Phase I Study of Cellular ImmunoTx Using Memory Enriched T Cells Lentivirally Transduced to Express an IL13Rα2-Specific, Hinge-Optimized, 41BB-Costimulatory Chimeric Receptor and a Truncated CD19 for Pts With Rec/Ref MaligGlioma
Phase: PHASE1
Conditions: Recurrent Glioblastoma, Recurrent Malignant Glioma, Recurrent WHO Grade II Glioma, Recurrent WHO Grade III Glioma, Refractory Glioblastoma, Refractory Malignant Glioma, Refractory WHO Grade II Glioma, Refractory WHO Grade III Glioma
Sponsor: City of Hope Medical Center

IRB Protocol No. 13384 
 
08/07/2023  
Packet:  21 
 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
DEPARTMENT OF HEMATOLOGY/ HEMATOPOEITIC CELL TRANSPLANTATION 
& 
DIVISION OF NEUROSURGERY 
 
TITLE:  
PHASE I STUDY OF CELLULAR IMMUNOTHERAPY USING MEMORY ENRICHED 
T CELLS LENTIVIRALLY TRANSDUCED TO EXPRESS AN IL13Rα2-SPECIFIC, 
HINGE-OPTIMIZED, 41BB-COSTIMULATORY CHIMERIC RECEPTOR AND A 
TRUNCATED CD19 FOR PATIENTS WITH RECURRENT/REFRACTORY 
MALIGNANT GLIOMA  
CITY OF HOPE PROTOCOL NUMBER: 
13384 
PROTOCOL DATE: 08/07/2023 
 
COH Initial Approval  
 
Protocol Dated 08/13/2014 
 
 
Version: 00 
COH Amendment V01  
 
Protocol Dated 04/06/2015 
 
 
Version: 01 
COH Amendment V02  
 
Protocol Dated 05/28/2015 
 
 
Version: 02 
COH Amendment V03  
 
Protocol Dated 08/13/2015 
 
 
Version: 03 
COH Amendment V04  
 
Protocol Dated 10/08/2015 
 
 
Version: 04 
COH Amendment V05  
 
Protocol Dated 11/25/2015 
 
 
Version: 05 
COH Amendment V06  
 
Protocol Dated 04/14/2016 
 
 
Version: 06 
COH Amendment V07  
 
Protocol Dated 10/13/2016 
 
 
Version: 07 
COH Amendment V08  
 
Title Page Dated 02/20/2017 
 
 
Version: 08 
COH Amendment V09  
 
Protocol Dated 02/21/2017 
 
 
Version: 09 
COH Amendment V10  
 
Protocol Dated 03/23/2017 
 
 
Version: 10 
COH Amendment V11  
 
Protocol Dated 09/07/2017 
 
 
Version: 11 
COH Amendment V12  
 
Protocol Dated 02/21/2018 
 
 
Version: 12 
COH Amendment V13  
 
Title Page Dated 08/06/2018 
 
 
Version: 13 
COH Amendment V14  
 
Protocol Dated 02/19/2019 
 
 
Version: 14 
COH Amendment V15 at Continuation Title Page Dated 01/28/2020 
 
 
Version: 15 
COH Amendment V16  
 
Title Page Dated 02/12/2020 
 
 
Version: 16 
COH Amendment V17  
 
Protocol Dated 03/27/2020 
 
 
Version: 17 
COH Amendment V18  
 
Protocol Dated 03/27/2020 (TP)  
 
Version: 18 
COH Amendment V19  
 
Protocol Dated 10/29/2021 
 
 
Packet: 19 
COH Amendment V20  
 
Protocol Dated 10/29/2021 (TP)  
 
Packet: 20 
COH Amendment V21  
 
Protocol Dated 08/07/2023 
 
 
Packet: 21 
 
SPONSOR/IND NUMBER:   BB IND 16226 
DISEASE SITE: 
 
Brain 
STAGE (if applicable): 
 
N/A 
MODALITY: 
 
Intracavitary/Intratumoral/Intraventricular Administration of Cellular 
Immunotherapy Using Autologous IL13(EQ)BBζ/CD19t+ T cells 
PHASE/TYPE: 
 
Phase I/Safety 
 
PRINCIPAL INVESTIGATOR: Behnam Badie, M.D., Neurosurgery  
 
COLLABORATING INVESTIGATOR(S): Christine Brown, Ph.D.; Stephen Forman, M.D.; Jana  

IRB Protocol No. 13384 
 
08/07/2023  
Packet:  21 
Portnow, M.D.; Leo Wang, M.D.; Russell Rockne, Ph.D.; Prativa Sahoo, Ph.D. (international 
investigator); Ryan Woodall, Ph.D.; Joseph Georges, D.O, Ph.D. 
 
PARTICIPATING CLINICIANS: 
Neurosurgery: Mike Chen, M.D.; Ph.D., Rahul Jandial, M.D., Ph.D.; Yuthana Kong, PA-C; Rosalind 
Munoz, PA-C 
Neuro-Radiology: Julie Ressler, M.D.; Bihong Chen, M.D. 
Pediatrics Oncology: Joseph Rosenthal, M.D.; Clarke Anderson, M.D.; Anna Pawlowska, M.D.; Nicole 
Karras, M.D.; Saro Armenian, D.O. 
Pathology: Massimo D’Apuzzo, M.D., Ph.D. 
Transfusion Medicine: Shirong Wang, M.D.  
 
STUDY STATISTICIAN: Suzette Blanchard, Ph.D., Information Sciences 
 
STUDY SPONSORS: City of Hope; Gateway for Cancer Research and Mustang Bio, Inc. 
 

Page 1 of 76 
IRB Protocol No. 13384 
 
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CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
DEPARTMENT OF HEMATOLOGY/ HEMATOPOEITIC CELL TRANSPLANTATION 
& 
DIVISION OF NEUROSURGERY 
 
TITLE:  
PHASE I STUDY OF CELLULAR IMMUNOTHERAPY USING MEMORY ENRICHED 
T CELLS LENTIVIRALLY TRANSDUCED TO EXPRESS AN IL13Rα2-SPECIFIC, 
HINGE-OPTIMIZED, 41BB-COSTIMULATORY CHIMERIC RECEPTOR AND A 
TRUNCATED CD19 FOR PATIENTS WITH RECURRENT/REFRACTORY 
MALIGNANT GLIOMA  
 
SPONSOR/IND NUMBER:   BB IND 16226 
DISEASE SITE: 
 
Brain 
STAGE (if applicable): 
 
N/A 
MODALITY: 
 
Intracavitary/Intratumoral/Intraventricular Administration of Cellular 
Immunotherapy Using Autologous IL13(EQ)BBζ/CD19t+ T cells 
PHASE/TYPE: 
 
Phase I/Safety 
 
PRINCIPAL INVESTIGATOR 
Behnam Badie, M.D.  
City of Hope National Medical Center 
Department of Neurosurgery 
T: 626-456-4673 x87100 
Email: bbadie@coh.org  
 
 
 
 
 
 
 
 
 

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Experimental Design Schema 
 
 *Optional additional cycles of CAR T cell infusions may be initiated after day 28. 
Table 13.1: Dose Schedule (CAR+) for Arms 1 to 5^ 
Planned 
Cycle 
Dose schedule 
1de 
Dose schedule 
1 
Dose schedule 
2de 
Dose schedule 
2 
Dose Schedule 
3de 
Dose schedule 
3 
1 
A: 2x106 
A: 2x106 
C: 10x106 
C: 10x106 
C:10x106 
F: 20x106 
2 
B: 5x106 
C: 10x106 
D: 25x106 
E: 50x106 
G:75x106 
H:100x106 
3 
B: 5x106 
C: 10x106 
D: 25x106 
E: 50x106 
G:75x106 
H:100x106 
Total 
Dose 
12x106 
22x106 
60x106 
110x106 
160x106 
220x106 
 
Evaluation/Restaging 
Optional 
Cycle# 
<5x106 
<10x106 
<25x106 
<50x106 
<75x106 
<100x106 
^ Infusion doses should not exceed 2.5x108 per 0.5mL (0.5x106/µL); a dose schedule consists of a participant receiving 3 infusions.
Reference Section 5.2.1. 
de = de-escalation schedule 
# The dose listed at each cycle is the CAR+ T cell dose intended for each delivery method, therefore in Arms 4 (TCM Dual Delivery) 
and 5 (TN/MEM Dual Delivery) 2 infusions doses will be prepared per infusion cycle, 1 for each delivery method. 
 
 
 

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Protocol Synopsis 
Protocol Title: 
Phase I Study of Cellular Immunotherapy using Memory Enriched T Cells Lentivirally Transduced 
to Express an IL13Rα2-specific, Hinge-optimized, 41BB-costimulatory Chimeric Receptor and a 
Truncated CD19 for Patients with Recurrent/Refractory Malignant Glioma 
Brief Protocol Title for the Lay Public (if applicable): 
IL13(EQ)BBζ/CD19t+ T cells for the treatment of malignant glioma 
Study Phase: 
Phase I 
Participating Sites: 
Not applicable 
Rationale for this Study: 
The treatment of high-grade malignant glioma (MG), including anaplastic astrocytoma (AA-grade 
III) and glioblastoma multiforme (GBM-grade IV), remains a significant therapeutic challenge.  
Currently available therapeutic options have limited curative potential and only less than 5% of 
patients survive more than five years after initial diagnosis. Adoptive cellular immunotherapy 
(ACIT) utilizing chimeric antigen receptor (CAR) engineered T cells may provide a safe and 
effective way to reduce recurrence rates of MG, since CAR T cells can be engineered to specifically 
recognize antigenically-distinct tumor populations,1 and T cells can migrate through the brain 
parenchyma to target and kill infiltrative malignant cells.2-4  We have developed a CAR T cell 
immunotherapy for MG targeting IL-13 receptor α2 (IL13Rα2), a cell surface receptor over-
expressed by a high percentage of MGs, but not expressed at significant levels on normal brain 
tissue. Pre-clinical studies have demonstrated that IL13Rα2-targeting CAR+ T cells exhibit potent 
MHC-independent, IL13Rα2-specific cytolytic activity against both stem-like and differentiated 
glioma cells, and induce regression of established glioma xenografts in vivo.5,6 Our experience with 
two FDA-authorized clinical trials evaluating intracranial administration of both autologous and 
allogeneic IL13Rα2-targeting CAR+ T cell clones in 9 research participants with 
recurrent/refractory glioblastoma has demonstrated the feasibility of this approach, the absence of 
serious therapy-related side-effects, and has provided evidence for transient anti-glioma responses 
for patients with IL13Rα2-expessing MG.   
The phase I clinical study proposed here now aims to build on this clinical experience by examining 
the feasibility and safety of intracavitary/intratumoral/intraventricular administration of  
autologous ex vivo expanded central memory-enriched T cells (TCM) that are genetically modified 
using a self-inactivating (SIN) lentiviral vector to express an IL13Rα2-specific, hinge-optimized, 
41BB-costimulatory chimeric antigen receptor (CAR) as well as a truncated human CD19 
(IL13(EQ)BBζ/CD19t+ TCM or TN/MEM) to patients with recurrent or refractory MG. The use of TCM 
or TN/MEM for genetic modification is based on studies using both murine xenograft models and a 
non-human primate model relevant for human translation,7,8 which suggest that autologous 
IL13(EQ)BBζ/CD19t+ TCM-derived effectors will retain their memory phenotype for persistence 
after their genetic modification and ex vivo propagation, and, upon adoptive transfer, will produce 
robust anti-tumor responses against IL13Rα2+ MG. 
In this protocol, research subjects with documented IL13Rα2+ recurrent/refractory high-grade 
glioma (Grades III and IV) will be enrolled and undergo PBMC collection. Concurrent with the 
manufacturing process to generate IL13(EQ)BBζ/CD19t+ TCM or TN/MEM, research participants will 
undergo biopsy or resection of their tumor, as applicable, followed by placement of a Rickham 
catheter and baseline imaging. Following recovery from surgery, research participants will then 

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receive an initial low dose (cycle 1) followed by 2 additional infusions at the 5-fold higher cell dose 
(cycles 2 and 3) of autologous IL13(EQ)BBζ/CD19t+ TCM or TN/MEM, potentially followed by 
additional cycles at up to the highest tolerated cell dose (cycles 4+). T cells will be administered in 
one of four ways: (1) directly into the tumor (Arm 1 = intratumoral), (2) into the tumor resection 
cavity (Arm 2 = intracavitary), (3) into the lateral ventricles (Arm 3 = intraventricular), or dual 
delivery (Arm 4= both intratumoral [includes delivery in to either the tumor OR tumor 
resection cavity] and intraventricular).  Arm 5 (TN/MEM Dual Delivery) will investigate 
autologous IL13(EQ)BBζ/CD19t+ TN/MEM administered via Dual Delivery.  
Objectives: 
The Primary Objectives are: 
• 
Assess the feasibility and safety of cellular immunotherapy utilizing ex vivo expanded 
autologous memory-enriched T cells that are genetically modified using a self-
inactivating (SIN) lentiviral vector to express a IL13Rα2-specific, hinge-optimized, 
41BB-costimulatory CAR, as well as a truncated human CD19 for participants with 
recurrent/refractory malignant glioma in one of the following ways: Arm 1 
(intratumoral delivery of IL13(EQ)BBζ/CD19t+ TCM), Arm 2 (intracavitary delivery 
of 
IL13(EQ)BBζ/CD19t+ 
TCM), 
Arm 
3 
(intraventricular 
delivery 
of 
IL13(EQ)BBζ/CD19t+ TCM), Arm 4 (dual delivery [both intratumoral and 
intraventricular] of IL13(EQ)BBζ/CD19t+ TCM) or Arm 5 (dual delivery [both 
intratumoral and intraventricular] of IL13(EQ)BBζ/CD19t+ TN/MEM), and  
• 
Determine maximum tolerated dose schedule (MTD)/maximum feasible dose schedule 
(MFD) and a recommend Phase II dosing plan (RP2D) for each arm based on dose 
limiting toxicities (DLTs) and the full toxicity profile.   
The Secondary Objectives are 
• 
In research participants who receive the full schedule of 3 CAR T cell doses:  
o Estimate disease response rates, 
o Estimate median overall survival, and 
o Estimate the mean change from baseline in quality of life using the EORTC 
QLQ-C30 during and post treatment; 
• 
Describe cytokine levels (CSF, tumor cavity fluid, peripheral blood) over the study 
period; 
• 
Describe CAR T cell and endogenous immune populations (CSF, tumor cavity fluid, 
peripheral blood) over the study period; and  
• 
Identify tumor and tumor micro-environment markers associated with response to 
CAR T cells.  
The Exploratory Objectives are 
• 
Assess the timing and extent of brain inflammation following CAR T cell 
administration;  
• 
Evaluate CAR T cell product characteristics; and  
• 
For research participants who undergo a second resection or autopsy: 
o Evaluate CAR T cell persistence in the tumor micro-environment and the 
location of the CAR T cells with respect to the injection site, and  
o Evaluate IL13Rα2 antigen expression levels pre and post CAR T cell therapy 
Study Design: 
This protocol is a Phase I feasibility/safety study of IL13(EQ)BBζ/CD19t+ T cells which 
implements both inter- and intra-patient dose escalation in five patient arms (TCM intratumoral, 
intracavity, 
intraventricular, 
and 
dual 
delivery 
[both 
intratumoral/intracavity 
and 

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intraventricular], as well as TN/MEM dual delivery [both intratumoral/intracavity and 
intraventricular]) for recurrent/refractory malignant glioma. 
Endpoints: 
Primary: Grade 3 toxicities, DLTs, and all other toxicities.  
Secondary: CAR T cell and cytokine levels in peripheral blood, CSF, and tumor cavity fluid; 
disease response by RANO criteria; endogenous immune cell detection; overall survival; scale, 
domain, and item scores from the EORTC QLQ-C30; and tumor/tumor micro-environment marker 
detection.  
Exploratory: Timing and extent of brain inflammation; CAR T cell product characteristics; 
Persistence and location of CAR T cells in tumor micro-environment; and IL13Rα2 antigen 
expression levels.  
Sample Size: 
As of 03/02/2018, we have closed Arm 1 (biopsy with an N=2) as biopsy participants can be 
included in the ICV or dual arms. Based on simulation results, we expect to study 15 participants 
in the dose escalation portion of the trial, plus 6 in the expansion portion plus 2 for replacement of 
unevaluable participants, giving an expected sample size of 23 per arm for each of the 4 open arms 
for a total of 92. 
Estimated Duration of the Study 
Accrual is expected to be 6 evaluable research participants per year per arm. Thus, we expect to 
complete accrual in 5years. 
Summary of Subject Eligibility Criteria: 
Inclusion Criteria: 
1. 
Participant has a prior histologically-confirmed diagnosis of a grade III or IV 
glioma, or has a prior histologically-confirmed diagnosis of a grade II glioma and 
now has radiographic progression consistent with a grade III or IV MG after 
completing standard therapy. 
2. 
Radiographic evidence of recurrence/progression recurrence of the measurable 
disease more than 12 weeks after the end of the initial radiation therapy. 
3. 
COH 
Clinical 
Pathology 
confirms 
IL13Rα2+ 
tumor 
expression 
by 
immunohistochemistry (> 20%, 1+).  
4. 
Male or female participants between 12 and 75 years of age at time of screening. 
5. 
KPS ≥60% 
6. 
Life expectancy > 4 weeks 
7. 
Negative serum pregnancy test for women of childbearing potential 
8. 
Informed Consent/Assent: All subjects must have the ability to understand and the 
willingness to sign a written informed consent 
Exclusion Criteria: 
1. 
Failure of research participant to understand the basic elements of the protocol 
and/or the risks/benefits of participating in this phase I study. A legal guardian may 
substitute for the research participant. 
2. 
Basic organ function testing as follows: 
• Pulmonary: Research participant requires supplemental oxygen to keep saturation 
greater than 95% and the situation is not expected to resolve within 2 weeks. 
• Cardiac: Research participant requires pressor support and/or has symptomatic 
cardiac arrhythmias. 

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• Renal: Research participant requires dialysis. 
• Neurologic: Research participant has uncontrolled seizure activity and/or clinically 
evident progressive encephalopathy.  
3. 
Research participants with any non-malignant intercurrent illness which is either 
poorly controlled with currently available treatment, or which is of such severity 
that the investigators deem it unwise to enter the research participant on protocol 
shall be ineligible 
4. 
Research participants with any other active malignancies. 
5. 
Research participants being treated for severe infection or who are recovering from 
major surgery are ineligible until recovery is deemed complete by the investigator 
6. 
Research participants with any uncontrolled illness including ongoing or active 
infection. Research participants with known active hepatitis B or C infection; 
research participants with any signs or symptoms of active infection, positive 
blood cultures or radiological evidence of infections. 
7. 
Research participants who have confirmed HIV positivity within 4 weeks of 
screening.  
Investigational Product Dosage and Administration: 
Autologous IL13(EQ)BBζ/CD19t+ T cells will be administered through a Rickham catheter either 
(1) directly into the tumor (Arm 1 = intratumoral), (2) into the tumor cavity (Arm 2 = intracavitary), 
(3) into the lateral ventricles (Arm 3 = intraventricular), or (4) into both the tumor/tumor cavity 
(intratumoral) and into the lateral ventricles (intraventricular) (Arms 4 and 5 = dual 
delivery). Research participants will receive an initial low dose (cycle 1) followed by 2 additional 
infusions at the 5-fold higher cell dose (cycles 2 and 3) of autologous IL13(EQ)BBζ/CD19t+ TCM 
or TN/MEM, potentially followed by additional cycles at up to the highest tolerated cell dose (cycles 
4+) as long as they continue to meet eligibility criteria AND have doses available for infusion. 
Depending on the participant’s disease status, T cells will be administered one of four ways: (1) 
directly into the tumor (Arm 1 = intratumoral), (2) into the tumor resection cavity (Arm 2 = 
intracavitary), (3) into the lateral ventricles (Arm 3 = intraventricular), or (4) into both the 
tumor/tumor cavity (intratumoral) and into the lateral ventricles (intraventricular) (Arm 4 = 
IL13(EQ)BBζ/CD19t+ TCM dual delivery and Arm 5 = IL13(EQ)BBζ/CD19t+ TN/MEM dual 
delivery).  
Clinical Observations and Tests to be Performed: 
Clinical observation will include assessment of performance and relapse status, CTCAE grading, 
and comprehensive metabolic and chemistry profiles, and EORTC QLQ-C30. Peripheral blood, 
tumor cavity aspirate, and CSF samples (when available) will also be collected from research 
participants at designated time points (defined in Section 10) for the purposes of correlative studies 
that will include, but are not limited to the following: 1) Antitumor responses following CAR T 
cell therapy; 2) determination of the frequency of CAR+ T cells in the tumor microenvironment 
and peripheral blood; 3) ex vivo immunophenotyping and functional analysis of infused cells; 4) 
serum cytokine analysis; and 5) evaluation of tumor IL13Rα2 expression and susceptibility to 
CAR+ T cells. 
Statistical Considerations: 
The statistical analysis will be done separately for each arm. Rate and associated 95% Clopper and 
Pearson binomial confidence limits (95% CI) will be estimated for participants’ experiencing DLTs 
at the RP2D schedule. In study participants that received the full schedule of 3 T cell doses, we will 
estimate the rate (95% CI) with disease response, and Kaplan Meier methods will be used to 
estimate median PFS and OS and graph the results. In study participants that receive at least 1 dose 

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of T cells we will estimate the mean and standard error for change from baseline during treatment 
and post treatment in the quality of life functioning scale, symptom scale and item scores from the 
EORTC QLQ-C30. Statistical and graphical methods will be used to describe persistence and 
expansion of the CAR T cells (peripheral blood, CSF, and tumor cavity fluid) and cytokine levels 
(CSF, tumor cavity  fluid, peripheral blood) over the study period. In study participants that undergo 
a second resection or following autopsy, T cells numbers, location, and antigen levels will be 
described. Tables will be created to summarize all toxicities and side effects by dose, time post 
treatment, organ, severity and arm. We will provide descriptive statistics for patient demographics. 
Sponsor/Licensee: 
City of Hope 
Case Report Forms 
Electronic Case Report Forms (eCRFs) 
All data will be collected using study designed electronic case report forms (eCRFs) 
 
Administrative Forms (Numbering to be Assigned) 
UPN Assignment, DAC Leukapheresis Instructions and Requisition for T Cell Infusion. 

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Table of Contents 
SECTION .............................................................................................................................. PAGE 
Experimental Design Schema ............................................................................................. 2 
Protocol Synopsis ............................................................................................................... 3 
1.0 
Goals and Objectives (Scientific Aims) ............................................................................ 15 
1.1 
Objectives: ........................................................................................................... 15 
1.1.1 
Primary Objectives: ................................................................................ 15 
1.1.2 
Secondary Objective: .............................................................................. 15 
1.1.3 
Exploratory Objectives ........................................................................... 15 
2.0 
Background ....................................................................................................................... 16 
2.1 
Introduction/Rationale for Development ............................................................. 16 
2.1.1 
Glioblastoma Multiforme ....................................................................... 16 
2.1.2 
Treatment Options for GBM ................................................................... 16 
2.1.3 
IL13Rα2 expression and GBMs: ............................................................ 16 
2.1.4 
Adoptive Cellular Immunotherapy ......................................................... 16 
2.1.5 
Immunotherapy of Glioblastoma with Gene Modified T Cells. ............. 17 
2.1.6 
Route of Administration and Dosing. ..................................................... 19 
2.2 
Overview of Proposed Study ............................................................................... 20 
2.3 
Preclinical Studies ................................................................................................ 21 
2.3.1 
IL13(EQ)BBζ/CD19t+ TCM. .................................................................... 21 
2.4 
Human Studies ..................................................................................................... 23 
2.4.1 
Clinical ACIT Experience at COH Using Genetically Modified T cells (CAR T 
cells). 23 
3.0 
Patient Eligibility .............................................................................................................. 26 
3.1 
Screening Inclusion Criteria ................................................................................ 26 
3.1.1 
Disease Status ......................................................................................... 26 
3.1.2 
Age Criteria, Performance Status and Life Expectancy ......................... 27 
3.1.3 
Child Bearing Potential ........................................................................... 27 
3.1.4 
Protocol-Specific Criteria ....................................................................... 27 
3.2 
Screening Exclusion Criteria ............................................................................... 28 
3.2.1 
Organ Function: ...................................................................................... 28 
3.2.2 
Study-Specific Exclusions ...................................................................... 28 
3.2.3 
Non-Compliance ..................................................................................... 29 
3.3 
Inclusion of Women and Minorities .................................................................... 29 
4.0 
Screening and Registration Procedures............................................................................. 29 

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4.1 
Screening Procedures ........................................................................................... 29 
4.2 
Informed Consent ................................................................................................ 29 
4.3 
Registration Requirements/Process ..................................................................... 29 
4.4 
Randomization and/or Dose Level Assignment................................................... 30 
5.0 
Treatment Program ........................................................................................................... 30 
5.1 
Treatment Overview ............................................................................................ 30 
5.1.1 
Schedule .................................................................................................. 30 
5.2 
Planned Duration of Therapy ............................................................................... 33 
5.3 
Criteria for Removal from Treatment .................................................................. 34 
5.4 
Subject Follow-Up ............................................................................................... 36 
5.4.1 
Follow-Up Post CAR T cell Infusion ..................................................... 36 
5.4.2 
AE and ConMed data collection: ............................................................ 36 
5.5 
Supportive Care, Other Concomitant Therapy, Prohibited Medications ............. 36 
5.5.1 
Supportive Care for Regimen Related Toxicities ................................... 36 
5.5.2 
Management of Constitutional Symptoms Associated with CAR T cell Infusion
 
37 
5.5.3 
Management of Acute Adverse Event(s) Attributable to This Study ..... 37 
5.6 
Additional Studies ................................................................................................ 38 
5.6.1 
Laboratory Studies .................................................................................. 38 
5.6.2 
Long-Term Follow-Up ........................................................................... 38 
5.7 
Definition of Dose-Limiting Toxicity (DLT) ...................................................... 38 
6.0 
Dose Delays/Modifications for Adverse Events ............................................................... 39 
7.0 
Data and Safety Monitoring, Unanticipated Problems and Adverse Event Reporting ..... 39 
7.1 
Data and Safety Monitoring ................................................................................. 39 
7.2 
Monitoring and Personnel Responsible for Monitoring ...................................... 39 
7.3 
Definitions ........................................................................................................... 39 
7.3.1 
Adverse Events and Serious Adverse Events ......................................... 39 
7.3.2 
Adverse event (AE): ............................................................................... 39 
7.3.3 
Reporting Non-serious Adverse Events .................................................. 39 
7.3.4 
Serious Adverse Event (SAE) [21 CFR 312.32]: ................................... 40 
7.3.5 
Reporting Serious Adverse Events ......................................................... 40 
7.3.6 
Adverse Event Name and Severity ......................................................... 40 
7.3.7 
Expected Adverse Event: ........................................................................ 40 
7.3.8 
Unexpected Adverse Event [21 CFR 312.32 (a)]: .................................. 40 
7.3.9 
Adverse Event Attribution ...................................................................... 40 

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7.3.10 COH Held IND ....................................................................................... 41 
8.0 
Agent Information and Risks ............................................................................................ 42 
8.1 
IL13(EQ)BBζ/CD19t+ T Cells (BB-IND 16226) ................................................ 42 
8.1.1 
Description .............................................................................................. 42 
8.1.2 
Toxicology .............................................................................................. 43 
8.1.3 
Pharmacology – Handling, Storage, Dispensing and Disposal ............... 44 
8.2 
ACTEMRA® (Tocilizumab) ............................................................................... 45 
8.2.1 
Description: ............................................................................................. 45 
8.2.2 
Toxicology: ............................................................................................. 45 
8.2.3 
Pharmacology – Handling, Storage, Dispensing and Disposal ............... 48 
9.0 
Correlative/Special Studies ............................................................................................... 48 
9.1 
Summary of Correlative Studies .......................................................................... 48 
9.1.1 
Antitumor Responses Following Adoptive Transfer of IL13(EQ)BBζ/CD19t+ T 
Cells. 48 
9.1.2 
Determination of Frequency of IL13(EQ)BBζ/CD19t+ T Cells in the Tumor 
Microenvironment and Peripheral Blood. ............................................................ 48 
9.1.3 
Ex vivo Immunophenotyping/Functional Analysis ................................. 48 
9.1.4 
Serum, CSF, and Tumor Cavity Cytokine Analysis ............................... 49 
9.1.5 
Evaluation of Tumor Antigen IL13α2 Expression and Susceptibility to Re-
directed T Cells .................................................................................................... 49 
9.1.6 
Evaluation of human anti-CAR antibodies (HACA) .............................. 49 
9.1.7 
Evaluation of changes in frequency and phenotype of endogenous immune cell 
populations and tumor microenvironment ........................................................... 50 
10.0 
Study Calendar .................................................................................................................. 51 
10.1 
Enrollment and Treatment Study Calendar:......................................................... 51 
10.2 
Short-Term Follow-Up Calendar ......................................................................... 54 
10.3 
Long-Term Follow-Up (or Modified Follow-Up for Participants that Progress):55 
11.0 
Endpoint Evaluation Criteria/Measurement of Effect ...................................................... 56 
11.1 
Response Criteria ................................................................................................. 56 
12.0 
Data Reporting/Protocol Deviations ................................................................................. 56 
12.1 
Data Reporting ..................................................................................................... 56 
12.1.1 Confidentiality and Storage of Records .................................................. 56 
12.1.2 Subject Consent Form ............................................................................. 56 
12.1.3 Data Collection Forms and Submission Schedule .................................. 56 
12.2 
Protocol Deviations .............................................................................................. 57 
12.2.1 Deviation Policy ..................................................................................... 57 

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12.2.2 Reporting of Deviations .......................................................................... 57 
12.2.3 Resolving Disputes ................................................................................. 57 
13.0 
Statistical Considerations .................................................................................................. 57 
13.1 
Study Design ........................................................................................................ 57 
13.1.1 Study Participant Staggering Rules ........................................................ 58 
13.2 
Dose Escalation Rules (each arm will be followed separately): .......................... 58 
13.2.1 Intra-patient dose escalation rules:.......................................................... 58 
13.2.2 Inter-cohort dose escalation rules ........................................................... 59 
13.3 
Optional additional cycles.................................................................................... 63 
13.4 
Study Endpoints: .................................................................................................. 64 
13.5 
Study Stopping Rules ........................................................................................... 64 
13.5.1 Rules for Holding Accrual Due to Toxicity ............................................ 64 
13.6 
Sample Size Accrual Rate .................................................................................... 64 
13.7 
Statistical Analysis Plan ....................................................................................... 64 
14.0 
Human Subject Issues ....................................................................................................... 65 
14.1 
Institutional Review Board .................................................................................. 65 
14.2 
Recruitment of Subjects ....................................................................................... 65 
14.3 
Advertisements .................................................................................................... 65 
14.4 
Study location and Performance Sites ................................................................. 65 
14.5 
Confidentiality ..................................................................................................... 65 
14.6 
Financial Obligations and Compensation ............................................................ 65 
14.7 
Informed Consent Processes ................................................................................ 66 
15.0 
References ......................................................................................................................... 67 
16.0 
Appendices ........................................................................................................................ 72 
16.1 
APPENDIX A – Toxicity Grading ...................................................................... 72 
16.2 
APPENDIX B – Response Criteria and Grading ................................................. 73 
16.2.1 Response Assessment in Neuro-Oncology (RANO) criteria (cited below).
 
73 
16.2.2 Retrospective Research Analysis - Mathematical Models of Tumor Invasion and 
Proliferation ......................................................................................................... 73 
16.3 
APPENDIX C: Cytokine Release Syndrome (CRS) in the Context of Cellular 
Immunotherapy (Clinical Symptoms & Revised Grading System) ..................... 74 
16.3.1 Clinical signs and symptoms associated with CRS ................................ 74 
16.3.2 Revised CRS Grading System ................................................................ 74 
16.3.3 High-dose vasopressors (all doses are required for > 3 hours) ............... 75 
16.4 
APPENDIX D – Case Report Forms ................................................................... 76 

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Abbreviations 
Abbreviation 
Meaning 
AA 
Anaplastic Astrocytoma 
ACIT 
Adoptive Cellular Immunotherapy 
ADCC 
Antibody-dependent Cell-mediated Cytotoxicity 
ACT 
Adoptive T Cell Therapy 
AE 
Adverse Event 
AED 
Antiepileptic Drug 
ALT 
Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase 
BM 
Bone Marrow 
CAR 
Chimeric Antigen Receptor 
CATD 
Center for Applied Technology Development 
CBG 
Center for Biomedicine and Genetics 
CD19t 
Truncated Human CD19 
CED 
Convection Enhanced Delivery 
CFR 
Code of Federal Regulations 
CofA 
Certificate of Analysis 
COH 
City of Hope 
CR 
Complete Response 
CRA 
Clinical Research Associate 
CRF 
Case Report Form 
CRP 
C-Reactive Protein 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
CTL 
Cytolytic T Lymphocyte 
DAC 
Donor Apheresis Center 
DLT 
Dose Limiting Toxicity 

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DSMC 
Data Safety Monitoring Committee 
eCRFs 
Electronic Case Report Forms 
FcRs 
Fc Receptors 
FDA 
Food and Drug Administration 
GBM 
Glioblastoma Multiforme 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practices 
HACA 
Human anti-chimeric antibodies 
HAMA 
Human anti-mouse antibodies 
HSA 
Human Serum Albumin 
IB 
Investigator Brochure 
IC 
Intracranial 
ICF 
Informed Consent Form 
ICV 
Intracranial ventricular 
IDS 
Investigational Drug Services 
IL13Rα2 
IL-13 receptor alpha 2 
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
LN 
Lymph Node 
LTR 
Long-Terminal Repeat 
MFD 
Maximum Feasible Dose 
MG 
Malignant Glioma 
MRI 
Magnetic Resonance Imaging 
MRS 
Magnetic Resonance Spectroscopy 
MTD 
Maximum Tolerated Dose 
NCI 
National Cancer Institute 
NIH OBA RAC 
National Institute of Health Office of Biotechnology Activities, 
Recombinant DNA Advisory Committee 
NSG 
NOD scid gamma mice , (NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ) 
OIDRA 
Office of IND Development and Regulatory Affairs 

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PBMC 
Peripheral Blood Mononuclear Cell 
PBT 
Primary Brain Tumor 
PD 
Progressive Disease 
PFNS 
Preservative-free Normal-saline 
PFS 
Progression Free Survival 
PI 
Principal Investigator 
PMT 
Protocol Monitoring Team 
PR 
Partial Response 
QA 
Quality Assurance 
Q-PCR 
Quantitative Polymerase Chain Reaction 
QS 
Quality Systems 
rhuIL-2 
Recombinant Human Interleukin-2 
RP2D 
Recommended Phase 2 Dose 
SAE 
Serious Adverse Event 
SD 
Stable Disease 
SEER 
Surveillance, Epidemiology and End Results Database 
SIN 
Self-Inactivating 
SSE 
Single Subject Exemption 
TCM 
Central Memory T cells 
TCTRL 
T Cell Therapeutics Research Laboratory 
TE 
Cytolytic Effector Memory T cells 
TM 
Memory T cells 
TN 
Naϊve T cells 
TN/MEM 
Naïve and Memory T Cells 
TReg 
Regulatory T cells 
TS 
Tumor Sphere 
UP 
Unanticipated Problem 
WBC 
White Blood Cell 
WPRE 
Woodchuck Hepatitis Virus Post-Transcriptional Regulatory Element 
 

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1.0 Goals and Objectives (Scientific Aims) 
1.1 Objectives:  
1.1.1 
Primary Objectives: 
• Assess the feasibility and safety of cellular immunotherapy utilizing ex vivo expanded 
autologous memory-enriched T cells that are genetically modified using a self-inactivating 
(SIN) lentiviral vector to express a IL13Rα2-specific, hinge-optimized, 41BB-
costimulatory CAR, as well as a truncated human CD19 for participants with 
recurrent/refractory malignant glioma in one of the following ways: Arm 1 (intratumoral 
delivery 
of 
IL13(EQ)BBζ/CD19t+ 
TCM), 
Arm 
2 
(intracavitary 
delivery 
of 
IL13(EQ)BBζ/CD19t+ TCM),  Arm 3 (intraventricular delivery of IL13(EQ)BBζ/CD19t+ 
TCM), 
Arm 
4 
(dual 
delivery 
[both 
intratumoral 
and 
intraventricular] 
of 
IL13(EQ)BBζ/CD19t+ TCM), or Arm 5 (dual delivery of IL13(EQ)BBζ/CD19t+ TN/MEM); 
and 
• Determine maximum tolerated dose schedule (MTD)/maximum feasible dose schedule 
(MFD) and a recommend phase II dosing plan (RP2D) for each arm based on dose limiting 
toxicities (DLTs) and the full toxicity profile.   
1.1.2 
Secondary Objective: 
• In research participants who receive the full schedule of three CAR+ T cell doses:  
o Estimate disease response rates,  
o Estimate median overall survival, and 
o Estimate the mean change from baseline in quality of life using the EORTC QLQ-C30 
during and post treatment; 
• Describe cytokine levels (tumor cavity fluid, CSF, peripheral blood) over the study period; 
• Describe CAR T cell and endogenous immune populations (CSF, tumor cavity fluid, 
peripheral blood) over the study period; and 
• Identify tumor and tumor micro-environment markers associated with response to CAR T 
cells.   
 
1.1.3 
Exploratory Objectives  
• Assess the timing and extent of brain inflammation following CAR T cell administration; 
• Evaluate CAR T cell product characteristics; and  
• For research participants who undergo a second resection or autopsy: 
o Evaluate CAR T cell persistence in the tumor micro-environment and the location of 
the CAR T cells with respect to the injection, and  
o Evaluate IL13Rα2 antigen expression levels pre and post CAR T cell therapy. 
 

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2.0 Background 
2.1 Introduction/Rationale for Development 
2.1.1 
Glioblastoma Multiforme 
Glioblastoma multiforme (GBM), a malignant form of astrocytoma, is the most common primary 
intracranial neoplasm.  The incidence of GBM increases steadily above 45 years of age with a prevalence 
of approximately 7500 cases in the USA.  Despite numerous attempts to improve the outcome of patients 
with GBM, the 3-year survival of these patients is only 6% with median survival of 14.6 months (SEERs 
database). 
GBM is a diffusely infiltrating tumor that spreads microscopically throughout the brain.  Therefore, all local 
therapies, such as surgery and radiation, are inherently palliative.  Long-term disease control requires 
therapies targeting tumor cells throughout the brain, such as chemotherapy, small molecule inhibitors or 
cellular immunotherapy. 
2.1.2 
Treatment Options for GBM 
Patients with newly diagnosed GBM who are treated with maximal surgical resection, followed by 
radiotherapy and Temozolomide, and then maintenance Temozolomide for 6 months, have a median 
survival of 14.6 months.9   
For recurrent GBM the prognosis is equally poor with a median survival of 3 to 9 months.10  Gliadel wafers 
and Avastin have been approved for subjects with recurrent GBM, but neither of these therapies appear 
curative. Several clinical trials have tested the efficacy of inhibitors of EGFR, VEGFR TK, PDGFR, or 
mTOR for recurrent malignant glioma (MG) - but despite initial enthusiasm, treatment with these single 
pathway inhibitors has generally been disappointing, with response/survival rates not being superior to that 
of traditional chemotherapies.10-19  In fact, analysis of pooled data from multiple phase II clinical trials for 
recurrent/progressive glioblastoma within the North American Brain Tumor Consortium was not 
encouraging.  This study demonstrated an overall 6-month progression-free survival (PFS) rate of 7% for 
patients with recurrent/progressive glioblastoma treated with small molecule inhibitors as a single agent 
and represents an update to the study published in 1999.10,20 Thus, due to the lack of salvage regimens with 
curative potential, patients with relapsed or refractory MG are prime candidates for referral to experimental 
studies such as the one proposed here. 
2.1.3 
IL13Rα2 expression and GBMs: 
The 42-kDa monomeric high affinity IL-13 receptor, IL13Rα2, is an attractive target for brain tumor 
therapy. It has been shown to promote tumor migration and invasion21, and protect tumor cells from 
apoptosis thereby contributing to tumor growth.22 Furthermore, IL13Rα2 is expressed by a high percentage 
of high-grade gliomas (approximately 58% of GBM), and is a prognostic indicator of poor patient 
survival.23 Importantly, IL13Rα2 is not expressed at significant levels on normal brain tissue.24-27 
2.1.4 
Adoptive Cellular Immunotherapy 
One area of significant translational research in the cancer Adoptive Cellular Immunotherapy (ACIT) field 
is the genetic manipulation of T cells to endow them with tumor specificity and countermeasures against 
tumor-mediated immunosuppression.28-37  Adoptive T cell therapy for melanoma is one example of the 
curative potential of cellular immunotherapy, even in settings of metastatic refractory disease.38  However, 
there are still hurdles to be overcome – e.g., the major cause of treatment failure in ACIT is the inability of 
the transferred cells to engraft and persist.36,39  This study intends to help address these issues. 
2.1.4.1 Immunobiology of Memory Enriched T Cell Adoptive Transfer.  
The in vivo persistence of cultured T cells is improved by depletion of host lymphocytes before cell transfer 
and by the administration of IL-2 after cell transfer; but in half of treated melanoma patients these 

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interventions still did not result in long-term persistence of transferred T cells or sustained tumor 
regression.40,41  We hypothesize that intrinsic properties of T cells may be a critical determinant of their fate 
in vivo following adoptive transfer.  The pool of peripheral blood lymphocytes from which T cell products 
are derived ex vivo consist of naïve T cells (TN), and antigen experienced memory T cells (TM), which 
include central memory T cells (TCM). TCM express CD62L and CCR7 which promote migration into lymph 
nodes, produce IL-2, and proliferate rapidly in response to antigen stimulation.  In response to antigen in 
vivo, TCM differentiate into cytolytic effector T (TE) cells that express high levels of granzymes and perforin, 
but are otherwise short-lived.42,43  Thus, differentiation to a terminal TE phenotype during culture has been 
suggested to explain the poor survival of transferred T cells in clinical trials.44,45 
In the normal host, T cell memory persists for life, suggesting that some TM have the ability to self-renew 
or to revert to the memory pool after differentiating to TE in response to antigen re-exposure.46  Using an 
immunodeficient mouse model, as well as a non-human primate model (Macaca nemestrina) relevant for 
human translation, we have observed that TE cells derived from sort-purified CD62L+ TCM persisted in the 
blood long-term after adoptive transfer, migrated to memory T cell niches in the lymph nodes (LN) and 
bone marrow (BM), reacquired phenotypic properties of TM, and responded to antigen challenge in vivo.7,8  
Thus, we hypothesize that human TCM-derived effectors will retain their programming for persistence after 
their genetic modification and ex vivo propagation, and, upon adoptive transfer to GBM patients shortly 
following tumor biopsy or resection, as applicable, and intracavitary catheter placement, will produce 
robust anti-tumor responses against IL13Rα2+ MG.  
2.1.5 
Immunotherapy of Glioblastoma with Gene Modified T Cells. 
2.1.5.1 Redirected Specificity of T Cells Expressing Chimeric Antigen Receptors (CAR) 
Chimeric antigen receptors (CAR) engineered to consist of an extracellular antigen-binding domain fused 
to the intracellular signaling domain of the T cell antigen receptor complex zeta chain have the ability, when 
expressed in T cells, to redirect antigen recognition and cytolytic activity.1  The design of CAR with target 
specificities for tumor cell-surface epitopes is a conceptually attractive strategy to generate anti-tumor 
immune effector cells for adoptive therapy as it does not rely on pre-existing anti-tumor immunity. These 
receptors are “universal” in that they bind antigen in an MHC independent fashion; and, thus, one receptor 
construct can be used to treat a population of patients with antigen positive tumors.  Several constructs for 
targeting human tumors have been described in the literature including receptors with specificities for 
CD19, Her2/Neu, CEA, ERB-B2 and CD44v6.47  These epitopes all share the common characteristic of 
being cell-surface moieties accessible to binding by the CAR.  In vitro studies have demonstrated that both 
CD4+ and CD8+ T cell effector functions can be triggered via these receptors to specifically lyse tumor 
targets and secrete an array of pro-inflammatory cytokines including IL-2, TNF, IFN-γ, and GM-CSF. 
Moreover, animal models have demonstrated the capacity of adoptively transferred CAR-expressing T cells 
to eradicate established tumors. 
2.1.5.1 IL13Rα2-specific CAR 
Based on the IL13Rα2 expression profile described in Section 2.1.3, we have been interested in genetically 
modifying T cells to express an IL13Rα2-specific CAR.  The proposed IL13Rα2-specific CAR 
(IL13(EQ)BBζ), consisting of a membrane-tethered human IL-13 ligand mutated at a single site (E13Y) to 
reduce potential binding to IL13Rα1,5 has the ability, when expressed in T cells, to redirect antigen 
recognition and targeting  against IL13Rα2-expressing MG cells, including glioma cells with stem-like 
characteristics.5,6  This IL13(E13Y) tumor targeting domain linked to a human CD3ζ signaling domain has 
also been previously evaluated in our recent glioma trials (COH Protocol Nos. 01020 and 07082).  The 
similarities of the CAR used in these past MG studies versus the current proposed clinical study is depicted 
in Figure 2.1. Indeed, prior clinical experience - by our group using CAR T cells (reference Section 2.4.1 
below), and others using an IL13-immunotoxin delivered intratumorally 48 - provide evidence that 
immunotherapeutic approaches targeting IL13Rα2 for high-grade glioma can be safe and well-tolerated in 
patients. 

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Figure 2.1. Characterization of past and current IL13Rα2-specific CAR.  The IL13(E13Y)-zetakine CAR used in IRBs 01020 
and 07082 (Left) is composed of the IL13Rα2-specific human IL-13 mutein (huIL-13(E13Y)), human IgG4 Fc spacer (huγ4Fc), 
human CD4 transmembrane (huCD4 tm), and human CD3ζ chain cytoplasmic (huCD3ζ cyt) portions as indicated.  The 
IL13(EQ)BBζ CAR of this study (Right) is the same as the IL13(E13Y)-zetakine with the exception of the two point mutations, 
L235E and N297Q indicated in red, that are located in the CH2 domain of the IgG4 spacer, and the addition of a costimulatory 4-
1BB cytoplasmic domain (4-1BB cyt). 
 
2.1.5.2 Hinge-optimized CAR 
This protocol will use an IL13Rα2-specific CAR that has been modified at two sites within the CH2 region 
(L235E; N297Q)  which have been known to be important for recognition and binding by Fc receptors 
(FcRs) (reviewed in Current Opinion Biotechnology, 200949).  FcRs on NK cells and macrophages are 
known to mediate various immune functions such as antibody-dependent cell-mediated cytotoxicity 
(ADCC) and phagocytosis.  Our preclinical findings suggest that, while the L235E/N297Q mutations do 
not alter the antigen-specific functionality of the CAR, they do decrease the binding of recombinant soluble 
FcR molecules, and improve the engraftment and therapeutic efficacy of CAR-expressing cells in in vivo 
mouse models.  
2.1.5.3 Second Generation Costimulatory CAR.  
Our work and others have established that CAR containing the costimulatory signaling domain of CD137 
(4-1BB) and/or CD28 in tandem with the cytolytic activating domain of CD3ζ exhibit enhanced 
proliferation and anti-tumor function as compared to CARs containing CD3ζ alone.1,50,51  For this protocol 
we will incorporate the human 4-1BB costimulatory signaling domain in series with human CD3ζ as part 
of our CAR design since this costimulatory domain meets all the criteria for providing costimulation, 
including improvement of the survival and maintenance of memory T cells.52,53  Such costimulatory CAR 
have been proven to be both safe and highly effective in the clinic.54-56 
2.1.5.4 CD19t as a tracking marker  
Finally, the proposed T cell product will also be modified to express a truncated human CD19 (CD19t), 
which lacks the cytoplasmic signaling tail (truncated at amino acid 323). Co-expression of CD19t provides 
an inert, non-immunogenic surface marker that will allow for accurate measurement of gene modified cells, 
as well as efficient cell tracking of the therapeutic T cells in vivo following adoptive transfer. 
2.1.5.5 Use of ‘bulk’ TCM 
The rationale for using TCM for genetic modification is based on studies described in Section 2.1.4.1, where, 
using both murine xenograft models and a non-human primate model relevant for human translation, it was 
found that effector T cells derived from sort-purified CD62L+ TCM persisted after adoptive transfer and 
responded to antigen challenge in vivo.7,8   

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Our use of a “bulk” TCM population that includes both CD4+ and CD8+ cells for gene modification is based 
on ACIT studies in animal models and in the clinic that have documented the importance of including CD4+ 
T helper cells for optimal CD8+ T cell effector function, as well as persistence.57-59  Furthermore, it has now 
become a standard in the field to include both CD4+ and CD8+ T cells in immunotherapies that use CAR-
modified T lymphocytes for the treatment of malignancy (reviewed in Molecular Therapy 201160).  
However, to reduce the presence of CD4+ regulatory T cells (Tregs) that might inhibit the anti-tumor 
efficacy of the cell product,61 it is important to note that, instead of a CD4-depletion, we are including a 
CD25-depletion step (i.e., since these Tregs are known to express high levels of CD25/IL-2 receptor). The 
feasibility of depleting functional CD25+ Tregs in large scale under clinical-grade conditions for use in 
ACIT has also been previously reported.62 
2.1.5.6 Use of ‘bulk’ TN/MEM 
As a separate arm for comparison to the use of TCM as a starting T cell population, this study will use 
enriched CD62L+ naïve and memory T cells (TN/MEM) for CAR engineering as an investigational cell 
product. TN/MEM cells include both the central memory (TCM) and stem cell memory (TSCM) populations 
along with naïve T cells (TN). The enrichment methods for the two CD62L+ T cell starting populations 
differ only in the inclusion (TCM) or elimination (TN/MEM) of the CD45RA-depletion step. Specifically, 
TN/MEM cells are produced by CliniMACS/AutoMACS™ depletion of the CD14+ monocytes and the 
CD25+ regulatory T cells, followed by AutoMACS™ selection of the CD62L+ memory population. This 
is in contrast to TCM cells which are produced by CliniMACS/AutoMACS™ depletion of the CD14+ 
monocytes, the CD25+ regulatory T cells, and the CD45RA+ TN and TSCM, followed by AutoMACS™ 
selection of the CD62L+ population. This use of TN/MEM-derived T cell products will increase the feasibility 
of our manufacturing platform as well as the potential efficacy of the clinically administered cell products. 
Indeed, elimination of the CD45RA-depletion step for TN/MEM enrichment allows for the recovery of more 
T cells as compared to the TCM enrichment platform, thus allowing for an increased number of T cells that 
can be used as a starting population for genetic engineering. This will increase the feasibility of 
manufacturing CAR T cell products for clinical use, especially with research participants whose CD3+ T 
cell count is already low due to prior therapy.  Furthermore, our pre-clinical in vivo studies suggest that 
TN/MEM-derived cell products mediate anti-tumor responses that are superior to those seen with TCM-derived 
cell products. This observation is supported by the literature (reviewed in63) demonstrating that adoptive 
cell transfer of less differentiated T cell subsets (including the TN and TSCM found in the TN/MEM population) 
consistently exhibit superior in vivo anti-tumor activities compared to more differentiated effector T cells.  
2.1.6 
Route of Administration and Dosing.   
For research participants who receive either intratumoral or intracavitary delivery of CAR T cells: CAR 
T cells will be administered manually followed by up to 0.5 mL preservative-free normal-saline (PFNS) 
over approximately 5 minutes through a Rickham catheter.  
For research participants who receive intraventricular delivery of CAR T cells: CAR T cells will be 
administered manually followed by up to 0.5 mL preservative-free normal-saline (PFNS) over 
approximately 5 minutes through a Rickham catheter, placed into the lateral ventricle.  
For research participants who receive dual delivery (both the intratumoral/intracavitary and 
intraventricular delivery) of CAR T cells: the listed CAR+ T cell doses will be delivered into both the tumor 
bed/cavity and the ventricle, thereby doubling the total infused dose. For example, in Dose Schedule 2 
Cycle 1: 10x106 CAR+ T cells will be delivered intratumorally/intracavitary and 10x106 CAR+ T cells will 
be delivered intraventricularly for a total Cycle 1 infused dose of 20x106 CAR+ T cells. The administration 
of each dose will follow the rules listed above.  
The PFNS flush is meant to clear the administration line and ‘push’ remaining CAR T cells through the 
catheter.  

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Successful manual administration through a Rickham catheter of similar gene-modified IL13Rα2-specific 
cellular products has been successful in COH IRB Protocol Nos. 01020 (BB-IND 10109) and 07082 (BB-
IND 14194).  
As of 03/02/2018, we have closed Arm 1 (biopsy with an N=2) as biopsy participants can be included in 
the ICV or dual arms. The study will continue to enroll participants in the remaining 4 arms, intracavitary 
(Arm 2), intraventricular (Arm 3), or dual delivery (both intratumoral and intraventricular) (Arms 4 and 5).  
Note: If a research participant progresses on either Arm 1 or 2 after the first three CAR T cell infusion 
cycles, at the discretion of the PI, the research participant may move to intraventricular administration of 
CAR T cells for the optional infusion cycles.   
2.2 Overview of Proposed Study 
This Phase I, open-label, nonrandomized study proposes to examine the feasibility and safety of 
intratumoral/intracavitary/intraventricular/dual delivery administration of autologous ex vivo expanded 
central memory-enriched T cells (TCM or TN/MEM) that are genetically modified using a self-inactivating 
(SIN) lentiviral vector to express an IL13Rα2-specific, hinge-optimized, 41BB-costimulatory chimeric 
antigen receptor (CAR) as well as a truncated human CD19 (IL13(EQ)BBζ/CD19t+ T cells) to adult 
research participants with recurrent or refractory malignant glioma (MG).   
In this protocol, research subjects with documented IL13Rα2-positive recurrent/refractory high-grade 
glioma (Grades III and IV) will be enrolled and undergo PBMC collection. Research participant TCM or 
TN/MEM will be enriched from peripheral blood mononuclear cells (PBMC) using the CliniMACS® device 
to immunomagnetically select for CD45RO+/CD62L+ TCM or CD62L+ TN/MEM. These cells will then be 
activated with anti-CD3/CD28 Dynal beads, transduced with a SIN lentiviral vector that directs the 
expression of an IL13Rα2-specific, hinge-optimized, 41BB-costimulatory CAR (IL13(EQ)BBζ) as well as 
a truncated human CD19 (CD19t), a non-immunogenic surface marker for both in vivo detection and 
potential ex vivo selection. The activated/genetically modified IL13(EQ)BBζ/CD19t+ T cells will be 
expanded in vitro with IL-2/IL-15 and then cryopreserved. Concurrent with the manufacturing process, 
research participants will undergo biopsy or resection of their tumor(s), as applicable, followed by 
placement of a Rickham catheter(s) and baseline imaging. Following recovery from surgery, research 
participants will then receive an initial low dose (cycle 1) followed by 2 additional infusions at the 5-fold 
higher cell dose (cycles 2 and 3) of autologous IL13(EQ)BBζ/CD19t+ T cells, potentially followed by 
additional cycles at up to the highest tolerated cell dose (cycles 4+). Depending on the participant’s disease 
status, CAR T cells will be administered one of four ways: (1) directly into the tumor (Arm 1), (2) into the 
tumor resection cavity (Arm 2), (3) into the lateral ventricles (intraventricularly; Arm 3) or (4) into either 
the tumor bed/cavity (intratumoral) and into the lateral ventricles (intraventricular) (Arms 4 and 5 = 
dual delivery).   
The primary objectives of the study are to assess the feasibility and safety of intratumoral (Arm 1), 
intracavitary (Arm 2), intraventricular (Arm 3), or dual delivery (Arm 4) cellular immunotherapy utilizing 
ex vivo expanded autologous IL13(EQ)BBζ/CD19t+ T cells for research participants with 
recurrent/refractory malignant glioma, and to determine the maximum tolerated dose schedule 
(MTD)/maximum feasible dose scheduled (MFD) and a recommend phase II dosing plan (RP2D) for each 
arm based on dose limiting toxicities (DLTs) as defined in Section 5.7.  The primary endpoints are grade 3 
toxicities, DLTs, and all other toxicities.   
This study will be conducted in compliance with the protocol, Good Clinical Practice (GCP) and the 
applicable regulatory requirements. 

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2.3 Preclinical Studies 
2.3.1 
IL13(EQ)BBζ/CD19t+ TCM.  
The methods for the in vitro enrichment of human TCM, their genetic modification and expansion to generate 
clinical cell products that express CAR have been developed in our lab using blood obtained from human 
donors.64  The feasibility of engineering the expression of both a costimulatory CAR and a truncated 
selection marker has also been published.65  Furthermore, the 13 autologous TCM clinical products made to 
date under COH IRB Protocol Nos. 09174 (BB-IND 14645) and 12224 (BB-IND 15490) also support our 
experience in manufacturing clinical products similar to that described in this protocol.   
In addition to this experience, we have also performed two small scale qualification runs (detailed below) 
on cells procured from healthy donors using the manufacturing platform described above in Section 2.2, as 
well as 3 clinical scale GMP qualification runs as described in BB-IND 16226.  Importantly, these 
qualification runs expanded >80 fold within 28 days (Table 2.1) and the expanded cells expressed the 
IL13(EQ)BBζ/CD19t transgenes (Table 2.1 and Figure 2.2), and exhibited IL13Rα2-specific effector 
function (Figure 2.3).  
Table 2.1. Summary of CAR expression and fold-expansion  
Cell Product 
CAR 
CD19 
CD4* 
CD8* 
Fold-Expansion 
HD006.5 
20% 
22% 
24% 
76% 
84-fold;  
28 days 
HD187.1 
18% 
25% 
37% 
63% 
259-fold 
28 days 
*Percentages of CD4 and CD8 are donor specific and within the normal expected range 
 
Figure 2.2. Flow cytometric analysis of surface transgene and T cell marker expression. IL13(EQ)BBζ/CD19t+ TCM 
HD006.5 and HD187.1 were co-stained with anti-IL13-PE and anti-CD8-FITC to detect CD8+ CAR+ and CD4+ (i.e., CD8 
negative) CAR+ cells (A), or anti-CD19-PE and anti-CD4-FITC to detect CD4+ CD19t+ and CD8+ (i.e., CD4 negative) CAR+ 
cells (B). C, IL13(EQ)BBZ/CD19t+ TCM HD006.5 and HD187.1 stained with fluorochrome-conjugated anti-CD3, TCR, CD4, 
CD8, CD62L and CD28 (grey histograms) or isotype controls (black histograms). A-C, Percentages based on viable lymphocytes 
(DAPI negative) stained above isotype. 
 
 
 
 
13%
9%
6%
14%
HD006.5
HD187.1
IL13-PE (CAR)
CD19-PE
CD4-FITC
CD8-FITC
A
B
12%
13%
7%
11%
C
HD006.5
HD187.1
CD3         TCR        CD4        CD8        CD62L      CD28
100%
85%
24%
76%
80%
93%
100%
85%
37%
63%
85%
95%

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Figure 2.3. Effector activity of IL13(EQ)BBζ/CD19t+ TCM. A, IL13(EQ)BBζ/CD19t+ TCM HD006.5 and HD187.1 were used 
as effectors in a 6-hour 51Cr-release assay using a 10E:1T ratio based on CD19t expression. The IL13Rα2-positive tumor targets 
were K562 engineered to express IL13Rα2 (K562-IL13Rα2) and primary glioma line PBT030-2, and the IL13Rα2-negative tumor 
target control was the K562 parental line. B, IL13(EQ)BBζ/CD19t+ TCM HD006.5 and HD187.1 were evaluated for antigen-
dependent cytokine production following overnight co-culture at a 10E:1T ratio with the same IL13Rα2-positive and negative 
targets as described in (A). Cytokine levels were measured using the Bio-Plex Pro Human Cytokine TH1/TH2 Assay kit and INF-
γ levels are depicted. 
 
The efficacy of the proposed strategy is further supported by our preclinical studies demonstrating that 
IL13(EQ)BBζ/CD19t+ TCM exhibit anti-tumor efficacy in in vivo mouse models. Specifically, we have 
evaluated the anti-tumor potency of IL13(EQ)BBζ/CD19t+ TCM against the IL13Rα2+ primary low-
passage glioblastoma tumor sphere line PBT030-2, which has been engineered to express both EGFP and 
firefly luciferase (ffLuc) reporter genes (PBT030-2 EGFP:ffLuc).6 Our group has generated a panel of 
primary lines (PBT) from patient glioblastoma specimens grown as tumor spheres (TSs) in serum-free 
media.6,66 These expanded TS lines exhibit stem cell-like characteristics, including expression of stem cell 
markers, multi-lineage differentiation and capacity to initiate orthotopic tumors in immunocompromised 
mice (NSG) at low cell numbers.6,66  The PBT030-2 EGFP:ffLuc TS-initiated xenograft model (0.1x106 
cells; 5 day engraftment) has been previously used to evaluate in vivo anti-tumor activity in NSG mice of 
IL13Rα2-specific CAR expressing T cells manufactured under our glioma trial (COH Protocol No. 01020),6 
whereby three injections of 2x106 cytolytic T lymphocytes (CTLs) over a course of 2 weeks were shown to 
reduce tumor growth. However, in these experiments the majority of the PBT030-2 tumors eventually 
recurred.  By comparison, a single injection of IL13(EQ)BBζ/CD19t+ TCM (1.1x106 CAR+ TCM; 2x106 total 
TCM) exhibited robust anti-tumor activity against PBT030-2 EGFP:ffLuc TS-initiated tumors (0.1x106 cells; 
5 day engraftment) (reference Figure 2.4).  As compared to NSG mice treated with either PBS or mock 
transduced TCM (no CAR), IL13(EQ)BBζ/CD19t+ TCM significantly reduce ffLuc flux (p < 0.001 at >18-
days) and significantly improve survival (p = 0.0008).  
 
 
 
 
 
 
 
 
 
 
 
%  S p e c ific  L y s is
H D 0 0 6 .5  
H D 1 8 7 .1
0
1 0
2 0
3 0
4 0
K 5 6 2
K 5 6 2 -IL 1 3 R α 2
P B T 0 3 0 -2
> 9x
> 3x
A
B
H D 0 0 6 .5
H D 1 8 7 .1
0
1 0 0 0
2 0 0 0
3 0 0 0
4 0 0 0
IN F -γ   (p g /m l)
K 5 6 2
K 5 6 2  IL 1 3 R a 2
P B T 0 3 0 -2

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Figure 2.4. Regression of established glioma tumor xenografts after adoptive transfer of IL13(EQ)BBζ/CD19t+ TCM. EGFP-
ffLuc+ PBT030-2 tumor cells (1×105) were stereotactically implanted into the right forebrain of NSG mice. On day 5, mice received 
either 2x106 IL13(EQ)BBζ/CD19t+ TCM (1.1x106 CAR+; n=6), 2x106 mock TCM (no CAR; n=6) or PBS (n=6). A, Representative 
mice from each group showing relative tumor burden using Xenogen Living Image. B, Quantification of ffLuc flux (photons/sec) 
shows that IL13(EQ)BBζ/CD19t+ TCM induce tumor regression as compared to mock-transduced TCM and PBS (#p<0.02, 
*p<0.001, repeated measures ANOVA). C, Kaplan Meier survival curve (n=6 per group) demonstrating significantly improved 
survival (p=0.0008; log-rank test) for mice treated with IL13(EQ)BBζ/CD19t+ TCM.  
 
 
2.4 Human Studies 
2.4.1 
Clinical ACIT Experience at COH Using Genetically Modified T cells (CAR T cells).  
We have significant experience (over 10 years) with clinical adoptive cellular immunotherapy at COH using 
genetically-modified T cells.4,67,68  Our studies to date have demonstrated the tolerability of cell doses and 
lack of lymphoproliferative sequelae based on in vivo proliferation of transferred cells. Our lymphoma trials 
(COH IRB Protocol Nos. 09174 and 12224) demonstrate the feasibility for manufacturing gene-modified 
CAR+ TCM.   Perhaps most relevant to this application, however, are the gene therapy trials for malignant 
glioma (MG) (COH Protocol Nos. 01020 and 07082) evaluating the safety in targeting IL13Rα2 with 
repetitive intratumoral/intracavitary doses of CAR-expressing T cells. Reference Table 2.2 for a summary 
of Safety and Tolerability of these MG trials. 
D4                  D8          D11         D14        D18          D26         D41
PBS
tumor
6 of 6
Mock 
Tcm
tumor
6 of 6
IL13-CAR
Tcm
tumor
0 of 6
A
B
C

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Table 2.2. Safety and Tolerability of previous MG trials at COH 
IND Trial 
Patient 
T-cell 
Doses 
Infusion 
Schedule 
Maximum 
Tolerated 
Dose 
Cumulative 
T-cell Dose 
Adverse Event a 
(Time of Occurrence)b 
Survival 
Post Relapse 
(months) c 
 
10109 
(IRB 
01020) 
 
UPN028 
 
11 
 
 
4 weekly 
cycles; 
3 x per week 
(2 weeks on, 
1 week rest, 
2 weeks on) 
 
108 
 
 
9.6x108 
 
Headache 
(day of 1st  infusion;  
day after final infusion) 
 
 
10.3 
 
UPN031 
12 
108 
 
10.6x108 
Neurologic – Other 
(day after final infusion) 
 
8.6 
 
UPN033 
12 
108 
10.6 x108 
None 
13.9 
 
10109 
(IRB 
06164) 
 
 
UPN033 
 
 
5 
 
 
Consecutive 
days 
 
 
108 
 
 
 
3.75x108 
 
Low WBC 
(day of infusion 2) 
 
Headache 
(days of  
infusions 2-5) 
 
Fatigue 
(day of infusion 5) 
 
 
 
11.8d 
 
14149 
(IRB 
07082) 
 
UPN100 
 
4 
 
 
 
2 weekly 
cycles; 
2 x per week 
 
108 
 
 
4x108 
 
Dehydration 
(day after final infusion) 
 
Stroke 
(two weeks after 
final infusion) 
 
 
3.6e 
 
UPN102 
4 
108 
 
4x108 
None 
3.5e 
 
UPN103 
4 
108 
 
4x108 
None 
7.5 
 
UPN104 
4 
108 
 
4x108 
Gait disturbance 
(2nd day of first week) 
2.8 
 
UPN105 
4 
108 
 
4x108 
None 
11.9 
 
UPN106 
4 
108 
 
4x108 
None 
3.1 
a Only events of Grade 3 or higher, according to NCI Common Toxicity Criteria, with possible attribution to the T 
cell administration are reported. 
b Occurrence reported as related to T cell infusion schedule. 
c Relapse prior to T cell therapy was used to calculate survival. 
d Calculated after biopsy/relapse diagnosed on day he was placed on compassionate use protocol. 
e Calculation based on estimated date (only month/year recorded) of diagnosed progression after standard 
therapy. 
 
 
 
 
 

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2.4.1.1 COH Experience with Zetakine Redirected CTLs for Glioma Immunotherapy 
COH has completed 2 clinical trials utilizing zetakine redirected CTLs for glioma immunotherapy.  The 
first study, COH Protocol No. 01020 (BB-IND 10109) opened in 2002.  The trial was designed as an initial 
pilot study to evaluate the feasibility and safety of delivering an autologous cloned CD8+ CTL genetically 
modified to co-express the IL13-zetakine and the bi-functional selection-suicide gene HyTK. Post re-
resection intracavitary cell doses were stratified based on intra-research participant dose escalation starting 
at 107 to 108 total cells over the first 3 infusions followed by 9 additional cell doses of 108 over 4-weeks.  
This trial enrolled research participants following initial therapy where cell products were produced and 
cryopreserved until tumor relapse necessitated re-resection.  This prospective cell product manufacturing 
strategy was employed based on a consensus view that the 10-12 week production time was too long for 
enrollment at the time of relapse given the typically rapid demise of these research participants facing 
recurrent/progressive disease.  Cell products meeting all FDA-mandated release criteria were successfully 
manufactured for research participants enrolled on to the protocol, however, only three research participants 
met treatment eligibility and subsequently underwent adoptive therapy. A case study on one of the research 
participants has been reported with respect to the non-invasive detection of the autologous IL13(E13Y)-
zetakine+/HyTK+ CD8+ CTL using 18F-FHGB PET.4  Overall, there were 3 total SAEs of grade three or 
higher that were possibly related to the infusion of the CAR T cells – one research participant had a 
headache at the start of her third cycle of infusions, and then again the day after her final T cell infusion; 
and a second research participant experienced a transient neurologic event that caused a shuffling gait and 
tongue deviation to the left one day following her final T cell infusion.  Together, the three patients under 
COH Protocol No. 01020 had a mean survival of 11 months after relapse, with best survival of almost 14 
months.  One research participant (UPN031) had evidence that their IL13Rα2-specific adoptively 
transferred T cells were able to eliminate antigen positive glioma cells (manuscript in preparation). Another 
one of the three research participants under COH Protocol No. 01020 relapsed (on the hemisphere opposite 
that of the T cell infusion site) 20 days after his last T cell infusion, and was placed on a compassionate use 
COH Protocol No. 06164, also filed under BB-IND 10109, where he received 5 daily intratumoral infusions 
of the previously manufactured CAR T cells, at doses that escalated from 2.5x107 to 1x108. This participant 
experienced 6xSAEs of grade three or higher that were possibly related to the infusion of CAR T cells – 
four of them were headaches each day he received the second through fifth T cell infusions; one was a low 
white blood cell count on the day of the second T cell infusion; and another was fatigue experienced on the 
final day of T cell infusion.  Importantly, this patient exhibited a regression of the recurrent IL13Rα2+ 
GBM lesion following the intratumoral delivery of the CTL, as detected by MRI (Figure 2.5).  
 
 

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Figure 2.5. Regression of recurrent IL13Rα2+ glioma. Post gadolinium MRI (Left images) and MRS analysis of necrotic volume 
(Right bar graph) before and after the 5 daily infusions of autologous IL13(E13Y)-zetakine+/HyTK+ CD8+ CTL under the 
compassionate use protocol. Lack of tumor recurrence at the original treatment site (right occipital) and increase in necrosis at the 
recurrent site that was re-treated with T-cells (left corpus callosum, red circles) are highly suggestive of therapeutic efficacy. 
 
The second study, COH Protocol No. 07082 (BB-IND 14194) opened in 2010.  The trial was designed as 
a phase I study to evaluate the safety of an allogeneic CD8+ CTL line genetically modified to express 
IL13(E13Y)-zetakine and HyTK, and to be resistant to glucocorticoids, administered intratumorally in 
conjunction with convection enhanced delivery (CED) of recombinant human Interleukin-2 (rhuIL-2), for 
research participants with recurrent or refractory/progressive malignant glioma (WHO Grades 3 or 4).  In 
this study six (6) research participants received 2 cycles of 2x CAR T cell infusions per week (total of 4 
infusions) at cell doses of approximately 108 cells.  There were a total of 3xgrade three SAEs in 2 patients 
that were possibly related to the infusion of the CAR T cells –  the first was dehydration one day after the 
2 week treatment cycle; the second was a stroke that occurred in this same participant nearly two weeks 
after the final T cells/IL-2 infusion and was distant from the injection site; and the third event was a gait 
disturbance which occurred in another research participant on the second day of his first week of treatment, 
but this did not delay his next infusion, and his treatment course was otherwise uncomplicated.   Overall, 
the therapy was well tolerated with a mean survival of 5 months after relapse, and best survival of almost 
12 months in one patient. Furthermore, four research participants had evidence of tumor necrosis at the site 
of CAR T cell administration.  
Taken together, our prior clinical experience treating a total of 9 patients demonstrates the safety of 
administering intratumoral/intracavitary IL13Rα2-specific CAR T cells and the potential efficacy of this 
therapeutic approach. 
3.0 Patient Eligibility 
3.1 Screening Inclusion Criteria  
3.1.1 
Disease Status 
• Participant has a prior histologically-confirmed diagnosis of a grade III or IV 
glioma, or has a prior histologically-confirmed diagnosis of a grade II glioma and 
now has radiographic progression consistent with a grade III or IV MG after 
completing standard therapy. 
• Radiographic evidence of progression/recurrence of the measurable disease more than 12 
weeks after the end of the initial radiation therapy.     

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3.1.2 
Age Criteria, Performance Status and Life Expectancy  
• Male or female research participants between 12-75 years of age  
• KPS ≥60% 
• Life expectancy > 4 weeks 
3.1.3 
Child Bearing Potential 
The effects of IL13(EQ)BBζ/CD19t+ T cells on the developing fetus are unknown. For this reason, women 
of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method 
of birth control or abstinence) prior to study entry and for six months following duration of study 
participation. Should a woman become pregnant or suspect that she is pregnant while participating on the 
trial, she should inform her treating physician immediately.  
3.1.4 
Protocol-Specific Criteria 
• COH Clinical Pathology confirms IL13Rα2+ tumor expression by immunohistochemistry 
(> 20%, 1+). 
• All research participants must have the ability to understand and the willingness to sign a 
written informed consent. 
3.1.4.1 Eligibility to Proceed with PBMC Collection 
• Research participant must not require more than 2 mg TID of Dexamethasone on the day 
of PBMC collection. 
• Research participant must have appropriate venous access.  
• At least 2 weeks must have elapsed since the research participant received his/her 
last dose of prior chemotherapy or radiation. 
3.1.4.2 Eligibility to Proceed with Rickham Placement 
• Adequate renal function as evidenced by creatinine <1.6 mg/dL; 
• Adequate bone marrow function as evidenced by WBC > 2,000/dl (or ANC>1,000) and 
platelets > 100,000/dl, and INR<1.3; 
• Normal liver function as evidenced by bilirubin <1.5 mg/dL, and ALT and AST<2.5X 
upper limits of normal; 
• An interval of at least 12 weeks must have elapsed since the completion of initial radiation 
therapy;  
• Wash-out requirements (standard or investigational): 
• 
At least 6 weeks since the completion of a nitrosourea-containing 
chemotherapy regimen; and  
• 
At least 23 days since the completion of Temodar and/or 4 weeks for any other 
non-nitrosourea-containing cytotoxic chemotherapy regimen. If a patient’s 
most recent treatment was with a targeted agent only, and s/he has recovered 
from any toxicity of this targeted agent, then a waiting period of only 2 weeks 
is needed from the last dose and the start of study treatment, with the exception 
of bevacizumab where a wash out period of at least 4 weeks is required before 
starting study treatment. 
 
 

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3.1.4.3 Eligibility for Enrollment and to Proceed with CAR T Cell Infusion 
Research participants will enroll to the study once they meet Eligibility to Proceed with CAR T Cell 
Infusion prior to Cycle 1. Once enrolled, subjects will be considered on ‘active’ treatment until they 
complete the DLT evaluation period (~28-days). 
• Research participant has a released cryopreserved T cell product. 
• Pulmonary: Research participant does not require supplemental oxygen to keep saturation 
greater than 95% and/or does not have presence of any radiographic abnormalities on chest 
x-ray that are progressive. 
• Cardiac: Research participant does not require pressor support and/or does not have 
symptomatic cardiac arrhythmias. 
• Active Infection: Research participant does not have a fever exceeding 38.5°C; there is an 
absence of positive blood cultures for bacteria, fungus, or virus within 48-hours prior to T 
cell infusion and/or there aren’t any indications of meningitis. 
• Hepatic: Research participant serum total bilirubin or transaminases does not exceed 2X 
normal limit. 
• Renal: Research participant serum creatinine <1.8 mg/dL. 
• Neurologic: Research participant does not have uncontrolled seizure activity following 
surgery prior to starting the first T cell dose. 
• Hematologic: Research participant platelet count must be >100,000. However, if platelet 
level is between 75,000-99,000, then T-cell infusion may proceed after platelet transfusion 
is given and the post transfusion platelet count is >100,000. 
• Steroid Dependency: Research participants must not require more than 2 mg TID of 
Dexamethasone during T cell therapy. 
3.2 Screening Exclusion Criteria 
3.2.1 
Organ Function:   
• Pulmonary: Research participant requires supplemental oxygen to keep saturation greater 
than 95% and the situation is not expected to resolve within 2 weeks. 
• Cardiac: Research participant requires pressor support and/or has symptomatic cardiac 
arrhythmias. 
• Renal: Research participant requires dialysis. 
• Neurologic: Research participant has uncontrolled seizure activity and/or clinically evident 
progressive encephalopathy.  
3.2.2 
Study-Specific Exclusions 
• Failure of research participant to understand the basic elements of the protocol and/or the 
risks/benefits of participating in this phase I study. A legal guardian may substitute for the 
research participant. 
• Research participants with any non-malignant intercurrent illness which is either poorly 
controlled with currently available treatment, or which is of such severity that the 
investigators deem it unwise to enter the research participant on protocol shall be ineligible. 
• Research participants with any other active malignancies.  

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• Research participants being treated for severe infection or who are recovering from major 
surgery are ineligible until recovery is deemed complete by the investigator. 
• Research participants with any uncontrolled illness including ongoing or active infection. 
Research participants with known active hepatitis B or C infection; research participants 
with any signs or symptoms of active infection, positive blood cultures or radiological 
evidence of infections. 
• Research participants who have confirmed HIV positivity within 4 weeks of screening.  
3.2.3 
Non-Compliance 
Subjects, who in the opinion of the investigator, may not be able to comply with the safety monitoring 
requirements of the study. 
3.3 Inclusion of Women and Minorities 
The study is open to anyone regardless of gender or ethnicity.  Efforts will be made to extend the accrual 
to a representative population, but in a trial which will accrue approximately 23 participants on each of the 
remaining four arms for a total of 92 participants, a balance must be struck between subject safety 
considerations and limitations on the number of individuals exposed to potentially toxic or ineffective 
treatments on the one hand and the need to explore gender, racial, and ethnic aspects of clinical research on 
the other.  If differences in outcome that correlate to gender, racial, or ethnic identity are noted, accrual may 
be expanded or additional studies may be performed to investigate those differences more fully. 
4.0 Screening and Registration Procedures 
4.1 Screening Procedures 
A screening consent will be utilized to consent participants to allow for screening their existing tumor tissue 
for IL13Rα2+ expression. Once the IL13Rα2+ expression is confirmed and participants decide to proceed 
with the treatment portion of the study, they will be asked to sign the main consent. All other diagnostic or 
laboratory studies performed exclusively to determine eligibility for this trial will be done only after 
obtaining written informed consent for the main consent. Studies or procedures that were for clinical 
indications (not exclusively to determine study eligibility) may be used for baseline values, even if the 
studies were done before informed consent was obtained.  Reference is made to Section 10.0 – Study 
Calendar. 
4.2 Informed Consent  
The investigational nature and objectives of the trial, the procedures and treatments involved and their 
attendant risks and discomforts, and potential alternative therapies will be carefully explained to the subject 
and a signed informed consent will be obtained.  Documentation of informed consent will be maintained in 
the subject’s research chart and medical record.   
4.3 Registration Requirements/Process 
Research participants will be identified through the clinical practices of the PI, co-Is and participating 
clinicians and through direct referrals from outside hospitals and physicians. No direct-to-patient 
advertising will be performed without IRB approval.  
The following criteria will be used for pre- screening: 
• 
History and/or verification of high-grade glioma: History of high-grade glioma (WHO grade III or 
IV) or has a prior, histologically-confirmed diagnosis of a grade II glioma and now has radiographic 
findings consistent with a high grade glioma (grade III or IV) after completing standard therapy.   

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• 
Imaging and/or Histopathological Confirmation: Imaging and/or histopathological confirmation of 
recurrent disease, or verification of “high risk” histology. 
• 
IL13Rα2 expression: Potential research participants will request COH Pathology Core to perform 
prescreening immunohistochemistry for IL13Rα2 tumor expression after signing the screening 
consent. IL13Rα2 tumor expression performed on paraffin-embedded tumor specimen will be 
evaluated by COH Clinical Pathology by immunohistochemistry. Tumor expression will be scored 
on a scale of 0 to 3 with 0 representing negative, 1+ low, 2+ moderate and 3+ high staining intensity. 
The criteria for inclusion will be at least 20% of the cells scoring 1+ staining intensity (> 20%, 1+). 
After research participants have signed the main informed consent, met all screening criteria and have 
undergone leukapheresis procedure that yielded a CAR T cell product for infusion, has undergone Rickham 
catheter placement, and has been scheduled for Cycle 1 of CAR T cell infusion they will be registered to 
the study. The research participant will be registered (and marked as “active”) at the time Cycle 1 CAR T 
cell infusion starts. 
4.4 Randomization and/or Dose Level Assignment  
Reference Section 13.2, Dose Escalation Rules. 
5.0 Treatment Program 
5.1 Treatment Overview 
This will be a Phase I, open-label, non-randomized trial with 15 participants in the dose escalation portion 
of the trial, plus 6 in the expansion portion plus 2 for replacement of unevaluable participants giving an 
expected sample size of 23 per arm for each of the 4 open arms for a total of 92. As of 03/02/2018, we have 
closed Arm 1 (biopsy with an N=2) as biopsy participants can be included in the ICV or dual arms. Research 
participants with recurrent/progressive high-grade glioma will receive an initial low dose (cycle 1) followed 
by 2 additional infusions at the 5-fold higher cell dose (cycles 2 and 3) of autologous IL13(EQ)BBζ/CD19t+ 
T cells (‘CAR T cells’) delivered to the tumor bed (Arm 1 = IL13(EQ)BBζ/CD19t+ TCM intratumoral 
delivery), tumor cavity (Arm 2 = IL13(EQ)BBζ/CD19t+ TCM intracavitary delivery), into the lateral 
ventricles (Arm 3 = IL13(EQ)BBζ/CD19t+ TCM intraventricular delivery), into either the tumor bed or 
cavity (intratumoral) and into the lateral ventricles (intraventricular) (Arm 4 = IL13(EQ)BBζ/CD19t+ TCM 
dual delivery, and Arm 5 = IL13(EQ)BBζ/CD19t+ TN/MEM dual delivery) via indwelling catheter(s).  
If participants continue to meet eligibility criteria and have sufficient CAR T cell doses available they may 
receive additional cycles (cycles 4+) at the highest tolerated cell dose that was studied and deemed to be 
safe. If a research participant progresses following completion of the intracranial administration 
(intracavitary or intratumoral), at the discretion of the PI, the research participant may move to 
intraventricular administration of CAR T cells for additional CAR T cell infusions and may receive the 
highest dose deemed safe for that delivery method (reference Section 13.3) as long as the participant 
continues to meet eligibility criteria. For subjects initially treated on Arms 4 or 5, should the PI or designee 
decide to treat at only 1 delivery site, then during the additional cycles, the infusion doses may be delivered 
at up to the highest dose deemed safe for that delivery method. 
5.1.1 
Schedule 
For a tabular view of the treatment, monitoring, and follow-up schedule as well as allowable evaluation 
windows (e.g., +/- 7 days), see study calendar in Section 10. 
 
 

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The study treatment outline will include the following steps: 
5.1.1.1 Screening Evaluation 
Evaluation of research participant eligibility after signing the informed consent will include the following. 
However, procedures completed within 6 weeks of signing the informed consent will not be duplicated and 
will, therefore, be used to document eligibility: 
• 
Review by COH pathologists of available pathologic specimens to confirm history of high-
grade glioma. 
• 
Review of available MRI and PET images. 
• 
COH clinical pathology confirms IL13Rα2+ tumor expression by immunohistochemistry (> 
20%, 1+).  
• 
History and Physical Exam, Vital Signs, KPS. 
• 
Females and males of reproductive potential must use a physician-approved contraceptive 
method for at least two weeks prior to, during, and two months after final T cell infusion. 
• 
Serum pregnancy test for post-menarchal women without a history of tubal ligation or 
hysterectomy 
• 
 
• 
Initiation of the following tests: 
o 
HIV Ag/Ab Combo Assay 
o 
CBC, Differential, Platelet Count 
o 
Comprehensive Metabolic Panel 
o 
QuantiFERON-TB Gold or equivalent 
• 
Peripheral Blood Correlative Draw 
5.1.1.2 PBMC Collection for CAR T Cell Manufacturing 
PBMC collection will take place at the COH Donor Apheresis Center (DAC) according to DAC operating 
procedures. Research participants must be evaluated by a physician prior to PBMC collection and not have 
a standard contraindication for this procedure per COH standard practices. The evaluation process may take 
approximately 1 hour. If the research participant has appropriate venous access they will be scheduled for 
a leukapheresis procedure, however, if they do not then they may require a temporary catheter for central 
venous access. Please refer to Section 3.1.4.1 for eligibility criteria to proceed with PBMC collection.  
A leukapheresis procedure will be a single apheresis run of approximately 2-4 hours. Apheresis duration 
may be modified by the DAC physician as required by DAC policies without prior notification to the PI 
and will not result in a deviation.  Should a technical issue arise during the procedure or in the immediate 
processing of the product, such that it cannot be used for CAR T cell production, or if the PI determines 
that the patient will benefit from additional cell product manufacturing additional procedures may be 
ordered. 
5.1.1.3 Preparation for Biopsy/Resection and Rickham Placement 
Research participants will be evaluated by standard surgical policies and procedures for eligibility to 
proceed to Rickham reservoir/catheter placement into the tumor bed (intratumoral) and/or into the tumor 
cavity (intracavitary). In addition, for research participants who will receive intraventricular (ICV) delivery 
of CAR T cells, the Rickham reservoir/catheter will be placed into the lateral ventricle.  Should patient 
material be available in excess of that needed for standard pathologic studies, this excess material will be 
used for correlative studies assessing therapeutic responses to include but not be limited to tumor IL13Rα2 

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expression levels and susceptibility to re-directed CAR T cell effector mechanisms, CAR T cell persistence, 
and anti-therapy immune responses.  During this evaluation time and prior to surgical procedures, the 
following must be performed: 
• 
Vital Signs, KPS 
• 
EORTC QLQ-C30 Questionnaire  
• 
CBC, Differential, Platelet Count 
• 
Comprehensive Metabolic Panel 
• 
35 cc peripheral blood will be collected for Correlative Studies (drawn prior to surgical 
procedure) including, but not limited to, the following: 
o 
Ex vivo Immunophenotyping/Functional Analysis 
5.1.1.4 Post Surgery Evaluations 
Following biopsy/resection/Rickham placement, but before initiation of CAR T cell infusions, the research 
participants will be evaluated for the following baseline studies (required 1-2 weeks before initiating the 
CAR T cell infusions): 
• 
FDG-PET scan 
• 
MRI +/- contrast 
5.1.1.5 Adoptive Transfer of Cryopreserved CAR T Cell Product 
Prior to Cycle 1 infusion, research participants will be evaluated for study enrollment, and then prior to 
each cycle, research participants will be evaluated for CAR T cell infusion eligibility (reference Section 
3.1.4.2).  CAR T cell infusion may be delayed no more than 2-weeks without resulting in a DLT (reference 
Table 13.2).  No doses will be skipped (reference Section 13.1 Study Design for dosing rules).  
• 
Progress notes including vital signs (pulse rate, temperature, respiratory rate, blood pressure) 
• 
KPS  
• 
EORTC QLQ-C30 Questionnaire (REQUIRED for Cycles 1, 2 and 3 while elective for 
additional cycles) 
• 
Complete blood count, differential, platelet count 
• 
Comprehensive Metabolic Panel  
• 
35 cc peripheral blood will be collected for Correlative Studies (drawn prior to CAR T cell 
infusion) including, but not limited to, the following: 
o 
WPRE Q-PCR 
o 
Ex vivo Immunophenotyping/Functional Analysis 
• 
When feasible, tumor cavity fluid/CSF will be aspirated from research participants for 
Correlative Studies. 
• 
CTCAE evaluation using version 4 and the revised CRS grading system (Appendix 16.3) 
After a research participant is deemed eligible to proceed with CAR T cell infusion, the PI or designee will 
alert the T cell Manufacturing Supervisor and COH Quality Systems to initiate preparation of the CAR T 
cell infusion product. 
On the morning of CAR T cell infusion, a sample of the CAR T cell product will be sent for sterility 
analysis.  Results will be obtained after the product has been infused.  In the event that there is a positive 
microbiology culture, the PI or designee must be notified immediately.  Standard of care will be followed 

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to treat research participants having a bacterial, fungal or viral infection in addition to standard prophylaxis, 
with the agent chosen to cover the specific organism identified while taking into account any patient specific 
antibiotic allergies.  Treatment will be at the PI or designee’s discretion. 
Research participants will be pre-medicated approximately 30 minutes prior to CAR T cell infusion with 
15 mg/kg of acetaminophen P.O. (max. 650 mg), and diphenhydramine 25-50 mg I.V. or PO (max dose 50 
mg).  Clinically acceptable alternatives may be used if research participant is intolerant.  
5.1.1.6 Evaluation Period 
Following the completion of cycles 1 through 3, research participants will be required to undergo 
evaluations. Evaluations for adverse events will be made during each cycle and 1 week following the 3rd 
cycle.  Assessments for disease response will be required to be completed within 2 weeks from Cycle #3 at 
the discretion of the PI/designee: 
• 
Progress notes including vital signs (pulse rate, temperature, respiratory rate, blood pressure) 
• 
KPS  
• 
EORTC QLQ-C30 Questionnaire  
• 
Complete blood count, differential, platelet count 
• 
Comprehensive Metabolic Panel  
• 
CRP 
• 
FDG-PET  
• 
MRI +/- contrast 
5.2 Planned Duration of Therapy 
Therapy as defined on this study consists of three, weekly, dose escalating autologous 
IL13(EQ)BBζ/CD19t+ T cell infusions (CAR T cell infusions).  Infusion doses will be prepared in 0.5 mL 
PFNS (+2% HSA). 
For research participants who receive intratumoral or intracavitary delivery of CAR T cells: CAR T cells 
will be administered manually followed by up to 0.5 mL preservative-free normal-saline (PFNS) over 
approximately 5 minutes through a Rickham catheter.   
For research participants who receive intraventricular delivery of CAR T cells: CAR T cells will be 
administered manually followed by up to 0.5 mL preservative-free normal-saline (PFNS) over 
approximately 5 minutes through a Rickham catheter, placed into the lateral ventricle for an intraventricular 
administration.  
For research participants who receive dual delivery (both the intratumoral/intracavitary and 
intraventricular delivery) of CAR T cells: the listed CAR+ T cell doses will be delivered into both the tumor 
bed/cavity and the ventricle, thereby doubling the total infused dose. For example, in Dose Schedule 2 
Cycle 1: 10x106 CAR+ T cells will be delivered intratumorally/intracavitary and 10x106 CAR+ T cells will 
be delivered intraventricularly for a total Cycle 1 infused dose of 20x106 CAR+ T cells. The administration 
of each dose will follow the rules listed above.  
Please note that as of 03/02/2018, we have closed Arm 1 (biopsy with an N=2) as biopsy participants can 
be included in the ICV or dual arms. The study will continue to enroll participants in the remaining 4 arms, 
intracavitary (Arm 2), intraventricular (Arm 3), or dual delivery (both intratumoral and intraventricular) 
(Arms 4 and 5).  
The PFNS flush is meant to clear the administration line and ‘push’ remaining CAR T cells through the 
catheter. 

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Immediately following CAR T cell infusion research participants will be monitored for at least 3 hours 
(e.g., vital status, O2, BP and temp). 
5.2.1.1 Additional Cycles 
Additional cycles of CAR T cell infusions will be offered to research participants after they complete their 
required evaluation period, provided the following criteria are met:   
• 
In the initial Dose Schedule the participant received a cell dose that was well tolerated (i.e., did not 
experience a DLT at that dose level), and therefore may receive additional cycles via the same 
delivery route at or below this tolerated cell dose. 
• 
Additional CAR T cell product is available or can be generated from excess material of the PBMC 
collection, and the PI feels that the participant will benefit from undergoing an additional apheresis 
procedure.  
After first progression, a participant may continue to receive additional CAR T cycles as long as the 
participant continues to meet eligibility criteria. For subjects initially treated on Arms 4 or 5, should the PI 
or designee decide to treat at only 1 delivery site, then during the additional cycles, the infusion doses may 
be delivered at up to the highest dose deemed safe for that delivery method. 
Note: additional leukapheresis procedures may be performed in order to manufacture additional CAR T cell 
doses at the PI determination and per COH Transfusion guidelines. Participants must continue to meet all 
eligibility criteria as listed in Section 3.1.4.2 at the time of each additional infusion.  Infusions via the same 
delivery route will be given at less than or equal to the highest tolerated dose in Cycles 1 through 3. The 
dose may be lowered based on available cryopreserved product.  
5.3 Criteria for Removal from Treatment 
Research participants may be removed from the study for any of the following reasons: 
• 
Research Participant Premature Discontinuation 
Research participants who DO NOT receive any CAR T cell infusion will be considered screen failures and 
will NOT be enrolled to the study.   
Research participants who screen fail will be replaced.  The reasons for screen failure must be recorded on 
the case report form and may include: 
o The judgment of the PI, or his designee, is that the research participant is too ill to enroll 
and receive CAR T cell infusion, 
o Significant and rapid progression of GBM prior to CAR T cell infusion requiring 
alternative medical intervention that, in the opinion of the PI or his designee, is not 
compatible with CAR T cell therapy.  If a research participant had successful generation 
of a therapeutic CAR T cell product but screen failed, s/he may be eligible to enroll on the 
trial at a future date if they meet the eligibility criteria and a study slot is available. 
o Inability to manufacture and/or release a CAR T cell product. 
o Patient failure to meet eligibility criteria on Section 3.1.4.2, Eligibility Criteria to Enroll 
and Undergo Infusion of Genetically Modified Autologous T Cells (CAR T cells). 
o Research participant/family noncompliance with study therapy and/or clinic appointments, 
o Pregnancy, 
o Voluntary withdrawal; a research participant or his/her parents/legal guardians may 
remove himself/herself from the study at any time without prejudice. 
• 
Research Participant - Off Active Treatment 

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Research participants AFTER receiving any CAR T cell infusion would still be required to adhere to long 
term follow up guidelines as mandated for research participants who receive gene modified cells (follow-
up for 15 years from the time a CAR T cell product is infused). 
All research participants are free to withdraw from participation at any time, for any reason, specified or 
unspecified, and without prejudice. 
Potential reasons for the study participant being taken off active treatment include: 
o The judgment of the PI, or his designee, the research participant is too ill to continue,  
o Research participant/family noncompliance with study therapy and/or clinic appointments, 
o Pregnancy, 
o Voluntary withdrawal; a research participant or his/her parents/legal guardians may 
remove himself/herself from the study at any time without prejudice, 
o Significant progression of GBM requiring alternative medical interventions that in the 
opinion of the PI or his/her, designee, are not compatible with CAR T cell therapy.  
Research participants who have progressive disease may begin the modified follow-up 
evaluations outlined in Section 10.3 until completion of the 1 year (12 month) follow-up 
period at which time they will be followed in accordance with the FDA guidance “Gene 
Therapy Clinical Trials – Observing Subjects for Adverse Events.” 
• 
CAR T Cell Infusion cancelled for the following reasons: 
o Patient failure to meet eligibility criteria on Section 3.1.4.2, Eligibility Criteria at Time of 
Infusion of Genetically Modified Autologous T Cells (CAR T cells). 
o Inability to manufacture and/or release a CAR T cell product. 
o Significant and rapid progression of GBM prior to CAR T cell infusion requiring 
alternative medical intervention that, in the opinion of the PI or his designee, is not 
compatible with CAR T cell therapy. 
• 
Other definitions include the following: 
o Off Active Treatment: this is the date when the study PI/team and/or the patient decide that 
he/she will no longer be receiving CAR T cells. This date is then inputted into the CTMS 
and EPIC systems to denote that the participant is no longer actively receiving CAR T 
cells. 
o Off Protocol Therapy: This is the censor date which could reflect any of the following 
situations: 
 
Date of first progression after receiving CAR T cells. 
 
The start date of disallowed therapy for participants who have not yet progressed. 
 
The last date of contact for participants who have not yet progressed. 
 
 

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5.4 Subject Follow-Up 
5.4.1 
Follow-Up Post CAR T cell Infusion 
• 
Immediate follow-up: Research participants will have follow-up evaluations (reference Section 
10.1 for details) at least twice weekly during each CAR T cell infusion week for toxicities, serum 
analysis, correlative studies and, when accessible, tumor cavity aspirate/CSF samples. 
• 
In research participants who exhibit and/or experience cytokine release syndrome symptoms or 
focal neurological signs or mental status changes following CAR T cell therapy will be admitted to 
the hospital for observation, management of clinical symptoms (as applicable), and additional 
testing which MAY include a neurological consultation, MRI/CT, tumor cavity aspirate/CSF 
samples and a lumbar puncture. Subsequent correlative studies will include analysis of serum for 
cytokine profiles (reference Section 10). 
• 
Short-term follow-up: Research participants will have follow-up evaluations at 4 weeks and 3 
months post last CAR T cell infusion, subsequently at 6 months they will continue with evaluations 
every other month for the first year post last CAR T cell infusion for toxicities, and correlative 
studies (as applicable, reference Section 10.2). 
• 
Long-term follow-up: Research participants will continue with annual evaluations (reference 
Section 10.3 for details) for a minimum of 15 years in accordance with the guidance “Gene Therapy 
Clinical Trials – Observing Subjects for Adverse Events”. 
5.4.2 
AE and ConMed data collection:  
• 
Research participants, who have received at least one cycle of CAR T cells, will be followed and 
considered on active therapy through one week post last cycle of CAR T cells for toxicity and DLT 
assessments. During this time, all AE grade changes and ConMeds (as new, ongoing or 
discontinued) will be captured regardless of disease status or additional therapy (reference Section 
10.1). 
• 
During short term follow-up, AEs (including worst grade and attribution) and ConMeds (as new, 
ongoing or discontinued) will be captured at the set evaluation periods for the first year (reference 
Section 10.2).   
• 
Once the participant has completed one week post last cycle of CAR T cells or if they undergo one 
or more of the following: (1) receives radiation and/or high dose steroids, and/or (2) has 
documented disease progression, the research participant may be taken off active therapy and 
continue to be followed as specified below: 
o In the event a research participant undergoes either radiation and/or high dose steroids, the 
research participant may then continue to be followed per Section 10.3 where only select 
AEs attributable to gene therapy are collected while ConMed collection is no longer 
required. At the end of the first year post last CAR T cell infusion, the research participant 
will continue to be followed per FDA guidance on gene therapy clinical trials. 
o In the event a research participant is found to have progressive disease, the research 
participant may continue to be followed per Section 10.3, where only select AEs 
attributable to gene therapy are collected while ConMed collection is no longer required. 
At the end of the first year post last CAR T cell infusion, the research participant will 
continue to be followed per FDA guidance on gene therapy clinical trials. 
5.5 Supportive Care, Other Concomitant Therapy, Prohibited Medications 
5.5.1 
Supportive Care for Regimen Related Toxicities 
All standard supportive care measures for patients with recurrent/progressive GBM will be used at the 
discretion of the research participant's COH oncologist.   

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5.5.1.1 Contra-Indicated Medications 
Unless the Principal Investigator or his designee provides an exception, the following agents, other than 
specified in the protocol, are not allowed once CAR T cell infusion commences through completion of the 
DLT Evaluation Period (unless otherwise specified): 
• 
chemotherapy 
• 
immunosuppressive agents, with the following exceptions: 
o Start of CAR T cell Cycles through completion of Cycle 3:<2 mg TID of 
Dexamethasone, 
o  During Rest Week: <4 mg QID of Dexamethasone 
• 
immunotherapy  
• 
other investigational agents 
5.5.2 
Management of Constitutional Symptoms Associated with CAR T cell Infusion 
5.5.2.1 Fever, and Chills: Fever, chills and temperature elevations >101°F will be managed with 
additional Tylenol (or equivalent) as clinically indicated.   Demerol I.V. (max dose 50 
mg) may be given for chills.  Additional methods such as cooling blankets may be 
employed for fevers resistant to these measures.  Research participants that develop fever 
or chills will have a blood culture drawn.  Appropriate selection of empiric antibiotics 
for treatment of neutropenic fever will be administered to research participants who, in 
the opinion of the physician in attendance, appear septic; alternate antibiotic choices will 
be used as clinically indicated. 
5.5.2.2 Headache: Headaches may be managed with Tylenol (or equivalent).  If unresponsive to 
Tylenol, manage with good clinical judgment. 
5.5.2.3 Nausea and Vomiting: Nausea and vomiting will be managed with ondansetron IV or PO 
as well as additional standard anti-emetic treatments per patient preference. 
5.5.2.4 Seizures: All patients will be started on prophylactic antiepileptic drugs (AED) prior to 
the surgery. However, in the event of worsening seizure activity, AED dose strength and 
frequency will be increased, or a second-line AED will be started. 
5.5.2.5 Hypoxemia: Hypoxemia will be managed with supplemental oxygen.  An etiology for 
hypoxemia will be worked up per standard clinical practice. 
5.5.3 
Management of Acute Adverse Event(s) Attributable to This Study 
5.5.3.1 Management of Acute Adverse Event(s) Attributable to Infused CAR T Cells:  
Potential acute toxicities experienced following CAR T cell therapy include fever, chills, CRS, and change 
in mental status.  The following rules will be applied for such acute adverse events attributed to CAR T cell 
infusion: 
• 
Research participants experiencing a new grade 3 or higher toxicity with an attribution of 
probable or definite to the infused CAR T cells rather than expected toxicities attributable to 
the surgery or catheter placement, that in the opinion of the Principal Investigator puts the 
research participant in significant risk of an untoward outcome if measures are not taken to 
ameliorate the toxicity should commence with corticosteroids and/or IL-6 antagonist 
Tocilizumab (reference Section 8.1.2).   
• 
Additional measures may also be taken to resolve the toxicity should the protocol specified T 
cell toxicity treatment plans fail to ablate side effects associated with CAR T cell infusion such 
as, but not limited to, immunosuppressive medications or chemotherapy agents with 
immunosuppressive properties. 

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• 
If applicable, research participants will be hospitalized for at least the first 72 hours of receiving 
any CAR T cell toxicity treatment plan (reference Section 8 for specific treatment schedules). 
5.6 Additional Studies 
Additional studies will include relevant laboratory tests for screening and baseline evaluations as well as 
applicable laboratory tests to be performed during the follow up period. 
Reference is made to Section 9.0 for any correlative studies to be conducted under this protocol.  
5.6.1 
Laboratory Studies 
Laboratory evaluations will be performed described in Section 10. 
5.6.2 
Long-Term Follow-Up 
Research participants treated on this study are required to be followed for 15 years to monitor potential late 
effects of gene therapy as specified in the guidance “Gene Therapy Clinical Trials – Observing Subjects 
for Delayed Adverse Events’.   
Long term follow-up will include the following: 
• 
Physical examination which will include assessment for reproductive risk and risk to the fetus; 
autoimmune toxicities (such as new evidence or exacerbation of a prior rheumatologic or other 
autoimmune disorder); 
• 
Continued annual testing with an HIV test by qPCR, or equivalent as determined by the LTFU 
PI, for the diagnosis of HIV positivity which could result from an RCL mediated event from 
the investigational agent (initial testing at the pre, 3, 6, and 12 month time points previously 
required under COH IRB 13384 follow-up, reference Section 10); 
o In the event of a confirmed positive HIV result COH will require further testing to 
interrogate for evidence of a recombination event due to the investigational agent to 
distinguish from HIV infection. This will include qPCR testing for VSV-G and 
transgene. 
o Reports of all confirmed positive HIV results must be submitted to the FDA. Contact 
the Office of IND Development and Regulatory Affairs for such reporting 
requirements. 
• 
Evaluation of CAR T cell persistence which will include testing for long-term vector 
persistence and insertional mutagenesis until at such time CAR T cells become undetectable. 
o In the event of continued CAR T cell persistence, the participant will be asked to return 
to COH so that additional peripheral blood samples may be evaluated for clonal T cell 
population(s), including the gene expression profile (i.e., insertional site mutagenesis) 
and the cytokine independent growth potential of any such population. 
All long-term toxicities will be reported to the Agency in accordance with CFR 312.32. 
In addition, research participants will be requested to send all future brain imaging studies for review by 
the investigative team. Autopsy reports and available tissues/specimens will be sought on expired research 
participants who consent to this procedure. 
5.7 Definition of Dose-Limiting Toxicity (DLT) 
A dose limiting toxicity will be defined as events attributable to the T-cell infusion (probable or definite) 
with the exception of those listed in Section 8.1.2, and occurring from the time of initial CAR T cell infusion 
through 1 week following the last infusion cycle (not including the optional cycles) unless otherwise 
specified within this definition:  
a) Two grade 3 toxicities at the same dose with the exception of those grade 3 toxicities listed 
below; 

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b) Any grade 3 CRS toxicity lasting more than 72 hours with intervention; 
c) Any grade 3 or higher allergic reaction; 
d) Any grade 3 or higher autoimmune reaction; 
e) Any grade 4 toxicity 
Note: each treatment arm will be followed and analyzed separately.  
6.0 Dose Delays/Modifications for Adverse Events 
A single CAR T cell infusion will be performed at each delivery site, as applicable, for each cycle. This is 
an intrapatient and interpatient dose escalation study where dose delays and dose modifications are defined 
in Section 13.2 as part of the study design.   
7.0 Data and Safety Monitoring, Unanticipated Problems and Adverse Event 
Reporting  
7.1 Data and Safety Monitoring 
This is a Risk Level 4 study, as defined in the City of Hope Institutional Data and Safety Monitoring Plan 
[policy dated 07/09/2014]. This determination was made because the study involves COH as the IND holder 
and a first-in-human gene therapy for ex vivo expanded autologous IL13(EQ)BBζ/CD19t+ T Cells for 
patients with recurrent/refractory high-grade malignant glioma. 
7.2 Monitoring and Personnel Responsible for Monitoring 
The Protocol Management Team (PMT) is responsible for monitoring the data and safety of this study. The 
PMT consists of the Principal Investigator (PI), Collaborating Investigator, Biostatistician, Research 
Protocol Nurse, and Clinical Research Coordinator. is responsible for monitoring the data and safety of this 
study, including implementation of the stopping rules for safety and efficacy. 
The PMT is required to submit periodic status reports (i.e., the PMT Report) according to the frequency 
prescribed in the City of Hope Institutional Data and Safety Monitoring Plan [policy dated 07/09/2014].  
Important decisions made during PMT meetings (i.e., dose escalation, de-escalation, etc.) only need to be 
noted in the PMT Report submitted to the Data and Safety Monitoring Committee (DSMC). 
This study will utilize the Phase I tracking log to monitor data and safety for dose escalation.  The tracking 
log will contain dose levels administered, dose limiting toxicities (DLT), DLT-defining adverse events, and 
any details regarding dose level escalation. The record of doses administered and resultant adverse events 
will be included in the PMT Report.  
7.3 Definitions 
7.3.1 
Adverse Events and Serious Adverse Events 
The PI will be responsible for determining the event name, assessing the severity (i.e., grade), expectedness, 
and attribution of all adverse events. 
7.3.2 
Adverse event (AE): 
An adverse event is any untoward medical experience or change of an existing condition that occurs during 
or after treatment, whether or not it is considered to be related to the protocol intervention. 
7.3.3 
Reporting Non-serious Adverse Events 
Adverse events will be collected after the patient is given the study treatment.  Adverse events will be 
monitored by the PMT.  Adverse events that do not meet the criteria of serious OR are not unanticipated 
problems will be reported only in the PMT Report.  

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7.3.4 
Serious Adverse Event (SAE) [21 CFR 312.32]: 
[Modified from the definition of unexpected adverse drug experience in 21 CFR 312.32] - defined as any 
expected or unexpected adverse event that results in any of the following outcomes: 
• 
Death 
• 
Is life-threatening experiences (places the subject at immediate risk of death from the event as it 
occurred); 
• 
Unplanned hospitalization equal or greater than 24 hours or prolongation of existing hospitalization; 
• 
A persistent or significant disability/incapacity; 
• 
A congenital anomaly/birth defect, or 
• 
Secondary Malignancy. 
Any other adverse event that, based upon appropriate medical judgment, may jeopardize the subject’s health 
and may require medical or surgical intervention to prevent one of the outcomes listed above (examples of 
such events include allergic bronchospasm requiring intensive treatment in the emergency room or at home, 
blood dyscrasisas of convulsions that do not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse). 
7.3.5 
Reporting Serious Adverse Events 
Begins at the start of study treatment: All SAEs occurring during this study, whether observed by the 
physician, nurse, or reported by the patient, will be reported according to the approved City of Hope’s 
Institutional policy [policy effective date:  05/14/14].  Serious Adverse Events that require expedited 
reporting will be submitted electronically using iRIS. 
7.3.6 
Adverse Event Name and Severity 
The PI will determine the adverse event name and severity (grade) by using the CTCAE v4.0, the revised 
CRS grading system (Section Appendix 16.3) as well as the modified neurological grading system (Section 
16.1, Appendix A) from data obtained at each clinical assessment as outlined in Section 10.   
7.3.7 
Expected Adverse Event: 
Any event that does not meet the criteria for an unexpected event OR is an expected natural progression of 
any underlying disease, disorder, condition, or predisposed risk factor of the research participant 
experiencing the adverse event. 
7.3.8 
Unexpected Adverse Event [21 CFR 312.32 (a)]: 
An adverse event is unexpected if it is not listed in the investigator’s brochure and/or package insert; is not 
listed at the specificity or severity that has been observed; is not consistent with the risk information 
described in the protocol and/or consent; is not an expected natural progression of any underlying disease, 
disorder, condition, or predisposed risk factor of the research participant experiencing the adverse event. 
7.3.9 
Adverse Event Attribution 
The following definitions will be used to determine the causality (attribution) of the event to the study agent 
or study procedure. 
Definite - The AE is clearly related to the investigational agent or study procedure and unrelated to any 
other cause. 
Probable - The AE is likely related to the investigational agent or study procedure and unlikely related 
to other cause(s). 
Possible -The AE may be related to the investigational agent or study procedure and may be related to 
another cause(s). 

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Unlikely -The AE is doubtfully related to the investigational agent or study procedure and likely related 
to another cause(s). 
Unrelated -The AE is clearly not related to the investigational agent or study procedure and is 
attributable to another cause(s). 
7.3.10 COH Held IND  
Serious Adverse Events meeting the requirements for expedited reporting to the Food and Drug 
Administration (FDA), as defined in 21 CFR 312.32, will be reported as an IND safety report using the 
MedWatch Form FDA 3500A for Mandatory Reporting. 
The criteria that require reporting using the Medwatch 3500A are: 
• 
Any unexpected fatal or life threatening adverse experience associated with use of the drug must 
be reported to the FDA no later than 7 calendar days after initial receipt of the information [21 CFR 
312.32(c)(2)] 
• 
Any adverse experience associated with use of the drug that is both serious and unexpected must 
be submitted no later than 15 calendar days after initial receipt of the information [21 CFR 
312.32(c)(1)] 
• 
Any follow-up information to a study report shall be reported as soon as the relevant information 
becomes available. [21 CFR 312.32(d)(3)] 
The PI or designee will be responsible for contacting the Office of IND Development and Regulatory 
Affairs (OIDRA) at COH to ensure prompt reporting of safety reports to the FDA.  OIDRA will assist the 
PI with the preparation of the report and submit the report to the FDA in accordance with the approved City 
of Hope’s Institutional policy [policy effective date:  05/14/14]. 
7.3.10.1   Deviations and Unanticipated Problems 
Deviation - A deviation is a divergence from a specific element of a protocol that occurred without prior 
IRB approval.  Investigators may deviate from the protocol to eliminate immediate hazard(s) for the 
protection, safety, and well-being of the study subjects without prior IRB approval.  For any such deviation, 
the PI will notify the COH DSMC and IRB within 5 calendar days of its occurrence via iRIS in accordance 
with the Clinical Research Protocol Deviation policy [policy effective date:  11/07/11].   
Single Subject Exception (SSE) - An SSE is a planned deviation, meaning that it involves circumstances 
in which the specific procedures called for in a protocol are not in the best interests of a specific patient.  It 
is a deviation that is anticipated and receives prior approval by the PI and the IRB.  The SSE must be 
submitted as a “Single Subject Exception Amendment Request” via iRIS in accordance with IRB guidelines 
and the Clinical Research Protocol Deviation policy [policy effective date:  11/07/11].  An IRB approved 
SSE does not need to be submitted as a deviation to the DSMC. 
Unanticipated problem (UP): 
Any incident, experience or outcome that meets all three of the following criteria: 
1. Unexpected (in term nature, severity, or frequency) given the following: a) the research 
procedures described in the protocol-related documents such as the IRB approved research 
protocol, informed consent document or Investigator Brochure (IB); and b) the characteristics 
of the subject population being studied; AND 
2. Related or possibly related to participation in the research (possibly related means there is a 
reasonable possibility that the incident, experience, or outcomes may have been caused by 
the drugs, devices or procedures involved in the research); AND 
3. Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm) than previously known or recognized. 
 

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Any UP that occurs during study conduct will be reported to the DSMC and IRB in accordance with the 
City of Hope’s Institutional policy [policy effective date:  05/14/14] using iRIS. 
 
7.3.10.2   ADDITIONAL REPORTING REQUIRMENTS  
The Office of IND Development and Regulatory Affairs (OIDRA) will assist the PI in reporting the event 
to the Food and Drug Administration (FDA). 
Studies Involving Gene Therapy and COH Held IND  
As this study involves gene therapy and a COH held IND, the PI is required to report adverse events using 
iRIS. The Office of IND Development and Regulatory Affairs (OIDRA) will be responsible for reporting 
the adverse event to National Institutes of Health-Office of Biotechnology Activities (NIH-OBA) using the 
MedWatch Form FDA 3500.  
Long Term Follow-Up of Gene Therapy Studies 
Study patients will be followed long term for up to 15 years in accordance with the guidance “Gene Therapy 
Clinical Trials – Observing Subjects for Adverse Events” (reference Section 10).  It is the PI’s responsibility 
to continue reporting data and safety concerns to the FDA, DSMC, and IRB as they arise during the follow-
up period. 
8.0 Agent Information and Risks 
8.1 IL13(EQ)BBζ/CD19t+ T Cells (BB-IND 16226) 
8.1.1 
Description 
The investigational agent in this protocol is IL13(EQ)BBζ/CD19t+ T Cells.  Autologous T cells will be 
isolated from patient’s PBMC collection after ficoll separation.  Peripheral blood mononuclear cell (PBMC) 
preparations will then undergo immunomagnetic selection to derive TCM enriched (Arms 1-4) or TN/MEM 
enriched (Arm 5) T cell preparations.  The resulting cell preparation, highly enriched for CD45RO+CD62L+ 
TCM, or CD62L+ TN/MEM, will then be activated with anti-CD3/CD28 beads.  Activated TCM or TN/MEM (as 
applicable) will undergo a lentiviral transduction to express the human IL13(EQ)BBζ CAR and human 
CD19t transgenes (description of the lentiviral vector is provided below), expanded in vitro to achieve cell 
numbers sufficient for the research participant’s planned clinical cell dose and all related product release 
testing, and then harvested, washed and formulated for cryopreservation until time of infusion.   
Lentiviral Vector IL13(EQ)BBZ-T2A-CD19t _epHIV7:Clinical grade IL13(EQ)BBZ-T2A-CD19t _epHIV7 
lentiviral vector was produced and released by COH Center for Biomedicine and Genetics (reference BB-
MF 9778).  All raw materials used for the production of the lentiviral vector were released by the Quality 
Assurance (QA) department of CBG prior to use.  Certificates of Analysis (CofAs) for all materials 
referenced in any lentiviral production batch record, as well as completion of batch records, labeling and 
tracking of the product are maintained by the Center for Applied Technology Development, Department of 
Quality Systems.  All processes were carried out according to SOPs and include QA oversight for cGMP 
compliance.   The cloned DNA that will be used for the genetic modification of autologous T cells consists 
of a IL13Rα2-specific, hinge-optimized, costimulatory chimeric immunoreceptor sequence (designated 
IL13(EQ)BBZ), a ribosome-skip T2A sequence,69 and a CD19t sequence. The IL13(EQ)BBZ sequence was 
generated by fusion of the human GM-CSF receptor alpha leader peptide with human IL13(E13Y) ligand,5 
L235E/N297Q-modified human IgG4 Fc hinge (where the double mutation interferes with FcR 
recognition49), human CD4 transmembrane, human 4-1BB cytoplasmic signaling domain, and human 
CD3ζ cytoplasmic signaling domain sequences. This sequence was synthesized de novo by Geneart after 
codon optimization. The T2A sequence was obtained from digestion of a T2A-containing plasmid. The 
CD19t sequence was obtained from that spanning the leader peptide sequence to the transmembrane 
components (i.e., base pairs 1-972) of a human CD19-containing plasmid.  All three fragments, 1) 

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IL13(EQ)BBZ, 2) T2A, and 3) CD19t, were cloned into the multiple cloning site of the epHIV7 lentiviral 
vector, so that its transcription is driven by the EF1 promoter.  The IL13(EQ)BBZ-T2A-CD19t _epHIV7 
construct does not contain an intact 3’ long terminal repeat (LTR) promoter, so the resulting expressed and 
reverse transcribed DNA proviral genome in targeted cells will have inactive LTRs. As a result of this 
design, no HIV-I derived sequences will be transcribed from the provirus and only the therapeutic 
IL13(EQ)BBZ and CD19t sequences will be expressed.  The removal of the LTR promoter activity in this 
self-inactivating vector is also expected to significantly reduce the possibility of unintentional activation of 
host genes.70 Furthermore, this study will employ replication-incompetent lentivirus produced by the 4-
plasmid co-transfection of producer cells (i.e., 293T renal carcinoma cells).Briefly, the crippled 
IL13(EQ)BBZ-T2A-CD19t _epHIV7 containing lentivirus was harvested from cultures of 293T cells that 
had been transiently transfected with the following four plasmids encoding the required components: 1) pCgp 
containing the HIV-1 gag and pol genes required for viral vector assembly; 2) pCMV-G containing the VSV-
G gene required for viral vector infectivity; 3) pCMV-rev containing the rev gene which assists in the 
transportation of the viral genome for efficient packaging; and 4) the above described IL13(EQ)BBZ-T2A-
CD19t _epHIV7 transfer vector. 
8.1.2 
Toxicology 
Anticipated “expected” adverse events associated with the intracranial infusion of genetically modified T 
cells (CAR T cells) include: 
• 
< Grade 3 Dyspnea lasting up to 72 hours with intervention 
• 
Grade 3 Fever lasting up to 5 days with intervention 
• 
Grade 4 Fever for less than 72 hours with intervention  
• 
≤ Grade 2 Chills lasting for less than 72 hours with intervention  
• 
Grade 3 Tachycardia not responding to intervention and lasting up to 72 hours 
• 
≤ Grade 3 Hypotension not responding to intervention and lasting up to 72 hours  
• 
≤ Grade 3 Headache lasting for less than 48 hours  
• 
≤ Grade 3 Nausea/vomiting lasting for less than 48 hours  
• 
< Grade 3 Neurological toxicities  
• 
< Grade 3 Rash lasting up to 72 hours with intervention 
• 
Cytokine Release Syndrome 
o Grade 2 Cytokine Release Syndrome lasting up to 5 days with intervention 
o Grade 3 or 4 CRS with hypotension alone requiring a single vasopressor for support (not 
requiring intubation) that resolves to < Grade 3 in ≤72 hours 
o Grade 3 or 4 hypotension (without other CRS symptoms) requiring a single vasopressor for 
support that resolves to < Grade 3 in ≤72 hours  
o Grade 3 encephalopathy for ≤7 days and resolves to baseline in ≤28 days 
As cytokine release syndrome consists of a combination of toxicities and can only be diagnosed 
through exclusion it is believed that a grade 2 event lasting up to 5 days or a grade 3 event 
lasting up to 3 days are toxicities that can both be managed and diagnosed within the given 
timeframes.  In the event either grade continues beyond the allowable timeframe with 
intervention the event will be considered a DLT (Reference Appendix 16.3).  
 
*Allowable ‘expected’ AEs will not result in administration of CAR T cell ablation methods, and will not 
be considered a DLT. 
 
Adverse events from the above list occurring within the specified time will: 
• 
Not result in an expedited adverse event reporting to the FDA 
• 
Not result in ablation of CAR T cells with corticosteroids 

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Management of Acute Toxicities associated with CAR T cell activity (i.e., grade 3 and above cytokine 
release syndrome, or macrophage activation syndrome) requiring the treatment of CAR T cell related side 
effects the participant will receive supportive management including Tocilizumab (using computerized 
order entry, reference Section 8.4), and/or high dose steroids. Recent literature supports the option of a 
rapid steroid taper within several days without recurrence of the CRS71. Dosing and choice of corticosteroid 
will be tailored to the individual patient, at the discretion of the principle investigator. Commonly used 
initial doses include methylprednisolone (2 mg/kg/day), which may be weaned over several days, 
depending on response to therapy. Alternatively, consideration may be given to using dexamethasone (0.5 
mg/kg; maximum, 10 mg/dose) due to more efficient penetration of the blood:brain barrier. Evidence for 
differential efficacy of methylprednisolone vs. dexamethasone in this setting has not been established. 
Reference is also made to the COH CRS Management SOP.   
Management of Chronic Toxicities associated with transferred CAR T cell (insertional mutagenesis, 
tumorigenesis of infused CAR T cells) requiring the ablation of CAR T cells, high dose steroids can be 
given. Chemotherapy treatment of the treatment physician’s choice is also allowed to eradicate aberrant 
CAR T cells.  
 
8.1.3 
Pharmacology – Handling, Storage, Dispensing and Disposal 
The IL13(EQ)BBζ/CD19t+ T Cell product will be prepared under BB-IND 16226 by the T Cell 
Therapeutics Research Laboratory (TCTRL) staff under the direction of Dr. Stephen Forman.  Cell products 
are prepared using approved standard operating procedures and manufactured under cGMP conditions on 
COH campus as described in Section 8.1.  All raw materials used for the production of the cell product are 
released by the QA department of CBG prior to use.  Certificates of Analysis for all materials referenced 
in any cell product batch record and all records for T cell manipulations, including cell selection and 
transduction, as well as completion of batch records, labeling and tracking of the cell product will be 
maintained by the Center for Applied Technology Development, Department of Quality Systems.  All 
processes are carried out according to SOPs and include QA oversight for cGMP compliance.  
Cryopreserved cell products as well as prepared infusion doses are Quality Control tested as required under 
IND and released for use by the Director of Quality Systems, or designee, Center for Applied Technology 
Development (CATD).   
Cryopreserved vials will be frozen using a controlled rate freezer and stored in vapor phase in a controlled 
access LN2 freezer until released for clinical use.  The required number of cryopreserved vials will be 
thawed, cooled and washed with a PBS/2% human serum albumin (HSA) Wash Buffer.  After 
centrifugation, the supernatant will be removed and the cells resuspended in a Preservative-Free Normal 
Saline (PFNS)/ 2% HSA infusion diluent.   
Research participants will be pre-medicated approximately 30 minutes prior to CAR T cell infusion with 
15 mg/kg of acetaminophen P.O. (max. 650 mg), and diphenhydramine 25-50 mg I.V. or PO (max dose 50 
mg).  Clinically acceptable alternatives may be used if research participant is intolerant. 
Upon receipt of the PI’s request for infusion preparation, the appropriate number of cryopreserved vial(s) 
will be thawed, washed and prepared at a concentration of no more than 0.5 x 106 cells/µL and released to 
the PI by the Director of Quality Systems, or designee.  Samples of the final product will be tested for 
sterility as required by the IND. 
Prepared infusion dose(s) will be maintained at room temperature on a rocker until transported to patient 
bedside by Quality Systems.  Expiration date and/or time will be provided on the product label as 
determined by stability testing performed by TCTRL and forwarded to the FDA by formal amendment. 
Any product released to the PI that is not infused to the patient will either be released back to the TCTRL 
for storage or discarded by clinical staff per institutional policy, and documented on the infusion record. 

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8.2 ACTEMRA® (Tocilizumab) 
8.2.1 
Description: 
ACTEMRA® (tocilizumab) is indicated for the treatment of adult patients with moderately to severely 
active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-
Rheumatic Drugs (DMARDs), active polyarticular juvenile idiopathic arthritis in patients 2 years of age 
and older, and active systemic juvenile idiopathic arthritis in patients 2 years of age and older. 
Tocilizumab binds specifically to both soluble and membrane-bound IL-6 receptors (sIL-6R and mIL-6R), 
and has been shown to inhibit IL-6-mediated signaling through these receptors. IL-6 is a pleiotropic pro-
inflammatory cytokine produced by a variety of cell types including T- and B-cells, lymphocytes, 
monocytes and fibroblasts. IL-6 has been shown to be involved in diverse physiological processes such as 
T-cell activation, induction of immunoglobulin secretion, initiation of hepatic acute phase protein synthesis, 
and stimulation of hematopoietic precursor cell proliferation and differentiation. IL-6 is also produced by 
synovial and endothelial cells leading to local production of IL-6 in joints affected by inflammatory 
processes such as rheumatoid arthritis. 
Recent clinical responses in the field of adoptive cellular immunotherapy related to the effective tumor 
targeting by engineered CAR T cell therapy have been associated with acute cytokine release syndrome 
(CRS) which often requires intensive care to manage.54  In one case of CRS, the use of steroids did not 
abrogate CRS, though this was subsequently controlled by the anti-cytokine antibodies54 implying that the 
antibodies not only provide an adequate alternative to steroids but that they are in fact likely a superior 
alternative. Furthermore, with the avoidance of steroids, these patients have been able to go on and have 
good responses to therapy. Although this anti-cytokine agent is associated with immune suppression when 
dosed repeatedly in the context of disease like arthritis or psoriasis there is little evidence to suggest risk in 
this on-off dosing context where the immediate benefits may well be life-saving.54  
For this study, Tocilizumab will be used per COH institutional SOPs to manage CRS (as described in 
Section 8.1 above). 
8.2.2 
Toxicology: 
ADVERSE REACTIONS: Most common adverse reactions (incidence ≥ 5%): upper respiratory tract 
infections, nasopharyngitis, headache, hypertension, increased ALT.  
WARNINGS and PRECAUTIONS: 
Serious Infections: Serious and sometimes fatal infections due to bacterial, mycobacterial, invasive fungal, 
viral, protozoal, or other opportunistic pathogens have been reported in patients receiving 
immunosuppressive agents including ACTEMRA for rheumatoid arthritis. The most common serious 
infections included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, 
diverticulitis, sepsis and bacterial arthritis. Among opportunistic infections, tuberculosis, cryptococcus, 
aspergillosis, candidiasis, and pneumocystosis were reported with ACTEMRA. Other serious infections, 
not reported in clinical studies, may also occur (e.g., histoplasmosis, coccidioidomycosis, listeriosis). 
Patients have presented with disseminated rather than localized disease, and were often taking concomitant 
immunosuppressants such as methotrexate or corticosteroids which in addition to rheumatoid arthritis may 
predispose them to infections. 
 
ACTEMRA should not be administered in patients with an active infection, including localized infections. 
The risks and benefits of treatment should be considered prior to initiating ACTEMRA in patients:  
• 
with chronic or recurrent infection;  
• 
who have been exposed to tuberculosis;  
• 
with a history of serious or an opportunistic infection;  
• 
who have resided or travelled in areas of endemic tuberculosis or endemic mycoses; or  
• 
with underlying conditions that may predispose them to infection.  

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Patients should be closely monitored for the development of signs and symptoms of infection during and 
after treatment with ACTEMRA, as signs and symptoms of acute inflammation may be lessened due to 
suppression of the acute phase reactants.  
 
ACTEMRA should be interrupted if a patient develops a serious infection, an opportunistic infection, or 
sepsis. A patient who develops a new infection during treatment with ACTEMRA should undergo a prompt 
and complete diagnostic workup appropriate for an immunocompromised patient, appropriate antimicrobial 
therapy should be initiated, and the patient should be closely monitored 
 
Tuberculosis: Patients should be evaluated for tuberculosis risk factors and tested for latent infection prior 
to initiating ACTEMRA. Anti-tuberculosis therapy should also be considered prior to initiation of 
ACTEMRA in patients with a past history of latent or active tuberculosis in whom an adequate course of 
treatment cannot be confirmed, and for patients with a negative test for latent tuberculosis but having risk 
factors for tuberculosis infection. Consultation with a physician with expertise in the treatment of 
tuberculosis is recommended to aid in the decision whether initiating anti-tuberculosis therapy is 
appropriate for an individual patient. Patients should be closely monitored for the development of signs and 
symptoms of tuberculosis including patients who tested negative for latent tuberculosis infection prior to 
initiating therapy. It is recommended that patients be screened for latent tuberculosis infection prior to 
starting ACTEMRA. The incidence of tuberculosis in worldwide clinical development programs is 0.1%. 
Patients with latent tuberculosis should be treated with standard antimycobacterial therapy before initiating 
ACTEMRA.  
 
Viral Reactivation: Viral reactivation has been reported with immunosuppressive biologic therapies and 
cases of herpes zoster exacerbation were observed in clinical studies with ACTEMRA. No cases of 
Hepatitis B reactivation were observed in the trials; however patients who screened positive for hepatitis 
were excluded. 
 
Gastrointestinal Perforations: Events of gastrointestinal perforation have been reported in clinical trials, 
primarily as complications of diverticulitis. ACTEMRA should be used with caution in patients who may 
be at increased risk for gastrointestinal perforation. Patients presenting with new onset abdominal 
symptoms should be evaluated promptly for early identification of gastrointestinal perforation.  
 
Laboratory Parameters  
Neutrophils  
Treatment with ACTEMRA was associated with a higher incidence of neutropenia. Infections have been 
uncommonly reported in association with treatment-related neutropenia in long-term extension studies and 
postmarketing clinical experience. It is not recommended to initiate ACTEMRA treatment in patients with 
a low neutrophil count i.e., absolute neutrophil count (ANC) <2000/mm3. In patients who develop an 
absolute neutrophil count <500/mm3 treatment is not recommended. Neutrophils should be monitored every 
4 to 8 weeks. 
 
Platelets  
Treatment with ACTEMRA was associated with a reduction in platelet counts. Treatment-related reduction 
in platelets was not associated with serious bleeding events in clinical trials. It is not recommended to 
initiate ACTEMRA treatment in patients with a platelet count below 100,000/mm3. In patients who develop 
a platelet count <50,000/mm3 treatment is not recommended. Platelets should be monitored every 4 to 8 
weeks. 
 
 
 

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Liver Function Tests  
Treatment with ACTEMRA was associated with a higher incidence of transaminase elevations. These 
elevations did not result in apparent permanent or clinically evident hepatic injury in clinical trials. 
Increased frequency and magnitude of these elevations was observed when potentially hepatotoxic drugs 
(e.g., MTX) were used in combination with ACTEMRA. In one case, a patient who had received 
ACTEMRA 8 mg/kg monotherapy without elevations in transaminases experienced elevation in AST to 
above 10x ULN and elevation in ALT to above 16x ULN when MTX was initiated in combination with 
ACTEMRA. Transaminases normalized when both treatments were held, but elevations recurred when 
MTX and ACTEMRA were restarted at lower doses. Elevations resolved when MTX and ACTEMRA were 
discontinued. It is not recommended to initiate ACTEMRA treatment in patients with elevated 
transaminases ALT or AST > 1.5x ULN. In patients who develop elevated ALT or AST > 5x ULN treatment 
is not recommended. ALT and AST levels should be monitored every 4 to 8 weeks. When clinically 
indicated, other liver function tests such as bilirubin should be considered.  
 
Lipids  
Treatment with ACTEMRA was associated with increases in lipid parameters such as total cholesterol, 
triglycerides, LDL cholesterol, and/or HDL cholesterol. Assessment of lipid parameters should be 
performed approximately 4 to 8 weeks following initiation of ACTEMRA therapy, then at approximately 
6 month intervals. Patients should be managed according to clinical guidelines [e.g., National Cholesterol 
Educational Program (NCEP)] for the management of hyperlipidemia.  
 
Immunosuppression  
The impact of treatment with ACTEMRA on the development of malignancies is not known but 
malignancies were observed in clinical studies. ACTEMRA is an immunosuppressant, and treatment with 
immunosuppressants may result in an increased risk of malignancies.  
 
Hypersensitivity Reactions  
Serious hypersensitivity reactions, including anaphylaxis, have been reported in association with infusion 
of ACTEMRA. Appropriate medical treatment should be available for immediate use in the event of an 
anaphylactic reaction during administration of ACTEMRA. 
 
Demyelinating Disorders  
The impact of treatment with ACTEMRA on demyelinating disorders is not known, but multiple sclerosis 
and chronic inflammatory demyelinating polyneuropathy were reported rarely in clinical studies. Patients 
should be closely monitored for signs and symptoms potentially indicative of demyelinating disorders. 
Prescribers should exercise caution in considering the use of ACTEMRA in patients with preexisting or 
recent onset demyelinating disorders.  
 
Active Hepatic Disease and Hepatic Impairment  
Treatment with ACTEMRA is not recommended in patients with active hepatic disease or hepatic 
impairment.  
 
Vaccinations  
Live vaccines should not be given concurrently with ACTEMRA as clinical safety has not been established. 
No data are available on the secondary transmission of infection from persons receiving live vaccines to 
patients receiving ACTEMRA. No data are available on the effectiveness of vaccination in patients 
receiving ACTEMRA. Because IL-6 inhibition may interfere with the normal immune response to new 
antigens, patients should be brought up to date on all recommended vaccinations, except for live vaccines, 
prior to initiation of therapy with ACTEMRA.  

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8.2.3 
Pharmacology – Handling, Storage, Dispensing and Disposal 
Tocilizumab 
will 
be 
used 
per 
COH 
institutional 
SOPs 
(https://cityofhope.my.salesforce.com/069d0000001W24A) especially in the management of severe CRS 
when (C-Reactive Protein) CRP is >/=20mg/dl, Marco Davila et al, Science Translational Medicine 2014.72 
Due to the 1-2 day turn-around time reasonably expected for cytokine results, it is reasonable to consider 
administration of Tocilizumab based on clinical evidence of CRS, and before having the cytokine data in 
hand. 
9.0 Correlative/Special Studies 
9.1 Summary of Correlative Studies 
Correlative studies will include collaborative efforts (not limited to) with Translational Genomics Research 
Institute (TGen),Dr. Swanson’s Laboratory at Mayo Clinic, and Dr. Roy’s Laboratory at Georgia Tech. 
Tumor specimen samples (either solid or residual fluid), CSF samples (when available) as well as peripheral 
blood will be collected from research participants at the designated time points defined in Section 10, Study 
Calendar.  Samples will be delivered, processed, stored, and evaluated in accordance with established 
laboratory practices at COH.  Correlative studies performed will provide information regarding the ability 
of CAR+ T cells to traffic through brain parenchyma and mediate antitumor responses and/or changes in 
disease status at the site of infusion as well as sites away from catheter placement.  These correlative studies 
will be assessed individually, and collectively, along with RANO criteria and CTCAE grading to provide 
a fuller understanding of observed toxicities and/or changes in disease/tumor status.  Correlatives studies 
to be performed, but not limited to, are as follows:  
9.1.1 
Antitumor Responses Following Adoptive Transfer of IL13(EQ)BBζ/CD19t+ T Cells.  
MRI/MRS and/or PET assessments will be used to evaluate changes in brain-inflammation, tumor size 
(e.g., maximal diameter and second perpendicular measurement), and tumor FDG-uptake. Progression free 
survival at 6 months, and disease response by RANO criteria will be evaluated and compared to historical 
survival rates to provide evidence of antitumor responses.  Additional areas of evaluation will be changes 
in tumor growth/necrosis near the site of catheter placement versus more distal sites of disease progression. 
Our ability to measure necrotic tumor volume for these studies is supported by the data presented in Figure 
2.5 above. We will also use mathematical modeling of image-based signatures (MRI) to assess the 
correlation between tumor growth phenotype and response to therapy on a patient-specific basis and as 
compared to a virtual control dataset.   
9.1.2 
Determination of Frequency of IL13(EQ)BBζ/CD19t+ T Cells in the Tumor 
Microenvironment and Peripheral Blood. 
The magnitude and duration of persistence of adoptively transferred IL13(EQ)BBζ/CD19t+ T Cells and 
their accumulation in tumor specimen samples (either solid or residual fluid) CSF samples (when available) 
and within the peripheral blood (circulation) will be quantified by Q-PCR with primers specific for the 
lentiviral WPRE (woodchuck hepatitis virus post-transcriptional regulatory element) sequence, and 
normalized to cell numbers to read out frequency of gene marked cells in mononuclear cell preps. 
IL13(EQ)BBζ/CD19t+ T Cells (stained for CD19t, CD3, CD4, CD8) will be also be monitored by flow 
cytometry and immunohistochemistry. Magnitude and duration of CAR T cell persistence will be evaluated 
with respect to observed toxicities and/or changes in disease/tumor status (referencing the correlatives 
within Section 9). 
9.1.3 
Ex vivo Immunophenotyping/Functional Analysis   
Direct ex vivo analyses of persisting infused cells will be performed directly on tumor aspirates and tumor 
resection material (when available), CSF samples (when available) as well as peripheral blood, using 
multiparameter flow cytometric analyses, immunohistochemistry, gene expression analysis, and 

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metabolomic/lipidomic profiles (i.e., qPCR, bulk and single-cell RNA-seq, TCR clonotyping analysis, mass 
spectrometry).We will analyze markers of CAR+ T cell activation (including but not limited to CD25, 
CD69, CD71, CD137, CD107a, Granzyme B) and exhaustion (including but not limited to PD-1, TIM-3, 
LAG-3). We will also analyze CAR+T cell metabolic state. Further, IL13(EQ)BBζ/CD19t+ T Cells 
adoptive transfer has the potential to alter the immune-environment of the tumor, and therefore we will also 
evaluate endogenous immune infiltrates in tumor resection material (when available) CSF samples (when 
available) and peripheral blood, including endogenous CD4+ and CD8+ T cells, Tregs (CD4/FoxP3+), and 
tumor associated macrophages (CD14, CD16, HLA-DR). These analyses will be evaluated with respect to 
observed toxicities and/or changes in disease/tumor status (referencing additional correlatives within 
Section 9) to the infused CAR T cells. 
These and other analyses will also be performed on manufactured CAR+ T cell product that will not be 
infused (i.e., “extra” product, defined as product that cannot be used clinically; most commonly, this will 
be because patients have withdrawn from the trial), to facilitate comparisons between patients and groups 
of patients. In those cases, patient product may be cultured and/stimulated in vitro or in in vivo animal 
systems before comparison. 
Additionally, for participants who continue to receive CAR T cells post progression where additional 
therapies, such as (but not limited to) bevacizumab, nivolumab, pembrolizumab, and dexamethasone, are 
allowed the concentration of these agents may be assessed in the CSF and or tumor fluid to evaluate the 
impact on CAR T cells and endogenous immune responses. Additional markers may be added depending 
on the post progression therapy(ies) administered to participants. 
9.1.4 
Serum, CSF, and Tumor Cavity Cytokine Analysis   
Tumor cavity aspirates, CSF samples (when available), and serum from peripheral blood draws will be 
analyzed for the presence of cytokines such as GM-CSF, IFN-γ, IL-2, IL-6, IL-10, IL-12, TNF-α, and 
VEGF, using the Human Cytokine 30-Plex assay (Life Technologies) which is standard in the field of 
ACT.54,55 Systemic Th1/Th2 cytokine imbalance has been observed in GBM patients – i.e., decreased 
circulating IL-12 (Th1) and increased circulating IL-10.73 Because  this favoring of Th2 responses is 
associated with immunosuppression and poor prognosis for a variety of cancers, 74 we will be interested in 
seeing if administration of our optimized IL13Rα2-specific CAR+ T cells alters this Th1/Th2 balance in 
any way. We will also test the level of these cytokines released by the corresponding final cell product after 
in vitro antigen stimulation. In addition, because cytokine levels provide a measure of T-cell functional 
activity that corresponds to associated clinical toxicity,55,75 these cytokine analyses will assist us in 
potentially attributing toxicities and/or changes in disease/tumor status (referencing additional correlatives 
within Section 9) to the infused CAR T cells. 
9.1.5 
Evaluation of Tumor Antigen IL13α2 Expression and Susceptibility to Re-directed T Cells 
Available biopsy/resection material collected prior to and/or after CAR T cell therapy will be used for PCR 
analysis as well as immunohistochemical analysis of IL13Rα2 as well as other tumor antigens (e.g., HER2, 
EGFRvIII, GD2, and tumor neoantigens).  These samples will also be used for analysis of the presence and 
location of IL13(EQ)BBζ/CD19t+ T Cells by either immunohistochemistry, imagine mass cytometry, or 
flow cytometry for more extensive phenotyping. Tumor antigen IL13Rα2 expression levels will be 
evaluated with respect to observed toxicities and/or antitumor response to the infused CAR T cells. 
9.1.6 
Evaluation of human anti-CAR antibodies (HACA)  
Serum samples will be evaluated for immune responses against our therapeutic agent due to the presence 
of unique junction-site sequences in the IL13(EQ)BBζ CAR.  Cryopreserved or fresh serum samples will 
be measured for human anti-CAR antibodies (HACA) using a flow cytometry based antibody binding 
assay.  

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9.1.7 
Evaluation of changes in frequency and phenotype of endogenous immune cell populations 
and tumor microenvironment 
Host immune subsets and alterations in the tumor microenvironment will be assessed by multiparameter 
flow cytometry, immunohistochemistry, gene expression profiling, and metabolomic/lipidomic analysis 
(e.g., qPCR, RNA-seq, mass spectrometry) on tumor cavity fluid (TCF), cerebrospinal fluid (CSF), 
peripheral blood, and tumor resection material, when available. We will evaluate changes in the expression 
of T cell inhibitory/exhaustion markers (such as PD-1, 2B4, TIM-3, LAG-3, BTLA), activation markers 
(such as 4-1BB, CD4 and CD8 subsets, CD40L, CD69, OX40 and intracellular level of IFNɣ) as well 
effector memory T cells (CD3+CD45RO+CD27+CD62L-), naïve T cells (CD3+CD45RA+CD127+ 
CD27+CD62L+), NK cells (CD56+CD3-) and regulatory T cells (CD4+, CD25High, FOXP3, CD127Low), both 
locally (CSF and TCF) and systemically (PB) pre- and post-CAR T cell therapy. Additionally, we will 
assess changes in the frequency and activation of myeloid subsets such as granulocytes/neutrophils (CD11b, 
CD15) and macrophages (CD14, CD86+, HLA-DR+), with intracellular measures of immunosuppressive 
phenotypes such as p-Stat3, Arg, IL-10 and TGFβ. For participants who demonstrate encouraging response 
to therapy, endogenous immune responses (e.g. circulating tumor-specific T cells) will be further assessed. 
T cells from PB and/or CSF of participants’ pre- and post-T cells infusion will be sorted for TCR deep 
sequencing and in vitro expansion and autologous tumor reactivity measurements as described previously. 
PB serum, CSF and TCF will also be evaluated for metabolomic/lipidomic changes by mass spectrometry 
to reveal treatment related changes in the tumor microenvironment. Additionally, the plan is to perform 
gene expression profiling at single-cell resolution to evaluate on changes in host immune responses 
following CAR T cell therapy. These analyses will be evaluated with respect to observed toxicities and/or 
antitumor response to the infused CAR T cells. 

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10.0 Study Calendar 
10.1 Enrollment and Treatment Study Calendar: 
 
 
CAR T Cell Infusions 
Post CAR T cell infusion assessments7 
Optional  
CAR T Cell 
Infusions 
Post CAR T cell infusion assessments7 
 
 
Cycle 1 
Cycle 2 
Cycle 3 
 
Pre-Study/Screening 
PBMC Collection 
Prior to  
Surgical Procedure5 
Surgical Procedure / Rickham 
Placement5 
Post Surgery Evaluations5 
Prior to CAR T cell 
Infusion/Enrollment 
Infusion  
Interim evaluations 6 
Prior to CAR T cell Infusion 
Infusion 
Interim evaluations6 
Prior to CAR T cell Infusion 
Infusion  
Interim evaluations6 
Prior to CAR T cell Infusion 
Infusion 
Interim evaluations6 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History and Physical 
X 
 
 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
 
X 
 
X 
 
Concurrent Meds 
X 
 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
Vital Signs, KPS 
 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Quality of Life 
Questionnaires 
 
 
X5 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
X11 
 
 
X11 
CBC, Differential 
X 
 
X 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
X 
X 
 
X 
X 
Comprehensive Metabolic 
Panel 
X 
 
X 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
X 
X 
 
X 
X 
CRP, Ferritin1 
 
 
 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
X 
X 
 
X 
X 
Serum Pregnancy Test 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QuantiFERON-TB Gold or 
equivalent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIV Ag/Ab Combo Assay  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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CAR T Cell Infusions 
Post CAR T cell infusion assessments7 
Optional  
CAR T Cell 
Infusions 
Post CAR T cell infusion assessments7 
 
 
Cycle 1 
Cycle 2 
Cycle 3 
 
Pre-Study/Screening 
PBMC Collection 
Prior to  
Surgical Procedure5 
Surgical Procedure / Rickham 
Placement5 
Post Surgery Evaluations5 
Prior to CAR T cell 
Infusion/Enrollment 
Infusion  
Interim evaluations 6 
Prior to CAR T cell Infusion 
Infusion 
Interim evaluations6 
Prior to CAR T cell Infusion 
Infusion  
Interim evaluations6 
Prior to CAR T cell Infusion 
Infusion 
Interim evaluations6 
IHC Target Confirmation 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor Biopsy/Resection3 
 
 
 
X5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FDG-PET 
 
 
 
 
X5,9 
 
 
 
 
 
 
 
 
 
X13 
 
 
 
X12 
MRI +/- contrast 
 
 
 
 
X5,9 
 
 
 
 
 
 
 
 
 
X 
 
 
 
X12 
Adverse Event Evaluation4 
 
 
 
 
 
------------------------   X   ------------------------ 
 
 
Apheresis 
 
X 
 
 
 
 
 
 
Correlative Studies 
Tumor Cavity 
Aspirate/CSF3  
 
 
 
 
 
 
X15 
X10, 14 
 
X14 
X10, 14 
 
X14 
X10, 14 
 
 
X14 
X10, 14 
 
5 cc Peripheral 
Blood Draw 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
35 cc Peripheral  
Blood Draw 
 
 
X5,8 
 
 
X 
 
X 
X 
 
X 
X 
 
X 
 
X 
X15 
X 
 
Drug 
Study Agent (CAR 
T cells) 
 
 
 
 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
 
1 Daily levels should be taken if a patient experiences persistent fevers (380C) and clinical indications of toxicity 
2 Positive results may require additional testing, and expedited FDA reporting. 
3 When feasible, tumor tissue, tumor cavity aspirate, or CSF samples may be collected for correlative studies during clinically-indicated and/or standard of care procedures. 
4 AE evaluations to begin on day of first CAR T cell infusion  

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5 For the optional infusions, evaluations are NOT required to be repeated for Rickham catheter placements that take place after completing the first three required CAR T cell infusions; may be conducted at the discretion of 
the PI/designee. Following catheter placement, the research participant will be followed per the ‘optional cycles’ calendar in Section 10.1.  
6 Interim evaluations, specifically correlative blood draws, will be done at least twice a week  
7 Assessments to occur no sooner than one week post last CAR T cell infusion 
8 Correlative samples may be drawn at time of pre-operative work-up 
9 Imaging required 1-2 weeks prior to the start of the first CAR T cell infusion 
10 When feasible, tumor cavity aspirate/CSF samples to be drawn, per PI/Designee discretion, in the event of toxicity management and/or interim evaluations  
11 QoL questionnaires MAY be administered but are not required 
12 For the optional infusions, imaging may be conducted per PI/Designee discretion 
13 Imaging required within 2 weeks from the third CAR T cell infusion 
14 At the discretion of the PI/designee, the following tests may be ordered (culture, cytology, cell count, glucose and/or protein) 
15 At the discretion of the PI/designee, additional correlative blood draws may be collected prior to the CAR T cell infusion.  
 

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10.2 Short-Term Follow-Up Calendar 
 
Post Final CAR T Cell Infusion 
Follow-Up 
Week +4 
(+/- 3 days) 
Month 3 
(+/- 4 weeks) 
Month 6 
(+/- 4 weeks) 
Month 8 
(+/- 4 weeks) 
Month 10 
(+/- 4 weeks) 
Month 12 
(+/- 4 weeks) 
H&P 
 
X 
X 
X 
X 
X 
Vital Signs, KPS 
X 
X 
X 
X 
X 
X 
Quality of Life Questionnaires 
X 
 
 
 
 
 
CBC, Differential, Platelet Count 
X 
X 
X 
X 
X 
X 
Comprehensive Metabolic Panel 
X 
X 
X 
X 
X 
X 
CRP, Ferritin 
 
 
 
 
 
 
HIV qPCR testing1 
 
X 
X 
 
 
X 
Tumor Biopsy/CSF2 
 
 
 
 
 
 
FDG-PET 
------------------------   X3   ------------------------ 
MRI +/- Contrast 
------------------------   X3   ------------------------ 
Adverse Event Evaluation 
------------------------   X   ------------------------ 
Correlative Studies 
35 cc Peripheral 
Blood 
------------------------   X4   ------------------------ 
 
1  Reference Section 5.6.2 (Long-Term Follow-Up). Testing may be done either by Ag/Ab combo assay or qPCR. Positive results may require 
additional testing, and expedited FDA reporting 
2  When feasible, to be collected at any time during clinically-indicated interventions or as part of patient’s standard of care management. 
3  FDG-PET & MRI +/- contrast are not required at the designated time-points but may be ordered per SOC timeline/PI or designee discretion 
4 Patients who do not have a local lab/oncologist office to assist with mailing kits to COH do not require correlative blood draw to be 
collected UNLESS they are reported to have a suspected AE theoretically related CAR T (per the list in Section 10.3).  
 
 
 

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10.3 Long-Term Follow-Up (or Modified Follow-Up for Participants that Progress): 
 
 
Post Final CAR T Cell Infusion  
Day 30  
(+ 7 days) 
Month 3  
(+/- 4 weeks) 
Month 6  
(+/- 4 weeks) 
Month 12  
(+/- 4 weeks) 
LTFU  Evaluation: 
Yearly  post final CAR T 
cells2 
H&P, Vital Signs, KPS 
X 
X 
X 
X 
 
Assessment for Reproductive Risk and Risk to 
Fetus 
X 
X 
X 
X 
X 
Assessment for Autoimmune Toxicities 
X 
X 
X 
X 
X 
CBC, Differential, Platelet Count 
X 
X 
X 
X 
 
Comprehensive Metabolic Panel 
X 
X 
X 
X 
 
CRP, Ferritin 
X 
 
 
 
 
HIV qPCR testing1 
 
X 
X  
X 
X 
Concurrent Meds 
----------X-------- 
Correlative Studies 
35 cc Peripheral Blood 
----------X3-------- 
Adverse Event Evaluation 
----------X-------- 
 1  Reference Section 5.6.2 (Long-Term Follow-Up). Testing may be done either by Ag/Ab combo assay or qPCR. Positive results may 
require additional testing, and expedited FDA reporting 
2 Research participants will be followed and data will be collected on IRB#13384 per FDA guidelines until a separate long term follow up 
protocol is executed. 
3 Patients who do not have a local lab/oncologist office to assist with mailing kits to COH do not require correlative blood draw to be 
collected UNLESS they are reported to have a suspected AE theoretically related CAR T. 

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11.0 Endpoint Evaluation Criteria/Measurement of Effect 
11.1 Response Criteria  
Endpoint Evaluation: Endpoint Evaluation is listed in Section 13.3. 
Response Criteria: Toxicity and adverse event will be assessed using CTCAE v4.0 and the revised CRS 
grading system (Section Appendix 16.3 from data obtained at each clinical assessment as outlined in 
Section 10.  Symptoms and toxicities will be evaluated as follows:  
• 
Physical exam and Blood Chemistry/Hematology results 
• 
Adverse event reporting 
Additionally, disease status will be assessed by the grading of the tumor responses performed according to 
the RANO criteria, reference Appendix 16.2. 
12.0 Data Reporting/Protocol Deviations 
12.1 Data Reporting 
12.1.1 Confidentiality and Storage of Records 
The original data collection forms will be sent to COH Clinical Trials Office (CTO) assigned Clinical 
Research Coordinator (CRC) and stored in a locked cabinet in within the assigned locked office of T Cell 
Therapeutics Research Laboratory (TCTRL) Clinical and Regulatory Support staff.  This protocol also uses 
Electronic Data Collection where data is stored in encrypted, password protected, secure computers that 
meet all HIPAA requirements. When results of this study are reported in medical journals or at meetings, 
identification of those taking part will not be disclosed.  Medical records of subjects will be securely 
maintained in the strictest confidence, according to current legal requirements.  They will be made available 
for review, as required by the FDA, HHS, or other authorized users such as the NCI, under the guidelines 
established by the Federal Privacy Act and rules for the protection of human subjects. 
12.1.2 Subject Consent Form 
At the time of registration, the original signed and dated Informed Consent form, HIPAA research 
authorization form, and the California Experimental Subject’s Bill of Rights (for the medical record) and 
three copies (for the subject, the research record, and the Coordinating Center) must be available.  All 
Institutional, NCI, Federal, and State of California requirements will be fulfilled. 
12.1.3 Data Collection Forms and Submission Schedule  
All data will be collected using study designed electronic Case Report Forms (eCRFs), as well as 
Administrative Forms which are maintained by the TCTRL Clinical and Regulatory Support Staff.  Data 
will be captured to the best of our ability within 10 working days of the event(s) being monitored.  Data 
will be sent to the location identified in Section 12.1.1 and stored in a secure location. 
12.1.3.1 Eligibility Checklist 
The Eligibility Checklist must be completed by a protocol nurse or clinical research associate and signed 
by an authorized investigator prior to registering the subject.  See Section 4.3 for the registration procedure. 
 
 

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12.1.3.2 Prior Therapy Forms and On-Study Forms 
Within 30 days of registration, the clinical research associate will submit study enrollment and baseline 
form as described in Section 12.1.1. 
12.2 Protocol Deviations 
12.2.1 Deviation Policy 
This protocol will be conducted in accordance with COH’s “Clinical Research Protocol Deviation Policy” 
located at http://www.coh.org/dsmc/Documents/Institutional%20Deviation%20Policy.pdf. 
Deviations from the written protocol that could increase patient risk or alter protocol integrity require prior 
IRB approval of a single subject exception (SSE) request.  In addition, if contractually obligated, the 
sponsor must also approve the deviation.  IRB pre-approved SSE protocol modifications are considered an 
amendment to the protocol and not a deviation.  The submission of a deviation report is not required. 
Brief interruptions and delays may occasionally be required due to travel delays, airport closure, inclement 
weather, family responsibilities, security alerts, government holidays, etc.  This can also extend to 
complications of disease or unrelated medical illnesses not related to disease progression.  The PI has the 
discretion to deviate from the protocol when necessary so long as such deviation does not threaten patient 
safety or protocol scientific integrity.  Examples include, but are not limited to:  a) dose adjustments based 
on excessive patient weight; b) alteration in treatment schedule due to non-availability of the research 
participant for treatment; c) laboratory test results which are slightly outside the protocol requirements but 
at levels that do not affect participant safety.  These instances are considered to be deviations from the 
protocol.  A deviation report will be submitted to the DSMC/IRB within five days. 
12.2.2 Reporting of Deviations 
All deviations will be reported to the COH DSMC within five days.  The DSMC will forward to report to 
the IRB following review. 
12.2.3 Resolving Disputes 
The COH Investigational Drug Service (IDS) cannot release a research agent that would cause a protocol 
deviation without approval by the PI.  Whenever the protocol is ambiguous on a key point, the IDS should 
rely on the PI to clarify the issue. 
In situations where there is misperception or dispute regarding a protocol deviation among the persons 
involved in implementing the protocol, it is the responsibility of the PI to resolve the dispute and the PI 
may consult with the DSMC chair (or designee) to arrive at resolution. 
13.0 Statistical Considerations 
13.1 Study Design 
This protocol is a Phase I feasibility/safety study of IL13(EQ)BBζ/CD19t+ T cells which implements both 
inter- and intra-patient dose escalation in five patient arms (TCM intratumoral, intracavity, intraventricular, 
and dual delivery; as well as TN/MEM dual delivery) in recurrent/refractory malignant glioma. 
Table 13.1: Dose Schedule (CAR+) for Arms 1 to 5^ 
Planned 
Cycle 
Dose  
schedule 1de 
Dose  
schedule 1 
Dose  
schedule 2de 
Dose  
schedule 2 
Dose  
Schedule 3de 
Dose  
schedule 3 
1 
A: 2x106 
A: 2x106 
C: 10x106 
C: 10x106 
C:10x106 
F: 20x106 
2 
B: 5x106 
C: 10x106 
D: 25x106 
E: 50x106 
G:75x106 
H:100x106 
3 
B: 5x106 
C: 10x106 
D: 25x106 
E: 50x106 
G:75x106 
H:100x106 

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Total 
Dose# 
12x106 
22x106 
60x106 
110x106 
160x106 
220x106 
 
Evaluation/Restaging 
Optional 
Cycles# 
<5x106 
<10x106 
<25x106 
<50x106 
<75x106 
<100x106 
^ Infusion doses should not exceed 2.5x108 per 0.5mL (0.5x106/µL); Reference Section 5.2.1. 
de = de-escalation schedule 
# The dose listed at each cycle is the CAR+ T cell dose intended for each delivery method, therefore in Arms 4 (TCM Dual Delivery) 
and 5 (TN/MEM Dual Delivery) 2 infusions doses will be prepared per infusion cycle, 1 for each delivery method. 
13.1.1 Study Participant Staggering Rules 
The first 4 research participants in Arms 1 through 3 will be treated sequentially, followed through the DLT 
period (3 infusions cycles plus 1-week for AE evaluations) before the next participant may receive their 
initial infusion; all further research participants will be treated in cohorts of 3. The first research participant 
in Arms 4 and 5 will be followed through the DLT period before the other 2 participants in that cohort are 
treated, all further participants will be followed in cohorts of 3. Dose escalation rules for intra-patient and 
inter-patient scheduling are provided in Section 13.2.  Study Stopping Rules are provided in Section 13.4.     
13.2 Dose Escalation Rules (each arm will be followed separately): 
Note that the dose escalation plan calls for intra-patient escalation through dose levels labeled with letters 
in Table 13.1, as well as inter-cohort dose escalation through schedules 1, 2 and 3 in the columns of Table 
13.1.  Schedules 1de, 2de and 3de describe possible de-escalation schedules (shown in grey).   
13.2.1 Intra-patient dose escalation rules:  
We implement intra-patient dose escalation starting with an initial low dose of CAR T cells to minimize 
the extent of unexpected on-tumor and off-tumor targeting toxicities, with the goal of determining a final 
dosing regimen of 3 weekly infusions with a DLT rate less than 33%. The intra-patient dose escalation/de-
escalation rules are based on toxicities with an attribution of probable or definitely related to CAR T cell 
infusion with the exception of those listed in Section 8.1 of the protocol will be the following (Table 13.2).  

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Table 13.2: Rules for CAR T cell dose on day of the infusion 
On the day of scheduled infusion, if an 
attributed toxicity from the previous 
infusion(s) is probably or definitely 
related to CAR T cells AND is: 
Then: 
Toxicities listed in Section 8.1 
These toxicities are considered manageable but would result in 
cancellation of the cell dose for that day. The next scheduled dose will 
restart at the planned dose level.  
Grade 2 CRS, and Grade 3 and above 
toxicities 
Defined as a medically significant but not immediately life threatening 
toxicity will result in cancellation of cell infusion for that day. The next 
scheduled infusion will re-start at the same dose level.  Before the 
study participant can escalate to the next dose level, they must receive 
the assigned cell infusion dose without experiencing a grade 3 (grade 2 
CRS) or higher toxicity not listed in section 8.1. 
If on re-start the study participant has a second grade 3 toxicity (or 
grade 2 CRS) at the same dose this will be considered a DLT. At the 
discretion of the PI the participant can either be taken off treatment or 
be de-escalated to the next lower dose for the next cycle. If there is no 
lower dose the study participant will be taken off treatment. 
If maximum attributed toxicity from 
the previous infusion(s) is probably or 
definitely related to CAR T cells AND 
is: 
Then: 
DLTs toxicities listed in Section 5.7b 
through e 
Will be defined as a DLT and the study participant will be taken off 
treatment. 
Any attributed toxicity that causes a 2 
week delay in dosing 
Will be defined as a DLT and the study participant will be taken off 
treatment. 
13.2.2 Inter-cohort dose escalation rules  
Inter-cohort dose escalation rules for escalating and de-escalating through the schedules follow a 3+3 design 
with de-escalation in half step as described below. 
1) The first cohort of 3 participants will receive dose schedule 1 with the option of receiving 
additional cycles of treatment at ≤ the individual participant’s maximum achieved safe dose after a 
minimum of 1 week break (Tables 13.1). Participants will be followed for DLTs from start of study 
until 1 week after the cycle 3 or the last infusion cycle in the DLT period. 
2) If all participants from a cohort complete a schedule without a DLT, the next cohort will escalate 
to the next schedule, moving through schedules 1, 2 and 3.   
3) If 2 of 3 participants cannot complete dose level A (i.e., the low dose) without experiencing a DLT 
we will put the study on hold to determine if a lower dose should be considered. 
4) If 2 of 3 participants in a cohort do not complete a schedule (i.e., all 3 cycles) without experiencing 
a DLT, we will de-escalate to the next lower schedule in Tables 13.1.   

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Schedule 1→Schedule 1de: 1 cycles of dose A followed by 2 cycles of dose B 
Schedule 2→Schedule 2de: 1 cycle of dose C followed by 2 cycles of dose D  
Schedule 3→Schedule 3de: 1 cycle of dose C followed by 2 cycles of dose G  
5) If 1 of 3 participants in a cohort does not complete a schedule without experiencing a DLT, a second 
cohort of 3 participants will repeat that schedule.  
i. If 5 of the 6 participants from the combined cohorts complete the schedule without 
experiencing a DLT, the next cohort of 3 participants will escalate to the next schedule. 
ii. If 4 or fewer of the 6 participants completes the current schedule without experiencing a DLT 
we will de-escalate to next lower schedule in Tables 13.1. 
6) The MTD/MFD schedule will be the highest dose schedule in which fewer than 33% of participants 
experience a DLT, when at least 6 participants were treated and are evaluable for toxicity. 
7) An expansion cohort of 6 participants will be added at the MTD/MFD dose schedule. 
8) The RP2D will be determined based on the maximum tolerated dose schedule/maximum feasible 
dose schedule, the results from the expansion cohort at the MTD/MFD schedule in combination 
with the number of additional weeks participants were able to stay on that dose and the activity 
data.   
 
Tables 13.3 to 13.5 provide operating characteristics for Arms 1 to 5 based on 1000 simulated trials 
for each set of toxicity schedules.  The operating characteristics include the rate each schedule was 
chosen as the MTD/MFD, and the mean DLT rate at the MTD/MFD and the median trial sample size.  
Note that trial seeks the highest schedule with a DLT rate < 33% (≤17%). 
 
 

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Table 13.3 
Sample Size: 
Median=15   
Toxicity Rates 
MTD/MFD 
rate 
Toxicity levels/ 
Dose Schedules 
Normal 
to 
Moderate 
Severe* 
Life 
Threatening* 
 
Mean DLT rate at the 
MTD/MFD (std.dev) 
 
0.098 (.082) 
All doses  are too toxic 
 
<0.01 
Schedule 1de 
 
0.10 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –B 
0.95 
0.025 
0.025 
  Cell Dose 3 –B 
0.95 
0.025 
0.025 
Schedule 1 
 
0.035 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –C 
0.875 
0.075 
0.05 
  Cell Dose 3 –C 
0.875 
0.075 
0.05 
Schedule 2de 
 
0.16 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –D 
0.85 
0.10 
0.05 
  Cell Dose 3 –D 
0.85 
0.10 
0.05 
 
Schedule 2 
0.17 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –E 
0.80 
0.15 
0.05 
  Cell Dose 3 –E 
0.80 
0.15 
0.05 
Schedule 3de 
  
0.19 
 Cell Dose 1 –C 
0.875 
0.075 
0.05 
 Cell Dose 2 –G 
0.75 
0.15 
0.01 
 Cell Dose 3 –G 
0.75 
0.15 
0.1 
Schedule 3 
 
 0.33 
 Cell Dose 1 –F 
0.85 
0.1 
0.05 
 Cell Dose 2 –H 
0.70 
0.2 
0.1 
 Cell Dose 3 –H 
0.70 
0.2 
0.1 
                   *The toxicity levels severe and life threatening are defined in Table 13.2. 
 
 
 
 
 
 
 
 
 
 
 

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Table 13.4 
Sample Size: 
Median=15  
Toxicity Rates 
MTD/MFD 
rate 
Toxicity levels/ 
Dose Schedules 
Normal 
to 
Moderate 
Severe* 
Life 
Threatening* 
 
Mean DLT rate at the 
MTD/MFD (std.dev) 
 
0.099 (.082) 
All doses  are too toxic 
 
<0.01 
Schedule 1de 
 
0.11 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –B 
0.95 
0.025 
0.025 
  Cell Dose 3 –B 
0.95 
0.025 
0.025 
Schedule 1 
 
0.20 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –C 
0.875 
0.075 
0.05 
 
  Cell Dose 3 –C 
0.875 
0.075 
0.05 
Schedule 2de 
 
0.23 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –D 
0.80 
0.10 
0.1 
  Cell Dose 3 –D 
0.80 
0.10 
0.1 
Schedule 2 
0.16 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –E 
0.70 
0.2 
0.1 
  Cell Dose 3 –E 
0.70 
0.2 
0.1 
Schedule 3de 
0.17 
 Cell Dose 1 –C 
0.875 
0.075 
0.05 
 Cell Dose 2 –G 
0.65 
0.25 
0.1 
 Cell Dose 3 –G 
0.65 
0.25 
0.1 
Schedule 3 
  0.13 
 Cell Dose 1 –F 
0.85 
0.1 
0.05 
 Cell Dose 2 –H 
0.60 
0.25 
0.15 
 Cell Dose 3 –H 
0.60 
0.25 
0.15 
                 *The toxicity levels severe and life threatening are defined in Table 13.2. 
 
 
 
 
 
 
 
 

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Table 13.5 
Sample Size: 
Median=15   
Toxicity Rates 
MTD/MFD 
rate 
Toxicity levels/ 
Dose Schedules 
Normal 
to 
Moderate 
Severe* 
Life 
Threatening* 
 
Mean DLT rate at the 
MTD/MFD (std.dev) 
 
0.094 (.083) 
All doses  are too toxic 
 
<0.01 
Schedule 1de 
 
0.12 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –B 
0.95 
0.025 
0.025 
  Cell Dose 3 –B 
0.95 
0.025 
0.025 
Schedule 1 
 
0.35 
  Cell Dose 1 –A 
0.98 
0.01 
0.01 
  Cell Dose 2 –C 
0.875 
0.075 
0.05 
 
  Cell Dose 3 –C 
0.875 
0.075 
0.05 
Schedule 2de 
 
0.39 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –D 
0.75 
0.15 
0.10 
  Cell Dose 3 –D 
0.75 
0.15 
0.10 
Schedule 2 
0.089 
  Cell Dose 1 –C 
0.875 
0.075 
0.05 
  Cell Dose 2 –E 
0.50 
0.30 
0.2 
  Cell Dose 3 –E 
0.50 
0.30 
0.2 
Schedule 3de 
  
 0.023 
 Cell Dose 1 –C 
0.875 
0.075 
0.05 
 Cell Dose 2 –G 
0.50 
0.30 
0.20 
 Cell Dose 3 –G 
0.50 
0.30 
0.20 
Schedule 3 
  0.021 
 Cell Dose 1 –F 
0.75 
0.15 
0.10 
 Cell Dose 2 –H 
0.80 
0.30 
0.05 
 Cell Dose 3 –H 
0.80 
0.30 
0.05 
 
13.3 Optional additional cycles 
Participants can continue receiving CAR T cell infusions at a rate where infusions are no more frequent 
than once a week. Additional cycles if administered through the same route of delivery as the first three 
cycles, will be administered at ≤ the highest tolerated cell dose in the initial dose schedule, provided that 
the participant continues to meet eligibility criteria and there are cell doses available from the already 
manufactured cell product. If a research participant on the intracranial administration arms (intracavitary 
or intratumoral) progresses after the first three CAR T cell infusion cycles, at the discretion of the PI, the 
research participant may move to intraventricular administration for the optional CAR T cell infusions. 
For research participants in Arms 4 and 5, based on clinical response after the first three infusions, the 
study PI may decide to continue with the optional infusions at either one or both sites (instead of 
requiring injections at both sites) ; these infusion doses may be delivered at up to the highest dose deemed 
safe for that delivery site..  

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13.4 Study Endpoints: 
• 
Primary: Grade 3 toxicities, DLTs, and all other toxicities. 
• 
Secondary: 
 
Disease response by RANO criteria from initial infusion method;  
 
Overall survival from time of surgery to death date or last contact date; 
 
Functioning scale, symptom scale, and item scores from the EORTC QLQ-C30;  
 
CAR T cells and cytokine levels in peripheral blood, tumor cavity fluid, and CSF; 
 
Endogenous immune cell detection in peripheral blood, tumor cavity fluid, and CSF; 
and 
 
Tumor/tumor micro-environment marker detection. 
• 
Exploratory:  
 
Timing and extent of brain inflammation following CAR T cell administration; 
 
CAR T cell product characteristics; 
 
Persistence and location of CAR T cells in tumor micro-environment; and  
 
IL13Rα2 antigen expression levels.  
 
13.5 Study Stopping Rules 
13.5.1 Rules for Holding Accrual Due to Toxicity 
The study will hold accrual and the data will be reviewed, if within 30 days of treatment either DLT level 
toxicities with attribution of probable or definite is observed in greater than 50% of participants out of at 
least 6 participants, or any grade 3 or higher organ toxicity (cardiac, dermatologic, gastrointestinal, 
hepatic, pulmonary, renal/genitourinary, or neurologic) not pre-existing or due to the underlying 
malignancy,  or a Grade 5 toxicity is observed with attribution of possibly, probably or definitely. 
13.6 Sample Size Accrual Rate 
As of 03/02/2018, we have closed Arm 1 (biopsy with an N=2) as biopsy participants can be included in 
the ICV or dual arms. Based on simulation results we expect to study 15 participants in the dose escalation 
portion of the trial, plus 6 in the expansion portion    plus 2 for replacement of unevaluable participants 
giving an expected sample size of 23 per arm for each of the 4 open arms for a total of 92. To be evaluable 
for defining the MTD/MFD a research participant must either complete three infusion cycles receiving at 
least 80% of each defined infusion dose and at least one rest cycle, or have had a DLT. A sample size of 12 
at the MTD/MFD will provide us with i) maximum margin of error of 0.25 for a 95% confidence interval 
(95% CI) for the DLT rate, and ii) to detect a toxicity with a true rate of 0.15 in 85% of trials.  The full 
sample size of 21 will provide us with a maximum margin of error 0.19 for a 95% CI for progression free 
survival at 6 months and disease response.  Accrual is expected to be 6 evaluable research participants per 
year per arm. Thus, we expect to complete accrual in 5 years. 
13.7 Statistical Analysis Plan 
The statistical analysis will be done separately for each arm. Rate and associated 95% Clopper and Pearson 
binomial confidence limits (95% CI) will be estimated for participants’ experiencing DLTs at the RP2D 
schedule. In study participants that received the full schedule of 3 CAR T cell doses, we will estimate the 
rate (95% CI) with disease response, and Kaplan Meier methods will be used to estimate median PFS and 
OS and graph the results. In study participants that receive at least 1 dose of CAR T cells we will estimate 
the mean and standard error for change from baseline during treatment and post treatment in the quality of 
life functioning scale, symptom scale and item scores from the EORTC QLQ-C30. Statistical and graphical 
methods will be used to describe persistence and expansion of the CAR T cells (peripheral blood, tumor 
cavity fluid, and CSF) and cytokine levels (CSF, tumor cavity fluid, peripheral blood) over the study period. 

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In study participants that undergo a second resection or following autopsy, CAR T cell numbers, location, 
and antigen levels will be described. Tables will be created to summarize all toxicities and side effects by 
dose, time post treatment, organ, severity and arm. We will provide descriptive statistics for patient 
demographics. 
14.0 Human Subject Issues 
14.1 Institutional Review Board 
In accordance with City of Hope policies, an Institutional Review Board (IRB) that complies with the 
federal regulations at 45 CFR 46 and 21 CFR 50, 56 and State of California Health and Safety code, Title 
17,  must review and approve this protocol and the informed consent form prior to initiation of the study.  
All institutional, NCI, Federal, and State of California regulations must be fulfilled. 
14.2 Recruitment of Subjects 
Research participants will be identified through the clinical practices of the PI, co-Is and participating 
clinicians and through direct referrals from outside hospitals and physicians. No direct-to-patient 
advertising will be performed without IRB approval.   
14.3 Advertisements  
Advertisements to include print, media (radio, television, billboards), telephone scripts, lay summary to be 
posted on City of Hope’s public Clinical Trials On-LineSM website, etc., will be reviewed and approved by 
the IRB prior to their use to recruit potential study subjects. 
14.4  Study location and Performance Sites 
This study will be performed at COH.   
14.5 Confidentiality  
This research will be conducted in compliance with federal and state of California requirements relating to 
protected health information (PHI).  The principal investigator, co-investigators, and laboratory technicians 
will have access to all study information captured in electronic data bases as well as any patient and study 
data documented in individual patient research binders, but all information will be treated confidentially. 
No identifiers will be used in any subsequent publication of these results.   
14.6 Financial Obligations and Compensation 
The investigational drug, autologous IL13(EQ)BBζ/CD19t+ T Cells, will be provided free of charge by City 
of Hope. Should this drug become commercially available during the course of your treatment, the research 
participant and/or the insurance carrier may be asked to pay for the costs of the drug. 
The standard of care drug(s) or devices and procedures provided will be the responsibility of the research 
participant and/or the insurance carrier. The research participant will be responsible for all copayments, 
deductibles, and other costs of treatment and diagnostic procedures as set forth by the insurance carrier.  
The research participant and/or the insurance carrier will be billed for the costs of treatment and diagnostic 
procedures in the same way as if the research participant were not in a research study.  However, neither 
the research participant nor the insurance carrier will be responsible for the research procedures related to this 
study. 
In the event of physical injury to a research participant, resulting from research procedures, appropriate 
medical treatment will be available at the City of Hope to the injured research participant, however, financial 
compensation will not be available. 
The research participant will not be paid for taking part in this study. 

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14.7 Informed Consent Processes  
The Principal Investigator or IRB approved named designate will explain the nature, duration, purpose of 
the study, potential risks, alternatives and potential benefits, and all other information contained in the 
informed consent document.  In addition, they will review the experimental subject’s bill of rights and the 
HIPAA research authorization form.  Research subjects will be informed that they may withdraw from the 
study at any time and for any reason without prejudice, including as applicable, their current or future care 
or employment at City of Hope or any relationship they have with City of Hope.  Research subjects will be 
afforded sufficient time to consider whether or not to participate in the research. 
Should sufficient doubt be raised regarding the adequacy of comprehension, further clarifications will be 
made and the questionnaire repeated until a satisfactory result is obtained.  Prospective research subjects 
who cannot adequately comprehend the fundamental aspects of the research study with a reasonable amount 
of discussion, education and proctoring will be ineligible for enrollment.  For those subjects who do 
comprehend the fundamental aspects of the study, consent will be obtained and documented, followed by 
eligibility testing.  The research team will review the results of eligibility testing and determine if the subject 
is a candidate for study enrollment.  
 
 

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chimeric antigen receptor. Blood 116, 1035-1044 (2010). 

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40. 
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virus infections. Nat Med 8, 379-385 (2002). 
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fates via the graded expression of T-bet transcription factor. Immunity 27, 281-295 (2007). 
44. 
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antitumor efficacy of adoptively transferred CD8+ T cells. J Clin Invest 115, 1616-1626 (2005). 
45. 
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recurrent malignant glioma: a report by the Cintredekin Besudotox Intraparenchymal Study 
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49. 
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receptor enhances in vivo persistence and antitumor efficacy of adoptively transferred T cells. 
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55. 
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establish memory in patients with advanced leukemia. Sci Transl Med 3, 95ra73 (2011). 
56. 
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infection not responding to antiviral chemotherapy. Blood 99, 3916-3922 (2002). 
58. 
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primary and secondary tumor rejection. Blood 106, 2995-3003 (2005). 

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59. 
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79. 
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(2014). 
 
 

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16.0 Appendices 
16.1 APPENDIX A – Toxicity Grading 
 
NCI Common Toxicity Criteria V.4.0 
Toxicity data being obtained at each clinical assessment will be graded using NCI Common Toxicity 
Criteria V.4.0 which may be downloaded from the NCI website (http://evs.nci.nih.gov/ftp1/CTCAE/) 
 
Any toxicity reported by research participants while receiving treatment or in follow-up for which there is 
no specific CTC designation will be graded on the following scale:  
 
 
Table 1:  Grading for Toxicities with no specific CTC designation 
Grade of toxicity 
Toxicity Description 
0 
No toxicity 
1 
Mild toxicity, usually transient, requiring no special treatment and generally not 
interfering with usual daily activities 
2 
Moderate toxicity that may be ameliorated by simple therapeutic maneuvers, and 
does not impair usual activities 
3 
Severe toxicity which requires therapeutic intervention and interrupts usual 
activities, hospitalization may be required or may not be required 
4 
Life-threatening toxicity which requires hospitalization 

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16.2 APPENDIX B – Response Criteria and Grading 
16.2.1 Response Assessment in Neuro-Oncology (RANO) criteria (cited below). 
• 
Complete Response (CR): Complete disappearance of all enhancing disease (measurable and non-
measurable) that is sustained for at least 4 weeks, stable or improved non-enhancing FLAIR/T2 
lesions, no new lesions, off corticosteroids (physiologic replacement doses allowed), and 
neurologically stable or improved.  
• 
Partial Response (PR): > 50% decrease of all measurable enhancing lesions, sustained for at least 
4 weeks, no progression of non-measurable disease, stable or improved non-enhancing FLAIR/T2 
lesions, no new lesions, corticosteroid dose stable or reduced (compared to baseline), and 
neurologically stable or improved. 
• 
Stable Disease (SD): Does not qualify for CR, PR or PD, stable non-enhancing FLAIR/T2 lesions, 
stable or reduced corticosteroids (compared to baseline), clinically stable.  
• 
Progressive Disease (PD): > 25% increase in enhancing lesions despite stable or increasing steroid 
dose, increase (significant) in non-enhancing FLAIR/T2 lesions that is not attributable to other non-
tumor causes, any new lesions, clinical deteriorations (not attributable to other non-tumor causes 
and not due to steroid decrease). 
 
16.2.2 Retrospective Research Analysis - Mathematical Models of Tumor Invasion and 
Proliferation  
Dr. Rockne’s Laboratory here at City of Hope, in collaboration with Dr. Swanson’s Laboratory at Mayo 
Clinic, will assess MRI and PET images pre and post T cell therapy to evaluate the impact of the therapy 
on tumor progression and survival outcomes. Dr. Rockne was a member of the Swanson lab, previously at 
Northwestern University, where their lab devised mathematical models of tumor invasion and proliferation 
that predict patient outcomes, and has an extensive image and survival database of glioma patients receiving 
standard of care treatments.76-79 Thus, Dr. Rockne, in collaboration with Dr. Swanson, will be able to assess 
therapeutic responses post therapy compared to a set of comparable recurrent glioblastoma patients who 
received standard of care treatments to infer potential therapeutic impact of the gene-modified T cells in 
this subject. Any data/records shared with Dr. Swanson’s Laboratory at Mayo Clinic will be de-identified. 

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16.3 APPENDIX C: Cytokine Release Syndrome (CRS) in the Context of Cellular 
Immunotherapy (Clinical Symptoms & Revised Grading System) 
 
16.3.1 Clinical signs and symptoms associated with CRS 
Organ System 
Symptoms 
Constitutional 
Fever ± rigors, malaise, fatigue, anorexia, myalgias, arthalgias, nausea, 
vomiting, headache 
Skin 
Rash 
Gastrointestinal 
Nausea, vomiting, diarrhea 
Respiratory 
Tachypnea, hypoxemia 
Cardiovascular 
Tachycardia, widened pulse pressure, hypotension, increased cardiac output 
(early), potentially diminished cardiac output (late) 
Coagulation 
Elevated D-dimer, hypofibrinogenemia ± bleeding 
Renal 
Azotemia 
Hepatic 
Transaminitis, hyperbilirubinemia 
Neurologic 
Headache, mental status changes, confusion, delirium, word finding difficulty 
or frank aphasia, hallucinations, tremor, dymetria, altered gait, seizures 
 
 
16.3.2 Revised CRS Grading System 
Grade 
Toxicity 
Grade 1 
Symptoms are not life threatening and require symptomatic treatment only; e.g: fever, 
nausea, fatigue, headache, myalgias, malaise 
Grade 2 
Symptoms require and respond to moderate intervention 
Oxygen requirement <40% or 
Hypotension responsive to fluids or low dose of one vasopressor or 
Grade 2 organ toxicity* 
Grade 3 
Symptoms require and respond to aggressive intervention 
Oxygen requirement ≥40% or 
Hypotension requiring high dose or multiple vasopressors or 
Grade 3 organ toxicity* or grade 4 transaminitis 
Grade 4 
Life-threatening symptoms 
Requirement for ventilator support or 
Grade 4 organ toxicity* (excluding transaminitis) 
Grade 5 
Death 
*Grades 2-4 refer to CTCAE v4.0 grading 
 
 

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16.3.3 High-dose vasopressors (all doses are required for > 3 hours) 
Pressor 
Dose 
Norepinephrine monotherapy  
≥20 μg /min 
Dopamine monotherapy 
≥10 μg/kg/min 
Phenylephrine monotherapy 
≥200 μg/min 
Epinephrine monotherapy 
≥10 μg/min 
If on vasopressin 
Vasopressin + norepinephrine equivalent of ≥10 
μg/min* 
If on combination vasopressors (not vasopressin) 
Norepinephrine equivalent of ≥20 μg/min* 
* VASST Trial vasopressor equivalent equation: norepinephrine equivalent dose = [norepinephrine 
(μg/min)] + [dopamine (μg/kg/min) ÷ 2] + [epinephrine (μg/min)] + [phenylephrine (μg/min) ÷10]. 
 
 
 

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16.4 APPENDIX D – Case Report Forms 
 
Case Report Forms 
To be determined 
 
Medidata Forms (eCRFs) 
All the eCRFs are accessible via Medidata Rave at  
https://coh.mdsol.com/MedidataRAVE/%28k444s3nsk0uw0b55z5d1zzff%29/Login.aspx