A Phase 3 Study of Lenti-D Drug Product After Myeloablative Conditioning Using Busulfan and Fludarabine in Subjects ≤17 Years of Age With Cerebral Adrenoleukodystrophy (CALD)
Phase: PHASE3
Conditions: Cerebral Adrenoleukodystrophy (CALD)
Sponsor: Genetix Biotherapeutics Inc.



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MEDICAL MONITOR CONTACT INFORMATION 
Country-Specific 24-hour Emergency Contact Phone Numbers 
Country 
Phone Number 
France 
Germany 
Italy  
The Netherlands 
UK 
USA 
PPD
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SUMMARY OF CHANGES 
Substantial changes compared to Study ALD-104 Protocol v7.2 are described in the table below 
and consist of a revised algorithm for integration site analysis, a revised schedule of events for 
closer hematologic monitoring and details on central review of core needle biopsy sections, bone 
marrow aspirate smears and peripheral blood smears, updated clinical triggers for repeat CBCs 
and bone marrow evaluations, enhanced frequency and scope of bone marrow evaluations with 
new criteria for triggering re-evaluation, new instructions for submitting bone marrow specimens 
for central review and storage, and additional details with respect to assessments performed as 
part of integration site analyses and clinical work-up for potential malignancy. In addition, the 
protocol has been amended to include increased external oversight through implementation of a 
quarterly DMC review of hematologic and ISA data. Furthermore, the Responsible Medical 
Officer has been replaced and the new Responsible Medical Officer’s information is provided on 
the cover page. 
Non-substantial changes are summarized below the table. 
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DESCRIPTION OF EACH SUBSTANTIAL AMENDMENT 
Note: added text is bold and deleted text shown in strikeout. Applicable sections of the synopsis are appropriately updated. 
Initial wording 
Amended or New Wording 
Change Reason/Justification  
1.2.1.  Ongoing Studies ALD-102 and LTF-304 
Study ALD-102 is an international, Phase 2/3, 
multicenter, open-label, single-arm, single-dose 
study designed to evaluate the efficacy and safety 
of eli-cel in male subjects with CALD aged ≤ 17 
years with active cerebral disease. In Study ALD-
102, a myeloablative conditioning regimen of 
busulfan and cyclophosphamide was utilized 
before infusion of eli-cel. Each subject in Study 
ALD-102 is evaluated for 2 years after eli-cel 
infusion of ≥ 5.0 × 106 CD34+ cells/kg. Subjects 
are then followed for an additional 13 years in 
Study LTF-304. Safety data from ALD‑102 and 
LTF-304 can be found in the Investigator’s 
Brochure. 
1.2.1.  Ongoing Studies ALD-102 and LTF-304 
Study ALD-102 is was an international, Phase 2/3, 
multicenter, open-label, single-arm, single-dose study 
designed to evaluate the efficacy and safety of eli-cel 
in male subjects with CALD aged ≤ 17 years with 
active cerebral disease. In Study ALD-102, a 
myeloablative conditioning regimen of busulfan and 
cyclophosphamide was utilized before infusion of eli-
cel. Each subject in Study ALD-102 is was evaluated 
for 2 years after eli-cel infusion of ≥ 5.0 × 106 CD34+ 
cells/kg. Subjects are then followed for an additional 
13 years in Study LTF-304. Study ALD-102 is now 
completed, while Study LTF-304 remains ongoing 
as of this protocol amendment. Safety data from 
ALD‑102 and LTF 304 can be found in the 
Investigator’s Brochure IB. 
The status of Studies ALD-102 and 
LTF-304 is updated as of this 
protocol amendment. 
1.4 
 Potential Risks 
[section contains no text] 
1.4 
 Potential Risks 
Potential risks, warnings and precautions are 
described in the Skysona U.S. product package 
insert (Skysona 2022); in addition, updated safety 
results for bluebird bio's CALD studies can be 
found in the IB. 
 
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1.4.1 Abnormal Proliferation of Hematopoietic Cells 
[…] 
The different nature of the Lenti-D LVV should 
minimize, but not completely eliminate, the risk of 
oncogenesis by insertional mutagenesis. Unlike the γ 
retroviral vectors that led to leukemia, self‑inactivating 
(SIN) LVVs, such as Lenti-D LVV, may represent a 
substantial improvement in terms of safety (Montini et 
al. 2006). SIN LVVs, in general, provide significant 
safety improvements over γ retroviral vectors used in 
earlier studies (Riviere et al. 2012). SIN LVVs lack the 
strong enhancer/promoter long terminal repeat (LTR) 
sequences of γ retroviral vectors, and, unlike γ 
retroviral vectors, do not preferentially integrate near 
gene promoter regions. Therefore, LVVs are less likely 
to transactivate oncogenes, and have demonstrated a 
significantly curtailed probability of oncogenic 
transformation in vitro and in vivo (Biffi et al. 2011). 
1.4.1 Abnormal Proliferation of Hematopoietic Cells 
[…] 
 
The different nature of the Lenti-D LVV should minimize, 
but not completely eliminate, the risk of oncogenesis by 
insertional mutagenesis. Unlike the γ-retroviral vectors that 
led to leukemia, self‑inactivating (SIN) LVVs, such as 
Lenti-D LVV, may represent a substantial improvement in 
terms of safety (Montini et al. 2006). SIN LVVs, in general, 
provide significant safety improvements over γ-retroviral 
vectors used in earlier studies (Riviere et al. 2012). SIN 
LVVs lack the strong enhancer/promoter long terminal 
repeat (LTR) sequences of γ-retroviral vectors, and, unlike 
γ retroviral vectors, do not preferentially integrate near gene 
promoter regions. Therefore, LVVs are less likely to 
transactivate oncogenes, and have demonstrated a 
significantly curtailed probability of oncogenic 
transformation in vitro and in vivo (Biffi et al. 2011). 
However, as described in the Skysona U.S. product 
package insert (Skysona 2022) and in the IB, insertional 
oncogenesis has been observed in the eli-cel clinical 
development program. 
Added note that to reflect that eli-cel 
has been approved by the U.S. FDA 
and to provide the citation for the 
product package insert where up to 
date potential risks are provided  
2.2.1. 
Efficacy Endpoints 
[…] 
 
2.2.1. 
Efficacy Endpoints 
[…] 
 
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3.1   Overall Design and Plan of the Study 
[…] 
 
The coordinating Investigator assigned on this study 
will be responsible for signing off on the final ALD-
104 Clinical Study Report. 
3.1   Overall Design and Plan of the Study 
[…] 
 
The coordinating Investigator assigned on this study will 
be responsible for signing off on the final ALD-104 
Clinical Study Report. 
Note: as of this Protocol Amendment (Version 8.0) 
enrollment in Study ALD-104 has been completed 
and patient followup remains ongoing. Further 
subject enrollment in this study is not anticipated. 
New final paragraph added to this 
section to update study recruitment 
status. The order of paragraphs 
within this section was updated to 
keep efficacy and safety content 
together (not shown as a change in 
this row as content was moved but 
not changed).  
4.1   Number of Subjects 
Approximately 35 subjects will be infused with eli-cel 
after myeloablative conditioning with busulfan and 
fludarabine. 
 
4.1   Number of Subjects 
Approximately 35 subjects will be infused with eli-cel after 
myeloablative conditioning with busulfan and fludarabine. 
As of this Protocol Amendment (Version 8.0) enrollment 
and treatment (N=35) in Study ALD-104 have been 
completed; subject follow-up is ongoing. Further 
enrollment in this study is not expected. 
The number of subjects and the 
status of Studies ALD-102 and LTF-
304 is updated as of this protocol 
amendment.  
No Section 4.7 
4.7. 
Protocol Deviation 
Categorization of protocol deviations into major/minor 
deviations will be determined prior to database lock, by 
a review of the protocol deviation data collected on the 
case report forms (CRFs). 
A new section has been added to 
describe characterization of protocol 
deviations 
Impact of Force of Nature (e.g., the COVID-19 
Pandemic) on Study Visits  
Due to force of nature (e.g., the COVID-19 pandemic), 
subjects may not be able to attend normal study visits. 
If a visit is missed due to a force of nature (e.g. unable 
to travel, unwilling to travel, family or subject affected 
by COVID-19, hospital closure, etc.), the subject may 
be able to complete study assessments via telemedicine 
or at a local facility. Sites should consult with the 
medical monitor and CRAs to consider alternate 
Impact of Force of Nature or War (e.g., the COVID-19 
Pandemic, the Russo-Ukrainian War) on Study Visits 
Due to force of nature or war (e.g., the COVID-19 
pandemic, the Russo-Ukrainian war), subjects may not be 
able to attend normal study visits. If a visit is missed due to 
force of nature or war reasons (e.g., unable to travel, 
unwilling to travel, family or subject affected by COVID-
19, hospital closure, etc.), the subject may be able to 
complete study assessments via telemedicine or at a local 
facility. Sites should consult with the medical monitor and 
clinical research associates to consider alternate 
Impact of force of nature text 
updated to include war due to the 
impact on subject visits of the Russo-
Ukrainian War. 
 
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arrangements, when possible, for completion of study 
assessments. 
arrangements, when possible, for completion of study 
assessments. 
Section 6.1 Schedule of Events 
Table 3 and Table 4 provide the Schedule of Events 
(SOE) to be conducted during the study. Detailed 
descriptions of the efficacy, safety, and exploratory 
procedures to be conducted during this study are 
provided in the following sections. Additional details, 
including administrative information, regarding the 
efficacy, safety, and exploratory procedures, will be 
provided by the Sponsor in the SOM. 
[…] 
During the first year after eli-cel treatment (Month 1 to 
Month 12), CBCs with differential will be collected 
every month as shown in Table 5. Subsequently, CBCs 
with differential will be collected every 4 months at the 
study site until Month 24. 
Note: Unscheduled visits may be performed at any 
time during the study whenever necessary to assess for 
or to follow-up on AEs or as deemed necessary by the 
Investigator. Evaluations and procedures identified in 
the SOE, or other evaluations and procedures deemed 
necessary for safety, may be performed at unscheduled 
visits, as clinically indicated, at the Investigator’s 
discretion in consultation with the Sponsor. 
[…] 
 
 
 
 
 
Table 3 Schedule of Events: Screening Through Drug 
Product Infusion 
“Serology panel” row in Table 3 was revised  
Section 6.1 Schedule of Events 
Table 3, and Table 4 and Table 5 provide the Schedule of 
Events (SOE) to be conducted during the study. Detailed 
descriptions of the efficacy, safety, and exploratory 
procedures to be conducted during this study are provided 
in the following sections. Additional details, including 
administrative information, regarding the efficacy, safety, 
and exploratory procedures, will be provided by the 
Sponsor in the SOM. 
[…] 
During the first year after eli-cel treatment (Month 1 to 
through Month 12), CBCs with differential will be 
collected every month as shown in Table 5. Subsequently, 
CBCs with differential will be collected every 4 months at 
the study site until through Month 24. Data collection as 
described in this paragraph will be obtained 
prospectively only (that is, data should not be collected 
retrospectively for subjects who have passed applicable 
study visits as of the date of implementation of this 
protocol amendment). 
Note: Unscheduled visits may be performed at any time 
during the study whenever necessary to assess for or to 
follow-up on AEs or to perform enhanced CBC and BM 
abnormality monitoring (Section 6.5.11.1.1 and Section 
6.5.11.1.2, respectively) or as deemed necessary by the 
Investigator. Evaluations and procedures identified in the 
SOE, or other evaluations and procedures deemed 
necessary for safety, may be performed at unscheduled 
visits, as clinically indicated, at the Investigator’s discretion 
in consultation with the Sponsor. 
[…] 
Table 3 Schedule of Events: Screening Through 
Conditioning Drug Product Infusion 
“Serology panel” row in Table 3 was revised as follows: 
Text has been revised to increase the 
number/frequency of collection 
timepoints for CBC with differential 
to occur monthly during the first year 
after eli-cel infusion, and thereafter 
every 4 months until Month 24. Text 
also edited to note that unscheduled 
visits may be performed for 
enhanced CBC and BM abnormality 
monitoring.  
A note was added that the 
retrospective collection of these data 
is not expected for visits that had 
occurred prior to this protocol 
amendment (e.g., if a subject had 
already had their Month 18 Visit 
prior to this protocol amendment 
being effective at their study site, 
then it is not expected that such 
subjects would return for updated 
Month 18 assessments). 
 
 
 
 
 
 
 
Table 3 title updated to denote that 
this table includes assessments 
through conditioning and serology 
row updated as shown for clarity. 
Lettered footnotes are now included. 
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[…] 
 
 
Table 4 edited rows original text 
Bone marrow biopsy and aspirate (with ISA) 
 
 
 
 
Table 4 original footnotes: 
4.  Hematology parameters include white blood cell 
(WBC) count with differential, hemoglobin, 
hematocrit, red blood cell (RBC), and platelet count. If 
the results from blood tests are not as expected, 
additional testing may need to be performed and may 
include a physical exam, blood tests, imaging tests, or a 
bone marrow biopsy. 
 
 
5. A repeat performance of CBC is required within one 
month for any CTCAE CBC abnormality that is of 
Grade 2 or higher severity. Specifically, this includes 
abnormalities in hemoglobin levels, total white blood 
cell count, neutrophil count and morphology, 
lymphocyte count and morphology, or monocyte 
counts and morphology. Any two consecutive (one 
month apart) platelet counts of < 100 × 109/L will 
trigger a bone marrow evaluation to be repeated every 
4 months. See Section 6.5.11.4. In addition, a re-
evaluation at the discretion of the Investigator of any 
new abnormal peripheral blood cell count or 
morphology at an interval commensurate with the 
severity of the change is recommended. 
[…] 
Serology panels I and II. 
[…] 
 
Table 4 rows edited 
Bone marrow core needle biopsy and aspirate (with 
including ISA, VCN and Storage) 
New row added under bone marrow assessments 
Additional BM evaluations may be triggered as detailed 
in Section 6.5.11.1.2 
 
Table 4 updated or new footnotes: 
d 4. Hematology parameters include white blood cell 
(WBC) count with differential, hemoglobin, hematocrit, red 
blood cell (RBC), and platelet count. If the results from 
blood tests are not as expected, additional testing may need 
to be performed and may include a physical exam, blood 
tests, imaging tests, or a BM biopsy (both BM core biopsy 
sections and aspirate smear collection should be 
performed to assess morphology). See Section 6.5.11.4. 
for blood sample collection and storage details.    
e 5. A repeat performance of CBC is required within one 
month for any CTCAE CBC abnormality that is of Grade 2 
or higher severity. Specifically, this includes (including 
abnormalities in hemoglobin levels, total white blood cell 
count, neutrophil count and morphology, lymphocyte count 
and morphology, or monocyte counts and morphology) Any 
two consecutive (one month apart) that is of CTCAE 
Grade 2 or higher severity or for platelet counts of <100 
× 109/L will trigger a bone marrow evaluation to be 
repeated every 4 months. See Section 6.5.11.1.16.5.11.4. In 
addition, a re-evaluation at the discretion of the Investigator 
of any new abnormal peripheral blood cell count or 
morphology at an interval commensurate with the severity 
of the change is recommended. Persistent, unexpected, 
abnormalities of peripheral blood cell counts or 
morphology, including but not limited to any two 
 
 
 
Table row relating to bone marrow 
assessments updated to clarify that it 
includes core needle biopsy and 
aspirate sampling and that samples 
will be used for ISA, VCN and 
storage purposes. 
 
 
Table 4 footnotes changed from 
numbered to lettered footnotes.   
Footnote d (formerly footnote 4) has 
been updated to clarify bone marrow 
collection and storage details. 
 
 
 
 
Footnote e (formerly footnote 5) has 
been updated to clarify which repeat 
CBC and platelet values would 
trigger bone marrow assessment. 
 
 
 
 
 
 
 
 
 
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consecutive (one month apart) CTCAE Grade 2 CBC 
values or platelet counts of <100 x 109/L will trigger a 
BM evaluation. For frequency of subsequent BM 
evaluations (see Section 6.5.11.1.2). See Section 6.5.11.4 
for sample collection and storage details.  
[…] 
 
New footnote 7 added (and subsequent footnote numbers 
updated accordingly) 
g. Peripheral blood smears will be created locally at the 
study site and submitted for central review by a single 
central hematopathologist. See Section 6.5.11.1.1 for 
further details. At the Investigator’s discretion local 
peripheral blood smears may also be performed by the 
study site to direct patient care.  
 
New footnotes 8 and 9 added (and subsequent footnote 
numbers updated accordingly. 
h.  Note that sites are required to collect BM aspirate 
post-drug product infusion per the SOE, unless 
discussed with the Sponsor's Medical Monitor for 
exceptions, such as if not clinically appropriate per local 
standard of care (e.g., BM aspirate would require 
general anesthesia, which would be considered an 
unacceptable risk to the subject) or not considered by 
the Investigator to be in the best interest of the subject 
to perform. For details, see Section 6.5.11.1.2.  
i. Bone marrow smear should be read locally; additional 
BM slides are to be created and submitted for central 
analyses as detailed in Section 6.5.11.1.2. See Section 
6.5.11.4 for BM sample collection details.  Additionally, 
BM aspirate (and an accompanying whole blood 
specimen) should be collected for storage at the time of 
BM sample collection to facilitate subsequent 
exploratory analyses that may include gene/genomic 
expression studies. 
 
 
 
 
 
 
New footnotes g, h and i have been 
added to Table 4 to note that central 
hematopathology review of the 
peripheral blood smear will be 
conducted.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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9. Additional blood may be collected for analysis in 
cell subtypes. If blood draw volume required exceeds 
the limit per Section 6.5.11.4, samples should be 
obtained over multiple days. 
[…] 
l. 9. Additional blood may be collected for analysis in cell 
subtypes, if requested by the Sponsor. If blood draw 
volume required exceeds the limit per Section 6.5.11.4, 
samples should be obtained over multiple days. 
 
Former footnote 9 (now letter l) 
updated to note that samples will 
only be collected for analysis in cell 
subtypes if requested by the Sponsor. 
Table 5 updated or new footnotes: 
a. Hematology parameters include white blood cell 
(WBC) count with differential, hemoglobin, 
hematocrit, red blood cell (RBC), and platelet count. If 
the results from blood tests are not as expected, 
additional testing may need to be performed and may 
include a physical exam, blood tests, imaging tests, or a 
bone marrow biopsy. 
b. A repeat performance of CBC is required within one 
month for any CTCAE CBC abnormality that is of 
Grade 2 or higher severity. Specifically, this includes 
abnormalities in hemoglobin levels, total white blood 
cell count, neutrophil count and morphology, 
lymphocyte count and morphology, or monocyte 
counts and morphology. Any two consecutive (one 
month apart) platelet counts of < 100 × 109/L will 
trigger a bone marrow evaluation to be repeated every 
4 months. See Section 6.5.11.4. In addition, a re-
evaluation at the discretion of the Investigator of any 
new abnormal peripheral blood cell count or 
morphology at an interval commensurate with the 
severity of the change is recommended. 
c Chemistry and hematology parameters will be 
measured at least twice per week until neutrophil 
engraftment occurs. 
 
 
 
Table 5 updated or new footnotes: 
1 a  Hematology parameters include white blood cell 
(WBC) count with differential, hemoglobin, hematocrit, red 
blood cell (RBC), and platelet count. If the results from 
blood tests are not as expected, additional testing may need 
to be performed and may include a physical exam, blood 
tests, imaging tests, or a bone marrow BM biopsy. 
2 b  A repeat performance of CBC is required within one 
month for any CTCAE CBC abnormality that is of Grade 2 
or higher severity. Specifically, this includes (including 
abnormalities in hemoglobin levels, total white blood cell 
count, neutrophil count and morphology, lymphocyte count 
and morphology, or monocyte counts and morphology). 
Any two consecutive (one month apart) that is of CTCAE 
Grade 2 or higher severity or for platelet counts of <100 
× 109/L will trigger a bone marrow evaluation to be 
repeated every 4 months. See Section 6.5.11.1.1 6.5.11.4. In 
addition, a re-evaluation at the discretion of the Investigator 
of any new abnormal peripheral blood cell count or 
morphology at an interval commensurate with the severity 
of the change is recommended. Persistent, unexpected, 
abnormalities of peripheral blood cell counts or 
morphology, including but not limited to any two 
consecutive (one month apart) CTCAE Grade 2 CBC 
values or platelet counts of <100 x 109/L will trigger a 
BM evaluation. For frequency of subsequent BM 
evaluations (see Section 6.5.11.1.2). 
 
3 c  Chemistry and hHematology parameters will be 
measured at least twice per week until neutrophil 
engraftment occurs. 
4  Peripheral blood smears will be created locally at the 
study site and submitted for central review by a single 
Table 5 footnotes updated to reflect 
current repeat CBC criteria and 
associated bone marrow assessment 
triggers.  
Footnote number 2 (formerly 
footnote b) was updated to clarify 
that, if needed, an unscheduled visit 
could provide CBC results and was 
updated to clarify which repeat CBC 
and platelet values would trigger 
bone marrow assessment. Specific 
clinical triggers for repeat CBCs, 
bone marrow evaluations, and ISA of 
bone marrow was also added. 
A new footnote number 4 has been 
added to note that central 
hematopathology review of 
peripheral blood smears will be 
conducted and to provide more 
details on requirements for collection 
of bone marrow samples, their 
submission to central review and for 
storage). 
 
 
 
 
 
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central hematopathologist. See Section 6.5.11.1.1 for 
further details. At the Investigator’s discretion local 
peripheral blood smears may also be performed by the 
study site to direct patient care. 
6.5.11  Clinical Laboratory Tests 
Laboratory tests of hematology and serum chemistries 
will be performed as specified in the following sub-
sections and in the SOE. 
Clinical laboratory tests are to be performed locally 
and reviewed by the Investigator or qualified designee 
(e.g., physician’s assistant, nurse practitioner) 
appropriately listed on the Delegation of Responsibility 
Log for this task.  
All hematology and chemistry results from assessments 
performed at unscheduled visits should also be entered 
into the clinical database.  
 
6.5.11  Clinical Laboratory Tests 
Laboratory tests of hematology and serum chemistries will 
be performed as specified in the following sub-sections and 
in the SOE. 
Clinical laboratory tests are to be performed locally and 
reviewed by the Investigator or qualified designee (e.g., 
physician’s assistant, nurse practitioner) appropriately listed 
on the Delegation of Responsibility Log for this task. 
In addition to the peripheral blood smears, BM core 
biopsy sections and BM aspirate smears required for 
routine local hematopathology review and per the SOE, 
additional peripheral blood smears (see Section 
6.5.11.1), BM core biopsy sections and BM aspirate 
smears (see Section 6.5.11.1.2) should be prepared for 
study purposes and submitted to a single centralized 
hematopathologist. Results of the central read will be 
provided to the Sponsor and subsequently shared with 
the Investigator. 
All hematology and chemistry results from assessments 
performed at unscheduled visits should also be entered into 
the clinical database.  
Additional instances of clinical laboratory tests listed in 
this section may be performed at the Investigator’s 
discretion as needed.  
Local tests and reads should be utilized for participant 
care decision making. 
Text updated to note that in addition 
to samples taken for routine local 
hematopathology review and local 
assessments performed per the SOE, 
additional peripheral blood smears, 
bone marrow core biopsy sections, 
and bone marrow aspirate smears 
should be prepared for study 
purposes and submitted to a single 
centralized hematopathologist for 
review and to note that results of the 
central read will be provided to the 
Sponsor and subsequently shared 
with the Investigator. Note added 
that additional tests may be 
conducted at the investigator’s 
discretion and that local tests and 
reads should be utilized for 
participant care decision making. 
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Section 6.5.11.1 Hematology, Clinical Chemistry, Liver 
and Adrenal Function 
Blood samples for hematology, clinical chemistry, liver 
and adrenal function are to be collected as specified in 
the SOE.  
The following clinical laboratory parameters are to be 
determined: 
[Table of laboratory parameters] 
Hematology: CBC with differential 
• 
White blood cell (WBC) count with 
differential 
• 
Platelet count 
• 
Red blood cell (RBC) count  
• 
Hemoglobin 
• 
Hematocrit 
[…] 
Effort should be made to obtain a platelet count 8 days 
after any platelet transfusion, until platelet engraftment 
occurs (as defined in Section 6.5.13). 
Additional instances of clinical laboratory tests listed 
in this section may be performed at the Investigator’s 
discretion as needed. 
Section 6.5.11.1 Hematology, Clinical Chemistry, Liver and 
Adrenal Function 
Blood samples for hematology, clinical chemistry, liver and 
adrenal function are to be collected as specified in the SOE.  
The following clinical laboratory parameters are to be 
determined: 
[Peripheral blood smear added to table of laboratory 
parameters] 
Hematology: CBC with differential 
• 
White blood cell (WBC) count with differential 
• 
Platelet count 
• 
Red blood cell (RBC) count  
• 
Hemoglobin 
• 
Hematocrit 
• 
Peripheral blood smear 
[…] 
Effort should be made to obtain a platelet count 8 days after 
any platelet transfusion, until platelet engraftment occurs 
(as defined in Section 6.5.13). 
Additional instances of clinical laboratory tests listed in this 
section may be performed at the Investigator’s discretion as 
needed. 
Peripheral blood smears added to 
table of laboratory parameters and 
removed from prior section relating 
to performance of additional test at 
the Investigator’s discretion.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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[no section heading] 
Complete blood counts with differential will be 
performed per the SOE. During the first year after eli-
cel treatment (Month 1 to Month 12), CBCs with 
differential will be collected every month as shown in 
Table 5. Subsequently, CBCs with differential will be 
collected every 4 months at the study site until Month 
24. A repeat performance of CBC is required within 
one month for any CTCAE CBC abnormality that is of 
Grade 2 or higher severity. Specifically, this includes 
abnormalities in hemoglobin levels, total white blood 
cell count, neutrophil count and morphology, 
lymphocyte count and morphology, or monocyte 
counts and morphology. Any two consecutive (one 
month apart) platelet counts of < 100 × 10 /L will 
trigger a bone marrow evaluation to be repeated every 
4 months. See Section 6.5.11.4. In addition, a re-
evaluation at the discretion of the Investigator of any 
new abnormal peripheral blood cell count or 
morphology at an interval commensurate with the 
severity of the change is recommended. 
A hematopathology review of a peripheral blood smear 
to assess for dysplastic features will be conducted per 
the SOE. This review will be conducted by a central 
reader. Refer to the Study Operations Manual for 
further details on central expert hematopathologist 
review and reporting. 
[added new heading] 6.5.11.1.1.  Complete Blood Count 
and Peripheral Blood Smear 
Complete blood counts with differential will be performed 
and analyzed locally at the study site per the SOE during 
the first year after eli-cel treatment (Month 1 to through 
Month 12), CBCs with differential will be collected every 
month as shown in Table 5. Subsequently, CBCs with 
differential will be collected every 4 months at the study 
site until through Month 24.  
A repeat performance of CBC is required within one month 
for any CTCAE CBC abnormality that is of Grade 2 or 
higher severity that includes (including abnormalities in 
hemoglobin levels, total white blood cell WBC count, 
neutrophil count and morphology, lymphocyte count and 
morphology, or monocyte counts and morphology) that is 
of CTCAE Grade 2 or higher severity or for platelet 
counts of <100 x 109/L. Any two consecutive (one month 
apart) platelet counts of < 100 × 109/L will trigger a bone 
marrow evaluation to be repeated every 4 months. See 
Section 6.5.11.4. In addition, a re-evaluation at the 
discretion of the Investigator of any new abnormal 
peripheral blood cell count or morphology at an interval 
commensurate with the severity of the change is 
recommended. Persistent, unexpected, abnormalities of 
peripheral blood cell counts or morphology, including 
but not limited to any two consecutive (one month 
apart) CTCAE Grade 2 CBC values or platelet counts 
of < 100 x 109/L will trigger a BM evaluation. For 
frequency of subsequent BM evaluations (see Section 
6.5.11.1.2). 
A hematopathology review of a In addition, peripheral 
blood smears should be prepared for study purposes and 
submitted to a single centralized hematopathologist for 
review to assess for dysplastic features will be conducted at 
Months 6, 12, 16, 20 and 24, per the SOE. This review will 
be conducted by a central reader. Results of the central 
read will be provided to the Sponsor and subsequently 
Revised collection timepoints for 
CBC with differential to occur at the 
local study site monthly during the 
first year after eli-cel infusion, and 
thereafter every 4 months until 
Month 24.  
Clarified specific clinical triggers for 
repeat CBCs, bone marrow 
evaluations, and ISA of bone 
marrow. Clarification is provided 
that peripheral blood smears should 
be prepared for study purposes and 
submitted to a single centralized 
hematopathologist for review to 
assess for dysplastic features and 
that, at the Investigator’s discretion, 
local peripheral blood smears may 
also be performed by the study site to 
direct patient care. 
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shared with the Investigator (although centrally read 
peripheral smear slides will not be returned to the study 
site). At the Investigator’s discretion local peripheral 
blood smears may also be performed by the study site to 
direct patient care. Refer to the Study Operations Manual 
SOM for further details on preparation of additional 
slides for central expert hematopathologist review and 
reporting. 
6.5.11.4  Specialty Laboratory Sample Collection 
[…] 
 
Bone Marrow Core Needle Biopsy and Aspiration 
A bone marrow evaluation (including ISA of the bone 
marrow) will be performed in the event of one or more 
of the following specific findings: 
i. 
Persistent, unexpected, abnormalities* of 
peripheral blood cell counts or morphology, including 
but not limited to any two consecutive (one month 
apart) CTCAE Grade 2 CBC values or platelet counts 
of <100 x 10^9/L. If bone marrow evaluation is 
triggered by platelet counts, perform bone marrow 
biopsies at four month intervals until a peripheral blood 
platelet value of ≥125 x 10^9/L is observed. 
ii. 
Any transfusion requirement after discharge 
from the initial hospitalization unless the need for 
transfusion was related to trauma or a 
procedure/intervention. 
iii. 
Abnormal results from the most recent bone 
marrow biopsy or aspirate (see below) 
iv. 
Relative frequency of ≥ 5% for the same 
insertion site observed at two consecutive time points, 
if the insertion site is located in a gene with known 
biological relevance to carcinogenesis; the latter is 
defined as a Tier 1 gene in the Cancer Gene Census 
(CGC) of the Catalogue of Somatic Mutations in 
Cancer (COSMIC) at the time of the ISA report review 
6.1.11.4.1.12  Specialty Laboratory Sample Collection 
Bone Marrow Core Needle Biopsy and Aspiration 
During the first year after eli-cel treatment (at Month 6 
and Month 12), BM will be collected to perform routine 
assessments, ISA and VCN assessments (and sample 
created for storage). A Additional bone marrow BM 
evaluations will also be performed in the event of one or 
more of the following specific findings: 
Persistent, unexpected, abnormalities* of peripheral blood 
cell counts or morphology, including but not limited to any 
two consecutive (one month apart) CTCAE Grade 2 CBC 
values or platelet counts of <100 x 109^9/L. If bone marrow 
BM evaluation is triggered by platelet counts, perform BM 
biopsies at four month intervals until a peripheral blood 
platelet value of ≥125 x 109^9/L is observed. Any 
transfusion requirement after discharge from the initial 
hospitalization unless the need for transfusion was related 
to trauma or a procedure/intervention. 
Abnormal results from the most recent bone marrow BM 
biopsy or aspirate (see below) 
ISA: IS in a known oncogene (i.e., relative frequency 
[RelFreq] of ≥ 5% for the same insertion site observed at 
two consecutive time points, if the insertion site IS is 
located in a gene with known biological relevance to 
carcinogenesis:; the latter is  defined as a Tier 1 gene in the 
Cancer Gene Census (CGC) of the Catalogue of Somatic 
Mutations in Cancer (COSMIC) at the time of the ISA 
report review. 
Section moved to new location 
(formerly was a subsection within 
Section 6.5.11.4) and updated to 
provide greater clarity on triggers for 
bone marrow evaluation and central 
reader review. 
 
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v. 
Persistent oligoclonality (i.e. relative 
frequency of ≥ 10% for the same IS observed at two 
consecutive time points, or relative frequencies of ≥ 
5% for the same two or more IS observed at two 
consecutive time points) 
vi. 
A two-fold increase in peripheral blood VCN 
over a 4-month period 
* these include abnormalities in hemoglobin levels; 
total white blood cell, neutrophil, lymphocyte, or 
monocyte counts.  
For new findings of moderate hypocellularity (defined 
for this protocol as 30-40%), marked hypocellularity 
(<30%), moderate dysplasia (>10%-40% of cells in 
one or more lineages), or marked dysplasia (>40% of 
cells in the pertinent lineage), one repeat evaluation is 
required at a 3-month interval.  
For new findings of moderate hypercellularity (80-
90%) or marked hypercellularity (>90%), one repeat 
evaluation is required which may be performed at a 3 
or 6-month interval, at the discretion of the 
Investigator.  
If bone marrow abnormalities on two consecutive 
assessments are stable or improved and CBC* is within 
normal limits, the bone marrow biopsy and aspirate 
should occur every 6 months until abnormalities are 
resolved. If there is worsening (e.g., change from 
moderate to marked) of dysplasia, decreasing 
hypocellularity or increasing hypercellularity, or 
abnormalities on CBC, bone marrow biopsies and 
aspirate collection frequency should remain at a 3-
month interval. 
*hemoglobin levels, total white blood cell count, 
neutrophil, lymphocyte, and monocyte counts. 
 
These recommendations are not intended to preclude 
prior re-evaluation as warranted. Additional bone 
ISA: persistent oligoclonality (i.e., relative frequency 
RelFreq of ≥ 10% for the same IS observed at two 
consecutive time points, or relative frequencies of ≥ 5% for 
the same two or more IS observed at two consecutive time 
points). 
A two-fold increase in peripheral blood VCN over a 4-
month period. 
*  these include abnormalities in hemoglobin levels, total 
white blood cell WBC, neutrophil, lymphocyte, or 
monocyte, or platelet counts and morphology. 
For new findings of moderate hypocellularity (defined for 
this protocol as 30-40%), marked hypocellularity (<30%), 
moderate dysplasia (>10%-40% of cells in one or more 
lineages), or marked dysplasia (>40% of cells in the 
pertinent lineage), one repeat evaluation is required at a 3-
month interval.  
For new findings of moderate hypercellularity (80-90%) or 
marked hypercellularity (>90%), one repeat evaluation is 
required which may be performed at a 3 or 6-month 
interval, at the discretion of the Investigator.  
If bone marrow BM abnormalities on two consecutive 
assessments are stable or improved and CBC** is within 
normal limits, the bone marrow BM biopsy and aspirate 
should occur every 6 months until abnormalities are 
resolved. If there is worsening (e.g., change from moderate 
to marked) of dysplasia, decreasing hypocellularity or 
increasing hypercellularity, or abnormalities on CBC, bone 
marrow BM biopsies and aspirate collection frequency 
should remain at a 3-month interval. 
** hemoglobin levels, total white blood cell WBC count, 
neutrophil, lymphocyte, and monocyte and platelet counts. 
These recommendations are not intended to preclude re-
evaluation as warranted. Additional bone marrow BM 
evaluations should be performed, at the discretion of the 
Investigator and at a frequency commensurate with the 
integrated findings and based upon recommendations from 
 
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marrow evaluations should be performed at the 
discretion of the Investigator and at a frequency 
commensurate with the integrated findings and based 
upon recommendations from the hematopathologist 
and hematologist investigator (or consulting 
hematologist).  
Bone marrow evaluation will include both core needle 
biopsy and aspiration to assess morphology, cellularity, 
fibrosis, and to perform flow cytometry, conventional 
karyotyping, FISH, next-generation sequencing (NGS), 
ISA, and VCN. The BM evaluations will be performed 
in accordance with institutional practices under aseptic 
conditions. It is anticipated that institutional guidelines 
will specify that approximately 5 to 20 mL of BM 
aspirate will be collected each time.  
Bone marrow core biopsy and aspirate smear slides 
will be submitted to a single centralized expert 
hematopathologist after local review has been 
completed. Results of the central read will be provided 
to the Sponsor and subsequently shared with the 
Investigator Refer to the Study Operations Manual for 
further details on central expert hematopathologist 
review and reporting. 
Additionally, sites will submit bone marrow aspirate to 
centralized specialty laboratories for the performance 
of FISH (using a probe panel for common mutations in 
pediatric AML, MDS, and probes for MLL [11q23], 
MECOM, and PRDM16 rearrangement) and NGS 
(spanning mutations commonly observed in myeloid 
and lymphoid malignancies). Refer to the SOM for 
further details. 
 
the hematopathologist and hematologist investigator (or 
consulting hematologist).  
Bone marrow Triggered BM evaluation will include both 
core needle biopsy and aspiration to assess morphology, 
cellularity, fibrosis, and to perform flow cytometry, and 
conventional karyotyping, FISH, next generation 
sequencing (NGS), ISA, and VCN. The BM that should be 
carried out locally as part of normal pathology 
assessments, including local smear assessment. 
Additional aliquots of triggered BM aspirate will be 
collected and sent to centralized specialty laboratories 
for the performance of fluorescence in situ 
hybridization (FISH) (using a probe panel for common 
mutations in pediatric AML, MDS, and probes for MLL 
[11q23], MECOM, and PRDM16 rearrangement), next-
generation sequencing (NGS) (spanning mutations 
commonly observed in myeloid and lymphoid 
malignancies), and ISA/VCN. Note that due to the time 
taken for central NGS and FISH results to be obtained, 
Investigators should initiate additional local NGS and 
FISH testing if results are needed more rapidly to direct 
participant care. An additional BM aspirate sample 
should be submitted to the Sponsor for storage to 
support potential future genetic/genomic studies. The 
BM evaluations will be performed in accordance with 
institutional practices under aseptic conditions. It is 
anticipated that institutional guidelines will specify that 
approximately 5 to 20 mL of BM aspirate will be collected 
each time. Bone marrow aspirate (and an accompanying 
whole blood specimen) should be collected for storage at 
the time of BM sample collection to facilitate subsequent 
exploratory analyses that may include gene/genomic 
expression studies. 
In addition to BM Bone marrow core biopsy sections and 
aspirate smear slides will created for routine local 
hematopathology review, additional BM core biopsy 
sections and aspirate smears should be prepared for 
study purposes and submitted to a single centralized 
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expert hematopathologist after local review has been 
completed. Results of the central read will be provided to 
the Sponsor and subsequently shared with the Investigator 
(although centrally read slides will not be returned to 
the study site). Refer to the SOM for further details on 
preparation of additional slides for submission to the 
single central hematopathologist and for submission of 
samples to centralized laboratories. 
Additionally, sites will submit bone marrow aspirate to 
centralized specialty laboratories for the performance of 
FISH (using a probe panel for common mutations in 
pediatric AML, MDS, and probes for MLL [11q23], 
MECOM, and PRDM16 rearrangement) and NGS 
(spanning mutations commonly observed in myeloid and 
lymphoid malignancies). Refer to the SOM for further 
details. 
Inserted new Section 6.5.11.1.3   
6.5.11.1.3 Blood Sample Collection for RCL Testing, 
Integration Site Analysis, and VCN in Blood 
Blood samples will be collected according to the SOE for 
assessments of the following: 
• 
RCL - If subject tested negative at all visits 
through M12, further samples will be archived for 
potential analysis in case of clinical outcomes suggesting 
the presence of RCL. 
• 
VCN in whole blood will be evaluated at every 
visit indicated for VCN in the SOE. 
• 
ISA at visits indicated (only to be performed if 
VCN is ≥ 0.01 vector copies per diploid genome, at the 
previous visit).  
Testing will be performed by central laboratories. Blood 
collection and processing details are included in the 
Laboratory Manual. 
Blood samples for ISA are to be collected according to 
the SOE; collection, processing and shipping details are 
included in the Laboratory Manual. Testing will be 
performed by a central laboratory. Additional blood 
New section added to provide more 
detail on sample collection for RCL 
Testing, Integration Site Analysis, 
and VCN in Blood 
 
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may be collected for additional investigations and 
analysis in cell subtypes, if requested by the Sponsor. 
6.5.11.2.  Immunological Studies 
Immunological testing includes measuring levels of T 
cell subsets (CD4, CD8), B cells (CD19), and NK cells 
(CD16 or CD56). In addition, levels of 
immunoglobulins (IgG, IgM, and IgA) will be 
quantified. 
6.5.11.2.  Immunological Studies 
Local iImmunological testing includes measuring levels of 
T cell subsets (CD4, CD8), B cells (CD19), and NK cells 
(CD16 or CD56). In addition, levels of immunoglobulins 
(IgG, IgM, and IgA) will be quantified. 
Text updated to clarify that 
immunological studies should be 
conducted locally. 
Section 6.5.11.4 Specialty Laboratory Sample 
Collection 
As this is a pediatric study, blood volume limitations 
will sometimes preclude the collection of all samples 
during a particular study visit. Table 7 enumerates the 
priorities for blood collection. Safety labs (see Section 
6.5) have been prioritized over labs for efficacy and 
exploratory analyses. 
 
[…] 
Table 7: Blood Collection: Order of Priority 
•  ABCD1 genotype  
•  Adrenal Function Tests 
•  Serology Panels (infectious disease screening) 
•  Chemistry 
•  Hematology 
•  VCN in Peripheral Blood Populations  
•  Proviral Integration Site Analysis (ISA) 
•  ALDP in Peripheral Blood Populations 
•  RCL testing  
•  VLCFA analysis (fasting) 
 
Vector Copy Number by qPCR: Peripheral Blood 
Populations  
Section 6.5.11.4 Specialty Laboratory Sample Collection 
As this is a pediatric study, blood volume limitations will 
sometimes preclude the collection of all samples during a 
particular study visit. Table 7 enumerates the priorities for 
blood and BM collection (BM core section slides and BM 
aspirates). Safety labs (see Section 6.5) have been 
prioritized over labs for efficacy and exploratory analyses. 
If the results from CBC or BM tests are not as expected, 
additional testing may need to be performed as detailed 
in Section 6.5.11.1.1 and Section 6.5.11.1.2, respectively. 
Local tests and reads should be utilized for patient care 
decision making. 
 
 
[…] 
With regard to bone-marrow, both core needle biopsy 
and aspiration collection should be performed to assess 
cellularity, fibrosis, and to perform flow cytometry, 
karyotyping, FISH, NGS, ISA, and VCN. The BM 
evaluations will be performed in accordance with 
institutional practices under aseptic conditions. It is 
anticipated that institutional guidelines will specify that 
approximately 5 to 20 mL of BM aspirate will be 
collected each time. See Section 6.5.11.1.2 for further 
details on BM collection and for further details on 
criteria that would trigger additional BM assessments 
over and above those noted in the SOE.  
If bone-marrow assessments are warranted, both core 
needle biopsy and aspiration collection should be 
Table 7 updated to refine order of 
priority of sample collection and to 
include bone marrow collection 
details and prioritization. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Blood samples for VCN determination by qPCR will 
be collected according to the SOE. Testing will be 
performed by a central laboratory. Additional blood 
may be collected for analysis in cell subtypes.  
 
[…] 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
performed to assess morphology, cellularity, fibrosis, 
and to perform flow cytometry, karyotyping, FISH, 
next-generation sequencing (NGS), ISA, and VCN. See 
Section 6.5.11.1.2 for further details on criteria that 
would trigger additional BM assessments over and 
above those noted in the SOE. Bone marrow evaluations 
will be performed in accordance with institutional 
practices under aseptic conditions. It is anticipated that 
institutional guidelines will specify that approximately 5 
to 20 mL of BM aspirate will be collected each time.  
In addition to the BM core biopsy sections and aspirate 
smears read locally for routine hematopathology review 
or per the SOE, additional BM core biopsy sections and 
aspirate smears should be prepared for study purposes 
and submitted to a single centralized hematopathologist. 
Additionally, BM aspirate (and an accompanying whole 
blood specimen) should be collected for storage at the 
time of BM sample collection to facilitate subsequent 
exploratory analyses that may include gene/genomic 
expression studies. See more details below for additional 
sample storage details. Results of the central read will 
be provided to the Sponsor and subsequently shared 
with the Investigator. 
 
Table 7: Blood and Bone Marrow Collection: Order of 
Priority 
Blood Collection Priority 
•  ABCD1 genotype  
•  Adrenal Function Tests 
•  Serology Panels (infectious disease screening) 
•  Chemistry 
•  Hematology (CBC [performed locally] and peripheral 
blood smear [created locally and submitted to central 
lab]) 
•  VCN in Peripheral Blood Populations  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 7 priority list updated 
 
 
 
 
 
 
 
 
 
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•  Proviral Integration Site Analysis (ISA) and VCN 
•  Immunological studies 
•  ALDP in Peripheral Blood Populations 
•  RCL testing 
•  VLCFA analysis (fasting) 
•  Whole blood specimen for storage at the time of BM 
assessment (to support exploratory analyses that may 
include gene/genomic expression)1 
 
Bone Marrow Aspirate2 Collection Priority   
•  Core needle biopsy sections and aspirate smears for 
morphologic assessment, including for cellularity and 
fibrosis 
•  Local FISH (if needed more rapidly than central 
FISH to direct patient care) 
•  Local NGS (if needed more rapidly than central NGS 
to direct patient care) 
•  ISA and VCN 
•  Karyotyping  
•  FISH for central laboratories 
•  NGS for central laboratories  
•  Storage BM specimens (to support exploratory 
analyses that may include genetic and genomic studies)1 
 
1 Whole blood collection at the time of BM sample 
collection should be stored to facilitate subsequent 
exploratory analyses 
2 Bone marrow evaluation should also include a core 
needle biopsy. 
 
 
 
 
 
 
 
 
 
 
 
 
Bone marrow aspirate collection 
priority list provided including both 
local (if needed) and centralized 
testing details. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Storage of Samples 
Leftover biological samples from protocol procedures 
(e.g., whole blood, DNA, serum) may be stored 
(optional) for potential future exploratory 
investigations in those samples to study CALD and/or 
gene therapy. Bone marrow specimens should be 
submitted to the Sponsor for storage to support 
potential gene expression studies. Such samples may 
be stored for up to 20 years. The Sponsor will be the 
custodian of the samples in the repository and any 
unused samples will be destroyed at the Sponsor’s 
discretion. If possible, optional blood, BM, and tissue 
samples also are to be collected in the event of a 
subject’s death if an autopsy is performed.  
[…] 
Vector Copy Number by qPCR: Peripheral Blood 
Populations 
Blood samples for VCN determination by quantitative 
polymerase chain reaction (qPCR) will be collected 
according to the SOE. Testing will be performed by a 
central laboratory. Additional blood may be collected for 
analysis in cell subtypes. 
 
Proviral Integration Site Analysis (ISA) 
Blood samples for ISA are to be collected according to the 
SOE; collection, processing and shipping details are 
included in the Laboratory Manual. Testing will be 
performed by a central laboratory. Additional blood may be 
collected for additional investigations and analysis in cell 
subtypes.  
 
Storage of Samples 
Bone marrow specimens (accompanied by a whole blood 
sample) should be submitted to the Sponsor for storage 
to support potential future genetic and genomic studies 
or other exploratory studies. Leftover biological samples 
from protocol procedures (e.g., whole blood, DNA, serum) 
may also be stored (optional) for potential future 
exploratory investigations in those samples, to study CALD 
and/or gene therapy. Bone marrow specimens should be 
submitted to the Sponsor for storage to support potential 
gene expression studies. Refer to the SOM for further 
details on the collection and submission of samples for 
storage.  
Such Samples may be stored for up to 20 years. The 
Sponsor will be the custodian of the samples in the 
repository and any unused samples will be destroyed at the 
Sponsor’s discretion. If possible, optional blood, BM, and 
tissue samples also are to be collected in the event of a 
subject’s death if an autopsy is performed.  
[…] 
Vector Copy Number by qPCR 
subheading deleted. 
 
 
 
 
 
Deleted Proviral Integration Site 
Analysis subsection as these details 
were redundant with other content. 
 
 
 
 
 
Added instructions for bone marrow 
specimens and whole blood storage 
to facilitate subsequent exploratory 
analyses that may include genetic 
and genomic studies 
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Section 6.5.12. 
Assessment of Oligoclonality and/or 
Suspicion of Malignancy 
 
Section 6.5.12.1.   Assessment of Oligoclonality by 
Integration Site Analysis 
Integration site analysis (ISA) will be performed to 
determine the insertion site (IS) profile of subjects over 
time, as indicated in the SOE. Figure 1 shows the 
algorithm that determines the frequency of monitoring 
by ISA to assess oligoclonality, in accordance with 
FDA Guidance (FDA 2020) and based on FDA 
consultation. While oligoclonality itself, or even 
monoclonality, will not a priori result in a malignancy, 
changes in IS relative frequency may be associated 
with an increase in the risk of a malignancy. Therefore, 
ISA monitoring is performed every 6 months 
throughout the study and during long-term followup. 
This is coupled with monitoring for hematological 
abnormalities via CBC with differential every 3 
months during the parent study and through Year 10 
during long-term follow-up and then every 6 months 
through Year 15 during long-term followup (see 
Section 6.9 for information on long-term follow-up).  
ISA monitoring may be repeated more frequently if 
there is an indication of oligoclonality or if otherwise 
triggered (see Section 6.5.11.4 for more details on 
triggered bone marrow evaluations). Such triggers 
include (but are not limited to) persistent unexpected 
CBC abnormalities (including age adjusted persistent 
CTCAE Grade 2 CBC values), post-discharge blood 
transfusion (unless due to trauma or a 
procedure/intervention), or a two-fold increase in 
peripheral blood vector copy number (PB VCN) over a 
6-month period, or other abnormal results from a 
subject’s most recent BM biopsy or aspirate or ISA 
findings of potential oligoclonality or IS of interest.  
 
Section 6.5.12 Assessment of Oligoclonality and/or 
Suspicion of Malignancy 
 
Section 6.5.12.1. Assessment of Oligoclonality by 
Integration Site Analysis 
Integration site analysis (ISA) ISA will be performed to 
determine the insertion site (IS) profile of subjects over 
time, as indicated in the SOE. Figure 1 shows the algorithm 
that determines the frequency set of ISA rules and 
resulting IS triggered enhanced monitoring by ISA (i.e., 
CBC and BM monitoring) to assess oligoclonality, in 
accordance with FDA Guidance (FDA 2020) and based on 
Food and Drug Administration (FDA) consultation. 
While oligoclonality itself, or even monoclonality, will not 
a priori result in a malignancy, changes in IS relative 
frequency (RelFreq) may be associated with an increase in 
the risk of a malignancy.  
Therefore, ISA monitoring is performed every 6 months 
throughout the study and during long-term followup. This is 
coupled with monitoring for hematological abnormalities 
via CBC with differential every 3 months during the parent 
study and through Year 10 during long-term follow-up and 
then every 6 months through Year 15 during long-term 
followup (see Section 6.9 for information on long-term 
follow-up).  
As discussed further below, ISA monitoring may be 
repeated more frequently if there is an indication of 
oligoclonality or if ISA should otherwise be triggered (see 
Section 6.5.11.4 6.5.11.1.2) for more details on triggered 
bone marrow BM evaluations). Such triggers include (but 
are not limited to) persistent unexpected CBC abnormalities 
(including age adjusted persistent [i.e., two consecutive] 
CTCAE Grade 2 CBC values), post-discharge blood 
transfusion (unless due to trauma or a 
procedure/intervention), or a two-fold increase in peripheral 
blood vector copy number (PB VCN) over a 4 or 6-month 
period (based on the SOE), or other abnormal results from 
Updated text to replace use of ISA 
algorithm terminology and replace 
with a figure and set of rules for 
retesting and enhanced monitoring 
that provides clear instructions for 
site staff.  
 
A link is provided for a more detailed 
IS decision tree in Appendix A. 
 
Reporting of applicable IS findings 
to relevant Health Authorities is 
clarified 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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As shown in Figure 1, if an IS is detected at ≥ 10% 
relative frequency (RelFreq) or an IS ≥ 5% RelFreq is 
detected in 2 or more IS, then ISA will be repeated 
within 3 months of receipt of this result. If ≥ 10% or 2 
or more IS ≥ 5% results are confirmed then a report of 
persistent oligoclonality will be submitted to the 
relevant Health Authorities within 30 days. This 
repeated observation will also trigger enhanced 
monitoring for hematological abnormalities, increasing 
the frequency of CBC with differential to every 3 
months (if not already occurring at the interval) along 
with ISA and VCN every 6 months until the frequency 
no longer meets criteria. 
 
Additionally, if an IS is detected at ≥ 5% RelFreq in a 
known oncogene (based upon Tier 1 oncogenes in the 
Cancer Gene Census [CGC] in the Catalogue of 
Somatic Mutations in Cancer [COSMIC] at the time of 
the ISA report review) such an IS would be considered 
an IS of interest and ISA will be repeated within 3 
months of receipt of this result (and would be 
considered a persistent IS of interest once confirmed 
during re-evaluation). Should the relative frequency of 
a persistent IS of interest reach ≥10% at two 
consecutive timepoints it would be considered 
persistent oligoclonality and a report will be submitted 
to the relevant Health Authorities within 30 days. 
Based on clinical and ISA findings, additional 
monitoring for malignancy may be instituted by the 
treating physician/Principal Investigator or Sponsor 
(see Section 6.5.11.4. for bone marrow evaluation 
recommendations and see Section 6.5.12.2 for 
recommended clinical work-up for potential 
malignancy). 
 
 
a subject’s most recent BM biopsy or aspirate or ISA 
findings of potential oligoclonality or IS of interest in a 
known oncogene. 
 
As shown in Figure 1, if an IS is detected at ≥ 10% relative 
frequency (RelFreq) or an IS ≥ 5% RelFreq is detected in 2 
or more IS, then this would be considered 
"oligoclonality" and ISA will be repeated within 3 
months of receipt of this result. If an IS ≥ 10% or 2 or 
more IS ≥ 5% results are confirmed, then a report of 
“persistent oligoclonality” will be submitted by the 
Sponsor to the relevant Health Authorities within 30 days 
of receipt of the ISA report confirming an IS meeting 
the criteria for persistent oligoclonality.  This repeated 
observation will also trigger enhanced monitoring for 
hematological abnormalities, increasing the frequency of 
CBC with differential to every 3 months (if not already 
occurring at the interval) along with ISA and VCN every 6 
months until the frequency no longer meets oligoclonality 
criteria. Persistent oligoclonality also triggers BM 
assessment (for the frequency of subsequent BM 
assessments see [Section 6.5.11.1.2]). If persistent 
oligoclonality is not observed after initial repeat testing, 
CBC and other monitoring reverts to routine 
assessments per the SOE. 
 
Additionally, if an IS is detected at ≥ 5% RelFreq in a 
known oncogene (based upon Tier 1 oncogenes in the CGC 
in the COSMIC at the time of the ISA report review) such 
an IS would be considered an IS of interest, then ISA (and 
ISA VCN) will be repeated within 3 months of receipt of 
this result (and would be considered. If an IS in a 
persistent IS of interest once known oncogene is confirmed 
during re-evaluation). Should the relative frequency of a 
persistent IS of interest reach ≥10% at two consecutive 
timepoints it would be considered persistent oligoclonality 
and a report will be submitted to the relevant Health 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Figure 1: Algorithm for Frequency of ISA and CBC 
Monitoring 
 
Abbrev.: BM, bone marrow; CBC, complete blood count 
with differential; IS, insertion site(s); ISA, integration site 
analysis; mo, Month; q3mo, every 3 months; q4mo, every 4 
months; q6mo, every 6 months; RelFreq, relative frequency; 
VCN, vector copy number; Y, Year. 
Note that this schematic includes the assessment schedule for 
ISA through the subsequent long-term follow-up study. 
a If an IS is found at a higher frequency in a bone marrow 
sample (than in peripheral blood) that bone marrow 
frequency would be used in the algorithm. 
b Tier 1 oncogenes in the Cancer Gene Census (CGC) of the 
Catalogue of Somatic Mutations in Cancer (COSMIC) at the 
time of the ISA report review). 
c Enhanced refers to Years 10 through 15 when more 
frequent CBC monitoring would be triggered relative to 
schedule of assessment. 
Authorities within 30 days. This repeated observation will 
trigger enhanced monitoring for hematological 
abnormalities, including a BM evaluation and 
increasing the frequency of CBC with differential to 
every 3 months (if not already occurring at the interval) 
until the frequency no longer meets criteria. ISA and 
VCN will continued per the SOE. 
 
Based on clinical and ISA findings, additional monitoring 
for malignancy may be instituted by the treating 
physician/Principal Investigator or Sponsor (see Section 
6.5.11.4 6.5.11.1.2. for bone marrow BM evaluation 
recommendations and see Section 6.5.12.2 for 
recommended clinical work-up for potential malignancy). 
See Section 7.4.5 for definitions of current oligoclonality 
and current persistent oligoclonality utilized during 
analyses and reporting. 
Figure 1:  Algorithm for Frequency of ISA and CBC 
Monitoring ISA Triggered Enhanced Monitoring 
 
Abbrev.: BM, bone marrow; CBC, complete blood count with 
differential; IS, insertion site(s); ISA, integration site analysis; mo, 
Month; q3mo, every 3 months; q4mo, every 4 months; q6mo, 
every 6 months; RelFreq, relative frequency; VCN, vector copy 
number; Y, Year. 
Note that this schematic includes the assessment schedule for ISA 
through the subsequent long-term follow-up study. 
Updated Figure 1 and footnotes to 
better reflect steps in identification of 
subjects with oligoclonality and 
persistent oligoclonality and 
associated enhanced monitoring. 
Also shows rules for repeat testing 
and reversion to routine monitoring 
as applicable. 
Figure footnotes are also updated as 
shown. 
 
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a ISA, VCN, CBC schedule is specified in Section 6.1 (SOE 
Tables). 
b IS can be measured from different types of samples 
(peripheral blood or BM). If an IS is found at a higher frequency 
in a BM sample (e.g., triggered by persistent ISA findings) than 
in a peripheral blood) sample, then that BM frequency would be 
used to assess followup in the algorithm.  
bc. Tier 1 oncogenes in the Cancer Gene Census (CGC) of the 
Catalogue of Somatic Mutations in Cancer (COSMIC) at the time 
of the ISA report review).  
c. Enhanced refers to Years 10 through 15 when more frequent 
CBC monitoring would be triggered relative to schedule of 
assessment. 
d. “Persistent oligoclonality” will be reported (once per 
pertinent IS/set of IS) to applicable Health Authorities within 
30 days of receipt of applicable repeat ISA result. 
e. Observation of Persistent Oligoclonality triggers increasing 
the frequency of CBC with differential and BM assessment to 
every 3 months (if not already occurring at the interval) along 
with ISA and VCN every 6 months until the frequency no 
longer meets criteria. See also Section 6.5.11.1.1 (CBC) and 
Section 6.5.11.1.2 (BM).   
Section 6.5.12.2 Clinical Work-up for Potential 
Malignancy 
 
In the event of any suspicion of hematologic 
malignancy (e.g., myelodysplasia, leukemia, or 
lymphoma), the Medical Monitor will be notified and a 
work-up will be performed by the Investigator per 
appropriate standard of care. A suspicion of 
hematologic malignancy could arise in the setting of 
otherwise unexplained cytopenia(s), and consideration 
of insertional oncogenesis could arise if cytopenia(s) 
occurs in conjunction with a rising RelFreq of an IS in 
a gene of known biological relevance to carcinogenesis 
(i.e., oncogene or tumor suppressor gene), 
accompanied by a rapid increase in PB VCN. 
 The clinical work-up may include the following: 
Section 6.5.12.2 Clinical Work-up for Potential Malignancy 
 
In the event of any suspicion of hematologic malignancy 
(e.g., myelodysplasia, leukemia, or lymphoma), the Medical 
Monitor will be notified and a work-up will be performed 
by the Investigator per appropriate standard of care. A 
suspicion of hematologic malignancy could arise in the 
setting of otherwise unexplained cytopenia(s), and 
consideration of insertional oncogenesis could arise if 
cytopenia(s) occurs in conjunction with a rising RelFreq of 
an IS, especially if that IS is in a gene of known biological 
relevance to carcinogenesis (i.e., oncogene or tumor 
suppressor gene), accompanied by a rapid increase in PB 
VCN (a doubling of VCN between two timepoints). 
 The clinical work-up may include the following: 
Updated text to clarify what is meant 
by rapid VCN increase and to 
include platelet counts as part of 
CBC with differential assessment 
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• 
Physical exam 
• 
CBC with differential - including repeat 
performance within one month for any Grade 2 or 
higher severity CTCAE CBC abnormality (these 
include abnormalities in hemoglobin levels, total white 
blood cell count, neutrophil count and morphology, 
lymphocyte count and morphology, or monocyte 
counts and morphology) 
• 
Lymphocyte subsets 
• 
Imaging studies 
• 
Local and Centralized bone marrow analysis. 
• 
Cytogenetic and molecular analyses which 
can include SNP microarray, karyotyping, or whole-
genome sequencing and must include centralized FISH 
and NGS (see Section 6.5.11.4 for details). 
[…] 
For clinical work-up after identification of persistent 
oligoclonality and confirmed presence of abnormal 
CBC, bone marrow analysis should be performed as 
warranted if not previously part of the clinical work-up 
or as triggered based upon 6.5.11.1.2 or as discussed in 
Section 6.5.11.4.   
Physical exam 
CBC with differential - including repeat performance 
within one month for any CTCAE Grade 2 or higher 
severity CTCAE CBC abnormality (these include 
abnormalities in hemoglobin levels, total white blood cell 
WBC counts, platelet counts [of <100 x 109/L], neutrophil 
counts and morphology, lymphocyte counts and 
morphology, or monocyte counts and morphology) (see 
Section 6.5.11.1.1 for details). 
Lymphocyte subsets 
Imaging studies 
Local and Centralized bone marrow BM analysis 
Cytogenetic and molecular analyses which can include 
single nucleotide polymorphism (SNP) microarray, 
karyotyping, or whole-genome sequencing and must 
include centralized FISH and NGS (see Section 6.5.11.4 
6.5.11.1.2 for details).  
[…] 
For clinical work-up after identification of persistent 
oligoclonality and confirmed presence of abnormal CBC, 
bone marrow BM analysis should be performed as 
warranted if not previously part of the clinical work-up or 
as triggered based upon Section 6.5.11.1.2 or as discussed 
in Section 6.5.11.4.   
7.4.1. 
General Methods 
[…] 
Tabulations will be produced for appropriate 
demographic, baseline, efficacy, safety, and 
exploratory parameters. For categorical variables, 
summary tabulations of the number and percentage of 
subjects within each category of the parameter will be 
presented. For continuous variables, the number of 
observations, mean, median, standard deviation, 
minimum, and maximum values will be presented, 
along with 1 or 2 sided exact CIs of the mean as 
appropriate. Time-to-event data will be summarized 
7.4.1. 
General Methods 
[…] 
Tabulations will be produced for appropriate demographic, 
baseline, efficacy, safety, and exploratory parameters. For 
categorical variables, summary tabulations of the number 
and percentage of subjects within each category of the 
parameter will be presented. For continuous variables, the 
number of observations, mean, median, standard deviation, 
minimum, and maximum values will be presented, along 
with the 2‑sided 95% CI of the mean, as appropriate , along 
with 1 or 2 sided exact CIs of the mean as appropriate. 
Time-to-event data will be summarized using Kaplan-Meier 
Clarified general statistical methods 
relating to analyses pertaining to 
subjects who undergo allo-HSCT. 
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using Kaplan-Meier methodology. The number and 
percent of censored observations and events will also 
be presented.  
[…] 
In addition to the analyses described below, supportive 
efficacy and safety analyses will be performed on the 
ITT population and the NEP for some of the study 
endpoints, as detailed in the SAP. Note, however, that 
in the likely event that there is no difference in the ITT 
and TP populations, reference to ITT analyses will not 
be necessary. 
 
methodology. The number and percent of censored 
observations and events will also be presented. For 
proportion endpoint variables, we presented the 
proportion along with 2-sided exact CIs of the 
proportion, as appropriate. 
[…] 
If a subject treated with eli-cel undergoes an allo-HSCT 
in Study ALD-104, the following additional analyses 
may be conducted for two periods (if sample size is 
sufficient):  
•  For safety and PD endpoints, the first period begins 
from day of eli-cel infusion and will end on the day 
before initiation of conditioning for the subsequent allo-
HSCT, and the second period will begin from the day of 
initiation of conditioning for allo-HSCT and will end at 
the date of last contact. For subjects who do not 
undergo conditioning prior to allo-HSCT, the day 
before allo-HSCT will be used. 
•  All the efficacy, PD, and safety endpoints will be 
included in the listings. 
7.4.2. 
Disposition of Subjects 
A tabulation of the disposition of subjects will be 
presented, including the number enrolled, the number 
with any post-drug product infusion data available for 
analysis, and the extent of data available. The number 
of subjects in each analysis population will be 
presented, with reasons for exclusion from any specific 
population. 
7.4.2. 
Disposition of Subjects 
A tabulation of the disposition of subjects will be presented, 
including the number enrolled, the number with any post-
drug product infusion data available for analysis, and the 
extent of data available. The number of subjects in each 
analysis population will be presented, with reasons for 
exclusion from any specific population. A tabulation of the 
disposition of subjects in the Study ALD-104 ITT 
population will be presented overall and by investigational 
site, for the following: 
• 
Number and percent of subjects who initiated 
mobilization 
• 
Number and percent of subjects who initiated 
conditioning 
• 
Number and percent of subjects who were infused 
with eli-cel 
Additional details are provided for 
the tabulation of disposition data. 
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• 
Number and percent of subjects who discontinued 
study, and reason for discontinuation 
• 
Number and percent of subjects who completed 
study, and subjects who will participate in the long-term 
follow-up study LTF-304 
• 
Number and percent of subjects who are in study 
at the time of data cut 
• 
Descriptive statistics for the duration of follow-up 
for subjects who were infused with eli‑cel 
• 
Subject-years of follow-up, which is the sum over 
all subjects’ duration of follow-up 
• 
The number of subjects receiving allo-HSCT, and 
the reason for receiving allo-HSCT during the study. 
7.4.3. 
Demographic and Baseline Characteristic 
The following demographic and Baseline characteristic 
factors will be summarized: age (age at enrollment, age 
at CALD diagnosis), country of origin, race and 
ethnicity, family history, time from informed consent 
to eli-cel infusion, method of diagnosis of CALD, 
number of prior gadolinium scans, NFS and Loes at 
Baseline, the presence of any significant co‑morbid 
conditions, and time from diagnosis of CALD to 
treatment. Subject genotype will be presented in a 
listing. 
7.4.3. 
Disposition of Subjects 
The following demographic and Baseline characteristic 
factors will be summarized: age (age at enrollment, age at 
CALD diagnosis), sex, age at eli-cel infusion, height at 
screening, weight at screening, body mass index (BMI) 
at screening, country of origin, race and ethnicity, family 
history, time from informed consent to eli-cel infusion, 
signs and symptoms of CALD, method of diagnosis of 
CALD, number of prior gadolinium scans, NFS and Loes at 
Baseline, the presence of any significant co‑morbid 
conditions, availability of matched sibling donor and time 
from diagnosis of CALD to treatment. Subject genotype 
will be presented in a listing. 
Additional demographic 
characteristics that will be 
summarized are noted. 
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7.4.5. 
Analysis of Safety Endpoints 
[…] 
New subsection added 
7.4.5. 
Analysis of Safety Endpoints 
[…] 
Oligoclonality 
Persistent oligoclonality at any time is defined as an IS 
≥10% RelFreq in an initial ISA, and the IS ≥10% 
RelFreq results are confirmed in the subsequent ISA; or 
at least 2 IS ≥5% RelFreq in an initial ISA, and the 
same IS ≥5% RelFreq results are confirmed in the 
subsequent ISA. 
Current persistent oligoclonality is defined as an IS 
≥10% relative frequency in an initial ISA, that is 
confirmed in the subsequent ISA as still being an IS 
≥10% relative frequency and the ≥10% relative 
frequency is maintained through the last two ISA (as of 
a specific data cut); or at least 2 IS ≥5% relative 
frequency in an initial ISA and the same IS ≥5% 
relative frequency results are confirmed in the 
subsequent ISA, and the ≥5% relative frequency is 
maintained through the last two ISA (as of a specific 
data cut). Current oligoclonality is defined as an IS 
≥10% relative frequency that is observed at the first 
time at the most recent ISA as of a specific data cut or at 
least 2 IS ≥5% relative frequency observed at the first 
time at the most recent ISA as of a specific data cut (i.e., 
not yet confirmed at a repeat assessment). 
A new safety analysis is added to 
provide the statistical definition of 
current oligoclonality and current 
persistent oligoclonality. 
Section 8.6 Direct Access to Source Data 
[…] 
The study will be monitored by bluebird bio or its 
designee. Monitoring will be done by personal visits 
from a representative of the Sponsor (site monitor) and 
will include on-site review of the CRFs for 
completeness and clarity, cross-checking with source 
documents, and clarification of administrative matters. 
The review of medical records will be performed in a 
manner to ensure that subject confidentiality is 
maintained. 
Section 8.6 Direct Access to Source Data 
[…] 
The study will be monitored by bluebird bio or its designee. 
Monitoring will be done by personal visits from a 
representative of the Sponsor (site monitor) and will include 
on-site and/or remote review of the CRFs for 
completeness and clarity, cross-checking with source 
documents, and clarification of administrative matters. The 
review of medical records will be performed in a manner to 
ensure that subject confidentiality is maintained. 
 
Note added that on site and/or remote 
review of CRFs may be utilized for 
review. 
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DESCRIPTION OF EACH NON-SUBSTANTIAL AMENDMENT 
• Updated text to note status of eli-cel clinical studies (including completion of Study 
ALD-102) and to note approval of Skysona by the U.S. FDA. 
• Updated the date on the Investigator Statement page. 
• Minor text edits were made to remove redundancy, improve clarity, and correct 
typographical errors. 
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CLINICAL STUDY SYNOPSIS 
Protocol Title: 
A Phase 3 Study of Lenti-D Drug Product After Myeloablative Conditioning 
Using Busulfan and Fludarabine in Subjects ≤ 17 Years of Age With Cerebral 
Adrenoleukodystrophy (CALD) 
Protocol Number: 
ALD-104 
EudraCT Number: 
2018-001145-14 
Objective: 
To evaluate the efficacy and safety of Lenti-D Drug Product (also known as 
elivaldogene autotemcel or Skysona, hereafter referred to as eli-cel) after 
myeloablative conditioning with busulfan and fludarabine in subjects with CALD  
Study Design: 
This will be an international, non-randomized, open-label, multi-site study in 
male subjects with CALD (≤ 17 years of age at enrollment). Approximately 
35 subjects will be infused with eli-cel after myeloablative conditioning with 
busulfan and fludarabine. 
The study has 4 distinct phases after informed consent/assent: 
• 
Screening and Enrollment. Subjects who meet eligibility criteria based on 
screening assessments are considered enrolled. Patients who do not meet 
eligibility criteria are considered screen failures. 
• 
CD34+ Cell Collection, Transduction, Disposition of eli-cel, and 
Reconfirmation of Eligibility  
• 
Conditioning and Washout, followed by eli-cel Infusion on Day 1 
• 
Maintenance (Follow-up) (Day 2 through Month 24) 
From Screening through when it is assessed that the subject is stably transplanted 
(by approximately the Month 3 Visit), visits will occur at one of a small number 
of sites (referred to as primary study sites). However, due to the rarity of CALD, 
it is likely that some subjects may have to travel far for participation at the 
primary study sites. Therefore, after the subject is stably transplanted, 
arrangements will be made wherever possible to open up a suitable site closer to 
the subject’s home (referred to as secondary study sites) where they should attend 
subsequent visits. In all cases, subjects will be asked to return to their primary 
study site for their assessments for Month 12 and Month 24 Visits to ensure 
consistency in key efficacy assessments. 
Screening Phase tests and procedures will determine study eligibility.  
Subjects who are confirmed to be eligible and are enrolled in the study will 
undergo hematopoietic stem cell (HSC) mobilization mediated by granulocyte 
colony stimulating factor (G-CSF, either filgrastim or lenograstim) and 
plerixafor, and cells will be harvested by apheresis using institutional practice 
treatment guidelines. The harvested cells will be selected for the CD34+ marker 
to enrich for HSCs, transduced with Lenti-D lentiviral vector (LVV), stored 
frozen in cryopreservation solution while aliquots are being tested to ensure they 
meet product quality specifications. 
Only after the transduced cells are dispositioned for clinical use and the drug 
product is at the clinical site will the subject undergo myeloablation with busulfan 
intravenous (IV) and fludarabine IV. There should be a minimum of 48 hours of 
washout after conditioning before drug product infusion. Eli-cel will be 
administered by IV infusion through a central venous catheter. 
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Back-up cells (mobilized peripheral blood mononuclear cells [PBMCs]) will also 
be harvested during apheresis and stored frozen in accordance with institutional 
guidelines. If back up cells cannot be procured from apheresis, a bone marrow 
(BM) harvest may be performed. 
All subjects will be followed for approximately 24 months post-drug product 
infusion under this protocol. Then, subjects are expected to be followed for an 
additional 13 years under a separate follow-up protocol (LTF-304). 
Number of Subjects 
Planned: 
Approximately 35 subjects will be infused with eli-cel after myeloablative 
conditioning with busulfan and fludarabine. 
As of this Protocol Amendment (Version 8.0) enrollment and treatment (N=35) in 
Study ALD-104 have been completed; subject follow-up is ongoing. Further 
enrollment in this study is not expected. 
Inclusion Criteria: 
1. Informed consent is obtained from a competent custodial parent or guardian 
with legal capacity to execute a local Institutional Review Board (IRB)/ 
Independent Ethics Committee (IEC) approved consent. Informed assent will 
be sought from capable subjects, in accordance with the directive of the 
IRB/IEC and with local requirements. 
2. Males aged 17 years and younger, at the time of parental/guardian consent 
and, where appropriate, subject assent. 
3. Active CALD as defined by: 
a. Elevated very long chain fatty acids (VLCFA) values, and 
b. Active central nervous system (CNS) disease established by central 
radiographic review of brain magnetic resonance imaging (MRI) 
demonstrating 
i. Loes score between 0.5 and 9 (inclusive) on the 34-point scale, and 
ii. Gadolinium enhancement (GdE) on MRI of demyelinating lesions. 
4. Neurologic Function Score (NFS) ≤ 1. 
Exclusion Criteria: 
1. Prior receipt of an allogeneic transplant or gene therapy. 
2. Use of statins, Lorenzo’s Oil, or dietary regimens used to lower VLCFA 
levels. Note: subjects must discontinue use of these medications at time of 
consent. 
3. Receipt of an investigational study drug or procedure within 3 months before 
Screening that might confound study outcomes. Use of investigational study 
drugs is prohibited throughout the course of the study. 
4. Any conditions that make it impossible to perform MRI studies (including 
allergies to anesthetics or contrast agents). 
5. Hematological compromise as evidenced by: 
a. Peripheral blood absolute neutrophil count (ANC) < 1500 cells/mm3, 
and either 
b. Platelet count < 100,000 cells/mm3 or 
c. Hemoglobin < 10 g/dL. 
6. Hepatic compromise as evidenced by: 
a. Aspartate transaminase (AST) value > 2.5 × upper limit of normal 
(ULN) 
b. Alanine transaminase (ALT) value > 2.5 × ULN 
c. Total bilirubin value > 3.0 mg/dL, except if there is a diagnosis of 
Gilbert’s Syndrome and the subject is otherwise stable 
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7. Baseline estimated glomerular filtration rate < 70 mL/min/1.73 m2, as 
determined using the Chronic Kidney Disease Epidemiology Collaboration 
creatinine equation (see 
https://www.kidney.org/professionals/KDOQI/gfr_calculatorPed) 
8. Cardiac compromise as evidenced by left ventricular ejection fraction < 40% 
9. Immediate family member with a known or suspected Familial Cancer 
Syndrome (including but not limited to hereditary breast and ovarian cancer 
syndrome, hereditary non-polyposis colorectal cancer syndrome, and familial 
adenomatous polyposis). 
10. Clinically significant uncontrolled, active bacterial, viral, fungal, parasitic, or 
prion-associated infection. 
11. Positive for human immunodeficiency virus type 1 or 2 (HIV-1, HIV-2); 
hepatitis B virus (HBV); hepatitis C virus (HCV); human T lymphotrophic 
virus 1 (HTLV-1). (Note that subjects who have been vaccinated against 
HBV [positive for HBV surface antibodies] who are negative for other 
markers of prior HBV infection [e.g., negative for hepatitis B core antibody 
{HBVc Ab}] are eligible. Subjects with past exposure to HBV [HBc 
antibodies {Ab} positive and/or hepatitis B e-antigen antibody {HBeAb}-
positive] are also eligible for the study provided they have a negative test for 
HBV deoxyribonucleic acid [DNA]. Also note that subjects who are positive 
for anti-hepatitis C Ab are eligible as long as they have a negative hepatitis C 
viral load). 
12. Any clinically significant cardiovascular, hematological, or pulmonary 
disease, or other disease or condition that would be contraindicated for any of 
the other study procedures. 
13. Absence of adequate contraception for fertile subjects. Male subjects and 
their female partners are required to use two different effective methods of 
contraception from Screening through at least 6 months after eli-cel infusion. 
If subjects are truly sexually abstinent (where true sexual abstinence is 
defined as being in line with the preferred and usual lifestyle of the subject), 
no second method is required. 
14. Any contraindications to the use of G-CSF or plerixafor during the 
mobilization of HSCs, and any contraindications to the use of busulfan or 
fludarabine, including known hypersensitivity to the active substances or to 
any of the excipients in their formulations. 
15. Known hypersensitivity to protamine sulfate. 
Duration of Subject 
Participation: 
Each subject will remain on this study for approximately 26 months from time of 
consent, inclusive of an approximately 24-months post-drug product infusion 
follow-up; subjects are expected to consent for follow-up in Study LTF-304 for 
another 13 years post-drug product infusion. 
Test Product, Dose 
and Mode of 
Administration: 
Eli-cel (autologous CD34+ cell-enriched population that contains cells transduced 
with LVV that encodes an ATP-binding cassette, sub-family D, member 1 
(ABCD1) complementary DNA (cDNA) for human adrenoleukodystrophy 
protein (ALDP), suspended in a cryopreservation solution) is administered IV; 
dose ≥ 5.0 × 106 CD34+ cells/kg. 
Reference Therapy, 
Dose and Mode of 
Administration: 
Not applicable. 
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Data Monitoring 
Committee:  
An independent data monitoring committee (DMC) composed of members with 
appropriate scientific and medical expertise to monitor the study will be convened 
before the study is opened. A charter describing the composition and conduct of 
the DMC will be drafted by the Sponsor and agreed to by all DMC members prior 
to the DMC’s initial meeting. The DMC will meet by teleconference for 
scheduled meetings biannually and ad hoc as circumstances require. In addition, 
the DMC will review hematologic and integration site analysis (ISA) data on a 
quarterly basis. The DMC will have the right to recommend halting the study at 
any time due to concerns for the safety of the subjects. 
Criteria for 
Evaluation – 
Efficacy: 
The primary efficacy endpoint is: 
• 
Proportion of subjects who are alive and have none of the 6 major 
functional disabilities (MFDs) at Month 24 (i.e., Month 24 MFD-free 
survival). MFDs are: loss of communication, cortical blindness, tube 
feeding, total incontinence, wheelchair dependence, complete loss of 
voluntary movement  
Secondary efficacy endpoints are the following: 
• 
Proportion of subjects without GdE on MRI (i.e., GdE-) at Month 24 
• 
Value and change in total NFS from Baseline to protocol scheduled visits  
• 
MFD-free survival over time 
• 
Overall survival 
• 
Detectable vector copy number (VCN) in peripheral blood cells by 
Month 6 
Criteria for 
Evaluation –  
Safety: 
The primary safety endpoint is: 
• 
The proportion of subjects with neutrophil engraftment after drug product 
infusion 
The secondary safety endpoints are the following: 
• 
The proportion of subjects who experience either acute (≥Grade II) or 
chronic graft versus host disease (GVHD) by Month 24 
• 
Time to neutrophil engraftment post-drug product infusion 
• 
The proportion of subjects with platelet engraftment by Month 24 
• 
Time to platelet engraftment post-drug product infusion  
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• 
The proportion of subjects with loss of neutrophil engraftment post-drug 
product infusion by Month 24 
• 
The proportion of subjects who undergo a subsequent HSC infusion by 
Month 24 
• 
The proportion of subjects who experience transplant-related mortality 
through 100 and 365 days post-drug product infusion 
• 
Proportion of subjects with clinical ≥ Grade 3 adverse events (AEs), all 
drug product-related AEs, all serious adverse events (SAEs), ≥ Grade 3 
infections, and clinically significant changes in laboratory parameters by 
Month 24 
• 
The proportion of subjects who experience ≥ Grade II acute GVHD by 
Month 24 
• 
The proportion of subjects who experience chronic GVHD by Month 24 
• 
Number of emergency room visits (post-neutrophil engraftment) by 
Month 24 
• 
Number and duration of in-patient hospitalizations (post-neutrophil 
engraftment) by Month 24 
• 
Number and duration of intensive care unit (ICU) stays (post-neutrophil 
engraftment) by Month 24 
• 
The number of subjects in which vector-derived replication competent 
lentivirus (RCL) is detected by Month 24 
• 
The number of subjects with insertional oncogenesis (myelodysplasia, 
leukemia, lymphoma, etc.) by Month 24 
Statistical Methods: Three populations will be evaluated for efficacy and safety.  
• 
The Intent-to-treat (ITT) population will consist of subjects who initiate 
any study procedures, beginning with mobilization by G-CSF.  
• 
The Transplant Population (TP) will consist of subjects who receive 
eli-cel.  
• 
The Successful Neutrophil Engraftment Population (NEP) will be 
defined as subjects who 1) receive eli-cel; 2) achieve neutrophil 
engraftment, defined as 3 consecutive ANC laboratory values of 
≥ 0.5 × 109 cells/L (after initial post-infusion nadir) obtained on different 
days by 42 days post-infusion of eli-cel. 
Statistical methods will be primarily descriptive in nature and will include point 
estimates and confidence limits as appropriate. 
The analysis of the primary efficacy endpoint, Month 24 MFD-free survival, will 
be based on the TP. The sample size of 35 subjects will provide a 95% two-sided 
exact confidence interval (CI) for the estimated MFD-free survival rate that is at 
most 34.6% wide (dependent on the observed MFD-free survival rate).  
The analyses of the secondary and 
 efficacy endpoints will be 
performed on the TP.  
The analysis of the primary safety endpoint will be the proportion of subjects 
with neutrophil engraftment after drug product infusion in the TP. The analyses 
of the secondary safety endpoints will also be performed on the TP. 
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AEs, laboratory assessments, vital signs, electrocardiogram (ECG) and physical 
examination findings will be summarized, as appropriate, for the ITT population.  
The planned statistical methodology will be presented in detail in the statistical 
analysis plan (SAP). 
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LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
ABCD1 
ATP-binding cassette, sub-family D, member 1 
ABW 
actual body weight 
ADL 
activities of daily living 
AE 
adverse event 
ALD 
adrenoleukodystrophy 
ALDP 
adrenoleukodystrophy protein 
allo-HSCT 
allogeneic hematopoietic stem cell transplantation 
Ab 
Antibodies 
ALT 
alanine transaminase 
ANC 
absolute neutrophil count 
AST 
aspartate transaminase 
AUC 
area under the curve 
BAER 
brain stem auditory evoked response 
Bayley-III 
Bayley Scales of Infant and Toddler Development, 3rd Edition 
BM 
bone marrow 
BUN 
blood urea nitrogen 
C 
conditioning 
CALD 
cerebral adrenoleukodystrophy 
CBC 
complete blood count 
CGC 
Cancer Gene Census 
cDNA 
complementary deoxyribonucleic acid 
CI 
confidence interval 
CMV 
cytomegalovirus 
CNS 
central nervous system 
CRF 
case report form 
CSR 
clinical study report 
CTCAE 
Common Terminology Criteria for Adverse Events 
DMC 
data monitoring committee 
DMSO 
dimethyl sulfoxide 
DNA 
deoxyribonucleic acid 
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Abbreviation 
Definition 
EBV 
Epstein-Barr virus 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
eli-cel 
elivaldogene autotemcel 
FDA 
Food and Drug Administration 
FISH 
Fluorescence in situ hybridization 
FSIQ  
full scale intelligence quotient 
GCP 
good clinical practice 
G-CSF 
granulocyte colony stimulating factor 
GdE 
gadolinium enhancement 
GMP 
good manufacturing practice 
GVHD 
graft versus host disease 
Hb 
hemoglobin 
HBcAb 
hepatitis B core antibody  
HBeAb 
hepatitis B e-antigen antibody 
HBsAg 
hepatitis B virus surface antigen 
HBV 
hepatitis B virus 
HCV 
hepatitis C virus 
HEENT 
head, eyes, ears, nose, and throat 
HIV-1 
human immunodeficiency virus type 1 
HIV-2 
human immunodeficiency virus type 2 
HLA 
human leukocyte antigen 
HPC, A 
hematopoietic progenitor cell, apheresis 
HRQoL 
health related quality of life 
HSC 
hematopoietic stem cell 
HSCT 
hematopoietic stem cell transplantation 
HSV 
herpes simplex virus 
HTLV-1 
human T lymphotrophic virus 1 
HTLV-2 
human T lymphotrophic virus 2 
IB 
Investigator’s Brochure 
IBW 
ideal body weight 
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Abbreviation 
Definition 
ICF 
informed consent form 
ICH 
International Council on Harmonisation 
ICU 
intensive care unit 
IEC 
Independent Ethics Committee 
Ig 
immunoglobulins (such as IgG, IgM, and IgA)  
IQ 
intelligence quotient 
IRB 
Institutional Review Board 
IS 
insertion site(s) 
ISA 
integration site analysis 
ITT 
Intent-to-treat 
IUD 
intrauterine device 
IUS 
intrauterine hormone-releasing system 
IV 
intravenous 
LTR 
long terminal repeat 
LVV 
lentiviral vector 
M 
mobilization 
MedDRA 
Medical Dictionary for Regulatory Activities 
MFD 
major functional disability 
mL 
milliliter 
MRI 
magnetic resonance imaging 
MUD 
matched unrelated donor 
NCI 
National Cancer Institute 
NE 
neutrophil engraftment 
NEP 
neutrophil engraftment population 
NFS 
neurologic function score 
NGS 
next-generation sequencing 
PBL 
peripheral blood leukocyte 
PBMC 
peripheral blood mononuclear cell 
PB VCN 
peripheral blood vector copy number 
PCR 
polymerase chain reaction 
PCS 
potentially clinically significant 
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Abbreviation 
Definition 
PD 
pharmacodynamic 
PedsQL 
pediatric quality of life inventory 
PIQ 
performance intelligence quotient 
PT 
preferred term 
qPCR 
quantitative polymerase chain reaction 
RBC 
red blood cell 
RCL 
replication competent lentivirus 
RelFreq 
relative frequency 
RNA 
ribonucleic acid 
SAE 
serious adverse event 
SAP 
statistical analysis plan 
SCID-X1 
X-linked severe combined immunodeficiency 
SES 
socioeconomic status 
SIN 
self-inactivating 
SNP 
single nucleotide polymorphism 
SOC 
System Organ Class 
SOE 
Schedule of Events 
SOM 
Study Operations Manual 
SUSAR 
suspected unexpected serious adverse drug reaction 
TNC 
total nucleated cells 
TP 
Transplant Population 
ULN 
upper limit of normal 
US 
United States 
VCN 
vector copy number 
VEP 
visual evoked potential 
VIQ 
verbal intelligence quotient 
VLCFA 
very long chain fatty acids 
VOD 
veno-occlusive disease 
VSV-G 
vesicular stomatitis virus glycoprotein G 
WAIS-IV 
Wechsler Adult Intelligence Scale, 4th Edition 
WBC 
white blood cell 
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Abbreviation 
Definition 
WHO 
World Health Organization 
WISC-V 
Wechsler Intelligence Scale for Children, 5th Edition 
WPPSI-IV 
Wechsler Preschool & Primary Scale of Intelligence, 4th Edition 
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TABLE OF CONTENTS 
MEDICAL MONITOR CONTACT INFORMATION ...................................................................2 
SUMMARY OF CHANGES ...........................................................................................................3 
CLINICAL STUDY SYNOPSIS ...................................................................................................31 
LIST OF ABBREVIATIONS ........................................................................................................37 
TABLE OF CONTENTS ...............................................................................................................42 
LIST OF TABLES IN THE TEXT ................................................................................................45 
LIST OF FIGURES IN THE TEXT ..............................................................................................45 
1. 
INTRODUCTION ......................................................................................................46 
1.1. 
Cerebral Adrenoleukodystrophy .................................................................................46 
1.2. 
Eli-cel ..........................................................................................................................46 
1.2.1. 
Studies ALD-102 and LTF-304 ..................................................................................47 
1.3. 
Rationale for Design of Study ALD-104 ....................................................................47 
1.4. 
Potential Risks ............................................................................................................48 
1.4.1. 
Abnormal Proliferation of Hematopoietic Cells .........................................................48 
1.4.2. 
Use of a Lentiviral Vector Derived from Human Immunodeficiency Virus 
Type 1 (HIV-1) ...........................................................................................................49 
1.4.3. 
Risks of Mobilization and Transplantation.................................................................49 
2. 
STUDY OBJECTIVES AND ENDPOINTS ..............................................................51 
2.1. 
Study Objective ..........................................................................................................51 
2.2. 
Study Endpoints ..........................................................................................................51 
2.2.1. 
Efficacy Endpoints ......................................................................................................51 
2.2.2. 
Safety Endpoints .........................................................................................................52 
3. 
INVESTIGATIONAL PLAN .....................................................................................53 
3.1. 
Overall Design and Plan of the Study .........................................................................53 
3.1.1. 
Data Monitoring Committee .......................................................................................55 
3.2. 
Rationale for the Study ...............................................................................................55 
3.3. 
Rationale for the Drug Product Dose ..........................................................................56 
3.4. 
Treatment Discontinuation and Enrollment Suspension Criteria ...............................56 
3.4.1. 
Stopping Rules Prior to Conditioning.........................................................................56 
3.4.2. 
Enrollment and Infusion of Drug Product Suspension Criteria ..................................57 
3.5. 
End of Trial Definition ...............................................................................................57 
4. 
STUDY POPULATION .............................................................................................58 
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4.1. 
Number of Subjects ....................................................................................................58 
4.2. 
Subject Inclusion Criteria ...........................................................................................58 
4.3. 
Subject Exclusion Criteria ..........................................................................................58 
4.4. 
Subject Identification and Registration ......................................................................60 
4.5. 
Subject Withdrawal from the Study ...........................................................................60 
4.6. 
Withdrawal of Subjects by Investigator or Sponsor ...................................................61 
4.7. 
Protocol Deviation ......................................................................................................61 
5. 
STUDY TREATMENTS............................................................................................62 
5.1. 
Description of the Lenti-D Lentiviral Vector and Eli-cel ...........................................62 
5.2. 
Summary of Treatments to be Performed or Administered ........................................62 
5.2.1. 
Mobilization and Apheresis Procedure .......................................................................62 
5.2.2. 
Bone Marrow Harvest Procedure ...............................................................................64 
5.2.3. 
Transduction Process and Release Testing .................................................................64 
5.2.4. 
Conditioning ...............................................................................................................64 
5.2.5. 
Infusion Procedures, Dose, and Administration .........................................................66 
5.3. 
Storage and Stability of Eli-cel ...................................................................................66 
5.4. 
Storage and Administration of Back-up Cells ............................................................67 
5.5. 
Method of Assigning Subjects to Treatment ..............................................................67 
5.6. 
Blinding, Packaging, and Labeling .............................................................................67 
5.6.1. 
Blinding and Breaking the Blind ................................................................................67 
5.6.2. 
Packaging and Labeling ..............................................................................................67 
5.7. 
Duration of Study Participation ..................................................................................67 
5.8. 
Assessment of Treatment and Study Compliance ......................................................67 
5.9. 
Product Accountability ...............................................................................................68 
5.10. 
Prior and Concomitant Medication and Therapy ........................................................69 
6. 
STUDY ASSESSMENTS ..........................................................................................70 
6.1. 
Schedule of Events .....................................................................................................70 
6.2. 
Concurrent Human Leukocyte Antigen Search for Allogeneic Donor ......................76 
6.3. 
Confirmation of Eligibility .........................................................................................77 
6.4. 
Fertility Preservation ..................................................................................................77 
6.5. 
Assessments ................................................................................................................77 
6.5.1. 
Demographics and Medical History ...........................................................................77 
6.5.2. 
Physical Examination .................................................................................................77 
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6.5.3. 
Vital Signs and Weight ...............................................................................................77 
6.5.4. 
Electrocardiogram/Echocardiogram ...........................................................................77 
6.5.5. 
Neurologic Examination .............................................................................................78 
6.5.6. 
Neurologic Functioning Score (NFS) Assessment .....................................................78 
6.5.7. 
Major Functional Disabilities (MFDs) .......................................................................78 
6.5.8. 
Neuropsychological Tests ...........................................................................................78 
6.5.9. 
Evoked Potential (Electrophysiology) ........................................................................81 
6.5.10. 
Brain Magnetic Resonance Imaging (Loes Score and Pattern) ..................................81 
6.5.11. 
Clinical Laboratory Tests ...........................................................................................81 
6.5.12. 
Assessment of Oligoclonality and/or Suspicion of Malignancy.................................89 
6.5.13. 
Engraftment and Engraftment Failure ........................................................................91 
6.6. 
Adverse Events ...........................................................................................................92 
6.6.1. 
Adverse Events Definitions ........................................................................................92 
6.6.2. 
Adverse Event Assessment of Severity and Relationship ..........................................93 
6.6.3. 
Procedures for AE and SAE Collection and Reporting ..............................................94 
6.6.4. 
Immediate Reporting of SAEs ....................................................................................95 
6.6.5. 
Safety Reporting to Regulatory Authorities, Ethics Committees, and 
Investigators ................................................................................................................95 
6.7. 
Pregnancy and Contraception .....................................................................................95 
6.8. 
Unscheduled Visits .....................................................................................................96 
6.9. 
Long-term Follow-Up Protocol ..................................................................................96 
7. 
STATISTICAL PROCEDURES ................................................................................97 
7.1. 
Sample Size Estimation ..............................................................................................97 
7.2. 
Populations for Analysis .............................................................................................97 
7.3. 
Planned Analyses ........................................................................................................97 
7.3.1. 
Interim Analysis ..........................................................................................................97 
7.3.2. 
Final Analysis .............................................................................................................97 
7.3.3. 
Additional Data Review .............................................................................................97 
7.3.4. 
Impact of the COVID-19 Pandemic ...........................................................................98 
7.4. 
Statistical Methods ......................................................................................................98 
7.4.1. 
General Methods .........................................................................................................98 
7.4.2. 
Disposition of Subjects ...............................................................................................98 
7.4.3. 
Demographic and Baseline Characteristics ................................................................99 
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7.4.4. 
Analysis of Efficacy Endpoints ..................................................................................99 
7.4.5. 
Analysis of Safety Endpoints ....................................................................................101 
8. 
ADMINISTRATIVE AND REGULATORY REQUIREMENTS ..........................104 
8.1. 
Good Clinical Practice (GCP) ..................................................................................104 
8.2. 
Ethical Considerations ..............................................................................................104 
8.3. 
Subject Information and Informed Consent .............................................................104 
8.4. 
Subject Confidentiality .............................................................................................104 
8.5. 
Protocol Compliance ................................................................................................105 
8.6. 
Direct Access to Source Data ...................................................................................105 
8.7. 
Electronic Case Report Form Completion ................................................................105 
8.8. 
Record Retention ......................................................................................................106 
8.9. 
Liability and Insurance .............................................................................................106 
8.10. 
Publication and Presentation of Study Findings and Use of Information ................106 
9. 
REFERENCES .........................................................................................................108 
10. 
APPENDICES ..........................................................................................................112 
10.1. 
Dose Adjustment Formulas for Ideal Body Weight .................................................112 
10.2. 
Major Functional Disabilities ...................................................................................112 
10.3. 
Neurologic Function Score for ALD ........................................................................113 
INVESTIGATOR STATEMENT ...............................................................................................116 
LIST OF TABLES IN THE TEXT 
Table 1: 
Dose specification of eli-cel and Back-up Cells for Rescue for CALD .....................56 
Table 2: 
Mobilization and Apheresis Schedule ........................................................................62 
Table 3: 
Schedule of Events: Screening through Conditioning ................................................72 
Table 4: 
Schedule of Events: Drug Product Infusion through End of Study ............................74 
Table 5: 
Schedule of Events: Hematology Month 1 through Month 12 Visits ........................76 
Table 6: 
Neuropsychological Tests to be Performed ................................................................79 
Table 7: 
Blood and Bone Marrow Collection: Order of Priority ..............................................87 
Table 8: 
Major Functional Disabilities ...................................................................................112 
Table 9: 
Neurologic Function Score for CALD .....................................................................114 
LIST OF FIGURES IN THE TEXT 
Figure 1: 
ISA Triggered Enhanced Monitoring .........................................................................90 
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1. 
INTRODUCTION 
1.1. 
Cerebral Adrenoleukodystrophy 
Cerebral adrenoleukodystrophy (CALD) is a rare X-linked genetic disease caused by a defect 
in the ATP-binding cassette, sub-family D, member 1 (ABCD1) gene, which encodes for 
adrenoleukodystrophy protein (ALDP), a peroxisomal transporter involved in the breakdown of 
very long chain fatty acids (VLCFA) (Moser et al. 2007). The resulting accumulation of VLCFA 
leads to progressive demyelination and cerebral inflammation within the brain, which 
(if untreated) leads to severe loss of neurological function over time, and death. In boys 
diagnosed with CALD, learning and behavioral problems are often observed in mid-childhood 
after the age of 3 years (median age 7). Most patients will die within a decade of diagnosis if 
they are not treated by stem cell transplantation (Moser et al. 2007). 
One of the hallmarks of inflammatory disease in CALD is the presence of a compromised 
blood‑brain-barrier behind the leading edge of demyelinating lesions, as evidenced by positive 
gadolinium enhancement (GdE) on brain magnetic resonance imaging (MRI), prior to treatment. 
Studies have shown that GdE is associated with disease progression in untreated patients as the 
severity of the inflammatory process appears to be correlated with the rapidity of progression. 
The goal of treatment for CALD is to delay or prevent progression of the disease, thereby 
preventing the development of impairments which compromise the ability to function 
independently. There is currently no treatment approved for CALD. A beneficial effect 
on clinical indices of disease and long-term survival has been observed with allogeneic 
hematopoietic stem cell transplantation (allo‑HSCT), in particular if performed early 
in the course of cerebral disease progression (Mahmood et al. 2007; Miller et al. 2011; Kühl et 
al. 2017). 
Allo-HSCT is optimally performed early in the course of the disease using a human leukocyte 
antigen (HLA)-matched sibling hematopoietic stem cell (HSC) donor. However, a matched 
sibling donor is available for only ≤ 30% of patients (Miller et al. 2011), so alternative options 
include transplantation with cells derived from an HLA-mismatched related donor, a matched 
unrelated donor  hematopoietic stem cell transplantation (MUD-HSCT), or transplant with cells 
derived from banked cord blood (umbilical cord blood transplantation). 
1.2. 
Eli-cel  
With an objective to provide an effective and safer alternative to allo-HSCT, bluebird bio is 
investigating the use of Lenti-D Drug Product (also known as elivaldogene autotemcel, hereafter 
referred to as eli-cel) in the treatment of subjects with CALD. The mode of action of eli-cel is 
based on treating patients with their own HSCs that have been transduced ex vivo with the 
Lenti‑D lentiviral vector (LVV) that encodes a normal ALDP. After transplantation, these HSCs 
then differentiate into different cell types, including cerebral microglia, which may produce 
functional ALDP. The functional ALDP can then enable the peroxisomal beta‑oxidation of 
VLCFAs, which in turn can stabilize the disease by preventing further inflammation and 
demyelination. 
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It is anticipated that transplantation of autologous CD34+ HSCs genetically modified ex vivo 
by the Lenti-D LVV should circumvent many of the limitations and risks associated with 
allo-HSCT, while providing efficacy similar to allo-HSCT. The use of a patient’s own stem cells
would eliminate the risks of graft rejection and acute and chronic graft versus host disease 
(GVHD) due to immune-incompatibility, as well as reduce complications due to long-term 
immunosuppression. 
1.2.1. 
 Studies ALD-102 and LTF-304 
Study ALD-102 was an international, Phase 2/3, multicenter, open-label, single-arm, single-dose 
study designed to evaluate the efficacy and safety of eli-cel in male subjects with CALD aged 
≤ 17 years with active cerebral disease. In Study ALD-102, a myeloablative conditioning 
regimen of busulfan and cyclophosphamide was utilized before infusion of eli-cel. Each subject 
in Study ALD-102 was evaluated for 2 years after eli-cel infusion of ≥ 5.0 × 106 CD34+ cells/kg. 
Subjects are then followed for an additional 13 years in a long-term followup (LTF) study (Study 
LTF-304). Study ALD-102 is completed, while Study LTF-304 remains ongoing as of this 
protocol amendment. Safety data from ALD‑102 and LTF-304 can be found in the IB. 
1.3. 
Rationale for Design of Study ALD-104 
The objective of the current study is to evaluate the efficacy and safety of eli-cel after 
myeloablative conditioning with busulfan and fludarabine in subjects with CALD. 
The study will enroll participants who have GdE on MRI, have a neurologic function score 
(NFS) ≤ 1, and a Loes score between 0.5 and 9 (inclusive) at Baseline because those with more 
advanced disease are unlikely to experience optimal outcomes from allo-HSCT (Miller et al. 
2011) and are therefore thought to be unlikely to significantly benefit from treatment with the 
eli-cel. 
The primary efficacy endpoint, as described in Section 2.2.1 is Month 24 major functional 
disability (MFD)-free survival, and the duration of 24 months follow-up was selected to allow 
sufficient time for potential MFDs to develop. MFDs were chosen based on their clinical 
significance and their impact on independent functioning, and are the following: 
•
loss of communication,
•
cortical blindness,
•
tube feeding,
•
total incontinence,
•
wheelchair dependence, and
•
complete loss of voluntary movement.
Recent published data indicate that the use of plerixafor in pediatric patients is safe and 
effective for the mobilization of peripheral blood stem cells for autologous transplantation 
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(Teusink et al. 2016). The addition of plerixafor to granulocyte colony stimulating factor 
(G‑CSF) in pediatric patients undergoing stem cell mobilization prior to transplantation as 
part of treatment of malignant tumors has also been shown to result in successful mobilization of 
the vast majority of patients who fail to mobilize with single agent G-CSF, as well as to produce 
larger yields of CD34+ cells (Maschan et al. 2015). Plerixafor is thus expected to incur minimal 
additional safety risks beyond the use of single agent G-CSF, to increase cell yield with reduced 
G-CSF exposure, and to reduce requirements for repeat apheresis attempts. 
In Study ALD-102, a myeloablative conditioning regimen of busulfan intravenous (IV) and 
cyclophosphamide IV was utilized before infusion of eli-cel (Eichler et al. 2017). However, a 
conditioning regimen of busulfan and fludarabine was demonstrated to be less toxic and equally 
effective as a regimen of busulfan and cyclophosphamide during allo-HSCT (Bartelink et al. 
2014). Specifically, literature data show that the cumulative busulfan dose determines both its 
efficacy and toxicity (Bartelink et al. 2012, 2014, 2016); and a cumulative busulfan exposure of 
between 78 mg × h/L and 101 mg × h/L, combined with the non-alkylating drug fludarabine, 
predicted the highest event-free survival in pediatric and young adult patients independent of 
indication and cell source. An increased risk of acute and chronic toxicity was noted at higher 
exposures, whereas an increased risk of graft rejection or disease relapse occurred at lower 
exposures (Bartelink et al. 2014). Pediatric patients who received busulfan in conjunction with 
fludarabine had lower rates of veno-occlusive disease (VOD) and chronic GVHD, as compared 
with pediatric patients who received busulfan in conjunction with cyclophosphamide. 
Additionally, the duration of neutropenia, with its associated infection risk, was shorter. 
Therefore, in Study ALD-104, a myeloablative conditioning regimen of busulfan (IV) and 
fludarabine (IV) is recommended before infusion of eli-cel. The selected dosing regimen for 
busulfan and fludarabine in Study ALD-104 is consistent with the recommendations from the 
European Society for Immunodeficiencies in pediatric patients (Lankester 2017). 
1.4. 
Potential Risks 
Potential risks, warnings and precautions are described in the Skysona U.S. product package 
insert (SKYSONA 2022); in addition, updated safety results for bluebird bio's CALD studies can 
be found in the IB. 
1.4.1. 
Abnormal Proliferation of Hematopoietic Cells 
LVVs are retroviruses, which integrate into the chromosome of target cells upon transduction. 
A potential risk of this type of vector is insertional mutagenesis leading to oncogenesis. 
The risk of mutagenesis for this study is limited to the hematopoietic cell compartment, since 
the LVV is designed not to mobilize after integration into the chromosomal deoxyribonucleic 
acid (cDNA) of HSCs. Gene transfer with γ-retroviral vectors has resulted in oncogenesis in the 
clinical studies for X-linked severe combined immunodeficiency (SCID-X1) (Hacein-Bey-Abina 
et al. 2008; Howe et al. 2008), chronic granulomatous disease (Stein et al. 2010), and 
Wiskott-Aldrich Syndrome (Boztug et al. 2010).  
Due to insertional mutagenesis, 5 of 20 participants in the SCID-X1 study developed acute 
lymphocytic leukemia. One of the 5 participants succumbed to leukemia, while the remaining 
4 were successfully treated. In the Wiskott-Aldrich study, 4 participants developed leukemia 
(Paruzynski et al. 2012). 
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The different nature of the Lenti-D LVV should minimize, but not completely eliminate, the 
risk of oncogenesis by insertional mutagenesis. Unlike the γ-retroviral vectors that led to 
leukemia, self‑inactivating (SIN) LVVs, such as Lenti-D LVV, may represent a substantial 
improvement in terms of safety (Montini et al. 2006). SIN LVVs, in general, provide significant 
safety improvements over γ-retroviral vectors used in earlier studies (Rivière et al. 2012). 
SIN LVVs lack the strong enhancer/promoter long terminal repeat (LTR) sequences of 
γ-retroviral vectors, and, unlike γ -retroviral vectors, do not preferentially integrate near gene 
promoter regions. Therefore, LVVs are less likely to transactivate oncogenes, and have 
demonstrated a significantly curtailed probability of oncogenic transformation in vitro and 
in vivo (Biffi et al. 2011). However, as described in the Skysona U.S. product package insert 
(SKYSONA 2022) and in the IB, insertional oncogenesis has been observed in the eli-cel clinical 
development program. 
Safety results for bluebird bio's CALD studies can be found in the IB. 
1.4.2. 
Use of a Lentiviral Vector Derived from Human Immunodeficiency Virus 
Type 1 (HIV-1) 
Because the Lenti-D LVV was derived from human immunodeficiency virus type 1 (HIV-1), a 
potential risk is mobilization or recombination with wild-type HIV-1. This risk is estimated to be 
very low for several reasons - the LVV is replication incompetent, the probability of producing a 
recombinant virus from a multi-plasmid transfection is very low, the transduction is ex vivo so 
there is no opportunity for the vector to be exposed to HIV, and a highly sensitive, validated 
assay is used prior to transduction to detect replication competent lentivirus (RCL). 
Participants treated with eli-cel will be monitored from Baseline for 24 months under the current 
protocol and then for an additional 13 years under the separate, long-term follow-up protocol that 
will focus on long-term safety with an emphasis on detection of insertional oncogenesis and 
RCL. If a vector‑derived RCL is detected in any participant, the Sponsor will conduct individual 
benefit/risk assessments, and consult with the data monitoring committee (DMC) and clinical 
sites, as appropriate, to determine whether enrollment should be suspended and/or any study 
procedures should be performed. 
1.4.3. 
Risks of Mobilization and Transplantation  
Reported warnings for G-CSF (where G-CSF is defined for this protocol to mean either 
filgrastim or lenograstim) can be found in the prescribing information for each product. They 
may include the potential for allergic reactions, splenic rupture, acute respiratory distress 
syndrome, and alveolar hemorrhage and hemoptysis (e.g., Neupogen [filgrastim] 
prescribing information; note that some additional warnings reported apply only to clinical 
populations with sickle cell disorders or severe chronic neutropenia and thus would not be 
relevant for the study population to be enrolled in Study ALD‑104). Additionally, reported 
precautions include the potential for immunogenicity or cutaneous vasculitis (Thornley et al. 
2004). Refer to the prescribing information (Neupogen PI 2016, SmPC 2015) for additional 
product details regarding G-CSF, including all reported adverse events (AEs) from clinical trials. 
Reported warnings for plerixafor include increased circulation of leukocytes, decreased 
platelet counts, and potential for splenic rupture (e.g., Mozobil prescribing information; note that 
some additional warnings reported apply only to patients with leukemia, female patients who 
may become pregnant, or patients with the potential for tumor cell mobilization). The most 
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common AEs, reported in ≥ 10% of patients, include diarrhea, nausea, fatigue, injection site 
reactions, headache, arthralgia, dizziness, and vomiting. Refer to the prescribing information 
(Mozobil PI 2017, SmPC 2017) for additional product details regarding plerixafor, including all 
reported AEs from clinical trials. 
Conditioning regimen-related toxicity is a frequent cause of morbidity and mortality in 
allo-HSCT (Clift et al. 1993; Thornley et al. 2004). Most notably, given that a goal of 
conditioning is immunosuppression, participants receiving such treatment are at significant risk 
for development of potentially fatal, opportunistic infections (e.g., cytomegalovirus [CMV], 
Epstein Barr Virus [EBV]). However, this risk is lower with autologous HSCT because the 
hematologic reconstitution is very rapid and long-term immunosuppression is not required. 
VOD, marked by weight gain due to ascites, hepatomegaly, and hyperbilirubinemia, may also 
occur (Nevill et al. 1991; Clift et al. 1993; Andersson et al. 2002). VOD can be severe, leading to 
multi‑organ failure and ultimately death in up to 30% of cases (Richardson et al. 1998). Central 
nervous system (CNS) toxicities, primarily seizure, also can occur with the conditioning 
regimen. Although generally less significant, mucositis, skin complications, and gastrointestinal 
disturbances, primarily nausea, vomiting and diarrhea, commonly occur with busulfan IV and 
fludarabine IV conditioning (Busilvex SmPC 2017; Busulfex PI 2018; Fludarabine PI 2010). 
Potential effects on male infertility are noted in package inserts for both busulfan IV and 
fludarabine IV conditioning agents (Busilvex SmPC 2017; Busulfex PI 2018; Fludarabine PI 
2010). Refer to the prescribing information regarding additional toxicities associated with 
busulfan IV and fludarabine IV (Busilvex SmPC 2017; Busulfex PI 2018; Fludarabine PI 2010). 
Management of neutrophil engraftment failure (as defined in Section 6.5.13) is at the discretion 
of the Investigator. Participant will be followed as per protocol scheduled- visits (Table 3 and 
Table 4). 
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2. 
STUDY OBJECTIVES AND ENDPOINTS 
2.1. 
Study Objective 
• To evaluate the efficacy and safety of eli-cel after myeloablative conditioning with 
busulfan and fludarabine in subjects with CALD 
2.2. 
Study Endpoints 
2.2.1. 
Efficacy Endpoints 
The primary efficacy endpoint is: 
• Proportion of subjects who are alive and have none of the 6 MFDs at Month 24 
(i.e. Month 24 MFD-free survival). MFDs are:  
− loss of communication 
− cortical blindness 
− tube feeding 
− total incontinence 
− wheelchair dependence 
− complete loss of voluntary movement 
Secondary efficacy endpoints are the following: 
• Proportion of subjects without GdE on MRI (i.e., GdE-) at Month 24 
• Value and change in total NFS from Baseline to protocol scheduled visits  
• MFD-free survival over time 
• Overall survival 
• Detectable vector copy number (VCN) in peripheral blood cells by Month 6 
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2.2.2. 
Safety Endpoints 
The primary safety endpoint is: 
• The proportion of subjects with neutrophil engraftment after drug product infusion 
The secondary safety endpoints are the following: 
• The proportion of subjects who experience either acute (≥ Grade II) or chronic 
GVHD by Month 24 
• Time to neutrophil engraftment after drug product infusion 
• The proportion of subjects with platelet engraftment by Month 24 
• Time to platelet engraftment post-drug product infusion 
• The proportion of subjects with loss of neutrophil engraftment post-drug product 
infusion by Month 24 
• The proportion of subjects who undergo a subsequent HSC infusion by Month 24 
• The proportion of subjects who experience transplant-related mortality through 
100 and 365 days post-drug product infusion 
• Proportion of subjects with clinical ≥ Grade 3 AEs, all drug product-related AEs, all 
serious adverse events (SAEs),  ≥ Grade 3 infections, and clinically significant 
changes in laboratory parameters by Month 24 
• The proportion of subjects who experience ≥ Grade II acute GVHD by Month 24 
• The proportion of subjects who experience chronic GVHD by Month 24 
• Number of emergency room visits (post-neutrophil engraftment) by Month 24 
• Number and duration of in-patient hospitalizations (post-neutrophil engraftment) by 
Month 24 
• Number and duration of intensive care unit (ICU) stays (post-neutrophil engraftment) 
by Month 24 
• The number of subjects in which vector-derived RCL is detected by Month 24 
• The number of subjects with insertional oncogenesis (myelodysplasia, leukemia, 
lymphoma, etc.) by Month 24 
Note: transplant-related mortality as determined by the Investigator; severity of AEs as assessed 
by the Investigator as described in Section 6.6.2 ; acute GVHD graded on the Acute GVHD 
Grading Scale (I-IV); chronic GVHD as determined by the Investigator. 
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3. 
INVESTIGATIONAL PLAN 
3.1. 
Overall Design and Plan of the Study 
This will be an international, non-randomized, open-label, multi-site study in male subjects with 
CALD (≤ 17 years of age at enrollment). Approximately 35 subjects will be infused with eli-cel 
after myeloablative conditioning with busulfan and fludarabine.  
Selected subjects must meet the inclusion criteria, have none of the exclusion criteria, and have 
provided informed consent and assent, when applicable. The study has 4 distinct phases after 
informed consent: 
• Screening and Enrollment. Subjects who meet eligibility criteria, based on screening 
assessments are considered enrolled. Patients who do not meet eligibility criteria are 
considered screen failures. 
• CD34+ Cell Collection, Transduction, Disposition of eli-cel, and Reconfirmation of 
Eligibility  
• Conditioning and Washout, followed by eli-cel Infusion on Day 1 
• Maintenance (Follow-up) (Day 2 through Month 24) 
From Screening through when it is assessed that the subject is stably transplanted 
(by approximately the Month 3 Visit), visits will occur at one of a small number of sites 
(referred to as primary study sites). However, due to the rarity of CALD, it is likely that some 
subjects may have to travel far for participation at the primary study sites. Therefore, after the 
subject is stably transplanted, arrangements will be made wherever possible to open up a suitable 
site closer to the subject’s home (referred to as secondary study sites) where they should attend 
subsequent visits. In all cases, subjects will be asked to return to their primary study site for their 
assessments for Month 12 and Month 24 Visits to ensure consistency in key efficacy 
assessments. 
Prior to the Screening Phase, the Investigator will identify candidates potentially meeting the 
study eligibility criteria, based on review of medical records and clinical test findings performed 
routinely as standard of care for the management of the subject’s disease. The competent legal 
parent(s)/guardian will be informed of the option to participate in the study and all associated 
risks of the study procedures as well as the investigational nature of gene therapy treatment 
(eli‑cel). Sites will follow their standard institutional practice for obtaining informed consent. 
(Informed assent will be sought from capable subjects, in accordance with the directive of the 
Institutional Review Board [IRB]/ Independent Ethics Committee [IEC] and with local 
requirements). The subject and his legal parent(s)/guardian should be provided with adequate 
time to ask questions about the study, treatment, and required procedures. A physician not 
associated with the study team, but knowledgeable about the gene therapy, HSCT, and CALD 
clinical management, must participate in the initial consent process to provide an independent 
perspective on the benefit-risk of study participation and other available treatment 
options. Written informed consent and assent (if applicable) must be obtained before the conduct 
of any screening tests not performed routinely in the treatment of the subject. The consent 
process will be performed in accordance with International Council on Harmonisation 
(ICH)/Good clinical practice (GCP).  
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Subjects who are pre-screened and considered by the Investigator to be potentially eligible and 
for whom written informed consent has been provided will enter the Screening Phase and 
undergo the tests and procedures necessary to confirm study eligibility.  
Subjects who are confirmed to be eligible, based on Screening assessments, are enrolled in the 
study and will undergo HSC mobilization mediated by G-CSF and plerixafor and harvest by 
apheresis using institutional practice treatment guidelines. G-CSF is defined for this protocol to 
mean either filgrastim or lenograstim. The harvested cells will be selected for the CD34+ marker 
to enrich for HSCs, transduced with Lenti-D LVV, stored frozen in cryopreservation solution 
while aliquots are being tested to ensure they meet product quality specifications, and returned 
by IV infusion through a central venous catheter to the same subject after the subject is 
myeloablated with busulfan IV and fludarabine IV. The subject will only undergo myeloablation 
after the transduced cells are dispositioned for clinical use and the drug product is at the clinical 
site.  
Back-up cells for rescue (mobilized peripheral blood mononuclear cells [PBMCs]) will also be 
harvested during apheresis and stored frozen in accordance with institutional guidelines. If back 
up cells cannot be procured from apheresis, a bone marrow (BM) harvest may be performed. 
All subjects will be followed for 24 months post-drug product infusion under this protocol. Then, 
subjects are expected to be followed for an additional 13 years under a separate follow-up 
protocol (Study LTF-304). The 13-year follow-up study will focus on long-term safety, with an 
emphasis on hematologic monitoring and integration site analysis (ISA) and long-term efficacy 
to evaluate durability of response. 
Efficacy evaluations to be performed during the study include an assessment of MFDs, as well as 
of functional status using NFS. Additional efficacy evaluations include determination of the 
extent of cerebral demyelination, as measured by Loes score, and GdE on MRI.
 
assessments will include age-appropriate Wechsler tests, PedsQL™, VLCFA levels in serum, 
and measurements of average VCN and fraction of cells expressing ALDP in peripheral blood.  
Safety evaluations to be performed during the study include determination of survival status; 
documentation of AEs, including SAEs; monitoring of vital signs; physical examinations; 
electrocardiogram (ECG); serology panel testing; standard clinical chemistry and hematology 
testing; concomitant medications; and testing for integration site analysis and testing for 
evidence of RCL.  
Periodic efficacy and safety examinations will be performed by pediatric specialists or qualified 
delegates, as appropriate. 
The success of the transplant procedure will be assessed by time to neutrophil engraftment 
(as defined in Section 6.5.13). Peri-transplant and post-drug product infusion morbidity and 
mortality will be recorded. Each subject will be evaluated on a predetermined schedule for 
24 months post-drug product infusion to assess disease progression using efficacy evaluations. 
Neutrophil engraftment failure is defined in Section 6.5.13. 
Subjects who experience neutrophil engraftment failure will be treated at the Investigator’s 
discretion, and will continue to be followed for efficacy and safety assessments as detailed in the 
Schedule of Events (SOE) (Table 3, Table 4 and Table 5). 
Platelet engraftment is defined in Section 6.5.13. 
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Additional details regarding study evaluations and procedures, including administrative 
information, will be provided by the Sponsor in the Study Operations Manual (SOM). 
The coordinating Investigator assigned on this study will be responsible for signing off on the 
final ALD-104 Clinical Study Report (CSR). 
Note: as of this Protocol Amendment (Version 8.0) enrollment in Study ALD-104 has been 
completed and patient followup remains ongoing. Further subject enrollment in this study is not 
anticipated. 
3.1.1. 
Data Monitoring Committee 
An independent DMC composed of members with appropriate scientific and medical expertise to 
monitor the study will be convened before the study is opened. A charter describing the 
composition and conduct of the DMC will be drafted by the Sponsor and agreed to by all DMC 
members prior to the DMC’s initial meeting. The DMC will meet by teleconference for 
scheduled meetings biannually and ad hoc as circumstances require. In addition, the DMC will 
review hematologic and ISA data on a quarterly basis. The DMC will have the right to 
recommend halting the study at any time due to concerns for the safety of the participants. (Refer 
to Section 3.4.2 for the enrollment suspension criteria). 
3.2. 
Rationale for the Study 
CALD is caused by an X-linked defect in the ABCD1 gene, which encodes for ALDP, a 
peroxisomal transporter involved in the breakdown of VLCFA. The result is an accumulation 
of VLCFA that results in significant cerebral demyelination and neurologic dysfunction in young 
boys (typically aged 3 to 15 years). If diagnosed early, CALD can be treated with allo-HSCT to 
supply hematopoietically-derived cells, such as brain microglia, with functional ALDP. 
However, allo‑HSCT carries a significant risk of procedure-related mortality, GVHD, and graft 
failure (Peters et al. 2004; Miller et al. 2011). Treatment with eli-cel, which utilizes a subject’s 
own cells, should restore ALDP function by introducing the functional gene into cells that could 
differentiate into microglia, without exposing the subject to most of the procedure-related 
morbidity and mortality risks of allogeneic transplant. The mortality risk for subjects undergoing 
autologous transplants using myeloablative conditioning is ~3.2% at centers with significant 
experience in this treatment (Ortega et al. 2003). 
There is a high unmet medical need for patients diagnosed with CALD. Allo-HSCT, a therapy 
with reported clinical benefits, is associated with significant morbidity and mortality, with a 
10% to 30% risk of failure of engraftment, life-threatening infection, and acute or chronic 
GVHD (Hahn et al. 2008; Miller et al. 2011), with the risk of chronic GVHD being 
approximately 30% (Carlens et al. 1998). In completed Study ALD-102 and ongoing Study 
LTF‑304, as of this protocol amendment, no cases of graft failure or GVHD have been observed. 
In Study ALD-102, a myeloablative conditioning regimen of busulfan and cyclophosphamide 
was utilized before infusion of eli-cel (Eichler et al. 2017). However, a conditioning regimen of 
busulfan and fludarabine was demonstrated to be less toxic and equally effective as a regimen of 
busulfan and cyclophosphamide during allo-HSCT (Bartelink et al. 2014). Thus, a conditioning 
regimen of busulfan and fludarabine is used in this study. 
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Therapies based on administration of autologous CD34+ HSCs transduced with an LVV, are 
anticipated to have no risk of GVHD, a low risk of engraftment failure, and a lower risk of death, 
and should have a safety advantage over allo-HSCT. 
See Section 1.3 for rationale for Study Design. 
3.3. 
Rationale for the Drug Product Dose  
Eli-cel consists of an autologous CD34+ cell-enriched population that contains cells transduced 
with LVV that encodes an ABCD1 cDNA for human ALDP, suspended in a cryopreservation 
solution in the final immediate container for the intended medical use. 
Eli-cel is administered via IV infusion.  
The dose for eli-cel is ≥ 5.0 × 106 CD34+ cells/kg. The minimum CD34+ dose accepted as 
safe practice and associated with favorable engraftment kinetics is approximately 1.5 × 106 
to 3.0 × 106 cells/kg (Bender et al. 1992; Perez-Simon et al. 1998; Miyamoto et al. 2004; Jillella 
and Ustun 2004). However, optimal neutrophil and platelet engraftment occurs at doses around 
5.0 × 106 cells/kg (Weaver et al. 1995; Hatzimichael and Tuthill 2010; Duong et al. 2014).  
Given these data, Table 1 outlines the source of subject cells, usage, and dose for eli-cel to be 
received and for back-up cells.  
Table 1: 
Dose specification of eli-cel and Back-up Cells for Rescue for CALD 
Source 
Usage 
Recommended Cell Dose 
Apheresis 
Drug Product 
≥ 5.0 × 106 CD34+ cells/kga 
Apheresis 
Back-up Cells 
≥ 1.5 × 106 CD34+ cells/kg 
Bone Marrow Harvest 
Back-up Cells 
≥ 1.5 × 106 CD34+ cells/kg OR 
 ≥ 1.0 × 108 TNC /kg 
Abbrev.: TNC, total nucleated cells  
a If more than one drug product lot is manufactured, the total dose of the resulting multiple drug product lots must 
meet this criterion. 
The results from each eli-cel lot’s completed release testing will be used along with the number 
of cells and viability to determine if it is appropriate to proceed with myeloablation. 
3.4. 
Treatment Discontinuation and Enrollment Suspension Criteria 
3.4.1. 
Stopping Rules Prior to Conditioning 
Subjects will be withdrawn from the study if they meet any of the following criteria as related to 
pre-conditioning assessments: 
• Failure to continue to satisfy eligibility criteria 
• Neurological decline (progression of cerebral disease) between Screening and Pre- 
conditioning Assessments as evidenced by an NFS > 1 or a Loes Score > 9.  
• Failure of eli-cel to be dispositioned for clinical use. Conditioning will not begin until 
it is confirmed that the eli-cel has been dispositioned for clinical use. 
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Once myeloablation with busulfan IV and fludarabine IV has begun, there are no stopping 
rules for conditioning, except for the enrollment and infusion of drug product suspension 
criteria for the study as outlined in Section 3.4.2. In the anticipated very rare event 
of consent withdrawal during conditioning or the development of a new medical condition 
that, in the Investigator’s opinion, puts the subject at risk with continued busulfan IV 
and fludarabine IV treatment, the Medical Monitor should be contacted immediately. 
In such situations in which busulfan IV and fludarabine IV conditioning has not been completed 
per protocol, eli-cel should not be given, and it is likely that rescue therapy with back-up cells 
(mobilized PBMCs), or with HSCs from an appropriately allogeneic donor if available, will 
be required. 
3.4.2. 
Enrollment and Infusion of Drug Product Suspension Criteria 
Enrollment in this study or infusion of drug product may be temporarily suspended at any time 
for safety reasons. In the event enrollment is suspended by the Sponsor, the initiation of new 
mobilization, conditioning, or drug product infusion of subjects will be based on the individual 
benefit: risk; subjects who have already been treated with eli-cel will continue in the study.  
The Sponsor will inform the regulatory authorities, Investigators, each site’s IRB/IEC and other 
appropriate institutional regulatory authorities if a decision to temporarily suspend the study is 
made.  
Following any of the events listed below, the Sponsor will conduct individual benefit/risk 
assessments, and consult with the DMC and clinical sites, as appropriate, to determine whether 
enrollment should be suspended and/or any study procedures should be performed. 
• Death, related to drug product or with unknown relationship to drug product  
• Detection of a hematological malignancy (e.g., myelodysplasia, leukemia, 
lymphoma; see Section 6.5.12). 
• Detection of vector-derived RCL in any subject  
• Failure in 1 subject to achieve detectable VCN by Month 6 
• Determination of unexpected, clinically significant, or unacceptable risk to 
subjects (e.g., development of study treatment-related Grade 3 or 4 toxicities in at 
least 3 subjects). 
Enrollment and/or study procedures will resume only after review and recommendation from the 
DMC. Note that a substantial amendment will be submitted to regulatory authorities before 
restarting enrollment if required by local regulations. 
3.5. 
End of Trial Definition 
The end of the trial is defined as the last visit of the last subject. 
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4. 
STUDY POPULATION 
Males aged 17 years and younger who have been definitively diagnosed with CALD (by finding 
elevated levels of VLCFA) who have an MRI Loes score between 0.5 and 9 (inclusive), an 
NFS ≤ 1, and GdE on MRI may be enrolled. 
4.1. 
Number of Subjects 
Approximately 35 subjects will be infused with eli-cel after myeloablative conditioning with 
busulfan and fludarabine. 
As of this Protocol Amendment (Version 8.0) enrollment and treatment (N=35) in Study ALD-
104 have been completed; subject follow-up is ongoing. Further enrollment in this study is not 
expected. 
4.2. 
Subject Inclusion Criteria 
Subjects must meet all of the following criteria to be eligible for inclusion in this study.  
1. Informed consent is obtained from a competent custodial parent or guardian with legal 
capacity to execute a local IRB/IEC approved consent. (Informed assent will be sought 
from capable subjects, in accordance with the directive of the IRB/IEC and with local 
requirements.) 
2. Males aged 17 years and younger, at the time of parental/guardian consent and, where 
appropriate, subject assent. 
3. Active CALD as defined by: 
a. Elevated VLCFA values, and 
b. Active CNS disease established by central radiographic review of brain MRI 
demonstrating 
i. Loes score between 0.5 and 9 (inclusive) on the 34-point scale, and 
ii. GdE on MRI of demyelinating lesions. 
4. NFS ≤ 1. 
4.3. 
Subject Exclusion Criteria 
Subjects meeting any of the following criteria are not eligible for inclusion in this study. 
1. Prior receipt of an allogeneic transplant or gene therapy. 
2. Use of statins, Lorenzo’s Oil, or dietary regimens used to lower VLCFA levels. 
Note: subjects must discontinue use of these medications at time of consent. 
3. Receipt of an investigational study drug or procedure within 3 months before Screening 
that might confound study outcomes. Use of investigational study drugs is prohibited 
throughout the course of the study. 
4. Any conditions that make it impossible to perform MRI studies (including allergies to 
anesthetics or contrast agents). 
5. Hematological compromise as evidenced by: 
a. Peripheral blood absolute neutrophil count (ANC) < 1500 cells/mm3, and either 
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b. Platelet count < 100,000 cells/mm3 or 
c. Hemoglobin < 10 g/dL. 
6. Hepatic compromise as evidenced by: 
a. Aspartate transaminase (AST) value > 2.5 × Upper limit of normal (ULN) 
b. Alanine transaminase (ALT) value > 2.5 × ULN 
c. Total bilirubin value > 3.0 mg/dL, except if there is a diagnosis of Gilbert’s 
Syndrome and the subject is otherwise stable. 
7. Baseline estimated glomerular filtration rate < 70 mL/min/1.73 m2, as determined 
using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation 
(see https://www.kidney.org/professionals/KDOQI/gfr_calculatorPed). 
8. Cardiac compromise as evidenced by left ventricular ejection fraction < 40% 
9. Immediate family member with a known or suspected Familial Cancer 
Syndrome (including but not limited to hereditary breast and ovarian cancer 
syndrome, hereditary non‑polyposis colorectal cancer syndrome, and familial 
adenomatous polyposis). 
10. Clinically significant uncontrolled, active bacterial, viral, fungal, parasitic, or 
prion‑associated infection. 
11. Positive for human immunodeficiency virus type 1 or 2 (HIV-1, HIV-2); hepatitis B virus 
(HBV); hepatitis C virus (HCV); human T lymphotrophic virus 1 (HTLV-1). Note that 
subjects who have been vaccinated against HBV (positive for HBV surface antibodies) 
who are negative for other markers of prior HBV infection (e.g., negative for HBV core 
Ab) are eligible. Subjects with past exposure to HBV [hepatitis B core antibody [HBcAb] 
-positive and/or hepatitis B e-antigen antibody [HBeAb]-positive] are also eligible for the 
study provided they have a negative test for HBV DNA. Also note that subjects who are 
positive for anti-hepatitis C Ab are eligible as long as they have a negative hepatitis C 
viral load). 
12. Any clinically significant cardiovascular, hematological or pulmonary disease, or other 
disease or condition that would be contraindicated for any of the other study procedures. 
13. Absence of adequate contraception for fertile subjects. Male subjects and their 
female partners are required to use two different effective methods of contraception from 
Screening through at least 6 months after eli-cel infusion. If subjects are truly sexually 
abstinent (where true sexual abstinence is defined as being in line with the preferred and 
usual lifestyle of the subject), no second method is required. 
14. Any contraindications to the use of G-CSF or plerixafor during the mobilization of HSCs 
and any contraindications to the use of busulfan or fludarabine, including known 
hypersensitivity to the active substances or to any of the excipients in their formulations. 
15. Known hypersensitivity to protamine sulfate. 
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4.4. 
Subject Identification and Registration 
Prior to the Screening Phase, the Investigator will identify candidates potentially 
meeting the study eligibility criteria, based on review of medical records and clinical test 
findings performed routinely as standard of care for the treatment of the subject.  
The legal parent(s)/ guardian of subjects who are determined by the Investigator to be potentially 
eligible, will be informed of the option to participate in the study and all associated risks of the 
study procedures as well as the investigational nature of gene therapy treatment (eli-cel). The 
subject’s consent/assent will be obtained as described previously in Section 3.1. Once consent is 
obtained, the potential subject will be registered and assigned a unique 10-digit subject number. 
If a subject is re-screened a new number will be assigned. Once a subject number has been 
assigned, it cannot be reused, and the number stays with the subject even if the subject is 
subsequently determined to be ineligible for the study or transfers to another study center. This 
subject number will also be carried into the long-term follow-up study. 
After provision of written informed consent and, if applicable, assent, the Investigator will 
further evaluate the subject for study eligibility through the screening assessments to ensure all 
entrance criteria are satisfied. Once eligibility to enter the study is confirmed, the subject is 
considered enrolled in the study. Subjects who fail to meet the eligibility criteria will be 
considered screen failures and therefore are not enrolled in the study. 
Additional details regarding the identification and registration of subjects, including details 
regarding the informed consent process, are outlined in the SOM. 
4.5. 
Subject Withdrawal from the Study 
In accordance with the Declaration of Helsinki, subjects have the right to withdraw from the 
study at any time for any reason, without prejudice to further medical follow-up. Should a 
subject decide to withdraw, all efforts will be made to complete and report the observations as 
thoroughly as possible. Subjects who receive drug product and withdraw before study 
completion will be asked to complete the same assessments as specified in the SOE for Month 24 
(Early Termination Visit assessments). 
Although subjects have the right to withdraw from the study at any time, withdrawal after the 
start of conditioning and before administration of the eli-cel is strongly discouraged, as this 
would be considered deleterious to the subject. In such cases, the subject’s stored back-up cells 
(mobilized PBMCs), or HSCs from an appropriately allogeneic donor, will be infused; see 
Section 5.2.1. The subject’s reason for and date of withdrawal from the study is to be recorded 
on the electronic case report form (eCRF).  
For subjects who withdraw for reasons other than withdrawal of consent, if withdrawal is before 
drug product infusion, subjects should remain on study for at least 30 days after any invasive 
study procedure (e.g., mobilization) before withdrawal and ongoing AEs should be followed for 
30 days. In the rare case a subject undergoes myeloablation and receives back-up cells instead of 
eli-cel, subject should remain on the study for at least 3 months post myeloablation and AEs 
should be followed for the 3 month duration. 
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If withdrawal is after drug product infusion, subjects will be asked to complete the same 
assessments as specified in the SOE for Month 24 (Early Termination Visit assessments) and are 
expected to enroll in the long-term follow-up Study LTF-304. 
 
4.6. 
Withdrawal of Subjects by Investigator or Sponsor  
The Investigator and Sponsor also have the right to withdraw subjects from the study at any 
time due to protocol noncompliance, poor tolerance, or potential safety risks, or stopping rules 
(see Section 3.4 for stopping rules). Subjects who have received infusion of eli-cel and are 
discontinued from the study prior to study completion will be asked to complete the same 
assessments as specified in the SOE for Month 24 (Early Termination Visit assessments) and are 
expected to participate in the long-term follow-up study (LTF-304). 
4.7. 
Protocol Deviation 
 
Categorization of protocol deviations into major/minor deviations will be determined prior to 
database lock, by a review of the protocol deviation data collected on the case report forms 
(CRFs). 
 
 
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5. 
STUDY TREATMENTS 
5.1. 
Description of the Lenti-D Lentiviral Vector and Eli-cel 
Lenti-D Lentiviral Vector: Lenti-D LVV is a replication defective, SIN, HIV-1 based LVV 
pseudotyped with the vesicular stomatitis virus glycoprotein G (VSV-G) envelope protein and 
containing the functioning human ABCD1 complementary DNA. Lenti-D LVV is produced by 
transient transfection using transfer vector pLBP100, 3 packaging plasmids, and the envelope 
plasmid. It is formulated in animal component free Stem Cell Growth Media. 
Eli-cel: Eli-cel is defined as an autologous CD34+ cell-enriched population that contains cells 
transduced with LVV that encodes an ABCD1 cDNA for human ALDP, suspended in 
cryopreservation solution. 
5.2. 
Summary of Treatments to be Performed or Administered 
After confirmation of eligibility, HSCs must be collected from the subject following stimulation 
by G-CSF and plerixafor (mobilization) (see Section 5.2.1) for 2 purposes – transduction for 
eli‑cel and for back-up cells (to be used if the subject fails to engraft). The isolated and 
transduced autologous CD34+ HSCs are infused back into the subject after they have received 
myeloablative conditioning with busulfan IV and fludarabine IV.  
In Section 3.3, Table 1 outlines the source of the subject cells, usage, and the minimum dose of 
eli-cel or back-up cells for rescue. Additional details are provided in the following subsections. 
5.2.1. 
Mobilization and Apheresis Procedure 
The mobilization and apheresis schedule is described in Table 2. 
Table 2: 
Mobilization and Apheresis Schedule 
Mobilization day 
G-CSF 
Peripheral CD34+ counta 
Apheresis 
Plerixafor (evening) 
1 
+ 
 
 
 
2 
+ 
 
 
 
3 
+ 
 
 
 
4 
+ 
+ 
 
+b 
5 
(+) 
+ 
+ 
+c 
(6) 
(+) 
(+) 
(+) 
(+) 
(7) 
(+) 
(+) 
(+) 
 
Abbrev.: G-CSF, granulocyte colony stimulating factor; WBC, white blood cell. 
Note: Parentheses indicate optional procedure or administration of medication only if needed. 
a Must be performed on the day prior to apheresis, as well as on the day of apheresis. 
b Do not administer in the evening of Day 4 if the WBC is > 70 × 109 cells/L on the morning of Day 4 
c Do not administer if CD34+ counts become available and indicate enough cells had been collected. 
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Up to 3 total apheresis collections may be performed as part of any one mobilization cycle. 
The 3 apheresis collection days may occur across 4 days after discussion with the Sponsor. 
Drug product will be manufactured from cells collected from either one day or over 
2 consecutive days.  
More than 1 mobilization cycle may be performed if needed in order to meet the required cell 
dose for eli-cel. If more than one mobilization cycle is required, mobilization cycles must be 
separated by at least 2 weeks. A BM harvest is also allowed, but only to procure back-up cells.  
For details regarding traceability of the collected HSCs, see Section 5.9. 
Mobilization Cycle 1 
Subjects will be mobilized with G-CSF (starting dose 10 μg/kg) for 4 to 7 days. Complete blood 
counts (CBCs) should be performed daily during mobilization and the dosage of G-CSF should 
be decreased if white blood cell (WBC) count is > 70 × 109 cells/L. After the 4th G-CSF dose, 
plerixafor will be administered daily for up to 3 days by subcutaneous injection (0.24 mg/kg of 
body weight) prior to each apheresis collection. The morning after the 4th G-CSF dose, apheresis 
will be performed according to standard clinical procedures.  
On each day of apheresis, the subject should have a physical exam, including abdominal 
palpation to rule out splenomegaly, and vital signs performed prior to beginning apheresis and 
again after completion of apheresis. Apheresis will be performed per standard clinical site 
practice.  
Apheresis product from Mobilization Cycle 1 should be evaluated and managed as follows: 
• If the Apheresis Procedure Day 1 collection is > 15 × 106 CD34+ cells/kg: Send a 
minimum of 12 × 106 CD34+ cells/kg to the transduction facility. The remainder 
(at least 1.5 × 106 CD34+ cells/kg) should be stored as back-up at the clinical site.  
• If the Apheresis Procedure Day 1 collection is between 12 and 15 × 106 CD34+ 
cells/kg, send the entire collection to the transduction facility. The subject should 
return for an additional apheresis procedure on Day 2 to collect back-up cells 
(≥ 1.5 × 106 CD34+ cells/kg), stored at the clinical site.  
• If the Apheresis Procedure Day 1 collection is < 12 × 106 CD34+ cells/kg, this 
collection should be held at an overnight, controlled storage facility at the clinical site 
and the subject should return for Apheresis Procedure Day 2. The collections from 
Apheresis Procedure Day 1 and Apheresis Procedure Day 2 will be sent for 
transduction. If the total collection over Day 1 and Day 2 is > 15 × 106 CD34+ 
cells/kg, back-up cells may first be removed. Otherwise, the subject should return for 
an additional apheresis procedure on Day 3 to collect back-up cells (≥ 1.5 × 106 
CD34+ cells/kg), stored at the study site. 
• If the Apheresis Procedure Day 1 collection is < 1 × 106 CD34+ cells/kg, this 
collection should be stored at the clinical site for back-up. The subject should return 
for Apheresis Procedures on Days 2-3 until the target of 12 × 106 CD34+ cells/kg is 
obtained for transduction.  
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Mobilization Cycle 2 
After completion of Mobilization Cycle 1, the Sponsor will inform the clinical site of the eli-cel 
dose. Once all release testing has been completed, the Sponsor will inform the clinical site if the 
drug product has met all applicable release criteria.  
If the minimum recommended cell dose has been met and the drug product has met specification, 
then the subject should only undergo Mobilization Cycle 2 if additional collection of autologous 
cells is needed for back up cells (i.e., if < 1.5 × 106 CD34+ cells/kg have been collected and 
stored for rescue during Mobilization Cycle 1).  
If additional autologous cells are needed, then the subject should begin Mobilization Cycle 2. 
Mobilization Cycle 2 should begin no sooner than 2 weeks after the completion of Mobilization 
Cycle 1 with the same guidelines as Mobilization Cycle 1.  
If Mobilization Cycle 2 is for the procurement of additional autologous cells for eli-cel, the 
management of the collection from each Apheresis Procedure day will be discussed with the 
Medical Monitor on a case-by-case basis prior to Apheresis Procedure Day 1.  
5.2.2. 
Bone Marrow Harvest Procedure 
If sufficient back-up cells for rescue are not procured after 1 or 2 mobilization cycles, the 
Investigator can proceed with a BM harvest. BM harvest will be performed according to 
institutional practice and will occur at a minimum of 2 weeks after completion of the last 
mobilization cycle.  
5.2.3. 
Transduction Process and Release Testing 
All cell manipulation procedures and release testing will be performed in accordance with 
Good Manufacturing Practice (GMP) following process-specific standard operating procedures.  
After each mobilization and apheresis procedure (Section 5.2.1), drug product manufacture will 
result in an independent drug product lot. Eli-cel lots which have been released for clinical use 
will be sent to the site with a Certificate of Analysis(es), documenting that all release testing is 
complete. 
In some circumstances, drug product that does not meet the established specification may be 
administered.  This requires justification of medical need as assessed by the Principal 
Investigator and Sponsor Responsible Medical Officer.  The subject must be informed and, if 
applicable, a notification to the appropriate IRBs/ECs and regulatory agency(ies) must occur 
prior to the start of myeloablative conditioning.      
5.2.4. 
Conditioning 
Pre-conditioning assessments will be performed on Day -7 (with a window of -5 days; 
i.e. Day -12 through Day -7) prior to myeloablative conditioning as outlined in the SOE. If 
neurological decline is observed (see Section 3.4.1), as evidenced by a NFS > 1 or a Loes Score 
> 9, the subject will be discontinued from the study. 
Conditioning will only begin once eli-cel has been dispositioned for clinical use and the drug 
product is at the clinical site. Myeloablative conditioning will be performed on an in-patient 
basis using busulfan IV and fludarabine IV. 
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On Days -6, -5, -4, and -3, fludarabine IV (40 mg/m2) will be given one hour before the first 
daily infusion of busulfan IV, per institutional standards. Glomerular filtration rate measured 
during Screening and Pre-conditioning assessments is used to help calculate fludarabine 
exposure. 
Additional information on busulfan dosing: 
Investigators may choose to dose using cumulative exposure or weight-based dosing. The 
Investigator is to record which method they choose and must use the same method for all four 
days of busulfan dosing. Patients will receive busulfan on Days –6, –5, –4, and –3. 
• Dosing based on cumulative exposure: 
− Busulfan dosed by cumulative exposure may be given every 6, 12 or 24 hours, 
with choice of dosing frequency at the investigator’s discretion. 
− The Investigator is to record which dosing frequency they choose and must use 
the same frequency for all four days of busulfan dosing.  
− The investigator should also note which pharmacokinetic method their site uses to 
calculate busulfan exposure (Bartelink et al. 2012, 2016). 
− If using cumulative exposure to calculate busulfan dose, the 
cumulative busulfan exposure (or cumulative area under the curve [AUC] 
[AUCcum]) will be targeted to provide an AUC 85 to 95 mg/L × h (target 90) 
= 85000 to 95000 ng/mL × h = 20706 to 23180 μmol*min/L with q24 hour 
dosing. If the Investigator uses a dosing frequency other than q24 hours, the target 
AUC after each individual dose will be lower though the AUCcum should be the 
same. 
− If using the first dose to calculate busulfan exposure, the target AUC range for a 
single dose with a dosing frequency of every 6 hours is 1335 to 1491 
µmol*min/L. 
− If the AUC for the 1st single dose falls outside the specified target range, 
subsequent doses can be adjusted to ensure appropriate exposure to the 
AUCcum target range.  
− Busulfan AUCcum should be measured on Day -6 and as appropriate to evaluate 
and adjust the cumulative exposure. 
• Busulfan IV weight-based dosing will be calculated as follows:  
− For subjects ≤ 12 kg: busulfan 1.1 mg/kg/dose IV every 6 hours on 
Days –6, –5, –4, and –3  
− For subjects > 12 kg: busulfan 0.8 mg/kg/dose IV every 6 hours on 
Days –6, –5, –4, and –3  
If any subjects are obese (i.e., actual body weight [ABW] is over 125% of ideal body weight 
[IBW]), dosing will be adjusted for IBW (see Section 10.1 for calculations). 
 
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Additional information: 
After completion of the 4 day course of fludarabine and busulfan, there should be a minimum of 
48 hours of washout before drug product infusion. 
Prior to and during the administration of busulfan IV and fludarabine IV, prophylactic and 
empiric anti-convulsive, antifungal, and antibiotic treatments, and all other supportive care, 
including management of any complications resulting from myeloablation, will be administered 
by the institutional transplant team per institutional standards.  
Refer to the current Package Inserts for busulfan IV and fludarabine IV, including associated 
AEs.  
5.2.5. 
Infusion Procedures, Dose, and Administration 
Infusion of eli-cel is to be given at least 48 hours after completion of the busulfan IV and 
fludarabine IV conditioning regimen.  
All procedures involving eli-cel must be performed using aseptic techniques by trained personnel 
per institutional practice at the clinical site, including a saline line flush. Prior to administration, 
the eli-cel is to be thawed in a 37°C water bath or an appropriate dry bath and must be infused 
immediately, but no later than 4 hours after it has been thawed.  
Eli-cel will be administered via IV infusion through a central venous catheter in a volume 
between 20 and 80 mL, according to institutional practice for infusion of hematologic 
stem cells at the clinical site. Do not use an infusion filter. The dose to be administered is 
≥ 5.0 × 106 CD34+ cells/kg. The subject’s weight immediately prior to the first apheresis 
collection will be used to calculate the final dose of eli-cel for that lot. If more than one lot of 
eli‑cel is manufactured to achieve the minimum cell dose, infusions of each lot will occur 
consecutively. Consecutive infusions will also occur if a single lot is split into 2 drug product 
bags due to volume constraints.  
There is no current evidence that eli-cel must be adjusted for obesity. If, during Screening, 
a subject is determined to be obese (i.e., subject ABW is over 125% of IBW), the Sponsor 
and the Investigator will discuss adjusting for IBW. IBW dosing that results in an ABW dose 
≤ 1.5 × 106 CD34+ cells/kg would not be acceptable.  
Each eli-cel bag contains 1 g dimethyl sulfoxide (DMSO). Limiting the amount of DMSO 
infused to no more than 1 g/kg/day is recommended (Júnior et al. 2008), and thus no subject in 
Study ALD-104 would exceed this amount. 
Vitals signs are to be monitored concurrently during eli-cel infusion per institutional practice at 
the clinical site, but no less frequently than at the start, once during, and upon completion of the 
infusion. Infusion reactions, including anaphylaxis, will be managed according to the medical 
judgment of the physician overseeing the infusion.  
5.3. 
Storage and Stability of Eli-cel 
Eli-cel will be frozen and stored in cryopreservation solution in the vapor phase of liquid 
nitrogen at the transduction facility until release testing and dispositioning for clinical use.  
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Once dispositioned for clinical use, eli-cel will be stored in the vapor phase of liquid nitrogen at 
the clinical site until thawed for clinical use. 
For details regarding traceability of eli-cel, see Section 5.9. 
5.4. 
Storage and Administration of Back-up Cells 
Mobilized back-up cells will be frozen and stored in accordance with institutional guidelines. 
In the event of primary neutrophil engraftment failure (as defined in Section 6.5.13), back-up 
cells will be administered at a dose of ≥ 1.5 × 106 CD34+ cells/kg, or ≥ 1.0 × 108 total nucleated 
cells (TNC)/kg (see Table 1). Back-up cells may also be administered in the event that the 
subject has received myeloablation and is unable to receive infusion of eli-cel for any reason (see 
Section 3.4). For details regarding traceability of back-up cells, see Section 5.9. 
5.5. 
Method of Assigning Subjects to Treatment 
In this open-label study, all subjects entered into the study will be assigned to active treatment. 
5.6. 
Blinding, Packaging, and Labeling 
5.6.1. 
Blinding and Breaking the Blind 
This is an unblinded, open-label study. 
5.6.2. 
Packaging and Labeling 
Eli-cel consists of an autologous CD34+ cell-enriched population that contains cells transduced 
with LVV that encodes an ABCD1 cDNA for human ALDP. Eli-cel is suspended in 
cryopreservation solution in the final immediate container for the intended medical use 
(infusion bag). 
Eli-cel will be labeled by the GMP-compliant contract manufacturing site. Refer to Section 5.9 
for additional details regarding product accountability. 
5.7. 
Duration of Study Participation 
Each subject will remain on this study for approximately 26 months from time of consent, 
inclusive of an approximately 24-months post-drug product infusion follow-up; subjects will 
then be expected to consent for a follow-up study for another 13 years post-drug product 
infusion. 
5.8. 
Assessment of Treatment and Study Compliance 
Treatment compliance will not be an issue in this study as eligible subjects receive a one-time 
administration of eli-cel, and will be monitored by hospital personnel. 
Subject compliance with the subsequent post-drug product infusion study visits will be assessed 
through Month 24. 
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5.9. 
Product Accountability 
Eli-cel accountability and traceability is ultimately the responsibility of the Investigator and 
Sponsor. However, this responsibility may be delegated to a suitably qualified Investigator who 
has had appropriate study-specific training and whose name has been appropriately listed on the 
Delegation of Responsibility Log for this task. 
Detailed records will be maintained throughout the duration of the study to enable accurate 
accountability of the subject’s autologous cells from procurement to eli-cel infusion. 
Procured CD34+ HSCs will be traceable back to the subject from apheresis through infusion via 
2 unique identifiers and their Hematopoietic Progenitor Cell, Apheresis [HPC,A] product 
number (unique for each HPC,A collection). In the event that two apheresis collections are 
required for a subject during the same mobilization cycle, the HPC,A product numbers will act 
as additional traceability to the collection event. Clinical sites will enter the HPC,A product 
number and the 2 unique identifiers on the label of the collection bag for each subject’s 
respective apheresis product.  
Once these cells have arrived at the transduction facility, GMP procedures will be utilized 
throughout each step of the manufacturing process to generate a final drug product (CD34+ 
HSCs transduced with Lenti-D LVV) to ensure traceability. Each drug product lot is assigned a 
unique manufacturing lot number. Eli-cel accountability is confirmed by utilization of the same 
2 unique identifiers, HPC,A product number(s), and drug product manufacturing lot number 
on the final drug product label. Clinical site staff will verify the 2 unique identifiers upon receipt 
of the drug product from the manufacturer and once again prior to infusion. The above procedure 
is also followed if more than one lot of eli-cel is manufactured to achieve the minimum cell dose 
or if a single lot is split into 2 drug product bags due to volume constraints. In this situation, the 
eli-cel lots or bags will be shipped together to clinical site staff. Each of these steps will be 
documented by the appropriate party who is handling subject cells. 
These records will include details of storage and use of the eli-cel as well as storage of back-up 
cells. Transfer of eli-cel from the transduction facility through administration to the subject will 
be recorded. 
The Investigator will ensure that the eli-cel is used only in accordance with this protocol. Drug 
accountability records indicating eli-cel inventory at the clinical site, administration to each 
subject, and disposal will be maintained by the clinical site. These records will adequately 
document that the subject was provided the eli-cel dose as specified in the protocol and should 
reconcile each eli-cel received by the clinical site. Accountability records will include dates, 
quantities, lot numbers, expiration dates (if applicable), and subject numbers. The Sponsor or its 
designee will review eli-cel accountability at the clinical site on an ongoing basis during 
monitoring visits. Additional information regarding traceability can be found in the SOM. 
All material containing eli-cel will be treated and disposed of as hazardous waste in accordance 
with governing regulations and clinical site procedures. 
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In the event that drug product cannot be administered due to triggering of stopping rules or other 
reasons, drug product will be kept cryopreserved in the vapor phase of liquid nitrogen until 
further instruction by the Sponsor. The Sponsor will instruct the site staff to either destroy the 
drug product via their institutional procedures or return the drug product to bluebird bio. 
5.10. 
Prior and Concomitant Medication and Therapy 
To avoid confounding the results of VLCFA changes after treatment with eli-cel, medications 
used to lower VLCFA levels (e.g., Lorenzo’s oil, statins) and other investigational therapies are 
to be excluded during study participation. In addition, the subject should not embark on a new 
low fat diet during study participation.  
Subjects should not use medications with anti-retroviral activity (such as those used for HIV 
prophylaxis) from within 1 month of initiating mobilization until after drug product infusion.  
There will be no other excluded concomitant medications. The Investigator should inquire about 
any intervention that may create a health hazard or other problem for study-related procedures 
(e.g. non-removable dentures with metal keepers that can distort brain MRI images).  
After infusion of eli-cel, G-CSF is to be given as follows: 
• Start G-CSF 5 days after infusion (Day 6; Day 1 is defined as day of eli-cel infusion), 
with dose at Investigator’s discretion per usual institutional practice. G-CSF may be 
held to start later at the Investigator’s discretion if the WBC has not fallen to nadir. 
• The earliest stopping point for G-CSF is after 3 consecutive days with an ANC > 500, 
but G-CSF may be stopped any time after that at the Investigator’s discretion. 
All concomitant medications from the time informed consent is obtained through the follow-up 
period will be recorded in the eCRF. Medications and therapies taken specifically for the 
management of CALD in the 6 months prior to consent will be recorded on the eCRF. 
For the purposes of this study, vaccines (e.g., COVID-19 vaccines) are considered concomitant 
medications. Although interactions between a vaccine and eli-cel are not expected, the protocol 
includes use of immunomodulatory (plerixafor, G-CSF) and immunosuppressive medication 
(busulfan, fludarabine). Local guidelines should be followed regarding a minimum time period 
between any medication to be provided as part of treatment with eli-cel and any vaccine; it is 
recommended that vaccines are not administered to subjects within 1 month of initiating 
mobilization for stem cell collection, within 1 week after receiving mobilization agents, within 
1 month of initiating myeloablative conditioning, or within 6 months after drug product infusion. 
Revaccination post-drug product infusion should be considered per Investigator's discretion due 
to potential loss of immunity after myeloablative conditioning and may be administered 
following local guidelines. 
The prescribing information of the vaccine administered should be referred to for the latest 
indication, contraindications and safety information as well as the latest general clinical 
recommendations on vaccine administration in the country or region. 
All vaccinations during the study period should be documented in the CRF. 
Concomitant therapies, for example, physical, or speech therapy, will be captured from the time 
of informed consent through the follow-up period. 
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6. 
STUDY ASSESSMENTS 
6.1. 
Schedule of Events 
Table 3, Table 4 and Table 5 provide the SOE to be conducted during the study. Detailed 
descriptions of the efficacy, safety, and exploratory procedures to be conducted during this study 
are provided in the following sections. Additional details, including administrative information, 
regarding the efficacy, safety, and exploratory procedures, will be provided by the Sponsor in the 
SOM. 
Subjects who experience neutrophil engraftment failure (as defined in Section 6.5.13) will 
receive infusion with back-up cells or with allogeneic HSCs. These subjects will continue to be 
followed for efficacy and safety assessments.  
Study treatments and evaluations can be considered as 4 distinct phases after informed consent: 
• Screening and Enrollment. Subjects who meet eligibility criteria, based on screening 
assessments are considered enrolled. Patients who do not meet eligibility criteria are 
considered screen failures. 
• CD34+ Cell Collection, Transduction, Disposition of eli-cel, and Reconfirmation of 
Eligibility 
• Conditioning and Washout, followed by eli-cel Infusion on Day 1 
• Maintenance (Follow-up) (Day 2 through Month 24) 
Study Day 1 is defined as the day of infusion. 
Subjects will be asked to comply with the protocol specified assessments according to the time 
periods enumerated in the SOE. If the timing of assessments is shifted due to scheduling 
conflicts (e.g., limited bed availability at the hospital, delays in screening assessments, repeat 
mobilization, delays in scheduling conditioning and eli-cel infusion, minimal delays in 
manufacturing or release testing of drug product), these will not be considered protocol 
deviations. In such cases, the subject will resume their schedule beginning on Day -6. If delays 
are greater than two weeks, the Investigator and Medical Monitor should discuss the continued 
eligibility of the subject for infusion.  
During the first year after eli-cel treatment (Month 1 through Month 12), CBCs with differential 
will be collected every month as shown in Table 5. Subsequently, CBCs with differential will be 
collected every 4 months at the study site through Month 24. Data collection as described in this 
paragraph will be obtained prospectively only (that is, data should not be collected 
retrospectively for subjects who have passed applicable study visits as of the date of 
implementation of this protocol amendment). 
Note: Unscheduled visits may be performed at any time during the study whenever necessary to 
assess for or to follow-up on AEs or to perform enhanced CBC and BM abnormality monitoring 
(Section 6.5.11.1.1 and Section 6.5.11.1.2, respectively) or as deemed necessary by the 
Investigator. Evaluations and procedures identified in the SOE, or other evaluations and 
procedures deemed necessary for safety, may be performed at unscheduled visits, as clinically 
indicated, at the Investigator’s discretion in consultation with the Sponsor. 
The study treatments are described in detail in Section 5.2. 
 
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Impact of Force of Nature or War (e.g., the COVID-19 Pandemic, the Russo-Ukrainian 
War) on Study Visits  
Due to force of nature or war (e.g., the COVID-19 pandemic, the Russo-Ukrainian War), 
subjects may not be able to attend normal study visits. If a visit is missed due to a force of nature 
or war (e.g., unable to travel, unwilling to travel, family or subject affected by COVID-19, 
hospital closure, etc.), the subject may be able to complete study assessments via telemedicine or 
at a local facility. Sites should consult with the medical monitor and clinical research associates 
to consider alternate arrangements, when possible, for completion of study assessments. 
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a If more than one mobilization cycle is required, they must be separated by an interval of at least 2 weeks. See 
Section 5.2.1 for additional details. 
b If a subject is below the legal age of consent and turns the legal age of consent per country regulations while on 
study, the subject must be re-consented at the next scheduled study visit, prior to the collection of additional study 
data. 
c A preliminary search for a suitable donor will be initiated at Screening for all subjects in the event that a subject is 
not eligible for drug product during Pre-Conditioning Assessments, experiences engraftment failure, or cannot 
receive eli-cel. HLA typing does not need to be performed if historical results are available. 
d Genotyping of ABCD1 gene will occur in subjects for whom no historical data are available; documented ABCD1 
mutation required prior to initiating myeloablative conditioning.  
e Adrenal function tests (cortisol and adrenocorticotropic hormone [ACTH]) are to be performed in the morning 
(approximately 8:00 am) during Screening before the subject has taken hydrocortisone unless subject is on steroid 
replacement therapy. If ACTH is significantly elevated, tests should be repeated 3 hours after taking 
hydrocortisone. Mineralocorticoid functions (aldosterone and plasma renin activity) are to be performed at the 
same time points with the subject sitting in an upright position. 
f May occur any time before conditioning; hormonal treatment, if applicable as part of banking, should stop at least 
7 days prior to conditioning. 
gFull physical examination, including height and weight measurements, will be performed at Screening only. Vital 
signs will include blood pressure, pulse, respiratory rate, and temperature. During hospitalization, focused physical 
examinations and vitals to be performed as standard of care. AEs identified during this time will be entered into 
the clinical database.  
h Focused physical examinations and vital signs will be performed prior to the first dose of G-CSF. 
i On each day of apheresis, the subject should have a focused physical exam, including abdominal palpation to rule 
out splenomegaly, and vital signs performed prior to beginning apheresis and again after completion of apheresis.  
j  Focused physical examinations and vital signs will be performed each day during conditioning. 
k  Hematology parameters include white blood cell (WBC) count with differential, hemoglobin, hematocrit, red 
blood cell (RBC), and platelet count. 
l  Hematology will be performed each day of mobilization and apheresis. 
m  Chemistry and hematology parameters will be measured daily during conditioning; blood will be collected prior 
to infusion of busulfan IV and fludarabine IV. 
n  Calculated from sex, age, height, weight, and creatinine. Unit = mL/min/1.73m2 
o  Blood for measurements of RCL, ALDP, and VCN will be drawn once, any time from Screening prior to start of 
conditioning. 
p  NFS assessments, MFD assessments, and brain MRIs may be repeated at any time during the study if there is 
evidence of clinical decline. These assessments must be repeated if more than 60 days has passed between the 
assessment at Screening and the start of Pre-Conditioning. However, if subject requires sedation for MRI, 
performing this repeat assessment is based on Investigator judgment.  
q  May be performed concurrently with NFS assessment. 
r  MRI performed within 5 days of signing of ICF can be used as the Screening MRI.  
s  The Brain Stem Auditory Evoked Response (BAER) and the Visual Evoked Potential (VEP) P100 latency will be 
performed at Screening. 
t  Peripheral blood CD34+ count should be performed either the day prior to or on the first planned day of apheresis. 
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Table 4: 
Schedule of Events: Drug Product Infusion through End of Study 
Eli-cel 
Infusion 
Follow -Up  
Week 2 
Follow -Up 
Month 1 
Follow -Up  
Month 2 
Follow -Up 
Month 3 
Follow -Up 
Month 6 
Follow-Up 
Month 9 
Follow- Up 
Month 12 
Follow-Up 
Month 16 
Follow -Up 
Month 18 
Follow-Up 
Month 20 
Follow -Up 
Month 24 
Early  
Termination 
Study Day (D): D 1 
D 15 D 30 D 60 
D 90 D 180 D 270 D 360 D 480 D 540 D 600 D 720 
- 
Visit Window (Days): 
- 
±7 
±7 
±14 
±14 
±14 
±14 
±30 
±30 
±60 
±30 
±30 
NA 
Health economic dataq 
 
+ 
+ 
+ 
+ 
+ 
 
+ 
+ 
 
+ 
+ 
+ 
Concomitant medication 
Continuous from ICF signing 
Adverse event monitoring 
Continuous from ICF signing 
a Start G-CSF5 days after infusion (Day 6; Day 1 is defined as day of eli-cel infusion), with dose at Investigator’s 
discretion per usual institutional practice. G-CSF may be held to start later at the Investigator’s discretion if the 
WBC has not fallen to nadir. 
b During hospitalization, focused physical examinations and vitals to be performed as standard of care. AEs 
identified during this time will be entered into the clinical database. Vital signs are to be monitored concurrently 
during eli-cel infusion according to institutional practice at the clinical site, but no less frequently than at the start, 
once during, and upon completion of the infusion. 
c Full physical examination, including height and weight measurements, will be performed. Focused physical 
examinations may be performed at other visits. 
 d Hematology parameters include white blood cell (WBC) count with differential, hemoglobin, hematocrit, red 
blood cell (RBC), and platelet count. If the results from blood tests are not as expected, additional testing may 
need to be performed and may include a physical exam, blood tests, imaging tests, or a BM biopsy (both BM core 
biopsy sections and aspirate smear collection should be performed to assess morphology). See Section 6.5.11.4 for 
blood sample collection and storage details.   
e A repeat performance of CBC is required within one month for any CBC abnormality (including abnormalities in 
hemoglobin levels, total white blood cell count, neutrophil count and morphology, lymphocyte count and 
morphology, or monocyte counts and morphology) that is of CTCAE Grade 2 or higher severity or for platelet 
counts of <100 × 109/L. See Section 6.5.11.1.1. In addition, a re-evaluation at the discretion of the Investigator of 
any new abnormal peripheral blood cell count or morphology at an interval commensurate with the severity of the 
change is recommended. Persistent, unexpected, abnormalities of peripheral blood cell counts or morphology, 
including but not limited to any two consecutive (one month apart) CTCAE Grade 2 CBC values or platelet counts 
of <100 x 109/L will trigger a BM evaluation. For frequency of subsequent BM evaluations (see 
Section 6.5.11.1.2). See Section 6.5.11.4 for sample collection and storage details.   
 
f Chemistry and hematology parameters will be measured at least twice per week until neutrophil engraftment 
occurs. 
g Peripheral blood smears will be created locally at the study site and submitted for central review by a single central 
hematopathologist. See Section 6.5.11.1.1 for further details. At the Investigator’s discretion local peripheral blood 
smears may also be performed by the study site to direct patient care. 
h Note that sites are required to collect BM aspirate post-drug product infusion per the SOE, unless discussed with 
the Sponsor's Medical Monitor for exceptions, such as if not clinically appropriate per local standard of care (e.g., 
BM aspirate would require general anesthesia, which would be considered an unacceptable risk to the subject) or 
not considered by the Investigator to be in the best interest of the subject to perform. For details, see 
Section 6.5.11.1.2.  
i Bone marrow smear should be read locally; additional BM slides are to be created and submitted for central 
analyses as detailed in Section 6.5.11.1.2. See Section 6.5.11.4 for BM sample collection details.  Additionally, 
BM aspirate (and an accompanying whole blood specimen) should be collected for storage at the time of BM 
sample collection to facilitate subsequent exploratory analyses that may include gene/genomic expression studies. 
j Two samples are required, one for RCL screening test, another for potential co-culture of peripheral blood 
leukocytes (PBLs) if RCL screening test is positive. 
k If a subject’s previous RCL tests were all negative, this sample will be archived. 
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l  Additional blood may be collected for analysis in cell subtypes, if requested by the Sponsor. If blood draw volume 
required exceeds the limit per Section 6.5.11.4, samples should be obtained over multiple days. 
m  ISA of BM will also be performed following specific triggers, see Section 6.5.11.4. 
n  NFS assessments, MFD assessments, and brain MRIs may be repeated at any time during the study if there is 
evidence of clinical decline. 
o  May be performed concurrently with NFS assessment. 
p  The BAER will be performed at Month 24. The VEP P100 latency will be performed at Month 12 and Month 24. 
q  Includes number and duration of in-patient hospitalizations (including ICU stay), clinic/doctor visits, therapy, and 
emergency room visits. 
 
Table 5: 
Schedule of Events: Hematology Month 1 through Month 12 Visits 
Follow-Up 
Month 1 
Follow-Up 
Month 2 
Follow-Up 
Month 3 
Follow-Up 
Month 4 
Follow-Up 
Month 5 
Follow-Up 
Month 6 
Follow-Up 
Month 7 
Follow-Up 
Month 8 
Follow-Up 
Month 9 
Follow-Up 
Month 10 
Follow-Up 
Month 11 
Follow- Up 
Month 12 
Study Day (D): D 30 
D 60 
D 90 D 120 D 150 D 180 D 210 D 240 D 270 D 300 D 330 D 360 
Visit Window 
(Days): 
+14 
+14 
+14 
+14 
+14 
+14 
+14 
+14 
+14 
+14 
+14 
±30 
Hematologya b c 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
 
+ 
+ 
Hematopathology 
review of 
peripheral blood 
smeard 
 
 
 
 
 
+ 
 
 
 
 
 
+ 
a Hematology parameters include white blood cell (WBC) count with differential, hemoglobin, hematocrit, red 
blood cell (RBC), and platelet count. If the results from blood tests are not as expected, additional testing may 
need to be performed and may include a physical exam, blood tests, imaging tests, or a BM biopsy. 
 b A repeat performance of CBC is required within one month for any CBC abnormality (including abnormalities in 
hemoglobin levels, total white blood cell count, neutrophil count and morphology, lymphocyte count and 
morphology, or monocyte counts and morphology) that is of CTCAE Grade 2 or higher severity or for platelet 
counts <100 × 109/L. See Section 6.5.11.1.1. In addition, a re-evaluation at the discretion of the Investigator of any 
new abnormal peripheral blood cell count or morphology at an interval commensurate with the severity of the 
change is recommended. Persistent, unexpected, abnormalities of peripheral blood cell counts or morphology, 
including but not limited to any two consecutive (one month apart) CTCAE Grade 2 CBC values or platelet counts 
of <100 x 109/L will trigger a BM evaluation. For frequency of subsequent BM evaluations, see Section 6.5.11.1.2. 
 c Hematology parameters will be measured at least twice per week until neutrophil engraftment occurs. 
d Peripheral blood smears will be created locally at the study site and submitted for central review by a single central 
hematopathologist. See Section 6.5.11.1.1 for further details. At the Investigator’s discretion local peripheral blood 
smears may also be performed by the study site to direct patient care. 
. 
6.2. 
Concurrent Human Leukocyte Antigen Search for Allogeneic Donor 
During Screening, HLA typing for the subject does not need to be performed if historical results 
are available. A preliminary search for a suitable donor will be initiated at Screening for all 
subjects in the event that a subject is not eligible for drug product during Pre-Conditioning 
Assessments (Section 5.2.4), experiences engraftment failure, or cannot receive eli-cel.  
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6.3. 
Confirmation of Eligibility 
Subject’s eligibility will be confirmed prior to the start of conditioning as detailed in the SOE. 
If a subject is determined to be ineligible, the Medical Monitor should be contacted. 
6.4. 
Fertility Preservation 
Fertility preservation (e.g., sperm or testicular tissue banking) will be done as appropriate at the 
discretion of the subject, their legal guardian (as applicable), and the Investigator. 
6.5. 
Assessments 
6.5.1. 
Demographics and Medical History 
Subject demographic data such as initials, gender, age, race, and ethnicity (if allowed by local 
regulation), will be obtained during Screening, and a complete medical history will be obtained 
during Screening and updated on Day 1 as needed. The medical history is to include all prior 
and current medical history, including relevant family history, and CALD disease history 
(including ABCD1 genotype and imaging information). 
6.5.2. 
Physical Examination 
Complete physical examinations (including general appearance; head, eyes, ears, nose, and 
throat [HEENT]; cardiovascular; dermatologic, abdominal; genitourinary; lymph nodes; hepatic; 
musculoskeletal; respiratory; and neurological), including height measurement, will be 
conducted at visits indicated in the SOE. Focused physical examinations are to be conducted at 
all other study visits according to the SOE. 
6.5.3. 
Vital Signs and Weight 
Vital signs to be measured include systolic/diastolic blood pressure, pulse, respiration rate, and 
temperature. Vital signs and subject weight (in kilograms) will be measured and recorded 
according to the SOE; measurement details are included in the SOM.  
See Section 6.5.11.4 for guidance on weight-based blood draws. 
6.5.4. 
Electrocardiogram/Echocardiogram 
A 12-lead ECG will be obtained as per the SOE and read locally.  
A standard 2D Doppler echocardiogram will be performed at Screening and read by the site 
cardiologist. Ejection fraction and overall clinical interpretation will be captured. 
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6.5.5. 
Neurologic Examination 
The neurologic examination is to include ophthalmologic and audiologic examinations 
administered by a pediatric neurologist or other appropriately trained and qualified physician 
according to the SOE. Visual acuity will be assessed using either a wall chart or a pocket 
eye chart. Visual fields will be assessed by perimetry testing or by visual confrontation by 
neurological examination. Examination details are included in the SOM. 
6.5.6. 
Neurologic Functioning Score (NFS) Assessment 
Assessment of subject status using NFS is to be performed by a pediatric neurologist or other 
appropriately trained and qualified physician, when the pediatric neurologist is unavailable, 
according to the SOE. The presence or absence of disabilities that prevent independent 
functioning will be recorded during these examinations using the definitions described in 
Section 10.3. As noted in the SOE, if the screening through pre-conditioning period exceeds 
60 days or there is clinical suspicion of neurological decline, the NFS assessment should be 
repeated ahead of myeloablative conditioning (see Section 3.4.1).  
As indicated in Table 9 of Section 10.3, a score of “0” denotes absence of clinical signs of 
cerebral disease. Maximal signs within a domain score the total of all grades within that domain. 
For example, score of a subject with cortical blindness is 3, which is sum of the scores of the 
vision impairment/field cut and cortical blindness.  
Study-specific training will be administered to the assessors and documented prior to study start 
and throughout the study to ensure standardization of administration of the NFS. Refer to the 
SOM for additional details regarding the administration of the NFS. AE and SAE reporting is 
described in Section 6.6.1. 
6.5.7. 
Major Functional Disabilities (MFDs) 
MFDs include loss of communication, cortical blindness, tube feeding, total incontinence, 
wheelchair dependence, and complete loss of voluntary movement, which are defined in Table 8 
of Section 10.2. MFDs, as assessed by a pediatric neurologist or other appropriately trained and 
qualified physician, must be immediately reported as SAEs (See Section 6.6.4). 
6.5.8. 
Neuropsychological Tests 
The goal of neuropsychological testing is to assess the subject in key areas for signs of 
dysfunction due to CALD. A series of neuropsychological tests are recommended based on the 
subject’s age at the time of the assessment. If possible, it is recommended that the same assessor 
administer the tests throughout the course of the study and that the tests be administered in the 
same order each time. Details regarding the sequence of testing administration and scoring are 
included in the SOM. The same test should be administered throughout the study even if the 
subject ages out of a particular test (e.g., if WPPSI-IV was administered during Pre-Conditioning 
assessments, WPPSI-IV should be administered at all subsequent visits). If an assessment cannot 
be administered or completed due to subject non-compliance or a language barrier, that will not 
be considered a protocol deviation. 
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Table 6: 
Neuropsychological Tests to be Performed 
Domain 
Neuropsychological Test 
Age Range at 
Screening 
(years: 
months)  
Approximate 
Administratio
n Timea 
General 
Intelligence 
Bayley Scales of Infant and Toddler Development, 
3rd ed. (Bayley-III) (Connolly et al. 2012)  
< 2:6 
25 minutes 
Wechsler Preschool & Primary Scale of 
Intelligenceb, 4th ed. (WPPSI-IV) 
(https://www.pearsonclinical.com/psychology.html) 
2:6 to 7:7 
30 minutes 
Wechsler Intelligence Scale for Childrenb, c, 5th ed. 
(WISC-V) 
(https://www.pearsonclinical.com/psychology.html)  
6:0 to 16:11 
65 minutes 
Wechsler Adult Intelligence Scaled, 4th ed. (WAIS-
IV) (Wisdom et al. 2012)  
≥ 16 
60 minutes 
Fine Motor 
Purdue Pegboard (Gardner and Broman 1979; 
Wilson et al. 1982; Yeudall et al. 1986) 
≥ 4 
5 minutes 
Health 
Related 
Quality of Life 
Peds Quality of Lifee (PedsQL) (Varni et al. 2001)  
Parent-reported 
Subject-reported 
 
2 to 18 
≥ 5 
 
45 minutes 
15 minutes 
Socioeconomic 
Status  
SES test derived from Hollingshead and Redlich 
(Hollingshead and Redlich 1954, 2007; 
Hollingshead 2011) 
All ages 
5 minutes 
 
a Approximate total administration time will range from: 1 to 2 hours for subjects aged 6 to 16 years and 1 hour for 
subjects aged 3 to 5 years; however this administration time will vary between subjects depending on reaction 
time, frustration thresholds, and the need for breaks. 
b Substitute Picture Completion for Picture Concepts on Wechsler Preschool and Primary Scale of Intelligence and 
Wechsler Intelligence Scale for Children. 
c Include the Visual Spatial Domain, Verbal Domain, Processing Speed, Fluid Reasoning, and Working Memory 
subtests of the WISC-V. For non-English speakers, only the Visual Spatial Domain, Processing Speed, and Fluid 
Reasoning should be included 
d Substitute Picture Completion for Visual Puzzles on Wechsler Adult Intelligence Scale 
e For subjects < 5 years of age, parents will complete the PedsQL. For subjects ≥ 5 years of age, both the parents 
and the subject will complete the appropriate PedsQL. Parent administered measures will require approximately 45 
minutes and will be completed while the subject is being evaluated 
Global Assessment:  
Behavioral assessments will be conducted at each neuropsychological assessment per SOE. This 
assessment is usually done at the beginning of each session and takes approximately 2 minutes. 
Information about the subject’s current academic status relative to his peers, in addition to 
qualitative assessment of the subject’s attention, motivation, word retrieval, visual and auditory 
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processing, and ability to participate in the evaluation will be conducted. Additional details are 
provided in the SOM. 
General Intelligence: Bayley Scales of Infant and Toddler Development, Wechsler Preschool 
and Primary Scale of Intelligence, Wechsler Intelligence Scale for Children, and Wechsler 
Adult Intelligence Scale  
The Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III) has been 
validated for subjects aged less than 2.6 years and takes approximately 25 minutes to 
administer (Connolly et al. 2012). The test was designed to identify young children with 
development delays by measuring performance in 5 different domains including cognition, 
language, social-emotional, motor and adaptive behavior. 
Performance intelligence quotient (PIQ), verbal intelligence quotient (VIQ), and full scale 
intelligence quotient (FSIQ) will be measured using the age-appropriate Wechsler Intelligence 
Scales. The Wechsler Preschool and Primary Scale of Intelligence 4th Edition (WPPSI-IV) is 
administered to preschool and early elementary-aged children to determine their intelligence 
quotient (IQ) (https://www.pearsonclinical.com/psychology.html). The test is validated for 
children aged 2:6 to 7:7 years. The version for children ages 2:6 to 3:11 includes 4 subtests that 
will be used to determine composite scores for VIQ, PIQ and FSIQ. The exam takes 
approximately 30 minutes to administer. 
The Wechsler Intelligence Scale for Children, 5th Edition (WISC-V) is an individually 
administered intelligence test that takes approximately 65 minutes to administer and has been 
validated in children aged 6 to 16:11 years (https://www.pearsonclinical.com/psychology.html). 
The test can be completed without reading or writing and generates an intelligence quotient 
which represents a child’s general cognitive ability. Validation testing was performed in children 
with diverse cognitive abilities ranging from gifted children, to those on the autism spectrum. 
WISC-V has also been validated with measures of achievement, memory, adaptive behaviour, 
emotional intelligence, and giftedness. Only the Nonverbal Domain, Verbal Domain, Processing 
Speed, Fluid Reasoning, and Working Memory subtests will be used. 
The Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV) has been validated for subjects 
aged 16 and older and takes approximately 60 minutes to administer (Wisdom et al. 2012). 
The WAIS was designed to measure intelligence and includes 10 subtests that will be used to 
determine composite scores for Verbal Comprehension, Perceptual Reasoning, Working 
Memory, Processing Speed and Full-Scale IQ. 
Fine Motor: Purdue Pegboard 
The Purdue Pegboard is a timed physical test that measures manual dexterity and brain 
function and is validated in children aged 4 years and older (Gardner and Broman 1979; Wilson 
et al. 1982; Yeudall et al. 1986). The test takes approximately 5 minutes to administer. 
Health Related Quality of Life Assessment: Peds Quality of Life 
In the absence of a validated tool to assess Health Related Quality of Life Assessment (HRQoL) 
in CALD, HRQoL will be assessed using tools developed for other diseases. The PedsQL™ 
Generic Core Scales (Varni et al. 2001) will be administered to the caregiver and/or subject by a 
qualified staff member, as appropriate to the age of the subject. This test can be administered in 
children aged 2 to 18 years and takes approximately 15 minutes to administer. Once the subject 
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reaches 5 years of age, both the parent-reported and the subject-reported PedsQL questionnaires 
should be completed. Positive treatment effects on PedsQL will provide supporting evidence of 
treatment benefit. PedsQL information collected in this study will also guide development of 
approaches to assess HRQoL in subjects with CALD. 
Socioeconomic Status 
Socioeconomic status (SES) will be assessed by obtaining maternal and paternal occupations and 
years of education based on a formula developed by Hollingshead and Redlich (Hollingshead 
and Redlich 1954, 2007). The test is validated for all ages and takes approximately 5 minutes to 
administer. It will only be done during Pre-Conditioning assessments. 
All of the neuropsychological examinations will be administered by a qualified healthcare 
professional according to the SOE. Study-specific training will be administered to the assessors 
and documented prior to study start and throughout the study to ensure standardization of 
administration of these tests. Refer to the SOM for additional details regarding the administration 
of the neuropsychological tests. 
6.5.9. 
Evoked Potential (Electrophysiology) 
Electrophysiological assessment to be performed according to the SOE, when feasible, and 
with consideration for the subject’s age. This will include the Visual Evoked Potential (VEP) 
P100 latency and Brain Stem Auditory Evoked Response (BAER). VEP provides objective 
information about the visual system; BAER tests auditory brainstem function. 
6.5.10. 
Brain Magnetic Resonance Imaging (Loes Score and Pattern) 
Brain MRI, with and without contrast, will be performed according to the SOE; image 
acquisition details and shipping details are included in the Site Procedure Manual. Additional 
advanced imaging techniques may be performed on an exploratory basis to better characterize 
the degree of cerebral involvement; refer to Site Procedure Manual for additional details. 
All MRIs will be assessed by a central reviewer, using the 34-point Loes scoring scale, which is 
widely used to diagnose and follow subjects with CALD (Loes et al. 2003). The Independent 
Review Manual will be used by the central reviewer. This charter describes the procedure for the 
image reading and scoring. 
MRIs will also be used to determine white matter lesion progression using volumetric analysis. 
As noted in the SOE, brain MRIs may be repeated at any time during the study if there is 
evidence of clinical decline. If more than 60 days has passed since the screening MRI was 
performed, or there is clinical suspicion of neurological decline, the MRI should be repeated 
ahead of myeloablative conditioning (see Section 3.4.1). However, if subject requires sedation 
for MRI, performing this repeat assessment is based on Investigator judgment.  
6.5.11. 
Clinical Laboratory Tests 
Laboratory tests of hematology and serum chemistries will be performed as specified in the 
following sub-sections and in the SOE. 
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Clinical laboratory tests are to be performed locally and reviewed by the Investigator or qualified 
designee (e.g., physician’s assistant, nurse practitioner) appropriately listed on the Delegation of 
Responsibility Log for this task.   
In addition to the peripheral blood smears, BM core biopsy sections and BM aspirate smears 
required for routine local hematopathology review and per the SOE, additional peripheral blood 
smears (see Section 6.5.11.1), BM core biopsy sections and BM aspirate smears (see 
Section 6.5.11.1.2)  should be prepared for study purposes and submitted to a single centralized 
hematopathologist. Results of the central read will be provided to the Sponsor and subsequently 
shared with the Investigator. 
Specialty laboratory evaluations including RCL testing, ISA, and VCN assessments are also to 
be performed. See Section 6.5.11.4 and Section 6.5.12 for further details. 
All hematology and chemistry results from assessments performed at unscheduled visits should 
also be entered into the clinical database.  
Additional instances of clinical laboratory tests listed in this section may be performed at the 
Investigator’s discretion as needed.  
Local tests and reads should be utilized for participant care decision making.  
6.5.11.1. Hematology, Clinical Chemistry, Liver and Adrenal Function 
Blood samples for hematology, clinical chemistry, liver and adrenal function are to be collected 
as specified in the SOE.  
The following clinical laboratory parameters are to be determined: 
Hematology: CBC with differential 
• White blood cell (WBC) count with 
differential 
• Platelet count 
• Red blood cell (RBC) count 
• 
Hemoglobin 
• 
Hematocrit 
• 
Peripheral blood smear 
 
Clinical chemistry (including Liver Function Tests) 
• 
Sodium (Na) 
• 
Blood urea nitrogen (BUN) 
• 
Potassium (K) 
• 
Creatinine 
• 
Chloride (Cl) 
• 
Glucose 
• 
Magnesium (Mg) 
• 
Calcium (Ca) 
• 
Phosphorus (P) 
• 
Aspartate aminotransferase (AST) 
• 
Alanine aminotransferase (ALT) 
• 
Alkaline phosphatase 
• 
Bilirubin (total and directa) 
 
Adrenal Function Tests 
• 
Cortisol 
• 
Adrenocorticotropic hormone (ACTH) 
• 
Aldosterone (subject in upright position) 
• 
Plasma renin activity (subject in upright 
position) 
a Direct bilirubin only required if total bilirubin is abnormal. 
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Effort should be made to obtain a platelet count 8 days after any platelet transfusion, until 
platelet engraftment occurs (as defined in Section 6.5.13). 
6.5.11.1.1. Complete Blood Count and Peripheral Blood Smear 
Complete blood counts with differential will be performed and analyzed locally at the study site 
per the SOE, during the first year after eli-cel treatment (Month 1 through Month 12). 
Subsequently, CBCs with differential will be collected every 4 months at the study site through 
Month 24.  
A repeat performance of CBC is required within one month for any CBC abnormality (including 
abnormalities in hemoglobin levels, total WBC count, neutrophil count and morphology, 
lymphocyte count and morphology, or monocyte counts and morphology) that is of CTCAE 
Grade 2 or higher severity or for platelet counts of <100 × 109/L. In addition, a re-evaluation at 
the discretion of the Investigator of any new abnormal peripheral blood cell count or morphology 
at an interval commensurate with the severity of the change is recommended. Persistent, 
unexpected, abnormalities of peripheral blood cell counts or morphology, including but not 
limited to any two consecutive (one month apart) CTCAE Grade 2 CBC values or platelet counts 
of < 100 x 109/L will trigger a BM evaluation. For frequency of subsequent BM evaluations (see 
Section 6.5.11.1.2). 
In addition, peripheral blood smears should be prepared for study purposes and submitted to a 
single centralized hematopathologist for review to assess for dysplastic features at Months 6, 12, 
16, 20 and 24, per the SOE. Results of the central read will be provided to the Sponsor and 
subsequently shared with the Investigator (although centrally read peripheral smear slides will 
not be returned to the study site). At the investigator’s discretion local peripheral blood smears 
may also be performed by the study site to direct patient care. Refer to the SOM for further 
details on preparation of additional slides for submission for central review. 
6.5.11.1.2. Bone Marrow Core Needle Biopsy and Aspiration 
During the first year after eli-cel treatment (at Month 6 and Month 12), BM will be collected to 
perform routine assessments, ISA and VCN assessments (and sample created for storage). 
Additional BM evaluations will also be performed in the event of one or more of the following 
specific findings: 
i. 
Persistent, unexpected, abnormalities* of peripheral blood cell counts or morphology, 
including but not limited to any two consecutive (one month apart) CTCAE Grade 2 CBC 
values or platelet counts of <100 x 109/L. If BM evaluation is triggered by platelet 
counts, perform BM biopsies at four month intervals until a peripheral blood platelet 
value of ≥125 x 109/L is observed. 
ii. 
Any transfusion requirement after discharge from the initial hospitalization unless the 
need for transfusion was related to trauma or a procedure/intervention. 
iii. 
Abnormal results from the most recent BM biopsy or aspirate (see below) 
iv. 
ISA: IS in a known oncogene (i.e., relative frequency [RelFreq] of ≥ 5% for the same IS 
observed at two consecutive time points, if the IS is located in a gene with known 
biological relevance to carcinogenesis:  defined as a Tier 1 gene in the Cancer Gene 
Census (CGC) of the Catalogue of Somatic Mutations in Cancer (COSMIC) at the time 
of the ISA report review. 
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v. 
ISA: persistent oligoclonality (i.e., RelFreq of ≥ 10% for the same IS observed at two 
consecutive time points, or relative frequencies of ≥ 5% for the same two or more IS 
observed at two consecutive time points).  
vi. 
A two-fold increase in peripheral blood VCN over a 4-month period. 
* these include abnormalities in hemoglobin levels, total WBC, neutrophil, lymphocyte, 
monocyte, or platelet counts and morphology. 
For new findings of moderate hypocellularity (defined for this protocol as 30-40%), marked 
hypocellularity (<30%), moderate dysplasia (>10%-40% of cells in one or more lineages), or 
marked dysplasia (>40% of cells in the pertinent lineage), one repeat evaluation is required at a 
3-month interval.  
For new findings of moderate hypercellularity (80-90%) or marked hypercellularity (>90%), one 
repeat evaluation is required which may be performed at a 3 or 6-month interval, at the discretion 
of the Investigator.  
If BM abnormalities on two consecutive assessments are stable or improved and CBC** is 
within normal limits, the BM biopsy and aspirate should occur every 6 months until 
abnormalities are resolved. If there is worsening (e.g., change from moderate to marked) of 
dysplasia, decreasing hypocellularity or increasing hypercellularity, or abnormalities on CBC, 
BM biopsies and aspirate collection frequency should remain at a 3-month interval. 
** hemoglobin levels, total WBC count, neutrophil, lymphocyte, monocyte and platelet 
counts. 
These recommendations are not intended to preclude re-evaluation as warranted. Additional BM 
evaluations should be performed, at the discretion of the Investigator and at a frequency 
commensurate with the integrated findings and based upon recommendations from the 
hematopathologist and hematologist investigator (or consulting hematologist). 
Triggered BM evaluation will include both core needle biopsy and aspiration to assess 
morphology, cellularity, fibrosis, and to perform flow cytometry and karyotyping that should be 
carried out locally as part of normal pathology assessments, including local smear assessment. 
Additional aliquots of triggered BM aspirate will be collected and sent to centralized specialty 
laboratories for the performance of fluorescence in situ hybridization (FISH) (using a probe 
panel for common mutations in pediatric AML, MDS, and probes for MLL [11q23], MECOM, 
and PRDM16 rearrangement), next-generation sequencing (NGS) (spanning mutations 
commonly observed in myeloid and lymphoid malignancies), and ISA/VCN. Note that due to the 
time taken for central NGS and FISH results to be obtained, Investigators should initiate 
additional local NGS and FISH testing if results are needed more rapidly to direct participant 
care. An additional BM aspirate sample should be submitted to the Sponsor for storage to 
support potential future genetic/genomic studies. The BM evaluations will be performed in 
accordance with institutional practices under aseptic conditions. It is anticipated that institutional 
guidelines will specify that approximately 5 to 20 mL of BM aspirate will be collected each time. 
Bone marrow aspirate (and an accompanying whole blood specimen) should be collected for 
storage at the time of BM sample collection to facilitate subsequent exploratory analyses that 
may include gene/genomic expression studies. 
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In addition to BM core biopsy sections and aspirate smear slides created for routine local 
hematopathology review, additional BM core biopsy sections and aspirate smears should be 
prepared for study purposes and submitted to a single centralized hematopathologist. Results of 
the central read will be provided to the Sponsor and subsequently shared with the Investigator 
(although centrally read slides will not be returned to the study site).   
Refer to the SOM for further details on preparation of additional slides for submission to the 
single central hematopathologist and for submission of samples to centralized laboratories. 
6.5.11.1.3. Blood Sample Collection for RCL Testing, Integration Site Analysis, and VCN in 
Blood 
Blood samples will be collected according to the SOE for assessments of the following: 
• RCL - If subject tested negative at all visits through M12, further samples will be 
archived for potential analysis in case of clinical outcomes suggesting the presence of 
RCL. 
• VCN in whole blood will be evaluated at every visit indicated for VCN in the SOE. 
• ISA at visits indicated (only to be performed if VCN is ≥ 0.01 vector copies per 
diploid genome, at the previous visit).  
Testing will be performed by central laboratories. Blood collection and processing details are 
included in the Laboratory Manual. 
Blood samples for ISA are to be collected according to the SOE; collection, processing and 
shipping details are included in the Laboratory Manual. Testing will be performed by a central 
laboratory. Additional blood may be collected for additional investigations and analysis in cell 
subtypes, if requested by the Sponsor. 
6.5.11.2. Immunological Studies 
Local immunological testing includes measuring levels of T cell subsets (CD4, CD8), B cells 
(CD19), and NK cells (CD16 or CD56). In addition, levels of immunoglobulins (IgG, IgM, and 
IgA) will be quantified. 
6.5.11.3. Serology Panel (Infectious Disease Testing) 
Screening: Serology Panel I 
Screening serology will be evaluated using standard methods. The serology panel for eligibility 
includes HIV-1 and HIV-2; hepatitis B virus surface antigen (HBsAg); anti-HBs and HBcAb; 
HCV Ab; and HTLV-1. Any other serology required by the contract drug product manufacturing 
organization or local guidelines or based on subject’s risk factors or clinical evidence of infection 
with other communicable disease agents or disease before mobilization or infusion of drug 
product (including for example testing for CMV, EBV, herpes simplex virus (HSV), HCV core 
antigen, VZV IgG, human T lymphotrophic virus 2 (HTLV-2), syphilis, toxoplasmosis, 
tuberculosis, Trypanosoma cruzi, and West Nile Virus) are permitted; if any of these tests are 
performed and a clinically relevant result is obtained, results must be discussed with the Medical 
Monitor to determine eligibility.  
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On Day 1 of Mobilization: Serology Panel II 
Blood samples will be collected according to country-specific and institutional guidelines. 
If screening serology (Panel I) was completed within the timeframe before HSC collection or 
transplant allowed by institutional and country-specific guidelines, those specific tests need not 
be repeated for Panel II. In case apheresis begins later than 30 days after screening, then 
infectious disease labs should be drawn again. 
6.5.11.4. Specialty Laboratory Sample Collection 
As this is a pediatric study, blood volume limitations will sometimes preclude the collection of 
all samples during a particular study visit. Table 7 enumerates the priorities for blood and BM 
collection (BM core section slides and BM aspirates). Safety labs (see Section 6.5) have been 
prioritized over labs for efficacy and exploratory analyses. If the results from CBC or BM tests 
are not as expected, additional testing may need to be performed as detailed in Section 6.5.11.1.1 
and Section 6.5.11.1.2, respectively. Local tests and reads should be utilized for patient care 
decision making.  
Per European recommendation on clinical trials conducted in the pediatric population, 
trial‑related blood loss per individual, should not exceed 3% of the total blood volume 
during a period of four weeks and should not exceed 1% at any single time 
(https://ec.europa.eu/health/sites/default/files/files/eudralex/vol-10/2017_09_18_ethical 
_consid_ct_with_minors.pdf). A CRF is included to calculate the maximum weight-based blood 
draw at each study visit. If blood draw volume required exceeds this limit, samples should be 
obtained over multiple days. Any deviations to these recommendations should be justified. 
United States (US) sites may follow European recommendations or may adhere to local 
institutional practices. 
Examples of guidelines for blood draw limits in pediatrics can be found at: http://www.who.int/
bulletin/volumes/89/1/BLT-10-080010-table-T2.html  
With regard to bone-marrow, both core needle biopsy and aspiration collection should be 
performed to assess cellularity, fibrosis, and to perform flow cytometry, karyotyping, FISH, 
NGS, ISA, and VCN. The BM evaluations will be performed in accordance with institutional 
practices under aseptic conditions. It is anticipated that institutional guidelines will specify that 
approximately 5 to 20 mL of BM aspirate will be collected each time. See Section 6.5.11.1.2 for 
further details on BM collection and for further details on criteria that would trigger additional 
BM assessments over and above those noted in the SOE.  
In addition to the BM core biopsy sections and aspirate smears read locally for routine 
hematopathology review or per the SOE, additional BM core biopsy sections and aspirate smears 
should be prepared for study purposes and submitted to a single centralized hematopathologist. 
Additionally, BM aspirate (and an accompanying whole blood specimen) should be collected for 
storage at the time of BM sample collection to facilitate subsequent exploratory analyses that 
may include gene/genomic expression studies. See more details below for additional sample 
storage details. Results of the central read will be provided to the Sponsor and subsequently 
shared with the Investigator. 
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Table 7: 
Blood and Bone Marrow Collection: Order of Priority 
Abbrev.: BM, bone marrow; CBC  
a Whole blood collection at the time of BM sample collection should be stored to facilitate subsequent exploratory 
analyses. 
b Bone marrow evaluation should also include a core needle biopsy 
Blood samples for VCN determination by quantitative polymerase chain reaction (qPCR) will be 
collected according to the SOE. Testing will be performed by a central laboratory. Additional 
blood may be collected for analysis in cell subtypes. 
Replication Competent Lentivirus Testing 
Blood samples for RCL testing will be collected and tested using a RCL screening assay as well 
as a confirmatory assay if the screening assay is positive. Testing will be performed by a central 
laboratory.  If RCL is confirmed, the site may be requested to perform local HIV testing to 
determine if the RCL is drug product-related or a result of a natural HIV infection. Once 
available, the results of these tests must be shared with the Sponsor immediately. 
Blood Collection Priority 
• 
ABCD1 genotype  
• 
Adrenal Function Tests 
• 
Serology Panels (infectious disease screening) 
• 
Chemistry 
• 
Hematology (CBC [performed locally] and peripheral blood smear [created locally and 
submitted to central lab]) 
• 
Integration Site Analysis (ISA) and VCN 
• 
Immunological studies 
• 
ALDP in Peripheral Blood Populations 
• 
RCL testing 
• 
VLCFA analysis (fasting) 
• 
Whole blood specimen for storage at the time of BM assessment (to support exploratory 
analyses that may include gene/genomic expression)a 
Bone Marrow Aspirateb Collection Priority   
• 
Core needle biopsy sections and aspirate smears for morphologic assessment, including for 
cellularity and fibrosis 
• 
Local FISH (if needed more rapidly than central FISH to direct patient care) 
• 
Local NGS (if needed more rapidly than central NGS to direct patient care) 
• 
ISA and VCN for central laboratories 
• 
Local karyotyping  
• 
FISH for central laboratories 
• 
NGS for central laboratories  
• 
Storage BM specimens (to support exploratory analyses that may include genetic and genomic 
studies)a  
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ABCD1 Genotype 
Blood samples for mutational analysis of the ABCD1 gene will be collected according to the 
SOE if a historical result is not available. The results of the mutational analysis are required 
before commencing conditioning. 
ALDP Expression: Peripheral Blood Populations 
Blood samples for determination of ALDP expression will be collected according to the SOE. 
Testing will be performed by a central laboratory. 
VLCFA Analysis 
Blood samples for measurement of VLCFA levels in serum are to be collected in the fasting state 
according to the SOE to determine if VLCFA levels decline following therapy compared to 
Baseline levels. Testing will be performed by a central laboratory. 
Storage of Samples 
Bone marrow specimens (accompanied by a whole blood sample) should be submitted to the 
Sponsor for storage to support potential future genetic and genomic studies or other exploratory 
studies. Leftover biological samples from protocol procedures (e.g., whole blood DNA, serum) 
may also be stored (optional) for potential future exploratory investigations in those samples, to 
study CALD and/or gene therapy. Refer to the SOM for further details on the collection and 
submission of samples for storage. 
Samples may be stored for up to 20 years. The Sponsor will be the custodian of the samples in 
the repository and any unused samples will be destroyed at the Sponsor’s discretion. If possible, 
optional blood, BM, and tissue samples also are to be collected in the event of a subject’s death if 
an autopsy is performed.  
Collection and storage of the optional samples described above will be subject to discretionary 
approval from each center’s IRB/IEC and the subject’s specific written consent. Samples will be 
labeled with a unique identification number that includes no subject identifying information. 
Note that apheresis product collected as part of the manufacture of the drug product may be used 
to study the manufacturing process. In particular, extra apheresis product may be used to 
understand how the process may be improved or made more robust. These potential studies are 
not optional.  
Other potential uses of the apheresis product are for non-manufacturing improvement research, 
such as biomarker analyses of proteins, DNA, ribonucleic acid (RNA), and other molecules to 
study CALD and/or gene therapy, are optional. 
 
 
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6.5.12. 
Assessment of Oligoclonality and/or Suspicion of Malignancy 
6.5.12.1. Assessment of Oligoclonality by Integration Site Analysis  
ISA will be performed to determine the insertion site (IS) profile of subjects over time, as 
indicated in the SOE. Figure 1 shows the set of ISA rules and resulting IS triggered enhanced 
monitoring (i.e., CBC and BM monitoring) to assess oligoclonality, in accordance with Food and 
Drug Administration (FDA) Guidance (FDA 2020) and based on FDA consultation. While 
oligoclonality itself, or even monoclonality, will not a priori result in a malignancy, changes in 
IS RelFreq may be associated with an increase in the risk of a malignancy.  
As discussed further below, ISA monitoring may be repeated more frequently if there is an 
indication of oligoclonality or if ISA should otherwise be triggered (see Section 6.5.11.1.2  for 
more details on triggered BM evaluations). Such triggers include (but are not limited to) 
persistent unexpected CBC abnormalities (including persistent [i.e., two consecutive] CTCAE 
Grade 2 CBC values), post-discharge blood transfusion (unless due to trauma or a 
procedure/intervention), or a two-fold increase in peripheral blood vector copy number (PB 
VCN) over a 4 or 6-month period (based on the SOE), or other abnormal results from a subject’s 
most recent BM biopsy or aspirate or ISA findings of potential oligoclonality or IS in a known 
oncogene. 
As shown in Figure 1, if an IS is detected at ≥ 10% RelFreq or an IS ≥ 5% RelFreq is detected in 
2 or more IS, this would be considered "oligoclonality" and ISA will be repeated within 3 
months of receipt of this result. If an IS ≥ 10% or 2 or more IS ≥ 5% are confirmed, then a report 
of “persistent oligoclonality” will be submitted by the Sponsor to the relevant Health Authorities 
within 30 days of receipt of the ISA report confirming an IS meeting the criteria for persistent 
oligoclonality.  This repeated observation will also trigger enhanced monitoring for 
hematological abnormalities, increasing the frequency of CBC with differential to every 3 
months (if not already occurring at the interval) until the frequency no longer meets 
oligoclonality criteria. Persistent oligoclonality also triggers BM assessment (for the frequency 
of subsequent BM assessments see [Section 6.5.11.1.2]). If persistent oligoclonality is not 
observed after initial repeat testing, CBC and other monitoring reverts to routine assessments per 
the SOE. 
Additionally, if an IS is detected at ≥ 5% RelFreq in a known oncogene (based upon Tier 1 
oncogenes in the CGC in the COSMIC at the time of the ISA report review), then ISA (and 
VCN) will be repeated within 3 months of receipt of this result. If an IS in a known oncogene is 
confirmed during re-evaluation it would be considered persistent. This repeated observation will 
trigger enhanced monitoring for hematological abnormalities, including a BM evaluation and 
increasing the frequency of CBC with differential to every 3 months (if not already occurring at 
the interval) until the frequency no longer meets criteria. ISA and VCN will continued per the 
SOE. 
Based on clinical and ISA findings, additional monitoring for malignancy may be instituted by 
the treating physician/Principal Investigator or Sponsor (see Section 6.5.11.1.2 for BM 
evaluation recommendations and see Section 6.5.12.2 for recommended clinical work-up for 
malignancy).  See Section 7.4.5 for definitions of current oligoclonality and current persistent 
oligoclonality utilized during analyses and reporting. 
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Figure 1: 
ISA Triggered Enhanced Monitoring 
 
Abbrev.: BM, bone marrow; CBC, complete blood count with differential; IS, insertion site(s); ISA, integration 
site analysis; RelFreq, relative frequency; VCN, vector copy number. 
a ISA, VCN, CBC schedule is specified in Section 6.1 (SOE Tables). 
b IS can be measured from different types of samples (peripheral blood or BM). If an IS is found at a higher 
frequency in a BM sample (e.g., triggered by persistent ISA findings) than in a peripheral blood sample, then that 
BM frequency would be used to assess followup. 
c Tier 1 oncogenes in the Cancer Gene Census of the Catalogue of Somatic Mutations in Cancer at the time of the 
ISA report review. 
d “Persistent oligoclonality” will be reported (once per pertinent IS/set of IS) to applicable Health Authorities 
within 30 days of receipt of applicable repeat ISA result. 
e Observation of Persistent Oligoclonality triggers increasing the frequency of CBC with differential and BM 
assessment to every 3 months (if not already occurring at the interval) along with ISA and VCN every 6 months 
until the frequency no longer meets criteria. See also Section 6.5.11.1.1 (CBC) and Section 6.5.11.1.2 (BM).   
6.5.12.2. Clinical Work-up for Potential Malignancy 
In the event of any suspicion of hematologic malignancy (e.g., myelodysplasia, leukemia, or 
lymphoma), the Medical Monitor will be notified and a work-up will be performed by the 
Investigator per appropriate standard of care. A suspicion of hematologic malignancy could arise 
in the setting of otherwise unexplained cytopenia(s), and consideration of insertional oncogenesis 
could arise if cytopenia(s) occurs in conjunction with a rising RelFreq of an IS, especially if that 
IS is in a gene of known biological relevance to carcinogenesis (i.e., oncogene or tumor 
suppressor gene), accompanied by a rapid increase in PB VCN (a doubling of VCN between two 
timepoints). 
 The clinical work-up may include the following: 
• Physical exam 
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• CBC with differential - including repeat performance within one month for any 
CTCAE Grade 2 or higher severity CBC abnormality (these include abnormalities in 
hemoglobin levels, total WBC counts, platelet counts [of <100 x 109/L], neutrophil 
counts and morphology, lymphocyte counts and morphology, or monocyte counts and 
morphology) (see Section 6.5.11.1.1 for details). 
• Lymphocyte subsets 
• Imaging studies 
• Local and centralized BM analysis 
• Cytogenetic and molecular analyses which can include single nucleotide 
polymorphism (SNP) microarray, karyotyping, or whole-genome sequencing and 
must include centralized FISH and NGS (see Section 6.5.11.1.2 for details). 
In addition, clinical work-up to rule out infectious cause or autoimmune disease may be 
considered. If the clinical work-up indicates a diagnosis of hematologic malignancy, the Sponsor 
will convene an urgent safety review meeting. Further analyses will be determined by the 
Sponsor, in consultation with the independent DMC. All efforts should be made to confirm the 
source of malignancy. It should be noted that it may not be possible to distinguish the source of 
malignancy (e.g., arising from underlying pathophysiology of the disease, transplant-related 
medications or procedures, or from expansion of gene-modified cells due to insertional 
oncogenesis). In cases of vector-containing hematologic malignancy, single BM colony in 
combination with IS-specific polymerase chain reaction (PCR) should be used to confirm the 
specific IS present in the same clone. 
For clinical work-up after identification of persistent oligoclonality and confirmed presence of 
abnormal CBC, BM analysis should be performed as warranted if not previously part of the 
clinical work-up or as triggered based upon Section 6.5.11.1.2 or as discussed in 
Section 6.5.11.4.   
6.5.13. 
Engraftment and Engraftment Failure 
For the purposes of this protocol, successful neutrophil engraftment is defined as 3 consecutive 
ANC laboratory values of ≥ 0.5 × 109cells/L (after initial post-infusion nadir) obtained on 
different days by Day 43. Platelet engraftment is defined as achieving 3 consecutive unsupported 
platelet counts of ≥ 20 × 109 cells/L (after initial post‑infusion nadir) obtained on different days 
while no platelet transfusions are administered for 7 days immediately preceding and during the 
evaluation period. 
Neutrophil engraftment failure will be defined as follows: 
• Primary neutrophil engraftment failure: failure to achieve 3 consecutive ANC 
laboratory values of ≥ 0.5 × 109cells/L (after initial post-infusion nadir) obtained on 
different days by 42 days post-infusion of eli-cel 
• Secondary neutrophil engraftment failure: i) achievement of neutrophil engraftment 
followed by ii) sustained decline in ANC to < 0.5×109 cells/L for 3 consecutive 
measurements on different days after 42 days post-infusion of eli-cel, without 
alternate etiology 
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6.6. 
Adverse Events 
Monitoring of AEs will be conducted from the signing of informed consent. AEs for all subjects 
(excluding screen failures) will be recorded in the CRFs starting from the time informed consent 
is signed through the Month 24 Visit. All SAEs (including screen failures) will be reported from 
the signing of informed consent/assent on the SAE report form. 
All AEs should be monitored until they are resolved or are clearly determined to be due to a 
subject’s stable or chronic condition or inter-current illness(es). For subjects who withdraw for 
reasons other than withdrawal of consent, any SAEs open at the time of discontinuation should 
be followed-up until resolution or are determined to be a stable or chronic condition. 
Note that at the completion of Study ALD-104, subjects are expected to enroll into a 
long‑term follow-up study (LTF-304), that will monitor the safety of subjects (including 
drug product-related AEs) through a total of 15 years after eli-cel infusion. 
6.6.1. 
Adverse Events Definitions 
6.6.1.1. 
Adverse Events 
An AE is any untoward medical occurrence associated with the use of a drug in subjects, 
whether or not considered drug related. An AE may include a change in physical signs, 
symptoms, and/or clinically significant laboratory change occurring in any phase of a clinical 
study. This definition includes intercurrent illnesses or injuries, and exacerbation of pre-existing 
conditions. A pre-existing condition is a clinical condition (including a condition being treated) 
that is diagnosed before the subject signs the Informed Consent Form (ICF) and is documented 
as part of the subject’s medical history.  
6.6.1.2. 
Unexpected Adverse Events 
An AE is considered unexpected with eli-cel if it is not consistent in nature or severity with the 
eli-cel reference safety information which is contained in the current Lenti-D Drug Product IB. 
6.6.1.3. 
Conditioning-related Adverse Events 
Busulfan and fludarabine are cytotoxic drugs that cause profound myelosuppression. 
Accordingly, subjects will experience intended hematologic events (e.g., neutropenia, 
thrombocytopenia, anemia) and expected non-hematologic events (e.g., mucositis [stomatitis], 
nausea, vomiting, alopecia, pyrexia) as a result of receiving busulfan IV and fludarabine IV. For 
the purposes of this protocol, the prescribing information for busulfan and fludarabine should be 
consulted for full information on these side effects. 
The intended profound myelosuppression (manifested by neutropenia, thrombocytopenia, and/or 
anemia) and expected events that occur after the initiation of busulfan IV and fludarabine IV 
conditioning are considered to be the direct consequence of the conditioning regimen and are to 
be reported as AEs, but should be attributed to conditioning on the AE eCRF, as applicable. 
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6.6.1.4. 
Serious Adverse Events 
An SAE is any AE that: 
• Results in death. 
• Is life-threatening. i.e., the subject was at immediate risk of death at the time of the 
event. It does not include an AE that, had it occurred in a more severe form, might 
have caused death. 
• Requires in-patient hospitalization or prolongation of existing hospitalization. 
Hospitalization admissions occurring during the study period that are for procedures 
planned prior to study entry do not meet this criterion, unless there is a complication 
resulting from procedure that prolongs hospitalization. 
• Results in persistent or significant disability/incapacity; or a substantial disruption of 
a subject’s ability to conduct normal life functions. 
• Is a congenital anomaly/birth defect. 
• Is an important medical event. 
− An important medical event is an AE that may not result in death, be 
life-threatening, or require hospitalization but may be considered serious when, 
based upon appropriate medical judgment, it may jeopardize the subject and may 
require medical or surgical intervention to prevent one of the outcomes listed in 
the definitions for SAEs. 
− For the purposes of this study, any new malignancy or new diagnosis of a 
neurologic, rheumatologic, or hematologic disorder that, in the Investigator’s 
opinion, is clinically significant and requires medical intervention will be 
considered medically important and therefore serious. 
The following should be reported as SAEs for the purposes of this study (see Section 6.6.4 for 
SAE reporting): 
• MFDs, as defined in Section 10.2 
• Engraftment failure, as defined in Section 6.5.13 
6.6.2. 
Adverse Event Assessment of Severity and Relationship 
For all AEs, the Investigator must determine the severity of the event and the relationship to 
eli-cel.  
For immediate reporting of SAEs, the Investigator must provide assessments of relationship and 
serious criteria at the time of SAE report submission to the Sponsor. 
Severity will be assessed by the Investigator using the following criteria per the NCI CTCAE, 
Version 4.03, including for AEs that are a result of a laboratory abnormality. 
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• Grade 1: Mild, asymptomatic, or mild symptoms; clinical or diagnostic observations 
only; intervention not indicated. 
• Grade 2: Moderate; minimal, local, or noninvasive intervention indicated; limiting 
age-appropriate instrumental activities of daily living (ADL) 
• Grade 3: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-
care ADL. 
• Grade 4: Life-threatening consequences; urgent intervention indicated. 
• Grade 5: Death related to AE. 
Relationship: The Investigator is required to provide an assessment of the relationship of eli-cel 
to all AEs. The following is a guideline for determining the relationship of eli-cel to an AE: 
• Not Related: Exposure to the study treatment did not occur, or the occurrence of the 
AE is not reasonably related in time, or the AE is considered not related to eli-cel. 
• Unlikely Related: The study treatment and the AE were not closely related in time, 
and/or the AE could be explained more consistently by causes other than exposure to 
eli-cel. 
• Possibly Related: The study treatment and the AE were reasonably related in time, 
and the AE could be explained equally well by causes other than exposure to eli-cel. 
• Related: The study treatment and the AE were reasonably related in time, and the AE 
was more likely explained by exposure to eli-cel than by other causes, or the study 
treatment was the most likely cause of the AE. 
For the purpose of safety reporting and analyses, all AEs that are classified as “possibly related” 
or “related” will be considered eli-cel treatment-related events. 
6.6.3. 
Procedures for AE and SAE Collection and Reporting 
Each subject must be carefully monitored for the development of any AEs. This information 
should be obtained in the form of non-leading questions (e.g., “How are you feeling?”) and from 
signs and symptoms detected during each examination, laboratory assessments, observations of 
study personnel, and spontaneous reports from subjects.  
AEs for all eligible subjects (i.e., excluding screen failures) will be recorded in the CRF. Any 
clinically significant laboratory abnormality or other clinically significant finding is considered 
an AE and the AE must be recorded on the appropriate pages of the CRF. The 
diagnosis/underlying etiology rather than the signs/symptoms should be reported as the AE, 
when possible. If no diagnosis is available, report only the signs and symptoms that met AE 
criteria as individual AE terms. 
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6.6.4. 
Immediate Reporting of SAEs 
All SAEs for all subjects, including screen failures, must be immediately reported on the SAE 
report form to the Sponsor (or designee) within 24 hours of the Investigator (or designee) 
becoming aware of the SAE. All SAEs must be reported whether or not they are considered 
causally related to eli-cel. The SAE report form completion guidelines can be found in the SOM. 
All follow-up information on SAEs must also be immediately reported to the Sponsor or 
designee (i.e., within 24 hours). 
Copies of all SAE reports and associated documentation submitted to the Sponsor or designee 
will be kept in the Investigator’s study site file. 
Please refer to the SAE report form and associated guidelines for information on how to 
immediately submit SAE reports to the Sponsor or designee. 
6.6.5. 
Safety Reporting to Regulatory Authorities, Ethics Committees, and 
Investigators 
If there are suspected unexpected serious adverse reactions (SUSARs) associated with the use of 
eli-cel, the Sponsor or designee will notify the appropriate regulatory agency(ies), central ethics 
committees, and all participating Investigators in accordance with applicable regulations.  
The Investigator or Sponsor will notify the IRB/EC and other appropriate institutional 
regulatory bodies of any SUSARs or unanticipated problems, in accordance with local 
requirements. 
6.7. 
Pregnancy and Contraception 
Pregnancy of female partners is neither an AE nor an SAE, unless a complication relating to the 
pregnancy occurs (e.g., spontaneous abortion, which requires reporting as an SAE). However, all 
pregnancies of female partners occurring during this study are to be reported in the same time 
frame as SAEs using the Pregnancy Form. SAEs experienced by a female partner of a male 
subject during the course of the pregnancy are required to be immediately reported (i.e., within 
24 hours) on the SAE report form. 
The course of all pregnancies, including perinatal and neonatal outcome, regardless of whether 
the subject has discontinued participation in the study, will be followed until outcome, including 
follow-up of the health status of the newborn at 6 weeks of age and annually thereafter for 
2 years. SAEs experienced by the newborn within 6 weeks of age are required to be immediately 
reported (i.e., within 24 hours) on the SAE report form. In cases of a male study subject, 
pregnancies resulting from sperm banking prior to the receipt of drug product will not be 
followed. 
Busulfan has been shown in animal studies to be teratogenic (see package insert for additional 
details). Male subjects and their female partners are required to use two different effective 
methods of contraception from Screening through at least 6 months after drug product infusion. 
Birth control methods considered to be highly effective include hormonal contraception 
associated with inhibition of ovulation, intrauterine device (IUD), intrauterine hormone-releasing 
system (IUS), bilateral tubal occlusion, vasectomized partner, and sexual abstinence. Acceptable 
birth control methods which may not be considered as highly effective include progestogen-only 
oral hormonal contraception where inhibition of ovulation is not the primary mode of action, 
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male or female condom with or without spermicide, and cap, diaphragm, or sponge with 
spermicide (http://www.hma.eu/fileadmin/dateien/Human_Medicines/01-About_HMA/
Working_Groups/CTFG/2014_09_HMA_CTFG_Contraception.pdf). If subjects are truly 
sexually abstinent (where true sexual abstinence should be defined as being in line with the 
preferred and usual lifestyle of the subject), no second method is required. (Periodic abstinence 
[calendar, symptothermal, post-ovulation methods], withdrawal [coitus interruptus], spermicides 
only, and lactational amenorrhoea method are not acceptable methods of contraception). Beyond 
6 months, subjects should discuss with their physician prior to resuming unprotected intercourse.  
6.8. 
Unscheduled Visits 
Unscheduled visits may be performed at any time during the study whenever necessary to 
assess for or to follow-up on AEs or as deemed necessary by the Investigator. Evaluations 
and procedures to be performed at unscheduled visits will be at the Investigator’s 
discretion in consultation with the Sponsor and may be based on those listed in the SOE. 
Unscheduled visits, including any unscheduled assessments or procedures performed at the visit, 
should be promptly entered into the CRF. 
6.9. 
Long-term Follow-Up Protocol 
All subjects will be followed for 24 months after drug product infusion under this protocol unless 
they withdraw consent. For subjects with 24 months follow-up, if appropriate consent (or assent 
if applicable) is obtained, subjects will be followed for an additional 13 years under a separate 
long-term follow-up protocol (LTF-304) which will focus on long-term safety and efficacy.  
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7. 
STATISTICAL PROCEDURES 
Details of the statistical analysis will be provided in a separate document (the Statistical Analysis 
Plan [SAP]). This section provides a general overview of these plans. 
7.1. 
Sample Size Estimation 
The number of subjects planned to be infused with eli-cel is approximately 35. 
The sample size of 35 subjects will provide a 95% two-sided exact confidence interval (CI) for 
the estimated MFD-free survival rate that is at most 34.6% wide (dependent on the observed 
MFD-free survival rate). If 17 out of 35 subjects are MFD-free, the exact 95% CI will be 
(31.4%, 66.0%) with a width of 34.6%; if 26 out of 35 subjects are MFD-free, the exact 95% CI 
will be (56.7%, 87.5%) with a width of 30.8%. This sample size is appropriate for nominal 
comparisons with other CALD studies. In study ALD-101, the allo-HSCT treated cohort meeting 
similar eligibility criteria as that of ALD-104, that excluded matched siblings had an MFD-free 
survival rate of 76% with exact 95% CI of 50.1% to 90.4%; while the untreated cohort had a 
MFD-free survival rate of 21% with exact 95% CI of 6.1% to 45.6%.  
7.2. 
Populations for Analysis 
Three populations will be evaluated for efficacy and safety. 
The Intent-to-treat (ITT) population will consist of those subjects who initiate any study 
procedures, beginning with mobilization by G-CSF.  
The Transplant Population (TP) will consist of subjects who receive eli-cel. 
The Successful Neutrophil Engraftment Population (NEP) will be defined as those subjects 
who 1) receive eli-cel; 2) engraft (as defined in Section 6.5.13) 
7.3. 
Planned Analyses 
7.3.1. 
Interim Analysis 
Interim analyses are planned in support of regulatory submissions. The timing of these analyses 
and the number of subjects included in each analysis will take into account specific requests 
from regulatory agencies and applicable regulatory guidance. The rationale for each analysis will 
be documented.  
7.3.2. 
Final Analysis 
A final analysis will be performed when all subjects treated with eli-cel complete the study.  
7.3.3. 
Additional Data Review 
Analyses of study data may also be performed for the purposes of internal data review, preparing 
for regulatory meetings, and updating the scientific community. 
 
Safety data are reviewed on an ongoing basis for signal detection and to support preparation of 
regulatory submission documents. 
 
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7.3.4. 
Impact of the COVID-19 Pandemic 
A review will be performed to determine which assessments are likely to have been affected by 
the COVID-19 pandemic, and if applicable, analyses will be performed to measure the effect of 
disruptions due to the pandemic on these assessments. 
7.4. 
Statistical Methods  
7.4.1. 
General Methods 
Statistical analyses are planned to support the study objective of evaluating the efficacy and 
safety of eli-cel after myeloablative conditioning with busulfan and fludarabine in subjects 
with CALD. This study is a single arm, non-randomized, open-label study due to the rarity and 
severity of the disease. Therefore, statistical methods will be primarily descriptive in nature, 
and will include point estimates and confidence limits as appropriate.  
Tabulations will be produced for appropriate demographic, baseline, efficacy, safety, 
and exploratory parameters. For categorical variables, summary tabulations of the number 
and percentage of subjects within each category of the parameter will be presented. 
For continuous variables, the number of observations, mean, median, standard deviation, 
minimum, and maximum values will be presented, along with the 2‑sided 95% CI of the mean, 
as appropriate. Time-to-event data will be summarized using Kaplan-Meier methodology. The 
number and percent of censored observations and events will also be presented. For proportion 
endpoint variables, we presented the proportion along with 2-sided exact CIs of the proportion, 
as appropriate. 
All study data will be included in subject level listings. For primary and secondary efficacy 
endpoints, Loes score and pattern, and the neuropsychological and quality-of-life endpoints, 
Baseline is defined as the closest timepoint that is prior to conditioning. For safety endpoints and 
all laboratory data, Baseline is defined as the closest timepoint that is prior to mobilization. 
In addition to the analyses described below, supportive efficacy and safety analyses will be 
performed on the ITT population and the NEP for some of the study endpoints, as detailed in the 
SAP. Note, however, that in the likely event that there is no difference in the ITT and TP 
populations, reference to ITT analyses will not be necessary. 
If a subject treated with eli-cel undergoes an allo-HSCT in Study ALD-104, the following 
additional analyses may be conducted for two periods (if sample size is sufficient):  
• 
For safety and PD endpoints, the first period begins from day of eli-cel infusion and will 
end on the day before initiation of conditioning for the subsequent allo-HSCT, and the second 
period will begin from the day of initiation of conditioning for allo-HSCT and will end at the 
date of last contact. For subjects who do not undergo conditioning prior to allo-HSCT, the day 
before allo-HSCT will be used. 
• 
All the efficacy, PD, and safety endpoints will be included in the listings. 
7.4.2. 
Disposition of Subjects 
A tabulation of the disposition of subjects will be presented, including the number enrolled, the 
number with any post-drug product infusion data available for analysis, and the extent of data 
available. The number of subjects in each analysis population will be presented, with reasons for 
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exclusion from any specific population. A tabulation of the disposition of subjects in the study 
ALD-104 ITT population will be presented overall and by investigational site, for the following: 
• Number and percent of subjects who initiated mobilization 
• Number and percent of subjects who initiated conditioning 
• Number and percent of subjects who were infused with eli-cel 
• Number and percent of subjects who discontinued study, and reason for discontinuation 
• Number and percent of subjects who completed study, and subjects who will participate 
in the long-term follow-up study LTF-304 
• Number and percent of subjects who are in study at the time of data cut 
• Descriptive statistics for the duration of follow-up for subjects who were infused with 
eli‑cel 
• Subject-years of follow-up, which is the sum over all subjects’ duration of follow-up 
• The number of subjects receiving allo-HSCT, and the reason for receiving allo-HSCT 
during the study. 
7.4.3. 
Demographic and Baseline Characteristics 
The following demographic and Baseline characteristic factors will be summarized: age 
(age at enrollment, age at CALD diagnosis), sex, age at eli-cel infusion, height at screening, 
weight at screening, body mass index (BMI) at screening, country of origin, race and ethnicity, 
family history, time from informed consent to eli-cel infusion, signs and symptoms of CALD, 
method of diagnosis of CALD, number of prior gadolinium scans, NFS and Loes at Baseline, the 
presence of any significant co‑morbid conditions, availability of matched sibling donor and time 
from diagnosis of CALD to treatment. Subject genotype will be presented in a listing. 
7.4.4. 
Analysis of Efficacy Endpoints 
7.4.4.1. 
Analysis of Primary Efficacy Endpoint 
Population to be analyzed 
The primary analysis of the primary efficacy endpoint, Month 24 MFD-free survival, will be 
performed on the TP. Analyses will also be performed on the ITT (if the ITT is different from 
the TP) and NEP, which will be considered as supportive (i.e., as sensitivity analyses) of the 
results in the TP. 
Analysis 
In order to be considered a success for the primary endpoint, a subject must be alive at or after 
the Month 24 Visit, and must not develop an MFD (i.e., subjects who do not have an MFD 
evaluation at Month 24, but are MFD-free after the Month 24 Visit window, will be considered a 
success for the primary endpoint). Subjects who (i) die or develop an MFD on or before their 
Month 24 Visit, (ii) withdraw or are lost to follow-up before their Month 24 Visit, (iii) require 
(and undergo) rescue cell administration or a second transplant before their Month 24 Visit, will 
be considered treatment failures in this primary efficacy analysis. 
7.4.4.2. 
Analysis of Secondary and 
Efficacy Endpoints 
Populations to be analyzed 
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The analyses of the secondary and exploratory efficacy endpoints (Section 2.2.1) will be 
performed on the TP unless otherwise specified. 
Analyses 
The following time-to-event endpoints will be analyzed using the Kaplan-Meier method: 
• MFD-free survival over time.  
Time from drug product infusion to either a rescue cell administration or second 
transplant, MFD, or death due to any cause, whichever occurs first, will be 
analyzed. Subjects who do not experience a rescue cell administration or 
second transplant, MFD, or death, and subjects who discontinue the study 
prematurely, will be censored at the time of the last observation at which they 
were MFD-free. 
• Overall survival 
All other secondary and exploratory efficacy endpoints will be descriptively summarized. 
In addition, the change over time in individual efficacy parameters will be described by 
presentation of summary statistics at each protocol scheduled evaluation time. Box-plots and by 
subject plots by visit may be presented as appropriate. 
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7.4.5. 
Analysis of Safety Endpoints 
The subject counts, percentages, and 95% CI (as appropriate) will be presented for following 
endpoints in the TP: 
• The proportion of subjects with neutrophil engraftment after drug product infusion 
(primary safety endpoint) 
• The proportion of subjects who experience either acute (≥ Grade II) or chronic 
GVHD by Month 24  
• The proportion of subjects with platelet engraftment by Month 24 
• The proportion of subjects with loss of neutrophil engraftment post-drug product 
infusion by Month 24 
• The proportion of subjects who undergo a subsequent HSC infusion by Month 24 
• The proportion of subjects who experience transplant-related mortality through 
100 and 365 days post-drug product infusion 
• Proportion of subjects with clinical ≥ Grade 3 AEs, all drug product-related AEs, all 
SAEs, ≥ Grade 3 infections, and clinically significant changes in laboratory 
parameters by Month 24 
• The proportion of subjects who experience ≥ Grade II acute GVHD by Month 24 
• The proportion of subjects who experience chronic GVHD by Month 24 
• The number of subjects in which vector-derived RCL is detected by Month 24 
• The number of subjects with insertional oncogenesis (myelodysplasia, leukemia, 
lymphoma, etc.) by Month 24 
• The number of subjects with persistent oligoclonality by Month 24 
The following endpoints will be descriptively summarized for the TP: 
• Time to neutrophil engraftment post-drug product infusion 
• Time to platelet engraftment post-drug product infusion 
• Number of emergency room visits (post-neutrophil engraftment) by Month 24 
• Number and duration of in-patient hospitalizations (post-neutrophil engraftment) by 
Month 24 
• Number and duration of ICU stays (post-neutrophil engraftment) by Month 24 
In addition, the general safety profile of treatment with eli-cel will be summarized in the 
ITT through the evaluation of all AEs, laboratory assessments, vital signs, ECG and physical 
examination findings, as appropriate, during the study.  
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Transplant-related Mortality 
Transplant-related mortality will be summarized for 2 intervals: from Study Day 1 through 
100 days post-drug product infusion, and from Study Day 1 through 365 days post-drug product 
infusion. The number and percent of transplant-related deaths as well as the exact 95% CIs will 
be presented for the TP. 
Adverse Events 
All subjects receiving any part of at least 1 dose of the mobilizing agent (G-CSF) prior to eli-cel 
infusion will be evaluated for safety (the ITT population). The safety analyses will include 
evaluation of the incidence of treatment emergent AEs (i.e., AEs that occur at or after the 
initiation of eli-cel infusion) by preferred term and body system coded using the 
Medical Dictionary for Regulatory Activities (MedDRA). AEs will be summarized for those 
events that occur: 
1. from signing the informed consent up to the start of mobilization; 
2. from the start of mobilization up to the start of conditioning;  
3. from the start of conditioning until the day before neutrophil engraftment; 
4. from the day of neutrophil engraftment through 12 months post-drug product infusion; 
5. from the day after 12 months post-drug product infusion through the entire 24-month 
study period. 
6. from the start of eli-cel infusion through the entire 24-month study period. 
See the SAP for a comprehensive list of study periods and additional details. 
All AEs will be tabulated by System Organ Class (SOC) and Preferred Term (PT) for each of the 
study periods defined above. The following AEs will also be tabulated in the same manner: 
SAEs, CTCAE ≥ Grade 3 AEs, all drug product-related AEs, all CTCAE ≥ Grade 3 infections, 
AEs leading to early termination, and AEs leading to death. 
All AEs occurring on study will be provided in data listings. Additionally, deaths will also be 
listed. 
Laboratory Data 
Baseline for laboratory data will be the value closest to but prior to mobilization.  
The actual value and change from baseline to each study Visit and to the last on-study 
assessment will be summarized for each clinical laboratory parameter (hematology, clinical 
chemistry, and liver function tests) using the ITT population.  
Potentially clinically significant (PCS) values will be defined and analyzed in the SAP. 
 
Oligoclonality 
Persistent oligoclonality at any time is defined as an IS ≥10% RelFreq in an initial ISA, and the 
IS ≥10% RelFreq results are confirmed in the subsequent ISA; or at least 2 IS ≥5% RelFreq in an 
initial ISA, and the same IS ≥5% RelFreq results are confirmed in the subsequent ISA. 
Current persistent oligoclonality is defined as an IS ≥10% relative frequency in an initial ISA, 
that is confirmed in the subsequent ISA as still being an IS ≥10% relative frequency and the 
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≥10% relative frequency is maintained through the last two ISA (as of a specific data cut); or at 
least 2 IS ≥5% relative frequency in an initial ISA and the same IS ≥5% relative frequency 
results are confirmed in the subsequent ISA, and the ≥5% relative frequency is maintained 
through the last two ISA (as of a specific data cut). Current oligoclonality is defined as an IS 
≥10% relative frequency that is observed at the first time at the most recent ISA as of a specific 
data cut or at least 2 IS ≥5% relative frequency observed at the first time at the most recent ISA 
as of a specific data cut (i.e., not yet confirmed at a repeat assessment). 
 
Vital Signs and Physical/Neurological Examinations 
The change from Baseline to each on-study evaluation will be summarized for each parameter of 
vital signs. A data listing of vital signs will be provided. 
Physical/neurological examination results, including status (normal/abnormal), will be presented 
in a subject level listing.  
 
Echo- and electro-cardiograms 
Echo- and electro-cardiogram data for each subject will be provided in a data listing. 
 
Concomitant Medications 
Concomitant medications will be coded using the World Health Organization (WHO) Drug 
Dictionary (the version of the WHO Drug Dictionary will be determined at the time of analysis). 
Results will be tabulated by anatomic therapeutic class and preferred term. Medications will be 
tabulated by interval, including ICF to < mobilization (M), M to < conditioning (C), C to < 
neutrophil engraftment (NE), NE to Month 12, >M12 to M24, D1 to Month 24. 
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8. 
ADMINISTRATIVE AND REGULATORY REQUIREMENTS 
8.1. 
Good Clinical Practice (GCP) 
The study will be conducted in accordance with the ICH Guideline for GCP and all other 
applicable local regulatory requirement(s). The consent (or assent if applicable) process will 
be performed in accordance with local regulations and site specific institutional practice, if 
applicable. The Investigator will be thoroughly familiar with the appropriate use of the eli-cel as 
described in the protocol and IB. Essential clinical documents will be maintained to demonstrate 
the validity of the study and the integrity of the data collected. Site Master Files should be 
established at the beginning of the study, maintained for the duration of the study, and retained 
according to the appropriate regulations. 
8.2. 
Ethical Considerations 
The study will be conducted in accordance with ethical principles founded in the Declaration of 
Helsinki. The IRB/IEC will review all appropriate study documentation in order to safeguard the 
rights, safety, and well-being of the subjects. The study will only be conducted at sites where 
IRB/IEC approval has been obtained. The Protocol, IB, ICF, advertisements (if applicable), 
written information given to the subjects, safety updates, annual progress reports, and any 
revisions to these documents will be provided to the IRB/IEC. 
8.3. 
Subject Information and Informed Consent 
After the study has been fully explained, written informed consent will be obtained from the 
subject’s parent, guardian, or legal representative prior to study participation. For subjects who 
have already received eli-cel, an ICF addendum may be used to share protocol updates or new 
information with the subject. If a subject is below the legal age of consent at the time of ICF 
signing and turns the legal age of consent per country regulations while on study, the subject 
must be re-consented at the next scheduled study visit, prior to the collection of additional study 
data. The method of obtaining and documenting the informed consent and the contents of the 
consent will comply with ICH-GCP and all applicable regulatory requirement(s). In addition, if 
consistent with local regulations, the Investigator will seek assent from the subject if he is at least 
7 years of age. Sites will follow their standard institutional practice for obtaining informed 
consent. See Section 3.1. Consent to this study indicates consent to 15 years of follow up, with 
the first 2 years in this Study ALD-104 and 13 additional years in long-term follow-up Study 
LTF-304. 
8.4. 
Subject Confidentiality 
In order to maintain subject privacy, all CRFs, eli-cel accountability records, study reports, and 
communications will identify the subject using initials (in compliance with local regulation) and 
the assigned subject number. The Investigator will grant monitor(s) and auditor(s) from bluebird 
bio or its designee and regulatory authority(ies) access to the subject’s original medical records 
for verification of data gathered on the CRFs and to audit the data collection process. The 
subject’s confidentiality will be maintained and will not be made publicly available to the 
extent permitted by the applicable laws and regulations. 
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8.5. 
Protocol Compliance 
The Investigator will conduct the study in compliance with the protocol provided by 
bluebird bio, and given approval/favorable opinion by the IRB/IEC and the appropriate 
regulatory authority(ies). Modifications to the protocol should not be made without 
agreement of both the Investigator and bluebird bio. Changes to the protocol will require 
written IRB/IEC approval/favorable opinion prior to implementation, except when the 
modification is needed to eliminate an immediate hazard(s) to subjects. The IRB/IEC 
may provide, if applicable regulatory authority(ies) permit, expedited review and 
approval/favorable opinion for minor change(s) in ongoing studies. bluebird bio will submit 
all protocol modifications to the regulatory authority(ies) in accordance with the governing 
regulations.  
When immediate deviation from the protocol is required to eliminate an immediate hazard(s) 
to subjects, the Investigator will contact bluebird bio, if circumstances permit, to discuss the 
planned course of action. Any departures from the protocol must be fully described in the 
CRF and source documentation. 
8.6. 
Direct Access to Source Data 
Monitoring and auditing procedures developed by bluebird bio will be followed in compliance 
with GCP guidelines. 
The study will be monitored by bluebird bio or its designee. Monitoring will be done by visits 
from a representative of the Sponsor (site monitor) and will include on-site and/or remote review 
of the CRFs for completeness and clarity, cross-checking with source documents, and 
clarification of administrative matters. The review of medical records will be performed in a 
manner to ensure that subject confidentiality is maintained. 
The site monitor will ensure that the investigation is conducted according to protocol design and 
regulatory requirements by frequent communications (letter, e-mail, telephone, and fax). 
Regulatory authorities, the IEC/IRB, and/or bluebird bio’s clinical quality assurance group may 
request access to all source documents, CRFs, and other study documentation for on-site audit or 
inspection. Direct access to these documents must be guaranteed by the Investigator, who must 
provide support at all times for these activities. 
8.7. 
Electronic Case Report Form Completion 
bluebird bio, Inc. will provide the study sites with an eCRF for each subject. Required study data 
will be captured on eCRFs via electronic data capture (EDC) unless otherwise specified in this 
document. Except for data points for which the protocol or SOM indicate that the eCRF may 
serve as source documentation, data are to be obtained from the subject’s source documents and 
then entered into the eCRF by authorized site personnel. Clinical data that are not recorded on 
the eCRF will be electronically captured and transferred to the Sponsor or its designee through a 
secure external data transfer process. 
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It is the Investigator’s responsibility to ensure the accuracy, completeness, and timeliness of the 
data reported in the subject’s eCRF. Source documentation supporting the eCRF data should 
indicate the subject’s participation in the study and should document the dates and details of 
study procedures, AEs, and subject status. 
The Investigator, or designated representative, should complete the eCRF as soon as possible 
after information is collected, preferably on the same day that a study subject is seen for an 
examination, treatment, or any other study procedure. Any outstanding entries must be 
completed immediately after the final examination. An explanation should be given for all 
missing data. 
The Investigator must sign and date the Investigator’s Statement at the end of the eCRF to 
endorse the recorded data. 
bluebird bio will retain the originals of all CRFs. The Investigator will retain a copy of all 
completed eCRFs. 
8.8. 
Record Retention 
The Investigator will maintain all study records according to ICH-GCP and applicable regulatory 
requirement(s). Records will be retained for at least 2 years after the last marketing application 
approval or 2 years after formal discontinuation of the clinical development of the investigational 
product or according to applicable regulatory requirement(s). If the Investigator withdraws from 
the responsibility of keeping the study records, custody must be transferred to a person willing to 
accept the responsibility. bluebird bio, Inc. must be notified in writing if a custodial change 
occurs. 
The Sponsor has full rights over any invention, discovery, or innovation, patentable or not, that 
may occur when performing the study. 
8.9. 
Liability and Insurance 
bluebird bio, Inc. has subscribed to an insurance policy covering, in its terms and provisions, its 
legal liability for injuries caused to participating persons and arising out of this research 
performed strictly in accordance with the scientific protocol as well as with applicable law and 
professional standards. 
8.10. 
Publication and Presentation of Study Findings and Use of 
Information 
All information regarding eli-cel supplied by bluebird bio to the Investigator is privileged and 
confidential information. The Investigator agrees to use this information to accomplish the study 
and will not use it for other purposes without consent from bluebird bio. It is understood that 
there is an obligation to provide bluebird bio with complete data obtained during the study. The 
information obtained from the clinical study will be used towards the development of eli-cel and 
may be disclosed to regulatory authority(ies), other Investigators, corporate partners, or 
consultants as required. 
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It is anticipated that the results of this study will be presented at scientific meetings and/or 
published in a peer reviewed scientific or medical journal. A Publications Committee comprised 
of Investigators participating in the study and representatives from bluebird bio, as appropriate, 
will be formed to oversee the publication of the study results, which will reflect the experience of 
all participating study centers. Subsequently, individual Investigators may publish results from 
the study in compliance with their agreement with bluebird bio. 
A pre-publication manuscript is to be provided to bluebird bio at least 30 days prior to the 
submission of the manuscript to a publisher. Similarly, bluebird bio will provide any company 
prepared manuscript to the Investigators for review at least 30 days prior to submission to a 
publisher. 
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9. 
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Thornley I, Lehmann LE, Sung L, et al (2004) A multiagent strategy to decrease regimen-related 
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Marrow Transplant 10:635–44. doi: 10.1016/j.bbmt.2004.06.004 
Varni JW, Seid M, Kurtin PS (2001) PedsQL 4.0: reliability and validity of the Pediatric Quality 
of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care 
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Weaver CH, Hazelton B, Birch R, et al (1995) An analysis of engraftment kinetics as a function 
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Wilson BC, Iacoviello JM, Wilson JJ, Risucci D (1982) Purdue Pegboard performance of normal 
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Yeudall LT, Fromm D, Reddon JR, Stefanyk WO (1986) Normative data stratified by age and 
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10. 
APPENDICES 
10.1. 
Dose Adjustment Formulas for Ideal Body Weight  
Ideal Body Weight Formulas (Subjects 1 to 18 Years of Age): 
Height (ht) less than 60 inches (less than 152 cm) 
IBW = [(ht2) × 1.65] ÷ 1000, where ht = cm, IBW = kg 
Height (ht) greater than 60 inches (greater than 152 cm) 
Males IBW = 39 + [2.27 × (ht – 60)], where ht = inches, IBW = kg 
Adjusted Ideal Body Weight Formula: 
AIBW = IBW + [(0.25) × (ABW- IBW)], where ABW= actual body weight 
10.2. 
Major Functional Disabilities  
The 6 disabilities considered MFDs in this study are defined in Table 8, and these were chosen 
based on their clinical significance and their impact on independent functioning. 
Table 8: 
Major Functional Disabilities 
MFD 
Definition 
Loss of 
communication 
Individual should meet one of the following criteria (psychogenic syndromes, 
such as catatonia, should be ruled out): (1) With normal consciousness and 
ability to perform movements, individual does not follow command and/or 
permanently fails to perform verbal or nonverbal simple task on neurologic 
evaluation, or (2) Individual is permanently mute and unable to communicate by 
verbal or non-verbal ways.  
Cortical blindness 
Individual fails to visually track, find objects, or count fingers. Individual has 
permanent and complete vision loss affecting bilateral vision. Pupils may react 
to light. 
Tube feeding 
Individual is not able to swallow safely by mouth to maintain nutrition and 
hydration. Alternative method of feeding required. 
Wheelchair 
dependence 
Individual is unable to take more than a few steps, restricted to wheelchair; may 
need aid to transfer; wheels himself, but may require motorized chair for full 
day’s activities. 
Complete loss of 
voluntary movement 
Individual is unable to effectively use his upper and lower extremities to perform 
simple or one-step activities. The criteria may still be met if there are singular 
apparently random movements of the arms. 
Total incontinence 
In an individual who was previously continent, the permanent and continuous 
loss of urinary and/or fecal control.  
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10.3. 
Neurologic Function Score for ALD 
The NFS is a 25-point composite scale that assesses functional disabilities (Moser et al. 2000). It 
was designed by Dr. Gerald Raymond and colleagues specifically for the consistent and 
reproducible clinical evaluation of patients with CALD. It assesses 15 functional domains 
affected by the disease and is the most common clinical evaluation tool used by clinical 
specialists caring for these patients (Moser et al. 2000; Miller et al. 2011).  
Assessment of subject status using NFS is to be performed by a pediatric neurologist or other 
appropriately trained and qualified physician as described in Section 6.5.6 .
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Table 9: 
Neurologic Function Score for CALD 
Symptom / Neuroexam 
Definition 
Score 
Hearing / auditory processing 
problems 
Individual with previously normal hearing develops permanent auditory processing difficulties and 
impairment of comprehension to verbal sounds on neurologic evaluation. 
1 
Aphasia / apraxia 
Individual should meet one of the following two criteria: (1) Individual with previously age appropriate 
speech and language development has impaired fluency or naming or repetition or content or comprehension 
or motor speech on the clinical examination; patient may have partial or incomplete aphasia or motor speech 
disorder of the speech, or (2) Individual with newly developed apraxia. Apraxia can be defined as ‘loss of the 
ability to execute or carry out any complicated learned and purposeful movements, despite having the desire 
and the physical ability to perform the movement’, examples of apraxia include, but are not limited to, limb-
kinetic apraxia, ideomotor apraxia, conceptual apraxia, speech apraxia etc. 
1 
Loss of communication 
Individual should meet one of the following criteria (psychogenic syndromes, such as catatonia, should be 
ruled out): (1) With normal consciousness and ability to perform movements, individual does not follow 
command and/or permanently fails to perform verbal or nonverbal simple task on neurologic evaluation, or (2) 
Individual is permanently mute and unable to communicate by verbal or non-verbal ways.  
3 
Vision impairment /field cut An individual with previously normal (corrected) vision develops visual field defect affecting one or both 
eyes, and/or maximal visual acuity (corrected) worse than 20/30 using bedside pocket vision screening card. 
1 
Cortical blindness 
Individual fails to visually track, find objects, or count fingers. Individual has permanent and complete vision 
loss affecting bilateral vision. Pupils may react to light. 
2 
Swallowing / other CNS 
dysfunctions 
Swallowing is safe; however individual requires minimal cueing to use compensatory strategies. The 
individual may occasionally self-cue. All nutrition and hydration needs are met by mouth at mealtime. 
2 
Tube feeding 
Individual is not able to swallow safely by mouth to maintain nutrition and hydration. Alternative method of 
feeding required. 
2 
Running difficulties / 
hyperreflexia 
An individual with previously normal gait develops minimal but permanent difficulties during running. He 
may be fully ambulatory without aid, or may have some limitation of full activity or requires minimal 
assistance. 
1 
Walking difficulties / 
spasticity / spastic gait 
(no assistance) 
Individual develops walking difficulties but is ambulatory without aid; disability severe enough to preclude 
full daily activities. 
1 
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Table 9: 
Neurologic Function Score for CALD 
Symptom / Neuroexam 
Definition 
Score 
Spastic gait (needs 
assistance) 
Individual requires constant bilateral assistance (canes, crutches, braces). 
2 
Wheelchair dependence 
Individual is unable to take more than a few steps, restricted to wheelchair; may need aid to transfer; wheels 
himself, but may require motorized chair for full day’s activities. 
2 
Complete loss of voluntary 
movement 
Individual is unable to effectively use his upper and lower extremities to perform simple or one-step activities. 
The criteria may still be met if there are singular apparently random movements of the arms. 
3 
Episodes of incontinence 
Individual who was previously continent for at least 6 months develops permanent and frequent episodes of 
hesitance, urgency, retention of bowel or bladder, or urinary incontinence during daytime and nighttime 
(diurnal and nocturnal enuresis). 
1 
Total incontinence 
In an individual who was previously continent, the permanent and continuous loss of urinary and/or fecal 
control.  
2 
Nonfebrile seizures 
Individual who develops non-febrile seizure. 
1 
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Protocol Title: 
A Phase 3 Study of Lenti-D Drug Product After Myeloablative Conditioning 
Using Busulfan and Fludarabine in Subjects ≤ 17 Years of Age With Cerebral 
Adrenoleukodystrophy (CALD) 
Protocol Number: 
ALD-104 Version 8.0, 30 November 2022 
INVESTIGATOR STATEMENT 
I have read, understood, and agree to abide by all the conditions and instructions contained in 
this protocol. 
I understand that all documentation provided to me by bluebird bio or its designated 
representative(s) concerning this study that has not been published previously will be kept in 
the strictest confidence. This documentation includes the study protocol, Investigator’s 
Brochure, case report forms, and other scientific data. 
I agree to personally conduct or supervise the described investigation(s). 
I agree to inform any subjects, or any persons used as controls, that the drug product is being 
used for investigational purposes and I will ensure that the requirements relating to obtaining 
informed consent, as per local regulations and under Good Clinical Practice (GCP), are met. 
I agree to report to the Sponsor adverse events that occur in the course of the investigation(s) 
in accordance with this protocol and as required by local regulations and under GCP.  
I have read and understand the information in the Investigator’s Brochure, including the 
potential risks and side effects of the drug product. 
I agree to maintain adequate and accurate records and to make those records available for 
inspection in accordance with local regulations and under GCP. 
I will ensure that an ethics committee that complies with all local regulations and GCP 
requirements will be responsible for the initial and continuing review and approval of the 
clinical investigation.  
I also agree to promptly report to the ethics committee all changes in the research activity and 
all unanticipated problems involving risks to human subjects or others.  
I agree that this study will not commence without the prior approval of the appropriate national 
health authorities together with a properly constituted ethics committee. I agree that no 
changes will be made to the study protocol without the prior written approval of bluebird bio 
and the aforementioned regulatory bodies, as applicable in the relevant laws and regulations. 
I agree to ensure that all associates, colleagues, and employees assisting in the conduct of the 
study(ies) are informed about their obligations in meeting the above commitments. 
 
Investigator Name 
 
Investigator Signature 
 
Date 
 
 
 
 
 
Investigational site or name of institution and location (printed) 
 
 
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