A Phase I/IIa, Dual-cohort, Two-site, Clinical Trial Evaluating the Safety and Activity of Redirected Autologous T Cells Expressing a High Affinity TCR Specific for NY-ESO-1 Administered Post ASCT in Patients With Advanced Myeloma
Phase: PHASE2
Conditions: Multiple Myeloma
Sponsor: GlaxoSmithKline

 
 
 
 
 
Protocol  ADP-01411  
 
 
 
 
 
 
Version 12.0 
 
A Phase I/IIa, dual-cohort, two-site, clinical trial evaluating the safety and activity of 
redirected autologous T cells expressing a high affinity TCR specific for NY-ESO-1 
administered post ASCT in patients with advanced myeloma 
Protocol Version: April 07, 2017 
 
SPONSOR IND:  IND14603   
Adaptimmune LLC 
351 Rouse Boulevard 
Philadelphia, PA 19112 
USA  
IND Number:  
14603  
Study Product: 
NY-ESO-1c259-T 
Study Number: 
01411 
Protocol Version: 
12.0 
 
 
STUDY CHAIR: 
 
Aaron P. Rapoport, M.D. 
Greenebaum Cancer Center, University of Maryland 
Stem Cell Transplant Program 
22 South Greene St., RM N9E12 
Baltimore, MD21201 
 
Co-Principal Investigators: 
Aaron P. Rapoport, M.D. 
Greenebaum Cancer Center,  
University of Maryland 
Stem Cell Transplant Program 
22 South Greene St., RM N9E12 
Baltimore, MD21201 
 
Edward Stadtmauer, M.D. 
Abramson Cancer Center,  
University of Pennsylvania 
PCAM 2 West Pavilion 
3400 Civic Center Boulevard 
Philadelphia, Pa19104 
 
CONFIDENTIALITY STATEMENT 
This document contains information which is the property of Adaptimmune Ltd, United Kingdom, and 
Adaptimmune LLC, USA, and therefore is provided in confidence for your review.  It is understood that 
this information will not be disclosed to others without written approval from Adaptimmune Ltd. or  
Adaptimmune LLC. 
 

 
Protocol  ADP-01411  
 
 
 
 
 
Date Final 07-Apr-2017 
Version 12.0 
 
 
Page 2 of 118 
 
SIGNATURES AND AGREEMENT WITH THE PROTOCOL 
 
I, the undersigned, have reviewed the original protocol, including the appendices, and I will conduct the 
clinical study as described and will adhere to International Conference on Harmonisation (ICH) guideline 
E6 (r2):Guideline for Clinical Practice (GCP) and all the ethical and regulatory considerations stated. I 
have read and understood the contents of the Investigator Brochure. 
 
 
 
 
 
 
 
 
Principal Investigator 
 
 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol  ADP-01411  
 
 
 
 
 
Date Final 07-Apr-2017 
Version 12.0 
 
 
Page 3 of 118 
 
 
Protocol Amendment 
 
Version:0.1 
22-Jul-2010 
Initial version 
Version:0.2 
26-Oct-2010  
To incorporate feedback from the NIH RAC, FDA and general improvements 
Version: 0.3 
30-Nov-2010 
To incorporate feedback from University of Maryland Greenebaum Cancer 
Center CRC 
Version: 1.0 
06-Jan-2011 
Final version for IRB submission.  
Version: 2.0 
22-Feb-2011 
Changes in response to IRB reviews at UMD and UPenn, and changes to 
harmonize the two protocol versions to each other. 
Version: 3.0 
07-Jul-2011 
Changes to include additional antigen in the eligibility for each cohort, since 
they are also known to be targeted by the TCRs used in this study.  Also, minor 
changes for clarification on study visit windows, and to explicitly state that 
frozen and previously collected apheresis product can be used in lieu of fresh. 
Version: 4.0 
29-Nov-2011 
Changes made to include increased cardiac monitoring in response to an SAE on 
a parallel trial in the Mage arm, and to extend the NYESO arm now that 
sufficient safety data is available and we wish to discern more robustly the 
clinical effect of the NYESO TCR from the high dose melphalan by comparing 
to recently published controls. Amend SAE reporting requirements to FDA as 
requested. 
Version: 5.0 
30-Apr-2012 
To allow for identical twin sibling stem cell transplant (SSCT) – Not submitted 
at University of Pennsylvania 
Version: 6.0 
16-Jul-12 
To add optional second T-cell infusion and to clarify eligibility criteria for 
patients to undergo second infusion, and to correct T cell release criteria to be 
consistent with the IND 14603 
Version: 7.0 
12-Mar-
2013 
Removal of MAGE T cells conducted under IND 14604 
Version: 8.0 
08-Jul-2013 
Changes to reflect changes in regulatory sponsorship from University of 
Pennsylvania to Adaptimmune.   Changes to remove the MAGE cohort from the 
study design, changes to the long term follow up (LTFU) plan, changes on study 
stopping rules and changes on protocol deviation reporting, administrative 
changes.  
Version: 9.0 
04-Oct-2013 
Administrative changes to comply with requests made by the CTSRMC at the 
University of Pennsylvania 
Version: 10.0 
20-Nov-2013 
Administrative changes to comply with requests made by the CTSRMC and IRB 
at the University of Pennsylvania 
Version: 11.0 
20-Jan-2015 
Administrative change under section 3.1 to correct misleading information on 
long term follow up for patients who disease progress.  Administrative changes 
to reinforce long term follow up plan.  
 
Version: 12.0 
07-Apr-2017 
Update of IMWG Disease Response Criteria [Rajkumar, 2011] to assess all 
disease responses up to Year 1 a posteriori. 
Clarification of efficacy objective and capture of disease progression dates for 
subjects who have porgressed beyond year 1 to assess duration of response and 
progression free survival. 
Once the Long-Term Follow-up (LTFU) protocol ADP-0000-002 is available at 
site, patients whose disease has progressed/relapsed will be considered having 
completed study ADP-01411 and be consented to the LTFU protocol ADP-
0000-002. 

 
Protocol  ADP-01411  
 
 
 
 
 
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Patients who remain disease-free at the time of study completion (decided at 
sponsor’s discretion) will also be enrolled in the LTFU protocol ADP-0000-002.  
Rewording of persistence and RCL risk sections to conform to current FDA 
approved LTFU procedures.  Additional changes throughout the protocol 
amendment are to align assessments and wording in this amendment with those 
of the LTFU protocol (ADP-0000-002). 
Harmonization of protocol versions across sites. 
 
 
 
CONFIDENTIALITY STATEMENT 
This document contains information which is the property of Adaptimmune Ltd, United Kingdom, and 
Adaptimmune LLC, USA, and therefore is provided in confidence for your review.  It is understood that 
this information will not be disclosed to others without written approval from Adaptimmune Ltd. or  
Adaptimmune LLC. 
 
DECLARATION 
 
This study will be conducted in compliance with ICH Good Clinical Practice (GCP), all 
applicable subject privacy requirements, and the guiding principles of the current version of the 
Declaration of Helsinki (with amendments), and in accordance with local legal and regulatory 
requirements.

 
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Clinical Trial Site - University of Maryland: 
 
Principal Investigator:  
 
Aaron P. Rapoport, MD 
 
Protocol Chair 
 
 
Clinical Trial Site - University of Pennsylvania (Coordinating Center):   
 
 
 
 
 
 
 
 
 
 
Principal Investigator:  
 
Edward Stadtmauer, MD 
 
Clinical PI 
 
 
 

 
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RESPONSIBLE SPONSOR STUDY PHYSICIAN/SPONSOR INFORMATION PAGE  
Sponsor Signatory  
_____________________________       ___ 07 April 2017___ 
Lini Pandite, MD       
  
  
  
  
  
Date  
SVP, Clinical Development      
Responsible Study Physician/SAE Contact Information  
Role  
Name  
Day Phone and 
email  
After hours 
phone  
Fax Number 
Primary Sponsor 
Study Physician  
Karen Chagin, MD
+1 (267) 254-5975 
+1 (267) 254-5975  +1 (215) 825-9459 
Secondary  
Sponsor Study  
Physician  
Lini Pandite, MD 
+1 (919) 889-0199 
+1 (919) 889-0199  +1 (215) 825-9459 
 
Sponsor Details  
Adaptimmune LLC  
351 Rouse Boulevard 
Philadelphia, PA 19112 
USA  
 
 

 
Protocol  01411 
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AGENT 
NSC / NDC # 
Supplier 
IND 
 
 
 
 
Autologous T-cells 
NSC 727300 
Investigator 
BB-IND014603 
Cyclophosphamide 
NSC 26271 
Commercial 
 
Melphalan 
NSC 8806 
Commercial 
 
Prevnar-13 
NSC 731759 
Commercial 
 
G-CSF (filgrastim) 
NSC 614629 
Commercial 
 
Plerixafor (Mozobil) 
NDC 58468-0140-01 
Commercial 
 
Lenalidomide 
NSC 703813 
Commercial 
 
Bortezomib 
NSC 681239 
Commercial 
 
 
 
 
 

 
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Investigator Contact Information 
 
Aaron P. Rapoport  
University of Maryland 
arapoport@umm.edu 
410-328-1230 
Edward Stadtmauer  
University of 
Pennsylvania 
Edward.stadtmauer@uphs.upenn 
215-662-7910 
 
 

 
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Table of Contents 
1 OBJECTIVES ....................................................................................................................... 13 
1.1 
PRIMARY OBJECTIVES .................................................................................................................... 13 
1.2 
SECONDARY OBJECTIVES ............................................................................................................... 13 
1.3 
DEFINITION OF EFFICACY ENDPOINTS ........................................................................................... 14 
2 INTRODUCTION AND RATIONALE FOR INVESTIGATIONAL AGENTS ........... 14 
2.1 
AUTOLOGOUS STEM CELL TRANSPLANTS (ASCT) FOR MYELOMA ................................................ 14 
2.2 
POST-TRANSPLANT INFECTIONS .................................................................................................... 14 
2.3 
POST-TRANSPLANT IMMUNOTHERAPY; CLINICAL DATA SUPPORTING THE RATIONALE FOR THE 
DESIGN OF THIS STUDY ............................................................................................................................... 15 
2.4 
CANCER TESTES ANTIGENS IN MULTIPLE MYELOMA .................................................................... 19 
2.5 
REDIRECTED T CELLS FOR CANCER IMMUNOTHERAPY ................................................................. 21 
2.6 
GENERATION AND PRECLINICAL TESTING OF HIGH AFFINITY TCRS TARGETING NY-ESO-1 ANTIGEN
 
26 
2.7 
EVALUATION OF PNEUMOCOCCAL CONJUGATE VACCINE (PCV, PREVNAR-13®) RESPONSES ...... 32 
3 STUDY DESIGN (SEE PROTOCOL FLOW DIAGRAM IN APPENDIX B)............... 33 
3.1 
OVERALL DESIGN............................................................................................................................ 33 
3.2 
STUDY DURATION .......................................................................................................................... 34 
3.3 
STUDY EVALUATIONS ..................................................................................................................... 35 
4 SUBJECT SELECTION AND WITHDRAWAL .............................................................. 35 
4.1 
TARGET POPULATION .................................................................................................................... 36 
4.2 
SUBJECT COMPLIANCE MONITORING ........................................................................................... 36 
4.3 
INCLUSION CRITERIA ...................................................................................................................... 36 
4.4 
EXCLUSION CRITERIA ..................................................................................................................... 38 
4.5 
SUBJECT RECRUITMENT AND SCREENING ..................................................................................... 39 
4.6 
EARLY WITHDRAWAL OF SUBJECTS ............................................................................................... 39 
5 TREATMENT PLAN ........................................................................................................... 39 
5.1 
ENROLLMENT PROCEDURES .......................................................................................................... 40 
5.2 
PRE-TRANSPLANT THERAPY ........................................................................................................... 40 
5.4 
STEADY-STATE T-CELL HARVESTING (DAY -30 [+/-10]) .................................................................. 41 
5.5 
STEM CELL MOBILIZATION (CYCLOPHOSPHAMIDE +/- BORTEZOMIB) (DAY -26 [+/-3])................ 41 
5.6 
HIGH-DOSE THERAPY (DAY -2) ....................................................................................................... 41 
5.7 
AUTOLOGOUS T-CELL EXPANSION AND INFUSION (DAY +2) ......................................................... 42 
5.8 
PCV (PNEUMOCOCCAL CONJUGATE VACCINE, PREVNAR-13®) BOOSTERS ................................... 48 
5.9 
SECOND INFUSION ......................................................................................................................... 48 
5.10 
MAINTENANCE THERAPY (LENALIDOMIDE) ................................................................................... 49 
5.11 
PROTOCOL MODIFICATIONS FOR SYNGENEIC STEM CELL TRANSPLANT (SSCT) ........................... 50 
5.12 
TOXICITY MANAGEMENT ............................................................................................................... 51 
6 SCHEDULE OF EVALUATIONS (INCLUDING CORRELATIVE RESEARCH 
STUDIES) .................................................................................................................................... 55 
6.1 
CLINICAL ASSESSMENTS (STANDARD OF CARE) ............................................................................. 55 
6.2 
MYELOMA ASSESSMENTS (STANDARD OF CARE) .......................................................................... 55 
6.3 
IMMUNOLOGICAL ASSESSMENTS (RESEARCH STUDIES) ............................................................... 56 
6.4 
LONG TERM FOLLOW-UP FOR OBSERVATION OF DELAYED ADVERSE EVENTS FOR GENE THERAPY57 
7 RESPONSE DEFINITIONS AND STATISTICAL TREATMENT ................................ 58 
7.1 
CLINICAL MYELOMA RESPONSES ................................................................................................... 58 

 
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7.2 
STUDY ENDPOINTS ......................................................................................................................... 60 
7.3 
STATISTICAL ANALYSES .................................................................................................................. 61 
7.4 
STOPPING RULES FOR TREATMENT TOXICITIES ............................................................................. 64 
7.5 
TOXICITY ASSESSMENTS AND DATA REPORTING........................................................................... 64 
8 SAFETY AND ADVERSE EVENTS .................................................................................. 67 
8.1 
DEFINITIONS ................................................................................................................................... 67 
8.2 
RECORDING OF ADVERSE EVENTS ................................................................................................. 69 
 
ADVERSE EVENT REPORTING ......................................................................................................... 69 
8.3 
PERIOD AND ADVERSE EVENT REPORTING .................................................................................... 69 
8.4 
INVESTIGATOR REPORTING RESPONSIBILITIES .............................................................................. 73 
8.5 
COORDINATION OF PATIENT REGISTRATION/REPORTING ............................................................ 74 
8.6 
PROTOCOL DEVIATIONS ................................................................................................................. 74 
9 THERAPEUTIC AND INVESTIGATIONAL AGENTS ................................................. 76 
9.1 
LENALIDOMIDE: DRUG INFORMATION .......................................................................................... 76 
9.2 
CYCLOPHOSPHAMIDE: DRUG INFORMATION ................................................................................ 82 
9.3 
MELPHALAN:  DRUG INFORMATION ............................................................................................. 84 
9.4 
G-CSF:  DRUG INFORMATION ........................................................................................................ 87 
9.5 
PLERIXAFOR:  DRUG INFORMATION .............................................................................................. 88 
9.6 
BORTEZOMIB:  DRUG INFORMATION ............................................................................................ 89 
9.7 
PREVNAR-13 (PNEUMOCOCCAL CONJUGATE VACCINE):  DRUG INFORMATION .......................... 94 
10 DATA HANDLING AND RECORD KEEPING ............................................................... 96 
10.1 
CONFIDENTIALITY .......................................................................................................................... 96 
10.2 
SOURCE DOCUMENTS .................................................................................................................... 96 
10.3 
CASE REPORT FORMS ..................................................................................................................... 97 
10.4 
RECORDS RETENTION .................................................................................................................... 97 
11 REFERENCES ...................................................................................................................... 98 
12 APPENDIX A: CRITERIA FOR DIAGNOSIS OF PLASMA CELL MYELOMA* .. 109 
13 APPENDIX B: STUDY SCHEMA .................................................................................... 110 
14 APPENDIX C:  SCHEDULE OF EVALUATIONS* ...................................................... 112 
15 APPENDIX D:  LENALIDOMIDE DOSE MODIFICATIONS .................................... 116 
LENALIDOMIDE DOSE MODIFICATIONS   .................................................................... 116 
LENALIDOMIDE DOSE MODIFICATIONS (CONTINUED) .......................................... 117 
LENALIDOMIDE DOSE MODIFICATIONS (CONTINUED) .......................................... 118 
 
 
 
 

 
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Protocol Summary  
 
Title 
A Phase I/II, dual-cohort, two-site, clinical trial evaluating the safety and 
activity of redirected autologous T cells expressing a high affinity TCR 
specific for NY-ESO-1 administered post ASCT in patients with advanced 
myeloma 
Sponsor 
Adaptimmune  
Study Centers 
Two Centers: University of Maryland Greenebaum Cancer Center; 
Hospital of the University of Pennsylvania 
Study Design  
A Phase I/II, study. Patients with advanced myeloma and who are candidates 
for autologous stem cell transplants, or syngeneic stem cell transplants 
(SSCT), will be eligible.  Prior to full screening on this study, patients will 
undergo prescreening to evaluate HLA-A type and presence of NYESO-
1/LAGE antigen.  
7-14 days after PCV (pneumococcal conjugate vaccine) immunization #1 all 
patients (or donors in the case of SSCT) will initially undergo a steady-state 
mononuclear cell apheresis for T cell collection, with an optional second 
collection.  Once mononuclear cells have been collected, patients (or donors 
in the case of SSCT) will then undergo hematopoietic stem cell mobilization. 
All patients will then receive high-dose melphalan followed by 
hematopoietic stem cell transplant on day 0. On day +2, patients will receive 
a dose of >0.1-1 x 1010 anti-CD3/anti-CD28-costimulated autologous T cells 
which have been genetically modified to express high affinity NYESO-1 
TCRs.  A minimum dose of 0.1-1 x 109 will be permitted, but patients 
receiving this low dose level will be evaluated separately for safety and 
efficacy. PCV immunizations #2, 3 and 4 will be given at days 14, 42, 90.  
At day 100, patients will start lenalidomide maintenance.   
 
Patients will undergo myeloma restaging at days +42, +100, 6 months, 9 
months, 1 year post infusion and at least every 3 months or per local standard 
of care thereafter, until disease progression.  In accordance with FDA 
Guidelines, all patients will be monitored at 3, 6, 9, and 12 months then 
biannually until 5 years post infusion then annually until 15 years post 
infusion for delayed gene therapy adverse events. From the time of their 
disease progression, patients will enter long-term follow-up (LTFU) phase 
and continue to be monitored for gene therapy delayed adverse events as per 
original schedule.  Subjects who are still alive will be consented to the LTFU 
protocol ADP-0000-002. 
 
   
 
 
 

 
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Study Products to 
be Administered 
• Activated/costimulated autologous genetically modified T-cells for 
expression of high affinity TCRs “NYESO-1-c259-T”  infusions at 
day +2 
• Pneumococcal Conjugate Vaccine (Prevnar-13®) 
• Lenalidomide 
 
Primary Objective 
To evaluate the safety and tolerability of autologous genetically modified T 
cells transduced to express the high affinity NYESO-1 TCR in HLA-A2 
subjects. 
Secondary 
Objective 
To evaluate the clinical response as specified in the International Myeloma 
Workshop Group (IMWG) criteria published in 2011 [Rajkumar, 2011]. 
Number of Subjects 26 evaluable patients in the NYESO cohort (originally 6, but extended to 
26). 
Study Population 
and Main Inclusion 
Criteria 
Study patients will have systemic or multifocal myeloma requiring 
autologous stem cell transplantation. Patients should have disease which 
has relapsed or incompletely responded to prior therapy or have high-risk 
features.  Patients must also have measurable disease on study entry, as 
defined by quantifiable or detectable levels of serum or urine paraprotein 
or elevated serum free light chains with an abnormal ratio. 
Primary Endpoints 
The primary endpoint of the study is: 
 
1) (SAFETY ENDPOINT) Occurrence of  adverse events, per NCI CTC 
v4 guidelines, including  > grade 4 laboratory toxicities at any time 
from Day-40 until year 1. This will include infusional toxicity, and any 
toxicity probably or definitely related to NYESO-1-c259-T including but 
not limited to: 
a. Fevers 
b. Rash 
c. Neutropenia, thrombocytopenia, anemia, marrow aplasia 
d. Hepatic dysfunction 
e. Pulmonary infiltrates or other pulmonary toxicity 
f. Development of GVHD 
NOTE: transplant-related toxicities, typically occurring within a 
month post-transplant, are excluded as investigational study-related 
adverse events. 
 
Antitumor efficacy will be evaluated in depth through clinical, 
molecular and immunological secondary endpoints. 
Secondary 
Endpoint 
To evaluate the clinical response by measuring:  
a. objective response rate (ORR) at day 42, 100, 180, 270 and 360. 
b. best objective response (BOR) prior to initiating lenalidomide 
and at day 360. 
c. duration of response (DOR) and progression-free survival 
(PFS), 

 
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d. overall survival (OS) will be followed in this interventional 
protocol and continue to be followed in the long-term follow-up 
protocol ADP-0000-002, once subjects have transferred. 
 
Initiation of lenalidomide as maintenance treatment will be addressed in a 
sensitivity analysis  
 
 
1 
OBJECTIVES 
 
1.1 
Primary Objectives 
 
1. To evaluate the safety and tolerability of autologous genetically modified T cells transduced 
to express the high affinity NYESO-1 TCR in HLA-A2 subjects. 
2. To measure the incidence of GVHD in patients following infusion of TCR modified 
autologous T cells. 
 
1.2 
Secondary Objectives 
 
1. 
To demonstrate product bioactivity, and establish proof of concept and mechanism for the 
function of gene-modified cells in vivo by evaluating:  
Selective migration and engraftment of gene-modified infused cells to the marrow. 
a. Ex-vivo immune functionality and phenotype of infused cells in marrow and 
periphery 
b. Modulation of cytokine milieu in marrow and periphery  
c. Development of an expanded patient immune response against tumor via epitope 
spreading 
d. Expression levels of NY-ESO-1 in marrow samples obtained pre- and post- 
treatment from patients in each of the respective cohorts  
2. 
To evaluate the effect of late (day+100) lenalidomide treatment on secondary 
objectives1a-e above.  
3. 
To evaluate post-transplant cellular and antibody pneumococcal conjugate vaccine (PCV) 
responses following adoptive transfer of up to 1 x 1010PCV-vaccine-primed and TCR-
gene-transduced autologous Tcells.  
4. 
To evaluate the clinical response in the NYESO cohort as specified in Rajkumar et al. on 
behalf of IMWG in 2011 [Rajkumar, 2011] by measuring: 
a. objective response rate (ORR) at day 42, 100, 180, 270 and 360. 
b. best objective response (BOR) prior to initiating lenalidomide and at day 360. 
c. duration of response (DOR) and progression-free survival (PFS),  
d. overall survival (OS) will be followed in this interventional protocol and continue 
to be followed in the long-term follow-up protocol, once subjects have transferred. 
Initiation of lenalidomide as maintenance treatment will be addressed in a sensitivity 
analysis 

 
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1.3 
Definition of efficacy endpoints 
• Objective Response Rate (ORR): percentage of subjects who have a positive response (PR, 
VGPR, CR, or sCR). 
• Best Objective Response (BOR): best response experienced by the subject from first 
assessment of positive response ((PR, VGPR, CR, or sCR). 
• Progression Free Survival (PFS): the time from T-cell infusion (Day 2) until the date on 
which disease is shown to have progressed or the date on which the patient dies, from any 
cause. 
• Duration of Response (DOR): the time from first assessment of positive response (PR, 
VGPR, CR, or sCR) until the date on which disease is shown to have progressed or the date 
on which the subject dies, from any cause. 
• Overall Survival (OS): survival time from T-cell infusion (Day 2) 
 
2 
INTRODUCTION AND RATIONALE FOR INVESTIGATIONAL AGENTS 
 
2.1 
Autologous Stem Cell Transplants (ASCT) for Myeloma 
 
Although allogeneic (donor) stem cell transplants can eradicate myeloma through a T-cell 
mediated “graft vs. myeloma” (GVM) effect (Tricot et al., 1996; Lokhorst et al., 2004), 
toxicities can be prohibitive.  High-dose chemotherapy followed by autologous stem cell rescue 
(ASCT) induces complete responses in about 20-40% of patients but cures are rare due in part 
to the lack of a GVM effect (Barlogie et al., 1997; Child et al., 2003).  Retrospective studies 
suggest that better clinical outcomes from auto-transplantation for myeloma and other 
hematologic neoplasms may be associated with more rapid lymphocyte recovery during the 
early post-transplant period (Porrata et al., 2001; Porrataet al., 2004). In addition, myeloma-
reactive T-cells have been detected at low frequencies in the marrow or blood of untreated 
myeloma patients (Dhodapkar et al., 2002; Noonan et al., 2005).  Thus, strategies to augment 
the recovery and function of autologous T-cells post-transplant may be beneficial. 
 
2.2 
Post-transplant Infections 
 
In addition to compromising the ability of auto-transplant patients to mount effective anti-tumor 
immune responses, post-transplant immune suppression including prolonged depletion of 
CD4+ T-cell numbers and function and altered dynamics of immune cell recovery (e.g. 
inversion of CD4/CD8 ratios) clearly increase the risk for serious infections with varicella-
zoster virus (VZV), cytomegalovirus (CMV), and S. pneumonia (Hoyle et al., 1994; Ketter et 
al., 1999).  Indeed, the 23-valent pneumococcal polysaccharide vaccine is recommended by the 
American Society for Blood and Marrow Transplantation for all auto-transplant recipients at 1 
and 2 years post-transplant (Dykewicz et al., 2001).  Unfortunately, immunogenicity for this 
vaccine is limited, with only 19% of patients achieving potentially protective antibody levels at 

 
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24 months post-transplant (Guinan et al., 1994).  A protracted delay in immune reconstitution 
following autologous stem cell transplantation may help to explain this pattern of defective 
immune responses (Anderson et al., 1990; Guillaume et al., 1998).   
 
2.3 
Post-transplant Immunotherapy; clinical data supporting the rationale for the design of 
this study 
2.3.1 Results of GCC-0065/UPCC-6401:   
 
Randomized Study of Combination Immunotherapy using Costimulated Autologous T-cells and pre 
and post-transplant Immunizations using the Pneumococcal Conjugate Vaccine (PCV, Prevnar®) 
 
We hypothesized that improved T-cell recovery through intravenous infusion of ex-vivo 
costimulated autologous T-cells might provide a platform for post-transplant immunotherapy 
of myeloma and enhance protection from post-transplant infections.  Autologous T-cells were 
stimulated by coculture with immunomagnetic beads to which anti-CD3 and anti-CD28 
monoclonal antibodies had been conjugated because signals through CD3 and CD28 can 
prevent T cell anergy (Li et al., 1999; Boussiotis et al., 2000).To test this hypothesis, a 
randomized clinical trial was conducted jointly at the University of Maryland Greenebaum 
Cancer Center and the University of Pennsylvania Abramson Cancer Center in which 54 
patients with myeloma received infusions of costimulated autologous T-cells after 
autotransplantation along with immunizations using the pneumococcal conjugate vaccine 
(PCV) (Rapoport, 2005).  The following observations were made from this trial:   
 
1. Infusions of 5-10 x 109 costimulated T-cells on day 12 post-transplant led to 
significantly higher CD4 and CD8 T-cell counts at day 42 post-transplant. 
2. Post-transplant infusions of costimulated T-cells were well-tolerated with 
patients experiencing the following common toxicities:  grade I/II chills and 
rigors (~50% of patients affected); grade I-III fevers (27% of patients affected); 
grade I/II nausea (15% of patients affected).  Uncommon toxicities included 
hypertension (8%, grade I-III), hypotension (4%, grade I), pain/headache (8%, 
grade I), and hypoxia (6%, grades I-III).   
3. The group of patients who were randomly assigned to receive3 PCV 
immunizations [including one pre-transplant and two post-transplant (at days 
30 & 90)] along with an “early” infusion of vaccine-primed costimulated T-
cells, exhibited robust and sustained antibody responses to the pneumococcal 
saccharide antigens and robust T-cell responses to the vaccine carrier protein 
(CRM-197).   
4. The group of CMV seropositive patients who were randomly assigned to 
receive costimulated T-cells “early” (day 12) after transplant exhibited 
enhanced recovery of CMV-directed CD8 T-cell responses.   
 
In addition, a smaller multicenter study of costimulated T-cells after autotransplantation for 
myeloma showed that infusions of 5-10 x 1010 T-cells on day 3 of transplantation were well-

 
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tolerated without grade 3 or 4 infusional toxicities (Vij et al., 2003).   When compared to 
historical controls, these infusions led to significantly higher lymphocyte and CD4 counts as 
early as day 10 post-transplant.   
 
The prior study of costimulated T-cells and PCV immunizations provided a basis for 
designing a new study that utilized T-cells and a candidate myeloma vaccine to determine if 
anti-tumor immune responses can be generated post-transplant through this strategy.  
Unfortunately, no myeloma vaccines have been licensed nor proven to be clinically effective.  
Efforts to develop a myeloma vaccine have focused on i) myeloma cell preparations, ii) 
myeloma-specific antigens (e.g. myeloma/idiotype protein), and iii) myeloma-associated 
antigens.  Candidate whole cell vaccines include mixtures of irradiated autologous myeloma 
cells and GM-CSF-secreting K562 bystander cells (Borrello et al.,2004.) as well as fusions of 
autologous myeloma cells and autologous dendritic cells (Vasir et al.,2005; Raje et al.,2004; 
Rosenblatt et al, 2010).  Other novel strategies for augmenting the immunogenicity of 
myeloma cells may include enzymatic synthesis of α-gal epitopes to permit invivo 
opsonization by naturally occurring IgG anti-Gal antibodies followed by internalization by 
antigen-presenting cells (Galili, 2004).  Vaccines consisting ofidiotype myeloma protein or 
idiotype-pulsed dendritic cells have generated anti-idiotype T-cell and B-cell responses in 
about 20% of vaccinated patients and perhaps rare clinical responses (Reichardt et al., 1999; 
Titzer et al., 2000).While investigation into clinically effective myeloma vaccines continues, 
current data supports the merit for alternative approaches for augmenting tumor specific 
immunity, such as gene-modified T-cell therapy to provide better cellular targeting against 
myeloma tumor targets. 
 
2.3.2 Results of Clinical Trial GCC-0610/UPCC-13406:  
 
Phase I/II combination immunotherapy after ASCT for advanced myeloma to study hTERT 
vaccination followed by adoptive transfer of vaccine-primed autologous T cells. 
 
In this second joint University of Maryland and University of Pennsylvania clinical trial which 
was recently completed in early 2009, 56 patients with advanced myeloma received auto-
transplants in conjunction with post-transplant transfers of vaccine-primed and ex-vivo 
costimulated autologous T cells.  In contrast to the earlier trial, this new trial incorporated the 
following modifications:  i)  The target dose of T cells was 5-fold higher (~5 x 1010 cells); ii)  
T cell transfers occurred at day +2 post-transplant to take greater advantage of endogenous 
homeostatic lymphocyte expansion mechanisms (e.g. increased IL-15, IL-7 levels);  iii)  HLA 
A2+ patients received pre- and post-transplant immunizations using a multi-peptide tumor 
antigen vaccine composed of HLA-A2 – restricted peptides derived from hTERT and survivin 
and CMV. 
 
hTERTis an attractive target for immunotherapy because it is widely expressed in myeloma 
cells and immunologic escape through mutation or down-regulation may be incompatible with 
long-term survival of neoplastic cells. In addition, telomerase expression and function may be 
necessary for survival of clonogenic myeloma stem cells which may ordinarily escape ablation 

 
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by high-dose therapy alone.  Nonetheless, the curative effect of allogeneic stem cell 
transplants for myeloma indicates that these neoplastic “stem cells” are susceptible to 
immunotherapy.   
 
The multipeptide tumor antigen vaccine was comprised of three hTERT peptides including 
I540 (ILAKFLHWL) (Vonderheide et al.,1999), R572Y (YLFFYRKSV) and D988Y 
(YLQVNSLQTV) (Scardion et al.,2002) the Sur1M2 (LMLGEGLKL) peptide derived from 
the anti-apoptotic protein survivin which is overexpressed in a broad range of malignancies 
including myeloma and which may confer a poor prognosis (Anderson et al.,2001) and a CMV 
control peptide (Mclaughlin-Taylor et al.,2001).  The multipeptide tumor antigen vaccine was 
given to HLA-A2+ patients (ARM A) at 4 timepoints:  i) ~ 10 days before steady-state T cell 
collection; ii) day +14 post-transplant; iii) day +42 post-transplant; and iv) day +90 post-
transplant.  All patients (HLA-A2 positive and negative) received the Prevnar® pneumococcal 
conjugate vaccine at these same timepoints.   
 
Among the observations from this trial was that rapid and robust T cell recovery (CD4+ & 
CD8+) occurred by day +14 post-transplant and this pattern of recovery was significantly 
improved compared to the earlier trial (Rapoport et al.,2005)in which costimulated T cells 
were transferred at day +12 post-transplant.  Day +2 serum IL-15 levels correlated 
significantly and positively to day +14 T cell counts.  Notably, a proportion of patients (~16%) 
developed an early and clinically significant form of autologous GVHD (graft-vs-host-
disease) which required a short course of systemic steroids in most cases.   This clinical 
syndrome may be due to a significant shift in the balance of T effector cells (Teff) and T 
regulatory cells (Treg) leading to an increase in the Teff/Treg ratio – a mechanism which may 
be necessary for effective cancer immunotherapy.  These observations formed the basis for a 
recent paper (Rapoport et al., 2009).   
 
The combination of enhanced immune cell recovery and reduced self-tolerance following 
high-dose therapy and adoptive transfer of activated autologous T cells may also promote the 
development of clinically significant immune responses to cancer vaccines.  Immunoassays 
which were performed showed that of 28 total ARM A (HLA A2 positive) patients analyzed 
to date, 10 patients (36%) had positive tetramer responses at one or more time-points after 
immunization, defined as tetramer staining by flow cytometry > 0.1% (and >3-fold increase 
vs. enrollment/baseline). Using a larger number of patients (54) the relatively high frequency 
and robust anti-pneumococcal antibody and T-cell responses that were reported previously 
with early transfers of vaccine-primed and costimulated autologous T cells (Rapoport et 
al.,2005) have been confirmed.  These data have been recently reported (Rapoport et al, 2010).   
 
The mean and median numbers of T cells infused were 4.26x1010 and 4.54 x1010 respectively, 
(range, 1.59 – 5.0).  The mean CD4/CD8 ratio was 2.48 (range, 0.62-11.09).  The day +2 T 
cell transfers were well-tolerated with common adverse effects being chills/rigors, 
nausea/vomiting and low grade fevers (see Table 2.3.2 below with events separated by ARM 
assignment, A=A2+, B=A2-).  All early infusion-related toxicities were grade I/II.  Later 
toxicities which were possibly, probably, or definitely considered to be related to the T cell 
infusions are also tabulated (see Table 1 below).  These toxicities, also mainly grade I/II, 

 
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included mild maculopapular rashes (typically involving the face/scalp/neck/upper chest, 
fevers, arthralgias, myalgias and conjunctivitis which was readily responsive to glucocorticoid 
eyedrops.  One patient had incomplete platelet recovery (grade III) (~ 40-50,000/mcl at 6 
months post-transplant) considered to be possibly related to the T-cell infusion. There were 
no documented cases of autoantibody formation (e.g. ANA, thyroid antibodies) or 
autoimmune endocrinopathies.  
 
Table 2.3.2:  T-Cell Related Toxicities (Arm A vs. Arm B)  
 
Event (0 to 48 hrs) 
 
I 
 
II 
 
III 
 
Totals 
 
P Value 
 
 
A 
 
B 
 
A 
 
B 
 
A 
 
B 
 
A 
 
B 
 
Rigors/Chills  
7 
6 
11 
7 
0 
0 
18(64) 
13(50) 
NS 
Nausea/Vomiting * 
1 
7 
0 
0 
0 
0 
1(4) 
7(27) 
0.02 
Fever 
3 
4 
0 
0 
0 
0 
3(11) 
4(15) 
NS 
Headache/Pain  
0 
3 
0 
0 
0 
0 
0 
3(12) 
NS 
Hypertension  
0 
0 
0 
1 
0 
0 
0 
1(4) 
NS 
Hypoxia/Pulmonary  
0 
1 
0 
0 
0 
0 
0 
1(4) 
NS 
Rash  
0 
0 
1 
0 
0 
0 
1(4) 
0 
NS 
Diarrhea 
1 
1 
0 
0 
0 
0 
1(4) 
1(4) 
NS 
Rash  
19 
19 
4 
4 
0 
0 
23(82) 
23(88) 
NS 
Fever 
6 
4 
1 
0 
1 
0 
8(29) 
4(15) 
NS 
Gut GVHD 
1 
0 
3 
2 
0 
  1 
4(14) 
3(12) 
NS 
Arthralgias 
3 
4 
0 
1 
0 
0 
3(11) 
5(19) 
NS 
Myalgias  
5 
0 
0 
0 
0 
0 
5(18) 
0 
0.05 
Headache/Pain  
4 
1 
3 
0 
0 
0 
7(25) 
1(4) 
0.05 
Anorexia/Nausea * 
6 
2 
2 
0 
1 
0 
9(32) 
2(8) 
0.04 
Conjunctivitis 
0 
0 
0 
3 
0 
0 
0 
3(12) 
NS 
Fatigue 
6 
0 
1 
1 
0 
0 
7(25) 
1(4) 
0.05 
Cytopenias 
1 
2 
0 
0 
0 
0 
1(4) 
2(8) 
NS 
Neuropathy  
1 
2 
0 
0 
0 
0 
1(4) 
2(8) 
NS 
Hepatic(↑AST/ALT) 
1 
1 
0 
1 
0 
0 
1(4) 
2(8) 
NS 
Eosinophilia 
0 
1 
1 
0 
0 
0 
1(4) 
1(4) 
NS 
Renal/Edema  
1 
0 
0 
1 
0 
0 
1(4) 
1(4) 
NS 
Diarrhea * 
10 
3 
6 
1 
2 
1 
18(64) 
5(19) 
0.001 
Mucositis 
1 
2 
2 
1 
1 
1 
4(14) 
4(15) 
NS 
Mental Status 
Changes 
0 
1 
0 
0 
0 
0 
0 
1(4) 
NS 
 
To determine whether the early lymphocyte recovery which followed day +2 adoptive T cell 
transfer had an effect on hematopoietic recovery, we compared the times to absolute 
neutrophil counts (ANC) > 500/mcl for 2 consecutive days for the current study patients with 
an historical control population of 102 myeloma patients who had standard autografts without 
additional T cells Gojo et al., 2006.  The median number of days to neutrophil recovery in the 
current trial was 12 days [range 10-18] versus 12 days in the historical cohort [P = 0.49].  

 
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Similarly, the median days to an unsupported platelet count > 20,000/mcl was similar for the 
two populations: 14 days [range 0-28] in the current trial versus 14.5 days in the historical 
cohort [P = 0.78].    
 
Seven patients developed a post-transplant T cell “engraftment syndrome” characterized by 
watery diarrhea (up to 2000 cc/day), abdominal pain, and fever (in six of the patients).  In six 
patients this syndrome developed at a median of 14 days post-transplant (range 9-17 days) 
while in one patient it occurred around day 60 post-transplant.  Two patients (including one 
who developed GI GVHD) developed early bright facial rashes at about day +9 post-
transplant.  The mean day 14 CD4 count for the 7 patients who developed early GVHD-like 
T cell engraftment syndromes was 2443 (range 863 – 4049) while the mean day 14 CD8 count 
for this subset of patients was 5822 (range 671 – 11571).  There were no significant differences 
in the CD4 and CD8 counts for the subset of patients who developed early “GVHD” versus 
the group of patients who did not.   
 
All 7 patients with apparent “GI-GVHD” had colonoscopic biopsies at a median of 17 days 
post-transplant (range, 15-81):  In 6 patients the biopsies were interpreted to show 
histopathologic grade II-III GVHD of the gut.  The biopsy for the patient with late onset 
symptoms was considered to be non-specific, although intraepithelial lymphocytosis and rare 
apoptotic bodies were observed.  All 7 patients were initially treated with 1-2 mg/kg of 
methylprednisolone and/or oral budesonide followed by a rapid taper over about 1 month and 
exhibited rapid and complete clinical responses.  
 
Four patients, including 3 patients who also had GI GVHD and a fourth patient with no GI 
symptoms, developed early skin rashes including generalized erythroderma or bright facial 
rashes at about day +9 post-transplant.  A biopsy of one of these rashes showed typical grade 
II skin GVHD with apoptotic keratinocytes, basal vacuolization and CD3+ T cell infiltration 
of the dermis and epidermis while the skin biopsy of a second patient with facial rash alone 
showed a follicular and eccrine duct-centric infiltration of lymphocytes in the superficial 
dermis.  These rashes resolved in about 1 week with (1 patient) or without (3 patients) systemic 
glucocorticoids.    
 
2.4 
Cancer testes antigens in multiple myeloma 
 
Cancer-testis antigens (CT antigens) are proteins with restricted expression in testicular germ 
cells and placenta, and are not normally expressed in other tissues of the body except in 
various cancers (Caballero and Chen, 2009).  Many of these genes are encoded as multigene 
families on the X chromosome, including the MAGE-A and NY-ESO-1 antigens, and are 
accordingly called the “CT-X” antigens.  CT antigens were first described in malignant 
melanoma as targets for cytotoxic T cells and humoral immunity. Specific members of the 
CTAg family including MAGE-A1, MAGE-A3, MAGE-A4, CT-7 and NY-ESO-1 have been 
shown to be overexpressed in myeloma as well (Dhodapkar et al.,2003).  CT antigens are 
attractive targets for tumor vaccines or redirected T cell gene therapy due to their tumor-
specific expression patterns. 

 
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2.4.1 NY-ESO-1 and relevance to myeloma 
 
NY-ESO-1 was originally identified as a human tumor antigen by a method called serological 
expression cloning of recombinant cDNA libraries from human tumors (SEREX) (Chen, et 
al., 1997). The function of NY-ESO is unknown.  NY-ESO-1expression is detected in testis, 
ovary and weakly in uterus specimens. No mRNA can be detected by RT-PCR in any other 
normal tissue (Chen et al., 1997). In multiple myeloma, expression figures vary widely 
depending on the study, with up to 80% of patients positive for the antigen, but the majority 
of reports quote figures of <50%.  Expression increases in relapsed patients, and reaches 100% 
in patients with advanced disease and abnormal cytogenetics (approximately a third of the 
total patient population).  A summary of the literature covering NY-ESO expression in 
myeloma is shown in Table 2.4.2. Of note, NY-ESO-1 (also known as LAGE-2) is very similar 
in sequence to LAGE-1, and both antigens contain the epitope (SLLMWITQC) recognized by 
the high affinity TCR evaluated in this protocol.  Therefore, both NY-ESO and LAGE-1 
expression levels are shown in the table. 
 
In addition to myeloma, solid tumors express NY-ESO at rates of up to 50%: bladder, 
melanoma, lung, ovarian, uterine and esophageal cancer (Chen et al, 1997).  Expression 
increases with tumor stage.  Reported expression rates vary between different studies; RT-
PCR is more sensitive than IHC, and tends to give higher figures for NY-ESO expression.  
Figures derived from IHC are more reliable, since this technique detects protein rather than 
RNA. CTL recognizing the A2 presented epitope NY-ESO157-165, SLLMWITQC, have been 
grown from the blood and lymph nodes of myeloma patients by several different groups (van 
Rhee et al., 2005; Atanackovic et al., 2007).  LAGE-1, a highly homologous TAA with an 
identical expression pattern, also shares the same epitope.  T cell clones specific for this 
epitope kill tumor cells (van Rhee et al., 2005).A high affinity TCR recognizing the NY-
ESO157-165epitope binds to A2, NY-ESO +ve melanoma cell lines and fresh myeloma samples 
(but not to cells that lack either A2 or NY-ESO). 
Table 2.4.2:  Incidence of NY-ESO-1 or LAGE-1 expression in patients with myeloma 
Method 
Disease Stage 
No. Myeloma 
Patients Analyzed 
% NY-ESO-1 
expression 
% LAGE-1 
expression 
Citation 
RNA1 and IHC 
Diagnosis 
161 
41 
ND 
Van Rhee et al, 2005 
RNA1 and IHC 
Relapse 
55 
74 
ND 
Van Rhee et al, 2005 
RNA2  
Advanced 
disease3  
39 
33 
49 
Andrade et al, 2008 
RNA2  
Stage III 
27 
33 
51 
Van Baren et al, 1999 
RNA2  
Stage I or II 
11 
0 
0 
Van Baren et al, 1999 
RNA2  
Advanced 
disease  
55 
7 
ND 
Atanackovic et al, 2007 
IHC 
Stage III 
13 
23 
ND 
Dhodapkar et al, 2003 
RNA2  
Not reported 
20 
0 
ND 
Lim et al, 1999 
1-Gene expression profiling 
 
 
 
 

 
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Table 2.4.2:  Incidence of NY-ESO-1 or LAGE-1 expression in patients with myeloma 
Method 
Disease Stage 
No. Myeloma 
Patients Analyzed 
% NY-ESO-1 
expression 
% LAGE-1 
expression 
Citation 
2-RT-PCR 
 
 
 
 
 
3-95% of patients were classified as "advanced" 
 
 
 
ND-Not Done 
 
 
 
 
 
 
 
2.5 
Redirected T cells for cancer immunotherapy 
 
 
It is now well established that human tumors have antigens, and that natural immune responses are associated 
with improved survival in a variety of cancers (Smyth, Dunn, and Schreiber, 2006). The central problem is 
tolerance: the repertoire of TCRs is generally of too low avidity to efficiently recognize tumor antigens, and 
this explains the failure of most cancer vaccines (Greenberg and Riddell, 1999; Rosenberg, Yang and 
Restifo, 2004; Pardoll and Allison, 2004). To address this issue we have worked with Dr. B. Jakobsen at 
Adaptimmune Ltd to develop high affinity TCRs. Results recently published in Nature Medicine present our 
exciting results using high affinity TCRs to improve the immune response to HIV20, and these TCRs are 
currently under investigation in a clinical trial at UPenn. Higher affinity recognition allows T cells to respond 
to lower levels of antigen; this is critically important for tumor immunotherapy where the tumor 
microenvironment has adapted itself to reduce expression of antigen and also decrease expression of MHC 
class I molecules (Marincola et al, 2000; Barrett and Blazar, 2009). 
 
To date at least 18 studies have been opened for TCR redirected T cells to date (Table 2.5), and are at various 
stages of completion.  Of these, two have been published (Morgan et al, 2006 and Johnson et al, 2009).  
These studies evaluated three different TCRs isolated from tumor infiltrating lymphocytes, and chosen based 
on medium or high affinity binding to HLA-peptide complexes (Johnson et al, 2006).  In the first trial 
evaluating medium affinity MART-1 DMF4 TCRs (identifier number: NCT00091104), 17 subjects were 
reported (to date, 31 have been enrolled).  Subjects received as high as 6 x 1010 antigen specific redirected T 
cells.  No toxicity related to T cell infusions was reported. 
 
In two other studies, (identifier numbers: NCT0050946 and NCT00509288) the higher affinity MART-1 
DMF5 and gp100 (154) TCRs were evaluated in 20 and 16 subjects, respectively (Johnson et al, 2009).  In 
the case of these trials, 29 of 36 subjects developed an erythematous skin rash that subsided within 48 hours 
and was treated with local application of steroids.  The reaction was an “on target” reaction of the TCRs 
against low levels of MART-1 and gp100 antigen that was present on normal melanocytes.  The response 
rate was correspondingly higher in this study than in the previous MART-1 DMF4 study (30% and 19% 
compared to 13%).  There was a correlation between the response rate and persistence of functional TCR 
redirected T cells.   
 
Of note, the NY-ESO-1 receptor that is proposed for use in Cohort 2 patients in this trial has already been 
used in the clinic (clinicaltrials.gov identifier NCT00670748).  Results from this trial were recently 
published (Robbins et al, 2011).  Eleven patients with melanoma and 6 patients with synovial sarcoma were 
enrolled.  Patients were HLA-A2 and the tumors expressed NY-ESO-1 as assessed by RT-PCR, 
immunohistochemistry, or serum reactive antibody.  No adverse events were reported.  Objective responses 
were found in 5/11 melanoma patients, and objective partial responses were observed in 4/6 synovial 

 
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sarcoma patients.  Ongoing complete responses >1.5 year were found in 2 patients and at 9 months in one 
patient with melanoma and a 1.5 year partial response was observed in one patient with synovial cell 
carcinoma.  
 
Table 2.5:  Clinical trials using TCR redirected T cells open to date 
Target 
Antigen 
TCR Type 
Indication 
Protocol Title 
Study Chair, Center 
ClinicalTrials.gov 
Identifier 
CEA 
anti-CEA 
TCR 
metastatic 
cancer 
expressing CEA 
antigen 
Phase II study of 
metastatic cancer 
that expressed 
carcinoembryonic 
antigen (CEA) using 
lymphocepleting 
conditioning 
followed by 
infusion of anti-CEA 
TCR gene 
engineered 
lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00809978 
CEA 
anti-CEA 
TCR 
metastatic 
cancer 
expressing CEA 
antigen 
Phase II Study of 
Metastatic Cancer 
That Expresses 
Carcinoembryonic 
Antigen (CEA) Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-
CEA TCR-Gene 
Engineered 
Lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00923806 
CEA 
anti-CEA 
TCR 
adenocarcinoma 
Phase I Study of T 
Cells Modified With 
Chimeric Anti-CEA 
Immunoglobulin-T 
Cell Receptors 
(IgTCR) in 
Adenocarcinoma 
Richard P. Junghans, 
BethIsraelDeaconessMedicalCenter 
NCT00004178 
gp100 
TCR gene-
engineered 
TILs 
melanoma 
Treatment of 
Patients With 
Metastatic 
Melanoma by 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of TCR-
Gene Engineered 
Lymphocytes and 
Subsequent 
Fowlpox gp100 
Vaccination 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00085462 

 
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Table 2.5:  Clinical trials using TCR redirected T cells open to date 
Target 
Antigen 
TCR Type 
Indication 
Protocol Title 
Study Chair, Center 
ClinicalTrials.gov 
Identifier 
gp100 
anti-
gp100:154-
162 TCR 
melanoma 
Phase II Study of 
Metastatic 
Melanoma Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-gp 
100:154-162 TCR-
Gene Engineered 
Lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00509496 
gp100 
anti-
gp100:154-
162 TCR, 
ALVAC virus 
melanoma 
Phase II Study of 
Metastatic 
Melanoma Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-gp 
100: 154-162 TCR-
Gene Engineered 
Lymphocytes and 
ALVAC Virus 
Immunization 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00610311 
  
gp100 
MART-1 
Anti-gp 
100:154 TCR 
melanoma 
Phase II Study of 
Metastatic 
Melanoma Using a 
Chemoradiation 
Lymphodepleting 
Conditioning 
Regimen Followed 
by Infusion of Anti-
Mart-1 and Anti-
gp100 TCR-Gene 
Engineered 
Lymphocytes and 
Peptide Vaccines 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00923195 
Anti-MART-
1 F5 TCR 
  
MART-1 
anti-MART-1 
F5 TCR, 
ALVAC virus 
melanoma 
Phase II Study of 
Metastatic 
Melanoma Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-
MART-1 F5 TCR-
Gene Engineered 
Lymphocytes and 
ALVAC Virus 
Immunization 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00612222 

 
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Table 2.5:  Clinical trials using TCR redirected T cells open to date 
Target 
Antigen 
TCR Type 
Indication 
Protocol Title 
Study Chair, Center 
ClinicalTrials.gov 
Identifier 
MART-1 
TCR anti-
MART-1 F5 
High-risk 
melanoma 
Transfer of 
Autologous T Cells 
Transduced With 
the Anti-MART-1 F5 
T Cell Receptor in 
High Risk 
Melanoma 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00706992 
MART-1 
CTL line 
expressing 
TCR ant-
MART-1  
melanoma 
Open Label, Non-
Randomized Phase 
I Dose Escalation 
Study of Adoptive 
Transfer of an anti-
MART-1 TCR 
Expressing CTL Line 
Administered by 
Intra-Tumoral 
Injection in Patients 
with Melanoma 
Hans von der Maase, Aarhus 
University Hospital 
  
MART-1 
(DMF4) 
anti- MART-
1 TCR-
engineered 
tumor-
infiltrating 
lymphocytes 
or PBLs 
melanoma 
A Study in 
Metastatic 
Melanoma Using a 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-
MART-1 TCR-Gene 
Engineered 
Lymphocytes and 
Subsequent 
Peptide 
Immunization 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00091104 
MART-1 
(DMF5) 
anti-MART-1 
F5 TCR 
melanoma 
Phase II Study of 
Metastatic 
Melanoma Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-
MART-1 F5 TCR-
Gene Engineered 
Lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00509288 
MART-1 
(DMF5) 
anti-MART-1 
F5 TCR 
melanoma 
Adoptive Transfer 
of MART-1 F5 TCR 
Engineered 
Peripheral Blood 
Mononuclear Cells 
(PBMC) After a 
Nonmyeloablative 
Conditioning 
Regimen, With 
Administration of 
MART-126•35-
Antoni Ribas, Bartosz Chmielowski, 
James S. Economou, John A 
Glaspy,UCLA 
NCT00910650 

 
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Table 2.5:  Clinical trials using TCR redirected T cells open to date 
Target 
Antigen 
TCR Type 
Indication 
Protocol Title 
Study Chair, Center 
ClinicalTrials.gov 
Identifier 
Pulsed Dendritic 
Cells and 
Interleukin-2, in 
Patients With 
Advanced 
Melanoma 
MART-1 
and 
gp100 
anti-MART-1 
and anti-
gp100 TCR 
melanoma 
Phase II study of 
metastatic 
melanoma using a 
chemoradiation 
lymphodepleting 
conditioning 
regimen followed 
by infusion of anti-
MART-1 and anti-
gp100 TCR gene 
engineered 
lymphocytes and 
peptide vaccines 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00814684 
NY ESO-
1 
anti-NY ESO-
1 TCR 
kidney cancer, 
melanoma, 
metastatic 
cancer 
expressing NY 
ESO-1 
Phase II study of 
metastatic cancer 
that expresses NY 
ESO-1 using 
lymphodepleting 
conditioning 
followed by 
infusion of anti-NY 
ESO-1 TCR gene 
engineered 
lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00670748 
NY-ESO-
1 
anti-NY ESO-
1 TCR 
Melanoma 
Phase I/II study in 
melanoma 
expressing NY-ESO-
1 antigen  using 
lymphodepleting 
conditioning 
followed by 
infusion of anti-NY-
ESO-1 gene 
engineered CD8 T 
cells, and 
administration of 
ipilumimab to 
evaluate its effects 
on persistence and 
activity of the gene 
modified cells  
AudeChapuis-
FredHutchinsonCancerResearchCenter 
NCT00871481 

 
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Table 2.5:  Clinical trials using TCR redirected T cells open to date 
Target 
Antigen 
TCR Type 
Indication 
Protocol Title 
Study Chair, Center 
ClinicalTrials.gov 
Identifier 
p53 
anti-p53 
TCR 
metastatic 
cancer with p53 
overexpression 
Phase II Study of 
Metastatic Cancer 
That Overexpresses 
P53 Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-P53 
TCR-Gene 
Engineered 
Lymphocytes 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00393029 
p53 
anti-p53 
TCR 
kidney cancer, 
melanoma, 
metastatic 
cancer 
expressing p53 
Phase II Study of 
Metastatic Cancer 
That Overexpresses 
p53 Using 
Lymphodepleting 
Conditioning 
Followed by 
Infusion of Anti-P53 
TCR-Gene 
Engineered 
Lymphocytes and 
Dendritic Cell 
Vaccination 
Steven A. Rosenberg, NCI - Surgery 
Branch 
NCT00704938 
TRAIL 
Bound 
to the 
DR4 
Receptor 
Anti-TRAIL 
TCR 
Metastatic 
Renal Cancer 
Phase 1/2 Study of 
Metastatic Renal 
Cancer Using T-
Cells Transduced 
With a T-Cell 
Receptor Which 
Recognizes TRAIL 
Bound to the DR4 
Receptor 
James C. Yang NCI - Surgery Branch 
NCT00923390 
 
2.6 
Generation and preclinical testing of high affinity TCRs targeting NY-ESO-1 antigen 
2.6.1 Design of Study Drugs: NYESO-1 TCR 
 
Isolation and validation of NYESO-1 specific TCR 
TCR gene cDNA sequences were isolated from the NY-ESO HLA-A*0201-SLLMWITQC 
restricted T cell clone 1G4 (Jager E. et al., 1998). NOTE: the SLLMWITQC peptide sequence is 
the identical sequence as is expressed by the LAGE antigen, and therefore LAGE antigen 
positive tumors are also targeted by the 1G4 T cell clone. The cDNA coding sequences for the 
mature extracellular regions of the α and β chain TCR proteins were cloned into separate E.coli 
plasmid vectors and expressed as protein inclusion bodies. These inclusion bodies were purified 
and solubilized in protein denaturant then refolded as soluble α/β heterodimeric TCR protein 
(sTCR) by dialysis. Both TCR chains were genetically truncated at the C terminus immediately 

 
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before the native intra-chain cysteine residues. The refolded TCR chains were joined together 
by means of an artificial disulphide bond engineered between the α and β chain TCR constant 
regions. The 1G4 sTCR protein was purified by ion exchange and size exclusion 
chromatography. Its HLA peptide antigen binding kinetics were analyzed by Surface Plasmon 
Resonance (SPR) using a BIAcore 3000. The 1G4 gene sequences were then chosen for antigen 
binding affinity enhancement by selection/enrichment from gene libraries of bacteriophage 
displaying large numbers of mutated 1G4 TCR proteins.  
 
Production of HLA-A*0201-SLLMWITQC antigen complex 
The HLA-A*0201-SLLMWITQC peptide antigen complex was required for validation of the 1G4 
T cell clone and sTCR validation, as well as for phage display based affinity enhancement. This 
complex was made in-house by cloning the heavy chain and β2m into E.coli expression vectors. 
These proteins were then expressed separately as inclusion bodies prior to solubilisation, mixing 
with the SLLMWITQC peptide and refolding by dialysis. Refolded antigen complex was then 
purified by ion exchange and size exclusion chromatography. Where required this complex was 
further modified by C-terminal enzymatic biotinylation. 
 
NY-ESO sTCR affinity enhancement 
A 1G4 sTCR phage display library was constructed with mutations covering the hypervariable 
complementarity determining region (CDR3 region) of the β chain Three rounds of selection/ 
enrichment for high affinity TCR clones were performed using streptavidin magnetic beads coated 
with biotinylated HLA-A*0201-SLLMWITQC complex. Competition ELISAs screens for high 
affinity mutant TCR phage identified several TCR β-chain CDR3 mutations. These high affinity 
β chain mutants then formed the basis of a library where the CDR3 α chain was also mutated. 
This complex library was then used to isolate still higher affinities. Further mutations were later 
introduced into the CDR2 regions of both chains and these libraries then re-selected (Li Y. et al., 
2005). Further CDR2-only high affinity 1G4 TCRs were identified by phage display (Dunn S. et 
al., 2006) 
 
Biochemical validation of the affinity enhanced NYESO-1 sTCR clones  
High affinity mutant TCR chain genes were cloned separately into E.coli expression vectors. 
These mutant TCR chains were expressed and refolded in various paired combinations including 
with wild type chains. They were then purified and analyzed for binding to HLA-A*0201-
SLLMWITQC antigen by SPR. Selected data showing the binding kinetics for several mutant 
TCRs is presented in Table 2.6.2(1) (see also Zhao et al., 2007). 
 
 
 
 
 
Table 2.6.2(1): Binding kinetics of the individual high affinity NYESO-1 sTCRs. 
Clone 
Ka (1/Ms) 
Kd (1/s) 
T1/2 
KD 
aWT/bWT 
– 
– 
2.2s 
9.30µM 
a259/bWT 
4.87e4 
0.036 
19s 
730nM 
a12/b2 
9.00e3 
4.00e-3 
4 min 
450 nM 
aWT/b51 
5.40e4 
0.0014 
8.3 min 
25 nM 
a10/b1 
1.65e4 
1.38e-3 
12 min 
84 nM 
a5/b100 
3.90e5 
1.97e-4 
98 min 
5 nM 
a58/b61 
5.70e5 
2.72e-5 
>425 min 
26 pM 

 
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Optimization of mutant NYESO-1 mTCR sequences to obtain affinities useful for 
adoptive T cell therapy. 
Studies with T cells transfected with high affinity TCRs indicated that a range of TCR with 
intermediate affinity should be evaluated (Zhao et al., 2007). To do this, the high affinity 
mutant CDR3α chain TCR sequences of Li et al., (ibid) and mutant CDR2β chain TCR 
sequences of Dunn et al.,(ibid) were partially back-mutated to the wild-type 1G4 TCR 
sequence. A panel of these phage-derived 1G4 TCR mutants was then assessed in TCR-
transfected T cells. Key mutant sTCR chains were then expressed and refolded in combination 
with wild type chains. They were then purified and analyzed for binding to HLA-A*0201-
SLLMWITQC antigen by SPR (Robbins et al., 2008). From these data TCRs anticipated to 
have good cellular properties were selected for comparison in lentiviral T cell transduction 
studies (Table 2.6.2(2)). 
 
 
 
 
 
 
 
 
 
 
 
 
 
The clones wt, c259 and c12/c2 were then introduced into the transfer plasmid pELNS for 
lentivirus-based expression in human T cells for further testing.  
 
2.6.2 In vitro studies showing the specificity and function of NYESO-1c259 TCRs 
 
 
2.6.2.1 NYESO-1c259 TCR 
 
Measurement of cytokine secretion by ELISpot. IFNγ secretion or granzyme B release by 
activated T cells at the single cell level in response to HLA/antigen was detected by ELISpot 
assay (BD Biosciences), according to the manufacturers’ instructions. Briefly, TCR-transduced 
T cells (5,000 per well) were incubated with target cells (50,000 per well) in 96-well capture 
anti-cytokine antibody pre-coated ELISpot plates. The ELISpot plate was then incubated 
overnight at 37oC/5% CO2, followed by washing and incubation for 2 hours with biotinylated 
anti-cytokine detection antibody and 1 hour with streptavidin-substrate and subsequent 
development. As controls and for specificity testing, redirected T cells were also stimulated 
with normal cell lines that lack expression of NYESO-1 antigen. Figure 2.6.2.1 demonstrates 
that IFNγ response was consistently higher for the high affinity c259 TCR transduced T cells 
than for the wt TCR transduced T cells. The c259- and c12c2-transduced T cells secrete IFNу 
in response to NYESO-1 positive tumor lines, and also with only a small response against the 
melanocytes cell line N9. A greater response to the primary melanocytes was observed with 
c12c2 than with c259 suggesting off-target activity. 
Table 2.6.2(2): Binding kinetics of 1G4 sTCRs 
Clone 
T1/2  
KD 
aWT/bWT  
(‘wt’) 
2.2 
sec 
9.30µM 
a259/bWT
(‘c259’) 
19.0 
sec 
730nM 
a12/b2(‘c1
2c2’) 
4 
min 
450 nM 

 
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NY-ESO c259-transduced T cells exhibit enhanced functional responses to tumor cell 
lines but not normal cells. A summary of functional testing of NYESO1 TCR redirected T 
cells as determined by various functional assays mentioned above together with molecular 
analysis of NY-ESO expression by RT-PCR in target tumor and normal cell lines is presented 
in Tables 2.6.2.1(1) and Table 2.6.2.2(2).  
 
Table2.6.2.2(1) underscores the superiority of c12c2- and c259-transduced T cells showing 
greater levels of response than WT transduced T cells in collective assays. These 
representations of response levels correspond to the general ELISpot counts as tabulated  as a 
reference in the earlier Table 2.6.2.1(2).  Interestingly, c12c2 occasionally showed a reduced 
level of response to some target tumor cell lines compared to c259-transduced T cells. 
Reactivity of these redirected T cell against normal cell lines (Table2.6.2.2(2))shows that WT 
and c259-transduced T cells do not respond to a variety of normal cells, with only minor, if 
 
 
NY-ESO+ 
NY-ESO - 
 
 
 
TCR affinity 
IM9 
Mel624 
Mel526 
SKMel37 
N9 
HEP2 
HA2 
ntd       wt       c259        c12c2 
Figure 2.6.2.1: IFNγ ELISpot: IFNγ-release by TCR-transduced T cells in response to 
incubation with HLA-A2+ target cells. Mixed CD8 and CD4 T cells (mixed 1:1 at stimulation) 
were either non-transduced (ntd) or transduced with NY-ESO wt-, c259, or c12c2-TCRs and 
expanded until d10-13 prior to cryopreservation. IFNg ELISpot was carried out asdescribed  
Figure 2.6.2.1: IFNγ ELISpot: IFNγ-release by TCR-transduced T cells in response to 
incubation with HLA-A2+ target cells. Mixed CD8 and CD4 T cells (mixed 1:1 at stimulation) 
were either non-transduced (ntd) or transduced with NY-ESO wt-, c259, or c12c2-TCRs and 
expanded until d10-13 prior to cryopreservation. IFNg ELISpot was carried out asdescribed 
previously. Data is representative of 3 independent experiments involving cells from 3 different 
T cell donors.  The origin of these cell lines is shown in Tables 8.2.2 (1 and 2). 

 
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any, responses seen to some primary melanocytes lots (N2 and N9). However, c12c2-
transduced cells showed a large response to renal epithelial cells suggesting than higher 
affinity TCR may have off-target effects.   
 
Table 2.6.2.2(1): Tumor cell lines analyzed in NY-ESO-1 efficacy studies 
Cell line 
* 
Origin  
NY-ESO-
1 
expression 
Reactivity to 
wt-TCR 
modified  
T cells** 
Reactivity to 
c259-TCR 
modified  
T cells** 
Reactivity to 
c12c2-TCR 
modified  
T cells** 
IM-9 
B cell (EBV) 
+++ 
++ 
++++ 
+++ 
Mel624 
Melanoma 
+++ 
++ 
++++ 
+++ 
Mel526 
Melanoma 
+ 
+/- 
+ 
+ 
SKMel37 
Melanoma 
+/- 
+ 
+++ 
++ 
A375 
Melanoma 
+ 
+ 
++++ 
++ 
U266 
Myeloma 
++ 
++ 
+++ 
ND 
OPM-2 
(A2-) 
Myeloma 
+ 
- 
- 
ND 
J82 
Bladder 
carcinoma 
- 
- 
- 
- 
* HLA-A2+ unless stated 
** data generated by different assays (ND indicates sample not tested). Data represents 3 
independent experiments (except n=1 for A375, U266, OPM-2 and J82) 
 
 
Table 2.6.2.2(2): Normal cells (HLA-A2+) analyzed in NY-ESO-1 efficacy studies 
Cell line  
Origin  
NY-ESO-
1 
expression 
Reactivity to 
wt-TCR 
modified  
T cells** 
Reactivity to 
c259-TCR 
modified  
T cells** 
Reactivity to 
c12c2-TCR 
modified  
T cells** 
HEP2 
Hepatocyte 
ND 
- 
- 
- 
HA2 
Astrocyte 
ND 
- 
- 
- 
HA10 
Astrocyte 
ND 
- 
- 
- 
N2 
Melanocyte 
ND 
--/+ 
--/+ 
-/+ 
N9 
Melanocyte 
ND 
- 
--/+ 
-/+ 
N10 
Melanocyte 
- 
- 
- 
- 
REN2 
Renal epithelial 
- 
- 
- 
+++ 
SMC3 
Smooth muscle 
-/+ 
- 
- 
- 
PF5 
Pulmonary fibroblast 
ND 
- 
- 
- 
HBSMC2 
Bronchial 
smooth 
muscle 
ND 
- 
- 
- 
HPEpC1 
Prostate epithelial 
ND 
- 
- 
- 
CM5 
Cardiac myocyte 
ND 
- 
- 
- 
SkMC3 
Skeletal muscle 
ND 
- 
- 
- 
** data generated by different assays (ND indicates sample not tested). Data represents at least 3 
independent experiments for HEP2, HA2 and N9 (n=1 for others) 
2.6.3 In vivo studies showing the antigen specific efficacy of the NYESO-1c259 TCRs in tumor 
bearing mice 
 
2.6.3.1  NALM-6 Leukemia Tumor Model 
 

 
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The effectiveness of NYESO-1 TCR transduced T cells was tested in the immunodeficient NSG 
(NOD/scid/γcnull) mouse model using the human B-cell precursor acute lymphoblastic leukemia 
cell line (NALM-6). The immunodeficient NOD/scid/γcnull(NOG) mouse is an excellent 
xenotransplantation model to measure the in vivo repopulation of human CD4 T cells (Ito et al,. 
2009). Following engraftment, the human hematopoietic cells can be maintained in NSG mice 
for at least 2 months or until fatal xenogeneic graft-versus-host-disease (xGVHD). Injection 
(i.v.) of NALM-6 into NSG mice provides a systemic tumor model with rapid evolution toward 
animal death within 20-23 days. Parental NALM-6 cells express both HLA-A1 and HLA-A2 
molecules and also low levels of MAGE A3 antigen, but no NYESO-1 antigen.  For a higher 
expression of this antigen, we transduced NALM-6 cells with lentiviruses expressing   NYESO-
1 proteins in conjunction with the GFP protein (NALM6-GFP-MAGE A3 and NALM6-GFP-
NYESO1). As a control cell line, we transduced NALM-6 cells with GFP only (NALM6-GFP). 
In a previous experiment we tested these three lines (NALM6-GFP-MAGE A3, NALM6-GFP-
NYESO1 and NALM6-GFP) in the NSG mouse model and found that similarly to the parental 
NALM-6 cells, they induce mouse death within 23 days.    
 
Our efficacy study used parental and transduced NALM-6 cell lines and evaluated the impact of 
CD4 and CD8 T cells, lentivirally transfected to express   NYESO-1 TCR on animal survival. 
The cohorts are detailed in the Table 2.6.3.1. NSG mice were engrafted with 2 x 106 NALM-6 
tumor alone, or expressing NYESO-1   antigens, via tail vein injection on day 0. On day 6, T 
cells were normalized for equivalent transduction percentages using untransduced cells and 5 x 
106 transduced/control T cells were injected into animals via tail vein injection.  Animals were 
followed weekly. The primary efficacy endpoint of the study was survival.   
 
The infused study drug cell number is 5 x 106CD4 and CD8 T cells.  This dose was chosen based 
on pilot data in the NALM-6 model which indicates that this is the effective dose required to 
observe an antitumor effect.  A human is on average 3000-fold larger than an average mouse.  
Our maximum cell infusion dose in humans is anticipated to be 1 billion cells. 5 x 106cells in a 
mouse corresponds to a human dose of >10 billion cells (5,000,000 x 3000).  Therefore, the dose 
evaluated in this experiment represents about 10 times greater than the maximum human dose 
that will be administered in Phase I trials.  
 
 
 
 
Table 2.6.3.1: Cohort summary for efficacy study in NSG-NALM6 mouse model 
Cohort 
# mice       Tumor 
T cells 
                    Question 
1 
8 
NALM-6/GFP 
           None 
Control 
2 
8 
NALM-6/GFP 
Non-transduced 
Control 
3 
8 
NALM-6/GFP 
NYESO-1 c259/wt 
Negative control 
4 
8 
NALM-6/NY-ESO-1 
           None 
Control tumor growth 
5 
8 
NALM-6/NY-ESO-1 
Non-transduced 
Control T cell effect on tumor 
6 
8 
NALM-6/NY-ESO-1 
MAGE-A3 WT 
Control WT-TcR effect on tumor 
7 
8 
NALM-6/NY-ESO-1 
MAGE-A3 a3a 
TcR effect on tumor 
8 
8 
NALM-6/NY-ESO-1 
NYESO-1 wt 
Control WT-TcR effect on tumor 
9 
8 
NALM-6/NY-ESO-1 
NYESO-1 c259/wt 
TcR effect on tumor 
10 
8 
NALM-6/MAGE A3 
Non-transduced 
Control  
11 
8 
NALM-6/MAGE A3 
MAGE-A3 WT 
Control WT-TcR effect on tumor 
12 
8 
NALM-6/ MAGE A3 
MAGE-A3 a3a 
TcR effect on tumor 

 
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As expected, all the control mice (injected with saline and mock/untransduced T cells) died 
between day 19 and 23. Also, the high affinity NYESO1 TCR (c259) transduced T cells did 
not give the mice any survival advantage when mice were carrying the NALM6 tumor cells. 
However when mice given the NALM6/NYESO1 tumor were treated with NYESO1 TCR 
transduced T cells, a significant survival advantage was seen regardless of the TCR affinity 
(wt or c259) (Figure 2.6.3.1(1)). This data suggests that both NYESO-1 TCRs are effective 
against tumor cells expressing the antigen. A limitation of this system is that we did not have 
a control group testing the efficacy of the TCR transduced T cells against targets expressing 
low antigen levels. 
 
 
2.7 
Evaluation of pneumococcal conjugate vaccine (PCV, Prevnar-13®) responses 
 
As a bridge to the prior studies involving post-transplant adoptive T-cell transfers and to assess 
whether the gene-modified T-cells would still be able to promote antibody and cellular responses 
to the Prevnar-13 vaccine, patients will receive pre and post-transplant immunizations using the 
same regimen that we have used previously.  This intervention also offers the potential for clinical 
benefit since we have previously shown that pre-and post-transplant PCV immunizations plus early 
post-transplant transfer of vaccine-primed T-cells can lead to protective antibody responses against 
multiple pneumococcal serotypes.  
 
2.8 Revlimid® (Lenalidomide) as Maintenance  
 
Lenalidomide is an immunomodulatory agent which is derived from thalidomide.       
Lenalidomide with or without dexamethasone has potent activity against myeloma which has 
relapsed after prior therapy (Weber et. al, 2007; Richardson et. al., 2009).  Recently, 
lenalidomide has also been used as a highly effective frontline treatment and in the 
maintenance setting.   Unpublished data in a phase III multicenter, randomized, double-blind 
study conducted by the CALGB (#100104), has shown that Lenalidomide decreased the risk 
of disease progression by 58% vs placebo when Lenalidomide was given as maintenance after 
autotransplantation.  Thus we plan to use lenalidomide maintenance at a dose of 10 mg per 
day, starting at day +100 post-transplant as a standard of care. 
 
 
 
Figure 2.6.3.1(1). Efficacy of NYESO-1 
TCR transduced T cells against parental and 
modified NALM-6 tumor line. NSG mice 
were injected with 2 x 106 NALM-6 tumor 
alone, or expressing NYESO-1 antigen, via 
tail vein injection on day 0. On day 6, 5 x 106 
transduced/control T cells were injected (iv) 
into animals.  Mice were followed weekly 
until death occurred. 

 
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3 
STUDY DESIGN (See Protocol Flow Diagram in Appendix B) 
 
3.1 
Overall Design 
 
This study will be a Phase I/II study of auto-transplantation for patients with myeloma followed by 
infusion of autologous T cells which have been genetically modified to target tumor antigen. 
Approximately twenty six (26) subjects will be enrolled from two institutions, the University of 
Maryland and the University of Pennsylvania. Before enrollment, patients will be tested for HLA 
A status and for tumor expression of   NY-ESO-1.  Patients who are HLA-A2+ (and express NY-
ESO-1 in the myeloma cells) will be eligible for enrollment.  The outline of the protocol is as 
follows. First patients will receive an immunization using the pneumococcal conjugate vaccine 
(Prevnar-13 ®).  About 7-14 days later, patients will initially undergo a steady-state mononuclear 
cell apheresis for T cell collection, with an optional second collection.  Once mononuclear cells 
have been collected, patients will then undergo hematopoietic stem cell mobilization using 
cyclophosphamide and G-CSF (unless they have stem cells stored from a previous collection). For 
transplant, all patients will receive high-dose melphalan followed by hematopoietic stem cells on 
day 0.  On day +2, patients with receive up to 1 x 1010anti-CD3/anti-CD28-costimulated autologous 
T cells which have been genetically modified to express high affinity   NYESO-1 TCRs.   
 
Patients will be followed closely until disease progression or 1 year post T-cell infusion, whichever 
is sooner, for safety evaluations and correlative research, blood and marrow sampling, and then at 
least about every 6 months up to year 5 and every 12 months from year 5 up to year 15 post 
transfusion for delayed gene therapy adverse events in accordance with FDA Guidelines.  The 2nd 
subject will not be infused until the 1st subject has completed the Day +21 visit.  
 
Patients will undergo myeloma restaging at day 42, day 100, 6, 9 and 12 months post infusion, then 
per local standard of care, until disease progression.  Shortly after the 3 month staging (day 100 
post infusion), patients will start lenalidomide maintenance therapy.   
 
After their disease progression, in accordance with FDA Guidelines, all patients will enter long 
term follow up (LTFU) and will continue to be monitored biannually  for delayed gene therapy 
adverse events and collection of samples for persistence, and annually for  collection of samples 
for RCL.     From year 5 post-infusion, all patients will require annual visits for monitoring of 
delayed gene therapy adverse events, and assessment of persistence and RCL until 15 years after 
receiving the last infusion of genetically modified T cells. Patients whose disease progresses prior 
to year 1 will enter LTFU at time of progression; however these patients will be seen quarterly from 
progression until year 1 post infusion and then follow the LTFU schedule above mentioned.   
 
Once the Long-Term-Follow-up protocol ADP-0000-002 will be available at site, subjects in LTFU 
will be considered having completed study ADP-01411 and be consented to the LTFU protocol 
ADP-0000-002. 
 
 

 
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3.1.1 Primary Objectives 
 
1. To evaluate the safety and tolerability of autologous genetically modified T cells 
transduced to express the high affinity NY-ESO-1 TCR in HLA-A2 subjects. 
2. To measure the incidence of GVHD in patients following infusion of TCR modified 
autologous T cells. 
 
3.1.2 Secondary Objectives 
1. 
To demonstrate product bioactivity, and establish proof of concept and mechanism for 
the function of gene modified cells in vivo by evaluating:  
Selective migration and engraftment of gene-modified infused cells to the marrow. 
a. Ex-vivo immune functionality and phenotype of infused cells in marrow and 
periphery 
b. Modulation of cytokine milieu in marrow and periphery  
c. Development of an expanded patient immune response against tumor via epitope 
spreading 
d. Expression levels of NY-ESO-1 in marrow samples obtained pre- and post- 
treatment from patients in each of the respective cohorts  
2. 
To evaluate the effect of late (day+100) lenalidomide treatment on secondary 
objectives1a-e above.  
3. 
To evaluate post-transplant cellular and antibody pneumococcal conjugate vaccine (PCV) 
responses following adoptive transfer of up to 1 x 1010PCV-vaccine-primed and TCR-
gene-transduced autologous Tcells.  
4. 
To evaluate the clinical response in the NYESO cohort as specified in Rajkumar et al. on 
behalf of IMWG in 2011 [Rajkumar, 2011] by measuring: 
a. objective response rate (ORR) at day 42, 100, 180, 270 and 360. 
b. best objective response (BOR) prior to initiating lenalidomide and at day 360. 
c. duration of response (DOR) and progression-free survival (PFS).  
d. overall survival (OS) will be followed in this interventional protocol and continue 
to be followed in the long-term follow-up protocol, once subjects have transferred. 
Initiation of lenalidomide as maintenance treatment will be addressed in a sensitivity 
analysis. 
 
3.2 
Study Duration 
 
Based on previous experience, it is anticipated that approximately 1 patient per month will be 
enrolled on the study.   Therefore, it will take approximately twenty six (26) months to recruit all 
26 evaluable patients into the study.  There are frequent visits for the study during the first 6 months 
of participation, but then the visit frequency lengthens out to about every 3 months until year 1, 
unless a problem develops which requires closer monitoring.  Patients will remain on study as long 
as they show no progression or relapse of myeloma or develop a complication which mandates that 

 
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they discontinue study treatment.   The criteria for progression of myeloma will be as defined under 
Section 7.1.  Patients whose disease has progressed/relapsed will enter the Long-Term Follow-up 
Phase of the study (LTFU). Patients will also be followed for survival until death from any cause 
or loss to follow up.  Once the Long-Term Follow-up protocol ADP-0000-002 will be available at 
site, patients in LTFU will be considered having completed study ADP-01411 and be consented to 
the LTFU protocol ADP-0000-002. 
Patients who remain disease-free at the time of study completion (timing at Sponsor’s discretion) 
will also be consented to the LTFU protocol ADP-0000-002. 
3.3 
Study Evaluations 
 
Patients will be monitored for myeloma activity throughout the study.   
 
Absolute counts for leukocyte and lymphocyte subset at each sample draw will be determined as 
part of standard clinical care. 
 
Bulk subset analysis (CD3/CD8+, CD3/CD4+, CD3+/CD4+/CD25+/CD127-, CD3-/CD16+, CD3-
/CD19+, CD3-/CD14+ will be determined fresh on each sample using lyse-no-wash protocols. 
 
Persistence and homing of infused cells will be evaluated using quantitative PCR (Q-PCR) on 
marrow and peripheral blood samples obtained pre-transplant and at multiple time-points post- 
infusion using transgene-specific primers.  If persistence levels allow, persistence will be 
corroborated by flow-based analysis using Vb specific antibodies that correspond to the infused-
cell clonotypes     
 
Ex-vivo functionality of infused and persisting cells (a) and development of an expanded immune 
response against tumor (b) will be assessed on marrow samples and peripheral blood samples 
obtained pre-and post-T cell infusion and post lenalidomide using flow-cytometry- based immune 
effector assays, specifically degranulation, proliferation, and intracellular cytokine secretion of 
gene-modified (a) and bulk (b) cells in response to autologous tumor. 
 
A decrease in target antigen expression in the marrow as a consequence of treatment (through 
immune-mediated tumor destruction or antigen-loss variant selection) will be evaluated on marrow 
samples obtained pre-and post-T cell infusion and post lenalidomide using Q-RT-PCR and 
primer/probe sets specific for NY-ESO-1. 
 
The effect of lenalidomide administration on infused cell persistence and functionality will be 
assessed in marrow and peripheral blood samples collected just prior to and post initiation of 
lenalidomide administration as described above. 
 
 
4 
SUBJECT SELECTION AND WITHDRAWAL 
 
 

 
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4.1 
Target Population 
 
Study patients will have systemic or multifocal myeloma requiring autologous stem cell 
transplantation. All of these patients will have received initial treatment previously.    Upon 
enrollment, patients will undergo marrow aspirations for staging purposes and to obtain myeloma 
cells for future immunoassays.   In addition, newly diagnosed patients can have myeloma cells 
collected and stored under a separate IRB-approved specimen collection protocol.   If during this 
initial assessment process, red top and lavender top tubes are collected as indicated in the schedule 
of study procedures, then additional marrow will not be required for collection during the screening 
phase of this protocol.  These patients would then be treated with myeloma cytoreductive therapy 
as recommended in the STUDY PROCEDURES section and enrolled after completion of pre-
transplant therapy. 
 
4.2 
Subject Compliance Monitoring 
 
The study team will be able to completely monitor compliance with, vaccinations, T- cell apheresis, 
stem cell collection process, high-dose melphalan, and re-infusions of both stem cells and T-cells. 
Any steps in this sequence that are missed must be recorded as protocol violations. Written 
informed consent must be obtained from all patients before entry into the study. 
 
 
4.3 
Inclusion Criteria 
 
Each subject must meet ALL of the following criteria during screening to be enrolled in the   study. 
No exceptions to eligibility will be granted:  
 
4.3.1  Written informed consent must be obtained from all patients before entry into the study 
 
4.3.2 Patients must have a diagnosis of myeloma (see Appendix A for diagnostic criteria).  
 
4.3.3 Patients must meet one of the following criteria: 
 
 
Myeloma has relapsed, progressed, or failed to respond after at least one prior 
course of therapy (consisting of at least 2 treatment cycles or months of therapy).  
Failure to respond would correspond to a reduction of less than or equal to 25% of 
the original, diagnostic serum or urine paraprotein measurement.   
 
Myeloma has responded partially to initial therapy but a complete response 
(immunofixation negative and normal serum free light chain studies) has NOT 
developed after a minimum of 3 cycles or months of initial therapy.    
 
Myeloma has high-risk features as defined by the presence of one or more 
cytogenetic abnormalities known to confer a poor outcome even after standard 
auto-transplants:  complex karyotype (> or =  to 3 abnormalities), t(4;14), t(14;16), 

 
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del (17) (p13.1), and/or chromosome 13 abnormalities.  These patients may be 
enrolled even while in complete or near-complete remission.  Extended disease-
free survival after auto-transplantation would be unexpected for these patients and 
therefore especially meaningful.   
 
4.3.4 Patients must have measurable disease on study entry.  Measurable disease may include 
quantifiable or detectable levels of serum or urine paraprotein.  For patients with minimally 
secretory disease or non-secretory myeloma on study entry, serum free λ or  κ  light chain 
levels or the serum free light chain ratio may be measured and used for disease monitoring 
if abnormal.   
 
Patients who are in complete remission at the time of proposed study entry (serum and 
urine immunofixation consistently negative and serum free light chains normal) are not 
eligible unless their disease meets the criteria for high-risk as defined in section 4.3.4.   
 
4.3.5 Patients must be between ages 18-80 (inclusive).  
 
4.3.7 Patients should have adequate vital organ function as defined below: 
 
• Serum creatinine <3.0 mg/dl and not on dialysis 
• WBC at least 3000/mm3, platelet count at least 100,000/mm3 
   
(See 
protocol section 5.9 for modified eligibility requirements pertaining to a second T-cell 
infusion) 
• SGOT< or = to 2 x upper limit of normal and bilirubin < or = to 2.0 mg/dl (unless due 
to Gilbert’s syndrome).   
• Left ventricular ejection fraction (LVEF) > 45%.  A lower LVEF is permissible if a 
formal cardiologic evaluation reveals no evidence for clinically significant functional 
impairment.   
• Adequate pulmonary function with mechanical parameters > 40% predicted (FEV1, 
FVC, TLC, DLCO).  Patients who are unable to complete PFTs due to bone pain or 
fracture must have a high  resolution CT scan of the chest and must have acceptable 
arterial blood gases defined as a room air PO2 greater than 70 mmHg. 
• Patients should have recovered from any toxicities related to prior therapy or at least 
returned to their baseline level of organ function.   
• Patients should be off of glucocorticoids for at least 2 weeks and/or other therapies for 
at least 1 week prior to enrollment.   
 
4.3.8    ECOG performance status 0-2 (unless due solely to bone pain. Also, see protocol section   
5.9 for modified eligibility requirements pertaining to a second T-cell infusion. ) 
 
4.3.9 Prior to Lenalidomide maintenance phase, all study participants must be registered into 
the mandatory RevAssist® program, and be willing and able to comply with the 
requirements of RevAssist®. 
 

 
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4.3.10 Females of childbearing potential (FCBP) must have a negative serum or urine pregnancy 
test with a sensitivity of at least 50 mIU/mL within 10 – 14 days prior to and again within 
24 hours of prescribing lenalidomide (prescriptions must be filled within 7 days) and must 
either commit to continued abstinence from heterosexual intercourse or begin TWO 
acceptable methods of birth control, one highly effective method and one additional 
effective method AT THE SAME TIME, at least 28 days before she starts taking 
lenalidomide.  FCBP must also agree to ongoing pregnancy testing.  Men must agree to 
use a latex condom during sexual contact with a FCBP even if they have had a successful 
vasectomy.  See Appendix: Risks of Fetal Exposure, Pregnancy Testing Guidelines and 
Acceptable Birth Control Methods 
 
4.3.11 Lenalidomide treatment phase:  able to take aspirin (81 or 325 mg) daily as prophylactic 
anticoagulation (patients intolerant to ASA may use warfarin or low molecular weight 
heparin). 
 
4.3.12  HLA-A201 patients must have confirmed expression of NY-ESO-1 and/or LAGE (these 
determinations will be under a pre-enrollment “screening” consent form using criteria 
listed below in study procedures). In addition HLA-A2 patients must have the A-201 allele  
 
4.4 
Exclusion criteria 
Subjects who meet ANY of the following criteria cannot be enrolled in the study. No 
exceptions to eligibility will be granted:  
4.4.1 Pregnant or nursing females 
4.4.2 HIV or HTLV-1/2 seropositivity 
4.4.3 Known history of myelodysplasia 
4.4.4 Known history of chronic active hepatitis or liver cirrhosis (if suspected by laboratory 
studies, should be confirmed by liver biopsy). 
4.4.5 Active Hepatitis B (as defined by + Hepatitis B surface antigen); + Hepatitis C virus (HCV) 
antibody is NOT an exclusion 
4.4.6 Prior allogeneic transplant 
4.4.7 History of severe autoimmune disease requiring steroids or other immunosuppressive 
treatments. 
4.4.8 Active immune-mediated diseases including:  connective tissue diseases, uveitis, 
sarcoidosis, inflammatory bowel disease, multiple sclerosis. 
4.4.9 Evidence or history of other significant cardiac, hepatic, renal, ophthalmologic, 
psychiatric, or gastrointestinal disease which would likely increase the risks of 

 
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participating in the study.  For any transplant patient over 60 and for patients with prior 
history of heart disease, a pre transplant cardiac stress test is recommended.  The specific 
type of stress test will be selected at the PI’s discretion. 
4.4.10 Active bacterial, viral or fungal infections. 
 
4.5 
Subject Recruitment and Screening 
 
Subjects will be recruited for this study from the clinical practices of the Hematology-
Oncology division at the University of Pennsylvania and from the University of Maryland. 
Subjects will be required to give written informed consent to participate in the study before 
any screening tests or evaluations are conducted.  
 
4.6 
Early withdrawal of subjects 
 
Subjects may withdraw from the study prior to the expected completion date for the following 
reasons: 
 Unacceptable toxicity and other safety reasons 
 Progression or disease relapse 
 Subject consent withdrawal 
 Decision by the investigators that withdrawing is in the patient’s best interest 
 Decision by the investigators because they determined the patient is unable to comply with 
the study procedures 
 Decisions from the Sponsor to terminate the study  
 Death 
 
Standard supportive therapy may be maintained for subjects withdrawn from active treatment. 
Every effort will be made to collect toxicity information on withdrawn patients.  
 
 
5 
TREATMENT PLAN 
 
*No study procedures may be performed prior to the patient signing informed consent.    In 
addition, since the study is complex, simplified protocol flow diagrams should be used along 
with the consent document to enable the prospective study patient to fully understand the 
procedures and multiple steps that are involved in the study.   
 
In order to enroll, patients must have the following HLA/tumor antigen combinations: 
 
 
1)  HLA-A201+ and NY-ESO-1 and/or LAGE positive myeloma 
 
To establish tumor antigen expression, the following procedures will be followed: 

 
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a)  If the patient has measureable disease, fresh marrow will be collected and tested for tumor 
antigen expression by RT-PCR (in lab of Dr. Kalos at UPENN). 
 
b)  If the patient has insufficient myeloma cells in the marrow (due to prior therapy) then the 
diagnostic marrow or tissue sample will be retrieved for antigen expression analysis by IHC 
(immunohistochemistry). 
 
c)  If no prior tumor samples are available and a current marrow specimen is inadequate, then the 
patient will not be eligible since cognate tumor antigen expression cannot be proven. 
 
5.1 
Enrollment Procedures 
 
The laboratory evaluation at enrollment will consist of the following studies: 
 Complete medical history, physical examination, performance status 
 CBC with differential 
 Comprehensive metabolic panel 
 Chest XRAY (Chest CT if clinically indicated) 
 Myeloma markers (SPEP + immunofixation; quantitative IgG, IgM, IgA; UPEP + 
immunofixation based on a 24 hour urine collection; serum free κ and λ light chain 
levels and κ/λ ratio determination; Beta-2 microglobulin, CRP) 
 Skeletal survey; MRI or PET scan if clinically indicated 
 Serology for hepatitis B and C; HIV; HTLV1/2; CMV 
 Pregnancy test if applicable 
 CD3,CD4 and CD8 T-cell levels 
 Staging marrow aspiration and biopsy (if not done within previous 2 months) 
 HLA A/B/DR determination (low resolution is acceptable): in most cases this will 
have been done prior to enrollment.   
 
5.2 
Pre-transplant Therapy 
 
Patients who are newly diagnosed should receive initial cytoreductive therapy with several cycles 
of a standard induction regimen (e.g. dexamethasone/thalidomide or dexamethasone/lenalidomide 
or bortezomib/dexamethasone or equivalent). Upon completion of initial therapy and in accordance 
with the eligibility criteria in section 4.0, patients may enroll as described in 5.1.  
 
5.3 PCV (Prevnar-13) Immunization (day -40 [+/-4]) 
 
Patients will also receive an intramuscular (IM) injection of the pneumococcal conjugate vaccine 
(PCV, Prevnar-13) [0.5 ml] into the non-dominant deltoid. 
 
 

 
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5.4 
Steady-State T-cell Harvesting (day -30 [+/-10]) 
 
 
After enrollment, patients will undergo a mononuclear cell apheresis procedure to collect steady-
state T-cells.  If a patient has previously undergone an apheresis for T cell collection, the frozen 
product may be used if, in the opinion of the investigator and the manufacturing facility these 
cells should be used in lieu of fresh product.  The collection goal will be about 1 x 108 
mononuclear cells/kg body weight. The minimum collection will be set a 0.5 x 108 mononuclear 
cells/kg. However, if the minimum collection is not reached, then a second apheresis procedure 
can be performed.  The cells will be transferred by courier to the manufacturing facility where 
they will be cryopreserved for later expansion. 
 
5.5 
Stem Cell Mobilization (Cyclophosphamide +/- Bortezomib) (day -26 [+/-3]) 
 
After completion of the mononuclear cell apheresis procedure, patients will be offered low-dose 
cyclophosphamide chemotherapy for stem cell mobilization at a dose of 1500-3000mg/m2 daily.  
At the discretion of the treating physician and particularly for patients with higher myeloma 
burdens at the time of stem cell mobilization, bortezomib may be added at a dose of 1.3 mg/m2 
on days 1, 4 and 8 (3 doses).  Use of bortezomib is recommended for patients with ≥20% marrow 
plasmacytosis at study enrollment, prior to stem cell mobilization, to decrease tumor burden before 
stem cell collection.Addition of bortezomib to mobilization chemotherapy does not adversely 
affect stem cell yield or engraftment (Oakervee et al., 2007; Badros et al., 2006).   
 
Patients should receive antibiotic prophylaxis upon completion of chemotherapy (e.g. 
moxifloxacin, acyclovir, mycelex troches or equivalent) and G-CSF daily, SQ, at a dose of 10 
mcg/kg body weight (rounded to nearest multiple of 300 mcg and 480 mcg vials) starting on the 
day after completion of chemotherapy. An acceptable alternative mobilization regimen would be 
plerixafor with G-CSF.   
 
The goal for stem cell collection will be ~8-10 x 106 CD34+ progenitors/ kg body weight with a 
minimum of 3 x 106/kg body weight needed to proceed with the transplant.  An additional stem 
cell mobilization using another mobilization regimen could be performed at the discretion of the 
treating physician in order to reach the stem cell collection target.   
 
Subject may receive treatment for myeloma prior to high dose therapy if there is a delay in stem 
cell transplant date due to scheduling, manufacturing delays, etc. Note, stem cell mobilization step 
may be skipped if the subject has stem cells already stored.  
 
5.6 
High-dose Therapy (day -2) 
 
High-dose therapy will consist of melphalan at a dose of 200 mg/m2 given IV over about 20 
minutes on approximately day -2.  For patients who are >70 years of age, the dose of melphalan 
will be reduced to 140 mg/m2. All patients will receive standard anti-emetic prophylaxis and 
standard antibiotic prophylaxis.  Stem cell infusion will take place on day 0, at least 18 hours after 

 
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the administration of the high-dose melphalan. Stem cells will be infused intravenously over about 
20-60 minutes following premedication with acetaminophen (650 mg) and diphenhydramine (25 
mg) with or without 1mg/kg of hydrocortisone, depending on institutional preference.   G-CSF 
should be administered SQ beginning on day +5 at a dose of 480 mcg/day (or 300 mcg/day if 
body weight is < 60 kg). Other supportive care measures such as transfusional support will be 
done in accordance with standard institutional guidelines.  At least 2 x 106 CD34 + progenitors/kg 
body weight should be infused after high-dose therapy.  In addition, at least 1 x 106 CD34 + 
progenitors/kg body weight should be available as a backup stem cell product to be infused in the 
event of delayed engraftment or late graft failure. 
 
5.7 
Autologous T-cell Expansion and Infusion (day +2) 
 
5.7.1 
Mononuclear Cell Transfer and transport to the manufacturing facility 
 
The manufacturing facility will prepare the expanded T cells for patients enrolled at both sites. 
The pre-expansion mononuclear cells will be transferred by express courier (same day delivery) 
in accordance with FDA-approved guidelines to the manufacturing facility.  Cell products will be 
packed and shipped according to (International Air Transport Association) IATA regulations, in 
specially designed Saf-T-Pak insulated shippers. For patients enrolled at each site, the cells will 
be washed and cryopreserved until approximately 12 days prior to the planned infusion and then 
thawed for expansion. The cells will be processed and expanded in a Class 100,000 clean room 
according to Standard Operating Procedures that are written to comply with Good Manufacturing 
Practices.  The flow diagram below outlines the manufacturing steps that will be followed: 
 

 
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5.7.2 
Apheresis Wash: 
 
The apheresis product is first washed before further processing in order to remove plasma 
or cell suspension solution, and reduce platelets and red blood cell contamination in the 
apheresis product using the Baxter CytoMate Cell Washer with X-VIVO 15 based media. 
Alternatively, cells may be washed on the COBE 2991 Blood Cell Processor. 
 
5.7.3 
Monocyte Depletion: 
 
Monocytes present in mononuclear cells collected during the apheresis may inhibit 
lymphocyte proliferation. Therefore, monocytes will depleted via adherence to Dynal M-
450 Epoxy beads or by counter flow centrifugal elutriation (Gambro ElutraTM Cell 
Separation System).  The bead adherence method can be performed on fresh or 
cryopreserved apheresis products, and is usually done on cell suspensions with ≥20% 
monocyte content. About 2-4 beads per monocyte are added to the cell suspension to be 
processed, followed by an incubation period.  The beads are then removed by magnetic 
separation by the MaxSep Magnetic Separator, and the numbers of recovered (monocyte-
depleted) cells are determined. An entire leukaphereis product can be monocyte depleted 
in 1-2 hours by either method.  
 
5.7.4 
Ex-vivo Costimulation of T-cells 
 
In the first trial (Rapoport et al.,2005), the cells were cultured using Dynal microbeads 
coated with anti-CD3 (OKT3)/anti-CD28 (9.3) monoclonal antibodies and were 
manufactured at UPenn under IND #6675. Since then, we have evaluated commercially 
available clinical grade microbeads produced by Dynal that are coated with anti-
CD3/CD28, but with different hybridoma clones. These Dynal microbeads are 
functionally equivalent to the beads produced at UPenn. We anticipate using beads 
manufactured at UPenn or the commercial beads produced by Dynal for the expansion of 
T cells for this study. 
The culture process in the phase I trial was done using Baxter Lifecell® flasks (Hami et 
al.,2005). We are currently culturing cells in the first 3-5 days in a Baxter Lifecell® or 
equivalent gas permeable bag such as the Origen PermaLife™.  Once cells are in log phase 
expansion, they are seeded into the WAVE® bioreactor system, which has been adapted 
for T cell expansion cultures by Xcyte Therapies (Levine et al., 1998; Rapoport et 
al.,2009) and subsequently validated by the CVPF. Because this system is more efficient 
in terms of cell yield and media requirements, we have switched from Lifecell® flasks to 
the WAVE bioreactor process. Cells will be grown in X-VIVOTM media supplemented 
with 5% commercial pooled human AB serum. The microbeads will be washed and added 
at a 3:1 ratio of beads per cell. The cultures will be maintained for up to 12 days prior to 
harvesting and preparation for reinfusion. The cells will be counted and fresh medium 
added daily and then perfused in the WAVE Bioreactor. 

 
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5.7.5 
Expansion and transduction of T cells 
 
The procedures for T-cell stimulation, TCR transduction, static cell culture, and Wave 
bioreactor cell culture are shown in the above figure.   Briefly, enriched lymphocytes (via 
elutriation) are stimulated with Dynabeads conjugated with mouse anti-human CD3 and 
CD28 in static tissue culture flasks at an approximate range of 5 x 108-1 x 109 cells in a 
supplemented XVIVO-15 media (Modified X-VIVO 15 Media). Beads are added at a 3:1 
bead to cell ratio.  This optimal bead: cell ratio was previously determined (IND#6675 
and Levine et al., 1997). Transduction is performed on day 1 of culture with a 
predetermined MOIby addition of the TCR lentiviral vector.  
 
Table 5.7.5:  T cell product release criteria 
Test 
Method 
SOP 
Criteria 
Cell Viability on 
Sentinel Tube 
Trypan Blue Exclusion 
0331 
≥70% 
% CD3 positive T 
cells 
Flow Cytometry 
0501 
≥80% 
Residual beads 
number 
Visual 
0263 
≤100 beads/3x106 cells 
Endotoxin 
Gel Clot 
0365 
≤ 3.5 EU/mL 
Mycoplasma 
MycoAlert Assay 
0367 
Negative 
VSV-G (RCL) 
PCR 
TBD 
< 50 copies/micrograms of 
DNA 
Transduction 
efficiency 
(TCR expression) 
Flow Cytometry 
TBD 
≥10% positive 
Transduction 
efficiency (copy 
number) 
PCR 
TBD 
0.1≤ x ≤5 average copies per 
CD8 cell** 
BSA 
ELISA 
0368 
≤1 μg/ml 
Bacterial culture 
Culture 
0361 
No growth 
Fungal culture 
Culture 
0358 
No growth 
 
On day 3, the vector is washed away in a Baxter CytoMate Cell Processing System. The 
T cell culture with beads are seeded back into gas permeable tissue culture flasks at a cell 
density of 5x105 cells/mL in fresh Modified X-VIVO 15 Media and placed at a 37ºC 
incubator with 5% CO2 and >90% of humidity for cultivation and further expansion.  The 
cell culture is maintained in a closed system. Tubing leads on the tissue culture flasks are 
connected or disconnected through a variety of sterile tubing connecting devices and heat 
sealers (e.g. spike connectors, tubing welds from the Terumo Sterile Connecting Device, 
heat seal from the Sebra Heat Sealer) to reduce the risk of contamination.   
 
 

 
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The Principal Investigator and Sponsor will be notified if any of these test results are 
positive or if any criterion is not met.  
 
5.7.6 
T cell quality control 
 
The manufacturing facility ensures that all operations and clinical trials conducted 
comply with GLP, GMP, and GCP.  
 
5.7.7 
Infusion of Autologous T-cells 
 
The cryopreserved costimulated (“activated”) T-cells will be thawed at the bedside using 
standard procedures and infused over about 20 minutes without a leukocyte filter on about 
day +2 of transplant.  As mentioned above, the cells will be re-suspended in 100-500 ml 
of Plasma-lyte A or other appropriate infusion solution containing 0.5%-1% human serum 
albumin.  Patients should be pre-medicated with acetaminophen and diphenhydramine 
(benadryl).  Corticosteroids will be available at the bedside in the event of an allergic-type 
reaction but should not be administered on a routine basis. The target dose of total T-
cells infused after gene transfer and expansion will be >0.1-1 x 1010since this was the 
dose of cells that was employed for the first study (Rapoport et al., 2005) and proved to 
very safe and did not appear to induce any cases of clinically significant autologous 
GVHD.  A minimum of 0.1-1 x 109cells in the final product will be permitted.  Since other 
gene-modified adoptive T-cell transfer studies have demonstrated biological activity at 
doses below 0.1 x 109, lower doses of T-cells will generally be permitted after assent of 
the PI, DSMC and Sponsor but this “low-dose” cohort will be analyzed separately for 
safety and immunoreactivity. 
 
Patients will be monitored for infusion related AE, which is facilitated by the fact that they 
are inpatients. Blood samples will be taken for cytokine monitoring prior to infusion, and 
at 1, 2, 4, 8, and 12 hours post infusion, and then at each visit thereafter as described in 
the table of study procedures.  Cytokine monitoring will be batched and done 
retrospectively and at a minimum IFNγ, GM-CSF, and IL-6 will be evaluated.  If toxicity 
is observed following infusion, review of the cytokine levels will be undertaken to assess 
risk to subsequent patients.  Cytokine levels will also be evaluated retrospectively for 
correlation with antitumor effects.  It is acknowledged that the high dose chemotherapy 
and stem cell infusion may contribute to changes in cytokine levels. 
Cytokine release syndrome  
Cytokine release syndrome is caused by a release of inflammatory cytokines such as IL2, 
IFN-γ, and TNF typically by macrophages, tumor cells and T cells.  This type of reaction 
is common in cancer immunotherapy where antibodies bind T cells that release large 
amounts of cytokines, or cause rapid destruction of tumor/target cells.  This causes a 
systemic inflammatory response similar to sepsis and includes fever, nausea, chills, rash 

 
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or flushing, rigors, hypotension, tachycardia, headache, rash, throat tightness, and 
dyspnea.  Capillary leak with fluid retention is worsened by hydration commonly given to 
treat hypotension.  The syndrome can be associated with pulmonary infiltrates, pulmonary 
edema, arrhythmias and cardiac arrest.  The syndrome is also associated with an elevation 
in LFTs, d-dimers, LDH, CR, uric acid, and phosphorous from immune-mediated 
cytolysis of targeted cells, with release of intracellular contents as well as a possible 
bystander effect (on neighboring, nontargeted cells). The potential of NYESO-1c259-T to 
cause cytokine release syndrome is unknown but is thought to be low because 1) the 
NYESO-1c259-T has been tested in a trial at the NCI has not caused CRS in patients with 
melanoma or sarcoma and 2) cytokine release syndrome has not occurred in any TCR trial 
to date.    
Premedication with anti-histamine, acetaminophen can help prevent cytokine release 
syndrome. Antihistamines and acetaminophen can be administered prior to infusion, while 
steroids cannot be administered because they are cytotoxic or inhibitory for the study drug. 
If a severe cytokine release syndrome develops, the patient will be administered a one-
time dose of Decadron 20-40 mg IV to prevent further cytokine activation and release, 
anti-histamines, and supportive care (fluids, pressors, intubation if needed). Management 
of the cytokine release syndrome is described on below. 
Cytokine release syndrome (CRS). CRS is managed in the same fashion as septic shock 
following infection with gram negative bacteria, with the exception that antibiotics are not 
required. Capillary leak with fluid retention is worsened by hydration commonly given to 
treat hypotension.  The syndrome can be associated with pulmonary infiltrates, pulmonary 
edema, arrhythmias and cardiac arrest.  The syndrome is also associated with an elevation 
in LFTs, d-dimers, LDH, CR, uric acid, and phosphorous from immune-mediated 
cytolysis of targeted cells, with release of intracellular contents as well as a possible 
bystander effect (on neighboring, nontargeted cells). Prophylactic measures to prevent 
CRS include correction of overhydration/volume overload before infusion with diuresis if 
necessary and pre-medication. Patients are pre-medicated with acetaminophen and an 
antihistamine before CIR infusion.  
As a routine, after infusion the vital signs (including pulse oximetry) will be monitored 
every 15 minutes for 4 h. In the event of CRS, patients with rigors will be treated 
symptomatically with hot pack, blankets, Demerol 12.5-50 mg IVP. An MD will be called 
immediately if subject experiences a decrease in blood pressure. Vital signs will be 
monitored 15 minutes before infusion, while infusing and after infusion. If a subject 
experiences hypotension, this will be managed by administering intravenous fluids in 
boluses as needed to maintain an adequate blood pressure.  Should the hypotension not 
respond to intravenous fluid boluses, admission to the CTRC or inpatient hospital will be 
performed to provide the appropriate level of care.  Should hypoxia or dyspnea develop 
that results in oxygen desaturation as detected by standard pulse oximetry, the patient will 
be administered nasal cannula oxygen and have a chest X-ray performed as deemed 
appropriate by the investigator. The use of ACE inhibitors and angiotensin-II receptor 
blockade may have benefit for CRS (Das et al, 2005). Corticosteroids have been reported 

 
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to block systemic effects of T cell toxicity (Lamers et al, 2006). See Wang et al, 2008 and 
Stebbings et al, 2009 for experimental management of CRS.  
5.8 
PCV (Pneumococcal Conjugate Vaccine, Prevnar-13®) Boosters 
 
At days 14, 42 and 90 post-transplant, patients will also receive booster intramuscular (IM) 
injections of the pneumococcal conjugate vaccine (PCV, Prevnar-13) [0.5 ml] into the non-
dominant deltoid.  
 
5.9 
Second Infusion 
 Patients enrolled at University of Pennsylvania are not eligible for receiving a second infusion. 
 
In patients who have progressive disease following initial infusion but whose tumors continue to 
express the appropriate HLA and antigen target, these patients will be eligible for a second 
infusion with redirected T cells.  Either the previously manufactured cell product will be used, or 
remaining apheresis product from collections prior to receipt of the gene modified T cells will be 
utilized for a new product manufacture.  Patients will not be re-apheresed for cells unless there is 
no detection of gene modified cells and approval to do so has been received by the FDA prior to 
the procedure.   
 
Following intensive animal and clinical research over the past decade, it is now generally accepted 
that the incorporation of lymphodepletion prior to adoptive T cell therapy enhances immune 
reconstitution by the transferred cells, and increases tumor specific responses.  Immune 
reconstitution is enhanced through homeostatic proliferation of T cells which is different from 
antigen driven T cell expansion in that it occurs in the absence of costimulation (Ernst, Lee et al. 
1999; Prlic, Blazar et al. 2001).  Homeostatic proliferation is promoted by an increase in 
availability of γ-chain cytokines IL-7, IL-15, and IL-21 (Wrzesinski and Restifo 2005; Rapoport, 
Stadtmauer et al. 2009; Wallen, Thompson et al. 2009), and also by MHC-peptide interactions 
against self or tumor antigens (Ernst, Lee et al. 1999; Wrzesinski and Restifo 2005).  
Lymphodepletion also enhances the activity of the adoptively transferred cells via the removal of 
inhibitory factors and activation of antigen presenting cells.   
 
Since patients receiving a second infusion will most likely not be undergoing another ASCT, an 
alternate conditioning regimen will be used comprised of Cytoxan 1.5 gm/m2 (+/- bortezomib x 
2 doses. If bortezomib is given, the first dose should be given ~ 72 hours before the Cytoxan and 
the second dose can be given on the same day as the Cytoxan).  The engineered T cells will be 
administered as previously described in this protocol, on day 2 following the Cytoxan.  For 
example, if Cytoxan is administered on Monday, the T cells can be given on Wednesday. A longer 
timeframe between the Cytoxan administration and the T cell infusion is allowable provided the 
patient is shown to have a white blood count (WBC) of ≤ 0.5(500 cells/mcl) within 24 hours prior 
to the planned T cell infusion.  This can be an outpatient procedure. 
 

 
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If there was no serious toxicity attributed to the initial infusion, the second infusion may be 
increased up to 5 x 10e10 total cells (5-fold higher than the first infusion dose target).  The second 
infusion must be a minimum of 1 e 8 total cells.   
 
Patients must continue to meet the eligibility requirements for this study in order to remain eligible 
to receive a second infusion, with the exception that 1) blood counts lower than that described in 
the inclusion criterion are acceptable if they are believed by the Investigator to be due to disease 
activity, and 2) a performance status of up to an ECOG=3 is acceptable. The rationale for these 
exceptions is that patients with relapsing disease are expected to have rapidly advancing disease, 
and this population will not be required to undergo the high intensity conditioning required for 
auto-HSCT.   Documentation of laboratory tests performed within the 60 days of the planned 
second T cell infusion may be used to confirm eligibility of other eligibility criteria. 
 
In cases where a second infusion is given, lenalidomide (see next section) will be held until day 
100 post the second infusion, unless otherwise recommended by the PI. 
 
For follow-up post second infusion, the Cytoxan administration will be day 0, and the T cell 
infusion will be day 2.  The patient will be followed in accordance with the schedule of procedures 
provided in Section 14 as shown.  Long term follow-up will be calculated from the second infusion 
date. 
5.10 
Maintenance Therapy (Lenalidomide) 
 
At about day 100 post-transplant, after completion of post-transplant immunological assessments 
and myeloma restaging studies, patients will be eligible to  receive low-dose lenalidomide for 
maintenance therapy (10 mg/day) until progression of myeloma or development of intolerance.  
This dose level and schedule is identical to the one that was used in a recently completed 
cooperative group randomized study of post-transplant maintenance therapy with lenalidomide 
which was conducted by the CALGB (CALGB Protocol # 100104).  Because of the increased 
risk of thrombo-embolic events, patients will also receive low-dose aspirin (81 mg/day or 325 
mg/day).  Preparations for lenalidomide maintenance therapy should be made at least 7-10 days 
before the day 100 visit in order to minimize delay in starting it.  In addition, at 1year post-
transplant, patients may receive a standard 23- valent pneumococcal polysaccharide vaccine in 
accordance with the recommendations of the American Society for Blood and Marrow 
Transplantation.   
 
Prior to starting the lenalidomide, patients should have adequate bone marrow function defined 
as:  PLT > 50,000/mcl and ANC (absolute neutrophil count) > 1000).  If patients develop 
excessive myelosuppression with the dose of 10 mg daily (PLT < 25,000/mcl or ANC < 500/mcl), 
then the schedule should be adjusted to 21 days of treatment per month (dose reduction #1) or 14 
days of treatment per month (dose reduction #2) once the blood counts rebound to the levels of 
PLT > 50,000/mcl and ANC (absolute neutrophil count) > 1000.  If patients develop excessive 
myelosuppression with the dose of 10 mg for 14 days per month (PLT < 25,000/mcl or ANC < 
500/mcl), then the dose level should be decreased to 5 mg daily for 21 days per month (dose 
reduction #3) and 5 mg daily for 14 days per month (dose reduction #4) (See table below).  

 
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Patients can be re-escalated by 1 dose level after 3 months of Lenalidomide if ANC >1000 and 
platelets are >75,000.  See following tables for dose modifications.  Guidelines for Lenalidomide 
dose modification and interruptions are provided below and in Appendix I.   
 
 
 
Lenalidomide Dose Reduction Levels 
* At physician discretion, lenalidomide 
dose may be increased, if CR not achieved 
and 
no 
grade 
II 
or 
higher 
myelosuppression develops during 3 
months of therapy.  
Dose Level 2 (only after 3 
months of 10mg) 
15mg daily days 1 – 28 of a 28 
day cycle 
 
Dose Level 1 
10mg daily days 1 – 28 of a 28 
day cycle 
Dose Reduction #1 
Dose Level -1 
10mg days 1 – 21 of a 28 day 
cycle 
Dose Reduction #2 
Dose Level -2 
10mg days 1 – 14 of a 28 day 
cycle 
Dose Reduction #3 
Dose Level -3 
5mg days 1 – 21 of a 28 day 
cycle 
Dose Reduction #4 
Dose Level -4 
5mg days 1 – 14 of a 28 day 
cycle 
5.11 Protocol Modifications for Syngeneic Stem Cell Transplant (SSCT) 
 
If available, a patient may receive stem cells and gene-modified T cells from an identical twin sibling.  
This is a rare event, and is not expected to occur more than once or twice on this protocol.  
 
In the event that an identical donor sibling is identified, the following things must occur: 
a) Submission to UPenn regulatory committees (for UPenn subjects only): 
i) For UPenn subjects an exception request must be submitted to the UPenn regulatory 
committees for review and approval prior to consenting the subjects (twin donor and 
donor recipient) 
b) Submission to the FDA regarding the following aspects of donor identity and screening: 
i) Confirmation that donor screening must adhere to the requirements outlined in 21 CFR 1271 
ii) A twin donor test must be performed by an accredited tissue typing laboratory to confirm that 
the donor and patient are indeed identical twins; this information must be submitted to the 
FDA by the regulatory sponsor 
c) Consent 
i) Unique consent forms for patient screening and for the patient and donor participation on the 
study have been developed.  These consent forms outline the study procedures that are specific 
to an SSCT, which are slightly different than for an ASCT due to the donor undergoing certain 
procedures. 
d) Modification in study procedures 
i) SSCT requires that the sibling donor perform the following procedures in lieu of the patient: 
(1) Receives initial prevnar vaccination at approximately day -40 

 
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(2) Undergoes initial apheresis for T cell collection at approximately day 30 
(3) Undergoes stem cell mobilization using G-CSF +/- plerixafor/Mozobil® starting at or 
around day -26 
(4) Undergoes stem cell collection by apheresis at or around day -20 
 
Allowing a patient with an identical twin donor to receive an SSCT on this protocol is an ethical way 
to proceed since overall outcomes following twin transplants may be more favorable than ASCT due 
to potential contamination with residual myeloma in autologous grafts (Bashey et al, 2008) which is 
lacking in syngeneic grafts.  However, whether an improvement in response rates and survival is truly 
associated with SSCT over ASCT does remain an active area of investigation in the field and is not 
firmly established. 
 
Since graft-vs-host-disease (GVHD) does not usually occur after identical twin/syngeneic transplants, 
it is expected that the primary endpoint of this study which is assessment of safety, can be equally 
assessed using twin donor cells or autologous T cells.  Therefore, patients receiving an SSCT will be 
considered evaluable under primary study endpoints 
5.12 
Toxicity Management 
5.12.1 Monitoring for and management of RCL 
RCL testing will be performed on the vector material, each cell lot, and as a patient 
monitoring assay.  RCL testing on the cell product will be performed by a DNA based 
assay. For ongoing patient monitoring for RCL, PBMC samples obtained from subjects at 
3, 6, 9, and 12 months, and annually from year 2-15 post treatment will be tested for VSV-
G DNA sequences.  If these tests are negative for 3 consecutive assessments, PBMC 
samples will be collected and archived yearly until 15 years post infusion.   
 
If a positive VSV-G DNA signal is obtained, the PI will be informed and the patient 
scheduled for a retest as soon as possible and no later than one month after the initial 
positive result was reported to the Sponsor.   A review by Adaptimmune’s Safety Review 
Team and Safety Governance Board will take place.  If the second test is positive, 
infusions for all patients receiving cells modified with the same vector lot will be 
postponed.   The patient with the confirmed positive VSV-G signal will be scheduled for 
apheresis and a biological RCL performed on the apheresed product. If the biological RCL 
is positive, all infusions using NY-ESO-1c259T in the interventional protocol(s) will be 
halted.  An action plan will be discussed with FDA and other regulatory authorities and 
experts as appropriate.  Additional subjects will not be treated with NY-ESO-1c259T cells 
until such time as a plan is completed, reviewed, and agreed upon..  If the test is negative, 
infusions for all patients can resume.   
 
A replication-competent lentivirus (RCL) may be generated during the production phase 
or subsequently after introduction of vector transduced cells into the patient.  However, 
an RCL resulting from the production phase is highly unlikely since elements are 
incorporated in the design of the vector system that minimize vector recombination and 
generation of RCL.  Furthermore, the vector used to transduce the product undergoes 

 
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sensitive assays for detection of RCL before it can be released for use in cell manufacture.  
Nevertheless, while an RCL has never before been reported, generation of an RCL 
following infusion of the vector product remains a theoretical possibility. The 
consequences of such recombination events could be neutral, could reduce the replication 
rate or pathogenicity of the subject's virus, or could increase the replication rate or 
pathogenicity of the subject's virus.  Since the development of a strain with increased 
pathogenicity would pose greater risk to both the patient and their close contact(s), 
periodic monitoring for RCL is conducted during the course of the trial.   
 
 
Regulatory agencies and the gene therapy community have previously discussed measures 
to be taken should an RCL be confirmed in a patient. However, because the probability 
and characteristics of an RCL are unknown, no concrete plans have been put in place.  
At the current time, it is agreed that the subject must be isolated and no additional subjects 
treated with NY-ESO-1c259T cells until a plan is agreed upon. 
The following approaches have been discussed for subject management: 
1. Intensive follow up of subject in consultation with FDA, and other regulatory 
authorities, NIH, gene therapy experts, study investigators, and HIV physicians. 
2. Provide targeted antiretroviral therapies based on genotyping of the RCL. 
 
 
5.12.2  Monitoring for and management of insertional oncogenesis 
Monitoring for insertional oncogenesis will be performed in accordance with FDA 
recommendation. The PBMC sample is used as the “surrogate sample” for testing for 
insertional oncogenesis. 
 
The current FDA Guidance (Guidance for Industry, Gene Therapy Clinical Trials-
Observing Subjects for Delayed Adverse Events; November 2006) recommends that if at 
least 1% of the cells in the surrogate sample are positive for vector sequences by PCR for 
a sustained period of three consecutive weeks, then cells will be analyzed for clonality (by 
TCR Vβ repertoire for example). In this protocol, the cytoreductive conditioning followed 
by infusion of T cell transduced at >20% with the transgene is guaranteed to result in >1% 
marking in the “surrogate sample”.   
 
Therefore, clonality analysis will be performed if greater than 1% of the PBMC is 
expressing NYESO TCR at 1 year or later post infusion.  
DNA from the subject’s PBMCs will be sent for Next-Gen Sequencing for integration site 
analysis by the University of Pennsylvania.  Integration site analysis assesses clonality 
and the possibility of insertional oncogenesis.  This integration site analysis method, used 
in previous clinical trials [Hacein-Bey Abina 2015], uses sonic length quantitation, an 
accurate method of measuring relative clonal abundance [Berry, 2012].   
Clonality is defined as follows: 1) monoclonality is 1 predominant clone at ≥5% of 
transduced T cells; 2) oligoclonality is defined as 2-5 predominant clones, each at ≥5% of 
transduced T cells; and 3) polyclonality is defined as no single predominant clone of ≥5% 
of transduced T cells. 

 
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If there is clonal dominance in the genetically modified T cell population (either 
monoclonality or oligoclonality) the persistence assessment will be repeated within 3 
months on a new sample.  If the repeated analyses demonstrates: 1) persistent 
monoclonality, 2) other evidence of insertional oncogenesis (for example, integration of 
the vector in the promoter region of a known oncogene or tumor suppressor gene), or 3) 
clonal expansion (an increase in percent predominance of a clone), there will be a review 
by Adaptimmune’s Safety Review Team and Safety Governance Board to develop a 
monitoring plan specific to the health care risk and strategies to inform appropriate 
subjects, investigators, FDA and other regulators of the findings.   
If the integration site analysis indicates polyclonality of the genetically modified T cell 
population then screening for persistence continues as scheduled.  
 
A summary of all integration site analyses will be presented in the annual report to the 
FDA.  If oligo or monoclonality is observed, this data will be entered as an information 
amendment to the IND with best efforts made to submit this amendment within 30 days 
of data confirmation. 
 
5.12.3  Risk of on target activity of NYESO-1c259against normal tissue 
As described in the background section of this protocol, cancer testes (CT) antigens have 
restricted expression on normal tissue, and have only been found in testicular germ cells 
and placenta.  This protocol has been designed to incorporate birth control procedures and 
pregnancy monitoring in order to protect any potential toxicity during pregnancy.  
Toxicity against testicular germ cells in men enrolled in this study is a theoretical risk.  
This risk is mitigated in part because the testes are an immune privileged site primarily 
due to their immune suppressive environment (induced by hormonal, cell based and 
cytokine based factors), and perhaps also in part by the physiologic barriers provided by 
the blood testes barrier (Fijak, Bhushan and Meinhardt, 2011; Fijak and Meinhardt, 2006).  
This reduces the opportunity for   NYESO-1c259-T to enter into and to activate against the 
germ line cells.  Nonetheless, immune reactivity is possible in testes, which is exemplified 
by the fact that >10% of male infertility can be attributable to immunopathology, and 
therefore this remains a risk that is noted in the informed consent document. 
 
A previous clinical study where T cells expressing the CT antigen specific NYESO-1c259 
TCR (the same TCR as proposed for cohort 1 in this study) were administered to patients 
with melanoma or synovial sarcoma was conducted and recently published (Robbins et al, 
2011). This study enrolled 11 men, who received a range of 1.6-13 x 1010 total cells 
transduced at >50%.  No toxicity was reported in this study, which supports the safety of 
our proposed study. 
 
5.12.4  Management of rash and diarrhea 
A common side effect of the melphalan conditioning and T cell infusion is a transient skin 
rash with lymphocytosis (favoring lower extremities) and a diarrheal syndrome that is later 
occurring than most melphalan mucositis not particularly full of lymphocytes that is taking 

 
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longer to recover (but eventually does) after the neutrophil recovery. The diarrhea can be 
confounded by c-diff colitis infection and melphalan mucositis and so is probably 
multifactorial. 
 
A non-mandatory guideline for treatment of patients with rash and diarrhea is as follows, 
and specifically the recommendation for treatment of diarrhea is taken from the published 
management guideline for diarrhea associated with Ipilumimab treatment (O’Day et al, 
2011). It is recommended to take 3-5 days to monitor and evaluate, with biopsy of skin 
and gut if indicated, and rule out infection or reaction to NYESO-1-T. If grade 1, institute 
and continue conservative and symptom management (change meds, treat infection, anti 
diarrheals). If no sign can’t improvement and/or if grade 2, institute topical steroids 
(hydrocortisone for skin, budesinide for gut) and if no significant improvement in 3-5 days 
start systemic steroids (solumedrol 1-2 mg per kg).  
5.12.5 Risks to patients with preexisting cardiac conditions 
Two patients treated with the Mage TCR died of cardiogenic shock following 
infusion.  The first death occurred in the first patient to be treated with the Mage 
TCR.  This patient was on a separate melanoma trial.  At the time of the death, all Mage 
cohorts in our studies were paused until the outcome of the investigation.  Upon autopsy, 
the patient was found to have severe underlying cardiovascular disease which had not 
previously been clinically detectable. After an extensive scientific and clinical 
investigation showing absence of correlation to the infused cells, and subsequent review 
of the data and this conclusion by the NIH RAC and FDA, the cohort pause was removed 
once: 1) the informed consents were updated to report the death to patients, 2) additional 
cardiac enzyme monitoring was added to all trials with the Mage arm, and 3) a cardiac 
stress test was added as a screening procedure to capture patients with underlying heart 
conditions which otherwise may not be picked up in routine medical exams.   The second 
patient treated with the Mage TCR was on this study.  This patient passed cardiac 
screening tests, and was informed that he was the first patient to be treated following a 
prior death, and he signed the updated informed consent document.  Data from this patient, 
including the absence of underlying heart disease, and pathologic evidence of acute 
rejection of the heart, indicated that the Mage TCR appeared to be targeting heart 
tissue.  Consequently extensive additional studies were carried out to investigate the 
specificity of the Mage TCR and we discovered that the Mage TCR recognized a protein 
that is expressed in heart tissue. This was not picked up in preclinical screens that were 
performed because the protein is only expressed in beating cardiac tissue, and not single 
cell cardiomyocytes.   As a result of these findings, which are to be submitted this week 
for publication, we have withdrawn the IND for the Mage TCR and no further patients 
will be treated.  The NY-ESO IND remains open, and is unaffected by these events. As a 
result of this SAE, additional cardiac monitoring has been implemented in this protocol 
for the first week post infusion in order to capture such events, consisting of daily 
troponins and EKG.  In addition, a recommended cardiac stress test for screening of 
patients upon enrollment was added for patients 60 years and older. 
 

 
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5.12.6 Autologous Graft Versus Host Disease (GVHD) Syndrome 
Autologous Graft Versus Host Disease (GVHD) could occur after receiving a routine autologous 
stem cell transplant (ASCT). GVHD develops when the transplanted immune cells mistakenly 
attack the patient's normal cells. Subjects could develop a skin rash, develop diarrhea and 
sometimes belly pain, jaundice (yellowing of the skin and white of the eyes). In a previous study 
of investigational T cells infused following ASCT, 1 out of 6 subjects developed mild to moderate 
GVHD. In the more severe cases, some patients had as much as 1-2 liters (quarts) of watery diarrhea 
per day. All patients got completely better after taking steroid medicines given IV or orally (pill) 
for a few weeks. No patients became seriously ill nor died from this side effect. However, it should 
be noted that GVHD is only rarely observed.   In the current study, several patients have developed 
diarrhea, nausea, and/or abdominal bloating that was worse and lasted longer than we would 
typically expect from the transplant chemotherapy. Prophylactic non-systemic steroids may be used 
for these symptoms as per institutional standards. It is possible that these symptoms could be related 
to the investigational “redirected” T cells. All of these cases either improved on their own or 
appeared to respond to treatment with steroids, though sometimes several weeks to months of 
steroids were required, which can cause additional side effects, like upset stomach, stomach ulcers, 
fluid retention, irritability, high blood sugar levels, fat redistribution, facial flushing, increased 
appetite and weight gain, and insomnia.”  
 
 
6 
SCHEDULE OF EVALUATIONS (Including Correlative Research Studies) 
 
6.1 
Clinical Assessments (STANDARD OF CARE) 
These will occur at: 
 
Enrollment 
Admit Stem Cell 
Mobilization 
Admit High Dose 
Melphalan 
~D0 
~D2,3,5,7,14 
~D21 
~D28 
~D42 
~D100 
~D130 
~D180 
~Q3 mo until  
disease progression 
Recent History and Physical 
Examination 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
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 
CD3, CD4, CD8 counts 
X 
 
 
 
X1 
 
 
X 
X 
 
X 
 
1-Day 14 only 
After year 1, only delayed gene therapy adverse events will be recorded. 
6.2 
Myeloma Assessments (STANDARD OF CARE) 
 
These will occur at: 

 
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Enrollment 
~D42 
~D100 
~D180 
~Q3 mo  
up to year 1  
~Q3 mo  
or per local 
standard of care 
after year 1 
Myeloma markers 
X 
X 
X 
X 
X 
X 
Bone Marrow Aspirate +/- Core Bx 
X 
 
X 
X 
X0 
X0 
Skeletal Survey 
X 
 
X 
X 
X0 
X0 
0-Optional 
The myeloma assessments will be performed and recorded in the eCRF per schedule above until 
year 1 or disease progression, whichever is first. Myeloma assessments beyond year 1 will be 
performed per local standard of care and only the date of progression will be recorded in the eCRF. 
These myeloma assessments will include the following: 
 
 Myeloma markers (SPEP with immunofixation; quantitative IgG, IgA, IgM,;  Beta 2 
microglobulin; 24 hour urine for UPEP and immunofixation; serum free light chain 
analysis) 
 Bone marrow aspirate +/- core biopsy 
 Skeletal surveys  
 
6.3 
Immunological Assessments (RESEARCH STUDIES) 
 
For molecular studies (Q-PCR and Q-RT-PCR), immune phenotyping and functional assays, 
peripheral blood and marrow samples will be collected in Lavender top tubes. For cytokine analyses 
peripheral blood and marrow samples will be collected in red top (no additive) tubes.  Samples will 
be collected according to the sample collection schedule (Appendix C).   Samples will be processed 
according to a single standard operating Protocol (SOP) at both the University of Pennsylvania and 
University of Maryland sites.  Samples should be delivered, processed within 2 hours of collection, 
and frozen as per SOP to the Translational and Correlative Studies Laboratory (TCSL) (University 
of Pennsylvania).  Samples will be stored in the TCSL at the University of Pennsylvania for storage 
and bulk analyses, 
University of Maryland samples will be shipped to 
 
Dr. Michael Kalos 
Translational and Correlative Studies Laboratory  
University of PennsylvaniaSchool of Medicine 
Stellar-Chance Laboratories, room 410 
422 Curie Boulevard, 
Philadelphia, PA19104 
 
 All research analyses will be performed based on principles of good laboratory practice, 
with assay-specific SOP using qualified and if possible validated assays.  Documentation 

 
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for sample -receipt, -processing, and storage and primary data from the research analyses 
will be collected and stored in the TCSL.   
6.4 
Long term follow-up for observation of delayed adverse events for gene therapy 
 
 All subjects will be followed for 15 years from time of T-cell infusion for observation of delayed 
adverse events in accordance with FDA and EMA requirements for gene therapy clinical trials 
[FDA, 2006b; FDA, 2010; EMA, 2009].  If a subject receives a second T cell infusion, the clock 
restarts with the second infusion.  These assessments will be collected in the Interventional Phase 
of the study until disease progression and thereafter in the long term follow up (LTFU) phase.  
Subjects will be rolled over to the LTFU protocol ADP-0000-002, when available at the site.  If the 
protocol ADP-0000-002 is not available, subjects will continue to be followed as described in 
Appendix C. 
Reporting criteria for delayed AEs related to gene therapy during LTFU are described below. Please 
refer to the table of procedures for Long Term Follow-up provided in Appendix C of the protocol.   
 
The most recently released (November 2006) Guidance on Monitoring for Delayed Adverse Events 
states that for the first five years, all subjects should undergo monitoring of vector sequences every 
6 months, and a full physical examination including a medical history, concomitant medications 
and examination of appropriate organ systems and a hemogram annually.  For the final 10 years, if 
vector sequences are no longer detected in PBMCs, a one page questionnaire or post card may be 
sufficient for reporting of any adverse events and questions relating to the patient’s status.   
 
From year 1 to year 5, patients will return to the clinic at biannual  intervals for a medical history, 
physical exam, and blood tests for disease monitoring, CBC, chemistries, monitoring for 
persistence of vector modified cells and annually for RCL testing/archive.  The physical exam and 
medical history (including concomitant medications and adverse events) will be conducted with 
careful attention to features possibly related to oncoretroviral diseases including: 1) New 
malignancies, 2) New incidence or exacerbation of a pre-existing neurologic disorder, 3) New 
incidence of exacerbation of a prior rheumatologic or other autoimmune disorder, 4) New incidence 
of a hematologic disorder, 5) Opportunistic and/or serious infections, and 6) Unanticipated illness 
or hospitalization deemed related to gene modified cell therapy. 
 
For the next 10 years (up to year 15 post-infusion), subjects will be asked to return annually for a 
physical exam, collection of blood and testing for persistence (if vector modified cells were 
detected in any of the 3 previous assessments), and RCL testing or archive.   
 
 

 
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7 
RESPONSE DEFINITIONS AND STATISTICAL TREATMENT 
 
7.1 
Clinical Myeloma Responses 
 
The following criteria will be used to evaluate myeloma response and progression.  The baseline 
for evaluation will be the myeloma parameters that are measured at screening (Day-50). 
 
Response 
IMWG criteria (Rajkumar et al., Blood 2011) 
sCR 
CR as defined below plus normal FLC ratio and absence of clonal cells in bone 
marrowa by immunohistochemistry or immunofluorescenceb 
CR 
Negative immunofixation on the serum and urine and disappearance of any soft tissue 
plasmacytomas and < 5% plasma cells in bone marrowa 
VGPR 
Serum and urine M-protein detectable by immunofixation but not on electrophoresis 
or ≥ 90% reduction in serum M-protein plus urine M-protein level < 100 mg/24 h 
PR 
≥ 50% reduction of serum M-protein and reduction in 24 hours urinary M-protein by ≥ 
90% or to < 200 mg/24 h 
If the serum and urine M-protein are unmeasurable,c a > 50% decrease in the difference 
between involved and uninvolved FLC levels is required in place of the M-protein 
criteria 
If serum and urine M-protein are not measurable, and serum free light assay is also not 
measurable, ≥ 50% reduction in plasma cells is required in place of M-protein, provided 
baseline bone marrow plasma cell percentage was ≥ 30% 
In addition to the above listed criteria, if present at baseline, a ≥ 50% reduction in the 
size of soft tissue plasmacytomas is also required 
MR 
Not Applicable 
No 
change/Stable 
disease 
Not meeting criteria for CR, VGPR, PR, or progressive disease 
Plateau 
Not Applicable 
 
 

 
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Response 
IMWG criteria (Rajkumar et al., Blood 2011) - continued 
Progressive diseasec 
Increase of 25% from lowest response value in any one or more of the following: 
• 
Serum M-component and/or (the absolute increase must be > 0.5 g/dL)d 
• 
Urine M-component and/or (the absolute increase must be > 200 mg/24 
h) 
• 
Only in patients without measurable serum and urine M-protein levels; 
the difference between involved and uninvolved FLC levels. The 
absolute increase must be > 10 mg/dL 
• 
Bone marrow plasma cell percentage; the absolute percentage must 
be > 10%e 
• 
Definite development of new bone lesions or soft tissue plasmacytomas 
or definite increase in the size of existing bone lesions or soft tissue 
plasmacytomas 
• 
Development of hypercalcaemia (corrected serum calcium > 11.5 mg/dL 
or 2.65 mmol/L) that can be attributed solely to the plasma cell 
proliferative disorder 
Relapse 
• 
Clinical relapse requires one or more of: 
Direct indicators of increasing disease and/or end organ dysfunction 
(CRAB features).d  It is not used in calculation of time to progression or 
progression-free survival but is listed here as something that can be 
reported optionally or for use in clinical practice 
• 
Development of new soft tissue plasmacytomas or bone lesions 
• 
Definite increase in the size of existing plasmacytomas or bone lesions. 
A definite increase is defined as a 50% (and at least 1 cm) increase as 
measured serially by the sum of the products of the cross-diameters of 
the measurable lesion 
• 
Hypercalcemia (> 11.5 mg/dL) [2.65 mmol/L] 
• 
Decrease in haemoglobin of > 2 g/dL [1.25 mmol/L] 
• 
Rise in serum creatinine by 2 mg/dL or more [177 mmol/L or more] 
Relapse from CRc (To 
be used only if the end 
point studied is DFS)f 
Any one or more of the following: 
• 
Reappearance of serum or urine M-protein by immunofixation or 
electrophoresis 
• 
Development of > 5% plasma cells in the bone marrowe 
• 
Appearance of any other sign of progression (i.e., new plasmacytoma, 
lytic bone lesion, or hypercalcaemia) 

 
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Source: Adapted from Durie BGM, et al. Leukemia 2006; 20: 1467-1473; and Kyle RA, Rajkumar SV. Leukemia 
2008;23:3-9. 
Note: A clarification to IMWG criteria for coding CR and VGPR in patients in whom the only measurable disease is 
by serum FLC levels: CR in such patients is defined as a normal FLC ratio of 0.26–1.65 in addition to CR criteria 
listed above. VGPR in such patients is defined as a >90% decrease in the difference between involved and uninvolved 
free light chain (FLC) levels.  
a Confirmation with repeat bone marrow biopsy not needed. 
b Presence/absence of clonal cells is based upon the kappa/lambda ratio. An abnormal kappa/lambda ratio by 
immunohistochemistry and/or immunofluorescence requires a minimum of 100 plasma cells for analysis. An 
abnormal ratio reflecting presence of an abnormal clone is kappa/lambda of > 4:1 or < 1:2. 
c All relapse categories require two consecutive assessments made at anytime before classification as relapse or 
disease progression and/or the institution of any new therapy. In the IMWG criteria, CR patients must also meet the 
criteria for progressive disease shown here to be classified as progressive disease for the purposes of calculating time 
to progression and progression-free survival. The definitions of relapse, clinical relapse and relapse from CR are not to 
be used in calculation of time to progression or progression-free survival.  
d For progressive disease, serum M-component increases of >1 gm/dL are sufficient to define relapse if starting M-
component is>5 g/dL. 
e Relapse from CR has the 5% cut-off versus 10% for other categories of relapse. 
f For purposes of calculating time to progression and progression-free survival, CR patients should also be evaluated 
using criteria listed above for progressive disease. 
Abbreviations: CR, complete response; FLC, free light chain; M, monoclonal; MR, minimal response; PD, progressive 
disease; PR, partial response; sCR, stringent complete response; SD, stable disease; VGPR, very good partial 
response. 
 
 
7.2 
Study Endpoints 
 
Primary Endpoint 
 
Occurrence of adverse events, per NCI CTC v4 guidelines, including > grade 4 laboratory toxicities 
at any time from day-40 until year 1. This will include infusional toxicity, and any toxicity probably 
or definitely related to NYESO-1-c259-T including but not limited to: 
a. Fevers 
b. Rash 
c. Neutropenia, thrombocytopenia, anemia, marrow aplasia 
d. Hepatic dysfunction 
e. Pulmonary infiltrates or other pulmonary toxicity 
f. Development of GVHD 
 
NOTE: transplant-related toxicities, typically occurring within a month post-
transplant, are excluded as study related adverse events. 
 
 
Secondary Endpoints 
 
Secondary endpoints will evaluate correlates of treatment efficacy by measuring clinical response 
rates to treatment:  

 
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a) progression-free survival (PFS) and duration of response (DOR),  
b) objective response rate (ORR) at day 42, 100, 180, 270 and 360. 
c) best objective response (BOR) prior to initiating lenalidomide and at day 360. 
d) overall survival (OS) will be followed in this interventional protocol and continue to 
be followed in the long-term follow-up protocol, once subjects have transferred. 
Initiation of lenalidomide as maintenance treatment will be addressed in a sensitivity analysis. 
 
 
 
Exploratory Endpoints 
 
Exploratory endpoints will evaluate correlates of treatment efficacy by measuring (i) the appearance 
of target antigen/MHC loss variants upon disease recurrence, as well as (ii) immunological parameters 
associated with product persistence, bioactivity and functionality. 
 
(i). Appearance of target antigen/MHC loss variants upon disease recurrence will be evaluated by 
quantifying expression of targeted antigens and MHC  in marrow samples obtained on disease 
recurrence, and comparing those values to the pre-treatment (diagnosis) samples.  NY-ESO-
1 and MHC expression will be evaluated by RNA and/or protein-based assays on tumor 
samples.  
(ii) Immunological parameters associated with product bioactivity and functionality will measure 
selective migration and engraftment of gene-modified infused cells to the marrow post 
infusion, the ex-vivo immune functionality and phenotype of infused cells in marrow and 
periphery, the modulation of cytokine milieu in marrow and periphery at baseline, and post 
T cell infusion and post lenalidomide treatment as well as the development of an expanded 
patient immune response against tumor via epitope spreading 
7.3 
Statistical Analyses 
7.3.1 Sample size determination 
 
Since the primary endpoint is the occurrence of study related adverse events, the sample size 
determination is based on testing the null hypothesis that the rate of study related adverse events 
is ≥40% against the alternative that this rate is <40%. Here a significant level of 25% is chosen 
because this study is an early stage feasibility trial meant to be tested further in future studies 
(Stallard et al., 2001). Hence, by using the two-stage procedure by Simon (Simon, 1989) with 
such a significance level and a power of 85% to reject the null when the true rate of study related 
adverse events is 10%, a maximum of 6 patients for each cohort are needed. At the first stage, 3 
patients per cohort will be entered. If 2 or more patients experience study related adverse events, 
we will conclude that the treatment is not worth pursuing. Otherwise, an additional 3 patients will 
be entered for the second stage. If there are 3 or more patients experiencing study related adverse 
events for the full two stages of 6 patients, we will conclude that the treatment is not worth 
pursuing. If there are 2 or less patients experiencing study related adverse effects out of a total of 
6 patients, the treatment will be considered worthy of further study.  

 
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If a patient is withdrawn from the study before infusion of the gene-modified T-cells then an 
additional patient may be enrolled so that, safety-permitting, up to 26 patients can be evaluated. 
Patients receiving the low dose (1-10 x 10e8) will be replaced with another patient so that a total 
of 26 patients will receive the target cell dose of >1-10e9. 
 
7.3.2 Data analysis plan and statistical power 
 
Two sided paired t-tests will be used to evaluate within-subject difference for measurements of 
interest  (not including binary or time to event endpoints) as mentioned in the Secondary 
Objectives. Some differences are between marrow and periphery at each time point and some are 
between pre- and post-treatment time points. Linear mixed effects model will be employed to 
estimate the trends of measurements of interest over time as appropriate. Thus an evaluable 
sample size of 6 will provide 80% power at a significance level of 5% to detect an effect size of 
1.5 for normally distributed measurements using a two-sided paired t-test. We expect the 
preliminary results from 6 patients will provide sufficient data to support the design of an 
adequately powered follow-on Phase II clinical trial. 
 
For evaluation of the response rate of the extension arm in comparison to the Krishnan et al 
published controls, at the time of the extension phase for the NYESO-1 arm, responses of 4 
patients (out of the initial 6 patients) are pending.  Therefore, taking a conservative approach, with 
an additional 20 patients we will have 24 patients for analysis. Based on the prior studies 
(Krishnan et al., 2011), the complete response (CR) rate after autologous stem cell transplant in 
patients is estimated to be 36%. We expect that the CR rate in this trial will be 66%. Using the 
one-sided Chi-square test, we have 91.6% power to detect this meaningful difference at a 
significant level of 5%. With only 20 patients, we have 85.8% power to detect this meaningful 
difference at a significant level of 5%. 
 
7.3.3 Study Populations 
Intent-to-Treat (ITT) population: all subjects who are enrolled in the study. 
Modified Intent-to-Treat (mITT) population: all ITT subjects who receive NY-ESO-1c259T 
cell infusion.  
The mITT population is the primary analysis population for efficacy and safety evaluations.  
If the ITT and mITT populations are identical, only analyses associated to the mITT population 
will be reported.   
 
A per-protocol population (PP) may be included if there are subjects in the mITT population who 
have protocol violations that are expected to affect efficacy assessments (e.g., subjects enrolled 
who do not meet key eligibility criteria) during the trial.  Protocol violators resulting in exclusion 
from the per-protocol population will be identified and documented prior to database lock. 
 

 
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7.3.4 Statistical Methods for Efficacy Endpoints 
 
Efficacy endpoints are defined in sections 1.2 and 1.3. 
 
Binary endpoints such as ORR, BOR will be analyzed as follows using Investigator 
assessments of responses in accordance with [Rajkumar, 2011].   
Subjects with unknown or missing response will be treated as non-responders, i.e. they will 
be included in the denominator when calculating the proportion.  
These endpoints will be summarized using Clopper-Pearson 95% (exact) confidence interval 
(CI). In addition, 95% confidence intervals will also be computed using the Wilson method.  
  
Time to event endpoints are defined as: 
• Progression Free Survival (PFS) is the interval between T-cell infusion (Day 2) and 
the earliest date of disease progression or death due to any cause. 
• Overall Survival (OS), is the interval between T-cell infusion (Day 2) and death.    
• Duration of Response (DOR), defined as the time from the initial date of the confirmed 
response to the date of progressive disease or death. 
 
 
No hypothesis testing is planned for these secondary endpoints.  
 
Time to event endpoints will be summarized and displayed graphically using Kaplan-Meier 
(K-M) methodology to estimate the median, and the 25th and 75th percentiles. Two-sided 
95% confidence intervals will be produced.    
 
Censoring rules: The following censoring rules will be applied in the analyses. 
• For PFS, subjects who do not have a documented date of disease progression or death 
will be censored at the date of the last assessment.  
• For OS, subjects who are lost to follow-up or still alive will be censored at the date of 
last contact. 
• For DOR, subjects who are still alive and who do not have a documented disease 
progression will be censored at the date of the last assessment.   
 
The proportion of censored observations will be summarized. 
 
7.3.5 Statistical Methods for Safety Endpoints 
 
Descriptive statistics will be provided for disposition, demography, exposure, safety and 
laboratory assessments.   
 
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Descriptive statistics on continuous data will include means, medians, standard deviations, 
and ranges, while categorical data will be summarized using frequency counts and 
percentages.  Graphical summaries of the data may be presented. 
All adverse events including SAEs will be listed and coded by appropriate version of 
MedDRA.  The number and percent of subjects reporting any adverse events will be tabulated 
by system organ class and preferred term. Adverse events will be further classified by severity, 
relationship to treatment and seriousness in tabulation.  Tables and/or narratives of any death, 
or serious or significant adverse event, including early withdrawals because of adverse events, 
will be provided should they occur. 
Laboratory tests will be summarized using appropriate statistics.  
No hypothesis tests of these data will be done. 
7.4 
Stopping Rules for Treatment Toxicities 
The trial will be suspended (and/or resumed), pending discussion with Sponsor and Investigators and 
to allow protocol review with institutional IRBs, as well as the DSMC if any of the following occurs 
among patients who receive the study drug:  
• Any death deemed to be probably or definitely related to the investigational medication/cell 
product by the principal investigator and study sponsor; 
• Any grade 4 events deemed to be probably or definitely related to the investigational 
medication/cell product by the principal investigator and study sponsor.  Please note: this 
criterion excludes autoimmune adverse events.  For autoimmune adverse events, two (2) or 
more grade 4 adverse events judged to be probably, or definitely related to the 
investigational medication/cell product by the principal investigator and study sponsor must 
occur prior to accrual to study be suspended; 
• Two (2) or more grade 4 autoimmune events deemed to be probably, or definitely related 
to the investigational medication/cell product by the principal investigator and study 
sponsor; 
Or 
• An apheresis confirmed positive biological RCL occurs and no additional lot of vector is 
available (see section on Monitoring for and Management of RCL) 
7.5 
TOXICITY ASSESSMENTS AND DATA REPORTING 
 
7.5.1 Toxicities Related to Investigational Therapies 
 
The adverse event reporting period starts at day -40 visit and ends at 1 year after T cells infusion. 
During long term follow-up (years 1 - 15), patients will only be monitored for delayed adverse events 
related to the gene transfer aspect of the protocol (See section on long term follow up). 
 

 
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Toxicities or adverse events, which are defined as any symptom, sign, illness or experience that 
develops or worsens in severity over the course of the study, will be primarily assessed in relation 
to the investigational parts of this trial.  The investigational parts include i) infusions of the gene-
modified T-cells.  These toxicities will be graded in accordance with the NIH Common Toxicity 
Criteria (CTC) (version 4.0).   A copy of the CTCAE Version 4.0 can be downloaded from the 
CTEP homepage (HTTP://CTEP.INFO.NIH.GOV).  All appropriate treatment areas should have 
access to a copy of the CTCAE Version 4.0.  All adverse clinical experiences, whether observed 
by the investigator or reported by the patient, must be recorded, with details about the duration 
and intensity of each episode, the action taken with respect to the test drug, and the patient’s 
outcome.  The investigator must evaluate each adverse experience for its relationship to the test 
agents and for its seriousness. 
 
The investigator must appraise all abnormal laboratory results for their clinical significance.  If 
any abnormal laboratory result is considered clinically significant, the investigator must provide 
details about the action taken with respect to the test agents and about the patient’s outcome. 
 
A pre-existing condition, defined as one that is present at the start of the study, should be recorded 
as an adverse event if the frequency, intensity, or the character of the condition worsens during 
the study period. Worsening of a pre-existing condition after enrollment in the study but prior to 
the initiation of study treatment will be recorded in the medical record but not reported as an 
adverse event.  
 
 
Post-Study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are resolved, the 
subject is lost to follow-up, or the adverse event is otherwise explained. At the last scheduled visit, the 
investigator should instruct each subject to report any subsequent event(s) that the subject, or the subject’s 
personal physician, believes might reasonably be related to participation in this study. The investigator 
should notify the study sponsor of any death or adverse event occurring at any time after a subject has 
discontinued or terminated study participation that may reasonably be related to this study. The sponsor 
should also be notified if the investigator should become aware of the development of cancer or of a 
congenital anomaly in a subsequently conceived offspring of a subject that has participated in this study. 
 
7.5.2 Toxicity Causation 
 
All adverse experience reports must include the patient number, age, sex, weight, severity of 
reaction (mild, moderate, severe), relationship to drug (probably related, unknown relationship, 
definitely not related), date and time of administration of test medications and all concomitant 
medications, and medical treatment provided.   The investigator is responsible for evaluating all 
adverse events to determine whether criteria for “serious” and as defined above are present.  The 
investigator is responsible for reporting lenalidomide adverse events to Celgene as described 
below. 
 

 
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Each toxic event will be considered for relationship to the T-cell infusions and to the peptide 
immunizations and lenalidomide as follows: 
 
 
7.5.2.1 
Unrelated 
 
This category applies to those adverse events which after careful medical consideration are 
clearly felt to be due to extraneous causes.  Operationally, this may be inferred from reversal of 
the adverse event following treatment of the putative extraneous cause.  
 
 
7.5.2.2 
Unlikely (must satisfy 1 and 2 and 3) 
 
This category applies to those adverse events which, after careful medical and sponsor 
consideration, are felt unlikely to be related to the investigational agent based on the 
following criteria: 
 
• It does not follow a reasonable temporal sequence from administration of the 
investigational agent. 
• It could readily have been a result of the patient’s condition, environmental or toxic 
factors, or other therapies administered to the patient.  
• No causative mechanism for the investigational agent can be identified. 
 
7.5.2.3 
Possible (must satisfy 1,2 and 3) 
 
This category applies to those adverse events which, after careful medical and sponsor 
consideration, are felt unlikely to be related to the investigational agent, but the possibility 
cannot be ruled out with certainty.  An adverse event can be considered to be possibly 
related if: 
 
• It follows a reasonable temporal sequence from administration of the investigational 
agent. 
• It could reasonably have been a result of the patient’s clinical condition, 
environmental or toxic factors, or other therapies administered to the patients 
• A possible causative mechanism for the investigational agent can be identified. 
 
 
7.5.2.4  Probable (must satisfy 1,2 and 3) 
 
This category applies to those adverse events which, after careful medical and sponsor 
consideration, are felt to be related to the investigational agent with a high degree of 
certainty.  Adverse event can be considered probably related if: 
 
• It follows a reasonable temporal sequence from administration of the investigational 
agent. 

 
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• It could not be reasonably explained by other clinical conditions or factors. 
• A probable causative mechanism for the investigational agent can be identified.   
 
 
7.5.2.1 
Definite (must satisfy 1 and 2 and 3) 
 
This category applies to those adverse events which, after careful medical and sponsor 
consideration, are felt to be related to the investigational agent.  An adverse event can be 
considered to be definitely related if:   
 
• It follows a reasonable temporal sequence from administration of the investigational 
agent. 
• There are no confounding clinical conditions or factors which could explain the 
event.  
• A probable causative mechanism for the investigational agent can be identified.  
 
8 
Safety and Adverse Events 
8.1 
Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency (i.e., not described in study-related documents such 
as the IRB-approved protocol or consent form, the investigators brochure, etc). 
• Related or possibly related to participation in the research (i.e., possibly related means there is a 
reasonable possibility that the incident experience or outcome may have been caused by the 
procedures involved in the research). 
• Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm). 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in 
severity during the course of the study. Intercurrent illnesses or injuries should be regarded as adverse 
events. Abnormal results of diagnostic procedures are considered to be adverse events if the 
abnormality: 
• results in study withdrawal. 
• is associated with a serious adverse event. 
• is associated with clinical signs or symptoms. 
• leads to additional treatment or to further diagnostic tests. 
• is considered by the investigator to be of clinical significance. 

 
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Suspected Adverse Reaction(21 CFR 312.32(a)) 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility that 
the drug caused the adverse event. For the purposes of IND safety reporting, "reasonable 
possibility" means there is evidence to suggest a causal relationship between the drug and the 
adverse event. Suspected adverse reaction implies a lesser degree of certainty about causality than 
adverse reaction, which means any adverse event caused by a drug. 
Unexpected Suspected Adverse Reaction (21 CFR 312.32(a))  
An adverse event or suspected adverse reaction is considered “unexpected” if it is not listed in the 
investigator brochure or is not listed at the specificity or severity that has been observed; or, if an 
investigator brochure is not required or available, is not consistent with the risk information described 
in the general investigational plan or elsewhere in the current application, as amended. For example, 
under this definition, hepatic necrosis would be unexpected (by virtue of greater severity) if the 
investigator brochure referred only to elevated hepatic enzymes or hepatitis. Similarly, cerebral 
thromboembolism and cerebral vasculitis would be unexpected (by virtue of greater specificity) if the 
investigator brochure listed only cerebral vascular accidents. “Unexpected,” as used in this definition, 
also refers to adverse events or suspected adverse reactions that are mentioned in the investigator 
brochure as occurring with a class of drugs or as anticipated from the pharmacological properties of 
the drug, but are not specifically mentioned as occurring with the particular drug under investigation. 
Serious Adverse Events 
 
A Serious Adverse Event (SAE) is any AE that is: 
 
 Fatal 
 Life-threatening1 
 Requires or prolongs hospital stay 
 Results in persistent or significant disability or incapacity2 
 A congenital anomaly or birth defect 
 An important medical event3 
1“Life-threatening” means that the subject was at immediate risk of death at the time of the serious adverse event; it 
does not refer to a serious adverse event that hypothetically might have caused death if it were more severe. 
2“Persistent or significant disability or incapacity” means that there is a substantial disruption of a person’s ability 
to carry out normal life functions. 
3Medical and scientific judgment should be exercised in deciding whether expedited reporting is appropriate in 
situations where none of the outcomes listed above occurred.  Important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the patient or may require 
intervention to prevent one of the other outcomes listed in the definition above should also usually be considered 
serious.  Examples of such events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home, blood dyscrasias or convulsions that do not result in inpatient hospitalization, or the development 
of drug dependency or drug abuse.  A new diagnosis of cancer during the course of a treatment should be 
considered as medically important.  
 
 
All Serious Adverse Events will be recorded and reported to the Sponsor, to IRBs, DSMCs and IBCs 
of both collaborating institutions (University of Maryland and University of Pennsylvania)  in 

 
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accordance with standard reporting procedures.  SAEs will be reported to the FDA and NIH OBA by 
the sponsor in accordance with established guidelines. .The following table also shows the expedited 
reporting guidelines for the University of Maryland (unless otherwise specified) of AEs to the IRBs 
and IBCs.  If not listed then the event need not be reported in an expedited fashion (also see 
“Pregnancies” section and Lenalidomide next page).   
 
 Attribution 
Grade II 
Grade III 
Grade III 
Grade IV-V 
 
Unexpected 
Expected 
Unexpected 
Expected 
& 
Unexpected 
Unrelated 
Unlikely 
Not required 
10 days (if pt 
hospitalized 
only) 
10 calendar days 
(if hospitalized) 
5 calendar days 
Possible 
Probable 
Definite 
10 calendar days 
10 days (if pt 
hospitalized 
only) 
5 calendar days  
5 calendar days 
8.2 
Recording of Adverse Events 
Adverse events will be assessed using CTC V4. At each contact with the subject, the investigator 
must seek information on adverse events by specific questioning and, as appropriate, by examination. 
Information on all adverse events should be recorded immediately in the source document, and also 
in the appropriate adverse event module of the case report form (CRF). All clearly related signs, 
symptoms, and abnormal diagnostic procedures results should recorded in the source document, 
though should be grouped under one diagnosis. 
All adverse events occurring during the study period must be recorded (section 8.3). The clinical 
course of each event should be followed until resolution, stabilization, or until it has been determined 
that the study treatment or participation is not the cause. Serious adverse events that are still ongoing 
at the end of the study period must be followed up to determine the final outcome. Any serious adverse 
event that occurs after the study period and is considered to be possibly related to the study treatment 
or study participation should be recorded and reported immediately. 
8.3 
Adverse Event Reporting Period and Adverse Event Reporting 
Patients will be monitored for the duration of the intervention protocol (Day -40 visit until 
relapse/progression or until 1 year, whichever comes first).  For patients who remain disease 
progression-free beyond Year 1 patients will only be monitored for delayed adverse events related 
to the gene transfer aspect of the protocol (see Section 6.4 for definition) until disease progression 
or until transferred into the long-term follow-up protocol. Post disease progression, patients will 
be rolled over to the LTFU protocol ADP-0000-002, when available at the site.  If the protocol 
ADP-0000-002 is not available, patients will continue to be followed as described in Appendix C.  
All serious adverse events must be reported to the study sponsor.  Any study related unanticipated 
problem posing risk of harm to subjects or others and is considered serious. Any study-related 

 
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unanticipated problem posing risk of harm to subjects or others, and any type of serious adverse 
event, must be reported to the study sponsor within 24 hours of knowledge of the event.  
For specific instructions for reporting SAEs to the Sponsor, please see the Manual of Procedures 
for the study, or contact the study manager at Adaptimmune. 
8.3.1 Investigator Reporting: Notifying the IRB 
Investigators at each site are responsible for safety reporting to their local IRB. Investigators are 
responsible for complying with their local IRB’s reporting requirements, though must submit the 
required reports to their IRB no later than 10 working days.  Copies of each report and 
documentation of IRB notification and receipt will be kept in the investigator’s study file.  
Sponsor Responsibility for Reporting Adverse Events 
All adverse events will be reported by the Sponsor to regulatory agencies, and investigators in 
accordance with all applicable laws and regulations.    
8.3.2 Investigator reporting: notifying the Penn IRB and IBC 
 
This section describes the requirements for safety reporting by investigators who are Penn faculty, 
affiliated with a Penn research site, or otherwise responsible for safety reporting to the Penn IRB 
and IBC. The University of Pennsylvania IRB and IBC (Penn IRB/IBC) requires expedited 
reporting of those events related to study participation that are unforeseen and indicate that 
participants or others are at increased risk of harm.  The Penn IRB will not acknowledge safety 
reports or bulk adverse event submissions that do not meet the criteria outlined below.  The Penn 
IRB requires researchers to submit reports of the following problems within 10 working days 
from the time the investigator becomes aware of the event: 
• Any adverse event (regardless of whether the event is serious or non-serious, on-site or 
off-site) that occurs any time during or after the research study, which in the opinion 
of the principal investigator is: 
Unexpected (An event is “unexpected” when its specificity and severity are not 
accurately reflected in the protocol-related documents, such as the IRB-approved 
research protocol, any applicable investigator brochure, and the current IRB-approved 
informed consent document and other relevant sources of information, such as product 
labeling and package inserts.) 
AND 
Related to the research procedures (An event is “related to the research procedures” if 
in the opinion of the principal investigator or sponsor, the event was more likely than 
not to be caused by the research procedures.) 
 
Reporting Process 
Unanticipated problems posing risks to subjects or others as noted above will be reported 
to the Penn IRB using the form: “Unanticipated Problems Posing Risks to Subjects or 
Others Including Reportable Adverse Events” or as a written report of the event (including 
a description of the event with information regarding its fulfillment of the above criteria, 

 
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follow-up/resolution and need for revision to consent form and/or other study 
documentation). 
 
Copies of each report and documentation of IRB notification and receipt will be kept in 
the Clinical Investigator’s study file. 
Reporting Deaths:  more rapid reporting requirements 
Concerning deaths that occur during the course of a research study, the following describes 
the more rapid reporting requirement of the Penn IRB for specific situations: 
• Report the event within 24 hours when the death is unforeseen (unexpected) and 
indicates participants or others are at increased risk of harm. 
• Report the event within 72 hours, for all other deaths, regardless of whether the death 
is related to study participation. 
 
For reportable deaths, the initial submission to the Penn IRB may be made by contacting 
the IRB Director or Associate Director. The AE/Unanticipated Problem Form is required 
as a follow up to the initial submission. 
 
Other Reportable events: 
For clinical drug trials, the following events are also reportable to the Penn IRB: 
- 
Any adverse experience that, even without detailed analysis, represents a serious 
unexpected adverse event that is rare in the absence of drug exposure (such as 
agranulocytosis, hepatic necrosis, Stevens-Johnson syndrome). 
- 
Any adverse event that would cause the sponsor to modify the investigators 
brochure, protocol or informed consent form, or would prompt other action by the 
IRB to assure protection of human subjects. 
- 
Information that indicates a change to the risks or potential benefits of the research, 
in terms of severity or frequency. For example:  
– An interim analysis indicates that participants have a lower rate of response 
to treatment than initially expected. 
– Safety monitoring indicates that a particular side effect is more severe, or 
more frequent than initially expected. 
– A paper is published from another study that shows that an arm of your 
research study is of no therapeutic value. 
• Change in FDA safety labeling or withdrawal from marketing of a drug, device, or 
biologic used in a research protocol. 
• Breach of confidentiality 
• Change to the protocol taken without prior IRB review to eliminate apparent 
immediate hazard to a research participant. 
• Incarceration of a participant when the research was not previously approved under 
Subpart C and the investigator believes it is in the best interest of the subject to 
remain on the study. 

 
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• Complaint of a participant when the complaint indicates unexpected risks or the 
complaint cannot be resolved by the research team. 
• Protocol violation (meaning an accidental or unintentional deviation from the IRB 
approved protocol) that in the opinion of the investigator placed one or more 
participants at increased risk, or affects the rights or welfare of subjects. 
8.3.3 Investigator reporting: notifying the Penn DSMC 
 
All events meeting the DSMC reporting requirements must be entered into the mandatory 
Velos AE/SAE form.  A study CRF does not replace the ACC central reporting form.   
 
Once an event is entered, please send an email alert to Doris Shank 
doris.shank@uphs.upenn.edu.  If your study has prospective DOCM monitoring (as determined 
by the CTSRMC) you should notify your study monitor. 
 
Every effort should be made to report an as a diagnosis, not as list of symptoms.  Symptoms that 
led to the diagnosis should be included in the event description, but should not be the actual 
event.   
 
Do not leave any of the fields blank. 
 
Once an event is reported, you must keep the information accurate and current in Velos.  If 
new/updated information is learned about the event, the event should be amended or corrected 
promptly.  
 
Off-site (external sponsors)  
• All SAEs (on the specific protocol opened here only) defined as reportable in the protocol for 
Phase I and II studies must be reported to the DSMC.  
• SAEs on cooperative or industry sponsored Phase III studies do not have to be reported.  
• SAEs on Other Externally Peer Reviewed Phase III have to be reported if the protocol defines 
them as reportable.  
 
Note: The DSMC reserves the right to modify the reporting window for certain types of studies 
i.e. gene therapy, adoptive therapies, Penn manufactured vaccines etc.  
8.3.4 Investigator reporting: Notifying a non-Penn IRB (See table on page 67 for UMD IRB reporting 
guidelines) 
 
Investigators who are not Penn faculty or affiliated with a Penn research site are responsible 
for safety reporting to their local IRB.  
 
8.3.5 Sponsor Reporting: Notifying the FDA 
The study sponsor is required to report certain study events in an expedited fashion to the 
FDA. These written notifications of adverse events are referred to as IND safety reports. The 
sponsor must report an IND safety reports as described in:   

 
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http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidanc
es/UCM227351.pdf   
 
The following describes the safety reporting requirements by timeline for reporting and 
associated type of event: 
• Within 7 Calendar Days 
Any study event that is: 
o Unexpected fatal or life-threatening suspected adverse reaction.  Including all 
deaths and grade 4 non-hematological events irrespective of attribution 
occurring within 30 days of study drug administration. 
• Within 15 Calendar Days 
Any study event that is: 
o unexpected 
o Suspected adverse reaction that is serious, but not fatal or life-threatening 
-or- 
o a previous adverse event that was not initially deemed  reportable but is later 
found to fit the criteria for reporting (reporting within 15 calendar days from 
when event was deemed reportable). 
 
Any finding from tests in laboratory animals that: 
o suggest a significant risk for human subjects including reports of 
mutagenicity, teratogenicity, or carcinogenicity or reports of significant organ 
toxicity at or near the expected human exposure. 
 
Increase in rate of occurrence of serious suspected adverse reactions: 
o any clinically important increase in the rate of a serious suspected adverse 
reaction over that listed in the protocol or investigator brochure. 
 
Additional Reporting Requirements 
Sponsor is also required to review all adverse events to make a causality determination on 
the basis of information from investigators and report these findings to the FDA in 
accordance with 21 CFR  312.32. 
 
If the adverse event does not meet expedited reporting requirements, the Sponsor will report 
the SAE as in the IND Annual Report. 
8.4 
Investigator Reporting Responsibilities 
The conduct of the study will comply with all FDA safety reporting requirements.   
 
IND Annual Reports 
If the FDA has granted an IND number, it is a requirement of 21 CFR 312.33, that an annual 
report is provided to the FDA within 60-days of the IND anniversary date.  21 CRF 312.33 
provides the data elements that are to be submitted in the report.  The Annual Report should 
be filed in the study's Regulatory Binder. 

 
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In the event of a grade 4 or 5 unexpected event the PI and the Research Coordinator will 
convene a meeting with the study team or have a teleconference to thoroughly discuss the 
adverse event.  This meeting will be convened within 24 business hours of knowledge of the 
grade 4 or 5 unexpected event and will not occur via email nor will the sponsor be involved in 
discussions about attribution. Meeting minutes capturing the review of and ongoing 
investigations of the grade 4 or 5 unexpected event, including next steps in the management of 
the subject and any proposed changes to the protocol will be forwarded to the DSMC.  
8.5 
Coordination of Patient Registration/Reporting 
 
To register a patient, the following documents should be completed by the research nurse or data 
manager and sent to the sponsor: 
 
1)  
Copies of screening documents (laboratory tests, radiology, 
PE, History, Concomitant Medications) 
 
 
 
 
2)   
Copy of signed patient consent form 
 
 
 
 
3)   
Copy of HIPAA authorization form 
 
 
 
 
4)   
Eligibility checklist 
 
 
 
 
5)   
Enrollment Form 
 
The research nurse or data manager at each site will then call or email the Monitor at the Sponsor  to 
confirm eligibility.  Afterwards, the patient will be assigned a study number and will formally register 
on the study.  
 
Clinical trial event scheduling and data collection and storage will be supported by Velos software. 
CRFs (case report forms) for each study event will be completed and submitted to Velos on-line or 
within time specified by study contract. 
 
8.6 
Protocol Deviations 
 
Exception 
A one time, intentional action or process that departs from the IRB and CTSRMC approved 
study protocol, intended for one occurrence. If the action disrupts the study progress, such that 
the study design or outcome (endpoints) may be compromised, or the action compromises the 
safety and welfare of study subjects, advance documented IRB and DSMC approval is 
required.  
 
 
For this study, there will be no exceptions to eligibility granted for this study. 
 
Deviation 
 

 
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Protocol deviations are defined as any variation from the requirements and procedures described 
in the study protocol and protocol amendments that occurs during the conduct of the study 
including deviations from ICH, GCP and local applicable regulatory requirements and laws. 
 
Any departure from the protocol that meets the following criteria should be submitted to the 
Sponsor: 
 
 Investigational Product  
 Concomitant Medications 
 Laboratory Procedures  
 Study visit schedules (safety / endpoints) 
 Serious adverse events reporting  
 Stopping criteria 
 Protocol specific discontinuation criteria 
 
 
 

 
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9 
THERAPEUTIC AND INVESTIGATIONAL AGENTS 
 
This section will describe all the therapeutic and investigational agents to be administered to the 
patient, including dose, route of administration, and possible adverse reactions that may be 
observed.  
 
9.1 
Lenalidomide: Drug information 
 
Copyright 1978-2009 Lexi-Comp, Inc. All rights reserved. 
 
PHARMACOLOGICCATEGORY 
Antiangiogenesis Agent Tumor Necrosis Factor (TNF) Blocking Agent.  
The mechanism of action of lenalidomide remains to be fully characterized. Lenalidomide possesses 
immunomodulatory and antiangiogenic properties.  Lenalidomide inhibited the secretion of pro-
inflammatory cytokines and increased the secretion of anti-inflammatory cytokines from peripheral 
blood mononuclear cells.  Lenalidomide inhibited cell proliferation with varying effectiveness 
(IC50s) in some but not all cell lines.  Of cell lines tested, lenalidomide was effective in inhibiting 
growth of Namalwa cells (a human B cell lymphoma cell line with a deletion of one chromosome 5) 
but was much less effective in inhibiting growth of KG-1 cells (human myeloblastic cell line, also 
with a deletion of one chromosome 5) and other cell lines without chromosome 5 deletions.  
Lenalidomide inhibited the expression of cyclooxygenase-2 (COX-2) but not COX-1 in vitro.   
PHARMACOKINETICS AND DRUG METABOLISM OF LENALIDOMIDE: 
Absorption:Lenalidomide, in healthy volunteers, is rapidly absorbed following oral administration 
with maximum plasma concentrations occurring between 0.625 and 1.5 hours post-dose. Co 
administration with food does not alter the extent of absorption (AUC) but does reduce the maximal 
plasma concentration (Cmax) by 36%. The pharmacokinetic disposition of lenalidomide is linear. 
Cmax and AUC increase proportionately with increases in dose. Multiple dosing at the recommended 
dose-regimen does not result in drug accumulation. 
Pharmacokinetic analyses were performed on 15 multiple myeloma patients treated in the phase I 
studies.  Absorption was found to be rapid on both Day 1 and Day 28 with time to maximum blood 
levels ranging from 0.7 to 2.0 hours at all dose levels (5mg, 10mg, 25mg, and 50mg).  No plasma 
accumulation was observed with multiple daily dosing.  Plasma lenalidomide declined in a 
monophasic manner with elimination half-life ranging from 2.8 to 6.1 hours on both Day 1 and 28 at 
all 4 doses.  Peak and overall plasma concentrations were dose proportional over the dosing range of 
5mg to 50mg.   Exposure (AUC) in multiple myeloma patients is 57% higher than in healthy male 
volunteers.  
Pharmacokinetic Parameters: 
Distribution:  In vitro (14C)-lenalidomide binding to plasma proteins is approximately 30%. 

 
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Metabolism and Excretion:  The metabolic profile of lenalidomide in humans has not been studied. 
In healthy volunteers, approximately two-thirds of lenalidomide is eliminated unchanged through 
urinary excretion. The process exceeds the glomerular filtration rate and therefore is partially or 
entirely active.  Half-life of elimination is approximately 3 hours. 
ADMINISTRATION  
Administer with water. Swallow capsule whole; do not break, open, or chew.  If a dose of 
lenalidomide is missed, it should be taken as soon as possible on the same day.  If it is missed for the 
entire day, it should not be made up. 
Patients who take more than the prescribed dose of lenalidomide should be instructed to seek 
emergency medical care if needed and contact study staff immediately. 
SUPPLIER  
Celgene Corporation will supply Revlimid® (lenalidomide) to study participants through the 
RevAssist® program.The RevAssist program is a restricted distribution program under which 
lenalidomide is provided by Celgene.  The reason for this program is to track and control the use of 
lenalidomide since it is a derivative of thalidomide and therefore there are serious reproductive safety 
concerns.  The purpose of the program is to ensure that patients receiving, and physicians 
administering, lenalidomide are aware of these concerns and take precautions to avoid prescribing 
lenalidomide while pregnant, and to take necessary precautions to avoid pregnancy while on 
lenalidomide.   
 
The program requires any prescriber of lenalidomide to be registered with the program.  Patients must 
also be enrolled in the program and agree to comply with the requirements of the program as described 
in the informed consent.  In addition, only RevAssist contract pharmacies are able to provide 
lenalidomide.  Additional details and information packets regarding lenalidomide and the RevAssist 
program can be found at http://www.revlimid.com. 
 
PACKAGING 
Lenalidomide will be shipped directly to patients.   Bottles will contain a sufficient number of capsules 
for one cycle of dosing. 
 
STORAGE  
Lenalidomide should be stored at room temperature away from direct sunlight and protected from 
excessive heat and cold. 
 
PRESCRIBING INFORMATION 
Lenalidomide will be provided in accordance with the RevAssist® program of Celgene Corporation.  
Patient insurance will be charged for the lenalidomide prescription.  Per standard RevAssist® 
requirements all physicians who prescribe lenalidomide for research subjects enrolled into this trial, 
and all research subjects enrolled into this trial, must be registered in and must comply with all 
requirements of the RevAssist® program.  Prescriptions must be filled within 7 days.  Only enough 
lenalidomide for one cycle of therapy will be supplied to the patient each cycle. 
 

 
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ADVERSE REACTIONS SIGNIFICANT 
 
  >10%: 
Cardiovascular: Peripheral edema (8% to 21%). Central nervous system: Fatigue (31% to 38%), 
insomnia (10% to 32%), pyrexia (21% to  23%), dizziness (20% to 21%), headache (20%). 
Dermatologic: Pruritus (42%), rash (16% to 36%), dry skin (14%). Endocrine & metabolic: 
Hyperglycemia (15%), hypokalemia (11%). Gastrointestinal: Diarrhea (29% to 49%), constipation 
(24% to 39%), nausea (22% to 24%), weight loss (18%), dyspepsia (14%), anorexia (10% to 14%), 
taste perversion (6% to 13%), abdominal pain (8% to 12%). Genitourinary: Urinary tract infection 
(11%). Hematologic: Thrombocytopenia (17% to 62%; grades 3/4: 10% to 50%), neutropenia 
(28% to 59%; grades 3/4: 21% to 53%), anemia (12% to 24%; grades 3/4: 6% to 9%); 
myelosuppression is dose-dependent and reversible with treatment interruption and/or dose 
reduction. Neuromuscular & skeletal: Muscle cramp (18% to 30%), weakness (15% to 23%), 
arthralgia (10% to 22%), back pain (15% to 21%), tremor (20%), paresthesia (12%), limb pain 
(11%). Ocular: Blurred vision (15%). Respiratory: Nasopharyngitis (23%), cough (15% to 20%), 
dyspnea (7% to 20%), pharyngitis (16%), epistaxis (15%), upper respiratory infection (14% to 
15%), pneumonia (11% to 12%) 
1% to 10%: 
Cardiovascular: Edema (10%), deep vein thrombosis (≤8%; grades 3/4: 7%), hypertension (6%), 
chest pain (5%), palpitation (5%), atrial fibrillation (grades 3/4: 3%), syncope (grade 3: 2%). 
Central nervous system: Hypoesthesia (7%), pain (7%), depression (5%). Dermatologic: Bruising 
(5% to 8%), cellulitis (5%), erythema (5%). Endocrine & metabolic: Hypothyroidism (7%), 
hypomagnesemia (6%), hypocalcemia (grades 3/4: 4%). Gastrointestinal: Vomiting (10%), 
xerostomia (7%), loose stools (6%). Genitourinary: Dysuria (7%). Hematologic: Leukopenia (8%; 
grade 3: 4%), febrile neutropenia (5%), lymphopenia (grade 3: 2%). Hepatic: ALT increased (8%). 
Neuromuscular & skeletal: Myalgia (9%), rigors (6%), neuropathy (peripheral 5%). Respiratory: 
Sinusitis (8%), rhinitis (7%), bronchitis (6%), pulmonary embolism (≤3%; grades 3/4: 3%). 
Miscellaneous: Night sweats (8%), diaphoresis increased (7%) 
 
<1% (Limited to important or life-threatening):  
Acute febrile neutrophilic dermatosis, acute leukemia, acute myeloid leukemia (AML), adrenal 
insufficiency, angina, angioedema, aortic disorder, aphasia, azotemia, bacteremia, Basedow's disease, 
biliary obstruction, blindness, bone marrow depression, bradycardia, brain edema, C-reactive protein 
decreased, cardiac arrest, cardiac failure, cardiogenic shock, cardiomyopathy, cardiopulmonary 
arrest, cellulitis, cerebellar infarction, cerebral infarction, cerebrovascular accident, CHF, 
cholecystitis, chondrocalcinosis, chronic obstructive airway disease, circulatory collapse, 
coagulopathy, colonic polyp, dehydration, delirium, delusion, diabetes mellitus, diabetic 
ketoacidosis, diverticulitis, dysphagia, encephalitis, erythema multiforme, gait abnormal, gastritis, 
gastroenteritis, gastrointestinal hemorrhage, gout, hematuria, hemoglobin decreased, hemolysis, 
hemolytic anemia, hemorrhage, hepatitis, herpesvirus infection, hyperbilirubinemia, hypernatremia, 
hypersensitivity, hypoglycemia, hypotension, hypoxia, infection, INR increased, interstitial lung 
disease, intestinal perforation, intracranial hemorrhage, intracranial venous sinus thrombosis, irritable 
bowel syndrome, ischemia, ischemic colitis, leukoencephalopathy, liver failure, liver function tests 

 
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abnormal, lung cancer, lung infiltration, lymphoma, melena, MI, migraine, myocardial ischemia, 
myopathy, neutropenic sepsis, orthostatic hypotension, pancreatitis, pancytopenia, performance 
status decreased, peripheral ischemia, phlebitis, post procedural hemorrhage, pseudomembraneous 
colitis, pulmonary edema, rectal hemorrhage, refractory anemia, renal calculus, renal failure, renal 
mass, renal tubular necrosis, respiratory failure, septic shock, sepsis, serum creatinine increased, skin 
desquamation, small bowel obstruction, somnolence, spinal cord compression, splenic infarction, 
Stevens-Johnson syndrome, stomatitis, subarachnoid hemorrhage, supraventricular arrhythmia, 
tachyarrhythmia, thrombophlebitis, thrombosis, toxic epidermal necrolysis, transient ischemic attack, 
troponin I increased, urinary retention, urosepsis, urticaria, ventricular dysfunction, wheezing 
 
CONTRAINDICATIONS  
Hypersensitivity to lenalidomide or any component of the formulation; pregnancy or women 
capable of becoming pregnant; patients unable to comply with the RevAssistSM program 
 
WARNINGS / PRECAUTIONS 
Boxed warnings: Hematologic toxicity: See "Concerns related to adverse effects" below. 
Pregnancy: See "Special populations" below.  Thrombosis/embolism: See "Concerns related to 
adverse effects" below.  
 
Special handling: Hazardous agent: Use appropriate precautions for handling and disposal.  
Concerns related to adverse effects: 
CNS effects: May cause dizziness or fatigue; caution patients about performing tasks which require 
mental alertness (eg, operating machinery or driving).  
Hematologic toxicity: [U.S. Boxed Warning]: Hematologic toxicity (neutropenia and 
thrombocytopenia) occurs in a majority of patients (grade 3/4: 80%) and may require dose reductions 
and/or delays; the use of blood product support and/or growth factors may be needed.  
Thromboembolic events: [U.S. Boxed Warning]: Lenalidomide has been associated with a significant 
increase in risk for thrombosis and embolism in multiple myeloma patients treated with combination 
therapy. Deep vein thrombosis (DVT) and pulmonary embolism (PE) have occurred; monitor for 
signs and symptoms of thromboembolism (shortness of breath, chest pain, or arm or leg swelling) 
and seek prompt medical attention with development of these symptoms.  
 
Disease-related concerns: 
Renal impairment: Use with caution in patients with renal impairment; may experience an increased 
rate of toxicities.  
 
Special populations: 
Pediatrics: Safety and efficacy have not been established in children.  
Pregnancy: [U.S. Boxed Warning]: Lenalidomide is an analogue of thalidomide (a human teratogen) 
and could potentially cause birth defects in humans. Distribution is restricted; physicians, 
pharmacists, and patients must be registered with the RevAssistSM program.  

 
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Other warnings/precautions: 
Blood donation: Patients should be advised not to donate blood during therapy and for 4 weeks 
following completion of therapy.  
Lactose intolerance: Product may contain lactose; avoid use in patients with Lapp lactase deficiency, 
glucose-galactose malabsorption, or glucose intolerance.  
RESTRICTIONS 
Lenalidomide is approved for marketing in the U.S. only under a Food and Drug Administration 
(FDA) approved, restricted distribution program called RevAssistSM (www.REVLIMID.com or 1-
888-423-5436). In Canada, distribution is restricted through RevAidSM (www.RevAid.ca or 1-888-
738-2431). Physicians, pharmacies, and patients must be registered; a maximum 28-day supply may 
be dispensed; a new prescription is required each time it is filled; pregnancy testing is required for 
females of childbearing potential. 
An FDA-approved medication guide must be distributed when dispensing an outpatient prescription 
(new or refill) where this medication is to be used without direct supervision of a healthcare provider. 
Medication guides are available at http://www.fda.gov/cder/Offices/ODS/medication_guides.htm. 
 
DRUG INTERACTIONS 
Abatacept: Anti-TNF Agents may enhance the adverse/toxic effect of Abatacept. An increased risk 
of serious infection during concomitant use has been reported. Risk D: Consider therapy modification  
 
Anakinra: Anti-TNF Agents may enhance the adverse/toxic effect of Anakinra. An increased risk of 
serious infection during concomitant use has been reported. Risk X: Avoid combination 
Dexamethasone: May enhance the thrombogenic effect of Lenalidomide. Risk D: Consider therapy 
modification 
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy 
modification 
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. 
Specifically, the risk of concurrent infection may be increased. Risk X: Avoid combination 
Rilonacept: Anti-TNF Agents may enhance the adverse/toxic effect of Rilonacept. Risk X: Avoid 
combination 
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy 
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines 
(Inactivated). Risk C: Monitor therapy 
Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). 
Vaccinal infections may develop. Immunosuppressants may also decrease therapeutic response to 
vaccines. Risk X: Avoid combination 
 

 
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PREGNANCY IMPLICATIONS  
[U.S. Boxed Warning]: Lenalidomide is an analogue of thalidomide (a human teratogen) and 
could potentially cause birth defects in humans. Animal studies with lenalidomide are ongoing; 
there are no adequate and well-controlled studies in pregnant women. Women of childbearing 
potential should be treated only if they are able to comply with the conditions of the RevAssistSM 
program. Two forms of effective contraception are required beginning 4 weeks prior to, during, 
and for 4 weeks after therapy and during therapy interruptions. Pregnancy tests (sensitivity of at 
least 50 mIU/mL) should be performed 10-14 days and 24 hours prior to beginning therapy; 
weekly for the first 4 weeks and every 4 weeks (every 2 weeks if menstrual cycle irregular) 
thereafter and during therapy interruptions. Lenalidomide must be immediately discontinued and 
the patient referred to a reproductive toxicity specialist if pregnancy occurs during treatment. 
Males (even those vasectomized) should use a latex condom during any sexual contact with 
women of childbearing age. Risk to the fetus from semen of male patients is unknown. The parent 
or legal guardian for patients between 12 and 18 years of age must agree to ensure compliance 
with the required guidelines. Any suspected fetal exposure should be reported to the FDA via the 
MedWatch program (1-800-FDA-1088) and to Celgene Corporation (1-888-423-5436) 
 
LACTATION  
Excretion in breast milk unknown/not recommended 
 
DIETARY CONSIDERATIONS  
Should be taken at least 1 hour after the evening meal. 
 
MONITORING PARAMETERS 
WBC with differential; signs of neuropathy monthly for the first 3 months, then periodically 
during treatment; consider monitoring of sensory nerve application potential amplitudes (at 
baseline and every 6 months) to detect asymptomatic neuropathy. In HIV-seropositive patients: 
viral load after 1 and 3 months, then every 3 months. Pregnancy testing is required within 24 
hours of initiation of therapy, weekly during the first 4 weeks, then every 4 weeks in women with 
regular menstrual cycles or every 2 weeks in women with irregular menstrual cycles. 
 
PHARMACODYNAMICS / KINETICS 
Absorption: Rapid 
Protein binding: ~30% 
Half-life elimination: ~3 hours 
Time, to peak, plasma: Healthy volunteers: 0.6-1.5 hours; Myeloma patients: 0.5-4 hours 
Excretion: Urine (~67% as unchanged drug) 

 
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PATIENT EDUCATION 
Patients will be given oral and written instructions regarding the special distribution program for 
Lenalidomide called RevAssist®.  
Lenalidomide is commercially available.  Additional information may be obtained from the 
FDA-approved package insert.  
  
9.2 
Cyclophosphamide: Drug information 
 
Copyright 1978-2009 Lexi-Comp, Inc. All rights reserved. 
U.S. BRAND NAMES — Cytoxan® 
 
PHARMACOLOGIC CATEGORY 
Antineoplastic Agent, Alkylating Agent 
 
ADMINISTRATION: I.V. infusions may be administered over 1-24 hours. Doses >500 mg to 
approximately 2 g may be administered over 20-30 minutes. To minimize bladder toxicity, increase 
normal fluid intake during and for 1-2 days after cyclophosphamide dose. Most adult patients will 
require a fluid intake of at least 2 L/day. High-dose regimens should be accompanied by vigorous 
hydration with or without mesna therapy. 
 
ADVERSE REACTIONS SIGNIFICANT 
>10%: 
Dermatologic: Alopecia (40% to 60%) but hair will usually regrow although it may be a different 
color and/or texture. Hair loss usually begins 3-6 weeks after the start of therapy. Endocrine & 
metabolic: Fertility: May cause sterility; interferes with oogenesis and spermatogenesis; may be 
irreversible in some patients; gonadal suppression (amenorrhea) Gastrointestinal: Nausea and 
vomiting occur more frequently with larger doses, usually beginning 6-10 hours after 
administration; anorexia, diarrhea, mucositis, and stomatitis are also seen. Genitourinary: Severe, 
potentially fatal acute hemorrhagic cystitis, believed to be a result of chemical irritation of the 
bladder by acrolein, a cyclophosphamide metabolite, occurs in 7% to 12% of patients and has been 
reported in up to 40% of patients in some series. Patients should be encouraged to drink plenty of 
fluids during therapy (most adults will require at least 2 L/day), void frequently, and avoid taking 
the drug at night. With large I.V. doses, I.V. hydration is usually recommended. The use of mesna 
and/or continuous bladder irrigation is rarely needed for doses <2 g/m2. Hematologic: 
Thrombocytopenia and anemia are less common than leukopenia Onset: 7 days Nadir: 10-14 days 
Recovery: 21 days. 
 
1% to 10%: 
Cardiovascular: Facial flushing. Central nervous system: Headache. Dermatologic: Skin rash. 
Renal: SIADH may occur, usually with doses >50 mg/kg (or 1 g/m2); renal tubular necrosis, which 
usually resolves with discontinuation of the drug, is also reported. Respiratory: Nasal congestion 
occurs when I.V. doses are administered too rapidly (large doses via 30-60 minute infusion); 

 
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patients experience runny eyes, rhinorrhea, sinus congestion, and sneezing during or immediately 
after the infusion. If needed, a decongestant or decongestant/antihistamine (eg, pseudoephedrine or 
pseudoephedrine/triprolidine) can be used to prevent or relieve these symptoms. 
<1% (Limited to important or life-threatening):  
High-dose therapy may cause cardiac dysfunction manifested as CHF; cardiac necrosis or 
hemorrhagic myocarditis has occurred rarely, but may be fatal. Cyclophosphamide may also 
potentiate the cardiac toxicity of anthracyclines. Other adverse reactions include anaphylactic 
reactions, darkening of skin/fingernails, dizziness, hemorrhagic colitis, hemorrhagic ureteritis, 
hepatotoxicity, hyperuricemia, hypokalemia, jaundice, neutrophilic eccrine hidradenitis, radiation 
recall, renal tubular necrosis, secondary malignancy (eg, bladder carcinoma), Stevens-Johnson 
syndrome, toxic epidermal necrolysis; interstitial pneumonitis and pulmonary fibrosis are 
occasionally seen with high doses. 
BMT: Cardiovascular: Heart failure, cardiac necrosis, pericardial tamponade. Endocrine & 
metabolic: Hyponatremia. Hematologic: Methemoglobinemia. Gastrointestinal: Severe nausea 
and vomiting. Miscellaneous: Hemorrhagic cystitis, secondary malignancy 
 
DRUG INTERACTIONS  
Substrate of CYP2A6 (minor), 2B6 (major), 2C8/9 (minor), 2C19 (minor), 3A4 (major); Inhibits 
CYP3A4 (weak); Induces CYP2B6 (weak), 2C8/9 (weak) 
Allopurinol may cause increase in bone marrow depression and may result in significant elevations 
of cyclophosphamide cytotoxic metabolites. 
Anesthetic agents: Cyclophosphamide reduces serum pseudocholinesterase concentrations and may 
prolong the neuromuscular blocking activity of succinylcholine; use with caution with halothane, 
nitrous oxide, and succinylcholine. 
Chloramphenicol results in prolonged cyclophosphamide half-life to increase toxicity. 
CYP2B6 inducers: May increase the levels/effects of acrolein (the active metabolite of 
cyclophosphamide). Example inducers include carbamazepine, nevirapine, phenobarbital, phenytoin, 
and rifampin. 
CYP2B6 inhibitors: May decrease the levels/effects of acrolein (the active metabolite of 
cyclophosphamide). Example inhibitors include desipramine, paroxetine, and sertraline. 
CYP3A4 inducers: CYP3A4 inducers may increase the levels/effects of acrolein (the active 
metabolite of cyclophosphamide). Example inducers include aminoglutethimide, carbamazepine, 
nafcillin, nevirapine, phenobarbital, phenytoin, and rifamycins. 
CYP3A4 inhibitors: May decrease the levels/effects of acrolein (the active metabolite of 
cyclophosphamide). Example inhibitors include azole antifungals, ciprofloxacin, clarithromycin, 
diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, 
protease inhibitors, quinidine, and verapamil. 
Digoxin: Cyclophosphamide may decrease digoxin serum levels. 
Doxorubicin: Cyclophosphamide may enhance cardiac toxicity of anthracyclines. 

 
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Tetrahydrocannabinol results in enhanced immunosuppression in animal studies. 
Thiazide diuretics: Leukopenia may be prolonged. 
 
MECHANISM OF ACTION 
 
Cyclophosphamide is an alkylating agent that prevents cell division by cross-linking DNA strands 
and decreasing DNA synthesis. It is a cell cycle phase nonspecific agent. Cyclophosphamide also 
possesses potent immunosuppressive activity. Cyclophosphamide is a prodrug that must be 
metabolized to active metabolites in the liver. 
 
PHARMACODYNAMICS / KINETICS 
Distribution: Vd: 0.48-0.71 L/kg; crosses placenta; crosses into CSF (not in high enough 
concentrations to treat meningeal leukemia) 
Protein binding: 10% to 56% 
Metabolism: Hepatic to active metabolites acrolein, 4-aldophosphamide, 4-
hydroperoxycyclophosphamide, and nor-nitrogen mustard 
Bioavailability: >75% 
Half-life elimination: 4-8 hours 
Time to peak, serum: Oral: ~1 hour 
Excretion: Urine (<30% as unchanged drug, 85% to 90% as metabolites) 
Cyclophosphamide is commercially available.  Additional information may be obtained from the 
FDA-approved package insert.   
 
 
 
9.3 
Melphalan:  Drug Information 
 
U.S. BRAND NAMES — Alkeran® 
 
PHARMACOLOGIC CATEGORY 
Antineoplastic Agent, Alkylating Agent 
 
DOSING: ADULTS  
Refer to individual protocols; dose should always be adjusted to patient response and weekly blood 
counts. High dose BMT: I.V.: 140-240 mg/m2 as a single dose or divided into 2-5 daily doses. 
Infuse over 20-60 minutes. 
 
ADMINISTRATION 
Parenteral: Due to limited stability, complete administration of I.V. dose should occur within 60 
minutes of reconstitution. I.V. infusion: I.V. dose is FDA-approved for administration as a single 
infusion over 15-20 minutes. I.V. bolus: I.V. may be administered via central line and via peripheral 
vein as a rapid I.V. bolus; there have not been any unexpected or serious adverse events specifically 

 
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related to rapid I.V. bolus administration; the most common adverse events were transient mild 
symptoms of hot flush and tingling sensation over the body.  Central line: I.V. bolus doses of 17-
200 mg/m2 (reconstituted and not diluted) have been infused over 2-20 minutes. Peripheral line: 
I.V. bolus doses of 2-23 mg/m2 (reconstituted and not diluted) have been infused over 1-4 minutes 
 
ADVERSE REACTIONS SIGNIFICANT 
>10%:  
Hematologic: Myelosuppressive: Leukopenia and thrombocytopenia are the most common effects 
of melphalan. Irreversible bone marrow failure has been reported. WBC: Moderate Platelets: 
Moderate.  Onset (days): 7.  Nadir (days): 8-10 and 27-32. Recovery (days): 42-50. 
 
1% to 10%: 
Cardiovascular: Vasculitis. Dermatologic: Vesiculation of skin, alopecia, pruritus, rash. 
Endocrine & metabolic: SIADH, sterility and amenorrhea. Gastrointestinal: Nausea and 
vomiting are mild; stomatitis and diarrhea are infrequent. Emetic potential: Low (<10%): <100 
mg/m2; high (>90%): >100 mg/m2. Genitourinary: Bladder irritation, hemorrhagic cystitis. 
Hematologic: Anemia, agranulocytosis, hemolytic anemia. Hepatic: Transaminases increased 
(hepatitis, jaundice have been reported). Respiratory: Pulmonary fibrosis, interstitial pneumonitis. 
Miscellaneous: Hypersensitivity, secondary malignancies 
BMT: Dermatologic: Alopecia. Gastrointestinal: Mucositis (severity increases with Clcr 40 
mL/minute), nausea and vomiting (moderate), diarrhea. Hematologic: Myelosuppression, 
secondary leukemia. Renal: Increased serum creatinine and azotemia possible without adequate 
hydration. Rare side effects: Abnormal LFTs, interstitial pneumonitis, secondary leukemia, SIADH, 
vasculitis 
DRUG INTERACTIONS 
Cyclosporine: Risk of nephrotoxicity is increased by melphalan. Nalidixic acid: Concomitant use of 
I.V. melphalan with nalidixic acid may increase risk of necrotic enterocolitis (reported with 
pediatric patients). 
MECHANISM OF ACTION  
Alkylating agent which is a derivative of mechlorethamine that inhibits DNA and RNA synthesis 
via formation of carbonium ions; cross-links strands of DNA 
 
PHARMACODYNAMICS / KINETICS 
 
Distribution: Vd: 0.5-0.6 L/kg throughout total body water 
Bioavailability: Unpredictable, decreasing from 85% to 58% with repeated doses 
Half-life elimination: Terminal: 1.5 hours 
Time to peak, serum: ~2 hours 
Melphalan is commercially available.   Additional information may be obtained from the 
FDA-approved package insert.   

 
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Additional risks of BMT may include some or all of the following side effects (this information 
is taken from the standard of care consent form used for Bone Marrow Transplants at UPENN):  
 
Chemotherapy:  
 
HAIR: partial or total hair loss, which is usually temporary  
SKIN: darkening and/or peeling of the skin, nail changes, rashes, flushing  
EARS: decreased hearing, loss of balance  
EYES: watery eyes, discomfort, blindness  
MOUTH: ulcers, unusual taste, sore throat, mouth pain, difficulty swallowing  
LUNGS: lung damage, difficulty breathing  
HEART: changes in heart beat, heart failure or damage, changes in blood  
pressure  
GI: ulcers, nausea, vomiting, constipation or diarrhea, weight loss, liver  
damage, abdominal pain  
URINARY SYSTEM: burning with urination, bloody urine, kidney damage  
ENDOCRINE: elevation of blood sugar, impairment or loss of reproductive function  
NERVOUS SYSTEM: tingling in the fingers/toes/arms/legs, jaw pain, muscle weakness,  
irritability, depression, confusion, seizures, dizziness, loss of  
coordination  
BONE MARROW: destroys bone marrow which may increase weakness, infections and  
Bleeding  
VEINS: hardening of the veins in and around the area of intravenous  
medication injection; ulcer formation, tissue damage or discomfort in 6 and around the area of 
intravenous medication injection  
 
 

 
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Stem Cell Infusion:  
 
• During infusion: o Shortness of breath, chest tightness, abdominal tightness, slowing of heart rate  
 
• Following infusion: o Red urine following infusion due to damage to red bloods cells during the 
thawing process  
o Breath odor for up to 24 hours following infusion due to DMSO used to protect stem cells while 
frozen  
o Engraftment failure (harvested stem cells may fail to grow normally to restore blood cell production 
or may be very delayed in re-growth, leading to complications, primarily infection and/or bleeding, 
which could be fatal)  
 
G-CSF:  
 
• Side effects are usually mild and short-lived and may include bone or joint pain, low-grade fever, 
and mild nausea.  
 
9.4 
G-CSF:  Drug Information 
 
U.S. BRAND NAMES — Neupogen® 
PHARMACOLOGIC CATEGORY 
Colony Stimulating Factor 
 
ADMINISTRATION 
May be administered undiluted by SubQ or by I.V. infusion over 15-60 minutes in D5W; 
incompatible with sodium chloride solutions. 
ADVERSE REACTIONS SIGNIFICANT  
Effects are generally mild and dose related 
>10%: 
Central nervous system: Neutropenic fever, fever. Dermatologic: Alopecia. Gastrointestinal: 
Nausea, vomiting, diarrhea, mucositis, splenomegaly (more common in patients who prolonged 
(>14 days) treatment, usually subclinical). Neuromuscular & skeletal: Medullary bone pain (24%) 
1% to 10%: 
Cardiovascular: Chest pain, fluid retention. Central nervous system: Headache. Dermatologic: 
Skin rash. Gastrointestinal: Anorexia, stomatitis, constipation. Hematologic: Leukocytosis. Local: 
Pain at injection site. Neuromuscular & skeletal: Weakness. Respiratory: Dyspnea, cough, sore 
throat 
<1% (Limited to important or life-threatening):  
Pericarditis, thrombophlebitis, transient supraventricular arrhythmia 
DRUG INTERACTIONS  

 
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 Drugs which may potentiate the release of neutrophils (eg, lithium) should be used with caution 
MONITORING PARAMETERS  
CBC and platelet count should be obtained twice weekly. Leukocytosis (white blood cell counts 
100,000/mm3) has been observed in ~2% of patients receiving G-CSF at doses >5 mcg/kg/day. 
Monitor platelets and hematocrit regularly. 
MECHANISM OF ACTION  
Stimulates the production, maturation, and activation of neutrophils, G-CSF activates neutrophils to 
increase both their migration and cytotoxicity. 
PHARMACODYNAMICS / KINETICS 
 
Onset of action: ~24 hours; plateaus in 3-5 days 
Duration: ANC decreases by 50% within 2 days after discontinuing G-CSF; white counts return to 
the normal range in 4-7 days; peak plasma levels can be maintained for up to 12 hours 
Absorption: SubQ: 100% 
Distribution: Vd: 150 mL/kg; no evidence of drug accumulation over a 11- to 20-day period 
Metabolism: Systemically degraded 
Half-life elimination: 1.8-3.5 hours 
Time to peak, serum: SubQ: 2-6 hours 
 
G-CSF is commercially available.   Additional information may be obtained from the FDA-
approved package insert.   
9.5 
Plerixafor:  Drug Information 
 
U.S. BRAND NAMES — Mozobil® 
 
PHARMACOLOGIC CATEGORY 
Hematopoietic Stem Cell Mobilizer 
 
ADMINISTRATION 
Dosing is based on actual body weight.  Begin plerixafor after patient has received filgrastim 10 
mcg/kg once daily for 4 days.  Filgrastim (G-CSF), Perixafor and apheresis should be continued 
daily until a sufficient cell collection. Administered undiluted by SubQ at dose of 0.24 mg/kg once 
daily ~ 11 hours prior to apheresis for up to 4 consecutive days; maximum dose = 40 mg/day.   
 
ADVERSE REACTIONS SIGNIFICANT  
Effects are generally mild and dose related. 
>10%: 
Central nervous system: Fatigue (27%), headache (22%), dizziness (11%). Gastrointestinal: 
Nausea (34%), diarrhea (37%). Local:  Injection site reactions (34% including erythemia, 
hematoma, hemorrhage, induration, inflammation, irritation, pain, paresthesias, pruritis, rash, 
swelling urticaria. Neuromuscular & skeletal: arthralgias (13%) 
 

 
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5% to 10%: 
Central nervous system: insomnia (7%). Gastrointestinal: vomiting (10%), flatulence (7%) 
 
<5% (Limited to important or life-threatening):  
Abdominal discomfort, abdominal distension, abdominal pain, constipation, diaphoresis, dyspepsia, 
dyspnea, erythema, hypesthesia, hypoxia, increased leukocytes, malaise, musculoskeletal pain, 
orthostatic hypotension, periorbital swelling, syncope, thrombocytopenia, urticaria, vasovagal 
reaction , xerostomia 
 
DRUG INTERACTIONS — None known 
 
MONITORING PARAMETERS — CBC with differential and platelets 
 
MECHANISM OF ACTION 
Reversibly inhibits binding of stromal cell-derived factor-1-alpha (SDF-1α), expressed on bone 
marrow stromal cells, to the CXC chemokine receptor 4 (CXCR4), resulting in mobilizationof 
hematopoietic stem and progenitor cells from the bone marrow into peripheral blood.  Plerixafor used 
in combination with Filgrastim results in syngergistic increase in CD34+ cell mobilization.  Mobilized 
CD34+ cells are capable of engrafting with extended repopulating capacity.   
 
PHARMACODYNAMICS / KINETICS 
Onset of action:monotherapy: 6-9 hours after administration; with G-CSF: 10-14 hours. Duration: 
white counts return to baseline at ~ 24 hours after administration. Absorption: SubQ: Rapid. 
Distribution: Vd: 0.3 L/kg, primarily to extravascular fluid space. Metabolism: not metabolized 
Half-life elimination: Terminal:  3-6 hours. Time to peak, serum: SubQ: 30-60 minutes. Excretion:  
Urine (~70% as parent drug).   
 
Mozobil® is commercially available.   Additional information may be obtained from the FDA-
approved package insert.   
 
9.6 
Bortezomib:  Drug Information 
 
MEDICATION SAFETY ISSUES 
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication 
among its list of drug classes which have a heightened risk of causing significant patient harm when 
used in error.  
 
U.S. BRAND NAMES — Velcade® 
 
PHARMACOLOGIC CATEGORY 
Antineoplastic Agent. Proteasome Inhibitor.  
 
DOSING: ADULTS  

 
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Details concerning dosing in combination regimens should also be consulted. Multiple myeloma 
(first-line therapy; in combination with melphalan and prednisone): I.V.: 1.3 mg/m2 days 1, 4, 8, 11, 
22, 25, 29, and 32 of a 42-day treatment cycle for 4 cycles, followed by 1.3 mg/m2 days 1, 8, 22 and 
29 of a 42-day treatment cycle for 5 cycles.  Relapsed multiple myeloma and mantle cell 
lymphoma: I.V.: 1.3 mg/m2 twice weekly for 2 weeks on days 1, 4, 8, and 11 of a 21-day treatment 
cycle. Consecutive doses should be separated by at least 72 hours. Therapy extending beyond 8 
cycles may be given once weekly for 4 weeks (days 1, 8, 15, and 22), followed by a 13-day rest 
(days 23 through 35). Non-Hodgkin's lymphoma, other than mantle cell (unlabeled use): I.V.: 1.3-
1.5 mg/m2 twice weekly for 2 weeks on days 1, 4, 8, and 11 of a 21-day treatment cycle. DOSING: 
ELDERLY — Refer to adult dosing. DOSING: RENAL IMPAIRMENT — No dosage adjustment 
necessary. Note: Dialysis may reduce bortezomib concentrations; administer postdialysis. DOSING: 
HEPATIC IMPAIRMENT — Specific guidelines are not available; clearance may be decreased; 
monitor closely for toxicity. DOSING: ADJUSTMENT FOR TOXICITY Myeloma (first-line 
therapy): Platelets should be ≥70,000/mm3, ANC should be ≥1000/mm3, and nonhematologic 
toxicities should resolve to grade 1 or baseline prior to therapy initiation.  Platelets ≤30,000/mm3 or 
ANC <750/mm3 on bortezomib day(s): Withhold bortezomib; if several consecutive bortezomib 
doses are withheld, reduce dose 1 level (1.3 mg/m2/dose reduced to 1 mg/m2/dose; 1 mg/m2/dose 
reduced to 0.7 mg/m2/dose). Grade ≥3 nonhematological toxicity (other than neuropathy): Withhold 
bortezomib until toxicity resolves to grade 1 or baseline. May reinitiate bortezomib at 1 dose level 
reduction (1.3 mg/m2/dose reduced to 1 mg/m2/dose; 1 mg/m2/dose reduced to 0.7 mg/m2/dose). 
Neuropathic pain and/or peripheral sensory neuropathy: See "Neuropathic pain and/or peripheral 
sensory neuropathy" toxicity adjustment guidelines below.  Relapsed multiple myeloma and mantle 
cell lymphoma:  Grade 3 nonhematological (excluding neuropathy) or Grade 4 hematological 
toxicity: Withhold until toxicity resolved; may reinitiate with a 25% dose reduction (1.3 
mg/m2/dose reduced to 1 mg/m2/dose; 1 mg/m2/dose reduced to 0.7 mg/m2/dose). Neuropathic pain 
and/or peripheral sensory neuropathy: Grade 1 without pain or loss of function: No action needed 
Grade 1 with pain or Grade 2 interfering with function but not activities of daily living: Reduce 
dose to 1 mg/m2. Grade 2 with pain or Grade 3 interfering with activities of daily living: Withhold 
until toxicity resolved, may reinitiate at 0.7 mg/m2 once weekly. Grade 4: Discontinue therapy. 
 
DOSAGE FORMS  
Excipient information presented when available (limited, particularly for generics); consult specific 
product labeling. Injection, powder for reconstitution [preservative free]:  Velcade®: 3.5 mg 
[contains mannitol 35 mg] 
 
DOSAGE FORMS: CONCISE 
Injection, powder for reconstitution [preservative free]: Velcade®: 3.5 mg  
 
GENERIC EQUIVALENT AVAILABLE — No 
 
ADMINISTRATION — Administer via rapid I.V. push (3-5 seconds) 
 
USE — Treatment of multiple myeloma; treatment of relapsed or refractory mantle cell lymphoma 
USE - UNLABELED / INVESTIGATIONAL — Treatment of non-Hodgkin's lymphomas (other 
than mantle cell lymphoma) 

 
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ADVERSE REACTIONS SIGNIFICANT 
>10%:  
Cardiovascular: Edema (11% to 28%), hypotension (12% to 15%; grades 3/4: 3%). Central 
nervous system: Fever (19% to 37%), psychiatric disturbance (35%), headache (17% to 26%), 
dysesthesia (9% to 27%), insomnia (18% to 21%), dizziness (14% to 23%; excludes vertigo), 
anxiety (5% to 11%). Dermatologic: Rash (17% to 28%), pruritus (11%). Endocrine & metabolic: 
Dehydration (7% to 11%). Gastrointestinal: Diarrhea (47% to 57%), nausea (44% to 57%), 
constipation (40% to 50%), anorexia (34% to 39%), vomiting (27% to 35%), abdominal pain (14% 
to 16%), abnormal taste (13%), dyspepsia (13%). Hematologic: Thrombocytopenia (21% to 38%; 
grade 4: 4% to 5%; nadir: day 11; recovery: by day 21), anemia (17% to 30%; grade 4: <1%), 
neutropenia (6% to 19%; grade 4: 2% to 3%; nadir: day 11; recovery: by day 21). Neuromuscular 
& skeletal: Weakness (61% to 72%; grades 3/4: 12% to 19%), peripheral neuropathy (36% to 55%; 
grade 3: 7% to 11%; grade 4: <1%), paresthesia (9% to 27%), arthralgia (13% to 18%), limb pain 
(5% to 17%), bone pain (2% to 16%), back pain (<1 % to 15%), myalgia (10% to 12%), muscle 
cramps (5% to 12%), rigors (11%). Ocular: Blurred vision (11%). Respiratory: Dyspnea (20% to 
23%), cough (19% to 21%), lower respiratory infection (15%), upper respiratory tract infection 
(11% to 15%), nasopharyngitis (8% to 14%), pneumonia (9% to 12%). Miscellaneous: Herpesvirus 
infections (7% to 13%). 
 
1% to 10%:  
Cardiovascular: Syncope (2%). Endocrine & metabolic: Hypercalcemia (grade 4: 2%). 
Frequency not defined (limited to important or life-threatening): Acute diffuse infiltrative 
pulmonary disease, acute respiratory distress syndrome, alkaline phosphatase increased, allergic 
reaction, amyloidosis, anaphylaxis, angina, angioedema, ascites, aspergillosis, atelectasis, atrial 
fibrillation, atrial flutter, AV block, bacteremia, bradycardia, cardiac amyloidosis, cardiac arrest, 
cardiac tamponade, cardiogenic shock, cardiopulmonary arrest, cerebral hemorrhage, 
cerebrovascular accident, CHF, cholestasis, coma, complete heart block, confusion, cranial palsy, 
deafness, deep venous thrombosis, diplopia, disseminated intravascular coagulation (DIC), 
duodenitis (hemorrhagic), dysautonomia, dysphagia, edema (facial), encephalopathy, embolism, 
epistaxis, fecal impaction, fracture, gastritis (hemorrhagic), gastroenteritis, GGT increased, 
glomerular nephritis, hematemesis, hematuria, hemoptysis, hemorrhagic cystitis, hepatic failure, 
hepatic hemorrhage, hepatitis, hepatocellular damage, herpes meningoencephalitis, 
hyperbilirubinemia, hyper-/hypoglycemia, hyper-/hypokalemia, hyper-/hyponatremia, 
hypersensitivity, hyperuricemia, hypocalcemia, hypoxia, immune complex hypersensitivity, 
injection site reaction, intestinal obstruction, intestinal perforation, intracerebral hemorrhage, 
ischemic colitis, ischemic stroke, laryngeal edema, leukocytoclastic vasculitis, leukopenia, 
listeriosis, lymphopenia, melena, mental status change, MI, myocardial ischemia, neuralgia, 
neutropenic fever, ophthalmic herpes, oral candidiasis, pancreatitis, paralytic ileus, paraplegia, 
pericardial effusion, pericarditis, peritonitis, pleural effusion, pneumonia, pneumonitis, portal vein 
thrombosis, proliferative glomerular nephritis, psychosis, pulmonary alveolar hemorrhage, 
pulmonary edema, pulmonary embolism, pulmonary hypertension, psychosis, QTc prolongation, 
renal calculus, renal failure, respiratory failure, respiratory insufficiency, reversible posterior 
leukoencephalopathy syndrome (RPLS), seizure, septic shock, sepsis, sinus arrest, spinal cord 
compression, stomatitis, stroke (hemorrhagic), stroke, subarachnoid hemorrhage, subdural 

 
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hematoma, suicidal ideation, tachycardia, torsade de pointes, toxic epidermal necrolysis, 
toxoplasmosis, transaminases increased, transient ischemic attack, tumor lysis syndrome, urinary 
incontinence, urinary retention, urinary tract infection, urticaria, ventricular tachycardia.  
 
CONTRAINDICATIONS 
Hypersensitivity to bortezomib, boron, mannitol, or any component of the formulation 
 
WARNINGS / PRECAUTIONS 
Special handling: Hazardous agent: Use appropriate precautions for handling and disposal.  
Concerns related to adverse effects: Bone marrow suppression: Hematologic toxicity, including 
neutropenia and severe thrombocytopenia may occur; risk is increased in patients with pretreatment 
platelet counts <75,000/µL; frequent monitoring is required throughout treatment; may require 
dosage adjustments; withhold treatment for platelets <25,000/µL. Hemorrhage (gastrointestinal and 
intracerebral) due to low platelet count has been observed.  
  
Cardiovascular effects: May cause hypotension (including postural and orthostatic); use caution 
with dehydration, history of syncope, or medications associated with hypotension. Has been 
associated with the development or exacerbation of congestive heart failure and decreased left 
ventricular ejection fraction; use caution in patients with risk factors or existing heart disease. Has 
also been associated with QTc prolongation.  
  
Hepatotoxicity: Acute liver failure has been reported (rarely) in patients receiving multiple 
concomitant medications; hepatitis, transaminase increases, and hyperbilirubinemia have also been 
reported. Use caution in patients with hepatic dysfunction; toxicities may be increased.  
  
Herpes reactivation: Herpes (zoster and simplex) reactivation has been reported with bortezomib; 
consider antiviral prophylaxis during therapy.  
  
Peripheral neuropathy: May cause peripheral neuropathy (usually sensory but may be mixed 
sensorimotor); risk may be increased with previous use of neurotoxic agents or pre-existing 
peripheral neuropathy; adjustment of dose and schedule may be required.  
  
Pulmonary toxicity: Pulmonary disorders including pneumonitis, interstitial pneumonia, lung 
infiltrates, and acute respiratory distress syndrome (ARDS) have been reported. Pulmonary 
hypertension (without left heart failure or significant pulmonary disease) has been reported rarely.  
  
Reversible posterior leukoencephalopathy syndrome (RPLS): Has been reported (rarely). Symptoms 
of RPLS include confusion, headache, hypertension, lethargy, seizure, blindness and/or other vision, 
or neurologic disturbances; discontinue if RPLS occurs. The safety of reinitiating bortezomib in 
patients previously experiencing RPLS is unknown.  
  
Tumor lysis syndrome: May cause tumor lysis syndrome; risk is increased in patients with high 
tumor burden prior to treatment  
 

 
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Disease-related concerns: Diabetes: Hyper-and hypoglycemia may occur in diabetic patients 
receiving oral hypoglycemics; monitor; may require adjustment of diabetes medications.  
Hepatic impairment: Use with caution in patients with hepatic impairment; clearance may be 
reduced; monitor for toxicity.  
 
Special populations: 
Pediatrics: Safety and efficacy have not been established in children.  
 
METABOLISM / TRANSPORT EFFECTS 
Substrate of CYP1A2 (minor), 2C9 (minor), 2C19 (major), 2D6 (minor), 3A4 (major); Inhibits 
CYP1A2 (weak), 2C9 (weak), 2C19 (moderate), 2D6 (weak), 3A4 (weak) 
 
DRUG INTERACTIONS 
(For additional information: Launch Lexi-Interact™ Drug Interactions Program 
) 
 
CYP2C19 Inducers (Strong): May increase the metabolism of CYP2C19 Substrates. Risk C: 
Monitor therapy  
 
CYP2C19 Inhibitors (Moderate): May decrease the metabolism of CYP2C19 Substrates. Risk C: 
Monitor therapy 
 
CYP2C19 Inhibitors (Strong): May decrease the metabolism of CYP2C19 Substrates. Risk D: 
Consider therapy modification 
 
CYP2C19 Substrates: CYP2C19 Inhibitors (Moderate) may decrease the metabolism of CYP2C19 
Substrates. Risk C: Monitor therapy 
CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates. Risk C: Monitor 
therapy 
 
CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Risk C: 
Monitor therapy 
 
CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates. Risk D: 
Consider therapy modification 
 
Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Risk C: Monitor therapy 
 
Deferasirox: May decrease the serum concentration of CYP3A4 Substrates. Risk C: Monitor 
therapy 
 
Herbs (CYP3A4 Inducers): May increase the metabolism of CYP3A4 Substrates. Risk C: Monitor 
therapy 
 
ETHANOL / NUTRITION / HERB INTERACTIONS 
Herb/Nutraceutical: Avoid St John's wort (may decrease bortezomib levels).  

 
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PREGNANCY RISK FACTOR — D (show table) 
 
PREGNANCY IMPLICATIONS 
Adverse effects (fetal loss and decreased fetal weight) were observed in animal studies. There are 
no adequate and well-controlled studies in pregnant women. Effective contraception is 
recommended for women of childbearing potential. 
LACTATION 
Excretion in breast milk unknown/not recommended 
BREAST-FEEDING CONSIDERATIONS 
Due to the potential for serious adverse reactions in the nursing infant, breast-feeding is not 
recommended. 
 
MONITORING PARAMETERS  
Signs/symptoms of peripheral neuropathy, dehydration, or hypotension; CBC with differential and 
platelets (monitor frequently throughout therapy); renal function, pulmonary function (with new or 
worsening pulmonary symptoms), liver function tests (in patients with existing hepatic impairment) 
 
CANADIAN BRAND NAMES — Velcade® 
 
INTERNATIONAL BRAND NAMES — Velcade (AR, AT, AU, BE, BG, CH, CL, CN, CO, CR, 
CZ, DE, DK, DO, EC, EE, ES, FI, FR, GB, GR, GT, HK, HN, ID, IE, IL, IT, MX, MY, NL, NO, 
PA, PH, PT, PY, RU, SE, TH, TR, TW, VE) 
 
MECHANISM OF ACTION 
Bortezomib inhibits proteasomes, enzyme complexes which regulate protein homeostasis within the 
cell. Specifically, it reversibly inhibits chymotrypsin-like activity at the 26S proteasome, leading to 
activation of signaling cascades, cell-cycle arrest, and apoptosis. 
 
PHARMACODYNAMICS / KINETICS 
Distribution: 498-1884 L/m2 
Protein binding: ~83%  
Metabolism: Hepatic primarily via CYP2C19 and 3A4 and to a lesser extent CYP1A2; forms 
metabolites (inactive) via deboronization followed by hydroxylation 
Half-life elimination: Single dose: 9-15 hours; multiple dosing: 1 mg/m2: 40-193 hours; 1.3 mg/m2: 
76-108 hours 
 
9.7 
Prevnar-13 (Pneumococcal Conjugate Vaccine):  Drug Information 
 
U.S. BRAND NAMES — Prevnar-13® 
 
PHARMACOLOGIC CATEGORY 
Vaccine 
 
DOSING: ADULTS  

 
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Dosing established for infants and toddlers 
 
DOSAGE FORMS —Injection, suspension: Prevnar 13™: 2 mcg of each capsular saccharide for 
serotypes 1, 3, 4, 5, 6A, 7F, 9V, 14, 18C, 19A, 19F, and 23F, and 4 mcg of serotype 6B [bound to 
diphtheria CRM197 protein ~34 mcg] per 0.5 mL (0.5 mL) [contains aluminum, polysorbate 80, soy, 
and yeast]  
 
ADMINISTRATION 
Do not inject I.V.; avoid intradermal route; administer I.M. (deltoid muscle or lateral mid-thigh) 
For patients at risk of hemorrhage following intramuscular injection, the ACIP recommends "it should 
be administered intramuscularly if, in the opinion of the physician familiar with the patients bleeding 
risk, the vaccine can be administered with reasonable safety by this route. If the patient receives 
antihemophilia or other similar therapy, intramuscular vaccination can be scheduled shortly after such 
therapy is administered. A fine needle (23 gauge or smaller) can be used for the vaccination and firm 
pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed 
concerning the risk of hematoma from the injection." 
 
ADVERSE REACTIONS SIGNIFICANT  
All serious adverse reactions must be reported to the U.S. Department of Health and Human Services 
(DHHS) Vaccine Adverse Event Reporting System (VAERS) 1-800-822-7967. 
 
>10%: 
Central nervous system: Drowsiness, fever, insomnia, irritability. Gastrointestinal: Appetite 
decreased. Local: Erythema, swelling, tenderness 
1% to 10%: 
Dermatologic: Rash. Gastrointestinal: Diarrhea, vomiting  
<1% (Limited to important or life-threatening):  
Abnormal crying, breath holding, febrile seizures, hypersensitivity reaction (bronchospasm 
dyspnea, facial edema), seizure, urticaria, urticaria-like rash. Adverse reactions observed with 
PCV7 which may also be seen with PCV-13: Anaphylactic reaction, angioneurotic edema, apnea, 
breath holding, edema, erythema multiforme, hypotonic hyporesponsive episode, injection site 
reaction (dermatitis, pruritus), lymphadenopathy, shock 
 
WARNINGS / PRECAUTIONS  
Caution in latex sensitivity. Children with impaired immune responsiveness may have a reduced 
response to active immunization. Safety and efficacy have not been established in children <6 weeks 
of age. Not for I.V. use. 
 
DRUG INTERACTIONS 
Immunosuppressants: May decrease response to active immunizations 
 
MECHANISM OF ACTION  
Promotes active immunization against invasive disease caused by S. pneumoniae capsular serotypes 
1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F, all which are individually conjugated to 

 
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CRM197 protein. Prevnar-13 is commercially available.  Additional information may be obtained 
from the FDA-approved package insert. 
 
10 Data Handling and Record Keeping 
 
10.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
Those regulations require a signed subject authorization informing the subject of the 
following: 
• What protected health information (PHI) will be collected from subjects in this study  
• Who will have access to that information and why  
• Who will use or disclose that information  
• The rights of a research subject to revoke their authorization for use of their PHI.  
Celgene, study supporter, affirms the subject’s right to protection against invasion of privacy.  
In compliance with United States federal regulations, Celgene requires the Investigator to 
permit representatives of Celgene Corporation and, when necessary, representatives of the 
FDA or other regulatory authorities to review and/or copy any medical records relevant to the 
study in accordance with local laws. 
Should direct access to medical records require a waiver or authorization separate from the 
subject’s statement of informed consent, it is the responsibility of the Investigator to obtain 
such permission in writing from the appropriate individual. 
In the event that a subject revokes authorization to collect or use PHI, the investigator and 
Sponsor by regulation, retains the ability to use all information collected prior to the 
revocation of subject authorization. For subjects that have revoked authorization to collect or 
use PHI, attempts should be made to obtain permission to collect at least vital status (i.e. that 
the subject is alive) at the end of their scheduled study period.  
10.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial. Source 
data are contained in source documents Examples of these original documents, and data 
records include: hospital records, clinical and office charts, laboratory notes, memoranda, 
subjects’ diaries or evaluation checklists, pharmacy dispensing records, recorded data from 
automated instruments, copies or transcriptions certified after verification as being accurate 
and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, 
subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial. 

 
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10.3 Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study. All 
data requested on the CRF/eCRF must be recorded. All missing data must be explained. If a 
space on the CRF/eCRF is left blank because the procedure was not done or the question was 
not asked, write "N/D". If the item is not applicable to the individual case, write "N/A". If any 
entry error has been made, to correct such an error, draw a single straight line through the 
incorrect entry and enter the correct data above it. All such changes must be initialed and 
dated. DO NOT ERASE OR WHITE OUT ERRORS. For clarification of illegible or 
uncertain entries, print the clarification above the item, then initial and date it. 
10.4 Records Retention 
Since this is an FDA-regulated study, it is the investigator’s responsibility to retain study 
essential documents for at least 2 years after the last approval of a marketing application in 
their country and until there are no pending or contemplated marketing applications in their 
country or at least 2 years have elapsed since the formal discontinuation of clinical 
development of the investigational product. These documents should be retained for a longer 
period if required by an agreement with the sponsor. In such an instance, it is the 
responsibility of the sponsor to inform the investigator/institution as to when these documents 
no longer need to be retained.  
 
 
 

 
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11 REFERENCES 
 
 
 
Alyea E, Weller E, Schlossman R et al. T-cell--depleted allogeneic bone marrow 
transplantation followed by donor lymphocyte infusion in patients with multiple 
myeloma: induction of graft-versus-myeloma effect. Blood. 2001; 98(4):934-939. 
 
Anderson KC, Soiffer R, DeLage R et al. T-cell-depleted autologous bone marrow 
transplantation therapy: analysis of immune deficiency and late complications. Blood. 
1990; 76(1):235-244. 
 
Andersen MH, Pedersen LO, Becker JC, Straten PT.  Identification of a cytotoxic T lymphocyte 
response to the apoptosis inhibitor protein survivin in cancer patients.  Cancer Res  2001; 61: 869-72. 
 
Andrade VCC, Vettore AL, Felix RS, Almeida MSS, de Carvalho F, et al. Prognostic impact of 
cancer/testis antigen expression in advanced stage multiple myeloma patients Cancer Immunity 2008; 
8: 2. 
 
Atanackovic D, Arfsten J, Cao Y, Gnjatic S, Schnieders F, Bartels K, Schilling G, Faltz C, Wolschke 
C, Dierlamm J, Ritter G, Eiermann T, Hossfeld DK, Zander AR, Jungbluth AA, Old LJ, Bokemeyer 
C, Kröger N. Cancer-testis antigens are commonly expressed in multiple myeloma and induce 
systemic immunity following allogeneic stem cell transplantation. Blood 2007; 109(3): 1103-12. 
 
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length in multiple myeloma: correlations with disease heterogeneity, cytogenetics status, and overall 
survival. Blood. June 15 2003;101(12):4982-9. 
 
Xu D, Zheng C, Bergebbrant S, Holm G, Bjorkholm M, Yi Q, Gruber A.  Telomerase activity in 
plasma cell dyscrasias. Br J Cancer. Mar 2 1001;84(5):621-5. 
 
Zhao Y, Alan D. Bennett, Zhili Zheng, Qiong J. Wang, Paul F. Robbins, Lawrence Y. L. Yu, Yi Li, 
Peter E. Molloy, Steven M. Dunn, Bent K. Jakobsen, Steven A. Rosenberg, and Richard A. Morgan. 
High-Affinity TCRs Generated by Phage Display Provide CD4+ T Cells with the Ability to Recognize 
and Kill Tumor Cell Lines. J. Immunol2007; 179: 5845 - 5854. 
 
Zhu X, Nishimura F, Sasaki K, Fujita M, Dusak JE, Eguchi J, Fellows-Mayle W, Storkus WJ, Walker 
PR, Salazar AM, Okada H. Toll like receptor-3 ligand poly-ICLC promotes the efficacy of peripheral 

 
Protocol  01411 
Version 12.0 
 
 
Page 108 of 118 
 
vaccinations with tumor antigen-derived peptide epitopes in murine CNS tumor models.  J Transl 
Med 2007; 5: 10.   
 
 

 
Protocol  01411 
Version 12.0 
 
 
Page 109 of 118 
 
 
 
12 Appendix A: Criteria for Diagnosis of Plasma Cell Myeloma* 
 
 
Major criteria 
  Plasmacytomas on tissue biopsy 
  Marrow plasmacytosis with > 30% plasma cells 
  Monoclonal globulin spike on serum electrophoresis > 3.5 g/dl for IgG or > 2.0 g/dl for  
  IgA; ≥ 1.0 g/24 h of κ or λ light-chain excretion on urine electrophoresis in the absence 
  of amyloidosis 
 
Minor criteria 
  Marrow plasmacytosis 10-30% 
  Monoclonal globulin spike present, but less than the levels defined above 
  Lytic bone lesions 
  Normal IgM < 0.05 g/dl, IgA < 0.1 g/dl, or IgG < 0.6 g/dl 
 
*The diagnosis of plasma cell myeloma is confirmed when at least one major and one minor criteria 
or at least three minor criteria are documented in symptomatic patients with progressive disease.  
The presence of features not specific for the disease may support the diagnosis, particularly if of 
recent onset:  anemia, hypercalcemia, azotemia, bone demineralization, or hypoalbulinemia.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol  01411 
Version 12.0 
 
 
Page 110 of 118 
 
13 APPENDIX B: Study Schema 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol  01411 
Version 12.0 
 
 
Page 111 of 118 
 
Study Schema for patients receiving a second infusion.  For patients enrolled at University of 
Maryland only.  Patients enrolled at Universtiy of Pennsylvania are not receiving a sencond infusion:  
 
 
 
 

 
Protocol  ADP-01411 - Version 12.0 
Page 112 of 118 
14 APPENDIX C:  SCHEDULE OF EVALUATIONS* 
Note: for patients receiving a second infusion (Protocol Section 5. 9), cytoxan administration will be day 0, and T cells will be 
given on day +2 and all other follow-up will continue on as shown.  Long term follow-up for observation of AEs potentially related 
to gene therapy will be calculated from the second infusion date. 
 
Intervention Protocol 
  
Enrollment 
D -50 
(+/-10) 
PVC 
immunizati
on 
T cell 
harvest     
D -30 (+/-
10) 
SC 
mobilizatio
n  D -26 
SC 
collectio
n           
D -16 
(+/-3) 
High dose 
melphalan  
D -2 
D 0 
D+2 
D+3 
D+5 
+/- 1 
D+7 
+/- 
1 
D+14 
(+/-1) 
D+21 
(+/-3) 
D+28 
(+/-3) 
D+42 
(+/-3) 
D +90 
(+/-3) 
D+100 
(+/-3) 
D+130 
(+/-3) 
D+180 
(+/-3) 
ADay 
+270 
and 
year 1   
(+/-7) 
Day -40  
(+/-10) 
Procedures 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Chemotherapy 
  
  
  
X 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
SC Infusion 
  
  
  
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Apheresis** 
  
  
X 
 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
T cell infusion 
  
  
  
  
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
Lenalidomide 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
XB 
  
  
  
PCV Immunization 
  
X 
  
  
  
  
  
  
  
  
 
 X 
  
  
X 
X 
  
  
  
  
Clinical Assessments 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Adverse Events  
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Consent 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Medical Hx, PE, PS 
X 
  
  
X 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
  
X 
  
X 
X 
CBC, differential 
X 
  
  
X 
  
X 
 X 
 X 
X 
X 
X 
X 
X 
X 
X 
  
X 
X 
X 
X 
Comprehensivemeta
bolicL 
X 
  
  
X 
  
X 
 X 
 X 
X 
X 
X 
X 
X 
X 
X 
  
X 
X 
X 
X 
Troponin 
 
 
 
 
 
 
 
XM 
X 
X 
X 
 
 
 
 
 
 
 
 
 
EKG 
 
 
 
 
 
 
 
XM 
X 
X 
X 
 
 
 
 
 
 
 
 
 
CD3, CD4, CD8 
X 
 
 
 
 
 
 
 
 
 
 
X 
 
 
X 
 
X 
 
X 
 
HLA-A2/A1 test 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Tumor 
antigen 
testingK 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Pregnancy testD,E 
X 
  
  
  
  
X 
  
  
  
  
  
  
  
  
X 
  
X 
X 
X 
X 
HIV, HTLV 1/2, Hep B, 
Hep C, CMV 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Register patient into 
RevAssist® program 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
XF 
  
  
  
  
  
PFT 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
MUGA/Echo 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

 
Protocol  ADP-01411 - Version 12.0 
Page 113 of 118 
Intervention Protocol 
  
Enrollment 
D -50 
(+/-10) 
PVC 
immunizati
on 
T cell 
harvest     
D -30 (+/-
10) 
SC 
mobilizatio
n  D -26 
SC 
collectio
n           
D -16 
(+/-3) 
High dose 
melphalan  
D -2 
D 0 
D+2 
D+3 
D+5 
+/- 1 
D+7 
+/- 
1 
D+14 
(+/-1) 
D+21 
(+/-3) 
D+28 
(+/-3) 
D+42 
(+/-3) 
D +90 
(+/-3) 
D+100 
(+/-3) 
D+130 
(+/-3) 
D+180 
(+/-3) 
ADay 
+270 
and 
year 1   
(+/-7) 
Day -40  
(+/-10) 
CXR (Chest CT if 
indicated) 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Cardiac Stress TestN 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RCL  monitoring 
X 
  
  
  
  
  
  
  
 
  
  
  
  
  
  
X  
  
  
X 
XG 
Myeloma 
Assessments 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Myeloma MarkersC 
X 
  
  
  
  
 
  
  
  
  
  
  
  
  
X 
  
X 
  
X 
X 
Bone Marrow 
BiopsyH 
X 
  
  
  
  
  
  
  
  
  
X 
  
X 
  
X 
  
X 
  
X 
 X 
Bone surveysI 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
X 
  
X 
X 
Research 
Assesments 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Peripheral blood (25 
cc) 
X 
  
  
  
  
  
  
XJ 
X 
x 
x 
x 
x 
x 
x 
  
x 
x 
x 
x 
DNA (persistence) 
X 
  
  
  
  
  
  
x 
x 
x 
x 
x 
x 
x 
x 
  
x 
x 
x 
x 
PBMC (functional 
assays, 
immunophenotyping
) 
X 
  
  
  
  
  
  
x 
x 
x 
x 
x 
x 
x 
x 
  
x 
x 
x 
x 
serum (2 cc) 
x 
  
  
  
  
  
  
XJ 
x 
x 
x 
x 
x 
x 
x 
  
x 
x 
x 
x 
multiplex cytokine  
x 
  
  
  
  
  
  
x 
x 
x 
x 
x 
x 
x 
x 
  
x 
x 
x 
x 
Marrow (20 cc) 
x 
  
  
  
  
  
  
  
  
  
x 
  
x 
  
x 
  
x 
  
x 
x*** 
DNA (homing) 
x 
  
  
  
  
  
  
  
  
  
x 
  
x 
  
x 
  
x 
  
x 
x 
MDMC (functional 
assays, 
immunophenotyping
) 
x 
  
  
  
  
  
  
  
  
  
x 
  
x 
  
x 
  
x 
  
x 
x 
Marrow serum (2 
cc) 
x 
  
  
  
  
  
  
  
  
  
x 
  
x 
  
x 
  
x 
  
x 
x*** 
multiplex cytokine  
x 
  
  
  
  
  
  
  
  
  
x 
  
x 
  
x 
  
x 
  
x 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Total Research 
blood draws 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Lavender top 
45 cc 
  
  
  
  
  
  
20 
cc 
25 
cc 
25 
cc 
45 
cc 
25 
cc 
45 
cc 
25 
cc 
25 cc 
  
45 cc 
25 cc 
45 cc 
25-
45*** 
cc 

 
Protocol  ADP-01411 - Version 12.0 
Page 114 of 118 
Intervention Protocol 
  
Enrollment 
D -50 
(+/-10) 
PVC 
immunizati
on 
T cell 
harvest     
D -30 (+/-
10) 
SC 
mobilizatio
n  D -26 
SC 
collectio
n           
D -16 
(+/-3) 
High dose 
melphalan  
D -2 
D 0 
D+2 
D+3 
D+5 
+/- 1 
D+7 
+/- 
1 
D+14 
(+/-1) 
D+21 
(+/-3) 
D+28 
(+/-3) 
D+42 
(+/-3) 
D +90 
(+/-3) 
D+100 
(+/-3) 
D+130 
(+/-3) 
D+180 
(+/-3) 
ADay 
+270 
and 
year 1   
(+/-7) 
Day -40  
(+/-10) 
red top 
4 cc 
  
  
  
  
  
  
4 cc 
2 cc 
2 
cc 
4 cc 
2 cc 
4 cc 
2 cc 
2 cc 
  
4 cc 
2 cc 
4 cc 
2-4*** 
cc 
Total 
49 cc 
  
  
  
  
  
  
24 
cc 
27 
cc 
27 
cc 
49 
cc 
27 
cc 
49 
cc 
27 
cc 
27 cc 
  
49 cc 
27 cc 
49 cc 
27-
49*** 
cc 
 
A-Visits ≥Year 1 will occur at least every 3 months or per local standard of care until disease progression. 
B-Start lenalidomide 10 mg PO daily 
C-SPEP + immunofixation; quantitative IgG, IgM, IgA; UPEP + immunofixation based on a 24 hour urine collection; serum free κ and λ light chain levels and κ/λ ratio determination; 
Beta-2 microglobulin, CRP. 
D-Pregnancy tests for females of childbearing potential.  A female of childbearing potential (FCBP) is a sexually mature female who: 1) has not undergone a hysterectomy or bilateral 
oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months). 
E-Pregnancy tests must occur within 10 – 14 days and again within 24 hours prior to prescribing lenalidomide (prescriptions must be filled within 7 days).  FCBP with regular or no 
menstruation must have a pregnancy test weekly for the first 28 days and then every 28 days while on therapy (including breaks in therapy), at discontinuation of lenalidomide and 
at Day 28 post the last dose of lenalidomide.  Females with irregular menstruation must have a pregnancy test weekly for the first 28 days and then every 14 days while on therapy 
(including breaks in therapy), at discontinuation of lenalidomide and at Day 14 and Day 28 post the last dose of lenalidomide (see Appendix: Risks of Fetal Exposure, Pregnancy 
Testing Guidelines and Acceptable Birth Control Methods).    
F-If patient is not registered in the RevAssist program, patient must be registered.  Patient can be registered approximately 1-2 weeks prior to day +100 as well. 
G-Procedure optional at these points, except for RCL sample which is collected on an annual basis 
H-a bone marrow biopsy will be requested on days 7, 21, 42 (optional); BM Bx will also be taken at disease progression (not indicated in schedule above) 
I-MRI or PET scan if clinically indicated 
J-2cc serum and 10cc lavender pre infusion and 2cc serum 1, 2, 4, 8, and 12 hours post infusion, and 10 cc lavender 2 hours post infusion. 
K-Tumor antigen testing will be performed on the marrow sample collected at this timepoint.  Testing will be performed by RT-PCR in the TSCL at UPenn.  Marrow for this timepoint 
only will be shipped fresh same day via courier if not collectected at UPenn. 
L-Glucose, Bun, Cr, NA, K, Cl, CO2, Ca, T. Protein, Albumin, T.Bili, Alk Phos, AST, ALT 
M-Performed prior to infusion 
N-Recommended for any transplant patient over 60 and for patients with a prior history of heart disease. The specific type of stress test will be at the PI’s discretion. 
P-Window refers to enrollment of subject with Sponsor 
Q-The synergistic twin will undergo these visits in lieu of the subject for a synergistic twin transplant (stem cell collection will be around day -20) 
 
**if available frozen apheresis product for the T-cell and/or stem cell product may be used in lieu of fresh apheresis as indicated in this table 
*** Marrow sample to be collected for research purposes semi-annually or whenever follow-up marrow aspiration collected at physician discretion 

 
Protocol  ADP-01411 - Version 12.0 
Page 115 of 118 
Long-Term Follow-up Schedule for Year 2-15 
 
Time post-infusion 
  
Year 2  
Year 3  
Year 4  
Year 5  
Years 6-15  
Months 
18 
24 
30 
36 
42 
48 
54 
60 
Annually  
Visit window 
± 3 month 
± 6 months 
Safety Assessments 
Medical History and Physical Exam1  
X 
X 
X 
X 
X 
X 
X 
X 
X 
Mutagenic agents, other investigational 
agents or anti-cancer therapies1  
X 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Events2  
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hematology 
 
X 
 
X 
 
X 
 
X 
X3  
Serum chemistry 
 
X 
 
X 
 
X 
 
X 
X3  
Central Lab 
 
 
 
 
 
 
 
 
 
VSV-G DNA (RCL) for safety 
 
X 
 
X 
 
X 
 
X 
X 
Vector Copies (Persistence) for safety 
X 
X 
X 
X 
X 
X 
X 
X 
X3 
Other Assessments 
 
 
 
 
 
 
 
 
 
Overall Survival 
X 
X 
X 
X 
X 
X 
X 
X 
X 
1. New medical history/medications/chemotherapies 
 
 
 
 
2. Adverse event collection is limited to: 
• 
New malignancies 
• 
New incidence or exacerbation of a pre-existing neurologic disorder 
• 
New incidence or exacerbation of a prior rheumatologic or other autoimmune disorder 
• 
New incidence of a hematologic disorder 
• 
Opportunistic and or serious infections 
• 
Unanticipated illness and/or hospitalization deemed related to gene modified cell therapy 
3. In year 6-15, laboratory assessments are performed for as long as persistence is analyzed.  If persistence samples are discontinued then laboratory 
assessments are discontinued.  
 

 
Protocol  ADP-01411 - Version 12.0 
Page 116 of 118 
15 APPENDIX D:  LENALIDOMIDE DOSE MODIFICATIONS 
 
Lenalidomide Dose Modifications   
NCI CTC Toxicity 
Grade 
Dose Modification Instructions for Lenalidomide 
Grade 3 neutropenia 
associated with fever 
(temperature ≥ 38.5º 
C) or Grade 4 
neutropenia 
• Hold (interrupt) lenalidomide dose. 
• Follow CBC weekly. 
• If neutropenia has resolved to ≤ grade 2 prior to Day 
21, restart lenalidomide at next lower dose level and 
continue through the scheduled end of the cycle.  
Otherwise, omit for remainder of cycle and reduce the 
dose of lenalidomide by 1 dose level at the start of the 
next cycle.  Omitted doses are not made up.If 
neutropenia is the only toxicity for which a dose 
reduction is required, G-CSF may be used and the 
lenalidomide dose maintained at the discretion of the 
investigator. 
Thrombocytopenia 
≥Grade 4 (platelet 
count < 25,000/mm³) 
• Hold (interrupt) lenalidomide dose. 
• Follow CBC weekly. 
• NOTE: Consider holding and then resuming 
prophylactic anti-coagulation, if applicable. 
• If thrombocytopenia resolves to >30,000 prior to day 
21 restart lenalidomide at next lower dose level and 
continue through the scheduled end of the cycle.  
Otherwise, omit for remainder of cycle and reduce the 
dose of lenalidomide by 1 dose level at the start of the 
next cycle.  Omitted doses are not made up. 

 
Protocol  ADP-01411 - Version 12.0 
Page 117 of 118 
Lenalidomide Dose Modifications (continued)   
NCI CTC Toxicity 
Grade 
Dose Modification Instructions for Lenalidomide 
Non-blistering rash 
 
Grade 3 
 
 
 
 
             Grade 4 
 
• If Grade 3, hold (interrupt) lenalidomide dose.  Follow 
weekly. 
• If the toxicity resolves to ≤ grade 1 prior to Day 21, 
restart lenalidomide at next lower dose level and 
continue through the scheduled end of the cycle.  
Otherwise, omit for remainder of cycle and reduce the 
dose of lenalidomide by 1 dose level at the start of the 
next cycle.  Omitted doses are not made up. 
 
 
• If Grade 4, discontinue lenalidomide. 
Desquamating 
(blistering) rash- any 
Grade  
• Discontinue lenalidomide.   
Neuropathy 
 
Grade 3 
 
 
 
 
Grade 4 
 
• If Grade 3, hold (interrupt) lenalidomide dose.  Follow 
at least weekly. 
• If the toxicity resolves to ≤ grade 1 prior to Day 21, 
restart lenalidomide at next lower dose level and 
continue through the scheduled end of the cycle.  
Otherwise, omit for remainder of cycle and reduce the 
dose of lenalidomide by 1 dose level at the start of the 
next cycle.  Omitted doses are not made up. 
 
 
• If Grade 4, discontinue lenalidomide.   

 
Protocol  ADP-01411 - Version 12.0 
Page 118 of 118 
Lenalidomide Dose Modifications (continued)   
NCI CTC Toxicity 
Grade 
Dose Modification Instructions for Lenalidomide 
Venous 
thrombosis/embolism 
≥ Grade 3 
• Hold 
(interrupt) 
lenalidomide 
and 
start 
anticoagulation; restart lenalidomide at investigator’s 
discretion (maintain dose level). 
• Omit lenalidomide for remainder of cycle. See 
Anticoagulation Consideration (Section 5.6.1.2) 
Hyperthyroidism or 
hypothyroidism 
• Omit lenalidomide for remainder of cycle, evaluate 
etiology, and initiate appropriate therapy.  
• See Instructions for Initiation of a New Cycle and 
reduce the dose of lenalidomide by 1 dose level. 
other non-
hematologic toxicity 
≥ Grade 3 
• Hold (interrupt) lenalidomide dose.  Follow at least 
weekly. 
• If the toxicity resolves to ≤ grade 2 prior to Day 21, 
restart lenalidomide and continue through the 
scheduled end of the cycle.  Otherwise, omit for 
remainder of cycle.  Omitted doses are not made up.  
For toxicity attributed to lenalidomide, reduce the 
lenalidomide dose by 1 dose level when restarting 
lenalidomide.