A Novel Sequential Treatment of Salvage and Reduced Intensity Conditioning (RIC) Chemotherapy for Allogeneic Stem-Cell Transplantation (SCT) for Primary Refractory and Relapsed Acute Myelogenous Leukemia (AML)

Inclusion Criteria:

1. Patients are included, if they fulfill at least one of the following criteria defining
refractory or relapsed AML according to previously established criteria 1-3: (1)
Primary induction failure (PIF) after ≥ 2 cycles of chemotherapy. (2) First relapse.
(3) Relapse refractory to salvage chemotherapy (4) Second or subsequent relapse.

2. Patients with MDS, either refractory anemia with excess blasts (RAEB) I or RAEB II

3. Age between 18 and 70 years old.

4. Patients must have a Karnofsky Performance Status > 70.

5. Each patient must be willing to participate as a research subject and must sign an
informed consent form.

6. If the patient has a history of a prior malignancy, they must be without any evidence
of disease of that prior malignancy for at least 2 years before being eligible for
transplant on this protocol. This excludes skin cancers that may have been excised
within that 2 year period.

7. Patients must have adequate physical function measured by:

1. Cardiac: asymptomatic or if symptomatic then left ventricular ejection fraction
(LVEF) at rest must be > 50% and must improve with exercise.

2. Hepatic: < 3x upper limit of normal (ULN) alanine aminotransferase (ALT) and <
1.5 total serum bilirubin, unless liver is involved with the disease or there is
congenital benign hyperbilirubinemia.

3. Renal: serum creatinine within normal range for age or if serum creatinine is
outside the normal range, then creatinine clearance > 60-ml/min.

4. Pulmonary: asymptomatic or if symptomatic, diffusing capacity of carbon monoxide
(DLCO) > 45% of predicted (corrected for hemoglobin)

Exclusion Criteria:

1. Impaired renal function with a measured or calculated creatinine clearance of less
than 60 ml/min.

2. Impaired hepatic function defined as a bilirubin greater than 1.5 x upper limit of
normal or alanine aminotransferase (ALT) or aspartate aminotransferase (AST) greater
than 3 x normal.

3. Serious active or uncontrolled infection (Infections are controlled when patients are
afebrile and hemodynamically stable for 72 hours) or medical condition.

4. Women who are pregnant or breast feeding. Women of childbearing age must use adequate
contraception and have a negative pregnancy test.

5. Impaired pulmonary function with a DLCO less than 45% predicted.

6. Impaired cardiac function with an ejection fraction less than 50% of predicted by
echocardiogram or multigated acquisition scan (MUGA).

7. Prior daunorubicin therapy with a cumulative dose of more than 368 mg/m2 or
equivalent. The anthracycline agents commonly used in treating myeloid malignancies
are doxorubicin, idarubicin and mitoxantron.

For example, a patient who receives 7 + 3 (daunorubicin 180 mg/m2) for induction and
MEC regimen (mitoxantrone, etoposide, cytaragine; mitoxantrone 48 mg/m2) for salvage.
The cumulative daunorubicin equivalent is 180 + (48x2) = 278 mg/m2.

8. Other systemic anticancer therapy or ongoing toxicities from such therapy.

9. Patients with a history of and/or current evidence of myocardial impairment (e.g.
cardiomyopathy, ischemic heart disease, significant valvular dysfunction, hypertensive
heart disease, congestive heart failure), resulting in heart failure by New York Heart
Association Class III or IV staging.

10. Patients with Wilson disease or other Copper-related disorders.