Specialized Blood Cell Transplants for Cancers of the Blood and Bone Marrow

Patients with malignant and non-malignant hematologic diseases including severe aplastic
anemia (SAA), paroxysmal nocturnal hemoglobinuria (PNH), myelodysplastic syndrome (MDS),
acute and chronic leukemias, Hodgkin's and non-Hodgkin's lymphoma and multiple myeloma (MM)
can now be cured by allogeneic bone marrow transplantation (BMT). This curative effect has
been ascribed to the use of high dose chemo-radiotherapy and the anti-tumor or anti-bone
marrow effect of the allograft. Dose intensification of conditioning regimens in attempts to
reduce disease recurrence has been largely unsuccessful because of increased toxicity and
mortality. Indeed, most evidence now points to donor-derived T-cells as being the principal
modality leading to the complete eradication of both malignant and non-malignant host
hematopoietic cells.

The assumption that successful allogeneic BMT relies on the myeloablative effect of intensive
but hazardous chemo-radiotherapy has largely restricted this therapeutic modality to patients
with malignant or life-threatening hematologic disorders under the age of 55 years.
Treatment-related mortality increases substantially with age, prior intensive treatment with
chemo-radiotherapy, worsening performance status, and co-morbid medical conditions. An
unacceptable risk of death from conventional BMT renders many patients ineligible for what
may otherwise be curative therapy.

Several in vitro studies have demonstrated the existence of donor-derived CD4 and CD8
positive lymphocytes with specific reactivity for the patient s leukemia. These cells provide
a potent graft-versus-leukemia (GVL) effect. This GVL effect is best seen in patients with
CML relapsing after BMT, where a single infusion of donor lymphocytes has been shown to
induce complete remission. In addition to the potent anti-leukemia effect of these cells,
there is now strong evidence that donor T-cells are capable of completely eradicating
residual host hematopoietic cells in a non-myeloablative transplant setting
(graft-versus-marrow) leading to successful and complete donor hematopoietic engraftment.

Non-myeloablative allogenic peripheral blood stem cell transplants are currently being
investigated in phase I/II trials assessing engraftment efficacy and toxicity at a number of
transplant centers. Preliminary data, including our own experience with greater than 150
patients undergoing this type of procedure, have shown a high rate of complete donor
engraftment with a low toxicity profile. Two recent studies investigating non-myeloablative
allo-transplantation in standard risk patients revealed an extremely low rate of
transplant-related complications and mortality.

The decreased risk of transplant-related complications associated with non-myeloablative
transplants expands the eligibility of transplant candidates as well as opens the possibility
to evaluate non-myeloablative regimens in patients at high risk for complications with
standard transplantation. Besides hematologic malignancies, allogeneic BMT has been shown to
be curative in a number of debilitating hematologic diseases which may behave in a relatively
indolent fashion, such as paroxysmal nocturnal hemoglobinuria (PNH) and refractory anemia
(RA) or refractory anemia with ringed sideroblasts (RARS). However, the 30% risk of
treatment-related mortality (TRM) with standard myeloablative allotransplantation usually
precludes these patients from potentially curative therapy, because of concerns about
shortening life in patients with these disorders. In this protocol we investigate
non-myeloablative allogeneic peripheral blood stem cell (PBSC) transplantation in two groups
of subjects where standard allogeneic transplantation is considered to have unacceptable
toxicity.

Group A: Subjects with hematologic malignancies with factors putting them at high risk for
transplant related complications and mortality, including prior intensive chemo-radiotherapy
and co-morbid diseases.

Group B: Subjects with hematologic diseases (both clonal and non-clonal) associated with
reasonable longevity not currently considered for allogeneic BMT because of prohibitive
procedural mortality with conventional BMT (enrollment closed October 2010).

In this protocol, eligible subjects are treated with an allogeneic PBSC transplant from an
HLA identical or single HLA antigen-mismatched family donor, using an intensive
immunosuppressive regimen without myeloablation in an attempt to decrease the transplant
related toxicities while preserving the anti-malignancy and/or anti-host marrow effect of the
graft. The low intensity non-myeloablative conditioning regimen should provide adequate
immunosuppression to allow stem cell and lymphocyte engraftment. T-cell replete,
donor-derived, granulocyte colony stimulating factor (G-CSF)-mobilized PBSCs will be used to
establish hematopoietic and lymphoid reconstitution. We will add back lymphocytes in
recipients with less than 100% donor T-cell chimerism in an attempt to prevent graft
rejection and enhance a graft-versus-malignancy effect.

The primary endpoint of this study is transplant related mortality (200 day survival). Other
end points include engraftment, degree of donor-host chimerism, incidence of acute and
chronic graft versus host disease (GVHD), transplant related morbidity as well as
disease-free and overall survival.

- INCLUSION CRITERIA - Recipients:

Group A: Subjects at high risk for transplant related complications and mortality as
defined below:

Ages 10 to 75 (both inclusive) with a history of one of the following:

- Treatment with dose intensive chemotherapy and/or radiotherapy

- Previous history of allo/auto transplant

- History of multiple myeloma or extramedullary plasmacytoma

- Chronic disease or co-morbid medical condition including subjects with symptoms or
signs of significant pulmonary disease, hepatic disease, kidney disease, cardiac
disease or disease of other organ systems which would result in increased risk of
morbidity or death from a standard myeloablative transplant.

Diseases to be included:

- CML chronic phase

- Acute lymphoblastic leukemia (ALL), all subjects in complete or partial remission.

- AML: AML in first complete or partial remission Exceptions: AML with good risk
karyotypes: AML M3 t(15:17), AML M4Eo (inv. 16), AML t(8;21). All AML in second or
subsequent complete remission.

- MDS: refractory anemia with excess blasts (RAEB), or chronic myelomonocyte leukemia
(CMML).

- Myeloproliferative diseases associated with either cytopenia or uncontrolled
proliferation.

- CLL or small lymphocytic lymphoma (SLL) with bulky or progressive disease despite
prior treatment with chemotherapy which includes purine analogs.

- NHL

A) Intermediate or high grade relapsed or progressive despite treatment with standard
therapy ineligible for autologous PBSC transplant.

B) NHL intermediate or high grade relapsing despite prior autologous transplant.

C) Low grade follicular or small lymphocytic lymphoma (1) high risk patients who have
relapsed following conventional chemotherapy, (2) relapsed following autologous marrow or
PBSC transplant, or (3) chemo resistant disease.

D) Mantle cell lymphoma

E) NHL intermediate or high grade with concurrent BCL2 and MYC translocations who are at
high risk for relapsed and who have low survival with conventional chemotherapy.

- HD, relapsed after prior autologous transplant or after 2 or more combination
chemotherapy regimens and ineligible for autologous PBSC transplant.

- EBV driven lymphoproliferative disorders progressing despite standard therapies.

- MM: MM subjects must be between the ages of 8 and 65 (both inclusive)

- Mycosis fungoides, which has been shown to be amenable to allogeneic stem cell
transplants.

Group B: (Closed to enrollment Oct 2010) Subjects with hematologic diseases associated with
reasonable longevity, shown to be curable by allogeneic BMT but where concern for a high
procedural mortality with conventional BMT may delay or prevent such treatment.

Ages 8 to 80 (both inclusive) with a history of one of the following

- PNH associated with either life-threatening thrombosis, cytopenia, transfusion
dependence or recurrent and debilitating hemolytic crisis.

- Aplastic anemia or PRCA (acquired or congenital) in subjects associated with
transfusion dependence and/or neutropenia who are not candidates for or who have
failed immunosuppressive therapy

- RA or RARS MDS subjects who have associated transfusion dependence and/or neutropenia.

Ability to comprehend the investigational nature of the study and provide informed consent.
The procedure will be explained to subjects age 8-17 years with formal consent being
obtained from parents or legal guardian.

Availability of HLA identical or single HLA locus mismatched family donor

INCLUSION CRITERIA - Donor:

HLA identical or single HLA mismatched family donor

Age greater than or equal to 2 up to 80 years old

Weight greater than or equal to 18 kg

Ability of donor or guardian of donor to comprehend the investigational nature of the study
and provide informed consent.

EXCLUSION CRITERIA - Recipient - any of the following:

Pregnant or lactating

Group A: age less than 10 or greater than 75 (multiple myeloma age less than 8 or greater
than 65);

Group B: Age less than 8 or greater than 80 years.

ECOG performance status of 3 or more (See NIH Bone and Marrow Consortium Supportive Care
Guidelines for Allogeneic Hematopoietic Stem Cell Transplant Recipients -
http://intranet.cc.nih.gov/bmt/_pdf/ECOG_Karnofsky_Lansky_Scales.pdf)

Psychiatric disorder or mental deficiency severe as to make compliance with the BMT
treatment unlikely and making informed consent impossible

Major anticipated illness or organ failure incompatible with survival from PBSC transplant

Diffusion capacity of carbon monoxide (DLCO) less than 40% predicted.

Left ventricular ejection fraction: less than 30%.

Serum creatinine greater than 2.5 mg/dl or creatinine clearance less than 50 cc/min by 24
hr urine collection

Serum bilirubin greater than 4 mg/dl, transaminases greater than 5x upper limit of normal,

Other malignant diseases liable to relapse or progress within 5 years.

EXCLUSION CRITERIA - Donor - any of the following:

Pregnant or lactating

Donor unfit to receive G-CSF and undergo apheresis (uncontrolled hypertension, history of
congestive heart failure or unstable angina, thrombocytopenia)

HIV positive donor. Donors who are positive for hepatitis B (HBV), hepatitis C (HCV) or
human T-cell lymphotropic virus (HTLV I/II) will be used at the discretion of the
investigator following counseling and approval from the recipient