T Cells Expressing a Fully-Human Anti-CD19 Chimeric Antigen Receptor for Treating B-cell Malignancies
Phase: PHASE1
Conditions: Lymphoma, B-Cell, Lymphoma, Non-hodgkins
Sponsor: National Cancer Institute (NCI)

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Abbreviated Title: Anti- CD19 CAR T-cells   
Version Date: September 17, 2020 
 
Abbreviated Title: Anti-CD19-CAR T cells  
NIH Protocol #: 16-C-0054 
OSP#: 1509-1459 
IBC#: RD-15-X-06 
Amendment: J 
Version Date: September 17, 2020 
NCT Number: NCT02659943 
 
Title:  T Cells Expressing a fully-human anti- CD19 Chimeric Antigen Receptor for treating B-
cell malignancies 
 
NCI Principal Investigator:             James N Kochenderfer, M.D.  
                                                                                          Surgery  Branch 
                                                            Center for Cancer Research, 
                                                            National Cancer Institute, National Institutes of Health 
                                                            10 Center Drive, Rm. 6B17, MSC 1203 
 
 
 
  
 
Telephone:  240-760-6062 
 
 
 
 
 
Email:  kochendj@mail.nih.gov 
Investigational Agents:     
Drug Name: 
Anti-CD19-CAR T cells 
IND Number: 
16682 
Sponsor: 
Center for Cancer Research 
 
Commercial Agents: Cyclophosphamide, Fludarabine, OKT3   
 

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PRÉCIS  
Background: 
• Improved treatments for a variety of treatment-resistant B-cell malignancies including B-
cell lymphomas, and chronic lymphocytic leukemia (CLL) are needed.  
• A particular need is development of new treatments for chemotherapy-refractory B-cell 
malignancies. 
• T cells can be genetically modified to express chimeric antigen receptors (CARs) that 
specifically target malignancy-associated antigens. 
• Autologous T cells genetically modified to express CARs targeting the B-cell antigen 
CD19 have caused complete remissions in a small number of patients with leukemia or 
lymphoma.  These results demonstrate that anti-CD19 CAR-expressing T cells have anti-
malignancy activity in humans. 
• The vast majority of B-cell malignancies express CD19. 
• CD19 is not expressed by normal cells except for B cells. 
• We have constructed a novel fully-human anti-CD19 CAR that can specifically recognize 
CD19-expressing target cells in vitro and eradicate CD19-expressing tumors in mice. 
• This fully-human CAR targeting CD19 has not been tested in humans before.  
• Possible toxicities include cytokine-associated toxicities such as fever, hypotension, and 
neurological toxicities.  Elimination of normal B cells is probable, and unknown 
toxicities are also possible. 
Objectives: 
Primary 
• Determine the safety and feasibility of administering T cells expressing a novel fully-
human anti-CD19 CAR to patients with advanced B-cell malignancies. 
Secondary 
• Evaluate the in vivo persistence and peak blood levels of anti-CD19 CAR T cells after 
initial and repeated CAR T-cell infusions.  CAR T-cell blood levels will be compared 
retrospectively to results with an anti-CD19 CAR containing an antigen-recognition 
moiety derived from a murine antibody.  
• Assess for evidence of anti-malignancy activity by anti-CD19 CAR T cells 
• Assess the impact of repeated CAR T-cell infusions on residual malignancy after an 
initial CAR T-cell infusion. 
• Assess the immunogenicity of the CAR used in this protocol. 
 
Eligibility: 

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• Patients must have any B-cell lymphoma, or CLL/SLL.  Lower grade lymphomas 
transformed to DLBCL are potentially eligible as is primary mediastinal B-cell 
lymphoma and all other subtypes of DLBCL.  
• Patients must have malignancy that is measurable on a CT scan or by flow cytometry of 
bone marrow or blood. 
• Patients must have a creatinine of 1.4 mg/dL or less and a normal cardiac ejection 
fraction. 
• An ECOG performance status of 0-1 is required. 
• No active infections are allowed including any history of hepatitis B or hepatitis C. 
• Absolute neutrophil count≥1000/µL, platelet count≥45,000/µL, hemoglobin≥8g/dL  
• Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal 
unless liver involvement by malignancy is demonstrated. 
• At least 14 days must elapse between the time of any prior systemic treatment (including 
corticosteroids) and initiation of protocol enrollment. 
• The patient’s malignancy will need to be assessed for CD19 expression by flow 
cytometry or immunohistochemistry performed at the NIH.  If unstained, paraffin-
embedded bone marrow or lymphoma sections are available from prior biopsies, these 
can be used to determine CD19 expression by immunohistochemistry; otherwise, patients 
will need to come to the NIH for a biopsy to determine CD19 expression.  The sample for 
CD19 expression can come from a biopsy obtained at any time before enrollment. 
• Patients who have never had an allogeneic hematopoietic stem cell transplant are 
potentially eligible. 
Design: 
• This is a phase I dose-escalation trial 
• Patients will undergo leukapheresis 
• T-cells obtained by leukapheresis will be genetically modified to express an anti-
CD19 CAR 
• Patients will receive a lymphocyte-depleting chemotherapy conditioning regimen 
with the intent of enhancing the activity of the infused anti-CD19-CAR-expressing T 
cells. 
• The chemotherapy conditioning regimen is cyclophosphamide 300 mg/m2 daily for 3 
days and fludarabine 30 mg/m2 daily for 3 days.  Fludarabine will be given on the 
same days as the cyclophosphamide. 
• Two days after the chemotherapy ends, patients will receive an infusion of anti-
CD19-CAR-expressing T cells. 
• The initial dose level of this dose-escalation trial will be 0.66x106 CAR+ T cells/kg of 
recipient bodyweight. 

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• The cell dose administered will be escalated until a maximum tolerated dose is 
determined. 
• Following the T-cell infusion, there is a mandatory 9-day inpatient hospitalization to 
monitor for toxicity. 
• Outpatient follow-up is planned for 2 weeks, and 1, 2, 3, 6, 9, and 12 months after the 
CAR T-cell infusion.  Long-term gene-therapy follow-up consisting of yearly visits 
to a doctor near the patient’s home for 4 more years and then yearly telephone 
contact for 10 additional years will be required.  
• Repeat treatments consisting of the conditioning chemotherapy followed by a CAR 
T-cell infusion are planned for eligible patients with any best responses except 
continuing complete remission or progressive malignancy. 
• Re-enrollment will be allowed for a small number of subjects. 
 
 
 
 

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TABLE OF ABBREVIATIONS 
alloSCT - allogeneic stem cell transplantation 
alloHSCT - allogeneic hematopoietic stem cell transplant 
AML - acute myeloid leukemia 
BSL – Biosafety level 
CAR - chimeric antigen receptor 
CFSE - carboxyfluorescein diacetate,succinimidyl ester 
CLL - Chronic lymphocytic leukemia  
CML - chronic myeloid leukemia 
CR – Complete remission 
CRO – Central Registration Office 
CRP - C-reactive peptide 
CTCAE - Common Terminology Criteria for Adverse Events 
DLBCL - Diffuse large B-cell lymphoma 
DCI - Donor Cell Infusion  
DTM - Department of Transfusion Medicine 
ELISA - enzyme-linked immunosorbent assay 
GVHD - Graft-versus-host disease 
GVM - graft-versus-malignancy 
HLA - human leukocyte antigen 
IBC - Institutional Biosafety Committee 
OSP - Office of Science Policy 
PBMC - peripheral blood mononuclear cells 
PD – Progressive disease 
PET - positron emission tomography 
PR – Partial remission 
RCL - replication competent lentiviruses 
SD – Stable disease 
SMC - Safety Monitoring Committee 
scFv - single chain variable fragment 
TBNK – T cell, B cell, and NK cell blood test 
TCR –T cell receptor 
URD – Unrelated donor 
WPRE - woodchuck post-transcriptional regulatory element 

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TABLE OF CONTENTS  
PRÉCIS .................................................................................................................................. 2 
TABLE OF ABBREVIATIONS .............................................................................................. 5 
1 
INTRODUCTION ......................................................................................................... 11 
1.1 
Study Objectives...................................................................................................... 11 
1.1.1 
Primary Objective ............................................................................................. 11 
1.1.2 
Secondary Objectives........................................................................................ 11 
1.2 
Background and Rationale ....................................................................................... 11 
1.2.1 
Introduction ...................................................................................................... 11 
1.2.2 
B-cell malignancies:  epidemiology and standard treatment ................................ 11 
1.2.3 
Allogeneic Stem Cell Transplantation for B-cell Malignancies ........................... 12 
1.2.4 
Donor Cell Infusion (DCI) ................................................................................ 13 
1.2.5 
Mechanism of the graft-versus-malignancy (GVM) effect .................................. 14 
1.2.6 
Definition and Assessment of Graft-versus-host Disease .................................... 15 
1.2.7 
T-cell gene therapy ........................................................................................... 15 
1.2.8 
Chimeric antigen receptors preclinical background ............................................ 16 
1.2.9 
CD19 ............................................................................................................... 17 
1.2.10 Clinical results with anti-CD19 CAR T cells...................................................... 17 
1.2.11 Anti-CD19 CAR development and preclinical testing ........................................ 20 
1.2.12 Rationale for immunosuppressive chemotherapy and selection of lymphocyte-
depleting........................................................................................................................ 25 
1.2.13 Rationale for dose-escalation and repeated chemotherapy plus CAR T-cell 
treatments ...................................................................................................................... 25 
1.2.14 Rationale for a fully-human CAR ...................................................................... 26 
1.2.15 Use of T cells from patients with malignancy versus healthy donor T cells to 
produce anti-CD19 CAR T cells ..................................................................................... 27 
1.2.16 Summary of risks and potential benefits ............................................................ 28 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT ................................................... 28 
2.1 
Eligibility Criteria .................................................................................................... 28 
2.1.1 
Inclusion Criteria .............................................................................................. 29 
2.1.2 
Exclusion criteria: ............................................................................................. 31 
2.2 
Screening Evaluation ............................................................................................... 32 
2.2.1 
Screening activities performed after a consent for screening has been signed ...... 32 

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2.3 
Participant Registration and Status Update Procedures .............................................. 33 
2.4 
Treatment Assignment Procedures: .......................................................................... 33 
3 
STUDY IMPLEMENTATION....................................................................................... 33 
3.1 
Study Design ........................................................................................................... 33 
3.1.1 
General study plan ............................................................................................ 34 
3.1.2 
Planned repeat treatments.................................................................................. 34 
3.1.3 
Inclusion of patients who have had allogeneic hematopoietic stem cell 
transplantation (alloHSCT)............................................................................................. 35 
3.1.4 
Protocol schema ............................................................................................... 36 
3.1.5 
Dose Limiting Toxicity ..................................................................................... 37 
3.1.6 
Dose Escalation ................................................................................................ 37 
3.2 
Dose Modifications/Delay........................................................................................ 40 
3.3 
Stopping Criteria ..................................................................................................... 41 
3.4 
Drug Administration ................................................................................................ 41 
3.4.1 
Leukapheresis................................................................................................... 41 
3.4.2 
Anti-CD19-CAR-expressing T-cell preparation ................................................. 41 
3.4.3 
Conditioning chemotherapy and anti-CD19 CAR T-cell administration-this can be 
either inpatient or outpatient ........................................................................................... 42 
3.4.4 
Potential repeat treatment .................................................................................. 43 
3.5 
Protocol Evaluation ................................................................................................. 44 
3.5.1 
Baseline evaluations and interventions............................................................... 44 
3.5.2 
Studies to be performed during the mandatory 9-day inpatient admission after cell 
infusion 46 
3.5.3 
Post-infusion outpatient evaluation .................................................................... 46 
3.6 
Study Calendar (Table 5) ......................................................................................... 48 
3.7 
Gene-therapy-specific follow-up .............................................................................. 52 
3.7.1 
Clinical Evaluation ........................................................................................... 52 
3.7.2 
Testing for persistence of CAR transduced cells................................................. 52 
3.7.3 
Replication competent lentivirus (RCL) testing .................................................. 52 
3.8 
Criteria for Removal from Protocol Therapy and Off Study Criteria .......................... 53 
3.8.1 
Criteria for removal from protocol therapy......................................................... 53 
3.8.2 
Off-study Criteria ............................................................................................. 53 
4 
CONCOMITANT MEDICATIONS/MEASURES .......................................................... 54 

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4.1 
Routine Supportive care ........................................................................................... 54 
4.2 
Blood product support.............................................................................................. 55 
4.3 
Anti-emetics ............................................................................................................ 55 
4.4 
Granulocyte colony-stimulating factor ...................................................................... 55 
4.5 
Avoidance of corticosteroids .................................................................................... 55 
4.6 
Guidelines for management of common acute toxicities that occur after CAR T cell 
infusions............................................................................................................................ 55 
5 
BIOSPECIMEN COLLECTION .................................................................................... 56 
5.1 
CORRELATIVE STUDIES FOR RESEARCH ........................................................ 56 
5.1.1 
Biospecimen collection before the start of the conditioning chemotherapy: ......... 56 
5.1.2 
Biospecimen collection after CAR T-cell infusion during the required 
hospitalization................................................................................................................ 56 
5.1.3 
Biospecimen collection during outpatient follow-up........................................... 56 
5.1.4 
Immunological Testing ..................................................................................... 57 
5.1.5 
Additional biopsies and additional blood draws ................................................. 58 
5.1.6 
Future studies ................................................................................................... 58 
5.2 
Sample Storage, Tracking and Disposition................................................................ 58 
5.2.1 
Samples Sent to Figg Lab.................................................................................. 59 
5.2.2 
Sample Storage, Tracking and Disposition......................................................... 59 
5.2.3 
Sample Storage, Tracking, and Disposition for Surgery Branch .......................... 60 
5.2.4 
Protocol Completion/Sample Destruction .......................................................... 61 
5.2.5 
Samples for Genetic/Genomic Analysis ............................................................. 61 
6 
DATA COLLECTION AND EVALUATION ................................................................ 62 
6.1 
Data Collection........................................................................................................ 62 
6.1.1 
Adverse event recording: .................................................................................. 63 
6.2 
Data Sharing Plans................................................................................................... 63 
6.2.1 
Human Data Sharing Plan ................................................................................. 63 
6.2.2 
Genomic Data Sharing Plan .............................................................................. 64 
6.3 
Response Criteria..................................................................................................... 64 
6.4 
Toxicity Criteria ...................................................................................................... 66 
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN.... 66 
7.1 
Definitions............................................................................................................... 66 
7.2 
OHSRP Office of Compliance and Training / IRB Reporting .................................... 66 

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7.2.1 
Expedited Reporting ......................................................................................... 67 
7.2.2 
IRB Requirements for PI Reporting at Continuing Review ................................. 67 
7.3 
NCI Clinical Director Reporting............................................................................... 67 
7.4 
Institutional Biosafety Committee (IBC) Reporting Criteria ...................................... 67 
7.4.1 
Serious Adverse Event Reports to IBC .............................................................. 67 
7.4.2 
Annual Reports to IBC...................................................................................... 67 
7.5 
NIH Required Data and Safety Monitoring Plan........................................................ 68 
7.5.1 
Principal Investigator/Research Team................................................................ 68 
7.5.2 
Safety Monitoring Committee (SMC) ................................................................ 68 
8 
Sponsor Safety Reporting ............................................................................................... 69 
8.1 
Definitions............................................................................................................... 69 
8.1.1 
Adverse Event .................................................................................................. 69 
8.1.2 
Serious Adverse Event (SAE) ........................................................................... 69 
8.1.3 
Life-threatening ................................................................................................ 70 
8.1.4 
Severity ............................................................................................................ 70 
8.1.5 
Relationship to Study Product ........................................................................... 70 
8.2 
Assessment of Safety Events .................................................................................... 70 
8.3 
Reporting of Serious Adverse Events........................................................................ 71 
8.4 
Reporting Pregnancy................................................................................................ 71 
8.4.1 
Maternal exposure ........................................................................................... 71 
8.4.2 
Paternal exposure.............................................................................................. 71 
8.5 
Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND ................. 71 
9 
CLINICAL MONITORING ........................................................................................... 72 
10 STATISTICAL CONSIDERATIONS ............................................................................ 72 
11 COLLABORATIVE AGREEMENTS ............................................................................ 73 
12 HUMAN SUBJECTS PROTECTIONS .......................................................................... 73 
12.1 
Rationale For Subject Selection ............................................................................ 73 
12.2 
Participation/selection rationale ............................................................................ 73 
12.3 
Participation of Children....................................................................................... 74 
12.4 
Participation of Subjects Unable to Give Consent .................................................. 74 
12.5 
Evaluation of Benefits and Risks/Discomforts ....................................................... 75 
12.5.1 Risks of exposure to Ionizing Radiation............................................................. 75 

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12.5.2 Risks of Scans and Contrast .............................................................................. 76 
12.5.3 Risks of blood Sampling ................................................................................... 76 
12.5.4 Risks of Bone marrow aspiration and biopsy...................................................... 76 
12.5.5 Risks of Intravenous Catheter............................................................................ 76 
12.5.6 Risks of Lumbar Puncture ................................................................................. 76 
12.5.7 Risks of Apheresis ............................................................................................ 76 
12.6 
Consent Process and Documentation ..................................................................... 76 
13 PHARMACEUTICAL INFORMATION ........................................................................ 77 
13.1 
Lentiviral Vector Containing the anti-CD19 CAR Gene......................................... 77 
13.2 
Commercial Agents .............................................................................................. 77 
13.2.1 Cyclophosphamide ........................................................................................... 77 
13.2.2 FLUDARABINE .............................................................................................. 78 
14 REFERENCES .............................................................................................................. 79 
15 APPENDICES ............................................................................................................... 90 
15.1 
Appendix A:  Performance Status Criteria ............................................................. 90 
15.2 
Appendix B:  Data Collection Elements Required By Protocol............................... 91 
15.3 
Appendix C:  Guidelines for management of common toxicities that occur after CAR 
T-cell infusions.................................................................................................................. 93 
15.4 
Appendix D:  Clinical Staging and treatment of Acute GVHD ............................... 97 
15.5 
Appendix E:  Infusion Instructions ...................................................................... 100 
 
 
 

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1 
 
INTRODUCTION 
1.1 
STUDY OBJECTIVES 
1.1.1 Primary Objective 
Determine the safety and feasibility of administering T cells expressing a novel fully-human 
anti-CD19 chimeric antigen receptor (CAR) to patients with advanced B-cell malignancies. 
1.1.2 Secondary Objectives 
• Evaluate the in vivo persistence and peak blood levels of anti-CD19 CAR T cells after 
initial and repeated CAR T-cell infusions.  CAR T-cell blood levels will be compared 
retrospectively to persistence results with an anti-CD19 CAR containing an antigen-
recognition moiety derived from a murine antibody.  
• Assess for evidence of anti-malignancy activity by anti-CD19 CAR T cells 
• Assess the impact of repeated CAR T-cell infusions on residual malignancy after an 
initial CAR T-cell infusion. 
• Assess the immunogenicity of the CAR used in this protocol. 
1.2 
BACKGROUND AND RATIONALE 
1.2.1 Introduction 
We have developed a fully-human anti-CD19 CAR, and we have demonstrated that T cells 
expressing this CAR have CD19-specific activity in vitro and in vivo.  Anti-CD19-CAR-
expressing T cells expressing this CAR can eradicate tumors in mice.  We propose to conduct a 
phase I clinical trial of anti-CD19-CAR-expressing T cells.  This clinical trial will enroll patients 
with advanced B-cell malignancies of all types.  Patients enrolled on the trial will receive a single 
cycle of chemotherapy that is designed to decrease endogenous lymphocyte counts because 
extensive evidence demonstrates that depleting endogenous lymphocytes, and possibly other cells, 
with chemotherapy or total body irradiation dramatically increases the anti-tumor activity of 
adoptively transferred T cells.1-3 After the lymphocyte-depleting chemotherapy, patients will 
receive an infusion of autologous anti-CD19-CAR T cells.  The T cell dose will escalate with 
sequential cohorts of patients until a maximum tolerated dose is determined.  Sequential 
chemotherapy plus CAR T cell treatments with intra-patient dose escalation of the CAR T-cell 
dose will be an integral part of the protocol so that the effect of repeated CAR T-cell infusions on 
residual malignancy after an initial CAR T-cell infusion can be assessed. 
1.2.2 B-cell malignancies:  epidemiology and standard treatment 
Annually in the United States, approximately twenty-three thousand people die of B cell 
malignancies 4.  B cell malignancies have quite heterogeneous clinical manifestations and 
prognoses.  Chronic lymphocytic leukemia (CLL) is a common disease that is incurable by 
chemotherapy 5.   Recently, the new tyrosine-kinase inhibitor drug ibrutinib has revolutionized 
the treatment of CLL, so most patients will be treated with ibrutinib or another signal 
transduction inhibitor before participating in a phase I clinical trial.  The tyrosine-kinase 
inhibitors have very high response rates, and progression-free survivals of greater than 2 years 
have been reported6, but follow-up is short, and some patients receiving these agents do develop 

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progressive CLL that in some cases has transformed to a higher grade6.  A B-cell malignancy for 
which new therapies are urgently needed is mantle cell lymphoma.  This disease is almost always 
incurable by chemotherapy and has an aggressive course that is characterized by short responses 
to chemotherapy 7.  The tyrosine kinase inhibitor ibrutinib has been shown to have significant 
activity against mantle cell lymphoma, but in most cases it is not curative, so new therapies for 
mantle cell lymphoma are a great need8.  Follicular lymphoma is a common lymphoma with an 
extremely variable course 9.  Patients with follicular lymphoma have a median survival of about 
4.5 years after first relapse 10,11.  Follicular lymphoma is susceptible to a variety of therapies, but 
many of the therapies are toxic, and patients are seldom cured of follicular lymphoma, so 
improved therapies are needed for follicular lymphoma 12.  Diffuse large B-cell lymphoma 
(DLBCL) is the most common B-cell malignancy.  DLBCL is often curable by standard 
chemotherapy, and autologous stem cell transplants are sometimes able to cure patients with 
relapsed large cell lymphoma 13.  However, patients with DLBCL that is refractory to 1st salvage 
chemotherapy have response rates to 2nd salvage therapy of only 14 to 43% 14-18.  Patients with 
DLBCL refractory to 2nd-line chemotherapy have very poor prognoses with a reported median 
survival of only 4 months and a 1-year survival rate of only 4% 18.  Allogeneic stem cell 
transplantation is a potentially curative treatment option for patients with advanced B cell 
malignancies, but allogeneic stem cell transplantation generally has a treatment-related mortality 
rate of 10-30% 19,20.  All in all, improved therapies for B cell malignancies are clearly needed. 
1.2.3 Allogeneic Stem Cell Transplantation for B-cell Malignancies 
In some patients with persistent or relapsed B-cell malignancies after extensive treatment with 
chemotherapy and monoclonal antibodies, allogeneic stem cell transplantation (alloSCT) can lead 
to long-term progression-free survival 21-26.  Khouri and coworkers reported the results of their 
experience treating patients with chemotherapy-sensitive follicular lymphoma with alloHSCT22.  
These investigators used a conditioning regimen that consisted of cyclophosphamide and 
fludarabine in nonmyeloablative doses plus high-dose rituximab.  The five-year progression-free 
survival of patients treated with this regimen was 83%.  There was evidence for a plateau in 
relapses because no relapses occurred more than 20 months after transplant 22.  Durable remissions 
can also be achieved with nonmyeloablative alloHSCT in patients with advanced chronic 
lymphocytic leukemia (CLL) 24,27,  and nonmyeloablative alloHSCT is a promising treatment for 
relapsed mantle cell lymphoma 21,28.  AlloHSCT is the only curative therapy for adults with 
relapsed acute lymphoblastic leukemia (ALL) 25. 
Although alloHSCT can be an effective therapy for B-cell malignancies, many patients develop 
persistent or relapsed malignancy after alloHSCT 24,25,28-30.  Evidence for an immunologic graft-
versus-malignancy effect exists for most B-cell malignancies 20,21,23,30-32 ; therefore, when patients 
that are receiving immunosuppressive drugs to prevent GVHD after alloHSCT develop persistent 
or relapsed malignancy, immunosuppressive drugs are usually discontinued.  In patients with 
persistent malignancy and without significant GVHD after immunosuppressive drugs are 
discontinued, relapsed B-cell malignancies after alloHSCT are usually treated with (donor 
lymphocyte infusion) DCI from the original transplant donor.  DCI are infusions of unmanipulated 
lymphocytes from the original transplant donor.   

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1.2.4 Donor Cell Infusion (DCI) 
DCI can induce remissions in 70-80% of patients with chronic myeloid leukemia (CML) that 
relapses into chronic phase after alloHSCT 33-35.  Susceptibility of B-cell malignancies to DCI after 
alloHSCT varies depending on disease histology 23.  Multiple reports of complete remission (CR) 
following DCI for persistent or relapsed follicular lymphoma after alloHSCT provide clear 
evidence of a GVM effect against this malignancy 20,31,36.    DCI administered without any other 
therapy have been reported to induce remissions in a small number of patients with progressive 
CLL after alloHSCT 20,30,37 .  While these reports of CR after DCI for CLL prove the existence of 
a GVM effect against CLL, DCI is probably not as effective against CLL as follicular lymphoma 
because some studies have shown a complete lack of CRs after DCI for CLL in a substantial 
number of patients 31,38.  There is some evidence of efficacy of DCI alone against relapsed mantle 
cell lymphoma after alloHSCT 21,39 , and four patients with mantle cell lymphoma achieved CR 
after DCI combined with chemotherapy 20.  Although diffuse large B-cell lymphoma (DLBCL) 
has been thought to be resistant to the GVM effect, the responses that sometimes occur after 
withdraw of immunosuppressive drugs and after DCI demonstrate that DLBCL does have some 
susceptibility to immunologic interventions 32.  Acute lymphoblastic leukemia (ALL) is resistant 
toDCI.  The percentage of adult ALL patient that obtain a CR after DCI for ALL ranges from 0% 
to 18% in multiple clinical trials 34,35,40,41. In the studies discussed in this paragraph, most of the 
DCIs that induced complete remissions of B-cell malignancies contained 1x107-5x107 T cells/kg 
of recipient bodyweight 20,31,36. 
The most important toxicity of DCI is GVHD.  In three studies cited in the previous paragraph, 
grade II-IV acute GVHD occurred in 28% to 44% of patients 20,31,36.  A recent review of DCI found 
that grade II-IV acute GVHD occurred after DCI in 34% to 48% of patients receiving DCI for 
various diseases and grade III-IV acute GVHD occurred after DCI in 20-35% of patients 40. 
Chronic GVHD occurs commonly afterDCI with an incidence of 33% to 83% and highly variable 
severity 20,31,36,40.  When DCI is used to treat CML, the incidence of GVHD increases as the number 
of T cells contained in the DCI increases 42,43.  For CML, DCIs with higher numbers of T cells had 
an equivalent anti-leukemia effect as DCIs containing lower numbers of T cells 42.  In another 
study, DCIs that contained greater than or equal to 1x107 T cells/kg of recipient bodyweight were 
associated with an increased incidence of GVHD compared to DCIs containing lower doses of T 
cells 44.  Miller and coworkers induced profound lymphodepletion with fludarabine and 
cyclophosphamide chemotherapy before DCI in an attempt to increase GVM 45  This therapy was 
associated with high levels of severe acute GVHD 45.  Forty-seven percent of patients treated with 
fludarabine and cyclophosphamide prior to a DCI of  1x108 T cells/kg of recipient bodyweight 
developed grade III-IV acute GVHD, and 5 of 15 patients suffered fatal outcomes directly 
attributable to GVHD 45.  Because many patients with relapsed malignancy after alloHSCT require 
urgent treatment for rapidly progressive disease, many patients receive chemotherapy prior to DCI 
20,31,32.  The chemotherapy regimens that are administered to patients for disease control prior to 
DCI are generally not as immunosuppressive as the fludarabine plus cyclophosphamide regimen 
administered by Miller and coworkers.  Patients with relapsed myeloid malignancy after alloHSCT 
were treated with the combination of chemotherapy and DCI.  These patients received DCIs with 
a median T cell dose of 1x108 T cells/kg of recipient bodyweight, and 44% of patients developed 
grade II-IV acute GVHD 46. The anti-leukemia activity of chemotherapy plus DCI appeared to be 
greater than the anti-leukemia activity achieved in historical control patients that were treated with 
DCI alone 46.  Porter and coworkers treated patients with a conventional DCI followed by an 

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infusion of T cells that had been activated ex vivo with beads that were conjugated to anti-CD3 
and anti-CD28 antibodies 37.  The number of ex vivo activated T cells that was administered to 
each patient was escalated from 1x106 to 1x108 T cells per kg of recipient bodyweight. The rate of 
GVHD observed after this therapy was not different from the rate that would be expected with 
conventional DCI alone 37. 
 
1.2.5 Mechanism of the graft-versus-malignancy (GVM) effect 
The prolonged remissions of advanced B-cell malignancies that have often occurred after 
nonmyeloablative alloHSCT demonstrate that there is an immunologic GVM effect against these 
diseases 21,22,24,26.  The GVM effect against B-cell malignancies is clearly demonstrated by the 
remissions that have sometimes occurred when these diseases were treated with DCI in the absence 
of other therapies after alloHSCT 20,31,33-35,47.  For CML, acute myeloid leukemia (AML) and ALL, 
the GVM effect is closely associated with GVHD.  When relapse rates of leukemia patients with 
and without GVHD were compared, relapse rates were lower for patients with GVHD than for 
patients without GVHD 48 49.   Comparisons of relapse rates of T cell-depleted alloHSCT and T-
replete alloHSCT indicated that transplantation of donor T cells prevented relapse after alloHSCT 
for ALL, AML and CML 48,50.  There was also a decreased rate of relapse for patients with AML 
and CML that received transplants from allogeneic donors compared to patients that received 
transplants from syngeneic (identical twin) donors 48, indicating an important role for allogeneic 
immunity in the GVM effect against these leukemias.  In contrast, no differences in relapse rates 
for lymphoma were detected when allogeneic T-cell replete, allogeneic T-cell-depleted, and 
syngeneic transplants were compared 51.  However, this study only assessed patients that were 
treated with myeloablative transplants between the years 1985 and 1998.  Nonmyeloablative 
transplants were excluded 51.  Because of these limitations it is possible that this study missed a 
subtle yet important GVM effect. 
Although the cellular mechanism of the GVM effect has not been defined and may be quite 
heterogeneous, substantial clinical evidence points to an important role for T cells and minor 
hisotcompatibility antigens 52.  Most importantly, when T cell-replete alloHSCT and T cell-
depleted alloHSCT were compared, there was an increased relapse risk in ALL, AML and CML 
patients that received T cell-depleted alloHSCT 48,50.  In addition, a patient with CML that had 
relapsed after standard DCI was treated with T cells that specifically recognized the patient’s CML 
cells 53.  The CML-specific T cells were derived by culturing T cells from the patient’s allogeneic 
donor with CML cells from the patient.  The patient entered a CR that lasted two years after 
treatment with these CML-specific T cells 53.  An important role for minor histocompatibility 
antigens in GVM was suggested by a study that showed a decreased rate of relapse among male 
patients with CML who received allogeneic transplants from female donors compared to all other 
donor/recipient sex combinations 54.  The transplant combination consisting of a female donor with 
a male recipient is the only transplant combination in which female donor T cells that are specific 
for minor histocompatibility antigens encoded by the Y-chromosome might make a contribution 
to GVM 54.   
CML is clearly very susceptible to an immunologic GVM effect 33-35,47.  The results obtained when 
acute leukemia and lymphoma are treated with DCI demonstrate that a weaker GVM effect is 
active against these diseases 33-35,20,31,55.  The strong GVM effect that is present when CML is 

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treated with T-cell-replete alloHSCT demonstrates that T cells can play an important role in 
mediating a clinically significant GVM effect.  Augmentation of the less powerful GVM effect 
associated with alloHSCT for B-cell malignancies might improve the outcomes of patients with 
these diseases.  One possible way to augment the GVM effect against B-cell malignancies is to 
genetically engineer donor T cells to express receptors that specifically recognize antigens 
expressed by malignant B cells.  
 
1.2.6 Definition and Assessment of Graft-versus-host Disease  
Graft-versus-host disease (GVHD) is an attack against normal recipient tissues that is mediated by 
the cells transferred with the transplant graft 56.  For GVHD to occur, there must be antigenic 
differences between the recipient and the allograft donor 56.  GVHD is divided into two broad 
categories, acute GVHD and chronic GVHD.  Characteristic features of acute GVHD include 
maculopapular rash, gastrointestinal disorders (nausea, diarrhea, or ileus), and cholesteric liver 
disease57.  Chronic GVHD can manifest with a wide variety of signs and symptoms57.  Formal 
definitions of four subsets of GVHD have published57. 
1. 
Classic acute GVHD: GVHD occurring less than or equal to 100 days after transplantation 
or DCI with characteristic features of acute GVHD and without characteristic features of 
chronic GVHD.  
2. 
Persistent, recurrent, or late-onset acute GVHD:  GVHD occurring greater than 100 days 
after transplantation or DCI with characteristic features of acute GVHD and without 
characteristic features of chronic GVHD. 
3. 
Classic chronic GVHD:  GVHD occurring at any time that has characteristic features of 
chronic GVHD but that does not have characteristic features of acute GVHD. 
4. 
Overlap syndrome:  GVHD occurring at any time that has characteristic features of both 
acute and chronic GVHD.  
Acute GVHD is graded according to standard grading systems as grades I through IV with grade 
IV being the most severe (see Section 13.4) 58,59.   Chronic GVHD is given a global score of mild, 
moderate, or severe according to the report of the NIH Consensus Development Project on Criteria 
for Clinical Trials in Chronic GVHD60 . ENREF_57  Based on organ scores detailed in Jagasia et 
al.  Chronic GVHD can be staged as described here.  Mild chronic GVHD involves only 1 or 2 
organs or sites (except the lung), with no clinically significant functional impairment (maximum 
of score 1 in all affected organs or sites). Moderate chronic GVHD involves (1) at least 1 organ or 
site with clinically significant but no major disability (maximum score of 2 in any affected organ 
or site) or (2) 3 or more organs or sites with no clinically significant functional impairment 
(maximum score of 1 in all affected organs or sites). A lung score of 1 will also be considered 
moderate chronic GVHD. Severe chronic GVHD indicates major disability caused by chronic 
GVHD (score of 3 in any organ or site). A lung score of 2 or greater will also be considered severe 
chronic GVHD. 
1.2.7 T-cell gene therapy 
In an attempt to develop effective immunotherapies for cancer that are less toxic than allogeneic 
stem cell transplantation, many investigators have developed T-cell gene therapy approaches to 

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specifically target T cells to tumor-associated antigens61.  T cells can be prepared for adoptive 
transfer by genetically modifying the T cells to express receptors that specifically recognize 
tumor-associated antigens.61-68  Genetic modification of T cells is a quick and reliable process, 
and clinical trials of genetically modified T cells targeting a variety of malignancies have been 
carried out.61,69-72  Genetically modified antigen-specific T cells can be generated from peripheral 
blood mononuclear cells (PBMC) in sufficient numbers for clinical treatment within 10 days.70  
Genetically modifying T cells with gammaretroviruses consistently causes high and sustained 
levels of expression of introduced genes without in vitro selection69,72-74, and genetic 
modification of mature T cells with gammaretroviruses has a long history of safety in humans.75-
77  There are two general approaches for generating antigen-specific T cells by genetic 
modification:   introducing genes encoding natural αβ T cell receptors (TCRs) or introducing 
genes encoding chimeric antigen receptors (CARs).61,63,65,67  CARs are fusion proteins 
incorporating antigen recognition moieties and T cell activation domains.66,78-80  The antigen-
binding domains of most CARs currently undergoing clinical and preclinical development are 
antibody variable regions.63,66,78,80  TCRs recognize peptides presented by human leukocyte 
antigen (HLA) molecules; therefore, TCRs are HLA-restricted, and a particular TCR will only be 
useful in patients expressing certain HLA molecules61,63,65,78, which limits the number of patients 
who could be treated with T cells genetically modified to express a TCR.  In contrast, CARs 
recognize intact cell-surface proteins and glycolipids, so CARs are not HLA-restricted, and 
CARs can be used to treat patients regardless of their HLA types.61,63,81-83 
1.2.8 Chimeric antigen receptors preclinical background 
Preclinical experiments evaluating CAR-expressing T cells as cancer therapy were initiated in 
1993.84,85  These experiments led to a clinical trial of CAR-transduced T cells targeting the α-
folate receptor on ovarian cancer cells; no tumor regressions were observed during this clinical 
trial.86  Preclinical studies have assessed a wide variety of factors that could affect in vivo 
function of CAR-expressing T cells.  Multiple approaches for inserting CAR genes into T cells 
by using gamma retroviruses69,72-75,87-89, lentiviruses70,90-93, or transposon systems94,95 have been 
assessed.  Because all methods of T-cell genetic modification require a period of in vitro culture, 
various T-cell culture techniques have been evaluated.70,87,96  Different portions of CARs 
including antigen-recognition moieties, extracellular structural components, costimulatory 
domains such as the cytoplasmic portion of the CD28 protein, and T-cell-activation moieties 
such as the signaling domains of the CD3ζ protein can all be important to the in vivo function of 
CAR-expressing T cells, and all of these portions of CARs remain the subject of intensive 
investigation.78,87,91,97-99   
Much of the preclinical work evaluating CARs has been performed with CARs targeting the B-
cell antigen CD19.87-89,94,100-102 Data suggesting that T-cell costimulation played an important 
role in the activity of CAR-expressing T cells in vivo led investigators to add signaling moieties 
from the costimulatory molecule CD28 to CARs.89,98  These studies showed that adding CD28 
moieties to CARs enhanced antigen-specific cytokine production and proliferation by anti-CD19 
CAR T cells.98,103,104  T cells expressing CARs with CD28 signaling moieties and CD3ζ 
signaling domains were more effective than T cells expressing CARs without CD28 moieties at 
eradicating human leukemia cells from mice.103,104  Subsequently, CARs incorporating other 
signaling domains from costimulatory molecules such as 4-1BB (CD137) were developed.90  
Anti-CD19 CARs containing the signaling domains of both 4-1BB and CD3ζ were superior to 

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CARs containing the signaling domains of CD3ζ without any costimulatory domains at 
eradicating human malignant cells from mice.91,97   Similar to CD28, including 4-1BB signaling 
moieties in CARs led to increased CD19-specific proliferation and enhanced in vivo 
persistence.91  In contrast to T cells expressing a CAR with a CD28 moiety, the increased in vitro 
proliferation and prolonged in vivo persistence of T cells expressing a 4-1BB-containing CAR 
occurred whether or not the T cells were exposed to the antigen that the CAR recognized.91,97   
1.2.9 CD19 
CD19 is commonly used as the target of CAR T cells because it is expressed on most malignant 
B cells 105,106, but the only normal cells that express CD19 are B cells and perhaps follicular 
dendritic cells 106,107.  Importantly, CD19 is not expressed on pluripotent hematopoietic stem 
cells 108.  While destruction of normal B cells is a drawback to targeting CD19, several factors 
indicate that destruction of normal B cells is tolerable.  When patients receive  the anti-CD20 
monoclonal antibody rituximab, the number of normal B cells is severely depressed for several 
months 109, yet patients that receive chemotherapy plus rituximab do not have an increased rate 
of common infections when compared to patients who receive chemotherapy alone 110.  Finally, 
patients can be treated with intravenous infusions of IgG if necessary to increase IgG levels111. 
1.2.10 Clinical results with anti-CD19 CAR T cells 
Results from several clinical trials of anti-CD19 CAR T cells have been reported to date in peer-
reviewed papers.69,70,72-74,112-116  The first evidence of antigen-specific activity of anti-CD19 CAR 
T cells in humans was generated during a clinical trial at the National Cancer Institute in a 
patient who experienced a dramatic regression of advanced follicular lymphoma.73  This clinical 
trial utilized a gamma retroviral vector to introduce an anti-CD19 CAR containing the signaling 
domains of the CD28 and CD3ζ molecules.73 The anti-CD19 CAR-transduced T cells were 
prepared by using a 24-day in vitro culture process.  The clinical treatment regimen consisted of 
lymphocyte-depleting chemotherapy followed by an infusion of anti-CD19 CAR T cells and a 
course of high-dose interleukin-2 (IL-2).  The first patient treated on this protocol had a large 
disease burden of follicular lymphoma.  This first patient experienced no acute toxicities except 
for a low grade fever that lasted for 2 days, and he obtained a partial remission (PR) that lasted 
for 32 weeks after treatment.73  Bone marrow biopsies revealed a complete elimination of 
extensive bone marrow lymphoma that was present before treatment; in addition, normal B-
lineage cells were completely eradicated from the bone marrow.73  The bone marrow B-cell 
eradication was confirmed by flow cytometry, and it persisted for over 36 weeks.73  B cells were 
also completely absent from the blood during this time, while T cells and other blood cells 
recovered rapidly.73  Seven months after the anti-CD19 CAR T cell infusion, progressive 
lymphoma was detected in the patient’s cervical lymph nodes.  The lymphoma remained CD19+, 
so the patient was treated a second time with anti-CD19 CAR T cells.  The first and second 
treatment regimens were the same except the patient received a higher dose of cells with the 
second treatment.  After the second treatment, the patient obtained a second partial remission that 
is ongoing over 5 years post-treatment.72    
Seven more patients were subsequently treated with the same regimen of chemotherapy, anti-
CD19 CAR T cells, and high-dose IL-2.72  In 4 of 7 evaluable patients on the trial, administration 
of anti-CD19 CAR T cells was associated with a profound and prolonged B-cell depletion.72,73  
In all 4 patients with B-cell depletion, the depletion lasted for over 36 weeks. The B-cell 

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depletion could not be attributed to the chemotherapy that was administered because blood B-
cells recovered to normal levels in 8 to 19 weeks in patients receiving the same chemotherapy 
plus infusions of T cells targeting NY-ESO or gp100, which are antigens that are not expressed 
by B cells.73  Because normal B cells express CD19, prolonged normal B-cell depletion after 
anti-CD19 CAR T-cell infusions demonstrated that CAR-expressing T cells had a powerful 
ability to eradicate CD19+ cells in humans.  All of the patients with long-term B-cell depletion 
obtained either complete or partial remissions of their malignancies, and the 4 patients with long-
term B cell depletion also developed hypogammaglobulinemia.  Hypogammaglobulinemia in 
these patients was routinely treated with infusions of intravenous immunoglobulins.  Of the eight 
patients treated, seven patients were evaluable for malignancy response; the one patient who was 
not evaluable died with pneumonia caused by influenza A.72  Six of the seven evaluable patients 
had remissions of their malignancies.  Two of the remissions were complete remissions (CRs) of 
CLL.72  Both of these CRs were confirmed by multicolor flow cytometry of bone marrow cells.72  
One of these CRs lasted 24 months, and the other is ongoing at 48 months.72  Most patients 
treated with this regimen of chemotherapy, anti-CD19 CAR T cells, and IL-2 experienced 
significant acute toxicities including fever, hypotension, and neurological toxicities such as 
delirium and obtundation.72  All of these toxicities peaked within 10 days after the cell infusion 
and resolved less than 3 weeks after the cell infusion.72  These acute toxicities correlated with 
serum levels of the inflammatory cytokines tumor necrosis factor and interferon-γ, and T cells 
producing these inflammatory cytokines in a CD19-specific manner were detected in the blood 
of patients after the anti-CD19 CAR T cell infusions.72  In our experience, patients with CLL and 
ALL tended to have more violent cytokine release syndromes than did patients with lymphoma.  
The severity of cytokine-release syndrome in patients leukemia tends to correlate with disease 
burden in our experience.  Patients with lymphoma tend to have a more varied clinical course 
with some patients experiencing hypotension and tachycardia, while others had isolated 
neurological toxicity.  
We continued studies using the same CAR as in our previously reported anti-CD19 CAR T-cell 
reports.  In these more recent studies, IL-2 was not administered to patients and the T-cell 
production process was shortened from 24 days to 10 days.  The elimination of IL-2 
administration was done in an attempt to lessen toxicity, and the shortening of the cell production 
process was done in an attempt to both simplify the cell production and to increase in vivo T-cell 
persistence and proliferation.  We reported the results of this modified clinical protocol in a very 
recent paper117.  In summary this paper reported treatment of 15 patients with advanced B-cell 
malignancies.  Nine patients had diffused large B-cell lymphoma (DLBCL), 2 patients had 
indolent lymphomas, and 4 patients had chronic lymphocytic leukemia (CLL).  Patients received 
a conditioning chemotherapy regimen of cyclophosphamide and fludarabine followed by a single 
infusion of anti-CD19-CAR T cells.  Of 15 patients, 8 obtained complete remissions (CRs), 4 
patients obtained partial remissions, 1 patient had stable lymphoma, and 2 patients were not 
evaluable for response.  CRs were obtained by 4 of 7 evaluable patients with chemotherapy-
refractory DLBCL; 3 of these 4 CRs are ongoing with durations ranging from 9 to 22 months.  
Acute toxicities including fever, hypotension, delirium, and other neurological toxicities 
occurred in some patients after infusion of anti-CD19-CAR T cells; these toxicities resolved 
within 3 weeks after cell infusion.  One patient died suddenly of an unknown cause 16 days after 
cell infusion.  CAR T cells were detected in the blood of patients at peak levels ranging from 9 to 

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777 CAR+ T cells/µL.  Elimination of exogenous IL-2 from our protocol did eliminate the 
toxicity that is known to occur with administration of high-dose IL-2, but cytokine-release type 
toxicity attributable to the CAR T cells still remained. 
In an attempt to further reduce the overall toxicity of our anti-CD19 CAR treatment protocol, we 
substantially reduced the dose of the chemotherapy regimen administered before CAR T-cell 
infusions.  We treated 9 patients with B-cell lymphoma who received a single infusion of 1x106 
anti-CD19-CAR-expressing T cells/kg bodyweight preceded by a low-dose chemotherapy 
regimen of 3 daily doses of cyclophosphamide 300 mg/m2 and fludarabine 30 mg/m2 
administered on the same days.  Eight of the 9 patients had DLBCL that was refractory to 
chemotherapy (chemo-refractory) or had relapsed less than 1 year after autologous stem cell 
transplantation.  Both of these clinical situations carry a grim prognosis, with median survivals of 
only a few months.  Despite the very poor prognosis of our patients, one patient with DLBCL 
obtained a CR and 4 DLBCL patients obtained PRs.  The PRs included complete resolution of 
large lymphoma masses.  Compared to our previous experience with anti-CD19 CAR T cells 
preceded by high-dose chemotherapy, toxicity was reduced when CAR T cells were infused after 
low-dose chemotherapy.  None of the 9 patients treated with low-dose chemotherapy and CAR T 
cells required vasopressor drugs or mechanical ventilation, although some patients did 
experience short-term neurological toxicity.  As expected, the severity of neutropenia and 
thrombocytopenia was reduced with the low dose chemotherapy compared to high-dose 
chemotherapy.  Blood anti-CD19 CAR T cell levels have been assessed in 6 patients with a 
quantitative PCR assay that can detect cells containing the CAR gene; we detected CAR+ cells 
in the blood of all 6 patients.  These results demonstrate that anti-CD19 CAR T cells 
administered after low-dose chemotherapy have significant activity against chemo-refractory 
DLBCL and could potentially become a standard treatment for patients with lymphoma.  
The effectiveness of anti-CD19 CAR T cells against advanced B-cell malignancies, particularly 
CLL and ALL has been reported by multiple groups92,114-116,118  Multiple groups have recently 
demonstrated the 70% to 90% complete remission rates when anti-CD19 CAR T cells are used to 
treat ALL114,116,118  These impressive response rates have been associated with significant 
toxicity that can be divided into 2 main categories.   The first category is “cytokine-release 
syndrome” that consists mainly of fever, tachycardia, hypotension, fatigue, and in some cases 
myocardial dysfunction; these toxicities typically last for a few days to approximately 2 weeks 
before resolving114,116,118 .  The second main category is neurological toxicity that sometimes 
occurs in patients not suffering from the typical cytokine-release syndrome toxicities.  
Commonly observed neurological toxicities include aphasia, tremor, seizures, and ataxia; similar 
to other toxicities, the neurological toxicities typically last from 1 or two days to 3 weeks before 
resolving116,118 .   
This clinical trial will also enroll patients who have had allogeneic hematopoietic stem cell 
transplants alloHSCT in the past.  The cells for producing anti-CD19 CAR T cells will be 
obtained from the transplant recipients (patients with malignancy) rather than the transplant 
donors.   In prior experience, administration of anti-CD19 CAR T cells, either T cells derived 
from normal transplant donors or from transplant recipients, graft-versus-host disease incidence 
has been extremely low 114,119,120 .   In our own experience with donor-derived allogeneic anti-
CD19 CAR T cells, no patient has developed acute GVHD out of a total of 19 patients treated 

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(unpublished data and 119).  Despite the low GVHD rate, many alloHSCT patients with persisting 
B-cell malignancies have obtained remissions on clinical trials of anti-CD19 CAR T cells 114,118-
120.     
1.2.11 Anti-CD19 CAR development and preclinical testing 
We designed a CAR that incorporated a single chain variable fragment (scFv) from the fully-
human anti-CD19 antibody 47G4121.  The 47G4 antibodies was derived by immunizing mice 
transgenic for human immunoglobulin genes.  This CAR also contained the hinge and 
transmembrane regions of the human CD8-alpha molecule, the cytoplasmic part of the CD28 
molecule, and the cytoplasmic region of the CD3-zeta molecule.  The CAR gene is encoded by a 
self-inactivating lentiviral vector122.  The CAR was designated LSIN-47G4-CD828Z.  LSIN 
stands for self-inactivating lentivirus.  A diagram of the CAR is shown in Figure 1.  After 
transductions, we found high levels of cell surface expression of the anti-CD19 CAR on the 
transduced T cells (Figure 2). 
Figure 1:    A diagram of the CAR 
 
 
 
 
Figure 2: the anti-CD19 CAR on the transduced T cells 
 
 
 
 
 
 
 
 
Figure 2 shows anti-CD19 CAR expression on T cells from Donor 1 five days after transduction 
with lentiviruses encoding the LSIN-47G4-CD828Z CAR.  Transductions were carried out 2 
days after the cultures were started, so the T cells had been in culture for a total of 7 days at the 
time of this analysis.  The plots are gated on live, CD3+ lymphocytes. 
We also performed a series of in vitro assays to assess the function of anti-CD19-CAR-
expressing T cells, and we found that CD19-CAR-expressing T cells exhibit CD19-specific 
activities including CD107a upregulation and cytokine production in vitro.  These experiments 
showed that anti-CD19-CAR-expressing T cells are activated in an antigen-specific manner. 
47G4-CD828Z 
Untransduced 
CD8 
CAR+ 
CD28   
CD8 hinge+TM 
CD3ζ 
Anti-CD19 scFv   
3’SIN LTR   
MSCV promoter 
5’SIN LTR   

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Figure 3: Upregulation of CD107a 
 
 
 
 
 
 
 
Figure 3shows upregulation of CD107a, which indicates degranulation and correlates with 
cytotoxicity123, when anti-CD19 CAR-expressing T cells from Donor 1 were cultured with the 
CD19-expressing cell line CD19-K562.  CD107a was not upregulated when anti-CD19-CAR-
expressing T cells from Donor 1 were cultured for 4 hours with the negative control cell line 
NGFR-K562, which does not express CD19.  Untransduced T cells from Donor 1 did not 
upregulate CD107a when cultured with either CD19-K562 or NGFR-K562.  The plots are gated 
on live CD3+ lymphocytes.  The T cells depicted in Figure 3 are from the same cultures as the 
cells shown in Figure 4 and were used in this experiment on the same day of culture as the cells 
shown in Figure 2.  
It is critical to test any new CAR for specificity.  To test for specificity, we cutured CAR-
expressing T cells or untransduced T cells from the same patient with target cells overnight, and 
then performed a standard IFNγ (enzyme-linked immunosorbent assay) ELISA to see if T cells 
are activated, as indicated by IFNγ release, when the T cells are cultured with particular target 
cells (Table 1).  Ideally, the anti-CD19 CAR T cells should only react with CD19+ target cells.  
We performed ELISA assays on culture supernatant from overnight co-cultures of T cells plus 
either CD19+ or CD19-negative target cells.   T cells transduced with the anti-CD19 CAR 
produced large amounts of IFNγ when they were cultured overnight with the CD19-expressing 
cell lines but only small amounts of IFNγ when cultured with CD19-negative cell lines or CD19-
negative primary human cells (Table 1).    In all of the experiments reported in Table 1, effector 
T cells from a patient were either transduced with 47G4-CD828Z or left untransduced (UT).  All 
numbers in the table are IFNγ levels in picograms/mL.  The CD19+ target cells used in these 
experiments were, primary chronic lymphocytic leukemia cells (CLL), the CD19+ lymphoma 
cell line SU-DHL-4, the NALM6 ALL cell line, and the Toledo lymphoma cell line.  These 
CD19-negative cell lines were used: melanoma cell line 624, the leukemia cell line NGFR-K562, 
the T-cell leukemia cell line CEM, Saos-2 (a bone sarcoma cell line); A549 (a lung carcinoma 
cell line); MDA-MB231 (a breast cancer cell line), 293T (a human embryonic kidney cell line), 
TC71 (a Ewings sarcoma cell line), COLO205 (a colon carcinoma cell line), U251 (a 
glioblastoma cell line). Panc10.05 (a pancreatic carcinoma cell line), and A431-H9 (an 
epidermoid (skin) carcinoma cell line that was transduced with the gene for mesothelin).  
Fibroblasts were primary human skin fibroblasts; endothelial cells were primary human 
endothelial cells. The primary microvascular endothelial cells and primary hepatocytes were 
CD8 
CD107a 
CD19-K562                             NGFR-K562 

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from Lonza.  The primary human cardiac myocytes were from Dr. Yongshun Lin, NHLBI, NIH 
In each experiment, the result for effector T cell cultured alone was also given.   
Table 1: Specificity of 47G4-CD828Z-transduced T cells 
Experiment 1 
Effector T cells 
CLL 
SU-DHL4 
624 
NGFR-
K562 
CEM 
T cells 
alone 
% CAR 
expressing 
47G4-CD828Z 
1625 
1238 
31 
37 
43 
19 
32.4 
Untransduced 
17 
23 
20 
14 
<12 
<12 
_ 
 
Experiment 2 
Effector T cells 
CD19-
K562 
CLL 
A549 
MDA-
MB231 
293T 
TC71 
CEM 
T cells 
alone 
% CAR 
expressing 
47G4-CD828Z 
29198 
3922 
<12 
<12 
26 
26 
171 
101 
36 
Untransduced 
431 
123 
<12 
<12 
143 
28 
21 
<12 
- 
 
Experiment 3 
Effector T cells 
NAL
M6 
CD19-
K562 
COL
O205 
U251 
Fibro
blasts 
Endothelial 
cells 
CEM 
T cells 
alone 
% CAR 
expressing 
47G4-CD828Z 
2784 
6985 
35 
33 
73 
36 
74 
53 
49.2 
Untransduced 
48 
98 
18 
15 
36 
16 
ND 
ND 
 
 
Experiment 4 
Effector T cells 
NALM6 
Toledo 
Panc10.05 
A431-
H9 
Saos-2 
CEM 
T cells 
alone 
% CAR 
expressing 
47G4-CD828Z 
2219 
1782 
31 
28 
23 
22 
17 
65.6 
Untransduced 
202 
159 
76 
65 
41 
75 
31 
- 
 
Experiment 5 
Effector T cells 
NALM6 
Primary cardiac 
microvascular 
endothelial cells 
Primary 
cardiac 
myocytes 
Primary 
hepatocytes 
HH 
CEM 
T cells 
alone 
47G4-CD828Z 
13746 
28 
21 
26 
96 
62 
27 
Untransduced 
136 
12 
12 
12 
26 
14 
<12 
 
LSIN-47G4-CD828Z-transduced T cells also proliferated in a CD19-specific manner.   

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Figure 4 shows a carboxyfluorescein diacetate,succinimidyl ester (CFSE) proliferation assay in 
which anti-CD19-CAR-transduced T cells were cultured for 4 days with either CD19-K562 cells 
or CD19-negative NGFR-K562 cells.  CFSE was diluted to a greater degree, indicating more 
proliferation, when the T cells were cultured with CD19-K562 target cells (solid histogram in 
Figure 4) compared to when anti-CD19-CAR T cells were cultured with CD19-negative NGFR-
K562 target cells.  The assay was conducted as described previously.124 
 
Figure 4: T cells were cultured with CD19-K562 target cells 
 
 
 
 
 
 
Figure 5 shows a comparison between LSIN-47G4-CD828Z and the CAR currently being used 
in NCI anti-CD19 CAR clinical trials, MSGV-FMC63-28Z.  In the experiment depicted in 
Figure 5, immunocompromised NSG mice were engrafted with NALM6 leukemia cells in a 
manner to form a solid mass.  Mice were then treated with a single infusion of  T cells that were 
transduced with either LSIN-47G4-CD828Z or MSGV-FMC63-28Z.  T cells expressing either 
CAR were able to eliminate tumors in the mice, and clear superiority of one CAR over the other 
has not been established in this model. 
Figure 5: Comparison between LSIN-47G4-CD828Z and the CAR currently being used in NCI 
anti-CD19 CAR clinical trials 
 
We constructed 2 CARs that had the same 47G4 scFv as LSIN-47G4-CD828Z.  Each of these 
CARs also contained the hinge and transmembrane regions of the human CD8-alpha molecule 
and the cytoplasmic region of the CD3-zeta molecule.  These CARs were encoded by the same 
lentiviral vector as LSIN-47G4-CD828Z.  These CARs had different costimulatory domains than 
LSIN-47G4-CD828Z, either CD27 or both CD27 and CD28.  We established NALM6 human 
  Normalized  
       event  
      number 
CFSE 

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CD19+ acute lymphoblastic leukemia cell line tumors in immunodeficient mice. In this model, 
the NALM6 cells formed a solid subcutaneous mass; in addition, systemic spread of the tumor 
cells to the blood and spleen also took place.  We allowed sizable tumors to develop over 6 days 
then we treated the mice with a single intravenous infusion of anti-CD19-CAR-transduced 
human T cells.  After infusion of LSIN-47G4-CD828Z CAR T cells,  regressions of tumors 
occurred between day 6 and day 15 after the T cell infusion, and a sizable fraction of mice 
receiving anti-CD19-CAR T cells were cured (Figure 6 and Figure 7) 124.   In contrast, tumors 
continued to increase in size in untreated mice and in all mice receiving infusions of T cells 
expressing CARs containing CD27 moieties even when the CD27 moiety was combined with a 
CD28 moiety.  This inability of CD27-containing CARs to eradicate established NALM6 tumors 
is unexplained, but it was repeated in multiple experiments.  All 3 CARs used in this experiment 
functioned well in vitro.  The mice receiving infusions of anti-CD19-CAR-transduced T cells 
had no signs of toxicity during this experiment. 
Figure 6:  
 
In the experiments depicted in (Figure 6 and Figure 7, anti-CD19-CAR T cells were infused on 
Day 0, and no other treatments were administered.  In the experiments reported in Figure 7, 
there were 5 mice in each group except the LSIN-47G4-CD82827z group, which had 4 mice.   
The experiment was terminated at day 40 because NSG mice receiving infusions of human T 
cells eventually develop graft-versus-host disease, which confounds experimental results. 
Figure 7 
 

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1.2.12 Rationale for immunosuppressive chemotherapy and selection of lymphocyte-depleting 
Chemotherapy regimen 
We plan to administer a conditioning chemotherapy regimen of cyclophosphamide and 
fludarabine before infusions of anti-CD19-expressing T cells because substantial evidence 
demonstrates an enhancement of the anti-malignancy activity of adoptively-transferred T cells 
when chemotherapy or radiotherapy are administered before the T cell infusions.1,2,125  In mice, 
administering chemotherapy or radiotherapy prior to infusions of tumor-antigen-specific T cells 
dramatically enhanced the anti-tumor efficacy of the transferred T cells.1-3,61,65,125  Administering 
chemotherapy or radiotherapy enhances adoptive T-cell therapy by multiple mechanisms 
including depletion of regulatory T cells and elevation of T-cell stimulating serum cytokines 
including interleukin-15 (IL-15) and interleukin-7 (IL-7), and possibly depletion of myeloid 
suppressor cells and other mechanisms.1-3,126  Removal of endogenous “cytokine sinks” by 
depleting endogenous T cells and natural killer cells caused serum levels of important T-cell 
stimulating cytokines such as IL-15 and IL-7 to increase, and increases in T-cell function and 
anti-tumor activity were dependent on IL-15 and IL-7.1  Experiments in a murine xenograft 
model showed that regulatory T cells could impair the anti-tumor efficacy of anti-CD19 CAR T 
cells.127  Myeloid suppressor cells have been shown to inhibit anti-tumor responses.126  
Experiments with a syngeneic murine model showed that lymphocyte-depleting total body 
irradiation (TBI) administered prior to infusions of anti-CD19-CAR-transduced T cells was 
required for the T cells to cure lymphoma.102   In these experiments, some mice received TBI, 
and other mice did not receive TBI.  All mice were then challenged with lymphoma and treated 
with syngeneic anti-CD19-CAR T cells.  Mice receiving TBI had a 100% cure rate and mice not 
receiving TBI had a 0% cure rate.102  
Strong suggestive evidence of enhancement of the activity of adoptively-transferred T cells has 
been generated in humans.69,128,129  Very few clinical responses have occurred and very little 
evidence of in vivo activity has been generated in clinical trials of autologous anti-CD19-CAR T 
cells administered without lymphocyte-depleting chemotherapy.69,74  In contrast, many 
regressions and evidence of long-term B-cell depletion have occurred in clinical trials in which 
patients received anti-CD19-CAR T cells after lymphocyte-depleting chemotherapy.70,72,73,92   
The chemotherapy regimen that best increases the anti-malignancy efficacy of CAR-expressing 
T cells is not known, but the most commonly used chemotherapy regimens that have been used 
in clinical trials and that convincingly demonstrate persistence and in vivo activity of adoptively 
transferred T cells have included cyclophosphamide and/or fludarabine.70-73,128,129  Both 
cyclophosphamide and fludarabine are highly effective at depleting lymphocytes.128,129  One 
well-characterized and commonly used regimen is the combination of 300 mg/m2 of 
cyclophosphamide administered daily for 3 days and fludarabine 30 mg/m2 administered daily 
for three days on the same days as the cyclophosphamide.130  Multiple cycles of this regimen can 
be tolerated by heavily pretreated leukemia and lymphoma patients.130    
1.2.13 Rationale for dose-escalation and repeated chemotherapy plus CAR T-cell treatments 
The clinical trial described in this protocol is planned as a dose escalation in which the number 
of anti-CD19-CAR T cells administered to patients will be increased with sequential dose levels.  
The rationale for conducting a dose-escalation trial of a cellular therapy is based on two main 
sources of evidence.  First, the anti-tumor efficacy of adoptively-transferred T cell treatments 

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increases as the dose of T cells administered to mice increases.131-133  Second, in the setting of 
allogeneic transplantation, relapsed malignancy is often treated with infusions of allogeneic 
donor lymphocytes (DCIs).134,135  The incidence of graft-versus-host disease, which is caused by 
T cells attacking allogeneic antigens on host tissues, increases as the dose of T cells administered 
in DCIs increases’.134,135    
In addition to sequentially escalating the dose of T cells administered with the first treatment 
received by patients on sequential dose levels, second and third treatments will be a planned part 
of the protocol.  The doses of cells received with the second treatment will be 3-fold higher than 
the dose received with the first treatment, and the dose of CAR T cells received with the 3rd 
treatment will be 3-fold higher than the dose received with the second treatment.  Administration 
of second and third treatments will involve both the same chemotherapy conditioning regimen 
given with the first treatment as well as an infusion of CAR T cells.  Second and third treatments 
will only be administered if the patient has measurable residual malignancy 2 months after the 
most recent prior treatment, and the patient did not experience dose-limiting toxicity with the 
most recent prior treatment.  The rationale for administering second and third treatments comes 
from the allogeneic transplant field where intra-patient dose escalation of donor lymphocyte 
infusions is a standard practice 44.  The planned dose escalation will allow for a more intensive 
treatment in only those patients who clearly still require additional treatment of some type 
because of their measurable residual malignancy.   Intra-patient dose escalation adds to the safety 
of the treatment because the response of each patient to prior treatments can be used to judge the 
risk of subsequent treatments.  Only those patients not experiencing DLTs with prior treatment(s) 
will receive a subsequent treatment.  Intra-patient dose escalation is especially promising for the 
CAR T-cell field because the toxicity experienced by individual patients varies widely.  Starting 
with a low or moderate dose of T cells is prudent, and intra-patient dose escalation will allow a 
higher dose of T cells for those patients needing a more intensive treatment to eradicate 
persisting malignancy.   The intra-patient dose-escalation strategy will be made feasible by the 
use of cryopreserved cell products. 
1.2.14 Rationale for a fully-human CAR 
Immune responses against genetically-modified T cells have previously been reported 113,136,137.  
Because treatment with anti-CD19 CAR T cells is expected to eliminate recipient B cells, the 
most concerning type of immune response against anti-CD19 CAR T cells is a cytotoxic T-cell 
response directed against foreign components of the CAR.  Such cytotoxic T-cell responses 
against suicide-gene-modified T cells have previously been documented 136.  The CARs used in 
all published CAR studies to date used antibody components that were derived from murine 
antibodies.  It would be expected that in at least some patients these murine components would 
be immunogenic.  Supporting this belief are data from a small number of patients that indicate 
that T-cell responses can develop against the FMC63 single chain variable fragment (scFv) that 
is a part of most anti-CD19 CARs that are currently being tested.  Jensen and coworkers and Lee 
and coworkers have reported T-cell responses against the FMC63 murine scFv 113,137.  Riddell 
and coworkers have reported cytotoxic T-cell responses against the FMC63 scFv (Riddell, 
Presentation at the American Society of Hematology Annual Meeting, 2013).  Because this 
protocol intends to give patients multiple doses of CAR-modified T cells, the risk of developing 
anti-CAR immune responses is possibly even higher than in most previous clinical trials that 
only administered a single infusion of CAR T cells.  All in all, use of a fully-human CAR will 

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decrease the risk of anti-CAR T-cell responses that we hypothesize could interfere with CAR T-
cell efficacy especially when multiple infusions of T cells are given.   
     The use of a fully-human CAR might increase persistence of CARs after a first dose of CAR 
T cells.  In our ongoing trials of murine anti-CD19 CARs, persistence of CAR T cells in the 
blood has been limited (Figure 8 )117, we hope that the fully-human anti-CD19 CAR will have 
longer persistence.  The graphs shown in Figure 8 are absolute numbers of CAR T cells in the 
blood of 5 patients as determined by a quantitative PCR assay that is specific for the CAR.  
These results show the usual pattern of T-cell persistence with the current anti-CD19 CAR used 
in ETIB CAR trials.  The CAR is called FMC63-28Z, and it contains a murine scFv.  After 
infusion, CAR T cells rapidly rise to a peak.  The cells do not persist in the blood long-term.  
Cells were undetectable in the blood by approximately 2 months after infusion. 
Figure 8; absolute numbers of CAR T cells in the blood of 5 patients 
 
1.2.15 Use of T cells from patients with malignancy versus healthy donor T cells to produce 
anti-CD19 CAR T cells 
While most clinical trials have assessed anti-CD19 CAR therapy in patients who had not 
undergone alloHSCT, some trials have addressed this question.  The trials fall into 2 main 
categories, those in which the CAR T cells were from the patient with malignancy 
(autologous)118,137 and those in which the CAR T cells were from normal healthy donors 
(allogeneic) 119,120.  Success has been seen with both approaches, and sufficient data has not 
been accrued to determine which approach is best.  The main advantage of use of autologous cells 
from the patient with malignancy is convenience as it avoids the need for a donor.  Potential 
advantages to use of use of allogeneic healthy donor-derived T cells are numerous.  First, many 
patients with advanced malignancy post-transplant have low lymphocyte counts, so use of healthy 
donor-derived cells allows collection of sufficient cells for CAR T-cell production.  Second, 
healthy donor-derived cells, in contrast to malignancy patient-derived cells, will not have been 
exposed to multiple cycles of lymphocyte-depleting chemotherapy, so the healthy donor-derived 
T cells might be less differentiated and contain a higher fraction of naïve and central memory T 
cells.  Naïve and central memory T cells have greater proliferative capacity than more 
differentiated T cells138, and might be more effective for treating malignancy139.   Another 
potential advantage of healthy donor T cells is that they are not tolerized against antigens on the 
malignant cells. 

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1.2.16 Summary of risks and potential benefits 
This clinical trial is being performed to evaluate a genetically-modified T-cell therapy for 
advanced B-cell malignancies, which are often incurable diseases 16,18,140.  Only patients with B-
cell malignancies persisting despite at least 2 prior lines of therapy will be enrolled. The risks of 
the study fall into 4 general categories.  First, chemotherapy that is part of the protocol treatment 
could cause cytopenias.  As with any chemotherapy that causes neutropenia and 
thrombocytopenia, this chemotherapy could cause toxicities such as infections and bleeding. The 
second category of toxicity is cytokine-release-type toxicities such as high fevers, tachycardia, 
transient abnormalities of liver function, and hypotension.  These cytokine-release-type toxicities 
have been detected in other clinical trials of CAR T cells during the first 2 weeks after anti-CD19 
CAR T cells were infused.72,115   A third category of potential toxicities are neurological 
toxicities such as delirium, obtundation, myoclonus, seizures, headache, and transient focal 
neurological toxicities including aphasia and focal paresis.  In previous anti-CD19 CAR trials, 
cytokine-release toxicities and neurological toxicities have been limited in duration with 
toxicities generally resolving within 2 days to 3 weeks.  The fourth possible category of toxicity 
is direct damage to normal tissues by the CAR T cells.  This could happen because of unexpected 
cross-reactivity of the anti-CD19 CAR with proteins other than CD19 in vivo.  This trial will be 
the first of a CAR containing the fully-human 47G4 variable regions, so cross-reactivity with 
normal proteins is not inconceivable.  We have performed extensive testing of 47G4 CARs by 
culturing 47G4-CD28Z CAR T cells with a variety of human cell lines, and we have not seen 
recognition of cell lines that did not express CD19.  A fifth category of toxicity caused by anti-
CD19 CAR T cells is hypogammaglobulinemia due to depletion of all B cells and some plasma 
cells.  Hypogammaglobulinemia has been a complication for many patients on clinical trials of 
anti-CD19 CAR-expressing T cells.72,73  Hypogammaglobulinemia in these patients was 
routinely treated with infusions of intravenous immunoglobulins.72   
The potential benefits to subjects enrolling on this trial include the possibility that the anti-CD19-
CAR T cells can cause a significant anti-malignancy effect.  Many patients enrolled on earlier 
trials of anti-CD19 CAR T cells obtained prolonged complete remissions of advanced 
malignancies70,72,141, so there is a chance that recipients of the anti-CD19 CAR T cells that are 
being evaluated in this protocol could derive a direct benefit from participation in this trial.  In 
contrast, some patients did not obtain remissions on prior anti-CD19 CAR trials and in some 
patients the remissions were not lasting, so further research aimed at improving anti-CD19 CAR 
T-cell therapies is needed.  Patients might also derive a benefit from knowing that they are 
contributing to the development of new cellular therapies for cancer.  Aiding in the development 
of new therapies might help future patients. 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT  
2.1 
ELIGIBILITY CRITERIA 
Note: if a patient meets an eligibility requirement as outlined below and is enrolled on the 
protocol but then is found to no longer meet the eligibility requirement after enrollment but 
before the start of protocol treatment, the treatment will be aborted or delayed. 

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2.1.1 Inclusion Criteria 
2.1.1.1 Malignancy criteria 
• Patients with the following malignancies are potentially eligible:  any B-cell lymphoma, 
and chronic lymphocytic leukemia (CLL).  Patients with indolent malignancies that have 
transformed to diffuse large B-cell lymphoma are eligible. 
• Clear CD19 expression must be uniformly detected on 75% or more of malignant cells 
from either bone marrow or a leukemia or lymphoma mass by flow cytometry or 
immunohistochemistry.  These assays must be performed at the National Institutes of 
Health.  It is preferable but not required that the specimen used for CD19 determination 
comes from a sample that was obtained after the patient’s most recent treatment.  If paraffin 
embedded unstained samples of bone marrow involved with malignancy or a lymphoma 
mass are available, these can be shipped to the NIH for CD19 staining; otherwise, new 
biopsies will need to be performed for determination of CD19 expression. 
• DLBCL patients must have received at least two prior chemotherapy-containing regimens 
at least one of which must have contained doxorubicin and a monoclonal antibody.  
Follicular lymphoma patients must have received at least 2 prior regimens including at 
least 1 regimen with chemotherapy.  All other lymphoma and leukemia patients must have 
had at least 1 prior chemotherapy-containing regimen. All patients with CLL or small 
lymphocytic lymphoma must have had prior treatment with ibrutinib or another signal 
transduction inhibitor. 
• Patients must have measurable malignancy as defined by at least one of the criteria 
below. 
 Lymphoma or leukemia masses that are measurable (minimum 1.5 cm in largest 
diameter) by CT scan is required for all diagnoses except CLL. All masses must be less 
than 10 cm in the largest diameter. 
 For a lymphoma mass to count as measurable malignancy, it must have abnormally 
increased metabolic activity when assessed by positron emission tomography (PET) 
scan. 
 For CLL and lymphoma with only bone marrow involvement no mass is necessary, but 
if a mass is not present, bone marrow malignancy must be detectable by flow cytometry 
in lymphoma and CLL. 
2.1.1.2   Other inclusion criteria: 
• Greater than or equal to 18 years of age and less than or equal to age 73.  
• 
Able to understand and sign the Informed Consent Document. 
• 
Clinical performance status of ECOG  0-1 
• 
Room air oxygen saturation of 92% or greater 
• 
Patients of both genders must be willing to practice birth control from the time of 
enrollment on this study and for four months after receiving the preparative regimen. 

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• 
Women of child bearing potential must have a negative pregnancy test because of the 
potentially dangerous effects of the preparative chemotherapy on the fetus. Women of 
child-bearing potential are defined as all women except women who are post-menopausal 
or who have had a hysterectomy.  Postmenopausal will be defined as women over the age 
of 55 who have not had a menstrual period in at least 1 year. 
• Seronegative for HIV antibody.  (The experimental treatment being evaluated in this 
protocol depends on an intact immune system.  Patients who are HIV seropositive can 
have decreased immune -competence and thus are less responsive to the experimental 
treatment and more susceptible to its toxicities.)  
• Patients with a known history of hepatitis B or hepatitis C are not eligible due to the risk 
of re-activation of hepatitis after prolonged B-cell depletion due to anti-CD19 CAR T 
cells. 
• Seronegative for hepatitis B antigen, positive hepatitis B tests can be further evaluated by 
confirmatory tests, and if confirmatory tests are negative, the patient can be enrolled. 
Patients with a known history of hepatitis B are not eligible. 
• Seronegative for hepatitis C antibody unless antigen negative.  If hepatitis C antibody test 
is positive, then patients must be tested for the presence of RNA by RT-PCR and be HCV 
RNA negative.  Patients with a known history of hepatitis C are not eligible. 
• Absolute neutrophil count greater than or equal to 1000/mm3 without the support of 
filgrastim or other growth factors.   
• Platelet count greater than or equal to 45,000/mm3 without transfusion support  
• Hemoglobin greater than 8.0 g/dl.   
• Less than 5% malignant cells in the peripheral blood leukocytes  
• Serum ALT and AST less or equal to 3 times the upper limit of the institutional normal 
unless liver involvement by malignancy is demonstrated. 
• Serum creatinine less than or equal to 1.4 mg/dL. 
• 
Total bilirubin less than or equal to 2.0 mg/dl.  
• 
At least 14 days must have elapsed since any prior systemic therapy prior to apheresis 
and prior to the initiation of chemotherapy (including systemic corticosteroids at any 
dose). Because this protocol requires collection of autologous blood cells by 
leukapheresis in order to prepare CAR T cells, systemic anti-malignancy therapy 
including systemic corticosteroid therapy of any dose are not allowed within 14 days 
prior to the required leukapheresis.  NOTE:  Because of the long half-life and potential to 
affect CAR T cells, 60 days must elapse from the time of administration of anti-PD-1 or 
anti-PD-L1 antibodies or other agents that in the opinion of the PI can stimulate immune 
activity and infusion of CAR T cells. 
• 
Normal cardiac ejection fraction (greater than or equal to 55% by echocardiography) and 
no evidence of hemodynamically significant pericardial effusion as determined by an 
echocardiogram within 4 weeks of the start of the treatment protocol. 

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• 
Patients must not take corticosteroids including prednisone, dexamethasone or any other 
corticosteroid for 14 days before apheresis and CAR T-cell infusion.  Patients must also 
not take corticosteroids at doses higher than 5 mg/day of prednisone or equivalent at any 
time after the CAR T cell infusion. 
• 
Patients who have been treated on other protocols of genetically-modified T cells at the 
NIH only are potentially eligible under these conditions: 
 At least 6 months have elapsed since the last genetically-modified T-cell therapy that 
the patient received and there is no evidence of replication-competent retroviruses 
(evidence must be provided from prior NIH gene-therapy protocol Principal 
Investigator) and persisting genetically-modified T cells are not detectable in the 
patient’s blood (evidence must be provided by prior NIH gene-therapy protocol 
Principal Investigator). 
2.1.2 Exclusion criteria:  
• 
Patients that require urgent therapy due to tumor mass effects or spinal cord compression. 
• 
Patients that have active hemolytic anemia. 
• 
Patients with second malignancies in addition to their B-cell malignancy are not eligible 
if the second malignancy has required treatment (including maintenance therapy) within 
the past 4 years or is not in complete remission. There are two exceptions to this 
criterion:  successfully treated non-metastatic basal cell or squamous cell skin carcinoma.    
• 
Women of child-bearing potential who are pregnant or breastfeeding because of the 
potentially dangerous effects of the preparative chemotherapy on the fetus or infant. 
• 
Active uncontrolled systemic infections (defined as infections causing fevers and 
infections requiring intravenous antibiotics when intravenous antibiotics have been 
administered for less than 72 hours), active coagulation disorders or other major 
uncontrolled medical illnesses of the cardiovascular, respiratory, endocrine, renal, 
gastrointestinal, genitourinary or immune system, history of myocardial infarction, 
history of ventricular tachycardia or ventricular fibrillation, active cardiac arrhythmias 
(active atrial fibrillation is not allowed, resolved atrial fibrillation not requiring current 
treatment is allowed (anticoagulants count as current treatment) ), active obstructive or 
restrictive pulmonary disease, active autoimmune diseases such as rheumatoid arthritis. 
• 
Patients will not be seen for screening appointments or enrolled on the protocol if they 
have been hospitalized within the 7 days prior to the screening appointment or the date of 
protocol enrollment. 
• 
Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency 
Disease).  
• 
Systemic corticosteroid steroid therapy of any dose is not allowed within 14 days prior to 
the required leukapheresis, or the initiation of the conditioning chemotherapy regimen.  
Corticosteroid creams, ointments, and eye drops are allowed. 
• 
History of severe immediate hypersensitivity reaction to any of the agents used in this 
study. 

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• 
Patients with current CNS involvement by malignancy (either by imaging or 
cerebrospinal fluid involvement or biopsy-proven). 
2.2 
SCREENING EVALUATION 
2.2.1 Screening activities performed after a consent for screening has been signed 
Note: Screening evaluation testing/procedures are conducted under the separate screening 
protocol, 01C0129 (Eligibility Screening and Tissue Procurement for the NIH Intramural 
Research Program Clinical Protocols).The following assessments must be completed 
within 30 days prior to starting the chemotherapy conditioning regimen unless otherwise 
noted (if not, then the evaluation must be repeated):  
• 
Complete history and physical examination, including, weight, height, and vital signs. 
Note in detail the exact size and location of any lesions that exist.  
• 
Confirmation of diagnosis of a B-cell malignancy by the NCI Laboratory of Pathology 
and confirmation of clear CD19 expression on greater than 75% of the malignant cells 
from either bone marrow or a lymphoma mass by flow cytometry or 
immunohistochemistry.  The sample used for this CD19 expression analysis can come 
from any time prior to enrollment on the protocol.  The sample can be a fresh biopsy or 
paraffin-fixed slides. 
• 
EKG  
• 
MRI of the brain 
• 
PET-CT if necessary, to document measurable malignancy 
• 
CT scan of neck, chest, abdomen, and pelvis if necessary, to document measurable 
malignancy. 
• 
Bone marrow biopsy with flow only if necessary, to document measurable CD19+ 
malignancy for enrollment purposes.  If not necessary for enrollment, the bone marrow 
biopsy can be delayed until the baseline evaluation.   
• 
Lumbar Puncture is required for patients with acute lymphoblastic lymphoma, and 
Burkitt's lymphoma only. 
• 
Donor venous assessment (will be performed within 6 months before apheresis.  Does not 
need to be repeated if no further apheresis needs to take place.) 
• 
Antibody screen for Hepatitis B and C; HIV, HTLV-I/II, T. cruzi (Chagas agent), West 
Nile, and syphilis (RPR) 
• 
Cardiac echocardiogram 
• 
(Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 (bicarbonate), Creatinine, 
Glucose, Urea nitrogen (BUN), Albumin, Calcium total, Magnesium total (Mg), 
Phosphorus, Alkaline Phosphatase, ALT, AST, Total Bilirubin, Direct Bilirubin, LDH, 
Total Protein, Total CK, Uric Acid) 

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• 
CBC with differential  
• 
PT/PTT 
• 
Glucose-6-phosphate dehydrogenase (G6PD) deficiency screening 
• 
Thyroid panel 
• 
Serum cortisol  
• β-HCG pregnancy test (serum or urine) on all women of child-bearing potential  
2.3 
PARTICIPANT REGISTRATION AND STATUS UPDATE PROCEDURES 
Registration and status updates (e.g., when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant 
Registration & Status Updates found here. 
2.4 
TREATMENT ASSIGNMENT PROCEDURES: 
Cohort:  
Number Name 
Description 
1 
Cohort 1 
Phase I dose escalation cohort who never 
had an alloHSCT 
 
Arms:  
Number Name 
Description 
1 
CAR T-cells + Immuno 
therapy 
All patients will be receiving starting dose: 0.66x106 anti-CD19 
CAR T cells/kg (weight based dosing) (up to a maximum dose of 
18x106 CAR+ T cells/kg) infuse on day 0 + Cyclophosphamide: 
300 mg/m2 IV infusion over 30 minutes on days -5, -4 and -3 + 
Fludarabine: 30 mg/m2 IV infusion over 30 minutes administered 
immediately following the cyclophosphamide on days -5, -4,and -
3 
Arm Assignment:  
Patients in cohort 1 will be directly assigned to arm 1. 
3 
STUDY IMPLEMENTATION 
Note: Cohort 2 (Patients who have had an HLA-matched sibling or an 8/8-matched unrelated 
donor transplant): Per amendment B this cohort has been closed to Accrual until further notice. 
3.1 
STUDY DESIGN  

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3.1.1 General study plan   
This protocol is a phase I dose-escalation study of autologous T cells that are genetically 
modified to express a fully-human anti-CD19 CAR.  The cell dose will be escalated unless 
occurrence of dose-limiting toxicities limits further escalation or until the maximum planed dose 
level is reached.  The protocol will enroll patients who have never had an allogeneic 
hematopoietic stem cell transplant (alloHSCT) and patients who have had alloHSCT.   
The protocol will enroll patients with B-cell malignancies that are resistant to standard therapies.  
Patients will be evaluated for general health with an emphasis on detecting cardiac and 
neurological abnormalities.  An assessment of CD19 expression will be an important part of the 
eligibility screening.  Patients enrolled on the study will undergo leukapheresis, and anti-CD19-
CAR-expressing T cells will be generated by transducing the patient’s T cells with a lentivirus 
encoding the anti-CD19 CAR.  Patients will receive a conditioning chemotherapy regimen of 
cyclophosphamide 300 mg/m2 daily for 3 days and fludarabine 30 mg/m2 IV daily for 3 days on 
the same days.  This is an extensively-used chemotherapy regimen that can be easily 
administered on an outpatient basis.  Two days after the end of the conditioning chemotherapy, 
patients will receive a single infusion of anti-CD19-CAR-expressing T cells.  A minimum 9-day 
hospitalization will be required after the cell infusion to monitor closely for acute toxicities.  
Patients are required to stay within 60 minutes driving time from the Clinical Center until day 14 
after the CAR T-cell infusion.  Patients will then be evaluated for toxicity, and malignancy will 
be staged at 1, 2, 3, 6, 9, and 12 months after the infusion.  
A small number of subjects may be eligible for re-enrollment if a patient is removed from the 
protocol BEFORE completing protocol therapy, and would be required to meet all eligibility 
criteria at the time of re-enrollment.  Patients will be assigned a new sequential study number for 
the reenrollment study period. Any cryopreserved anti-CD19 CAR T cells produced from a 
patient who was removed from the study can be used to treat that patient after re-enrollment.  We 
do not anticipate changes in the risk profile for the initial versus re-enrollment 
3.1.2 Planned repeat treatments 
An integral part of the protocol is a planned second treatment for patients obtaining all responses 
except continuing complete remission (CR) or progressive disease at the 1-month follow-up.  
This second treatment will include chemotherapy and a CAR T-cell infusion and will be identical 
to the first except that the Principal Investigator (PI) has the option of giving either the same cell 
dose as the first CAR T-cell infusion or a cell dose one dose level higher than the first cell 
infusion (up to a maximum dose of 18x106 CAR+ cells/kg).  A third treatment with a cell dose 
either the same as the second infusion or one dose level higher than the second cell infusion (up 
to a maximum dose of 18x106 CAR+ cells/kg) is also possible if the malignancy response is any 
response except continuing CR or progressive malignancy 1 months after the second treatment.  
Patients experiencing a dose-limiting toxicity (DLT) at any time will not be eligible for 
retreatment, and patients must continue to meet the same eligibility requirements that were 
required for original protocol enrollment to receive second or third treatments.  The eligibility 
screening (Section 2.2) will need to be repeated for each treatment except for the infectious 
disease serology.  The maximum number of treatments that a patient can receive on this protocol 
is 3. 

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3.1.3 Inclusion of patients who have had allogeneic hematopoietic stem cell transplantation 
(alloHSCT) 
This trial will enroll patients with a history of alloHSCT.  Because patients who have had an 
alloHSCT might be more prone to a variety of toxicities than patients who have not had a 
transplant and because the biology of adoptively-transferred T cells could be different in the 
allogeneic transplant setting, alloHSCT patients will be enrolled on a separate cohort than 
patients who have not had an alloHSCT.  Cohort 1 will enroll patients who have not had an 
allogeneic hematopoietic stem cell transplant, and Cohort 2 (closed as of Amendment B) will 
enroll patients who have had an HLA-(human leukocyte antigen)-matched sibling or an 8/8-
HLA-matched unrelated donor transplant.  

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3.1.4 Protocol schema 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Leukapheresis
In vitro generation of  
Anti-CD19-expressing 
T cells (7-9 days) 
Pretreatment staging 
Infusion of recipient with 
Anti-CD19-CAR-expressing T-Cells 
(Inpatient for 9-days minimum post 
infusion) 
At least 8 weeks after infusion, potential 
repeat treatments  
Follow-up 2 weeks and 1, 2, 3, 6, 9, and 12 
months post-infusion followed by continued 
long-term up follow-up. 
Outpatient or inpatient 
cyclophosphamide plus fludarabine 
conditioning chemotherapy 
Protocol enrollment screening 

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3.1.5 Dose Limiting Toxicity   
Dose-limiting toxicities are defined as the following toxicities that are possibly, probably, or 
definitely attributable to protocol interventions and occurring within 60 days of CAR T-cell 
infusion. 
• Grade 3 toxicities possibly or probably related to either the anti-CD19 CAR T cells or the 
fludarabine and cyclophosphamide chemotherapy and lasting more than 7 days 
• Grade 4 toxicities possibly or probably related to the study interventions with the 
exceptions listed below 
The following specific toxicities will not be dose-limiting toxicities: 
• Neutropenia (ANC<500/µL) lasting continuously 9 days or less 
• Anemia (Hgb<8 g/dL) lasting continuously 9 days or less 
• Grade 3 or 4 thrombocytopenia lasting 21 days or less 
• All cytopenias except neutropenia, anemia, or thrombocytopenia 
• Hypotension requiring treatment with vasopressors (norepinephrine dose of >2 
mcg/minute or equivalent, doses less than or equal to 2 mcg/minute are not a DLT) for 
120 hours or less.  The 120 hours is measured from the first institution of vasopressors 
even if vasopressors are temporarily discontinued and then re-started.  
• Fever 
• Hypophosphatemia 
• Grade 4 elevation in alanine aminotransferase, aspartate aminotransferase, or bilirubin 
that resolves to Grade 3 or less within 3 days or less 
• Grade 4 creatinine kinase elevation that resolves to Grade 3 or less within 3 days or less 
• Grade 4 prothrombin time (PT) or partial thromboplastin time (PTT) that resolves to 
Grade 3 in 3 days or less with no evidence of clinically-significant bleeding or 
thrombosis 
• Asymptomatic electrolyte disturbances regardless of grade 
For past recipients of allogeneic hematopoietic stem cell transplants only, the following will also 
be DLTs (Allogeneic Cohort 2 closed as of Amendment B) 
• Grade IV acute GVHD by 60 days after infusion of anti-CD19 T cells (see Section 
13.4) 
• Grade III acute GVHD by 60 days after infusion of anti-CD19 T cells that does not 
resolve to a Grade 0-I with corticosteroid therapy within 30 days of onset (see Section 
12.4) 
3.1.6 Dose Escalation 
The trial will be a dose-escalation with 4 dose levels based on the patient’s actual bodyweight. 

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As noted above, there will be two separate cohorts of patients enrolled on the trial, Cohort 1:  
Patients who have not had an allogeneic hematopoietic stem cell transplant (alloHSCT) and Cohort 
2: Patients who have had an HLA-matched sibling or an 8/8-matched unrelated donor transplant 
(closed as of amendment B).  Each cohort will have a completely separate dose escalation, DLTs 
occurring in alloHSCT recipients will not affect dose escalation on the cohort of patients who have 
not had an alloHSCT.  Likewise, the dose escalation of the alloHSCT patients will not be affected 
by the no-alloHSCT patient dose escalation. A separate dose MTD will be established for each 
cohort. 
The following dose escalation plan refers to the first dose of CAR T cells received by patients on 
both cohorts of the protocol.  CAR+ T cells are defined as CD3+CAR+ cells as measured by flow 
cytometry according to Department of Transfusion Medicine (DTM) SOPs.  The number of anti-
CD19-CAR-expressing T cells transferred for each dose level will be as follows:  
Table 2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Each dose level will include a minimum of 3 patients.  All cell doses will be cryopreserved cells 
thawed just before infusion.  All infusions will be preceded by the fludarabine and 
cyclophosphamide conditioning regimen.  The percentage of CAR+ T cells and the number of 
total cells to infuse to obtain the indicated numbers of CAR+ T cell will be determined prior to 
cryopreservation.  There will be a minimum of 9 days between the CAR T-cell infusion of a 
patient and the start of the conditioning chemotherapy regimen for the next patient on the same 
cohort.  This will cause a 14- day delay between sequential CAR T-cell infusions on each cohort.  
To be clear, a patient on Cohort 1 could receive an infusion of anti-CD19 CAR T cells less than 
First-dose Escalation Plan:  separate but identical dose escalation plans will 
be used for both Cohort 1 (patients who never had an alloHSCT) and Cohort 
2 (patients who have had an alloHSCT- closed as of amendment B) Doses +/- 
10% from the listed doses are acceptable. 
Dose Level 
Dose of antri-CD19 CAR T cells  
Level -1 
0.3x106 CAR+ T cells per kg of recipient bodyweight 
Level 1 
0.66x106 CAR+ T cells per kg of recipient bodyweight 
Level 2 
2.0x106 CAR+ T cells per kg of recipient bodyweight  
 
Level 3 
6.0x106 CAR+ T cells per kg of recipient bodyweight  
 
Level 4 
18.0x106 CAR+ T cells per kg of recipient bodyweight 
 

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2 weeks after the most recent infusion on Cohort 2 or vice versa. There will be a 4-week wait 
from the time of cell infusion to the last patient on a dose level of a cohort until treatment start 
(which means starting the chemotherapy) of the first patient on the next dose level of that same 
cohort. 
Following each patient’s first infusion, second and third infusions might be administered.  The 
dose of cells administered with the second dose of cells will either be the same as or 3-fold 
higher than the first dose (up to a maximum dose of 18x106 CAR+ T cells/kg).  A patient’s 
potential third dose will either be the same or 3-fold higher than the second dose up to a 
maximum dose of 18x106 CAR+ T cells/kg).  At least 8 weeks (56 days) must elapse between 
sequential cell infusions.   
Patients will be enrolled sequentially; therefore, enrollment will not proceed to a higher dose 
level until all patients have been treated in the prior cohort.  If sufficient cells cannot be grown to 
meet the criteria for the first dose of cells for the assigned dose level, the treatment will be 
aborted.  A second attempt will be made to prepare cells for the patient if the patient agrees and 
if the patient still meets all eligibility criteria.  
Should none of the first 3 patients treated on a dose level experience a DLT enrollment can start 
on the next higher dose level.  Should 1 of 3 patients experience a dose limiting toxicity on a 
particular dose level, three more patients would be treated at that dose level to confirm that no 
greater than 1/6 patients have a DLT prior to proceeding to the next higher level.  If 1/6 patients 
have a DLT at a particular dose level, accrual can proceed to the next higher dose level.  If a 
level with 2 or more DLTs in 3-6 patients has been identified, 3 additional patients will be 
accrued at the next-lowest dose for a total of 6, in order to further characterize the safety of the 
maximum tolerated dose.  The maximum tolerated dose is the dose at which a maximum of 1 of 
6 patients has a DLT. If 2 DLTs occur on dose level 1, accrual will proceed at dose level -1, as 
indicated in Table 2. 
After a maximum tolerated dose is defined, additional patients can be treated on this trial.  Up to 
8 total additional recipients can be treated with the MTD after an MTD is established.  If cell 
growth limitations preclude administration of the maximum tolerated dose, the patient will 
receive as many cells as possible up to the maximum tolerated dose.  If it proves to be 
technically impossible or impractical to achieve the higher dose levels due to cell production 
constraints and a maximum tolerated dose has not been reached, the highest achievable dose 
level will be declared the maximum feasible dose. 
3.1.6.1 Effect of repeat doses on the dose escalation plans 
Note that repeated dosing of chemotherapy plus CAR T cells for each patient is a planned part of 
the protocol for both patients who have not had allogeneic hematopoietic stem cell transplants 
(alloHSCT) and for patients who have not had alloHSCT.   
Repeat doses in which the same patient receives 2 or 3 infusions of CAR T cells will not count 
toward escalating the dose to the next dose level on the dose escalation plans for first cell infusions.  
In other words, repeat doses of CAR T cells cannot be used to accelerate the protocol dose 
escalation plan for initial T-cell infusions.  In contrast, DLTs that occur with repeat doses at a 
given dose level will preclude dose escalation of the first dose of CAR T cells administered at the 
same dose level if more than 1 of the first 3 or more than 2 of the first 6 total patients (patients 
receiving first doses+repeat doses) to receive a particular dose of CAR T cells experiences a DLT.  

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If more than 1 of the first 3 or more than 2 of the first 6 total patients on one of the cohorts to 
receive a particular dose of CAR T cells experiences a DLT, this dose will be declared the 
maximum administered dose for that cohort, and the First-dose Escalation Plan described above 
(Table 1) will be abandoned.  All subsequent doses administered to patients on that cohort (both 
repeat doses and first doses) will be one dose level lower than the maximum administered dose;  
if at least 6 patients receive this dose with no more than 1 DLT, this dose will be declared the 
maximum tolerated dose.  Note that toxicities occurring with repeat doses on Cohort 1 (no-
alloHSCT) will not affect the dose escalation of Cohort 2 (allo HSCT) and vice versa. 
Dose escalations will follow the rules outlined in the Table below. 
Table 3 
Number of Patients with 
DLT 
at a Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter up to 3 patients at the next dose level 
> 2 
Dose escalation will be stopped.  This dose level will 
be declared the maximally administered dose 
(highest dose administered).  Up to three (3) 
additional patients will be entered at the next lowest 
dose level if only 3 patients were treated previously 
at that dose. 
1 out of 3 
Enter up to 3 more patients at this dose level. 
• If 0 of these 3 patients experience DLT, 
proceed to the next dose level. 
• If 1 or more of this group suffer DLT, then 
dose escalation is stopped, and this dose is 
declared the maximally administered dose.  
Up to three (3) additional patients will be 
entered at the next lowest dose level if only 3 
patients were treated previously at that dose. 
<1 out of 6 at highest dose 
level below the maximally 
administered dose 
This is the MTD and is generally the recommended 
phase 2 dose.  
 
3.2 
DOSE MODIFICATIONS/DELAY 
Other Toxicity: 
• Patients may be removed from further treatment if they have active infections defined 
as infections causing fevers or infections requiring intravenous anti-microbial therapy 

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and intravenous anti-microbial therapy has been initiated less than 72 hours before the 
start of chemotherapy.  This means that patients are on-study but have not yet started 
treatment could have treatment cancelled or delayed; however such patients are eligible 
for treatment after the infection resolves.  If a patient experiences a grade 3 or greater 
toxicity (with the exception of cytopenias or nausea) while on-study before the CAR T-
cell infusion, the CAR T-cell infusion must be delayed until the toxicity improves to a 
grade 2 or less or cancelled.  
3.3 
STOPPING CRITERIA 
• If no responses of PR of CR occur after 2 patients are treated on the highest dose level for 
both Cohort 1 and Cohort 2, the protocol will be stopped. 
• Instructions for how to proceed when toxicity occurs will be as instructed by the dose 
escalation section of the protocol (3.1.6). 
3.4 
DRUG ADMINISTRATION 
3.4.1 Leukapheresis 
The patient will undergo a 15 liter leukapheresis (generally, 15 liters will be processed to target a 
yield of 6-10 x109 mononuclear cells) in the Department of Transfusion Medicine (DTM) 
Dowling Apheresis Clinic according to DTM standard operating procedures.  The procedure 
requires dual venous access, and takes approximately 3-4 hours to complete.  A central line will 
be placed if peripheral venous access is not sufficient.  
3.4.2 Anti-CD19-CAR-expressing T-cell preparation 
After cells are obtained by apheresis, further cell processing to generate anti-CD19 CAR-
expressing T cells will occur in the DTM according to standard operating procedures (SOPs).  
Either freshly-collected cells or cryopreserved cells can be used to initiate the cell-preparation 
process.  Peripheral blood mononuclear cells will be isolated. Sufficient cells for the initial cell 
production and 1 complete back-up cell production will be retained in the Department of 
Transfusion Medicine.  The excess cells will be sent to the Surgery Branch Cell Production 
Facility SB-CPF. Bldg. 10 3W-3808.  Phone: 240-858-3755 for cryopreservation at 200 to 300 
million PBMC per vial.  C.  The anti-CD3 monoclonal antibody OKT3 will be used to stimulate 
T-cell proliferation. The cells will be transduced by exposing them to replication-incompetent 
lentiviruses encoding the anti-CD19 CAR by using DTM SOPs.  The cells will continue to 
proliferate in culture.  Anti-CD19-CAR T cells will be cryopreserved between day 7 and day 9 of 
culture.  CAR+ T cells defined as cells staining for both CD3 and protein L in flow cytometry 
assays conducted in accordance with DTM SOPS will be quantitated by flow cytometry.  
Sufficient cells will be cryopreserved for a second dose that will be one dose-level higher (up to 
a maximum of 18x106 CAR+ T cells/kg) than the first dose.  Only for patients entering the study 
on the first 2 dose levels, sufficient cells will also be cryopreserved for a third dose that will be 
the same as the second dose or one dose level higher than the second dose (up to a maximum of 
18x106 CAR+ T cells/kg).  For example for a patient receiving a first dose of 2x106 CAR+ T 
cells/kg, sufficient cells need to be produced and cryopreserved for a second dose of 6x106 CAR+ 
T cells/kg and a 3rd dose of 18x106 CAR+ T cells/kg.  Cryopreserved cells will be used for all 
infusions unless poor cell growth precludes obtaining enough cells rapidly enough for 

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cryopreservation on day 7 of culture in which case, cells can be infused without 
cryopreservation. 
Ten vials of the infused cells will be cryopreserved for research use and stored in the Surgery 
Branch Cell Production Facility SB-CPF preclinical core.  Each vial will contain 10-20 million 
cells. 
Before cryopreservation, the percentage of T cells expressing the anti-CD19 CAR will be 
determined by flow cytometry, and this percentage of anti-CD19 CAR+ T cells will be used in 
calculating the total number of cells to be cryopreserved in a single-infusion bag to meet the dose 
requirements of the dose-escalation plan described in Table 1, Section 3.1  As noted above, cells 
for potential 2nd doses will also be cryopreserved.   For the first 2 dose levels, third infusions will 
also be cryopreserved at this time.  In addition to flow cytometry, further testing of the cells will 
take place prior to infusion to evaluate for microbial contamination, replication-competent 
lentiviruses, and viability.  Details of this testing can be found in the appropriate DTM SOPs. 
When a patient is no longer eligible for retreatment on this protocol due to meeting any of the 
off-study criteria listed in section 3.8.2, any remaining cryopreserved cells from this protocol 
will be de-identified and used for research or discarded after approval of the Principal 
Investigator of this protocol.    
Note: All cells sent to the Surgery Branch Cell Production facility will be transferred to NCI 
Frederick Biorepository. 
3.4.3 Conditioning chemotherapy and anti-CD19 CAR T-cell administration-this can be 
either inpatient or outpatient 
3.4.3.1 Overall summary of the treatment plan 
Table 4 
Drug 
Dose  
Days 
Cyclophosphamide  
300 mg/m2 IV infusion over 
30 minutes  
Daily x 3 doses on days -5, -4, 
-3 
Fludarabine 
30 mg/m2 IV infusion over 30 
minutes administered 
immediately following the 
cyclophosphamide on day 
 -5, -4, -3 
Daily x 3 doses on days -5, -4, 
-3 
 
Anti-CD19 CAR T cells 
Variable.  
Infuse on day 0 
 
3.4.3.2 Detailed treatment plan 
Day -5, -4, and -3:  Patients will receive pre-hydration with 1000 mL 0.9% sodium chloride I.V. 
over 1 to 3 hours.  
Patients will receive anti-emetics following NIH Clinical Center guidelines, but dexamethasone 
will not be administered.  One suggested regimen is ondansetron 16 to 24 mg orally on days -5, 

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-4, and -3 1 hour before chemotherapy (I.V. ondansetron can be substituted).    Patients should be 
provided with anti-emetics such as lorazepam and prochlorperazine to use at home.   
Next, on days -5, -4, and -3, cyclophosphamide at a dose of 300 mg/m2 I.V. will be diluted in 100 
ml 5% dextrose solution and infused over 30 minutes.  After the cyclophosphamide on days -5, -
4, and -3, patients will receive 30 mg/m2 I.V. fludarabine in 100 mL 0.9% sodium chloride over 
30 minutes.  Note: in patients with a creatinine clearance calculated by the CKD-EPI equation 
less than 80 ml/minute/1.73 m2of body surface are, the daily dose of fludarabine will be 
reduced by 20%.  
Following the fludarabine infusion, patients will receive 1000 mL 0.9% sodium chloride I.V. over 
1-2 hours.  Furosemide will be given if needed.   
Days -2 and -1:  No interventions except as needed for general supportive care such as anti-emetics.  
To minimize bladder toxicity, patients should increase normal oral fluid intake to at least 2 L/day. 
Day 0:  Anti-CD19 CAR T cells will be administered.  Premedication for the cell infusion will be 
given approximately 30 to 45 minutes prior to the infusion.  The premedications are acetaminophen 
650 mg orally and diphenhydramine 12.5 mg IV.  Cells will be delivered to the patient care unit 
from the Department of Transfusion Medicine.  Prior to infusion, the cell product identity label is 
double-checked by two authorized staff (MD or RN), and identification of the product and 
documentation of administration are entered in the patient’s chart as is done for blood banking 
protocols.  The cells are to be infused intravenously over 20-30 minutes.  Details of the infusion 
procedure are included in section 13.5, Appendix E. 
Days 1 to 9: Mandatory hospitalization for observation and treatment as necessary.  In addition, 
patients are required to stay within 60 minutes driving time from the Clinical Center until day 14 
after the CAR T-cell infusion.   
Guidelines for dealing with toxicities that often occur after CAR T cell infusions including 
hypotension, fever and tachycardia are given in 15.3, Appendix C.   
A CBC with differential will be obtained daily.  If the absolute neutrophil count becomes less 
than 500/microliter, filgrastim will be initiated at a dose of 300 micrograms daily 
subcutaneously for patients under 70 kg in weight and at a dose of 480 micrograms daily for 
patients 70 kg and over in weight.  Filgrastim will be given daily and then discontinued as soon as 
the absolute neutrophil count recovers to 1500/microliter. 
3.4.4 Potential repeat treatment 
• The chemotherapy component of repeat treatments will be initiated a minimum of 8 
weeks after the most recent prior CAR T-cell infusion.  There is no maximum time 
interval between treatments. 
• Patients with any response except progressive disease or continuing complete remission 
after an initial or second CAR T-cell infusion are potentially eligible for repeat treatments 
consisting of conditioning chemotherapy followed by an infusion of CAR T cells.  
• Patients experiencing a DLT with any prior treatment on this protocol will not be eligible 
for re-treatment.   

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• To be eligible for repeat treatments, patients must meet the same eligibility requirements 
listed in Section 2.1.   
o Uniform CD19 expression needs to be documented on the malignant cells after 
previous anti-CD19 CAR T-cell infusions in patients undergoing a subsequent 
CAR T-cell infusion unless a biopsy is not technically possible or is unsafe by 
interventional radiology methods. In all patients with palpable adenopathy or bone 
marrow involvement, a biopsy to evaluate for CD19 expression will be performed 
prior to 2nd and prior to 3rd treatments 
o The patients must undergo screening evaluation as listed in Section 2.2 except 
infectious disease serology is not required to be repeated unless clinically 
indicated.  Follow-up testing for retreatment will be the same as for the first 
treatment.  A maximum of 3 total treatments can be administered to any one 
patient, and at least 8 weeks must elapse between each cell infusion. 
• The dose of anti-CD19 CAR T cells administered during repeat treatments: 
o The second dose of CAR T cells will be either the same or one dose-level higher 
(up to a maximum of 18x106 CAR+ T cells/kg) than the first dose.  Whether the 
second dose will be the same as the first dose or one doses level higher than the 
first dose will be determined by the PI of the protocol based on toxicity and the 
anti-malignancy response experienced by the patient after the first dose. 
o A potential third dose will be either the same or one dose-level higher (up to a 
maximum of 18x106 CAR+ T cells/kg) than the second dose.  Whether the third 
dose will be the same as the second dose or one doses level higher than the second 
dose will be determined by the PI of the protocol based on toxicity and anti-
malignancy response experienced by the patient after the second dose. 
o If a maximum tolerated dose has been determined as stated under 3.1.4, the dose 
of cells for repeat doses will be the maximum tolerated dose. 
o It is possible that a patient might receive only 1 dose of CAR T cells even if the 
patient is eligible for repeat doses if this is the preference of either the patient or 
the PI of the protocol. 
o A maximum of 3 treatments will be administered 
3.5 
PROTOCOL EVALUATION 
3.5.1 Baseline evaluations and interventions 
The following tests must be completed within 14 days of the start of the conditioning 
chemotherapy regimen: 
• Patients must have a central venous access before the time of cell infusion.  This might 
require placement of a non-valved P.I.C.C line or other device.  Non-valved PICC lines 
are greatly preferred over valved PICC lines for this protocol. 
• Physical exam with vital signs and oxygen saturation 
• CT scan of neck, chest, abdomen, and pelvis  

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• PET-CT of the torso for all patients except patients with CLL 
• Bone marrow aspirate and biopsy:  specifically ask for CD19 immunohistochemistry 
staining of the bone marrow biopsy.  Flow cytometry must be performed.  The bone 
marrow biopsy must take place at some time after the patient’s most recent malignancy 
treatment.  Collect one tube of bone marrow aspirate to be sent to Surgery Branch Cell 
Production Facility SB-CPF. Bldg. 10 3W-3808.  Phone: 240-858-3755 for research 
purposes.    If a bone marrow biopsy was performed at the NIH as part of protocol 
screening within 4 weeks of the start of treatment, it does not have to be repeated unless 
necessary for staging. 
• Peripheral blood flow cytometry for patients with CLL 
• Neurology Consult if clinically indicated 
• G-banding cytogenetics on the bone marrow if there is a suspicion of myelodysplastic 
syndrome. 
• 250 microgram cosyntropin stimulation test if suspicious for adrenal insufficiency based 
on low serum sodium or high serum potassium or hypotension or a low serum cortisol or 
a history  of adrenal insufficiency or other clinical indication 
• Anti CMV antibody titer, HSV serology, and EBV panel, T cruzi serology, toxoplasmosis 
serology (Note: patients who are known to be positive for any of the above do not need to 
be retested; may be performed within 3 months of chemotherapy start date) 
• Blood will be collected for research purposes.  Twelve CPT tubes (8 mL each) of blood 
will be collected within 3 days prior to initiation of the conditioning chemotherapy 
regimen. This is a total of 96 mL of blood.  Some of this blood will be used for 
immunology assays and some will be used for RCL assays. This blood can be collected 
on different days as long as a total of 12 CPT tubes are collected prior to initiation of the 
chemotherapy.  Send to Surgery Branch Cell Production Facility SB-CPF. Bldg. 10 3W-
3808.  Phone: 240-858-3755. 
• In addition to the CPT tubes, draw 16 mL of blood to obtain serum for research purposes 
(2 SST tubes, 8 mL per tube) within 3 days prior to the start of the chemotherapy.  Send 
to Figg lab; For sample pick-up, page 102-11964. 
The following tests must be completed within 7 days of the start of the conditioning 
chemotherapy regimen: 
• TBNK (T, B, and NK cell) 
• Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 (bicarbonate), Creatinine, 
Glucose, Urea nitrogen (BUN), Albumin, Calcium total, Magnesium total (Mg), 
Phosphorus, Alkaline Phosphatase, ALT, AST, Total Bilirubin, Direct Bilirubin, LDH, 
Total Protein, Total CK, Uric Acid (to be repeated on  the first day of the chemotherapy 
at the discretion of the PI)  
• Serum quantitative immunoglobulins 
• ABO typing 

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• CBC with differential and platelet count (to be repeated on  the first day of the 
chemotherapy at the discretion of the PI)  
• PT/PTT 
• Urinalysis; if results are abnormal, send for urine culture 
• β-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
• C-reactive peptide (CRP) 
3.5.2 Studies to be performed during the mandatory 9-day inpatient admission after cell 
infusion 
• Vital signs including pulse oximetry will be monitored q1h x 4 hours after completion of 
the CAR T cell infusion and then every 4 hours otherwise unless otherwise clinically 
indicated. 
• Daily physical exam 
• CBC twice daily from day 0 until day 9 with differential once daily. After day 9 do a 
CBC with differential daily until discharge. 
• C-reactive peptide (CRP) within 7 days before the first dose of chemotherapy on day -5 
and daily while hospitalized. 
• TBNK on the day of CAR T-cell infusion (day 0) and day 7 after infusion 
• Chemistries twice daily starting from day 0 to day 9.  After day 9, do chemistries once 
daily until discharge: (Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 
(bicarbonate), Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total, 
Magnesium total (Mg), Phosphorus, Alkaline Phosphatase, ALT/GPT, AST/GOT, Total 
Bilirubin, Direct Bilirubin, LDH, Total Protein, Uric Acid ) 
• PT/PTT 4 days and 7 days after cell infusion 
• Other tests will be performed, as clinically indicated. 
• Research blood:  Every Monday, Wednesday, and Friday during hospitalization, starting 
on the first Monday, Wednesday, or Friday after the day of CAR T-cell infusion and 
lasting up to 14 days after infusion of CAR-transduced T cells, 56 mL of patient 
peripheral blood will be obtained (6 CPT tubes 8 mL each and 1 SST tube 8 mL).  Send 
CPT tubes to the Surgery Branch Cell Production Facility SB-CPF. Bldg. 10 3W-
3808.  Phone: 240-858-3755. Send 1 SST tube to the Figg lab; for sample pick-up, page 
102-11964. 
3.5.3 Post-infusion outpatient evaluation 
Patients will be seen at the NIH in follow-up to evaluate disease status and late problems related 
to CAR T-cell infusion at the following time-points:  +14 (+/- 1 day),  +21 (+/- 1 day), +30 (+/- 5 
days), +60 (+/- 7 days), +90 (+/- 7 days), and at 180 (+/- 14 days), 270 (+/- 14 days), and 365 
(+/- 30 days) after CAR T-cell infusion. After 12 months, the patient will be seen approximately 
every 6 months (+/- 30 days) up to three years; subsequently, patients will be seen annually (+/- 

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30 days). At all outpatient follow-up visits unless otherwise noted, patients will have the 
following tests performed to determine clinical response: 
• 6 CPT tubes of Research Blood (48 mL) will be collected to obtain blood for 
immunological testing. Send CPT tubes to the Surgery Branch Cell Production Facility SB-
CPF. Bldg. 10 3W-3808.  Phone: 240-858-3755.  EXCEPT: Day 30 after CAR T-cell 
infusion (+- 7days), a 5 liter research apheresis will be conducted to obtain cells for 
research purposes instead of 6 CPT tubes of blood.  Only if the research apheresis cannot 
be done, 30 days after anti-CD19-CAR-transduced T cell infusion, 6 CPT tubes of blood 
will be collected to obtain blood for immunological testing. 
• 1 SST tube (8 mL) of Research Blood will be obtained for serum collection.  Send 1 SST 
tube to the Figg lab; for sample pick-up, page 102-11964. 
Note: after the first year of follow-up, research blood will be reduced to 4 CPT tubes 
(32 mL total) during required protocol visits.  Research blood will not be collected after 
the 5 year follow-up. 
• CT scan of neck, chest, abdomen, and pelvis and/or PET scan at outpatient follow-up 
appointments starting 1 month after infusion (as necessary to stage malignancy only).  All 
lymphoma patients should get a PET scan at the 1 month, 2 month, and 3 month and 6 
month follow-up visits and anytime progression or relapse is suspected on the CT scan or 
anytime a PET scan is clinically indicated.  CLL patients should not get PET scans.  
• For CLL, obtain peripheral blood flow cytometry at all outpatient follow-up visits. 
• For lymphoma, post-treatment bone marrow biopsies are needed only to document CR in 
patients in CR at all other sites and with pre-treatment bone marrow lymphoma 
involvement.   For CLL, post-treatment bone marrow biopsies will only be done to 
document CR if the patient is in CR at all other sites.    Aspirate must be sent for flow 
cytometry to the lab of Dr. Maryalice Stetler-Stevenson.  CD19 staining must be 
requested for the flow cytometry.  CD19 immunohistochemistry should also be requested 
on the bone marrow biopsies.  For each bone marrow aspirate performed, send one tube 
of bone marrow aspirate to Surgery Branch Cell Production Facility SB-CPF. Bldg. 10 
3W-3808.  Phone: 240-858-3755. 
• Physical exam with vital signs and oxygen saturation 
• (Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 (bicarbonate), Creatinine, 
Glucose, Urea nitrogen (BUN), Albumin, Calcium total, Magnesium total (Mg), 
Phosphorus, Alkaline Phosphatase, ALT, AST, Total Bilirubin, Direct Bilirubin, LDH, 
Total Protein, Total CK, Uric Acid) 
• 
TBNK 
• 
Blood for serum quantitative immunoglobulins 
• 
CBC with differential. NOTE: Patients must have an additional CBC with 
differential performed at 6 weeks (+/- 5 days) and at 10 weeks (+/- 5 days) after the 
CAR T-cell infusion. 
• Gene-therapy-specific follow-up must be carried out as described in section 3.7 

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3.6 
STUDY CALENDAR (TABLE 5) 
Procedures a 
Screening/ 
Baseline 
Pre-cell 
infusion/ 
Day 0 
Day 
+7b 
Day+14 
and 
Day+21 
(+/- 1 
day) and 
Day +30 
(+/- 5 
days) 
Day +60 
(+/- 7 
days) 
Day +90 
(+/- 7 
days) 
Day 
+180 
(+/- 14 
days) 
Day 
+270 
(+/- 14 
days) 
Day 
+365 
(+/- 30 
days) 
Every 6 
month after 
day 365 up 
to 3 years 
then 
annually 
(+/- 30 days)  
Clinical Assessments 
History and PE 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs, O2 saturation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height, weight 
X 
X 
 
 
 
 
 
 
 
 
Performance Score 
X 
X 
 
 
 
 
 
 
 
 
Laboratory Assessments 
CBC with differential  
X 
X 
X 
XP 
XP 
X 
X 
X 
X 
X 
Sodium, Potassium 
Chloride, CO2, 
Creatinine, Glucose, BUN, 
Albumin, Calcium, 
Magnesium, Phosphorus, 
Alkaline Phosphatase, 
ALT, AST, T. Bilirubin, D. 
Bilirubin, LDH, Total 
Protein, CK, Uric Acid 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PT/PTT  
X 
 
X  
(also 
on day 
4) 
 
 
 
 
 
 
 
Thyroid Stimulating 
Hormone, T3 
X 
 
 
 
 
 
 
 
 
 
Quantitative 
immunoglobulins  
X 
 
 
X 
X 
X 
X 
X 
X 
X 

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Procedures a 
Screening/ 
Baseline 
Pre-cell 
infusion/ 
Day 0 
Day 
+7b 
Day+14 
and 
Day+21 
(+/- 1 
day) and 
Day +30 
(+/- 5 
days) 
Day +60 
(+/- 7 
days) 
Day +90 
(+/- 7 
days) 
Day 
+180 
(+/- 14 
days) 
Day 
+270 
(+/- 14 
days) 
Day 
+365 
(+/- 30 
days) 
Every 6 
month after 
day 365 up 
to 3 years 
then 
annually 
(+/- 30 days)  
Anti-CMV, HSV, EBV, 
t.cruzi,toxoplasma 
Xh 
 
 
 
 
 
 
 
 
 
Antibody screen for 
Hepatitis B and C; HIV, 
HTLV-I/II, T. cruzi 
(Chagas agent), West Nile, 
and syphilis (RPR) 
Xh 
 
 
 
 
 
 
 
 
 
TBNK  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
G6PD 
X 
 
 
 
 
 
 
 
 
 
Urinalysis (culture prn) 
X 
 
 
 
 
 
 
 
 
 
ABO typing 
X 
 
 
 
 
 
 
 
 
 
CT neck, chest, abdomen, 
pelvis c 
X 
 
 
Xn 
X 
X 
X 
X 
X 
X 
PET d 
X 
 
 
Xn 
X 
X 
X 
Xe 
Xe 
Xe 
Brain MRI 
X 
 
 
 
 
 
 
 
 
 
Lumbar Puncture 
Xk(  
ALLymph 
and Brk 
only) 
 
 
 
 
 
 
 
 
 
Neurology Consulte 
Xj   
 
 
 
 
 
 
 
 
 
Peripheral 
blood 
flow 
cytometry 
Xj (CLL 
only) 
 
 
X (CLL  
only) 
X (CLL 
only) 
X (CLL 
only) 
X (CLL 
only) 
X (CLL 
only) 
X (CLL 
only) 
X (CLL 
only) 
Other Specific Assessments 
Documentation of CD19 
expression by malignancy 
X 
 
 
 
 
 
 
 
 
 

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Procedures a 
Screening/ 
Baseline 
Pre-cell 
infusion/ 
Day 0 
Day 
+7b 
Day+14 
and 
Day+21 
(+/- 1 
day) and 
Day +30 
(+/- 5 
days) 
Day +60 
(+/- 7 
days) 
Day +90 
(+/- 7 
days) 
Day 
+180 
(+/- 14 
days) 
Day 
+270 
(+/- 14 
days) 
Day 
+365 
(+/- 30 
days) 
Every 6 
month after 
day 365 up 
to 3 years 
then 
annually 
(+/- 30 days)  
Serum cortisol 
X 
 
 
 
 
 
 
 
 
 
250 microgram 
cosyntropin teste 
X 
 
 
 
 
 
 
 
 
 
EKG, echocardiogram 
X 
 
 
 
 
 
 
 
 
 
RCL (replication 
competent lentivirus) 
X 
 
 
 
 
X 
X 
 
X 
Xi 
Central Venous catheter 
placement 
 
X 
 
 
 
 
 
 
 
 
Donor Venous Assessment 
X 
 
 
 
 
 
 
 
 
 
Bone marrow 
aspirate/biopsy with flow f 
X 
 
 
 
 
 
 
 
 
 
Research Blood 
 
X 
X 
Xo 
X 
X 
X 
X 
X 
Xl 
Research Apheresis 
 
 
 
Xo 
 
 
 
 
 
 
Adverse Event 
 
     X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medications  
X 
     X 
X 
X 
X 
X 
X 
X 
X 
X 
a see section 2.2 and section 3.4 for details 
 
b see section 3.4 for details of testing during hospitalization 
 
c CT scan for lymphoma and CLL patients at the indicated time-points including within 14 days of chemo start. 
 
d PET-CT at indicated time-points including within 14 days of chemo start for all lymphoma patients.  No PET-CT scans should be 
done for CLL patients unless CLL is transformed to DLBCL. 

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e only if clinically indicated or if needed to document relapse suspected on CT  
f All patients need a pre-treatment bone marrow biopsy.  Post-treatment bone marrow biopsies are only done if useful for staging.  
CLL patients only need post-treatment bone marrow biopsies if in CR at all other sites.  Lymphoma patients only need bone marrow 
biopsies post-treatment if the pre-treatment bone marrow was positive and the patient is in CR at all other sites. 
g only at 2, 3, 4, 5 year post-infusion time points, see section 3.6 for details 
 
h Patients who are known to be positive for any of these tests do not need to be retested; may be performed within 2 months of 
chemotherapy start date 
 
i  Annually RCL blood collection will only continue after the 1 year time-point if a previous RCL test has been positive 
 
j Only at Baseline 
 
k Only at Screening.  Lumbar punctures may also need to be repeated after treatment if clinically indicated. 
 
l until 5 years after infusion 
 
m Only if positive before protocol treatment or if clinically indicated 
 
n CT and PET will be performed only at day 30 
 
o For Day 30 only, a 5L apheresis will be collected instead of 6CPT tubes of blood.  If the apheresis is unable to be performed, only 
then will 6CPT tubes of blood be collected.  The 1SST of blood will be collected as normal. 
 
p An additional  CBC with diff will be performed at 6 weeks (+- 5days) and 10 weeks (+- 5days) between the regular time point visits.

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3.7 
GENE-THERAPY-SPECIFIC FOLLOW-UP 
3.7.1 Clinical Evaluation 
Long-term follow up of patients receiving gene transfer is required by the FDA and must 
continue even after the patient comes off the study for other follow-up.  Physical examinations 
will be performed and documented annually for 5 years following cell infusion to evaluate long-
term safety.  Physical exams can be performed by other physicians if clinic notes are obtained 
and retained in ETIB.  A complete blood count should be done at these physician visits for the 
first 5 years after infusion.  After 5 years, health status data will be obtained from surviving 
patients via telephone contact or mailed questionnaires for 10 additional years for a total of 15 
years after cell infusion.  
3.7.2 Testing for persistence of CAR transduced cells 
Persistence of CAR transduced cells will be assessed by quantitative PCR and/or flow cytometry 
at 1, 2, 3, 6 and 12 months after cell infusion or until they are no longer detectable or until a 
stable or decreasing level of CAR T cells is present at least 3 years after infusion.  If any patient 
shows a high level of persistence of CAR gene transduced cells or an increasing population of 
CAR gene transduced T cells at month 6 or later (by FACS staining or qPCR), the previously 
archived samples will be subjected to techniques that would allow the identification of 
predominant clonal populations of transduced cells. 
3.7.3 Replication competent lentivirus (RCL) testing 
Patients’ blood samples will be obtained for analysis for detection of replication competent 
lentiviruses (RCL) by VSV-G-specific PCR prior to cell infusion and at 3, 6, and 12 months post 
cell administration.  If all of these samples are negative for RCL, blood collection for RCL will 
be discontinued after the 12 month time-point.  
• In case of detection of replication-competent lentivirus, the following actions will be 
taken: 
a.  Immediately report the finding of RCL to the FDA, the NCI IRB, the NIH Institutional 
Biosafety Committee, the OSP, and the Indiana University Vector Production Facility 
(where the vector was made). 
b.  Repeat the S+L- and RCL PCR on the infused cells for the patient in question.  Repeat 
the RCL PCR on the sample that was found to be positive.   
c.  Have the patient come to the NIH for a clinic visit.  Perform a complete history and 
physical exam.  Draw blood for a complete blood count with differential, flow cytometry 
to assess T, B, and NK cell numbers in the blood, repeat RCL PCR, perform standard HIV 
screening, repeat PCR to assess for the presence of CAR-expressing T cells in the blood.  
Perform a bone marrow biopsy with flow cytometry, and assess the bone marrow for the 
presence of CAR-expressing T cells. 
d.  If no abnormalities requiring intervention are found after evaluating the patient, the 
patient should return monthly for a history, physical, CBC, and repeat RCL PCR tests on 
the blood. 

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3.8 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA 
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days after the last dose of study therapy. 
3.8.1 Criteria for removal from protocol therapy 
Note that the treatment consists of a conditioning chemotherapy regimen followed by a T-cell 
infusion, so off-treatment criteria mainly apply to eligibility for potential repeat treatments and 
cancellation of cell infusion for toxicity arising during the conditioning chemotherapy.  
Patients will be taken off treatment for the following: 
• Occurrence of a dose-limiting toxicity makes a patient ineligible for repeat treatments. 
• The patient no longer meets the eligibility criteria for the protocol after enrolling but 
before start of the chemotherapy conditioning regimen.  If the reason that the patient is 
not eligible can be rapidly resolved within 2 weeks, the treatment can proceed if not, the 
patient will be off-study. 
• The patient receives any other treatment for their malignancy (including corticosteroids at 
a dose higher than 5 mg/day of prednisone or equivalent) except the planned protocol 
treatment within 3 weeks of the start of the initial protocol treatment or if the patient 
receives any treatment for their malignancy at any time after their initial CAR T-cell 
infusion.  If a patient receives corticosteroids in doses greater than 5 mg/day of 
prednisone or an equivalent dose of another corticosteroid within 2 weeks of the start of 
protocol treatment, the treatment will need to be delayed or cancelled.  
• General or specific changes in the patient’s condition render the patient unacceptable for 
further treatment on this study in the judgment of the Principal Investigator.  Patient will 
be taken off study after the 30-day safety visit if they have received any part of the 
treatment. 
• Participant requests to be withdrawn from active therapy 
• Investigator discretion 
• Positive pregnancy test 
3.8.2 Off-study Criteria 
• The patient voluntarily withdraws 
• There is significant patient noncompliance 
• Death 
• Development of progressive or relapsed malignancy after the CAR T cell infusion in 
patients not desiring or not eligible for re-treatment on this protocol. 
• The patient receives any anti-malignancy therapy after the CAR T-cell infusion except 
for repeat treatments on this protocol.   
• Taking corticosteroids for any reason after CAR T-cell infusion at a dose higher than 5 
mg/day of prednisone or equivalent dose of another corticosteroid. 

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• PI decision to end this study  
Note: Patients must be followed until all adverse events that are at least possibly, probably or 
definitely attributable to protocol treatment will be followed until return to baseline or 
stabilization of event.  If an adverse event is not expected to resolve to baseline this will be noted 
in the patient medical record and the patient will be taken off study. In addition, all patients must 
be followed for the gene therapy specific follow up as outlined in section 3.7 even after being 
taken off-study.  Patients taken off-study will be enrolled on a different protocol (NCI 15-C-
0141), which has been IRB approved, specifically to continue the FDA-required gene-therapy 
follow-up.     
4 
CONCOMITANT MEDICATIONS/MEASURES 
4.1 
ROUTINE SUPPORTIVE CARE 
• Patients with a CD4 T-cell count less than 200/µL will be maintained on pneumocystis 
prophylaxis Because of the potential to cause cytopenias, trimethoprim sulfamethoxazole 
will not be used for infection prophylaxis, an alternative pneumocystis prophylaxis will 
be used.   PCP prophylaxis will be stopped after 2 consecutive CD4 counts greater than 
200/µL are documented. If ganciclovir, valganciclovir, or foscarnet are started, val- 
acyclovir or acyclovir will generally be discontinued. 
• Patients with a CD4 T-cell count less than 200/µL will be maintained on valacyclovir or 
acyclovir.  This prophylaxis will be stopped after 2 consecutive CD4 counts greater than 
200/µL are documented. 
• Patients with serum IgG level less than 400 mg/dL will receive intravenous 
immunoglobulin replacement as needed to maintain an IgG level above 400 mg/dL.  An 
example of an intravenous immunoglobulin infusion to be used for this purpose would be 
Gammunex 500 mg/kg given as a single dose.  Intravenous immunoglobulin infusions 
should be preceded by premedication with diphenhydramine and acetaminophen, and rate 
of infusion should be started at low rates and escalated in a step-wise manner. 
• Neutropenic patients will start on broad spectrum antibiotics with a first fever of 38.30 C 
or greater or two fevers of 38.0 separated by at least 1 hour and concomitant ANC < 
500/ml.  
• Aminoglycosides will be avoided unless there is clear evidence of sepsis. 
• A CBC with differential will be obtained daily.  During inpatient hospitalization within 
10 days after cell infusion, if the absolute neutrophil count becomes less than 
500/microliter, filgrastim will be initiated at a dose of 300 micrograms daily 
subcutaneously for patients under 70 kg in weight and at a dose of 480 micrograms daily 
for patients 70 kg and over in weight.  During inpatient hospitalization within 10 days of 
cell infusion, filgrastim will be given daily and then discontinued as soon as the absolute 
neutrophil count recovers to 1500/microliter. 
If an outpatient develops an absolute neutrophil count less than 1000/microliter, the 
patient will be required to stay in the Bethesda, MD area for close follow-up at the NIH 
Clinical Center until the absolute neutrophil count is above 1000/microliter for at least 2 

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days.  Any outpatient with an absolute neutrophil count less than 800/microliter will 
immediately be started on filgrastim, and filgrastim will be continued until the absolute 
neutrophil count is at least 2000/microliter. 
• Outpatients with absolute neutrophil counts less than 1000/mL will be advised to check 
their temperatures twice daily and to report to a local health care facility immediately for 
any temperature of 100.5 degrees or higher. 
• Any patient who develops a temperature of 100.5 degrees or higher during the first year 
after CAR T-cell infusion should be seen immediately at a local health care facility for a 
complete blood count with differential to detect possible neutropenia. 
• Patients with a neutrophil count less than 1000/microliter 1 month or more after CAR T-
cell infusion will get a blood quantitative PCR for CMV. 
4.2 
BLOOD PRODUCT SUPPORT 
• Leukocyte filters will be utilized for all blood and platelet transfusions with the exception 
of the CAR-transduced T cell infusions to decrease sensitization to transfused WBC and 
decrease the risk of CMV infection. 
• Patients who are seronegative for CMV should receive CMV-negative blood products 
whenever possible. 
• Using daily CBC’s as a guide, the patient will receive platelets and packed red blood cells 
(PRBC’s) as needed.  Attempts will be made to keep Hgb >8.0 gm/dl, and platelets 
>12,000/µL.   
• All blood products with the exception of the CAR-transduced T cells will be irradiated.  
4.3 
ANTI-EMETICS 
Anti-emetics will follow NIH Clinical Center Guidelines (except that corticosteroids will be 
avoided).  
4.4 
GRANULOCYTE COLONY-STIMULATING FACTOR 
During the planned inpatient admission after CAR T-cell infusion, if the absolute neutrophil 
count becomes less than 500/microliter, filgrastim will be initiated at a dose of 300 micrograms 
daily for patients under 70 kg in weight and a dose of 480 micrograms daily for patients over 70 
kg in weight.  Filgrastim will be discontinued as soon as the absolute neutrophil count recovers 
to 1500/microliter. 
4.5 
AVOIDANCE OF CORTICOSTEROIDS 
Patients should not take systemic corticosteroids including prednisone, dexamethasone or any 
other corticosteroid at any dose for any purpose without approval of the Principal Investigator. 
4.6 
GUIDELINES FOR MANAGEMENT OF COMMON ACUTE TOXICITIES THAT OCCUR AFTER 
CAR T CELL INFUSIONS 

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Please see section 13.3, Appendix C.  These are guidelines only.  It is understood that treatment 
of these toxicities must be individualized for each patient.  Not following the exact 
recommendations in Section 13.3 is not a protocol deviation. 
5 
BIOSPECIMEN COLLECTION 
Biospecimen collection on this protocol will consist of blood draws and acquisition of bone 
marrow aspirates and possible biopsies of tumors for research purposes. The amount of blood 
that may be drawn from adult patients for research purposes shall not exceed 10.5 mL/kg or 550 
mL, whichever is smaller, over any eight-week period. 
5.1 
CORRELATIVE STUDIES FOR RESEARCH  
5.1.1 Biospecimen collection before the start of the conditioning chemotherapy: 
• 
One heparinized syringe containing 5 to 8 mL of bone marrow aspirate to be sent to 
Surgery Branch Cell Production Facility SB-CPF, Bldg. 10 3W-3808, Phone: 240-858-
3755. 
• 
Blood will be collected for research purposes.  A total of 12 CPT tubes (8 mL each of 
blood will be collected prior to initiation of the conditioning chemotherapy regimen. This 
is a total of 96 mL of blood.  This blood can be collected on different days as long as a 
total of 12 CPT tubes are collected prior to the start of the chemotherapy and within 7 
days of the start of the chemotherapy.  Send to Surgery Branch Cell Production Facility 
SB-CPF, Bldg. 10 3W-3808, Phone: 240-858-3755. 
• 
16 mL of blood will be drawn to obtain serum for research purposes (2 SST tubes, 8 mL 
per tube) within 14 days prior to the start of the chemotherapy.  The SST tubes  will be 
sent to Figg lab; For sample pick-up, page 102-11964. 
• 
Specimens will be cryopreserved and assays will be performed retrospectively. 
5.1.2 Biospecimen collection after CAR T-cell infusion during the required hospitalization 
Every Monday, Wednesday, and Friday during hospitalization, starting on the first Monday, 
Wednesday, or Friday after the CAR T-cell infusion and lasting up until 14 days after infusion of 
anti-CD19-CAR-transduced T cells, 56 mL of patient peripheral blood will be obtained (6 CPT 
tubes 8 mL each and 1 SST tube 8 mL). The 1 SST tube will be sent to the Figg lab; For sample 
pick-up, page 102-11964. The 6 CPT tubes sent to Surgery Branch Cell Production Facility SB-
CPF, Bldg. 10 3W-3808, Phone: 240-858-3755. 
5.1.3 Biospecimen collection during outpatient follow-up 
• Patients will return for outpatient follow-up clinic visits 2 weeks, 1 month, 2 months, 3 
months, 6 months, 9 months and 12 months after the CAR T-cell infusion. After the 12-
month follow-up appointment patients will return for follow-up every 6 months up until 3 
years after treatment.  After 3 years, follow-up will be annual.  The specimens listed 
below will be performed at each outpatient clinic visit during the first year of follow up. 
 6 CPT tubes of Research Blood (48 mL) will be collected to obtain blood for 
immunological testing. Send CPT tubes to Surgery Branch Cell Production Facility 
SB-CPF, Bldg. 10 3W-3808, Phone: 240-858-3755.  

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 1 SST tube (8 mL) of Research Blood will be obtained for serum collection.  The 
SST tubes will be sent to Figg lab; For sample pick-up, page 102-11964 . 
After 1 year research blood collected will be reduced to 4 CPT tubes at each visit. 
• When bone marrow aspirate and biopsy is performed, part of the aspirate will be sent to 
the ETIB Preclinical Core and will be cryopreserved.   
5.1.4 Immunological Testing 
• T-cell assays: Direct immunological monitoring will consist of quantifying CD3+ T cells 
that express the CAR by quantitative PCR, and/or by flow cytometry.  These assays will 
be performed to measure the persistence and estimate the proliferation of the infused 
CAR+ T cells.  A quantitative PCR assay or a flow cytometry assay will be used to 
quantitate CAR+ T cells at all post-infusion time-points up to at least 2 months after 
infusion, and CAR+ T cell analysis will continue until the CAR+ T cell level drops to 
undetectable levels unless a stable low level of CAR+ T cells is present at more than 3 
years after infusion.  The absolute number of CAR+ PBMC will be estimated by 
multiplying the percentage of CAR+ PBMC by the absolute number of lymphocytes plus 
monoctyes per microliter of blood.  Ex vivo immunological assays might be used to 
measure the antigen-specific functional activity of the CAR+ T cells and will consist of 
assays such as enzyme-linked immunosorbent assays (ELISAs), intracellular cytokine 
staining, and anti-CD107a degranulation assays. Immunological assays will be 
standardized by the inclusion of pre-infusion recipient PBMC and in some cases an 
aliquot of the engineered T cells cryopreserved at the time of infusion.  
• Serum cytokine levels will also be measured by enzyme-linked immunosorbent assays 
(ELISAs) or similar assays.              
• Gene expression studies will be performed on patient lymphoma cells and on the infusion 
CAR T cells of each patient.  Methods used will be either Nanostring and/or RNAseq 
(RNA sequencing). 
• Patients’ blood samples will be obtained and saved for analysis for detection of 
replication competent lentiviruses (RCL) by PCR at 3 months, 6 months, and 12 
months after cell administration.  Infusion cells will be tested for RCL prior to infusion 
by PCR targeting the VSV-G gene. Blood collection for RCL monitoring will be 
discontinued if all patient samples have been negative for RCL at the 12 month time-
point. If any post-treatment samples are positive, further analysis of the RCL and more 
extensive patient follow-up will be undertaken, in consultation with the FDA.   RCL PCR 
assays are performed by the National Gene Vector Laboratory at Indiana University The 
results of these tests are maintained by the National Gene Vector Laboratory at Indiana 
University and by the Surgery Branch (SB) research team. 
• Due to nature of these studies, it is expected that expansion of specific T-cell clones will 
be observed as T-cell proliferate in response to the targeted antigen.  Therefore, care will 
be taken to track T-cell persistence, but presence of an oligoclonal T cell population does 
not indicate an insertional mutagenesis event.    If any patient shows an increasing 
population of CAR gene transduced T cells at month 6 or later (by FACS staining or 
qPCR), the previously archived samples will be subjected to techniques that would allow 

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the identification of predominant clonal populations of transduced cells.  Such techniques 
may include T cell cloning or LAM-PCR.  If a predominant or monoclonal T cell clone 
derived from CAR gene transduced cells is identified during the follow-up, the 
integration site and sequence will be identified and subsequently analyzed against human 
genome database to determine whether the sequences are associated with any known 
human cancers.  If a predominant integration site is observed, the T cell cloning or LAM-
PCR test will be used at an interval of no more than three months after the first 
observation to see if the clone persists or is transient.  In all instances where 
monoclonality is persistent and particularly in instances where there is expansion of the 
clone, regardless of whether or not the sequence is known to be associated with a known 
human cancer, the subject should be monitored closely for signs of malignancy, so that 
treatment, if available, may be initiated early. 
5.1.5 Additional biopsies and additional blood draws 
Patients might be asked to undergo biopsies (up to 3) or additional blood draws for research 
purposes. Additional blood draws might be necessary to investigate T cell responses and serum 
cytokine levels in cases of clinical events such as rapid regressions of malignancy or toxicity.  
Biopsies including open surgical biopsies, fine needle aspirations, and core needle biopsies could 
be used to investigate CAR T-cell persistence or function at tumor sites. Open surgical, fine needle, 
or core needle biopsies might also be needed in some but not all patients to confirm continued 
antigen expression by tumor cells in order to meet protocol eligibility requirements for antigen 
expression on the tumor cells before any CAR T-cell infusion.  For core needle biopsies 2 to 4 
cores will be obtained. For fine needle aspirations, 1 to 3 aspirations will be performed  Standard 
techniques will be used for biopsies which may include CT and/or ultrasound guided biopsy.  
These research biopsies or blood draws are optional, and patients can participate in this trial 
whether or not they agree to undergo biopsies for research purposes unless the biopsies are needed 
to prove that the target antigen is expressed on the tumor for protocol eligibility.  These biopsies 
will only be performed if minimal morbidity is expected based on the procedure performed and 
the granulocyte and platelet count.  Biopsy tissue will be processed in the NIH Department of 
Pathology. Studies will be performed to evaluate the antigen expression by the tumor and to 
evaluate the presence of transduced cells. Remainder material from any clinical biopsies obtained 
may also be utilized for research purposes. 
5.1.6 Future studies  
Blood and tissue specimens collected in the course of this research project may be banked and 
used in the future to investigate new scientific questions related to this study. However, this 
research may only be done if the risks of the new questions were covered in the consent 
document.  Patient PBMC not needed for future clinical use can be used for experiments aimed 
at developing new T-cell therapies not directly related to individual patients with permission of 
the PI.  If new risks are associated with the research (e.g. analysis of germ line genetic 
mutations) a protocol amendment will be required, and informed consent will be obtained from 
all research subjects to whom these new studies and risks pertain.  
5.2 
SAMPLE STORAGE, TRACKING AND DISPOSITION 

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5.2.1 Samples Sent to Figg Lab 
• Venous blood samples will be collected in either a 4-mL or an 8-mL SST tube to be 
processed for serum and stored for future research. 
o Record the date and exact time of draw on the tube. Blood tubes may be kept in the 
refrigerator until pick-up.  
o For sample pick-up, page 102-11964. 
o For immediate help, call 240-760-6180 (main Blood Processing Core number) or, if 
no answer, 240-760-6190 (main clinical pharmacology lab number). 
o For questions regarding sample processing, contact the Blood Processing Core (BPC) 
at NCIBloodcore@mail.nih.gov or 240-760-6180. 
o The samples will be processed, barcoded, and stored in the Figg lab until requested by 
the investigator. 
After delivery to the SB-CPF, peripheral blood mononuclear cell samples will be sent to the 
Head, Clinical Support Laboratory Clinical Services Program, Applied/Developmental 
Directorate Frederick National Laboratory for Cancer Research for processing and 
cryopreservation. They will be stored long-term at the NCI Frederick Repository. 
5.2.2 Sample Storage, Tracking and Disposition 
Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system. 
Should a CRIS screen not be available, the CRIS downtime procedures will be followed. All 
samples will be sent to Blood Processing Core (BPC) and/or SB-CPF for processing and/or and 
storage until they are distributed to the designated place of analysis as described in the protocol. 
Samples will not be sent outside NIH without IRB notification and an executed MTA.  
5.2.2.1 Samples Managed by Dr. Figg’s Blood Processing Core (BPC)  
5.2.2.1.1 BPC Contact Information  
Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the 
Friday before is preferred). 
For sample pickup, page 102-11964. 
For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 
240-760-6190 (main clinical pharmacology lab number). 
For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov. 
5.2.2.1.2 Sample Data Collection 
All samples sent to the Blood Processing Core (BPC) (Dr. Figg’s lab) will be barcoded, with data 
entered and stored in the Labmatrix utilized by the BPC. This is a secure program, with access to 
Labmatrix limited to defined Figg lab personnel, who are issued individual user accounts. 
Installation of Labmatrix is limited to computers specified by Dr. Figg. These computers all have 
a password restricted login screen.  

6 0  
A b bre vi ate d Titl e:  A nti - C D 1 9 C A R T -c ells   
V ersi o n D at e:  Se pte mb er 1 7, 2 0 2 0  
 
La b m atri x  cre ates a u ni q u e b arc o de I D f or e v er y s a m ple a n d s a m ple b o x, w hic h c a n n ot b e tra c e d 
b a c k t o p atie nts wit h o ut La b m atri x  a c c ess. T h e d ata re c or d e d f or e a c h s a m ple i n cl u d es t h e 
p atie nt I D, n a m e, trial n a m e/ pr ot o c ol n u m ber, ti m e dra w n, c y cle ti m e p oi nt, d os e, m aterial t y p e, 
as w ell as b o x a n d fre e z er l o c ati o n. Patie nt d e m o gra p hics ass o ciate d wit h t h e cli nic al c e nter 
p atie nt n u m b er are pr o vi de d i n t h e s yste m. F or e a c h s a m ple, t h ere are n otes ass o ciate d wit h t h e 
pr o c essi n g m et h o d ( d ela y i n s a m ple pr o cessi n g, st ora ge c o n diti o ns o n t h e w ar d, etc.).  
 
5. 2.2.1. 3  S a m ple St ora ge  a n d D estr u cti o n  
Barc o d e d s a m ples are st ore d i n b arc o d e d b o xes i n a l o c k e d fre e zer at eit h er -2 0 or -8 0 C 
a c c or di n g t o sta bilit y re q uire m e nts. T h es e free z ers are l o c ate d o nsite i n t h e B P C a n d offsite at 
N CI Fre d eric k Ce ntral Re p osit or y Ser vic e s i n Fre d eric k, M D. Visit ors t o t h e la b orat or y are 
re q uire d t o b e a c c o m p a nie d b y la b orat or y staff at all ti m es.  
A c c ess t o st ore d cli nic al s a m ples is restricte d. Sa m ples will b e st ore d u ntil re q u este d b y a 
res e arc h er n a m e d o n t h e pr ot o c ol. All re q u ests are m o nit ore d a n d tra c k e d i n La b m atri x . All 
res e arc h ers are re q uire d t o si g n a f or m stati n g t h at t h e s a m ples are o nl y t o b e us e d f or res e arc h 
p ur p os es ass o ciate d wit h t his trial (as p er t h e I R B -a p pr o v e d pr ot o c ol) a n d t h at a n y u n us e d 
s a m ples m ust b e ret ur n e d to t h e B P C. It is t h e res p o nsi bilit y of t h e N CI Pri n ci p al I n v esti gat or t o 
e ns ure t h at t h e s a m ples re q u este d are b ei n g us e d i n a m a n n er c o nsiste nt wit h I R B a p pr o v al.  
F oll o wi n g c o m pleti o n of t his st u d y, s a m ples will re m ai n i n st ora ge as d etaile d a b o ve. A c c es s t o 
t h es e s a m ples will o nl y b e gra nte d f oll o wi n g I R B a p pr o val of a n a d diti o nal pr ot oc ol, gra nti n g 
t h e ri g hts t o us e t h e m aterial. 
If, at a n y ti m e, a p atie nt wit h dra ws fr o m t h e st u d y a n d d oes n ot wis h f or t h eir e xisti n g s a m ples to 
b e utiliz e d, t h e i n di vi d u al m ust pr o vi d e a writte n re q u est. F oll o wi n g re c ei pt of t his re q u est, t h e 
s a m ples will b e d estr o y e d or ret ur n e d t o t h e p atie nt, if s o re q u este d. T h e PI will re c or d a n y l oss 
or u n a ntici p ate d d estr ucti o n of s a m ples as a d e viati o n. Re p orti n g will b e p er t h e r e q uire m e nts of 
s e cti o n 7. 2 . 
Sa m ple b ar -c o d es are li n k e d t o p atie nt d e m o gra p hics a n d li mite d cli nic al i nf or mati o n. T his 
i nf or m ati o n will o nl y b e pr o vi d e d t o i n v esti gat ors liste d o n t his pr ot o c ol, via re gistere d us e of the 
La b m atri x . It is critic al t h at t h e s a m ple re m ai ns li n k e d t o p atie nt i nf or m ati o n s u c h as ra c e, a ge, 
d ates of dia g n osis a n d d e at h, a n d hist ol o gic al i nf or m ati o n a b o ut t h e t u m or, i n or d er t o c orrelate 
ge n ot y p e wit h t h es e v aria bles.  
5. 2.3  Sa m ple St ora ge, Tra c ki n g, a n d Dis p ositi o n f or S ur ger y Bra n c h  
Sa m ples re c ei v e d b y t h e S ur ger y Bra n c h res earc h la b will b e tra c k e d usi n g p ass w or d pr otecte d 
w e b -b as e d N CI d ata b ase La b m atri x. All s p e ci m e ns will b e tra c k e d f or d ate of re c ei pt i n t h e 
S ur ger y Bra n c h la b, d ate a n al y z e d, d a te ret ur ne d t o t h e ori gi n ati n g h os pital a n d/ or d ate 
d estr o y e d. S p e ci m e ns will b e st ore d i n a l o c k e d la b orat or y c a bi net or refri gerat ors i n a l o c k e d 
res e arc h la b. All s p e ci m e ns will b e e ntere d i nt o La b m atri x wit h i d e ntific ati o n a n d st ora ge 
l o c ati o n. A c c ess t o t h e st ore d s p e ci me ns will b e restricte d. A c c ess t o La b m atri x will b e gra nte d 
u p o n PI a p pr o v al o nl y. It is t h e res p o nsi bilit y of t h e N CI PI t o e ns ure t h at t h e s p e ci m e ns are 
b ei n g us e d a n d st ore d i n a m a n n er c o nsiste nt wit h I R B a p pr o val. All s a m ples are s t ore d i n 
m o nit ore d fre e zers/refri gerat ors i n 3 N W N CI -S B la b orat ories at s p e cifie d te m perat ures wit h 
alar m s yste ms i n pla c e.  

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5.2.4 Protocol Completion/Sample Destruction 
All specimens obtained in the protocol are used as defined in the protocol.  
If the patient withdraws consent, the participant’s data will be excluded from future distributions, 
but data that have already been distributed for approved research use will not be able to be 
retrieved. 
The PI will record any loss or unanticipated destruction of samples as a deviation. Reports will 
be made per the requirements of section 7.2 
5.2.5 Samples for Genetic/Genomic Analysis 
Samples used for gene expression analysis will be RNAseq and/or NanostringTM.  These studies 
will be used to determine gene expression in lymphoma cells and infusion CAR T cells.  The 
purpose of these studies is to assess gene expression at the RNA level not to study germline 
mutations. 
5.2.5.1 Description of the scope of genetic/genomic analysis 
RNAseq and/or NanostringTM will be used to determine gene expression in lymphoma cells and 
infusion CAR T cells.  The purpose of these studies is to assess gene expression at the RNcrisA 
level not to study germline mutations.  One purpose of these studies is to determine if different 
levels of gene expression in malignant cells are associated with response to CAR T-cell therapy.  
Another purpose of these studies is to determine if different levels of gene expression in infusion 
CAR T cells are associated with anti-malignancy responses caused by CAR T cells or persistence 
of CAR T cells. 
5.2.5.2 Certificate of Confidentiality  
As part of study efforts to provide confidentiality of subject information, this study has obtained a 
Certificate of Confidentiality, which helps to protect personally identifiable research information. 
The Certificate of Confidentiality allows investigators on this trial to refuse to disclose identifying 
information related to the research participants, should such disclosure have adverse consequences 
for subjects or damage their financial standing, employability, insurability or reputation. The 
informed consent includes the appropriate coverage and restrictions of the Certificate of 
Confidentiality. 
5.2.5.3 Management of Results 
The analyses that we perform in our laboratory are for research purposes only; they are not nearly 
as sensitive as the tests that are performed in a laboratory that is certified to perform genetic testing. 
Changes that we observe unrelated to our research may or may not be valid. Therefore, we do not 
plan to inform participants of the results of testing on the tissue and blood that is performed in our 
research lab. However, subjects will be contacted if a clinically actionable gene variant is 
discovered. Clinically actionable findings for the purpose of this study are defined as disorders 
appearing in the American College of Medical Genetics and Genomics recommendations for the 
return of incidental findings that is current at the time of primary analysis. (A list of current 
guidelines 
is 
maintained 
on 
the 
CCR 
intranet: 
https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists) Subjects will 
be contacted at this time with a request to provide a blood sample to be sent to a CLIA certified 
laboratory. The CLIA testing may be funded by the PI or the CCR. If the research findings are 

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verified in the CLIA certified lab, the subject will be referred to the NCI Genetics Branch for 
genetic counseling on the implications of the results. Subjects that do not wish to return to the NCI 
will be referred to a local genetics health care provider (at their expense).  
This is the only time during the course of the study that incidental findings will be returned. No 
interrogations regarding clinically actionable findings will be made after the primary analysis.  
6 
DATA COLLECTION AND EVALUATION 
6.1 
DATA COLLECTION 
Data will be prospectively collected and entered in real time into the Cancer Center Clinical Data 
System database (NCI C3D database). It is expected that clinical data be entered into C3D no later 
than after 10 business days of the occurrence. The NCI PI and research nurse will have access to 
these data via web access. 
The medical record will maintain complete records on each patient including any pertinent 
supplementary information obtained from outside laboratories, outside hospitals, radiology 
reports, laboratory reports, or other patient records. The NCI C3D will serve as the primary source 
from which all research analyses will be performed.   
Data collection will include the eligibility criteria checklist, patient history, specialty forms for 
pathology, radiology, toxicity monitoring, and relapse data and an off-study summary sheet, 
including a final assessment by the treating physician. After patients are seen in clinic at each 
scheduled follow up, the database will be updated in real-time.  
All data will be kept secure. The PI will be responsible for overseeing entry of data into an in-
house password protected electronic system and ensuring data accuracy, consistency and 
timeliness. The principal investigator, associate investigators/research nurses and/or a contracted 
data manager will assist with the data management efforts.  
All data obtained during the conduct of the protocol will be kept in secure network drives or in 
approved alternative sites that comply with NIH security standards. Primary and final analyzed 
data will have identifiers so that research data can be attributed to an individual human subject 
participant. 
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. Document 
AEs from the first study intervention, Study Day 1, through 30 days after the study treatment was 
last administered. Beyond 30 days after the last intervention, only adverse events which are serious 
and related to the study intervention need to be recorded.   
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following: 
• 
Results in discontinuation from the study 
• 
Is associated with clinical signs or symptoms  
• 
Requires treatment or any other therapeutic intervention 
• 
Is associated with death or another serious adverse event, including hospitalization.  

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• 
Is judged by the Investigator to be of significant clinical impact 
• 
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in section 7.2.1.  
6.1.1 Adverse event recording: 
• Grade 1 adverse events will not be captured in the database. 
• All grade 2, 3, 4, and 5 adverse events will be recorded regardless of attribution. 
• All adverse events are recorded in the medical record. 
6.2 
  DATA SHARING PLANS 
6.2.1 Human Data Sharing Plan 
What data will be shared? 
I will share human data generated in this research for future research as follows: 
  x__ Coded, linked data in an NIH-funded or approved public repository.   
_x__ Coded, linked data in BTRIS (automatic for activities in the Clinical Center) 
_x__ Coded, linked or identified data with approved outside collaborators under appropriate 
agreements. 
 
How and where will the data be shared?  
Data will be shared through: 
  x__ An NIH-funded or approved public repository.  Insert name or names: ClinicalTrials.gov. 
_x__ BTRIS (automatic for activities in the Clinical Center) 
_x__ Approved outside collaborators under appropriate individual agreements. 
_x__ Publication and/or public presentations. 
 
When will the data be shared 
_x__ Before publication. 
_x__ At the time of publication or shortly thereafter. 

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6.2.2   Genomic Data Sharing Plan 
Unlinked genomic data will be deposited in the database of genotypes and phenotypes (dbGaP) 
in compliance with the NIH Genomic Data Sharing Policy. 
6.3 
RESPONSE CRITERIA 
Response Criteria for Lymphoma 
Note: Do not evaluate for response until at least 4 weeks after cell infusion (Cheson et al. 
Revised Response Criteria for Malignant Lymphoma, Journal of Clinical Oncology 2007 142 and 
Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and 
Non-Hodgkin Lymphoma: The Lugano Classification Journal of Clinical Oncology, 2014143) 
 
• Complete Remission (CR):   
1.       CR requires all of the following:   Complete disappearance of all detectable clinical 
          evidence of disease and disease-related symptoms if present before therapy.  
          Regardless of FDG-avidity, if all extranodal masses and lymph nodes are less than 1.0 
          cm or less in longest diameter, the patient is considered to be in CR.  
2.      Typically FDG-avid lymphoma (large cell, mantle cell and follicular lymphomas are 
     all typically FDG-avid):  in patients with no pretreatment PET scan or when the PET 
     scan was positive before therapy, a post-treatment residual mass of any size is 
      permitted as long as it is PET negative.   
3. Variably FDG-avid lymphomas/FDG avidity unknown:  in patients without a 
pretreatment PET scan, or if a pretreatment PET scan was negative, all lymph nodes 
and nodal masses must have regressed to normal size (≤ 1.5 cm in greatest diameter if 
> 1.5 cm before therapy).  Previously involved nodes that were 1.1 to 1.5 cm in their 
long axis and more than 1 cm in their short axis before treatment must have decreased 
to ≤ 1.0 cm in their short axis after treatment.   
4. The spleen and/or liver, if considered to be enlarged before therapy on basis of physical 
exam or CT scan, must be normal size on CT scan for FDG-negative lymphoma.  If 
FDG-avid lesions were present in the spleen or liver before treatment, these FDG-avid 
lesions must have resolved.   
5. A bone marrow aspirate and biopsy is performed only when the patient had bone 
marrow involvement with lymphoma prior to therapy (all patients must have a pre-
treatment bone marrow biopsy) or if new abnormalities in the peripheral blood counts 
or blood smear cause clinical suspicion of bone marrow involvement with lymphoma 
after treatment.  The bone marrow aspirate and biopsy must show no evidence of 
disease by morphology or if indeterminate by morphology it must be negative by 
immunohistochemistry.    
• Partial Remission (PR): PR requires all of the following: 
1. ≥ 50% decrease in sum of the product of the diameters (SPD) of up to 6 of the largest 
dominant nodes or nodal masses.  Dominant nodes or nodal masses should be clearly 
measurable in at least 2 perpendicular dimensions, should be from different regions of 
the body if possible and should include mediastinal and retroperitoneal nodes if 
possible.   
2. No increase in size of nodes, liver or spleen and no new sites of disease.   

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3. If multiple splenic and hepatic nodules are present, they must regress by ≥ 50% in the 
SPD.  There must be a > 50% decrease in the greatest transverse diameter for single 
nodules.    
4. Bone marrow is irrelevant for determination of a PR.  If patient has persistent bone 
marrow involvement and otherwise meets criteria for CR the patient will be considered 
a PR. 
5. Typically FDG-avid lymphoma:  for patients with no pretreatment PET scan or if the 
PET scan was positive before therapy, the post-treatment PET scan should be positive 
in at least one previously involved site.  Note: in patients with follicular lymphoma or 
mantle-cell lymphoma, a PET scan is only indicated in patients with one or at most two 
residual masses that have regressed by 50% on CT scan. 
• Progressive Disease (PD):  Defined by at least one of the following:   
1. ≥ 50% increase from nadir in the sum of the products of at least two lymph nodes, or if 
a single node is involved at least a 50% increase in the product of the diameters of this 
one node.   
2. Appearance of a new lesion greater than 1.5 cm in any axis even if other lesions are 
decreasing in size 
3. Greater than or equal to a 50% increase in size of splenic or hepatic nodules  
4. At least a 50% increase in the longest diameter of any single previously identified node 
more than 1 cm in its short axis.  
5. Lesions should be PET positive in typically FDG-avid lymphomas unless the lesion is 
too small to be detected by PET (<1.5 cm in its long axis by CT) 
• Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase 
to qualify for PD.  PET should be positive in typically FDG-avid lymphomas. 
1. Flow cytometric, molecular or cytogenetic studies will not be used to determine 
response. 
 
Response criteria for CLL: 
(Hallek et al. Guidelines for the diagnosis and treatment of chronic lymphocytic  leukemia:  A 
report from the International Workshop on Chronic Lymphocytic Leukemia updating the National 
Cancer Institute-Working Group 1996 guidelines 144)   
• Complete Remission: The designation of a complete response of CLL for this protocol 
requires all of the following as assessed at least 2 months after anti-CD19-CAR-transduced 
T cell infusion: 
1. Absence of lymphadenopathy (physical exam, relevant CT scans)     
2. No hepatomegaly or splenomegaly (physical exam, relevant CT scans) 
3. Absence of constitutional symptoms 
4. Normal CBC as exhibited by PMN’s ≥ 1500/ul, platelets >100,000/ul, hemoglobin > 
11.0 g/dl (untransfused), and  
5. Blood B lymphocyte count<4,000/ul  
6. Bone marrow aspirate and biopsy should be performed only after requirements a-d are 
first met.  Bone marrow aspirate and biopsy that is normocellular for age with <30% 
of the nucleated cells being B cells (CD19 or CD 20) positive.  Lymphoid nodules 

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must be absent.  If the marrow is hypocellular, a repeat determination should be 
performed in one month. 
7. Patients who fulfill all of the criteria for CR except for having bone marrow lymphoid 
nodules will be considered to be in a PR. 
• Partial Remission: The designation of partial response requires at least one of the 
following:  a ≥ 50% decrease in peripheral B lymphocyte count from pre-treatment value, 
a 
 
≥ 
50% reduction in 
lymphadenopathy, 
or a 
≥ 
50% reduction in 
splenomegaly/hepatomegaly for a period of at least 8 weeks based on physical exam and 
relevant CT scans.  No increase in any lymph node or appearance on newly enlarged nodes 
is allowed.  Additionally, designation of PR requires at least one of the following: 
1. PMN’s ≥ 1,500/ul, or a 50% improvement from pre-treatment value 
2. Platelets > 100,000/ul or 50% improvement from pre-treatment value 
3. Hemoglobin > 11.0 g/dl (untransfused) or 50% improvement from pre-treatment value 
• Progressive Disease: The designation of progressive disease is characterized by any one of 
the following: 
1. A ≥ 50% increase in the greatest diameter of any lymph node that was enlarged pre-
treatment. 
2. The appearance of new palpable lymph nodes 
3. A ≥ 50% increase in the absolute number of circulating B lymphocytes (value must 
exceed 5,000/ul) 
4. ≥50% increase in the size of the liver and/or spleen as determined by measurement 
below the respective costal margin or by CT scan; appearance of palpable 
hepatomegaly or splenomegaly, which was not previously present. 
5. Transformation to a more aggressive histology 
6. Patients not fulfilling the above criteria for progressive disease but demonstrating a 
decrease in hemoglobin value of > 2 gm/dl from baseline or a decrease of > 50% in 
platelet or granulocyte count will not be considered as evidence of progressive disease, 
because these changes may occur as both a consequence of many therapies or of 
underlying CLL/SLL; in such cases, a repeat bone marrow biopsy is recommended. 
• Stable Disease:  Patients who do not fulfill the criteria for complete or partial response and 
do not fulfill the criteria for progressive disease will be considered as having stable disease. 
6.4 
TOXICITY CRITERIA 
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study.  The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE 
reporting.  All appropriate treatment areas should have access to a copy of the CTCAE version 
5.0.  A copy of the CTCAE version 4.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).  
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN 
7.1 
DEFINITIONS 
Please refer to definitions provided in Policy 801: Reporting Research Events found here. 
7.2 
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING 

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7.2.1 Expedited Reporting 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 Non-Compliance Human Subjects Research found here. Note: Only IND Safety Reports that 
meet the definition of an unanticipated problem will need to be reported per these policies. 
7.2.2 IRB Requirements for PI Reporting at Continuing Review 
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here.  
7.3 
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reported to the OHSRP/IRB in iRIS will also be reported to the NCI 
Clinical Director.  A separate submission is not necessary as reports in iRIS will be available to 
the Clinical Director. 
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to 
progressive disease.   
To report these deaths, please send an email describing the circumstances of the death to  
NCICCRQA@mail.nih.gov within one business day of learning of the death. 
7.4 
INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) REPORTING CRITERIA 
7.4.1 Serious Adverse Event Reports to IBC 
 The Principal Investigator (or delegate) will notify the IBC of any unexpected fatal or life-
threatening experience associated with the use of the study agent as soon as possible but in no 
event later than 7 calendar days of initial receipt of the information.  Serious adverse  events that 
are unexpected and associated with the use of the study agent, but are not fatal or life-
threatening, must be reported to the NIH IBC as soon as possible, but not later than 15 calendar 
days after the investigator’s initial receipt of the information.  Adverse events may be reported 
by using the FDA Form 3500a. 
7.4.2 Annual Reports to IBC 
Within 60 days after the one-year anniversary of the date on which the IBC approved the initial 
protocol, and after each subsequent anniversary until the trial is completed, the Principal 
Investigator (or delegate) shall submit the information described below.  Alternatively, the IRB 
continuing review report can be sent to the IBC in lieu of a separate report.  Please include the 
IBC protocol number on the report. 
7.4.2.1 Clinical Trial Information  
A brief summary of the status of the trial in progress or completed during the previous year. The 
summary is required to include the following information:  
• the title and purpose of the trial  
• clinical site 
• the Principal Investigator 
• clinical protocol identifiers  

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• participant population (such as disease indication and general age group, e.g., adult or 
pediatric);  
• the total number of participants planned for inclusion in the trial; the number entered into 
the trial to date whose participation in the trial was completed; and the number who 
dropped out of the trial with a brief description of the reasons  
• the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, 
or fully completed,  
• if the trial has been completed, a brief description of any study results.  
7.4.2.2 Progress Report and Data Analysis  
Information obtained during the previous year's clinical and non-clinical investigations, 
including:  
• a narrative or tabular summary showing the most frequent and most serious adverse 
experiences by body system 
• a summary of all serious adverse events submitted during the past year 
• a summary of serious adverse events that were expected or considered to have causes not 
associated with the use of the gene transfer product such as disease progression or 
concurrent medications 
• if any deaths have occurred, the number of participants who died during participation in 
the investigation and causes of death 
• a brief description of any information obtained that is pertinent to an understanding of the 
gene transfer product’s actions, including, for example, information about dose-response, 
information from controlled trials, and information about bioavailability.  
7.5 
NIH REQUIRED DATA AND SAFETY MONITORING PLAN 
7.5.1 Principal Investigator/Research Team  
The clinical research team will meet on a regular (i.e., weekly) basis when patients are being 
actively treated on the trial to discuss each patient. Decisions about dose level enrollment and 
dose escalation if applicable will be made based on the toxicity data from prior patients.  
All data will be collected in a timely manner and reviewed by the principal investigator. Events 
meeting requirements for expedited reporting as described in section 7.2.1 will be submitted 
within the appropriate timelines. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff.  
7.5.2 Safety Monitoring Committee (SMC) 
This protocol will be periodically reviewed by an intramural Safety Monitoring Committee. 
Initial review will occur as soon as possible after the annual IRB continuing review date.   

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Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting 
schedule permits or more frequently as may be required by the SMC based on the risks presented 
in the study.   For initial and subsequent reviews, protocols will not be reviewed if there is no 
accrual within the review period.  
The SMC review will focus on unexpected protocol-specific safety issues that are identified 
during the conduct of the clinical trial. 
Written outcome letters will be generated in response to the monitoring activities and submitted 
to the Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI. 
8 
SPONSOR SAFETY REPORTING 
8.1 
DEFINITIONS 
8.1.1 Adverse Event  
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a medicinal (investigational) product, whether or not related to the medicinal 
(investigational) product (ICH E6 (R2)) 
8.1.2 Serious Adverse Event (SAE) 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following: 
• 
Death, 
• 
A life-threatening adverse event (see section 8.1.3) 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
o A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery 
arranged prior to the start of the study), a planned hospitalization for pre-existing 
condition, or a procedure required by the protocol, without a serious deterioration in 
health, is not considered a serious adverse event. 
o A hospitalization/admission that is solely driven by non-medical reasons (e.g., 
hospitalization for patient convenience) is not considered a serious adverse event.  
o Emergency room visits or stays in observation units that do not result in admission to 
the hospital would not be considered a serious adverse event. The reason for seeking 
medical care should be evaluated for meeting one of the other serious criteria. 
• 
Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect. 
• 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 

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appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
8.1.3 Life-threatening  
An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of 
either the investigator or sponsor, its occurrence places the patient or subject at immediate risk of 
death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a 
more severe form, might have caused death. (21CFR312.32) 
8.1.4 Severity 
The severity of each Adverse Event will be assessed utilizing the CTCAE version 4.0. 
8.1.5 Relationship to Study Product 
All AEs will have their relationship to study product assessed using the terms:  related or not 
related.   
• Related – There is a reasonable possibility that the study product caused the adverse 
event. Reasonable possibility means that there is evidence to suggest a causal relationship 
between the study product and the adverse event. 
• Not Related – There is not a reasonable possibility that the administration of the study 
product caused the event. 
8.2 
ASSESSMENT OF SAFETY EVENTS 
AE information collected will include event description, date of onset, assessment of severity 
and relationship to study product and alternate etiology (if not related to study product), date of 
resolution of the event, seriousness and outcome. The assessment of severity and relationship to 
the study product will be done only by those with the training and authority to make a diagnosis 
and listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  AEs 
occurring during the collection and reporting period will be documented appropriately regardless 
of relationship.  AEs will be followed through resolution. 
SAEs will be: 
• 
Assessed for severity and relationship to study product and alternate etiology (if not 
related to study product) by a licensed study physician listed on the Form FDA 1572 as 
the site principal investigator or sub-investigator. 
• 
Recorded on the appropriate SAE report form, the medical record and captured in the 
clinical database. 
• 
Followed through resolution by a licensed study physician listed on the Form FDA 1572 
as the site principal investigator or sub-investigator. 
For timeframe of recording adverse events, please refer to section 6.1 All serious adverse events 
recorded from the time of first investigational product administration must be reported to the 
sponsor with the exception of any listed in section 8.4  

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8.3 
REPORTING OF SERIOUS ADVERSE EVENTS 
Any AE that meets a protocol-defined serious criterion or meets the definition of Adverse Event 
of Special Interest that require expedited reporting must be submitted immediately (within 24 
hours of awareness) to OSRO Safety using the CCR SAE report form. Any exceptions to the 
expedited reporting requirements are found in section 8.4. 
All SAE reporting must include the elements described in section 8.2. 
SAE reports will be submitted to the Center for Cancer Research (CCR) at: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator.  CCR SAE report form 
and instructions can be found at:   
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=157942842  
Following the assessment of the SAE by OSRO, other supporting documentation of the event 
may be requested by the OSRO Safety and should be provided as soon as possible. 
8.4 
REPORTING PREGNANCY  
8.4.1 Maternal exposure 
If a patient becomes pregnant during the study, the study treatment should be discontinued 
immediately, and the pregnancy reported to the Sponsor no later than 24 hours of when the 
Investigator becomes aware of it. The Investigator should notify the Sponsor no later than 24 
hours of when the outcome of the Pregnancy becomes known, 
Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects 
and spontaneous miscarriages that meet serious criteria (section 8.1.2) should be reported as 
SAEs.  
The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic 
pregnancy, normal birth, or congenital abnormality) should be followed up and documented. 
8.4.2 Paternal exposure 
Male patients should refrain from fathering a child or donating sperm during the study and for 4 
months after the last dose of receiving protocol treatment. 
Pregnancy of the patient’s partner is not considered to be an AE. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or 
congenital abnormality) occurring from the date of the first dose until (120 days) after the last 
dose should, if possible, be followed up and documented. 
8.5 
REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER CCR-SPONSORED IND 
Following notification from the investigator, CCR, the IND sponsor, will report any suspected 
adverse reaction that is both serious and unexpected.  CCR will report an AE as a suspected 
adverse reaction only if there is evidence to suggest a causal relationship between the study 
product and the adverse event.  CCR will notify FDA and all participating investigators (i.e., all 
investigators to whom the sponsor is providing drug under its INDs or under any investigator’s 
IND) in an IND safety report of potential serious risks from clinical trials or any other source, as 
soon as possible, in accordance to 21 CFR Part 312.32.  
All serious events will be reported to the FDA at least annually in a summary format. 

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9 
CLINICAL MONITORING  
As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring 
program. The CCR’s program allows for confirmation of study data, specifically data that could 
affect the interpretation of primary and secondary study endpoints; adherence to the protocol, 
regulations, ICH E6, and SOPs; and human subjects protection. This is done through 
independent verification of study data with source documentation focusing on: 
• Informed consent process 
• Eligibility confirmation 
• Drug administration and accountability 
• Adverse events monitoring 
• Response assessment. 
The monitoring program also extends to multi-site research when the CCR is the coordinating 
center. 
This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified 
by training and experience to monitor the progress of clinical trials. Personnel monitoring this 
study will not be affiliated in any way with the trial conduct. 
10 STATISTICAL CONSIDERATIONS   
Note: Cohort 2 (Patients who have had an HLA-matched sibling or an 8/8-matched unrelated 
donor transplant): Per amendment B this cohort has been closed to Accrual until further notice. 
The primary endpoint of this trial is to determine the safety of administering CAR-expressing T 
cells to patients with relapsed or persistent B-cell malignancies.  Secondary objectives of this 
trial are to measure any anti-malignancy effect that might occur, to assess the feasibility of 
administering CAR-expressing T cells, to assess repeated CAR T-cell treatments, and to measure 
persistence and function of CAR-expressing T cells.  The study will be conducted using a 
standard 3+3 approach as defined in section 3.1. 
Patients will be enrolled on a 2 different cohorts:  Cohort 1:  Patients who have not had an 
allogeneic hematopoietic stem cell transplant (alloHSCT) and Cohort 2 (closed as of amendment 
B):  Patients who have had an HLA-matched sibling or a 8/8-matched unrelated donor transplant.  
Each cohort will have a separate but identical dose-escalation scheme.  The dose escalation 
schemes are separate because of the possibility of greater toxicity in the patients who have 
undergone prior alloHSCT.  DLTs occurring on one cohort’s dose escalation will not affect dose 
escalation of the other cohort.  Both cohorts can undergo repeat treatments following an identical 
re-treatment plan. 
The trial will be conducted as 2 different dose escalation schemes, one for Cohort 1 (non-
alloHSCT) and Cohort 2 (alloHSCT recipients).  For each cohort, a dose escalation scheme with 
up to 4 doses and up to 6 patients per dose level will be carried out. In addition, up to 8 
additional patients can be treated at the MTD for each cohort to establish additional safety and 
toxicity data at that level. Thus, up to 64 patients may be enrolled onto the trial. 

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The fraction of post-allogeneic transplant patients experiencing Grade 3 or 4 toxicities will be 
compared to the fraction of patients who never had an allogeneic transplant experiencing Grade 3 
or 4 toxicities by using a Fisher’s exact test. 
The degree of persistence of anti-CD19-CAR-transduced T cells will be evaluated by a 
quantitative measure (flow cytometry or quantitative PCR) in all patients.  Anti-malignancy 
effects will be measured by clinical response and categorized according to Section 6.2. The 
clinical responses will be interpreted cautiously in the context of a pilot study which may be used 
to guide parameters for study in future protocols if warranted. 
All other evaluations of secondary objectives will be performed using exploratory techniques. 
No formal adjustment for multiple comparisons will be used since the evaluations are being done 
to generate hypotheses. 
As of approval of Amendment C, we will treat a maximum of 14 more patients on this protocol 
(6 on Dose Level 3 plus an expansion cohort of 14 patients). 
Despite 2/6 patients experiencing strictly-defined DLTs on dose level 2 of the study, the second 
DLT on this dose level was actually not definitively related to CAR T cells and likely unrelated 
to dose, so the dose escalation is allowed to proceed to dose level 3 starting with the 13th patient 
to receive CAR T cells on this trial.  If more than 1 of the first 3 patients experience a DLT on 
dose level 3, enrollment will continue on dose level 2.  In other words, if more than 1 of the first 
3 patients treated on dose level 3 has a DLT, Dose Level 2 will be declared the MTD despite the 
fact that 2 DLTs have occurred on Dose Level 2.  If Dose Level 2 is declared the MTD, an 8 
patient expansion cohort will be treated at this dose level.  If 1 of the first 3 patients on dose level 
3 experiences a DLT, 3 more patients will be enrolled on dose level 3.    
11 COLLABORATIVE AGREEMENTS 
There is a Collaborative Research and Development Agreement (CRADA# 03019) in place 
between Kite Pharma, Inc. and the National Cancer Institute for this protocol. 
12 HUMAN SUBJECTS PROTECTIONS  
12.1 RATIONALE FOR SUBJECT SELECTION 
The patients to be entered in this protocol have advanced B-cell malignancies that are almost 
always incurable diseases.  These patients have limited life expectancies.  Subjects from both 
genders and all racial/ethnic groups are eligible for this study if they meet the eligibility criteria.  
To date, there is no information that suggests that differences in disease response would be 
expected in one group compared to another.  Efforts will be made to extend accrual to a 
representative population, but in this preliminary study, a balance must be struck between patient 
safety considerations and limitations on the number of individuals exposed to potentially toxic 
and/or ineffective treatments on the one hand and the need to explore gender and ethnic aspects 
of clinical research on the other hand.  If differences in outcome that correlate to gender or to 
ethnic identity are noted, accrual may be expanded, or a follow-up study may be written to 
investigate those differences more fully. 
12.2 PARTICIPATION/SELECTION RATIONALE 

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• The eligibility criteria for this protocol only allow enrollment of patients with advanced 
B-cell malignancies that are usually incurable despite recent advances in standard 
therapies. 
• Patients with treatment options with proven efficacy and limited toxicity will not be 
enrolled. 
• Improving the treatment of advanced B-cell malignancies is an important area of clinical 
research. 
• In previous studies, anti-CD19 CAR T cells have demonstrated dramatic activity against 
B-cell lymphoma and B-cell leukemia. Many patients have obtained remissions lasting 
more than 2 years on multiple clinical trials of anti-CD19 CAR T cells.  Some of these 
studies were clinical trials conducted by the Principal Investigator of this trial, and some 
patients treated on the Principal Investigator’s prior trials have been in complete 
remission for over 3 years.  Despite these impressive results, improvements in anti-CD19 
CAR T cells to increase efficacy and to decrease toxicity are still needed.  This trial aims 
to improve upon prior results by evaluating several important changes in the administered 
CAR T cells including:  use of a fully-human CAR, use of a new lentiviral vector, use of 
a new CAR design, and use of planned second and third CAR T-cell treatments. 
• Because patients on previous trials of CAR T cells have experienced hypotension, 
tachycardia, prolonged fevers, neurological toxicities, and depressed myocardial function, 
participation in this trial clearly carries significant risk.  In many patients on prior CAR 
trials, toxicities were severe enough to require intensive care unit admission. We will 
limit enrollment to patients 73 years of age or less because based on our admittedly 
limited experience with prior CAR-T cell clinical trials, younger patients tolerate and 
recover from these toxicities better than elderly patients. 
12.3 PARTICIPATION OF CHILDREN 
Children will not be enrolled on this study, since the efficacy of this experimental procedure is 
unknown, it does not seem reasonable to expose children to this risk without further evidence of 
benefit.   
12.4 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol.  However re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 12.4), all subjects ≥ age 18 will be offered the opportunity to fill 
in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH 
Ability to Consent Assessment Team for evaluation. For those subjects that become 
incapacitated and do not have pre-determined substitute decision maker, the procedures 
described in NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects 

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who are (a) decisionally impaired, and (b) who do not have a legal guardian or durable power of 
attorney, will be followed.  
12.5 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
The experimental treatment has a chance to provide clinical benefit although it is quite possible 
that patients will obtain no clinical benefit.  A goal of this study is to improve upon the number 
of patients who may benefit from adoptive cell therapy by using genetically-modified T-cells, 
specifically CAR T cells.  The risks of the study fall into 5 general categories (see section 13 for 
details).  First, chemotherapy that could cause cytopenias is part of the protocol.  As with any 
chemotherapy that causes neutropenia and thrombocytopenia, this chemotherapy could cause 
toxicities such as infections and bleeding. The second category of toxicity is cytokine-release 
type toxicities such as high fevers, hypotension, and fever.  A third area of toxicity is 
neurological toxicity such as delirium, obtundation, myoclonus, seizures, headache, and transient 
focal neurological toxicities including aphasia and focal paresis.  Cytokine-release-type toxicities 
and neurological toxicities have appeared in other clinical trials of CAR T cells during the first 2 
weeks after CAR T cells were infused.72,115  The 4th main category of toxicity is direct damage 
to normal tissues by the CAR T cells.  This could happen because of unexpected cross-reactivity 
of the anti-CD19 CAR with proteins other than CD19 in vivo.  A 5th possible toxicity is 
hypogammaglobulinemia.  Hypogammaglobulinemia has been a complication of many patients 
on clinical trials of anti-CD19 CAR-expressing T cells.72,73  Hypogammaglobulinemia in these 
patients was routinely treated with infusions of intravenous immunoglobulins.72   
The lentiviral vector used in this trial inserts into the T-cell DNA of patients, so in theory, 
insertional mutagenesis could occur, but insertional mutagenesis has not occurred in any of the 
hundreds of patients treated with mature T cells that were genetically modified by 
gammaretroviral or lentiviral vectors.75-77 
The risks associated with biopsies are pain and bleeding at the biopsy site. In order to minimize 
pain, local anesthesia will be used. Rarely, there is a risk of infection at the sampling site.  
The success of this clinical trial cannot be predicted at this time.  Because all patients in this 
protocol have advanced B-cell malignancies and limited life expectancies, the potential benefit is 
thought to outweigh the potential risks.  It is also anticipated that this study will provide 
scientific information relevant to tumor immunotherapy.   
12.5.1 Risks of exposure to Ionizing Radiation 
The procedures for performing the CT scans will follow clinical policies, no special procedures 
apply to these additional assessments for research purposes.  In summary, subjects may receive 
additional radiation exposure from up to seven (7) CT neck +CAP, three (3) CT-Guided biopsies 
and seven (7)18FDG-PET/CT scans in the first year of the study. 
The total additional radiation dose for research purposes will be approximately 19.9 rem in the 
first year of the study. This amount is more than would be expected from everyday background 
radiation. Being exposed to too much radiation can cause harmful side effects such as an increase 
in the risk of cancer. The risk of getting cancer from the radiation exposure in this study is 2.0 out 
of 100 (2.0%) and of getting a fatal cancer is 1.0 out of 100 (1.0%). 

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12.5.2 Risks of Scans and Contrast 
If contrast dye is used, there is a small chance of developing an allergic reaction from the contrast 
material, which may cause symptoms ranging from mild itching or a rash to severe difficulty 
breathing, shock or rarely, death.  The contrast material may also cause kidney problems. Common 
reactions include pain in the vein where the contrast was given, a metallic or bitter taste in the 
mouth, headache, nausea and a warm or flushing feeling that lasts from 1-3 minutes.  
An IV line may need to be inserted for administration of the contrast agent or anesthetic, which 
may cause pain at the site where the IV is placed and there is a small risk of bruising or infection 
12.5.3 Risks of blood Sampling 
Side effects of blood draws include pain and bruising, lightheadedness, and rarely, fainting. 
12.5.4 Risks of Bone marrow aspiration and biopsy 
Side effect of bone marrow aspiration and biopsy may feel a pressure sensation when the needle 
is being inserted and a pulling sensation and brief pain as the marrow is withdrawn. Potential 
complications of this procedure are local bleeding, pain at the site, and infection. Both of these 
are very rare. Bleeding can be stopped by applying local pressure and an infection can be treated 
with antibiotics. 
12.5.5 Risks of Intravenous Catheter 
Side effect of placing some catheters include pain, bleeding, infection and rarely, collapsed lung.  
The long- term risks of the catheter rarely include infection and clotting of veins.   
12.5.6 Risks of Lumbar Puncture 
Side effect of lumbar puncture may cause pain at the site where the needle goes in and the spinal 
fluid is taken.  There is a small risk of infection or bleeding. A third or fewer patients may 
experience some headache while the body replaces the fluid that is removed. 
12.5.7 Risks of Apheresis 
The risks of apheresis are similar to whole blood donation and include pain and bruising at the 
needle insertion site in the arms, lightheadedness, dizziness, nausea, and rarely fainting due to a 
rare reflex reaction to needle placement and to the temporary decrease in blood volume during 
apheresis.  It may also feel tingling around your mouth or in your fingers caused by a blood 
thinner given during the procedure.  The tingling may reduce by giving calcium containing 
chewable antacid.  All the symptoms usually go away within a few minutes of stopping the 
procedure.    
12.6 CONSENT PROCESS AND DOCUMENTATION 
The informed consent document will be provided to the participant or consent designee(s) (e.g., 
legally authorized representative [LAR] if participant is an adult unable to consent) for review 
prior to consenting.  A designated study investigator will carefully explain the procedures and 
tests involved in this study, and the associated risks, discomforts and benefits. In order to 
minimize potential coercion, as much time as is needed to review the document will be given, 
including an opportunity to discuss it with friends, family members and/or other advisors, and to 

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ask questions of any designated study investigator. A signed informed consent document will be 
obtained prior to entry onto the study. 
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms) per discretion of the 
designated study investigator and with the agreement of the participant/consent designee(s).  
Whether in person or remote, the privacy of the subject will be maintained. Consenting 
investigators (and participant/consent designee, when in person) will be located in a private area 
(e.g., clinic consult room). When consent is conducted remotely, the participant/consent designee 
will be informed of the private nature of the discussion and will be encouraged to relocate to a 
more private setting if needed. 
Consent for the optional biopsies performed on this study will be obtained at the time of the 
procedure. If the patient refuses the optional biopsy at that time, the refusal will be documented 
in the medical record and in the research record.. 
13 PHARMACEUTICAL INFORMATION  
 Note: The commercial drugs used in this study will not alter labelling of the FDA approved 
drugs and nor does the investigation involve a route of administration or dosage level in use in a 
patient population or other factor that significantly increases the risks (or decreases the 
acceptability of the risks) associated with the use of the drug product. 
13.1 LENTIVIRAL VECTOR CONTAINING THE ANTI-CD19 CAR GENE  
The lentiviral vector (LSIN-47G4-CD828Z) encoding a chimeric antigen receptor (CAR) directed 
against CD19 was prepared and preserved following cGMP conditions in the Indiana University 
Vector Production Facility. This self-inactivating 3rd generation lentiviral vector includes the 
murine stem cell virus promoter, and a truncated version of the woodchuck post-transcriptional 
regulatory element (WPRE) designated oPRE122.  The anti-CD19 CAR protein encoded by this 
vector contains a signal peptide from human CD8-alpha, 47G4 fully-human antibody light chain 
variable region (47G4 VL), linker peptide, 47G4 fully-human antibody heavy chain variable 
region (47G4 VH), human CD8-alpha (hinge and transmembrane), CD28 (cytoplasmic region), 
and the CD3-zeta (cytoplasmic region) T-cell activation domain.    
The vector will be stored at –80° C in the Dept. of Transfusion Medicine, NIH.  Both storage 
facilities are equipped with around-the-clock temperature monitoring. Vector will be used in in 
vitro transductions of T cells. There will be no re-use of the same unit of supernatant for different 
patients.  Handling of the vector should follow the guidelines of Biosafety Level-2 (BSL-
2).   The specific guidelines for Biosafety Level-2 (BSL-2) can be viewed at 
http://bmbl.od.nih.gov/sect3bsl2.htm  
13.2 COMMERCIAL AGENTS 
Please refer to the US approved package insert for the full prescribing information here: 
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails 
13.2.1 Cyclophosphamide 
13.2.1.1 Source 

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Cyclophosphamide will be purchased by the NIH Clinical Center Pharmacy Department from 
commercial sources and is supplied as a lyophilized powder in various vial sizes. 
13.2.1.2 Administration procedures 
The cyclophosphamide used in this regimen will be given as Intravenous infusion over 60 minutes.  
13.2.2 FLUDARABINE 
13.2.2.1 Source  
Fludarabine monophosphate will be purchased by the NIH Clinical Center Pharmacy Department 
from commercial sources and is supplied as a white, lyophilized powder. Each vial contains 50 mg 
of fludarabine phosphate, 50 mg of mannitol, and sodium hydroxide to adjust pH.  Fludarabine is 
stored at room temperature.   
13.2.2.2 Administration procedures 
Fludarabine is administered as an IV infusion in 100 ml 0.9% sodium chloride, USP over 15 to 
30 minutes.  The doses will be based on body surface area (BSA).    
 
 

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Cheson BD, Pfistner B, Juweid ME, et al. Revised response criteria for malignant 
lymphoma. Journal of Clinical Oncology. 2007;25(5):579-586. 
143. 
Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, 
staging, and response assessment of hodgkin and non-hodgkin lymphoma: The lugano 
classification. Journal of Clinical Oncology. 2014;32(27):3059-3067. 
144. 
Hallek M, Cheson BD, Catovsky D, et al. Guidelines for the diagnosis and treatment of 
chronic lymphocytic leukemia: a report from the International Workshop on Chronic 
Lymphocytic Leukemia updating the National Cancer Institute-Working Group 1996 
guidelines. Blood. 2008;111(12):5446-5456. 
 
 
 

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15 APPENDICES 
15.1 APPENDIX A:  PERFORMANCE STATUS CRITERIA 
ECOG Performance Status Scale* 
 
Grade 
Descriptions 
0 
Normal activity.  Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory.  Restricted in physically strenuous activity, 
but ambulatory and able to carry out work of a light or sedentary nature 
(e.g., light housework, office work). 
2 
In bed <50% of the time.  Ambulatory and capable of all self-care, but 
unable to carry out any work activities.  Up and about more than 50% 
of waking hours. 
3 
In bed >50% of the time.  Capable of only limited self-care, confined to 
bed or chair more than 50% of waking hours. 
4 
100% bedridden.  Completely disabled.  Cannot carry on any self-care.  
Totally confined to bed or chair. 
5 
Dead. 
* As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, 
T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative 
Oncology Group. Am J Clin Oncol 5:649-655, 1982. 
 
 
 
 

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15.2 APPENDIX B:  DATA COLLECTION ELEMENTS REQUIRED BY PROTOCOL  
All of the following elements will be recorded in the C3D database: 
 
A. Patient Enrollment 
 
• Date of birth, age, gender, race, ethnicity 
• Height 
• Weight 
• Performance Status 
• Date of original diagnosis 
• Stage at diagnosis 
• Tumor Histology and date of confirmation 
• CD19 expression by tumor type of tissue studied and date of confirmation 
• Date of Informed Consent signature, consent version and date of registration 
• Baseline History/Physical 
• Baseline Symptoms  
• Number of prior lines of therapy 
• Findings of consultations done at screening 
 
B. Study Drug administration and response for each course of therapy given 
• Dates anti-CD19-CAR-transduced T cells given 
• Dose level, actual dose, schedule and route given 
• Height, weight, and body surface area at start of each course (a course is defined as 
chemotherapy followed by a CAR T-cell infusion) 
• Response assessment for each restaging performed 
• Concomitant medications will not be collected in C3D 
         
C. Laboratory and Diagnostic Test Data 
 
1.  All Clinical laboratory and diagnostic test results done at screening and until day 30 
post infusion with the following exceptions: 
Diagnostic tests which are not specified in the protocol, and if the results are not 
needed to document the start or end of an adverse event that requires reporting. 
Serologies-CMV, HSV, EBV, toxoplasmosis, adenovirus (patient and donor) 
TTV data  
2. All staging studies including CT scan, PET scan results and bone marrow biopsy and 
peripheral blood flow cytometry results will be reported at the scheduled follow-up 
points at 1 months and 2 months after infusion; after 2 months only the overall 
malignancy status (CR, PR, stable disease, progression) will be reported.   
D. Adverse Events 
Please see section 6.1.1 Adverse Event Reporting 
E.  Tumor response and measurements 

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• Restaging studies performed at protocol specified time points and as clinically 
indicated. 
• Any physical exam findings, will be collected as Adverse Events and labs results. 
• Years 5-15 follow-up is only for survival. 
 
F.   Off study 
• Date and reason for off study 
• Date and cause of death 
• Autopsy findings 

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15.3 APPENDIX C:  GUIDELINES FOR MANAGEMENT OF COMMON TOXICITIES THAT OCCUR 
AFTER CAR T-CELL INFUSIONS 
Infusions of CAR T cells are often complicated by significant acute toxicities in the first 2 to 3 
weeks after the infusion.  In many cases the toxicities correlate with serum inflammatory cytokine 
levels.72 
The toxicities most often experienced by patients receiving infusions of CAR T cells include, but 
are not limited to, tumor lysis syndrome, fever, fatigue, hypotension, tachycardia, acute renal 
failure, and neurological toxicities such as aphasia, ataxia, headache, somnolence, and coma.  
Fever is usually the first toxicity to occur.   
Note these are guidelines that might require modification based on clinical circumstances of each 
patient, and failure to exactly follow these guidelines is not a protocol deviation or violation. 
  Administration of corticosteroids should be avoided if at all possible to avoid killing or impairing 
the function of the CAR T cells. 
1. All patients with significant malignancy burdens and without a contradiction such as allergy 
should be started on allopurinol at the time of the start of the chemotherapy conditioning 
regimen or 1 day before the CAR T cell infusion.  The suggested allopurinol dose is 200 to 
300 mg/day with a possible loading dose of 300 to 400 mg.  
2. Vital signs should be checked a minimum of every 4 hours during hospitalization.  Increasing 
the time interval between vital sign checks for patient convenience or other reasons should be 
avoided. 
3. Strict ins and outs should be recorded on all patients. 
4. As a minimum, keep hemoglobin greater than 8.0 g/dL and platelets greater than 
20K/microliter. 
5. Administer fresh frozen plasma (FFP) for a PTT 1.5-fold or more above the upper limit of 
normal. 
6. For patients with an increased PTT, check the fibrinogen level and keep the fibrinogen level 
above 100 mg/dL with cryoprecipitate. 
7. Fevers should be treated with acetaminophen and comfort measures. NSAIDs and 
corticosteroids should be avoided. 
8. Patients with a heart rate persistently higher than 115/minute and fever should have vital signs 
checked every 2 hours. 
9. Patients who are neutropenic and febrile should be receiving broad-spectrum antibiotics. 
10. Patients at risk of syncope    
Patients on this protocol will be placed on strict fall precautions including instructions to get out 
of bed only with assistance under the following conditions: 
 
 

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1.  Any history of syncope or near-syncope within 1 month before CAR T-cell infusion or 
any time after CAR T-cell infusion. 
2. Any blood pressure reading of less than 90 mm Hg systolic blood pressure after anti-
CD19 CAR T-cell infusion. 
3. Heart rate greater than 100 beats per minute. 
 
Any patient with syncope, near-syncope, or light-headedness will have orthostatic blood pressure 
and heart rate checked and receive intravenous fluids as appropriate.  These patients will also 
receive an ECG. 
11. A CBC will be obtained twice daily while the patient is inpatient.  If the absolute neutrophil 
count becomes less than 500/microliter, Filgrastim will be initiated at a dose of 300 
micrograms daily for patients under 70 kg in weight and a dose of 480 micrograms daily for 
patients over 70 kg in weight only in patients with absolute neutrophil counts less than 
500/microliter.  Filgrastim will be discontinued as soon as the absolute neutrophil count 
recovers to 1500/microliter. 
12. Hypotension is a common toxicity requiring intensive care unit (ICU) admission.  In general 
patients should be kept well-hydrated.  Maintenance I.V. fluids (normal saline (NS) should 
be started on most patients with high fevers especially if oral intake is poor or the patient has 
tachycardia.  I.V. fluids are not necessary for patients with good oral intake and mild fevers.  
For patients who are not having hypotension or tumor lysis syndrome, a generally even fluid 
balance should be strived for after allowing for insensible fluid losses in patients with high 
fevers.  The baseline systolic blood pressure is defined for this protocol as the average of all 
systolic blood pressure readings obtained during the 24 hours prior to the CAR T-cell infusion.  
The first treatment for hypotension is administration of IV NS boluses.   
• Patients with a systolic blood pressure that is less than 80% of their baseline blood 
pressure and less than 100 mm Hg should receive a 1 L NS bolus.  
•  Patients with a systolic blood pressure less than 85 mm Hg should receive a 1 L 
NS bolus regardless of baseline blood pressure.  
     
These I.V. fluid management suggestions may need to be modified based on the clinical 
characteristics of individual patients such as pulmonary status, cardiac function, edema and other 
factors. 
 
13. Patients receiving more than 1 fluid bolus for hypotension should have a stat EKG and 
troponin, and a cardiac echocardiogram within 24 hours of the second fluid bolus. 
14. Patients should be transferred to the ICU under these circumstances.  Patients not meeting 
these criteria could also require ICU admission at the discretion of the clinical team caring for 
the patient.  
• Systolic blood pressure less than 75% the patient’s baseline blood pressure and less than 
100 mm Hg after administration of a 1L NS bolus. 

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• Anytime the systolic blood pressure is less than 90 mm Hg after a 1L NS bolus if 90 
mm Hg is less than the patient’s baseline systolic blood pressure. 
• Continuous tachycardia with a heart rate higher than 125 beats per minute on at least 2 
occasions separated by 4 hours. 
• Oxygen requirement of more than a 4L standard nasal cannula 
• Greater than grade 2 neurological toxicity 
15.  All patients transferred to the ICU for hypotension or tachycardia should have a stat EKG 
and a cardiac echocardiogram within 24 hours of the time of transfer. 
16. Patients with hypotension not responding to IV fluid resuscitation should be started on 
norepinephrine at doses called for by standard ICU guidelines. 
17. Patients should have a cardiac echocardiogram and an EKG within 12 hours of starting 
norepinephrine. 
18. Patients in the ICU should get twice-daily labs (CBC with differential, acute care panel, 
mineral panel, hepatic panel, uric acid, LDH.  Patients in the ICU should also get a daily 
troponin level).  
19. Anecdotal evidence suggests that the IL-6 receptor blocker tocilizumab can be an effective 
treatment for cytokine-release syndrome toxicities after CAR T-cell infusions.  Tocilizumab 
should be administered under the following circumstances if the listed disorders are thought 
to be due to cytokine release from CAR T cells.  Tocilizumab is administered at a dose of 4 
mg/kg infused IV over 1 hour (dose should not exceed 800 mg). 
• Left ventricular ejection fraction less than 40% by echocardiogram 
• Creatinine greater than 2.5-fold higher than the most recent level prior to CAR T-cell 
infusion 
• Norepinephrine requirement at a dose greater than 2 µg/minute for 48 hours since the 
first administration of norepinephrine even if norepinephrine administration was not 
continuous. 
• Systolic blood pressure of 90 mm Hg cannot be maintained with norepinephrine. 
• Oxygen requirement 55% or greater fraction of inspired oxygen (FIO2) for more than 
2 continuous hours. 
• Dyspnea that is severe enough to potentially require mechanical ventilation. 
• PTT or INR>2x upper limit of normal 
• Clinically-significant bleeding 
• Creatine kinase greater than 5x upper limit of normal for greater than 2 days 
 
20. THERE IS NO EVIDENCE THAT TOCILIZUMAB HELPS NEUROLOGICAL       
TOXICITY, SO IT SHOULD NOT BE ADMINISTERED FOR THIS PURPOSE. 

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21. If no improvement in hypotension or tachycardia occurs within 6 hours of tocilizumab 
infusion, consider other agents such as methylprednisolone 1 to2 mg/kg every 12 hours or 
etanercept. 
22. Avoid meperidine due to seizure risk. 
23. All patients with grade 2 or greater neurological toxicities should get a neurology consult. 
24. The following patients should receive dexamethasone 10 mg intravenously every 6 hours 
until the toxicities improve to Grade 1 or resolve or until at least 8 doses of dexamethasone 
have been given.  Note:  for seizures administer standard seizure therapies in addition to 
dexamethasone. 
1.  Patients with Grade 3 or 4 neurological toxicities except that dexamethasone is not 
recommended for isolated Grade 3 headaches.  
2. Any generalized seizure 
 
 

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15.4 APPENDIX D:  CLINICAL STAGING AND TREATMENT OF ACUTE GVHD 
Clinical Staging and treatment of Acute GVHD 58,59 
 
Stage 
Skin 
Liver 
Gut 
1 
Rash < 25% BSAa 
Total bilirubin 2.0-2.9 
mg/dlb 
Diarrhea >500-
1000ml/day, or  
upper GI symptoms 
2 
Rash 25-50% BSA 
Total bilirubin 3.0-6.0 
mg/dl 
Diarrhea 1001-
1500ml/day 
3 
Rash >50% BSA 
Total bilirubin 6.1-15.0 
mg/dl 
Diarrhea 1501 to 
2000 ml/d 
4 
Bullae 
Total bilirubin > 15.0 
mg/dl 
Diarrhea >2000 mL 
/day or severe 
abdominal pain or 
ileus 
aBSA = body surface area; use “rule of nines” or burn chart to determine extent of rash. 
bRange given as total bilirubin.  
Note:  Elevation of transaminase without elevation of bilirubin is not recognized as acute GVHD 
( a note should say “GVHD transaminitis” and mention if biopsy proven or not. 
c Persistent nausea with histologic evidence of GVHD in the stomach or duodenum.  
The nominal stage is reduced by one if the organ is simultaneously and unequivocally affected by 
a complication other than GVHD. 
 
Clinical Grading of Acute GVHD 58,59  
 
Gradee 
Skin 
Liver 
Gut 
0 (none) 
None 
None 
None 
I 
Stage 1-2 
None 
None 
II 
Stage 3   
Stage 1   
Stage 1 
III 
 
Stage 2-3   
Stage 2-4 
IVd 
Stage 4e  
Stage 4       
Stage 4 

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eCriteria for grading given as minimum degree of organ involvement required to confer that grade.  
The highest single organ stage determines the overall grade. 
dPatients with Stage 4 gut GVHD are usually Grade IV.  Stage 4 gut GVHD can only be a part of 
Grade III when it is not severe enough to cause a substantially impaired performance status.  A 
substantially impaired performance status would be an ECOG performance status of 3 or 4. 
eDesignation of Grade III is appropriate for only scattered bullae. 
The NIH Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-
host Disease defines classic acute GVHD as maculopapular rash, nausea, vomiting, anorexia, 
profuse diarrhea, ileus, or cholestatic hepatitis occurring within 100 days after transplantation or 
Donor Cell Infusion (DCI) 57.  We will define acute GVHD in the same manner for this trial. 
This schema is intended to serve as a guideline and to promote consistency in our clinical practice; 
it may be modified for individual patients as clinical circumstances warrant.  Failure to follow 
these guidelines is not a protocol deviation. 
Grade I GVHD:  
1) Topical corticosteroids (usually 0.1% triamcinolone; 1% hydrocortisone to face) applied to 
rash BID. 
Grade II-IV GVHD:  
1) Methylprednisolone (MP) 1 mg/kg per dose IV, BID for 4 consecutive days. 
2) If no response after 4 days, continue until response (7-day maximum trial); the dose may be 
doubled (4 mg/kg/day). 
3) If response within 7 days, taper as follows: 
a) 0.75 mg/kg per dose IV BID for 2 days. 
b) 0.5 mg/kg per dose IV BID for 2 days. 
c) 0.375 mg/kg per dose IV BID for 2 days. 
d) If clinically appropriate, change MP to oral prednisone to equivalent of IV dose) daily for 
2 days.  MP may be converted to prednisone later in the taper at the investigators’ 
discretion. 
e) After this, steroids will be reduced by 10% of starting oral dose each week until a dose of 
10 mg/day is reached.  Subsequent reductions will be made at the investigators’ discretion. 
f) If GVHD worsens during taper, steroids should be increased to previous dose. 
g) During steroid taper, maintain cyclosporine at therapeutic levels. 
4) If no response is observed within 7 days of MP treatment: 
a) Increase Methylprednisolone to 10 mg/kg per dose IV, BID for 2 days. 
b) If there is no improvement, consideration will be given to using second-line 
immunosuppressive therapy, e.g., tacrolimus, mycophenolic acid, monoclonal antibodies, 
or studies of investigational agents for acute GVHD, if they are available. 
5) Antifungal prophylaxis with agents effective against mould will be started when it is 
anticipated that the patient will be receiving steroids at > 1 mg/kg/day of methylprednisolone 
(or equivalent) for > 2 weeks. Voriconazole, caspofungin, liposomal amphotericin B 
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During prophylaxis with any of the above agents, fluconazole should be discontinued.  In 
patients with therapeutic cyclosporine levels at the initiation of voriconazole therapy, the 
cyclosporine or tacrolimus dose should be decreased by approximately 50%. In patients with 
therapeutic sirolimus levels at the initiation of voriconazole therapy, the sirolimus dose should 
be decreased by approximately 90%. 
6) Determination of GVHD treatment response should be made within 96 hours of starting the 
treatment.  The following are criteria to determine definitions of response to GVHD treatment: 
a) Complete response:  Complete resolution of all clinical signs and symptoms of acute 
GVHD. 
b) Partial Response: 50% reduction in skin rash, stool volume or frequency, and/or total 
bilirubin.  Maintenance of adequate performance status (Karnofsky Score > 70%). 
c) Non-responder: < 50% reduction in skin rash, stool volume or frequency, and/or total 
bilirubin.  Failure to maintain adequate performance status (Karnofsky Score ≤ 70%). 
d) Progressive disease:  Further progression of signs and symptoms of acute GVHD, and/or 
decline in performance status after the initiation of therapy. 
 
 

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15.5 APPENDIX E:  INFUSION INSTRUCTIONS    
Equipment:   
Primary IV tubing (2) 
Secondary IV tubing (1) 
NS (sodium chloride 0.9%) 250cc bags (2) 
IV infusion pump 
Gloves 
Steps: 
Key Points: 
1. RN will be informed of the approximate 
time of cell arrival at the bedside. 
 
2.  Verify the physician orders: 
- to administer the cells 
- for the date of administration 
- for premedication orders  
- protocol number 
 
a. Premeds are acetaminophen 650 mg PO 
and diphenhydramine 12.5 mg IV. 
3.  Verify that the protocol consent and DPA 
are signed. 
 
4.  Ensure that emergency and monitoring  
equipment are available in the patient’s 
room: 
-  oxygen 
-  suction 
-  vital sign monitor with pulse oximeter 
   and thermometer    
 
5.  Provide patient education covering 
infusion procedure, potential complications 
and associated symptoms to report.  
 
7.  Measure and record baseline vital signs, 
respiratory and circulatory assessments. 
 

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8.  Verify the patency of the patient’s IV 
access. 
A central venous access device such as a 
non-valved PICC line should be used. 
9.  Hang a primary line of 250cc NS at a kvo 
rate - NEW bag and NEW tubing.  
This MUST be ready and infusing prior to 
the cells being delivered to the unit. 
The patient’s primary IV hydration can 
infuse via a separate lumen while the cells 
are infusing, but NO MEDs should be 
administered during this time.  
Have a second bag of 250cc NS and tubing 
ready as an emergency line. 
This will be the dedicated NS line for 
infusing the cells.  Under no circumstances 
are any other substances to be infused into 
the line.   
Cell death occurs quickly – the infusion 
must be initiated immediately.  
Do not infuse medication during the cell 
infusion.  If emergency meds must be 
administered, 
use 
the 
hydration 
or 
emergency NS IV line.  
 This will be the emergency IV solution and 
can be used for medication administration. 
 
Do not use an inline filter for cells.  
10.  The primary RN will be notified 
approximately 10 minutes before the cells 
arrive on the unit.  The cells will be hand 
delivered to the bedside. 
It is critical to be at the bedside awaiting the 
arrival of the cells for infusion.   
 
 
It is critical to be at the bedside awaiting the 
arrival of the cells for infusion; have 
baseline VS, assessment, and IV lines 
hooked up when the cells arrive.  Cell death 
occurs as soon as the cells are removed 
from the laboratory.  Initiate the infusion 
as quickly as possible. 
 
12.  Prior to spiking the cell bag, two RNs 
will perform the identification procedure.  
Both RNs must sign the tag on the cell bag. 
 
13.   Infuse the cells by infusion pump or 
syringe over 20-30 minutes. 
a. Piggyback the cells into the dedicated 
NS line; use the backflush technique 
to prime the line. 
b.   While the cells are infusing, gently 
agitate the bag of cells every few 
minutes. When the cell bag is 
empty, backflush NS to rinse the bag 
 
 
 
 
 
 
This prevents the cells from clumping in the 
bag.  

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and infuse this at the same rate as the 
cells; rinse bag until NS runs clear.  
        c.  Note: in some cases cells will arrive 
from DTM in a syringe.  In this case 
infuse the cells via syringe over 20-30 
minutes. 
14.  Measure and record VS before and after 
the cell infusion, q1h x 4, and then q4h after 
completion of the infusion.   
a. Assess and document the  patient’s 
respiratory and circulatory status 
post cell infusion.   
 
15.  Documentation: 
a. After the cells have infused, remove 
the adhesive backed “cell therapy 
product” tag from the cell bag and 
place it on a progress note in the 
patient’s chart.  
b.    Document the cell infusion in   
CRIS using the appropriate screens.