Adoptive Transfer of T Regulatory Cell for Suppression of Acute Graft-vs-Host-Disease After an Umbilical Cord Blood Transplant for Hematologic Malignancies
Phase: PHASE2
Conditions: Acute Lymphoblastic Leukemia, Burkitt Lymphoma, Natural Killer Cell Malignancies, Chronic Myelogenous Leukemia, Myelodysplastic Syndromes, Large-cell Lymphoma, Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma, Marginal Zone B-Cell Lymphoma, Follicular Lymphoma, Lymphoplasmacytic Lymphoma, Mantle-Cell Lymphoma, Prolymphocytic Leukemia, Hodgkin Lymphoma, Multiple Myeloma, Acute Myelogenous Leukemia, Biphenotypic Leukemia, Undifferentiated Leukemia
Sponsor: Masonic Cancer Center, University of Minnesota

Masonic Cancer Center, University of Minnesota 
Cancer Experimental Therapeutics Initiative 
Blood and Marrow Transplantation Program 
 
 
Adoptive Transfer of T Regulatory Cell for Suppression of Acute 
Graft-vs-Host-Disease after an Umbilical Cord Blood Transplant for 
Hematologic Malignancies 
MT2016-17 
CPRC # 2016LS107 
IND 12559 
 
 
IND Sponsor/Principal Investigator: 
Claudio G. Brunstein, MD, PhD 
 
 
Co-Investigators: 
John E Wagner, MD (Co-PI) 
Keli Hippen, PhD* 
Bruce R Blazar, MD 
Jeffrey S Miller, MD 
Kathryn E Dusenbery, MD* 
David H McKenna, Jr, MD* 
*will not consent patients 
 
Biostatistician: 
Todd E De For, MS 
 
 
Version Date: 
January 4, 2018 
 
 
 
 
 
 
 
Confidential 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 2 of 47 
CPRC #2016LS107 
Revision History 
 
 
Revision 
# 
Version 
Date 
Summary Of Changes 
Consent 
Changes 
 
06/23/2016 
Original to CPRC 
n/a 
 
09/14/2016 
in response to CPRC stipulations 
n/a 
 
10/04/2016 
Prior to IRB submission - Updated eligibility to standard language 
and definitions, other minor edits. 
n/a 
 
01/05/2017 
Expand enrollment to include single cord blood transplants – 
update title and through-out protocol 
Section 9.2 - correct the volume of the serum tube (10 ml, not 5 ml) 
yes 
 
02/03/2017 
In response to IRB stipulations: 
Section 5.3 and appendix I – revise  to read “Voluntary written 
consent signed by the subject (or the subject’s legally authorized 
representative)” 
Section 6 - revise 1st sentence to read: Registration will occur after 
voluntary written consent from the subject (or the subject’s legally 
authorized representative) the patient has signed the subject 
consent, and eligibility is confirmed, but before the performance of 
study related procedures  
Yes 
1 
5/25/17 
Section 7.5 - Added ULD IL2 dose adjustment plan in the case of 
capillary leak syndrome 
Section 9.2 - clarified that research bloods should be obtained pre 
cord blood infusion 
Section 10.2 - clarified that AEs will not be collected in the case of 
early treatment withdrawals 
Sections 10.2 and 12.4 - added grade 2 or 4 GVHD to stopping 
rules 
Updated references 
Yes 
2 
01/04/2018 • Through-out protocol document, including title change – delete IL-
2 from the treatment plan 
• Section 5.2 and Appendix I – modify definition of complete 
remission for acute leukemia patients to around 5% blasts, but < 
20% blasts by morphology 
• Other minor edits to update to current template language 
Yes 
 
 
IND Sponsor/Principal Investigator Contact Information: 
Claudio Brunstein, MD, PhD 
Division of Hematology/Oncology/Transplantation 
MMC 480 
420 Delaware Street SE 
Minneapolis, MN 55455 
612 625-3918 (phone) 
bruns072@umn.edu (email) 
612 899-6170 (pager) 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 3 of 47 
CPRC #2016LS107 
Table of Contents 
 
Protocol Synopsis ................................................................................................................................... 5 
Study Schema ........................................................................................................................................ 7 
1 
Objectives ....................................................................................................................................... 8 
1.1 
Primary Objective ................................................................................................................... 8 
1.2 
Secondary Objectives ............................................................................................................. 8 
1.3 
Transplant Related Objectives ............................................................................................... 8 
2 
Background ..................................................................................................................................... 8 
2.1 
Adoptive Transfer of UCB-derived Regulatory T Cells ........................................................... 8 
2.2 
Treg Manufacture ................................................................................................................... 9 
2.3 
Clinical Results with Bead Expanded Tregs ......................................................................... 10 
2.4 
Maximum Tolerated Dose: Treg Infusional Toxicity Profile and Detection Kinetics of Bead 
Expanded Tregs ............................................................................................................................... 11 
2.5 
Engraftment with Bead Expanded Tregs .............................................................................. 12 
2.6 
Graft-Versus-Host Disease (GVHD) with Bead Expanded Tregs ........................................ 12 
2.7 
Opportunistic Infections with Bead Expanded Tregs ............................................................ 13 
2.8 
Relapse, Non-Relapse Mortality and Disease-Free Survival with Bead Expanded Tregs ... 14 
2.9 
Results of KT64/86 Expanded Tregs.................................................................................... 14 
2.10 
Ultra-Low IL-2 for GVHD Prophylaxis (removed from the treatment plan with the January 
2018 protocol version) ...................................................................................................................... 16 
3 
Summary and Rationale ............................................................................................................... 17 
4 
Study Design ................................................................................................................................ 17 
5 
Patient Selection ........................................................................................................................... 18 
5.1 
Age, Graft Cell Dose and Graft HLA Criteria and Treg Unit ................................................. 18 
5.2 
Disease Criteria .................................................................................................................... 18 
5.3 
Performance Status, Organ Function, Contraception Use ................................................... 20 
5.4 
Exclusions ............................................................................................................................. 20 
6 
Patient Registration and Study Enrollment ................................................................................... 21 
6.1 
Registration with the Masonic Cancer Center Clinical Trials Office ..................................... 21 
6.2 
Study Enrollment with the Masonic Cancer Center Clinical Trials Office ............................. 21 
6.3 
Patients Who Do Not Begin Study Treatment ...................................................................... 21 
7 
Treatment Plan ............................................................................................................................. 22 
7.1 
Preparative Regimen (Day -6 to Day -1) .............................................................................. 22 
7.2 
GVHD Prophylaxis (start Day -3) .......................................................................................... 24 
7.2.1 
Sirolimus ........................................................................................................................... 24 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 4 of 47 
CPRC #2016LS107 
7.2.2 
Mycophenolate Mofetil (MMF) .......................................................................................... 24 
7.3 
UCB Infusion (Day 0) ............................................................................................................ 25 
7.4 
Infusion of the Treg Cells (Day 0 after UCBT) ...................................................................... 25 
7.5 
Supportive Care .................................................................................................................... 27 
7.6 
Duration of Study Participation ............................................................................................. 27 
8 
Expected Toxicities of Treg Cell Product...................................................................................... 27 
9 
Schedule of Patient Activities ....................................................................................................... 27 
9.1 
Standard of Care .................................................................................................................. 28 
9.2 
Research Related Procedures and Activities ....................................................................... 29 
10 
Adverse Event Reporting .......................................................................................................... 29 
10.1 
Definitions ............................................................................................................................. 29 
10.2 
Adverse Event Documentation ............................................................................................. 31 
10.3 
Required Reporting: FDA, IRB and Masonic Cancer Center’s SAE Coordinator ................ 32 
11 
Study Data Collection and Monitoring ...................................................................................... 33 
11.1 
Data Management ................................................................................................................ 33 
11.2 
Case Report Forms .............................................................................................................. 34 
11.3 
Data and Safety Monitoring Plan (DSMP) ............................................................................ 34 
11.4 
IND Annual Reports .............................................................................................................. 34 
11.5 
Monitoring ............................................................................................................................. 34 
11.6 
Record Retention .................................................................................................................. 35 
12 
Statistical Considerations ......................................................................................................... 35 
12.1 
Study Design and Endpoints ................................................................................................ 35 
12.2 
Statistical Analysis ................................................................................................................ 36 
12.3 
Sample Size Justification ...................................................................................................... 36 
12.4 
Monitoring Guidelines (Stopping Rule Events) ..................................................................... 36 
13 
Conduct of the Study ................................................................................................................ 37 
13.1 
Good Clinical Practice .......................................................................................................... 37 
13.2 
Ethical Considerations .......................................................................................................... 37 
13.3 
Informed Consent ................................................................................................................. 38 
14 
References ............................................................................................................................... 38 
Appendix I – Eligibility Checklist ........................................................................................................... 40 
Appendix II – Karnofsky Performance Status ....................................................................................... 42 
Appendix III – Expected Risks of the Preparative Regimen, GVHD Prophylaxis and UCB Transplant
 .............................................................................................................................................................. 43 
Appendix IV – GVHD Scoring ............................................................................................................... 46 
Appendix V – Targeted Toxicity............................................................................................................ 47 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 5 of 47 
CPRC #2016LS107 
Protocol Synopsis 
Adoptive Transfer of T Regulatory Cell for Suppression of Acute Graft-vs-
Host-Disease after an Umbilical Cord Blood Transplant for Hematologic 
Malignancies 
MT2016-17 
Study Design: 
This is a single center pilot study of a non-myeloablative umbilical cord blood transplant for the 
treatment of a hematological malignancy with a single infusion of T regulatory (Treg) given 
shortly after UCB transplantation..  
 
The nTreg cells are manufactured from a cord blood unit that is not part of the graft for infusion 
on day 0 at least 1 hour after the UCB transplant. The CD3+ cell content from the graft UCB 
unit(s) is enumerated upon thaw (day 0) from which the Treg cell dose for the final product is 
calculated using assigned 1:1 Treg:CD3+ cell ratio.  
 
Primary 
Objective: 
To obtain preliminary estimates of efficacy as measured by length of Treg survival after 
infusion of Treg 
 
Secondary  
Objectives: 
To obtain preliminary estimates of safety as measured by 
• 
Probability of grade II-IV aGVHD 
• 
Probability of grade III-IV aGVHD 
• 
Probability of treatment related mortality (TRM) at 6 months 
• 
Probability of relapse at 1 year 
• 
Probability of viral and fungal infections at 1 year 
• 
The proportion of patients with detectable Treg cells at Day 14 post infusion 
• 
Pattern of immune reconstitution 
• 
Toxicity 
 
Transplant 
Related 
Objectives: 
• 
Determine the incidence of chimerism at Day 100  
• 
Determine the probability of survival at 1 year  
• 
Determine the incidence of neutrophil recovery at Day 42  
• 
Determine the incidence of platelet recovery at 1 year  
• 
Determine the incidence of chronic GVHD at 1 year  
 
Age and UCB 
Graft 
Requirements  
Must be ≥18, but < 70 years of age with no available medically suitable 7/8 or 8/8 HLA-
matched sibling donor, considering HLA A, B, C and DRB1 - patients ≥ 70 and ≤ 75 years of 
age may be eligible if they have a Co-Morbidity score ≤ 2  
 
Graft units will be selected according to the current University of Minnesota umbilical cord 
blood graft selection algorithm. The UCB unit that is not part of the graft will serve as the 
source of Treg cells.  
 
Eligible 
Diseases: 
• 
Acute Leukemias 
• 
Burkitt’s Lymphoma 
• 
Natural Killer Cell Malignancies 
• 
Chronic Myelogenous Leukemia 
• 
Myelodysplastic Syndrome 
• 
Large-Cell Lymphoma, Hodgkin Lymphoma, and Multiple Myeloma 
• 
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Marginal Zone B-Cell 
Lymphoma, Follicular Lymphoma:   
• 
Lymphoplasmacytic Lymphoma, Mantle-Cell Lymphoma Prolymphocytic Leukemia 
Refer to Section 5.2 of the protocol for complete disease information. 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 6 of 47 
CPRC #2016LS107 
Other Inclusion 
Criteria: 
• Karnofsky performance status of ≥ 70% 
• Adequate organ function defined as: 
o Renal: creatinine ≤ 2.0 mg/dL, if > 1.2 mg/dL must have eGFR of ≥ 40 
o Hepatic: AST, ALT, and ALP ≤5 x upper limit of normal, total bilirubin ≤ 2.5 mg/dL  
o Pulmonary function: DLCO, FEV1, FVC ≥40% predicted and absence of O2 requirements  
o Cardiac:  Absence of decompensated congestive heart failure, or uncontrolled arrhythmia 
and left ventricular ejection fraction ≥ 40% 
• Must have been exposed to highly immunosuppressive single agent or multi-agent 
chemotherapy within prior 3 months OR an ablative preparative regimen for autologous 
hematopoietic stem cell transplant within previous 1 year 
• Voluntary written consent signed by the participant 
 
Patient 
Exclusion: 
• 
Untreated active infection at time of transplantation  
• 
History of HIV infection 
• 
Pregnant or breast feeding  
• 
Prior allogeneic transplantation 
• 
Less than 3 months from myeloablative conditioning for autologous transplantation 
 
Treatment Plan: 
An 18 day lead time is required for the manufacturing of the Treg cells 
 
A non-myeloablative cyclophosphamide/fludarabine/TBI prep with sirolimus/MMF as GVHD 
prophylaxis is administered followed by an umbilical cord blood transplant on Day 0 per 
institutional guidelines 
 
The Treg cell infusion is given no sooner than 1 hour, but within 24 hours after the cord blood 
infusion. 
  
Begin G-CSF Day +5 continuing until ANC ≥ 2,500 for 2 consecutive days. 
 
Supportive care will follow institutional guidelines 
 
Enrollment: 
10 patients will be enrolled over a period of 18 months 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 7 of 47 
CPRC #2016LS107 
Study Schema 
 
Identify cord blood units: 1 or 2 for the UCBT and an additional cord for culture 
 
Treg product manufacturing at MCT: 
Day -18:  Initiate UCB Treg Isolation and Ex Vivo Expansion Culture from clinical grade research 
directed UCB unit 
Day 0:  Prepare final Treg cell product:  Thaw of UCB graft unit(s) and enumerate CD3+ cells, 
calculate Treg cell dose at a 1:1 Treg:CD3+ cell ratio for final Treg cell product  
 
 
Admit patient to hospital and begin allopurinol evening of day -7 
 
 
 
 
Cyclophosphamide 50 mg/kg IV over 2 hours on Day -6 
 
     
Fludarabine 30mg/m2 IV over 1 hour on Day -6, -5, -4, -3, and -2 
 
TBI Total Body Irradiation 200 cGy as a single dose 
 
DUCBT followed by Tregs –umbilical cord blood transplant (FIRST) followed by the Treg cell infusion 
(SECOND) no sooner than 1 hour, but within 24 hours after the cord blood infusion. 
 
 
 
Note: The 1st 3 patients enrolled in this study received ultra-low dose IL-2 post cell infusion; however due 
unacceptable toxicity, IL-2 was eliminated from the treatment plan effective with the January 2018 protocol 
version.  
 
 
 
 
 
 
Fludarabine 
Cyclophosphamide 
TBI 
Day   -18                -6         -5        -4         -3         -2         -1          0        +1        +5                  +28            +42   
Monitor for 
infusion 
toxicity 
 
UCBT followed 1 
hour later after 
infusion end by 
infusion of Treg 
product 
Start MMF Day -3, continue until Day +30 
Start sirolimus Day -3, continue until Day +100 
Initiate Treg Isolation 
and Ex Vivo Expansion 
Culture from 
designated UCB unit 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 8 of 47 
CPRC #2016LS107 
1 Objectives 
1.1 Primary Objective 
 
To obtain preliminary estimate of efficacy as measured by the length of Treg 
survival after infusion of Treg 
1.2 
Secondary Objectives 
To obtain preliminary estimates of safety as measured by: 
• Probability of grade II-IV aGVHD 
• Probability of grade III-IV aGVHD 
• Probability of treatment related mortality (TRM) at 6 months 
• Probability of relapse at 1 year 
• Probability of viral and fungal infections by 1 year 
• Pattern of immune reconstitution 
• The proportion of patients with detectable Treg cells at Day 14 post 
infusion 
• Toxicity 
1.3 
Transplant Related Objectives 
• 
Determine the incidence of chimerism at Day +100  
• 
Determine the probability of survival at 1 year  
• 
Determine the incidence of neutrophil recovery at Day 42  
• 
Determine the incidence of platelet recovery at 1 year  
• 
Determine the incidence of chronic GVHD at 1 year  
2 Background 
2.1 Adoptive Transfer of UCB-derived Regulatory T Cells  
Regulatory T cells (Treg) represent a novel cell-based approach for 
potentially reducing the risk of severe acute graft-versus-host disease 
(aGVHD). Treg are a subset of CD4+ T cells that co-express CD25 (IL-2Rα 
chain) and high levels of Foxp3 (1) and are dependent on IL-2 (2). Our group 
and others have shown that in murine models lethal acute GVHD can be 
prevented by Treg with enhanced survival (3-8). We tested different Treg:T-
effector cell ratios and observed moderate suppression at a 1:1 ratio, but 
almost complete suppression of GVHD at a 3:1 ratio. Further, in these models 
of acute GVHD CD4+/CD25+ Treg cells functioned at least in part through the 
suppression of CD8+ effector cells expansion in GVHD target organs (7). In 
contrast, depletion of CD4+/CD25+ Treg cells increased aGVHD lethality (5). 
Further, Treg inhibited the development of chronic GVHD (9-11) and 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 9 of 47 
CPRC #2016LS107 
facilitated engraftment in murine models of allogeneic transplantation (7, 12, 
13). 
Double umbilical cord blood transplantation (DUCBT) has been shown to 
overcome the cell dose limitation that often prevents the use of this treatment 
modality in adults and larger adolescents (14-16). However, compared to 
single UCBT, a significantly higher risk of grade 2 aGVHD (17) is observed 
after DUCBT. Regardless of the source of allogeneic hematopoietic stem 
cells (HSC), severe forms of aGVHD are associated with an increased risk of 
morbidity and mortality (15, 17). 
 
We conducted a phase I dose escalation trial to study the safety and 
feasibility of the infusion of Treg isolated from a partially HLA-matched UCB 
unit and ex vivo expanded in culture (18). The dose levels tested were 1, 3, 
10 or 30 x 105 Treg/kg actual body weight on day +1 with an additional cohort 
who received a second dose of 30 x 105 Treg/kg on day +15 after UCBT. The 
cell dose levels were planned based on the murine studies and on what we 
estimated we would be able to achieve with the available manufacturing 
methodology. Since all our prior dUCBT experience incorporated CsA 
immunoprophylaxis, the MTD was first determined in patients concomitantly 
receiving CsA. As CsA has been shown to potentially interfere with optimal 
Treg function and survival (19-22), the last cohort received Treg at the 
maximal dose but in the presence of MMF and sirolimus rather than CsA.  
2.2 
Treg Manufacture 
In the dose escalation study, CD25+ Treg enriched cells were isolated from a 
partially HLA matched third UCB unit that was 4-6/6 HLA matched to the 
patient. As the Treg unit was not expected to persist long-term, no inter-unit 
matching was required between the Treg donor unit and the two HSC graft 
units. Enrichment of CD25+ cells was accomplished by positive selection with 
directly conjugated anti-CD25 magnetic microbeads (Miltenyi Biotec, Bergish 
Gladbach, Germany) and the CliniMACS device (23). Isolated cells were 
subsequently cultured with anti-CD3/anti-CD28 monoclonal antibody (mAb)-
coated Dynabeads (Provided under Food and Drug Administration 
Investigational New Drug # 6675 by Dr. Carl June, University of 
Pennsylvania) at a 3:1 bead to cell ratio for 18 ± 1 days. On day 3, cultures 
were supplemented with 300 IU/ml IL-2 (Proleukin, Chiron Corporation, 
Emeryville, CA). All products passed lot release criteria that included: 7AAD 
viability ≥70%, CD4+CD25+ purity ≥60%, less than 10% CD4-/CD8+ cells, 
anti-CD3/anti-CD28 mAB bead count <100 per 3x106 cells, negative gram 
stain, and absence of endotoxin (<5 EU/kg). Remaining cells were frozen 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 10 of 47 
CPRC #2016LS107 
using a standard cryopreservative cocktail with Plasma-Lyte A (Baxter 
Healthcare Corp, Deerfield, IL), dimethylsulfoxide (final concentration 10%), 
and human serum albumin and stored in Cryocyte bags (Baxter Healthcare 
Corp, Deerfiled, IL), for the planned second infusion on day +15. For the 14 
patients receiving a second infusion at day +15, cells were thawed, diluted 
with 5% albumin /10% Dextran 40 and underwent limited additional lot 
release testing that included acceptable pre-freeze lot release and post-thaw 
acridine orange/propidium iodine (AOPI) viability > 50%; all met lot release 
criteria. In six products the expansion failed to achieve the target dose level 
requiring the patients to be treated at a lower dose level. 
 
In this study we were able to achieve the highest target cell dose level but in 
the absence of dose limiting toxicities, the maximum tolerated dose was not 
reached. Thus, we amended the protocol in order to be able to test higher cell 
doses. Based on pre-clinical data, we modified the manufacturing 
methodology by introducing an anti-CD3/anti-CD28 mAB bead re-stimulation 
on day 12 of the UCB-derived Treg expansion culture period. Clinical 
validation runs suggested we would be able to achieve Treg cell doses in 
order 100 x105/kg. However, only 1 of 4 clinical products achieved the target 
cell dose.  
 
We modified ex vivo UCB-derived Treg expansion methodology by 
substituting anti-CD3/anti-CD28 mAB bead stimulation by genetically modified 
K562 cell line named KT64/86. This cell line expresses the CD64, the high 
affinity receptor for the Fc portion of antibodies loaded anti-CD3 and the 
CD86, the natural ligand of CD28. This allowed us to achieve 10-100–fold 
greater expansion, of a Treg product that is as suppressive and with lower 
proportion of IL-2-producing T-cells (non-Treg cells) as compared to the 
bead-based manufacture methodology. This methodology consistently 
produced Tregs in doses up to 100 x 106/kg without dose limiting toxicity 
making us confident that a Treg:CD3+ ratio up to 7:1 was achievable in this 
clinical trial. 
2.3 Clinical Results with Bead Expanded Tregs 
Twenty-three patients, median age of 52 years (r, 24-68yrs) and median 
weight 77kg (r, 50-133 kg), were treated between 9/2007 and 10/2009. The 
median expansion was 211-fold (range, 13-1796). Prior to and after 
expansion, the median proportion of CD4+/CD25+ cells was 65% (range, 11-
87%) upon selection and 86% (range, 62-97%) and the end of the culture 
period. All Treg products were suppressive in vitro with median suppression 
at the end of the culture period of 86% (r, 39-95%) at a 1:4 ratio with an 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 11 of 47 
CPRC #2016LS107 
inverse correlation between post-expansion absolute number of CD4+/CD25+ 
cells and the level of suppression (R=-0.48, p=.03). In contrast, there was no 
correlation between the absolute number or proportion of CD4+/CD25+ cells 
pre-expansion and proportion of CD4+/CD25+ cells post-culture, fold 
expansion and degree of suppression.  
 
Seventeen of 23 (74%) received the Treg infusion at the target cell dose level. 
Five patients received a Treg dose less than the prescribed cell dose due to 
insufficient culture expansion (1 received a lower than prescribed dose 
because of peri-transplant morbidities prior to infusion on day +15). Of the 14 
patients scheduled to receive two doses, 13 received the targeted dose of 30 
x 105/kg on days +1 and +15 and 1 patient receive 2 doses of 21 x 105/kg 
(less than the planned dose due to insufficient culture expansion). Overall, 18 
patients received a total Treg cell dose ≥30 x 105/kg. 
2.4 Maximum Tolerated Dose: Treg Infusional Toxicity Profile and 
Detection Kinetics of Bead Expanded Tregs 
No dose limiting toxicity was observed. There were 2 patients with three 
Grade 3 hypertension, one following infusion of a fresh and two following 
infusion of cryopreserved Treg product, with all resolving with standard 
clinical management. Two patients had Grade 2 neurological changes prior to 
the infusion that were attributed to previously prescribed narcotic medication.  
 
In the 23 patients studied, the median proportion of peripheral CD4+ T cells 
that were FoxP3+CD127- was 27% (range, 1-78%) at 4 hours post infusion 
(T4),  30% (range, 8-77%) on day +2, 27% (range, 5-72%) on day +4, 21% 
(range, 7-83%) on day +7, and 10.% (range, 1-36%) on day +14. Notably, 
among the 18 patients who received ≥ 30 x105/kg Treg, the median proportion 
of peripheral blood CD4+/FoxP3+/CD127- was not statistically different for all 
time points in recipients of CsA (n=12,) and sirolimus (n=6,). Specifically, the 
proportion of CD4+/FoxP3+/CD127- cells in recipients of CsA vs. sirolimus 
was 27% (range, 1.-78%) vs. 43% (range,  27-46%) at T4,  35% (range, 10-
77%) vs. 41% (range,30-54%) on day +2, 35% (range, 5-71%) vs. 49% 
(range, 27-54%) on day +4, 27% (range, 13-83%) vs. 34% (range, 17-47%) 
on day +7, and 12% (range, 1-36%) vs. 13% (range, 9-29%) on day +14 after 
UCB-transplantation. The absolute number of CD4+/FoxP3+/CD127- cells in 
the peripheral blood of the cryopreserved product infused on day +15 (CsA 
n=8; sirolimus n=6) was lower compared to freshly infused Treg on day +1.  
 
As expected, Treg circulating after transplant were derived from the patient 
and HSC UCB graft as well as the manufactured Treg product. Based on 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 12 of 47 
CPRC #2016LS107 
informative HLA-marker on the UCB-Treg unit we were able to track the ex 
vivo expanded Treg after infusion in 7 patients. The absolute number of 
product derived Treg in the peripheral blood for all patients peaked on day +2 
at 30% (range, 8-77%), and for those who received ≥ 30 x 105/kg at day +4  
representing up to 40% (range, 5-72%) of all Treg in the circulation. UCB-
derived Treg were detected for up to 14 days with no difference in the kinetics 
in recipients of CsA vs. sirolimus.  
2.5 Engraftment with Bead Expanded Tregs 
Sustained donor-derived neutrophil engraftment was observed in 87% (95%CI, 70-
97%) in recipients of Treg and 89% (95%CI, 70-98%) for those patients who 
received ≥ 30 x105/kg. Of the 2 patients who had graft failure both had HHV-6 
viremia. 
One 
patient 
recovered 
counts at 
day 
+51 
with 
donor-derived 
hematopoiesis without further intervention; the second patient received a 
second UCBT at day +60. The incidence of platelet recovery by day +100 
was 74% (95%CI, 51-97) at a median of 46 days (range, 27-87 days) and for 
those patients who received ≥ 30 x105/kg was 78% (95%CI, 53-100%) at a 
median of  43 days (range, 29-83). Neither sustained donor engraftment nor 
platelet recovery was adversely affected by Tregs as compared to historical 
controls where recoveries were 86% (95%CI, 79-92%) and 67% (95%CI, 56-
78%), respectively. The median marrow chimerism at day +21 was 91% (r, 
37-100%) with 12 of 21 (57%) engrafted patients having dual chimerism. The 
prevalence of dual chimerism after Treg tended to be higher than that 
observed in historical controls which was 36% (p=.06). By day + 100, 2 
patients (11%), both receiving 30 x105/kg Treg on days +1 and +15 with 
CsA/MMF immunosuppression, had persistent dual chimerism which is 
similar to that observed in historical controls (11%, p=.68). While 
immunological properties of infused UCB Treg may be promoting early dual 
chimerism, the pattern of long-term single donor chimerism is unchanged. 
2.6 Graft-Versus-Host Disease (GVHD) with Bead Expanded Tregs 
The incidence of grades II-IV aGVHD for all patients was 43% (95%CI, 23-
64%) at a median time of 38 days (range, 24-86), and was similar in those 
who received a total Treg dose ≥ 30 x105/kg (39% [95%CI, 16-61%)  at a 
median of 39 days [range, 29-86]). This was lower than that observed in 
historical controls (61% [95%CI, 51-72%] at a median of 30 days [range, 14-
73). The incidence of grades III-IV acute GVHD for all patients was 17% 
(95%CI, 2-23%) at a median time of 51.5 days (range, 24-86), and for those 
who received a Treg dose ≥ 30 x105/kg, it was 11% (95%CI, 0-25) at a 
median time of 76 days (range, 66-86). This was similar to that observed in 
historical controls (23% [95%CI, 15-31%] at a median of 29 days [range, 14-
72]). Two of 14 (14 %) patients at risk developed chronic GVHD. Thus far, 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 13 of 47 
CPRC #2016LS107 
chronic GVHD has not been observed among patients who received a Treg 
dose ≥30 x105/kg. These results compare favorably with historical controls 
where the incidence of chronic GVHD was 26% (95%CI, 17-35%). Taken 
together these data support further investigation to determine whether ex vivo 
expanded and activated UCB Treg can suppress GVHD.  
2.7 Opportunistic Infections with Bead Expanded Tregs 
While nTregs are potentially immune suppressive, in our initial report we did 
not observe an increase in the cumulative incidence of opportunistic 
infections (OI) (24). However, there was still the possibility that individual 
patients were having a greater number of recurrent infections. Thus, we 
revisited the risk of infection question by estimating the cumulative density of 
infections in nTreg recipients and historical controls. The incidence of OI at 
day +180 was 58% (95%CI, 38-79%) in nTreg recipients and 60% (95%CI, 
46-74%) historical controls (p=0.89), at a median of 28 (9-87) and 41 (1-110) 
days after UCB transplantation, respectively. Viral infections represented the 
majority of OI observed for nTreg (58% [95%CI, 38-79%]) and historical 
control (55% [95%CI, 42-69%]) patient populations (p=.67). The overall day 0 
to day +180 cumulative density of OI was 2.10 infections/1000 patient-days in 
nTreg and 1.52 infections/1000 patient-days in non-Treg patients (RR 1.39, 
p=.08). However, in our initial report we showed that adoptively transferred 
nTregs were present in the peripheral blood of patients up to 14 days after the 
infusion of fresh and up to 4 days after the infusion of cryopreserved product 
(18). Notably, between day zero and day +30 post-UCB transplantation there 
was significantly higher cumulative density of OI in Treg (18.06 
infections/1000 patient-days) as compared to historical controls (7.71 
infections/1000 patient-days) patients (univariate RR 5.35, p=.02). In contrast, 
there was no statistical difference in the cumulative incidence of  OIs from day 
+31 to day +180 post-UCB transplantation, with the density of infection in 
nTreg of 4.22/1000 patient-days versus 7.22/1000 patient-days in historical 
controls (univariate RR 0.58, p=.07) when nTregs were no longer detectable 
in the peripheral blood of patients. However, as we are comparing patients in 
a phase I study, who are very closely monitored, to historical controls, it is 
possible that our findings were the result of observation bias. Close 
monitoring of opportunist infection will remain part of Treg recipient’s clinical 
care. 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 14 of 47 
CPRC #2016LS107 
2.8 Relapse, Non-Relapse Mortality and Disease-Free Survival with Bead 
Expanded Tregs 
At a minimum follow-up of 2 years for all patients, long-term outcomes remain 
unaffected by nTreg infusion. The median follow up of survivors is 2.6 years 
(range, 2.0-3.3) for nTreg and 4.8 years (range, 2.0-6.9) for historical control 
patients. The cumulative incidence of relapse at 2 years was 45% (95%CI, 
23-67%) for nTreg and 52% (95%CI, 37-66) for historical controls (p=.58). 
The cumulative incidence of non-relapse mortality at 2 years was 45% 
(95%CI, 23-67%) for nTreg and 52% (95%CI, 38-66%) for historical controls 
(p=.62). The DFS at 2 years was 33% (95%CI, 16-52%) for nTreg and 34% 
(95%CI, 46%) for historical controls (p=.95). 
2.9 Results of KT64/86 Expanded Tregs 
Thirteen Treg products were manufactured and eleven were infused. Five 
products did not reach the target dose level, and 2 of these 5 products failed 
to reach the minimum required dose of 3 x 106/kg for infusion. Among the 11 
infused products the median number of nucleated cells was 40 billion (range 
(r), 2-147 billion; inter-quartile range, 39-44 billion) corresponding to a median 
TNC expansion of 13,000-fold (r, 1,352-27,183 fold), of which the median 
proportion of CD4+CD25+ cells was 97% (r, 88-99%) and with 87% (r, 78-
95%) expressing CD4+FoxP3+CD127-. In 6 evaluable products, the median 
in vitro suppressor function of CD3+ bead stimulated T cells at a 1:4 T 
effector to Treg ratio was 53% (range, 45-71%).  
Infusional toxicities were monitored prior to the Treg product infusion, and 
then at 24 and 48h post-infusion. Toxicities were mild and no dose limiting 
toxicity was observed in doses up to 100 x 106/kg. 
An informative HLA-marker (unique to the Treg donor unit) was available in 7 
of 11 patients. The presence of the Treg product in the peripheral blood was 
tracked by flow cytometry with progressively greater detection correlating with 
higher infused Treg cell doses. Despite a higher peak, greater infused cell 
doses did not yield longer persistence of peripheral blood Tregs; none 
persisted after 14 days.  
Acute Graft-versus-Host Disease 
Among 11 recipients of 3-100 x 106 Treg/kg, the cumulative incidence of 
grade II-IV acute GVHD at 100 days was 9% (95%CI, 0-25%). One patient 
developed a limited skin rash (50% of body surface) on day +16 with a skin 
biopsy not diagnostic for acute GVHD. The patient was treated with steroids 
with a clinical differential diagnosis of either engraftment syndrome or early 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 15 of 47 
CPRC #2016LS107 
onset grade II acute GVHD. Steroids were tapered rapidly over 4 weeks 
without recurrence of rash or development of other possible GVHD 
symptoms. 
One 
other 
patient 
developed 
biopsy-proven 
grade 
III 
gastrointestinal acute GVHD on day +119, responded promptly to systemic 
steroids and was tapered off all immune suppression within 6 months. In 
contrast, in the contemporary control group, that consisted of patients who 
received same conditioning regimen and immune suppression but no Tregs, 
10 of 22 patients developed grades II-IV acute GVHD, with 4 cases of grade II 
and 6 cases of grade III-IV acute GVHD, for a cumulative incidence of grade 
II-IV GVHD of 45% (95%CI, 24-67%) (p=.05) and grade III-IV of 27% (95%CI, 
9-46%) (p=.06). None of the Treg recipients and 3 (14%) patients in the 
control group developed chronic GVHD during follow-up to date.  
Hematopoietic Recovery 
The cumulative incidence of neutrophil recovery by day +42 was 91% 
(95%CI, 67-99%) in Treg recipients as compared to 86% (95%CI, 69-97%) in 
controls. There was 1 primary graft failure in the 11 Treg recipients versus 3 
in 22 controls. The cumulative incidence of platelet recovery > 20,000/µL by 
day +180 was 82% (95%CI, 55-100%) for Treg recipients and 82% (95%CI, 
59-100%) for controls. The median combined unit bone marrow chimerism at 
day +21 was 90% (r, 66-100%) for Treg recipients and 90% (95%CI, 19-
100%) (p=.99) for controls, and at day +100 was 100% (r, 100-100) for Treg 
recipients and 100% (r, 97-100%) for controls (p=.77).  
Infections and Immune Reconstitution  
In the Treg group there were a total of 17 infection events before day +100 in 
9 patients versus 31 in 14 of the Siro/MMF controls. The density of bacterial, 
viral and fungal infections (infections per 1000 patient days) was similar in the 
two groups. There were 2 CMV and 9 HHV-6 reactivations in Treg recipients 
compared to 1 CMV and 8 HHV-6 reactivations in controls. Out to day +180, 
there was faster recovery of the absolute number of CD4+ and a subset of 
naïve CD4+CD45RA+CCR7+ lymphocytes in Treg recipients as compared to 
controls. In contrast, the recovery of other CD4+ subsets and CD8+ and its 
subsets, CD19+ and CD56+ cells were similar in the two groups.  
 
Relapse, Non-Relapse Mortality, Survival and Disease-Free Survival   
Malignant relapse has occurred in only 3 of 9 surviving patients treated with 
Treg and 8 of 20 in the control group. At 6 months, 2 Treg patients and 2 
controls died of non-relapse causes resulting in similar cumulative incidence 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 16 of 47 
CPRC #2016LS107 
of NRM. Disease-free survival at 1 year is 55% (95%CI, 23-78%) among Treg 
recipients and 55% (95%CI, 32-72%) in the control group (p=.76). The 
estimated overall survival at 1 year was 81% (95%CI, 42-95%) among Treg 
recipients and 61% (95%CI, 37-79%) in the control group (p=.30). The causes 
of death in the Treg group were graft rejection and acute respiratory distress 
syndrome (1 each), while in the control group causes of death were graft 
rejection (n=1), acute GVHD (n=2), and relapse (n=5).  
In summary, we 1) demonstrated the ability to consistently manufacture Treg 
doses up to 100 x10e6/kg which allows for Treg:Teffector ratio of up to 7:1, 
and 2) observed a remarkably low risk of acute GVHD. This promising result 
is the first clear demonstration that ex vivo expanded UCB Treg are potent 
suppressors of acute GVHD in humans and sets the stage for a future pivotal 
clinical trial that will assess the clinical impact of Treg GVHD prophylaxis on 
immune recovery and risk of leukemia relapse. 
2.10 Ultra-Low IL-2 for GVHD Prophylaxis (removed from the treatment plan 
with the January 2018 protocol version) 
As described above, Tregs do not produce but are dependent on IL-2 for 
survival and proliferation. After studying the administration of ultra-low dose 
(ULD) IL-2 in normal volunteers (25, 26), researchers at Baylor conducted a 
study 
administering 
ULD 
IL-2 
to 
patients 
undergoing 
allogeneic 
transplantation from matched sibling and unrelated donors (25, 26). The IL-2 
was started within 30 days of transplantation and administered at 100,000-
200,000 IU/m2, subcutaneously (SQ), thrice weekly for 6 to 12 weeks. They 
demonstrated a very low incidence of GVHD with 3 of 16 patients developing 
grade I GVHD of the skin. The also observed a significant increase in the 
proportion of circulating Tregs from 4.8% to 11.1%. Notably, the increase on 
the proportion of circulating Tregs was observed after just 1 week of IL-2 
administration. Adverse effects after IL-2 administration were all grade 1 and 
included muscle aches, arthralgias, fatigue, nausea, and decreased appetite. 
While sample was limited, there was no excess risk of GVHD, infections or 
relapse. 
 
After treating two patients on this protocol with ULD-IL2 we observed fevers, 
chills, fluid, retention, creatinine elevation, and lung infiltrates. One of these 
patients also had transient mental status changes. While both cases had 
multiple confounding factors we could not rule out that the observed toxicity 
was at least in part related to ULD-IL2. In addition, this early post-
transplantation time when fevers, infections and several of these side effects 
are common, the addition of ULD-IL2 added complexity to patient 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 17 of 47 
CPRC #2016LS107 
management. Thus, we decided to discontinue the administration of ULD-IL2 
with the January 2018 protocol revision and continue this study in our UCB 
Treg adoptive transfer, which we demonstrated in the previous study to be 
safe and well tolerated. 
3 Summary and Rationale 
Our preclinical studies demonstrated a marked reduction in GVHD at Treg:T 
effector ratios of 1:1 and 3:1 (7), necessitating infusion of Treg doses of >15 x 
106/kg to achieve that ratio for the median infused CD3 cell dose in double UCB 
grafts. In our KT64/86 expanded Tregs we achieved Treg:Teffector ratio of up to 
7:1. Despite the relatively high dose of adoptively transferred Tregs, they become 
undetectable in the patient’s blood by 14 days post-infusion.  
 
As our ultimate goal is to design a strategy that will a) significantly reduce the risk 
of GVHD, b) eliminate the requirement of prolonged immune suppressive 
pharmacological therapy, and c) enhance T cell immune reconstitution. In order 
to progress towards this goal, we propose this pilot study to provide preliminary 
estimates of efficacy, safety and to show the feasibility after combining a fixed 
Treg:CD3+ cells ratio (1:1).  
This pilot study will help in designing future larger scale studies to hopefully 
provide evidence on improved survival of adoptively transferred Tregs. This could 
have implications on the effectiveness of Treg in preventing GVHD and establish 
a new platform for evaluating new methods for further enhancing T cell recovery 
and reducing the risk of opportunistic infection—the single greatest barrier to 
successful allogeneic HSC transplant.  
4 Study Design 
This is single center pilot study of a non-myeloablative umbilical cord blood 
transplant for the treatment of a hematological malignancy with a single infusion 
of T regulatory (Treg) given shortly after UCB transplantation.  
 
The nTreg cells are manufactured from a cord blood unit that is not part of the 
graft for infusion on Day 0 at least 1 hour after the UCB transplant. The CD3+ cell 
content from the graft UCB unit(s) is enumerated upon thaw (Day 0) from which 
the Treg cell dose for the final product is calculated using assigned 1:1 
Treg:CD3+ cell ratio.  
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 18 of 47 
CPRC #2016LS107 
If any of the cord blood unit(s) used for the graft are unlicensed, the participant 
will co-enroll on University of Minnesota protocol MT2011-13R “Infusion of Cell 
Populations from Unlicensed Umbilical Cord Blood Units” as the unit(s) used for 
the transplant will be minimally manipulated. 
5 Patient Selection 
Study entry is open to adult patients regardless of gender or ethnic background. 
While there will be every effort to seek out and include women and minority 
patients, the patient population is expected to be no different than that of other 
high risk malignancies transplant studies at the University Of Minnesota.  
5.1 
Age, Graft Cell Dose and Graft HLA Criteria and Treg Unit 
• Must be ≥18, but < 70 years of age with no matched 7/8 or 8/8 sibling 
donor - patients ≥ 70 and ≤ 75 years of age may be eligible if they have a 
Co-Morbidity score ≤ 2 (http://www.qxmd.com/calculate-online/hematology/hct-
ci) 
• UCB unit(s) composing the graft will be selected according to the current 
University of Minnesota umbilical cord blood graft selection algorithm plus 
an additional cord blood unit to be used as the source to manufacture the 
Treg product. This UCB unit must be matched at 4-6/6 to the patient, 
considering HLA-A, B at the antigen level and DRB1 at the allele level. 
5.2 
Disease Criteria 
Acute Leukemias: Must be in remission by morphology (around 5% blasts 
but < 20% blasts by morphology). Also a small percentage of blasts that is 
equivocal between marrow regeneration versus early relapse are acceptable 
provided there are no associated cytogenetic markers consistent with relapse. 
• Acute Lymphoblastic Leukemia (ALL) second or greater CR; CR1 unable to 
tolerate 
consolidation 
chemotherapy 
due 
to 
chemotherapy-related 
toxicities; CR1 high-risk ALL. 
High risk ALL is defined as having one of the following:  
o Evidence of high risk cytogenetics such as t(9;22), t(1;19), t(4;11), 
other MLL rearrangements, IKZF1  
o 30 years of age or older at diagnosis  
o White blood cell counts of greater than 30,000/mcL (B-ALL) or 
greater than 100,000/mcL (T-ALL) at diagnosis 
o CNS leukemia involvement during the course of disease 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 19 of 47 
CPRC #2016LS107 
o Slow cytologic response (>10% lymphoblasts in bone marrow on 
Day 14 of induction therapy) 
o Evidence of persistent immonophenotypic or molecular minimal 
residual disease (MRD) at the end of induction and consolidation 
therapy 
 
• Acute Myelogenous Leukemia (AML) and related precursor neoplasms: 
2nd or greater complete remission (CR); first complete remission (CR1) in 
patients > 60 years old; CR1 in ≤ 60 years old that is NOT considered as 
favorable-risk.   
Favorable risk is defined as having one of the following: 
o t(8,21) without cKIT mutation 
o inv(16) or t(16;16) without cKIT mutation  
o Normal karyotype with mutated NPM1 and wild type FLT-ITD 
o Normal karyotype with double mutated CEBPA 
o Acute prolymphocytic leukemia (APL) in first molecular remission at 
end of consolidation 
 
• Biphenotypic/Undifferentiated/Prolymphocytic 
Leukemias 
in 
first 
or 
subsequent CR, adult T-cell leukemia/lymphoma in first or subsequent CR 
Burkitt’s Lymphoma in CR2 or subsequent CR 
Natural Killer Cell Malignancies 
Chronic Myelogenous Leukemia: all types except refractory blast crisis. 
Chronic phase patients must have failed at least two different tyrosine-kinase 
inhibitors (TKIs), or been intolerant to all available TKIs or have T315I 
mutation.  
Myelodysplastic Syndrome: IPSS INT-2 or High Risk; R-IPSS High or Very 
High; WHO classification: RAEB-1, RAEB-2; Severe Cytopenias: ANC < 0.8, 
Anemia or thrombocytopenia requiring transfusion; Poor or very poor risk 
cytogenetics based on IPSS or R-IPSS definitions; therapy-related MDS. 
Blasts must be < 5% by bone marrow aspirate morphology. If ≥5% blasts, 
patient requires chemotherapy for cytoreduction to <5% blasts prior to 
transplantation. 
Large-Cell Lymphoma, Hodgkin Lymphoma and Multiple Myeloma with 
chemotherapy sensitive disease that has failed or patients who are ineligible 
for an autologous transplant.  

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 20 of 47 
CPRC #2016LS107 
Chronic 
Lymphocytic 
Leukemia/Small 
Lymphocytic 
Lymphoma 
(CLL/SLL), Marginal Zone B-Cell Lymphoma, Follicular Lymphoma, 
which have progressed within 12 months of achieving a partial or complete 
remission. Patients who had remissions lasting > 12 months are eligible after 
at least two prior therapies. Patients with bulky disease should be considered 
for debulking chemotherapy before transplant. Patients with refractory 
disease are eligible, unless has bulky disease and an estimated tumor 
doubling time of less than one month.  
Lymphoplasmacytic 
Lymphoma, 
Mantle-Cell 
Lymphoma, 
Prolymphocytic Leukemia are eligible after initial therapy if chemotherapy 
sensitive. 
Patients must have undergone an autologous transplant ≤ 12 months prior to 
transplant on this study or have received multi-agent or immunosuppressive 
chemotherapy within 3 months of the preparative regimen. 
5.3 Performance Status, Organ Function, Contraception Use 
• Karnofsky score ≥ 70% (Appendix II) 
• Adequate organ function within 14 days (30 days for cardiac and 
pulmonary) of registration on-study defined as: 
o Renal: creatinine ≤ 2.0 mg/dL, for patient with a creatinine > 1.2 mg/dL 
or a history of renal dysfunction an estimated glomerular filtration rate 
≥ 40 mL/min/1.73 m2 is required  
o ALT, AST and alkaline phosphatase ≤ 5 x upper limit of normal and 
total bilirubin ≤ 2.5 mg/dL except for patients with Gilbert’s syndrome or 
hemolysis 
o Pulmonary function: DLCO, FEV1, FVC ≥ 40% predicted, and absence 
of O2 requirements.  
o Cardiac: Absence of decompensated congestive heart failure, or 
uncontrolled arrhythmia and left ventricular ejection fraction ≥ 40%. 
• Sexually active females of childbearing potential and males with partners of 
child-bearing potential must agree to use adequate birth control during 
study treatment. 
• Voluntary written consent  
5.4 Exclusions 
• Untreated active infection  
• History of HIV infection 
• Pregnant or breast feeding. The agents used in this study may be 
teratogenic to a fetus and there is no information on the excretion of agents 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 21 of 47 
CPRC #2016LS107 
into breast milk. Females of childbearing potential must have a blood test 
or urine study within 14 days prior to registration to rule out pregnancy 
• Prior allogeneic transplantation 
• Less than 3 months from myeloablative conditioning for autologous 
transplantation (if applicable) 
• Evidence of progressive disease by imaging modalities or biopsy - 
persistent PET activity, though possibly related to lymphoma, is not an 
exclusion criterion in the absence of CT changes indicating progression. 
• CML in blast crisis 
• Large cell lymphoma, mantle cell lymphoma and Hodgkin disease that is 
progressing on salvage therapy  
• Active central nervous system malignancy 
6 Patient Registration and Study Enrollment 
Written consent must be obtained prior to the performance of any research 
related tests or procedures. Consent is usually obtained before final eligibility is 
determined.  
6.1 Registration with the Masonic Cancer Center Clinical Trials Office 
Any patient who has been consented is to be registered in OnCore by the 
Primary Clinical Research Coordinator (PCRC) or designee. If a patient is 
consented, but not enrolled, the patient’s record is updated in OnCore as a 
screen failure and reason for exclusion recorded. 
6.2 Study Enrollment with the Masonic Cancer Center Clinical Trials Office 
To be eligible for study enrollment, the patient must sign the treatment 
consent and meet each of the inclusion criteria and none of the exclusion on 
the eligibility checklist (Appendix I) based on the eligibility assessment 
documented in the patient’s medical record. 
The Primary Clinical Research Coordinator (PCRC) or designee will assign 
the study treatment arm and add the on-treatment date to complete 
enrollment. 
6.3 Patients Who Do Not Begin Study Treatment 
If a patient is enrolled to the study, and is later found not able to the 
preparative regimen, for whatever reason, the patient will be considered a 
screen failure and treated (transplanted) at the physician’s discretion. The 
Primary Clinical Research Coordinator or designee will update OnCore of the 
patient’s non-treatment status and notify the Principal Investigator. Study data 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 22 of 47 
CPRC #2016LS107 
will be collected until the time the patient is taken off study. The patient will be 
replaced as needed to fulfill enrollment requirements.  
7 
Treatment Plan 
In order to provide optimal patient care and to account for individual medical 
conditions, investigator discretion may be used in the prescribing of all 
supportive care drug therapy (i.e. acetaminophen, diphenhydramine, 
methylprednisone, G-CSF, etc.), and will not be considered a protocol 
deviation. 
All patients will receive the non-myeloablative conditioning regimen below: 
 
7.1 Preparative Regimen (Day -6 to Day -1) 
Administer fludarabine and cyclophosphamide per University Of Minnesota 
institutional guidelines for a non-myeloablative preparative regimen. 
Fludarabine 30 mg/m2 is administered as a 30-60 minute infusion per 
institutional guidelines on Day -6 through Day -2. Dose adjustments will be 
made for adult patients with renal impairment defined as CrCL < 
70mL/minute. Fludarabine dose MAY also be reduced to this dose if there is 
Treatment 
Day 
Treatment 
Protocol 
Section 
Day -7 
Begin allopurinol (Day -7 to day 0) 
 
Day -6 
Fludarabine 30 mg/m2 IV over 1 hour 
Cyclophosphamide 50 mg/kg IV over 2 hours 
Antiemetics and fluid flush per institutional guidelines 
7.1 
Day -5 
Fludarabine 30 mg/m2 IV over 1 hour 
7.1 
Day -4 
Fludarabine 30 mg/m2 IV over 1 hour 
7.1 
Day -3 
Fludarabine 30 mg/m2 IV over 1 hour 
Begin MMF and Sirolimus 
7.1 
7.2 
Day -2 
Fludarabine 30 mg/m2 IV over 1 hour 
7.1 
Day -1 
TBI 200 cGy 
7.1 
Day 0 
Umbilical cord blood transplant (FIRST) followed by the Treg cell 
infusion (SECOND) no sooner than 1 hour, but within 24 hours 
after the end of the cord blood infusions  
7.3 and 7.4 
 
Day +5 
Begin G-CSF day +5 continuing until ANC ≥ 2,500 for 2 
consecutive days 
7.5 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 23 of 47 
CPRC #2016LS107 
prior malignancy involvement of the central nervous system with intrathecal 
chemotherapy and/or cranio-spinal irradiation 
Cyclophosphamide Hydration prior to cyclophosphamide will be given 
according to recommended institutional standards, starting 12 hours prior to 
cyclophosphamide. 
Mesna dose will be 100% of the cyclophosphamide dose being given and 
divided into 5 doses. 20% of the total dose will be given prior to the start of 
cyclophosphamide, and then 3, 6, 9, and 12 hours after the start of 
cyclophosphamide.  
Cyclophosphamide 50 mg/kg will be administered as a 2 hour intravenous 
infusion on Day –6. Cyclophosphamide dosing is calculated based on ABW 
(actual weight) unless ABW is >150% of the IBW (Ideal Body Weight). Then 
the dose should be computed using adjusted body weight.  
Ideal body weight is calculated using 50kg + [2.3kg x(height in inches – 60)] 
for men; 45.5kg + [2.3kg x(height in inches – 60)] for women.  
Adjusted body weight = IBW + 0.5(ABW-IBW).  
Total Body Irradiation (TBI)  
All patients who have had previous radiation therapy or TBI will be seen by 
Radiation Oncology prior to entrance on the protocol for approval for 
additional 200 cGy of TBI. TBI may be delivered by local guidelines provided 
the effective dose is equivalent to what is recommended in the TBI 
Guidelines. 
Patients ineligible for this protocol include those who have had previous 
irradiation to areas of the body such that the Radiation Oncologist feels that 
even a relatively small dose of total body irradiation (TBI) cannot safely be 
given.  
Total Body Irradiation 200 cGy administered on Day -1 in a single fraction will 
be given at a dose rate of 10-19 cGy/minute prescribed to the midplane of the 
patient at the level of the umbilicus. 
The TBI will be delivered with right and left lateral fields with the patient semi-
recumbent in a semi-fetal position with their arms at their sides. 
Based on measurement of transverse thickness, aluminum compensators will 
be used to ensure that the dose homogeneity across the fields is within 10% 
of the prescribed dose. Usually head/ neck, leg and lung compensators are 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 24 of 47 
CPRC #2016LS107 
used 
(although 
based 
on 
calculated 
mid-mediastinal 
doses, 
lung 
compensators are often not needed if the thickness of the arms, which 
partially shield the lung, are taken into the thickness consideration). 
TBI will be delivered with a linear accelerator using 6, 10, or 18 MV photons. 
The energy used will be based on the calculated dose to midline at points 
along the patient's torso. The lowest energy that gives 90-100% of the 
prescriptions point dose will be used. 
A beam "spoiler" will be used to ensure a full skin dose. 
Half value layer lung and kidney blocks will not be utilized for patients who 
have not previously received total body irradiation. 
Refer to appendix III for side effects related to the preparative regimen.  
7.2 GVHD Prophylaxis (start Day -3) 
Immunosuppression will consist of sirolimus and mycophenolate mofetil 
(MMF).  
7.2.1 Sirolimus 
Sirolimus will be administered starting at Day -3 with 8mg-12mg oral 
loading dose followed by single dose 4 mg/day with a target serum 
concentration of 3 to 12 mg/mL by high-performance liquid 
chromatography (HPLC). Levels are to be monitored 3 times/week in 
the first week, weekly until Day +60, and as clinically indicated until 
Day +100 post-transplantation. In the absence of acute GVHD 
sirolimus may be tapered starting at Day +100 and eliminated by Day 
+180 post-transplantation. 
7.2.2 Mycophenolate Mofetil (MMF) 
Mycophenolate mofetil (MMF) 3 gram/day IV/PO divided in 2 or 3 
doses. MMF dosing will be monitored and altered as clinically 
appropriate based on institutional guidelines. Patients will be eligible 
for MMF dosing and pharmacokinetics studies. 
Stop MMF at Day +30 or 7 days after neutrophil recovery, whichever 
day is later, if no acute GVHD. (Definition of engraftment is 1st day of 2 
consecutive days of absolute neutrophil count [ANC) ≥ 0.5 x 109 /L]).  
If at Day 28 the WBC is < 200 and marrow cellularity is < 5%, but there 
is donor chimerism, MMF should be discontinued and institutional 
guidelines for the management of delayed neutrophil recovery should 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 25 of 47 
CPRC #2016LS107 
be followed. In the absence of improvement a second transplant may 
be considered as clinically indicated.  
If the patient has acute GVHD requiring systemic therapy, MMF may 
be stopped 7 days after initiation of systemic therapy for acute GVHD 
(e.g. resolution of skin rash, vomiting, and diarrhea).  
7.3 UCB Infusion (Day 0) 
There will be a minimum interval of 1 hour between the infusion of the UCB 
grafts (FIRST) and the Treg cell product (SECOND).  
The pre-medication and hydration regimen will be given following University 
of Minnesota institutional guidelines. No planned steroids are to be given in 
the 24 hours prior to the Treg infusion. 
The graft UCB units will be administrated by IV infusion without in-line 
filtration per University of Minnesota institutional guidelines. The infusion of 
the first UCB unit should begin within 15 minutes, and no later than 30 
minutes after arrival on the Unit. Both cords will be infused within 30-60 
minutes of each other as deemed clinically safe by the BMT attending or 
designee.  
Vital signs will be checked before and every 15 minutes during the infusions, 
at the completion of each infusion, and one hour post infusion the 2nd unit 
infusion prior to the Treg infusion.  
7.4 Infusion of the Treg Cells (Day 0 after UCBT) 
7.4.1 Product Final Preparation at MCT 
On day 0, the dose of UCB derived Treg cells will be determined by the 
enumeration of the CD3+ cell from the UCB graft unit(s). A 1:1 Treg:CD3+ 
cell ratio will be calculated. 
 
The UCB Treg cells may be infused fresh out of culture or cryopreserved in 
case the patient requires a delay in the transplant procedure for clinical 
reasons.  
 
Leftover/un-infused cells may be stored frozen for future research. 
Failure to Achieve Target Ratio Dose  
If the product fails to achieve the planned 1:1 Treg:CD3+ cell ratio, the 
product may still be infused as long as there are at least ≥3 x 106/kg. Patients 
who receive Tregs will be evaluable for the purposes of the study. 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 26 of 47 
CPRC #2016LS107 
Lot Release Failure 
Following FDA regulations, if lot release criteria are not achieved, as 
described in the CMC document, the patient does not receive the product. 
Lab staff will notify the Medical Director and the Sponsor/Investigator who will 
contact the patient physician’s (if applicable) in a timely fashion, for 
appropriate clinical action. If appropriate, the Sponsor/Investigator or his 
designee may contact the FDA to request permission to infuse the cell 
product. In the case where the Treg cells cannot be administered, the patient 
will be replaced.  
7.4.2 Pre-Infusion Medication and Hydration Regimen 
The hydration and pre-medication regimen will be given following University 
of Minnesota institutional guidelines. Patients weighing less than 40 kg may 
have the dose adjusted.  
NO planned steroids will be given in the 24 HOURS PRIOR to the Treg 
infusion. 
7.4.3 Infusion of the Treg Cell Product 
The Tregs will be infused IV without in-line filtration within 1 to 4 hours of 
formulation and at least 1 hour after the second UCB unit has been infused, 
but no later than 24 hours after. If the Treg cells cannot be infused within 24 
hours, the cells may be frozen for administration as soon as clinically 
possible.  
Potential infusion related toxicity include acute allergic reactions. Patients will 
be closely monitored for the occurrence of hypotension, dyspnea and 
angiodema during the infusion and immediately thereafter. Infusion of Treg 
cells will be stopped if severe acute allergic reactions occur (e.g. Grade 4 
toxicity based on the NCI’s CTCAE 4 except for fevers alone). 
A health care professional must be present during the nTreg cell infusion and 
available for 1 hour afterwards. 
Emergency drugs such as epinephrine, hydrocortisone, diphenhydramine and 
atropine in appropriate dosages and dilutions should be available and 
administered according to institutional guidelines. Oxygen with nasal prongs 
for standby use should be present in the room. 
7.4.4 Treg Cell Infusion Assessments 
Vital signs will be monitored before the infusion start and every 15 minutes 
through 2 hours after the completion of the infusion, hourly for 4 additional 
hours and then vitals per post-transplant unit guidelines. 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 27 of 47 
CPRC #2016LS107 
Patients will be monitored for infusion related toxicity for 24 hours following 
administration of the Treg cell product. Infusion related toxicity is defined as 
any non-hematologic reaction within 24 hours of administration of the cell 
product that cannot be explained by other transplant related procedures.  
7.5 Supportive Care 
Patients will receive transfusions, infection prophylaxis, growth factor and 
nutritional support according to the current University of Minnesota support 
protocol guidelines. 
Begin G-CSF Day +5. Continue until ANC ≥ 2,500 for 2 consecutive days. 
7.6 Duration of Study Participation 
The study follow-up period is completed 100 days post-transplant when 
patient are evaluable for safety and efficacy of adoptive transfer of UCB Treg 
at a 1:1 ratio with CD3+ cells.   
Patients will be followed for 2 years post-transplant per the standard of care 
schedule in Section 9.1; however direct study participation (endpoints, 
research sample collection, etc.) will end at Day 100.  
Follow-up after 2 years will be per the University of Minnesota standard 
hematopoietic stem cell transplantation protocol for long-term follow-up. 
8 Expected Toxicities of Treg Cell Product  
Although Treg cells helped the donor cells to take hold (engraft) and reduced 
GVHD in laboratory models, it is not known how Treg cells will work in humans. 
Studies in animal showed that Treg cells are not detectable after 4-6 weeks. 
While no side effects were identified in the animal testing, possible risks include: 
allergic reaction, increased risk of infection, increased risk of graft-versus host 
disease (the opposite effect), and increased risk of relapse or disease 
recurrence.  
9 Schedule of Patient Activities 
Scheduled evaluations after screening and until engraftment may be performed 
+/-3 days from the targeted date; assessments performed after engraftment and 
through day 100 may be done +/-7 days of the targeted date. After day 100 
assessments may be done +/- 30 days of the targeted date. In addition, targeted 
days may be altered as clinically appropriate. 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 28 of 47 
CPRC #2016LS107 
9.1 
Standard of Care 
Activity 
Pre-BMT 
Work-Up 
Day 1 To 
Engraftment1 
Follow-Up 
Days 42-100 
Follow-Up ( >Day 100 
through Day 720) 
Consent 
X 
 
 
 
Baseline Assessment 
X 
 
 
 
Medical History 
X 
daily 
weekly 
X (day 180, 360, 720) 
Physical Exam 
X 
daily 
weekly 
X (day 180, 360, 720) 
Karnofsky 
Performance Status 
X 
 
day 100 
X (day 180, 360, 720) 
GVHD Assessment 
 
daily 
weekly, day 
100 
X (day 180, 360) 
CBC/diff/plt 
X 
daily 
weekly 
X (day 180, 360, 720) 
PT/PTT 
X 
 
 
 
Viral Screen 
X 
 
 
 
Basic metabolic panel  
 
daily (on days 
CMP not done) 
 
 
Comprehensive 
metabolic panel 
X 
2x/wk 
weekly 
X (day 180, 360, 720) 
Testing for anti-HLA 
antibodies3  
X 
 
 
 
Urinalysis 
X 
 
 
 
eGFR for adults with 
creat > 1.2 or hx or 
renal dysfunction 
X 
 
 
 
Pregnancy test for 
FOCBP 
X 
 
 
 
BM Biopsy chimerism  
 
BM (day 21) 
BM (day 100) 
BM (day 360, 720) 
Blood chimerism  
Patient and UCB 
PB (day 21) 
PB (day 60) 
Day 180 
PFT/DLCO 
X 
 
 
 
MUGA or Echo 
X 
 
 
 
Chest CT 
X2 
 
 
 
Disease Evaluation 
X 
X(day 21 to 
28) 
X (day 100) 
X (day 360, 720) 
1 
engraftment defined as absolute neutrophil count (ANC) ≥ 5 X 108/L for 3 consecutive days  
2 
Patients with a history of MDS or a history of 2 or more consecutive inductions/re-inductions to 
treat acute leukemia or CML blast crisis or prolonged neutropenia of at least 2 months 
immediately preceding transplant should have a chest CT without contrast to exclude occult 
fungal infection prior to transplant. 
3 
obtain as soon as possible once the patient is determined to be a candidate for UCB 
transplantation in order to guide unit selection 
NOTE: In certain clinical circumstances (e.g. relapsed or terminally ill patients) study tests may be 
omitted at the physician’s discretion).  
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 29 of 47 
CPRC #2016LS107 
9.2 Research Related Procedures and Activities 
Patients will be monitored for the persistence and function of UCB-derived 
regulatory T cells. Testing includes flow cytometry analysis of peripheral 
blood as shown in the table below. Immune cell subsets will include T 
regulatory and T effector cell populations.  
Activity/ 
Laboratory 
Upon 
Admission 
Pre Chemo 
Days Post-UCBT 
+0  
Prior to 
cord 
blood 
infusion 
+4, +7, +14 
+28, (±3 days) 
+60  
+100 
(±7 
days) 
180 (±30),  
360 (±30),  
720 (±30) 
Evaluation of 
Treg cell infusion 
toxicity – per 
section 10.2  
 
For 48 
hours 
post-
infusion 
 
 
 
Monitoring for 
early stopping 
rule events 
 
Through Day +100 
Treatment related mortality and  
Grade III/IV acute GVHD 
 
6 – 10 ml green 
top tubes 
1 – 10 ml red top 
tube 
X 
X 
X 
X 
X 
Call TTL at 5-6165 for sample pick-up 
It is recognized that with novel therapies as used in this study, the timing of 
protocol directed research samples may miss important patient specific 
events. For this reason, additional sets of research samples may be drawn at 
up to 3 time points that are not specified above.  
Note: if a patient is not abiding by the required clinical care calendar (Section 
9.1), the collection schedule of the toxicity data and research related samples 
may be altered or discontinued on an individual patient basis, as appropriate. 
10 Adverse Event Reporting 
Toxicity and adverse events will be classified according to NCI's Common 
Terminology Criteria for Adverse Events V 4.0 (CTCAE). A copy of the CTCAE 
can 
be 
downloaded 
from 
the 
CTEP 
home 
page 
http://evs.nci.nih.gov/ftp1/CTCAE/About.html  
 
10.1 Definitions 
The following definitions are based on the Code of Federal Regulations Title 
21 Part 312.32 (21CFR312.32(a)). 
Adverse Event: Any untoward medical occurrence associated with the use of 
a drug in humans, whether or not considered drug related.  

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 30 of 47 
CPRC #2016LS107 
Suspected Adverse Reaction: Any adverse event for which there is a 
reasonable possibility that the drug caused the adverse event.  For the 
purposes of IND safety reporting, "reasonable possibility" means there is 
evidence to suggest a causal relationship between the drug and the adverse 
event. Suspected adverse reaction implies a lesser degree of certainty about 
causality than adverse reaction, which means any adverse event caused by a 
drug. 
Life-Threatening Adverse Event Or Life-Threatening Suspected Adverse 
Reaction: An adverse event or suspected adverse reaction is considered 
“life-threatening” if, in the view of either the investigator or sponsor, its 
occurrence places the patient or subject at immediate risk of death. It does 
not include an adverse event or suspected adverse reaction that, had it 
occurred in a more severe form, might have caused death. 
Serious Adverse Event Or Serious Suspected Adverse Reaction:  An 
adverse event or suspected adverse reaction is considered “serious” if, in the 
view of either the investigator or sponsor, it results in any of the following 
outcomes:  
• Death 
• A life-threatening adverse event 
• Inpatient hospitalization or prolongation of existing hospitalization 
• A persistent or significant incapacity or substantial disruption of the ability 
to conduct normal life functions 
• A congenital anomaly/birth defect 
• Important medical events that may not result in death, be life-threatening, 
or require hospitalization may be considered serious when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition 
If either the IND sponsor or the investigator believes the event is life-
threatening or serious, the event must be evaluated by the sponsor for 
expedited reporting (21CRF 312.32(a)).  
Unexpected adverse event or unexpected suspected adverse reaction: 
An adverse event or suspected adverse reaction is considered “unexpected” 
if it is not listed in the investigator brochure or is not listed at the specificity or 
severity that has been observed; or, if an investigator brochure is not required 
or available, is not consistent with the risk information described in the 
general investigational plan or elsewhere in the current application, as 
amended.  

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 31 of 47 
CPRC #2016LS107 
Major Clinical (Protocol/Patient) Minor Deviations as defined by the 
Masonic Cancer Center: 
Major Deviation: A deviation or violation that impacts the risks and benefits of 
the research; may impact subject safety, affect the integrity of research data 
and/or affect a subject’s willingness to participate in the research. Deviations 
that place a subject at risk, but do not result in harm are considered to be 
major deviations. 
Minor Deviation: A deviation or violation that does not impact subject safety, 
compromise the integrity of research data and/or affect a subject’s willingness 
to participate in the research. 
Expedited (Rapid) Reporting: Certain events may require rapid notification 
to entities providing patient safety oversight (e.g. IRB, FDA) as detailed in 
Section 10.3. For the IRB this is 5 business days from discovery. For studies 
under an IND, it is 7 or 15 calendar days. 
10.2 
Adverse Event Documentation 
Due to the intentional clearing of the marrow with chemotherapy as 
preparation for the UCB transplantation, it is expected that all patients will 
experience severe depression of their blood counts and other related 
toxicities as detailed in appendix III – Expected Side Effects of the 
Preparative Regimen, UCB infusion and GVHD prophylaxis. Therefore, 
adverse event collection for the purposes of this study will focus on targeted 
adverse events and unexpected adverse events within 48 hours of the 
Treg Cell Infusion. If a subject discontinues treatment early, AEs will no 
longer be collected. 
For the purposes of this study, targeted adverse events (Appendix VI) and 
unexpected events will be collected at the following time points in relation to 
the Treg Infusion:   
• Prior to Treg infusion  
• 1 to 4 hours after the Treg infusion  
• 24 hours (±2 hours) after Treg infusion 
• 48 hours (±2 hours) after Treg infusion 
• 1 week after Treg infusion if ongoing grade 3 toxicity (grade 2 
neurotoxicity) at the 48 hour assessment  
In addition the following event outcomes impact the progress of the study and 
must be reported as an early stopping rule event per Section 10.3: 
• Grade III or IV acute GVHD within 100 days of the cell infusion 
• Treatment related mortality (TRM) by day 100 post-transplant 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 32 of 47 
CPRC #2016LS107 
Refer to Section 12.4 for the full definition of the stopping rule events. 
FOR UNLICENSED UCB UNITS ONLY: Selected expected adverse reactions 
determined to be caused by or at least possibly caused by the UCB units 
based on objective evidence will be reported in an expedited manner to the 
FDA under University of Minnesota IND BB-14797 (C. Brunstein, MD, PhD – 
sponsor/investigator). 
10.3 Required Reporting: FDA, IRB and Masonic Cancer Center’s SAE 
Coordinator 
# following the sponsor’s initial receipt of the information 
In each IND safety report, the sponsor must identify all IND safety reports 
previously submitted to the FDA concerning a similar suspected adverse 
reaction and must analyze the significance of the suspected adverse reaction 
in light of the previous, similar reports. 
The SAE Coordinator will provide the Masonic Cancer Center’s Data and 
Safety Monitoring Council (DSMC) with the SAE in an appropriate format 
depending on the individual SAE (as reported or in a summary format). 
Agency 
Criteria for reporting 
Timefra
me 
Form to 
Use 
Submission 
address/ fax 
numbers 
U of MN 
IRB 
Events requiring prompt reporting including, but not limited to 
unanticipated death of a locally enrolled subject(s); new or 
increased risk; any adverse event  that require a change to the 
protocol or consent form or any protocol deviation that resulting 
in harm  For a complete list refer to 
http://www.research.umn.edu/irb/guidance/ae.html#.VC7xraI0-
sh  
Within 5 
business 
days of 
event 
discovery 
 
Report 
Form 
irb@umn.edu 
 
FDA 
 
Unexpected and fatal or unexpected and  life threatening 
suspected adverse reaction 
no later 
than 7 
Calendar 
Days# 
MCC 
SAE 
Submit to CBER 
as an 
amendment to 
IND 
1) Serious and unexpected suspected adverse reaction or 
2) increased occurrence of serious suspected adverse 
reactions over that listed in the protocol or investigator 
brochure or 
3) findings from other sources (other studies, animal or in vitro 
testing) 
no later 
than 15 
Calendar
-Days# 
All other events per CRF 312.33 
At time of 
IND 
annual 
report 
Summary 
format 
Submit as part of 
the IND annual 
report 
Masonic 
Cancer 
Center 
SAE 
Coordinator 
Events that count toward the early study stopping rule. 
At time of 
reporting 
Event 
Form 
SAE Coordinator 
mcc-
saes@umn.edu 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 33 of 47 
CPRC #2016LS107 
11 Study Data Collection and Monitoring 
11.1 Data Management 
This study will collect regulatory and clinical data using University of 
Minnesota CTSI’s instance of OnCore®(Online Enterprise Research 
Management Environment).  
 
The Oncore database resides on dedicated secure and PHI compliant 
hardware consisting of 3 physical servers: dev, DR, and production. The dev 
server is located in the University of Minnesota (UMN) datacenter (WBOB) 
and houses six database instances (test, train, sandbox, mcc reports, oncdm, 
and vendor) that are backed up locally because the data is refreshed from 
Oncore production data. The production server is located in the UMN 
datacenter (WBOB). All the data servers are managed by the Academic 
Health Center – Information Systems (AHC-IS) virtual servers which utilize 
clustered infrastructure to provide real-time failover of virtual servers. This 
real-time clustering is physically limited to the UMN data center. All relevant 
AHC IS procedures related for PHI compliant servers (as required by the 
Center of Excellence for HIPAA Data) apply to Oncore databases. 
 
The integrated data will be stored in PHI compliant servers managed by AHC 
IS with access given to those authorized users in the Clinical and Translation 
Science Institute Informatics team (CTSI BPIC and MCC CISS). The data will 
be integrated and extracted to researchers through the CTSI Informatics team 
and will be delivered through secure and compliant mechanisms (e.g. AHC IE 
data shelter, BOX, sftp, etc). If data de-identification is needed, then 
compliant AHC IE data de-identification tools will be used. The informatics 
team will grant the IRB approved study team members access to data. 
 
Additional immune monitoring data about correlative laboratory samples 
generated by the Masonic Cancer Center Translational Therapy Laboratory 
(TTL) from the protocol-directed correlative research samples is stored in 
their Laboratory Information Management System (LIMS). The LIMS 
database application is also stored on a production server located in the UMN 
datacenter (WBOB) and is managed by the Academic Health Center. 
 
Key study personnel are trained on the use of OnCore and will comply with 
protocol specific instructions embedded within the OnCore. 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 34 of 47 
CPRC #2016LS107 
11.2 Case Report Forms 
Participant data will be collected using protocol specific electronic case report 
forms (e-CRF) developed within OnCore based on its library of standardized 
forms. The e-CRF will be approved by the study’s Principal Investigator and 
the Biostatistician prior to release for use. The Primary Clinical Research 
Coordinator or designee will be responsible for registering the patient into 
OnCore at time of study entry, completing e-CRF based on the patient 
specific calendar, and updating the patient record until patient death or end of 
required study participation.  
11.3 Data and Safety Monitoring Plan (DSMP) 
The study’s Data and Safety Monitoring Plan will be in compliance with the 
University of Minnesota Masonic Cancer Center's Data & Safety Monitoring 
Plan (DSMP), which can be accessed at http://z.umn.edu/dmsp. 
For the purposes of data and safety monitoring, this study is classified as high 
risk (under a locally held IND). Therefore the following requirements will be 
fulfilled: 
 The Masonic Cancer Center Data and Safety Monitoring Council (DSMC) 
will review the study’s progress at least quarterly with the understanding 
the Cancer Protocol Review Committee (CPRC) may require more frequent 
reporting. 
 The PI will comply with at least twice yearly monitoring of the project by the 
Masonic Cancer Center monitoring services. 
 The PI will oversee the submission of all reportable adverse events per the 
definition of reportable in Section 10.3 to the Masonic Cancer Center’s SAE 
Coordinator, the University of Minnesota IRB, and the FDA.  
11.4 IND Annual Reports 
In accordance with regulation 21 CFR § 312.33, the sponsor-investigator with 
assistance from the MCC Clinical Trials Office (CTO) will submit a progress 
report annually. The report will be submitted within 60 days of the anniversary 
date that the IND went into effect.   
11.5 Monitoring 
The investigator will permit study-related monitoring, audits, and inspections 
by the sponsor-investigator and/or sponsor/investigator designee, IRB, 
government regulatory bodies, and University of Minnesota compliance 
groups. The investigator will make available all study related documents (e.g. 
source documents, regulatory documents, data collection instruments, study 
data, etc.). The investigator will ensure the capability for inspections of 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 35 of 47 
CPRC #2016LS107 
applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.) 
will be available for trial related monitoring, audits, or regulatory inspections. 
11.6 Record Retention 
The investigator will retain study records including source data, copies of 
case report form, consent forms, HIPAA authorizations, and all study 
correspondence in a secured facility for at 6 years after the study file is closed 
with the IRB and FDA.  
In addition, the Clinical Trials Office (CTO) will keep a master log of all 
patients participating in the study with sufficient information to allow retrieval 
of the medical records for that patient.  
Please contact the CTO before destroying any study related records. 
12 
Statistical Considerations 
12.1 Study Design and Endpoints 
This is a single center pilot study that will help with the design of a future full 
scale study of the efficacy and safety of our method by determining feasibility 
and providing estimates and variances of the endpoints for both safety and 
efficacy.  
Feasibility will be determined by demonstration of a workable protocol, 
including the proportion of patients advancing from enrollment to receipt of 
the full course IL-2. (This endpoint was no longer applicable as of the January 
2018 protocol version which removed IL-2 from the treatment plan due to 
unacceptable toxicity) 
Safety 
• Probability of grade II-IV aGVHD 
• Probability of grade III-IV aGVHD 
• Probability of treatment related mortality (TRM) at 6 months 
• Probability of relapse at 1 year 
• Probability of viral and fungal infections by 1 year 
• Pattern of immune reconstitution 
The proportion of patients with detectable Treg cells at Day 14 post infusion 
 
Efficacy 
• Length of Treg survival after infusion of Treg 
• Probability of grade II-IV aGVHD 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 36 of 47 
CPRC #2016LS107 
• Probability of relapse at 1 year 
• Probability of viral and fungal infections by 1 year 
• Pattern of immune reconstitution 
• The proportion of patients with detectable Treg cells at Day 14 post 
infusion 
Transplant Related Objectives 
• Determine the incidence of chimerism at Day 100  
• Determine the probability of survival at 1 year  
• Determine the incidence of neutrophil recovery at Day 42  
• Determine the incidence of platelet recovery at 1 year  
• Determine the incidence of chronic GVHD at 1 year  
12.2 Statistical Analysis 
Analysis will primarily be descriptive. Safety, efficacy and transplant-related 
endpoints will be evaluated with descriptive statistics and plots or cumulative 
incidence curves if enough evaluable patients are available for time-to-event 
endpoints. If censoring or competing risk is an issue in cumulative incidence 
of GVHD, relapse, infection and engraftment, non-event death will be treated 
as a competing risk. Likewise, relapse will be treated as a competing risk in 
estimation of TRM. If sufficient patients are evaluable, survival will be 
estimated by Kaplan-Meier curves. The primary efficacy variable is the length 
of Treg survival after Treg infusion. Continuous endpoints such as this will be 
described by medians, ranges and interquartile ranges as well as means and 
standard deviations if normally distributed. Categorical endpoints will be 
described with simple proportions and descriptive plots.  
12.3 Sample Size Justification 
Due to the nature of the pilot study and allowable resources, study accrual will 
stop when a total of 10 treated patients have been enrolled.  
12.4 Monitoring Guidelines (Stopping Rule Events) 
Early stopping rules for treatment related morality (TRM) and Grade III-IV 
Acute Graft versus Host Disease (AGVHD) by Day 100 will be in place to 
continuously monitor safety. In the event that a monitoring boundary is 
triggered, study enrollment will be suspended and the PI and IRB will be 
notified.  
The stopping rules for TRM and AGVHD were developed using an adaptation 
of Pocock stopping boundaries (28). 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 37 of 47 
CPRC #2016LS107 
Treatment Related Mortality 
Treatment related mortality (TRM) is defined as death due to any cause other 
than relapse by day 100 after transplant. The study will stop and the protocol 
will be re-evaluated if the rate exceeds the boundary. We expect that the rate 
of TRM will be about 25%. The goal is to construct a boundary based on 
mortality such that the probability of early stopping is at most 10% if the rate 
is equal to 25% and our sample size is 10. With these stipulations, the trial 
will be stopped and reviewed if 3/4, 4/6, 5/9 or 6 patients have TRM. The 
probability of hitting the stopping boundary if the rate is 60% is 77%.  
 
Grade III-IV AGVHD 
Grade III-IV AGVHD will be monitored through day 100 after transplant. The 
study will stop and the protocol will be re-evaluated if the rate exceeds the 
boundary. We expect that the rate of AGVHD will be about 20%. The goal is 
to construct a boundary based on AGVHD such that the probability of early 
stopping is at most 10% if the rate is equal to 20% and our sample size is 10. 
With these stipulations, the trial will be stopped and reviewed if 2/2, 3/4, 4/8 or 
5 patients have AGVHD. The probability of hitting the stopping boundary if the 
rate is 50% is 72%.  
 
13 
Conduct of the Study 
13.1 Good Clinical Practice 
The study will be conducted in accordance with the appropriate regulatory 
requirement(s). 
Essential 
clinical 
documents 
will 
be 
maintained 
to 
demonstrate the validity of the study and the integrity of the data collected. 
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.  
13.2 Ethical Considerations 
The study will be conducted in accordance with ethical principles founded in 
the Declaration of Helsinki. The IRB will review all appropriate study 
documentation in order to safeguard the rights, safety and well-being of the 
patients. The study will only be conducted at sites where IRB approval has 
been obtained. The protocol, consent, written information given to the 
patients, safety updates, annual progress reports, and any revisions to these 
documents will be provided to the IRB by the investigator.  
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 38 of 47 
CPRC #2016LS107 
13.3 Informed Consent 
All potential study participants will be given a copy of the IRB-approved 
consent to review. The investigator or designee will explain all aspects of the 
study in lay language and answer all questions regarding the study. If the 
participant decides to participate in the study, he/she will be asked to sign and 
date the consent document. Patients who refuse to participate or who 
withdraw from the study will be treated without prejudice. 
14 
References 
1. Godfrey WR, Spoden DJ, Ge YG, Baker SR, Liu B, Levine BL, et al. Cord blood 
CD4(+)CD25(+)-derived T regulatory cell lines express FoxP3 protein and manifest 
potent suppressor function. Blood. 2005;105(2):750-8. 
2. Randolph DA, Fathman CG. Cd4+Cd25+ regulatory T cells and their therapeutic 
potential. Annu Rev Med. 2006;57:381-402. 
3. Cohen JL, Trenado A, Vasey D, Klatzmann D, Salomon BL. CD4(+)CD25(+) 
immunoregulatory T Cells: new therapeutics for graft-versus-host disease. J Exp Med. 
2002;196(3):401-6. 
4. Hoffmann P, Ermann J, Edinger M, Fathman CG, Strober S. Donor-type CD4(+)CD25(+) 
regulatory T cells suppress lethal acute graft-versus-host disease after allogeneic bone 
marrow transplantation. J Exp Med. 2002;196(3):389-99. 
5. Taylor PA, Noelle RJ, Blazar BR. CD4(+)CD25(+) immune regulatory cells are required 
for induction of tolerance to alloantigen via costimulatory blockade. J Exp Med. 
2001;193(11):1311-8. 
6. Taylor PA, Lees CJ, Blazar BR. The infusion of ex vivo activated and expanded 
CD4(+)CD25(+) immune regulatory cells inhibits graft-versus-host disease lethality. 
Blood. 2002;99(10):3493-9. 
7. Taylor PA, Panoskaltsis-Mortari A, Swedin JM, Lucas PJ, Gress RE, Levine BL, et al. L-
Selectin(hi) but not the L-selectin(lo) CD4+25+ T-regulatory cells are potent inhibitors of 
GVHD and BM graft rejection. Blood. 2004;104(12):3804-12. 
8. Trenado A, Charlotte F, Fisson S, Yagello M, Klatzmann D, Salomon BL, et al. 
Recipient-type specific CD4+CD25+ regulatory T cells favor immune reconstitution and 
control graft-versus-host disease while maintaining graft-versus-leukemia. J Clin Invest. 
2003;112(11):1688-96. 
9. Anderson BE, McNiff JM, Matte C, Athanasiadis I, Shlomchik WD, Shlomchik MJ. 
Recipient CD4+ T cells that survive irradiation regulate chronic graft-versus-host 
disease. Blood. 2004;104(5):1565-73. 
10. Broxmeyer HE, Srour EF, Hangoc G, Cooper S, Anderson SA, Bodine DM. High-
efficiency recovery of functional hematopoietic progenitor and stem cells from human 
cord blood cryopreserved for 15 years. Proc Natl Acad Sci U S A. 2003;100(2):645-50. 
11. Zhong JF, Zhan Y, Anderson WF, Zhao Y. Murine hematopoietic stem cell distribution 
and proliferation in ablated and nonablated bone marrow transplantation. Blood. 
2002;100(10):3521-6. 
12. Steiner D, Brunicki N, Bachar-Lustig E, Taylor PA, Blazar BR, Reisner Y. Overcoming T 
cell-mediated rejection of bone marrow allografts by T-regulatory cells: synergism with 
veto cells and rapamycin. Exp Hematol. 2006;34(6):802-8. 
13. Joffre O, Gorsse N, Romagnoli P, Hudrisier D, van Meerwijk JP. Induction of antigen-
specific tolerance to bone marrow allografts with CD4+CD25+ T lymphocytes. Blood. 
2004;103(11):4216-21. 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 39 of 47 
CPRC #2016LS107 
14. Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, McGlave PB, Miller JS, et al. 
Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance 
engraftment in adults with hematologic malignancy. Blood. 2005;105(3):1343-7. 
15. Brunstein CG, Barker JN, Weisdorf DJ, DeFor TE, Miller JS, Blazar BR, et al. Umbilical 
cord blood transplantation after nonmyeloablative conditioning: impact on transplantation 
outcomes in 110 adults with hematologic disease. Blood. 2007;110(8):3064-70. 
16. Verneris MR, Brunstein CG, Barker J, MacMillan ML, DeFor T, McKenna DH, et al. 
Relapse risk after umbilical cord blood transplantation: enhanced graft-versus-leukemia 
effect in recipients of 2 units. Blood. 2009;114(19):4293-9. 
17. MacMillan ML, Weisdorf DJ, Brunstein CG, Cao Q, DeFor TE, Verneris MR, et al. Acute 
graft-versus-host disease after unrelated donor umbilical cord blood transplantation: 
analysis of risk factors. Blood. 2009;113(11):2410-5. 
18. Brunstein CG, Miller JS, Cao Q, McKenna DH, Hippen KL, Curtsinger J, et al. Infusion of 
ex vivo expanded T regulatory cells in adults transplanted with umbilical cord blood: 
safety profile and detection kinetics. Blood. 2011;117(3):1061-70. 
19. Lim DG, Joe IY, Park YH, Chang SH, Wee YM, Han DJ, et al. Effect of 
immunosuppressants on the expansion and function of naturally occurring regulatory T 
cells. Transpl Immunol. 2007;18(2):94-100. 
20. Coenen JJ, Koenen HJ, van Rijssen E, Hilbrands LB, Joosten I. Rapamycin, and not 
cyclosporin A, preserves the highly suppressive CD27+ subset of human CD4+CD25+ 
regulatory T cells. Blood. 2006;107(3):1018-23. 
21. Zeiser R, Nguyen VH, Beilhack A, Buess M, Schulz S, Baker J, et al. Inhibition of 
CD4+CD25+ regulatory T-cell function by calcineurin-dependent interleukin-2 
production. Blood. 2006;108(1):390-9. 
22. Bocian K, Borysowski J, Wierzbicki P, Wyzgal J, Klosowska D, Bialoszewska A, et al. 
Rapamycin, unlike cyclosporine A, enhances suppressive functions of in vitro-induced 
CD4+CD25+ Tregs. Nephrol Dial Transplant.25(3):710-7. 
23. McKenna DH, Sumstad DJ, Brunstein CG, Kadidlo DM, Hippen KL, Curtsinger J, et al. 
cGMP Production of Umbilical Cord Blood-Derived T-Regulatory Cells in Support of a 
First in Human Clinical Trial. Cytotherapy. 2010;12 (suppl 1):19. 
24. Brunstein CG, Blazar BR, Miller JS, Cao Q, Hippen KL, McKenna DH, et al. Adoptive 
transfer of umbilical cord blood-derived regulatory T cells and early viral reactivation. Biol 
Blood Marrow Transplant. 2013;19(8):1271-3. 
25. Ito S, Bollard CM, Carlsten M, Melenhorst JJ, Biancotto A, Wang E, et al. Ultra-low dose 
interleukin-2 promotes immune-modulating function of regulatory T cells and natural 
killer cells in healthy volunteers. Molecular therapy : the journal of the American Society 
of Gene Therapy. 2014;22(7):1388-95. Epub 2014/04/02. 
26. Kennedy-Nasser AA, Ku S, Castillo-Caro P, Hazrat Y, Wu MF, Liu H, et al. Ultra low-
dose IL-2 for GVHD prophylaxis after allogeneic hematopoietic stem cell transplantation 
mediates expansion of regulatory T cells without diminishing antiviral and antileukemic 
activity. Clin Cancer Res. 2014;20(8):2215-25. Epub 2014/02/28. 
27.  
Brunstein CG, Miller JS et al, Umbilical cord blood-derived T regulatory cells to 
prevent GVHD: kenetics, toxicity profile and clinical effect. Blood. 2016 Feb; 
127(8):1044-51 
28. Ivanova A, Qaqish BF, Schell MJ. Continuous toxicity monitoring in phase II trials in 
oncology. Biometrics. 2005;61(2):540-5. 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 40 of 47 
CPRC #2016LS107 
Appendix I – Eligibility Checklist 
Adoptive Transfer of T Regulatory Cell for Suppression of Acute Graft-vs-Host-Disease after 
an Umbilical Cord Blood Transplant for Hematologic Malignancies 
  
Eligibility Checklist – page 1 of 2 
Patient initials   
     
 
 
Patient ID
 
 
 
 
1st 2 initials of first name + 1st 2 initials of last name 
        Seq # (i.e. 01, 02, 03, etc.) 
 
 
INCLUSION CRITERIA  
A "NO" response to any of the following disqualifies the patient from study entry. 
 
 
 
 
Yes      No 
1. 
Must be ≥18, but < 70 years of age with no matched 7/8 or 8/8 sibling donor - patients ≥ 70 and ≤ 75 years of 
age may be eligible if they have a Co-Morbidity score ≤ 2 (http://www.qxmd.com/calculate-
online/hematology/hct-ci) 
 
 
2. 
UCB unit(s) composing the graft will be selected according to the current University of Minnesota umbilical cord 
blood graft selection algorithm and an additional cord blood unit to be used as the source to manufacture the 
Treg product. This UCB unit must be matched at 4-6/6 to the patient, considering HLA-A, B at the antigen level 
and DRB1 at the allele level 
 
 
3. 
Acute Leukemias: Must be in remission by morphology (around 5% blasts, but < 20% blasts by morphology). 
Also a small percentage of blasts that is equivocal between marrow regeneration versus early relapse are 
acceptable provided there are no associated cytogenetic markers consistent with relapse. Refer to Section 5.2 
for complete definitions. 
Burkitt’s Lymphoma in CR2 or subsequent CR 
Natural Killer Cell Malignancies 
Chronic Myelogenous Leukemia: all types except refractory blast crisis. Chronic phase patients must have 
failed at least two different tyrosine-kinase inhibitors (TKIs), or been intolerant to all available TKIs or have 
T315I mutation.  
Myelodysplastic Syndrome: IPSS INT-2 or High Risk; R-IPSS High or Very High; WHO classification: RAEB-
1, RAEB-2; Severe Cytopenias: ANC < 0.8, Anemia or thrombocytopenia requiring transfusion; Poor or very 
poor risk cytogenetics based on IPSS or R-IPSS definitions; therapy-related MDS. Blasts must be < 5% by 
bone marrow aspirate morphology. If ≥5% blasts, patient requires chemotherapy for cytoreduction to <5% 
blasts prior to transplantation. 
Large-Cell Lymphoma, Hodgkin Lymphoma and Multiple Myeloma with chemotherapy sensitive disease 
that has failed or patients who are ineligible for an autologous transplant.  
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL), Marginal Zone B-Cell 
Lymphoma, Follicular Lymphoma, which have progressed within 12 months of achieving a partial or 
complete remission. Patients who had remissions lasting > 12 months are eligible after at least two prior 
therapies. Patients with bulky disease should be considered for debulking chemotherapy before transplant. 
Patients with refractory disease are eligible, unless has bulky disease and an estimated tumor doubling time of 
less than one month.  
Lymphoplasmacytic Lymphoma, Mantle-Cell Lymphoma, Prolymphocytic Leukemia are eligible after 
initial therapy if chemotherapy sensitive. 
Patients must have undergone an autologous transplant ≤ 12 months prior to transplant on this study or have 
received multi-agent or immunosuppressive chemotherapy within 3 months of the preparative regimen. 
 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 41 of 47 
CPRC #2016LS107 
 
 
Adoptive Transfer of T Regulatory Cell for Suppression of Acute Graft-vs-Host-Disease after 
an Umbilical Cord Blood Transplant for Hematologic Malignancies 
 
Eligibility Checklist – page 2 of 2 
Patient initials   
     
 
INCLUSION CRITERIA (continue) 
A "NO" response to any of the following disqualifies the patient from study entry. 
 
EXCLUSION CRITERIA 
A "YES" response to any of the following disqualifies the patient from study entry. 
 
Having obtained consent and reviewed each of the inclusion/exclusion criteria, I verify that this patient is 
eligible  
 
 
 
 
 
 
 
 
 
 
 
 
Signature of enrolling physician 
 
 
Date 
 
 
 
Yes      No 
4. 
Karnofsky score ≥ 70% 
 
 
5. 
Adequate organ function within 14 days (30 days for cardiac and pulmonary) of registration on-study defined 
as: 
 Renal: creatinine ≤ 2.0 mg/dL, for patient with a creatinine > 1.2 mg/dL or a history of renal dysfunction an 
estimated glomerular filtration rate ≥ 40 mL/min/1.73 m2 is required  
 Hepatic: AST, ALT, alkaline phosphatase ≤ 5 x upper limit of normal and total bilirubin ≤ 2.5 mg/dL except for 
patients with Gilbert’s syndrome or hemolysis 
 Pulmonary function: DLCO, FEV1, FVC ≥ 40% predicted, and absence of O2 requirements.  
• Cardiac:  Absence of decompensated congestive heart failure, or uncontrolled arrhythmia and left ventricular 
ejection fraction ≥ 40%. 
 
 
6. 
Sexually active females of childbearing potential and males with partners of child-bearing potential must agree 
to use adequate birth control during study treatment 
 
 
7. 
Voluntary written consent  
 
 
 
 
Yes      No 
8. 
 Untreated active infection  
 
 
9. 
 History of HIV infection 
 
 
10.  Pregnant or breast feeding 
 
 
11.  Prior allogeneic transplantation 
 
 
12.  Less than 3 months from myeloablative conditioning for autologous transplantation 
 
 
13.  Evidence of progressive disease by imaging modalities or biopsy - persistent PET activity, though possibly 
related to lymphoma, is not an exclusion criterion in the absence of CT changes indicating progression. 
 
 
14.  CML in blast crisis 
 
 
15.  Large cell lymphoma, mantle cell lymphoma and Hodgkin disease that is progressing on salvage therapy. 
 
 
16.  Active central nervous system malignancy 
 
 

Appendix II – Karnofsky Performance Status 
Karnofsky Performance Scale 
Percent 
Description 
100 
Normal, no complaints, no evidence of disease. 
90 
Able to carry on normal activity; minor signs or symptoms of disease. 
80 
Normal activity with effort; some signs or symptoms of disease. 
70 
Cares for self, unable to carry on normal activity or to do active work. 
60 
Requires occasional assistance, but is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and frequent medical care. 
40 
Disabled, requires special care and assistance. 
30 
Severely disabled, hospitalization indicated. Death not imminent. 
20 
Very sick, hospitalization indicated. Death not imminent. 
10 
Moribund, fatal processes progressing rapidly. 
0 
Dead. 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 43 of 47 
CPRC #2016LS107 
Appendix III – Expected Risks of the Preparative Regimen, GVHD 
Prophylaxis and UCB Transplant 
 
Preparative Regimen: 
Cyclophosphamide 
common 
less common 
rare, but may be serious 
• low white blood cell count 
with increased risk of 
infection  
• hair loss or thinning, 
including face and body hair 
(usually grows back after 
treatment)  
• nausea  
• vomiting  
• loss of appetite  
• sores in mouth or on lips  
• bleeding from bladder, with 
blood in urine  
• diarrhea  
• long-term or short-term 
infertility (inability to have 
children) in women and men 
• 
low platelet count (mild) 
with increased risk of 
bleeding  
• 
darkening of nail beds  
• 
acne  
• 
tiredness  
• 
infection 
• 
fetal changes if you 
become pregnant while 
taking cyclophosphamide  
 
• heart problems with high 
doses, with chest pain, 
shortness of breath, or 
swollen feet 
• severe allergic reactions 
• skin rash  
• scarring of bladder 
• kidney damage (renal 
tubular necrosis) which can 
lead to kidney failure 
• heart damage, with trouble 
getting your breath, swelling 
of feet, rapid weight gain 
• scarring of lung tissue, with 
cough and shortness of 
breath 
• second cancer, which can 
happen years after taking 
this drug 
• death from infection, 
bleeding, heart failure, 
allergic reaction, or other 
causes 
 
 
Fludarabine 
common 
less common 
rare, but may be serious 
• low white blood cell count 
with increased risk of 
infection  
• low platelet count with 
increased risk of bleeding  
• low red blood cell count 
(anemia) with tiredness and 
weakness 
• tiredness (fatigue)  
• nausea  
• vomiting  
• fever and chills 
• infection 
• 
pneumonia  
• 
diarrhea  
• 
loss of appetite 
• 
weakness 
• 
pain 
 
• numbness and tingling in 
hands and/or feet related to 
irritation of nerves  
• changes in vision  
• agitation  
• confusion 
• clumsiness 
• seizures 
• coma  
• cough  
• trouble breathing  
• intestinal bleeding 
• weakness  
• death due to effects on the 
brain, infection, bleeding, 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 44 of 47 
CPRC #2016LS107 
Fludarabine 
common 
less common 
rare, but may be serious 
severe anemia, skin 
blistering, or other causes 
• death from infection, 
bleeding, heart failure, 
allergic reaction, or other 
causes 
 
Total Body Irradiation 
common 
less common 
rare, but may be serious 
• nausea and vomiting 
• diarrhea 
• cataracts 
• sterility 
• endocrinopathies 
• growth failure 
• intestinal cramps 
• mucositis 
• parotitis 
• interstitial pneumonitis 
• generalized mild erythema 
• veno-occlusive disease 
 
• dysphagia 
• vertebral deformities 
• nephropathy 
• risk of 2nd malignancy years 
later (when given along with 
chemotherapy) 
 
GVHD Prophylaxis: 
Mycophenolate Mofetil (MMF) 
Sirolimus (Rapamycin) 
• pancytopenia 
• headache 
• insomnia 
• electrolyte imbalances 
• leg cramps/bone pain 
• hypertension 
• dizziness 
• hyperglycemia 
• rash 
• nausea 
• diarrhea 
 
• fast heart rate 
• pain when breathing, feeling short of breath 
• chest pain, feeling weak or tired 
• coughing up blood or mucus 
• feeling like you might pass out 
• pale skin, easy bruising or bleeding, 
weakness 
• fever, chills, body aches, flu symptoms 
• night sweats, weight loss 
• swelling of face, stomach, hands or feet 
• rapid weight gain 
• pain or burning when urinating 
• slow healing of a wound 
• joint pain 
• nausea, vomiting, diarrhea, constipation, 
stomach pain 
• headache 
• acne or skin rash 
• high triglycerides and cholesterol 
 
 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 45 of 47 
CPRC #2016LS107 
Umbilical Cord Blood Transplant: 
• 
nausea and vomiting  
• 
allergic infusion reaction (including itching, hives, flushing [red face], shortness of breath, 
wheezing, chest tightness, skin rash, fever, chills, stiff muscles, or trouble breathing) 
• 
graft-versus-host-disease (GVHD) 
• 
veno-occlusive disease,  
• 
mucositis,  
• 
infections (sepsis)  
• 
failure to engraft 
 
To improve engraftment G-CSF will be administered beginning Day +5 
G-CSF 
Less Common 
Rare, but may be serious 
• bone or muscle pain 
• injection site reaction (redness, pain, or 
swelling) 
 
• allergic reaction 
• spleen enlargement or rupture –symptoms 
of an enlarged spleen include a feeling 
discomfort, fullness, or pain on the upper 
left side of the abdomen; this pain may 
spread to the left shoulder 
• serious lung problems (ARDS)  
• coughing up blood 
 
 

MT2016-17: Treg for Suppression of Acute GVHD 
 
 
 
 
 
 
January 4, 2018 
Page 46 of 47 
CPRC #2016LS107 
Appendix IV – GVHD Scoring 
Acute GVHD 
Organ involvement will be staged using the criteria outlined in the table below. Biopsy of 
each organ site at diagnosis or major change in disease activity will be performed unless 
clinical circumstances make it impossible. 
Consensus Clinical Stage and Grade of Acute GVHD (Przepiorka et al, 1995) 
Stage 
Skin 
Liver 
Lower 
Gastrointestinal 
Tract 
Upper 
Gastrointestinal 
Tract 
1 
Maculopapular rash 
<25% of body 
surface 
Bilirubin 2.0 – 3.0 
mg/dl 
Diarrhea 500 – 1000 
mL/day or 280 – 555 
mL/m2 
No protracted 
nausea and 
vomiting 
2 
Maculopapular rash 
25-50% body 
surface 
Bilirubin 3.1 – 6.0 
mg/dl 
Diarrhea 1000 – 1500 
mL/day or 556 – 833 
mL/m2 
Persistent nausea, 
vomiting or anorexia 
3 
Generalized 
erythroderma 
Bilirubin 6.1 – 15.0 
mg/dl 
Diarrhea >1500 
mL/day or    >833 
mL/m2 
 
4 
Generalized 
erythroderma with 
bullous formation 
and desquamation 
Bilirubin > 15 mg/dl 
Severe abdominal 
pain, with or without 
ileus, or stool with 
frank blood or melena 
 
 
Grading for Treatment Criteria: 
Mild GVHD  
 
Skin stage I-II only (Equivalent to Seattle Grade I). 
Moderate GVHD 
Skin stage I-III and/or liver I-IV and/or Gastrointestinal tract (GI) I-III 
and/or Upper GI (UGI). (Equivalent to Seattle Grade II, III). 
Severe GVHD Any stage IV along with severe clinical illness. 
Late Acute and Chronic GVHD 
Late acute and chronic GVHD will be assessed using the National Institutes of Health (NIH) 
Consensus Criteria. 

Appendix V – Targeted Toxicity 
 Patient Initials:  _______ Date of Assessment:  _________ Assessment Time point:  _________ 
ADL = activities of daily living     CTCAE v 4.0   Refer to Section 10.2 for time points. 
Toxicity 
Grade 0 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Infusion 
related 
reaction 
None 
Mild transient reaction; 
infusion interruption not 
indicated; intervention 
not indicated 
Therapy or infusion interruption 
indicated but responds promptly to 
symptomatic treatment; prophylactic 
medications indicated for ≤ 24 hrs 
Prolonged (e.g., not rapidly 
responsive to symptomatic 
medication and/or brief 
interruption of infusion);  
Life-threatening 
consequences; urgent 
intervention indicated 
Dyspnea 
None or no 
change 
Shortness of breath 
with moderate exertion 
Shortness of breath with minimal 
exertion; limiting instrumental ADL 
Shortness of breath at 
rest;limiting self care ADL 
Life-threatening 
consequences; urgent 
intervention indicated 
Hypoxia 
None 
……………… 
Decreased O2 saturation with exercise 
(e.g., pulse oximeter < 88%) intermittent 
supplemental oxygen 
Decreased oxygen saturation 
at rest (e.g., pulse oximeter < 
88% or PaO2 ≤ 55 mm Hg) 
Life-threatening airway 
compromise; urgent 
intervention indicated (e.g., 
tracheotomy or intubation) 
Fever  
None 
38.0 - 39.0 degrees C 
(100.4 -102.2 F) 
> 39.0 - 40.0 degrees C (102.3 - 104.0 
degrees F) 
> 40.0 degrees C (>104.0 
degrees F) for ≤ 24 hours 
> 40.0 degrees C (>104.0 
degrees F) for > 24 hours 
Febrile 
neutropenia 
 
……………… 
……………… 
temperature of >38.3 degrees 
C (101 degrees F) or a temp 
of ≥38 degrees C (100.4 
degrees F) for > 1 hour 
Life-threatening 
consequences; urgent 
intervention indicated 
Chills 
None 
Mild sensation of cold; 
shivering; chattering of 
teeth 
Moderate tremor of the entire body; 
narcotics indicated 
Severe or prolonged, not 
responsive to narcotics 
……………………… 
Hypertension 
None 
Pre-hypertension 
(systolic BP 120 - 139 
mm Hg or diastolic BP 
80 - 89 mm Hg) 
Stage 1 hypertension (systolic BP 140 - 
159 mm Hg or diastolic BP 90 - 99 mm 
Hg); medical intervention indicated; 
recurrent or persistent  ≥ 24 hrs); 
symptomatic increase by >20 mm Hg 
(diastolic) or to >140/90 mm Hg if 
previously WNL; monotherapy indicated 
Stage 2 hypertension 
(systolic BP ≥ 160 mm Hg or 
diastolic BP ≥ 100 mm Hg); 
medical intervention 
indicated; > drug or more 
intensive therapy than 
previously used indicated.  
Life-threatening 
consequences (e.g., 
malignant hypertension, 
transient or permanent 
neurologic deficit, 
hypertensive crisis); urgent 
intervention indicated.  
Hypotension 
None 
Asymptomatic, 
intervention 
not indicated 
Non-urgent medical 
intervention indicated 
Medical intervention or 
hospitalization indicated 
Life-threatening and urgent 
intervention indicated 
Edema 
None 
Localized to dependent 
areas, no disability or 
functional impairment 
Moderate localized edema 
and intervention indicated; 
limiting instrumental ADL 
Severe localized edema and 
intervention indicated; limiting 
self care ADL 
……………………… 
Pneumonitis 
None 
Asymptomatic; clinical 
or diagnostic 
observations only;  
Symptomatic; medical 
intervention indicated; limiting 
instrumental ADL 
Severe symptoms; limiting 
self care ADL; oxygen 
indicated 
Life-threatening respiratory 
compromise; urgent 
intervention indicated (e.g. 
intubation or tracheotomy) 
Fatigue 
None 
Fatigue relieved by rest  Fatigue not relieved by rest; limiting ADL 
instrumental  
Fatigue not relieved by rest; 
limiting self care 
……………………… 
Rash 
None 
Covering < 10% body 
surface area (BSA) 
Covering 10-30% body surface area 
(BSA) 
>30% body surface area 
(BSA) 
Generalized exfoliative, 
ulcerative, or bullous dermatitis
Weight Gain 
None 
5 - <10% from baseline  10 - <20% from baseline  
≥20% from baseline 
……………………… 
 
Person Completing Form: