Gemcitabine/Clofarabine/Busulfan and Allogeneic Transplantation for Aggressive Lymphomas

Study Drug Administration and Pharmacokinetic (PK) Testing:

The days before you receive your stem cells are called minus days, such as Day -2, Day -1.
The day you receive the stem cells is called Day 0. The days after you receive the stem cells
are called plus days, such as Day +1, Day +2.

Between Days -15 and -8, you will receive a low-level "test" dose of busulfan by vein over
about 45 minutes to 1 hour. Test doses are used to study how your body breaks down busulfan
and decide the dose of busulfan that you will receive. You may receive the test dose before
Day -8 as an outpatient in the clinic, or on Day -8 as an inpatient in the hospital.

Blood (about 1 teaspoon each time) will then be drawn for PK testing up to 11 times over the
11 hours after the busulfan test dose. PK testing measures the amount of study drug in the
body at different time points. The study staff will tell you more about the PK testing
schedule.

A heparin lock line will be placed in your vein before the PK testing to lower the number of
needle sticks needed for these draws. If for any reason it is not possible for the PK tests
to be performed, you will receive the standard dose of busulfan.

On Day -9 or Day -7, you will be admitted to the hospital and given fluids by vein to hydrate
you.

On Days -6 and -4, you will receive gemcitabine by vein over 40-180 minutes. The dose you
receive will be based on when you join the study. The length of time it takes to infuse the
gemcitabine will be based on when you join this study and the dose amount you are assigned.
Up to 6 dose levels of gemcitabine will be tested. Up to 3 participants will be enrolled at
each dose level. The first group of participants will receive the lowest dose level. Each new
group will receive a higher dose than the group before it, if no intolerable side effects
were seen. This will continue until the highest tolerable dose of gemcitabine is found. After
the highest dose is found, additional participants will be enrolled at that dose. The number
of patients in the group that receives the highest tolerable dose will depend on how many
have been enrolled in the other groups.

On Days -6 through -3, you will receive clofarabine by vein over 1 hour, followed by your
dose of busulfan by vein over 3 hours. If for any reason you could not have the PK tests
performed, you will receive the standard busulfan dose on these days.

On Days -3 through -1, if your stem cell donor is not related to you, you will receive
antithymocyte globulin (ATG) by vein over 4 hours each day. ATG is designed to weaken your
immune system in order to lower the risk that your body will reject the transplant. If your
stem cell donor is related to you, you will not receive this drug.

Beginning on Day -2, you will receive tacrolimus by vein over 24 hours every day until you
are able to take it by mouth. Tacrolimus is designed to weaken the immune system and lower
the risk of graft-versus-host-disease (GVHD - a reaction of the donor's immune cells against
your body). After you are able to take tacrolimus by mouth, you will take it every day for
about 6 months, or until the doctor thinks it is safe to stop.

On Day 0, you will receive the donor's stem cells by vein. The infusion will last anywhere
from about 30 minutes to several hours. After the stem cell infusion, you will begin
receiving mycophenolate mofetil (MMF) by vein over about 2 hours, 3 times a day. When your
doctor thinks you can tolerate taking it by mouth, you will switch to taking MMF by mouth 3
times a day with food. If you do not have GVHD by Day 60, MMF will be stopped. If you miss a
dose of MMF you should tell your study doctor. You should not try to make up the dose later.
If you develop GVHD, you may have to take MMF for a longer period of time.

Starting 1 week after the transplant (Day +7), you will receive filgrastim (G-CSF) as an
injection under the skin 1 time each day until your blood cell levels return to normal.
Filgrastim is designed to make white blood cells grow, which may help to fight infections.

You may be given other standard drugs to help lower the risk of side effects. Also, if the
doctor thinks it is appropriate based on having the CD20 protein on specific blood cells
(CD20+ disease), you will receive standard therapy with rituximab. You may ask the study
staff for more information about how these drugs are given and their risks.

Study Visits:

About 30 days before receiving the stem cells, you will have computed tomography (CT) and/or
positron emission tomography (PET) scans to check the status of the disease.

About 4 weeks after the stem cell transplant:

- You will have a physical exam, including measurement of your height, weight, and vital
signs (blood pressure, heart rate, temperature, and breathing rate).

- You will be asked about how you are feeling and about any side effects you may be
having.

- You will be checked for possible reactions to the study treatment, including GVHD.

- Blood (about 4 tablespoons) will be drawn for routine tests, to see how the transplant
has taken, and to check the status of the disease.

Follow-Up Visits:

About 3, 6, and 12 months after the transplant, and then every 6 months for 4 more years:

- You will have a physical exam, including measurement of your vital signs.

- You will be asked about how you are feeling and about any side effects you may be
having.

- You will be checked for possible reactions to your treatment, including GVHD.

- Blood (about 4 tablespoons) will be drawn for routine tests, to see how well the
transplant has taken, and to check the status of the disease.

- At any point that your doctor thinks they are needed, you will have a bone marrow
aspiration and CT and/or PET scans to check the status of the disease. To collect a bone
marrow aspirate, an area of the hip or other site is numbed with anesthetic, and a small
amount of bone marrow is withdrawn through a large needle.

The study staff will also stay in contact with your local doctor to find out if the disease
comes back and to check how you are doing.

Length of Treatment:

You will be on study for about 5 years. After 1 year, there is no study specific testing you
will be required to complete. Your transplant doctor will perform routine standard of care
follow-up that all patients receiving allogeneic stem cell transplantation receive.

You may be removed from the study early if the doctor thinks it is in your best interest, if
the disease gets worse or comes back, if intolerable side effects occur, if you have graft
failure (the transplanted cells do not grow), or if you are unable to follow study
directions.

If for any reason you want to leave the study early, you must talk to the study doctor. It
may be life-threatening to leave the study after you have started to receive the study drugs
but before you receive the stem cell transplant because your blood cell counts will be
dangerously low.

Inclusion Criteria:

1. Age 12 to 65 years of age.

2. Patients with refractory B-cell or T-cell non-Hodgkin's lymphoma or Hodgkin's lymphoma
who are eligible for allogeneic transplantation.

3. An 8/8 HLA matched (high resolution typing at A, B, C, DRB1) sibling or unrelated
donor.

4. Left ventricular EF >/= 45%.

5. FEV1, FVC and corrected DLCO >/= 50%.

6. Adequate renal function, as defined by estimated serum creatinine clearance >/=50
ml/min (using the Cockcroft-Gault formula: creatinine clearance =
[(140-age)*kg/(72*serum creatinine)] * 0.85 if female) and/or serum creatinine mg/dL.

7. Serum bilirubin
8. SGPT
9. Voluntary signed IRB-approved informed consent before performance of any study-related
procedure not part of normal medical care, with the understanding that consent may be
withdrawn by the subject at any time without prejudice to future medical care.

10. Men and women of reproductive potential must agree to follow accepted birth control
methods for the duration of the study. Female subject is either post-menopausal or
surgically sterilized or willing to use an acceptable method of birth control (i.e., a
hormonal contraceptive, intra-uterine device, diaphragm with spermicide, condom with
spermicide, or abstinence) for the duration of the study. Male subject agrees to use
an acceptable method for contraception for the duration of the study.

Exclusion Criteria:

1. Patient with active CNS disease.

2. Pregnancy (positive Beta HCG test in a woman with child bearing potential defined as
not post-menopausal for 12 months or no previous surgical sterilization) or currently
breast-feeding. Pregnancy testing is not required for post-menopausal or surgically
sterilized women.

3. Active hepatitis B, either active carrier (HBsAg +) or viremic (HBV DNA >/=10,000
copies/mL, or >/= 2,000 IU/mL).

4. Evidence of either cirrhosis or stage 3-4 liver fibrosis in patients with chronic
hepatitis C or positive hepatitis C serology.

5. HIV infection.

6. Active uncontrolled bacterial, viral or fungal infections.

7. Exposure to other investigational drugs within 2 weeks before enrollment.

8. Grade >/= 3 non-hematologic toxicity from previous therapy that has not resolved to

9. Radiation therapy to head and neck (excluding eyes), and internal organs of chest,
abdomen or pelvis in the month prior to enrollment.

10. Prior whole brain irradiation.

11. Prior autologous SCT in the prior 3 months.