A Phase I/II Study to Evaluate the Safety of Cellular Immunotherapy Using Autologous T Cells Engineered to Express a CD20-Specific Chimeric Antigen Receptor for Patients With Relapsed or Refractory B Cell Non-Hodgkin Lymphomas
Phase: PHASE1
Conditions: Recurrent B-Cell Non-Hodgkin Lymphoma, Recurrent Chronic Lymphocytic Leukemia, Recurrent Diffuse Large B-Cell Lymphoma, Recurrent Follicular Lymphoma, Recurrent Lymphoplasmacytic Lymphoma, Recurrent Mantle Cell Lymphoma, Recurrent Marginal Zone Lymphoma, Refractory B-Cell Non-Hodgkin Lymphoma, Refractory Diffuse Large B-Cell Lymphoma, Refractory Follicular Lymphoma, Refractory Lymphoplasmacytic Lymphoma, Refractory Mantle Cell Lymphoma, Refractory Transformed Non-Hodgkin Lymphoma, Recurrent Transformed B-Cell Non-Hodgkin Lymphoma, Recurrent Transformed Chronic Lymphocytic Leukemia, Refractory Marginal Zone Lymphoma, Refractory Transformed B-Cell Non-Hodgkin Lymphoma, Refractory Transformed Chronic Lymphocytic Leukemia, Recurrent Small Lymphocytic Lymphoma, Refractory Chronic Lymphocytic Leukemia, Refractory Small Lymphocytic Lymphoma, Recurrent Central Nervous System Lymphoma, Refractory Central Nervous System Lymphoma
Sponsor: Fred Hutchinson Cancer Center

 
 
Official Title 
A Phase I/II Study to Evaluate the Safety of Cellular 
Immunotherapy Using Autologous T cells Engineered to 
Express a CD20-Specific Chimeric Antigen Receptor for 
Patients with Relapsed or Refractory B-cell Non-Hodgkin 
Lymphomas 
NCT Number 
NCT03277729 
Document Type 
Protocol and Statistical Analysis Plan 
Document Date 
8/2/2023 
 
 

Protocol 9738 
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FRED HUTCHINSON CANCER CENTER 
 
Title:  
A Phase I/II Study to Evaluate the Safety of Cellular Immunotherapy 
Using Autologous T cells Engineered to Express a CD20-Specific 
Chimeric Antigen Receptor for Patients with Relapsed or Refractory B-
cell Non-Hodgkin Lymphomas 
 
Protocol Number:  
9738 
Current Version: 
Version 18 –01/06/2023 
Prior Version(s):  
Version 17 –10/10/2022 
IND Number: 
17383 
Investigational Agent: 
Autologous T cells Transduced with Lentiviral Vector Expressing CD20-
specific Chimeric Antigen Receptor Gene for the treatment of Refractory B 
Cell Non-Hodgkin Lymphomas (“CD20 CAR T cells”) 
Study Regimen: 
Cyclophosphamide, cyclophosphamide plus fludarabine, or bendamustine 
chemotherapy followed by CD20 CAR T cell infusion 
Principal Investigator: 
Mazyar Shadman, MD, MPH 
 
Associate Professor, Fred Hutchinson Cancer Center 
 
Sponsor:  
Fred Hutchinson Cancer Center 
 
1100 Fairview Ave N, M/S J3-329 
 
Seattle, WA 98109-1024 
 
(O): 206-667-4247 
 
ISIOC@fredhutch.org 
 
Medical Monitor:  
Mary-Elizabeth Percival, MD 
 
Associate Professor, Fred Hutch Clinical Research Division 
 
(O): 206-606-1320 
 
mperciva@uw.edu 
 
Authorized Sponsor Representative: 
Name: Mary-Elizabeth Percival, MD  
 
Signature:  ______________________________________________  
 
Fred Hutch IRB
Approved 
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09 JAN 2023
SIGN

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Signature Page: 
Investigator Statement: 
I have carefully read Protocol 9738 entitled “A Phase I/II Study to Evaluate the Safety of Cellular 
Immunotherapy Using Autologous T cells Engineered to Express a CD20-Specific Chimeric Antigen 
Receptor for Patients with Relapsed or Refractory B Cell Non-Hodgkin Lymphomas” (“Protocol”) version 
date 01/06/2023.   
I agree to carry out my responsibilities in accordance with the Protocol, applicable laws, and regulations 
(including 21 CFR Part 312), Good Clinical Practice: Consolidated Guidance (ICH-E6), and applicable 
policies of Fred Hutch. 
Principal Investigator: 
Name:  
Mazyar Shadman, MD, MPH 
Institution:  
Fred Hutchinson Cancer Center 
 
 
1100 Fairview Avenue N, M/S D5-396 
 
 
Seattle, WA 98109-1024 
(O) 206-667-5467 
 
Signature: ______________________________________________  
Fred Hutch IRB
Approved 
8/2/2023
SIGN

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TABLE OF CONTENTS 
1 
INTRODUCTION AND BACKGROUND ........................................................................................... 6 
1.1 
INTRODUCTION ............................................................................................................................ 6 
1.2 
BACKGROUND .............................................................................................................................. 7 
2 
OBJECTIVES .................................................................................................................................. 18 
2.1 
PRIMARY OBJECTIVE .................................................................................................................... 18 
2.2 
SECONDARY OBJECTIVES.............................................................................................................. 18 
2.3 
 TERTIARY OBJECTIVES ................................................................................................................. 18 
3 
SUBJECT SELECTION ..................................................................................................................... 18 
PLEASE NOTE: ALL POTENTIAL STUDY CANDIDATES WILL HAVE AN INITIAL CLINIC VISIT AND WILL 
SIGN A SCREENING CONSENT THAT INCLUDES ALL THE SCREENING PROCEDURES 
DESCRIBED IN SECTION 8.1., INCLUDING TUMOR BIOPSY. THE FOLLOWING ELIGIBILITY 
CRITERIA WILL BE EVALUATED AFTER THE SCREENING STAGE, PRIOR TO STUDY 
ENROLLMENT, WHICH OCCURS JUST PRIOR TO LEUKAPHERESIS (AS DEFINED IN SECTION 
4.1.3). ........................................................................................................................................... 18 
3.1 
INCLUSION CRITERIA .................................................................................................................... 19 
3.2 
EXCLUSION CRITERIA .................................................................................................................... 20 
3.3 
ELIGIBILITY FOR LYMPHODEPLETION CHEMOTHERAPY ............................................................... 21 
4 
STUDY DESIGN ............................................................................................................................. 22 
4.1 
OVERVIEW OF THE SCREENING AND ENROLLMENT PROCESS ..................................................... 22 
5 
INFORMED CONSENT OF SUBJECTS ............................................................................................. 23 
6   
SUBJECT REGISTRATION ............................................................................................................... 23 
7 
PLAN OF TREATMENT .................................................................................................................. 23 
7.1 
OVERVIEW .................................................................................................................................... 23 
7.2 
LEUKAPHERESIS ............................................................................................................................ 24 
7.3 
GENERATION OF CD20 CAR CELLS ............................................................................................... 25 
7.4 
CYTOREDUCTIVE CHEMOTHERAPY .............................................................................................. 25 
7.5 
LYMPHODEPLETION CHEMOTHERAPY ......................................................................................... 25 
7.6 
CAR T CELL INFUSION ................................................................................................................... 27 
7.7 
CD20 CAR T CELL DOSE ................................................................................................................ 27 
7.8 
CELL ADMINISTRATION ................................................................................................................ 27 
7.9 
RECOMMENDED SUPPORTIVE CARE, ADDITIONAL TREATMENT, AND MONITORING ................ 28 
8 
PATIENT EVALUATION.................................................................................................................. 28 
8.1 
SCREENING EVALUATIONS (SHOULD BE PERFORMED WITHIN 30 DAYS OF ENROLLMENT 
UNLESS OTHERWISE SPECIFIED) .................................................................................................. 28 
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8.2 
EVALUATIONS PRIOR TO LYMPHODEPLETING CHEMOTHERAPY (SHOULD BE PERFORMED 
WITHIN 1 WEEK OF INITIATION OF LYMPHODEPLETING CHEMOTHERAPY UNLESS 
OTHERWISE SPECIFIED) ................................................................................................................ 31 
8.3 
EVALUATIONS PRIOR TO T CELL INFUSION .................................................................................. 32 
8.4 
EVALUATIONS FOLLOWING T CELL INFUSION .............................................................................. 32 
8.5 
RESPONSE ASSESSMENT .............................................................................................................. 37 
8.6 
LONG-TERM FOLLOW-UP ............................................................................................................. 38 
9 
TOXICITIES AND COMPLICATIONS ............................................................................................... 38 
9.1 
T CELL-RELATED TOXICITIES ......................................................................................................... 38 
9.2 
CHEMOTHERAPY .......................................................................................................................... 41 
10 
SUBJECT DISCONTINUATION ....................................................................................................... 41 
10.1 
SCREEN FAILURE........................................................................................................................... 41 
10.2 
WITHDRAWAL AND OFF-STUDY CRITERIA ................................................................................... 41 
11 
ADVERSE EVENT REPORTING ....................................................................................................... 42 
11.1 
ADVERSE EVENT DEFINITIONS ..................................................................................................... 42 
11.2 
MONITORING AND RECORDING AES ........................................................................................... 43 
11.3 
GRADING OF THE SEVERITY OF AN ADVERSE EVENT ................................................................... 43 
11.4 
ATTRIBUTION OF ADVERSE EVENT ............................................................................................... 43 
11.5 
ADVERSE EVENT REPORTING PERIOD .......................................................................................... 44 
11.6 
ADVERSE EVENT REPORTING REQUIREMENTS ............................................................................ 45 
12 
STATISTICAL CONSIDERATIONS .................................................................................................... 46 
12.1 
STUDY DESIGN AND OBJECTIVES ................................................................................................. 46 
12.2 
DEFINITION OF ENDPOINTS ......................................................................................................... 47 
12.3 
INTERIM ANALYSES TO EVALUATE LYMPHODEPLETION REGIMEN ............................................. 48 
12.4 
DOSE ALLOCATION ....................................................................................................................... 49 
12.5 
STOPPING AND SUSPENSION RULES ............................................................................................ 50 
12.6 
PATIENT ACCRUAL AND EXPECTED DURATION OF TRIAL ............................................................ 50 
12.7 
OPERATING CHARACTERISTICS OF STUDY DESIGN ...................................................................... 51 
12.8 
DATA ANALYSIS ............................................................................................................................ 52 
12.9 
ETHNIC AND GENDER ACCRUAL ESTIMATES ................................................................................ 53 
13 
DATA AND SAFETY MONITORING PLAN ....................................................................................... 53 
13.1 
OVERALL SCOPE OF MONITORING ACTIVITIES............................................................................. 53 
13.2 
MONITORING THE PROGRESS OF TRIAL AND SAFETY OF PARTICIPANTS .................................... 54 
14 
DATA MANAGEMENT/CONFIDENTIALITY .................................................................................... 54 
15 
TERMINATION OF STUDY ............................................................................................................. 55 
16 
REFERENCES ................................................................................................................................. 56 
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APPENDIX A:  STUDY CALENDAR ............................................................................................................... 66 
APPENDIX B:  KARNOFSKY PERFORMANCE STATUS SCALE ...................................................................... 71 
APPENDIX C:  GRADING CRITERIA FOR CRS (ASTCT CRS CONSENSUS GRADING - 2019) .......................... 72 
APPENDIX D:  LUGANO RESPONSE CRITERIA ............................................................................................ 73 
APPENDIX E: IWCLL RESPONSE CRITERIA .................................................................................................. 76 
APPENDIX F:  LONG TERM FOLLOW-UP .................................................................................................... 77 
APPENDIX G: LONG TERM FOLLOW-UP PROVIDER QUESTIONNAIRE ...................................................... 78 
APPENDIX H: LONG TERM FOLLOW-UP SUBJECT QUESTIONNAIRE ......................................................... 80 
APPENDIX I: ASTCT ICANS CONSENSUS GRADING FOR ADULTS ............................................................... 82 
 
 
APPENDIX J:  IWWM RESPONSE CRITERIA……………………………………………………………………………………………..84 
 
 
APPENDIX K: CNS LYMPHOMA RESPONSE CRITERIA………………………………………………………………………………85 
 
 
 
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1 
INTRODUCTION AND BACKGROUND  
 
1.1 
Introduction 
More than 70,000 new cases of non-Hodgkin Lymphoma (NHL) are diagnosed each year in the USA, and 
more than 19,000 patients die of this group of diseases annually.1 Aggressive B cell lymphomas such as 
diffuse large B cell lymphoma (DLBCL) are the most common subset, accounting for 35-40% of NHL.2 The 
majority of patients with aggressive B-NHL are successfully treated with combination chemotherapy, but 
a significant proportion relapse or have refractory disease, and the outcome of these patients is poor. 
Approximately 30% of such cases can be salvaged with autologous stem cell transplant (ASCT), but the 
majority die of progressive disease.3 Indolent forms of NHL, including follicular lymphoma (FL), marginal 
zone lymphoma, lymphoplasmacytic lymphoma, and small lymphocytic lymphoma account collectively 
for ~40% of all cases of NHL,4 and are also incurable with available therapies, except high dose 
chemoradiotherapy with hematopoietic cell transplantation (HCT).5-7 Mantle cell lymphoma (MCL) is a 
distinct subtype defined by clinical, morphologic, immunophenotypic, cytogenetic, and molecular 
characteristics and accounts for 5-10% of NHL cases.2,8,9  The International Lymphoma Study Group 
determined that MCL has the worst failure-free survival (11% at 5 years) and overall survival (27% at 5 
years) of any type of B-cell NHL.2 No curative treatment is available for advanced MCL, with the possible 
exception of allogeneic stem cell transplantation.10-12 Chronic lymphocytic leukemia is the most common 
leukemia in the Western world and despite the introduction of several novel therapeutic agents, still 
remains incurable.13 Furthermore, treatment of high-risk CLL remains an unmet clinical and research need 
and allogeneic stem cell transplant is still considered standard of care for selected patients.14 Since many 
patients with relapsed B-NHL lack histocompatible donors or are not suitable candidates for stem cell 
transplantation, innovative new treatments are urgently needed.  This proposal will develop and test a 
new immunotherapeutic approach for relapsed B-NHL using autologous T lymphocytes that have been 
genetically modified with a novel lentiviral vector to express a chimeric antigen receptor (CAR) recognizing 
the CD20 antigen.   
    
Cellular immunotherapy using adoptive T cells expressing a CAR specific for tumor-associated B-cell 
antigens CD19 or CD20 has emerged as a potent therapy for B lymphoid malignancies. The CD20 antigen 
has proved to be an effective target for antibody therapy in treating variety of NHLs. It is expressed at a 
high density on the surface of more than 95% of B-NHL. It is minimally shed, internalized, or modulated 
upon antibody binding.  It usually continues to be expressed on B-NHL lymphoma cells despite repetitive 
therapy with rituximab, an anti-CD20 antibody. Unfortunately, many patients who initially benefit from 
rituximab develop resistance, while others never respond. Our group has conducted two proof-of-concept 
phase I clinical trials that demonstrated the feasibility, safety, and minimal toxicity of treating patients 
with relapsed or refractory B-NHLs with autologous T cells that had been genetically modified to express 
an anti-CD20 CAR via plasmid DNA transfection. However, several limitations of the initial approach 
became apparent during the conduct of these trials: 1) the low transfection efficiency achieved with 
electroporation as a gene transfer method, which required antibiotic selection and prolonged in vitro 
expansion, 2) suboptimal cell surface expression of the CAR on T cells (<10,000 molecules per cell), 3) the 
long time interval required to expand genetically modified T cells to sufficient numbers to perform 
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therapeutic infusions (2-4 months), 4) T cell exhaustion resulting from the prolonged culture times and 
multiple restimulation cycles, and 5) short in vivo persistence of infused T cells (a few weeks). To address 
these limitations, we have generated and successfully tested a lentiviral based vector containing a third-
generation, fully human anti-CD20 CAR and a truncated CD19 (trCD19) selectable marker. The goal of this 
phase I/II study is to develop and test this immunotherapeutic approach for patients with relapsed or 
refractory B-NHL. 
 
1.2 
Background   
 
1.2.1 
Conventional chemotherapy for B-cell lymphomas 
Induction therapy for B-NHL generally consists of a combination of an anti-CD20 antibody (rituximab) and 
chemotherapy (CHOP, bendamustine, DA-EPOCH, HyperCVAD, or other regimens). R-CHOP is curative of 
approximately 60% of patients with advanced stage DLBCL, but patients who are refractory to or relapse 
after R-CHOP have poor outcomes.  Indolent lymphomas, including follicular, marginal zone, small 
lymphocytic and lymphoplasmacytic lymphomas typically present in elderly patients with disseminated 
disease. Despite their clinically “indolent” nature initially, these lymphomas progress inexorably to death, 
which occurs at a median of 10-15 years after diagnosis. With the exception of a small fraction of patients 
(10-15%) with truly localized involvement, the majority of indolent lymphoma patients do not achieve 
long-term durable remissions with conventional treatment regimens, and there is no current consensus 
among experts on the best treatment approach for this group of diseases.15 Studies have not 
demonstrated a curative potential for patients treated with currently tested conventional 
chemotherapeutic agents including single alkylating agents, bendamustine monotherapy or 
combinational regimens such as R-CVP, or R-CHOP (rituximab, cyclophosphamide, doxorubicin, 
vincristine, and prednisone).15 Mantle cell lymphoma is typically treated in younger patients with an 
intensive high-dose cytarabine-containing induction regimen (such as Nordic regimen or alternating R-
CHOP/rituximab, dexamethasone, high-dose Ara-c, and cisplatin [R-DHAP]) followed by autologous HCT 
in first remission.16,17 Older patients with MCL are typically treated with either rituximab plus 
bendamustine or rituximab, bortezomib, cyclophosphamide, doxorubicin, and prednisone (VR-CAP).18,19 
The response rates for these regimens are high, but relapse is inevitable. Historically, 
chemoimmunotherapy regimens have been used in treatment of CLL. Fludarabine, cyclophosphamide and 
rituximab (FCR), bendamustine and rituximab (BR), and chlorambucil and obinutuzumab were some of 
the more commonly utilized regimens until the introduction of more recent novel agents.13,20 Despite 
long-term remissions from the FCR regimen in patients with normal TP53, the regimen is associated with 
a 5-7% risk of secondary myeloid malignancies (AML/MDS).21 More importantly, and in a number of head-
to-head randomized trials, novel agents (ibrutinib, acalabrutinib, and venetoclax) have been shown to be 
superior compared to chemoimmunotherapy in both first-line and relapsed settings. 22-29 As a result, 
chemotherapy is only a reasonable option for selected patients in the first line setting and is rarely used 
in previously treated patients.20  All investigators agree on the necessity of developing better treatment 
regimens for patients with B-cell lymphomas.  
 
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1.2.2 
High dose therapy with autologous stem cell transplantation (ASCT) for relapsed/refractory B-
NHL  
High dose therapy with autologous stem cell rescue is commonly employed for treatment of patients with 
relapsed lymphomas of all types. The Parma trial demonstrated an overall survival benefit for patients 
with relapsed or refractory aggressive NHL that was responsive to salvage chemotherapy who underwent 
high-dose therapy with autologous stem cell transplantation compared with standard chemotherapy 
alone.30 More recent studies in the rituximab era indicate that higher cure rates with induction therapy 
have resulted in worse outcomes for patients who fail frontline treatment. Patients who develop 
progressive disease within 12 months of R-CHOP have a 3-year progression-free survival (PFS) of only 
23%.31 ASCT is frequently employed in the treatment of MCL as consolidation of frontline therapy in 
younger patients, and appears to have resulted in improved overall survival in this disease. For patients 
with relapsed indolent B-NHL, a small randomized trial showed that ASCT led to an improvement in PFS 
and suggested an overall survival benefit as well, although this was performed in the pre-rituximab era.32 
It is important to note that despite these improvements in disease control, ASCT trials for MCL and 
indolent NHL often fail to demonstrate convincing plateaus on the survival curves, and even these high 
dose regimens are generally not considered to be curative.33-36  
 
1.2.3 
Allogeneic stem cell transplantation for relapsed/refractory B-NHL   
Several studies have examined the role of allogeneic transplantation in relapsed/refractory B-NHL.5,6,12 
This treatment approach, which relies on an immunologic graft-versus-lymphoma effect mediated by 
alloreactive donor T cells, has the potential to lead to cures. However, many B-NHL patients are not 
candidates for this therapy due to advanced age, poor performance status, or lack of a suitable HLA 
matched donor. Furthermore, allogeneic stem cell transplantation is associated with high rates of 
morbidity and non-relapse mortality due to acute and chronic graft-versus-host disease (GVHD) and 
infection, limiting the applicability of this approach. 
 
1.2.4 
Targeted small molecule therapies for B-NHL 
Recent improvements in the understanding of lymphoma biology has led to the development of several 
new small molecule agents targeting proteins involved with active signaling pathways in malignant B cells. 
Inhibitors of B cell receptor pathway proteins such as Bruton’s tyrosine kinase (BTK), phosphotidylinositol-
3 kinase (PI3K), and spleen tyrosine kinase have proven to be very active in this group of diseases. 
Ibrutinib, a BTK inhibitor, has shown unprecedented activity for a single agent in relapsed MCL, with an 
overall response rate of 68% and median PFS of 13 months in this setting.37 Idelalisib, a PI3K inhibitor, led 
to a 57% response rate and median PFS of 11 months in heavily pre-treated patients with indolent B-
NHL.38 Venetoclax, a Bcl-2 inhibitor that is approved for CLL/SLL, has also shown promising single agent 
activity in relapsed or refractory MCL, with a response rates of 75%.39 These therapies are often safe and 
well-tolerated, however rare serious complications such as intracranial bleeding can occur with ibrutinib, 
and fatal pneumonitis and hepatitis may occur with idelalisib. Although the drugs in this new class are 
valuable additions to the armamentarium of lymphoma therapies, they are not curative, require indefinite 
therapy, and are very costly.   
 
 
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1.2.5 
Novel therapeutic agents for CLL/SLL and role of cellular therapy (allogeneic transplant and 
CAR-T therapy) 
Treatment of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) has been 
revolutionized since the introduction of novel therapeutic agents including BTKis (ibrutinib and 
acalabrutinib), PI3Kis (idelalisib and duvelisib), and the Bcl-2 inhibitor, venetoclax. Chemotherapy-free 
regimens are currently standard of care for the majority of CLL patients and all high-risk patients with an 
abnormal TP53 (del17p or a mutated TP53). 13,20,22,24,26-28,40,41 Despite these advancements, clinical 
outcomes of patients who progress on a BTKi or venetoclax are poor, and treatment options are limited 
for this population. Cellular therapy, namely allogeneic stem cell transplant, is recommended at least as 
a consideration for fit patients with available donors who have disease progression on either a BTKi or 
venetoclax. This is consistent with guidelines published by the American Society of Transplant and Cellular 
Therapy (ASTCT) as well as by the European Bone Marrow Transplant (EBMT) and the European Research 
Initiative for CLL (ERIC).14,42,43 Despite the efficacy (long-term PFS ~40%), allogeneic transplant is 
associated with a high rate of treatment related mortality ranging from 10-25%.  Therefore, other cellular 
therapy approaches with high efficacy but less toxicity are needed. 42,44 
 
Studies using CD19-targeted CAR-Ts have shown promising results in treatment of high-risk CLL, including 
in patients with abnormal TP53 and those with prior disease progression on a BTKi and/or venetoclax. 
Experience from the Fred Hutch group using a second generation CAR with 4-1BB co-stimulatory domain, 
showed a 1-year progression-free survival of 38% and 50% when CAR-T was administered with or without 
concurrent ibrutinib, respectively.45,46  Also, an ongoing multicenter study using lisocabtagene maraleucel 
(liso-cel) for high-risk CLL patients showed high response rates (CR 45% and PR 36%).The same promising 
signal was observed in patients who had disease progression on BTKi and venetoclax (double refractory), 
with CR rate of 67% and PR rate of 22%. The rate of elimination of measurable residual disease as 
measured by flow cytometry with a sensitivity of 10-4 (uMRD4) was 75% and 65% in all and 87% and 75% 
in double-refractory patients in the blood and bone marrow, respectively.47 The uMRD status after CAR-T 
seems to be a strong predictor of long-term remissions based on the studies from Fred Hutch. 45,46   
 
1.2.6   CAR-T therapy for lymphoma patients with CNS involvement  
Primary and secondary CNS lymphomas are considered unmet clinical needs.48 Despite the recent 
advancement in treatment of lymphoma, none of the recently  approved drugs for B-NHL are effective or 
available for patients with CNS lymphoma.49-51 Outcome of patients with primary CNS lymphoma with 
poor response to first-line treatment or with relapsed/refractory disease remains extremely poor. 
Patients with secondary CNS lymphoma also have inferior clinical outcomes compared to patients 
without CNS involvement.52 Most importantly, secondary CNS involvement by lymphoma commonly 
excludes patients from clinical trials testing novel investigational treatments.   
 
Patients with CNS involvement were excluded from the ZUMA-1 and JULIET trials, that led to the approval 
of axicabtagene ciloleucel and tisagenlecleucel, respectively.53 Therefore, the FDA label for those two 
products does not include patients with active CNS disease and the published clinical experience with 
axicabtagene ciloleucel and tisagenlecleucel in treatment of CNS lymphoma patients is based on small 
case series. Despite this limitation, an increasing number of publications confirm the safety and efficacy 
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of CAR-T products in patients with active CNS lymphoma. Frigault et. al. reported on a case series of 8 
patients who received tisagenlecleucel for secondary CNS lymphoma at the FDA approved standard dose. 
Only 1 patient had grade 1 neurotoxicity, and activity was demonstrated in those heavily pretreated 
patients.54 Based on these results the group at the Massachusetts General Hospital (MGH) designed and 
conducted a phase I/II study of tisagenlecleucel for primary CNS lymphoma. Twelve patients were treated 
on the protocol and only 1 patient developed grade 3 ICANS and other AEs (CRS and ICANS) only occurred 
at grade 1-2. There was no treatment-related deaths and 3 of 12 patients had ongoing complete 
remissions. Authors also showed persistent CAR-T cells in blood and trafficking to CSF. 55Ghafouri and 
colleagues also reported safety and efficacy of axicabtagene ciloleucel in 5 patients with secondary CNS 
lymphoma. They reported no CAR-T related deaths and they only observed grade 1-2 CRS and grade 3 
ICANS. 4 of 5 pts showed response although responses were not durable.56  
 
Unlike ZUMA-1 and JULIET trials in the TRANSCEND NHL 001 study, the pivotal registration trial that led 
to the approval of lisocabtagene maraleucel for DLBCL, patients with secondary CNS involvement were 
eligible for the study and comprised 3% of the study population. 57Patients received CAR-T at the same 
dose other patients on the study. Neurological events occurred in 2 patients and both patients developed 
grade 3 ICANS. Of note, no patients developed CRS and no patients died from neurological events. Of 7 
patients, 6 were evaluable for efficacy and all 3 achieved a CR.  
 
There is more limited data on primary CNS lymphoma. Investigators at the City of Hope medical center 
reported on 5 patients with primary CNS lymphoma who received an investigational CD19 targeted CAR-
T58 They only observed grade 1-2 CRS and ICANS. In this phase 1 trial, 2 dose levels were tested and there 
was no difference in rate of grade 2 CRS between the 2 dose levels. Importantly, 3 of 5 patients achieved 
a CR after treatment.  
 
Overall and despite the limited clinical experience, there does not seem to be concerning safety signal 
when CAR-T is used for treatment of patients with active CNS lymphoma. Additionally, the observed 
responses justify including these patients in investigational studies.   
1.2.7 
Immune-based therapies targeting CD20  
CD20 is a  non-glycosylated, tetrapass, 35 KD B-cell lineage-specific phosphoprotein that is expressed in 
high, homogeneous density on the surface of more than 95% of B-NHL59. CD20 is minimally shed, 
internalized, or modulated upon antibody binding.60 Importantly, CD20 continues to be expressed on the 
lymphoma cells of most patients with relapsed B-NHL despite repetitive rituximab treatments.61,62 Thus, 
loss of CD20 expression is not a major contributor to treatment resistance. These attributes of CD20 make 
it a particularly attractive molecular target for immune-based therapies.    
 
1.2.8 
Humoral immunotherapy with anti-CD20 Abs 
The availability of monoclonal anti-CD20 antibodies has revolutionized the management of patients with 
CD20+ B-NHL. Over the past 15 years, the safety and efficacy of the anti-CD20 antibody rituximab has 
resulted in its use in virtually all patients with B-NHL.63 Unfortunately, despite the fact that CD20 is an 
excellent target for antibody-mediated humoral immunotherapy, many patients who initially benefit from 
rituximab develop resistance while others never respond.63 Newer anti-CD20 antibodies have been 
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developed, including obinutuzumab and ofatumumab. Obinutuzumab is a humanized type II antibody 
with glycoengineered Fc regions designed to enhance antibody-dependent cellular cytotoxicity, and is 
approved for newly diagnosed CLL and also follicular lymphoma that has relapsed after rituximab.64,65 
Ofatumumab is a type I fully human anti-CD20 antibody that is approved for several indications for CLL 
patients.66,67   Ofatumumab binds to both the small and large extracellular loops of CD20 at a non-
overlapping epitope compared with rituximab, whereas obinutuzumab binds an overlapping epitope with 
rituximab, albeit in a different orientation.68 
 
1.2.9 
Cellular Immunotherapy with adoptive antigen-specific T cells 
Adoptive T cell therapy, involving the ex vivo selection and expansion of antigen-specific T cells, provides 
a means of augmenting antigen-specific immunity without the in vivo constraints that can accompany 
vaccine-based strategies. Many preclinical studies have focused on testing this approach in treating a 
variety of cancers as well as viral diseases. Its feasibility and efficacy have been demonstrated in studies 
with viral antigen-specific T cells against HIV, CMV, EBV, and other viral diseases,69,70 though its success in 
cancer is still far from satisfactory. Major obstacles include difficulties in identifying and characterizing 
common tumor-specific or tumor-associated antigens and peptides, the inability of transferred T cells to 
expand and migrate to desired sites, host immune tolerance, tumor immune evasion and limitation of 
therapeutic efficacy to a highly selected group of patients due to MHC restriction.71,72   
 
1.2.10 Chimeric antigen receptor (CAR) T cell 
therapy 
Eshhar et al.73,74 developed an alternative strategy for 
adoptive T cell immunotherapy that involves redirecting 
the specificity of cytotoxic T cells in an MHC-independent 
fashion via genetic modification with engineered receptor 
constructs. This method allows targeting tumor cell 
surface antigens that are unavailable to endogenous T cell 
receptors due to poor immunogenicity, clonal deletion, or 
immune tolerance during T cell development. In other 
words, this approach does not require pre-existing anti-
tumor immunity. CARs are constructed by fusing a gene 
encoding the antigen binding region of an Ab against a 
tumor-associated antigen with a gene responsible for 
activating signal transduction of T cells such as the ζ chain 
of the CD3 molecule. This fusion gene product is delivered 
into T cells and equips them with newly redirected specificity to the desired target. The biggest advantage 
of this approach is that one receptor construct can theoretically be used to treat any patient with a tumor 
expressing the target antigen.  
 
An emerging group of CARs for targeting human tumors including breast cancer, colon cancer, renal 
cancer, prostate cancer, neuroblastoma, and lymphoma have been described.71,75,76 In vitro studies have 
shown that both CD4+ and CD8+ effector T cell functions can be triggered via these receptors and result in 
Figure 1.1: Diagram of a 3rd generation 
CD20-specific chimeric antigen receptor 
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antigen-specific lysis of tumor targets and production of cytokines such as IL-2, TNF-α, and IFN-γ.71,75,77 
Several studies have now been reported using CD19-targeting CARs to treat relapsed or refractory B cell 
lymphoid malignancies, with very promising results (see below).  
 
1.2.11 T cells with CD20 specific CAR  
Michael Jensen, in his work at the City of Hope, was the first to document the feasibility of engineering an 
anti-CD20 CAR plasmid construct, its ability to transfect T cells, its anti-CD20 specific tumor activity in 
vitro, the ability to expand transfected CD8+ effector T cells to large numbers, and the tolerability of 
infusing such cells into humans.78-80 
 
In a collaborative effort, our group and Dr. Jensen’s group have confirmed the potent CTL activity of T cells 
genetically modified to express a 1st generation anti-CD20 scFvFc-ζ CAR, derived from the Leu16 murine 
anti-human CD20 antibody, for both lymphoma cell lines and freshly isolated lymphoma cells from 
patients with NHL.81 Our group also demonstrated the ability to generate large numbers of T cell clones 
and to infuse the cells safely into lymphoma patients.82 Our group successfully completed a proof-of-
concept phase I clinical trial which demonstrated the feasibility, safety, and minimal toxicity of treating 
patients with relapsed B-NHL with autologous T cells that have been genetically modified to express an 
anti-CD20 CAR via plasmid transfection.83 An improved version of a plasmid-based CAR with anti-CD20 
specificity, co-stimulatory domains from CD28 and CD137, and a SP163 translational enhancer (a so-called 
“3rd generation” CAR) was generated in our laboratory and tested in vitro. T cells transfected with this 
vector expressed 2 to 3 fold higher levels of surface anti-CD20 CAR, enhanced cytokine secretion, and 
improved proliferation when compared with 1st generation plasmid.84 Additionally, faster ex-vivo 
expansion was observed when transfected T cells were cultured in bulk mixtures instead of after limiting 
dilution cloning.84   
 
1.2.12 Phase I clinical trials using autologous T cells transfected with anti-CD20 scFvFc-ζ CAR 
Our laboratory previously conducted two phase I clinical trials testing adoptive immunotherapy with 
CD20-specific CAR+ T cells. In the first trial, T cells were transfected with a CD20-specific 1st generation 
CAR plasmid.83 Therapeutic numbers of transfected T cells expressing the CAR and exhibiting CD20-specific 
effector activity were generated in 7 out of 10 patients.  Seven patients completed a total of 20 T cell 
infusions. All toxicities were grade 2 or less and were due to IL-2 injections. No adverse events were 
associated with T cell infusions. No cellular immune responses to the CAR or NeoR gene products were 
detected, although two patients subsequently developed human anti-mouse antibodies (HAMA). 
Modified T cells were detectable ranging from 5 to 65 days after infusions by a quantitative PCR (Q-PCR) 
technique. The in vitro expansion durations ranged from 5 to 8 re-stimulation cycles. One partial remission 
was observed out of 5 patients with measurable disease. Four patients experienced stable disease for 3, 
5, 12, and 48 months. Two additional patients without evidence of disease remained progression-free for 
3 and 13 months. 
 
A second phase I clinical trial using autologous T cells transfected with an improved 3rd generation anti-
CD20 CAR containing CD28 and 4-1BB co-stimulatory domains for patients with relapsed or refractory 
CD20+ indolent NHL and mantle cell lymphoma was published by our group in 2012.85  In this study, 4 
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patients with B-NHL were enrolled, and 3 were infused sequentially with 108, 109, and 3.3 x 109 T cells/m2, 
followed by low-dose subcutaneous IL-2 (250,000 IU/m2 every 12 hours for 14 days). Treatment was well 
tolerated, although one patient developed transient, reversible infusional symptoms of fever, orthostatic 
hypotension, and hypoxemia. There were no other adverse events attributable to the nine infusions of T 
cells. In this second trial, infused T cells were detectable in the blood of patients for up to 1 year after 
treatment by Q-PCR, albeit at low levels. No cellular or humoral immune responses against the transgene 
were detected. Genetically modified T cells trafficked to tumor sites including lymph nodes (LN) and/or 
bone marrow (BM) in all 3 patients, as documented by biopsies. Anti-tumor activity of the regimen was 
suggested by an objective partial remission observed in one patient lasting 9+ months. The other two 
patients had no evaluable disease at the time of therapy and remained NED for 12 and 24 months after 
therapy. The patient who achieved a partial remission developed a late near-complete response 
approximately 2 ½ years after the infusions, and remains in remission more than 5 years after treatment. 
Another patient underwent an additional infusion of CAR T cells after relapse and now remains in 
complete remission more than 4 ½ years later.   
 
1.2.13 Advantages of using a lentiviral mediated gene transfer approach 
Despite numerous efforts to augment the plasmid-based gene transfer approach, persistent problems 
have hindered further exploitation of this method. These difficulties include low transfection efficiency 
(<0.1%), suboptimal cell surface expression of the CAR (<10,000 molecules per cell), and the long 
expansion duration (2 to 4 months) required to achieve sufficient numbers of genetically modified T 
cells.83,84 Retrovirus-mediated gene transfer has been embraced by the field of gene therapy because of 
its ability to provide higher transduction efficiencies, higher levels of target gene expression, and more 
rapid in vitro selection and expansion. Among the currently available retroviral vectors, self-inactivating 
(SIN) lentiviral vectors may have advantages over gamma-retroviral vectors in several areas, including 
resistance to gene silencing and a potentially safer integration site profile.86-88 
 
To improve upon the results of our previous clinical trials, we transferred the anti-CD20 CD28-41BB CAR 
to a self-inactivating 3rd-generation lentiviral vector89 and made several additional modifications to 
optimize efficacy in pre-clinical models. Recently published data from our center revealed that cellular 
immune rejection of the CAR transgene is a frequent cause of poor persistence of CD19-targeted CAR T 
cells, with immunogenic epitopes mapping to the murine single-chain variable fragment (scFv).90 We 
therefore replaced our murine scFv with one derived from the fully human 1.5.3 monoclonal antibody,91 
with the expectation that it will reduce CAR immunogenicity and thus diminish the need for intensive 
lymphodepletion.  
 
Data from our laboratory and others have demonstrated the importance of intercellular distance with 
respect to CAR T cell triggering,83,92,93 suggesting that for a given target epitope, an ideal extracellular 
spacer length exists for each CAR.94 CD20 has a membrane-proximal epitope, and we and others have 
tested extracellular spacer domains of varying lengths and found that a long spacer is required for optimal 
T cell function.95 and unpublished data However, full length spacers derived from human IgG Fc domains, such as 
the one used in our CAR construct, can bind Fcγ receptors and trigger activation-induced cell death.96 We 
therefore modified the IgG1 Fc spacer region to abrogate binding to Fcγ receptors.96  
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The question of which intracellular signaling domain(s) to include in CARs is controversial, with different 
groups favoring different costimulatory domains. We tested 41BB-only, CD28-only, and CD28-41BB 
constructs and found that the CD28-41BB CAR led to superior activity in mouse xenograft experiments 
compared with 41BB-only and CD28-only constructs. This is consistent with our previous studies with 
murine-derived scFvs that showed superior proliferation and cytokine secretion of a 3rd generation CD20-
targeted CAR compared with 1st or 2nd generation CARs.84 These data led us to select this construct for 
clinical testing (Figure 1.2).  
The vector also encodes a non-functional truncated cell surface human CD19 (tCD19) separated from the 
CAR cassette by a self-cleavable E2A element that ensures coordinate expression of both proteins. The 
truncation of tCD19 abrogates all conserved tyrosine residues that serve as phosphorylation sites,97 but 
retains the extracellular epitopes recognized by anti-CD19 antibodies. The tCD19 facilitates tracking of CAR 
T cells in vivo, and could potentially be used as a target for anti-CD19 antibodies or antibody-drug 
conjugates to eliminate CAR T cells if uncontrolled toxicity occurs.  
 
The genes are expressed under the control of a truncated EF1α promoter. A synthetic WPRE sequence 
modified to remove the protein X open reading frame exists downstream of the 2 transgenes and proximal 
to the 3’ polyadenylation signal to further enhance the expression of transgenes.  In vitro, 1.5.3-based 
CARs function as well or better than those derived from the Leu16 or 1F5 murine anti-CD20 antibodies, 
and are capable of eradicating established lymphoma xenografts in NSG mice, with cure rates of 
approximately 80% (Figure 1.3 and data not shown).  
T cells from healthy donors transduced with this lentivirus have demonstrated far superior surface CAR 
Figure 1.3: In vivo antitumor effect of fully human CD20-specific CAR. NOD-SCID-ᵧ-/-mice were injected i.v. with Raji-ffLuc 
tumor cells, followed 2 days later by i.v. injection of T cells transduced either with the 1.5.3-NQ-28-BB-ζ CAR or an empty 
vector. A) Tumor burden over time as assessed by bioluminescence imaging. B) Kaplan-Meier plot of overall survival. 
Figure 1.2: Lentiviral vector encoding bicistronic 3rd generation fully human CAR 
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expression than we were previously able to achieve using plasmid DNA transfection methods. The 
lentiviral transduction efficiency is 20-75%, compared to <0.1% with electroporation. These transduced T 
cells readily exhibited CD20-specific cytolytic toxicity when tested by standard chromium release  
assays using several different CD20 expressing lymphoma cell lines (data not shown).  
   
1.2.14 Effect of rituximab on CD20 CAR T cell function 
The proposed use of CD20-targeted CAR T cell therapy in a patient population that will have been 
uniformly previously treated with rituximab and/or other anti-CD20 antibodies raises two concerns. The 
first is that the cause of rituximab resistance could also confer resistance to the CAR T cells targeting the 
same antigen. The mechanism of resistance to rituximab is poorly understood, but only infrequently 
involves CD20 mutation or loss of CD20 expression.98,99 Preclinical data from our lab indicate that CD20 
CAR T cells retain cytolytic activity against rituximab-refractory cells and are capable of rejecting 
rituximab-refractory tumors in vivo.100 The second concern is that residual levels of rituximab in the serum 
could block binding of the CD20 CAR to its target epitope, which is shared by rituximab, and thereby impair 
CAR T cell activity. We conducted extensive in vitro and in vivo tests on the impact of various levels of 
rituximab on CD20 CAR T cell function and found that levels of rituximab typically found in the serum of 
patients who have undergone recent rituximab-containing salvage therapy only minimally impaired the 
function of CD20 CAR T cells in vitro, and there was no negative impact of rituximab administered prior to 
CAR T cells in a xenograft mouse model (Figure 1.4).100 
 
 
1.2.15 Clinical trials using CD19-targeted CAR T cells to treat B cell malignancies 
Several groups have conducted clinical trials testing CD19-specific CAR T cells as therapy for relapsed or 
refractory B lymphoid tumors. The most responsive disease subtype appears to be acute lymphoblastic 
leukemia (ALL), with complete response rates of 80-90% in multiple studies.90,101,102 The response rates 
for NHL and chronic lymphocytic leukemia have been lower, in the 50-70% range, with complete 
remissions in the 40-50% range.103-105 Since the follow-up of most patients is still short, the durability of 
responses is still not yet well established, but a few patients have been reported to have long-term 
remissions without additional therapy.  
 
Figure 1.4. Effect of residual 
rituximab on CAR T cell activity 
in vivo. NOD-SCID-γc-/- mice were 
injected 
with 
rituximab-
refractory Raji-ffLuc tumors i.v., 
followed 
5 
days 
later 
by 
rituximab 25 or 200 μg i.p. Third-
generation CD20-CAR T cells 
were administered 1 day after 
rituximab 
and 
tumor 
bioluminescence was measured 
twice weekly.  
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A hallmark of CAR T cell activity has been cytokine release syndrome (CRS), marked by fever, hypotension, 
elevated serum levels of cytokines as well as LDH, ferritin, and CRP.27,90,101 This can resemble septic shock 
clinically, and some patients require vasopressor support in the intensive care unit (ICU). The severity of 
CRS correlates closely with tumor burden, particularly in patients with ALL.90 This complication can be 
managed by intervening with tocilizumab (anti-IL-6 receptor antibody) and/or dexamethasone. Another 
sequela of CAR T cell therapy, particularly in patients who develop severe CRS, is neurotoxicity, including 
delirium, hallucinations, seizures, and coma. Patients at high risk of CRS and neurotoxicity are often 
treated prophylactically with anticonvulsant therapy. The mechanism of neurological manifestations 
following CAR T cell therapy is poorly understood but symptoms are fully reversible in the vast majority 
of patients. 
 
1.2.16 Adoptive therapy using defined T cell subsets  
To date, most groups conducting CAR T cell clinical trials have generated T cell products from unselected 
patient-derived PMBC. Since patients have variable ratios of T cell subsets, particularly after treatment 
with various lymphotoxic regimens, the composition of the infused cell products in these patients has 
been highly variable, with some patients receiving products consisting of > 95% CD4+ cells, and others 
with > 95% CD8+ T cells.85,101,103,104,106  The Darcy group in Australia showed that a 1:1 infusion of CD4+ to 
CD8+ CAR T cells led to the most effective antitumor activity in mouse models.107 Subsequently, the Riddell 
Laboratory performed detailed studies evaluating various CD4+ and CD8+ T cell subsets, and found that 
adoptively transferred cells derived from central memory T cells have a unique ability to expand and 
persist in vivo and respond to antigen re-challenge,108 and that combinations of CD4+ and CD8+ cells, 
particularly CD8+ central memory cells, led to the most effective antitumor activity in a xenograft mouse 
model.96 Other groups have also demonstrated that CD4+ T cells are known to enhance the proliferation, 
survival, effector function, and anti-tumor potency of CD8+ T cells.91,107,109 and in some models CD4+ cells 
alone can mediate a cytotoxic effect and in vivo anti-tumor activity.110  
 
On this clinical trial, we observed poor ex-vivo expansion of the CD8+ cell cultures for 6 of the first 8 
patients for whom a cell product was generated. We hypothesized that the reason for the poor CD8+ cell 
growth is lack of CD4+ cell help inherent with culturing each subset in isolation, and that combining CD4+ 
and CD8+ cells into a single culture, mirroring the physiologic state, would improve CD8+ cell growth. We 
subsequently conducted extensive pre-clinical tests evaluating the co-culture of CD4+ and CD8+ cells, and 
found that CD8+ cells cultured together with CD4+ cells have significantly better ex vivo expansion, less 
exhausted phenotype, higher cytokine secretion, and improved anti-tumor function in a mouse lymphoma 
model, compared with CD8+ cells grown separately.26 We also found that while a precise 1:1 ratio cannot 
be achieved in the same way possible with separate CD4+ and CD8+ expansion, initiating the cell cultures 
at a defined CD4:CD8 ratio led to a more consistent CD4:CD8 ratio in the final cell product than what has 
historically been reported in CAR T cell trials using unselected T cells.111  
 
1.2.17 Phase I/II clinical trial with CD19-targeted cells using defined T cell subsets. 
In an ongoing clinical trial at Fred Hutch, Drs. Maloney, Turtle, and Riddell have generated T cell products 
using a 1:1 ratio of CD4+ to CD8+ T cells, with some patients receiving unselected CD8+ T cells and others 
receiving CD8 central memory T cell-derived cells.90,105 In this study, 103 patients have been treated to 
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date, including 37 patients with ALL, 50 with NHL, and 16 with CLL. Of 29 evaluable ALL patients, 27 (93%) 
achieved a complete remission. The defined subset approach facilitated analyses that defined response 
and toxicity relationships with cell dose as well as rates of T cell expansion. Toxicities were also dependent 
on the tumor burden, particularly in ALL. For patients with lymphoma, the overall response rate was 63%. 
For patients conditioned with cyclophosphamide +/- etoposide, the complete response rate was only 
1/12, but among patients who were treated with fludarabine-containing lymphodepletion regimens (see 
below), the CR rate improved to 50%, with an overall response rate of 73%. It should be noted that this 
regimen was not without toxicities. Four of 32 NHL patients and 7 of 30 ALL patients developed severe 
cytokine release syndrome requiring ICU-level care, and approximately 50% of patients had mild-
moderate cytokine release syndrome. Neurotoxicity was also prevalent, with 15 of 30 ALL and 28% of NHL 
patients developing grade ≥ 3 toxicities.  
 
One limitation of this study was initially short persistence of the infused CAR T cells, due to host cellular 
immune responses mounted against transgenic peptides. Epitope mapping studies indicated that immune 
responses were predominantly against epitopes derived from the murine scFv domain. The addition of 
fludarabine to the conditioning regimen has significantly reduced the incidence of transgene rejection and 
has resulted in improved CAR T cell expansion and persistence.90 
 
1.2.18 The role of lymphodepletion in promoting proliferation and expansion of genetically modified 
T cells in vivo. 
Studies in mice and humans have revealed an intricate homeostatic system that controls the numbers of 
T lymphocytes in the body.112,113 Though details of this feedback regulatory system are still under 
investigation, concentrations of IL-2, IL-7, IL-15, and perhaps IL-21 appear to be important.81,113 As a result 
of this feedback homeostatic regulation, the proliferation, persistence, and expansion of adoptively 
transferred anti-tumor T cells is restricted in the presence of large numbers of endogenous T cells which 
compete for these trophic T cell cytokines. Conversely, expansion of infused T cells is augmented if 
endogenous T cells are depleted prior to T cell therapy, presumably due to availability of higher 
concentrations of IL-2, IL-7, IL-15, and IL-21.114,115  One such approach is chemotherapy-mediated 
lymphodepletion prior to adoptive T cell infusion.115-117 Specifically, the homeostatic system and the tumor 
microenvironment may be modulated to be more favorable for adoptively transferred tumor targeted T 
cells through lymphodepleting chemotherapy with cyclophosphamide and/or fludarabine.90,115-119 
Reduction of endogenous CD4+CD25+ regulatory T cells is an additional expected advantage, since Treg 
cells suppress the anti-tumor effects of adoptively transferred effector T cells. Investigators at the NCI 
have demonstrated impressive persistence of tumor-specific T cells for many months after using a 
lymphodepletion regimen of cyclophosphamide prior to infusion of ex vivo expanded tumor infiltrating T 
cells isolated from melanoma patients.120  
 
In the ongoing CD19 CAR T cell trial at Fred Hutch, Drs. Maloney and Turtle initially used lymphodepletion 
with high-dose cyclophosphamide (CY) with or without etoposide. Initially, patients who were re-treated 
with a second infusion of T cells had poor expansion of T cells, and this was found to be to the result of 
cellular immune responses directed against the transgene. Consequently, fludarabine was added to the 
regimen, with most patients receiving a regimen of CY 60 mg/kg followed by 3 days of fludarabine 25 
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mg/m2/day. Patients who were lymphodepleted with fludarabine-containing regimens had significantly 
higher IL-7 and IL-15 levels in the serum, better persistence and expansion of CAR T cells, and better 
complete response rates as noted above. Furthermore, patients who received 2nd infusions of CAR T cells 
also had good expansion and persistence and the rate of anti-transgene immune responses appeared to 
be significantly lower. 
 
1.2.19 
Summary 
We therefore plan to test autologous T cells modified with a fully human 3rd-generation anti-CD20 CAR 
lentiviral vector, manufactured using CD4+ to CD8+ T cells combined at a defined ratio at culture initiation, 
in patients with relapsed or refractory lymphoma and CLL patients. 
   
 
2 
OBJECTIVES 
 
2.1 
Primary Objective 
To estimate the maximum tolerated dose (MTD) of adoptive cellular immunotherapy using ex vivo 
transduced and expanded autologous T cells expressing a 3rd-generation fully human CD20-specific 
chimeric antigen receptor (CAR) in patients with relapsed or refractory CD20+ B-NHL or CLL/SLL. 
 
2.2 
 Secondary Objectives 
2.2.1 
To evaluate the safety and toxicity associated with CD20 CAR T cell infusions. 
2.2.2 
To evaluate preliminary antitumor activity of adoptively transferred T cells in patients with 
measurable tumor burden prior to treatment as measured by overall response rate (ORR) and 
complete remission (CR) rate.  
2.2.3 
To evaluate progression-free survival (PFS) and overall survival (OS) among patients treated with 
adoptively transferred CD20-specific T cells. 
 
2.3 
 Tertiary Objectives 
2.3.1 
To evaluate baseline tumor characteristics predictive of response or treatment resistance. 
2.3.2 
To evaluate mechanisms of treatment failure in patients who relapse or do not respond, including 
both T cell- and tumor-related factors. 
2.3.3 
To evaluate the duration of in vivo persistence of adoptively transferred CD20-specific T cells. 
2.3.4 
To evaluate the trafficking of transferred CD20-specific T cells to tumor sites, lymph nodes, and 
bone marrow, and to evaluate their immunophenotypes. 
2.3.5 
To assess development of endogenous anti-tumor responses and epitope spreading. 
2.3.6 
To evaluate the development of host immune responses against the CD20 CAR T cells in patients. 
 
 
3 
SUBJECT SELECTION  
Please note: All potential study candidates will have an initial clinic visit and will sign a 
screening consent that includes all the screening procedures described in section 8.1., 
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including tumor biopsy. The following eligibility criteria will be evaluated after the screening 
stage, prior to study enrollment, which occurs just prior to leukapheresis (as defined in 
Section 4.1.3).   
 
3.1 
Inclusion Criteria  
3.1.1 
Patients must have B-cell non-Hodgkin lymphoma or chronic lymphocytic leukemia/small 
lymphocytic lymphoma. Eligible lymphoma subtypes include (but are not limited to): mantle cell, 
follicular, lymphoplasmacytic, marginal zone, transformed indolent B cell lymphoma (including 
transformed CLL), or diffuse large B cell lymphoma that has relapsed after a response to at least 
one prior therapy regimen or is refractory to prior therapy. Patients with mantle cell lymphoma 
must have previously been treated with a BTK inhibitor and have either had disease progression, 
intolerance, or exposure to the drug for at least 3 months. Patients with CLL/SLL are eligible if they 
had disease progression or intolerance to BTKis and/or a BCL-2 inhibitors. They are also required 
to have been treated with the other agent for at least 3 months (i.e. patients with 
progression/intolerance to BTKi need to be treated with a BCL-2 inhibitor for at least 3 months, 
and patients with progression/intolerance to BCL-2 inhibitor need at least 3 months of exposure 
to a BTKi).  
 
Patients with de novo DLBCL must meet one of the following criteria: 
a. Biopsy-proven refractory disease after a frontline regimen containing both an 
anthracycline and rituximab or other anti-CD20 antibody (i.e. “primary refractory”), 
where any disease recurring within 6 months of completion of the regimen is considered 
refractory. 
b. Relapsed or refractory disease after at least one of the following: 
i. 
At least 2 lines of therapy (including at least one with an anthracycline and anti-
CD20 antibody) 
ii. 
Autologous stem cell transplant 
iii. 
Allogeneic stem cell transplant 
3.1.2 
Patients with large cell lymphoma transformed from indolent lymphomas are eligible if 
previously treated with anthracycline-containing regimen for either the indolent or large cell 
histology. 
3.1.3 
Patients with CNS lymphoma need to meet one of the following criteria: 
Primary CNS lymphoma: 
a. Progressive disease after 3 cycles or an inadequate response after at least 4 cycles of a 
high-dose methotrexate (MTX) containing regimen in the opinion of the treating 
physician, OR  
b. Not eligible for MTX therapy due to comorbidities or tolerance issues per treating 
physician, OR 
c. Recurrent disease after an initial response to MTX-based treatment. 
Secondary CNS lymphoma 
a. An inadequate response to at least 2 cycles of a MTX containing regimen, OR 
b. Recurrent disease after an initial response to MTX-based treatment. 
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3.1.4 
Patients must be 18 years of age or older, of any gender, race or ethnicity. 
3.1.5 
Patients must be capable of understanding and providing a written informed consent.  
3.1.6 
Negative serum pregnancy test within 2 weeks before enrollment for women of childbearing 
potential, defined as those who have not been surgically sterilized or who have not been free of 
menses for at least 1 year. 
3.1.7 
Fertile male and female patients must be willing to use an effective contraceptive method before, 
during, and for at least 4 months after the CAR T cell infusion.  
3.1.8 
Patients must have a Karnofsky performance status (KPS) of ≥ 60%. Patients with CNS lymphoma 
with KPS of ≥ 50% are eligible if performance status is low because of the active lymphoma. 
3.1.9 
Confirmation of diagnosis by internal pathology review of initial or subsequent biopsy or other 
pathologic material at Fred Hutch/UW/HMC.  
3.1.10 Evidence of CD20 expression by immunohistochemistry or flow cytometry on the tumor specimen 
obtained with the biopsy performed with screening. If the CD20 expression on the screening 
tumor biopsy is unclear or could not be assessed due to technical reasons, CD20 expression on a 
concomitant tumor specimen (such as marrow biopsy or circulating tumor cells) may be used to 
satisfy this requirement. For CLL/SLL and lymphoplasmacytic lymphoma/Waldenström 
macroglobulinemia (WM) patients, a peripheral blood or bone marrow specimen will suffice to 
document CD20 expression for eligibility purposes. For patients with CNS lymphoma, a screening 
tumor biopsy is not required and evidence of CD20 expression can be documented from a 
previous biopsy.  
3.1.11 Patients must have acceptable organ function, as defined as: 
a. Serum creatinine ≤ 2.5. 
b. Total bilirubin ≤ 3.0 mg/dL (except in patients with a confirmed Gilbert’s syndrome by 
genetic test), AST and ALT ≤ 5x the upper limit of normal. 
c. Adequate pulmonary function, defined as ≤ grade 1 dyspnea and SaO2 ≥ 92% on room air. 
If PFTs are performed based on the clinical judgment of the treating physician, patients 
with FEV1 ≥ 50% of predicted and DLCO (corrected) of ≥ 40% of predicted will be eligible. 
d. Adequate cardiac function, defined as left ventricular ejection fraction (LVEF) of ≥ 50% as 
assessed by echocardiogram or MUGA scan, or LVEF of 45-49% and clearance by a 
cardiologist. 
3.1.12 Measurable disease that can be accurately measured in at least one dimension as ≥ 1.5 cm with 
CT, ultrasound, or MRI techniques. Extranodal disease that is measurable by FDG-PET imaging 
only will also be allowed. Note that if an excisional biopsy was performed that removed the sole 
site of measurable disease, the patient will not be eligible for leukapheresis and generation of 
CAR T cell product. 
3.1.13 For patients with CNS lymphoma, a lesion ≥ 1 cm on brain or spine MRI is required.  
3.1.14 Patients with WM without radiologic evidence of disease are eligible if they have measurable 
disease, as defined by serum monoclonal M-spike of ≥ 0.5 g/dL.  
3.2 
Exclusion Criteria  
3.2.1 
Active autoimmune disease requiring systemic immunosuppressive therapy. 
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3.2.2 
Patients requiring corticosteroid therapy at a dose of 15 mg or more per day of prednisone or 
the equivalent.  Pulsed corticosteroid dose for disease control is acceptable. 
3.2.3 
Patients who are HIV seropositive.  
3.2.4 
Women who are pregnant or breastfeeding.  
3.2.5 
Significant cardiovascular diseases within the past 6 months including uncontrolled congestive 
heart failure (>NYHA class II), myocardial infarction, unstable angina, or uncontrolled arrhythmia.  
3.2.6 
History of severe immediate hypersensitivity reaction to cyclophosphamide or fludarabine. 
3.2.7 
History or presence of clinically relevant non-lymphoma central nervous system pathology, 
including seizures that are uncontrolled on anticonvulsant therapy (≥ 1 seizure in the last year), 
paresis, aphasia, stroke, severe brain injuries, dementia, Parkinson disease, cerebellar disease, 
or psychosis.  
3.2.8 
Treatment with any investigational agent on a different clinical trial within 4 weeks prior to 
enrollment, unless the patient is documented to be unresponsive to the therapy and at least 3 
half-lives have elapsed prior to enrollment.  
3.2.9 
Treatment with any anti-CD19 or anti-CD20 antibody or antibody-drug conjugate therapy within 
4 weeks before enrollment.   
3.2.10 
Previous treatment with CD19-targeted CAR T cells that has resulted in ongoing B cell aplasia at 
the time of enrollment. Patients that demonstrate recovery of normal B cells (≥ 20 B cells/μl) by 
flow cytometry at any point 28 days or later after CD19 CAR T cell infusion will be considered to 
have functional loss of CD19 CAR T cells and are potentially eligible. 
3.2.11 
Patients with systemic disease without radiologic evidence of CNS involvement and with isolated 
CSF involvement detectable by flow cytometry are eligible for enrollment in systemic disease 
cohorts if neurologically asymptomatic. CSF involvement is not an exclusion for patients enrolled 
as primary or secondary CNS lymphoma. 
3.2.12 
Presence of active acute or chronic GVHD. 
3.2.13 
Uncontrolled active infection (bacterial, fungal, viral, mycobacterial) not responding to 
treatment with intravenous antibiotics, antiviral or antifungal agents.  
3.2.14 
Patients with concurrent known additional malignancy that is progressing and/or requires active 
treatment. Exceptions include squamous or basal cell carcinoma of the skin and low grade 
prostate carcinoma (Gleason grade ≤ 6). Maintenance anti-hormone therapies for breast or 
prostate cancers are allowed and are not considered active treatment.  
3.2.15 
Patients with blood or platelet transfusion within 1 week prior to signing Consent A, or with 
platelets < 50,000/mm3, neutrophils < 750/mm3, or hemoglobin < 8.5 g/dL, unless the cytopenias 
are considered by the treating physician to be largely due to marrow involvement by their B-cell 
malignancy.  
 
3.3 
Eligibility for Lymphodepletion Chemotherapy  
3.3.1 
Absence of uncontrolled active infection (bacterial, fungal, viral, mycobacterial) not responding 
to treatment with antibiotics, antiviral agents, or antifungal agents. 
3.3.2 
Absence of active autoimmune disease requiring ongoing systemic immunosuppressive therapy. 
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3.3.3 
Negative serum pregnancy test within 2 weeks before lymphodepletion chemotherapy for 
women of childbearing potential, defined as those who have not been surgically sterilized or who 
have not been free of menses for at least 1 year. 
3.3.4 
No treatment with any investigational agent on a different clinical trial between enrollment and 
lymphodepleting chemotherapy. 
3.3.5 
Patients must have acceptable organ function, as defined as: 
a. Serum creatinine ≤ 2.5. 
b. Total bilirubin ≤ 3.0 mg/dL, AST and ALT ≤ 5x the upper limit of normal. 
c. Adequate pulmonary function, defined as ≤ grade 1 dyspnea and SaO2 ≥ 92% on room air. 
If PFTs are performed based on the clinical judgment of the treating physician, patients 
with FEV1 ≥ 50% of predicted and DLCO (corrected) of ≥ 40% of predicted will be eligible. 
d. Adequate cardiac function, defined as left ventricular ejection fraction (LVEF) of ≥ 50% as 
assessed by echocardiogram or MUGA scan, or LVEF of 45-49% and clearance by a 
cardiologist. If subject receives cardiotoxic chemotherapy after enrollment, repeat 
echocardiogram or MUGA is required to reestablish eligible LVEF.  
3.3.6 
Patients must have a Karnofsky performance status of ≥60%. Patients with CNS lymphoma with 
KPS of ≥ 50% are eligible if performance status is low because of the active lymphoma. 
3.3.7  Measurable disease that can be accurately measured in at least one dimension as ≥ 1.5 cm with CT, 
ultrasound, or MRI techniques. Extranodal disease that is measurable by FDG-PET imaging only will 
also be allowed. Note that if an excisional biopsy was performed that removed the sole site of 
measurable disease, the patient is not eligible for lymphodepletion and CAR T cell infusion. 
Measurable disease can be based on the imaging study done during the screening unless the patient 
received treatment in the interim, in which case imaging should be repeated. For patients with CNS 
lymphoma, a lesion ≥ 1 cm on brain or spine MRI is required. Patients with WM without radiologic 
evidence of disease are eligible if they have measurable disease, as defined by serum IgM level ≥ 
0.5 g/dL.  
3.3.8  Patients must require no corticosteroid therapy or dose of less than 15 mg per day of prednisone 
or the equivalent.  Pulsed corticosteroid dose for disease control is acceptable until the day before 
the start of lymphodepletion. 
3.3.9  Patients must have no active acute or chronic GVHD. 
 
4 
   STUDY DESIGN 
This is a phase I/II, open-label, non-randomized study. We plan to treat 50 DLT-evaluable patients with 
CD20+ relapsed or refractory B-cell NHL or CLL/SLL. Each treated patient will undergo a tumor biopsy, 
leukapheresis, lymphodepletion chemotherapy, and adoptive transfer of autologous T cells modified with 
a CD20-CAR.  
 
4.1 Overview of the Screening and Enrollment Process 
4.1.1 
Following arrival to the immunotherapy service, patients will have an arrival conference with the 
Immunotherapy Attending Physician, who will provide an overview of the treatment process, and 
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then patients will sign the screening consent that includes screening evaluations, restaging, bone 
marrow biopsy, and tumor biopsy (see Section 8.1). 
4.1.2 
If patients are determined to be ineligible or do not proceed to leukapheresis, they will be 
documented as a screen failure per Section 10.1.  
4.1.3 
If, after undergoing screening evaluations, patients meet all eligibility criteria outlined in Sections 
3.1 and 3.2 they will have a data review conference during which they will sign the consent form 
for leukapheresis, lymphodepleting chemotherapy, and T cell infusion (Consent A), at which point 
they will be considered enrolled. They will then proceed with leukapheresis and generation of a 
CD20 CAR T cell product. If a patient is unable to collect cells or generation of T cells is 
unsuccessful, they will be considered off-study. 
4.1.4 
Prior to lymphodepleting chemotherapy patients should have another brief conference with the 
attending physician, who will re-review the risks of chemotherapy and T cell infusions that were 
discussed with the patient at the data review conference. No written consent will be obtained at 
this conference unless re-consent is required.  
4.1.5 
Once patients meet criteria outlined in Section 3.3, they will proceed with lymphodepletion 
chemotherapy and T cell infusion as outlined in Section 7. 
 
5 
INFORMED CONSENT OF SUBJECTS 
Subjects will be referred to the Fred Hutch by their primary care hematologists or oncologists for 
consideration of this protocol and will be completely evaluated.  The protocol should be discussed 
thoroughly with the subject and other family members if appropriate, and all known and potential risks 
should be described. The procedures (including tumor biopsies, leukapheresis, lymphodepletion, and T 
cell infusion) and alternative forms of therapy should be presented as objectively as possible, and the risks 
and hazards explained. Consent will be obtained using forms approved by the Institutional Review Board 
of the Fred Hutchinson Cancer Center (Fred Hutch). Two consent forms will be used: 1) a screening 
consent to collect serum specimens for screening eligibility testing (HIV, and hepatitis B and C), perform 
restaging studies, obtain a blood sample to screen for circulating T cells, a tumor biopsy and bone marrow 
biopsy, and 2) a main study consent form that describes the research study procedures and risks for 
leukapheresis, lymphodepletion chemotherapy, T cell infusion, and study-related evaluations. A summary 
of the clinic visit detailing what was covered should be dictated for the medical record. 
 
6   
SUBJECT REGISTRATION 
Potentially eligible subjects will be identified and registered into the system by the Clinical Coordinators 
Office (CCO) / Intake Office and assigned a UPN (Unique Patient Number). The CCO will register enrolled 
subjects on to the protocol through the Data Management Office.  
 
7 
PLAN OF TREATMENT 
 
7.1 
Overview 
As described in Figure 7.1, patients who sign the screening consent will undergo screening evaluations, 
including a tumor biopsy and restaging studies. Eligible patients will be enrolled into the study and 
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undergo leukapheresis. The PBMCs obtained by leukapheresis will be sorted to yield CD4 and CD8 T cells, 
which will be activated, transduced with CD20 CAR lentivirus, and expanded in the Good Manufacturing 
Practices (GMP)-compliant Cell Processing Facility at Fred Hutch. Prior to CAR T cell infusion, subjects will 
receive lymphodepletion chemotherapy intravenously (i.v.) ending 36-96 hours prior to T cell infusion. At 
7-16 days following T cell infusion, patients will be asked to undergo a second tumor biopsy (if safe and 
feasible). 
 
 
 
7.2 
Leukapheresis 
Each patient will undergo a leukapheresis procedure to obtain a sufficient quantity of peripheral blood 
mononuclear cells (PBMCs) to generate the CAR T cell product. Corticosteroid therapy (> 10 mg/day of 
prednisone or equivalent) should be avoided within 4 days of leukapheresis. The leukapheresis procedure 
will be performed by Fred Hutch staff, using standard operating procedures for obtaining PBMCs. Should 
a technical issue arise during the procedure or in the processing or manufacturing of the CAR T-cell 
product, or insufficient CD20 CAR T cells be manufactured for the prescribed CAR T cell dose, a second 
apheresis procedure may be performed. 
 
Patients ineligible for a vein-to-vein apheresis may elect to have a percutaneous central venous catheter 
placed to permit this collection. Patients ineligible for apheresis who have a hematocrit of at least 38% 
and a total non-malignant (normal) lymphocyte count of > 2000/mcl may undergo phlebotomy of 400 ml 
of blood to obtain PBMCs necessary for generation of the CAR T cells. This approach would only be taken 
in patients that would be enrolled at dose levels 0 (1 x 105 tCD19+ cells/kg), 1 (3.3 x 105 tCD19+ cells/kg) 
and 2 (1 x 106 tCD19+ cells/kg). 
 
Figure 7.1 Study Schema
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The leukapheresis or phlebotomy product will be delivered to the Cell Processing Facility (CPF) at the Fred 
Hutch and undergo CD4 and CD8 cell selection, processing, and quality release testing according to the 
procedures described under the Investigational New Drug (IND) application associated with this study. 
PBMCs from the leukapheresis or cell selection products may be archived for research.  
 
7.3 
Generation of CD20 CAR cells 
Patient-derived apheresis PBMC will be selected for CD4+ and CD8+ T cells, transduced with purified 
lentivirus encoding the CD20 CAR and truncated CD19 transduction marker, and expanded under Good 
Manufacturing Practice (GMP) conditions. The specific methods for generating the T cell product and the 
release tests are outlined in the IND application to the U.S. Food and Drug Administration (FDA). 
Modifications to the IND will be submitted to the FDA. A single T cell product consisting of combined CD4+ 
and CD8+ T cells will be prepared for each infusion according to protocols established in the GMP Cell 
Processing Facility and will be formulated to provide a cell product at the specified cell dose of CAR+ T 
cells, defined as the number of cells expressing the truncated CD19 transduction marker, which is 
expressed coordinately with the CAR in the vector. Cell products may either be infused fresh or following 
cryopreservation. Quality control and release testing will be performed on the CAR T cell product prior to 
its release for patient infusion. Investigational studies assessing phenotypic and functional status will also 
be performed on aliquots of expanded CAR T cells. Additionally, if cryopreserved T cells are available and 
deemed not to be needed for clinical use (for example, because a patient has died, or has already received 
an infusion, or is ineligible for infusion), these cells may be used for research purposes provided the 
patient has allowed use of “leftover tissues” for research in the consent form.  
 
7.3.1 
Products that cannot be formulated to meet target cell dose  
If a T cell product cannot be formulated to meet the target dose because of low transduction efficiency or 
suboptimal cell growth, the cell product should be infused at or as close to possible to the specified total 
CAR T cell dose. The minimum acceptable number of cells that may be infused is 5 x 104 tCD19+ cells/kg.  
Patients receiving cell products that do not meet ≥ 85% of the target dose specification will not be 
considered evaluable for the safety analysis in the assigned dose cohort for the purposes of the CRM 
design (as described in Section 12) to escalate to the next dose level (though a DLT occurring in such a 
patient would still count towards dose de-escalation—see Section 12.4), and a replacement subject will 
be added to the cohort. However, if such a patient receives a dose that meets the specification for a lower 
dose level, they would be considered evaluable for inclusion of the safety analysis for that dose level.  
  
 
7.4 
Cytoreductive chemotherapy 
Patients may receive treatment after leukapheresis to control disease during production of CD20 CAR T 
cells. Decisions regarding chemotherapy in this interval should be discussed with the study PI. Treatment 
with any investigational agent on a clinical trial or with any agent targeting CD19 or CD20 is not allowed.  
 
7.5 
Lymphodepletion chemotherapy 
Patients will receive lymphodepleting chemotherapy, which will be scheduled to be completed 36-96 
hours prior to the anticipated infusion of CD20 CAR T cells. The goals of administering chemotherapy are 
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to provide lymphodepletion to facilitate survival of transferred T cells, and to reduce the tumor burden 
prior to infusion of CD20 CAR T cells. As outlined in the statistical considerations (Section 12), patients 
were initially treated with a single dose of cyclophosphamide (CY) i.v. 1 g/m2. However, the response rate 
with CY only in the first 4 patients treated on this protocol was inadequate in order to continue this 
regimen (as per Table 12.3). The lymphodepleting regimen was changed to CY + fludarabine, as outlined 
in Table 12.3. Patients should be treated with cyclophosphamide 300 mg/m2 IV on days 1-3 and 
fludarabine 30 mg/m2 IV on days 1-3 and should be scheduled for T cell infusions starting 36-96 hours 
after the last dose of chemotherapy. For patients with impaired renal function, please refer to the 
fludarabine package insert for dose modifications.  Alternative lymphodepletion regimens can be 
considered after discussion with the PI if CY + fludarabine is considered clinically inappropriate (such as in 
the case of prior allergy, drug intolerance or other medically significant reason) or if one or both drugs are 
not available. A preferred alternative lymphodepleting regimen is bendamustine as a single agent given 
at the dose of 90 mg/m2/day for 2 days, typically on days -4 and -3 before CAR-T infusion.  
 
Bendamustine is a chemotherapeutic agent with both alkylating and purine analog activities. 
Bendamustine has been utilized as one of the options for lymphodepletion (LD) before autologous CAR-T 
therapy. In the JULIET study, which was a registration trial that led to the approval of tisagenlecleucel for 
patients with diffuse large B-cell lymphoma after two prior lines of therapy, 20% of patients received 
bendamustine for lymphodepletion.121 It was given at the dose of 90 mg/m2 for 2 days on days -4 and -3 
before CAR-T infusion. Response to CAR-T treatment was not different based on the type of 
lymphodepleting regimen (cyclophosphamide and fludarabine [CY-Flu] versus bendamustine). Similarly, 
the ELARA trial for patients with relapsed refractory follicular lymphoma allowed for the use of 
bendamustine as one of the lymphodepletion options.122 Bendamustine is currently included in the 
prescribing information for tisagenlecleucel.123  
 
In a multicenter retrospective study, investigators at the University of Pennsylvania, Oregon Health and 
Science University, and the Medical University of Vienna compared the safety and efficacy of CAR-T 
therapy with tisagenlecleucel between patients who received CY-Flu vs. bendamustine for 
lymphodepleting regimen.124 They reported similar efficacy between the two groups. They also observed 
lower rates of cytokine release syndrome, neurotoxicity, and hematologic toxicities with bendamustine. 
There were also fewer episodes of infections, febrile neutropenia, and post-CAR-T hospitalization in the 
bendamustine cohort. The authors reported that the regimen was commonly used in their practices. 
 
In 2021 and with the unexpected national shortage of fludarabine in the United States, the use of 
bendamustine as the lymphodepleting regimen was recommended by a panel of experts to avoid delay in 
delivering potentially life-saving treatments to patients in need of CAR-T therapy.125 In a single-institution 
study conducted by the Stanford group, bendamustine was used for lymphodepletion before 
axicabtagene ciloleucel. The results of this study will be presented at the Annual meeting of the American 
Society of Hematology (ASH) in December 2022. Per verbal communication with the study’s principal 
investigator, CAR-T expansion was comparable to what is seen in the post CY-Flu setting and there was no 
concerning signal for safety or efficacy.  
 
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7.6 
CAR T cell infusion 
There must be at least a 36-hour interval between the last dose of chemotherapy and the T cell infusion.   
 
On the day of scheduled T cell infusion the patients should undergo a clinical evaluation and a clinical 
determination for appropriateness to proceed with CAR-T cell administration. 
 
Patients who receive lymphodepleting chemotherapy but are deemed not clinically appropriate for the T 
cell administration or who were unable to undergo CAR-T cell infusion due to CAR-T cell manufacturing or 
release issues may be eligible to receive the T cell infusion outside the 36-96 hour window, for up to 14 
days after the end of the 36-96 hour window, if clinical concerns and problems with manufacturing or 
release criteria are resolved. Discussion with the study PI is required for dose delay or need for repeat 
lymphodepletion chemotherapy. Patients who receive CAR-T cell infusion more than 14 days after 
lymphodepletion will not be considered DLT-evaluable for the purposes of dose escalation.  
 
7.7 
CD20 CAR T cell dose 
Dosing will be based on transduced cell number, as determined by tCD19 expression. The starting dose 
will be dose level 1 (3.3 x 105 tCD19+ cells/kg), and dose escalation/de-escalation will occur as described 
under Section 12.4. 
 
Table 7.2: Dose Levels to be used (see Section 12.4 for further explanation of dose escalation) 
Dose level 
CD20 CAR T Cell Dose 
0
1 x 105 tCD19+ cells/kg (± 15%)
1 (starting dose)
3.3 x 105 tCD19+ cells/kg (± 15%)
2
1 x 106 tCD19+ cells/kg (± 15%)
3
3.3 x 106 tCD19+ cells/kg (± 15%)
4
1 x 107 tCD19+ cells/kg (± 15%)
 
These cell doses are lower than the doses used by us and others in previous T cell protocols with CARs 
and in the same range as those in current CAR trials led by Drs. Riddell, Turtle, and Maloney.83,126 (Our two 
previous CAR trials administered three infusions per patient with escalating doses of 108, 109 and 3.3 x 109 
cells/m2 given 2-5 days apart.)  The current trial utilizes lower cell doses for safety reasons since the T cells 
used in this trial are expected to be more potent due to higher CAR expression and shorter in vitro 
incubation times. Cell dose modifications may be required for toxicities or technical difficulties.   
 
7.8 
     Cell administration 
Each patient will receive a single intravenous infusion of CD20 CAR T cells between 36-96 hours following 
completion of lymphodepleting chemotherapy.  At least the first patient treated at each dose level will be 
admitted to the Institute of Translational Health Sciences Clinical Research Center at the University of 
Washington Medical Center for the T cell infusion. 
 
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Vital signs: All patients will be monitored during the T cell infusion. Vital signs (including oxygen 
saturation) should be recorded before infusion, approximately every 15 minutes during the infusion, and 
approximately hourly for 2 hours after the infusion. Subjects will remain in the infusion unit for a minimum 
of 2 hours following infusion, or until resolution of any infusion-related toxicity deemed to pose a 
significant risk to the study subject as an outpatient.  
 
Infusion rate: Each cell infusion should be administered intravenously over approximately 20-30 minutes, 
adjusted as needed to comply with guidelines for endotoxin limits for parenteral drugs ( 5 EU/kg/hour). 
The infusion rate can also be adjusted if subjects experience mild infusion-related adverse events (grade 
2 or lower). 
       
7.9 
Recommended Supportive Care, Additional Treatment, and Monitoring 
Patients at risk for tumor lysis syndrome based on the judgment of the treating physician should receive 
prophylactic measures per institutional or clinical standards. Supportive care for the management of 
cytokine release syndrome is detailed in Section 9.1.3. Transfusion of red blood cells or platelets, and/or 
use of myeloid growth factors is permitted per institutional or clinical standards. Administration of daily 
G-CSF after T cell infusion until absolute neutrophil count is > 1000/μl should be considered. 
 
The use of prophylactic or empiric antibiotics such as trimethoprim/sulfamethoxazole for pneumocystis 
pneumonia prophylaxis, broad spectrum antibiotics, antifungals, or antiviral agents is permitted per 
institutional standards. 
 
The following should be considered for infection prophylaxis, as clinically indicated: 
1) Antibiotic (such as a quinolone): while neutropenic. 
2) Antifungal: start fluconazole on the day of CAR T cell infusion and continue for approximately 
21 days. 
3) Antiviral: start before chemotherapy and continue for 3-6 months after CAR T cell Infusion. 
4) Pneumocystis jiroveci pneumonia (PJP) prophylaxis (e.g. trimethoprim/sulfamethoxazole): 
start approximately day 21 after CAR T cell infusion and continue until 3-6 months after 
infusion.  
Patients with a history of seizures or history of CNS involvement by lymphoma should receive prophylactic 
treatment with anticonvulsants (levetiracetam or similar) following CAR T cell infusion for approximately 
4 weeks. 
 
8 
PATIENT EVALUATION 
 
8.1 
Screening evaluations (should be performed within 30 days of enrollment unless 
otherwise specified) 
 
Please note that results of tests and procedures conducted as per standard of care purposes prior to 
screening may be used for research purposes if conducted within the protocol-defined window.  
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The screening consent and HIPAA authorization must be signed before any non-standard of care 
evaluations are performed. 
 
8.1.1 
Medical history and physical examination, including prior therapies and response to therapy, if 
known, and Karnofsky performance status. 
8.1.2 
Laboratory tests, including: 
a. CBC, differential, platelet count 
b. Basic metabolic panel 
c. Hepatic function panel with LDH 
d. Fred Hutch (PSBC) Donor Battery Panel (should be performed within 30 days of leukapheresis) 
e. 2 microglobulin level 
f. 
Serum ferritin 
g. Serum CRP 
h. Uric acid 
i. 
Phosphate 
j. 
Serum IL-6 
k. Quantitative serum immunoglobulin levels (IgG, IgA, IgM) 
l. 
Serum protein electrophoresis and immunofixation (for patients with WM) 
m. Prothrombin time (PT), partial thromboplastin time (PTT) 
n. Serum pregnancy test for females of childbearing potential within 14 days of  enrollment 
8.1.3 
Confirmation of diagnosis by internal pathology review of initial or subsequent biopsy or other 
pathologic material at the Fred Hutch/UW/HMC 
8.1.4 
Baseline chest x-ray  
8.1.5 
Baseline pulse oximetry and documentation of O2 saturation on room air 
8.1.6 
Baseline 12-lead EKG 
8.1.7 
Echocardiogram or MUGA scan 
8.1.8 
Flow cytometric analysis for B cell quantitation and screening for circulating lymphoma 
cells/minimal residual disease (MRD) to Fred Hutch Hematopathology.   
8.1.9 
A CT scan (preferably diagnostic quality) and, if possible, a PET scan should be performed to 
evaluate disease status. If a PET/ CT is not performed then the CT scan must be of diagnostic 
quality.  Imaging studies may be omitted in patients who have had recent imaging within 42 days 
before enrollment AND have not received anti-tumor therapy in the interim. Imaging should be 
performed prior to tumor biopsy (Section 8.1.13) in patients without palpable adenopathy. For 
patients with palpable adenopathy, the PET-CT scan may be performed after leukapheresis unless 
needed to confirm the presence of measurable disease.  
8.1.10 MRI of the brain and spine with and without contrast (for CNS lymphoma patients only) 
8.1.11 A unilateral bone marrow biopsy and aspirate should be performed, with pathology and flow 
cytometry. PCR for IgH clonality and/or FISH and other molecular studies may be performed as 
indicated by the disease. This may be omitted if another bone marrow biopsy was performed 
within 42 days of enrollment AND the patient has not received anti-tumor therapy in the interim. 
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8.1.12 Lumbar puncture with CSF evaluation is required for any patient with a history of CNS disease or 
signs or symptoms of CNS or epidural disease. This may be omitted if a lumbar puncture 
performed within 42 days of enrollment did not show evidence of CNS disease. 
 
Research samples: 
8.1.13 RESEARCH tumor biopsy (within 30 days prior to enrollment): 
Patients will be asked to undergo either an imaging-guided biopsy or excisional biopsy.  
Radiologic-guided biopsies should be core needle biopsies, if possible the equivalent of 6-8 cores, 
1 cm in length, using a 16-18 gauge needle, as well as 2-4 fine-needle aspirates (FNAs). All biopsy 
cores (or excisional biopsy tissue) and FNAs should be placed in RPMI medium and sent directly 
to the Fred Hutch pathology lab for processing via a dedicated STAT courier. A portion of the tissue 
will be submitted for clinical evaluation and assessment of CD20 expression by flow cytometry 
and/or immunohistochemistry (IHC), and the remainder will be used for correlative research 
assays such as gene expression profiling and analysis of immune cell subsets by flow cytometry. If 
adequate tissue is obtained, archival tumor cells may also be taken and cryopreserved for future 
studies. The tumor biopsy is optional for patients with primary or secondary CNS lymphoma, and 
for CLL/SLL and WM patients who have bone marrow or peripheral blood involvement. 
8.1.14 Lumbar puncture (for primary and secondary CNS lymphoma patients). Clinical samples for cell 
count and flow cytometry should be collected, as well as a 2 ml research sample that should be 
sent to the Till Lab (D3-367). 
8.1.15 Immunophenotyping of CD3, CD4, and CD8 T cells: A 10 ml blood sample (in EDTA [lavender top] 
tube) should be sent to the Till Lab.  
8.1.16 PBMC Baseline Samples: A 60 ml blood sample (in EDTA [lavender top] tube) for research should 
be sent to the Specimen Processing/Research Cell Bank lab at the Fred Hutch for PBMC isolation 
and cryopreservation. These cells will be used as PBMC baseline samples for comparison to post-
treatment samples for all cellular correlative tests, including CAR T cell persistence and 
immunophenotype by flow cytometry or Q-PCR, B cell reconstitution (IGH, IGK, IGL, Bcl-2) or TCR-
β deep sequencing (Adaptive Biotechnologies) assays, assessment of anti-transgene and anti-
tumor immune responses. 
8.1.17 Baseline serum: A 20 ml blood sample (serum separator tube) should be sent to the Specimen 
Processing/Research Cell Bank lab at the Fred Hutch to be used as serum baseline to assess anti-
transgene and anti-tumor immune responses. These tests may be performed depending on tumor 
response and CAR T cell persistence. 
8.1.18 Serum cytokine levels: A 10 ml blood sample (serum separator tube) should be obtained for 
measurement of serum cytokine levels and sent as soon as possible to the Specimen 
Processing/Research Cell Bank lab at the Fred Hutch.  
8.1.19 PBMC Archive Specimens: A 30 ml blood sample (in EDTA [lavender top] tubes) should be sent to 
the Specimen Processing/Research Cell Bank lab at the Fred Hutch for processing and 
cryopreservation as PBMC archive specimens for future correlative tests. 
8.1.20 Serum archival specimens: A 10 ml blood sample (serum separator tube) should be sent to the 
Specimen Processing/Research Cell Bank lab at the Fred Hutch for processing as serum archival 
specimens for future correlative tests. 
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8.1.21 Bone marrow aspirate: If a bone marrow biopsy is performed, then an additional 5-10 ml of 
marrow aspirate should be obtained and sent in EDTA [lavender top] tubes to the Specimen 
Processing/Research Cell Bank Lab at the Fred Hutch, as archival tissue for tumor cells and as 
baseline for assessing CAR T cell migration to tumor sites. For patients with CLL/SLL or WM who 
forego a tumor biopsy, an additional 3 ml bone marrow aspirate sample should be obtained in an 
EDTA [lavender top] tube and sent to the Till Lab (D3-367). 
8.1.22 Other biopsy or sample: If biopsy or sampling of tissues other than bone marrow (i.e. CSF, pleural 
fluid, etc.) is performed for clinical indications, then additional tissue may be obtained during the 
same procedure and sent to the Specimen Processing/Research Cell Bank Lab at the Fred Hutch 
for research studies. Please discuss the planned procedure with the study PI. 
8.1.23 RCL Testing: A 10 ml (EDTA/lavender top) blood sample should be collected as baseline for RCL 
testing and sent to the Specimen Processing Lab/ Research Cell Bank Lab at the Fred Hutch. 
 
 
8.2 
Evaluations prior to lymphodepleting chemotherapy (should be performed within 1 
week of initiation of lymphodepleting chemotherapy unless otherwise specified) 
8.2.1 
Interval history and physical exam (with documentation of Karnofsky performance status). 
8.2.2 
Laboratory evaluations:  
a. CBC, differential, and platelets 
b. Basic metabolic panel 
c. Hepatic function panel with LDH 
d. Serum ferritin 
e. Serum C-reactive protein (CRP) 
f. 
Uric acid 
g. Phosphate 
h. Serum protein electrophoresis with immunofixation (for WM patients who received 
interim therapy since baseline assessments) 
i. 
Serum pregnancy test for females of reproductive potential within 14 days prior to 
starting lymphodepleting chemotherapy 
8.2.3 
Research Labs: 
PBMC Archive Specimens: A 30 ml blood sample (in EDTA [lavender top] tubes) should be sent 
to the Specimen Processing/Research Cell Bank lab at the Fred Hutch for processing and 
cryopreservation as PBMC archive specimens for future correlative tests. 
8.2.4     Repeat imaging (CT or PET/CT, or brain/spine MRI for CNS lymphoma patients) is required in 
patients who received interim cytoreductive treatment. This can be performed any time after 
the completion of treatment and before initiation of lymphodepletion chemotherapy.  
8.2.5     Repeat assessment of LVEF (echocardiogram or MUGA) is required in patients who received 
cardiotoxic treatment with potential effect on the ejection fraction after enrollment. This can 
be performed any time between completion of the cardiotoxic therapy and initiation of 
lymphodepletion.  
 
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8.3 
Evaluations prior to T cell Infusion 
8.3.1 
Interval history and physical exam. 
8.3.2 
Blood draw for laboratory studies: 
a. CBC, differential, and platelets 
b. Basic metabolic panel 
c. Hepatic function panel with LDH  
d. Uric acid 
e. Phosphate 
f. 
Serum ferritin 
g. Serum CRP 
h. Serum IL-6 level 
i. 
DIC panel without platelets (PT, PTT, fibrinogen, D-dimer) 
8.3.3 
Research Labs: 
a. Serum cytokine levels: A 10 ml serum separator tube should be sent as soon as possible 
to the Fred Hutch Specimen Processing/Research Cell Bank lab for cryopreservation, to 
be used for measurement of serum cytokine levels. 
 
8.4 
Evaluations following T cell infusion 
The following evaluations will be performed after the T cell infusion.  
8.4.1 
Record new findings on history and physical exam 1 day after the T cell infusion and at least weekly 
for 4 weeks.  
8.4.2 
Karnofsky performance status should be recorded for the day 28 evaluation. 
8.4.3 
The following laboratory studies at least twice weekly for 2 weeks, then weekly until 4 weeks after 
the infusion: 
a. CBC, differential, and platelet count 
b. Basic metabolic panel 
c. Hepatic function panel with LDH 
d. Uric acid  
e. Phosphate 
f. 
C-reactive protein (CRP) 
g. Serum ferritin 
h. Serum IL 6 level 
i. 
DIC panel without platelets (PT, PTT, fibrinogen, D-dimer) 
8.4.4 
Additional time points for CBC with differential and platelet count: at 3, 6, and 12 months after 
the T cell infusion. These may be discontinued if patients proceed to other systemic anti-
lymphoma therapy. 
8.4.5 
If patients become febrile or develop symptoms of cytokine release or tumor lysis between the 
indicated time points, we may measure serum ferritin, CRP, DIC panel, and tumor lysis markers at 
additional times, as clinically indicated. 
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8.4.6 
Immunoglobulin levels 
a. Recommendations will be made to monitor IgG levels at day 28 (± 5 days), and 3, 6, and 
12 months after T cell infusion, and to administer intravenous immune globulin (IVIG) as 
clinically indicated for hypogammaglobulinemia.  
b. Serum IgG, IgA, and IgM levels may be measured at approximately 3 and 12 months after 
the T cell infusion in patients who develop B cell aplasia. 
8.4.7 
Serum protein electrophoresis with immunofixation (for WM patients only) at day 28 (± 5 days), 
and 3, 6, and 12 months after T cell infusion. 
8.4.8 
 Flow cytometry for MRD: Blood (5 ml in EDTA [lavender top] tube) should be sent to the Fred 
Hutch Hematopathology laboratory around day 28, and at approximately 3, and 6, and 12 months 
after the T cell infusion for measurement of minimal residual disease (MRD) by flow cytometry. 
Except for day 28 flow cytometry, which is required in all patients, the MRD tests will only be done 
at the above-mentioned time points if the prior test showed evidence of disease. This assessment 
may cease if the patient initiates other non-CAR T cell therapy. 
8.4.9 
Research tumor biopsy: between approximately 7 and 16 days following the T cell infusion, all 
patients with pathologic, palpable or radiologically accessible lymphadenopathy or extranodal 
solid tumor will be asked to undergo either an excisional or a core biopsy of the tumor site. The 
requirement for a tumor biopsy will be waived for patients who do not have a tumor site 
amenable to either excisional or core needle biopsy. The timing of the biopsy may be delayed to 
beyond day 16 if it is deemed unsafe due to clinical concerns such as cytopenias. The tumor biopsy 
is optional for patients with primary or secondary CNS lymphoma, and for CLL/SLL and WM 
patients who did not undergo a baseline tumor biopsy. 
8.4.10 Patients may also be asked to undergo a tumor biopsy at the time of relapse. 
a. 
Image guided biopsies: should be core needle biopsies, if possible the equivalent of 6-
8 cores, 1 cm in length, using a 16-18 gauge needle, as well as 2-4 FNAs, should be 
obtained. All biopsy cores and FNAs should be placed in RPMI medium and sent directly 
to the Fred Hutch pathology lab for processing via a dedicated STAT courier. A portion 
of the tissue will be submitted for clinical evaluation and assessment of CD20 
expression by flow cytometry and/or immunohistochemistry (IHC), and the remainder 
will be used for correlative research assays. One or more of the following tests will be 
performed, depending on the number of available tumor cells: gene expression 
profiling by RNA Seq and/or 10x Genomics single cell RNA-seq analysis, flow cytometry 
for CAR T cells, immune cell subsets, and CD20 expression, multiplex 
immunohistochemistry, and deep sequencing of the TCR-β locus (Adaptive 
Biotechnologies). If any tissue remains after the correlative tests, it may be banked for 
future studies. 
b. 
Excisional biopsies: the tissue should be placed in RPMI medium and sent directly to 
the Fred Hutch pathology lab for processing via a dedicated STAT courier. A portion of 
the tissue will be submitted for clinical evaluation and assessment of CD20 expression 
by flow cytometry and/or immunohistochemistry (IHC), and the remainder will be used 
for correlative research assays. One or more of the following tests will be performed, 
depending on the number of available tumor cells: gene expression profiling by RNA 
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Seq and/or 10x Genomics single cell RNA-seq analysis, flow cytometry for CAR T cells, 
immune cell subsets, and CD20 expression, multiplex immunohistochemistry, and deep 
sequencing of the TCR-β locus (Adaptive Biotechnologies). If any tissue remains after 
the correlative tests, it may be banked for future studies.  
c. 
Patients with CLL/SLL with suspected marrow relapse may have a bone marrow biopsy 
instead of a tumor biopsy. A core biopsy should be obtained and sent to the Fred Hutch 
pathology lab for clinical evaluation and assessment of CD20 expression by IHC. A 3 ml 
aspirate sample should be sent to University of Washington Hematopathology for 
clinical flow cytometry. An additional 3 ml aspirate sample should be sent in an 
EDTA/lavender tub to the Till Lab (D3-367), and a 5 ml aspirate sample should be sent 
in an EDTA/lavender tube to the Fred Hutch Specimen Processing/Research Cell Bank 
for storage for future studies as noted above. 
8.4.11 Patients achieving a partial or complete response who subsequently develop disease progression 
or suspected disease progression may be asked to undergo a research biopsy (optional) to 
understand the biological changes in the tumor after treatment that allowed tumor re-growth. 
Patients who were not able to undergo a day 7-16 biopsy or who had a biopsy but inadequate 
tissue was obtained, may also undergo an additional biopsy at the time of disease progression or 
suspected disease progression. The biopsy may be either an excisional biopsy or core needle 
biopsy. If the biopsy is being performed for clinical purposes, attempts should be made to acquire 
additional tissue for research purposes. Samples should be processed as described in 8.4.9. 
8.4.12 Bone marrow aspirate: For patients who had detectable lymphoma (by morphology, flow 
cytometry, or molecular testing) in the baseline bone marrow biopsy, a repeat bone marrow 
biopsy and aspirate will be performed at day 28 (± 5 days, with pathology and flow cytometry. 
PCR for IgH clonality and/or FISH and other molecular studies should be performed if positive at 
baseline. If a marrow biopsy is performed, an additional 5 ml in a lavender top tube may be sent 
to the Specimen Processing/Research Cell Bank Lab at Fred Hutch for research purposes (optional, 
see below). 
8.4.13 Lumbar puncture (for primary and secondary CNS lymphoma patients) at day 14 (± 3 days) and 
day 28 (± 5 days). Clinical samples for cell count and flow cytometry should be collected, as well 
as a 2 ml research sample that should be sent to the Till Lab (D3-367). Additional research samples 
may be obtained on any lumbar punctures that are done at later timepoints for clinical reasons. 
8.4.14 Research labs: 
a. Serum storage for measurement of serum cytokine levels 
i. 
Serum cytokine levels: A blood sample (up to 10 ml, serum separator tube) should be 
obtained on approximately days 1, 4, 7, 10, 14, 21, and 28 after the T cell infusion for 
measurement of select cytokine levels. Samples should be sent to the Specimen 
Processing/Research Cell Bank Lab at Fred Hutch. 
ii. 
If patients become febrile, develop signs of cytokine release syndrome, or cytokine 
assessment is clinically appropriate at times other than those indicated, we may 
measure cytokine levels at additional times. 
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b. Evaluation for persistence and phenotype of CD20 CAR T cells 
i. 
PBMC for CAR T cell persistence:  Blood samples (20 ml, EDTA [lavender top] tube) 
should be obtained on approximately days 1, 4, 7, 10, 14, 21, and 28 during the first 
month after the T cell infusion, and also at 3, 6, and 12 months after the T cell infusion 
for analysis of the persistence and phenotype of transferred T cells. Samples should 
be sent to the Specimen Processing/Research Cell Bank Lab at Fred Hutch. Additional 
samples may be collected at other times than those indicated, including beyond 12 
months, if required for evaluation of persistence of CAR T cells. Conversely, 
persistence monitoring may be discontinued beyond day 28 in patients who proceed 
to allogeneic stem cell transplantation and/or who do not have detectable transgene-
expressing T cells on two consecutive occasions. The cells from these blood samples 
may also be analyzed by multiparameter flow cytometry for the phenotype of 
persisting CAR T cells (optional). Markers that may be analyzed include CD19, CD4, 
CD8, CD62L, CCR7, CD28, CD27, CD127, PD1, Lag-3, Tim-3, and PD-L1.  
ii. 
If patients become febrile, develop possible signs of toxicity, or assessment of CAR T 
cell persistence is clinically appropriate at times other than those indicated, we may 
measure the persistence of transferred T cells at additional times. 
c. B-cell quantitation. Blood (5 ml in EDTA [lavender top] tube) should be sent to the Fred Hutch 
Hematopathology laboratory around day 28, and at approximately 3, and 6, and 12 months 
after the T cell infusion for B cell quantification by flow cytometry. B cell quantitation may be 
discontinued beyond day 28 in patients who proceed to other systemic therapy. 
d. B cell deep sequencing – A blood sample (10 ml EDTA [lavender top] tube) should be collected 
for the evaluation of MRD and B cell reconstitution by deep sequencing of the IGH and IGK/L 
loci (Adaptive Biotechnologies) around day 14, day 28, and at approximately 3, 6, and 12 
months. These samples should be sent to the Fred Hutch Specimen Processing/Research Cell 
Bank lab for processing. If a deficiency of B cells persists beyond 12 months or there are 
persisting CD20 CAR T cells, additional samples may be obtained to monitor B cell numbers 
every 6 months either with the Adaptive assay or by flow cytometry. B cell deep sequencing 
monitoring may be discontinued beyond day 28 in patients who proceed to other systemic 
therapy, or if CAR T cell engraftment is lost, or at the discretion of the PI. 
e. Evaluation of transgene immunogenicity – patients may develop immune responses against 
the transgene leading to rejection of the transferred T cells.  
i. 
Serum transgene immunogenicity: Serum (10 ml, serum separator tube) may be 
collected around day 28, and for patients in whom persistence of the CAR T cells is 
lost before day 30, at approximately 3 and 6 months after the T cell infusion. Collected 
serum will be banked for potential assessment of antibody or cellular immune 
responses against the transgene (optional). These samples should be sent to Fred 
Hutch Specimen Processing/Research Cell Bank. 
ii. 
PBMC transgene immunogenicity: PBMC (20 ml, EDTA [lavender top] tube) may be 
collected around day 28, and for patients in whom persistence of the CAR T cells is 
lost before day 30, at approximately 3 and 6 months after the T cell infusion. Collected 
PBMC will be banked for potential assessment of antibody or cellular immune 
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responses against the transgene (optional). These samples should be sent to Fred 
Hutch Specimen Processing/Research Cell Bank. 
f. 
Archival samples for future studies of T cell function 
i. 
PBMC archive specimens: Blood (30 ml, EDTA [lavender top] tubes) may be obtained 
from patients once between days 0 and 21 and once between days 22 and 90 after 
CD20 CAR T cell infusion, and at approximately 3, 6, and 12 months after the T cell 
infusion for archival purposes. Samples should be sent to the Specimen 
Processing/Research Cell Bank lab at Fred Hutch for processing and cryopreservation 
as PBMC archive specimens. 
ii. 
Serum archive specimens: Serum (up to 10 ml, serum separator tube) may be 
obtained from patients at approximately 3, 6, and 12 months after the T cell infusion 
for archival purposes. Samples should be sent to the Specimen Processing/Research 
Cell Bank lab at Fred Hutch for processing and cryopreservation as serum archive 
specimens. 
g. Evaluation of migration of adoptively transferred CD20 CAR T cells 
i. 
If bone marrow aspirations are performed for evaluation of tumor response or other 
clinical indications, then additional aspirates (5-10 ml in EDTA [lavender top] tubes) 
may be obtained and sent to the Specimen Processing/Research Cell Bank lab at Fred 
Hutch (optional). 
ii. 
If biopsy of other tissues is performed for clinical indications, including lumbar 
puncture for patients who develop neurological symptoms, then additional tissue 
may be obtained during the same procedure for research studies. Please discuss the 
planned procedure with the PI. 
h. Evaluation for development of endogenous anti-tumor immune responses and epitope 
spreading 
For patients who experience at least a partial remission, we may evaluate whether any cellular or 
humoral anti-tumor immune responses resulting from activation of endogenous immune cells 
have occurred. For this purpose, we will collect the following: 
i. 
Serum anti-tumor immune responses: Serum (10 ml, SST tube) for humoral immune 
responses around day 28, and at approximately 3, 6, and 12 months after T cell infusion 
to the Specimen Processing/Research Cell Bank lab at Fred Hutch.  
ii. 
PBMC anti-tumor immune responses: (20 ml, EDTA [lavender top] tubes) for cellular 
immune responses around day 28, and at approximately 3, 6, and 12 months after T cell 
infusion to the Specimen Processing/Research Cell Bank lab at Fred Hutch. 
iii. 
T-cell repertoire by deep sequencing: Blood (10 ml EDTA [lavender top] tubes) around day 
28, and at approximately 3 and 6 months after the T cell infusion to the Specimen 
Processing/Research Cell Bank lab at Fred Hutch to evaluate the T-cell repertoire by deep 
sequencing of TCR-β sequence (Adaptive Biotechnologies). 
Whole exome sequencing and RNA Seq: For patients in whom endogenous immune responses are 
detected, more detailed evaluation may be performed to characterize T cell responses by 
predicting which tumor mutations are likely to be immunogenic and then evaluating peripheral 
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blood T cells for reactivity to these epitopes. To identify mutations and determine the patient’s 
HLA alleles, whole exome sequencing and RNA Seq of baseline tumor as well as whole exome 
sequencing of normal tissue may be performed (optional).  
i. 
RCL testing 
Blood samples (10 ml, EDTA [lavender top] tube) should be collected at approximately 3, 6, and 
12 months after the CAR T cell infusion and sent to the Specimen Processing Lab for RCL testing, 
as per FDA guidelines. 
 
8.5 Response Assessment 
Objective responses to the therapeutic regimen will be assessed using physical examination, imaging, and 
if necessary, bone marrow biopsies according to standard response criteria as previously published 
(Appendices D, E, J, and K).127,128  A CT scan of the neck, chest, abdomen, and pelvis, preferably of 
diagnostic quality, and, if possible, a PET scan, should be obtained at day 28 (± 5 days) after the T cell 
infusion, and should be performed before the patient receives additional anti-tumor therapy. The PET 
scan is optional for patients with CLL/SLL. The day 28 PET-CT is also optional for primary CNS lymphoma 
patients without evidence of systemic disease on baseline PET-CT. The imaging can be done earlier in 
patients with concerns for clinical progression.  If a PET/ CT is not performed then the CT scan must be of 
diagnostic quality. Patients with a response to treatment may have CT or PET-CT scans performed at 6 and 
12 months after the T cell infusion, as clinically indicated. Patients with CNS lymphoma must also undergo 
a brain/spine MRI with and without contrast at day 28 (± 5 days) and at 6 and 12 months. Additional brain 
and spine MRIs may be performed at the discretion of the treating physician per standard clinical practice. 
 
Response assessment in CLL/SLL patients will be done per criteria published by international workshop 
for CLL (iwCLL).129 (Appendix E) 
 
Response assessment in WM patients will be done per criteria published by the 6th International 
Workshop on WM.130 (Appendix J) 
 
Response assessment in CNS lymphoma patients will be done per published CNS lymphoma response 
criteria80 (Appendix K). A bone marrow aspirate and biopsy will be performed at day 28 (± 5 days) as per 
Section 8.4.9 after the T cell infusion if the baseline bone marrow aspirate/biopsy had any detectable 
lymphoma by morphology or flow cytometry. Additional bone marrow procedures may be performed at 
6 and 12 months only if the prior bone marrow samples showed evidence of disease. 
 
A peripheral blood flow cytometry for MRD should be performed around the time of restaging by imaging 
as per Section 8.4.8.  
 
B cell deep sequencing: A blood sample (10 ml EDTA [lavender top tube] should also be collected at the 
time of restaging as per Section 8.4.10.c, which will be used to assess minimal residual disease by deep 
sequencing of the IGH and/or IGK/L locus (Adaptive Biotechnologies). 
 
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All evaluations of response may be discontinued in patients who proceed to other lymphoma-directed 
therapies. 
 
8.6 Long-term follow-up 
Enrolled patients who receive CD20 CAR T cells will be asked to participate in long-term follow-up (LTFU) 
according to guidelines set forth by the FDA’s Biologic Response Modifiers Advisory Committee that apply 
to gene transfer studies (Appendix F). Current recommendations from the FDA suggest a minimum of 15 
years of follow-up. Recommendations will be made for an autopsy to be conducted if the research 
participant dies.   
 
9  TOXICITIES AND COMPLICATIONS 
9.1 T cell-related toxicities  
9.1.1 
Management of toxicities during or immediately following T cell infusion 
The results of prior studies at our center of adoptive immunotherapy for CMV, HIV, leukemia, lymphoma, 
and melanoma, suggest that serious acute toxicities resulting simply from infusing the numbers of T cells 
proposed in this study are unlikely to occur. However, fevers and other transient constitutional symptoms 
are often observed with T cell infusions and may occur in patients being treated with CD20-specific T cells, 
particularly in patients with a high antigen (tumor) burden.  
 
Examples of potential symptoms/signs due to T cell infusions and their initial management are: 
a. Fever, chills, and temperature elevations >38.3° C may be initially managed with acetaminophen 
as clinically indicated (e.g. 650 mg PO q4-6 hrs), ibuprofen p.o. (400 mg) for breakthrough fevers, 
and meperidine 25 mg i.v. for rigors.  Additional methods such as cooling blankets may be 
employed for fevers resistant to these measures.  Since fevers may also be caused by an infection, 
all subjects that develop fever or chills should have a blood culture drawn, and empiric broad-
spectrum antibiotics may be given at the discretion of the treating physician if clinically indicated.   
b. Headache may be managed with acetaminophen. 
c. Nausea and vomiting should be treated with antiemetics (excluding corticosteroids) per 
institutional Standard Practice Guidelines. 
d. Hypotension should initially be managed by intravenous fluid administration; however, patients 
with persistent hypotension will be admitted to the hospital for definitive medical treatment. 
e. Hypoxemia should be managed initially with supplemental oxygen; however, patients with 
persistent hypoxemia will be admitted for definitive medical treatment. 
f. 
For severe symptoms concerning for cytokine release syndrome, see Section 9.1.3 below. 
 
If a subject experiences an acute T cell infusion reaction, the infusion should be stopped for patient 
assessment and treatment.  
  
If assessment by the treating investigator determines that the subject’s condition is stable, then infusion 
may be resumed as long as subject stability is confirmed within 2 hours after cell thaw. If the subject 
cannot resume treatment within 2 hours due to ongoing clinical instability, the PI will decide whether the 
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subject may continue cell infusion and whether the subject is DLT-evaluable. If an infusion is terminated 
due to infusion reaction or acute toxicity, the residual T cells will be returned to Fred Hutch Therapeutic 
Products Program Quality Control Department for analysis. Investigation of possible causes should 
proceed and, if necessary, additional medical treatment must be instituted.  
  
Subjects requiring discontinuation of the infusion may be eligible for retreatment if the cause is deemed 
not related to the infusion, after discussion with the PI.  
 
9.1.2 
Tumor lysis syndrome 
All patients will be considered at risk of tumor lysis syndrome and should be treated prophylactically with 
allopurinol before chemotherapy begins, unless contraindicated. Allopurinol should be continued for as 
long as the medical team determines appropriate after the T cell infusion. They may receive additional 
hydration and urine alkalinization if clinically indicated. 
  
If tumor lysis syndrome develops, as defined by the Cairo Bishop criteria,131,132 the attending physician will 
direct patient management with guidance from the study staff and according to published 
guidelines.132,133 Consideration should be given to hospitalization, and conservative therapy, including 
urinary alkalinization and i.v. fluid hydration, may be instituted immediately. Hyperkalemia may be 
treated with potassium binding resins, diuresis, or insulin/dextrose therapy. Hyperphosphatemia may be 
treated with phosphate binding resins. In severe cases, rasburicase (in non-G6PD-deficient individuals) or 
renal dialysis may be necessary. 
 
9.1.3 
Cytokine release syndrome (CRS) 
Prior studies of CD19-targeted T cells have demonstrated that administration of CAR T cells is associated 
with CRS. CRS is characterized by one or more of the following symptoms: high fever, fatigue, nausea, 
headache, dyspnea, tachycardia, rigors, hypotension, hypoxemia, myalgias, arthralgias, rash, and 
anorexia. Although it is often self-limited or reversible, CRS can be severe and in rare cases, fatal. 
 
If a patient becomes febrile or develops clinical evidence of cytokine release syndrome, we may obtain 
additional blood samples to measure cytokine levels (such as IL-2, IL-6, IL-7, IL-10, IL-12, IL-15, IFN-γ, TNF-
α, and MIP1-α.), serum ferritin, C-reactive protein, and markers of tumor lysis syndrome (e.g. chemistry, 
uric acid, LDH) and coagulopathy (INR, PTT, platelet count, fibrinogen), and evaluate persistence and 
phenotype of the transgene-expressing cells, as clinically indicated. 
 
Symptoms and grading of cytokine release syndrome are provided in Appendix C. Patients developing 
clinical evidence of symptoms related to cytokine release will also have a workup to exclude infection or 
other causes. Initial treatment should consist of supportive measures as dictated by the clinical and 
laboratory findings, and may include fluid replacement, medications to support blood pressure, 
antipyretics, oxygen supplementation, and broad-spectrum antibiotics if infection cannot be excluded as 
a potential etiology for the signs and symptoms.  
 
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Management of CRS should be based on institutional Standard Practice Guidelines. In general, patients 
with grade 3-4 CRS (severe CRS) and/or grade 2 CRS with progressive symptoms and signs should be 
treated with tocilizumab (4-8 mg/kg IV) and corticosteroids (dexamethasone 10 mg IV every 12 hours). 
Higher doses of steroids may be given after discussion with the PI or designee, and repeated doses of 
tocilizumab may be given if necessary. Additional anti-inflammatory agents such as siltuximab, ruxolitinib, 
or anakinra may also be considered.  
 
 
Additional measures would also be considered in serious cases after discussion with the PI, such as anti-
thymocyte globulin, cytotoxic agents, or infusion of high-dose rituximab (e.g. 1000 mg/m2) or other CD20-
targeting antibodies such as ofatumumab or obinutuzumab to block CAR binding, since our preclinical 
data suggest that at high concentrations of rituximab or low concentrations of ofatumumab, cytokine 
secretion of CAR T cells is reduced.100 Another possible intervention for refractory cytokine release 
syndrome would be to administer ruxolitinib based on data suggesting that blockade of JAK signaling 
mitigates hemophagocytic lymphohistiocytosis.134  
 
9.1.4 
Neurologic Toxicities 
Neurotoxicity, manifesting as delirium, seizures, and or focal neurologic deficits, has been reported after 
CD19 CAR T cell therapy. Management of neurotoxicity should be based on institutional Standard Practice 
Guidelines. In general, neurotoxicity that is attributed to the T cell infusion may be treated with 
corticosteroids (e.g. dexamethasone 10 mg IV q 4-12 hours). Tocilizumab or other anti-inflammatory 
agents such as siltuximab, ruxolitinib, or anakinra may also be given, preferably after discussion with the 
study PI or designee. Patients with a history of seizures or history of CNS involvement by lymphoma should 
receive prophylactic treatment with anticonvulsants (levetiracetam or similar) following CAR T cell 
infusion for approximately 4 weeks. Patients who develop significant neurotoxicity should also be treated 
with anti-convulsants if not already started. Rare cases of fatal cerebral edema have been reported in ALL 
patients receiving CD19 CAR T cells, but the mechanism of this complication and interventions to prevent 
or treat it are unknown at this time. 
 
9.1.5 
Prolonged B cell aplasia 
Prolonged absence of mature B cells is an expected potential consequence of CD20 directed T cell therapy. 
Patients experiencing prolonged B cell aplasia may have depressed immunoglobulin levels. If clinically 
indicated, they may be managed with i.v. immunoglobulin (IVIG) infusions at the discretion of the treating 
physician. 
 
9.1.6 
Persistent uncontrolled T cell proliferation 
Uncontrolled proliferation of CAR T cells has not been observed in clinical trials to date. However, in the 
unlikely event of uncontrolled proliferation of CD20 CAR T cells occurring in a study subject, initial therapy 
may involve treatment with corticosteroids (e.g. methylprednisolone 1 g IV). Subsequent measures may 
include cytotoxic agents. Additionally, the truncated CD19 transduction marker provides a potential 
therapeutic target to eliminate CAR T cells. Thus, CD19-directed agents such as blinatumomab (or other 
anti-CD19 targeting agents, if they become approved) may be considered. If we observe an increase in 
CAR+ cells to greater than 10% of T cells at more than 3 months after the last infusion we will analyze for 
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clonal expansion by deep sequencing of the TCR beta gene (Immunoseq by Adaptive Biotechnology) as an 
investigational test. 
 
9.1.7 
Replication-competent lentivirus (RCL) 
Patients should be monitored for RCL for up to 15 years after the last infusion of CAR T cells per FDA 
guidelines (Food and Drug Administration 2006, and also the 11/19/2010 FDA Gene Therapy Advisory 
Committee Meeting  – see Appendix F). All patients should be monitored for evidence of unexpected CAR 
T cell expansion and the emergence of a new malignancy, particularly one of T cell origin. 
 
9.1.8 
Other toxicities 
Patients experiencing other toxicities, excluding expected hematologic toxicities associated with 
cyclophosphamide and other specific toxicities discussed above, should be evaluated and treated 
according to standard medical practice. 
 
9.2 
Chemotherapy 
All patients will receive anti-emetic prophylaxis prior to cyclophosphamide, and/or fludarabine or 
bendamustine infusions. If hemorrhagic cystitis occurs, it will be managed with i.v. hydration, correction 
of any underlying coagulopathy, and other measures as clinically indicated. Other side effects with 
cyclophosphamide or fludarabine will be managed per standard clinical practice. 
 
10 
SUBJECT DISCONTINUATION 
10.1 
Screen Failure 
Subjects who sign the screening consent will be documented as a screen failure for the following reasons: 
 
Determined to be ineligible per the eligibility criteria outlined in Sections 3.1 and 3.2. 
For screen failures, the signed screening consent form and documentation of subject ineligibility must be 
documented in the subject’s research chart. 
 
10.2 
Withdrawal and Off-study Criteria 
Subjects may withdraw from this study at any time at their discretion. Subjects may also be removed from 
this protocol if they develop any untoward side effects from the study medications.  
If a subject withdraws consent to participate in the study or aspects of the study, attempts should be 
made to obtain permission to record survival data up to the protocol-described end of the subject follow-
up period. Survival data are important to the integrity of the final study analysis. Documentation in the 
medical record should state that the subject is withdrawing from the study and what, if any, selected data 
and research samples the subject will permit the investigator to obtain and continue to collect.  
 
Subjects in this study will be considered off study for the following reasons: 
 
If the Sponsor decides to stop the study 
 
If leukapheresis is incomplete or insufficient 
 
Insufficient generation of T cell product 
 
At Investigator’s discretion for any other reason that is not explicitly listed here 
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 
Subject is unable to complete regimen or follow the protocol as outlined in the consent form 
 
Lost to follow-up 
 
Patient death 
 
Patient Withdrawal: 
Patients may decide to withdraw from the study at any time and for any reason. If a patient expresses a 
desire to withdraw then the PI will discuss with the patient the desired level of withdrawal (i.e. complete, 
study related procedure, etc.) and determine which research-related procedures will cease. Depending 
on the level of withdrawal requested, we may continue to follow patients for disease status and toxicity. 
If patients are willing, we may continue to draw research blood.  
 
Long-term follow-up should commence at patient withdrawal from the study or one year after the T cell 
infusion.  
 
11 
ADVERSE EVENT REPORTING 
 
11.1 
Adverse Event Definitions 
 
 
Adverse Event 
An Adverse Event (AE) is any untoward medical occurrence in a clinical investigation subject 
administered a medicinal product; the event does not necessarily have a causal relationship with 
study drug administration or usage. An adverse event can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal product, whether or not considered related to the medicinal 
product. 
 
 
Serious Adverse Event  
A serious adverse event (SAE) is defined as an untoward medical occurrence that results in any of the 
following outcomes: 
1. Death. 
2. Life-threatening situation (i.e., with an immediate risk of death from the event as it occurred 
but not including an event that, had it occurred in a more serious form, might have caused 
death). 
3. In-patient hospitalization or prolongation of existing hospitalization. Inpatient hospitalization 
comprises formal admission to a hospital for medical reasons, for any length of time, whether 
or not hospitalization extends overnight. However, hospital admissions for administration of 
the study drug, procedures required by the study protocol, or tumor-related diagnostic 
procedures are not considered serious. 
4. Persistent or significant disability/incapacity or substantial disruption of the ability to conduct 
normal life functions. 
5. Congenital anomaly/birth defect. 
6. An important medical event that requires intervention to prevent one of the above outcomes. 
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 
Unexpected Adverse Event 
An unexpected adverse event is defined as an event that has a nature or severity, or frequency that 
is not consistent with the investigator brochure, protocol, or consent form. In addition, the events 
described in Section 9 of this protocol have been shown to be associated with other CAR T products 
in previous clinical trials and therefore will not be considered unexpected for the purposes of this 
protocol.   
 
11.2 
Monitoring and Recording AEs 
Adverse events will be assessed by the investigator or qualified designee and recorded in the CRFs. The 
investigator should attempt to establish a diagnosis of the event on the basis of signs, symptoms and/or 
other clinical information. In such cases, the diagnosis should be documented as the adverse event and/or 
serious adverse event and not described as the individual signs or symptoms. The following information 
should be recorded: 
 
Description of the adverse event using concise medical terminology 
 
Description as to whether or not the adverse event is serious  
 
The start date (date of adverse event onset) 
 
The stop date (date of adverse event resolution or return to baseline) 
 
The severity (grade) of the adverse event  
 
A description of the potential relatedness of the adverse event to study drug or a study procedure  
 
Expectedness of the adverse event based on prior observed and documented adverse events 
 
The outcome of the adverse event 
11.3 
Grading of the Severity of an Adverse Event 
AEs will be graded in severity according to the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) Version 4.0. If a CTCAE criterion does not exist, the investigator should use the grade or adjectives: 
Grade 1 (mild), Grade 2 (moderate), Grade 3 (severe), Grade 4 (life-threatening), or Grade 5 (fatal) to 
describe the maximum intensity of the adverse event.  For cytokine release syndrome, the CRS Grading 
Scale provided in Appendix C will be used to grade severity. While the ASTCT 2019 consensus grading 
system26 will be used as the primary grading system for this protocol (including for DLT purposes), we will 
also capture the CRS grading using the Lee 2014 criteria.27 For neurotoxicity, we will use the ASTCT 
Immune effector cell-associated neurotoxicity syndrome (ICANS) consensus grading system for adults 
(Appendix I). 
11.4 
Attribution of Adverse Event 
Association or relatedness to the study agent will be assessed by the investigator as follows: 
 
Definite 
(must have all 4) 
 
Has a reasonable temporal relationship to the intervention 
 
Could not have readily been produced by the subject's clinical 
state or have been due to environmental or other interventions 
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 
Follows a known pattern of response to intervention 
 
Disappears or decreases with reduction in dose or cessation of 
intervention and recurs with re-exposure 
Probable 
(must have 3) 
 
Has a reasonable temporal relationship to the intervention 
 
Could not have readily been produced by the subject's clinical 
state or have been due to environmental or other interventions 
 
Follows a known pattern of response to intervention 
 
Disappears or decreases with reduction in dose or cessation of 
intervention 
Possible 
(must have 2) 
 
Has a reasonable temporal relationship to the intervention 
 
Could not have readily been produced by the subject's clinical 
state 
 
Could not readily have been due to environmental or other 
interventions 
 
Follows a known pattern of response to intervention 
Unlikely 
(must have 2) 
 
Does not have a temporal relationship to the intervention 
 
Could readily have been produced by the subject's clinical state 
 
Could have been due to environmental or other interventions 
 
Does not follow a known pattern of response to intervention 
 
Does not reappear or worsen with reintroduction of intervention 
 
 
For general AE assessment, an AE is considered related if it is assessed as definitely, probably, or possibly 
related; unrelated if it is assessed as unlikely related or unrelated.  
 
For determination of IND safety reporting, AE attribution will be assessed according to the suspected 
adverse reaction definition described in 21 CFR 312.32 as an AE for which there is a reasonable possibility 
that the drug caused the adverse event where “reasonable possibility” means there is evidence to suggest 
a causal relationship between the drug and the AE. The IND Sponsor will report  suspected adverse 
reactions that are both serious and unexpected to the FDA as an IND safety report, in accordance with 
regulations under 21 CFR 312.32. 
11.5 
Adverse Event Reporting Period 
Adverse events of ≥ grade 2 and all grades of nervous system adverse events will be monitored and 
recorded in study-specific case report forms (CRFs) throughout the investigative phases of the study: 
during and for 48 hours after invasive study related procedures, then during and for 48 hours after 
leukapheresis and then from the start of lymphodepletion chemotherapy through day 28 after the T cell 
infusion.  Adverse events will continue to be monitored and recorded in conjunction with standard follow-
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up time points during the first year following T cell infusion. The detailed collection of AEs will stop at the 
time of commencement of new anti-tumor therapy. However, limited AEs will continue to be recorded 
annually during long-term follow-up as described in Appendix F. 
 
AEs with an onset date prior to apheresis will not be recorded, except in the case of clinically significant 
worsening of the AE during the specified monitoring time frame. A subject withdrawn from the study 
because of an adverse event must be followed until the clinical outcome from the adverse event is 
determined.  
 
The following events are not identified as AEs in this study: 
 
Disease progression or relapse.  However, clinical events associated with progression/relapse may be 
reportable as AEs during the first 28 days after the T cell infusion. 
 
Hospitalization for the purpose of facilitating lymphodepleting chemotherapy and/or T cell infusion is 
not considered an AE.  Any AE requiring prolongation of this hospitalization will be recorded and 
subject to applicable SAE reporting. 
 
Medical or surgical procedures in and of themselves, including those that require hospitalization (e.g., 
surgery, endoscopy, biopsy procedures) are not considered AEs.  However, an event or condition 
requiring such procedures may be an AE. 
11.6 
Adverse Event Reporting Requirements 
11.6.1 Research Site Reporting Requirements 
Classification of an event as serious or non-serious (see Section 11.1) determines the reporting procedures 
to be followed by the site for reporting the event to the IND Sponsor. The investigator must report events 
to the Fred Hutch IRB in accordance with the policies of the IRB. 
TABLE 11.1: PI to IND Sponsor Reporting Requirements for Adverse Events 
Classification 
Reporting Time 
Reporting Action 
Contact Information 
Serious 
Adverse 
Event 
(SAE) 
Fatal or life-
threatening 
Within 24 hours of 
research team 
awareness 
Email notification to IND Sponsor’s 
Medical Monitor and ISIOC 
Administrator 
Medical Monitor email: 
mperciva@uw.edu 
ISIOC email: 
ISIOC@fredhutch.org 
All SAEs 
Within 2 business 
days of research 
team awareness 
Submit completed Institution-
Sponsored IND SAE Reporting Form 
signed by PI or designated sub-
Investigator 
ISIOC email: 
ISIOC@fredhutch.org 
Non-serious Adverse 
Event 
Per CRF completion 
guidelines 
Record information on appropriate 
CRFs 
N/A 
*Research team is defined as the individuals listed on the delegation of authority log. Physicians listed on the study’s delegation 
of authority log as attending physicians with delegated authority to administer informed consent will not be considered part of 
the research team unless additional responsibilities related to the conduct of the study have been delegated to them by the 
Principal Investigator.  
The information in the Institution-Sponsored IND SAE Reporting Form must match or be reconciled with 
the information recorded in the adverse events section of the CRF and study database. For example, the 
same adverse event term should be used on both forms. 
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The IND sponsor or its designee will provide all investigators with a safety letter notifying them of an event 
that meets FDA IND Safety Reporting criteria.  A courtesy copy will also be provided to the study-specific 
DSMB. 
In the event of study closure due to toxicities, or activation of any other stopping/suspension rule, the PI 
would notify the IRB, DSMB, IBC, and OSP within 7 days of the determination. 
11.6.2 Fred Hutch IND Sponsor Reporting Requirements 
The sponsor assumes responsibility for IND safety reporting to the FDA and participating investigators, in 
accordance with regulations under 21 CFR 312.32. 
Each serious adverse event report received from the investigator will be evaluated by the Medical Monitor 
who will assess the seriousness of the event (see Section 11.1), the expectedness of the event (see Section 
11.1), and the relationship to participation in the study (see Section 11.4). For regulatory reporting 
purposes, the IND Sponsor will determine expectedness relating to the investigational product using 
safety information specified in the Investigator Brochure. An event will be classified as related if either 
the investigator or the IND Sponsor determines that the event may be related to the study drug. 
 
The IND Sponsor or its designee will provide all investigators with a safety letter notifying them of an event 
that meets FDA IND Safety Reporting criteria. Investigators will be requested to provide written 
notification of safety report to the Fred Hutch IRB as soon as is practical, consistent with IRB requirements. 
 
12 
STATISTICAL CONSIDERATIONS 
 
12.1 
Study Design and Objectives  
This is a phase I/II study. The primary objective of this study is to estimate the maximum tolerated dose 
(MTD) of adoptively transferred autologous CD4+ and CD8+ T cells transduced to express a CD20-specific 
CAR and infused following lymphodepletion chemotherapy for patients with relapsed or refractory CD20+ 
B cell lymphomas or CLL/SLL. Secondary objectives include an assessment of antitumor activity of adoptive 
T cell therapy with autologous CD4+ and CD8+ T cells transduced to express a CD20-specific CAR as 
measured by complete and partial remissions, progression-free survival, and overall survival.   
 
These dose levels will be initially evaluated in combination with CY alone, evaluating the CR rate to 
determine if CY alone has sufficient activity or if fludarabine will be added (CY/flu). See Section 12.3 for 
details. The following table describes the dose levels for CD20-specific CAR infused following 
lymphodepletion chemotherapy.  
Table 12.1.1 Dose levels of CD20 CAR T cell infusions 
Dose Level 
CAR T cell Dose 
Level 0
1 x 105 tCD19+ T cells/kg 
Level 1
3.3 x 105 tCD19+ T cells/kg 
Level 2
1 x 106 tCD19+ T cells/kg 
Level 3
3.3 x 106 tCD19+ T cells/kg 
Level 4
1 x 107 tCD19+ T cells/kg 
 
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Dose-limiting toxicity (DLT) is a binary outcome (yes/no) and will be determined by adverse events 
occurring after CAR T cell infusion through day 28 post infusion (see Section 12.2.1 for DLT definition). 
The MTD is defined as the dose combination with a DLT rate closest to the target DLT rate of 25%. Section 
12.4 describes the method for dose allocation and MTD estimation. Initially, the study will accrue 
participants in cohorts of 2 patients each. Once 10 patients have been treated at a given dose level, the 
study can accrue patients in cohorts of up to 4 patients (minimum 2). The starting dose level for the study 
will be dose level 1. If the recommended dose level for the next cohort would not be changed by the 
occurrence of a DLT in the current cohort, the first patient in the next cohort may be treated without 
waiting for completion of the 28-day DLT period from the infusion of the last patient in the current cohort. 
 
Due to the manufacturing process, a patient may not be able to receive their assigned dose level of cells.  
Such patients will be evaluated within the study design (using DLTs to estimate the MTD) at the dose level 
received.  The following table defines the range of cells that will be associated with a given dose level.  
Doses between -15% of a dose level to +85% of the next dose level up will be attributed to that dose level.  
 
Table 12.1.2 Dose levels Range for Dose Attribution  
Dose Level 
CAR T cell Dose
CAR T cell Dose Inclusion Range
Level 0
1 x 105 tCD19+ T cells/kg
8.51 x 104 –2.80 x 105  tCD19+ T cells/kg
Level 1
3.3 x 105 tCD19+ T cells/kg
2.81 x 105 – 8.50 x 105 tCD19+ T cells/kg
Level 2
1 x 106 tCD19+ T cells/kg
8.51 x 105 –2.80 x 106  tCD19+ T cells/kg
Level 3
3.3 x 106 tCD19+ T cells/kg
2.81 x 106 – 8.50 x 106 tCD19+ T cells/kg
Level 4
1 x 107 tCD19+ T cells/kg
> 8.5 x 106  tCD19+ T cells/kg
 
The lowest cell count allowed is 5 x 104 tCD19+ T cells/kg. If any patient receives between 5 x 104  and 8.50 
x 104 tCD19+ T cells/kg those patients’ DLT and adverse event data will be evaluated as a separate “Level 
-1” dose level cohort.  
 
12.2 
Definition of endpoints 
12.2.1 Primary Endpoint 
The primary endpoint for this study is dose-limiting toxicity (DLT). DLT is defined as the occurrence of any 
of the following that is attributed as at least possibly related to the T cell infusion. Grading will be done in 
accordance with the NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. CRS and 
neurotoxicity will be graded per ASTCT consensus guidelines 2019 26 unless otherwise specified. 
a. Grades 3-5 allergic reaction related to the CAR T cell infusion. 
b. Grades 3-5 autoimmune reactions, excluding B cell depletion, which is expected to occur as a 
consequence of elimination of CD20+ B cells. 
c. Any Grade 3 or 4 non-hematologic event that has not resolved to < grade 3 by day 28 post T cell 
infusion 
d. Grade ≥ 3 neurotoxicity of greater than 7 days duration 
e. Grade ≥ 3 neurotoxicity that does not revert to Grade 1 or baseline by day 28 post T cell infusion 
f. Grade ≥ 3 seizures that do not resolve to < grade 3 within 3 days 
g. Grade ≥ 4 CRS  
h. Grade 3 CRS that does not resolve to < grade 3 within 7 days  
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i. 
Any other toxicity not meeting the above criteria that is deemed by the PI to represent a DLT 
 
The DLT evaluation period is 28 days from infusion. All patients who receive an infusion will be considered 
evaluable for DLTs.  
 
12.2.2 Secondary Endpoints 
Secondary endpoints include: complete remission (CR), progression-free survival (PFS), overall survival 
(OS), and toxicity. These endpoints are defined as: 
a. 
Complete remission, based on the Lugano criteria (ref128 and Appendix D).  
b. 
Progression-free survival (PFS): the duration from study enrollment to progression or death due 
to any cause (whichever comes first).  PFS for patients last known to be alive and progression free 
will be censored at the date of their last disease assessment. 
c. 
Overall survival (OS): the duration from study enrollment to death due to any cause. OS for 
patients last known to be alive will be censored at the date of last contact.  
d. 
Toxicity: Toxicity grading according to NCI CTCAE version 4.0. 
 
12.3 Interim Analyses to Evaluate Lymphodepletion Regimen  
At the time of study initiation, interim analyses were proposed to allow escalation in the 
lymphodepletion regimen, as outlined in Table 12.3 below. The goal of the analyses was to determine if 
the study would proceed with CY alone or if fludarabine would be added to the lymphodepletion 
regimen. CR was chosen as the criterion to escalate lymphodepletion since it encompasses multiple 
potential reasons for suboptimal efficacy including low homeostatic cytokines, inadequate depletion of 
inhibitory cells, and anti-CAR immune responses. Patients who did not receive the target dose 
specification for T cells as defined in Section 7.3.1 would not be included in this assessment of CR rate 
(i.e. are not evaluable for CR).   
 
The interim analyses proposed at study initiation are summarized below for reference in the following 
table. Based on interim analysis #1 in July 2018 after the first 4 patients were treated, the switch from CY 
to CY + fludarabine was made. 
 
Table 12.3 Interim analyses to assess whether to intensify lymphodepletion chemotherapy. 
Interim 
Interim Sample 
Size* 
Decision Rules 
Action 
#1 
First 4 patients 
If 0 patients achieve a CR
 
Switch to CY + 
fludarabine† 
If 1 or more patients achieve a CR
Continue with CY alone
 
#2 
First 8 patients 
If 1 patient achieves a CR 
Switch to CY + 
fludarabine† 
If 2 or more patients achieve a CR
Continue with CY alone
 
#3 
First 16 patients 
If 3 or fewer patients achieve a CR 
Switch to CY + 
fludarabine† 
If 4 or more patients achieve a CR
Continue with CY alone
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#4 
First 20 patients 
If 7 or fewer patients achieve a CR AND < 40% 
of patients treated at the interim 
recommended dose** achieve a CR 
Switch to CY + 
fludarabine† 
If 8 or more patients achieve a CR OR at least 
40% of patients treated at interim 
recommended dose** 
Continue with CY alone 
*  Assessment is based on patients evaluable for CR as defined above 
** See the following paragraph for the definition of the interim recommended dose 
† See section 7.5 for dosing of CY and fludarabine 
 
After the first 4 patients, criteria were met to switch to CY/fludarabine. The cell dose allocation (Section 
12.4) was reinitiated starting at one dose level below the interim recommended dose (with CY alone) in 
combination with CY/fludarabine. The interim recommended cell dose was defined as the lower of the 
maximum dose evaluated to date at time of interim analysis 1 (treatment of 4 patients) or the next cell 
dose that would have been selected. Once the switch was made to CY + fludarabine, analysis of the  
lymphodepletion regimen was discontinued.  
 
A simulation study was conducted to estimate the switching/continuation probabilities for the interim 
analyses, and simulations were repeated 1,000 times. It is challenging to provide an exhaustive summary 
of the properties as the number of patients at dose levels will depend on the observed data, and the CR 
rates may increase with increasing dose levels. Therefore, we provide a summary of a few scenarios. 
Assuming the true CR rate is 10% for all dose levels, the cumulative probability of recommending adding 
fludarabine by patients 4, 8, 16, or 20 is estimated to be 66%, 84%, 96%, and 100%, respectively.  Similarly, 
if the true CR rate is 50%, then the cumulative probability of recommending adding fludarabine by patients 
4, 8, 16, or 20 is estimated to be 7%, 8%, 9%, and 19%, respectively. 
 
12.4  Dose Allocation  
Dose allocation will be based upon a Bayesian continual reassessment method (CRM),135 which uses a 
model for the probability of DLT and the accumulated DLT data at each dose level to sequentially allocate 
each new patient cohort. Toxicity assessment is based on the occurrence of DLTs, and the minimum 
follow-up for determination of escalation is 28 days. The DLT probabilities are modeled using a one-
parameter working model 𝑅(𝑑௜) = 𝑃r(DLT at dose level 𝑖) ≈𝛼௜
ୣ୶୮(௔), where 𝛼௜ is the skeleton of the 
working model. The skeleton values are pre-specified constants and were chosen according to the 
algorithm of Lee and Cheung,99 which yields a working model that results in well-performing operating 
characteristics in a broad range of scenarios. For this study, the skeleton values are 𝛼௜=
(0.01,0.05,0.10,0.15, 0.25). The prior distribution 𝑓(𝑎) on the parameter 𝑎 is specified by a Normal 
distribution with a mean of 0 and a variance of 𝑋; 𝑎~N(0,0.4), which was chosen according to the 
algorithm of Lee and Cheung99 to the yield the least informative normal prior so that each dose level has 
approximately equal prior probability of being the MTD. Based on the available DLT data 𝐷= {(𝑦௜, 𝑛௜); 𝑖=
0, … ,4}, where where 𝑦௜ is the number of DLT’s and 𝑛௜ is the number of subjects treated on study dose 
level 𝑖, the likelihood is given by 
𝐿(𝐷|𝑎) ∝∏
ቀ𝛼௜
ୣ୶୮ (௔)ቁ
௬೔ቀ1 −𝛼௜
ୣ୶୮ (௔)ቁ
௡೔ି௬೔
ସ
௜ୀ଴
. 
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After accrual of each patient cohort into the trial, the DLT probability estimates, 𝑅෨(𝑑௜), are updated via 
𝑅෨(𝑑௜) = 𝛼௜
ୣ୶୮(௔෤);   𝑎෤= න𝑎 𝐿(𝐷|𝑎)𝑓(𝑎)
∫𝐿(𝐷|𝑎)𝑓(𝑎) 𝑑𝑎 
These estimates are used to sequentially allocate patients to the dose indicated by the modeling to have 
the estimated DLT rate closest to 25%. The study will sequentially repeat the estimation procedure after 
the enrollment and follow-up of each cohort (see Section 12.1 for definition of cohort size). The approach 
will be used to identify recommended dose levels for the next cohort, but a recommendation to dose 
escalate can be overridden by the PI for clinical considerations. The allocation procedure will be repeated 
until sufficient information about the MTD has been obtained according to the stopping rules described 
in the following section.  
 
12.5 Stopping and Suspension Rules 
In addition to the interim evaluations described in Section 12.3, if at any point during study conduct there 
exists sufficient evidence to suggest that the true probability of treatment-related death by day 100 
exceeds 20% (regardless of dose), enrollment of patients will be suspended pending a detailed review by 
the PI, study monitor and statistician, and DSMB. Sufficient evidence for this purpose will be defined as 
any observed outcome with lower 80% confidence limit exceeding 20%.  Operationally, the observation 
of the following ratios of treatment-related deaths to patients treated would trigger such a rule: 
 
 
 
 
 
 
 
 
 
 
 
 
 
12.6 Patient Accrual and Expected Duration of Trial 
The study is expected to be open for enrollment for 4-5 years to enroll up to 50 DLT-evaluable subjects, 
and follow up will continue for an additional 15 years following patient treatment to provide data on 
secondary malignancies or neurologic, autoimmune, or hematologic disorders. It is possible that some 
enrolled patients may either not be treated due to treatment exclusion criteria, or that treated patients 
may not be DLT-evaluable due to an inadequate dose of CAR T cells (i.e. < 5 x 104 tCD19+ cells/kg). Such 
patients will be replaced, and thus the total accrual may be higher than 50 to achieve 50 DLT-evaluable 
subjects. 
 
Table 12.5. Stopping guidelines for Treatment-related Deaths < 100 days
Number of participants
Boundary
2-4
≥ 2
5-7
≥ 3
8-11
≥ 4
12-14
≥ 5
15-18
≥ 6
19-22
≥ 7
23-26
≥ 8
27-30
≥ 9
31-34
≥ 10
35
≥ 11
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12.7 Operating Characteristics of Study Design  
Simulations were run to display the performance of the design characteristics using the CRM web 
application located at http://uvatrapps.uvadcos.io/crmb/. For each scenario, 1000 simulated trials were 
run using a random seed of 1973. The confidence level used to define the safety stopping guidelines was 
80%. Each table reports the true DLT probability at each dose level, the percentage of trials in which 
each dose level was recommended as the MTD, the average number of participants  treated at each 
dose level, the average sample size, and the percentage of trials stopped early for safety. The results 
displayed in Table 12.7 were based upon a maximum target accrual of 50 subjects.  
 
Table 12.7. Operating characteristics of statistical design   
 
 
 
Operating characteristics for Bayesian continual reassessment method 
(CRM) with cohorts of size 2. Bold font indicates the level that is the MTD 
corresponding to a target DLT rate of 40% 
Scenario 
 
Dose
level 0 
Dose
level 1 
Dose
Level 2 
Dose
Level 3 
Dose
Level 4 
% stopped
for safety 
1:  
Little  
toxicity 
True DLT 
prob:            
0.01 
0.1 
0.15 
0.20 
0.25 
0% 
MTD 
selection 
% 
0% 
2.1% 
20.7% 
42.1% 
35.1% 
Avg # of 
patients 
< 1 
5.3 
9.4 
11.2 
7.4 
2: 
Moderate 
toxicity 
True DLT 
prob:            
0.10 
0.15 
0.2 
0.25 
0.30 
0.6% 
MTD 
selection 
% 
1.5% 
16.0% 
33.0% 
32.3% 
16.6% 
Avg # of 
patients 
2.1 
8.9 
10.5 
8.8 
3.6 
3: High 
toxicity 
True DLT 
prob:            
0.20 
0.25 
0.35 
0.45 
0.55 
11.7% 
MTD 
selection 
% 
19.9% 
48.1% 
18.5% 
1.7% 
0.1% 
Avg # of 
patients 
8.1 
14.1 
7.6 
1.6 
<1 
4: Too 
Toxic 
True DLT 
prob:            
0.30 
0.35 
0.45 
0.55 
0.65 
41.4% 
MTD 
selection 
% 
38.9% 
17.3% 
2.3% 
0.1% 
0% 
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12.8 
Data Analysis 
All subjects who are put on-study will be assessed for inclusion in the final report.  
 
12.8.1 Safety 
All subjects who receive any protocol treatment will be monitored for adverse events. Adverse events will 
be described beyond the summary of DLTs.  At study conclusion frequency, proportion and severity of 
adverse events, and DLTs by study dose level will be tabulated.  
 
12.8.2 Efficacy 
Secondary objectives of the study include an examination of efficacy (in terms of rate of remissions, 
progression-free survival, and in vivo persistence of T cells). These analyses will be performed using 
patients treated with all doses combined with the final lymphodepletion regimen (either CY alone or 
CY/fludarabine), modeling outcomes as a function of dose.  A logistic regression model will be used to 
evaluate binary outcomes (CR and CR/PR).  A Cox proportional hazards model will be used to evaluate 
time-to-event outcomes (PFS, OS). No formal statistical hypotheses will be tested with respect to these 
endpoints, rather estimates and associated confidence interval will be provided descriptively. Moreover, 
the data will be depicted graphically. Depending on the outcome of lymphodepletion regimen evaluation 
(see Table 12.3), 10, 14, 22, or 50 patients will be evaluable for these outcomes; the associated precision 
(based on 95% confidence interval width) for binary estimates with these sample sizes are: 32%, 27%, 
21%, and 17%.   
 
Tertiary objectives are to evaluate of the duration of persistence of adoptively transferred CD20 CAR T 
cells and the migration of adoptively transferred CD20 CAR T cells. To evaluate the persistence of the CAR 
T cells, the patient-level area under the curve (AUC) will be estimated and the summary statistics of the 
AUCs will be evaluated.  Migration (if CAR T cells are present post treatment), is defined as the presence 
of CAR T cells in the tumor at day 10-16 and, if applicable, the BM at approximately day 28.  The association 
between AUC and migration with clinical outcomes will be mostly descriptive in nature, including graphical 
presentation.  
 
To evaluate the tertiary objectives associated with evaluating biological causes of treatment resistance, 
the following analyses will be performed. A paired t-test will be used to compare the biomarker profiles 
Avg # of 
patients 
13.9 
8.9 
2.6 
< 1 
< 1 
5: All 
safe 
True DLT 
prob:            
0.01 
0.05 
0.10 
0.15 
0.2 
0% 
MTD 
selection 
% 
0 
0.1% 
4.5% 
28.8% 
66.6% 
Avg # of 
patients 
< 1 
3.2 
6.2 
11.3 
13.1 
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between baseline tumors and post-treatment tumors with appropriate transformation if needed.  A 
logistic regression model will be used to evaluate the association between baseline biomarker values and 
response.  A landmark analysis among patients achieving a CR or PR at 1 month, measuring survival times 
(PFS and OS) from the landmark time, using a Cox proportional hazard regression model to evaluate the 
association of correlates measured at the time of CR/PR for patients in whom a biopsy is acquired at that 
time. Models will include values for all patients/dose levels and include a variable for dose level.    
 
With respect to the endpoint of assessing development of endogenous anti-tumor responses and epitope 
spreading, the analysis will be largely exploratory. Data at each time point will be summarized, and with 
sufficient data, a mixed effect model will be used to model time-varying outcomes. Differential gene 
expression analysis will be conducted between patients with and without demonstrated epitope 
spreading to identify the biomarker associated with immune response. 
 
12.9 Ethnic and Gender Accrual Estimates 
All eligible patients will be included in this study without regard to gender or ethnicity. It is expected that 
the distribution of these 50 patients will reflect the general demographic distribution of lymphoma 
patients seen at our institution. 
 
Table 12.9: TARGETED / PLANNED ENROLLMENT: Number of Subjects   
Ethnic Category 
Sex / Gender 
 
Females
Males
Total
Hispanic or Latino 
2 
1 
3 
Not Hispanic or Latino 
18 
29 
47 
Ethnic Category Total of All Subjects 
20 
30 
50 
Racial Categories 
 
 
American Indian / Alaska Native 
1 
1 
2 
Asian 
1 
1 
2 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
0 
1 
1 
White 
18 
27 
45 
Racial Categories: Total of All Subjects* 
20 
30 
50 
 
 
13 
DATA AND SAFETY MONITORING PLAN 
13.1 
Overall Scope of Monitoring Activities 
Institutional support of trial monitoring will be in accordance with the Fred Hutch/University of 
Washington Cancer Consortium Institutional Data and Safety Monitoring Plan (DSMP).  Under the 
provisions of this plan, Fred Hutch Clinical Research Support coordinates data and compliance monitoring 
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conducted by consultants, contract research organizations, or Fred Hutch employees unaffiliated with the 
conduct of the study.  Independent monitoring visits occur at specified intervals determined by the 
assessed risk level of the study and the findings of previous visits per the institutional DSMP.  
 
In addition, protocols are reviewed at least annually and as needed by the Consortium Data and Safety 
Monitoring Committee (DSMC), Fred Hutch Scientific Review Committee (SRC) and the Fred 
Hutch/University of Washington Cancer Consortium Institutional Review Board (IRB).  The review 
committees evaluate accrual, adverse events, stopping rules, and adherence to the applicable data and 
safety monitoring plan for studies actively enrolling or treating patients.  The IRB reviews the study 
progress and safety information to assess continued acceptability of the risk-benefit ratio for human 
subjects.  Approval of committees as applicable is necessary to continue the study. 
 
The trial will comply with the standard guidelines set forth by these regulatory committees and other 
institutional, state and federal guidelines. The conduct of this trial will be further monitored by an 
independent Data and Safety Monitoring Board (DSMB) in accordance with an approved DSMB Charter. 
 
Any temporary or permanent suspension of this clinical research trial, as determined by the Principal 
Investigator, IRB, DSMC, IND Sponsor or FDA, will be reported to the NCI grant program director by the 
Principal Investigator. 
 
13.2 
Monitoring the Progress of Trial and Safety of Participants 
The first level of trial oversight for this protocol will be provided by the principal investigator and the 
research nurse, who will provide continuous oversight of the trial.  These individuals will meet at least 
monthly to review recently acquired data, stopping rules, and adverse events. Serious adverse events will 
be reviewed upon occurrence to ensure prompt and accurate reporting to the IND Sponsor, appropriate 
committees, and regulatory agencies as described above.  The data recorded in the research charts and 
protocol database will be compared with the actual data available from the medical record and/or clinical 
histories.  Data detailed in the research case report forms (CRFs) will include the nature and severity of all 
toxicities.  Dr. Shadman and all other investigators on the protocol have received formal training in the 
ethical conduct of human research. 
 
The IND Sponsor will ensure routine trial monitoring as described above, and will review Serious Adverse 
Events and other reports of safety issues promptly upon receipt from the PI. 
 
14 
DATA MANAGEMENT/CONFIDENTIALITY 
The medical record containing information regarding treatment of the patient will be maintained as a 
confidential document, within the guidelines of the Fred Hutchinson Cancer Center, and the University of 
Washington Medical Center. The investigators will ensure that data collected conform to all established 
guidelines for coding collection, key entry and verification. Each subject is assigned a unique subject 
number to assure subject confidentiality. Information forwarded to the FDA, NCI, OSP, or other agencies 
about patients on this protocol refers to patients by a coded identifier and not by name.  Subjects will not 
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be referred to by this number, by name, or by any other individual identifier in any publication or external 
presentation. The licensed medical records department, affiliated with the institution where the subject 
receives medical care, maintains all original inpatient and outpatient chart documents. Additional clinical 
data may be made available from the Fred Hutch core database (Gateway), which is managed and verified 
independent of the research group.   
The research team will maintain Case Report Forms (CRFs) and associated research documentation for 
each patient treated under the protocol.  This documentation includes both clinical data and study-specific 
documents for each patient.  The Principal Investigator or a designee will verify completed CRFs against 
source documentation on an ongoing basis as they are completed for individual patients.  CRFs should be 
complete and data entered into the study database within 30 days after the day 28 restaging tests are 
completed. Data required for analysis of patients treated on this protocol will be maintained in a 
password-protected study-specific database. Data from the CRFs are keyed directly into the database by 
authorized research staff and verified on an ongoing basis.  
 
15 
TERMINATION OF STUDY 
The study will terminate after the last treated patient has completed 15 years of follow-up as described 
in this protocol.  
 
The PI or IND Sponsor may terminate the study at any time. The IRB and FDA also have the authority to 
terminate the study should it be deemed necessary. 
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16 
REFERENCES 
 
1. 
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. Jan 2012;62(1):10-29. 
doi:10.3322/caac.20138 
2. 
Armitage JO, Weisenburger DD. New approach to classifying non-Hodgkin's lymphomas: clinical 
features of the major histologic subtypes. Non-Hodgkin's Lymphoma Classification Project. J Clin Oncol. 
Aug 1998;16(8):2780-95.  
3. 
Gisselbrecht C, Glass B, Laurent G, et al. Maintenance with rituximab after autologous stem cell 
transplantation in relapsed patients with CD20 diffuse large B-cell lymphoma (DLBCL): CORAL final 
analysis. J Clin Oncol. 2011;29:Abstract #8004.  
4. 
Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and 
Lymphoid Tissues. International Agency for Research on Cancer; 2008. 
5. 
Khouri IF, McLaughlin P, Saliba RM, et al. Eight-year experience with allogeneic stem cell 
transplantation for relapsed follicular lymphoma after nonmyeloablative conditioning with fludarabine, 
cyclophosphamide, and rituximab. Blood. Jun 15 2008;111(12):5530-6.  
6. 
Rezvani AR, Storer B, Maris M, et al. Nonmyeloablative allogeneic hematopoietic cell 
transplantation in relapsed, refractory, and transformed indolent non-Hodgkin's lymphoma. J Clin Oncol. 
Jan 10 2008;26(2):211-7.  
7. 
van Besien K, Loberiza FR, Jr., Bajorunaite R, et al. Comparison of autologous and allogeneic 
hematopoietic stem cell transplantation for follicular lymphoma. Blood. Nov 15 2003;102(10):3521-9.  
8. 
Press OW, Grogan TM, Fisher RI. Evaluation and Management of Mantle Cell Lymphoma. 
Advances in Leukemia and Lymphoma. 1996;6:3-11.  
9. 
Press O. Treatment of mantle-cell lymphoma: stem cell transplantation, radioimmunotherapy, 
and management of mantle-cell lymphoma subsets. . American Society of Clinical Oncology Education 
Book. 2002; 
10. 
Khouri IF, Lee MS, Saliba RM, et al. Nonablative allogeneic stem-cell transplantation for 
advanced/recurrent mantle-cell lymphoma. J Clin Oncol. ÿ%\   h°  1 2003;21(23):4407-12.  
11. 
Khouri IF, Lee MS, Romaguera J, et al. Allogeneic hematopoietic transplantation for mantle-cell 
lymphoma: molecular remissions and evidence of graft-versus-malignancy. Ann Oncol. Nov 
1999;10(11):1293-9.  
12. 
Maris MB, Sandmaier BM, Storer BE, et al. Allogeneic hematopoietic cell transplantation after 
fludarabine and 2 Gy total body irradiation for relapsed and refractory mantle cell lymphoma. Blood. Dec 
1 2004;104(12):3535-42.  
13. 
Hallek M. Chronic lymphocytic leukemia: 2020 update on diagnosis, risk stratification and 
treatment. Am J Hematol. Nov 2019;94(11):1266-1287. doi:10.1002/ajh.25595 
14. 
Dreger P, Ghia P, Schetelig J, et al. High-risk chronic lymphocytic leukemia in the era of pathway 
inhibitors: integrating molecular and cellular therapies. Blood. Aug 30 2018;132(9):892-902. 
doi:10.1182/blood-2018-01-826008 
15. 
Press OW. Follicular Lymphoma. In: Kaushansky K, Lichtman M, Beutler E, Kipps TJ, Seligsohn, 
Prchal, eds. Williams' Hematology. 8th ed. McGraw-Hill, Medical Pub. Division; 2010:1565-74. 
16. 
Geisler CH, Kolstad A, Laurell A, et al. Long-term progression-free survival of mantle cell 
lymphoma after intensive front-line immunochemotherapy with in vivo-purged stem cell rescue: a 
nonrandomized phase 2 multicenter study by the Nordic Lymphoma Group. Blood. Oct 1 
2008;112(7):2687-93.  
17. 
Hermine O, Hoster E, Walewski J, et al. Addition of high-dose cytarabine to immunochemotherapy 
before autologous stem-cell transplantation in patients aged 65 years or younger with mantle cell 
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 57 of 84 
lymphoma (MCL Younger): a randomised, open-label, phase 3 trial of the European Mantle Cell Lymphoma 
Network. Lancet. Aug 6 2016;388(10044):565-75. doi:10.1016/S0140-6736(16)00739-X 
18. 
Robak T, Huang H, Jin J, et al. Bortezomib-based therapy for newly diagnosed mantle-cell 
lymphoma. Clinical Trial, Phase III 
Comparative Study 
Multicenter Study 
Randomized Controlled Trial 
Research Support, Non-U.S. Gov't. The New England journal of medicine. Mar 5 2015;372(10):944-53. 
doi:10.1056/NEJMoa1412096 
19. 
Rummel MJ, Niederle N, Maschmeyer G, et al. Bendamustine plus rituximab versus CHOP plus 
rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, 
multicentre, randomised, phase 3 non-inferiority trial. Clinical Trial, Phase III 
Comparative Study 
Multicenter Study 
Randomized Controlled Trial 
Research Support, Non-U.S. Gov't. Lancet. Apr 6 2013;381(9873):1203-10. doi:10.1016/S0140-
6736(12)61763-2 
20. 
Iovino L, Shadman M. Novel Therapies in Chronic Lymphocytic Leukemia: A Rapidly Changing 
Landscape. Curr Treat Options Oncol. Mar 13 2020;21(4):24. doi:10.1007/s11864-020-0715-5 
21. 
Thompson PA, Tam CS, O'Brien SM, et al. Fludarabine, cyclophosphamide, and rituximab 
treatment achieves long-term disease-free survival in IGHV-mutated chronic lymphocytic leukemia. Blood. 
Jan 21 2016;127(3):303-9. doi:10.1182/blood-2015-09-667675 
22. 
Fischer K, Al-Sawaf O, Bahlo J, et al. Venetoclax and Obinutuzumab in Patients with CLL and 
Coexisting Conditions. The New England journal of medicine. Jun 6 2019;380(23):2225-2236. 
doi:10.1056/NEJMoa1815281 
23. 
Shanafelt TD, Wang V, Kay NE, et al. Ibrutinib and Rituximab Provides Superior Clinical Outcome 
Compared to FCR in Younger Patients with Chronic Lymphocytic Leukemia (CLL): Extended Follow-up from 
the E1912 Trial. Blood. 2019;134(Supplement_1):33-33. doi:10.1182/blood-2019-126824 
24. 
Sharman JP, Egyed M, Jurczak W, et al. Acalabrutinib with or without obinutuzumab versus 
chlorambucil and obinutuzmab for treatment-naive chronic lymphocytic leukaemia (ELEVATE TN): a 
randomised, controlled, phase 3 trial. Lancet. Apr 18 2020;395(10232):1278-1291. doi:10.1016/S0140-
6736(20)30262-2 
25. 
Woyach JA, Ruppert AS, Heerema NA, et al. Ibrutinib Regimens versus Chemoimmunotherapy in 
Older Patients with Untreated CLL. The New England journal of medicine. Dec 27 2018;379(26):2517-2528. 
doi:10.1056/NEJMoa1812836 
26. 
Byrd JC, Hillmen P, O'Brien S, et al. Long-term follow-up of the RESONATE phase 3 trial of ibrutinib 
vs ofatumumab. Blood. May 9 2019;133(19):2031-2042. doi:10.1182/blood-2018-08-870238 
27. 
Furman RR, Sharman JP, Coutre SE, et al. Idelalisib and rituximab in relapsed chronic lymphocytic 
leukemia. 
The 
New 
England 
journal 
of 
medicine. 
Mar 
13 
2014;370(11):997-1007. 
doi:10.1056/NEJMoa1315226 
28. 
Ghia P, Pluta A, Wach M, et al. Acalabrutinib vs Rituximab Plus Idelalisib (IdR) or Bendamustine 
(BR) by Investigator Choice in Relapsed/Refractory (RR) Chronic Lymphocytic Leukemia: Phase 3 ASCEND 
Study. Hematological Oncology. 2019;37(S2):86-87. doi:10.1002/hon.54_2629 
29. 
Seymour JF, Kipps TJ, Eichhorst BF, et al. Four-Year Analysis of Murano Study Confirms Sustained 
Benefit of Time-Limited Venetoclax-Rituximab (VenR) in Relapsed/Refractory (R/R) Chronic Lymphocytic 
Leukemia (CLL). Blood. 2019;134(Supplement_1):355-355. doi:10.1182/blood-2019-123930 
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 58 of 84 
30. 
Philip T, Guglielmi C, Hagenbeek A, et al. Autologous bone marrow transplantation as compared 
with salvage chemotherapy in relapses of chemotherapy-sensitive non-Hodgkin's lymphoma. The New 
England journal of medicine. Dec 7 1995;333(23):1540-5.  
31. 
Gisselbrecht C, Glass B, Mounier N, et al. Salvage regimens with autologous transplantation for 
relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. Sep 20 2010;28(27):4184-90. 
doi:JCO.2010.28.1618 [pii] 
10.1200/JCO.2010.28.1618 
32. 
Schouten HC, Qian W, Kvaloy S, et al. High-Dose Therapy Improves Progression-Free Survival and 
Survival in Relapsed Follicular Non-Hodgkin's Lymphoma: Results From the Randomized European CUP 
Trial. J Clin Oncol. November 1, 2003 2003;21(21):3918-3927.  
33. 
Freedman AS, Neuberg D, Mauch P, et al. Long-term follow-up of autologous bone marrow 
transplantation in patients with relapsed follicular lymphoma. Blood. Nov 15 1999;94(10):3325-33.  
34. 
Schouten HC, Qian W, Kvaloy S, et al. High-dose therapy improves progression-free survival and 
survival in relapsed follicular non-Hodgkin's lymphoma: results from the randomized European CUP trial. 
J Clin Oncol. Nov 1 2003;21(21):3918-27.  
35. 
Finke J. The role of stem cell transplantation in the treatment of follicular lymphoma. Semin 
Cancer Biol. Jun 2003;13(3):233-9.  
36. 
Jacobsen E, Freedman A. An update on the role of high-dose therapy with autologous or allogeneic 
stem cell transplantation in mantle cell lymphoma. Curr Opin Oncol. Apr 2004;16(2):106-13.  
37. 
Wang ML, Rule S, Martin P, et al. Targeting BTK with ibrutinib in relapsed or refractory mantle-
cell 
lymphoma. 
The 
New 
England 
journal 
of 
medicine. 
Aug 
8 
2013;369(6):507-16. 
doi:10.1056/NEJMoa1306220 
38. 
Gopal AK, Kahl BS, de Vos S, et al. PI3Kdelta inhibition by idelalisib in patients with relapsed 
indolent lymphoma. The New England journal of medicine. Mar 13 2014;370(11):1008-18. 
doi:10.1056/NEJMoa1314583 
39. 
Gerecitano JF, Roberts AW, Seymour JF, et al. A Phase 1 Study of Venetoclax (ABT-199 / GDC-
0199) Monotherapy in Patients with Relapsed/Refractory Non-Hodgkin Lymphoma. Blood. 
2015;126:Abstract #254.  
40. 
Seymour JF, Kipps TJ, Eichhorst B, et al. Venetoclax-Rituximab in Relapsed or Refractory Chronic 
Lymphocytic Leukemia. The New England journal of medicine. Mar 22 2018;378(12):1107-1120. 
doi:10.1056/NEJMoa1713976 
41. 
Shanafelt TD, Wang XV, Kay NE, et al. Ibrutinib-Rituximab or Chemoimmunotherapy for Chronic 
Lymphocytic Leukemia. The New England journal of medicine. Aug 1 2019;381(5):432-443. 
doi:10.1056/NEJMoa1817073 
42. 
Gribben JG. How and when I do allogeneic transplant in CLL. Blood. May 11 
2018;doi:10.1182/blood-2018-01-785998 
43. 
Kharfan-Dabaja MA, Kumar A, Hamadani M, et al. Clinical Practice Recommendations for Use of 
Allogeneic Hematopoietic Cell Transplantation in Chronic Lymphocytic Leukemia on Behalf of the 
Guidelines Committee of the American Society for Blood and Marrow Transplantation. Biol Blood Marrow 
Transplant. Dec 2016;22(12):2117-2125. doi:10.1016/j.bbmt.2016.09.013 
44. 
Shadman M, Maloney DG, Storer B, et al. Rituximab-based allogeneic transplant for chronic 
lymphocytic leukemia with comparison to historical experience. Bone Marrow Transplant. Sep 3 
2019;doi:10.1038/s41409-019-0660-8 
45. 
Gauthier J, Hirayama AV, Hay KA, et al. Comparison of Efficacy and Toxicity of CD19-Specific 
Chimeric Antigen Receptor T-Cells Alone or in Combination with Ibrutinib for Relapsed and/or Refractory 
CLL. Blood. 2018;132(Suppl 1):299-299. doi:10.1182/blood-2018-99-111061 
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 59 of 84 
46. 
Turtle CJ, Hay KA, Hanafi LA, et al. Durable Molecular Remissions in Chronic Lymphocytic Leukemia 
Treated With CD19-Specific Chimeric Antigen Receptor-Modified T Cells After Failure of Ibrutinib. J Clin 
Oncol. Sep 10 2017;35(26):3010-3020. doi:10.1200/JCO.2017.72.8519 
47. 
Siddiqi T, Soumerai JD, Dorritie KA, et al. Rapid Undetectable MRD (uMRD) Responses in Patients 
with Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) 
Treated with Lisocabtagene Maraleucel (liso-cel), a CD19-Directed CAR T Cell Product: Updated Results 
from Transcend CLL 004, a Phase 1/2 Study Including Patients with High-Risk Disease Previously Treated 
with Ibrutinib. Blood. 2019;134(Supplement_1):503-503. doi:10.1182/blood-2019-127603 
48. 
Calimeri T, Steffanoni S, Gagliardi F, Chiara A, Ferreri AJM. How we treat primary central nervous 
system lymphoma. ESMO Open. Aug 2021;6(4):100213. doi:10.1016/j.esmoop.2021.100213 
49. 
Caimi PF, Ai W, Alderuccio JP, et al. Loncastuximab tesirine in relapsed or refractory diffuse large 
B-cell lymphoma (LOTIS-2): a multicentre, open-label, single-arm, phase 2 trial. Lancet Oncol. Jun 
2021;22(6):790-800. doi:10.1016/S1470-2045(21)00139-X 
50. 
Duell J, Maddocks KJ, Gonzalez-Barca E, et al. Long-term outcomes from the phase II L-MIND study 
of tafasitamab (MOR208) plus lenalidomide in patients with relapsed or refractory diffuse large B-cell 
lymphoma. Haematologica. Aug 19 2021;doi:10.3324/haematol.2021.279802 
51. 
Kalakonda N, Maerevoet M, Cavallo F, et al. Selinexor in patients with relapsed or refractory 
diffuse large B-cell lymphoma (SADAL): a single-arm, multinational, multicentre, open-label, phase 2 trial. 
Lancet Haematol. Jul 2020;7(7):e511-e522. doi:10.1016/S2352-3026(20)30120-4 
52. 
Grommes C, DeAngelis LM. Primary CNS Lymphoma. J Clin Oncol. Jul 20 2017;35(21):2410-2418. 
doi:10.1200/JCO.2017.72.7602 
53. 
Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory 
Large B-Cell Lymphoma. The New England journal of medicine. Dec 28 2017;377(26):2531-2544. 
doi:10.1056/NEJMoa1707447 
54. 
Frigault MJ, Dietrich J, Martinez-Lage M, et al. Tisagenlecleucel CAR T-cell therapy in secondary 
CNS lymphoma. Blood. Sep 12 2019;134(11):860-866. doi:10.1182/blood.2019001694 
55. 
Frigault MJ, Dietrich J, Gallagher KME, et al. Safety and Efficacy of Tisagenlecleucel in Primary CNS 
Lymphoma: A phase I/II clinical trial. Blood. Feb 15 2022;doi:10.1182/blood.2021014738 
56. 
Ghafouri S, Timmerman J, Larson S, Mead MD. Axicabtagene Ciloleucel CAR T-cell therapy for 
relapsed/refractory secondary CNS non-Hodgkin lymphoma: comparable outcomes and toxicities, but 
shorter remissions may warrant alternative consolidative strategies? Bone Marrow Transplant. Apr 
2021;56(4):974-977. doi:10.1038/s41409-020-01099-4 
57. 
Abramson JS, Palomba ML, Gordon LI, et al. Lisocabtagene maraleucel for patients with relapsed 
or refractory large B-cell lymphomas (TRANSCEND NHL 001): a multicentre seamless design study. Lancet. 
Sep 19 2020;396(10254):839-852. doi:10.1016/S0140-6736(20)31366-0 
58. 
Siddiqi T, Wang X, Blanchard MS, et al. CD19-directed CAR T-cell therapy for treatment of primary 
CNS lymphoma. Blood Adv. Oct 26 2021;5(20):4059-4063. doi:10.1182/bloodadvances.2020004106 
59. 
Chang KL, Arber DA, Weiss LM. CD20:  A Review. Applied Immunohistochem. 1996;4:1-15.  
60. 
Reff ME, Carner K, Chambers KS, et al. Depletion of B cells in vivo by a chimeric mouse human 
monoclonal antibody to CD20. Blood. Jan 15 1994;83(2):435-45.  
61. 
Liu SY, Eary JF, Petersdorf SH, et al. Follow-up of relapsed B-cell lymphoma patients treated with 
iodine-131-labeled anti-CD20 antibody and autologous stem-cell rescue. J Clin Oncol. Oct 
1998;16(10):3270-8.  
62. 
Press OW, Eary JF, Gooley T, et al. A phase I/II trial of iodine-131-tositumomab (anti-CD20), 
etoposide, cyclophosphamide, and autologous stem cell transplantation for relapsed B-cell lymphomas. 
Blood. 2000;96(9):2934-42.  
63. 
Martin P, Furman RR, Ruan J, et al. Novel and engineered anti-B-cell monoclonal antibodies for 
non-Hodgkin's lymphoma. Semin Hematol. Apr 2008;45(2):126-32.  
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 60 of 84 
64. 
Sehn LH, Chua N, Mayer J, et al. Obinutuzumab plus bendamustine versus bendamustine 
monotherapy in patients with rituximab-refractory indolent non-Hodgkin lymphoma (GADOLIN): a 
randomised, controlled, open-label, multicentre, phase 3 trial. Lancet Oncol. Aug 2016;17(8):1081-93. 
doi:10.1016/S1470-2045(16)30097-3 
65. 
Goede V, Fischer K, Busch R, et al. Obinutuzumab plus Chlorambucil in Patients with CLL and 
Coexisting Conditions. The New England journal of medicine. Jan 8 2014;doi:10.1056/NEJMoa1313984 
66. 
Cortelezzi A, Sciume M, Liberati AM, et al. Bendamustine in combination with ofatumumab in 
relapsed or refractory chronic lymphocytic leukemia: a GIMEMA Multicenter Phase II Trial. Leukemia. Mar 
2014;28(3):642-8. doi:10.1038/leu.2013.334 
67. 
Wierda WG, Kipps TJ, Mayer J, et al. Ofatumumab as single-agent CD20 immunotherapy in 
fludarabine-refractory chronic lymphocytic leukemia. J Clin Oncol. Apr 1 2010;28(10):1749-55. 
doi:10.1200/JCO.2009.25.3187 
68. 
Klein C, Lammens A, Schafer W, et al. Epitope interactions of monoclonal antibodies targeting 
CD20 
and 
their 
relationship 
to 
functional 
properties. 
MAbs. 
Jan-Feb 
2013;5(1):22-33. 
doi:10.4161/mabs.22771 
69. 
Fujita Y, Leen AM, Sun J, et al. Exploiting cytokine secretion to rapidly produce multivirus-specific 
T cells for adoptive immunotherapy. J Immunother. Sep 2008;31(7):665-74.  
70. 
Riddell SR, Warren EH, Gavin MA, et al. Immunotherapy of human viral and malignant diseases 
with genetically modified T-cell clones. Cancer J. May 2000;6 Suppl 3:S250-8.  
71. 
Berger C, Berger M, Feng J, Riddell SR. Genetic modification of T cells for immunotherapy. Expert 
Opin Biol Ther. Aug 2007;7(8):1167-82.  
72. 
Levine BL. T lymphocyte engineering ex vivo for cancer and infectious disease. Expert Opin Biol 
Ther. Apr 2008;8(4):475-89.  
73. 
Gross G, Eshhar Z. Endowing T cells with antibody specificity using chimeric T cell receptors. Faseb 
J. Dec 1992;6(15):3370-8.  
74. 
Eshhar Z, Waks T, Gross G, Schindler DG. Specific activation and targeting of cytotoxic lymphocytes 
through chimeric single chains consisting of antibody-binding domains and the gamma or zeta subunits of 
the immunoglobulin and T-cell receptors. Proc Natl Acad Sci U S A. Jan 15 1993;90(2):720-4.  
75. 
Eshhar Z. The T-body approach: redirecting T cells with antibody specificity. Handb Exp Pharmacol. 
2008;181(181):329-42.  
76. 
Gonzalez S, Naranjo A, Serrano LM, Chang WC, Wright CL, Jensen MC. Genetic engineering of 
cytolytic T lymphocytes for adoptive T-cell therapy of neuroblastoma. J Gene Med. Jun 2004;6(6):704-11.  
77. 
Brentjens RJ. Novel approaches to immunotherapy for B-cell malignancies. Curr Hematol Rep. Jan 
2005;4(1):64-72.  
78. 
Jensen MC, Clarke P, Tan G, et al. Human T lymphocyte genetic modification with naked DNA. Mol 
Ther. Jan 2000;1(1):49-55.  
79. 
Jensen MC, Cooper LJ, Wu AM, Forman SJ, Raubitschek A. Engineered CD20-specific primary 
human cytotoxic T lymphocytes for targeting B-cell malignancy. Cytotherapy. 2003;5(2):131-8.  
80. 
Abrey LE, Batchelor TT, Ferreri AJ, et al. Report of an international workshop to standardize 
baseline evaluation and response criteria for primary CNS lymphoma. J Clin Oncol. Aug 1 
2005;23(22):5034-43. doi:10.1200/JCO.2005.13.524 
81. 
Wang J, Press OW, Lindgren CG, et al. Cellular immunotherapy for follicular lymphoma using 
genetically modified CD20-specific CD8+ cytotoxic T lymphocytes. Mol Ther. Apr 2004;9(4):577-86.  
82. 
Chen EY, Press OW, Jensen MC. CD8 immunomagnetic selection and interleukin-15 (IL-15) 
facilitate the isolation of human CD8+ cytotoxic T-lymphocytes (CTL) genetically engineered to express an 
anti-CD20 chimeric T-cell receptor (cTCR). ASCO Meeting Abstracts. September 3, 2004 
2004;22(14_suppl):2542.  
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 61 of 84 
83. 
James SE, Greenberg PD, Jensen MC, et al. Antigen sensitivity of CD22-specific chimeric TCR is 
modulated by target epitope distance from the cell membrane. J Immunol. May 15 2008;180(10):7028-
38.  
84. 
Wang J, Jensen M, Lin Y, et al. Optimizing adoptive polyclonal T cell immunotherapy of 
lymphomas, using a chimeric T cell receptor possessing CD28 and CD137 costimulatory domains. Hum 
Gene Ther. Aug 2007;18(8):712-25.  
85. 
Till BG, Jensen MC, Wang J, et al. CD20-specific adoptive immunotherapy for lymphoma using a 
chimeric antigen receptor with both CD28 and 4-1BB domains: pilot clinical trial results. Blood. Apr 26 
2012;119(17):3940-50. doi:blood-2011-10-387969 [pii] 
10.1182/blood-2011-10-387969 
86. 
Logan AC, Lutzko C, Kohn DB. Advances in lentiviral vector design for gene-modification of 
hematopoietic stem cells. Curr Opin Biotechnol. Oct 2002;13(5):429-36.  
87. 
Levine BL, Humeau LM, Boyer J, et al. Gene transfer in humans using a conditionally replicating 
lentiviral vector. Proc Natl Acad Sci U S A. Nov 14 2006;103(46):17372-7.  
88. 
Dropulic B, June CH. Gene-based immunotherapy for human immunodeficiency virus infection 
and acquired immunodeficiency syndrome. Hum Gene Ther. Jun 2006;17(6):577-88.  
89. 
Becker PS, Taylor JA, Trobridge GD, et al. Preclinical correction of human Fanconi anemia 
complementation group A bone marrow cells using a safety-modified lentiviral vector. Research Support, 
N.I.H., Extramural 
Research Support, Non-U.S. Gov't. Gene therapy. Oct 2010;17(10):1244-52. doi:10.1038/gt.2010.62 
90. 
Turtle CJ, Hanafi LA, Berger C, et al. CD19 CAR-T cells of defined CD4+:CD8+ composition in adult 
B cell ALL patients. J Clin Invest. Jun 1 2016;126(6):2123-38. doi:10.1172/JCI85309 
91. 
Bornstein GG, Queva C, Tabrizi M, et al. Development of a new fully human anti-CD20 monoclonal 
antibody for the treatment of B-cell malignancies. Invest New Drugs. Oct 2010;28(5):561-74. 
doi:10.1007/s10637-009-9291-z 
92. 
Guest RD, Hawkins RE, Kirillova N, et al. The role of extracellular spacer regions in the optimal 
design of chimeric immune receptors: evaluation of four different scFvs and antigens. J Immunother. May-
Jun 2005;28(3):203-11. doi:00002371-200505000-00005 [pii] 
93. 
Haso W, Lee DW, Shah NN, et al. Anti-CD22-chimeric antigen receptors targeting B-cell precursor 
acute lymphoblastic leukemia. Research Support, N.I.H., Intramural. Blood. Feb 14 2013;121(7):1165-74. 
doi:10.1182/blood-2012-06-438002 
94. 
Hudecek M, Lupo-Stanghellini MT, Kosasih PL, et al. Receptor affinity and extracellular domain 
modifications affect tumor recognition by ROR1-specific chimeric antigen receptor T cells. Clin Cancer Res. 
Jun 15 2013;19(12):3153-64. doi:10.1158/1078-0432.CCR-13-0330 
95. 
Zah E, Lin MY, Silva-Benedict A, Jensen MC, Chen YY. T Cells Expressing CD19/CD20 Bispecific 
Chimeric Antigen Receptors Prevent Antigen Escape by Malignant B Cells. Cancer Immunol Res. Apr 8 
2016;[Epub ahead of print]doi:10.1158/2326-6066.CIR-15-0231 
96. 
Hudecek M, Sommermeyer D, Kosasih PL, et al. The nonsignaling extracellular spacer domain of 
chimeric antigen receptors is decisive for in vivo antitumor activity. Cancer Immunol Res. Feb 
2015;3(2):125-35. doi:10.1158/2326-6066.CIR-14-0127 
97. 
Budde LE, Berger C, Lin Y, et al. Combining a CD20 Chimeric Antigen Receptor and an Inducible 
Caspase 9 Suicide Switch to Improve the Efficacy and Safety of T Cell Adoptive Immunotherapy for 
Lymphoma. PloS one. 2013;8(12):e82742. doi:10.1371/journal.pone.0082742 
98. 
Davis TA, Czerwinski DK, Levy R. Therapy of B-cell lymphoma with anti-CD20 antibodies can result 
in the loss of CD20 antigen expression. Clin Cancer Res. Mar 1999;5(3):611-5.  
99. 
Johnson NA, Leach S, Woolcock B, et al. CD20 mutations involving the rituximab epitope are rare 
in diffuse large B-cell lymphomas and are not a significant cause of R-CHOP failure. Research Support, 
Non-U.S. Gov't. Haematologica. Mar 2009;94(3):423-7. doi:10.3324/haematol.2008.001024 
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 62 of 84 
100. 
Rufener GA, Press OW, Olsen P, et al. Preserved Activity of CD20-Specific Chimeric Antigen 
Receptor-Expressing T Cells in the Presence of Rituximab. Cancer Immunol Res. Jun 2016;4(6):509-19. 
doi:10.1158/2326-6066.CIR-15-0276 
101. 
Davila ML, Riviere I, Wang X, et al. Efficacy and toxicity management of 19-28z CAR T cell therapy 
in B cell acute lymphoblastic leukemia. Research Support, Non-U.S. Gov't. Sci Transl Med. Feb 19 
2014;6(224):224ra25. doi:10.1126/scitranslmed.3008226 
102. 
Maude SL, Frey N, Shaw PA, et al. Chimeric antigen receptor T cells for sustained remissions in 
leukemia. Clinical Trial, Phase I 
Clinical Trial, Phase II 
Research Support, N.I.H., Extramural 
Research Support, Non-U.S. Gov't. The New England journal of medicine. Oct 16 2014;371(16):1507-17. 
doi:10.1056/NEJMoa1407222 
103. 
Kochenderfer JN, Dudley ME, Kassim SH, et al. Chemotherapy-refractory diffuse large B-cell 
lymphoma and indolent B-cell malignancies can be effectively treated with autologous T cells expressing 
an anti-CD19 chimeric antigen receptor. Clinical Trial 
Research Support, N.I.H., Extramural 
Research 
Support, 
N.I.H., 
Intramural. 
J 
Clin 
Oncol. 
Feb 
20 
2015;33(6):540-9. 
doi:10.1200/JCO.2014.56.2025 
104. 
Porter DL, Hwang WT, Frey NV, et al. Chimeric antigen receptor T cells persist and induce 
sustained remissions in relapsed refractory chronic lymphocytic leukemia. Sci Transl Med. Sep 2 
2015;7(303):303ra139. doi:10.1126/scitranslmed.aac5415 
105. 
Sommermeyer D, Hudecek M, Kosasih PL, et al. Chimeric antigen receptor-modified T cells derived 
from defined CD8 and CD4 subsets confer superior antitumor reactivity in vivo. Leukemia. Sep 15 
2015;doi:10.1038/leu.2015.247 
106. 
Brentjens RJ, Riviere I, Park JH, et al. Safety and persistence of adoptively transferred autologous 
CD19-targeted T cells in patients with relapsed or chemotherapy refractory B-cell leukemias. Blood. Nov 
3 2011;118(18):4817-28. doi:blood-2011-04-348540 [pii] 
10.1182/blood-2011-04-348540 
107. 
Moeller M, Haynes NM, Kershaw MH, et al. Adoptive transfer of gene-engineered CD4+ helper T 
cells induces potent primary and secondary tumor rejection. Blood. Nov 1 2005;106(9):2995-3003.  
108. 
Berger C, Jensen MC, Lansdorp PM, Gough M, Elliott C, Riddell SR. Adoptive transfer of effector 
CD8+ T cells derived from central memory cells establishes persistent T cell memory in primates. J Clin 
Invest. Jan 2008;118(1):294-305.  
109. 
Toes RE, Ossendorp F, Offringa R, Melief CJ. CD4 T cells and their role in antitumor immune 
responses. J Exp Med. Mar 1 1999;189(5):753-6.  
110. 
Adusumilli PS, Cherkassky L, Villena-Vargas J, et al. Regional delivery of mesothelin-targeted CAR 
T cell therapy generates potent and long-lasting CD4-dependent tumor immunity. Sci Transl Med. Nov 5 
2014;6(261):261ra151. doi:10.1126/scitranslmed.3010162 
111. 
Fraietta JA, Lacey SF, Orlando EJ, et al. Determinants of response and resistance to CD19 chimeric 
antigen receptor (CAR) T cell therapy of chronic lymphocytic leukemia. Nat Med. May 2018;24(5):563-
571. doi:10.1038/s41591-018-0010-1 
112. 
Dudley ME, Wunderlich JR, Yang JC, et al. Adoptive cell transfer therapy following non-
myeloablative but lymphodepleting chemotherapy for the treatment of patients with refractory 
metastatic melanoma. J Clin Oncol. Apr 1 2005;23(10):2346-57.  
113. 
Gattinoni L, Finkelstein SE, Klebanoff CA, et al. Removal of homeostatic cytokine sinks by 
lymphodepletion enhances the efficacy of adoptively transferred tumor-specific CD8+ T cells. J Exp Med. 
Oct 3 2005;202(7):907-12.  
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 63 of 84 
114. 
Proietti E, Greco G, Garrone B, et al. Importance of cyclophosphamide-induced bystander effect 
on T cells for a successful tumor eradication in response to adoptive immunotherapy in mice. J Clin Invest. 
Jan 15 1998;101(2):429-41.  
115. 
Bracci L, Moschella F, Sestili P, et al. Cyclophosphamide enhances the antitumor efficacy of 
adoptively transferred immune cells through the induction of cytokine expression, B-cell and T-cell 
homeostatic proliferation, and specific tumor infiltration. Clin Cancer Res. Jan 15 2007;13(2 Pt 1):644-53.  
116. 
Rosenberg SA, Dudley ME. Adoptive cell therapy for the treatment of patients with metastatic 
melanoma. Curr Opin Immunol. Apr 2009;21(2):233-40.  
117. 
Koike N, Pilon-Thomas S, Mule JJ. Nonmyeloablative chemotherapy followed by T-cell adoptive 
transfer and dendritic cell-based vaccination results in rejection of established melanoma. J Immunother. 
May 2008;31(4):402-12.  
118. 
Muranski P, Boni A, Wrzesinski C, et al. Increased intensity lymphodepletion and adoptive 
immunotherapy--how far can we go? Nat Clin Pract Oncol. Dec 2006;3(12):668-81.  
119. 
Wallen H, Thompson JA, Reilly JZ, Rodmyre RM, Cao J, Yee C. Fludarabine modulates immune 
response and extends in vivo survival of adoptively transferred CD8 T cells in patients with metastatic 
melanoma. PloS one. 2009;4(3):e4749. doi:10.1371/journal.pone.0004749 
120. 
Berd D, Mastrangelo MJ. Effect of low dose cyclophosphamide on the immune system of cancer 
patients: reduction of T-suppressor function without depletion of the CD8+ subset. Cancer Res. Jun 15 
1987;47(12):3317-21.  
121. 
Schuster SJ, Bishop MR, Tam CS, et al. Tisagenlecleucel in Adult Relapsed or Refractory Diffuse 
Large B-Cell Lymphoma. The New England journal of medicine. Jan 3 2019;380(1):45-56. 
doi:10.1056/NEJMoa1804980 
122. 
Fowler NH, Dickinson M, Dreyling M, et al. Tisagenlecleucel in adult relapsed or refractory 
follicular lymphoma: the phase 2 ELARA trial. Nat Med. Feb 2022;28(2):325-332. doi:10.1038/s41591-021-
01622-0 
123. 
Kymriah (tisagenlecleucel) [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals 
Corporation ;May 2022.  
124. 
Ghilardi G, Chong EA, Svoboda J, et al. Bendamustine is safe and effective for lymphodepletion 
before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas. Ann Oncol. Sep 
2022;33(9):916-928. doi:10.1016/j.annonc.2022.05.521 
125. 
Maziarz RT, Diaz A, Miklos DB, Shah NN. Perspective: An International Fludarabine Shortage: 
Supply Chain Issues Impacting Transplantation and Immune Effector Cell Therapy Delivery. Transplant Cell 
Ther. Aug 6 2022;doi:10.1016/j.jtct.2022.08.002 
126. 
Riddell SR, Elliott M, Lewinsohn DA, et al. T-cell mediated rejection of gene-modified HIV-specific 
cytotoxic T lymphocytes in HIV-infected patients. Nat Med. Feb 1996;2(2):216-23.  
127. 
Cheson BD, Pfistner B, Juweid ME, et al. Revised response criteria for malignant lymphoma. J Clin 
Oncol. Feb 10 2007;25(5):579-86.  
128. 
Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and 
response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. Sep 
20 2014;32(27):3059-68. doi:10.1200/JCO.2013.54.8800 
129. 
Hallek M, Cheson BD, Catovsky D, et al. iwCLL guidelines for diagnosis, indications for treatment, 
response assessment, and supportive management of CLL. Blood. Jun 21 2018;131(25):2745-2760. 
doi:10.1182/blood-2017-09-806398 
130. 
Owen RG, Kyle RA, Stone MJ, et al. Response assessment in Waldenstrom macroglobulinaemia: 
update 
from 
the 
VIth 
International Workshop. 
Br 
J 
Haematol. 
Jan 
2013;160(2):171-6. 
doi:10.1111/bjh.12102 
131. 
Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J 
Haematol. Oct 2004;127(1):3-11. doi:10.1111/j.1365-2141.2004.05094.x 
Fred Hutch IRB
Approved 
8/2/2023

Protocol 9738 
 Version 18 – 01/06/2023                      Page 64 of 84 
132. 
Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. The New England journal of medicine. 
May 12 2011;364(19):1844-54. doi:10.1056/NEJMra0904569 
133. 
Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and 
adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. Jun 1 2008;26(16):2767-78. 
doi:10.1200/JCO.2007.15.0177 
134. 
Das R, Guan P, Sprague L, et al. Janus kinase inhibition lessens inflammation and ameliorates 
disease in murine models of hemophagocytic lymphohistiocytosis. Blood. Mar 31 2016;127(13):1666-75. 
doi:10.1182/blood-2015-12-684399 
135. 
O'Quigley J, Pepe M, Fisher L. Continual reassessment method: a practical design for phase 1 
clinical trials in cancer. Biometrics. Mar 1990;46(1):33-48.  
136. 
Lee DW, Santomasso BD, Locke FL, et al. ASTCT Consensus Grading for Cytokine Release Syndrome 
and Neurologic Toxicity Associated with Immune Effector Cells. Biol Blood Marrow Transplant. Apr 
2019;25(4):625-638. doi:10.1016/j.bbmt.2018.12.758 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDICES 
Appendix A: 
Study Calendar  
Appendix B: 
Karnofsky Performance Status Scale  
Appendix C: 
Grading Criteria for CRS 
Appendix D:     Lugano Response Criteria 
Appendix E:     iwCLL Response Criteria 
Appendix F: 
Long-term follow-up 
Appendix G:  Long term follow-up provider questionnaire 
Appendix H: 
Long term follow-up subject questionnaire 
Appendix I:      ASTCT ICANS consensus grading of neurological toxicity  
Appendix J:      iwWM Response Criteria 
Appendix K:     CNS Lymphoma Response Criteria 
  
 
 
 
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APPENDIX A:  STUDY CALENDAR 
 
 
Screening
Leuka-
pheresis 
Prior to 
lympho-
depleting 
chemo-
therapy 
Lympho-
depleting 
Chemo-
therapy 
Prior to T 
cell 
infusion 
CD20 CAR 
T cell 
infusion 
Days after T cell infusion 
Months after T cell 
infusion27 
Annually for 
15 years 
following T cell 
infusion 
 
1 
4 
7 
10 
14 
21 
28 
3 
6 
12 
Informed Consent 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History, 
Physical Exam1,3 
x 
 
x 
 
x 
 
x 
 
x 
 
x 
x 
x 
 
 
 
 
Karnofsky performance 
status 
x 
 
x 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
Vital Signs including 
pulse oximetry 
x 
 
 
 
 
x24 
 
 
 
 
 
 
 
 
 
 
 
CBC w/ differential 
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
Basic metabolic panel 
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Hepatic panel w/LDH  
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Fred Hutch (PSBC) 
Donor Battery Panel  
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum pregnancy test2 
x 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Beta-2 microglobulin 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum ferritin25 
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Serum CRP25 
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Serum protein 
electrophoresis & 
immunofixation27 
x 
 
X28 
 
 
 
 
 
 
 
 
 
x 
x 
x 
x 
 
Uric acid  
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Phosphate 
x 
 
x 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Serum IL-6 
x 
 
 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
PT/PTT 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DIC panel without 
platelets4 
 
 
 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
IgG level 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
x 
 
IgA, IgG, IgM  
x 
 
 
 
 
 
 
 
 
 
 
 
 
x5 
 
x5 
 
12-lead EKG 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest x-ray 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echo or MUGA 
x 
 
 
 
x23 
 
 
 
 
 
 
 
 
 
 
 
 

Protocol 9738 
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Screening
Leuka-
pheresis 
Prior to 
lympho-
depleting 
chemo-
therapy 
Lympho-
depleting 
Chemo-
therapy 
Prior to T 
cell 
infusion 
CD20 CAR 
T cell 
infusion 
Days after T cell infusion 
Months after T cell 
infusion27 
Annually for 
15 years 
following T cell 
infusion 
 
1 
4 
7 
10 
14 
21 
28 
3 
6 
12 
Flow cytometry for MRD 
x 
 
 
 
 
 
 
 
 
 
 
 
x 
x17 
x17 
x17 
 
CT scans of neck, chest, 
abdomen and pelvis 
x6 
 
 
 
 
 
 
 
 
 
 
 
x 
 
x7 
x7 
 
PET scan6, 7 
x6,7 
 
 
 
 
 
 
 
 
 
 
 
x6,7
, 31 
 
x6,7 
x6,7 
 
MRI29 
x 
 
x 
 
 
 
 
 
 
 
 
 
x 
 
x 
x 
 
BM biopsy/aspirate8 
x32 
 
 
 
 
 
 
 
 
 
 
 
x9 
 
x9 
x9 
 
Lumbar puncture10 
x 
 
 
 
 
 
 
 
 
 
x 
 
x 
 
 
 
 
Tumor biopsy 
x11, 30 
 
 
 
 
 
 
 
x12 
 
 
 
 
 
x12 
Immunophenotyping for 
CD3, CD4, CD8 
10 mL EDTA (lavender 
top) tube13 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PBMC baseline samples 
60 mL EDTA (lavender 
top) tube 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum baseline sample 
20 mL serum separator 
tube 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serum cytokine levels  
10 mL serum separator 
tube14 
x 
 
 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
 
 
 
 
Leukapheresis 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lymphodepleting 
chemotherapy 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
CD20 CAR T cell infusion 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
PBMC for CAR T cell 
persistence 
20 mL EDTA (lavender 
top) tube15 
 
 
 
 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
x16 

Protocol 9738 
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Screening
Leuka-
pheresis 
Prior to 
lympho-
depleting 
chemo-
therapy 
Lympho-
depleting 
Chemo-
therapy 
Prior to T 
cell 
infusion 
CD20 CAR 
T cell 
infusion 
Days after T cell infusion 
Months after T cell 
infusion27 
Annually for 
15 years 
following T cell 
infusion 
 
1 
4 
7 
10 
14 
21 
28 
3 
6 
12 
B cell deep sequencing 
10 mL EDTA (lavender 
top) tube  
 
 
 
 
 
 
 
 
 
 
x 
 
x 
x17 
x17 
x17 
x18 
Bone marrow aspirate 
5-10 mL EDTA (lavender 
top) tube 
x19 
 
 
 
 
 
x17,19 
 
Other tissue 
e.g. CSF, pleural fluid 
x19 
 
 
 
 
 
x17,19 
 
PBMC transgene 
immunogenicity 
20 mL EDTA (lavender 
top) tubes 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x20 
x20 
 
 
Serum transgene 
immunogenicity 
10 mL serum separator 
tube 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 x20 
x20 
 
 
PBMC anti-tumor 
immune response 
20 mL EDTA (lavender 
top) tube 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x21 
x21 
x21 
 
Serum anti-tumor 
immune response 
10 mL serum separator 
tube 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x21 
x21 
x21 
 
T cell repertoire by deep 
sequencing (PBMC) 
10 mL EDTA (lavender 
top) tube 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x21 
x21 
 
 
B cell quantitation  
5 ml EDTA (lavender 
top) tube 
x26 
 
 
 
 
 
 
 
 
 
 
 
x 
x17 
x17 
x17 
 
PBMC archive sample 
30 mL EDTA (lavender 
top) tube 
x 
 
x 
 
 
 
x 
x  
x 
x 
x 
 

Protocol 9738 
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Screening
Leuka-
pheresis 
Prior to 
lympho-
depleting 
chemo-
therapy 
Lympho-
depleting 
Chemo-
therapy 
Prior to T 
cell 
infusion 
CD20 CAR 
T cell 
infusion 
Days after T cell infusion 
Months after T cell 
infusion27 
Annually for 
15 years 
following T cell 
infusion 
 
1 
4 
7 
10 
14 
21 
28 
3 
6 
12 
Serum archive sample 
10 mL serum separator 
tube 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
RCL testing by  
VSV-G Q-PCR 
10 mL EDTA (lavender 
top) tube 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
x22 
Long-term follow-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x22 
 
 
1: History to include hematologic, cytogenetic, flow cytometric, and histologic findings at diagnosis and at present (if available) as well as prior therapies and response to therapy.  
2: For women of childbearing potential, within 14 days of leukapheresis and lymphodepletion. 
3: Adverse Events should be monitored as outlined in section 11 of the protocol. 
4: Additional PT/PTT, fibrinogen, and D-dimer labs may be drawn if patients develop symptoms of cytokine storm. 
5: Recommended testing as per 8.4.5. 
6: PET obtained if possible. PET/CT scan and diagnostic contrast-enhanced CT scans of the neck, chest, abdomen, and pelvis within 42 days of enrollment. PET scan is optional for patients with CLL/SLL. 
Post-treatment scans should be performed at day 28 (± 5 days). 
7: Post-treatment PET-CT scans do not need to be repeated after a CR is achieved. Subsequent imaging after a CR should be a CT scan only. Further imaging studies may be ceased if the patient proceeds 
to other anti-tumor therapy. 
8: Bone marrow aspirates/biopsies should be sent for pathology analysis as clinically indicated and according to the protocol. A 5-10 ml aliquot of the bone marrow aspirate in an EDTA [lavender top] 
tube should be sent to the Specimen Processing / Research Cell Bank Lab at Fred Hutch. 
9: A day 28 BM biopsy is needed if there was lymphoma detectable in the screening BM biopsy. See section 8.4.9. Other BM biopsies may be necessary at 6 or 12 months if the prior bone marrow 
samples showed evidence of disease 
10: Lumbar puncture (for primary and secondary CNS lymphoma patients). Clinical samples for cell count and flow cytometry should be collected, as well as a 2 ml research sample that should be sent 
to the Till Lab. 
11: See section 8.1.12. 
12: See sections 8.4.7 and 8.4.8 
13: Fresh sample to Till Lab. 
14: In addition to these times, blood samples should be sent to the Specimen Processing / Research Cell Bank Lab at Fred Hutch if there is a suspicion of cytokine storm or macrophage activation 
syndrome. Discuss with PI or designee. 
15: In addition to these times, blood samples should be sent to the Specimen Processing / Research Cell Bank Lab at Fred Hutch if there is a significant clinical event that may be related to CAR T cells, 
in the opinion of the treating physician. Discuss with PI or designee.  
16: Monitor PBMC by PCR every 6 months for years 1 to 5 and every year for years 6-15 until the transgene becomes undetectable. 
17: May be discontinued after day 28 in patients who proceed to other systemic therapy, or if CAR T cell engraftment is lost, or at the discretion of the PI. 
18: If a deficiency of B cells persists beyond 12 months or there are persisting CD20 CAR T cells, additional samples may be obtained to monitor B cell numbers every 6 months.  
19: Any time a bone marrow biopsy/aspirate/lumbar puncture/other tissue collection is performed for a clinical indication. Additional tissue may be obtained during a procedure and sent to the 
Specimen Processing/Research Cell Bank Lab at the Fred Hutch for research studies. Please discuss the planned procedure with the study PI. 
20: In the event CAR T cell persistence is lost by day 30. 

Protocol 9738 
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21: Only in patients who achieved at least a partial remission before this point. 
22: See Appendix F. 
23: Necessary if patient has received cardiotoxic chemotherapy since signing enrollment consent form. 
24: Vital signs including pulse oximetry on the day of the CAR T infusion: Before infusion, every 15 minutes during infusion, and every hour for 2 hours after end of infusion.  
25: Additional tests such as serum ferritin, CRP, and PFT may be performed as clinically indicated. 
26: For the screening timepoint, the B cell quantitation can be performed using the same 5 ml EDTA tube as for “Flow cytometry for MRD.”27: T cell infusion time points represent guidelines for 
performance of required evaluations. Due to numerous factors influencing scheduling (subject and provider availability, testing services limitations, etc.), variation in evaluation performance dates is 
anticipated and acceptable to the protocol (i.e. within ± 5 days of time points < day 30; ± 30 days for timepoints > day 30. 
27: For patients with WM only 
28: Only needed for WM patients who received interim therapy since baseline assessments 
29: Only for patients with CNS lymphoma.  
30: The tumor biopsy is optional for patients with primary or secondary CNS lymphoma, and for WM and CLL/SLL patients who have peripheral blood or bone marrow involvement that can be used to 
document CD20 expression. 
31: The day 28 PET-CT is optional for primary CNS lymphoma patients without evidence of systemic disease on baseline PET-CT. 
32: see section 8.1.21 for details. Patients with CLL/SLL and WM who did not undergo a tumor biopsy at baseline should have an additional 3 ml bone marrow aspirate sample in an EDTA tube to the 
Till Lab.

9738  
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APPENDIX B:  KARNOFSKY PERFORMANCE STATUS SCALE 
 
 
General 
Index (%) 
Specific Criteria 
Able to carry on normal activity; no 
special care needed 
100 
Normal, no complaints, no evidence of 
disease 
90 
Able to carry on normal activity, minor 
signs or symptoms of disease 
80 
Normal activity with effort, some signs or 
symptoms of disease 
Unable to work, able to live at home and 
care for most personal needs, varying 
amount of assistance needed 
70 
Cares for self, unable to carry on normal 
activity or to do work 
60 
Requires occasional assistance from 
others but able to care for most needs 
50 
Requires considerable assistance from 
others and frequent medical care 
Unable to care for self, requires 
institutional or hospital care or 
equivalent; disease may be rapidly 
progressing 
40 
Disabled; requires special care and 
assistance 
30 
Severely disabled, hospitalization 
indicated, death not imminent 
20 
Very sick, hospitalization necessary, 
active supportive treatment necessary 
10 
Moribund 
0 
Dead 
 
 
 
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APPENDIX C:  GRADING CRITERIA FOR CRS (ASTCT CRS CONSENSUS GRADING - 2019) 
 
CRS PARAMETER 
GRADE 1 
GRADE 2 
GRADE 3 
GRADE 4 
FEVER * 
TEMPERATURE ≥ 38°C 
TEMPERATURE ≥ 38°C 
TEMPERATURE ≥ 38°C 
TEMPERATURE ≥ 38°C 
 
WITH 
HYPOTENSION  
NONE 
NOT REQUIRING 
VASOPRESSORS 
REQUIRING A VASOPRESSOR 
WITH OR WITHOUT 
VASOPRESSIN 
REQUIRING MULTIPLE 
VASOPRESSORS 
(EXCLUDING VASOPRESSIN) 
 
AND/OR † 
HYPOXIA 
NONE 
REQUIRING LOW-
FLOW NASAL 
CANNULA ** OR 
BLOW-BY 
REQUIRING HIGH-FLOW 
NASAL CANNULA,** 
FACEMASK,  
NONREBREATHER 
MASK, OR VENTURI MASK 
REQUIRING POSITIVE 
PRESSURE (EG, 
CPAP, BIPAP, INTUBATION 
AND 
MECHANICAL VENTILATION) 
* Fever is defined as temperature 38°C not attributable to any other cause. In patients who have CRS then receive antipyretic or anticytokine therapy such as tocilizumab 
or steroids, fever is no longer required to grade subsequent CRS severity. In this case, CRS grading is driven by hypotension and/or hypoxia. 
 †CRS grade is determined by the more severe event: hypotension or hypoxia not attributable to any other cause. For example, a patient with temperature of 39.5°C, 
hypotension requiring 1 vasopressor, and hypoxia requiring low-flow nasal cannula is classified as grade 3 CRS. 
** Low-flow nasal cannula is defined as oxygen delivered at ≤6 L/minute. Low flow also includes blow-by oxygen delivery, sometimes used in pediatrics. High-flow 
nasal cannula is defined as oxygen delivered at >6 L/minute. 
(Adopted from Lee et al. BBMT, 2019)  
Please refer to the publication for details 136 
 
 

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APPENDIX D:  LUGANO RESPONSE CRITERIA 
 
Response and Site 
PET-CT−Based Response 
CT-Based Response 
Complete Response 
Complete metabolic response 
Complete radiologic response (all of the following): 
Lymph nodes and extralymphatic sites 
Score 1, 2, or 3a with or without a residual mass on 5PSb  
It is recognized that in Waldeyer’s ring or extranodal sites with high 
physiologic uptake or with activation within spleen or marrow (e.g., 
with chemotherapy or myeloid colony-stimulating factors), uptake 
may be greater than normal mediastinum and/or liver. In this 
circumstance, complete metabolic response may be inferred if 
uptake at sites of initial involvement is no greater than surrounding 
normal tissue even if the tissue has high physiologic uptake. 
 Target nodes/nodal masses must regress to ≤ 1.5 cm in LDi 
 No extralymphatic sites of disease 
Nonmeasured lesion 
Not applicable 
Absent 
Organ enlargement 
Not applicable 
Regress to normal 
New lesions 
None 
None 
Bone marrow 
No evidence of FDG-avid disease in marrow 
Normal by morphology; if indeterminate, IHC-negative 
Partial Response 
Partial metabolic response 
Partial remission (all of the following): 
Lymph nodes and extralymphatic sites 
Score 4 or 5b with reduced uptake compared with baseline and 
residual mass(es) of any size 
At interim, these sites suggest responding disease;  
At end of treatment, these findings indicate residual disease 
 ≥ 50% decrease in SPD of up to 6 target measurable nodes 
and extranodal sites 
 When a lesion is too small to measure on CT, assign 5 mm x 5 
mm as the default value 
 When no longer visible, 0 mm x 0 mm 
 For a node >5 mm x 5 mm, but smaller than normal; use 
actual measurement for calculation 
Nonmeasured lesion 
Not applicable 
Absent/normal, regressed, but no increase 
Organ enlargement 
Not applicable 
Spleen must have regressed by > 50% in length beyond normal  
New lesions 
None 
None 
Bone marrow 
Residual uptake higher than uptake in normal marrow but reduced 
compared with baseline (diffuse uptake compatible with reactive 
changes from chemotherapy allowed). If there are persistent focal 
changes in the marrow in the context of a nodal response, 
consideration should be given to further evaluation with MRI or 
biopsy or an interval scan 
 
No Response or Stable Disease 
No metabolic response 
Stable disease 

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Target nodes/nodal masses, extranodal 
lesions 
Score 4 or 5 with no significant change in FDG uptake from baseline 
at interim or end of treatment 
< 50% decrease from baseline in SPD of up to 6 dominant, 
measurable nodes and extranodal sites; no criteria for 
progressive disease are met.  
Nonmeasured lesion 
Not applicable 
No increase consistent with progression 
Organ enlargement 
Not applicable 
No increase consistent with progression 
New lesions 
None 
None 
Bone marrow 
No change from baseline 
Not applicable 
Progressive Disease 
Progressive metabolic disease 
Progressive disease requires at least one of  
the following: 
Individual target nodes/nodal masses 
Score 4 or 5 with an increase in intensity of uptake from baseline  
and/or 
 
An individual node/lesion must be abnormal with: 
Extranodal lesion 
New FDG-avid foci consistent with lymphoma 
 LDi > 1.5 cm AND  
 Increase by ≥ 50% from PPD nadir AND  
 An increase in LDi or SDi from nadir  
 
0.5 cm for lesions ≤ 2 cm  
 
1.0 cm for lesions > 2 cm  
 In the setting of splenomegaly, the splenic length must 
increase by >50% of the extent of its prior increase beyond 
baseline (e.g., a 15 cm spleen must increase to >16 cm). If no 
prior splenomegaly, must increase by at least 2 cm from 
baseline  
• New or recurrent splenomegaly 
Nonmeasured lesions 
None 
New or clear progression of preexisting nonmeasured lesions
New Lesions 
 
 
 
New FDG-avid foci consistent with lymphoma rather than another 
etiology (e.g., infection, inflammation). If uncertain regarding 
etiology of new lesions, biopsy or interval scan may be considered.  
 Regrowth of previously resolved lesions 
 A new node >1.5 cm in any axis 
 A new extranodal site >1.0 cm in any axis; if < 1.0 cm in any 
axis, its presence must be unequivocal and must be 
attributable to lymphoma 
 Assessable disease of any size unequivocally attributable to 
lymphoma   
Bone Marrow 
New or recurrent FDG-avid foci 
New or recurrent involvement 
   
5PS= 5-point scale; CT= computed tomography; FDG= fluorodeoxyglucose; GI = gastrointestinal; IHC= immunohistochemistry; LDi, longest transverse diameter of a lesion; MRI = magnetic 
resonance imaging; PET= positron emission tomography; PPD = cross product of the LDi and perpendicular diameter; SDi = shortest axis perpendicular to the LDi; SPD = sum of the product 
of the perpendicular diameters for multiple lesions.  
 
a score of 3 in many patients indicates a good prognosis with standard treatment, especially if at the time of an interim scan. However, in studies involving PET where de-escalation is 
investigated, it may be preferable to consider a score of 3 as inadequate response (to avoid undertreatment). Measured dominant lesions: up to six of the largest dominant nodes, nodal 
masses, and extranodal lesions selected to be clearly measurable in two diameters. Nodes should preferably be from disparate regions of the body and should include, where applicable, 

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mediastinal and retroperitoneal areas. Non-nodal lesions include those in solid organs (e.g., liver, spleen, kidneys, lungs), GI involvement, cutaneous lesions, or those noted on palpation. 
Nonmeasured lesions: any disease not selected as measured, dominant disease and truly assessable disease should be considered not measured. These sites include any nodes, nodal 
masses, and extranodal sites not selected as dominant or measurable or that do not meet the requirements for measurability but are still considered abnormal, as well as truly assessable 
disease, which is any site of suspected disease that would be difficult to follow quantitatively with measurement, including pleural effusions, ascites, bone lesions, leptomeningeal disease, 
abdominal masses, and other lesions that cannot be confirmed and followed by imaging. In effusions, ascites, bone lesions, leptomeningeal disease, abdominal masses, and other lesions 
that cannot be confirmed and followed by imaging. In Waldeyer’s ring or in extranodal sites (e.g., GI tract, liver, bone marrow), FDG uptake may be greater than in the mediastinum with 
complete metabolic response, but should be no higher than surrounding normal physiologic uptake (e.g., with marrow activation as a result of chemotherapy or myeloid growth factors).  
 
b PET 5PS: 1, no uptake above background; 2, uptake ≤ mediastinum; 3, uptake > mediastinum but ≤ liver; 4, uptake moderately > liver; 5, uptake markedly higher than liver and/or new 
lesions; X, new areas of uptake unlikely to be related to lymphoma. 
 

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APPENDIX E:  IWCLL RESPONSE CRITERIA  
 
 
Response Definition After Treatment for CLL Patients
Group 
Parameter 
CR 
PR 
PD
SD
A 
Lymph nodes  
 
None ≥1.5 cm  
 
Decrease 
≥50% (from 
baseline)a 
Increase ≥50% 
from baseline or 
from response 
Change of -49% 
to +49% 
 
Liver and/or 
spleen sizeb 
 
Spleen size 
<13 cm; liver 
size normal 
Decrease 
≥50% (from 
baseline) 
Increase ≥50% 
from baseline or 
from response 
Change of -49% 
to +49% 
 
Constitutional 
symptoms 
None  
Any  
Any  
Any 
 
Circulating 
lymphocyte 
count 
Normal  
 
Decrease 
≥50% from 
baseline 
Increase ≥50% 
over baseline 
 
Change of -49% 
to +49% 
B 
Platelet count  
 
≥100,000/μL 
≥100,000/μL 
or increase 
≥50% over 
baseline 
Decrease of 
≥50% from 
baseline 
secondary to CL 
Change of -49% 
to +49% 
 
  Hemoglobin  
≥11.0 g/dL 
(untransfused 
and without 
erythropoietin) 
 
≥11 g/dL or 
increase 
≥50% over 
baseline 
 
Decrease of ≥2 
g/dL from 
baseline 
secondary to 
CLL 
 
Increase 
<11.0 g/dL or 
<50% over 
baseline, or 
decrease 
>2 g/dL 
 
Marrow  
 
Normocelluar, 
no CLL cells, 
no B-lymphoid 
nodules 
 
Presence of 
CLL cells, or 
of B lymphoid 
nodules, or 
not done 
Increase of CLL 
cells by ≥50% 
on successive 
biopsies 
 
No change in 
marrow 
infiltrate 
Abbreviations: CLL=chronic lymphocytic leukemia; CR=complete response; 
CT=computed tomography; PD=progressive disease; PR=partial response; 
SD=stable disease. 
Note: CR, complete remission: all of the criteria have to be met; PR, partial response: for a PR at least 1 of the 
parameters of group A and 1 parameter of group B need to improve if previously abnormal. If only one parameter 
of both groups A and B is abnormal prior to therapy, only 1 needs to improve. PD, progressive disease: at least one 
of the above criteria of group A or group B has to be met; SD, stable 
disease: all of the above criteria have to be met. Constitutional symptoms alone do 
not define PD.  
a. Sum of the products of 6 or less lymph nodes (as evaluated by CT scans and physical 
examination in clinical trials, or by physical examination in general practice). 
b. Spleen size is considered normal if <13 cm. There is not firmly established, 
international consensus of the size of a normal liver; therefore, liver size should be 
evaluated by imaging and manual palpation in clinical trials and be recorded 
according to the definition used in a study protocol. 
For a detailed description of the response parameters see Hallek et al. 2018.129
 
 
 
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APPENDIX F:  LONG TERM FOLLOW-UP  
 
Study participants should be asked to participate in long term follow-up, as directed by the FDA Guidance for Industry 
– Gene Therapy Clinical Trials: Observing Subjects for Delayed Adverse Events.  
 
(http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGen
eTherapy/ucm072957.htm#5) 
 
Long term follow-up should commence one year after the T cell infusion. The planned recommendations for follow-up 
are as follows:  
 
Years 1 - 15:  
1. Recommendation that patients undergo at least annual history and physical examination with their primary 
physician:  
 
A gene therapy LTFU-directed screening survey may be provided. Particular attention is paid to 
malignancies, hematological, neurological, and rheumatologic or autoimmune disorders. Provider 
questionnaire example is provided in Appendix G. 
 
A request for the study team to be notified of all new malignancies and unexpected illnesses.  
 
The primary physician may be provided with a blood draw courier kit to enable samples to be returned 
to the Specimen Processing Lab/Research Cell Bank for archival purposes, and for analysis for 
transgene and vector persistence, and RCL, as dictated by studies of transferred T cell persistence. 
Blood samples should be collected during a routine clinical lab draw. A prepaid shipping label will be 
provided for use when shipping blood samples back to Fred Hutch.  
 
2. Annual phone call survey or questionnaire to the participant to screen for adverse events. Subject 
questionnaire example is provided in Appendix H. 
3. Offer the opportunity to return to Fred Hutch for an annual LTFU clinic visit.  
4. Compliance with 21 CFR 312.32 in adverse event reporting.  
5. Research studies collected during a routine clinical lab draw: 
5.i. Evaluation for transgene vector sequence by PCR of PBMC every 6 months for years 1 to 5 and every year 
for years 6-15 until the transgene becomes undetectable.  
 
5.ii. If > 1% of cells express the transgene or if clonality is suggested, vector integration sites or TCRB sequence 
utilization will be analyzed in PBMC, CAR T cells or other tissue. If clonality is suggested, repeat testing may be 
performed 3 months later. Persistent monoclonality, clonal expansion or vector integration near a known 
oncogenic locus should precipitate careful attention to the possibility of malignancy, and should be reported 
to the FDA within 30 days. However, the need for additional intervention should be guided by the clinical 
circumstances and not solely by the presence of these factors.  
 
5.iii. Annual testing of PBMC for RCL by VSVG Q-PCR. If there is no evidence of transgene persistence, RCL 
assays may be suspended after one year and samples may be archived. 
 
 
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APPENDIX G: LONG TERM FOLLOW-UP PROVIDER QUESTIONNAIRE 
 
 
 
 
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APPENDIX H: LONG TERM FOLLOW-UP SUBJECT QUESTIONNAIRE 
 
 
 
 
 
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APPENDIX I: ASTCT ICANS CONSENSUS GRADING FOR ADULTS  
 
ICE
 
Orientation: orientation to year, month, city, hospital: 4 points  
 
Naming: ability to name 3 objects (e.g., point to clock, pen, button): 3 points  
 
Following commands: ability to follow simple commands (e.g., “Show me 2 fingers” or “Close your eyes and stick out 
your tongue”): 1 point  
 
Writing: ability to write a standard sentence (e.g., “Our national bird is the bald eagle”): 1 point  

Attention: ability to count backwards from 100 by 10: 1 point
Scoring: 10, no impairment;  
7-9, grade 1 ICANS;  
3-6, grade 2 ICANS;  
0-2, grade 3 ICANS;  
0 due to patient unarousable and unable to perform ICE assessment, grade 4 ICANS
 
 
 
(Adopted from Lee et al. BBMT, 2019)  
Please refer to the publication for details136 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX J: IWWM RESPONSE CRITERIA 
 
Response Category
Definition
Complete response (CR)
 
Absence of serum monoclonal IgM protein by immunofixation 
 
Normal serum IgM level 
 
Complete resolution of extramedullary disease, i.e., lymphadenopathy 
and splenomegaly if present at baseline 
 
Morphologically normal bone marrow aspirate and trephine biopsy 
 
Very good partial response (VGPR)
 
Monoclonal IgM protein is detectable 
 
≥90% reduction in serum IgM level from baselinea 
 
Complete resolution of extramedullary disease, i.e., 
lymphadenopathy/splenomegaly if present at baseline 
 
No new signs or symptoms of active disease 
 
Partial response (PR)
 
Monoclonal IgM protein is detectable 
 
≥50% but<90% reduction in serum IgM level from baselinea 
 
Reduction in extramedullary disease, i.e., 
lymphadenopathy/splenomegaly if present at baseline 
 
No new signs or symptoms of active disease 
 
Minor response (MR)
 
Monoclonal IgM protein is detectable 
 
≥25% but<50% reduction in serum IgM level from baseline a 
 
No new signs or symptoms of active disease 
Stable disease (SD)
 
Monoclonal IgM protein is detectable 
 
<25% reduction and <25% increase in serum IgM level from baseline a 
 
No progression in extramedullary disease, 
i.e.,lymphadenopathy/splenomegaly 
 
No new signs or symptoms of active disease 
 
Progressive disease (PD)
 
≥25% increase in serum IgM level a from lowest nadir (requires 
confirmation) and/or 
 
progression in clinical features attributable the disease 
 
a Sequential changes in IgM levels may be determined either by M protein quantitation by densitometry or total 
serum IgM quantitation by nephelometry. 
Please refer to the publication for details130 
 
 
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APPENDIX K: CNS LYMPHOMA RESPONSE CRITERIA 
  
Response
Brain Imaging
Corticosteroid 
Dose 
Eye Examination
CSF Cytology
CR
No contrast enhancement
None
Normal
Negative
CRu
No contrast enhancement
Minimal abnormality 
Any
Any 
Normal
Minor RPE abnormality 
Negative
Negative 
PR
50% decrease in enhancing tumor
No contrast enhancement 
Irrelevant
Irrelevant 
Minor RPE abnormality 
or normal 
Decrease in vitreous 
cells or retinal infiltrate 
Negative
Persistent or 
suspicious 
PD
25% increase in lesion
Any new site of disease: CNS or systemic 
Irrelevant
Recurrent or new 
ocular disease 
Recurrent or 
positive 
Abbreviations: CR, complete response; CRu, unconfirmed complete response; RPE, retinal pigment epithelium; PR, 
partial response; PD, progressive disease. 
Please refer to the publication for details80 
 
 
 
 
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