A Phase I Study of Intracranially Administered Carboxylesterase-Expressing Neural Stem Cells in Combination With Intravenous Irinotecan in Patients With Recurrent High-Grade Gliomas
Phase: PHASE1
Conditions: Recurrent Anaplastic Astrocytoma, Recurrent Anaplastic Oligoastrocytoma, Recurrent Anaplastic Oligodendroglioma, Recurrent Glioblastoma, Recurrent Gliosarcoma, Recurrent Malignant Glioma, Recurrent WHO Grade III Glioma
Sponsor: City of Hope Medical Center

 
IRB 14108 
 
08/28/2019 
Packet: 14 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DEPARTMENT OF MEDICAL ONCOLOGY   
 
 
TITLE:  
A Phase I Study of Intracranially Administered Carboxylesterase-Expressing Neural Stem Cells 
in Combination with Intravenous Irinotecan in Patients with Recurrent High-Grade Gliomas 
 
CITY OF HOPE PROTOCOL NUMBER/VERSION: IRB # 14108  
 
Protocol Dated: 08/28/19  
 
DATE(S)/ OF AMENDMENT(S)/REVISION(S): 
 
 
COH Initial Approval 
Protocol Dated 08/01/14                                                          Version: 00 
 
COH Amendment 01  
Protocol Dated 11/03/14 
 
 
 
 
   Version: 01 
 
COH Amendment 02  
Protocol Dated 03/04/16 
 
 
 
 
   Version: 02 
 
COH Amendment 03  
Title Page Dated 08/11/16 (Personnel Update) 
 
   Version: 03 
COH Amendment 04  
Protocol Dated 12/29/16  
 
    
 
 
   Version: 04 
COH Amendment 05  
Protocol Dated 04/05/17  
 
    
 
 
   Version: 05 
COH Amendment 06  
Title Page Dated 07/07/17 (Personnel Update) 
   
   Version: 06 
COH Amendment 07  
Protocol Dated 01/30/18 
 
 
 
 
   Version: 07 
COH Amendment 08  
Protocol Dated 04/12/18 
 
 
 
 
   Version: 08 
COH Amendment 09  
Protocol Dated 11/27/18 
 
 
 
 
   Version: 09 
COH Amendment 10  
Title Page Dated 06/24/2019 (Personnel Update) 
 
   Version: 10 
COH Amendment 11  
Protocol Dated 08/28/2019 
 
 
 
 
   Version: 11 
COH Amendment 12  
Title Page Dated 03/10/2020 (Personnel Update) 
 
   Version: 12 
COH Amendment 13  
Protocol Dated 08/28/2019 ((TP)(Personnel Update) 
Packet: 13 
COH Amendment 14 at Continuation  
Protocol Dated 08/28/19                                Packet: 14 
 
 
 
SITE:  
 
 
 
 
Brain  
STAGE (If applicable): 
 
 
Recurrent High Grade 
 
 
MODALITY:  
 
 
 
Neural Stem Cells/Chemotherapy 
TYPE:  
 
 
 
 
Phase I 
PRINCIPAL INVESTIGATOR: 
 
Jana Portnow, M.D. 
 
 
COLLABORATING INVESTIGATOR(S): 
Behnam Badie, M.D.  Julie Ressler, M.D. Timothy Synold, 
Pharm.D., Mark Agulnik, MD; Yan Xing, MD 
 
 
 
 
 
 
 
PARTICIPATING CLINICIANS: 
Mike Chen, M.D., Ph.D.,  
Rahul Jandial, M.D., Ph.D.,  
 
NON CONSENTING  
PARTICIPATING CLINICIANS:  
 
Molly Diaz, PA 
 
Study Statistician: 
Suzette Blanchard, Ph.D. 
 
 

Page 1 of 94 
IRB Protocol No. 14108 
 
Version Date:  08/28/2019 
Version:  11 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DEPARTMENT OF MEDICAL ONCOLOGY 
 
A Phase I Study of Intracranially Administered Carboxylesterase-Expressing Neural Stem Cells in 
Combination with Intravenous Irinotecan in Patients with Recurrent HighGrade Gliomas 
CITY OF HOPE PROTOCOL NUMBER: 
14108 
VERSION: 
11 
DATE(S) OF AMENDMENT(S)/REVISION(S): 
COH Initial Approval 
Protocol Dated 08/01/14 
Version: 00 
COH Amendment 1 
Protocol Dated 11/03/14 
Version: 01 
COH Amendment 2 
Protocol Dated 03/04/16 
Version: 02 
COH Amendment 3 
Title Page Dated 08/11/16 
Version: 03 
COH Amendment 4 
Protocol Dated 12/29/16 
Version: 04 
COH Amendment 5 
Protocol Dated 04/05/17 
Version: 05 
COH Amendment 6  
Title Page Dated 07/07/17 
Version 06 
COH Amendment 7 
Protocol Dated 01/30/18 
Version 07 
COH Amendment 8  
Protocol Dated 04/12/18 
Version 08 
COH Amendment 9 
Protocol Dated 11/27/18  
Version 09 
COH Amendment 10 
Title Page Dated 06/24/19 
Version 11 
COH Amendment 11 
Protocol Dated 08/28/19 
Version 11 
 
 
 
SPONSOR/IND NUMBER: City of Hope/ 16265. 
PRINCIPAL INVESTIGATOR: 
Designs protocol, responsible for study conduct and 
data analysis 
Jana Portnow, MD 
 
 
 

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IRB Protocol No. 14108 
 
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COLLABORATING INVESTIGATOR(S): 
Key individual(s); Assist in study design and 
development; 
May be involved in analysis of data 
 
Behnam Badie, MD 
Massimo D’Apuzzo, MD, PhD 
Julie Ressler, MD 
Timothy Synold, Pharm D 
 
 
PARTICIPATING CLINICIANS: 
Enrolls and follows eligible patients on study; 
Not involved in study development or data analysis 
(Physician or research support staff) 
Mike Chen, MD, PhD 
Rahul Jandial, MD, PhD 
Mihaela Cristea, MD 
Marianna Koczywas 
STUDY STATISTICIAN: 
Suzette Blanchard, PhD 
PARTICIPATING SITES: 
City of Hope 
STUDY SPONSOR AND MONITOR: 
City of Hope 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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IRB Protocol No. 14108 
 
Version Date:  08/28/2019 
Version:  11 
Experimental Design Schema 
Dose Escalation Schema 
NSC Dose Level 
Initial 
Enrollment 
 
If 1 DLT, 
Addt’l 
Enrollment 
NSC Dose 
 
NSC and Irinotecana 
Administration 
Week 
1          2          3         4 
-1 
3 
3 
2.5 x 107 
X* 
 
** 
 
1b 
3 
3 
5 x 107 
X 
 
** 
 
2c 
3 
3 
5 x 107 
X 
 
X 
 
3 
3 
3 
1 x 108 
X 
 
X 
 
4d 
3 
3 
1.5 x 108 
X 
 
X 
 
Expansion Cohort e 
8 
 
MTD/MFD 
X 
 
X 
 
* ”X” denotes treatment weeks for NSCs and irinotecan. NSCs are administered intracranially on Day 1 and 15, 
followed by intravenousirinotecan, two days later, on Days 3 and 17 of a 28 day cycle.  
**Patients on dose levels 1 and -1will only receive 1 dose of NSCs, but they will continue to receive irinotecan 
every 2 weeks as long as they are tolerating it well, and there is no evidence of tumor progression. 
aDose schedule A, B, and C will be the NSC dose schema in combination with an irinotecan dose of 180mg/m2, 
150 mg/m2, or 125 mg/ m2, respectively. We will start with irinotecan dose schedule A, de-escalating through 
doses B and C in order as necessary. 
b The starting NSC dose level is dose level 1. The first 6 study participants will undergo intracerebral microdialysis 
to measure levels of irinotecan and NSC-mediated SN-38 production in the brain. Since the dose of NSCs remains 
the same for dose level 1 and 2, all of these first 6 study patients would receive the same dose of NSCs and 
irinotecan when undergoing intracerebral microdialysis, even allowing for escalation to dose level 2. 
c Starting with dose level 2, a Rickham reservoir/catheter system will be placed at the time of surgery for 
administering repeat doses of NSCs.  
d Six patients will be treated on the maximum tolerated dose(MTD), or, if the MTD is not reached, at the 
maximum feasible dose (MFD). Since it is anticipated that the MTD/MFD will be 150 million NSCs (dose level 4), 
the 6 patients who will be treated on dose level 4 will undergo intracerebral microdialysis and be counted as 
part of the expansion cohort.  
e An expansion cohort of 8 patients will be treated at the MTD or MFD to gain more experience with the 
tolerability of this treatment regimen. These patients will also undergo intracerebral microdialysis to assess how 
much SN-38 is produced by highest dose of NSCs and evaluate the biologic activity of the NSCs by directly 
measuring how much the addition of NSCs to treatment with irinotecan increases intracerebral levels of SN-38. 
As such, 4 patients in the expansion cohort will undergo intracerebral microdialysis after receiving NSCs on the 
day of surgery followed 2 days later by IV irinotecan, and the other 4 patients in this cohort will not receive NSC 
administration on the day of surgery. Instead they will be given IV irinotecan 2 days after surgery and dialysate 
samples will be collected from them to determine how much SN-38 is present in the brain from treatment with 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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IRB Protocol No. 14108 
 
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IV irinotecan alone. These 4 patients will then receive their first dose of NSCs through the Rickham on day 15 of 
cycle 1 followed by irinotecan on day 17. 
 
 
 
Simplified Treatment Schema for Cycle 1 
Day 1 
Tumor resection or biopsy is performed. 
hCE1m6-NSCs are administered intracranially.^ 
A Rickham catheter is placed (except in patients on dose levels 1 or -1). 
The first 6 study patients and those in the expansion cohort: microdialysis catheter(s) is/are placed, and 
a post-operative CT scan is obtained to confirm correct placement. 
^Four participants in the expansion cohort will not receive Day 1 NSCs; they will initiate NSC 
administration on Day 15. 
Day 3  
 
Irinotecan is administered intravenously. 
Patients undergoing intracerebral microdialysis:  serial dialysate and bloodsamples are collected. 
Day 15 
 
hCE1m6-NSCs are administered intracranially via the Rickham catheter.* 
Blood is drawn for immunologic correlative studies.* 
* Patients in dose level 1 or -1 will not receive NSCs on Day 15, and blood samples for immunologic 
correlative studies will be drawn on Day 17 when these patients return to clinic to receive irinotecan. 
Day 17 
Irinotecan is administered intravenously. 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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IRB Protocol No. 14108 
 
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Version:  11 
Protocol Synopsis 
Protocol Title: 
A Phase I Study of Intracranially administered Carboxylesterase-Expressing Neural Stem Cells in Combination 
with Intravenous Irinotecan in Patients with Recurrent High Grade Gliomas. 
Brief Protocol Title for the Lay Public (if applicable): 
A Phase I study of Neural Stem Cells and Irinotecan in Patients with High-Grade Gliomas 
Study Phase: 
Phase I 
Participating Sites: 
City of Hope 
Rationale for this Study: 
High-grade gliomas are difficult to treat due to their highly invasive nature and relative resistance to 
chemotherapy and radiation. Human neural stem cells (NSCs), modified to express a therapeutic transgene, 
hold great promise for glioma therapy due to their inherent tumor-tropic properties, enabling their use as 
vehicles for delivering chemotherapy directly to infiltrating glioma cells.This NSC-mediated delivery approach 
has the potential to overcome obstacles that limited gene therapy efficacy in the past and minimize off target 
toxicities of current treatment approaches. 
Data from animal models have demonstrated the safety and efficacy of NSCs for tracking to invasive tumor cells 
as well as to distant micro-tumor foci and delivering therapeutic gene products to tumor cells. In our first-in-
human pilot study of cytosine deaminase (CD)-expressing NSCs given in combination with oral 5-fluorocytosine 
(5-FC), we showed that 1 dose of CD-expressing NSCs followed by a 7 day course of 5-FC in recurrent high-grade 
glioma patients is safe and feasible. With intracerebral microdialysis, we documented proof-of-concept—that 
the NSCs converted the prodrug 5-FC to its active metabolite 5-FU locally in the brain. Results of immunologic 
correlative studies documented no findings of NSC immunogenicity after first exposure. Magnetic resonance 
imaging (MRI) of iron-labeled NSCs showed preliminary evidence of NSCs migrating away from the injection 
sites, and autopsy results from 2 study patients showed evidence that NSCs had traveled to distant sites of 
tumor in the brain. 
This well characterized, v-myc-immortalized, clonal, human fetal NSC line has been further modified by 
adenoviral transduction to secrete a highly active modified human form (hCE1m6) of carboxylesterase (CE) for 
efficient conversion of irinotecan to its more potent metabolite, SN-38.We hypothesize that in patients with 
recurrent high-grade gliomas, CE-secreting NSCs will distribute throughout the primary tumor site as well as co-
localize with infiltrating tumor cells within 2 days of administration. Study patients will then be treated with 
intravenously administered irinotecan. The CE-secreting NSCs will locally convert irinotecan to SN-38, thereby 
generating concentrated cytotoxicity at sites of tumor in the brain. 
Objectives: 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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IRB Protocol No. 14108 
 
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Primary Objectives: 
To define the recommended phase II dose (RP2D) of intracraniallyadministered hCE1m6-NSCs in combination 
with intravenous irinotecan in patients with recurrent high grade glioma. The RP2D will be based on the 
maximum-tolerated dose (MTD), or if the MTD is not reached, the maximum feasible dose (MFD),and 
the full toxicity profile including toxicities associated with repeat doses of NSCs.  
Secondary Objectives: 
 To describe the relationship between hCE1m6-NSC dose and SN-38 concentrations in brain interstitium. 
 To characterize the relationship between intracerebral and systemic concentrations of irinotecan and 
SN-38. 
 To investigate the biologic activity of hCE1m6 NSCs by comparing SN-38 concentrations in the brain 
after treatment with hCE1m6 NSCs and irinotecan versus irinotecan alone. 
 To assess for possible development of adenovirally transduced NSC immunogenicity after first exposure 
and with repeat doses of NSCs. 
 To describe the clinical benefit (defined as stable disease, partial response, or complete response) in 
patients who receive treatment with repeat cycles of NSCs and irinotecan. 
 To determine, at time of autopsy, the fate of the NSCs. 
Study Design: 
This phase I clinical trial will define the recommended phase II dosing (RP2D)based on dose-limiting toxicities 
(DLTs)and the full toxicity profile of the combination of hCE1m6-NSCs and irinotecan using a standard “3 + 3” 
dose escalation schema in patients with recurrent highgrade gliomas who are undergoing a debulking 
craniotomy or stereotactic brain biopsy. Except for dose levels 1 and -1, where only 1 dose of NSCs will be 
given(these patients can continue toreceive treatment with irinotecan every 2 weeks),NSCswill be administered 
intracranially on days 1 and15, andirinotecan will be given intravenously 2 days later, on days 3 and 17 of a 28 
day cycle.With subsequent cohorts of patients, the NSC dose will be increased as tolerated, but the dose of 
irinotecan will remain the same unless DLTs occur that necessitate lowering the dose of irinotecan.A Rickham 
reservoir/catheter system will be placed at the time of surgery for delivering repeat doses of NSCs intracranially. 
MRIs and PET/CT scans of the brain will be performed at least every two months (at the end of every even cycle 
of study treatment to evaluate response).  
Three doses of NSCs will be assessed. The starting dose will be 5 x 107NSCs, which was well-tolerated in the 
first-in-human study of CD-expressing NSCs. Due to volume limitations for intracerebral administration, the 
highest dose of NSCs to be tested will be 1.5 x 108 cells.Study participants will receive repeat cycles of study 
treatment(dose level 1 and -1 patients will only receive repeat doses of irinotecan) as long as they are tolerating 
the treatment well, and there is no evidence of progressive disease.  
An important secondary objective of this study will be to determine the biologic activity of the hCE1m6-NSCs 
by measuring concentrations of SN-38 in brain interstitium using intracerebral microdialysis. The first 6 patients 
to enroll in the study and the last 8 patients in the expansion cohort will undergo microdialysis to collect data 
regarding intracerebral levels of irinotecan and SN-38 when patients are treated with the lowest and highest 
NSC doses. Please note, the same dose of NSCs (5 x 107) is given to patients on dose levels 1 and 2, so whether 
the first 6 patients are all treated on dose level 1 or the first 3 dose level 1 and the next 3 on dose level 2, they 
will all receive the same dose of NSCs.  
Once the maximum tolerated doseof the combination therapy has been determined, or, if the maxiumum 
tolerated dose is not met, the maximum feasible dose,patients in the expansion cohort will undergo 
intracerebral microdialysis to investigate if treatment with a higher dose of NSCs results in more SN-38 in the 
brain and to directly determine how much the addition of NSCs to treatment with irinotecan increases 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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IRB Protocol No. 14108 
 
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intracerebral levels of SN-38. As such, 4 patients in the expansion cohort will undergo intracerebral microdialysis 
after receiving NSCs at the time of surgery followed 2 days later by IV irinotecan, but the other 4 patients in this 
cohort will not receive NSCs on the day of surgery. Instead they will be given IV irinotecan 2 days after surgery, 
and dialysate samples will be collected from them to determine how much SN-38 is present in the brain from 
treatment with IV irinotecan alone. These 4 patients will then receive their first dose of NSCs through the 
Rickham on day 15 of cycle 1 followed by irinotecan on day 17.Another key secondary objective will be to assess 
for possible development of immune responses to these allogeneic, adenovirally transduced NSCs. Serial blood 
samples will be collected during treatment cycles to assess for the possible development of T cell and antibody 
responsesto the NSCs and/or cell surface-expressed adenoviral proteins, and we will follow adenoviral antibody 
titers.  
Other secondary objectives include describing the clinical benefit in patients who receive treatment with repeat 
cycles of NSCs and irinotecan by obtaining MRIs and PET/CT scans of the brainat least every two months to 
assess response and, when feasible, determining at time of autopsy the fate of the NSCs.  
Endpoints: 
Safety and Feasibility:  1) For Dose Escalation: Dose Limiting Toxicities  
2) Toxicity Profile: All Attributable Toxicities  
Pharmacokinetics: Cmax and AUC of irinotecan and SN-38 in dialysate and plasma. 
Immunogenicity: Evaluate patient blood samples for the development of T cell responses and antibodies 
against the NSCsand/or cell surface-expressed adenoviral proteins using TcR Vβ spectratyping, CD 107 
degranulation assays, and flow cytometry. Measure patients’ serial adenoviral antibody titers. 
Clinical Benefit: Tumor response based on brain MRI and PET/CT scan results. 
Determine the Fate of the NSCs: NSC Persistence 
Sample Size: 
The anticipated sample size is 29patients: minimum=6; maximum=53 (allowing for 42 patients for dose 
escalation through 5 possible dose levels of NSCs and 3 dose schedules of irinotecan, estimating ~3 patients to 
replace unevaluable/ineligible patients and an additional 8 patients for the expansion cohort). 
Estimated Duration of the Study: 
36monthsto complete accrual 
Summary of Subject Eligibility Criteria: 
Inclusion Criteria 
 Patient has a prior, histologically-confirmed, diagnosis of a grade III or IV glioma, or has a prior, 
histologically-confirmed, diagnosis of a grade II glioma and now has radiographic findings consistent 
with a high-grade glioma (grade III or IV). 
  Imaging studies show evidence of recurrent tumor(s). If a patient is going to be enrolled to dose level 
two or higher, the patient must have a component of supratentorial disease (so as to enable placement 
of a Rickham reservoir/catheter) that is amenable to resection or biopsy. 

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 Patient must be in need of a craniotomy for tumor resection or a stereotactic brain biopsy for the 
purpose of diagnosis or differentiating between tumor progression versus treatment-induced effects 
following radiation therapy  chemotherapy. 
 Patient’s high-grade glioma has recurred or progressed after prior treatment with brain radiation and 
temozolomide. 
 Patient must be at least 18 years old and less than 70years old. 
 Patient has a Karnofsky Performance Status of  70%. 
 No limit to prior number of therapies. 
Exclusion Criteria 
 Patient is homozygous for the UGT 1A1*28 allele and/or has Gilbert’s disease. 
 Patient must not be taking any hepatic enzyme-inducing anticonvulsants (phenytoin, carbamazepine, 
phenobarbital, primidone, oxcarbazepine) for at least 2 weeks prior to enrollment.  
 Patients has anti-HLA antibodies specific for HLA class I antigens expressed by the hCE1m6-NSCs. 
 Patient is taking flucytosine. 
Investigational Product Dosage and Administration: 
Dose Escalation Schema 
NSC Dose Level 
Initial 
Enrollment 
 
If 1 DLT, 
Addt’l 
Enrollment 
NSC Dose 
 
NSC and Irinotecana 
Administration 
Week 
1          2          3         4 
-1 
3 
3 
2.5 x 107 
X* 
 
** 
 
1b 
3 
3 
5 x 107 
X 
 
** 
 
2c 
3 
3 
5 x 107 
X 
 
X 
 
3 
3 
3 
1 x 108 
X 
 
X 
 
4d 
3 
3 
1.5 x 108 
X 
 
X 
 
Expansion        
Cohort e 
8 
 
MTD/MFD 
X 
 
X 
 
* ”X” denotes treatment weeks for NSCs and irinotecan. NSCs are administered on Day 1, and irinotecan, 180 
mg/m2/dose, is administered two days post-NSCs on Day 3 of each treatment week. The length of a treatment 
cycles is 28 days.  
**Patients on dose levels 1 and -1 will only receive 1 dose of NSCs, but they will continue to receive irinotecan 
every 2 weeks as long as they are tolerating it well, and there is no evidence of tumor progression. 
aDose schedule A, B, and C will be the NSC dose schema in combination with an irinotecan dose of 180mg/m2, 
150 mg/m2, or 125 mg/ m2, respectively. We will start with irinotecan dose schedule A, de-escalating through 
doses B and C in order as necessary. 
b The first 6 study participants will undergo intracerebral microdialysis to measure levels of irinotecan and NSC-
mediated SN-38 production in the brain. Since the dose of NSCs remains the same for dose level 1 and 2, and 
microdialysis will be performed only with the first dose of irinotecan, all of these first 6 study patients would 

Phase I CE-Secreting NSCs with Irinotecan for High Grade Glioma 
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receive the same dose of NSCs and irinotecan when undergoing intracerebral microdialysis, even allowing for 
escalation to dose level 2. 
c Starting with dose level 2, a Rickham reservoir/catheter system will be placed at the time of surgery for 
administering repeat doses of NSCs.  
d Six patients will be treated on at the maximum tolerated dose (MTD), or, if the MTD is not reached, at the 
maximum feasible dose (MFD). Since it is anticipated that the MTD/MFD will be 150 million NSCs (dose level 4), 
the 6 patients who will be treated on dose level 4 will undergo intracerebral microdialysis and be counted as 
part of the expansion cohort.  
e An expansion cohort of 8 patients will be treated at the MTD or MFDto gain more experience with the 
tolerability of this treatment regimen. These patients will undergo intracerebral microdialysis to assess how 
much SN-38 is produced by highest dose of NSCs and evaluate the biologic activity of the NSCs by directly 
measuring how much the addition of NSCs to treatment with irinotecan increases intracerebral levels of SN-38. 
As such, 4 patients in the expansion cohort will undergo intracerebral microdialysis after receiving NSCs on the 
day of surgery followed 2 days later by IV irinotecan, and the other 4 patients in this cohort will not receive NSC 
administration on the day of surgery. Instead they will be given IV irinotecan 2 days after surgery and dialysate 
samples will be collected from them to determine how much SN-38 is present in the brain from treatment with 
IV irinotecan alone. These 4 patients will then receive their first dose of NSCs through the Rickham on day 15 of 
cycle 1 followed by irinotecan on day 17. 
Clinical Observations and Tests to be Performed: 
Collection of dialysate and blood samples to determine the neuropharmacokinetics of irinotecan and SN-38. 
Only in patients who undergo intracerebral microdialysis—Onday 3 of cycle 1, dialysate samples will be collected 
every 60 minutes for 24 hours and then every 3 hours for the next 24 hours. Blood samples will be drawn just 
prior to the start of the irinotecan infusion and at 90 minutes (just prior to the end of the infusion), and then at 
30 minutes, 1, 2, 4,  8, 24, and 48 hours after the end of the infusion. 
Collection of blood samples for immunologic correlative studies: To assess for possible development of T cell 
and antibody responses to the NSCs and/or cell surface-expressed adenoviral proteins, adenoviral vector (Ad5) 
antibody titers and total adenoviral antibody titers, as well as presence of the NSCs and hCE1m6 in the systemic 
circulation, blood samples will be drawn: prior to surgery, on day 15 of cycle 1 (prior to administering the 2nd 
dose of NSCs), days 1 and 15 of cycle 2,, and then only on day 15 of subsequent treatment cycles.  
Collection of blood samples to perform replication competent retrovirus (RCR) testing as part of long-term 
follow-up: Prior to surgery, at 3 months, 6 months, 1 year, and annually thereafter. 
Brain MRIs and PET/CT scans to assess response: At least every 2 months. 
Statistical Considerations: 

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Tables will be created to summarize all toxicities and side effects by dose, course, organ severity (by NCI CTCAE 
version4.0), and attribution. Rates and associated 95% Clopper Pearson confidence limits will be estimated for 
the DLTsand clinical benefit at the RP2D.Descriptive statistics will be provided for study patient demographics.  
Pharmacokinetic data from patients who undergo intracerebral microdialysis will be summarized using 
descriptive statistics and graphical methods.The biologic activity of the hCE1m6-NSCs, based on comparison of 
microdialysis SN38 PK data from patients receiving NSCs + irinotecan vs patient s receiving irinotecan alone will 
be assessed using a one-sided two-sample t test.Regression analysis will be used to assess the relationship 
between hCE1m6-NSC dose and SN-38 concentrations in brain interstitium using microdialysis data from the 
patientstreated with the initial NSC dose (n=6) and from the patients in the expansion cohort treated with the 
highest NSC dose (n=4).Other secondary objectives include assessing for possible development of NSC 
immunogenicity after first and repeat exposuresand—when feasible—evaluating the fate of the NSCs at 
autopsy. These results will be summarized using descriptive statistics and graphical methods. 
Sponsor: 
City of Hope 
 
 

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Table of Contents 
Experimental Design Schema ........................................................................................................................................ 3 
Protocol Synopsis .......................................................................................................................................................... 5 
List of Abbreviations .................................................................................................................................................... 14 
1 
Goals and Objectives (Scientific Aims) ............................................................................................................... 15 
1.1 
Primary Objectives ............................................................................................................... 15 
1.2 
Secondary Objectives ........................................................................................................... 15 
2 
Background and Rationale ................................................................................................................................. 16 
2.1 
Introduction ........................................................................................................................ 16 
2.2 
Obstacles to Successful Brain Tumor Therapy......................................................................... 17 
2.3 
Human Neural Stem Cells ..................................................................................................... 17 
2.4 
Preclinical Data .................................................................................................................... 18 
2.5 
Clinical Data ........................................................................................................................ 24 
2.6 
Irinotecan for the Treatment of Gliomas ................................................................................ 29 
2.7 
Use of a Rickham reservoir/catheter system for repeat intracranial administration of NSCs. ...... 30 
2.8 
Intracerebral Microdialysis ................................................................................................... 31 
2.9 
Overview of Study Design and Rationale ................................................................................ 32 
3 
Participant Selection .......................................................................................................................................... 34 
3.1 
Eligibility Inclusion Criteria .................................................................................................... 34 
3.2 
Eligibility Exclusion Criteria ................................................................................................... 35 
3.3 
Inclusion of Women and Minorities ....................................................................................... 36 
4 
Screening and Registration Procedures ............................................................................................................. 37 
4.1 
Informed Consent ................................................................................................................ 37 
4.2 
Screening Procedures ........................................................................................................... 37 
4.3 
Registration Requirements/Process ....................................................................................... 37 
4.4 
Dose Level Assignment and Assignment for the Expansion Cohort ........................................... 37 
4.5 
Screen Failures and Registered Participants Who Do Not begin Study Treatment ...................... 37 
5 
Treatment Plan ................................................................................................................................................... 38 
5.1 
Overall Treatment Plan ........................................................................................................ 41 
5.2 
Assigning Treatment and Correlative Study Regimen .............................................................. 42 
5.3 
Phase I Study Design – Determining the MTD ......................................................................... 42 
Table 5.3.1  Phase I Dose Levels for NSCs and Irinotecan ......................................................................... 43 
5.4 
Treatment Plan: Expansion Cohort ........................................................................................ 45 
5.5 
Criteria for Removal from Participation or Treatment ............................................................. 45 
5.6 
Study Stopping Rules ............................................................................................................ 46 
5.7 
Subject Follow-Up ................................................................................................................ 46 

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Concomitant medications, supportive care, and increased monitoring following toxicities ............................. 47 
6.1 
Prophylaxis, Supportive Treatment and Increased Monitoring ................................................. 47 
6.2 
Concomitant Medications ..................................................................................................... 48 
Table 6.2   CYP3A4 Inhibitors and Inducers ............................................................................................. 49 
7 
Expected Toxicities and Dosing Delays/Dose Modifications .............................................................................. 51 
7.1 
Anticipated Toxicities ........................................................................................................... 51 
7.2 
Dose Modifications/Delays/Start of Cycle Criteria................................................................... 52 
Table 7.2.4 Criteria for Disrupting Treatment, Dose Modification or Discontinuation................................. 53 
7.3 
Adjustments to the Treatment Cycle Following an Interruption in Agent Administration ........... 56 
8 
Study Procedures Including Agent Administration ............................................................................................ 58 
8.1 
Pathology Review on Real-Time Frozen Section ...................................................................... 58 
8.2 
Surgery, Catheter Placement, and NSC Administration at the time of Surgery ........................... 58 
Table 8.2a    Craniotomy Procedure ....................................................................................................... 59 
Table 8.2b    Biopsy Procedure .............................................................................................................. 60 
8.3 
Microdialysis Catheter- Related Procedures (Post-Surgery) ..................................................... 63 
8.4 
Administration of Irinotecan ................................................................................................. 65 
8.5 
Intracerebral Administration of NSCs via the Rickham............................................................. 65 
Table 8.5.1  Post-recovery NSC administration on day of surgery ............................................................. 66 
Table 8.5.2  Repeat NSC administration via Rickham ............................................................................... 66 
8.6 
Samples for Performing the Immunological Studies and RCR Testing ....................................... 67 
9 
Agent Information and Risks .............................................................................................................................. 68 
9.1 
hCE1m6 - NSCs (IND # 16265) ............................................................................................... 68 
9.2 
Irinotecan ............................................................................................................................ 68 
10 
Study Calendar ................................................................................................................................................... 70 
Table 10    Study Activity Calendar ......................................................................................................... 71 
11 
Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting ....................................... 75 
11.1 
Data and Safety Monitoring .................................................................................................. 75 
11.2 
Monitoring and Personnel Responsible for Monitoring ........................................................... 75 
Table 11.2   City of Hope PMT Reporting Timelines for the DSMC ............................................................ 75 
11.3 
Definitions ........................................................................................................................... 76 
11.4 
Reporting of Unanticipated Problems and Adverse Events ...................................................... 76 
Table 11.4  City of Hope Adverse Event and Unanticipated Problem Reporting Timelines .......................... 77 
11.5 
Additional Reporting Requirements: FDA and NIH-OBA Reporting ........................................... 78 
11.6 
Medical Device Reportable Events ........................................................................................ 78 
12 
Correlative/Special Studies ................................................................................................................................ 79 
12.1 
Intracerebral microdialysis.................................................................................................... 79 

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12.2 
Immunological Correlative Studies ........................................................................................ 79 
12.3 
Brain Tissue Correlates ......................................................................................................... 81 
13 
Endpoint Evaluation Criteria/Measurement of Effect ........................................................................................ 82 
13.1 
Response Criteria ................................................................................................................. 82 
14 
Data Reporting/Protocol Deviations .................................................................................................................. 83 
14.1 
Data Reporting .................................................................................................................... 83 
Table 14.1.3 Data Submission Schedule ................................................................................................. 83 
14.2 
Protocol Deviations .............................................................................................................. 84 
15 
Statistical Considerations ................................................................................................................................... 85 
15.1 
Sample Size ......................................................................................................................... 85 
15.2 
Accrual Rate ........................................................................................................................ 85 
15.3 
Statistical Design and Analysis ............................................................................................... 85 
16 
Human Subject Issues ......................................................................................................................................... 87 
16.1 
Institutional Review Board .................................................................................................... 87 
16.2 
Recruitment of Subjects ....................................................................................................... 87 
16.3 
Advertisements ................................................................................................................... 87 
16.4 
Study Location and Performance Sites ................................................................................... 87 
16.5 
Confidentiality ..................................................................................................................... 87 
16.6 
Financial Obligations and Compensation ................................................................................ 87 
16.7 
Informed Consent Processes ................................................................................................. 88 
17 
References .......................................................................................................................................................... 89 
Appendix A Karnofsky Performance Status ................................................................................................................. 94 
 
Tables 
Table 5.3.1   Phase I Dose Levels for NSCs and Irinotecan ................................................................. 43 
Table 6.2    
CYP3A4 Inhibitors and Inducers ..................................................................................... 49 
Table 7.2.4  Criteria for Disrupting Treatment, Dose Modification or Discontinuation .................... 53 
Table 8.2a     Craniotomy Procedure ................................................................................................... 59 
Table 8.2b     Biopsy Procedure ........................................................................................................... 60 
Table 8.5.1   Post-recovery NSC administration on day of surgery .................................................... 66 
Table 8.5.2   Repeat NSC administration via Rickham ........................................................................ 66 
Table 10     
Study Activity Calendar .................................................................................................. 71 
Table 11.2    City of Hope PMT Reporting Timelines for the DSMC ................................................... 75 
Table 11.4   
City of Hope Adverse Event and Unanticipated Problem Reporting Timelines ............. 77 
Table 14.1.3 Data Submission Schedule ............................................................................................. 83 

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List of Abbreviations 
Abbreviation 
Meaning 
AE 
Adverse event 
Ad5 
Adenoviral vector Ad5 
AUC 
Area under the curve 
BBB 
Blood brain barrier 
CD 
Cytosine deaminase 
CE 
Carboxylesterase 
CFR 
Code of Federal Regulations 
CICSL 
Clinical Immunobiology Correlative Studies Laboratory 
CNS 
Central nervous system 
COH 
City of Hope 
CR 
Complete response 
CRA 
Clinical research associate 
CRF 
Case report form 
CTCAE 
Common Terminology Criteria for Adverse Events 
DLT 
Dose limiting toxicity 
DNA 
Deoxyribonucleic acid 
DSMC 
Data Safety Monitoring Committee 
FC 
Fluorocytosine 
FDA 
Food and Drug Administration 
FISH 
Fluorescence in situ hybridization 
GCP 
Good clinical practice 
HLA 
Human leukocyte antigen 
IB 
Investigator Brochure 
i.c. 
intracranial 
ICD 
Informed consent document 
IDS 
Investigational Drug Services 
IHC 
Immunohistochemistry 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
KPS 
Karnofsky Performance Status 
LC-MS 
Liquid chromatography – mass spectrometry 
MD 
Microdialysis 
MFI 
Mean fluorescence intensity 
MRI 
Magnetic resonance imaging 
MS 
Mass spectrometry 
MFD 
Maximum feasible dose 
MTD 
Maximum tolerated dose 
NCI 
National Cancer Institute 
NSC 
Neural stem cell 
PBMC 
Peripheral blood mononuclear cell 
PCNA 
Proliferating cell nuclear antigen 
PCR 
Polymerase chain reaction 
PD 
Progressive disease 
PI 
Principal investigator 
PMT 
Protocol Monitoring Team 
PR 
Partial response 
RCR 
Replication competent retrovirus 
RP2D 
Recommended phase II doses 
SAE 
Serious adverse event 
SD 
Stable disease 
SOP 
Standing operating procedure 
SWI 
Susceptibility weighted imaging 
TE 
Echo time 
USPIO 
Ultrasmall superparamagnetic iron oxide 
 
 

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1 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
Primary Objectives 
To define the recommendedphase II doses (RP2D) of intracranially administered hCE1m6-NSCs in combination 
with intravenous irinotecan in patients with recurrent high grade glioma. The RP2D will be based on the 
maximum-tolerated dose (MTD), or if the MTD is not reached, the maximum feasible dose (MFD), and the full 
toxicity profile including toxicities associated with repeat doses of NSCs.  
Secondary Objectives 
 
To describethe relationship between hCE1m6-NSC dose and SN-38 concentrations in brain interstitium. 
 
To characterize the relationship between intracerebral and systemic concentrations of irinotecan and 
SN-38. 
 
To investigate the biologic activity of hCE1m6 NSCs by comparing SN-38 concentrations in the brain after 
treatment with hCE1m6-NSCs and irinotecan versus irinotecan alone.  
 
To assess for possible development of adenovirally transduced NSC immunogenicity after first exposure 
and with repeat doses of NSCs.  
 
To describe the clinical benefit (defined as stable disease, partial response, or completeresponse) in 
patients who receive treatment with repeat cycles of NSCs and irinotecan.  
 
To determine, at time of autopsy, the fate of the NSCs. 

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2 
BACKGROUND AND RATIONALE 
Introduction 
High-grade gliomas are difficult to treat due to their relative resistance to chemotherapy and radiation, as well 
as their highly invasive nature. Human neural stem cells (NSCs), modified to express a therapeutic transgene, 
hold great promise for glioma therapy due to their inherent tumor-tropic properties and their potential use as 
vehicles for delivering chemotherapy directly to infiltrating glioma cells. Data from animal models have 
demonstrated the safety and efficacy of NSCs for tracking to invasive tumor cells as well as to distant micro-
tumor foci and delivering therapeutic gene products to tumor cells.  
In our recently completed first-in-human pilot study of the parent NSC line (cytosine deaminase(CD)-expressing 
NSCs given in combination with oral fluorocytosine (5-FC), we showed that treatment with 1 dose of CD-
expressing NSCs followed by a 7 day course of 5-FC was safe and feasible in patients with recurrent high-grade 
gliomas. With intracerebral microdialysis, we documented proof-of-concept—that the NSCs converted the 
prodrug 5-FC to its active metabolite 5-FU locally in the brain. Results of immunologic correlative studies 
documented no findings of NSC immunogenicity after first exposure. Magnetic resonance imaging (MRI) of iron-
labeled NSCs showed preliminary evidence of NSCs migrating away from the injection sites, and autopsy results 
from 2 study patients showed evidence that NSCs had traveled to distant sites of tumor in the brain. 
NSCs can overcome obstacles of drug-delivery that limit current gene therapy strategies and provide an effective 
anti-tumor response.  In this phase I clinical trial we will use a v-myc-immortalized human NSC line (HB1.F3.CD) 
that has been adenovirally transduced to express a highly active modified human form (hCE1m6) of 
carboxylesterase (CE) for efficient conversion of the prodrug irinotecan to its more potent metabolite, SN-38. 
The HB1.F3.CD NSC line has been well-characterized, favorably reviewed by the NIH RAC, and established as a 
Master Cell Bank at the COH Center for Biomedicine & Genetics. 
We hypothesize that in patients with recurrent high-grade glioma, hCE1m6-NSCs will distribute throughout the 
primary tumor site as well as co-localize with infiltrating tumor cells within 2 days of administration. Study 
patients will then be treated with intravenously administered irinotecan. The CE-secreting NSCs will locally 
convert irinotecan to SN-38 (Figure 1), thereby generating concentrated cytotoxicity at sites of tumor in the 
brain. 
 
 
Figure1. Schematic showing NSCs secreting CE enzyme, which converts irinotecan into the more cytotoxic SN-
38. 

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Obstacles to Successful Brain Tumor Therapy 
Despite recent advances in molecularly targeted therapies for cancer, brain tumors remain a serious challenge 
for oncologists. Approximately 22,500 people a year are diagnosed with a malignant primary brain tumor in the 
United States (CBTRUS 2008). Gliomas account for the majority of these tumors and are virtually incurable. 
Despite recent advances in molecularly targeted therapies for cancer, primary brain tumors, particularly high-
grade gliomas, remain a serious clinical challenge for oncologists. A major obstacle to successful pharmacologic 
treatment of central nervous system (CNS) tumors is the blood-brain barrier (BBB), which prevents most anti-
cancer agents from entering the CNS.  Another key reason for the lack of success in treating gliomas is their 
diffuse and highly infiltrative nature; no clear border exists between tumor and normal brain. Glioma cells 
disseminate from the primary site, forming micro-tumor foci throughout the brain that often “hide behind” an 
intact BBB.  
The inability to deliver therapeutic agents to where they are needed likewise inhibits the effectiveness of gene 
therapy. Cell-mediated vector delivery is limited by the ability of the carrier cell line to migrate through the brain 
with sufficient biodistribution throughout primary and distant tumor sites. To make a significant impact on the 
survival of brain tumor patients, new therapies must not only be able to navigate through or around the BBB, 
but they should also specifically target the invasive tumor cells that escape currently available treatments while 
minimizing toxicity to normal tissue. 
Human Neural Stem Cells 
Because NSCs (murine and human) demonstrate an inherent ability to distribute throughout a tumor mass and 
can target distant tumor foci, NSCs that are genetically modified to express a therapeutic transgene have the 
potential to overcome many of the obstacles facing current strategies for brain tumor therapy.  Tumor-tropic 
human NSCs potentially offer a major therapeutic breakthrough for brain tumors, overcoming limitations of 
currently available therapies by efficient tumor distribution and the ability to deliver a wide range of therapeutic 
agents directly to invasive tumor cells and distant tumor micro-foci throughout the brain. 
NSCs can be engineered to express various therapeutic agents.  Several studies in rodent models of orthotopic 
glioma have demonstrated the ability of intracranially administered NSCs that express a therapeutic transgene, 
to significantly reduce tumor burden and/or increase long-term survival.  Therapeutic agents delivered via NSCs 
include prodrug activating enzymes (Aboody et al., 2000, 2006; Brown et al., 2003; Danks et al., 2007; Kim et al., 
2006a) viral vectors {Herrlinger, 2000 #247}, apoptotic agents {Kim, 2005 #653;Shah, 2005 #716}, anti-angiogenic 
agents {Kim, 2005 #222}, monoclonal antibodies (Frank et al., 2009), interleukins {Benedetti, 2000 
#572;Ehtesham, 2002 #601;Yuan, 2006 #2069}, and IFN- β {Dickson, 2007 #1521}. 
HB1.F3 NSCs were generated from human fetal telencephalon, retrovirally immortalized with the v-myc 
oncogene, cloned and extensively characterized over time and passage for tumor tropism, genetic stability and 
non-tumorigenicity. (Kim et al., 2002, 2004, 2005a; Jeong et al., 2003; Ryu et al., 2003; Schmidt et al., 2005). 
Both parental HB1.F3 NSCs and HB1.F3 NSCs modified to express therapeutic transgenes (Aboody et al., 2000) 
have demonstrated efficacy in pre-clinical models of glioma (Aboody et al., 2013), breast cancer brain 
metastases (Joo et al., 2009), medulloblastoma (Kim et al., 2006a; Gutova et al., 2012), and metastatic 
neuroblastoma (Aboody et al., 2006a; Danks et al., 2007).  In addition to being used as a vehicle to target 
therapeutic agents to invasive tumors, this parental HB1.F3 line has also been modified to demonstrate 
therapeutic efficacy in models of Parkinson’s disease (Kim et al., 2004, 2006b; Ryu et al., 2005) Huntington’s 
disease (Kim et al., 2004, 2007; Ryu et al., 2004; Lee et al., 2007), cerebral ischemia (Chu et al., 2003, 2004a; Lee 
et al., 2007a, 2007b) and spinal cord injury (Kim et al., 2007). 

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Preclinical Data 
2.1.1 
Human NSC Tumor Tropism 
Human NSCs possess an inherent ability to distribute throughout a tumor mass and can target distant tumor 
foci. We (Aboody et al., 2000) were the first to demonstrate the tumor tropic properties of NSCs with a v-myc–
immortalized, clonal murine NSC line (C17.2).  When injected either directly into orthotopic experimental glioma 
or at a distance (contralateral hemisphere, contralateral ventricle, or intravasculary via the tail vein), C17.2 
murine NSCs migrated to and efficiently distributed throughout the main tumor mass, as well as localized to 
satellite tumor foci. These ground-breaking observations have been confirmed for multiple NSC lines and 
primary pools in many laboratories (reviewed in Aboody et al., 2008). 
NSCs can migrate to tumor sites regardless of tumor size, anatomic location, or tissue of origin (reviewed by 
Aboody et al., 2008). When administered intracranially or intravenously in pre-clinical brain tumor models, NSCs 
migrate to orthotopic gliomas {Aboody, 2000 #557;Kim, 2005 #653}, medulloblastoma {Kim, 2006 
#1523;Shimato, 2007 #2970}, and melanoma brain metastases {Aboody, 2006 #2213}. Migration of HB1.F3.CD 
NSCs is not affected by the presence of dexamethasone or prior radiation to the brain (Aboody, unpublished 
data). The ability of NSCs to efficiently cross the BBB provides an attractive advantage in treating CNS tumors.   
Transduction with retrovirus, lentivirus, or adenovirus does not affect their migratory potential, as similarly 
assessed {Najbauer, 2007 #13162;Kendall, 2008 #16627;Aboody, 2008 #13268;Mingozzi, 2007 #29278;Muller, 
2006 #676;Passier, 2008 #29292;Bhagavati, 2008 #29293}. Studies with HB1.F3 cells that were adenovirally-
transduced with a transgene to express rabbit(r) CE, (HB1.F3.C1) showed that NSCs localized to neuroblastoma 
metastases in the liver, lung, ovaries and bone marrow. NSCs were rarely found in non-tumor-bearing tissues 
(lung, liver, and spleen) at 3-4 days post- tail vein injection, and none were found in non-tumor-bearing brain, 
kidney, heart, intestine, or skin (Aboody, et al., 2006c). 
2.1.2 
Immortalized Human NSCLines Do Not Cause Secondary Tumors 
Preclinical data and results of early clinical trials indicate that the most likely toxicity of cell-based gene therapies 
is the development of secondary malignancies {Pike-Overzet, 2007 #13201}. All of our studies haveincluded 
tissue assessment for potential NSC-induced tumors.  To date, NSCs have not initiated tumors in any of the 
normal control or tumor model animals, when followed up to 12 months. All published pre-clinical in vivo studies 
using HB1.F3 cells for CNS disease applications have reported no HB1.F3 tumorigenicity, even up to 1 year 
following NSC administration {Kim, 2004 #654;Lee, 2007 #1518;Lee, 2007 #1519;Kim, 2007 #1517;Danks, 2007 
#1515;Yasuhara, 2006 #1522;Kim, 2006 #1527;Kim, 2006 #1523;Aboody, 2006 #2212;Kim, 2005 #1538;Kim, 
2005 #653;Chu, 2005 #1531;Kim, 2004 #654}. 
2.1.3 
NSCImmunogenicity Data 
Aboody and colleagues (Aboody et al., 2013) investigated whether HB1.F3.CD NSCs induce an immune response 
from the host, resulting in possible rejection of the NSCs.  In an immunocompetent, syngeneic orthotopic glioma 
model (Gl261 glioma in C57B mice), although HB1.F3.CD NSCs do elicit a subacute, localized immune response 
characterized by detectable T-cell infiltration (similar to the reaction generated by other types of cellular 
injections), viable HB1.F3.CD NSCs persisted for at least 2 weeks.  Of note, no immunosuppression was given to 
the mice, and no global adverse immunogenic responses were observed.  
Based on these data, we do not expect the NSCs to be immuno-rejected in the first 2–3 weeks after 
administration. When NSCs are used as delivery vehicles, they do not need to engraft. They must only survive 
long enough to mediate the effective therapy. Therefore, although the NSCs may be immuno-rejected over time, 
this would not likely happen before the end of a treatment cycle.  

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HLA typing results of HB1.F3 cells found that while these NSCs do have HLA class I antigens (A*01, A*31, B*07, 
B*15, C*07), they do not express HLA class II antigens (DRB1*10, DRB1*13, DQB1*05, DQB1*06, DPB1*02, 
DPB1*15). Other investigators(Kim, 2009) have reported extremely low levels of expression of HLA class II 
antigens by HB1.F3 cells. In the presence of tumor, the NSCs do not appear to differentiate, and therefore, they 
would not express HLA class II antigens. Whether or not the clinical utility of these NSCs will be limited by 
development of immune responses from repeat exposure to these allogeneic NSCs, which have been further 
modified by adenoviral transduction to also express CE, is unknown (and will be investigated in this phase I 
study)but preclinical data indicate that the immunogenicity of the HB1.F3.CD NSC line is not prohibitive. 
2.1.4 
Iron Particle Cellular MRI for Real-Time Assessment of NSC Biodistribution 
Ultrasmall superparamagnetic iron oxide (USPIOs) preparations can enable non-invasive, real-time tracking of 
NSCs by MRI. Inprevious studies, we demonstrated the effectiveness of MRI to track NSCs labeled with clinical 
grade SPIO, ferumoxide (Feridex®) in orthotopic glioma-bearing mice (Thu et al., 2009). Safe use of SPIO MRI 
contrast agents in patients has been demonstrated for central nervous system tumor visualization and diagnostic 
MRI purposes (Neuwelt et al., 2007). We have now developed a cell labeling technique that can be safely and 
effectively used in the clinical setting for MRI tracking of NSCs in the brain. Specifically, we modified a previously 
developed protocol (Thu et al., 2012) for cell labeling with a clinical grade USPIO, ferumoxytol (Feraheme®) to 
optimize labeling of the NSCs. We have demonstrated in orthotopic glioma xenograft mouse models that 
Feraheme-labeled HB1.F3.CD.hCE1m6.NSCs or Fehe-NSCs) can be detected in a typical 7 Tesla mouse imaging 
voxel as hypointense signal (black)after intracranial (i.c.) administration (Fig. 2A-D). Note that the Fehe-NSCs 
(blue) distributed within tumor (dark pink) and at invasive tumor edges and foci (Fig. E-H), corresponding with 
hypointense signal by MRI. Tumor cells confirmed by staining with eGFP-DAB (brown, Fig. I-L). 
 

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Figure 2.  Intracranially injected Feraheme-labeled NSCs migrate and distribute to orthotopic U251 human gliomas in an 
immunodeficient mouse model. Intracerebral glioma xenografts in mice were established by stereotactic implantation of 2 
× 105  U251.eGFP.ffluc human glioma cells into the right frontal hemisphere.  Three days later, varying numbers of Fehe-
NSCs(1 × 104, 5 × 104, 1 × 105, 2 × 105) were injected ipsilaterally, caudal-lateral to the tumor. (A-D): T2-weighted MR images 
of mouse brains obtained 4 days after NSC administration.  Red arrows indicate hypointense (black) signals associated with 
Fehe-NSCs. Boxed areas are magnified in the image insets. (E-H) Prussian blue stained and pararosaniline counterstained 
mouse brain sections containing tumor and NSCs.  Fehe-NSCs that migrated to tumor are stained blue. (I-L) Tissue sections 
adjacent to Prussian blue sections in (E-H) were immunohistochemically stained for eGFP-DAB to identify tumor cells 
(brown). Sections were counterstained with hematoxylin. Note blue NSCs within tumor nodules and at infiltrative tumor 
sites. Scale bars, 200 µm. 
The iron-labeled cells do not exhibit significant changes in viability, proliferation, and migratory properties, or 
transgene expression compared to non-labeled cells (Gutova et al, Stem Cells Trans Med, in press, 2013). 
Preclinical safety/toxicity studies in mice using intracranially injected Feraheme-labeled HB1.F3.CD NSCs, 
demonstrated no clinical adverse effects, and histopathologic analysis revealed no evidence of neurotoxicity or 
toxicity to other organs (Gutova et al., Stem Cells Trans Med, in press, 2013).  
2.1.5 
Preclinical Development of hCE1m6, A Modified Form of Human CE 
Comparison of rabbit liver CE (rCE) to human CE (hCE1) revealed that the former enzyme more efficiently cleaved 
irinotecan to SN-38 (Danks, Morton et al. 1999; Bencharit, Morton et al. 2002). The reaction catalyzed by CE 
requires a relatively anhydrous environment, thus CEs have evolved to accommodate this by having a deep 
catalytic site, termed the catalytic gorge. Crystallographic studies revealed that for the human isozyme, large 
substrates such as irinotecan are unable to enter the catalytic gorge due to the lack of flexibility of the amino 
acids present in nearby loop domains (Bencharit, Morton et al. 2003). Based on these observations and extensive 
enzymologic studies carried out on CE, a chimera was designed incorporating sequences from the rabbit CE (rCE) 
enzyme into the human isozyme, hCE1 (Wierdl, Tsurkan et al. 2008). Eight amino acids were substituted in this 
engineered recombinant hCE which was termed hCE1m6 (Hatfield, Wierdl et al. 2008; Wierdl, Tsurkan et al. 
2008). For preclinical development, our group chose to test both the rCE and hCE1m6 in parallel. The CE that 
performed the best in vitro and in preliminary in vivo microdialysis studies was to be carried forward in more 
extensive animal studies. 
Our data supported the equivalence of hCE1m6 to rCE: (1) both enzymes had comparable enzymatic activity in 
vitro, (2) both equally sensitized glioma cells to irinotecan in vitro, (3) the conversion of irinotecan to SN-38 was 
roughly the same in rat brain when each were expressed by intracranially-administered NSCs and administered 
intracranially. Given the equivalency of the two enzymes in a variety of studies, the final choice to use hCE1m6 
was based primarily on the potential for eliciting an immune response in humans using a lymphocyte 
degranulation assay. The hCE1m6-expressing NSCscaused less degranulation by CD4+ t cells than those 
expressing rCE. The difference in the degranulation response was statistically significant at p = 0.028. 
The gene therapy agent that will be used in this phase I study is HB1.F3.CD. hCE1m6 NSCs, which will be produced 
by thawing HB1.F3.CD NSCs from the Master Cell Bank at passage (p)20 and expanding to p27-p28 under 
standard culture conditions at a seeding density of 2 x 104 cells/cm2; 30-40 ten layer cell factories will be used. 
The NSCs will then be transduced with clinical grade hCE1m6 adenovirus (at a multiplicity of infection of 20) 
from the Master Viral Seed Stock produced at the City of Hope Center for Biomedicine and Genetics and 
harvested 24 hours later for freeze down in Cryostor 10 at 50 million cells per vial. 
2.1.6 
hCE1m6-Expressing-NSCs Increase the Concentration of SN-38 in Tumor-Bearing Brain Tissue 
The purpose of this experiment was to determine irinotecan and SN-38 levels at various times afteririnotecan 
treatment in normal and tumor-bearing brain tissue in the presence and absence of hCE1m6-NSCs.  

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Es1(e)/SCID mice bearing intracranial U251T human glioma were injected i.c. with either 500,000 hCE1m6-NSC 
or PBS. Three days later, irinotecan was given at 3.75 mg/kg or 7.5 mg/kg via tail vein injection. Groups of 3 mice 
each were then sacrificed at 1 or 4 hours post-irinotecan administration, and brains were harvested and 
quartered. Normal brain tissue was sampled from brain contralateral to where the tumor was engrafted. Normal 
brain and tumor tissues wereanalyzed by LC-MS/MS to determine irinotecan and SN-38 levels.  
We observed levels of irinotecan in the 500 nM range in normal brain and slightly more elevated levels in tumor-
bearing tissue, with no observable difference in irinotecan concentrations in the presence or absence of 
hCE1m6-NSC (data not shown). In the absence of hCE1m6-NSCs, SN-38 in brain would be predicted to come 
from systemic metabolism of irinotecan in organs such as the liver and gut, but because this compound crosses 
the blood brain barrier even more poorly than irinotecan, the levels in brain would be expected to be very low, 
and this was indeed the case (Figure 3). With the addition of hCE1m6-NSC, SN-38 concentrations in tumor tissue 
were approximately 3-fold higher than in the absence of NSCs. Moreover, there was an irinotecan dose-
dependentincrease in SN-38 levels in tumor tissue. In normal brain, we did not observe an increase in SN-38 
concentrations with the addition of hCE1m6-NSC likely because the NSCs were administered contralateral to 
where the sample was taken and remained in the vicinity of the tumor.  
Taken together, these findingsunderscore the basic tenet of this technology: CE-expressing NSCs can increase 
SN-38 locally at the tumor site while limiting exposure to normal tissue. The in vitro IC50’s of various glioma cells 
to SN-38 are in the range of 5 to 100nM. The average intratumoral SN-38 levels at one and four hours after 7.5 
mg/kg irinotecan administration in animals that received hCE1m6-NSCs were 31.3 and 7.9 nM, respectively. In 
contrast, average SN-38 levels in tumor tissue of the animals that did not receive NSCs were 12.7 nM and 1.4 
nM at one and four hours, respectively. These results provide in vivo proof-of-principleregarding hCE1m6.NSC 
mediated conversion of irinotecan to SN-38, resulting in exposure of the tumor tissue to cytotoxic concentrations 
of SN-38.  
 
Figures 3. Es1(e)/scid mice bearing intracranial U251T human gliomas were injected i.c. with either 500,000 
HB1.F3.CD.hCE1m6 or PBS. Three days later, the mice were given 3.75 mg/kg or 7.5 mg/kg irinotecan via tail vein injection. 
Groups of 3 mice each were then sacrificed at 1 hour and 4 hours after irinotecan administration, and tumor-bearing and 
normal brain tissue were harvested for irinotecan (not shown) and SN-38measurement by LC-MS/MS. 
2.1.7 
Conversion of Irinotecan to SN-38 is Highest on Day 2 Following hCE1m6-NSCAdministration. 
In order to determine the optimal timing of irinotecan administration after injection of NSCs, we performed an 
experiment where irinotecan was given intravenouslyto tumor-bearing mice either 2, 4,or 7 days afteri.c. 
3.75 mg/kg irinotecan
1 hr
4hr
0
10
20
30
40
50
No NSC, Normal brain tissue
NSC.CE, Normal brain tissue
No NSC, Tumor-bearing brain
NSC.CE, Tumor-bearing brain
SN-38 Concentration [nM]
p=.084
p=0.086
7.5 mg/kg irinotecan
1 hr
4hr
0
10
20
30
40
50
SN-38 Concentration [nM]
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administration of hCE1m6-NSCs. Figure 4 shows the average SN-38 concentrations in tumor tissue one hour after 
irinotecan was given through the tail vein. These results demonstrate that peak SN-38 production occurs2 days 
following NSC administration. As in our previous tissue PK experiment, there were no differences in SN-38 levels 
in normal brain with or without NSCs (data not shown), further demonstrating the tumor specificity of the 
increased production of SN-38 by the NSCs. The average difference in SN-38 levels in tumor from animals that 
received NSCs and those that did not was approximately 8-fold higher. The fold difference in tumoral SN-38 
levels 4 days after NSC administration dropped to approximately 2-fold, and there was no difference in tumor 
tissue SN-38 when we waited 7 days between NSC and irinotecan administration. The average SN-38 level in 
tumor tissue 2 days after NSCs was 111 nM compare to 14 nM without NSCs.Based on these results, for the 
phase I clinical trial irinotecan will be given 2 days after the NSCs are administered.  
 
Figure 4. SN-38 concentration in tumor tissue harvested 1 hr post irinotecan administration [7.5 mg/kg] either 2, 4, or 7 
days following intracranial injection of hCE1m6-NSCs or harvested at equivalent times but without NSCs (n=6 mice per 
group). Data were analyzed using 2-Way ANOVA. All possible comparisons were made using Holm-Sidek method to correct for 
multiple comparisons. SN-38 concentrations were greatest when irinotecan was administered on day 2 in the presence of hCE1m6-
NSCs.  
2.1.8 
Production of SN-38 by hCE1m6-NSCsin Tumor is Irinotecan Dose and Schedule Dependent. 
Once the optimal timing of irinotecan dosing relative to NSC administration was determined, we performed an 
experiment to assess the effect of irinotecan dose and schedule on intratumoral levels of SN-38. For this 
experiment, irinotecan was given intravenously to tumor-bearing mice at doses of 7.5 mg/kg or 18.75 mg/kg 
beginning 2 days after i.c. administration of hCE1m6-NSCs. Animals in the group receiving 7.5 mg/kg were given 
3 daily irinotecan doses to simulate the multiple daily dosing schedule, while mice in the 18.75 mg/kg group 
received a single dose to simulate the bolus dosing schedule. Cohorts of  mice (n=5) were sacrificed at 1, 4, and 
8 hours after either the third dose of 7.5 mg/kg (daily dosing group) or after the single irinotecan dose of 18.75 
mg/kg (bolus dosing group). Additional control groups of mice were given a single dose of 18.75 mg/kg in the 
absence of NSCs. Tumor and contralateral brain tissues were collected for analysis of SN-38 concentrations by 
LC-MS/MS.  
Figure 5 shows the average SN-38 concentrations in tumor tissue over an 8 hour time course following the 
administration of irinotecan via tail vein. As seen in the figure, the average peak SN-38 level following a dose of 
18.75 mg/kg plus NSCs was >10-fold higher than following the same irinotecan dose given without NSCs (92.7 vs 
8.6 ng/gm; p=0.018). The AUC0-8hr of SN-38 after a dose of 18.75 mg/kg was >8-fold higher when given with NSCs 
 SN-38 Levels in Tumor-Bearing Brain 
Day 2
Day 4
Day 7
0
50
100
150
200
250
Days Post NSCs
SN-38 Concentration [nM]
No hCE1m6.NSC
+hCE1m6.NSC
p<0.0001
p<0.0001
p<0.0001

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compared to without (286.4 versus 33.8 ng/gm x hr). As in our previous tissue PK experiments, there were no 
differences in SN-38 levels in normal brain with or without NSCs (data not shown). Average tumoral SN-38 
concentrations following the third daily irinotecan dose of 7.5 mg/kg plus NSCs were similar to the 
concentrations measured following a dose of 18.75 mg/kg given without NSCs. Therefore, the average peak SN-
38 level following a dose of 18.75 mg/kg plus NSCs was >7-fold higher than following the third daily dose of 7.5 
mg/kg plus NSCs (92.7 vs 12.4 ng/gm; p=0.021). Furthermore, the tumoral AUC0-8hr of SN-38 after a single dose 
of 18.75 mg/kg plus NSCs was >6.5-fold higher than after the third dose of 7.5 mg/kg plus NSCs (286.4 versus 
41.8 ng/gm x hr). 
 
 
 
 
 
 
 
 
 
 
Figure 5. SN-38 concentration in tumor tissue post administration of 18.75 mg/kg plus hCE1m6-NSCs (blue bars), 18.75 
mg/kg without NSCs (red bars), or 7.5 mg/kg/day x 3 days (green bars). N=5 for each group. 
These results demonstrate that the production SN-38 by hCE1m6-NSCs is highly dependent on the dose and 
schedule of irinotecan administration.  In other words, higher doses of irinotecan result in higher SN-38 peak 
levels and total exposures (i.e. AUC) specifically in tumor.  Taken together, the results of this experiment and 
the previous experiment regarding the optimal timing indicate that the maximum benefit of the addition of 
hCE1m6-NSCs to irinotecan treatment will be obtained by giving the highest irinotecan dose possible within 2 
days of NSC administration. 
2.1.9 
Efficacy of NSC-Mediated Therapy in Preclinical Models 
HB1.F3 NSCs modified to express the therapeutic transgenes, CD and/or rCE,have demonstrated efficacy in pre-
clinical models of glioma (Aboody et al., 2000 and unpublished data), medulloblastoma (Kim et al., 2006; Gutova, 
et al., 2012) and metastatic neuroblastoma (Aboody et al, 2006b; Danks et al., 2007).  
 Results from our long term survival efficacy study in U251 bearing Es1(e)scid mice (Figure 6)  demonstrate a 
statistically significant increase in survival with 2 or 4 weekly treatment rounds of hCE1m6-NSCs (250,000) in 
combination with irinotecan 37.5 mg/kg (equivalent to the human dose of 125 mg/m2) as compared to irinotecan 
alone. Group D receiving two rounds of CE-NSCs + irinotecan treatment had significantly longer survival times 
than group B receiving two rounds of irinotecan only (p=0.0362). Similarly, group E receiving four rounds of CE-
NSCs + irinotecan had significantly longer survival times than group C receiving four rounds of irinotecan only 
(p<0.0001). 
0
20
40
60
80
100
120
140
160
1
4
8
Tissue SN-38 conc. (ng/gm)
Time (hours)
Intratumoral SN-38 PK
hCE1m6 + 18.25 mg/kg
No NSCs + 18.25 mg/kg
hCE1m6 + third dose of 7.5 mg/kg

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Figure 6. Survival advantage of mice treated with hCE1m6-NSCs + irinotecan. Five groups of twelve mice bearing orthotopic 
U251.eGFP.ffluc were left untreated (grp A); treated with 2 or 4 weekly IC injections of hCE1m6-NSCs (grps D and E) followed 
2 days later by in IV bolus of irinotecan (37.5 mg/kg/wk) or 2 or 4 weeks of irinotecan alone (grps B and C). 
Clinical Data 
We recently completed a pilot feasibility study  (Portnow et al., 2013a)of the first generation of genetically-
modified NSCs (HB1.F3.CD NSCs) and oral 5-fluorocytosine (5-FC), which the NSCs convert to 5-fluorouracil (5-
FU). In this first-in-human study, patients with recurrent high-grade glioma were given one dose of CD-
expressing NSCs intracranially at the time of tumor resection or biopsy followed by one 7-day course of 5-FC.  
2.1.10 Safety 
A total of 18 patients were consented for the study. Three of these patients were determined to be ineligible 
prior to the start of study treatment due to testing positive for an antibody to one of the NSC HLA antigens, 
which was one of the study’s exclusion criteria. Of the 15 patients who received study treatment, 3 had to be 
replaced due to being inevaluable for toxicity: 2 died from early progression of disease, and 1 died from a post-
surgical complication. This 3rd patient died from an intracerebral bleed occurring in a vessel at the surgical 
margin. NSCs had not been injected in that area. 
All of the patients tolerated the NSCs well.There were no toxicities associated with intra-operative injection of 
the NSCs into the wall of the tumor resection cavity or tumor biopsy site. Furthermore, no grade 3 or 4 toxicities 
related to the NSCs occurred. There was 1 dose-limiting toxicity which was felt to possibly be due to 5-FC. A 
patient on dose level 3 developed transient grade 3 increased ALT and AST. Since elevation of liver function tests 
is a known side effect of 5-FC, this grade 3 toxicity was attributed as being possibly related to the 5-FC, but the 
patient also had gallstones, and it was felt that the clinical presentation of his transaminitis was most consistent 
with an episode of biliary colic. Nonetheless, since an association with 5-FC could not be ruled out, dose level 3 

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was expanded to treat 3 additional patients. No further hepatic toxicity has occurred in those 3 patients, 
although 2 of them have not yet completed the full toxicity evaluation period.  
With this first-in-human study the FDA would only allow patients to be treated with one round of NSCs and 5-
FC, thus clinical benefit was not a primary or secondary objective of the study. The starting dose of NSCs was 
approximately 60% lower than the human equivalent of the lowest dose tested in safety/efficacy studies in mice. 
Although in most study patients, tumor growth was seen on the one month follow-up MRI, 1 patient on dose 
level 3 did not have evidence of progressive disease until 5 months after tumor resection and start of study 
treatment. 
2.1.11 Establishing Proof-of-Concept 
Using the technique of intracerebral microdialysis (please see section 2.8 for details of this technique), we 
demonstrated proof-of-concept—that the CD-expressing NSCs are converting 5-FC to 5-FU in the brain—by 
measuring intracerebral levels of 5-FC and 5-FU and comparing them to concentrations in plasma. Intracerebral 
microdialysis data from all 3 dose levels (figure 7) document that the NSCs are converting 5-FC to 5-FU in the 
brain. At the highest dose level of NSCs, the average steady-state concentrations of 5-FU in the brain was 
63.9±7.9 nM. The average maximum 5-FU level in brain was 104±88 nM compared to 24±36 nM in plasma, 
indicating local production of 5-FU in the brain by the NSCs. 
 
 
 
 
 
 
 
 
 
 
 
Figure 7. 5-FC and 5-FU Intracerebral Microdialysis Data. 
Analysis of the plasma samples revealed 5-FC concentrations similar to previously reported values in patients 
taking 5-FC to treat infections. Brain interstitial 5-FC levels were approximately 20-30% of plasma levels. Plasma 
5-FU was detectable in roughly one third of patients studied, but plasma levels were always well below the brain 
interstitial 5-FU concentrations in these patients. We conclude that 5-FU is produced by enterobacteria in the 
gut in a subset of patients taking 5-FC; however, the resulting systemic levels of 5-FU cannot explain the levels 
measured in the brain. Therefore, most, if not all, of the 5-FU measured in brain interstitium must be coming 
from local production by the CD-transduced neural stem cells. Figure 8shows documentation that the NSCs 
continued to convert 5-FC to 5-FU during the entire 5-FC dosing interval. 
 
0.1
1
10
100
1000
10000
100000
1000000
0
4
8
12
16
20
24
28
32
Conc. (nM)
Hours
Arm 1 - 5FC (N=4)
Arm 2 - 5FC (N=2)
Arm 3 - 5FC (N=3)
Arm 1 - 5FU (N=4)
Arm 2 - 5FU (N=2)
Arm 3 - 5FU (N=3)
5-FU 
5-FC 
5-FC Start 

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Figure8. Intracerebral microdialysis data from a study patient demonstrate the ability of the NSCs to convert 5-FC to 5-FU 
in the brain throughout the 7-day course of oral 5-FC. In this particular patient there were no detectable levels of 5-FU in 
the plasma, indicating that all of the 5-FU measured in the brain came from NSC conversion of 5-FC. 
2.1.12 Immunologic Correlative Studies 
2.5.3.1Evaluation of T Cell Responses 
Serial blood samples were obtained from patients prior to surgery and on days 4, 10, 32, and 60 to assess for T 
cell responses to the NSCs. Peripheral blood mononuclear cells (PBMCs) were evaluated by co-culture with the 
NSCs followed by flow cytometry assessment of degranulation (CD 107 mobilization). Results from patients in 
dose levels 1 and 2, as well as the first 4 patients in dose level 3, show no evidence of persistently elevated levels 
of degranulating T-helper (CD4+) or cytotoxic T lymphocyte (CD8+) responses to the NSCs (figure 9). 
B. 
 
Figure 9 Evaluation of T Cell Responses: Representative Patient Examples. A) CD4+ and CD8+ T cells from patient #1 
fluctuated in the range of 0-2%, beginning and ending low. Natural killer (NK) cells were under 1%. B) CD4+ and CD8+ T cells 
from patient #4 had very low levels of degranulation (<2%) at all time points. NK cells in this patient’s samples degranulated 
at 2-10%, but there was no evidence of increase over time.  
2.5.3.2Evaluation of Humoral Responses 
Blood samples were obtained prior to surgery, and on days 32 and 60 to look for evidence of development of 
anti-NSC antibodies in patients’ sera by flow cytometric evaluation of antibody binding to NSCs. Data from 
patients in dose levels 1 and 2, as well as the first 4 patients in dose level 3 (figure 10), show no detection of 
anti-NSC antibodies outside the normal range after first exposure (Portnow et al., 2012). 
1
10
100
1000
10000
100000
1000000
0
24
48
72
96
120
144
168
Hours
Conc. (nM)
Brain 5-FC
Brain 5-FU
Plasma 5-FC
Plasma 5-FU
Study Patient #1
0
20
40
60
0
5
10
15
CD4 Degranulation %
CD8 Degranulation %
CD4 Positive Control
CD8 positive control
Days
% of cells degranulating
Study Patient #4
0
20
40
60
0
5
10
15
CD4 Degranulation %
CD8 Degranulation %
CD4 Positive Control
CD8 positive control
Days
% of cells degranulating

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Figure 10. Results of anti-NSC antibody testing. Normal donor sera: n=10. Each data point for normal sera 
represents the mean of 5 independent experiments. Each data point for study patients’ sera represents the 
mean of triplicate assays. The dotted lines indicate a “normal mean fluorescence intensity (MFI)” range of 0.55 
to 2.59 that represents a 95% prediction interval based on a 2.3 standard deviationin each direction (Hahn and 
Meeker, Statistical Intervals, Wiley and Sons, 1991). The “positive control” is the mean of triplicate assays on 
serum from a patient who was determined to be ineligible for the study due to having an antibody to one of the 
HLA antigens (A1) on the NSCs .  
2.5.3.3 Evaluation of Possible Presenceof NSCs or Replication Competent Retrovirus (RCR) in the Systemic 
Circulation 
Quantitative polymerase chain reaction (PCR) methods using v-myc primers was performed on patients’ PBMCs 
prior to surgery, and on days 4,10, 32, and 60. All patient samples from dose levels 1, 2 and the first 4 patients 
in dose level 3 have been negative for detection of systemic presence of v-myc (i.e. NSCs), indicating no evidence 
of the NSCs traveling and persisting outside of the brain.  
Testing for RCR was performed by analyzing patient DNA from whole blood by PCR for RCR-specific sequences 
prior to surgery, at 3 months, 6 months, and 1 year after study treatment, and then annually thereafter. RCR 
testing has been negative on all patient samples to date for up to 1 year out. 
2.1.13 Assessment of NSCDistribution in the Human Brain 
Based on the preclinical safety and imaging data in mice (section 2.3.5) an amendment to the study’s IND 
(#14041) to allow administration of Feraheme-labeled NSCs was approved by the FDA while the pilot feasibility 
study was finishing dose level 3. As a result the last 3 patients to enroll in the study received Feraheme-labeled 
NSCs to non-invasively assess NSC migration in the brain by MRI. No toxicity from the Feraheme-labeled NSCs 
was observed in the 3 study patients. 
For these patients, the standard MRI brain imaging protocol used at City of Hope was modified by adding 
susceptibility weighted imaging (SWI) sequences (Figure 11, panel A)to visualize the ultrasmall 
superparamagnetic iron oxide (USPIO) in the NSCs. To facilitate anatomical correlation, clinical imaging 
sequences were revised to be performed at a uniform slice thickness of 2mm, instead of the standard 4 mm 
thickness, with the 2nd and 3rd patients who received Feraheme-labeled NSCs. SWI sequences were acquired 
using the clinical SWI sequence with an echo time (TE) = 20 msec and research SWI multi-echo sequences with 
TEs ranging from 2.28 to 46.28 msec. Post-processing included automatic alignment, stripping, and evaluation 

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of multiple algorithms for identification and quantification of USPIO, including use of SWI quantitative mapping 
(SWI-M; Zheng et al., 2013) (Figure 11, panel B). 
Image analysis demonstrated a trend of decreasing USPIO susceptibility over serial brain MRIs. Feraheme-
labeled NSCs were detectable on SWI as areas of hypointense signal at the injection sites (Figure 11). Although 
the resolution used does not enable visualization of smaller amounts of Feraheme-labeled NSCs that may have 
moved away, signal density at the injection sites did decrease over time. It is unknown whether the continued 
decrease in signal density is due to NSCs migrating away from the injection sites, macrophages clearing the iron 
particles and NSCs, or a combination of both. Early changes in hypointense signal at the injection sites (i.e., from 
post-operative days 1 to 10) would likely be too soon to be explained by macrophage clearance (Muldoon et al., 
2005). Preliminary post-processing analysis of imaging data from 2 of the 3 patients who received Feraheme-
labeled NSCs showed a 20-30% decrease in the volume of NSCs at the injection sites between days 1 to 10.  
A.
Pre-op                        Day 1 
            Day 3 
 
Day 10Day 31 
B. 
 
Figure 11.  Magnetic resonance images of NSC injection sites that initially contained approximately 5 million USPIO-labeled 
NSCs each. Serial images of 1 patient demonstrate a gradual decrease in the size of signal density during the 31-day period 
after intracranial administration of USPIO-labeled NSCs. To facilitate visualization of Feraheme at the injection sites over 
time, a maximum intensity projection was performed across five individual SWI slice images. Yellow arrows point to 3 NSC 
injection sites that decrease in intensity over time, indicating migration of viable NSCs away from injection sites. Blue arrow 
indicates air bubble resolving over time. A) SWI images; B) SWI-M: quantitative mapping of images in A. 
 
2.1.14 Brain Autopsy Results 
Autopsies were performed on the brains of 2 study patients, showing evidence of NSC migration and no 
development of secondary tumors.  
The first patient was a woman who initially had a glioblastoma in her left occipital lobe, which was treated with 
resection, radiation and chemotherapy. She then developed recurrent tumor in her right frontal lobe more than 
10 years later. She died 44 days after tumor resection and start of study treatment. She received a total of 10 
million NSCs divided into 10 injections (1 million cells/100 ul per injection) into the wall of the resection cavity.  
SWI
SWI-M

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Nested PCR for v-myc to identify the presence or absence of NSCs was performed on 38 cassettes containing 
brain tissue from all regions of the brain. Five tissue block samples were positive for v-myc. Results showed no 
evidence of NSCs in the immediate proximity of the resection cavity. The v-myc positive areas were distant from 
the primary injection site and included tissue with scattered infiltrating tumor cells (right frontal parietal lateral 
and right posterior basal ganglia) and tissue devoid of obvious tumor cells, displaying moderate to marked anoxic 
ischemic changes (left parietal lateral, left parietal medial and right temporal posterior).  
The second autopsy patient was a man who died 79 days after biopsy of tumor in the right parietal lobe and start 
of study treatment. He received 10 million NSCs in 1 ml, administered into the biopsy site.Detection of NSCs by 
PCR for v-myc was positive in three tissue block samples, 2 of which were located in the contralateral cerebral 
hemisphere (left frontal lobe/corpus callosum and left occipital lobe). Microscopic evaluation showed diffuse 
tumor in each of these blocks. 
Since the NSCs were derived from female fetal tissue, XY FISH analysis was performed on 5 micron tissue samples 
from the same brain tissue blocks that were positive for v-myc and tumor. Results from the City of Hope 
Cytogenetics Core showed interspersed cells consistent with female NSCs among male host cells (Fig. 12). These 
data support the conclusion that NSCs migrated away from the injection site to distant tumor foci.  
 
Figure12. Selected female cells (circled in white) interspersed among host male tumor cells. XY FISH analysis (X gene green, 
Y gene red; 5 micron sections scanned at 63X) suggest the presence of single interspersed female NSCs(2 green 
chromosomes) among the male tumor cells (1 red and 1 green chromosome). Individual cells identified.Second image is a 
magnification of the first image.  
Staining was then done for proliferating cell nuclear antigen (PCNA), a cell division marker.To determine the 
genotype of PCNA-positive cells in these tissue blocks, PCNA cells were mapped and sequential FISH was 
performed with XY probes. The slides were then scanned on a BioView Duet Image Analyzer to capture 
immunohistochemistry (IHC) images, and PCNA-positive cells were selected/mapped for targeted FISH analysis. 
FISH slides were realigned with IHC brightfield images and comparison images were acquired. One hundred 
PCNA-positive cells were classified for each block, and all cells were male. There was no evidence of actively 
dividing female cells in any of the tissue analyzed.  These data support the conclusion that the identified 
remaining NSCs were not dividing and creating secondary tumors. 
Irinotecan for the Treatment of Gliomas 
 Irinotecan produces cytotoxicity by inhibiting topoisomerase I, an enzyme required for DNA replication and 
transcription, ultimately resulting in apoptosis. CE converts irinotecan to its active metabolite, SN-38, which is 
approximately 100-1,000 times more potent for inhibiting topoisomerase I (Kawato et al., 1991). Irinotecan is 

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an attractive drug for the treatment of malignant gliomas because its mechanism of action differs from alkylating 
agents, the only class of drugs that has demonstrated improvement in survival in these patients. Although highly 
protein-bound, irinotecan can cross the BBB to a certain extent. Using the presence of drug in the CSF as a 
surrogate for the ability of a drug to penetrate into brain, a study in non-human primates documented that 
irinotecan has an AUC ratio of CSF to plasma of 14% (Blaney et al., 1998).SN-38 is more highly protein-bound 
than irinotecan, and only very lowconcentrations of SN-38 have been detected in the brains of rats after 
intravenous administration of irinotecan (Tim Synold, unpublished data). Combining irinotecan with tumor-
tropic CE-secreting NSCshas the potential to significantly increase concentrations of SN-38 in brain tumor via 
localizedNSC-mediated CE conversion of irinotecan to SN-38. 
Irinotecan is approved by the FDA for use in patients with metastatic colorectal cancer,as either a single agent 
given at a dose of 125 mg/m2 weekly for 4 weeks followed by a 2 week rest or 350 mg/m2 once every 3 weeks—
orin combination with 5-FU and leucovorin. Irinotecan has also been studied alone (Gilbert et al., 2003; Batchelor 
et al., 2003, Raymond et al., 2003, Prados et al., 2006) and in combination with other chemotherapy agents 
(Gruber et al., 2004, Brandes et al., 2004) in patients with recurrent gliomas. Irinotecan has demonstrated only 
modest activity in these glioma clinical trials, likely due to the poor ability of systemically converted SN-38 to 
cross into the central nervous system (Blaney et al., 1998). Although not FDA approved for the treatment of 
gliomas, when irinotecan is use for recurrent glioblastoma, it is commonly given at a dose of 125 mg/m2 every 2 
weeks with bevacizumab (Friedman et al., 2009; Moller et al., 2012).  However, when administered with 5-FU 
and leucovorin as part of the colon cancer regimen FOLFIRI, irinotecan is given at a dose of 180 mg/m2 every 2 
weeks. We have chosen to use this higher dose of irinotecan every two weeks because we want to maximize the 
amount of prodrug available to the NSCs for conversion to SN-38 at sites of tumor in the brain, and since 180 
mg/m2 of irinotecan is well tolerated in combination therapy, it should also be well tolerated when given as a 
single agent. If this dose is found to be too toxic, the starting dose will be de-escalated first to 150mg/m2 every 
other week, followed by a further dose de-escalation to 125 mg/m2 every other week if necessary. 
 
 
Use of a Rickham reservoir/catheter system for repeat intracranial administration of NSCs. 
In this study we will slowlyadminister repeat infusions of NSCsthrough an indwelling Rickham reservoir/catheter 
system (a Rickham). The catheter will be inserted into the tumor mass at the time of resection or biopsy and 
connected proximally to a Rickham reservoir (6 mm diameter).  
The Brain Tumor Program at City of Hope has significant experience with this delivery system.  In a recently 
completed immunotherapy study of genetically-modified T cells, we successfully infused repeat doses of the T 
cells during a 2 week period via a Rickham catheter placed within tumor tissue (Badie, unpublished data).  
In order to determine whether it would be feasible to use a Rickham to deliver repeat doses of NSCs 
intracranially, an experiment was performed to assess the viability and binding of  hCE1m6-NSCs when 
administered through a Rickham. hCE1m6-NSCs were thawed and washed 3 times with 2% human serum 
albumin (HSA)/artificial CSF (25% HSA diluted by Perfusion Fluid CNS for a final HSA concentration of 2%). At the 
last wash, the total viable cell count was 1.53 x 108 cells. The cell pellet was resuspended in 2.23 ml of artificial 
CSF to give a concentration of 6.67 x 107/ml.An aliquot of the cell suspension was taken and counted 
immediately. The cell count of the aliquot taken up in the syringe was1.45 x 108. The cells were administered 
slowly at a flow rate of 0.5 ml/hr through extension tubing attached to a Gripper Plus needle that was inserted 
into the reservoir of a Rickham and collected at room temperature over 4 hours into a single tube, followed by 
a 1 ml flush of 2% HSA/artificial CSF over 2 hours. Samples from the collection tube were taken every hour and 
immediately counted. At the 6 hour sampling, cells were stored at 4°C for 18 hours. The viability of the hCE1m6-

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NSCs at room temperature remained above 90% over 6 hours and above 83% overnight at4°C. The final cell 
count was 1.27 x 108, which represents a cell recovery of 87.6%. 
Intracerebral Microdialysis 
Microdialysis is a technique for continuously analyzing the concentration of a drug or biomolecule in the 
extracellular fluid (ECF) of body tissues, without significantly disturbing tissue function. This technique, first 
developed in the 1970s, consists of implanting into a body tissue a catheter that contains a semi-permeable 
membrane at its tip. The dialysis membrane acts as an artificial capillary, so that when perfusion fluid is slowly, 
continuously pumped through the microdialysis catheter, diffusion of molecules occurs down their 
concentration gradients as the ECF equilibrates with the perfusion fluid. The dialysate, i.e. solution that exits the 
probe, is then collected at regular intervals for analysis. The dialysate will contain a representative proportion 
of the molecule or drug that is in the ECF. The concentration of drug in the dialysate is not the true concentration 
in the tissue, because full equilibration does not take place across the dialysis membrane when the flow of 
perfusion fluid is constant. However, the fraction of drug that is recovered in the dialysate is an indirect 
measurement of the free drug concentration in the interstitium.  
Microdialysis has mainly been applied clinically to the study of head trauma Goodman et al. 1999; Vespa et al., 
2003; Vespa et al., 2005; Vespa et al., 2006) subarachnoid hemorrhage (Staub et al., 2000; Sarrafzadeh et al., 
2002; Kett-White et al., 2003) and epilepsy (During et al., 1993; Lindberger et al., 2002; Scheyer et al., 1994). In 
these settings, intracerebral microdialysis catheters are used to monitor metabolic changes (for example, varying 
levels of lactate, glucose, and glutamic acid) in order to detect possible complications and to evaluate the effects 
of a therapeutic intervention. Intracerebral microdialysis is also a suitable method for measuring levels of 
chemotherapy in the brain (De Lange et al., 2000; Benjamin et al., 2004) because microdialysis catheters can 
serially sample free drug concentrations in the peritumoral cerebral cortex or within the brain tumor itself 
(Bergenheim et al., 2005; Blakeley et al., 2009; Portnow et al., 2009). 
The Brain Tumor Program at City of Hope has developed expertise in performing intracerebral microdialysis. 
Having now placed microdialysis catheters in nearly 40 patients with brain tumors (Portnow et al., 2009,  2010 
2013a, 2013b) we have the largest experience in the country with the application of this technique to perform 
neuropharmacokinetic and neuropharmacodynamic assessments of chemotherapy agents. 
Unique and compelling data about new anticancer drugs can be obtained in vivo from patients with brain tumors 
using intracerebral microdialysis. Unlike studies in which the tumor is removed in order to measure intratumoral 
drug concentrations at one time point, intracerebral microdialysis can not only determine the time course of 
changes in drug concentrations in the brain, since tumor is left in place, it also allows observation of the clinical 
outcomes associated with the drug concentrations measured in vivo. 
2.1.15 Intracerebral Microdialysis Catheters 
The 70 Brain MD Catheter (M Dialysis, Solna, Sweden) has a semi-permeable membrane with a molecular weight 
cut-off of 20,000 daltons, and has received 510(k) clearance from the Food and Drug Administration as a Cerebral 
Tissue Monitoring System for adjunct use in monitoring brain trauma patients at risk for ischemia. This 
microdialysis catheter is smaller in caliber than the catheters that are typically used for performing 
ventriculostomies and monitoring intracranial pressure. With the use of image guidance, the catheter can be 
safely and accurately placed in brain interstitium. Stereotactic placement of intracerebral microdialysis catheters 
has been shown to be a safe procedure, with bleeding and infectious complication rates similar to those seen 
with stereotactic biopsy, craniotomy, and other types of intracerebral monitoring (Benjamin et al., 2004).  In a 
study of intracerebral microdialysis catheter use in neurointensive care patients (Poca et al., 2006), 4 of 97 
patients (3%) were found to have a small (≤ 1mL) collection of blood around the catheter on follow-up CT scans. 
None of these bleeds were clinically significant, and no catheter-related infections were reported.  

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Each catheter has a gold tip that makes it visible on CT scan. Thus, confirmation of correct placement of the 
catheters can readily be obtained with a non-contrast CT scan of the brain. These catheters have safely remained 
in patients for 1-2 weeks (Kett-White et al., 2003). Sample collections are done while patients are awake and 
mobile. 
2.1.16 In Vitro Recovery Data for Irinotecan and SN-38 
As was done in the pilot feasibility study of CD-expressing NSCs where microdialysis was used to measure 
intracerebral levels of 5-FC and 5-FU (section 2.5.2), we plan to likewise use microdialysis catheters in this phase 
I study to measure NSC-mediated hCE1m6 conversion of irinotecan to SN-38 locally in the brain. In preparation 
for this clinical trial, we performed in vitro studies to estimate the recovery of SN-38 and irinotecan with the 
same microdialysis catheter, pump, and perfusion fluid that will used in the clinical trial. At a flow rate of 1 
µl/minute, the in vitro fractional recovery of SN-38 and irinotecan was determined to be 60±10% and 108±2%, 
respectively. 
Overview of Study Design and Rationale 
Combining irinotecan with tumor-tropic CE-secreting NSCs has the potential to significantly increase 
concentrations of SN-38, a potent topoisomerase I inhibitor, in brain tumor via localized NSC-mediated CE 
conversion of irinotecan to SN-38. This phase I clinical trial will define the RP2D based on DLTs of the combination 
of CE-secreting NSCs and irinotecan using a standard “3 + 3” dose escalation schema in patients with recurrent 
high grade gliomas who are undergoing a debulking craniotomy or stereotactic brain biopsy. Except for dose 
level 1 (where only 1 dose of NSCs will be administered, but these patients can continue to receive treatment 
with irinotecan every 2 weeks), NSCs will be administered intracranially on days 1 and 15, and irinotecan will be 
given intravenously 2 days later, on days 3 and 17 of a 28 day cycle. With subsequent cohorts of patients, the 
NSC dose will be increased as tolerated, but the dose of irinotecan will remain the same unless a DLT occurs that 
necessitates lowering dose of irinotecan. Beginning with dose level two, a Rickham reservoir/catheter system 
will be placed at the time of surgery for delivering repeat doses of NSCs intracranially.  Brain MRI and PET/CT 
scans will be performed at least every two months (at the end of every second treatment cycle) to evaluate 
response. 
The schedule of dosing is based on pre-clinical data which demonstrates the greatest increase in tumor SN-38 
levels is achieved when irinotecan is administered 2 days after NSC administration. Pre-clinical data showing 
increased SN-38 concentrations in tumor but not normal brain and a survival advantage in mice support 
maximizing the dose of NSCs and irinotecan administered.  
Three different doses of NSCs will be assessed. The starting dose level will be a single administration of 5 x 107 
NSCs, which was well-tolerated in the first-in-human study of CD-expressing NSCs. The second dose level will 
assess the same dose of NSCs given every other week. The third and fourth dose levels will increase the number 
of NSCs to be administered. Due to volume limitations for intracerebral administration, the highest dose of NSCs 
to be tested will be 1.5 x 108 cells.  
The dose of irinotecan to be administered on this trial will be 180mg/m2 every other week. This irinotecan dose 
and schedule is FDA approved for use in colorectal cancer patients as part of the combination chemotherapy 
regimen FOLFIRI, and is expected to be well tolerated in the glioma population. If this dose is found to be too 
toxic, the starting dose will be de-escalated first to 150mg/m2 every other week, followed by a further dose de-
escalation to 125 mg/m2 every other week if necessary. 
Study participants will receive repeat cycles of study treatment (dose level 1 and -1 patients will only receive 
repeat doses of irinotecan) as long as they are tolerating the treatment well, and there is no evidence of 
progressive disease.  

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An important secondary objective of this study will be to determine the biologic activity of the hCE1m6-NSCs by 
measuring concentrations of SN-38 in brain interstitium using intracerebral microdialysis. The first 6 patients to 
enroll in the study and the last 8 patients in the expansion cohort will undergo microdialysis to collect data 
regarding intracerebral levels of irinotecan and SN-38 when patients are treated with the lowest and highest 
NSC doses. Please note, the same dose of NSCs (5 x 107) is given to patients on dose levels 1 and 2, so whether 
the first 6 patients are all treated on dose level 1 or the first 3 dose level 1 and the next 3 on dose level 2, they 
will all receive the same dose of NSCs.  
Once the maximum tolerated doseof the combination therapy has been determined, or, if the maximum 
tolerated dose is not reached, the maximum feasible dose,patients in the expansion cohort will undergo 
intracerebral microdialysis to investigate if treatment with a higher dose of NSCs results in more SN-38 in the 
brain and to directly determine how much the addition of NSCs to treatment with irinotecan increases 
intracerebral levels of SN-38. As such, 4 patients in the expansion cohort will undergo intracerebral microdialysis 
after receiving NSCs at the time of surgery followed 2 days later by IV irinotecan, but the other 4 patients in this 
cohort will not receive NSCs on the day of surgery. Instead they will be given IV irinotecan 2 days after surgery, 
and dialysate samples will be collected from them to determine how much SN-38 is present in the brain from 
treatment with IV irinotecan alone. These 4 patients will then receive their first dose of NSCs through the 
Rickham on day 15 of cycle 1 followed by irinotecan on day 17. Another key secondary objective will be to assess 
for possible development of immune responses to these allogeneic, adenovirally transduced NSCs. Serial blood 
samples will be collected during treatment cycles to assess for the possible development of T cell and antibody 
responses to the NSCs and/or cell surface-expressed adenoviral proteins, and we will follow adenoviral antibody 
titers. Other secondary objectives include describing the clinical benefit in patients who receive treatment with 
repeat cycles of NSCs and irinotecan by obtaining brain MRI and PET/CT scans to assess response after every 
two cycles and, when feasible, determining at time of autopsy the fate of the NSCs. 
 

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3 
PARTICIPANT SELECTION 
Eligibility Inclusion Criteria 
Participants must meet the following criteria on screening examination to be eligible to participate in the study: 
Informed consent 
1. Patient must be able to understand and be willing to sign a written informed consent document. 
2. Participant must be willing to comply with study and/or follow-up procedures. 
Age Criteria, Performance Status, Life Expectancy and Informed Consent 
3. At least 18 years old and less than 70 years old. 
4. Karnofsky Performance Status  70% (Appendix A). 
5. Life expectancy of  3 months. 
Nature of Illness and Treatment History 
6. Histologically-confirmed diagnosis of a grade III or IV glioma (including glioblastoma, anaplastic 
astrocytoma, gliosarcoma, anaplastic oligodendroglioma, or anaplastic oligoastrocytoma), or 
has a prior, histologically-confirmed, diagnosis of a grade II glioma and now has radiographic 
findings consistent with a high-grade glioma (grade III or IV). 
7. Imaging studies show evidence of recurrent tumor(s).If a patient is going to be enrolled to dose 
level two or higher, the patient must have a component of supratentorial disease (so as to 
enable placement of a Rickham reservoir/catheter) that is amenable to resection or biopsy. 
8. High-grade glioma has recurred or progressed after prior treatment with brain radiation and 
temozolomide. 
9. Participant must be in need of a craniotomy for tumor resection or a stereotactic brain biopsy 
for the purpose of diagnosis or differentiating between tumor progression versus treatment-
induced effects following radiation therapy chemotherapy. 
10. Based on the neurosurgeon’s judgment, there is no anticipated physical connection between 
the post-resection tumor cavity and the cerebral ventricles. 
11. Neurosurgeon finds the prospective participant is able to undergo neurosurgery. 
12. Any number of prior therapies is permitted.  From the start of study treatment, the following 
time periods must have elapsed: 6 weeks from nitrosourea-containing chemotherapy, 4 weeks 
from non-nitrosourea-containing cytotoxicchemotherapy(except 23 days from last daily dose of 
temozolomide taken in a 5 of 28 day regimen),  and 2 weeks from last dose of a targeted agent 
(except 4 weeks for bevacizumab). There is no time period requirement for prior radiation 
therapy. 
13. Any clinically significant toxicity from prior therapy must have improved to grade 0 or grade 1. 
Clinical, Genetic, and Immunological Labs 
14. ANC ≥ 1,500 cells/l, platelets > 100,000 cells/l 
15. Total bilirubin ≤ 2.0 mg/dl,  AST (SGOT) ≤4 times institutional upper limit of normal 
16. Serum creatinine ≤ 1.5 x the institutional upper limit of normal.   

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17. Homozygous negativefor the UGT 1A1*28 allele. 
18. Absence anti-HLA antibodies specific for HLA class I antigens expressed by the F3.CD.CE NSCs. 
19. Negative serum pregnancy test (women of childbearing potential only) 
Child Bearing Potential 
20. Agreement by females of childbearing potential and sexually active males to use an effective 
method of contraception while participating in this study. The effects of study treatment on a 
developing fetus have the potential for teratogenic or abortifacient effects. Women of 
childbearing potential must have a negative pregnancy test <2 weeks prior to registration. 
Eligibility Exclusion Criteria 
Prospective participants who meet any of the following criteria will not be eligible for admission into the study: 
Previous therapies 
1. Prior therapy with Neural Stem Cells 
Concomitant medications 
2. Use of CYP3A4 inducers including hepatic enzyme-inducing anticonvulsants (phenytoin, 
fosphenytoin, carbamazepine, phenobarbital, primidone, oxcarbazepine) within 2 weeks prior 
to start of study treatment (See Table 6.2). 
3. Use of moderate to strong CYP3A4 inhibitors within 2 weeks prior to start of study treatment 
(See Table 6.2). 
4. Use of drugs known to inhibit UGT1A1, such as Atazanir, Gemfibrozil, Indinavir, or Ketoconazole, 
within 2 weeks prior to start of study treatment). 
5. Co-medication that may interfere with study results; e.g. immuno-suppressive agents other than 
corticosteroids, such as systemic cyclosporine and tacrilomus. Consult Principal Investigator for 
questions, including necessary washout period for the specific drug. 
6. Flucytosine within 2 weeksprior to start of study treatment. 
7. Use of herbal medications. 
8. Current use (or planned use during the treatment period) of other investigational agents, or 
biological, chemotherapy, radiation or other anti-tumor therapy. See Inclusion Criterion 12, for 
required washout periods from these therapies. 
Other illnesses or conditions 
9. Patient has known human immunodeficiency virus (HIV) or hepatitis C infection; baselinetesting 
for HIV or hepatitis C is not required. 
10. Prospective participant is unable to undergo an MRI with contrast agent. 
11. Known chronic or active viral infections of the CNS. 
12. Clinically significant uncontrolled illness 
13. Active infection requiring antibiotics.  
14. Diagnosis of Gilbert’s disease 

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15. History of allergic reactions attributed to compounds of similar chemical or biologic composition 
to irinotecan. 
16. Known sensitivity to any of the products to be administered during dosing.  
17. Any other active malignancy 
18. Pregnant women and women who are lactating. Irinotecan is an agent with the potential for 
teratogenic or abortifacient effects. There is an unknown but potential risk for adverse events 
in nursing infants secondary to treatment of the mother with irinotecan.  
19. Serious medical or psychiatric illness that could, in the investigator’s opinion, potentially 
interfere with the safety monitoring requirements and completion of treatment according to 
this protocol. 
Noncompliance 
20. Prospective participants who, in the opinion of the investigator, may not be able to comply with 
all study procedures (including compliance issues related to feasibility/logistics). 
Inclusion of Women and Minorities 
The study is open to anyone regardless of gender or ethnicity.  Efforts will be made to extend the accrual to a 
representative population, but in a trial which will accrue between 6 and 29subjects, a balance must be struck 
between subject safety considerations and limitations on the number of individuals exposed to potentially toxic 
or ineffective treatments on the one hand and the need to explore gender, racial, and ethnic aspects of clinical 
research on the other.  If differences in outcome that correlate to gender, racial, or ethnic identity are noted, 
accrual may be expanded or additional studies may be performed to investigate those differences more fully. 
 

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4 
SCREENING AND REGISTRATION PROCEDURES 
4.1 
Informed Consent 
The investigational nature and objectives of the trial, the procedures and treatments involved and their 
attendant risks and discomforts, and potential alternative therapies will be carefully explained to the subject 
and a signed informed consent will be obtained. Documentation of informed consent for screening will be 
maintained in the subject’s research chart and medical record. (See Section 16.7 for additional detail). 
Screening Procedures 
Diagnostic or laboratory studies performed exclusively to determine eligibility for this trial, including initiated 
wash-out for prohibited agents, will be done only after obtaining written informed consent. Studies or 
procedures that were for clinical indications (not exclusively to determine study eligibility) may be used for 
baseline values, even if the studies were done before informed consent was obtained. All screening procedures 
and their respective windows are detailed in Section 10, Table 10, Study Activity Calendar. 
Registration Requirements/Process 
Registration of participantsis to be via completion of the following steps:  
 
 
Prospective participants must complete the informed consent process, including a signed informed 
consent, prior to proceeding to study screening. 
 
Screening procedures and windows are detailed in Section 10 and Table 10, Study Activity Calendar. 
 
A study specific eligibility checklist developed by the Clinical Trials Office at the City of Hope will be used 
to facilitate confirmation that a prospective participant meets all eligibility criteria.  
 
Once all the pre-study requirements have been fulfilled, including a completed eligibility checklist, the 
study coordinator can register the eligible patient into MIDAS. 
 
Patients failing to meet all protocol eligibility criteria, including informed consent, may not be registered 
for the trial.  
Dose Level Assignment and Assignment for the Expansion Cohort 
See Section 5.2 of this protocol document. 
Screen Failures and Registered Participants Who Do Not begin Study Treatment 
Participants who complete the informed consent process and undergo screening procedures, but do not register 
to the trial will have their blood samples taken for immunologic and RCR testing destroyed.  Similarly, 
participants who register for the trial but do not begin study treatment will have these blood samples destroyed.   
The reason for screen failure or failure to begin treatment for registered participants will be documented. 
 

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5 
TREATMENT PLAN 
This is an open-label Phase I study, with an expansion cohort once the MTD has been established. The schemas 
thatfollowprovide an introduction of the treatment plan. 
Dose Escalation Schema 
NSC Dose 
Level 
Initial 
Enrollment 
 
If 1 DLT, 
Addt’l 
Enrollment 
NSC Dose 
 
NSC and Irinotecana 
Administration 
Week 
1          2          3         4 
-1 
3 
3 
2.5 x 107 
X* 
 
** 
 
1b 
3 
3 
5 x 107 
X 
 
** 
 
2c 
3 
3 
5 x 107 
X 
 
X 
 
3 
3 
3 
1 x 108 
X 
 
X 
 
4d 
3 
3 
1.5 x 108 
X 
 
X 
 
Expansion     
Cohort e 
8 
 
MTD/MFD 
X 
 
X 
 
* ”X” denotes treatment weeks for NSCs and irinotecan. NSCs are administered on Day 1, and irinotecan, 180 
mg/m2/dose, is administered two days post-NSCs on Day 3 of each treatment week. The length of a treatment 
cycles is 28 days.  
**Patients on dose levels 1 and -1 will only receive 1 dose of NSCs, but they will continue to receive irinotecan 
every 2 weeks as long as they are tolerating it well, and there is no evidence of tumor progression. 
aDose schedule A, B, and C will be the NSC dose schema in combination with an irinotecan dose of 180mg/m2, 
150 mg/m2, or 125 mg/ m2, respectively. We will start with irinotecan dose schedule A, de-escalating through 
doses B and C in order as necessary. 
b The first 6 study participants will undergo intracerebral microdialysis to measure levels of irinotecan and NSC-
mediated SN-38 production in the brain. Since the dose of NSCs remains the same for dose level 1 and 2, and 
microdialysis will be performed only with the first dose of irinotecan, all of these first 6 study patients would 
receive the same dose of NSCs and irinotecan when undergoing intracerebral microdialysis, even allowing for 
escalation to dose level 2. 
c Starting with dose level 2, a Rickham reservoir/catheter system will be placed at the time of surgery for 
administering repeat doses of NSCs.  
d Six patients will be treated on at the maximum tolerated dose (MTD), or, if the MTD is not reached, at the 
maximum feasible dose (MFD) . Since it is anticipated that the MTD/MFD will be 150 million NSCs (dose level 4), 
the 6 patients who will be treated on dose level 4 will undergo intracerebral microdialysis and be counted as 
part of the expansion cohort.  
 
e An expansion cohort of 8 patients will be treated at the MTD or MFD to gain more experience with the 
tolerability of this treatment regimen. These patients will undergo intracerebral microdialysis to assess how 

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much SN-38 is produced by highest dose of NSCs and evaluate the biologic activity of the NSCs by directly 
measuring how much the addition of NSCs to treatment with irinotecan increases intracerebral levels of SN-38. 
As such, 4 patients in the expansion cohort will undergo intracerebral microdialysis after receiving NSCs on the 
day of surgery followed 2 days later by IV irinotecan, and the other 4 patients in this cohort will not receive NSC 
administration on the day of surgery. Instead they will be given IV irinotecan 2 days after surgery and dialysate 
samples will be collected from them to determine how much SN-38 is present in the brain from treatment with 
IV irinotecan alone. These 4 patients will then receive their first dose of NSCs through the Rickham on day 15 of 
cycle 1 followed by irinotecan on day 17. 
Simplified Treatment Schema for Cycle 1 
Day 1 
Tumor resection or biopsy is performed. 
hCE1m6-NSCs are administered intracranially.^ 
A Rickham catheter is placed (except in patients on dose level 1or -1). 
The first 6 study patients and those in the expansion cohort: microdialysis catheter(s) is/are placed, and 
a post-operative CT scan is obtained to confirm correct placement. 
^Four participants in the expansion cohort will not receive Day 1 NSCs; they will initiate NSC 
administration on Day 15. 
Day 3  
 
Irinotecan is administered intravenously. 
Patients undergoing intracerebral microdialysis:  serial dialysate and blood samples are collected. 
Day 15 
 
hCE1m6-NSCs are administered intracranially via the Rickham catheter.* 
Blood is drawn for immunologic correlative studies.* 
*Patients in dose level 1 or -1 will not receive NSCs on Day 15, and blood samples for immunologic 
correlative studies will be drawn on Day 17 when these patients return to clinic to receive irinotecan. 
Day 17 
Irinotecan is administered intravenously. 
 
 
 

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Study Treatment Schema 
Follow-up
≥ Cycle 2   (28 days)
All Patients
Procedures A-K
Patients at NSC Dose 
Levels 2, 3 & 4
Procedures E-K
Cycle 1   (28 days)
First 6 enrolled, and all 
8 in expansion cohort 
Procedures A, C, G, I, K
All Patients at NSC 
Dose Levels 1 and -1 
Procedures A-D
Enroll patients with recurrent high grade glioma who are planning to have craniotomy or stereotactic biopsy
Day 1:  Surgery + NSCs
Day3: IV Irinotecan 
Day 15: NSCs via 
Rickham catheter
Day 17: IV Irinotecan
Treatment Regimen and Assessment for 
Response
Intracranial and 
peripheral blood SN-
38 and Irinotecan 
concentrations
Pre-surgery:  T cells,  
IgG/M, peripheral 
NSCs, replication 
competent retrovirus 
(RCR)
Immunological Studies 
with NSC and virus 
testing 
Day2: Baseline MRI
Day 1: Microdialysis 
catheters inserted  at 
surgery  
Day 1: CT post-surgery 
to confirm catheter 
placement, catheter  
set-up
Day 3-5: Microdialysis 
samples and blood 
samples pre- and post-
irinotecan
Day 15 pre-tx:  T cells, 
IgG/M, peripheral NSCs  
•First 3 participants to a dose level will be staggered, whereby each awaits for the previous participant to have 
completed the 1st cycle.
•3+3 dose escalation/de-escalation where at least 6 pts are treated at MTD/MFD   for which <33% have DLT
3 + 3 
stage
•8 participants to be enrolled at MTD (or MFD if MTD is not reached), all undergoing microdialysis. 
•To determine impact of NSCs on SN-38 and irinotecan concentrations, 4 will receive first dose of NSCs at Day 15 
after microdialysis, to compare with 4 who will receive first dose of NSCs on Day of Surgery.
Expansion 
Cohort
Day 1:  NSCs via 
Rickham catheter
Day3: IV Irinotecan 
Day 15: NSCs via 
Rickham catheter
Day 28: MRI to assess progression  
(even cycles only)
Day 1 pre-tx:  T cells,  
IgG/M, peripheral 
NSCs, (cycle 2 only);
RCR (cycle 4 &7)
Day 15 pre-tx:  T cells, 
IgG/M, peripheral NSCs 
Day 17: IV Irinotecan
If the maximum tolerated dose (MTD) is not 
reached, the maximum feasible dose (MFD) 
will be used. 
Procedure letters  are used throughout the 
protocol for operational guidance for the 
protocol user. Procedure legend is located in 
Tables 8.2a/b.
Dose Levels 1 and -1 (procedures A-D) will 
have cycle 1 extended to 30 days to maintain 
14 days between irinotecan administrations.
Four participants in the expansion cohort 
(procedure K) will not receive NSCs on Day 1.
Participants undergoing biopsy at NSC dose 
levels 3 and 4 (biopsy procedures G-J) will 
have Day 1 NSCs administered during surgery 
and post-recovery via the Rickham catheter.
30 days after last tx: assessment of vital status 
and toxicities
RCR  at 3 and 6 months 
and yearly from the day 
of surgery
Annual medical 
history
Tissue from autopsy, if 
family consents
Day 17: IV Irinotecan
Day1: IV Irinotecan 
Day 15: IV Irinotecan
Day 1:  Surgery + NSCs
Day3: IV Irinotecan 
Day2: Baseline MRI
b
c
b
c
c
b
a
d
a
a
 

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Overall Treatment Plan 
The following is an overview of the treatment plan: 
1. Treatment cycles are defined by Day 1 study agent administration, except for Cycle 1 where Day 1 is 
defined as day of surgery.  After Cycle 1, Day 1 agent administration will be NSCs, or for participants who 
are no longer receiving NSCs, Day 1 agent administration can be irinotecan. 
2. Cycles are planned to be 28 days in duration, however the cycle may be extended for any of the following 
reasons: 
a. A delay in administering the Day 1 treatment, resulting in an extension of the prior cycle. 
b. A delay in administering the mid-cycle (Day 3, 15, 17) administrations, resulting in an extension 
of the respective cycle.  
c. Dose level 1 or -1 participants will complete NSC treatmentduring cycle 1, and will start cycle 2 
with irinotecan administration. As such, cycle 1 will be extended as needed (e.g. from 28 days 
to 30 days) to ensure that the cycle 2 day 1 irinotecan dose occurs 14 days after the previous 
irinotecan dose.  
3. All safety assessments and immunology and RCR testing must be performed prior to administration of 
any study medication, and per the windows defined in Section 10. For planned assessments outside of 
schedule, written approval must be granted by the Principal Investigator.   
4. Start of cycle criteria must be met in order to begin the treatment cycle. See Section 7.2.2. 
5. Prior to administering any study agent at any time point, criteria for holding or modification of dose 
must be reviewed. See Section 7.2.4.  
6. Adjustments to the schedule following a hold in study agent(s) are described in Section 7.3. 
7. There will be no intra-patient dose escalation of NSCs or irinotecan.  
8. Participants who discontinue irinotecan will discontinue all study treatment. 
9. If administration of agents must be interrupted, dose reduced or terminated because of unacceptable 
toxicity or issues with the Rickham catheter, agent dosing will be modifiedaccording to rules described 
in Section 7. All changes to study agent administration must be recorded.  
10. Prior to commencing treatment with NSCs, participants must have confirmed recurrent high grade 
glioma based on tumor taken during the Day 1 neurosurgery (Section 8.1). If recurrent high grade glioma 
is not confirmed, participants will be removed from therapy and replaced. 
11. Prior to commencing treatment with irinotecan (day 3 of cycle 1) participants must have recovered well, 
per the neurosurgeon, from any immediate post-operative effects, and the patient must require ≤ 16 
mg/day of dexamethasone. Otherwise the participant will be removed from further study agent 
administration (Section 7.2.3). 
12. For participants who receive their initial doses of NSCs and irinotecan, treatment will continue until 
either evidence of progressive disease, unacceptable toxicity, non-compliance with study follow-up, or 
withdrawal of consent.    

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Assigning Treatment and Correlative Study Regimen 
A participant’s starting NSC dose level, irinotecan dose schedule, correlative study procedures, and NSC regimen 
will be assigned by the Principal Investigator based on the following criteria: 
1. Except where planned in the expansion cohort, participants who do not receive Day 1 NSCs will be 
replaced. 
2. During the 3+3 stage of the trial, any participants who are not evaluable for dose escalation will be 
replaced.  
3. During the 3+3 stage of the trial, the NSC dose level (-1,1,2,3, or 4) and irinotecan dose schedule 
(A, B, or C) will be determined using criteria defined in Section 5.3. 
4. The first six patients enrolled to the trial will have microdialysis catheters inserted and undergo 
microdialysis and accompanying blood plasma PK studies. If one or more of the six patients does 
not receive cycle 1 day 3 irinotecan, the patient(s) will be replaced with the next patient(s) 
enrolled.  
5. During the expansion cohort, all eight participants will have microdialysis catheters inserted and 
undergo microdialysis and accompanying blood plasma PK studies. N.B., since it is anticipated that 
the MTD/MFD will be 150 million NSCs (dose level 4), the 6 patients who will be treated on dose 
level 4 will undergo intracerebral microdialysis and be counted as part of the expansion cohort.  
6. During the expansion cohort, all 8 participants will follow the NSC dose level and irinotecan dose 
schedule per the MTD (or if the MTD is not reached, the MFD), however 4 participants will receive 
their initial NSCadministration on the day of surgery (Day 1), and 4 participants will receive their 
first NSC administration on Day 15. Participants will be grouped according to surgery type 
(craniotomy or biopsy). As each group enrolls participants, it will alternate between enrolling the 
participant to the Day 1 NSC start date and the Day 15 NSC start date. (See Section 5.4 for further 
explanation). 
Based on the above criteria, the Principal Investigator will communicate to the clinical research team and the 
neurosurgeon the assigned biopsy or craniotomy procedure A-K as detailed in table 8.2a and table 8.2b. 
Phase I Study Design – Determining the MTD 
The study will implement a standard 3+3 design. The goal will be to determine the maximum tolerated dose 
(MTD) of NSCs with irinotecan.   If the maximum tolerated dose is not reached, then the maximum dose will be 
the maximum feasible dose (MFD). 
 
 

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5.1.1 
Phase I Dose Levels and Schedules for NSCs and Irinotecan 
Table 5.3.1  Phase I Dosing for NSCs and Irinotecan 
 
NSC Dose 
Level 
NSC Number and Administrations 
 
 
Irinotecan 
Schedule 
Irinotecan Dose  
(ongoing Day 3 and Day 17 
administration)* 
 
-1 
2.5 x 107 NSCs 
one administration 
only – C1D1 
 
 
C 
125 mg/ m2 irinotecan 
Initial 
Cohort 
1 
5.0 x 107 NSCs 
one administration 
only – C1D1 
 
 
B 
150 mg/ m2 irinotecan 
 
2 
5.0 x 107 NSCs 
ongoing: Day 1 and 
Day15  
 
Initial 
Cohort 
A 
180 mg/ m2 irinotecan 
 
3 
1.0 x 108 NSCs 
ongoing: Day 1 and 
Day15  
 
 
 
 
 
4 
1.5 x 108 NSCs 
ongoing: Day 1 and 
Day15  
 
 
 
 
*Dose level 1 and -1 participants will only receive one dose of NSCs, but will continue to receive irinotecan. As such, starting 
with cycle 2, their irinotecan administrations will be on Day 1 and Day 15 instead of Day 3 and Day 17. 
5.1.2 
Phase I Cohorts and Dose Escalation and De-escalation Criteria 
Phase I Cohorts will be of 3 or 6 participants, as indicated by the dose-escalation criteria.   
Enrollment of the first 3 patients to a dose level will be staggered by requiring that each of the first 3 patients 
be separately observed for 4 weeks (or until the DLT assessment period has ended) before the next patient can 
start treatment on that dose level.  
Dose escalation will proceed through the identified doses without skipping any dose levels. 
To be counted for dose escalation, a study patient must receive at least 80% of the assigned NSCs and 80% of 
the irinotecan for a particular dose level and be followed for 4 weeks OR have experienced a DLT as defined in 
Section 5.3.3. 
All study patients enrolled are to be fully followed for toxicity; any study participant who is not evaluable for 
dose escalation will be replaced. 
The NSC dose levels and irinotecan dose schedulesare provided in Table 5.3.1.  The first cohort will start at NSC 
dose level 1 and irinotecan schedule A. 
The following dose escalation rules will be used, using the DLT definition as provided in Section 5.3.2: 
 
If 0/3 study participants experiences a DLT, the next cohort of 3 study patients will be treated at the 
next higher dose level. 
 
If 1/3 study participants experiences a DLT, the cohort will be expanded by another 3 study participants 
who will be treated at the same dose level for a total of 6 study participants.  
 
If 1/6 participants experiences a DLT, the next cohort of 3 study participants will be treated at the next 
higher dose level. 
 
If 2 or more participants of either a 3 participant or 6 participant cohort encounter a DLT, then the MTD 
has been exceeded. If applicable, three (more) participants will be enrolled at the next lower dose level. 
 
At least 6 patients will be treated at the MTD (or MFD, if the MTD is not reached). 

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If the 3+3 design rules indicate a need for de-escalation, the followingwill apply: 
 
If all DLTs in a dose level areattributed uniquely to irinotecan,then only the irinotecan schedule will de-
escalate.  
 
If all DLTs in a dose level are attributed uniquely to NSCs, and are not attributed to ‘NSCs with 
irinotecan’, nor to irinotecan alone, then only the NSC dose level will de-escalate. 
 
If all the DLTs in a dose level are attributed to a combination of NSCs and irinotecan, then the PMT will 
evaluate the details of each toxicity to determine whether the NSC dose level or the irinotecan dose 
schedule should be de-escalated.  
 
If the situation occurs when one DLT in a dose level is attributed to irinotecan alone and another is 
attributed to NSCs alone, then the PMT will evaluate the specific details of these toxicities and make a 
decision as to whether the dose of NSCs or irinotecan should be de-escalated.  
 
5.1.3 
Definition of Dose-Limiting Toxicity (DLT) 
Toxicities will be graded according to the NCI Common Terminology Criteria for Adverse Events version 4.0. All 
patients receiving any number of NSCs will be evaluated for dose limiting toxicity criteria. 
A DLT is defined as an adverse event that:  
(a) is related to the administration of NSCs, irinotecanor the combination of NSCs with irinotecan, with 
an attribution of possible, probable, or definite, and  
(b) occurs during the first treatment cycle (including Cycle 2 Day 1 safety assessments), and  
(c) meets any of the following criteria:    
Discontinuation toxicities 
1. Receives less than 80% of study treatments due to a toxicity related to NSCs or irinotecan, 
except CNS toxicities that are present at baseline and attributable to the location of the 
tumor or the neurosurgery. 
Hematological toxicities 
1. Grade 4 thrombocytopenia 
2. Grade 4 neutropenia lasting > 7 days 
3. Grade 4 anemia  
4. Febrile  neutropenia if ANC < 0.5 x 109/L  
Nervous system disorders 
5. Grade 3 CNS disorder lasting > 7 days that is not present at baseline and is not attributable 
to the location of the tumor or the neurosurgery. 
6. Second occurrence of a grade 3 CNS disorder that is not present at baseline and is not 
attributable to the location of the tumor or the neurosurgery.  
7. Any grade 4 CNS disorder that is not present at baseline and is not attributable to the 
location of the tumor or the neurosurgery. 
Non-hematological, non-nervous system toxicities 
8. Grade 3 toxicity despite maximal medical therapy lasting > 7 days. 

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9. Grade 3 toxicity resulting in study agent discontinuation (permanently removed from study 
treatment). 
10. Grade 4 toxicity, except grade 4 diarrhea that responds to maximal medical therapy within 
3 days. 
Please note: An allergic reaction to the NSCs is excluded from the DLT definition, because NSC dose reduction is 
not appropriate in this situation. The possible occurrence of allergic reactions to the NSCs is addressed by the 
study stopping rules (Section 5.6).  
5.1.4 
Definition of Maximum Tolerated Dose and Maximum Feasible Dose 
The MTD/MFD will be based on the assessment of DLTs as defined in Section 5.3.3. The MTD is the dose levelat 
which 0/6 or 1/6 participants experience a DLT with the next higher dosehaving at least 2/3 or 2/6 participants 
encountering a DLT. If the MTD has not been reached with NSC dose level 4 and irinotecan schedule A, then 
that dose level will be termed the maximum feasible dose (MFD). 
Treatment Plan: Expansion Cohort 
After the MTD/MFD of the combination therapy is defined, an expansion cohort of 8 patients will be treated to 
gain more experience regarding the tolerability of study treatment at the MTD/MFD and to assess the biological 
activity of the hCE1m6-NSCs using intracerebral microdialysis. Since it is anticipated that the MTD/MFD will be 
150 million NSCs (dose level 4), the 6 patients who will be treated on dose level 4 will undergo intracerebral 
microdialysis and be counted as part of the expansion cohort.  
Four patients in the expansion cohort will undergo intracerebral microdialysis after receiving NSCs at the time 
of surgery followed 2 days later by IV irinotecan, but the other 4 patients in this cohort will not receive NSCs on 
the day of surgery. Instead they will be given IV irinotecan 2 days after surgery, and dialysate samples will be 
collected from them to determine how much SN-38 is present in the brain from treatment with IV irinotecan 
alone. These 4 patients will then receive their first dose of NSCs through the Rickham on day 15 of cycle 1 
followed by irinotecan on day 17. 
To determine who will receive their initial NSCs administration on the day of surgery, and who will receive their 
first NSC administration on Day 15 via the Rickham catheter, participants will be stratified according to surgery 
type (craniotomy or biopsy), and,as each group enrolls participants, it will alternate between enrolling the 
participant to the Day 1 NSC start date and the Day 15 NSC start date. For example, the first craniotomy 
participant will be assigned Day 1 NSC start date, the second craniotomy participant will be assigned Day 15 NSC 
start date, the third will be assigned Day 1 NSC start date, the fourth will be assigned Day 15 NSC start date, and 
so on as applicable.  The same alternate enrollment scheme will apply to participants undergoing the biopsy 
procedure.  The rationale for this plan is to ensure to the degree possible an even distribution of start dates for 
each surgery group which should increase the ability for direct comparison. There is no requirement for specific 
number of biopsy or craniotomy participants in the expansion cohort.  
If the DLT rate in the expansion cohortexceeds 34%, the toxicity data will be reviewed. 
Criteria for Removal from Participation or Treatment 
For participants who begin treatment, duration of therapy will depend on individual response, evidence of 
disease progression and tolerance. In the absence of treatment delays due to adverse events, treatment may 
begin and continue until or unless one of the following criteria applies: 
 
Pathology review of the frozen section obtained at the time of surgery does not confirm recurrent high 
grade glioma (Section 8.1). Such participants will not continue on to receive any study agents, and all 
study procedures will end.  

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 
Participant does not meet the criteria for initiating irinotecan dosing following surgery (Section 7.2.3).  
During cycle 1, if a participant requires more than 16 mg/day of dexamethasone to control cerebral 
edema at the time s/he is ready to begin treatment with irinotecan, then s/he will be considered 
neurologically unstable and will not continue with study treatment; however, the patient will still be 
evaluable for toxicity. 
 
Evidence of disease progression. 
 
Unacceptable adverse event(s) (see Section 7.2). 
 
Intercurrent illness that prevents further administration of treatment. 
 
Participant needs a treatment not allowed by the protocol. 
 
A participant may always be removed from treatment whenever s/he wishes. 
 
General or specific changes in the participant's condition render the participant unacceptable for 
further treatment in the opinion of the treating investigator. 
Participants will be removed from study treatment when any one of the criteria listed above applies. The reason 
for study treatment removal and the date the participant was removed must be documented. Alternative care 
options will be discussed with the participant. 
Study Stopping Rules 
The study will be discontinued if i) the incidence of DLT level toxicities that are probably or definitely attributable 
to the NSCs or NSCs and irinotecan in study patients exceeds 50% in more than 6 patients, or ii) two grade 4 
allergic reactions that are probably or definitely related to NSCs. Note death from tumor progression will be 
scored as a grade 5 toxicity (with very low level of attribution—unlikely or not related), and only deaths occurring 
< 30 days from intracerebral administration of NSCs will be considered for the purposes of defining conditions 
for discontinuation of the study. 
Subject Follow-Up 
Patients will continue to be followed once they have finished active study treatment. They will be asked to 
participate in long-term follow-up per the guidelines set forth by the FDA’s Biological Response Modifiers 
Advisory Committee (BRMAC) that apply to gene transfer studies. Current recommendations from the BRMAC 
require a minimum of 15 years of follow-up. This long-term follow-up will consist of annual requests from the 
patient/patient’s primary oncologist for clinical information regarding other anti-cancer therapy, progression of 
disease, survival, as well as information pertaining to de novo cancer, neurologic, autoimmune and hematologic 
disorders. In addition, unexpected medical problems including information on hospitalizations and medications 
will be collected. Alternatively, participants may be seen at the COH clinic to obtain this information. 
Testing for replication competent retrovirus (RCR) will be part of the long-term follow-up of study patients and 
will be performed by analysis of DNA from whole blood by PCR for RCR-specific sequences at the following time 
points: pre-treatment, 3 months, 6 months, 1 year, and annually thereafter. 
 

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6 
CONCOMITANT MEDICATIONS, SUPPORTIVE CARE, AND INCREASED MONITORING FOLLOWING 
TOXICITIES 
6.1 
Prophylaxis, Supportive Treatment and Increased Monitoring 
Unless expressly indicated elsewhere in this section, increased monitoring, prophylaxis, and ancillary treatment 
after any toxicity is left to the clinical judgment of the investigator and must be compliant with Section 6.2 
Concomitant Medications. 
6.1.1 
REQUIRED Peri- and post-operative Prophylaxis 
Levetiracetem (Keppra)—or another anticonvulsant that does not cause significant induction of hepatic 
metabolic enzymes, such as lacosamide or valproic acid—will be administered to all study patients. Those who 
have never had a seizure will start taking levetiracetam within 1 week prior to surgery and continue taking the 
anti-seizure medication for 4 weeks after craniotomy or biopsy. 
Peri-operative antibiotics, corticosteroids, and deep vein thrombosis prophylaxis will be used according to the 
standard of care for the surgical procedure. 
For participants with microdialysis catheters, prophylactic antibiotic use will continue as long as the microdialysis 
catheter(s) remains in place. 
6.1.2 
REQUIRED Catheter Infection Prophylaxis and Monitoring for Infection 
Also, to monitor for possible catheter-related infections, an attempt to aspirate fluid from the Rickham 
reservoir will be done prior to administering a dose of hCE1m6-NSCs. The fluid will be sent for culture, as well 
as routine cell count, glucose and protein levels, depending on the amount of fluid obtained. 
 
A 14 day culture for bacteria and a 28 day culture for fungus will be started on every final NSC product. The 
NSC product will be administered to the study patient before the results of the sterility testing are known. If 
these culture results were to become positive for bacteria, or fungus, then an Infectious Diseases consultation 
would be obtained for recommendations regarding appropriate treatment of the isolate that grows out. 
 
6.1.3 
REQUIRED Nausea Prophylaxis, Participant Education, and Treatment 
Participants will be pre-medicated with ondansetron 16 mg p.o. at least 30 minutes prior toeach infusion of 
irinotecan.  
Additional use of anti-emetics is at the discretion of the investigator. 
6.1.4 
REQUIRED Diarrhea Treatment and Participant Education 
Diarrhea is a common side effect of irinotecan, and aggressive management with anti-diarrheal agents is 
necessary. All study patients will be counseled about the importance of early recognition and treatment of 
diarrhea.  
Orders will be written for standard use of atropine (to prevent early onset diarrhea) and loperamide (for 
management of later diarrhea) as needed. Prophylactic use of atropine to prevent early onset diarrhea 
accompanied by cholinergic symptoms is left to investigator discretion. 
Each patient should be instructed to have loperamide readily available and to begin treatment for diarrhea at 
the first episode of poorly formed or loose stools or the earliest onset of bowel movements more frequent than 
normally expected for the patient. Loperamide 4 mg should be taken at the first loose stool or more frequent 

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than usual bowel movements, followed by 2 mg as needed, no more frequently than every 4 hours not to exceed 
a total of 16 mg in 24 hours. If the diarrhea persists (> grade 1)despite use of loperamide, then s/he should start 
taking diphenoxylate/atropine (Lomotil) 2 tablets every 6 hours. 
6.1.5 
REQUIRED Increased Monitoring following Initial Indications of Possible Immune Response to the NSCs 
If a patient starts exhibiting signs/symptoms concerning for a possible immune response to the NSCs (such as 
development of a new neurologic deficit that cannot be attributed to the location of the patient’s brain tumor, 
fever without a localizing source of infection, or rash not likely due to a concomitant medication), then serum 
samples will be collected from the patient as soon as possible, and if feasible without putting the participant 
at increased risk, prior to administration of supportive care.  A second sample, and additional samples if 
possible, should be taken approximately every 2 days to determine response to supportive care for the 
immune response.The patient’s stored serum samples from prior to start of study treatment, will alsobe 
analyzed for the same cytokine panel. See Section 8.6 for blood collection information. 
In particular, we would be looking for changes in levels of IL-1RA, IL-6, IFN-γ, IP-10, MIP-1β, MCP-1, IL-2RA, IL-8, 
IL-10, MIP-1α, G-CSF, IL-15, IL-7, IL-2, TNF-α, IL- 1β. Findings consistent with the presence of a “cytokine storm” 
would add strength to the conclusion that the patient is experiencing an immune reaction to the NSCs. See 
Section 12.2.5 for additional information regarding the cytokine panel. 
A decision to stop study treatment will be based on development of clinical signs/symptoms of an immune 
response rather than a particular level of anti-NSC T cells or antibodies. 
See Section 6.1.5 for required supportive care. 
6.1.6 
REQUIREDManagement ofPossible Immune Response to the NSCs 
Participants who develop a grade 2 or higher Immune Response to NSCs, will take dexamethasone to a maximum 
dose of 4 mg twice daily until symptoms resolve to ≤ Grade 1. For participants continuing to receive NSCs, 
dexamethasone should continue at a dose determined by the treating investigator and per consultation with 
the principal investigator. For participants no longer receiving NSC administration may continue dexamethasone 
at the discretion of the treating investigator and per consultation with the principal investigator. 
6.1.7 
Prophylaxis and management of cholinergic irinotecan-related syndrome 
Patients may experience an acute syndrome of lacrimation, diaphoresis,abdominal cramping, and diarrhea (early 
diarrhea) during or shortly after irinotecanadministration; this syndrome is thought to be cholinergically 
mediated. Prophylactic ortherapeutic administration of atropine should be considered in patients experiencing 
cholinergic symptoms. 
6.1.8 
REQUIREDSerum electrolyte abnormalities ≥ CTCAEv3 grade 3 
If serum chemistries ≥ CTCAEv4 grade 3 or greater: 
Patient’s potassium, calcium, phosphorous or magnesium should be immediately supplemented or otherwise 
corrected following the availability of those laboratory results, in order to minimize the time patients have 
abnormal values. 
More frequent testing should be done if clinically indicated, e.g. patient has had prior low values, patient is 
experiencing gastro-intestinal toxicities or is taking medications that can result in lowering of their potassium, 
magnesium, phosphorus or calcium levels. 
6.2 
Concomitant Medications 

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Participants must be instructed not to take any additional medications (including over-the-counter products) 
during the trial without prior consultation with the investigator. All medications taken within 30 days of 
screening should be recorded. If concomitant therapy must be added or changed, including over-the-counter 
medications or alternative therapies, the reason and name of the agent/therapy should be recorded. 
In general, the use of any concomitant medication/therapies deemed necessary for the care of the participant 
are allowed, including drugs given prophylactically (e.g. antiemetics) with the following exceptions: 
o No other investigational therapy should be given to patients 
o No anticancer agents other than the study medications administered as part of this studyprotocol 
should be given to patients. If such agents are required for a patient then the patientmust first be 
withdrawn from the study. 
o CYP3A4 Inducers and Moderate to Strong Inhibitors: Because concomitant use of CYP3A4  hepatic-
enyzme inducing anticonvulsants can result in decreased blood levels of irinotecan, the following 
anticonvulsants are not allowed while the patient is participating in treatment phase of this study: 
phenytoin (Dilantin), fosphenytoin (Cerebyx), carbamazepine (Tegretol), phenobarbital (Luminal, 
Solfoton), primidone (Mysoline), and oxcarbazepine (Trileptal).  
Additionally, patients must not take other medications that are moderate to strong CYP3A4 inhibitors 
or strong inducers (Table 6.2) while undergoing study treatment.  
Table 6.2   CYP3A4 Inhibitors and Inducers 
Strong CYP3A4 Inhibitors 
(5-fold increase in AUC) 
Moderate CYP3A4 Inhibitors 
(2-but < 5-fold increase in AUC) 
Strong CYP3A4 Inducers 
Atazanavir 
Amprenavir 
Aminoglutethimide 
Clarithromycin 
Aprepitant 
Bexarotene 
Indinavir 
Diltiazem 
Bosentan 
Itraconazole 
Erythromycin 
Carbamazepine 
Ketoconazole 
Fluconazole 
Efavirenz 
Nefazodone 
Fosamprenavir 
Fosphenytoin 
Nelfinavir 
Grapefruit juice 
Griseofulvin 
Ritonavir 
Pomegranate juice 
Modafinil 
Saquinavir 
Verapamil 
Nafcillin 
Telithromycin 
 
Nevirapine 
Suboxone 
 
Oxcarbazepine 
 
 
Phenobarbital 
 
 
Phenytoin 
 
 
Primidone 
 
 
Rifabutin 
 
 
Rifampin 
 
 
Rifapentine 
 
 
St. John’s wort 
 
If over the course of study treatment the patient receives any of these drugs, efforts should be made 
to discontinue the use of inhibitors or potent inducers as soon as possible. Such patients may 
continue studytreatment only at the discretion of the principal investigator. Patients who cannot be 
discontinued from use of a prohibited CYP3A4 inducer or inhibitor must be removed from the 
treatment phase of the study.  

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o Use of flucytosine (5-FC) during study treatment is also not allowed. These NSCs also have the ability to 
convert 5-FC to 5-fluorouracil, but the safety of the combination of 5-FC and irinotecan in brain tumor 
patients being treated with these NSCs is unknown at this time. 
o Use of drugs known to inhibit UGT1A1, such as Atazanir, Gemfibrozil, Indinavir, or Ketoconazole, are 
prohibited while undergoing study treatment as they are likely to increase SN-38 levels and increase 
overall toxicity to irinotecan. 
o Co-medication that may interfere with study results; e.g. immuno-suppressive agents other than 
corticosteroids, such as systemic cyclosporine and tacrilomus are prohibited during the treatment phase 
of the study. 
o Use of herbal medications may have unknown interactions with the metabolism of the study agents, and 
therefore are prohibited from use during the treatment phase of the trial. 
 
 

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7 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS 
Anticipated Toxicities 
NOTE: See Section 6.1 for required and recommended prophylaxis and management. 
7.1.1 
Neurosurgery Toxicities 
Bleeding, infection, headache, seizures, cerebral edema, pain, changes in neurologic function, 
thromboembolism.  
7.1.2 
NSCToxicities 
All toxicity studies to date in mice have shown no evidence of organ damage or tumorigenicity due to hCEm16-
NSCs.  
In the first-in-human study of HB1.F3.CD.NSCs (i.e., the parent cell line that was adenovirally transduced to 
create the hCE1m6-NSCs being studied in this clinical trial), no grade 3 or 4 toxicities attributable to the NSCwere 
observed.  
Immune responses to other cellular or gene therapy agents have occurred and may occur to hCE1m6-NSCs. 
7.1.3 
Microdialysis Catheter Toxicities 
Bleeding along the catheter tract, infection localized to or clearly emanating from the catheter. Minor bleeding 
(less than 1 mL) has been observed in 3% of patients (Poca et al., 2006), and there have been no documented 
microdialysis catheter-related infections. 
7.1.4 
Irinotecan Toxicities 
Common: 
Neutropenia and/or late diarrhea (occurring more than 8 hours after irinotecan administration) are common 
dose-modifying toxicities. 
Other commonly observed adverse events includenausea and vomiting, anorexia, weight loss, abdominal 
cramping, constipation, alopecia, asthenia,lymphocytopenia, anemia, fever, and dehydration as a result of 
diarrhea and/or vomiting. 
Patients may experience an acute syndrome of lacrimation, diaphoresis,vasodilation (flushing), abdominal 
cramping, and diarrhea (early diarrhea) during or shortly after irinotecanadministration; this syndrome is 
thought to be cholinergically mediated.  
Less common: mucositis, colitis (sometimes with gastrointestinal bleeding), skin irritation at infusion site, 
headache, dizziness, confusion, somnolence, flatulence, dyspepsia, rash, minor infection 
Rare, but serious: pulmonary toxicity (manifested as shortness of breath, non-productive cough, and transient 
infiltrates on chest x-ray), elevated hepatic enzymes, increased serum creatinine, thrombocytopenia, infusion 
reaction, neutropenic infection, febrile neutropenia 
 

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Dose Modifications/Delays/Start of Cycle Criteria 
7.1.5 
General Information 
1. The study will use the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 to grade 
toxicities.  A copy of the version 4.0 can be downloaded from: 
http://evs.nci.nih.gov/ftp1/CTCAE/About.html 
2. Whenever treatment is held pending resolution of toxicity to grade 1 or return to baseline, this criterion 
may also be met if the toxicity resolves to within 1 grade of the baseline value for a pre-existing 
laboratory abnormality. Baseline values are from screening assessments.  
3. Study agents are always held together, regardless of the attribution of the toxicity.  
4. NSC or irinotecan dose re-escalation is never permitted in this study. 
5. If, for the best interest of the patient, the investigator wants to hold the study agent(s) or dose reduce 
(including increasing the dose reduction) after an adverse event in a manner not outlined in Table 7.2.4, 
this is permissible following discussion with and written approval the Principal investigator.* 
6. For situations where a participant experiences a toxicity which the treating investigator feels is unlikely 
related to treatment with either study agent, but which requires hold or reduction of either agent 
according to Table 7.2.4, maintaining treatment or maintaining treatment dose is allowable per 
discussion with and written approval by the Principal Investigator.* 
7. For holds due to toxicities related to study agent(s), if the participant does not meet criteria to resume 
treatment within 28 days of their last NSC administration (or irinotecan for Dose Level 1/-1 participants 
after they have completed cycle 1), the participant must permanently discontinue study treatment (both 
agents). However, if the participant is clearly benefiting from the study, the investigator may contact the 
Principal Investigator to determine if the participant can remain on study and at what dose level. 
Agreement of the Principal Investigator is to be documented in writing.* 
8. For holds for reasons other than treatment related toxicities, such as inclement weather or adverse 
events unrelated to study agents, if the participant does not meet criteria to resume treatment within 
28 days of their last NSC administration, the study agent(s) may be restarted with written approval from 
the Principal Investigator, as long as there has been no significant evidence of disease progression during 
the treatment interruption.* 
9. Section 7.3 details resuming agent administration following a treatment hold. 
*The principal investigator will document assessment of the impact of these determinations on the study 
design, objectives and endpoints or risk to participants. If any modifications to the treatment plan might 
affect the study design, objectives, and endpoints, or impact the risk of participants, a single subject 
exception will be sought by the IRB.  If the treating investigator is the principal investigator, the 
determination and the rationale for the determination will clearly be documented in the medical record. 
7.1.6 
Start of Cycle Criteria 
In order to proceed with the next cycle of study treatment: 
a) adverse events (except for alopecia) that occurred in the preceding cycle must have improved to a CTCAE 
v 4.0 grade ≤ 1 (or within 1 grade of starting values for pre-existing laboratory abnormalities), 
b) ANC must be ≥ 1500 cells/mm3,  

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c) platelet count ≥ 100,000 cells/mm3, and  
d) treatment-related diarrhea has resolved.  
For participants who received two administrations of NSCs with irinotecan (or irinotecan only for participants in 
dose level 1/-1 ≥ cycle 2) in the previous treatment cycle, a delay of up to 14 days in starting the next cycle is 
allowed in order for the patient to have time to recover from toxicities of the prior cycle. 
7.1.7 
Criteria for First Administration of Irinotecan 
For Cycle 1 Day 3 irinotecan administration, the participant must have recovered well from any immediate post-
operative effects and requires no more than 16 mg/day of dexamethasone. Otherwise the participant will be 
removed from treatment.  Criteria found in 7.2.4 also apply. 
7.1.8 
Dose Modifications 
Table 7.2.4 details the criteria for disrupting treatment, dose modification and treatment discontinuation 
following an adverse event. See section 7.2.1 for general guidelines. The agent listed in Table 7.2.4 indicates the 
drug to which the toxicity is likely attributed based on previous trials to irinotecan and possible anticipated 
toxicities to the hCE1m6-NSCs. The investigator will determine attribution of all toxicities.  
Table 7.2.4 Criteria for Disrupting Treatment, Dose Modification or Discontinuation 
Adverse Event 
Agent most 
likely 
attributed 
to toxicity 
Treatment modification 
Immune Response to NSCs 
(i.e. development of a new neurologic deficit not attributed to the location of brain tumor, fever without localizing 
source of infection, new or progressive rash, cough etc.) 
Grade 2 allergic reaction to the 
NSCs.  
 
NOTE: a decision to stop study 
treatment will be based on 
development of clinical 
signs/symptoms of an immune 
response rather than a 
particular level of anti-NSC T 
cells or antibodies. 
 
NSCs 
Hold study treatment. 
Initiate immunological testing:  
Take 3-5 ml of blood in red top tube, kept upright at room 
temperature until delivery to CICSL. Store at 4 C after sample clots 
if unable to deliver sample the same day.  Take additional samples 
(at least one additional sample) every two days. 
Initiate supportive care: 
Restart dexamethasone to a dose of 4 mg twice daily; if patient is 
already taking dexamethasone, then increase dexamethasone to 
at least 4 mg twice daily.  
Hold study treatment until sign/symptoms ≤ grade 1, and resume 
treatment at the same dose, while continuing dexamethasone at 
a dose determined by the discretion of the treating investigator 
in consultation with the PI.  
 

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Grade 3 or 4 allergic reaction to 
NSCs  
 
NOTE: a decision to stop study 
treatment will be based on 
development of clinical 
signs/symptoms of an immune 
response rather than a 
particular level of anti-NSC T 
cells or antibodies. 
 
Hold study treatment. 
Initiate immunological testing:  
Take 3-5 ml of blood in red top tube, kept upright at room 
temperature until delivery to CICSL. Store at 4 C after sample clots 
if unable to deliver sample the same day.  Take additional samples 
(at least one additional sample) every two days. 
Initiate supportive care: 
Restart dexamethasone to a dose of 4 mg twice daily; if patient is 
already taking dexamethasone, then increase dexamethasone to 
at least 4 mg twice daily. Continue dexamethasone until event 
resolves to ≤ Grade 1, and thereafter at a dose determined by 
treating investigator as clinically indicated. 
 
If an immune response to the NSCs is considered at least possible, 
discontinue study treatment 
 
Hematological Toxicities 
Thrombocytopenia Grade 1 
(75 x 109/L -<LLN) 
Irinotecan 
 
Maintain treatment 
Thrombocytopenia Grade 2 
(50 – <75 x 109/L) 
Maintain treatment 
Thrombocytopenia Grade 3 
(25 – <50 x 109/L) 
Hold treatment until recovery to ≤ grade 2 (plts ≥ 50 x 109/L).  
Thrombocytopenia Grade 4 
(<25 x 109/L) 
Hold treatment until recovery to ≤ grade 1 (plts ≥ 75 x 109/L). 
Resume treatment with an irinotecan dose reduction of 30 
mg/m2. 
Neutropenia (ANC) Grade 1 
(1.5x 109/L -<LLN) 
Irinotecan 
Maintain treatment 
Neutropenia (ANC) Grade 2 
(1.0 – <1.5x 109/L) 
Maintain treatment 
Neutropenia (ANC) Grade 3 
(0.5 – <1.0x 109/L -<LLN) 
Hold treatment until recovery to ≤ grade 2 (ANC ≥ 1.0 x 109/L).  
First 
occurrence: 
Resume 
treatment 
with 
no 
dose 
modifications. 
Each occurrence thereafter:  Resume treatment with an 
irinotecan dose reduction of 30 mg/m2. 
Neutropenia (ANC) Grade 4 
(<0.5x 109/L -<LLN) 
Hold treatment until recovery to ≤ grade 2 (ANC ≥ 1.0 x 109/L). 
Resume treatment with an irinotecan dose reduction of 30 
mg/m2. 
Febrile neutropenia ≥ Grade 3 
(ANC< 1.0x 109/L, fever > 
38.5°C) 
Irinotecan 
Hold treatment until recovery to ≤ grade 1 (ANC ≥ 1.5 x 109/L). 
Resume treatment with an irinotecan dose reduction of 30 
mg/m2. 
Serum Electrolytes 
Serum Electrolytes ≥ Grade 3 
Calcium ,  Potassium, 
Magnesium,Phosphorous 
Irinotecan 
(via 
diarrhea) 
Provide supportive care per Section 6.7. Maintain treatment per 
investigator discretion. 
Gastrointestinal 
Diarrhea Grade 1 
(2-3 stools/day >pretreatment) 
Irinotecan 
Maintain treatment 
Diarrhea Grade 2 
(4-6 stools/day > pretreatment) 
Hold both study drugs until resolved to ≤ grade 1, then resume 
treatment at pre-hold dose 

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Diarrhea  Grade 3 
(7-9 stools/day > pretreatment) 
Event present while on optimal anti-diarrheal therapy:  Hold 
study treatment until the diarrhea decreases to ≤ grade 1, and 
then restart treatment with the dose of irinotecan reduced by 30 
mg/m2  
Diarrhea  Grade 4 
(≥10 stools/day > 
pretreatment) 
Event present while on optimal anti-diarrheal therapy: Hold study 
treatment until the diarrhea decreases to ≤ grade 1, and then 
restart treatment with the dose of irinotecan reduced by 60 
mg/m2. 
Vomiting or Nausea Grade 1 
Irinotecan 
Maintain treatment 
Vomiting or Nausea Grade 2  
Maintain treatment 
Vomiting or Nausea  Grade 3, 
despite maximal medical 
management 
1st event present when on optimal anti-nausea therapy: Hold  
until resolved to ≤ grade 1, then resume treatment at pre-hold 
dose 
 
 ≥ 2nd event present when on optimal anti-nausea therapy: Hold  
until resolved to ≤ grade 1, then resume with an irinotecan 
decrease of 30 mg/m2  dose reduction 
Vomiting Grade 4 
Event present while on optimal antiemetic therapy: Hold study 
treatment until the vomiting decreases to ≤ grade 1, and then 
restart treatment with the dose of irinotecan reduced by 30 
mg/m2. 
Nervous System Disorders 
Grade 
3 
Nervous 
System 
Disorder that is not attributable 
to 
tumor 
location 
or 
neurosurgery and is considered 
a least possibly attributable to 
NSCs with or without irinotecan, 
and is not an immune response 
to study agents. 
NSCs with or 
without 
irinotecan 
Hold treatment until resolution to ≤ grade 1. 
 
First event: 
If resolves within 7 days, resume treatment at pre-hold dose. 
 
If does not resolve within 7 days, resume treatment with then 
dose reduce NSCs by 25% and dose reduce irinotecan* by 30 
mg/m2. 
 
Second event: 
Resume treatment with then dose reduce NSCs by 25% and dose 
reduce irinotecan* by 30 mg/m2. 
 
*If the event occurred after recent administration with NSCs but 
before administration with irinotecan, dose reductions indicated 
only apply to NSCs. Otherwise both agents will be dose reduced. 
Grade 
4 
Nervous 
System 
Disorder that is not attributable 
to 
tumor 
location 
or 
neurosurgery and is considered 
a least possibly attributable to 
NSCs with or without irinotecan, 
and is not an immune response 
to study agents. 
NSCs with or 
without 
irinotecan 
Hold until ≤ grade 1, then perform brain MRI and PET/CT scans. If 
objective evidence of clinical benefit, continue tx* with dose 
reduce NSCs by 25% and dose reduce irinotecan by 30 mg/m2. If 
no objective evidence of clinical benefit, discontinue treatment. 
 
*If the event occurred after recent administration with NSCs but 
before administration with irinotecan, dose reductions indicated 
only apply to NSCs. Otherwise both agents will be dose reduced. 
Other unspecified Non-Hem Toxicities considered Related only  to Irinotecan 
Grade 1 
Irinotecan 
Maintain treatment 
Grade 2  
Maintain treatment 
Grade 3 
Hold treatment until resolution to ≤ grade 1, then dose reduce 
irinotecan by 30 mg/m2. 
Grade 4 
Hold treatment until resolution to ≤ grade 1, then dose reduce 
irinotecan by 60 mg/m2. 

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Other unspecified Non-Hem Toxicities considered Related only to NSCs  
Grade 1 
NSCs 
Maintain treatment 
Grade 2  
Maintain treatment 
Grade 3 
Hold until ≤ grade 1, then dose reduce NSCs by 25% and dose 
reduce irinotecan by 30 mg/m2. 
Grade 4 
Hold until ≤ grade 1, then perform brain MRI and PET/CT scans. If 
objective evidence of clinical benefit, continue treatment with 
dose reduce NSCs by 25%. If no objective evidence of clinical 
benefit, discontinue treatment. 
Other unspecified Non-Hem Toxicities considered Related  NSCs with irinotecan 
Grade 1 
NSCs with 
irinotecan 
Maintain treatment 
Grade 2  
Maintain treatment 
Grade 3 
Hold until ≤ grade 1, then dose reduce NSCs by 25% and dose 
reduce irinotecan by 30 mg/m2. 
Grade 4 
Hold until ≤ grade 1, then perform brain MRI and PET/CT scans. 
If objective evidence of clinical benefit, continue tx with dose 
reduce NSCs by 25% and dose reduce irinotecan by 30 mg/m2. If 
no objective evidence of clinical benefit, discontinue treatment. 
Other unspecified Non-Hem Toxicities considered UNRELATED to study agents  
Other unspecified events of any 
grade considered unlikely to be 
related or not related to study 
agents. 
UNRELATED 
Maintain treatment with study agents.  Interruption of study 
treatment is permitted if the investigator consults with the 
Principal Investigator to determine that this is in the best 
interest of the participant.  
Adjustments to the Treatment Cycle Following an Interruption in Agent Administration 
The day count continues despite a hold in agent administration.   
Should a hold or delay in treatment occur, evaluations required by the protocol (see Section 10) will be 
conducted at the original times during the cycle and safety assessments (clinical laboratory tests, neuro-exam, 
physical exam, vitals, KPS) will be repeated prior to resuming agent administration. For instance, if the 
participant is unable to take Day 15 NSCs, he/she will still have all procedures performed on Day 15, but will 
have safety assessments performed again prior to taking NSCs later in the cycle. 
The timing of resumption (whether in the same cycle or as part of the subsequent cycle) depends on where in 
the cycle agent was held, and when criteria to resume are met.  Details are described in the sections that follow. 
7.1.9 
Holding Day 15 NSCs with Day 17 irinotecan 
If Day 15 NSCs with Day 17 irinotecan are held, resultant start dates are as follows:  
 
If participant is able to resume treatment by or on Day 22, he/she will resume study agents as soon as 
logistically feasible during the same treatment cycle.  The cycle length would be extended accordingly, 
so that 14 days between NSC administrations would be maintained.  
 
If participant is not able to resume treatment by or on Day 22, he/she will continue the current cycle 
without a second Day 15 NSC and resume study agents at the start of the next treatment cycle. The 
current cycle would be 28 days in length and the participant will forgo the Day 15/17 NSCs/irinotecan. 
7.1.10 HoldingDay 17 irinotecan after administering Day 15 NSCs 
If Day 17 irinotecan is held, and the participant has already received Day 15 NSCs, resultant start dates are as 
follows:  

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 
If participant is able to resume treatment by or on Day 24, he/she will resume irinotecan. The cycle 
length will be extended so that 14 days between irinotecan administrations (the second administration 
of the current cycle and the first administration of the subsequent cycle) would be maintained.  
 
If participant is not able to resume treatment by or on Day 24, he/she will continue the current cycle 
without a second irinotecan administration and resume study agents at the start of the next treatment 
cycle. The current cycle would be 28 days in length and the participant will forgo Day 17 irinotecan.  
7.1.11 HoldingDay 3 irinotecan after administering Day 1 NSCs 
If Day 3 irinotecan is held, and the participant has already received Day 1 NSCs, resultant start times are as 
follows:  
 
If participant is able to resume treatment by or on Day 10, he/she will resume irinotecan. The 
subsequent NSC administration will be timed such that 14 days between irinotecan administrations will 
be maintained. The total cycle length will be maintained accordingly 
 
If participant is not able to resume treatment by or on Day 10, he/she will continue the current cycle 
without a ‘Day 3’irinotecan administration and resume NSC with irinotecan administration on Day 15 
and Day 17, respectively, of the treatment cycle. Assuming there is no delay is starting the subsequent 
treatment cycle, the current cycle would 28 days in length and the participant will forgo Day 3 irinotecan.  
7.1.12 HoldingDay 15 irinotecan – Dose Level 1/-1 for ≥ cycle 2 
If Day 15 irinotecan is held, resultant start dates are as follows:  
 
If participant is able to resume treatment by or on Day 26, he/she will resume irinotecan. The cycle 
length will be extended so that 14 days between irinotecan administrations (the second administration 
of the current cycle and the first administration of the subsequent cycle) would be maintained.  
 
If a participant is not able to resume treatment by or on Day 26, he/she will end the current treatment 
cycle and resume irinotecan as part of the next treatment cycle. The current cycle may be cut short to 
avoid further delay in agent administration. 

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8 
STUDY PROCEDURES INCLUDING AGENT ADMINISTRATION 
All required study procedures, their timepoints and corresponding windows are detailed in Section 10 and Table 
10 Study Activity Calendar. The Principal Investigator will clarify to the participant’s treating investigators and 
clinical research team which study procedures (microdialysis, expansion cohort omission NSC start date) and 
which NSC dose level and irinotecan dose schedule the participant will undergo, when the participant begins the 
trial. 
Procedures performed by the clinical research team that require additional clarification beyond that provided in 
Table10 Study Activity Calendar, are detailed in this section. 
Pathology Review on Real-Time Frozen Section 
Study patients must have confirmation of recurrent tumor documented on frozen section at the time of surgery 
before proceeding with direct intracerebral injection of the NSCs. 
Confirmation of recurrent high-grade glioma by pathological frozen section of a tissue sample taken from a site 
different from the initial tumor presentation requires the simple identification of high grade glioma features 
(nuclear atypia, increase in cellularity, significant proliferative activity).  
In suspected recurrences at the site of initial presentation or in areas subjected to radiation treatment 
previously, a higher threshold will be used for diagnosing recurrent tumor. In order to distinguish patients who 
have“quiescent” paucicellular residual tumor foci (who would thus be ineligible to proceed with administering 
NSCs) from those with true tumor recurrences, 
 one or more of the following findings should be present for confirmation of recurrent HGG: 
- neoplastic cells with high nuclear to cytoplasmic ratio (with the exception of giant cell glioblastoma) 
- high mitotic activity 
- pseudopalisading necrosis 
- micro-endothelial proliferation 
- infiltrated parenchyma devoid of radiation changes 
Surgery, Catheter Placement, and NSC Administration at the time of Surgery 
The Principal Investigator will communicate the procedure (A-K) to the neurosurgeon.  
 
 

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Table 8.2a    Craniotomy Procedure 
Dose 
Level 
Craniotomy 
Procedure 
Microdialysis 
Catheters 
Number of 
NSCs 
Final 
volume 
Rickham 
-1 
A 
Microdialysis 
Catheters 
2.5x 107 
0.375 mL 
- 
-1 
B 
- 
2.5x 107 
0.375 mL 
- 
1 
C 
Microdialysis 
Catheters 
5 x 107 
0.75 mL 
- 
1 
D 
- 
5 x 107 
0.75 mL 
- 
2 
E 
Microdialysis 
Catheters 
5 x 107 
0.75 mL 
Rickham 
2 
F 
- 
5 x 107 
0.75 mL 
Rickham 
3 
G 
Microdialysis 
Catheters 
1 x 108 
1.5 mL 
Rickham 
3 
H 
- 
1 x 108 
1.5 mL 
Rickham 
4 
I 
Microdialysis 
Catheters 
1.5 x 108 
2.25 mL 
Rickham 
4 
J 
- 
1.5 x 108 
2.25 mL 
Rickham 
- 
K 
Microdialysis 
Catheters 
N/A 
N/A 
Rickham 
 
 

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Table 8.2b    Biopsy Procedure 
Dose 
Level 
Biopsy 
Procedure 
Number of 
NSCs 
Total  
volume 
Rickham 
NSC # and volume 
administered 
during surgery 
over 10 minutes 
Microdialysis 
Catheters 
NSC # and volume 
administered post 
recovery, duration of 
administrationa 
-1 
A 
2.5x 107 
0.375 mL 
- 
2.5 x 107 (.375 mL) 
Microdialysis 
Catheters 
- 
-1 
B 
2.5x 107 
0.375 mL 
- 
2.5 x 107 (.375 mL) 
- 
- 
1 
C 
5 x 107 
0.75 mL 
- 
5 x 107 (.75 mL) 
Microdialysis 
Catheters 
- 
1 
D 
5 x 107 
0.75 mL 
- 
5 x 107 (.75 mL) 
- 
- 
2 
E 
5 x 107 
0.75 mL 
Rickham 
5 x 107 (.75 mL) 
Microdialysis 
Catheters 
- 
2 
F 
5 x 107 
0.75 mL 
Rickham 
5 x 107 (.75 mL) 
- 
- 
3 
G 
1 x 108 
1.5 mL 
Rickham 
5 x 107 (.75 mL) 
Microdialysis 
Catheters 
5 x 107 (.75 mL) -
1.5hrs 
3 
H 
1 x 108 
1.5 mL 
Rickham 
5 x 107 (.75 mL) 
- 
5 x 107 (.75 mL) -
1.5hrs 
4 
I 
1.5 x 108 
2.25 mL 
Rickham 
6.7 x 107(1 mL) 
Microdialysis 
Catheters 
8.3 x 107 (1.25mL) – 
2.5 hrs 
4 
J 
1.5 x 108 
2.25 mL 
Rickham 
6.7 x 107(1 mL) 
- 
8.3 x 107 (1.25mL) – 
2.5 hrs 
- 
K 
N/A 
N/A 
Rickham 
 
Microdialysis 
Catheters 
- 
aPost-recovery NSC administration is detailed in Section 8.5.2. 
 
 
 

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8.1.1 
Craniotomy 
The following procedures are listed in the order they would occur, if they are applicable: 
2. Pathology Real-Time Review for Recurrent High Grade Glioma – all participants 
Pathologist criteria detailed in Section 8.1.  
****Participants who do not have confirmation of recurrent tumor via the pathology review of 
frozen sections will not proceed with study procedures.  
After resecting as much tumor as safely possible, and after confirmation of recurrent high grade tumor, and at 
the study neurosurgeon’s discretion: 
3. Microdialysis Catheter – A, C, E, G, I, K 
 
Before placing catheter(s) into brain, flush with sterile artificial CSF 
 
Tunnel catheter subcutaneously, then insert into residual tumor or peritumoral tissue. 
 
Insert 1 to 2 catheters 
4. Injection of NSCs – A-J 
 
Cells will arrive in the operating room already diluted into the final volume of 2% 
HSA/artificial CSF (per Table 8.2a). The cells are to remain at room temperature. Sterile 
technique will be used in the handling of cells. Refer to Table 8.2a for the number and 
volume of NSCs. 
 
For procedures A,C,E,G,I (MD catheter present), inject between two to four 100-150 µL 
suspensions of NSCs at the margins of the catheter(s). The remaining number of NSCs will 
be injected in divided 100-150 µL volumesas evenly spaced as possible throughout the wall 
of the resection cavity, administering them only into areas that are surgically safe and 
feasible.  
 
For procedures B,D,F,H,J(no MD catheter), inject the NSC volumes as evenly spaced as 
possible throughout the wall of the resection cavity, administering them only into areas that 
are surgically safe and feasible.  
 
TheNSCs will be injected 2.5 cm deep and tracked up to approximately 1 cm deep, (slowly 
injecting as the needle is withdrawn, so as to distribute the NSCs from 2.5 cm – 1 cm depth). 
5. Placement of Rickham – E-K 
 
After the NSCs are injected, the study neurosurgeon will place a 9.5mm Rickham in residual 
tumor tissue which will be used to deliver subsequent doses of NSCs. 
6. Wound Closure–all participants 
 
The wound will then be closed in standard fashion, anchoring the catheter(s) to the scalp with 
suture and sterile dressings. 
 
 

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8.1.2 
Biopsy 
The following procedures are listed in the order they would occur, if they are applicable: 
1. Pathology Real-Time Review for Recurrent High Grade Glioma – all participants 
Pathologist criteria detailed in Section 8.1.  
****Participants who do not have confirmation of recurrent tumor via the pathology review of 
frozen sections will not proceed with study procedures.  
After resecting as much tumor as safely possible, and after confirmation of recurrent high grade tumor, and at 
the study neurosurgeon’s discretion: 
2. Placement of Rickham –  E-K 
 
Before the NSCs are injected, the study neurosurgeon will place a 9.5mm Rickham in residual 
tumor tissue which will be used to deliver subsequent doses of NSCs. 
3. Injection of NSCs –  A-J  
 
Cells will arrive in the operating room already diluted into the appropriate volume of 2% 
HSA/artificial CSF (per Table 8.2b). The cells are to remain at room temperature. Sterile 
technique will be used in the handling of cells.  
 
For procedures A-D (no Rickham),the study neurosurgeon will slowly inject the cells over 10 
minutes along the original biopsy track, followed by a 0.3 mL 2% HSA/artificial CSF flush as 
the biopsy needle is slowly being withdrawn over one minute to minimize reflux of the NSCs.  
 
For procedures E-J, the neurosurgeon will be manually inject the cells over 10 minutes 
through the Rickham, followed by a 0.3 mL 2% HSA/artificial CSF flush as the biopsy needle 
is slowly being withdrawn over one minute to minimize reflux of the NSCs. 
4. Microdialysis Catheter – A, C, E, G, I, K 
 
Before placing catheters into brain, flush with sterile artificial CSF 
 
For procedures A and C (no Rickham), a 70 Brain MD Catheter will be passively introduced 
into the injection site through the needle track. When feasible, a second microdialysis 
catheter will be inserted into a geographically different part of the tumor, as per the next 
bullet point. 
 
If a Rickham catheter or first MD catheter are in the biopsy site, tunnel an MD catheter 
subcutaneously, then insert into residual tumor or peritumoral tissue. 
 
Insert 1 to 2 MD catheters 
5. Wound Closure - all participants 
 
The wound will then be closed in standard fashion, anchoring the catheter(s) to the scalp 
with suture and sterile dressings. 
8.1.3 
Peri- and post-operative Prophylaxis 
Levetiracetem (Keppra)—or another anticonvulsant that does not cause significant induction of hepatic 
metabolic enzymes, such as lacosamide or valproic acid—will be administered to all study patients. Those who 

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have never had a seizure will start taking levetiracetam within 1 week prior to surgery and continue taking the 
anti-seizure medication for 4 weeks after craniotomy or biopsy. 
Perioperative antibiotics, corticosteroids, and deep vein thrombosis prophylaxis will be used according to the 
standard of care for the surgical procedure. 
For participants with microdialysis catheters, prophylactic antibiotic use will continue as long as the microdialysis 
catheter(s) remains in place. Furthermore, these participants will be transferred to the Intensive Care Unit (ICU) 
after they leave the post-anesthesia care unit. These participants will stay in the ICU as long as the microdialysis 
catheter(s) remain in place. Microdialysis catheter(s) will be removed ahead of schedule if they stop functioning. 
Study patients will be discharged from the hospital when medically ready, except for participants with 
microdialysis catheters who will remain in the ICU for as long as the microdialysis catheter(s) is/are in place. 
Microdialysis Catheter- Related Procedures (Post-Surgery) 
Procedures A, C, E, G, I, K. 
8.1.4 
Confirmation of Microdialysis Catheter Position 
A CT scan without contrast will be obtained as soon as possible post-operatively to determine if the microdialysis 
catheter(s) was/were placed correctly. If the CT scan shows poor positioning of a catheter, such as placement in 
a ventricle or within the surgical cavity but not in brain tissue, it will be removed. 
For participants who will undergo post-recovery NSC administration though the Rickham catheter (biopsy 
procedures G and I), the CT scan and microdialysis set up is to precede NSC administration. 
8.1.5 
Materials needed for microdialysis set up, maintenance and dialysis 
For each microdialysis catheter, the following materials will be used: 
- 
One 2.5mL syringe (106 Pump Syringe, ref. no. 8010191, M Dialysis, Solna, Sweden) filled 
with sterile artificial CSF (Perfusion Fluid CNS) for each day the MD catheter is in place.  
- 
1 portable syringe pump (107 MD Pump, ref. no. P000127, M Dialysis, Solna, Sweden).   
- 
Roughly sixty microvials (Ref. No. P000001, M Dialysis, Solna, Sweden), pre-silanized and 
acidified by the City of Hope Analytical Pharmacology Core Facility. 
- 
Dry ice for the collection of all microvials removed from the catheter. 
8.1.6 
Microdialysis Setup, Maintenance, and Collection of Dialysate 
Once the CT scan confirms correct placement of the microdialysis catheter(s), the microdialysis tubing and pump 
will be set up as follows (and for biopsy procedures G and I, will occur prior to post-recovery NSC administration): 
 
Inlet tubing of each catheter will be connected to a 2.5 mL syringe filled with sterile artificial CSF.  
 
The syringe will then be placed in a portable syringe pump. 
 
The flow control on the pump will be set at 1µL/min and the pump will be turned on.  
 
A plastic microvial will be placed in the vial holder at the end of the outlet tubing to collect dialysate. 
This microvial can hold up to 200 L of fluid.  It will need to be replaced with a new one every 3 hours 
until the dose of irinotecan is administered (see Section 8.3.5). 
 
When replacing the microvials, compare volumes of dialysate in the microvial to a control microvial to 
check for clogging. Should clogging occur, as indicated by dialysate not exiting from the outlet tubing, 

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open the lid with the pump still on.  The pump will automatically go into a flushing cycle.  If the clog does 
not clear, the microdialysis set up and catheter are to be removed.  PK blood samples will not proceed 
once there is no longer a functional catheter in place. 
 
A new syringe containing sterile artificial CSF will be placed in microdialysis pump daily, as follows: 
o First stop the pump by taking the batteries out, not by opening the lid. (If the lid is opened while 
the batteries are still in, the pump will automatically go into a flushing cycle).  
o Open the lid and replace the syringe. 
o Once the new syringe is in place, close the lid and put the batteries back in. The pump will then 
resume its flow rate of 1µL/min without going into a flushing cycle. 
 
Once treatment with irinotecan has started, it is important not to flush the catheter unless it becomes 
clogged. 
 
All microvials containing dialysate will be placed on dry ice until they can be moved to an ultralow 
temperature freezer (-70°C) where they will be stored until shipped to the City of Hope Analytical 
Pharmacology Core Facility.During the period of dialysate collection, a patient may be mobile within the 
confines of the collection system. For example, s/he may move from bed to chair or commode and so 
on. 
 
For patients with more than one intracerebral microdialysis catheter, it is important to consistently 
distinguish the catheter source.  
8.1.7 
Set up for Blood Sample Collection and Procedures for Blood Sample Collection and Processing 
Sampling will be performed to define the plasma concentration-time profiles of irinotecan and SN-38. On day 3, 
prior to administering irinotecan, a large gauge peripheral catheter (e.g., 19 or 20 gauge angiocath straight set with 
T-connector, or similar IV access device) will be placed within a vein in the arm of the patient for the collection of 
pharmacokinetic blood samples. Patency of the sampling catheter should be maintained between blood draws 
using either a heparin lock (e.g., 10 U/mL in normal saline) or a slow drip of Normal Saline for Injection, USP (e.g., 
10 mL/hr). 
At each sample time point a discard blood volume appropriate for the IV access device must be drawn prior to 
the sample.  Blood (3 mL) will be drawn from a peripheral vein in the patient’s arm and collected in plasma tubes 
containing sodium heparin anticoagulant.  Promptly mix the plasma collection tube by gently inverting 6-times 
and then place it on wet ice, until centrifuged at 1,300 x g for 10 min at 4°C.  Samples will be centrifuged for 
harvesting plasma as soon as possible after collection (within 1 hour). Upon centrifugation, separate the plasma 
from the blood cells using a pipet and transfer the plasma to an appropriately labeled polypropylene freezer vial. 
Polypropylene freezer vials containing 10 µL 3N HCL will be provided. Plasma will be stored frozen at <-70°C until 
sent to the City of Hope Analytical Pharmacology Core Facility. 
8.1.8 
Blood and Dialysate Collection Timepoints 
Dialysate microvials will be collected as the microvials are changed every three hours from the time of 
microdialysis set to irinotecan administration. 
On day 3, just prior to the start of the irinotecan infusion, a new microvial will be placed in the holder(s) of the 
outlet tubing of the microdialysis catheter(s). The microvials will be changed to new ones every 60 minutes for 
the next 24 hours, and then the microvial(s) will be switched every 3 hours to new ones for the subsequent 24 
hours. 

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On day 3, blood samples will be drawn just prior to the start of the irinotecan infusion and at 90 minutes (just 
prior to the end of the infusion), and then at 30 minutes, 1, 2, 4,  8, 24, and 48 hours after the end of the infusion. 
While it is important to collect samples as close to hour as possible, it will not be a deviation if the samples are 
not taken at the specified time, so long as the actual time of collection is recorded.   
The time of each sample collection is to be recorded.  
If the microdialysis catheter becomes non-functional, then blood draws for plasma PKs will stop.  
8.1.9 
Removal of the Microdialysis Catheter 
After microdialysis procedures have finished (approximately 48 hours after irinotecan administration), the 
microdialysis catheter will be removed percutaneously at the bedside by neurosurgery personnel. Xylocaine for 
local anesthesia will be used as needed. The entry site of the catheter will be closed with a suture or steri-strips 
as necessary and a clean dressing applied. 
Following the removal of the Microdialysis Catheter, the patient may leave the ICU, per the discretion of the 
neurosurgeon. 
Administration of Irinotecan 
Please see section 7.2 for criteria that a patient must meet in order to proceed with irinotecan administration.   
8.1.10 Nausea and Diarrhea Prophylaxis 
Patients will be pre-medicated with ondansetron 16 mg p.o. at least 30 minutes prior to the infusion of 
irinotecan. 
Orders will also be written for standard use of atropine (to prevent early onset diarrhea) and loperamide (for 
management of later diarrhea) as needed. 
See Section 6 for additional details regarding ancillary treatments and prophylaxis. 
8.1.11 Cycle 1 Day 3 Irinotecan Special Considerations 
For Cycle 1 Day 3 irinotecan administration, the participant must have recovered well from any immediate post-
operative effects and requires no more than 16 mg/day of dexamethasone. Otherwise the participant will be 
removed from treatment (Section 7.2.3).  
In addition, for participants undergoing microdialysis (Procedures A, C, E, G, I, K), the cycle 1 day 3 administration 
of irinotecan is accompanied by various samples before and after irinotecan administration.  See section 8.3.3-
5 for details. 
8.1.12 Intravenous Administration of Irinotecan 
Irinotecan will be diluted with D5W to a total volume of 500 ml and infused intravenously over 90 minutes. Start 
and end time of the administration are to be recorded. 
 
Intracerebral Administration of NSCs via the Rickham 
8.1.13 Post-recovery NSC administration on day of surgery 
NSCs will be brought from the Aboody Laboratory to the outpatient clinic at room temperature and already 
resuspended at the indicated volume in 2% HSA/articial CSF.   

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The NSCs followed by a flush will be administered post-recovery following surgery, in the hospital room. 
Table 8.5.1  Post-recovery NSC administration on day of surgery 
Dose 
Level 
Biopsy 
Procedure 
Number of 
NSCs 
Volume 
Duration of NSC administration 
(rate of 0.5 ml/hr) 
3 
G-H 
5.0 x 107 
0.75 mL 
1.5 hrs 
4 
I-J 
8.3 x 107 
1.25 mL 
2.5 hrs 
 
Flush 2% HSA/artificial CSF 
1.0 mL 
2.0 hrs 
Method of Administration 
 
Prime the infusion tubing with the NSC suspension before beginning a slow infusion of the 
NSCs at 0.5 mL/hr.  
 
Follow with a 1 mL 2% HSA artificial CSF flush at a rate of 0.5ml/hr. 
8.1.14 NSC administration via Rickham (not including day of surgery) 
Please see section 7.2 for criteria that a patient must meet in order to proceed with NSC repeat administration.  
NSCs will be brought from the Aboody Laboratory to the outpatient clinic at room temperature and already 
resuspended at the indicated volume in 2% HSA/articial CSF.   
If a participant has a dose reduction of NSC’s the NSCs will be resuspended to a concentration of 6.7 x 
107NSCs/mL, and infused at a rate of 0.5mL/hr. 
The NSCs followed by a flush will be administered in the outpatient setting. 
Table 8.5.2  Repeat NSC administration via Rickham 
Dose 
Level 
Procedure Number of 
NSCs 
Volume 
Duration of NSC administration 
(rate of 0.5 ml/hr) 
2 
E-F 
5.0 x 107 
0.75 mL 
1.5 hrs 
3 
G-H 
1.0 x 108 
1.5 mL 
3.0 hrs 
4 
I-J 
1.5 x 108 
2.25 mL 
4.5 hrs 
 
Flush 2% HSA/artificial CSF 
1.0 mL 
2.0 hrs 
 
Method of Administration 
 
Prime the infusion tubing with the NSC suspension before beginning a slow infusion of the 
NSCs at 0.5 mL/hr.  
 
Follow with a 1 mL flush of 2%HSA/artificial CSF at a rate of 0.5ml/hr. 

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Samples for Performing the Immunological Studies and RCR Testing 
All assays to be performed by CICSL and Clinical Pathology are detailed in Section 12.2. 
8.1.15 Immunological Studies- Correlative Studies 
Notify the CICSL prior to sample collection. Notification should be at least 24 hours in advance (the earlier the 
better) in the form of Outlook calendar notifications by e-mail to vtran@coh.org. CICSL would prefer samples to 
be delivered before 4 pm each day. 
To assess for possible development of T cell responses to the adenovirally transduced NSCs and to evaluate for 
systemic presence of the NSCs and/or hCE1m6, approximately 30 ml of blood will be collected in lavender top 
tubes (liquid potassium EDTA).  The samples will be placedon wet ice and delivered to City of Hope’s CICSL for 
processing. 
To assess for possible antibody responses to the NSCs and/or adenoviral proteins, approximately 10 ml of blood 
will be collected in red top tubes (free of any anti-coagulant reagent). Samples should be kept in an upright 
position at room temperature for 1 – 2 hours before processing to allow blood to clot.  If processing cannot be 
done the same day, samples should be kept in an upright position at 4°C and processed within 24 hours.  
Centrifuge the sample at 1000 x g for 15 minutes at 4°C.  Remove the serum without disrupting the blood at the 
bottom of the tube.  Serum samples will be aliquoted and distributed to CICSL and Clinical Pathology. 
8.1.16 Immunological Studies – Suspected NSC Immune Response 
If a patient develops an adverse event that is suspected of being due to an immune response to the NSCs, 3-5 
ml of blood will be collected in a red top tube (free of any anti-coagulant reagent) at least twice (separated by 
approximately 2 days) during the event for analysis of serum cytokine levels via Luminex cytokine panels. 
Samples should be kept in an upright position at room temperature for 1 – 2 hours to allow blood to clot. Take 
samples to CICSL for processing.  If unable to take to CICSL the same day, samples should be kept in an upright 
position at 4°C until delivery the next day.  For the first sample, communicate to CICSL that the pre-treatment 
sample is also to be assayed to provide a baseline for comparison. 
8.1.17 RCR Testing 
For RCR testing, at least 10 ml of blood will be collected from each patient in EDTA treated (lavender top) tubes 
maintained at room temperature with occasional gentle agitationand sent to City of Hope’s CICSL.  
 

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9 
AGENT INFORMATION AND RISKS 
 
hCE1m6 - NSCs (IND # 16265) 
9.1.1 
Animal Toxicity Data 
All toxicity studies to date in mice have shown no evidence of organ damage or tumorigenicity due to NSCs. 
Please see sections 2.4.2 and 2.4.3. 
9.1.2 
Human Toxicity Data 
See sections 2.5 and 7.1.2. 
9.1.1 
Handling 
Following thawing and resuspension in the Karen Aboody Laboratory, cells are to be maintained at room 
temperature until administration. Sterile technique is to be used in the handling of cells. 
9.1.2 
Administration 
Intracranial administration---either through direct injection into tumor at the time of surgery, or via a Rickham 
that is placed in tumor tissue. 
9.1.3 
Supplier 
City of Hope –Karen Aboody Laboratory will provide NSCs, already thawed and resuspended (per SOP) for 
administration. To order cells, call COH extension 63613 or email Marianne Metz at mmetz@coh.org or her 
designee.  
Irinotecan 
Irinotecan (CAMPOSTAR) is an FDA approved chemotherapy agent. Please refer to the Package Insert for 
additional details not provided in this section. 
9.1.4 
Description 
Irinotecan 
hydrochloride 
trihydrate 
{CPT-11, 
(4S)-4, 
11-diethyl-4-hydroxy-9-{(4-piperidinopiperidino) 
carbonyloxy}-IH-pyroano{3',4':6,7}indolzino{1,2-b}quino line-3, 14(4H,12H)dione hydrochloride trihydrate} is a 
topoisomerase I inhibitor. 
9.1.5 
Human Toxicity 
See section 7.1.4. 
9.1.6 
Formulation 
Irinotecan is supplied in three forms: 2 mL vials containing 40 mg of drug, 5mL vials containing 100 mg of drug, 
and 15 mL vials containing 300 mg of drug. The drug is supplied in brown vials and appears as apale-yellow-to-
yellow crystalline powder and pale yellow transparent solution whenreconstituted. 
9.1.7 
Storage and Stability 
Irinotecan vials must be stored in a cool, dry place, protected from lightin a locked cabinet accessible only to 
authorized individuals.  It is stable to the expiration date on its label. Irinotecan is stable for at least 24 hours in 
glass bottles or plastic bags after reconstitution with D5W. 

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9.1.8 
Handling 
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and the 
environment, should undertake the preparation, handling, and safe disposal of the chemotherapeutic agent. 
9.1.9 
Administration 
Irinotecan will be diluted with D5W to a total volume of 500 ml and infused intravenously over 90 minutes. 
Nothing else should be added to the bag. 
9.1.10 Supplier 
 
City of Hope will purchase irinotecan formulated for human use from a commercial source, but separate supplies 
for this investigational protocol will be accounted for by the Investigational Drug Service.

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10 STUDY CALENDAR 
Table10, Study Activity Calendar, describes required procedures and provides references where additional information is necessary.  All procedures may increase 
in frequency if clinically indicated or oriented following a toxicity/adverse event.  See Section 7.3 for adjustments to the study calendar following a delay of study 
agent administration. 
Study tests and procedures may be done +/- 3 days for patient convenience and scheduling. A window period of +/- 1 day is allowed for intracranial administration 
of NSCs, but there must still be at least an interval of  2 days between administration of the NSCs and irinotecan.  
During the treatment cycle, on days of agent administration, all safety assessments must be performed and reviewed prior to administration of any study agent.   
 
 

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Table 10 Study Activity Calendar 
 
Screen
ingb 
Cycle 1a 
Cycle 2+ 
End 
of 
Txg 
30-Day 
Post 
Txh 
Long Term 
Follow-Up, 
Autopsyi 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
8 
Day 
10 
Day 
15 
Day 
17 
Day 
22 
Day 
1c,d 
Day 
3 
Day 
15e 
Day 
17 
Day 
28f 
Informed consentj 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Background/medical history k 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion criterial 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Histology confirmation 
Xm 
Xn 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vitals, KPS, neuro &physical examso 
X 
 
X 
X 
 
 
 
 
Xp 
 
 
X 
 
X 
 
 
X 
Xq 
 
Adverse event assessment r 
X 
 
X 
X 
 
 
X 
 
Xp 
 
X 
X 
 
X 
 
 
X 
X 
 
Concomitant meds review s 
X 
 
X 
X 
 
 
 
 
Xp 
 
 
X 
 
X 
 
 
X 
X 
 
HLA antibody screening u 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UGT1A1 polymorphismv 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunological studies w 
Xx 
 
 
 
 
 
 
 
Xp 
 
Xy 
 
X 
 
 
X 
 
 
RCR testingz 
Xx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Coagulation: PT/INR, PTT 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC with ANCaa 
X 
 
 
X 
 
 
X 
 
Xp 
 
 
Xc 
 
Xc 
 
 
X 
 
 
Comprehensive Metabolic Panelbb 
X 
 
 
X 
 
 
 
 
Xp 
 
 
Xc 
 
 
 
 
X 
 
 
Serum Pregnancy Test cc 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-ray and EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Imaging – MRI 
Xdd 
Xee 
Xff 
 
 
 
 
 
 
 
 
 
 
 
 
Xff 
Xhh 
 
 
Imaging – PET/CT scan of the brain 
 
Xgg 
 
 
 
 
 
 
 
 
 
 
 
 
 
Xgg 
Xhh 
 
 
Response Assessmentii 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Xii 
 
 
Neurosurgery 
 
Xjj 
 
 
 
Xkk 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administration of hCE1m6 - NSCs 
 
Xll 
 
 
 
 
 
 
Xm
m 
 
 
Xm
m 
 
Xm
m 
 
 
 
 
 
Non-contrast Brain CT 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dialysate, blood pK collectionoo 
 
 
 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV administration of irinotecanpp 
 
 
 
Xrr 
 
 
 
 
 
X 
 
Xss 
Xtt 
Xss 
Xtt 
 
 
 
 
Post-Study Tx Medical History uu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Tissue from autopsy vv 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 

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a. For patients on dose level 1 /-1, Cycle 1 will be a minimum of 30 days to ensure that 14 days have passed between irinotecan doses. 
b. To be performed within 14 days from planned date of surgery, except for MRI (footnote ee) to be performed within 28 days of registration. 
c. 
Laboratory evaluations to be performed and results reviewed within 2 days prior to agent administration. Laboratory evaluations may be performed at a clinic local to 
the participant. 
d. ‘Start of Cycle’ criteria are found in Section 7.2.2. All assessments to occur prior to administration of NSCs (or irinotecan for dose levels 1/-1). 
e. All assessments to occur prior to administration of NSCs (or irinotecan for dose levels 1/-1). 
f. 
Imaging (brain MRI and PET/CT scans) should at least be done at the end of every 2 cycles (Day 28 -3days).Imaging can be done more frequently than after every 2 cycles 
to closely follow up on changes of unknown significance seen on a prior brain MRI or PET/CT scan. 
g. 
End of treatment assessments to be performed within 7 days after last study agent administration or within 7 days after decision to end treatment.  Assessments may 
continue for ongoing reportable adverse events or events resulting in a dose modification. 
h. A contact/visit for review of adverse events, KPS, concomitant medication review, and vital status is to be performed at 30 days +/- 2 days after the last study agent is 
given.  This may be performed via documented phone conversation with a study nurse or clinician. All participants will be followed until resolution or stabilization of any 
serious or reportable adverse events occurring during treatment or starting within 30 days of last study agent. 
i. 
Long-term follow-up to occur until death for updated medical history, RCR testing, and tissue at autopsy.  Required elements occur at 3 months (+/-14 days), 6 months 
(+/-14 days) and annually from start of study treatment, and upon patient death.  See footnotes z, rr, andss for details.   
j. 
Performed by MD attending only. Informed consent process to be fully documented. 
k. 
Background/medical history – to include review of treatment history for glioma, any ongoing medical conditions and medical history pertaining to eligibility on study and 
involvement during study.  
l. 
Inclusion/exclusion criteria. Source documentation providing investigator’s confirmation that patient has met all eligibility criteria must be available prior to registration. 
In addition, source documentation by neurosurgeon that (a) a physical connection between the post-resection tumor cavity and cerebral ventricles is not anticipated, (b) 
a gross total resection is not anticipated, (c) the prospective participant is able to undergo neurosurgery, and (d) documentation that patient “needs a 
biopsy/craniotomy” is needed. 
m. Histology confirmation for to be performed by COH pathologist.  
n. Real-time histology confirmation to occur during surgery on fresh frozen section. See section 8.1 for pathology criteria.  If confirmation of high grade glioma not 
obtained, all further study procedures will cease. 
o. Vital signs:  Weight, heart rate, blood pressure, respiration rate, temp.  Height required only at baseline.  KPS not required at Day 2 and 3.  See Appendix A for KPS scale. 
p. Participants no longer receiving NSCs (e.g. Dose Levels 1 and -1) may have their Day 15 assessments performed  on Day 17, prior to irinotecan dosing.  

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q. KPS and vital status only.  Vital signs and Neuro-Physical exam are not required. 
r. 
Adverse events experienced by participants will be collected and recorded from signing of informed consent document up to 30 days of the last dose of study 
medication.  The period for collection and recording of AEs is extended for participants with ongoing “reportable” adverse events that are related to study agent. 
Adverse event reporting begins for events that occur on Day 1 (day of neurosurgery). 
s. 
The only concomitant medication that needs to be documented in the case report form is whether the patient is taking dexamethasone (or another corticosteroid), and 
if so, what the dose is.  
t. 
For HLA testing, collect blood in1 red top tube. Maintain at room temperature.  Bring samples to COH Histocompatibility Laboratory.  
u. Participants who have already undergone UGT1A1 genotyping may use those results and do not the procedure repeated. 
v. 
For immunological correlative studies:notify CICSL by e-mail to vtran@coh.org at least 24 hours in advance of sampling. Collect six 6-ml lavender top (K-EDTA) tubes, 
keep on wet ice,  and send to COH CICSL; collect approximately 10 ml of blood in red top tubes, keep upright at room temperature and process as per Section 8.6.1 
before sending to the COH CICSL and Clinical Pathology.On days where study agent is administered, samples are always to be taken prior to agent administration. 
w. If participant is removed (or withdraws) from the trial prior to receiving study agent, the samples are to be discarded. 
x. 
Cycle 2 only.  
y. 
For RCR testing, collect two 6-ml lavender top (K-EDTA) tubes (or a volume of 10ml) maintained at room temperature with gentle agitation ~hourlyand send to CICSL.On 
days where study agent is administered, samples are always to be taken prior to agent administration. Notify CICSL by e-mail to vtran@coh.org in advance of sampling, 
z. 
RCR testing is required for all patients at 3 months* and 6 months*and annually* thereafter post start of study treatment, whether patient is on treatment on in long 
term follow-up.  For patients still on treatment, assuming there are no delays in treatment, this means RCR testing is to be performed at C4D1 and C7D1.  Take RCR 
testing at most appropriate clinic visit for patients still on study treatment.  For patients in long term follow-up, samples may be obtained via local physician and shipped 
to COH for testing.  (*+/-14 days) 
aa. CBC with ANC: hemoglobin, hematocrit, platelets, total WBC and neutrophils 
bb. Comprehensive metabolic panel: Sodium, potassium, chloride, carbon dioxide, creatinine, urea nitrogen, calcium, glucose, albumin, total bilirubin, alkaline phosphatase, 
total protein, ALG/SGPT and AST/SGOT. 
cc. Serum pregnancy test only for women of child bearing potential. 
dd. A contrast, non-contrast MRI is to be performed for screening within 28 days from registration. (Day 2 post-surgical MRI will serve as the baseline MRI).  
ee. A pre-surgical planning post-registration MRI may be performed if indicated by the neuro-surgeon.   
ff. A contrast, non-contrast MRIwill be performed for all patients at least every two months. 
gg. A PET/CT scan will be performed within 7 days after surgery to serve as the baseline scan, and then a PET/CT scan will performed whenever possible at the time follow 
up brain MRIs are done. 

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hh. Imaging to be performed if the prior assessments occurred > 21 days before decision to end treatment, if patient is agreeable to have this procedure. The absence of this 
MRI and/or PET/CT scan with corresponding response assessment will not be considered a protocol deviation. 
ii. 
Response assessment using RANO criteria, at time of imaging and as indicated clinically. Dexamethasone dose to be integrated into response determination. See Section 
13 for RANO criteria. 
jj. Neurosurgery will include real-time pathology review and may include Rickham Catheter and/or Microdialysis Catheter placement and/or NSC administration.  See 
section 8.2 for details. 
kk. For participants undergoing microdialysis (procedures A, C, E, G, I, K) only, microdialysis catheter is to be removed following completion of microdialysis by the 
neurosurgical team.  See section 8.3.6for all relevant information.  
ll. 
On day of surgery, NSC administration will occur either fully during surgical procedure (craniotomy procedure A-J, biopsy procedure A-F), or will occur both duringthe 
surgical procedure and following the surgical procedure via the Rickham (biopsy procedures G-J only).  Half of the participants in the expansion cohort will not receive 
Day 1 NSCs (procedure K). 
mm. Dose level 2, 3, 4 (procedures E-J) participants only.  Via Rickham catheter. See Section 8.5 for procedure.  
nn. For participants undergoing Microdialysis only (procedures A, C, E, G, I, K). Post surgical non-contrast CT used to confirm appropriate placement of catheter. See section 
8.3.1 for details. 
oo. For participants undergoing Microdialysis only (procedures A, C, E, G, I, K). Sampling of blood and dialysate to begin prior Day 3 irinotecan administration and up to 48 
hours after irinotecan administration. For the blood pKs, a venous catheter is required.  See Section 8.3.2 to 8.3.5 for details.  
pp. Irinotecan administration is detailed in Section8.4, including required prophylaxis, observation periods and documentation for required elements  
qq. (This has been deleted) 
rr. In order to receive Day 3 irinotecan, participant must have recovered well, per the neurosurgeon (documented in clinical record), from any immediate post-operative 
effects, and the patient must require ≤  16mg/day of dexamethasone.  Otherwise the participant will be removed from all study treatments. 
ss. Dose level 1 and -1(procedures A-D) participants will have irinotecan administration on Day 1 and Day 15.  NOTE: it is imperative that Cycle 1 is extended as needed (e.g. 
from 28 days to 30 days) to ensure that the Day 1 irinotecan dose occurs 14 days after the previous irinotecan dose.  
tt. Dose level 2, 3 and 4 (procedures E-J) participants only 
uu. Post-Study Treatment Medical History will consist of annual requests from the patient/patient’s primary oncologist for clinical information regarding other anti-cancer 
therapy, progression of disease, survival, as well as information pertaining to de novo cancer, neurologic, autoimmune and hematologic disorders. In addition, 
unexpected medical problems including information on hospitalizations and medications will be collected. To occur annually (+/-14 days) from the start of study 
treatment. Alternatively, participants may come into the clinic to provide the previous year’s medical history. 
vv. Efforts will be made to obtain tissue at the time of autopsy. 

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11 DATA AND SAFETY MONITORING, UNANTICIPATED PROBLEMS AND ADVERSE EVENT REPORTING 
Data and Safety Monitoring 
This is a Risk Level 4 study, as defined in the “City of Hope Data and Safety Monitoring Plan”, 
http://www.coh.org/dsmc/Pages/forms-and-procedures.aspx involving gene therapy, and City of Hope holds 
the study’s IND. 
Monitoring and Personnel Responsible for Monitoring 
The Protocol Management Team (PMT) consisting of the PI, collaborating investigators, CRA, protocol nurse, and 
statistician is responsible for monitoring the data and safety of this study, including implementation of the 
stopping rules for safety.  
This study will use a phase I tracking log to monitor data and safety for dose escalation, recording doses 
administered and resultant adverse events. The tracking log will contain dose levels administered, DLT-defining 
adverse events, and documentation that the data from a dose level is complete before dose escalation. Those 
data and safety elements will be reported to the COH DSMC as applicable with the PMT report, which will be 
submitted quarterly from the anniversary date of activation, as noted in Table 3 below. Protocol specific data 
collection will include the following items: adverse events per dose level, patient outcomes, and protocol 
deviations.  
A decision to escalate to the next dose level will be made by the PMT only after all patients on the current dose 
level have been observed for 4 weeks. Enrollment of the first 3 patients to a dose level will be staggered by 
requiring that each of the first 3 patients be separately observed for 4 weeks before the next patient can start 
treatment on that dose level.  
Reporting of data and safety to the DSMC will occur on a quarterly basis using the PMT report until the last study 
patient has been observed for 4 weeks.  
Table 11.2  City of Hope PMT Reporting Timelines for the DSMC 
Risk Level 
Phase 
Standard Reporting Requirement 
RL 1, RL2, and Compassionate 
Use Studies 
No reports required 
3 
I 
Every 3 months from activation date, as 
indicated in MIDAS 
3 
Pilot, Feasibility, 
II-IV 
Every 6 months from activation date, as 
indicated in MIDAS 
4 
Pilot, Feasibility, 
I-IV 
Every 3 months from activation date, as 
indicated in MIDAS 
Data and safety will also be reported to the FDA.  All IND safety reports that are submitted to the FDA regarding 
this protocol will also be submitted to the DSMC for review. As required by the FDA, study patients will be 
followed long term (up to 15 years or until death; see section 5.16), and the PMT will continue to report data 
and safety concern to the FDA, City of Hope DSMC, and IRB as they arise during this follow-up period.  

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Definitions 
Adverse event (AE) - An adverse event is any untoward medical experience or change of an existing condition 
that occurs during or after treatment, whether or not it is considered to be related to the protocol intervention.  
UnexpectedAdverse Event [21 CFR 312.32 (a) – An adverse event is unexpected if it is not listed in the 
investigator’s brochure and/or package insert; is not listed at the specificity or severity that has been observed; 
is not consistent with the risk information described in the protocol and/or consent; is not an expected natural 
progression of any underlying disease, disorder, condition, or predisposed risk factor of the research participant 
experiencing the adverse event. 
ExpectedAdverse Event - Any event that does not meet the criteria for an unexpected event OR is an expected 
natural progression of any underlying disease, disorder, condition, or predisposed risk factor of the research 
participant experiencing the adverse event 
Serious Adverse Event (SAE) [21 CFR 312.32] is defined as any expected or unexpected adverse event that results 
in any of the following outcomes: 
 
Death 
 
Is life-threatening experiences (places the subject at immediate risk of death from the event as it 
occurred); 
 
Unplanned hospitalization equal or greater than 24 hours)) or prolongation of existing hospitalization; 
 
A persistent or significant disability/incapacity; 
 
A congenital anomaly/birth defect 
 
Secondary Malignancy, or 
 
Any other adverse event that, based upon appropriate medical judgment, may jeopardize the subject’s 
health and may require medical or surgical intervention to prevent one of the outcomes listed above 
(examples of such events include allergic bronchospasm requiring intensive treatment in the emergency 
room or at home, blood dyscrasias of convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse). 
Unanticipated problem (UP) – Any incident, experience or outcome that meets all threeof the following criteria: 
1. Unexpected (in term nature, severity, or frequency) given the following: a) the research procedures 
described in the protocol-related documents such as the IRB approved research protocol, informed 
consent document or Investigator Brochure (IB); and b) the characteristics of the subject population 
being studied; AND 
2. Related or possibly related to participation in the research (possibly related means there is a reasonable 
possibility that the incident, experience, or outcomes may have been caused by the agents, devices or 
procedures involved in the research); AND 
3. Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm) than previously known or recognized. 
Reporting of Unanticipated Problems and Adverse Events 
Unanticipated Problems: Unanticipated problems must be reported to the COH DSMC and IRB within 5 calendar 
days accordingto definitions and guidelines at http://www.coh.org/hrpp/Pages/hrpp-policies.aspx.  Any 
unanticipated problem that occurs during the study conduct will be reported to the DSMC and IRB by submitting 
electronically in iRIS (http://iris.coh.org). 

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Serious Adverse Events - All SAEs occurring during this study, whether observed by the physician, nurse, or 
reported 
by 
the 
patient, 
will 
be 
reported 
according 
to 
definitions 
and 
guidelines 
at 
http://www.coh.org/hrpp/Pages/hrpp-policies.aspx and Table 1 below.  Those SAEs that require expedited 
reporting will be submitted electronically in iRIS (http://iris.coh.org/). 
Adverse Events - Adverse events will be monitored by the PMT.  Adverse events that do not meet the criteria of 
serious OR are not unanticipated problems will be reported only in the continuation reports and PMT reports 
(see Table 11.4 below). 
Table 11.4City of Hope Adverse Event and Unanticipated Problem Reporting Timelines for the DSMC 
and IRB 
Required Reporting Timelines to DSMC for AE/SAEs 
Investigator Initiated Studies 
Required Reporting Timeframe to DSMC 
Attribution 
UNEXPECTED 
EXPECTED 
  
Death while on active treatment or within 30 days of last day of 
treatment 
Possibly, Probably, Definitely 
5 calendar days 
Unlikely, Unrelated 
  
Death after 30 days of last active treatment/therapy 
Possibly, Probably, Definitely 
5 calendar days 
No reporting required 
Unlikely, Unrelated 
No reporting required 
No reporting required 
  
Grades 3 and 4 AND meeting the definition of "serious" 
Possibly, Probably, Definitely 
5 calendar days 
10 calendar days 
Unlikely, Unrelated 
5 calendar days 
10 calendar days 
  
Grades 1 and 2 AND resulting in "hospitalization" 
Possibly, Probably, Definitely 
5 calendar days 
10 calendar days 
Unlikely, Unrelated 
10 calendar days 
10 calendar days 
An event determined by the IRB of record to be an Unanticipated Problem (UP) will be communicated to the 
Investigator and COH DSMC through the COH IRB Operations Director. The DSMC will review the case and make 
a determination as to whether the study will be suspended, terminated, amended, or allowed to continue 
without amendment. 
Required Reporting Timeframe to IRB of Record 
Attribution 
UNEXPECTED 
EXPECTED 
 
Death 
Possibly, Probably, Definitely 
5 calendar days 
Annual 
Unlikely, Unrelated 
Annual 
Annual 
 
Grades 3 and 4 AND meeting the definition of a UP 
Possibly, Probably, Definitely 
5 calendar days 
Annual 

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Required Reporting Timeframe to IRB of Record 
Attribution 
UNEXPECTED 
EXPECTED 
Unlikely, Unrelated 
Annual 
Annual 
 
Grade 1 and 2 AND meeting the definition of a UP 
Possibly, Probably, Definitely 
5 calendar days 
Annual 
Unlikely, Unrelated 
Annual 
Annual 
 
Additional Reporting Requirements: FDA and National Institutes of Health – Office of 
Biotechnology Activities (NIH-OBA) Reporting 
Since this study involves gene therapy, and City of Hope holds the IND, adverse events must also be reported to 
the FDA and the NIH-OBA. 
SAEs meeting the requirements for expedited reporting to the FDA, as defined in 21 CFR 312.32, will be reported 
as an IND safety report using the MedWatch Form FDA 3500A for Mandatory Reporting which can found at: 
http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/default.htm 
The PI or designee will be responsible for contacting the Office of IND Development and Regulatory Affairs 
(OIDRA) at COH to ensure prompt reporting of safety reports to the FDA and NIH-OBA.  OIDRA will assist the PI 
with the preparation of the report and submit the report to the FDA and NIH-OBA in accordance with the 
following: 
 
Any unexpected fatal or life threatening adverse experience associated with use of the agent must be 
reported to the FDA no later than 7 calendar days after initial receipt of the information [21 CFR 
312.32(c)(2)]; 
 
Any adverse experience associated with use of the agent that is both serious and unexpected must be 
submitted no later than 15 calendar days after initial receipt of the information [21 CFR 312.32(c)(1)] 
 
Any follow-up information to a study report shall be reported as soon as the relevant information 
becomes available. [21 CFR 312.32(d)(3)] 
The PI/designee will submit the adverse event report through the City of Hope electronic reporting system, and 
then OIDRA will take responsibility for reporting of the adverse event to NIH-OBA.  
As required by the FDA, study patients will be followed long term (up to 15 years) and the PI will continue to 
report data and safety concerns to the FDA, DSMC, and IRB as they arise during this follow-up period.  
Medical Device Reportable Events 
Medical devices that will be used in this study include intracerebral microdialysis catheters and Rickham 
reservoir/catheter systems.  
Medical Device Reportable (MDR) Events are the AEs or problems that the medical device regulation requires to 
be reported.  These events include patient deaths and serious injuries that the medical devices have or may have 
caused or contributed to, i.e., the devices may have directly caused the events or played a role in the events. 
The timely reporting of MDR reportable events is required by the FDA, and will be handled by OIDRA. 

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12 CORRELATIVE/SPECIAL STUDIES 
Intracerebral microdialysis 
In order to gather data regarding intracerebral levels of irinotecan and SN-38 when brain tumor patients are 
treated with CE-secreting NSCs and irinotecan, microdialysis catheters will be used to obtain samples of brain 
interstitial fluid, as described in sections 8.3, from the first 6 study patients and 8 patients treated at the 
MTD/MFD level in the expansion cohort. During dialysate collection, blood samples will also be drawn in order 
to compare systemic and intracerebral levels of irinotecan and SN-38 as described in sections 8.3.  
Analysis will be performed by the City of Hope Analytical Pharmacology Core Facility. 
Immunological Correlative Studies 
In order to 1) assess for possible development of T cell and antibody responses to the NSCs and/or cell surface-
expressed adenoviral proteins, 2) measure adenoviral vector (Ad5) antibody titers and total adenoviral antibody 
titers, and 3) look for systemic presence of the NSCs and/or hCE1m6, samples of study patients’ blood will be 
collected for isolation and storage of PBMCs and serum prior to surgery, on day 15 of cycle 1, days 1 and 15 of 
cycle 2, and on day 15 of subsequent  treatment cycles. We will also test for replication competent retrovirus 
(RCR) (section 12.2.6). 
The following studies, which were successfully performed in the first-in-human neural stem cell study of 
HB1.F3.CD NSCs and oral 5-FC, will be done by the City of Hope Clinical Immunobiology Correlative Studies 
Laboratory (CICSL), with the exception of the total adenoviral antibody titers, which will be performed by City of 
Hope Clinical Pathology: 
12.1.1 Assessment of the Development of Anti-NSC T Cell Responses 
Development of a T cell response to the adenovirally transduced NSCs will be evaluated by a combination of TcR 
Vβ spectratyping and CD107 degranulation assays using established laboratory SOP and protocols. Briefly, Vβ 
spectratyping of patient PBMCs collected prior to and after NSC administration will identify unique clonal 
populations of T cells that have expanded post-NSC administration. Such expanded populations have the 
potential to be specific for and to eliminate the administered NSCs. The specificity of the clonally-expanded T 
cells for the NSCs will be evaluated by 1) incubating pre- and post-infusion PBMC samples with the NSCs, 
followed by flow cytometric analysis using commercially available monoclonal antibodies specific for the 
identified clonotypes to determine the candidate T cells and 2) assessing surface CD 107 (a measure of 
cytotoxicity) on the surface of those T cells. 
12.1.2 Determination of Development of Antibody Responses to the Adenoviral Vector and/or NSCs. 
We will assess for development of antibody responses to the NSCs and/or cell surface-expressed adenoviral 
proteins.   
An evaluation of humoral responses to NSCs will be performed in the CICSL by flow cytometric evaluation of 
antibody binding to NSCs. Briefly, aliquots of cultured NSCs will be incubated on ice with cryopreserved patient 
serum samples that have been heat treated to inactivate complement. Following incubation the NSCs will be 
washed and any bound antibodies will be detected using a secondary goat anti-human Fc antibody conjugated 
to FITC. After a second washing step, the NSCs will be analyzed by flow cytometry. Binding of human antibodies 
to the NSCs will be detected as a shift in the mean fluorescence intensity (MFI) compared to NSCs not treated 
with human serum. All samples obtained from individual subjects prior to and after therapy will be evaluated in 
parallel to evaluate possible development of humoral anti-NSC responses over time. The statistical significance 
of any detected MFI shifts will be evaluated by comparison with data from the NSC binding of a reference panel 

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of normal human sera. The assay will include as controls the parental NSC (not transduced with the CD gene) 
and the CD-expressing NSCs that have not been transduced with adenovirus to evaluate whether antibody 
responses are directed against the CD, CE, or adenoviral gene products.  
If evidence of an immune responses are observed in patients, then we will assess for expression of the 72Kd DNA 
binding protein, which is specific to the adenoviral vector that was used to transduce the NSCs, and evaluate 
anti-hCE1m6 antibody titers to try to understand whether the immune response is to the NSCs themselves or 
the result of adenoviral transduction of the NSCs. 
12.1.3 Measurement of Adenoviral Antibody Titers 
Serum adenoviral vector (Ad5) IgG and IgM antibody titers as well as total adenoviral IgG and IgM antibody titers 
will be assessed at baseline and then at the same time points when blood is collected for investigating the 
presence of T cell and antibody responses to the adenovirally transduced NSCs.  
These blood samples will be sent to CICSL (adenoviral vector [Ad5] antibody titers) and Clinical Pathology (total 
adenoviral antibody titers) for processing and determining of adenoviral antibody titers by complement fixation 
testing and ELISA.  
12.1.4 Evaluation of Possible Presence of NSCs and/or hCE1m6 in the Systemic Circulation Using QPCR 
An evaluation of possible presence of NSCs and/or hCE1m6 in the systemic circulation will be performed in the 
CICSL by quantitative PCR using established laboratory SOP and primer pairs specific for the vMyc gene and 
CD.  For example, a standard curve will be generated using DNA isolated from the administered NSCs titrated 
into DNA from PBMCs (negative for vMyc); in parallel reactions, DNA isolated from patient samples will be 
subjected to amplification.  The % NSC DNA (i.e. the % of total nucleated cells in samples that contain vMyc DNA) 
in patient PBMC samples will be determined from the standard curve.  A parallel set of amplification reactions 
using genomic p21 primers (amplifying equivalently from all samples) will be used to normalize across samples. 
12.1.5 Assessment of Serum Cytokine Levels in the Event that a Patient Develops a Suspected Immune 
Response to the NSCs 
The Human Cytokine Thirty-Plex Antibody Bead Kit (Invitrogen, Camarillo, CA) will be used to analyze serum 
samples for 30 cytokines: epidermal growth factor (EGF); eotaxin; basic fibroblast growth factor (FGF-basic); 
granulocyte colony-stimulating factor (G-CSF); granulocyte macrophage colony-stimulating factor (GM-CSF); 
hepatocyte growth factor (HGF); interferon alpha (IFN-α); IFN-gamma (γ); interleukin-1 beta (IL-1β); interleukin-
1 receptor antagonist (IL-1RA); IL-2; interleukin-2 receptor (IL-2R); IL-4; IL-5; IL-6; IL-7; IL-8; IL-10; IL-12p40/p70; 
IL-13; IL-15; IL-17; IFN- γ-inducible protein 10 (IP-10); monocyte chemoattractant protein-1 (MCP-1); monokine 
induced by IFN- γ (MIG); monocyte inflammatory protein-1 alpha (MIP-1α); monocyte inflammatory protein-1 
beta (MIP-1β); regulated upon activation, normal T-cell expressed and secreted cytokine (RANTES); tumor 
necrosis factor (TNF)-α; and vascular endothelial growth factor (VEGF). The assay plate will then be transferred 
to the Bio-plex HTF Luminex System (Bio Rad Laboratories, Inc., Hercules, CA) instrument for analysis. Cytokine 
concentrations will be calculated using Bio-plex Manager 3.0 Software with a 5 parameter curve-fitting algorithm 
applied for standard curve calculations for duplicate samples. 
12.1.6 Replication Competent Retrovirus (RCR) Testing 
The City of Hope CICSL will process samples, with DNA being isolated and stored, according to established 
laboratory SOP, until RCR testing is performed by PCR.Samples will be taken at 3 months, 6 months, and annually 
thereafter until their passing or withdrawal from follow-up. 

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Brain Tissue Correlates 
12.1.7 Determining the Fate of the NSCs at the time of Autopsy 
As part of the consenting process, study patients will be asked to give permission for a brain autopsy. The brain 
autopsy will focus on detecting the presence or absence of NSCs, their location, and tumor pathology. 
Specifically, brain tissue samples will be collected from the center and periphery of the tumor, as well as grossly 
affected and unaffected areas from distant and contralateral sites. Tissue samples will be formalin fixed and 
paraffin embedded for sectioning and analysis. When possible, fresh frozen tissue samples will be taken. 
NSCs will be detected by PCR methods using specific primers for v-myc (only present in the transplanted NSCs). 
Fluorescence in situ hybridization and immunocytochemistry techniques will be used for the detection and 
further characterization of the NSCs (including proliferation and differentiation markers). We will also look for 
the presence of hCE1m6 in brain tissue samples. 
12.1.8 Collecting Tumor Tissue for Future Research 
If there is resection material available in excess of that needed for standard pathologic studies, this excess 
material will be used for research purposes. 
Excess surgical material will be grown as a dissociated primary cell culture in the Aboody laboratory for NSC 
migration and toxicity assays under City of Hope IRB#07047.  Additional material will be banked (fixed and 
frozen) for potential future research under IRB #07047.  Such research may include: 1) comparison of gene 
expression profiles in the tumor and adjacent tissue (if available) prior and after treatment with 
HB1.F3.CD.CE/irinotecan; 2) presence of immune cells (B-cells, T-cells, macrophages, microglia, dendritic cells); 
3) determination of mitotic index in the tumor by Ki67 immunohistochemistry. 

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13 ENDPOINT EVALUATION CRITERIA/MEASUREMENT OF EFFECT 
Response Criteria 
The Response Assessment in Neuro-Oncology (RANO) criteria (Wen et al., 2010) will be used to assess 
response: 
Complete Response (CR)Complete disappearance of all enhancing disease (measurable and non-
measureable) that is sustained for at least 4 weeks, stable or improved non-enhancing FLAIR/T2 lesions, 
no new lesions, off corticosteroids (physiologic replacement doses allowed), and neurologically stable 
or improved.  
Partial Response (PR) ≥ 50% decrease of all measurable enhancing lesions, sustained for at least 4 weeks, 
no progression of non-measurable disease, stable or improved non-enhancing FLAIR/T2 lesions, no new 
lesions, corticosteroid dose stable or reduced (compared to baseline), and neurologically stable or 
improved.  
Stable Disease (SD)Does not qualify for CR, PR, or PD, stable non-enhancing FLAIR/T2 lesions, stable or 
reduced corticosteroids (compared to baseline), clinically stable.  
Progressive Disease (PD)≥ 25% increase in enhancing lesions despite stable or increasing steroid dose, 
increase (significant) in non-enhancing T2/FLAIR lesions that is not attributable to other non-tumor 
causes, any new lesions, clinical deterioration (not attributable to other non-tumor causes and not due 
to steroid decrease). 
 

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14 DATA REPORTING/PROTOCOL DEVIATIONS 
Data Reporting 
14.1.1 Confidentiality and Storage of Records 
Electronic Data Collection will be used for this protocol. The data will be stored in encrypted, password 
protected, secure computers that meet all HIPAA requirements. When results of this study are reported in 
medical journals or at meetings, identification of those taking part will not be disclosed. Medical records of 
subjects will be securely maintained in the strictest confidence, according to current legal requirements. They 
will be made available for review, as required by the FDA, HHS, or other authorized users such as the NCI, under 
the guidelines established by the Federal Privacy Act and rules for the protection of human subjects. 
14.1.2 Subject Consent Form 
At the time of registration, the original signed and dated Informed Consent form, HIPAA research authorization 
form, and the California Experimental Subject’s Bill of Rights (for the medical record) and three copies (for the 
subject, the research record, and the Coordinating Center) must be available.  All Institutional, NCI, Federal, and 
State of California requirements will be fulfilled. 
14.1.3 Data Collection Forms and Submission Schedule 
All data will be collected using electronic data collection, stored as indicated in Section 14.1.1, and will be 
submitted according to the timelines indicated in Table 14.1.3. 
Table 14.1.3 
Data Submission Schedule 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration  
On Study Forms 
Within 14 calendar days of registration 
Baseline Assessment Forms 
Within 14 calendar days of registration 
Treatment Forms 
Within 10 calendar days of treatment administration 
Adverse Event Report Forms 
For cycle 1 only, within 7 calendar days of AE 
assessment/notification; for all other cycles, within 10 
calendar days of AE assessment/notification 
Response Assessment Forms 
Within 10 calendar days of the response assessment 
Other Assessment Forms (concomitant 
medications, chemistry, hematology, 
neuro exam, physical exam etc.) 
Within 10 calendar days of the assessment 
Off Treatment/Off Study Forms 
Within 10 calendar days of completing treatment or being 
taken off study for any reason 
Follow up/Survival Forms 
Within 14 calendar days of the protocol defined follow up 
visit date or call 
 
Eligibility Checklist 
The eligibility checklist must be completed by a protocol nurse or clinical research associate and signed by an 
authorized investigator prior to registering the subject.  See Section 4.3 for the registration procedure. 

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Protocol Deviations 
14.1.4 Deviation Policy 
This protocol will be conducted in accordance with COH’s “Clinical Research Protocol Deviation Policy” located 
at http://www.coh.org/dsmc/Documents/Institutional%20Deviation%20Policy.pdf. 
Deviations from the written protocol that could increase patient risk or alter protocol integrity require prior IRB 
approval of a single subject exception (SSE) request.  In addition, if contractually obligated, the sponsor must 
also approve the deviation.  IRB pre-approved SSE protocol modifications are considered an amendment to the 
protocol and not a deviation.  The submission of a deviation report is not required. 
Brief interruptions and delays may occasionally be required due to travel delays, airport closure, inclement 
weather, family responsibilities, security alerts, government holidays, etc. This can also extend to complications 
of disease or unrelated medical illnesses not related to disease progression. The PI has the discretion to deviate 
from the protocol when necessary so long as such deviation does not threaten patient safety or protocol 
scientific integrity. Examples include, but are not limited to:  a) dose adjustments based on excessive patient 
weight; b) alteration in treatment schedule due to non-availability of the research participant for treatment; c) 
laboratory test results which are slightly outside the protocol requirements but at levels that do not affect 
participant safety.  These instances are considered to be deviations from the protocol.  A deviation report will 
be submitted to the DSMC/IRB within five days. 
14.1.5 Reporting of Deviations 
All deviations will be reported to the COH DSMC within five days.  The DSMC will forward to report to the IRB 
following review. 
14.1.6 Resolving Disputes 
The COH Investigational Drug Service (IDS) cannot release a research agent that would cause a protocol deviation 
without approval by the PI.  Whenever the protocol is ambiguous on a key point, the IDS should rely on the PI to 
clarify the issue. 
In situations where there is misperception or dispute regarding a protocol deviation among the persons involved 
in implementing the protocol, it is the responsibility of the PI to resolve the dispute and the PI may consult with 
the DSMC chair (or designee) to arrive at resolution. 

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15 STATISTICAL CONSIDERATIONS 
Sample Size 
The anticipated sample size is 29patients: minimum=6; maximum= 53(allowing for 42 patients for dose 
escalation through 5 possible dose levels of NSCs and 3 dose schedules of irinotecan, estimating ~3 patients to 
replace unevaluable/ineligible patients and an additional 8 patients for the expansion cohort).A sample size of 
6 at the MTD/MFD will allow us to i) achieve a maximum margin of error for a 95% confidence interval for the 
DLT rate of 0.38 and ii) detect a 0.25 toxicity rate in approximately 82% of trials. The additional 8 patients in the 
expansion cohort, for a total of 14 patients treated at the MTD/MFD, will allow us to i) achieve a maximum 
margin of error for a 95% confidence interval for the DLT rate of 0.27 and ii) detect a 0.15toxicity rate in 
approximately 90% of trials. 
An important purpose of the expansion cohort is to obtain information about the biologic activity of the hCE1m6-
NSCs using intracerebral microdialysis. Sample size calculations based on preclinical results for the AUC from 0 
to 20 hours (nMxhr) for SN38in rats (the combination therapy group mean= 7, sd=4.4;  irinotecan alone 
mean=1.8, sd=1.2) implementing a natural log scale (mean difference 1.36 and sd=0.66) indicate 4 participants 
per group could provided 80% power todetermine if the addition of NSCs to treatment with irinotecan increases 
intracerebral concentrations of SN-38, using a one-sided two-sample t test with a 0.05 level of significance. As 
we expect our patient data to be more variable than the preclinical rat data we consider these results to be 
exploratory.  
Accrual Rate 
Given that the first 3 patients entering a cohort until the MTD/MFD is determined will enter sequentially after 
the prior patient completes cycle 1, the study time is mostly determined by cycle length. It is anticipated that 
this study will complete accrual within approximately 36 months. 
Statistical Design and Analysis 
15.1.1 Design: 
The dose escalation plan is based on a standard 3+3 design and is described in section 5.3.  
15.1.2 Primary Objectives  
To define the recommended phase II dose (RP2D) of intracranially administered hCE1m6-NSCs in combination 
with intravenous irinotecan in patients with recurrent high grade glioma. The RP2D will be based on the 
maximum-tolerated dose (MTD), or if the MTD is not reached, the maximum feasible dose (MFD), and the full 
toxicity profile including toxicities associated with repeat doses of NSCs.  
15.1.3 Secondary Objectives 
 
To describe the relationship between hCE1m6-NSC dose and SN-38 concentrations in brain interstitium. 
 
To characterize the relationship between intracerebral and systemic concentrations of irinotecan and 
SN-38. 
 
To investigate the biologic activity of hCE1m6 NSCs by comparing SN-38 concentrations in the brain after 
treatment with hCE1m6-NSCs and irinotecan versus irinotecan alone.  
 
To assess for possible development of adenovirally transduced NSC immunogenicity after first exposure 
and with repeat doses of NSCs.  

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 
To describe the clinical benefit (defined as stable disease, partial response, or complete response) in 
patients who receive treatment with repeat cycles of NSCs and irinotecan.  
 
To determine, at time of autopsy, the fate of the NSCs. 
15.1.4 Primary Endpoints: 
 
Safety and Feasibility: 
- 
For Dose Escalation: Dose Limiting Toxicities 
- 
Toxicity Profile: All Attributable Toxicities 
15.1.5 Secondary Endpoints: 
 
Pharmacokinetics:Cmax and AUC of irinotecan and SN-38 in dialysate and plasma. 
 
Immunogenicity:Evaluate patient blood samples for the development of T cell responses and antibodies 
against the NSCs using TcR Vβ spectratyping, CD 107 degranulation assays, and flow cytometry. Measure 
patients’ serial adenoviral antibody titers. 
 
Clinical benefit: Tumor response based on brain MRI  and PET/CT scans results 
 
Determine the Fate of the NSCs: NSC persistence 
15.1.6 Analysis Plan: 
Tables will be created to summarize all toxicities and side effects by dose, course, organ severity (by NCI CTCAE 
version 4.0), and attribution. Rates and associated 95% Clopper Pearson confidence limits will be estimated for 
DLTs and clinical benefit at the RP2D. Descriptive statistics will be provided for study patient demographics.  
Pharmacokinetic data from patients who undergo intracerebral microdialysis will be summarized using 
descriptive statistics and graphical methods. The biologic activity of the hCE1m6-NSCs, based on comparison of 
microdialysis SN38 PK data from patients receiving NSCs + irinotecan vs patients receiving irinotecan alone, will 
be assessed using a one-sided two-sample t test.Regression analysis will be used to assess the relationship 
between hCE1m6-NSC dose and SN-38 concentrations in brain interstitium using microdialysis data from the 
patientstreated with the initial NSC dose (n=6) and from the patients in the expansion cohort treated with the 
highest NSC dose (n=4).Other secondary objectives include assessing for possible development of NSC 
immunogenicity after first and repeat exposures, and—when feasible—evaluating the fate of the NSCs at 
autopsy. These results will be summarized using descriptive statistics and graphical methods. 

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16 HUMAN SUBJECT ISSUES 
Institutional Review Board 
In accordance with City of Hope policies, an Institutional Review Board (IRB) that complies with the federal 
regulations at 45 CFR 46 and 21 CFR 50, 56 and State of California Health and Safety code, Title 17, must review 
and approve this protocol and the informed consent form prior to initiation of the study. All institutional, NCI, 
Federal, and State of California regulations must be fulfilled. 
Recruitment of Subjects 
Study subjects will be recruited from patients undergoing treatment for their brain tumors at the City of Hope 
Cancer Center. 
Advertisements 
Advertisements to include print, media (radio, television, billboards), telephone scripts, lay summary to be 
posted on City of Hope’s public Clinical Trials On-LineSM website, etc., will be reviewed and approved by the IRB 
prior to their use to recruit potential study subjects. 
Study Location and Performance Sites 
This study will be performed at City of Hope.  
Confidentiality 
This research will be conducted in compliance with federal and state of California requirements relating to 
protected health information (PHI). The study will record individual side effects to study treatment, brain 
interstitial and plasma levels of irinotecan and SN-38, radiologic findings, immunological correlative study 
results, and autopsy findings (if possible), and these will be linked to the subject’s identity using a coded study 
number. The principal investigator, co-investigators, and laboratory technicians will have access to this 
information, but all information will be treated confidentially. No identifiers will be used in any subsequent 
publication of these results.   
Financial Obligations and Compensation 
There will be no increased financial obligations incurred by subjects because of participating in this study.  
Neither the research participant nor the insurance carrier will be responsible to pay for the research procedures 
related to this study. For example, the NSCs, irinotecan, and microdialysis equipment will be provided free of 
charge to the patient. Expenses due to hospital stay in excess of what is standard for the surgical procedure will 
not be billed to the patient or her/his insurance company. All laboratory tests that will be done solely for research 
purposes will be covered by the study sponsor. All standard-of-care laboratory tests and neuro-imaging will be 
billed to the subjects’ insurance company.The research participant will be responsible for all copayments, 
deductibles, and other costs of treatment and diagnostic procedures as set forth by the insurance carrier. The 
research participant and/or the insurance carrier will be billed for the costs of treatment and diagnostic 
procedures in the same way as if the research participant were not in a research study.   
In the event of physical injury to a research participant, resulting from research procedures, appropriate medical 
treatment will be available at City of Hope to the injured research participant, however, financial compensation 
will not be available.The research participant will not be paid for taking part in this study. 

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Informed Consent Processes 
The Principal Investigator or IRB approved named designate will explain the nature, duration, purpose of the 
study, potential risks, alternatives and potential benefits, and all other information contained in the informed 
consent document. In addition, s/he will review the experimental subject’s bill of rights and the HIPAA research 
authorization form. Research subjects will be informed that they may withdraw from the study at any time and 
for any reason without prejudice, Research subjects will be afforded sufficient time to consider whether or not 
to participate in the research. 
Prospective research subjects who cannot adequately comprehend the fundamental aspects of the research 
study with a reasonable amount of discussion, education and proctoring will be ineligible for enrollment. For 
those subjects who do comprehend the fundamental aspects of the study, consent will be obtained and 
documented, followed by eligibility testing. The research team will review the results of eligibility testing and 
determine if the subject is a candidate for study enrollment.  
 
 

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Appendix A Karnofsky Performance Status 
Patient's performance status will be graded according to the following scale: 
 
 
Karnofsky Performance Status 
KPS 100 Normal; no complaints; no evidence of disease 
KPS 90 Able to carry on normal activity; minor signs or symptoms of disease 
KPS 80 Normal activity with effort; some sign or symptoms of disease 
KPS 70 Cares for self; unable to carry on normal activity or do active work 
KPS 60 Requires occasional assistance, but is able to care for most personal needs 
KPS 50 Requires considerable assistance and frequent medical care 
KPS 40 Disabled; requires special care and assistance 
KPS 30 Severely disabled; hospitalization is indicated, although death not imminent 
KPS 20 Very sick; hospitalization necessary; active support treatment is necessary 
KPS 10 Moribund; fatal processes progressing rapidly 
KPS 0 Dead