem cell transplantation: a phase II study in patients with acute leukemia at high risk or relapse. J Clin Oncol 2005;23(15): Aversa F. Haploidentical haematopoietic stem cell transplantation for acute leukaemia in adults: experience in Europe and the United States. Bone Marrow Transplant 2008;41(5): Luznik L, O'Donnell PV, Symons HJ, et al. HLA haploidentical bone marrow transplantation for hematologic malignancies using nonmyeloablative conditioning and high dose, posttransplantation cyclophosphamide. Biol Blood Marrow Transplant 2008;14(6):

32 Not for publication or presentation Attachment Di Bartolomeo P, Santarone S, De Angelis G, Picardi A, et al. Haploidentical, unmanipulated, G CSF primed bone marrow transplantation for patients with high risk hematologic malignancies. Blood 2013;121: Ji S Q, Chen H R, Yan H M, et al. Anti CD25 monoclonal antibody (basiliximab) for prevention of graft versus host disease after haploidentical bone marrow transplantation for hematological malignancies. Bone Marrow Transplant 2005;36(4): Lu D P, Dong L, Wu T, et al. Conditioning including antithymocyte globulin followed by unmanipulated HLA mismatched/haploidentical blood and marrow transplantation can achieve comparable outcomes with HLA identical sibling transplantation. Blood 2006;107(8): Huang X J, Liu D H, Liu K Y, et al. Treatment of Acute Leukemia with Unmanipulated HLA Mismatched/Haploidentical Blood and Bone Marrow Transplantation. Biol Blood Marrow Transplant 2009;15(2): Brunstein CG, Fuchs EJ, Carter SJ, et al. Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA mismatched related bone marrow or unrelated double umbilical cord blood grafts. Blood 2011;118(2): Velardi A. Haplo BMT: which approach? Blood 2013;121:

33 Not for publication or presentation Attachment 7 Characteristic of patients who underwent first haploidentical allogeneic transplant and reported to CIBMTR, Variable N (%) N (%) N (%) Number of patients Number of centers Age at transplant, years <10 48 (28) 70 (33) 217 (18) (15) 43 (20) 137 (11) (20) 27 (13) 122 (10) (8) 24 (11) 109 (9) (11) 19 (9) 158 (13) (12) 17 (8) 227 (19) (6) 13 (5) 245 (20) Disease AML 66 (39) 70 (33) 393 (32) ALL 34 (20) 43 (20) 165 (14) MDS 7 (4) 15 (7) 103 (8) CLL 3 (2) 2 (<1) 47 (4) NHL 12 (7) 19 (9) 181 (15) HL 1 (<1) 3 (1) 65 (5) SCID and other immune system disorders 9 (5) 16 (8) 82 (7) Other disease 39 (23) 45 (21) 179 (15) 33

34 Not for publication or presentation Attachment 8 Study Proposal Study Title: Association between recipient and donor sex and clinical outcome after allogeneic hematopoietic stem cell transplantation Philippe Armand, MD, PhD, Dana Farber Cancer Institute, Haesook T. Kim, PhD, Dana Farber Cancer Institute, [email protected] Specific Aim: To determine whether recipient gender or recipient/donor gender match is associated with clinical outcome after allogeneic HSCT, and whether this association varies by disease. Scientific Justification: In patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT), it has been previously reported that gender mismatch between donor and recipient adversely affects HSCT outcome. However, there are few modern data supporting this across the spectrum of HSCT indications. Moreover, in two large recent studies of disease risk, one conducted at a single institution (Dana Farber Cancer Institute) and one through the CIBMTR (CK12 03), we found that the only significant prognostic factor related to gender was recipient gender, with a hazard ratio for mortality of approximately 0.9 for female compared to male recipients. The concordance of those 2 large studies raises the possibility that recipient gender, and not gender mismatch, is in fact the most important gender related variable in HSCT. This finding would have significant implication for donor selection. It is also possible that the effect of recipient gender or donor/recipient gender match on HSCT outcome depends on the disease type or disease risk. We propose to reconsider the gender question through a multivariable analysis of patients transplanted between 2008 and 2010 and reported to the CIBMTR. The primary endpoint would be overall survival; progression free survival, non relapse mortality, relapse, acute and chronic GVHD would all be secondary endpoints. Patient Eligibility Population: All patients (adult and pediatric) who underwent first allogeneic transplantation from 2008 to 2010, excluding syngeneic transplants. There are no other exclusion criteria. Data Requirements: We propose to use the dataset already assembled for study CK12 03, which contains over approximately 17,000 patients transplanted between 2008 and The following variables are already included in the dataset: Date of allogeneic HCT Disease type and subtype (already stratified by disease risk index) Disease status at HSCT Patient Age Patient Sex Donor Sex Patient and donor CMV serostatus Donor HLA Type Graft source: PB, BM, cord Cytogenetics for AML, ALL and MDS Conditioning Regimen intensity 34

35 Not for publication or presentation Attachment 8 Karnofsky score at HSCT HCT CI Survival information (which could be updated for this project) The following data would be needed for this project: GVHD prophylaxis regimen Acute GVHD grade and onset date Chronic GVHD severity and onset date Relapse occurrence and date Study Design: This would be a retrospective analysis using CIBMTR data. We propose to build multivariable models for the various endpoints of interest, and examine the prognostic significance of recipient gender and recipient/donor gender mismatch in those models. We will also build disease specific models by disease type (myeloid/lymphoid), and by disease risk (using the DRI). We can perform all of the statistical work at Dana Farber with our transplant biostatistician Dr. Haesook Kim. We would therefore only require statistician time to collect the missing data. References: Randolph SS, Gooley TA, Warren EH, Appelbaum FR, Riddell SR. Female donors contribute to a selective graft versus leukemia effect in male recipients of HLA matched, related hematopoietic stem cell transplants. Blood Jan 1;103(1): Epub 2003 Sep 11. Gratwohl A, Hermans J, Goldman JM, et al: Risk assessment for patients with chronic myeloid leukaemia before allogeneic blood or marrow transplantation. Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Lancet 352: , 1998 Gratwohl A: The EBMT risk score. Bone Marrow Transplant 47:749 56,

36 Not for publication or presentation Attachment 8 Characteristic of adult patients who underwent first allogeneic transplant in USA and reported to CIBMTR, Variable N (%) Number of patients Age < (23) (20) (46) > (10) Gender Male 7615 (58) Female 5594 (42) Disease AML 5325 (40) ALL 1747 (13) CLL 746 ( 6) CML 556 ( 4) NHL 1890 (15) HD 436 ( 3) MDS 1539 (120 Multiple myeloma 489 ( 4) Myeloproliferative Neoplasms 481 ( 4) Donor recipient gender match Male Male 4480 (34) Male Female 2977 (23) Female Male 2572 (19) Female Female 2118 (16) Donor gender unknown 1062 ( 8) 36

37 Not for publication or presentation Attachment 9 Study Proposal Study Title: Peripheral stem cell graft composition of female donors and transplant outcome Johannes Schetelig, MD, MSc, DKMS Clinical Trials Unit, Germany, [email protected] Arnon Nagler, MD, Professor, Chaim Sheba Medical Center Tel Hashomer, Israel, [email protected] Avichai Shimoni, MD, PhD, Chaim Sheba Medical Center Tel Hashomer, Israel, [email protected] Gerhard Ehninger, MD, Professor for Internal Medicine, Medical Department I, University Hospital, Technical University Dresden, Germany, gerhard.ehninger@uniklinikum dresden.de Specific Aims: The goal of this study is to challenge the preferential activation of unrelated male peripheral blood stem cell (PBSC) donors. The willingness of female volunteers to donate peripheral blood stem cell (PBSC) contrasts with the preferential activation of male donors for stem cell donation. Overall female donations accounted for 27% of all DKMS PBSC donations between 2010 and The goal of this study is to describe the effect of sex mismatch in matched unrelated donor recipient peripheral blood stem cell transplantation (PBSCT). Better understanding of the impact of sex mismatches in unrelated PBSCT may have important clinical impact on donor selection. Further this information is highly valuable for the strategic decisions with respect to donor recruitment worldwide. Scientific Justification: According to recent data 1, PBSC grafts from female donors contain relatively more CD3+ cells in relation to CD34+ cells (Yeshurun & unpublished data). Whether or not the different composition of the graft or the immunologic effects of Y chromosome coded peptides and of pregnancies have an impact on transplant outcome in the context of matched unrelated PBSCT remains controversial. After HLA identical sibling transplantation female to male (F M) donor/recipient sex mismatch is associated with a higher incidence of GVHD, more non relapse mortality (NRM) and a net negative effect on overall survival despite a lower cumulative incidence of relapse (CIR) compared to male to male (M M) donor/recipient pairs 2 4. According to a mega file analysis of the EBMT covering transplantations between 1980 and 2005, these results can be translated to unrelated transplantation 5. However, shortcomings of this analysis are the data quality with respect to HLA typing and baseline risk adjustment. Due to early reports on graft rejection after F M transplantation dating back to the 80ies it cannot be excluded that male patients who received female grafts represented a slight negative selection. Better risk adjustment for confounding factors could allow for a more precise estimate of the effect of an F M sex mismatch in PBSCT nowadays. Remarkably, in the largest available analysis on the effect of high resolution HLA typing on unrelated bone marrow transplantation (BMT) after myeloablative conditioning from Stephanie Lee et al 6 donor sex is no major outcome predictor (adjusted hazard ratio for F M versus M M donor/recipient sex 0.99, 95% CI ) for overall survival (OS). Also, donor parity was not predictive for OS (adjusted hazard ratio for a positive history of pregnancies versus no pregnancies or being male 1.1, 95% CI

38 Not for publication or presentation Attachment ). Data on secondary outcomes like NRM, CIR or GVHD in relation to donor sex is not available from this publication. Research Questions: 1. Is a F M sex mismatch associated with a higher incidence of GVHD, NRM and a negative net effect on event free survival (EFS) compared to a M M match after allogeneic PBSCT in high resolution typed 8/8 HLA matched unrelated donor recipient pairs? 1.1 If a F M sex mismatch is associated with a higher incidence of GVHD and NRM compared to a M M match can this finding be explained better by the consequences of an H Y mismatch (sex mismatch) or by the slightly different graft composition (T cell content)? 2. Is a M F sex mismatch associated with a lower incidence of GVHD, NRM and net positive effect on event free survival compared to a F F match after allogeneic PBSCT in high resolution typed 8/8 HLAmatched unrelated donor recipient pairs? 2.2 If a M F sex mismatch is associated with a lower incidence of GVHD and NRM compared to a F F match can this finding be explained better by the slightly different graft composition of female compared to male PBSC donors? Patient Eligibility Population: Graft source: GCSF mobilized peripheral blood stem cells Date of transplantation between January, 1, 2000 and January 1, 2013 HLA identical sibling donor or 8/8 matched unrelated donor AML, ALL or MDS as indication for allogeneic transplantation Data Requirements: Mandatory data: CD34+ count of the PBSC graft CD3 count (if not available, this information can be added for all DKMS procured transplantations) 4 digit typing results for the HLA loci A, B, C, and DRB1 Cytogenetic data Desirable data: Information on donor age and parity Donor and recipient CMV status In vivo / ex vivo T cell depletion Further, data for baseline risk adjustment in patients with AML, ALL and MDS and standard transplant outcomes (EFS, OS, NRM, CIR, agvhd, cgvhd) are required. No supplemental data will be requested from the centers. Sample Requirements: No biological samples will be analyzed in this study. 38

39 Not for publication or presentation Attachment 9 Study Design: This is a proposal for a registry based retrospective study. Standard CIBMTR definitions for disease stage, cytogenetic classification and conditioning intensity will be applied. Baseline risk adjustment apart from donor/recipient sex and graft composition will be done with a standard CIBMTR set of variables. In order to deal with the correlation of donor sex and the CD34 count and the CD3 count of the grafts we propose to enter the CD34 count and the ratio of the CD3 / CD34 count per kg recipient weight into the multivariate models. Plausibility checks for the cell counts should be done for extreme values. Logarithmic transformations for the CD34 count and the ratio may be considered after inspection of the data. Information on non linear effects of the CD34 count which could come from the ongoing study GS12 01 (Role of stem cell dose in reduced intensity conditioning transplants for acute myeloid leukemia/myelodysplastic syndrome and acute lymphoblastic leukemia) should be considered. The main objective of this study is to dissect the effect of the graft composition (CD34 count and CD3/CD34 ratio), donor type (sibling versus unrelated) and donor/recipient sex (F M, F F, M F, M M). The effect of these variables on EFS will be analyzed in a Cox regression model as primary endpoint. The proportionality assumption should be checked with the specific knowledge of the publication by Martin Stern 5. Interactions between donor type and sex match have to be tested. Information on EFS will be complemented by OS, and explanatory analyses for NRM, acute and chronic GVHD and CIR as secondary endpoints. References: 1. Yeshurun M, Ram R, Shpilberg O, Herscovici C, Vidal L, Zuckerman T, Haddad N, Rowe JM, Yerushalmi R, Nagler A, Shimoni A. Female Donor Allografts Have a Higher CD3 Content Than Male Donor Allografts: Potential Impact On Transplantation Outcomes in Male Recipients. ASH Annual Meeting Abstracts. 2012;120(21): Gratwohl A, Hermans J, Niederwieser D, van Biezen A, van Houwelingen HC, Apperley J. Female donors influence transplant related mortality and relapse incidence in male recipients of sibling blood and marrow transplants. Hematol J. 2001;2(6): Gahrton G, Iacobelli S, Apperley J, Bandini G, Bjorkstrand B, Blade J, Boiron JM, Cavo M, Cornelissen J, Corradini P, Kroger N, Ljungman P, Michallet M, Russell NH, Samson D, Schattenberg A, Sirohi B, Verdonck LF, Volin L, Zander A, Niederwieser D. The impact of donor gender on outcome of allogeneic hematopoietic stem cell transplantation for multiple myeloma: reduced relapse risk in female to male transplants. Bone Marrow Transplant. 2005;35(6): Randolph SS, Gooley TA, Warren EH, Appelbaum FR, Riddell SR. Female donors contribute to a selective graft versus leukemia effect in male recipients of HLA matched, related hematopoietic stem cell transplants. Blood. 2004;103(1): Stern M, Brand R, de Witte T, Sureda A, Rocha V, Passweg J, Baldomero H, Niederwieser D, Gratwohl A. Female versus male alloreactivity as a model for minor histocompatibility antigens in hematopoietic stem cell transplantation. Am J Transplant. 2008;8(10): Lee SJ, Klein J, Haagenson M, Baxter Lowe LA, Confer DL, Eapen M, Fernandez Vina M, Flomenberg N, Horowitz M, Hurley CK, Noreen H, Oudshoorn M, Petersdorf E, Setterholm M, Spellman S, Weisdorf D, Williams TM, Anasetti C. High resolution donor recipient HLA matching contributes to the success of unrelated donor marrow transplantation. Blood. 2007;110(13):

40 Not for publication or presentation Attachment 9 Characteristic of patients who underwent peripheral blood, first allogeneic transplant for AML/ALL/MDS from HLA identical sibling or 8/8 HLA matched unrelated donor, and reported to CIBMTR, /8 HLA matched Variable Identical siblings N (%) unrelated N (%) Number of patients Number of centers Age at transplant, years < (1) 63 (2) (7) 135 (4) (12) 376 (12) (13) 404 (13) (22) 577 (19) (30) 833 (27) (15) 692 (22) Disease AML 2843 (60) 1816 (59) ALL 996 (21) 574 (19) MDS 922 (19) 690 (22) Gender Male 2691 (57) 1714 (56) Female 2070 (43) 1366 (44) Donor recipient sex match Male Male 1530 (32) 1251 (41) Male Female 1115 (23) 867 (28) Female Male 1161 (24) 463 (15) Female Female 955 (20) 499 (16) CD34 cell dose, x10^6/kg < (45) 942 (31) (31) 1326 (43) Not reported 1152 (24) 812 (26) 40

41 Not for publication or presentation Attachment 10 Study Proposal Study Title: The impact of graft T cell subset doses on the outcomes of allogeneic peripheral blood stem cell transplants after reduced intensity conditioning in patients with hematologic malignancies. Ran Reshef, MD, University of Pennsylvania, [email protected] David L. Porter, MD, University of Pennsylvania, [email protected] Specific Aims: 1. To assess the impact of CD3, CD4 and CD8 cell doses on overall survival, relapse free survival, acute and chronic GvHD and treatment related mortality in patients with hematologic malignancies undergoing allogeneic peripheral blood stem cell transplantation with reducedintensity conditioning. This aim will analyze data for all patients and for each disease (AML, MDS, lymphoma, ALL) separately. 2. To determine whether the impact of T cell subset doses differs based on conditioning intensity (reduced intensity vs. non myeloablative) and disease risk categories. 3. To identify donor characteristics that predict CD3, CD4 and CD8 graft cell doses. * Based on data availability we will determine if the optimal approach is to analyze all hematologic malignancies together or analyze each disease separately. Scientific Justification: Currently, 40% of allogeneic transplants performed for AML and the majority of transplants for MDS and lymphomas are performed with reduced intensity conditioning (RIC) regimens (CIBMTR data). Disease relapse remains the most common reason for failure of these transplants. In an attempt to improve the outcomes of RIC transplants, previous studies have identified patient and disease characteristics that predict outcomes such as the comorbidity index, cytogenetic risk and disease status at the time of transplant but our ability to alter these factors is limited. Previous studies of the graft composition have shown that the CD34 cell dose in peripheral blood stem cell transplants correlates with engraftment, relapse, GvHD and survival but these results have not been consistent across studies1 5. The T cell composition of the graft in T cell replete transplants was previously assessed in the myeloablative setting but did not correlate with outcomes6. RIC transplants heavily rely on a potent graft versus leukemia effect, which is thought to be primarily T cell mediated. Therefore, it can be hypothesized that the graft T cell composition can be more meaningful after RIC. This was previously assessed in a study of Flu/TBI transplants, which identified correlations between CD8 cell doses and freedom from progression and survival7. A different study found that higher CD8 doses correlated with a higher risk for acute GVHD following an ATG containing RIC regimen8. To the best of our knowledge, the impact of graft T cell subset doses has not been validated in large scale studies. In addition, donor factors that predict the T cell graft composition have not been identified. At the University of Pennsylvania we recently summarized the data on 202 consecutive patients who were allografted with peripheral blood stem cells after RIC with a uniform regimen of fludarabine and busulfan. A summary of these data was submitted as an abstract to the Tandem meeting. The disease mix included AML (80), MDS (46), NHL (35) and other disorders (41). The impact on relapse rate, acute and chronic GvHD, RFS and OS was analyzed for the total nucleated, CD34, CD3, CD4 and CD8 cell doses with adjustment for standard variables in a multivariate analysis. The median follow up was 24.8 months (range months). A higher CD8 cell dose, analyzed as a continuous variable, was associated with a lower relapse risk (HR=0.43, p=0.02) and with a higher risk for 41

42 Not for publication or presentation Attachment 10 chronic GvHD (HR=3.41, p=0.04). There were no significant associations with acute GvHD grade 2 4 or grade 3 4. The net effect on RFS and OS significantly favored a higher CD8 dose (RFS: HR=0.48, p=0.01; OS: HR=0.52, p=0.05). In our analysis, CD34, CD4 and total CD3 doses did not predict any transplant outcomes. Subset analyses revealed that a high CD8 cell dose may correlate with improved relapse free survival in patients with lymphoma (HR=0.19, p=0.02) and there was a strong trend of improved overall survival in patients with MDS (HR=0.28, p=0.06). Further subset analyses were limited by sample size. The rationale for the importance of T cell doses specifically in RIC transplants is further supported by the outcomes of T cell depletion in RIC. A recent CIBMTR analysis showed that the addition of ATG or alemtuzumab to RIC regimens decreased the rates of GvHD but had a detrimental effect on OS due to poor disease control and immune reconstitution. Together these published studies and the recent analysis from the University of Pennsylvania suggest that the doses of T cell subsets impact the outcomes of RIC transplants and that a high CD8 cell dose may have an overall survival benefit, primarily driven by a reduction in disease relapse rates. If supported by an analysis of a CIBMTR dataset, this hypothesis is an actionable finding; stem cell collections can be designed to target a specific CD8 dose goal, and CD8 cells can be expanded ex vivo to increase the dose. In addition, there may be ways to predict the CD8 cell dose by phenotyping donor lymphocytes during screening, which then can be used for better donor selection. A study that aims to identify donor related factors that predict the T cell graft composition is currently underway at Penn. We therefore propose a study that will study the impact of T cell doses on the outcome of allogeneic peripheral blood stem cell transplant with RIC regimens. Our preliminary data did not point to a specific disease and the direction of the associations was similar in all malignant diseases. We therefore propose to take a broad approach and investigate these associations across all malignant disorders. We will 1) analyze the impact of T cell doses on RIC transplant outcomes in patients with hematologic malignancies and in each disease separately, 2) analyze the differential impact of T cell subset doses across regimen intensities and in different disease risk categories, where the risk/benefit ratio of a high CD8 cell dose may be different, and 3) analyze donor factors that predict the T cell subset composition of the graft. Patient Eligibility Population: Patients with a hematologic malignancy who received a first allogeneic peripheral blood stem cell transplantation from related or unrelated, HLA matched or single antigen mismatched donors with a RIC regimen will be eligible for this study. Recipients of ex vivo T cell depleted grafts and recipients who received T cell depleting antibodies as part of their conditioning regimen will not be eligible. Product manipulation other than RBC depletion or cryopreservation will not be eligible. Patients with acute leukemia who were not in CR at the time of transplant will also be excluded. Data Requirements: Graft related variables (continuous) Total nucleated cell dose, CD34 cell dose, CD3 cell dose, CD4 cell dose, CD8 cell dose * The analysis is currently planned with the existing registry data. If the number of eligible patients is too low to provide sufficient power, we will request centers to report cell dose data that was not reported originally on their forms. 42

43 Not for publication or presentation Attachment 10 Patient related variables Patient age, years will be treated as a continuous variable, in groups (0 21, 21 40, 41 60, >60) and adult (>21) vs. pediatric Patient gender male vs. female Patient CMV status pos vs. neg Performance score <90% vs. 90% Disease related variables For AML: Type of AML: de novo vs. secondary Status at time of transplant: CR1 vs. CR2 or greater (active disease excluded) Cytogenetic risk: favorable vs. intermediate vs. unfavorable (according to ECOG/SWOG classification) Flt3 status: abnormal vs. normal For MDS: IPSS at transplant: low int.1 vs. int.2 high Cytogenetic risk: favorable vs. intermediate vs. unfavorable (according to ECOG/SWOG classification) Marrow status at time of transplant: <5% blasts vs. 5 10% blasts vs % blasts in the bone marrow Disease status at time of transplant: early vs. advanced (according to CIBMTR criteria) For ALL: Cytogenetic risk: Ph pos vs. Ph neg Status at the time of transplant: CR1 vs. CR2 or greater (active disease excluded) Lineage: T cell vs. B cell For Lymphoma: Disease subtype: Indolent Non Hodgkin lymphoma vs. Aggressive non Hodgkin vs. Hodgkin lymphoma Disease status: Chemo sensitive vs. resistant Donor related variables Donor type: HLA identical sibling vs. HLA identical unrelated donor vs. 7/8 mismatched unrelated donor Donor age: continuous Donor gender: male vs. female Donor CMV status: pos vs. neg Donor EBV status: pos vs. neg Donor ethnicity, race and parity Days of stem cell collection: 1 vs. >1 Product processing: fresh vs. cryopreserved Product manipulation: RBC depletion vs. none Transplant related variables Conditioning regimen intensity: reduced intensity vs. non myeloablative Conditioning regimen: Flu/Bu vs. Flu/Mel vs. Flu/loTBI vs. others Year of transplant: in groups GvHD prophylaxis: CNI based + MTX vs. CNI based + MMF vs. others Center: will be used to rule out center effect in cell dose measurements 43

44 Not for publication or presentation Attachment 10 Sample Requirements: This proposal does not include a request for samples at this time. However, if our ongoing studies suggest that an optimal graft composition can be predicted by measureable donor parameters, we will append our protocol with a request for donor samples from the NMDP repository in order to validate these findings. Study Design: Analyzed outcomes will include relapse, acute grade 2 4 and 3 4 GvHD, chronic GvHD, treatment related mortality, relapse free survival and overall survival. The main effects to be analyzed will be the impact of CD3, CD4 and CD8 cell doses on each outcome. Probabilities of survival and relapse free survival will be calculated using the Kaplan Meier estimator. Other outcomes will be analyzed using cumulative incidence estimates adjusting for competing risks. We plan to conduct the analysis on all hematologic malignancies together and then separately for AML, MDS, ALL and lymphomas. The impact of each T cell subset dose on outcomes will be assessed using Cox regression models and cumulative incidence regression models. A stepwise forward method will be used to build a multivariate model for each outcome. Separate models will be built for CD3, CD4 and CD8 cell doses due to the significant interactions between them. Interactions with variables that define disease subsets, disease status, cytogenetic risk and conditioning regimen intensity will be used to identify specific populations where the impact of cell doses may be greater than others. Donor related variables that predict CD3, CD4 and CD8 doses will be assessed using t test or ANOVA for categorical variables and Pearson correlations for continuous variables. The correlations between the total nucleated cell dose, CD34, CD3, CD4 and CD8 doses will also be assessed. References: 1. Pulsipher MA, Chitphakdithai P, Logan BR, et al. Donor, recipient, and transplant characteristics as risk factors after unrelated donor PBSC transplantation: beneficial effects of higher CD34+ cell dose. Blood. 2009;114(13): Zaucha JM, Gooley T, Bensinger WI, et al. CD34 cell dose in granulocyte colony stimulating factormobilized peripheral blood mononuclear cell grafts affects engraftment kinetics and development of extensive chronic graftversus host disease after human leukocyte antigen identical sibling transplantation. Blood. 2001;98(12): Mielcarek M, Martin PJ, Heimfeld S, Storb R, Torok Storb B. CD34 cell dose and chronic graft versushost disease after human leukocyte antigen matched sibling hematopoietic stem cell transplantation. Leuk Lymphoma. 2004;45(1): Mohty M, Bilger K, Jourdan E, et al. Higher doses of CD34+ peripheral blood stem cells are associated with increased mortality from chronic graft versus host disease after allogeneic HLA identical sibling transplantation. Leukemia. 2003;17(5): Nakamura R, Auayporn N, Smith DD, et al. Impact of graft cell dose on transplant outcomes following unrelated donor allogeneic peripheral blood stem cell transplantation: higher CD34+ cell doses are associated with decreased relapse rates. Biol Blood Marrow Transplant. 2008;14(4): Cao TM, Wong RM, Sheehan K, et al. CD34, CD4, and CD8 cell doses do not influence engraftment, graft versus host disease, or survival following myeloablative human leukocyte antigen identical peripheral blood allografting for hematologic malignancies. Exp Hematol. 2005;33(3): Cao TM, Shizuru JA, Wong RM, et al. Engraftment and survival following reduced intensity allogeneic 44

45 Not for publication or presentation Attachment 10 peripheral blood hematopoietic cell transplantation is affected by CD8+ T cell dose. Blood. 2005;105(6): Mohty M, Bagattini S, Chabannon C, et al. CD8+ T cell dose affects development of acute graft vs host disease following reduced intensity conditioning allogeneic peripheral blood stem cell transplantation. Exp Hematol. 2004;32(11): Soiffer RJ, Lerademacher J, Ho V, et al. Impact of immune modulation with anti T cell antibodies on the outcome of reduced intensity allogeneic hematopoietic stem cell transplantation for hematologic malignancies. Blood. 2011;117(25):

46 Not for publication or presentation Attachment 10 Characteristic of patients who underwent non myeloablative/reduced intensity, peripheral blood, first allogeneic transplant for AML/MDS/NHL from HLA identical sibling or HLA matched unrelated donor, and reported to CIBMTR, /8 HLA matched unrelated N (%) 8/8 HLA matched unrelated N (%) Identical siblings Variable N (%) Number of patients Number of centers Age at transplant, years (1) 2 (2) 5 (1) (6) 2 (2) 16 (5) (19) 16 (14) 40 (12) (42) 46 (41) 138 (40) (32) 46 (41) 142 (42) Disease AML 391 (54) 79 (71) 228 (67) NHL 283 (39) 22 (20) 87 (26) MDS 46 (6) 11 (10) 26 (8) Conditioning regimens TBI 200 cgy + other 224 (31) 55 (49) 147 (43) Mel + Flud 133 (18) 23 (21) 81 (24) Cy + Flud 181 (25) 12 (11) 46 (13) Bu + Flud 182 (25) 22 (20) 67 (20) 46

47 Not for publication or presentation Attachment 11 Study Proposal Study Title: Using landmark analysis to provide updated relapse and leukemia free survival estimates to patients after umbilical cord blood transplantation Claudio G. Brunstein, MD PhD University of Minnesota Mayo Mail Code Delaware St SE Minneapolis, MN Telephone: Fax: Stephanie J. Lee, MD MPH Fred Hutchinson Cancer Research Center 1100 Fairview Ave N, D5 290 Seattle, WA Telephone: Fax: Specific Aims: To provide clinically understandable estimates of the likelihood of future events to patients surviving disease free after umbilical cord blood (UCB) transplantation. The estimates will be dynamic and based on the duration of leukemia free survival (i.e., landmarks) already experienced. Specifically, to provide estimates of the risks for: 1. Relapse within the next year 2. Leukemia free survival for the next 3 years 3. Leukemia free survival for the next 5 years Additional factors that impact long term disease free survival, such as patient age, cytogenetics and whether or not chronic GVHD has developed, will be incorporated into the estimates if possible. Scientific Justification: Most clinical reports in the literature present overall survival curves and cumulative incidences of relapse and transplant related mortality starting from the time of transplantation. Other studies provide standard mortality ratios to allow comparison to the general population. A few provide updated estimates of future survival for patients surviving disease free at least 2 years post transplant. 1,2 However, it is very difficult to extrapolate from these reports in order to answer a patient s question: So, now that I m 1 [or 3, 4 etc] years out, what can I expect? In order to precisely answer this question, one needs to know the future outcomes for similar patients. The CIBMTR recently addressed this issue for patient with AML (n=3,339) and ALL (n=1,434) who received an allogeneic transplant after myeloablative conditioning with grafts from related or matched/mismatched unrelated volunteer donors between Based on Poisson models, the authors developed calculators that can be used to estimate the risk of developing chronic GVHD and leukemia free survival for individual patients. Recipients of UCB grafts were excluded from this recent analysis. While the LFS after UCB 47

48 Not for publication or presentation Attachment 11 transplantation has been shown to be similar to other donor types, there are significant differences on the incidences of hematopoietic recovery and acute and chronic GVHD. UCB grafts have lower cell doses and there is more tolerance for HLA mismatching. As the number of acute leukemia patients who received an UCB transplant has grown significantly in the last decade, the question So, now that I m 1 [or 3, 4 etc] years out, what can I expect? is equally relevant to these patients. Thus, as in the published CIBMTR study, we hypothesize that many previously identified prognostic factors are no longer relevant once a patient survives one year without relapsing. Identification of the important prognostic factors for survivors will allow more accurate estimates of future risks of relapse and treatment related mortality. While the main factors that determine mortality in the first year may be different between adult donors and UCB, we hypothesize that predictors of subsequent survival for patients who survive the first year will be similar to those found in the adult donors. We propose to limit the study to patients with AML and ALL because 1) diagnosing relapse in AML and ALL is usually clinically obvious and relies less on testing methods and frequency, 2) relapse does not have a long latency since symptoms arise early, 3) treatment requires aggressive interventions, 4) the overall prognosis of patients who relapse after a transplant is extremely poor, and 5) other diseases, such as NHL and MM, are quite heterogeneous and information on disease stage is more difficult to interpret from CIBMTR forms. AML and ALL are also more common diagnoses for UCB. Patient Eligibility Population: The study population will include all patients aged 18 or older who have undergone first UCB transplant for AML or ALL between 1995 and 2010, reported to the CIBMTR, and who survived for at least one year without disease relapse. Patients receiving 1 or 2 UCB units after myeloablative or non myeloablative conditioning regimens will be included. Only centers with 80% completeness index at four years (3 years of follow up for 1 year survivors) will be included in the analysis. Data Requirements: Patient related: Current age Sex: donor recipient sex match (FM vs. others) 4 considering the greatest mismatch in double UCB grafts CMV seropositive Karnofsky performance status at transplant 5 : <90 vs. 90 Race: White vs. African American vs. Hispanic vs. Asian vs. Other Disease related: Disease: AML vs. ALL Disease stage at transplant: CR1 vs. CR2 vs. >CR2 vs. PIF vs. Relapse Cytogenetic: good, intermediate/normal, poor risk 6 10 White blood count at diagnosis: < 30 x 10 9 /L 11 vs. Intermediate x 10 9 /L 12 vs. 100 x 10 9 /L 12. Consider low wbc group (<3K) Time from first CR to transplant, months: <6m vs. 6 12m vs. >12m Percent peripheral blood blasts at transplant 13 Percent blasts in bone marrow at transplant Duration of first remission: < 1 year vs. > 1 year Extramedullary involvement any time before transplant: yes vs. no 48

49 Not for publication or presentation Attachment 11 ALL: o Ph+/BCR ABL+: yes/no o Time from diagnosis to first CR > 8 weeks 12 o T cell vs. B cell AML: o FAB subtype 14,15 o Secondary vs. de novo Transplant related: Cryopreserved and infused TNC considering the combined dose in double UCB grafts HLA match: considering the greatest mismatch in double UCB grafts Graft type: single UCB vs. double UCB Conditioning regimen intensity and type: based on distribution GVHD prophylaxis: based on distribution In vivo T cell depletion: ATG Time to neutrophil engraftment: dichotomized at median, assuming all 1 year survivors have engrafted Time to platelet engraftment: dichotomized at median, assuming all 1 year survivors have engrafted Acute GVHD grade II IV: yes vs. no Limited vs. Extensive vs. no chronic GVHD ever diagnosed (need date) Year of transplant: based on distribution Center Although emerging data suggest that molecular markers such as NPM1, FLT3, CEBPA, and MLL, 16 pretransplant ferritin level, 9 and post transplant minimal residual disease assessments 17 have prognostic significance, these variables are not captured in the CIBMTR database. Co morbidities were only collected from 2008 onward, so will not be included. Likewise, we cannot include important posttransplant information because of missing data (e.g., performance status at one year, weight etc) Sample Requirements: None Study Design: No additional data collection is necessary. Dr. Barry Storer, head of Clinical Statistics at Fred Hutchinson Cancer Research Center, was the biostatistician for the adult donor paper and is available to conduct the proposed analysis. Univariate screening of candidate patient and transplant variables will be performed separately for ALL and AML among one year leukemia free survivors, using two year LFS as the endpoint. Risk factors significant at the 0.05 level will then be included in a multivariate analysis with stepwise backwards selection at the 0.01 level of significance. The risk factors that are identified will then be used at each subsequent landmark year to predict survival in the subsequent year. Analyses will be based on Poisson regression with additive risk structure. For multi category variables, categories with similar risk contributions will be pooled for simplicity. A competing risk analysis will not be used because the overwhelming causes of death in the first five years after transplant are related to the transplant or underlying malignancy. 49

50 Not for publication or presentation Attachment 11 When similar outcomes and predictive factors are identified, patients will be grouped into cohorts for subsequent analyses. For example, we may need categories for 1 year survivors, 2 year survivors and 3 5 year survivors and separate analyses for AML and ALL. In a secondary analysis, we will investigate predictive factors for subsequent development of extensive chronic GVHD in the next year in patients who survive 1 or 2 years without developing this complication prior to the landmark. References: 1. Socie G, Stone JV, Wingard JR, et al. Long term survival and late deaths after allogeneic bone marrow transplantation. Late Effects Working Committee of the International Bone Marrow Transplant Registry. N Engl J Med. 1999;341(1): Bhatia S, Francisco L, Carter A, et al. Late mortality after allogeneic hematopoietic cell transplantation and functional status of long term survivors: report from the Bone Marrow Transplant Survivor Study. Blood. 2007;110(10): Lee SJ, Storer B, Wang H, et al. Providing personalized prognostic information for adult leukemia survivors. Biol Blood Marrow Transplant. 2013;19(11): Gorin NC, Labopin M, Polge E, et al. Risk assessment in adult acute lymphoblastic leukaemia before early haemopoietic stem cell transplantation with a geno identical donor: an easy clinical prognostic score to identify patients who benefit most from allogeneic haemopoietic stem cell transplantation. Leukemia. 2003;17(8): Song KW, Lipton J. Is it appropriate to offer allogeneic hematopoietic stem cell transplantation to patients with primary refractory acute myeloid leukemia? Bone Marrow Transplant. 2005;36(3): Grimwade D, Walker H, Oliver F, et al. The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. The Medical Research Council Adult and Children's Leukaemia Working Parties. Blood. 1998;92(7): Fung HC, Stein A, Slovak M, et al. A long term follow up report on allogeneic stem cell transplantation for patients with primary refractory acute myelogenous leukemia: impact of cytogenetic characteristics on transplantation outcome. Biol Blood Marrow Transplant. 2003;9(12): Moorman AV, Harrison CJ, Buck GA, et al. Karyotype is an independent prognostic factor in adult acute lymphoblastic leukemia (ALL): analysis of cytogenetic data from patients treated on the Medical Research Council (MRC) UKALLXII/Eastern Cooperative Oncology Group (ECOG) 2993 trial. Blood. 2007;109(8): Armand P, Kim HT, Cutler CS, et al. A prognostic score for patients with acute leukemia or myelodysplastic syndromes undergoing allogeneic stem cell transplantation. Biol Blood Marrow Transplant. 2008;14(1): Pullarkat V, Slovak ML, Kopecky KJ, Forman SJ, Appelbaum FR. Impact of cytogenetics on the outcome of adult acute lymphoblastic leukemia: results of Southwest Oncology Group 9400 study. Blood. 2008;111(5): Laport GG, Alvarnas JC, Palmer JM, et al. Long term remission of Philadelphia chromosomepositive acute lymphoblastic leukemia after allogeneic hematopoietic cell transplantation from matched sibling donors: a 20 year experience with the fractionated total body irradiationetoposide regimen. Blood. 2008;112(3): Marks DI, Perez WS, He W, et al. Unrelated donor transplants in adults with Philadelphianegative acute lymphoblastic leukemia in first complete remission. Blood. 2008;112(2):

51 Not for publication or presentation Attachment Wong R, Shahjahan M, Wang X, et al. Prognostic factors for outcomes of patients with refractory or relapsed acute myelogenous leukemia or myelodysplastic syndromes undergoing allogeneic progenitor cell transplantation. Biol Blood Marrow Transplant. 2005;11(2): Thomas X, Le Q, Botton S, et al. Autologous or allogeneic stem cell transplantation as postremission therapy in refractory or relapsed acute myeloid leukemia after highly intensive chemotherapy. Leuk Lymphoma. 2005;46(7): Jourdan E, Boiron JM, Dastugue N, et al. Early allogeneic stem cell transplantation for young adults with acute myeloblastic leukemia in first complete remission: an intent to treat long term analysis of the BGMT experience. J Clin Oncol. 2005;23(30): Schlenk RF, Dohner K, Krauter J, et al. Mutations and treatment outcome in cytogenetically normal acute myeloid leukemia. N Engl J Med. 2008;358(18): Stirewalt DL, Guthrie KA, Beppu L, et al. Predictors of relapse and overall survival in Philadelphia chromosome positive acute lymphoblastic leukemia after transplantation. Biol Blood Marrow Transplant. 2003;9(3):

52 Not for publication or presentation Attachment 11 Additive effects on subsequent 1 year event rate among AML/ALL disease free survivors at various landmark time post HCT (patients 18 years old who underwent 1 st UCB transplant from for AML/ALL and were 1 year survivors) HCT 1 year 2 years 3 years 4 years 5 years 6 years No. at risk AML ALL