TK008: Randomized Phase III Trial of Haploidentical HCT With or Without an Add Back Strategy of HSV-Tk Donor Lymphocytes in Patients With High Risk Acute Leukemia
Phase: PHASE3
Conditions: Acute Leukemia (Category)
Sponsor: AGC Biologics S.p.A.



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Synopsis of the Protocol  
Title 
TK008: Randomized phase III trial of haploidentical HCT 
with or without an add back strategy of HSV-Tk donor 
lymphocytes in patients with high risk acute leukemia 
Sponsor 
MolMed S.p.A.  
Indication 
Patients suitable for haploidentical HCT affected by high risk 
acute leukemia in 1st or subsequent complete remission, or 
in relapse. 
Objectives 
Primary: 
To compare disease-free survival (DFS) in high risk 
leukemia patients who underwent haploidentical HCT 
followed by an add back strategy of HSV-Tk donor 
lymphocytes or standard haploidentical HCT  
Secondary: 
a. To compare overall survival (OS) in the two treatment 
arms 
b. To compare the cumulative incidence of non-relapse 
mortality (NRM) 
c. To compare the chronic graft-versus-host disease 
(GvHD)-free, relapse-free survival (GRFS)  
d. To compare the time to T-cell immune reconstitution 
e. To compare the engraftment rate 
f. To compare the cumulative incidence of grade II-IV 
acute GvHD 
g. To compare the cumulative incidence of chronic GvHD 
h. To compare time to GvHD resolution and use of agents 
with immunosuppressive activity 
i. 
To compare the cumulative incidence of relapse (CIR) 
j. 
To compare incidence and duration of infectious 
episodes and infectious disease mortality 
k. To evaluate the acute and long-term toxicity related to 
the HSV-Tk infusions  
l. 
To assess quality of life (QoL) and Medical Care 
Utilization (MCU) in both arms 
Study design 
This is a randomized (3:1), 2-arm, open-label, multicenter, 
multinational, phase III study with a comparison of an add 
back strategy of HSV-Tk donor lymphocytes versus standard 
strategy in high risk acute leukemia patients underwent 
haploidentical HCT.  
Patients will be randomly assigned to the treatment group 
through a centralized randomization process using the 
following stratification factors: status of the disease at the 
time of transplantation (e.g. first or subsequent complete 
remission or relapse), ECOG performance status (0 or 1), and 
country. 
In the experimental group A, patients will receive infusion of 
CD34+ cells plus a dose of T cells (approximately 1x104/Kg) 
followed by infusion of HSV-Tk genetically modified CD3+ 
cells  
In the control group B, the physician will choice if the patient 
will receive either infusion of CD34+ cells plus a dose of T 

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cells 
(approximately 
1x104/Kg) 
or 
unmanipulated 
haploidentical 
bone 
marrow 
or 
peripheral 
blood 
transplantation followed by high-dose cyclophosphamide 
As part of the Conditional Marketing Authorisation (CMA) 
granted by the European Medicines Agency (EMA) for the 
medicinal product, the present phase III trial TK008 has been 
classified as a Category 2 study, and EMA will review the 
safety data of the study on an every-6-month basis through 
the Periodic Safety Update Reports (PSURs), and the 
benefits and risks of the medicinal product on an annual basis 
for the renewal of the CMA. 
Number of patients 
170 patients will be enrolled: 127 patients in the arm A 
(experimental group) and  43 patients in the arm B (control 
group) 
Study population 
Inclusion Criteria: 
1. Age ≥ 18 years  
2. Any of the following conditions: 
a. 
AML and ALL in 1st complete remission 
(CR1)  
b. 
AML and ALL in 2nd or subsequent CR 
c. 
secondary AML in CR 
d. 
AML and ALL in 1st or 2nd relapse or 
primary refractory  
3. Family donor with patient-donor number of HLA 
mismatches ≥ 2 (full haploidentical), or family donors 
sharing one HLA-haplotype with the patient 
4. Stable clinical conditions and life expectancy  3 months
5. PS ECOG < 2 
6. Serum creatinine < 1.5 x ULN 
7. Bilirubin < 1.5 x ULN; transaminases < 3 x ULN 
8. Left ventricular ejection fraction > 45% 
9. QTc interval < 450 ms 
10. DLCO > 50%   
11. Patients and donors, or independent witnesses, must sign 
an informed consent indicating that they are aware this 
is a research study and have been told of its possible 
benefits and toxic side effects 
Exclusion Criteria: 
1. Patients with life-threatening condition or complication 
other than their basic condition 
2. Contraindication to haploidentical HCT as defined by 
the Investigator 
3. Patients with active CNS disease 
4. Pregnant or lactation 
 
Study procedures 
ARM A (experimental group): 
Haploidentical HCT with the infusion of CD34+ cells plus a 
dose of T cells (approximately 1 x 104/Kg), followed by:  
 
Infusion of approximately 1±0.2 x 107 HSV-Tk 
genetically modified CD3+ cells/Kg between day 

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+21 and day +49 after haploidentical HCT in the 
absence of spontaneous immune reconstitution (IR 
has to be documented by two consecutive findings 
of circulating CD3+ cells ≥ 100/μl) and/or 
development of GvHD.  
In absence of immune reconstitution and GvHD further 
infusions will be administered with the following dosages 
and timelines: 
 
30 days (±2 days) after 1st infusion: in the absence of 
both active GvHD and immune reconstitution (IR has to 
be documented by two consecutive findings of 
circulating CD3+ cells ≥ 100/μl) genetically modified 
lymphocytes will be infused at a dose of 1±0.2 x 107 
cells/kg. 
 
30 days (±2 days) after 2nd infusion: in the absence of 
both active GvHD and immune reconstitution (IR has to 
be documented by two consecutive findings of 
circulating CD3+ cells ≥ 100/μl) genetically modified 
lymphocytes will be infused at a dose of 1±0.2 x 107 
cells/kg. 
 
30 days (±2 days) after 3rd infusion: in the absence of 
both active GvHD and immune reconstitution (IR has to 
be documented by two consecutive findings of 
circulating CD3+ cells ≥ 100/μl) genetically modified 
lymphocytes will be infused at a dose of 1±0.2 x 107 
cells/kg. 
HSV-Tk infusion shall not be infused in case of: 
1. Infections requiring administration of ganciclovir or 
valganciclovir at the time of infusion 
2. GvHD requiring systemic immunosuppressive therapy 
3. Ongoing systemic immunosuppressive therapy after 
haploidentical HCT 
4. Administration of G-CSF after haploidentical HCT 
HSV- Tk cells can be administered after and adequate wash 
out period (24 hours). 
ARM B (control group) : 
Haploidentical HCT with either infusion of CD34+ cells plus 
a dose of T cells (approximately 1x104/Kg) or unmanipulated 
haploidentical 
bone 
marrow 
or 
peripheral 
blood 
transplantation followed by high-dose cyclophosphamide  
Product 
 
 
 
 
 
 
Frozen haploidentical donor T lymphocytes genetically 
modified to express HSV-Tk gene with the retroviral vector 
SFCMM-3 Mut2 #48 (SFCMM-3 Mut2 #48 transduced 
lymphocytes), encoding for the ΔLNGFR and HSV-Tk Mut2 
genes in the final formulation and container closure system, 
ready for intended medical use. 
In case of GvHD related to the experimental product: 
Ganciclovir (10 mg/kg/day in 2 administrations) or 
Valganciclovir (900 mg bid po) for 14 days 

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Comparator 
Haploidentical HCT with either infusion of CD34+ cells plus 
a dose of T cells (approximately 1x104/Kg) or unmanipulated 
haploidentical 
bone 
marrow 
or 
peripheral 
blood 
transplantation followed by high-dose cyclophosphamide  
Efficacy 
Primary variable:  
Disease-Free Survival (DFS; Event-Free Survival, EFS) will 
be measured for all patients from the date of randomization 
(regardless of disease status at HCT) until the date of relapse 
(or progression), or death from any cause, whichever occurs 
first. 
Secondary variables: 
a. Overall Survival (OS) will be measured for all patients 
from the date of randomization until death from any 
cause. 
b. Non-relapse mortality (NRM) will be defined for all 
patients as any death without previous occurrence of a 
documented relapse (or progression). 
c. Chronic 
GvHD-free/relapse-free 
survival 
(GRFS) 
defined as the time from the date of randomization to 
chronic GvHD, relapse/progression or death from any 
cause, whichever occurs first. 
d. Immune reconstitution (IR) will be defined as the time to 
reach a level of circulating CD3+ ≥ 100/μl for two 
consecutive observations. 
e. Engraftment will be defined as the persistent blood cells 
count above a predefined level (ANC ≥ 1x109/L per 3 
consecutive 
days 
with 
evidence 
of 
donor 
haematopoiesis; platelets ≥ 50x109/L, unsupported by 
transfusions, for 7 days) and will be computed from the 
date (day 0) of transplantation. 
f. Cumulative incidence of grade 2, 3, or 4 acute GVHD 
(aGvHD), diagnosed and graded according to standard 
criteria, will be computed from the transplantation. 
g. Cumulative incidence of chronic GvHD (cGvHD) 
diagnosed and graded according to standard NIH 
consensus criteria, will be computed from the 
transplantation. 
h. Duration of GvHD episodes computed from the date of 
start to the date of resolution and duration of 
immunosuppressive 
treatments 
administered 
for 
controlling GvHD 
i. 
Cumulative incidence of relapse (CIR) will be defined 
on the basis of morphologic evidence of leukaemia in 
bone marrow or other sites.  The events are relapses (or 
progressions). Patients alive without relapse (or 
progression) will be censored at last contact. Death 
without experiencing a relapse (or progression) will be 
considered as competing event 
Safety and tolerability 
 
Adverse Events (AE) and laboratory abnormalities 
graded according to the CTCAE v 4.02.  

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 
Serious Adverse Events (SAE)  
 
Suspected Unexpected Serious Adverse Reaction 
(SUSAR) 
 
Long term follow-up 
Pharmacokinetics 
Not applicable  
Pharmacodynamics 
Not applicable  
Quality of life/Pharmacoeconomics 
 
An assessment of the quality of life by questionnaire will 
be performed before HCT, at month 9 and 12 and then 
yearly after HCT. The objective will be to summarize 
and evaluate treatment group differences in patient 
convenience and satisfaction. 
 
An exploratory pharmacoeconomic analysis will be 
performed on medical care utilization (MCU). The 
objective will be to summarize and evaluate treatment 
group differences in total resource use, and more 
specifically, in resource use associated with diagnosis, 
monitoring and treatment of relevant events (i.e., acute 
and 
chronic 
GvHD, 
infectious 
episodes, 
etc). 
Pharmacoeconomic data may be combined with other 
data such as cost data or other clinical parameters in the 
production of a final pharmacoeconomic report. The 
analysis and reporting of resource use data will be 
handled separately from the clinical study report 
Statistical design 
This is a randomized (3:1 allocation experimental arm: 
control arm), 2-arm, open-label, multicenter, multinational, 
phase III study. The primary endpoint of the study is disease-
free survival (DFS). The disease-free survival following 
standard haploidentical HCT (with either infusion of CD34+ 
cells plus a dose of T cells (approximately 1x104/Kg) or 
unmanipulated bone marrow transplantation followed by 
high-dose cyclophosphamide) reported in the available 
studies averages at approximately 30%, and this figure can 
be used as a reasonable estimate of DFS expected in the 
control group of the present study. The estimated DFS in the 
phase II study (TK007) evaluating the add back of HSV-Tk 
donor lymphocytes strategy was 52%. In order to detect with 
α = 0.05 (2-sided) and β = 0.20 an increase from 30% to 52% 
in DFS associated with the experimental treatment (hazard 
ratio = 0.55), 96 events (relapses or deaths from any cause) 
need to be observed in the 2 groups combined. To this aim, 
170 patients (127 in experimental arm and 43 in control arm) 
need to be enrolled and followed for at least one year. 
Duration of the study 
Study duration: 4 years. Recruitment period: 3 years  
Follow-up for last patient included: 1 year 

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Table of contents 
1 
Introduction .............................................................................................................. 11 
1.1 
Background .......................................................................................................................... 11 
1.2 
Drug Description ................................................................................................................. 11 
1.3 
Drug activity ........................................................................................................................ 12 
 
Non clinical studies ............................................................................................................................. 13 
 
In vitro tolerability studies .................................................................................................................................. 13 
 
In vivo efficacy and tolerability .......................................................................................................................... 14 
 
Clinical studies .................................................................................................................................... 15 
1.4 
Rationale .............................................................................................................................. 17 
2 
Objectives .................................................................................................................. 21 
2.1 
Primary aim ......................................................................................................................... 21 
2.2 
Secondary aims .................................................................................................................... 21 
3 
Trial design ............................................................................................................... 22 
4 
Patient selection criteria .......................................................................................... 23 
4.1 
Target population ................................................................................................................ 23 
4.2 
Inclusion criteria .................................................................................................................. 23 
4.3 
Exclusion criteria ................................................................................................................. 23 
4.4 
Conditioning regimens ........................................................................................................ 23 
4.5 
Recommended Supportive Care ........................................................................................ 24 
5 
Experimental arm (Arm A) ..................................................................................... 25 
5.1 
Drug information ................................................................................................................. 25 
5.2 
Drug Product supply ........................................................................................................... 25 
5.3 
Drug Product formulation, packaging, labelling and storage ......................................... 25 
5.4 
Drug administration ............................................................................................................ 26 
5.5 
Dosage schedule ................................................................................................................... 26 
5.6 
Treatment duration ............................................................................................................. 26 
5.7 
Dose modification ................................................................................................................ 27 
5.8 
Treatment in case of disease relapse or progression ........................................................ 27 
6 
Study Assessments and Procedures ........................................................................ 28 
6.1 
Pre HCT phase ..................................................................................................................... 28 
 
Confirmation of eligibility (Randomization procedures) ................................................................ 28 
 
Screening phase .................................................................................................................................. 28 
 
Lymphocytoaphaeresis collection procedures for experimental Arm A ....................................... 29 
6.2 
Haploidentical transplantation (HCT) - Study day 0 ....................................................... 29 
 
Arm A: experimental group = haploidentical T-depleted HCT + HSV-Tk cells .......................... 29 
 
Arm B: control group = haploidentical HCT (T-cell depleted graft OR unmanipulated T-cell 
replete graft followed by high-dose cyclophosphamide and immunosuppressive therapy) ..................................... 30 
6.3 
Post HCT phase - Arm A and Arm B ................................................................................ 30 
 
Disease evaluation .............................................................................................................................. 30 
 
Laboratory assessment ...................................................................................................................... 30 
 
Physical examination ......................................................................................................................... 30 
 
Functional Studies .............................................................................................................................. 31 
 
Immune phenotype analysis ................................................................................................................................ 31 
 
Survival follow-up .............................................................................................................................. 32 
 
Quality of life assessment ................................................................................................................... 32 

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Safety ................................................................................................................................................... 32 
 
Treatment of GvHD related to HSV-Tk cells .................................................................................................... 33 
 
Treatment of GvHD not related to HSV-Tk cells .............................................................................................. 33 
6.4 
Specific assessments for Arm A (centralized analyses) .................................................... 34 
 
Real time PCR-TK ............................................................................................................................. 34 
 
Analysis of retrovirus competent for replication (RCR) ................................................................ 34 
 
Sampling procedures ......................................................................................................................... 34 
6.5 
Study Flow Chart ................................................................................................................ 35 
7 
Pharmaeconomics .................................................................................................... 36 
8 
Response evaluation criteria in Acute Leukaemia ................................................ 37 
9 
Statistical considerations ......................................................................................... 38 
9.1 
Statistical design .................................................................................................................. 38 
9.2 
Study endpoints ................................................................................................................... 38 
 
Primary endpoint: Disease-free survival (DFS) ............................................................................... 38 
 
Secondary endpoints .......................................................................................................................... 38 
9.3 
Statistical analyses ............................................................................................................... 40 
 
Primary study analyses ...................................................................................................................... 40 
 
Secondary analyses ............................................................................................................................ 40 
9.4 
Sample size ........................................................................................................................... 41 
10 
Safety ......................................................................................................................... 42 
10.1 
Definitions ............................................................................................................................ 42 
10.2 
Criteria of evaluation .......................................................................................................... 42 
10.3 
Reporting procedures .......................................................................................................... 43 
 
Adverse events .................................................................................................................................... 43 
 
Serious Adverse Events ...................................................................................................................... 43 
10.4 
Procedures to be followed in the event of pregnancy ....................................................... 44 
10.5 
Risk management plan ........................................................................................................ 44 
 
RCR ..................................................................................................................................................... 44 
 
Safety monitoring ............................................................................................................................... 45 
 
RCR monitoring during manufacturing .......................................................................................... 46 
 
Long term follow-up after HSV-Tk treatment ................................................................................ 46 
11 
Ethics and General study administration .............................................................. 47 
11.1 
Ethical aspects ...................................................................................................................... 47 
11.2 
Independent Ethics Committees/Institutional Review Board ......................................... 47 
11.3 
Informed consent ................................................................................................................. 47 
11.4 
Conditions for modifying the protocol .............................................................................. 48 
11.5 
Conditions for terminating the study ................................................................................ 48 
11.6 
Study documentation: CRF and record keeping .............................................................. 48 
11.7 
Source documents and background data .......................................................................... 49 
11.8 
Audits and inspections ........................................................................................................ 49 
11.9 
Case Report Forms .............................................................................................................. 49 
11.10 
Monitoring the study ........................................................................................................... 49 
11.11 
Confidentiality of trial documents and subject records ................................................... 49 
11.12 
Publication of data and protection of trade secrets .......................................................... 49 
12 
References ................................................................................................................. 51 

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Index of tables 
 
Table 1. 
TK007: adverse events related to HSV-Tk by worst grade per patient ......................... 16 
Table 2. 
Summary of the criteria to define the outcomes in survival analysis ............................. 39 

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List of appendices 
Appendix A: Recommended conditioning regimens .................................................................................. 54 
Appendix B: Tests for Donor Lymphocytoaphaeresis collection (Arm A) ............................................... 56 
Appendix C: Acute GvHD grading .............................................................................................................. 57 
Appendix D: Chronic GvHD grading .......................................................................................................... 58 
Appendix E: ECOG performance status scale ............................................................................................ 61 
Appendix F: Optional Functional studies ................................................................................................... 62 
Appendix G: Common terminology criteria for Adverse Events ............................................................. 64 
Appendix H: Glossary ................................................................................................................................... 65 
Appendix I: Creatinine clearance formula ................................................................................................. 67 
Appendix J: Quality of life assessment ........................................................................................................ 68 
Appendix K: Long term follow up questionnaire (LTFUQ) ..................................................................... 71 
Appendix L: Amendment history ................................................................................................................ 77 
 

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1 Introduction 
1.1 Background 
Many patients with high risk acute leukaemia potentially curable by transplantation of haematopoietic 
cells (HCT) are generally not considered for such treatment because an HLA identical family donor 
is lacking. 
For these patients, the only curative option is represented by a transplant obtained from a partially 
HLA matched related donor or haploidentical donor (haploidentical HCT). Such transplants are 
feasible although still presenting some drawback. When the allograft is not T cell depleted, graft 
versus host disease (GvHD) becomes the most significant limitation with severe onset occurring in 
about half of the patients. Therefore, T cell depletion is usually performed to reduce the risk of GvHD 
but although this is a successful strategy for GvHD prophylaxis, often results in an increased risk of 
graft rejection and delayed immune reconstitution, thus leading to relapse and post-transplant 
infections. 
The feasibility of haploidentical HCT has increased significantly over the last decade due to several 
improvements in the conditioning regimen and graft manipulation. The use of high doses of purified 
CD34+ haematopoietic progenitor cells combined with a highly immunosuppressive chemo-
radiotherapy treatment has provided sustained engraftment in over 90 percent of transplant recipients 
in spite of extensive T cell depletion. The incidence of acute and chronic GvHD has been reduced 
due to the improvements in T cell depleting technology and the use of pre-transplant anti thymocyte 
globulin (ATG) 1. In this setting the major causes of morbidity and mortality still relate to delayed 
immune reconstitution resulting from the paucity of infused immune cells.  
It was hypothesized and confirmed in a series of clinical trials that immune recovery following 
haploidentical HCT could be improved by the infusion of donor T lymphocytes engineered to express 
the thymidine kinase of the Herpes Simplex Virus (HSV-Tk), a suicide gene activated upon 
ganciclovir administration. Recent data related to a multicenter Phase II trial (TK007) identified a 
dose of transduced cells corresponding to 107c/kg, proved to be sufficient for the induction of a stable 
level of immune reconstitution. These levels were obtained within a median time of 77 days (66-88) 
from transplant and 21 days (14-28) from the infusion of HSV-Tk cells leading to a reduction in late 
mortality due to infections2. 
The objective of the proposed trial is to demonstrate the superiority in terms of non-relapsed mortality 
reduction and overall survival improvement of HSV-Tk add back strategy versus a standard strategy 
following haploidentical HCT. 
1.2 Drug Description  
The drug product is defined as frozen haploidentical donor T lymphocytes genetically modified to 
express the HSV-Tk gene with the retroviral vector SFCMM-3 Mut2 #48 (SFCMM-3 Mut2 #48 
transduced lymphocytes), encoding for the ΔLNGFR and HSV-Tk Mut2 genes in the final 
formulation and container closure system, ready for intended medical use. It is a patient specific 
product prepared starting from a lymphocytoaphaeresis of a dedicated donor. 
The retroviral vector SFCMM-3 Mut2 is generated from SFCMM-3 vector (vector used for a phase 
I-II TK007 trial) by site-directed mutagenesis with the introduction of a silent TC transition at the 
splicing donor site. 
The mutation introduced in the SFCMM-3 Mut2 vector has been proved to avoid the generation of 
the HSV-Tk gene spliced form thus improving the safety of the drug substance. Therefore, SFCMM-

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3 Mut2 vector was chosen for the development of a packaging cell bank system and for the production 
of retroviral vector to be used in the proposed Phase III clinical study. 
HSV-Tk gene encodes the thymidine kinase enzyme of Herpes Simplex Virus I. 
The derived enzyme is functional and used both in vitro and in vivo to selectively eliminate the 
transduced cells in presence of ganciclovir. 
∆LNGFR is the gene that encodes for the intracellular truncated form of the low-affinity receptor of 
Nerve Growth Factor. 
The loss of the intracellular domain makes the molecule inert from a functional point of view, while 
allowing for correct cell surface expression. Such localization allows for the recognition of cells that 
express ∆LNGFR using FACS analysis with a specific antibody.  
A potential problem associated with the thymidine kinase/ganciclovir system is the emergence of 
ganciclovir resistance in HSV-Tk transduced cells. This is of particular importance, since the relative 
proportion of cells which are resistant to ganciclovir may rapidly increase through the course of 
treatment. 
The molecular mechanism responsible for ganciclovir resistance consists in a 227 base pair deletion 
in the HSV-Tk gene. This deletion has been documented both in vitro in human primary T cells 
transduced with SFCMM-3 vector as well as with a different retroviral vector (G1TkSvNa; and in 
vivo in blood samples from 12 patients treated with HSV-Tk transduced donor T cells3.  
The cause of this deletion is the presence of nucleotide sequences in the HSV-Tk mRNA which act 
as splice sites to cause the production of a proportion of virus particles having an aberrant form of the 
gene, the remaining viral particles having the full length gene.  
SFCMM-3 Mut2 vector has been generated from the parental SFCMM-3 vector by site-directed 
mutagenesis, with the introduction of a silent T>C transition at the splice donor site. The presence of 
this mutation substantially prevents the splicing phenomenon.  
The SFCMM-3 Mut2 construct has been used to transfect the ecotropic GP+E86 packaging cells line 
(ATCC n° CRL-9642). The supernatant from the transient transfection was harvested and used to 
infect the packaging amphotropic GP+env Am12 packaging cell line (ATCC n° CRL 9641) from now 
on referred to as Am12.  
The integration of the construct in the packaging cell lines DNA allows for the production of retroviral 
vectors with an amphotropic spectrum, able to infect a broad range of mammalian cells, including 
human cells. The Am12 bulk cell population was selected following transduction on the basis of 
expression of ∆LNGFR using specific antibodies conjugated to magnetic beads in order to recover 
positively transduced cells. 
The resulting cell population was than plated in limited dilution conditions in order to obtain single 
producer cell clones.  
The clones were tested for expression of ∆LNGFR, sensitivity to ganciclovir, good growth capacity 
in culture, efficiency of transduction of T lymphocytes, stability, and absence of contaminating 
adventitious viruses and of replication competent forms, as described elsewhere. 
1.3 Drug activity 
HSV-Tk Mut2 is the gene encoding for a mutated form of the thymidine kinase of Herpes Simplex 
Virus I and once integrated into donor lymphocytes DNA, makes them sensitive to Ganciclovir 
(GCV). Following its administration, GCV is firstly monophosphorylated by HSV thymidine kinase 
enzyme expressed in the genetically modified cells and then transformed to the triphosphate form by 
other cellular kinases.  
This active, triphosphopate form of ganciclovir, induces the blockage of synthesis of newly DNA 
strand during mitosis, and in this way provokes the death of proliferating cells.  

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The gene ΔLNGFR encodes for a low affinity form of the nerve growth factor (NGF) receptor, which 
has been deleted of its intracellular portion in order to be no longer able to transmit signals. 
The expression of ΔLNGFR on the cell membrane allows for the immunoselection of genetically 
modified cells using monoclonal antibodies conjugated to magnetic beads. Furthermore, the 
expression of the ΔLNGFR protein is used in vivo as a marker of genetically modified cells once 
infused into the patients and allows the assessment of the Drug Product persistence in the human body 
following treatment, possible cell population expansion or reduction and characterization, in terms of 
lymphocyte subtype and state of activation. 
 Non clinical studies 
 
In vitro tolerability studies 
The ectopically expression of transgenes in genetically modified lymphocytes does not seem to alter 
either their proliferative potential or functionality.  
In particular, repeated laboratory tests on genetically modified lymphocytes have shown: 
The expression of these proteins does not affect the phenotype of the cells, which continue to express 
the characteristic lineage, activation and adhesion molecules. The transduced and cultivated 
lymphocytes express the panlymphocyte marker CD2. Even though, a large percent of the transduced 
lymphocytes are T lymphocytes (CD3+), a variable number of cells (between 3 and 18%) have a NK 
phenotype (CD2+, CD3-, CD56+). NK cells are one of the subgroups implicated in the antitumoral 
response. CD3+ lymphocytes after manipulation, generally retained an inversion in the CD4/CD8 
ratio in favour of the cytotoxic population which represent the effector arm of anti-tumoral and anti-
viral immune responses. The in vitro stimulation required for transduction results in a polyclonal 
activation of the cells. With the aim of characterizing the level of activation resulting from in vitro 
manipulation, the expression of the following activation markers was analyzed, on the manipulated 
cells 14 days after stimulation: CD25, HLA-DR, CD69, CD95, CD45RA, CD45RO and CD28. 
Essentially, all the transduced lymphocytes showed to have encountered antigen (CD45RA-, 
CD45RO+) and the proportion of cells displaying activation markers was variable: 14 days after 
stimulation a large part of the transduced cells expressed HLA-DR and CD95 but have lost membrane 
expression of CD25 and, in some cases, CD69 suggesting that the cells have reached a new stage of 
quiescence. Furthermore, it has been noted that a significant percentage of the transduced cells 
maintained expression of CD62L, a molecule crucial for the migration of lymphocytes into lymph 
nodes, suggesting that the in vitro manipulation does not alter the homing capacity of T lymphocytes. 
An elevated percentage of manipulated lymphocytes maintained expression of CD28. 
Physiologically, the counter of CD28 with its ligand results in the recruitment into proximity with the 
TCR of molecules able to reduce the threshold for activation of the lymphocytes. Therefore, CD28+ 
transduced T lymphocytes should be rapidly activated with low doses of antigen in comparison with 
unmanipulated lymphocytes4. All the phenotypic alterations observed in transduced cells were also 
noted on non-transduced cells that were activated and cultured under the same conditions. This 
implies that the in vitro activation/culture, and not the selection/transduction, is responsible for the 
observed changes. 
No notable changes were observed in the transduced cells in terms of survival and proliferation 
evaluated as spontaneous annexin 5 expression or tritiated thymidine incorporation. These data 
suggests that the introduction of new genetic material did not contribute to cell immortalization, 
transformation, or any other cellular toxicity5. 
Engineered cells maintain the same IL-2 dependency as unmanipulated cells in terms of survival and 
growth. When deprived of IL-2, the culture growth slows and induces programmed cell death. 

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The expression HSV-Tk, that renders the lymphocytes sensitive to ganciclovir, but in its absence of 
any alterations in terms of proliferation, lytic activity and cytokine production in the transduced cells 
could be observed. Indeed, lymphocytes genetically modified with SFCMM-3 maintain the same 
proliferative and cytotoxic activities then untransduced T cells as assessed in a 51Cr release assay 
performed after 7 days stimulation in the presence of the below listed targets relevant in the context 
of allogeneic transplantation: 
 allogeneic lymphocytes; 
 autologous cell lines that have been immortalized with Epstein-Barr; 
 autologous cell lines pulsed with the M58-64 peptide from influenza virus; 
 autologous fibroblasts infected with cytomegalovirus. 
Furthermore, stimulation of both unmanipulated cells or genetically modified lymphocytes with 
autologous fibroblasts infected with cytomegalovirus showed that the same antigen specificity was 
obtained, thus indicating that the manufacturing process does not impair functionality of lymphocytes 
against immunodominant cytomegalovirus antigens. 
 
In vivo efficacy and tolerability 
The efficacy and tolerability of the HSV-Tk/GCV suicide system has been shown in several animal 
models. There have been used: 
 The murine T lymphoma YC8 that when inoculated into balb/c mice gives rise to solid 
tumors (after subcutaneous injection, sc) and metastasis (after intravenous injection, iv). 
104 YC8 cells transduced and expressing HSV-Tk were infused both sc and iv into 2 
groups of 10 balb/c mice per group. 5 days after infusion 5 mice/group received a dose of 
ganciclovir of 100 mg/kg/day ip for 5 days. The administration of ganciclovir significantly 
reduced the dimensions of the solid tumors and both the number and dimension of 
metastasis (data available at H.S. Raffaele Scientific Institute); 
 Hagenbeek, Department of Hematology, Utrecht, has developed a model of GvHD in the 
Brown Norway Rat (BN). In this model, splenic T cells from Wag/Rij rats (donor) are 
transduced with the vector SFCMM-3 and then infused together with hematopoietic stem 
cells in to the recipient BN after a conditioning regime using TBI + ATG + FK506. The 
result is an acute GvHD. The administration of ganciclovir at the development of GvHD 
postpones the death due to GvHD from day 18-20 to day 28-30. Ganciclovir given in 
prophylaxis significantly augments the survival; 
 J. Apperley, Department of Hematology, Hammersmith H., London, has developed a 
murine model of transduction of RMA cells with SFCMM-3. RMA transduced with 
SFCMM-3 are inoculated sc at variable doses from 105-106 in C57BL/6 mice. One cohort 
of mice was then treated with ganciclovir at 20 mg/kg ip in prophylaxis the day of 
inoculation of the cells, while the second cohort was treated the moment at which the 
tumor nodule reached 1 cm in diameter. The administration of ganciclovir prevents (in the 
first cohort) or reduces (in the second cohort) the development of tumors6; 
 P. Tiberghein, Centre Hospitalier Universitoire (CHU), Besancon, has developed a model 
in balb/c and C57/BL/6 mice transplanted with FBV stem cells with an addition of 
splenocytes from HSV-Tk+ mice (derived from the FBV mouse which is transgenic for 
HSV-Tk). At emergence of the GvHD, ganciclovir augments the survival to 40-60% from 
0-6% in the control mice7; 

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 M. Helene has developed a murine model consisting of stem cell administration B10.A + 
5x106 B10.A (5R) splenocytes which are transgenic for HSV-Tk into DBA/2 mice that 
have been lethally irradiated. In this model, the prophylactic administration of ganciclovir 
in the third and tenth days reduces the recipient mouse GvHD induced death from 50% to 
0%8; 
 Bondanza et al.9 developed a GvHD model using NOD/SCID mice treated with human 
SFCMM-3 transduced and selected lymphocytes. In this setting, GvHD induced by TK+ 
lymphocytes could be controlled by GCV administration. 
 Clinical studies 
A phase I/II clinical trial, named TK007, was completed in its main cohort which consisting in the 
administration of HSV-Tk lymphocytes (genetically modified with SFCMM-3 #35 vector) as fresh 
product after haploidentical HCT10. The recruitment of additional patients for a sub-cohort receiving 
HSV-Tk lymphocytes frozen at the end of the transduction procedure was pursued. 
The aim of the TK007 study was to obtain immune reconstitution as well as reduction of infective 
episodes and disease relapse in patients with haematological malignancies who underwent 
haploidentical HCT (and subsequent T lymphocytes infusions) selectively controlling GvHD.  
According to the protocol a patient was considered evaluable for the main end point of the study 
(immune reconstitution) if he/she received at least one dose of HSV TK transduced T cells.  
In presence of acute Graft versus Host Disease related to the investigational product, ganciclovir was 
administered in order to eliminate of the HSV TK transduced T cells and to the resolve of the adverse 
reaction. The clinical protocol foresaw infusion of escalating doses of HSV-Tk cells administered 
immediately after the transduction process. The escalating dose were the following: 
 
 1st infusion: 1 x 107 CD3+ c/kg or alternatively 1x106 CD3+ c/kg; 
 2nd infusion: 1 x 107 CD3+ c/kg;  
 3rd infusion: 1 x 106 CD3+ c/kg + IL-2 (6.000.000 IU/m2 sc x 5 days);  
 4th infusion: 1 x 107 CD3+ c/kg + IL-2 (6.000.000 IU/m2 sc x 5 days). 
 
57 patients were enrolled and five did not undergo HCT. Among 52 transplanted patients (median 
age, 49 years; 22 males and 30 females) 30 patients (17 in the fresh cohort and 13 in the frozen cohort) 
were treated.  
22 patients did not receive treatment because of early death (n=12), graft failure/rejection (n=7), 
prolonged administration of ganciclovir or immunosuppressive therapy (n=3). The following 
diagnoses were reported: 26 AML, 10 sAML, 3 ALL, 7 RAEB-T/MDS, 1 biphenotipic AL, 1 CML-
AP, 4 NHL/HD.  
Status of disease at date of haploidentical-HCT: 21 patients in relapse/progression/advanced disease, 
31 patients in CR. 
23 patients (77%) out of 30 treated achieved immune reconstitution (IR), with a median time of 77 
days from haplo-HCT and 31 days from first HSV-Tk infusion. 
No difference between frozen and fresh cohort were observed when comparing time to IR in the two 
cohorts. These results denote a substantial bio-similarity of frozen cells compared to the fresh cells. 
The HSV-Tk add back strategy provide the basis for a rapid and efficient reconstitution, with absence 
of severe toxicity. Safety data referred to 30 treated patients; the adverse events (AEs) related to the 
experimental product are reported in table 1. 

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Table 1. 
TK007: adverse events related to HSV-Tk by worst grade per patient 
 
Preferred Term 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
NA 
Total  
number  
of patients 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
Acute graft versus host 
disease 
1 
3.3 
7 
23.3 
1 
3.3 
1 
3.3 
0 
0.0 
10 
33.3 
Pyrexia 
1 
3.3 
0 
0.0 
0 
0.0 
1 
3.3 
0 
0.0 
2 
6.7 
Febrile neutropenia 
0 
0.0 
0 
0.0 
1* 
3.3 
0 
0.0 
0 
0.0 
1 
3.3 
Intestinal haemorrhage 
1* 
3.3 
0 
0.0 
0 
0.0 
0 
0.0 
0 
0.0 
1 
3.3 
Hepatic failure 
0 
0.0 
0 
0.0 
1* 
3.3 
0 
0.0 
0 
0.0 
1 
3.3 
Chronic graft versus host 
disease 
0 
0.0 
0 
0.0 
0 
0.0 
0 
0.0 
1 
3.3 
1 
3.3 
Bronchitis 
0 
0.0 
1 
3.3 
0 
0.0 
0 
0.0 
0 
0.0 
1 
3.3 
Haemoglobin decreased 
0 
0.0 
1* 
3.3 
0 
0.0 
0 
0.0 
0 
0.0 
1 
3.3 
Platelet count decreased 
0 
0.0 
0 
0.0 
0 
0.0 
1* 
3.3 
0 
0.0 
1 
3.3 
Post-transplant 
lymphoproliferative 
disorder 
0 
0.0 
0 
0.0 
1* 
3.3 
0 
0.0 
0 
0.0 
1 
3.3 
NA: not applicable 
 
*Same patient TK8 
 
The most frequently HSV-Tk related AEs, reported in at least 10% of patients, was represented by 
GvHD (in bold type in table 1). No grade 5 related-events were reported. 
The potential risk of development of GvHD could be efficiently controlled by the suicide system 
operated by ganciclovir/valganciclovir thus rendering the therapy safely administrable. In the current 
trial, acute GvHD was reported for 10 patients out of the 30 treated patients.  
The most common adverse event related to HSV-Tk cells was represented by graft-versus-host 
disease (GvHD). Among 30 treated patients, acute graft-versus-host disease (GvHD) occurred in 10 
patients (33%) with a median time to onset of 90 days (range, 20 to 162) after HCT and 32 days 
(range, 8 to 91) after the last infusion of HSV-Tk cells. 
All acute GvHD events fully resolved after a median duration of 12 days (range, 7 to 64). Only one 
patient (3%) developed extensive chronic GvHD that occurred 159 days and 129 days after HCT and 
last infusion, respectively, and fully resolved after 107 days.  
By timing of onset, acute GvHD developed in 6 of 30 patients (20%) who initially received HSV-Tk 
cells during the treatment phase at a median of 94 days from HSTC, 48 days from first infusion of 
HSV-Tk cells and 17 days from immune reconstitution.  
Additionally, acute GvHD occurred in 4 of 8 patients (50%) who had received subsequent infusions 
of HSV-Tk cells given as donor lymphocyte infusion (DLI) for treating disease relapse or progression 
at a median time of 21 days after last HCT and 32 days after first infusion of HSV-Tk cells. None of 
these four patients had previously experienced HSV-Tk-related GvHD and none of other four 
retreated patients developed de novo GvHD. 
The clinical treatment and outcome of patients experiencing GvHD was as follow:  
 1 patient grade 1 (skin), no treatment; 
 7 patients grade 2 (skin), 7 treated with GCV and 5 also with steroids; 
 1 patient grade 3 (skin), treated with GCV alone; 
 1 patient grade 4 (gut and liver), treated with GCV, steroids and mycophenolate; 

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 1 patient chronic GvHD (skin, mouth and eyes), treated with GCV and mycophenolate 
mofetil. 
GvHD completely resolved in all cases. No GvHD related deaths occurred in this study. 
Despite the small number of patients, our results indicate no differences in the efficacy and safety of 
GCV and valGCV for the treatment of GvHD in patients treated with HSV-Tk cells, as already 
demonstrated for the treatment of CMV infection. 
In addition, RCR detection was performed on all TK007 treated patients pre-post infusion, at 3 
months, 6 months, at one year and then yearly post-treatment, in compliance with the FDA guideline 
(FDA/CBER, “Guidance for Industry, Supplemental Guidance on testing for Replication Competent 
Retrovirus in Retroviral Vector Based Gene Therapy Products and During Follow-up of patients in 
Clinical Trials Using Retroviral Vectors”, October 2000). The outcome of all performed RCR tests 
was negative. 
1.4 Rationale 
AML is currently classified combining clinical and laboratory data in three broad prognostic groups: 
favourable, standard (or intermediate), and unfavourable. The favourable prognostic subgroup, which 
includes approximately 20 percent of cases among patients who are 60 years of age or younger, is 
defined by the presence of leukemic blasts with the t(15; 17), t(8;21), or inv(16) mutation or molecular 
evidence of these abnormalities. These mutations are more frequent in younger patients who have 
high (more than 85 percent) rates of complete remission and a relatively low risk of relapse (30 to 40 
percent).  
On the other end of the spectrum there is the unfavourable prognostic subgroup, which includes 
approximately 15 percent of the cases among patients who are 15 to 60 years of age.  
These unfavourable cases are defined by the presence of leukemic blasts with cytogenetic 
abnormalities involving more than two chromosomes, monosomies of chromosome 5 or 7, deletion 
of the long arm of 5 (del5q), or abnormalities of the long arm of chromosome 3. These abnormalities 
are more frequent in older patients and in patients with secondary AML, but even among younger 
patients, the survival rate is less than 20 percent at five years. Between these two groups there are 
patients who are characterized as having a standard (or intermediate) risk of relapse. The leukemic 
blasts of these patients have either a normal karyotype or cytogenetic abnormalities that are not 
included in the definition of the other subgroups. In some series this includes patients with cytogenetic 
abnormalities of 11q23, whereas in others these patients are included in the unfavourable prognostic 
subgroup. Patients older than 60 years generally have a poor prognosis, with a probability of survival 
at five years of less than 10 percent. In summary, there is general consensus in considering high risk 
AML with the following conditions at diagnosis: secondary AML following Myelodysplastic 
Syndrome; WBC > 50 x 109 L; marrow blasts > 15% after course 1 of induction chemotherapy; FAB 
subtypes M0,5,6,7; high risk cytogenetic group: -5/del5q, del(7q), 3q-, complex, t(6;9), t(9;22), 11q, 
21q, 17p; standard risk cytogenetic group (normal, +8) with FLT3 internal tandem duplication, or 
hepatosplenomegaly, extramedullary disease at diagnosis. Although the outcome of patients with 
AML has improved because of cytarabine and anthracycline based chemotherapy and introduction of 
HCT, relapse continues to represent the major cause of death in the vast majority of patients. The 
probability of relapse depends on risk factors such as age, pre-treatment, cytogenetics and number of 
cycles of induction chemotherapy required for attaining the first complete hematologic response 
(CR). In addition, treatment of AML in first relapse is associated with relatively low response rates. 
Whenever second CR is attained, the median duration of the second relapse-free interval (RFI) is 
generally considerably shorter than that of the first RFI. Factors predicting outcome of patients with 
AML in first relapse have been reported, and include RFI, age, and cytogenetics. However, proposed 

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stratification methods for selecting therapies for patients with relapsed AML have only been based 
on the duration of RFI, thus neglecting the influence of other known prognostic factors. Predictive 
scores for patients with AML in first relapse that include more covariates could be generally 
applicable, if they would furnish a simple and statistically valid prognostic index. Recently, HOVON 
cooperative group proposed a score including RFI, cytogenetics, age and previous HCT as 
covariates11. According to this large retrospective analysis, allogeneic HCT is indicated in vast 
majority of patients with AML in CR2. The prospect of transplantation would increase if it is intended 
to deliver earlier as soon a CR2 obtained. Similarly to AML, ALL is currently classified combining 
clinical and laboratory data25-33. According to standard consensus criteria age is one of the most 
important prognostic factor. OS continuously decreases with increasing age from 34-57% below 30 
years to 15-17% above 50 years. An elevated WBC at diagnosis is associated with a higher relapse 
risk, with risk of complications during induction and with an increased risk of CNS relapse. A 
complete immunologic characterization at diagnosis is required to identify subtypes with different 
presentations and prognoses. Pro-B-ALL and/or t(4;11)+ ALL is considered a poor prognostic 
subgroup, it appears to be particularly susceptible to SCT. The survival was 74% for all of sibling 
SCT in CR1, indicating that pro-B-ALL has the most favourable outcome after SCT compared to 
other ALL subgroup in the GMALL studies. Common/pre-B-ALL bears a large proportion of 
Ph/BCR-ABL+ ALL condition that identified a population at very high risk, with absolute indication 
to allogeneic transplantation. Many group have confirmed the superior outcome of T-lineage ALL 
compared to B-lineage. The LFS was significant poorer for early T-ALL (25%) and mature T-ALL 
(28%) compared to thymic T-ALL (63%). The former subgroup are considered as indications for 
SCT in CR1 in the GMALL studies. Besides age the most relevant prognostic factor in ALL is the 
achievement of CR, further prognostic factor are delayed time to CR or response to prednisone 
therapy. A more accurate approach to assess individual response is minimal residual disease (MRD), 
actually under evaluation for broader application. According to the literature it is possible identified 
adverse prognostic factors as: WBC >30.000 in B-ALL, >100.000 in T-ALL, complex karyotype 
[t(9;22)/BCR-ABL, t(4;11)/ALL1-AF4, t(1;19)/PBX1-E2A], age >35 years, late CR, MRD 
persistence >10-4 for 3-4 months. According to EBMT standard practice recommendations patients 
with ALL with poor prognostic features, or delayed time to obtain remission are candidates for 
allogeneic HCT in first remission. Allogeneic HCT for standard risk patients in first CR should be 
performed within a clinical protocol. Patients who relapse after chemotherapy and achieve a second 
CR are candidates for allogeneic HCT, in fact outcome of HCT is superior to chemotherapy alone. A 
steady stream of advances in allogeneic HCT has not only improved the clinical outcome in a variety 
of malignant and non-malignant diseases but also widened the indications for such transplants12,13. 
The immunological role of donor T lymphocytes in the eradication of the tumours is universally 
recognized and the added Graft versus Leukaemia effect (GvL) makes this therapeutic method the 
preferential choice for patients who have a consanguineous or marrow bank donor. Furthermore 
donor lymphocytes infusions (DLI) have been shown to be effective in the treatment of a large number 
of post-transplant relapses, with a success rate of between 15 to 80 % depending on the type of 
disease. The infusion of donor T lymphocytes also mediates the reconstitution of the immune 
responses against viruses (for example induced Epstein Barr Virus lymphoma or Cytomegalovirus 
reactivation) and fungi, as demonstrated by the lower incidence and severity of these infections in the 
context of unmanipulated transplantation versus T depleted transplant. However, the infusion of 
donor T lymphocytes increases the risk of GvHD and the incidence and severity of the disease 
correlates with the number of infused lymphocytes. Currently, the therapeutic options for GvHD are 
limited to immunosuppressive agents and can result in severe infections and/or disease relapse. In 
recent years, different strategies for the prevention and treatment of GvHD have been developed. 
These include the modulation of the infusion parameters (time and number of administrations and 

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dose of infused lymphocytes), enrichment of lymphocytes thought to be responsible for the 
antitumoral (GvL) or antiviral activities and depletion of the population responsible for GvHD. 
Although widely recognized as effective therapeutic tool, the sources of hematopoietic stem cells 
from HLA-identical siblings, are available to only about 30 percent of potential recipients. For 
situations in which a matched unrelated donor cannot be found within a reasonable time, 
haploidentical family donors has emerged as an attractive source of stem cells14. The EBMT Acute 
Leukaemia Working Party collected data on 273 haploidentical transplants from 75 centers in adults 
patients with de novo acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL) 
reported to the EBMT from 1995 to 2002 and analysed the outcome of this procedure according to 
the known risk factors. Overall, 170 AML patients, median age 38 years (16-70) underwent 
transplantation in CR1 (39), CR2 (34) or in advanced disease (97). In addition 103 ALL patients, 
median age 26y (16-56). Underwent transplantation in CR1 (31), CR2 (22) or in advanced disease 
(50). Primary engraftment was documented in 87% AML and in 83% of ALL patients. The 
cumulative incidence of acute GvHD >=II was 16% in AML and 15% in ALL. At a median follow-
up of 19 months (1-85), the estimated leukaemia-free survival (LFS) at 2 years was 39% for AML 
and 28% for ALL transplanted in CR1. The non-relapse mortality (NRM) at 2 years in AML was 
52% for CR1 and 44% for ALL in CR1. Analysis on center effect on LFS, RI and NRM showed no 
differences on outcome. In conclusion, the EBMT registry analysis of allogeneic transplantation from 
haploidentical family donors confirmed relevant LFS at 2 years for patients with high risk AML while 
revealing a pattern of late Transplant related Mortality and late relapse due to failure of immune 
reconstitution15. However, although feasible, one of the main problems of haploidentical HCT is 
represented by the delayed immune reconstitution1. The risk of severe infections remains high for 
several months and CD4+ cells reconstitution could take more than 10 months. The low number of 
lymphocytes infused with the graft, the degree of HLA disparity, a reduced thymic function in adults 
and differences in host/donor antigen presenting cells are all contributing causes. Attempts to 
overcome this problem with infusions of donor lymphocytes have been associated with a high 
incidence of GvHD 16-18.The infusion of HSV-Tk transduced lymphocytes should allow for early 
immunological reconstitution and reduce the risk of infections and disease relapse. Data in the 
literature showed that the infusion of lymphocytes transduced with HSV-Tk were able to control in 
principle the development of GvHD without resulting in any severe side effect related to the in vitro 
manipulation of lymphocytes2,19-22. A completed phase I/II multicenter trial (TK007) was designed 
based on historical data demonstrating the anti-leukemic potential of HSV-Tk cells in HLA-matched 
setting and their ability to control GvHD. In TK007 study, among the 30 treated and the 23 immune-
reconstituted patients the non-relapse mortality was 30% and 17%, the disease-free survival was 30% 
and 39% and the overall survival was 40% and 52%, respectively. 
It has been shown in animal models that both graft rejection and GvHD after histoincompatible bone 
marrow transplantation (BMT) can be inhibited by post‐transplant administration of high‐dose 
cyclophosphamide, which is known to be highly toxic to lymphocytes proliferating in response to 
recent antigen stimulation. Based on this experience, Luznik et al41 first demonstrated in 68 patients 
with hematologic malignancies the feasibility of unmanipulated T-cell repleted BMT from 
haploidentical related donors followed by post‐transplant high‐dose cyclophosphamide on days 3 and 
4. As GvHD prophylaxis, the patients received also tacrolimus and mycophenolate mofetil. Low 
incidences of acute GvHD (grades 2‐4, 34% and grades 3‐4, 6%) and non‐relapse mortality at 1 year 
(15%) were observed, although there was a relatively high incidence of graft rejection (13%) and 
relapse rate at 1 year (51%). After a median follow‐up of 745 days, the actuarial disease‐free survival 
(DFS) at 1 year was approximately 30%. 

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The results of multicenter, prospective phase II TK007 trial provide the basis for the present phase 
III trial aimed to compare the add back HSV-Tk strategy versus a standard haploidentical HCT, which 
consists of haploidentical HCT either with infusion of CD34+ cells plus a dose of T cells 
(approximately 1 x 104/Kg) or with unmanipulated haploidentical BMT, at Investigator discretion. 
 
 

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2 Objectives 
The objective of this randomized trial is to demonstrate the efficacy in increasing disease-free survival 
(DFS) of HSV-Tk add back strategy versus a standard strategy, following haploidentical HCT in 
patients with acute high risk leukaemia. 
2.1 Primary aim 
To compare disease-free survival (DFS) in high risk leukaemia patients who underwent 
haploidentical HCT followed by add back strategy of HSV-Tk donor lymphocytes or standard 
haploidentical HCT. 
2.2 Secondary aims 
a. To compare overall survival (OS) in the two treatment arms 
b. To compare cumulative incidence of non-relapse mortality (NRM) 
c. To compare the chronic graft-versus-host disease (GvHD)-free, relapse-free survival 
(GRFS) 
d. To compare time to T-cell immune reconstitution 
e. To compare engraftment rate 
f. To compare cumulative incidence of grade II-IV acute GvHD 
g. To compare cumulative incidence of chronic GvHD 
h. To compare time to GvHD resolution and use of agents with immunosuppressive activity 
i. To compare cumulative incidence of relapse (CIR) 
j. To compare incidence and duration of infectious episodes and infectious disease mortality 
k. To evaluate the acute and long-term toxicity related to the HSV-Tk infusions 
l. To assess quality of life (QoL) and Medical Care Utilization (MCU) in both arms 
 
 

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3 Trial design 
Prospective, randomized (3:1), 2-arm, open label, multicenter, multinational phase III trial. 
As part of the Conditional Marketing Authorization (CMA) granted in August 2016 by the European 
Medicines Agency (EMA) for the medicinal product (www.ema.europa.eu/EPAR/Zalmoxis), the 
present phase III trial TK008 has been classified as a Category 2 study, and EMA will review the 
safety data of the study on an every-6-month basis through the Periodic Safety Update Reports 
(PSURs), and the benefits and risks of the medicinal product on an annual basis for the renewal of 
the CMA.  

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4 Patient selection criteria 
4.1 Target population 
Patients suitable for haploidentical HCT affected by high risk acute leukaemia in 1st or subsequent 
complete remission or in relapse. 
4.2 Inclusion criteria 
1. Patients ≥ 18 years 
2. Any of the following conditions: 
a. AML and ALL in 1st complete remission (CR)  
b. AML and ALL in 2nd or subsequent CR 
c. Secondary AML in CR 
d. AML and ALL in 1st or 2nd relapse or primary refractory 
3. Family donor with patient-donor number of HLA mismatches ≥ 2 (full haploidentical) or  
family donors sharing one HLA-haplotype with the patient 
4. Stable clinical conditions and life expectancy > 3 months 
5. PS ECOG < 2 
6. Serum creatinine < 1.5 x ULN 
7. Bilirubin < 1.5 x ULN; transaminases < 3 x ULN 
8. Left ventricular ejection fraction > 45% 
9. QTc interval < 450 ms 
10. DLCO > 50%    
11. Patients and donors, or independent witnesses must sign an informed consent indicating that 
they are aware this is a research study and have been told of its possible benefits and toxic 
side effects. 
4.3 Exclusion criteria 
1. Patients with life-threatening condition or complication other than their basic condition 
2. Contraindication to haploidentical HCT as defined by the Investigator 
3. Patients with active CNS disease 
4. Pregnant or lactation. Patients both males and females with reproductive potential (i.e. 
menopausal for less than 1 year and not surgically sterilized) must practice effective 
contraceptive measures throughout the study. Women of childbearing potential must provide 
a negative pregnancy test (serum or urine) within 14 days prior to registration. 
4.4 Conditioning regimens 
Investigators can use conditioning regimens for haploidentical HCT according to Institutional clinical 
practice.  
Some suggested conditioning regimens have been listed in appendix A. 

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4.5 Recommended Supportive Care 
Investigators can use supportive care (including prophylaxis and treatment with antibacterial, 
antiviral, antifungal and antimycobacteria therapy), according to Institutional clinical practice.

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5 Experimental arm (Arm A) 
5.1 Drug information 
The drug product is defined as frozen haploidentical donor T lymphocytes genetically modified with 
the retroviral vector SFCMM-3 Mut2 #48 (SFCMM-3 Mut2 #48 transduced lymphocytes), encoding 
for the ΔLNGFR and HSV-Tk Mut2 genes in the final formulation and container closure system, 
ready for intended medical use. It is a patient specific product prepared starting from a 
lymphocytoaphaeresis of a dedicated donor. 
The lymphocytoaphaeresis is performed at the clinical center according to common clinical 
procedures and sent to MolMed for the transduction process.  
For dose preparation, the frozen peripheral blood mononuclear cells (PBMC), isolated from 
lymphocytoapheresis by density gradient, are thawed, stimulated, transduced in the presence of the 
SFCMM-3 Mut2 #48 retroviral vector and positively transduced cells immunoselected using an anti-
LNGFR specific monoclonal antibody (mAb 20.4) conjugated with magnetic microbeads, in order to 
obtain a highly purified population of positively transduced cells. 
After the culture for expansion, the transduced lymphocytes are harvested and re-suspended in 
freezing medium (Saline solution + HSA 7% + 10% DMSO) at the concentration of 5-20x106 cells/ml 
in ethylene vinyl acetate EVA CryoMACS freezing bags, frozen in decreasing temperature controlled 
conditions and stored in liquid nitrogen vapour phase.  
5.2 Drug Product supply 
The genetically modified T donor lymphocytes will be supplied by MolMed S.p.A. as one individual 
treatment dose in a 50-500 mL ethylene-vinyl-acetate cryo bags. Further details about procedures and 
forms are provided in the Study Manual. 
The investigator or designee is responsible for investigational product accountability. 
To this end, it is assumed that all clinical trial supplies will be delivered to and under the responsibility 
of a suitably qualified and authorized person, who will document drug disposition and accountability 
for the duration of the trial. 
5.3 Drug Product formulation, packaging, labelling and storage 
The genetically modified T donor lymphocytes will be supplied in EVA cryo-bag, in saline solution 
containing 7% HSA and 10% DMSO at the concentration of 5-20x106 cells/ml, in a volume of 10-
100 ml  
The primary packaging of the drug product will bear a label with at least the following information: 
the protocol name, the Principal Investigator name, the batch number, the patient code, the donor 
code, the storage conditions, the manufacturing date, the total number of cells, the route of 
administration, the Sponsor name, “For clinical trial use only” and the expiry date. Text might be in 
different order on the labels and will be adapted to the country specific local requirements.  
The drug product will be stored in liquid nitrogen vapor phase in a locked facility. 
The donor lymphocytoaphaeresis, the genetically modified T donor lymphocytes and all 
documentation related to storage, manipulation, testing, production and shipping will be recorded and 
traceability will be guarantee by dedicated logbooks. 

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5.4 Drug administration  
Before the infusion, the cryo-bag with the transduced donor T-lymphocytes, must be thawed, when 
completely thawed the entire volume of the bag must be infused as quickly as possible. The 
recommended infusion time is around 20-60 minutes. 
In order to administer completely the HSV-Tk cells it is recommended to wash the bag 2-3 times with 
physiological solution using a sterile solution. The washing procedure must be performed during the 
infusion in a sterile way. Further details about procedures will be provided in the Study Manual. 
After the infusion, the cryo-bag will be disposed of according the local site procedures for the 
biological material. 
Information on shedding and any precautions required are reported on safety data sheet. 
 
During infusion of HSV-Tk cells monitoring of vital signs (pulse rate and blood pressure) should be 
done: 
1. before infusion (baseline)  
2. after the completion of infusion: 
a. every 15 minutes for the first hour, 
b. every 30 minutes for the second hour, and  
c. hourly through the end of the fourth hour. 
5.5 Dosage schedule 
Patients randomized for arm A will receive the treatment, up to a maximum of 4 infusions, with an 
interval between each infusion of 30 days (±2 days), in the absence of spontaneous immune 
reconstitution (IR has to be documented by two consecutive findings of circulating CD3+ cells ≥ 
100/μl) and/or development of GvHD.  
The 1st infusion of HSV-Tk genetically modified T-lymphocytes will be administered between day 
+21 and day +49 after haploidentical HCT.  
Administration of the first infusion earlier than day +21 should be discussed with the Sponsor.  
 
HSV-Tk infusion must not be infused in case of: 
1.  Infections requiring administration of ganciclovir or valganciclovir at the time of infusion.  
2. GvHD requiring systemic immunosuppressive therapy  
3. Ongoing systemic immunosuppressive therapy after haploidentical HCT 
4. Administration of G-CSF after haploidentical HCT 
 
HSV- Tk cells can be administered after and adequate wash out period (24 hours). 
 
A delay in the treatment administration over 1 week must be justified in the patient’s CRF. 
The calculation of the dose of TK cells to be infused is based on the weight of the patient at the 
screening phase (i.e. before HCT), reported on documents of lymphocytoapheresis (such as Apheresis 
Shipping/Transduction Request Form); the patient’s weight must also be provided in case of further 
request of transduction if more HSV-Tk doses are needed. 
The dose of HSV-Tk cells of each infusion is 1 ± 0.2 x 107 cells/kg.  
5.6 Treatment duration 
The planned treatment foresees the administration of up to 4 infusions of HSV-Tk donor lymphocytes 
with the purpose to induce immune reconstitution. Schedule and doses recommended for the phase 

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III, were obtained from the results of a Phase I-II trial (TK007) demonstrating safety and activity of 
the experimental product.  
 
The HSV-Tk infusion will be discontinued only in presence of the following conditions: 
1. CD3+ cells ≥100/μl (immune reconstitution) 
2. Any grade 3-4 adverse event related to HSV-Tk infusion  
3. Any grade 2 adverse event related that does not resolve to no more than grade 1 before the 
next infusion, for infusion that follow the first (unless investigator considers it to be in the 
best interest of patient to continue treatment).  
 
The duration of the treatment will be related to the clinical outcome (achievement of immune-
reconstitution). 
For the long-term follow-up after HSV-Tk infusion(s) see section 10.5.4 
5.7 Dose modification 
A standard dose modification scheme is not applicable. 
5.8 Treatment in case of disease relapse or progression 
Leukaemia relapse or disease progression will be treated according to local Institutional policy, 
including chemotherapy, other antiproliferative agents, donor lymphocyte infusions or allogeneic 
transplantation from an alternative donor. 
 
 

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6 Study Assessments and Procedures 
6.1 Pre HCT phase 
 Confirmation of eligibility (Randomization procedures) 
Eligible patients who provided the informed consent to participate into the study will be randomly 
assigned to either treatment strategy before HCT, through a centralized randomization process using 
the following stratification factors: status of the disease at the time of transplantation (e.g., first or 
subsequent complete remission or relapse), ECOG performance status (0 or 1), and country.  
In the experimental group A, patients will receive infusion of CD34+ cells plus a dose of T cells 
(approximately 1 x 104/Kg) followed by infusion of HSV-Tk genetically modified CD3+ cells.  
In the control group B, the physician will choice if the patient will receive either infusion of CD34+ 
cells plus a dose of T cells (approximately 1 x 104/Kg) or unmanipulated haploidentical (bone marrow 
or peripheral blood ) transplantation followed by high-dose cyclophosphamide. 
Paper randomization lists, balanced within each stratum in blocks of varying size in random sequence, 
will be kept in MolMed headquarter. For each patient who undergoes screening, an Eligibility 
Screening Form (ESF) has to be filled in. The form is submitted to MolMed by fax/e-mail. The 
enrolment will be confirmed by fax/e-mail by the sponsor with the Confirmation of Enrolment Form, 
in which is reported the patient and donor (for arm A only) identification codes that must be used for 
the entire duration of the study, for the CRF and for all the other study forms. On the Confirmation 
of Enrolment Form will be also indicated the treatment arm (A: experimental arm; B: control arm). 
The ESF should be sent to the sponsor maximum 30 days before HCT. 
The investigator or designee will use the Case Report Form (CRF). He/she will enter the assigned 
patient code number and treatment group allocation, reported in the confirmation of enrolment, in the 
appropriate place on each patient’s CRF. 
 Screening phase 
Written informed consent must be obtained prior to the patient and donor undergoing any study-
specific procedures. 
The screening phase will be performed maximum 30 days before haploidentical HCT and will 
include: 
a. Patient and donor informed consents 
b. Medical history and complete objective examination 
c. Blood and chemistry: WBC (with formula), RBC, platelets, Hb, Hct, MCV, MPV, reactive C 
protein, albumin, albumin/globulin, IgG, IgA, IgM, glucose, AST, ALT, γGT, total bilirubin, 
LDH, alkaline phosphatase, creatinine, BUN, creatinine clearance (if appropriate) according 
to Cockroft-Gault formula (Appendix F), electrolytes (Na+, K+, Ca++)  
d. Serology: CMV status, EBV-status, HCV, HBV and HIV 
e. Evaluation of the neoplastic disease on bone marrow or peripheral blood 
f. Cytogenetics and/or molecular tests of bone marrow and/or peripheral blood for markers of 
disease, according to center guideline 
g. Left ventricular ejection fraction by MUGA scan or echocardiography 
h. Spirometry with Diffusing Lung Capacity of Carbon Oxide (DLCO) 
i. A serum or urine pregnancy test in women with reproductive potential 
j. QTc interval by ECG 
k. Donor’s tests for: serology (CMV status, EBV status, HCV, HBV, HIV, Treponema 
Pallidum), mycoplasma (only Arm A), screening for Human transmissible spongiform 

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encephalopathy, including Creutzfeldt-Jakob disease, Human T-Lymphotropic virus, West 
Nile Virus*, Neisseria gonorrhoeae* and Chlamydia trachomatis*. The investigator shall 
select the donor in compliance with the 21 CFR 1271*, directive 2006/17EC** and applicable 
local guidelines. 
*For US centers only. **For EU centers only. 
The Donor’s tests specific for patients randomized in arm A must be performed according to 
Appendix B. 
 Lymphocytoaphaeresis collection procedures for experimental Arm A 
The donor lymphocytes will be collected before mobilization with G-CSF or marrow harvesting to 
avoid alterations in the immune repertoire, functionality, phenotype and cytokine production. 
The collection will be via lymphocytoaphaeresis, upon donor informed consent.  
The lymphocytoaphaeresis should be delivered to MolMed S.p.A. at least 20 days before the 
transplant. 
Different timing of lymphocytoaphaeresis collection should be discussed with the Sponsor. 
The lymphocytoaphaeresis (at least 10x109 total WBC) is collected according to Institutional practice 
and sent to MolMed at 2-8°C, where it is processed in GMP area. 
Clinical study centre should provide together with the lymphocytoapheresis bag, the declaration of 
biological tests performed within 30 days the collection (see appendix B) and the donor’s blood 
group. Frozen commercial homogroup plasma will be used for transduction process.  
Lymphocytoaphaeresis will be labelled indicating at least protocol code, donor code, site code or 
name, collection date, total volume, type of cells (i.e. lymphocytes) and according to the regulations. 
Further details about procedures and forms are provided in the Study Manual. 
In the event that a further lymphocytoaphaeresis is needed, it will be done at least 30 days after 
administration of G-CSF.  
If indicated, in case of graft failure/rejection it will be possible to perform further HCT; in case of 
different donor a new lymphocytoaphaeresis will be sent to MolMed for transduction procedures. In 
this case, the investigator must inform the sponsor (using an appropriate form) in order to receive a 
new donor code. 
6.2 Haploidentical transplantation (HCT) - Study day 0  
 Arm A: experimental group = haploidentical T-depleted HCT + HSV-Tk cells 
Patients randomized in the experimental group, will receive a haploidentical T-depleted transplant 
followed by infusion(s) of HSV-Tk cells.  
The first infusion will be administered between days +21 and +49  (see section 5.5 “Dosage 
schedule”). 
Administration of the first infusion earlier than day +21 should be discussed with the Sponsor.  
The donor CD34 positive cells selection will be performed with the CliniMACS device.  
Donor stem cells will be mobilised with G-CSF.  
The graft composition should contain a recommended 7x106 CD34+/kg stem cells and should be 
adjusted to contain approximately 1x104 CD3+/kg. 
If indicated, in case of graft failure/rejection it will be possible to perform further HCT. 

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 Arm B: control group = haploidentical HCT (T-cell depleted graft OR unmanipulated 
T-cell replete graft followed by high-dose cyclophosphamide and immunosuppressive 
therapy) 
Patients randomized in the control group, will receive a haploidentical T-depleted transplant as 
reported above for arm A, OR an unmanipulated transplant (bone marrow or peripheral blood) 
followed by cyclophosphamide (50 mg/kg iv) on day +3 and +4. 
In addition, after unmanipulated transplant, patients will receive filgrastim on day +4 (5 mg/kg/day 
by subcutaneous injection continuing until recovery of neutrophils to >1000/µL for 3 days) and, as 
GvHD prophylaxis, from day +5 tacrolimus or cyclosporine until day 180 and mycophenolate mofetil 
until day 35. 
If indicated, in case of graft failure/rejection it will be possible to perform further HCT. 
6.3 Post HCT phase - Arm A and Arm B 
 Disease evaluation 
The disease evaluation will be collected after HCT (day O): 
 monthly up to month 6 (±7 days) 
 at month 9 and month 12 (±7 days) 
 yearly until disease relapse or progression (±1 month) 
 
The following disease examinations will be performed: 
 Morphology (bone marrow or peripheral blood)   
 Confirmation of mixed or full chimerism (evaluation of the degree of chimerism between 
donor/host, according to institutional clinical practice, on bone marrow or peripheral blood) 
 Cytogenetic and/or molecular and/or other tests, according to institutional clinical practice 
(bone marrow or peripheral blood). 
 
After disease relapse or progression, patients will be followed up for further antileukemia treatments, 
survival (see section 6.3.5), safety (see section 6.3.7) and for patients treated with HSV-Tk cells, also 
for RCR (see section 6.4.2) and Long Term Follow-up (see section 10.5.4). 
 Laboratory assessment 
The laboratory assessments will be performed after HCT (day O), at the following time-points: 
 at day 15 of 1st month (±2 days ) 
 monthly up to month 6 (±7 days)  
 at month 9 and month 12 (±7 days) 
 
Blood and chemistry assessment includes: AST, ALT, γGT, total bilirubin, LDH, WBC (with 
formula), RBC, platelets, Hb, Hct, MCV, MPV, creatinine, CMV PCR or antigenemia. Exception 
will be made for the 1st examination after HCT that will be performed as indicated in the screening 
phase. 
 Physical examination 
Physical examination will be performed after HCT (day O), at the following time-points: 
 monthly up to month 6 
 at month 9 and month 12  

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The following assessments will be performed: 
 Vital signs (blood pressure, pulse rate)  
 Body weight 
 ECOG performance status (see appendix E) 
 Evaluation of clinical signs of GvHD 
 Functional Studies 
Functional studies, aimed at quantifying and characterizing immune reconstitution are planned for 
patients enrolled in arm A and arm B. 
Studies involving the identification of genetically modified lymphocytes (LNGFR marking) will be 
performed only in patients randomized for Arm A.  
 
Immune phenotype analysis 
The number of circulating CD3+, CD3+CD4+ and CD3+CD8+ cells will be quantified and used to 
evaluate immune-reconstitution. These analyses shall be performed with flow cytometrically using 
an immunological gating strategy; a technique similar to the ISHAGE (International Society of 
Hematotherapy and Graft Engineering) sequential gating protocol used for the enumeration of CD34+ 
stem cells23. Immunological gating of CD45+ leukocytes minimizes interference from debris which 
antibodies can bind non-specifically. The single platform method will be used to determine absolute 
counts. This method employs an internal standard of fluorescent microbeads which enables the direct 
enumeration of cells bearing each phenotype. 
 
Immune phenotype analysis to quantify circulating lymphocytes will be performed after hematologic 
engraftment of haploidentical HCT in both arms, as follows: 
 
 weekly up to IR achievement  
and after IR: 
 monthly up to 6 months (±7 days) 
 at month 9 and month 12 (±7 days) 
  
Aliquots of whole blood specimens for both arms will be stained with the following panel of 
monoclonal antibodies  
CD3 
CD3/CD4 
CD3/CD8 
CD45/CD3/CD19 
CD45/CD16/CD56 
CD45/LNGFR/CD3 (Arm A only) 
 
CD45/CD3/CD4/CD8 (at all time points with CD3 ≥ 100/µl) 
CD45/LNGFR/CD4/CD8 (Arm A only; at all time points with LNGFR > 20/µl) 
 
In addition, in the arm A, in presence of GvHD related to HSV-Tk cells and treated with GCV/VCV, 
immune phenotype analysis will be performed at the following time-points: 
 
 before GCV/VCV treatment 

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 4 days after the beginning of GCV/VCV treatment 
 1 day after the discontinuation of GCV/VCV treatment 
 
Further optional analyses regarding the functional characterization of immune reconstitution have 
been listed in Appendix F. 
Analysis and reporting of these data will be handled separately from the clinical study report. 
 Survival follow-up 
After the first year from HCT or after disease relapse/progression, patients of both arms will be 
followed on an every 6-month basis for further anti-leukemia treatments and survival. 
For patients of both arms who withdraw their consent, every effort must be made to document if a 
subject withdrew consent from study treatment or for all study procedures and follow-up. Unless 
specifically stated by the patient who withdrew consent for follow-up, further anti-leukemia 
treatments and survival follow-up will continue as indicated. 
 Quality of life assessment  
An assessment of the quality of life (QoL) by questionnaire (see Appendix J) will be performed: 
 before HCT 
 at month 9 and 12 
 yearly after HCT until disease relapse 
The objective of quality of life questionnaire will be to summarize and evaluate treatment group 
differences in patient convenience and satisfaction. 
 Safety  
The safety study data will be collected as follows: 
 Starting from HCT, only unexpected serious adverse events (SAEs) and study endpoints (graft 
failure/rejection, disease relapse, grade II-IV acute and all chronic GvHD, and death) will be 
collected as SAE until day 21.  
 From day 21 through day 180, all adverse events (AEs) will be collected  
 In case of HSV-Tk infusion before day 21, AEs have to be collected from the day of first 
infusion through day 180 (or at least 30 days after last infusion, whichever is longer). 
 Any event that was present before day 21 and that remains unchanged or improved should not 
be recorded as an AE. If the event gets worse on day 21, this should be considered an AE. 
 Related AE/SAE, infections and GvHD not resolved at day 180 will be followed through the 
resolution. All other AEs will be closed as not resolved or unknown and the end date will be 
not available 
 From day 181 (or 30 days after last infusion of HSV-Tk), only related SAEs and study 
endpoints will be collected (as SAE) through end of study. 
In case of disease relapse AE/SAE collection will be stopped with the following exception: 
 Related AE/SAE and infections not resolved when the relapse occurred will be followed 
through resolution 
 Death (as study end point) and related SAE will be collected as SAE through end of study 
 Only for patients in arm A, AE/SAE unrelated will be collected until day of relapse or 30 
days after the last HSV-Tk infusion (whichever happens later) 
 

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The table below summarizes the data safety collection: 
 
 
1 for ARM A=day of first infusion (if anticipated) 
2 for ARM A= day 180 or 30 days after last infusion (whichever happens later)  
3 EoS= End of Study 
4 until date of relapse or 30 days after last infusion (whichever happens later)  
5 only if not resolved at day 180 
6 only if not resolved when the relapse occurred  
*Study endpoints (graft failure/rejection, disease relapse, GvHD, death) have to be reported as Serious Adverse Events on SAE Form 
 
For further details on safety reporting see also section 10.3. 
 
 
Treatment of GvHD related to HSV-Tk cells 
The classification of acute and chronic GvHD are reported in Appendix C and D, respectively. 
If at any time during the study, a grade of acute GvHD equal or greater than 2 or a chronic GvHD 
occurs, related to HSV-Tk cells, the patient will be treated with ganciclovir at a dose of 10 mg/kg/day 
divided into 2 administrations, or valganciclovir 900 mg twice per day orally for 14 days. 
For more detailed information about the ganciclovir (GCV) or valganciclovir (VCV) administration, 
the investigator should refer to the related “Summary of Product Characteristics”. 
In case of GvHD progression after 3 days of treatment with only GCV/VCV, a standard 
immunosuppressive therapy (including corticosteroids, cyclosporine, mycophenolate mofetil, 
tacrolimus, etc) will be added as per standard practice and according to clinical center protocol. 
HSV-Tk cells could be administered after a 24-hour discontinuation period of GCV/VCV or 
immunosuppressive therapy. 
 
Immune phenotype analysis (see Section 6.3.4.1) will be performed for patients treated with 
GCV/VCV, in order to monitor the control of GCV/VCV on GvHD, at the following time points: 
 before GCV/VCV treatment  
 four days after the GCV/VCV beginning  
 one day after the discontinuation of GCV/VCV treatment. 
 
Treatment of GvHD not related to HSV-Tk cells 
If acute GvHD or chronic GvHD develop, a standard immunosuppressive therapy will be used 
according to center guideline. 
 
Day 0 (HCT) Day 211 
Day 211 Day 1802 
Day 180  EoS3 
 
AFTER RELAPSE 
Arm A 
Arm B 
Study endpoints* 
X 
X 
X 
 
Only Death 
 
Unexpected SAE 
X 
 
 
 
 
AE/SAE Unrelated  
 
X 
 
X4 
 
AE Related 
 
X 
X5 
X6 
SAE Related 
 
X 
X 
X 
Infection 
 
X 
X5 
X6 

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6.4 Specific assessments for Arm A (centralized analyses) 
 Real time PCR-TK 
PCR analysis for HSV-Tk aims at verifying the presence of transduced donor lymphocytes, will be 
performed at the following time points: 
 baseline (i.e. immediately before 1st HSV-Tk infusion) 
 monthly starting from the 1st HSV-Tk infusion up to 6 months after last administration (± 7 
days) 
 Analysis of retrovirus competent for replication (RCR)  
RCR search will be carried out using molecular tests (Q-PCR env) according to the following time 
schedule: 
 at baseline (i.e. immediately before 1st HSV-Tk infusion) 
 at 3 months after 1st HSV-Tk infusion (± 7 days) 
 at 6 months after 1st HSV-Tk infusion (± 7 days) 
 at 1 year after 1st HSV-Tk infusion then (± 1 month) 
 yearly for at least 5 years (± 1 month) 
 
In case the samples collected during the first year were always negative, the subsequent yearly 
samples will be taken but not analysed; in case of one or more positive samples, the culture test will 
be performed for confirmation. 
 Sampling procedures 
For each test, at least 5x106 PBMC post Ficoll are requested, that are obtained in general from a 
sample of 10 ml blood. Double volumes are generally necessary at baseline to obtain 5 x 106 PBMC.  
The frozen samples will be sent in dry ice to Sponsor.  
All documentation related to collection, shipment, delivery, receipt, storage and destruction must be 
filed and the related information recorded. 
Details about procedures and forms are specified in the Study Manual. 

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6.5 Study Flow Chart 
 
Pre-Randomization 
Screening Phase 
Study Treatment Phase 
(for both experimental and 
control arm) 
Follow up Phase 
 
Haplo-
HCT 
 
Study Month 
- 1 
0 
1 to 6 
9 and 12 
24 to end of 
study 
Study Day 
-30 to -1 
0 
1 to 180 
181 to 
365 
366 to end of 
study 
Weekly 
Monthly 
Every 3 
months 
Yearly 
Informed Consent1 
X2 
 
 
 
 
 
Demographic Data 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
Leukemia Treatment History 
X 
 
 
 
 
 
Pregnancy Test (if applicable) 
X2 
 
 
 
 
 
Serology  
X 
 
 
 
 
 
Functional tests (DLCO, LVEF and QTC) 
X2 
 
 
 
 
 
Concomitant Treatments 
X 
 
X 
X 
 
 
Physical Examination3 
X2 
 
 
X 
X 
 
Hematological & biochemical exams 
X2 
 
X4 
X 
X 
 
Study Treatment Administration 
 
 
 
X5 
 
 
Immunophenotype (quantification) 
 
 
X6 
X7 
X7 
 
Disease evaluation   
X2 
 
 
X 
X 
X8 
QoL Questionnaire 
X 
 
 
 
X 
X8 
Real Time PCR-TK (arm A only) 
 
 
 
X9 
 
 
RCR analysis (by PCR) (arm A only) 
 
 
 
X10 
 
X10 
Safety 
 
On an ongoing basis 
Survival follow-up 
 
 
 
 
 
X11 
Long-term follow up (arm A treated only) 
 
 
 
 
 
X 
Further antileukemia treatment 
 
 
 
 
 
X11 
1 Informed consent must be obtained before any study specific screening procedures are performed. 
2 Data used by investigator to evaluate patients’ eligibility. 
3 Including evaluation for clinical signs of GvHD 
4 To be performed at day 15 of 1st month from HCT  
5 1st infusion from day +21 to +49, the subsequent every month up to a maximum of 4 infusions 
6 To be performed from engraftment to immune reconstitution 
7 To be performed after IR, monthly for 6 months and then at M 9 and M12 
8 To be performed until disease relapse or progression 
9 To be performed immediately before the 1st infusion and monthly starting from the first HSV-Tk infusion up to 6 months from last 
administration  
10To be performed immediately before the 1st infusion and at 3-6-12 months after first TK infusion and then yearly for 5 years 
11 To be assessed every 6 months after the first year from HCT or after disease relapse/progression 
 
 
 

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7  Pharmaeconomics 
An exploratory pharmacoeconomic analyses will be performed on medical care utilization (MCU). 
The objective will be to summarize and evaluate treatment group differences in total resource use, 
and more specifically, in resource use associated with diagnosis, monitoring and treatment of relevant 
events (i.e., acute and chronic GvHD, infectious episodes, etc.). 
Pharmacoeconomic data may be combined with other data such as cost data or other clinical 
parameters in the production of a final pharmacoeconomic report. 
The analysis and reporting of resource use data will be handled separately from the clinical study 
report. 
 

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8 Response evaluation criteria in Acute Leukaemia 
Response to treatment will be assessed according to standard international criteria24,33. 
Evaluation of disease status will be performed accordingly to the schedule reported in Chapter 6. 
For the assessment of outcome, relapse is defined as bone marrow blasts ≥ 5%; or reappearance of 
blasts in the blood; or development of extramedullary disease. In cases with low percentages (5-10%), 
a repeat marrow should be performed to confirm relapse. Relapse will be evaluated and classified for 
each patient by Investigator.  

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9 Statistical considerations 
9.1 Statistical design 
This is a randomized (with a 3:1 allocation experimental group: control group), 2-arm, open-label, 
multicenter, multinational, phase III study. 
The unbalanced randomization has been chosen in order to enhance the safety database and also to 
make the study more attractive to patients and/or investigators (ICH E10 “Choice of Control Group 
in Clinical Trials, CPMP/ICH/364/96”). 
Eligible patients who provided the informed consent to participate into the study will be randomly 
assigned to the either treatment strategy before HCT, through a centralized randomization process 
using the following stratification factors: status of the disease at the time of transplantation (first or 
subsequent complete remission or relapse), ECOG performance status (0 or 1) and country. Random 
lists, balanced within each stratum in blocks of varying size in random sequence, will be prepared 
and kept at the Study Coordination Center in MolMed headquarter.  
The study will be conducted according to GCP, and will undergo formal monitoring. 
All randomised patients will be followed until death or study closure, whichever first. 
The primary endpoint of the study is disease-free survival (DFS), which allows to assess all the 
potential effects of the experimental treatment on patients’ outcome, including infectious mortality, 
GVHD-related mortality, as well as incidence of relapse.  
9.2 Study endpoints 
 Primary endpoint: Disease-free survival (DFS) 
The primary endpoint of the study is disease-free survival (event-free survival, EFS) that will be 
measured for all patients from the date of randomization (regardless of disease status at HCT) until 
the date of relapse (or progression), or death from any cause, whichever occurs first. 
Patients without an event will be censored at the last time known to be alive and free of relapse. 
Patients without any follow-up information will be censored at the date of randomization. 
  Secondary endpoints 
a. Overall Survival (OS) will be measured for all patients from the date of randomization until death 
from any cause. Patients without any follow-up information will be censored at the time of 
randomization. Patients alive and lost to follow-up before study closure will be followed by phone 
contacts and by contacting census offices for assessing their vital status at study closure. In case 
of failure, they will be censored at the last follow-up examination, but reported and analysed for 
possible biases. 
b. Non-relapse mortality (NRM) will be defined for all patients as any death without previous 
occurrence of a documented relapse (or progression), which is a competing event. Patients alive 
without relapse (or progression) will be censored at last contact. 
c. Chronic GvHD-free/relapse-free survival (GRFS) defined as the time from the date of 
randomization to chronic GvHD, relapse/progression or death from any cause, whichever occurs 
first.  
d. Time to immune reconstitution (IR) will be defined as the time to reach a level of circulating 
CD3+ ≥ 100/μl for two consecutive observations, starting from the date (study day 0) of 
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e. Engraftment will be defined as the persistent blood cells count above a predefined level (ANC ≥ 
1x109/L per 3 consecutive days with evidence of donor haematopoiesis; platelets ≥ 50x109/L, 
unsupported by transfusions, for 7 days), and is computed from the date (day 0) of transplantation 
f. Cumulative incidence of grade 2, 3, or 4 acute GVHD (aGvHD), diagnosed and graded according 
to standard criteria, will be computed from the date (study day 0) of transplantation. 
g. Cumulative incidence of chronic GvHD (cGvHD) diagnosed and graded according to standard 
NIH consensus criteria, will be computed from the date (study day 0) of transplantation. 
h. Duration of GvHD episodes computed from the date of start to the date of resolution and duration 
of immunosuppressive treatments administered for controlling GvHD. 
i. Cumulative incidence of relapse (CIR) will be defined on the basis of morphologic evidence of 
leukaemia in bone marrow or other sites. The events are relapses (or progressions). Patients alive 
without relapse (or progression) will be censored at last contact. Death without experiencing a 
relapse (or progression) will be considered as competing event. 
 
Safety: all safety parameters will be analysed and presented in terms of listings and summary tables. 
Adverse events and laboratory parameters will be assessed according to the CTC-AE v4.02.  
Adverse events will be displayed in standard frequency tables. 
For laboratory parameters, descriptive summary tables of change from day 21 over time based on SI 
units will be produced. Summary tables of the worst grades according to CTC-AE v4.02 observed 
during the treatment will be presented.  
Descriptive summary tables of change from day 21 over time will be provided for vital signs 
parameters. 
 
A summary of the criteria to define the outcomes in survival analysis is listed in the following table: 
Table 2. 
Summary of the criteria to define the outcomes in survival analysis 
 
Outcome 
Event 
Censored cases 
Competing events 
Population
Disease-free 
survival 
Relapse  
(or progression) or 
death regardless of 
cause 
Patients alive without 
relapse  
(or progression) at last 
contact 
- 
All 
patients 
Overall survival Death regardless of 
cause 
Patients alive at last 
contact 
- 
All 
patients 
Cumulative 
incidence 
of 
relapse  
Relapse  
(or progression) 
Patients alive without 
relapse  
(or progression)  
at last contact 
Death 
without 
evidence of relapse 
(or progression) 
All 
patients 
Non-relapse 
mortality 
Death 
without 
previous relapse  
(or progression) 
Patients alive without 
relapse  
(or progression)  
at last contact 
Relapse  
(or progression) 
All 
patients 
GRFS 
Chronic 
GvHD, 
relaps 
(or 
progression) or death 
regardless of cause 
Patients alive without 
chronic 
GvHD 
or 
relapse  
(or progression) at last 
contact 
- 
All 
patients 

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Engraftment 
Persistent blood cells 
counts 
above 
the 
predefined level 
Patient alive with no 
recovery at last follow-
up 
Death and relapse (or 
progression) before 
recovery  
All 
patients 
Time to immune 
reconstitution 
Persistent CD3+ cells 
above the predefined 
level 
Patient alive with no 
recovery at last follow-
up 
Death and relapse (or 
progression)  before 
recovery 
All 
patients 
Acute GvHD 
aGvHD 
Patient alive with no 
occurrence of aGvHD 
Death and relapse (or 
progression)  without 
aGvHD 
All 
patients 
Chronic GvHD 
cGvHD 
Patient alive with no 
occurrence of cGvHD 
Death and relapse (or 
progression)  without 
cGvHD 
All 
patients 
 
9.3 Statistical analyses 
The primary study analysis will be based on the Intention To Treat (ITT) approach, in that all 
randomised patients, regardless of their eligibility and compliance to the assigned treatment and to 
the follow-up protocol will be included in the analyses and considered in the group assigned at 
randomization. For explorative purpose, efficacy analyses will be repeated on the Standard 
Population (STDP) that includes all randomised patients who have received at least one haploidentical 
HCT. 
 Primary study analyses 
The log-rank test will be used to compare disease-free survival (DFS) in the two treatment arms with 
stratification for ECOG PS and disease status at randomization. The choice of not including the other 
randomization stratification factor, i.e. country, among the analysis stratification factor is dictated by 
the risk of a loss of power, since the primary endpoint is a time-to-event variable, and the number of 
strata for a fully stratified analysis would be rather large when compared to the number of the enrolled 
patients. Kaplan-Meier curves will be displayed and 1-year DFS with confidence limits will be given. 
Cox regression analyses will be performed. Covariates included in these analyses will be, among 
others, age, gender, disease, ECOG PS, disease status at randomization and country.  
 Secondary analyses 
Overall survival (OS) curves will be estimated by the Kaplan-Meyer method and compared using the 
log-rank test. 
In order to take into account the plausible lack of independence between non-relapse mortality (NRM) 
and cumulative incidence of relapse (CIR), a standard competing risks analysis will be performed, 
where the cumulative incidence of events, computed as 1-cumulative Kaplan Meier curve, will be 
partitioned into its components, the crude cumulative incidence of non-relapse mortality and the crude 
cumulative incidence of relapse. The Gray test34 will be used to compare the sub-distribution 
functions of the two competing events in the two treatment groups. 
Time to immune reconstitution, incidence of acute GvHD, chronic GvHD and GvHD resolved with 
immunosuppressive agents and incidence of engraftment will be compared in two groups by means 
of five separate competing risk analyses. In each of these analyses, the competing events will be death 
and relapse before the event of interest. The Gray test will be used to compare the distribution of 
events of interest in two treatment arms. 

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9.4 Sample size 
The primary study endpoint is disease-free survival (DFS). The 1-year DFS following standard 
haploidentical HCT (with either infusion of CD34+ cells plus a dose of T cells (approximately 
1x104/Kg) or unmanipulated bone marrow or peripheral blood transplantation followed by high-dose 
cyclophosphamide) reported in the available studies averages at approximately 30%, and this figure 
can be used as a reasonable estimate of the cumulative incidence of DFS expected in the control group 
of the present study. The estimated 1-year DFS in the phase II study (TK007) evaluating the add back 
of HSV-Tk donor lymphocytes strategy was 52%, corresponding to a hazard ratio (HR) of 0.55, when 
compared to historical controls. In order to detect with α=0.05 (2-sided) and β=0.20 a hazard ratio of 
0.55, 96 events (relapses or deaths) need to be observed in the 2 groups combined. To this aim, 170 
patients (127 in experimental arm and 43 in control arm) need to be enrolled and followed for at least 
one year. 
 
 

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10 Safety 
10.1 Definitions 
An Adverse Event (AE) is any untoward medical occurrence in a patient or clinical investigation 
subject administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment. An adverse event (AE) can therefore be any unfavourable and 
unintended sign (including an abnormal laboratory finding, for example), symptom, or disease absent 
before day 21 and temporally associated with the use of the medicinal product, whether or not 
considered related to the medicinal product.  
 
Any event that was present before day 21 and that remains unchanged or improved should not be 
recorded as an AE. If the event gets worse on day 21, this should be considered an AE. 
 
An Adverse Drug Reaction (ADR) is any untoward and unintended response to an investigational 
medicinal product related to any dose administered. 
 
An Unexpected Adverse Drug Reaction is any adverse reaction, the nature or severity of which is 
not consistent with the applicable product information (e.g. Investigator’s Brochure). 
 
A Serious Adverse Event (SAE) or a Serious Adverse Drug Reaction (SADR) is any untoward 
medical occurrence that at any dose: 
 results in death 
 is life-threatening 
 requires inpatient hospitalization or prolongation of existing hospitalization 
 results in persistent or significant disability or incapacity 
 is a congenital anomaly or birth defect 
 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately life-
threatening or result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the outcomes listed in the definitions above. These situations should 
also usually be considered Serious Adverse Events. 
Any clinically significant laboratory test value that meets the definition of a SAE must be reported as 
a SAE. 
10.2 Criteria of evaluation 
All adverse events will be recorded according to CTC version 4.02 (CTC reference: 
http://ctep.cancer.gov/reporting/ctc.html) on the case report forms (CRFs); the investigator will 
decide if those events are drug related and his/her decision will be recorded on the forms for all 
adverse events. The grading of acute and chronic GvHD are reported in Appendix C and D, 
respectively. 
The adverse events not listed on the NCI CTC grading system will be graded on a five points scale 
and reported in detail on the CRF, as indicated: 
 
 

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Mild = Grade 1 
Discomfort noticed but no disruption of normal daily activity 
Moderate = Grade 2 
Discomfort sufficient to reduce or affect daily activity 
Severe = Grade 3 
Inability to work or perform normal daily activity 
Life-threatening = Grade 4 
Represents an immediate threat of life 
Death = Grade 5 
Death related to the adverse event 
 
Relationship of the adverse event to the treatment should also be assessed using the foreseen 
categories for determining relationship: 
 
Not related 
The adverse event is clearly not related to the investigational product or 
HCT  
Related to HSV-Tk 
The adverse event is clearly related to the investigational product 
Related to HCT  
The adverse event is clearly related to HCT  
Unknown 
This category should be used when it is difficult to strongly appoint if 
the adverse event is drug related or not, or information about it is 
unavailable, missing or incomplete 
 
10.3 Reporting procedures 
 Adverse events 
All AEs will be collected from day 21 through day 180 or at least 30 days after last dose of HSV-Tk, 
whichever will be longer. 
In case of HSV-Tk infusion before day 21, AEs have to be collected from the day of first infusion 
through day 180 (or at least 30 days after last infusion, whichever is longer). 
Hematological and biochemical adverse event have to be reported, unless investigator consider them 
not clinically significant. 
After disease relapse, AE collection will be stopped (except for AE related or patients in arm A, for 
whom the AE collection have to be continued until 30 days after last HSV-Tk infusion). 
 Serious Adverse Events 
Only unexpected Serious Adverse Events (SAEs) and study endpoints (graft failure/rejection, disease 
relapse, grade II-IV acute and all chronic GvHD, death) will be collected from HCT to day 21 (as 
SAEs). 
From day 21 through day 180, all SAEs and study endpoints (to be reported as SAEs) will be 
collected. 
Only related SAEs and study endpoints will be collected (as SAE) from day 181 (or 30 days after last 
infusion of HSV-Tk) through end of study (i.e. end of long term follow-up). 
All grades 3-5 infusion reactions, late graft rejection and grades 3-4 acute GvHD will be reported in 
an expedited fashion in addition to the unexpected SAEs. 
After disease relapse, SAE collection will be stopped (except for patients in arm A, for whom the 
SAE collection have to be continued until 30 days after last HSV-Tk infusion) and only related SAEs 
and deaths will be collected (as SAEs) through end of study. 
 
All the SAE must be reported to MolMed S.p.A. within 24 hours of the initial observation of the 
event. 
This must be done by faxing or emailing a specific SAE form to the following address: 

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Antonio Lambiase, MD  
Qualified Person for PharmacoVigilance  
(QPPV) 
Phone +39 02 21277 232 
Mobile +39 334 6694051 
Fax +39 02 21277 239 
E-mail safety@molmed.com  
 
It is the responsibility of the investigators to promptly send a safety report to the Ethics Committee 
according to the local regulation. 
 
Hospitalization for elective treatment of a pre-existing condition, including also the administration of 
therapy for CMV infections, should NOT be reported as AE/SAE unless worsening or complications. 
 
It should be recognized that Serious Adverse Drug Reactions (SADR) which have not been previously 
documented in the Investigator’s Brochure, or which occur in a more severe form than anticipated 
(i.e. they are “unexpected” by nature or severity), are subject to rapid reporting to the Regulatory 
Authorities by the Sponsor.  
10.4 Procedures to be followed in the event of pregnancy 
If a female patient or the partner of a male patient becomes pregnant during the active treatment phase 
or within 6 months from discontinuation of the study drug, she/he must immediately inform the 
investigator. 
In case of pregnancy the female patient will be withdrawn from the active treatment. 
The investigator should report the event of pregnancy within 24 hours to the Sponsor, using the form 
for Serious Adverse Events and the additional specific form (Clinical Trial Pregnancy Follow up 
Reporting Form). 
The investigator should counsel the patient and discuss the risk of continuing with pregnancy and the 
possible effects on the fetus. The patient will be monitored until the conclusion of the pregnancy. 
10.5 Risk management plan 
As part of the Conditional Marketing Authorisation (CMA) granted in August 2016, by the 
European 
Medicines 
Agency 
(EMA) 
for 
the 
medicinal 
product 
(www.ema.europa.eu/EPAR/Zalmoxis), the following events have been classified as important 
identified risks: GvHD, severe systemic infection, CMV and EBV reactivation, febrile neutropenia, 
hepatic failure, concomitant administration of ganciclovir/valganciclovir; while the following 
events have been classified as important potential risks: concomitant immunosuppressive therapy, 
development of RCR, carcinogenicity, genotoxicity, late complications as malignancies or 
autoimmunity, immunological events (antibody formation), DMSO-related side effects, local and 
systemic donor reaction and failure of GvHD treatment with ganciclovir. 
 RCR 
It is well known that lymphocytes can be efficiently transduced by retroviral vectors. A number of 
different retroviral vectors based on the Moloney Murine Leukaemia Virus (MolMLV) backbone 
have been engineered and used in gene transfer into human hematopoietic cells. Although vectors are 

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designed to be replication defective, recombination events during vector production could lead to the 
generation of replication competent retroviruses (RCR). While replication defective vector carry risk, 
the risk of insertional mutagenesis is believed to be greater if RCR is present, since ongoing viral 
infection is likely to result in a much greater number of insertional events. Data obtained in primates 
have demonstrated RCR contaminating retroviral vector preparations could cause malignancy, but 
tumours may develop only in primates that are very immunodepressed35,36 .The technologies available 
today for the RCR monitoring in both the packaging cell lines and the ex vivo engineered tissues 
allow for a very effective quality control for RCR presence, thus virtually eliminating this risk even 
in immunodepressed patients. The clinical trials performed-up to now using engineered lymphocytes 
via retroviral vectors have never recorded any toxic reactions or side effects due to the retroviral 
vector, the engineering procedure or the exogenous protein.  
RCR arises by recombination between the vector and viral genes, and was frequently detected in early 
versions of vector packaging cell lines in which all the viral genes (gag/pol/env) were expressed from 
a single plasmid. By segregating gag-pol and env genes onto separate plasmids and minimizing 
homology between vector and packaging sequences, the rate of RCR development has been 
substantially decreased, but not eliminated.  
In addition, the marked decrease in RCR generation resulting from decreased homologous 
recombination has resulted in rare recombination between vector and cellular sequences leading to 
RCR, or rescue of endogenous viruses especially when murine-based packaging cell lines are utilized. 
To date, there have been no documented exposures of patients treated with gene therapy to RCR. The 
clinical trials performed up to now using engineered lymphocytes via retroviral vectors have never 
recorded any toxic reactions or side effects due to the retroviral vector, the engineering procedure or 
the exogenous protein (except for lymphocytes expressing TCR and CAR)37,38. HSV-Tk cells 
infusion have shown to not to affect biological and function of transplanted T cells39. Analysis of 102 
independent transductions of human peripheral lymphocytes with two different vectors (SFCMM-3 
and SFCM) encoding the same HSV-Tk and ΔLNGFR detected no change in the expression of 
markers of lineage, activation or adhesion, or in the proliferative capacity of T cells, as assayed by 
limiting dilution after polyclonal in vitro stimulation. All cells remained strictly dependent on IL-2 
for growth and survival, and the addition of potentially stimulatory doses of 50- 100 ng/ml of nerve 
growth factor did not induce cell proliferation, expression of the CD25 activation marker or secretion 
of tumor necrosis factor, thus providing direct evidence that ΔLNGFR is a safe and inert gene marker 
for T lymphocytes even in the presence of high concentrations of the ligand. Most importantly, no 
toxicity or other adverse effects have been associated with the clinical use of HSV-Tk and ΔLNGFR. 
Treatment of 31 patients with donor lymphocytes transduced with two different vectors (SFCMM-2 
or SFCMM-3) encoding the same HSV-Tk and ΔLNGFR resulted in engraftment (up to 40% of 
circulating mononuclear cells) and long-term persistence (>80 months) of transduced cells. No acute 
or chronic adverse or toxic events related to the gene transfer procedure or to transgene expression 
were observed during these trials, which involved infusion of >1011 cells generated by >50 
independent transductions.40 The HSV-Tk and ΔLNGFR therapeutic approach utilizes donor 
lymphocytes that are also equipped with an efficient suicide system, and no evidence of insertional 
oncogenesis has been recorded over long-term clinical experience with HSV-Tk-treated lymphocytes. 
In case of one or more positive samples collected for the study, the case(s) will be considered a 
SUSAR and therefore subject to rapid reporting to the Regulatory Authorities by the Sponsor. 
 Safety monitoring 
The safety will be monitored during the study according to the following schedule: 

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Blood and chemistry examination (for all patient) at day 15 of 1st month, monthly for 6 months 
(±2 days) and then at month 9 (±2 days)  and 12 (±2 days) after HCT. The examination foresees: 
AST, ALT, γGT, total bilirubine, LDH, WBC (with formula), RBC, platelets, Hb, Hct, MCV, 
MPV, creatinine, CMV PCR or antigenemia). Exception will be made for the 1st examination 
after HCT that will be performed as indicated in the screening phase (for details see § 6.1.2).  
RCR test (for patients in Arm A only) at baseline (i.e. immediately before 1st HSV-Tk infusion), 
3 months, 6 months and 1 year after 1st HSV-Tk infusion, and then yearly for at least 5 years (for 
details see § 6.4.2). 
Long term follow-up (for details see § 10.5.4). 
 RCR monitoring during manufacturing 
RCR may develop at any step during manufacturing from development of the initial master cell bank 
through production of the retroviral vector supernatant. In addition, the growth of ex vivo transduced 
cells provides the potential for amplification of any RCR contaminant which may be below the level 
of detection in the retroviral vector supernatant.  
The RCR test should be performed at the following time point: 
- 
Vector Producer Cell Master Cell Banks (one time testing): both Vector Producer Cells and 
the culture are tested by a cultural RCR assay. 
- 
Testing of Retroviral Vector Supernatant Product and End of Production Cells are tested by a 
cultural RCR assay 
- 
Ex-vivo Transduced lymphocytes, which according to the manufacturing protocol  are 
cultured for more than 4 days, are tested by a molecular RCR assay. (Supplemental Guidance 
on Testing for Replication Competent Retrovirus in Retroviral Vector Based Gene Therapy 
Products and During Follow-up of Patients in Clinical Trials Using Retroviral Vectors FDA 
Guidelines-11.2006). 
 Long term follow-up after HSV-Tk treatment 
This study foresees a long term follow-up period of 15 years after the first year from HCT, as follows: 
- 
Every year a general health evaluation, including new/recurrent malignancies, neurologic 
disorders, hematologic disorders, autoimmune disorders, unexpected medical problems and 
hospitalizations, will be collected by a specific questionnaire (see appendix K)  
- 
For the first 5 year a blood sample for RCR test will be collected from patients treated with 
HSV-Tk cells, as specified in section 6.4.2. 
- 
The long term follow up of patients treated with HSV-Tk cells has the aim to detect early or 
delayed signals of adverse reactions, to prevent clinical consequences of such reactions and 
to ensure timely treatment and to gain information on the long-term safety of the treatment. 
For these reasons, also patients, who have interrupted the treatment, the long term follow up 
should be maintained, as well as, every efforts should be done for patients withdrew from the 
study, subject to the consent of the subject. Patient alert cards that inform treating physicians 
about the product used will be provided to patients. These alert cards, which should have been 
previously approved by the Ethics Committee, should contain as minimum the name of the 
patient, the investigator contact number and information regarding the medical treatment 
received.    
 

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11 Ethics and General study administration 
11.1 Ethical aspects 
The responsible investigator will ensure that this study is conducted in full conformance with either 
the principles of the "Declaration of Helsinki" (as amended in Tokyo, Venice, Hong Kong, South 
Africa, Edinburgh, Seoul and Fortaleza) or the laws and regulations of the country in which the study 
was conducted, whichever affords the greater protection to the individual.  
The protocol has been written and the study will be conducted in conformity to the "Guideline for 
Good Clinical Practice" (recommended for adoption at step 4 of the ICH process on 1 May 1996 and 
on 10 June 1996 by the ICH Steering Committee and acknowledged as ministerial decree, on 15 July 
1997, by the Italian Ministry of Health) and “Detailed guidelines on good clinical practice specific to 
advanced therapy medicinal products”. 
11.2 Independent Ethics Committees/Institutional Review Board 
This protocol and any accompanying material provided to the subject, such as subject information 
sheets or descriptions of the study used to obtain informed consent, will be submitted by the 
investigator to an Ethics Committee. 
Approval from the Committee must be obtained before starting the study and should be documented 
in a letter to the investigator specifying the date on which the Committee met and granted the 
approval. 
Any modifications made to the protocol after receipt of the Independent Ethics Committee approval 
must also be submitted by the Sponsor to the Committee in accordance with local procedures and 
regulatory requirements. 
When no local review board exists, the Sponsor is expected to submit the protocol to a regional 
committee. 
11.3 Informed consent 
All patients and donors will be informed of the aims of the study, the possible adverse events, the 
procedures and possible hazards to which he/she will be exposed, and the mechanism of treatment 
allocation. They will be informed as to the strict confidentiality of their patient data, but that their 
medical records may be reviewed for trial purposes by authorized individuals other than their treating 
physician. 
It will be emphasized that the participation is voluntary and that the patient is allowed to refuse further 
participation in the protocol whenever he/she wants. This will not prejudice the patient’s subsequent 
care. 
It is responsibility of the investigator or a person designated by the investigator (if acceptable by local 
regulations) to obtain written informed consent from each subject participating in this study before 
his/her registration in the trial. 
For patients and donor unable to read and write, impartial witnesses should be present during the 
entire informed consent discussion. After the subject and representative have orally consented to 
participation in the trial, the witness’ signature on the form will attest that the information in the 
consent form was accurately explained and understood. 
In the case of a minor donor (<18 years), parents or legal representatives must give permission by 
signing a specific informed consent form and according to local laws.  
If new safety information results in significant changes in the risk/benefit assessment, the consent 
form is reviewed and approved, if necessary. All patients, including those already being treated, 

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should be informed of the new information and give their consent to continue the study after receiving 
a copy of the revised informed consent form. 
11.4 Conditions for modifying the protocol 
All protocol modifications must be submitted to the appropriate regulatory agencies: Ethics 
Committee (EC/IRB) and Competent Agency (CA) in accordance with local requirements. Approval 
must be awaited before any changes can be implemented except for changes necessary to eliminate 
an immediate hazard to trial subjects or when the change(s) involve only logistical or administrative 
aspect of the trial (change in monitor, change in telephone-fax number). 
11.5 Conditions for terminating the study 
Both the Sponsor and the investigator reserve the right to terminate the study at any time.  
If this should be necessary, both parties will arrange the procedures on an individual study basis after 
review and consultation. In terminating the study MolMed and the investigators will assure that 
adequate consideration is given to the protection of the patient’s interest. 
11.6 Study documentation: CRF and record keeping 
The investigator must maintain adequate and accurate records to enable the conduct of the study to 
be fully documented and the study data to be subsequently verified. These documents should be 
classified into 2 different categories: 
1. Investigator’s study file 
2. Subject clinical source documents 
The investigators’ study file will contain the protocol/amendments, CRF (Case Report Form) and 
query forms, regulatory approvals (EC/IRB and CA) with correspondence, sample of informed 
consent, drug/product records, staff CVs and authorization forms and other appropriate 
documents/correspondence. 
Subject clinical source documents would include patient hospital/clinic records, physician’s and nurse 
notes, appointment book, original laboratory reports, ECG, EEG, x-ray, pathology and special 
assessment reports, signed informed consent forms, consultant letters and subject screening and 
enrolments logs.  
All traceability records should be kept for a minimum of 30 years after the end of study by each party: 
lymphocytoapheresis establishments/procurement, manufacturer, Sponsor and investigator/clinical 
site, as outlined in the annex of “Detailed guidelines on good clinical practice specific to advanced 
therapy medicinal products” and in Regulation 1394/2007   
After that period of time the documents may be destroyed, subject to local regulations and sponsor 
agreement. 
Should the investigator cannot guarantee this archiving requirement at the investigational site for any 
or all the documents special arrangements must be made between the investigator and MolMed to 
store these in a sealed container outside of the site so that they can be returned sealed to the 
investigator in case of regulatory audit where source documents are required for the continued care 
of the patient appropriate copies should be made for storing outside of the site. 
Unless other local law requires archiving for a longer period, the Sponsor and the investigator shall 
archive the content of the clinical trial master file for at least 25 years after the end of the clinical 
trial. However, the medical files of subjects shall be archived in accordance with national laws 
 

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11.7 Source documents and background data 
The investigator shall supply the Sponsor on request with any required background data from the 
study documentation or clinic records. In case of special problems and/or governmental queries or 
request for audit inspections it is also necessary to have access to the complete study records provided 
that patient/donor confidentiality is protected. 
11.8 Audits and inspections 
The investigator should understand that source documents for this trial should be made available to 
appropriately qualified personnel from MolMed or its designees or to health authorities. 
11.9 Case Report Forms 
For each patient enrolled an electronic  case report form (eCRF) must be completed and signed by 
the principal investigator or one of his/her authorized staff members. 
This also applies to records for those patients who fail to complete the study. If a patient withdraws 
from the study the reason must be noted on the CRF. 
If a patient is withdrawn from the study because of a treatment limiting adverse event thorough efforts 
should be made to clearly document the outcome. 
The investigator should ensure the accuracy, the consistency with source data. It’s recommended to 
fill in the eCRF on an ongoing basis and submit the data no later than 7 working days after a patient’s 
last visit. Manuals on eCRF use and data collection are available on website of eCRF. 
11.10 Monitoring the study 
It is understood that the responsible MolMed monitor or designee will contact and visit the 
investigator regularly and will be allowed on request to inspect the various records of the trial 
provided that patient confidentiality is maintained in accord with local requirements. 
It will be the monitor’s responsibility to inspect the CRFs at regular intervals throughout the study to 
verify the adherence to the protocol and the completeness, consistency and accuracy of the data being 
entered on them. 
The monitor should have access to laboratory test reports and other patient/donor records needed to 
verify the entries on the CRF. 
The investigator agrees to cooperate with the monitor to ensure that any problems detected in the 
course of these monitoring visits are resolved. 
The end of the study corresponds to the date of the last close-out visit in the last center. 
11.11 Confidentiality of trial documents and subject records 
The investigator must assure that subjects’ anonymity will be maintained and that their identities are 
protected from unauthorized parties. On CRFs or other documents submitted to the sponsor subjects 
should not be identified by their names but by an identification code and fake initials . The investigator 
should keep a subject enrolment log showing codes names. The investigator should maintain 
documents not for submission to MolMed (e.g. written informed consent) in strict confidence. 
11.12 Publication of data and protection of trade secrets 
The results of this study may be published or presented at scientific meetings. In this case the 
investigator agrees to discuss all manuscript or abstract with MolMed prior to submission. 

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This allows the Sponsor to protect proprietary information and to provide comments based on 
information from other studies that may not be yet available to the investigator. 
In accord with standard editorial and ethical practice MolMed will generally support publication of 
multicentric trials only in their entirety and not as individual centre data. Authorship will be 
determined by mutual agreement. 
 

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Fowler, D. H., J. Breglio, et al. Allospecific CD8+ Tc1 and Tc2 populations in graft-versus-
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Ciceri F, Bonini C, Lupo Stanghellini MT, et al. Infusion of suicide-gene-engineered donor 
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Breems DA, Van Putten WL, Huijgens PC, et al. Prognostic index for adult patients with acute 
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Thomas ED. Karnofsky Memorial Lecture: Marrow transplantation for hematological 
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O'Reilly RJ. Allogeneic BMT: current status and future directions. Blood. 1983;62:941-964. 
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Ciceri F, M. Labopin, F. Aversa, et al. A survey of fully haploidentical hematopoietic stem 
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Porter DL, Collins RH, Jr., Hardy C, et al. Treatment of relapsed leukaemia after unrelated 
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Bonini C, Ciceri F, Marktel S, Bordignon C. Suicide-gene-transduced T-cells for the 
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Bonini C, Grez M, Traversari C, et al. Safety of retroviral gene marking with a truncated NGF 
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Ciceri F, Bordignon C. Suicide-gene-Transduced donor T-cells for controlled graft-versus-
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donor lymphocytes provide immune reconstitution after haplo-identical stem cell transplantation. 
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Cheson B et al. Revised Recommendation of the International Working Group for Diagnosis, 
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Gokbuget N and Hoelzer D. Treatment of Adult Acute Lymphoblastic Leukemia. Seminar in 
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Hahn T, Wall D, Camitta B et al. The role of cytotoxic therapy with hematopoietic stem cell 
transplantation in the therapy of Acute Lymphoblastic Leukemia in adults: an evidence-based review. 
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P Ljungman, A Urbano-Ispizua, M Cavazzana-Calvo et al. Allogeneic and autologous 
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Dirnhofer S, Went P, Tichelli A. Diagnostic problems in follow-up bone marrow biopsies of 
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Lazarus HM and Luger S. Which Patients with Adult Acute Lymphoblastic Leukemia Should 
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Hoelzer D and Gokbuget N. I17 Treatment of acute lymphoblastic leukemia in adults. Blood 
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Bassan R, Gatta G, Tondini C and Willemze R.  Adult acute lymphoblastic leukaemia. Critical 
Reviews in Oncology / Hematology June 2004 (Vol. 50); Issue 3: 223-61. 
32. 
Bachanova V and Weisdorf D. Unrelated donor allogeneic transplantation for adult acute 
lymphoblastic leukemia: a review. Bone Marrow Transplantation 2008; 455-464. 
33. 
Dohner H, Estey E, et al. Diagnosis and management of AML in adults: 2017 ELN 
recommendations from an international expert panel. Blood. 2017;129(4):424-447 
34.     Gray RJ. A class of k-sample tests for comparing the cumulative incidence of a competing risk. 
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35.     Cornetta, K., Nguyen, N., Morgan, R.A., Muenchau, D.D., Hartley, J., and Anderson, W.F. 
(1993) Infection of human cells with murine amphotropic replication-competent retroviruses . Hum 
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36.     Donahue, R.E., Kessler, S.W., Bodine, D., McDonagh, K., Dunba , C., Goodman, D., et-al. 
(1992) Helper virus induction T cell lymphoma in nonhuman primates after retroviral mediated gene 
transfer. J Exp Med 176 ,1125–1135). 
37.  Sastry L. et al. Detection of replication competent retrovirus and lentivirus. Methods in Molecular 
Biology, Methods and Protocols, vol. 506, LLC 2009;  
38.    Bonini C et al. HSV-Tk gene transfer into donor lymphocytes for control of allogeneic graft-
versus-leukemia. Science Jun 13;276(5319):1719-241;1997). 
39.  Recchia A. et al Retroviral vector integration deregulates gene expression but has no consequence 
on the biology and function of transplanted T cells. Proc Natl Acad Sci U S A. 2006 Jan 
31;103(5):1457-62). 

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40.   Marktel et al. Immunologic potential of donor lymphocytes expressing a suicide gene for early 
immune reconstitution after hematopoietic T-cell-depleted stem cell transplantation. Blood. 2003 Feb 
15;101(4):1290-8) 
41.  Luznik et al. HLA-haploidentical bone marrow transplantation for hematologic malignancies 
using nonmyeloablative conditioning and high-dose, post-transplantation cyclophosphamide. 
Biology of Blood and Marrow Transplantation 2008 14:641-650  
 
 
 

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Appendix A: Suggested conditioning regimens 
 
REDUCED TOXICITY CONDITIONING REGIMEN* 
Drug  
Dose  
Timing 
Treosulfan 
14 g/sqm iv 
days -6 to -4 
Fludarabine 
30 mg/sqm/die iv  
days -6 to -2 
ATG-Thymoglobuline ® 
ATG-Fresenius 
2.5 mg/kg/die OR                      
10 mg/kg/die iv ** 
 
days -5 to -2 
days -4 to -2 
Rituximab 
500 mg iv 
 
day -1 
TBI 
200 cGy, single fraction 
day 0 
*For non-US centers only.** If ATG Fresenius® is approved in the country
 
 
TOTAL BODY IRRADIATION (TBI) CONTAINING REGIMEN 
Drug  
Dose  
Timing 
TBI 
7.5 Gy delivered in a single fraction OR 
2 Gy twice daily  
day -9 
days -8, -7, -6 
Thiotepa 
10 mg/kg iv, divided in two 4 hours infusions (5 
mg/kg/q12h) 
day -8 
Fludarabine 
40 mg/sqm/die iv 
day -7 > -3 
ATG-Thymoglobuline ® 
1. ATG-Fresenius 
2.5 mg/kg/die OR                      
10 mg/kg/die iv ** 
 
days -5 to -2 
days -4 to -2 
Rest 
- 
day –1 
** If ATG Fresenius® is approved in the country
 
 
REDUCED INTENSITY CONDITIONING REGIMEN WITHOUT TBI 
Drug  
Dose  
Timing 
Melphalan 
140 mg/sqm iv 
days -9 
Thiotepa 
13 mg/kg iv, divided in two infusions (6.5 mg/kg/q12h) 
days -8 
Fludarabine 
40 mg/sqm/die iv 
day -7 > -3 
ATG-Thymoglobuline ® 
2. ATG-Fresenius 
2.5 mg/kg/die OR                      
10 mg/kg/die iv ** 
 
days -5 to -2 
days -4 to -2 
Rest 
- 
day –1 
** If ATG Fresenius® is approved in the country
 
REDUCED-INTENSITY CONDITIONING REGIMEN WITH HIGH-DOSE, POST HCT 
CYCLOPHOSPHAMIDE 
Drug  
Dose  
Timing 
Cyclophosphamide  
14.5 mg/kg/die 
days -6 and -5 
Fludarabine 
30 mg/sqm/die iv 
days -6 to -2 
TBI 
2 Gy 
day –1 
 
 
 

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 MYELOABLATIVE CONDITIONING REGIMEN WITH HIGH-DOSE, POST HCT 
CYCLOPHOSPHAMIDE 
Drug  
Dose  
Timing 
Busulfan 
110 mg/sqm 
days -7 and -4 
Cyclophosphamide  
14.5 mg/kg/die 
days -3 and -2 
Fludarabine 
25 mg/sqm/die iv 
days -6 to -2 
 
 
 

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Appendix B: Tests for Donor Lymphocytoaphaeresis collection (Arm A) 
 
The following tests have to be performed within 30 days before lymphocytoaphaeresis collection: 
 
Test* 
Anti-HCV Antibody (Ab) 
HCV RNA (NAT1) 
HIV 1-2 p24 AB and Ag 
HIV RNA (NAT1) 
Anti Treponema Pallidum (Total Ig) - Non specific test  
In the case of positive result perform specific test 
Anti Treponema Pallidum - Specific Test (if applicable) 
AUSTRALIA HBsAg 
Total anti HB core Ab 
In the case of positive result perform HBV DNA (NAT1) 
HBV DNA (NAT1) 
Anti-Mycoplasma IgM 
HTLV I 
HTLV II 
West Nile Virus** 
* according to 2006/17/EC;   ** for US sites only 
 
 
 

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Appendix C: Acute GvHD grading 
* Use “Rule of Nines” or burn chart to determine extent of rash 
** Range given as total bilirubin. Downgrade one stage if an additional cause of elevated bilirubin has been documented 
# Downgrade one stage if an additional cause of diarrhoea has been documented  
§ Persistent nausea with histologic evidence of GvHD in the stomach or duodenum 
 
 
GRADE 
SKIN 
LIVER 
GASTROINTESTINAL 
1 
Stage 1-2 
none 
None 
2 
Stage 3 or  
Stage 1 or  
Stage 1 
3 
- 
Stage 2-3 or  
Stage 2-4 
4† 
Stage 4 or  
Stage 4 
- 
† Grade 4 may also include lesser organ involvement but with extreme decrease in performance status 
 
 
According to: 
Przepiorka P, Weisdorf D, Martin P et al, 1994 Consensus Conference on Acute GVHD Grading. BMT, 1995 
Jun;15(6):825-8 
 
STAGE 
SKIN 
LIVER 
GASTROINTESTINAL 
1 
Rash on  < 25% of skin* 
Bilirubin 2-3 mg/dl** 
Diarrhoea > 500 ml/day#  
or persistent nausea§ 
2 
Rash on 25-50% of skin 
Bilirubin 3-6 mg/dl 
Diarrhoea > 1000ml/day 
3 
Rash on > 50% of skin 
Bilirubin 6-15 mg/dl 
Diarrhoea > 1500 ml 
4 
Generalized erythroderma 
with bullous formation 
Bilirubin > 15 mg/dl 
Severe abdominal pain with or 
without ileus 

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Appendix D: Chronic GvHD grading 
 

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Grade 
Specification  
Score 
Mild  
Involves 1 or 2 organs or sites (exception the lung see below), 
with no clinically significant functional impairment 
1 in all affected organs or sites 
Moderate  
Involves at least 1 organ or site with clinically significant but 
no major disability 
2 in any affected organ or site 
Involves ≥3 organs or sites with no clinically significant 
functional impairment 
1 in all affected organs or sites 
lung 
1 
Severe  
Major disability  
3 in any organ or site 
lung 
≥ 2 
 
 
According to: 
Filipovich AH, Weisdorf D, Pavletic S et al. National Institutes of Health consensus development project on criteria for 
clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow 
Transplant. 2005 Dec;11(12):945-56. 
 
 

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Appendix E: ECOG performance status scale 
 
Grade 
Performance scale 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g. light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities; 
up and about more than 50% of waking hours 
3 
Capable of only limited self-care; confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled; cannot carry on any self-care; totally confined to bed or chair
5 
Dead  
* As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, 
E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 
5:649-655, 1982. 
 
 
 

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Appendix F: Optional Functional studies 
 
The following optional additional phenotyping panels regarding the functional characterization of 
immune reconstitution will be performed locally by participating sites at 15 days, 6 months and 1 
year after IR: 
 
CD45/CD3/CD4/CD8/CD27/CD28 
CD45/CD3/CD4/CD45RA/CD62L/CD31/CD127 
CD45/CD3/CD4/CD25/HLA-DR 
 
For Arm A only: 
CD45/LNGFR/CD4/CD8/CD27/CD28  
CD45/LNGFR/CD4/CD45RA/CD62L/CD31/CD127 
CD45/LNGFR/CD4/CD25/HLA-DR 
 
After staining, the red cells in each tube will be lysed and the remaining cells may be fixed with 
paraformaldehyde. During analysis in the flow cytometer, initial gating will be performed to include 
all events bearing CD45. Lymphocytes will be further identified and electronically gated on forward 
and orthogonal light scatter signals. The fluorescent signals for phenotype analyses will be 
accumulated for the gated lymphocytes. Events representing cells binding the relevant markers will 
be identified by their light scatter and fluorescence signatures. The internal standard of microbeads 
shall be used to calculate the absolute numbers of pertinent cells in each assay tube. The instrument 
raw data shall be stored electronically for archiving, data processing, and reporting. 
 
Immune competence analyses 
Functional studies aimed to characterize the pattern of immune-reconstitution will be performed 
centrally at  MolMed laboratory: 
 Before conditioning regimen 
 Before the first TK cell infusion (applicable for patients enrolled in arm A) 
 Fifteen days after IR  
 6 months after IR 
 1 year after IR 
 
The following analyses will be performed: 
 
1. Analysis of cytokine produced by lymphocytes  
This assay is performed by intracytoplasmic staining with PE or FITC-conjugated antibodies directed 
to IFN, IL-2, IL-4 after 6 hours exposure to polyclonal mitogens, and block of cytokine secretion by 
exposure to Brefeldin. Cells are stained also with anti-CD3 antibodies and results are analysed on 
CD3+ cells. Cells from healthy donors are utilized as controls. 
 
2. IFNγ production to cells expressing viral antigens such as CMV, EBV  
This assay is performed by ELISPOT for IFN. Briefly, circulating lymphocytes from treated patients 
will be challenged with: 1) Anti-CD3+anti-CD28 (positive controls); 2) Immunodominant peptides 
from viral antigens (samples); 3) Medium (negative control). 
  

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3. Molecular analysis for rearrangement of the T cell receptor. This assay will be performed by 
spectratyping. 
Analysis of the cytokine pattern produced by transduced lymphocytes  
This assay is performed by intracytoplasmic staining with PE or FITC-conjugated antibodies directed 
to IFN, IL-2, IL-4, after 6 hours exposure to polyclonal mitogens, and block of cytokine secretion 
by exposure to Brefeldin. Cells are stained also with anti-LNGFR antibodies and results are analysed 
on LNGFR+ cells. Cells from healthy donors are utilized as controls. 
 
4. Detection of antigen-specific transduced T cells by the use of tetramers/pentamers  
This analysis can be performed on those patients with donor or host HLA typing matched to the 
available tetramers or pentamers, commercially available, designed to detect T cells specific CMV 
and EBV-related antigens. The analysis is performed by staining with antibodies conjugated with 
fluorochromes, specific for CD3, LNGFR, CD8 and a tetramer or pentamer of HLA- molecules bound 
to a CMV or EBV immunodominant peptides restricted. This analysis allows the quantification of T 
cells specific for antigens relevant in the transplant setting within the total population of circulating 
T lymphocytes and circulating transduced cells.  
 
For Arm A, at the first determination of circulating LNGFR+ cells > 50/µl, 50 ml of blood will be 
harvested. Cells will be processed and stocked at each center site (if possible), to allow potential 
future determination of safety profile. 
 
Immunological follow-up for selected clinical conditions 
In case of unexpected disappearance of transduced donor lymphocytes from circulation, an immune 
response to the transgene will be investigated. 
In the presence of GvHD, PBMC are harvested before ganciclovir treatment, 4 days after the 
beginning of ganciclovir or valganciclovir treatment and 1 day after the discontinuation of ganciclovir 
or valganciclovir. Analysis of host-reactivity will be performed by 72 hours by ELISPOT for IFN. 
 
Sample collection procedures 
Each sample will be collected into vacutainer tube bearing an appropriate label. 10 ml blood sample 
should allow to collect at least 5 x 106 PBMC/cryotube whereas the 50 ml blood sample should allow 
to collect approximately 20 x 106 PBMC/vials slip into two vials. 
Each sample of collected PBMC will be harvested, processed (by density gradient centrifugation) and 
frozen as viable cells. MolMed will arrange the shipment of the stored samples from the clinical site 
to central laboratory in MolMed. 
 
 
 

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Appendix G: Common terminology criteria for Adverse Events 
 
In the present study adverse events and/or adverse drug reactions will be recorded according to the 
Common Terminology Criteria for Adverse Events (CTCAE), version 4.02. 
At the time this protocol was issued, the full CTC document was available on the NCI web site, at 
the following address: 
http://ctep.cancer.gov/reporting/ctc.html 

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Appendix H: Glossary 
 
AE 
Adverse Event 
AL 
Acute Leukemia 
ALL 
Acute Lymphoblastic Leukemia 
ALT 
Alanine Amino Transferase 
AML 
Acute Myeloid Leukemia 
AST 
Aspartate Transaminase 
ATG 
Anti-Thymocyte Globuline 
BM 
Bone Marrow 
BSE 
CMV 
BUN 
Blood Urea Nitrogen 
CAR 
Chimeric Antigen Receptor 
CML 
Chronic Myeloid Leukemia  
CMV 
Cytomegalovirus 
CNS 
Central Nervous System 
CY 
Cyclophosphamide 
DLCO 
Diffusing Lung Capacity of Carbon Oxide 
DLI 
Donor Lymphocyte Infusion 
DMSO 
Dimethyl Sulfoxide 
DNA 
Deoxyribonucleic acid 
EBV 
Epstein-Barr Virus 
EFS 
Event Free Survival 
EVA 
Ethylene Vinyl Acetate 
FDA 
Food and Drug Administration 
G-CSF 
Granulocyte colony-stimulating factor 
GCV 
Ganciclovir 
γGT 
Gamma-glutamyl transpeptidase 
GMP 
Good Manufacturing Practice 
GvHD 
Graft versus Host Disease 
GvL 
Graft versus Leukemia 
Hb 
Haemoglobin 
HCT 
Hematopoietic Cell Transplantation 
HD 
Hodgkin Disease 
HLA 
Human Leukocyte Antigen 
HSA 
Human Serum Albumin 
HSC 
Hematopoietic Stem Cell 
HCT 
Hematopoietic Stem Cell Transplantation 

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HSV-Tk 
Herpes Simplex Virus Thymidine Kinase 
Hct 
Haematocrit 
IFNγ 
Interferon Gamma 
IL-2 
Interleukin 2 
IL-4 
Interleukin 4 
IR 
Immune reconstitution 
ITT 
Intention To Treat 
IU 
International Units 
LDH 
Lactate Dehydrogenase 
LFS 
Leukemia Free Survival 
LNGFR 
Low Affinity Nerve Growth Factor Receptor 
MCV 
Mean Corpuscolar Volume 
MDS 
Myelodysplastic Syndrome 
MPV 
Mean Platelet Volume 
MUGA 
Multigated acquisition  
NGF 
Nerve Growth Factor 
NHL 
Non Hodgkin's Lymphoma 
NIH 
National Institutes of Health 
NK 
Natural Killer 
NRM 
Non Relapse Mortality 
OS 
Overall Survival 
PBMC 
Peripheral Blood Mononuclear Cells 
PCR 
Polymerase Chain Reaction 
RAEB-T 
Refractory anemia with excess blasts 
RCR 
Replication Competent Retrovirus 
RNA 
Ribonucleic acid 
SADR 
Seriuos Adverse Drug Reaction 
SAE 
Serious Adverse Event 
SCT 
Stem Cell Transplantation 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TBI 
Total body irradiation 
TCR 
T-Cell Receptor 
TRM 
Transplant Related Mortality 
 

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Appendix I: Creatinine clearance formula 
 
Evaluation of estimated creatinine clearance according to Cockcroft-Gault formula 
 
If serum creatinine is expressed in mg/dl 
 
 
 
 
FOR MALES 
Creatinine clearance =  
(140 – age [years]) x (body weight [Kg]) 
 
 
(serum creatinina [mg/dl]) x 72 
 
 
 
 
FOR FEMALES 
Creatinine clearancewoman =  
0.85 x male value 
 
 
 
 
If serum creatinine is expressed in µmol/l 
 
 
 
 
FOR MALES 
Creatinine clearance =  
(140 – age[years]) x (body weight [Kg]) 
 
 
(serum creatinina [µmol/l]) x 0.81 
 
 
 
 
FOR FEMALES 
Creatinine clearancewoman =  
0.85 x male value 
 
 
 
 

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Appendix J: Quality of life assessment 
 
 
 
 

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Appendix K: Long term follow up questionnaire (LTFUQ) 
 
Patient 
code 
 
 
 
 
 
 
 
 
Patient’s 
initials
 
 
 
 
 
Date of 
birth 
 
 
 
 
 
 
D 
D 
M 
M 
Y 
Y 
Date of visit
 
 
 
 
 
 
D 
D 
M 
M 
Y 
Y 
Since the last annual physical exam and/or questionnaire, does the patient develop any of the following 
potential risks? 
Please add additional pages if necessary 
1. Immune system (e.g. infections) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
2. Ocular (e.g. cataracts, sicca syndrome, microvascular retinopathy) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
3. Oral (e.g. caries, sicca syndrome) 

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 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
4. Respiratory (e.g. idiopathic pneumonia syndrome, bronchiolitis obliterans syndrome, cryptogenic organizing pneumonia, 
sinopulmonary infections) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
5. Cardiac & vascular (e.g. cardiomyopathy, congestive heart failure, arrhythmias, valvular anomaly, coronary artery disease, 
cerebrovascular disease, peripheral arterial disease) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
6. Liver (e.g. GvHD, HBV, HCV, iron overload) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 

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7. Renal & genitourinary (e.g. chronic kidney disease, bladder dysfunction, urinary tract infections) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
8. Muscle & connective tissue (e.g. myopathy, fascitis/scleroderma, polymyositis) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
9. Skeletal (e.g. osteopenia/osteoporosis, avascular necrosis) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
10. Nervous system (e.g. leukoencephalopathy, late infections, neuropsychological & cognitive deficits, calcineurin 
neurotoxicity, peripheral neuropathy) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 

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11. Endocrine (e.g. hypothyroidism, hypoadrenalism, hypogonadism, growth, retardation) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
12. Mucocutaneous (e.g. cutaneous sclerosis, genital GvHD) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
13. Second cancer (e.g. solid tumors, hematologic malignancies, PTLD) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 

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14. Psychosocial & sexual (e.g. depression, anxiety, fatigue, sexual dysfunction) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
15. Fertility (infertility) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
16. General health 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 

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17.1. Events of special interest: Graft versus Host Disease 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
17.2. Events of special interest 
Development of Immunological events, e.g. autoimmunity, allergic reaction, antibody formation,  
_______________________________________________________________________ 
(please specify) 
 NO    YES 
If Yes, please specify, including onset date, duration, severity and outcome of event(s):  
 
 
 
 
 
 
 
 
 
Severity 
Onset date                              Duration 
 
 
 
 
 mild 
|__|__|__|__|__|__|__|  |____|     Days    Weeks     Months  
 moderate 
   D     D    M    M    M    Y     Y          
 
 
 
 
 
 severe 
 
 
 
 
 
 
 
 
 
 life‐threatening 
 
 
 
 
 
 
 
 
 
 death 
Outcome: 
 Fatal  
 Resolved 
 Resolved with sequelae 
 
 
 
 Improved 
 Persistent 
 Worsened 
 Unknown 
General remarks 
 
 
 
 
Hospital address 
 
Physician name 
 
Signature 
 
Date 
 
 
 
 
 
 
D 
D 
M 
M 
Y 
Y 
 
 
 
 
 
 
 

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Appendix L: Amendment history 
 
Protocol Version 
Protocol Approval Date 
Substantial Changes 
IPR/21.B 
21/02/2011 
 
It has been changed the primary objective of the study, from 
non-relapse mortality (NMR) to disease-free survival 
(reference § 2 and 2.1) 
 
It has been modified the sample size, from 152 to 170 
patients (reference § 11.4). 
 
It has been included the comorbidity index, the definition of 
high risk of relapse and liver, cardiac, kidney and 
pulmonary parameters in the inclusion criteria (reference § 
4.2, appendix H and I). 
 
It has been defined the use of ATG Fresenius only if 
approved in the Country (reference § 4.5.1). 
 
It has been included the monitoring of vital signs during the 
infusion of HSV-Tk cells (reference §5.4). 
 
It has been defined the donor’s test (reference §6.1.2) 
 
It has been specified the procedure for AE&SAE collection 
(reference §6.4.3)  
 
It has been included a sample collection at baseline for 
functional studies (reference §8.2) 
IPR/21.C 
28/07/2011 
 
It has been specified the donor’s tests to perform according 
to EU and US regulations  (reference 6.1.2) 
 
It has been included the molecular analysis for 
rearrangement of the T cell receptor in the immune 
competence analyses and during the long term follow-up 
(reference §8.2 and 13.5.4) 
IPR/21.D 
13/06/2012 
 
It has been added in the inclusion criteria patients with  
AML and ALL in 1st or 2nd relapse or primary refractory 
(reference §4.2) 
 
It has been included in the Control Arm B the investigator’s 
choice to perform the unmanipulated haploidentical bone 
marrow 
transplantation 
followed 
by 
high-dose 
of 
cyclophosphamide on days +3 and +4. (Reference §6.1 and 
6.2.2).  
IPR/21.E 
18/02/2016 
 
The comparison of time to GvHD resolution and use of 
immunosuppressive agents has been added among the 
secondary study aims for specific request of the European 
Medicines Agency (reference §2.2).  
 
Study results of the phase I/II study TK007 have been 
updated (reference §1.3.2). 
IPR/21.F 
23/06/2017 
 
The comparison of GRFS has been added among the 
secondary study aims (reference §2.2).  
 
TK008 trial has been classified as a category 2 study, as a 
part of Conditional Marketing Authorization of the 
medicinal product Zalmoxis (Reference §3). 
 
The comorbidity index and the term “high risk of relapse” 
have been eliminated from the inclusion criteria #1 and 2.1, 
respectively, because already foreseen by the exclusion 
criteria #2 “contraindication to haploidentical HCT” 
(Reference §4.2). 
 
The inclusion criteria # 3 has been better defined (Reference 
§4.2). 

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 
The wash-out period of 24 hours after G-CSF and 
immunosuppressive therapy administration has been further 
defined (Reference §5.5). 
 
The recommended conditioning regimens have been 
reported as  Appendix A  
 
It has been specified that the supportive care can be 
administered according to institutional clinical practice 
(Reference §4.5). 
 
Procedures of drug administration have been further 
detailed (Reference §5.4). 
 
Donor tests for lymphocytoapheresis collection have been 
listed as Appendix B  
 
The HLA testing for patients of Arm A has been deleted 
 
Disease assessments and the follow-up after disease relapse 
or progression have been better defined (Reference §6.3.1). 
 
Survival follow up and procedures of safety collection have 
been better defined (Reference §6.3.5, 6.3.7, 10.3.1 and 
10.4). 
 
Analyses regarding functional characterization of immune 
reconstitution have been defined as optional studies and 
reported in Appendix F 
 
Considering that as part of the CMA granted for the 
medicinal product, EMA will review the safety data of this 
study on an every-6-month basis through the PSURs and the 
benefits and risks of the medicinal product on an annual 
basis, the Data and Safety Monitoring Board will no longer 
be operational. The risk management plan has been updated 
(Reference § 10.5) 
 
The long term follow-up has been further defined and the 
test of rearrangement of TCR repertoire has been 
eliminated, as it is considered no longer appropriate 
(Reference §10.5.4)  
 
The use of the alert card for treated patients has been 
included (Reference §10.5.4) 
 
The section 11 of ethics and general study administration on 
guidance, traceability records, informed consent and 
electronic CRF has been updated.