Phase I/II Study of Immunotherapy for Advanced CD19+ Chronic Lymphocytic Leukemia, Acute Lymphoblastic Leukemia/Lymphoma and Non-Hodgkin Lymphoma With Defined Subsets of Autologous T Cells Engineered to Express a CD19-Specific Chimeric Antigen Receptor
Phase: PHASE1
Conditions: CD19-Positive Neoplastic Cells Present, Recurrent Adult Acute Lymphoblastic Leukemia, Recurrent Chronic Lymphocytic Leukemia, Recurrent Diffuse Large B-Cell Lymphoma, Recurrent Mantle Cell Lymphoma, Recurrent Non-Hodgkin Lymphoma, Recurrent Small Lymphocytic Lymphoma, Refractory Acute Lymphoblastic Leukemia, Refractory Chronic Lymphocytic Leukemia, Refractory Diffuse Large B-Cell Lymphoma, Refractory Mantle Cell Lymphoma, Refractory Non-Hodgkin Lymphoma, Refractory Small Lymphocytic Lymphoma
Sponsor: Fred Hutchinson Cancer Center

 
1 
FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
 
PROTOCOL 2639.00 
 
Current Version: 06/01/2021 
Previous Version: 09/19/2018 
 
1.  TITLE OF PROTOCOL: Phase I/II study of immunotherapy for advanced CD19+ chronic 
lymphocytic leukemia, acute lymphoblastic leukemia/lymphoma and non-Hodgkin lymphoma with 
defined subsets of autologous T cells engineered to express a CD19-specific chimeric antigen 
receptor. 
 
 
Investigators 
 
 
Professional Title 
 
 
Telephone Number 
Jordan Gauthier, MD 
 
Assistant Professor, FHCRC  
 
206-667-2713  
Brian Till, MD 
 
 
Associate Professor, FHCRC  
 
206-667-7269 
Michael Jensen, MD 
 
Professor of Pediatrics, UW  
 
206-987-1241 
Shelly Heimfeld, PhD 
 
Affiliate Investigator, FHCRC 
 
 
Stanley Riddell, MD 
 
Professor, FHCRC 
 
 
 
206-667-5249  
 
Immunotherapy MD on call 
 
 
 
 
 
Pager 206-314-3907 
 
Biostatistician 
Ted Gooley, PhD  
 
Professor, FHCRC 
 
 
 
206-667-6533 
 
 
 
 
 
 
Emergency (24 hour) Phone:  206-598-5520 
 
 
 
 
 
IRO received 10/04/21
FHCRC IRB Approval  
NOV 03 2021 
Document Released Date

 
2 
Table of Contents 
 
2. Introduction .............................................................................................................................................. 4 
 
3. Background .............................................................................................................................................. 4 
 3A. Chronic Lymphocytic Leukemia......................................................................................................... 4 
 3B. Indolent and Mantle Cell Lymphoma .................................................................................................. 5 
 3C. Diffuse Large Cell and other Aggressive B cell Lymphomas .............................................................. 6 
 3D. Adoptive T cell therapy for human malignancy .................................................................................. 6 
 3E. Transfer of tumor targeting receptors into T cells to confer tumor-specificity ...................................... 7 
 3F. Rationale for targeting CD19 on B cell malignancies with CAR-T cells .............................................. 7 
 3G. Clinical experience with the adoptive transfer of T cells genetically modified to express a CAR  ....... 8 
 3H. Lymphodepleting chemotherapy improves persistence of transferred T cells ...................................... 9 
 3I. Heterogeneity of T cell products in adoptive transfer studies ................................................................ 9 
 3J. Rationale for deriving CAR-T cell products from defined T cell subsets .............................................. 9 
 3K. Development of a self-inactivating (SIN) lentiviral vector encoding a CD19-specific CAR ................ 9 
 3L. Safety considerations for adoptive therapy with genetically modified T cells ...................................... 10 
 3M. Overview of the study ........................................................................................................................ 11 
    3N. Modification to extend Stage 1 of the trial ……………………………………………………………. 11 
    3O. Modification to Refine Dose in NHL and CLL (following Cy/Flu lymphodepletion) ……………….. 13 
3P.  Planned Dose Dense Cohort Expansion for NHL ……………………………………………………...13 
3Q. Dose revision for low tumor burden ALL …………………………………………………………….. 14 
3R. Dose Revision for Low-Tumor Burden ALL for expanded Stage 2. ..…………………………………14 
3S. Cohort expansion for CLL patients with concurrent Ibrutinib…………………………………………..14   
3T. Special Consideration for Patients Previously Leukapheresed, but NOT Treated………………………15   
 
4. Objectives................................................................................................................................................. 13  
4A. Primary  ............................................................................................................................................. 13 
4B. Secondary  .......................................................................................................................................... 13  
 
5. Patient Selection ....................................................................................................................................... 14 
5A. Inclusions ........................................................................................................................................... 14  
5B. Exclusions .......................................................................................................................................... 14 
 
6. Evaluation and counseling of patient ......................................................................................................... 15 
 
7. Protocol registration ................................................................................................................................. 15 
 
8. Study Agent .............................................................................................................................................. 15 
 
9. Plan of treatment....................................................................................................................................... 16 
9A. Leukapheresis or blood-draw to obtain T cells for lentiviral transduction............................................ 16 
9B. Lymphodepleting Chemotherapy ........................................................................................................ 17  
9C. Clinical and/or Laboratory Exclusion Criteria for T Cell Infusions...................................................... 17  
9D. Infusions of CD19 CAR-T cells .......................................................................................................... 18 
 
10. Management of Toxicities and Complications ......................................................................................... 19 
10A. Management of toxicity associated with the T cell infusion .............................................................. 19 
10B. Cytokine release ............................................................................................................................... 20 
10C. Management of tumor lysis syndrome............................................................................................... 20 
10D. Management of neurotoxicity ........................................................................................................... 20 
10E. Management of other toxicities ......................................................................................................... 21 
10F. Additional measures for toxicity ........................................................................................................ 21 
 
11.Schedule of Patient Evaluations ............................................................................................................... 21 
11A. Enrollment Evaluation ...................................................................................................................... 21 

 
3 
11B. Patient Evaluation to be performed within 14 days of the T cell infusion .......................................... 22 
11C. Patient Evaluation During and Following Each T Cell Infusion ........................................................ 23 
12. Protocol Enrollment ................................................................................................................................ 26  
 
13. Records .................................................................................................................................................. 27 
 
14. Evaluation and statistical considerations ................................................................................................. 27 
14A. Type of study ................................................................................................................................... 27 
14B. Definition of endpoints ..................................................................................................................... 27 
14C. Endpoint evaluation .......................................................................................................................... 28 
 
15. Guidelines for reporting adverse events, unanticipated problems and non-compliance ............................ 29 
15A. General issues and IRB reporting requirements................................................................................. 29 
15B. Data safety monitoring plan .............................................................................................................. 31 
 
16. Termination of the study ......................................................................................................................... 32 
 
17. References .............................................................................................................................................. 32 
  
18. Appendices ............................................................................................................................................. 37 
A. Suggested cytoreduction/lymphodepletion chemotherapy regimens .................................................. 37 
B. Karnofsky Performance Score ........................................................................................................... 38 
C. Table of Evaluations ......................................................................................................................... 39 
D. Research sample checklist …………………………………………………………………………. ... 41  
E. Response Criteria for CLL and NHL ................................................................................................. 45 
F.  Long Term Follow-up....................................................................................................................... 46 
 
 
 
 
 

 
4 
2. 
INTRODUCTION 
Patients with CD19+ B cell malignancies such as chronic lymphocytic leukemia (CLL), 
indolent and mantle cell lymphoma, and diffuse large cell lymphoma that progress after first and 
second line conventional chemotherapy have a poor long-term prognosis, especially if they are 
not eligible for hematopoietic stem cell transplant due to the lack of a donor, or if stem cell 
transplant is contraindicated. This protocol will evaluate the safety and antitumor activity of 
adoptively transferring autologous T cells that are genetically modified with a self-inactivating 
(SIN) lentiviral vector to express a CD19-specific chimeric antigen receptor (CAR) to patients 
with advanced CD19+ B-lineage malignancies.  
 
3. 
BACKGROUND 
3A. 
Chronic Lymphocytic Leukemia (CLL)   
 
CLL is the most prevalent adult leukemia and patients may have an indolent or 
aggressive clinical course.  Tumor cells nearly universally express the CD19 antigen and variable 
to low density of CD20.  Asymptomatic patients without a large disease burden at diagnosis are 
usually observed until their disease progresses and requires therapy.  Patients with high risk 
features including non-mutated immunoglobulin genes, expression of ZAP-70, CD38, and/or 
adverse genetic changes (11q23 or 17p-) detected by cytogenetics or FISH often progress more 
rapidly to symptomatic disease and require treatment to control disease burden and reduce 
symptoms 1.   
 
For patients requiring antitumor therapy, the recent addition of monoclonal antibody 
therapy to combination chemotherapy has become standard of care.  For medically fit patients 
less than 65 years of age, the CLL8 trial by the German CLL group demonstrated higher 
complete remission (CR) rates, longer progression free survival (PFS) and overall survival (OS) 
for patients randomized to fludarabine, cyclophosphamide, rituximab (FCR) chemotherapy 
compared to FC chemotherapy alone 2.  In this trial, lower levels of minimal residual disease 
(MRD) as detected by flow cytometry 2 months after the completion of therapy were correlated 
with improved PFS and OS 3. Other approaches include combinations of fludarabine and 
rituximab or bendamustine and rituximab and are often used in older patients or those with 
comorbid medical conditions.  
 
Unfortunately, current treatments for CLL are not curative and patients remain at a 
continuous risk of relapse.  The prognosis for patients relapsing after first line therapy is variable 
but largely dependent on the duration and depth of first remission and on the interim 
development of adverse genetic risk features such as 17p deletion.  For patients with long 
remissions (> 2 years), the initial treatment can often be repeated.  However, the response rate, 
depth and duration of remission are usually shorter with subsequent therapy. Patients with short 
remissions after initial aggressive chemoimmunotherapy or who have developed fludarabine 
refractory disease (less than partial response (PR) to therapy or relapse within 6-12 months) have 
a poor prognosis with median OS of < 2 years and are candidates for aggressive treatments, 
including allogeneic hematopoietic cell transplantation (HCT).   
 
Patients beyond first or second relapse are in need of novel experimental treatments.  
Current approaches include the use of new agents targeting the B cell Ig receptor signaling 
pathway including PI3kinase-delta with GS-1101 (CAL-101) and the Brutons Tyrosine kinase 
(BTK) inhibitor, ibrutinib (PCI32765) 4, 5.  Allogeneic HCT using HLA matched related or 
unrelated donors following non-myeloablative conditioning may provide a curative option, 
however there is significant risk of non relapse mortality of approximately 25% at 1 year due to 

 
5 
GVHD and/or infections 6.  The recent demonstration that adoptive T cell therapy with 
autologous T cells engineered to express a chimeric antigen receptor specific for CD19 induced 
complete and sustained remissions in 2 of 3 patients with refractory CLL provides an additional 
treatment option for these patients 7, 8.   
 
3B.  
Indolent Lymphoma and Mantle Cell Lymphoma   
 
The indolent lymphomas represent a wide group of tumors predominately comprising 
follicular, small lymphocytic, marginal cell and lymphoplasmacytic histologies that often have a 
long natural history characterized by continuous relapses.   Patients with asymptomatic disease at 
presentation and with low tumor bulk are usually observed and not treated until the development 
of symptoms or significant disease progression.  Several recent studies presented in abstract form 
have demonstrated that single agent rituximab, given for short or extended schedules has a high 
response rate and delays the time to requiring next therapy 9, 10.   However, these studies have not 
yet shown an impact on OS and this practice is not standard.  For medically fit patients requiring 
therapy, combination chemo-immunotherapy is emerging as the standard of care.  Multiple 
studies have demonstrated that the addition of rituximab to combination or single agent 
chemotherapy (CHOP, CVP or Bendamustine) results in longer PFS and in some trials prolonged 
OS 11-13.  Following initial therapy, many patients are treated for up to 2-years with maintenance 
rituximab using a variety of schedules.  The PRIMA study in patients with follicular non-
Hodgkins lymphoma (NHL) demonstrated a decrease in the risk of progression at 2 years by 
50% by this strategy, although there was no difference in OS 14.   
 
As in CLL, patients with indolent lymphoma who relapse following initial therapy may 
be treated again with the same or similar regimen.  Patients with early relapse, or those who 
progress on rituximab maintenance are considered rituximab refractory.  There is no standard of 
care for the treatment of patients with relapsed indolent NHL, and the usual approaches include 
the use of agents singly or in combination that had not been given as initial therapy (such as 
bendamustine and rituximab in patients failing R-CVP or R-CHOP), or more aggressive salvage 
therapies and autologous HCT.  Unfortunately, these treatments are generally not curative.   
 
Patients with recurrent or progressive indolent lymphoma may be candidates for 
allogeneic HCT, which can result in long-term disease free survival 15.  However, as in CLL, the 
treatment is dependent on the identification of an appropriate donor and is associated with 
significant risks of acute and chronic GVHD and infections.  For transplant eligible patients, the 
decision to proceed to transplantation is often a matter of personal choice of risk-vs-benefit.  
Patients without donors, those who are not transplant candidates, and those who elect not to 
undergo allogeneic HCT are in need of novel therapies.   
 
 
Mantle cell lymphoma (MCL) represents a chronic relapsing NHL with a more 
aggressive clinical course.  Current standard of care includes induction chemo-immunotherapy 
with regimens such as R-CHOP or HyperCVAD/Mtx/Ara-C 16.  Patients with responsive disease 
are considered for high-dose therapy and autologous HCT as consolidation in first remission.  A 
study by the German low-grade lymphoma group demonstrated improved PFS and OS with 
autologous HCT in first remission compared with interferon maintenance therapy 17, 18.  Data 
from the MD Anderson Cancer Center suggest that patients receiving full course HyperCVAD 
may have similar outcomes without autologous HCT 16. Even with the use of autologous HCT, 
patients appear to remain at risk of relapse with no evidence of a plateau on the PFS curve.  
Patients who relapse following autologous HCT, or those unable to receive autologous HCT 

 
6 
have a poor outcome and are considered for experimental approaches and for allogeneic HCT.  
Surprisingly, allogeneic HCT appears to provide powerful graft-versus-tumor effect against 
MCL and several studies have demonstrated high CR rates and a low rate of relapse 19. This 
suggests MCL is susceptible to T cell recognition however as discussed above, the considerable 
risk of morbidity and mortality from GVHD and infection makes proceeding to an allogeneic 
HCT a difficult decision for many patients.  Patients unable to find a donor or unwilling to accept 
the risk of allogeneic HCT are usually treated with single agent or combination chemotherapy 
with palliative intent.   
 
3C. 
Diffuse Large Cell and Other Aggressive B Cell Lymphomas 
 
The most common histologic type of lymphoma is diffuse large B cell (DLBCL), 
representing approximately 30% of the annual incidence of NHL.  In contrast to the indolent 
NHL’s, these lymphomas require immediate treatment with curative intent. The addition of anti-
CD20 antibody therapy with rituximab to standard CHOP chemotherapy has improved the 
outcome for patients with DLBCL 20.  The goal of treatment is to obtain a CR as demonstrated 
by a negative positron emission tomography (PET) scan.  Current standards for patients with 
limited stage disease include a short course of R-CHOP followed by involved field irradiation or 
full course R-CHOP.   Patients with advanced stage disease usually receive 6-8 cycles of R-
CHOP or 6 cycles of dose adjusted EPOCH-R.  Patients who fail to achieve a PET negative CR 
or those who relapse following CR are treated with salvage therapy with plans for high-dose 
chemotherapy and autologous HCT for those who respond to the salvage regimen.   High dose 
therapy with regimens such as BEAM or CY/TBI/VP-16 or BuMelTT can cure 20-50% of 
chemotherapy responsive patients and is considered the standard of care for patients responding 
to salvage chemotherapy who are medically fit for transplant. Unfortunately, patients who 
relapse early after primary therapy with a regimen containing rituximab, have a worse prognosis 
even with salvage high-dose therapy and autologous HCT 21. 
 
Patients who are unable to undergo autologous HCT or those who relapse following 
autologous HCT have a poor prognosis with a median survival of 6 to12 months.  Allogeneic 
HCT may be considered in patients who have appropriate donors and chemotherapy sensitive 
disease that can be rendered into CR or near CR prior to the transplant 22.  Evidence for a graft-
versus-lymphoma effect for DLBCL is more limited, perhaps because class I MHC is absent on a 
high proportion of DLBCL 23, and long-term survival is achieved in only 30-40% of patients who 
have minimal disease at the time of allogeneic HCT.  Thus, patients with relapsed aggressive 
lymphoma who have previously had an autologous HCT or those medically unable to receive 
autologous HCT have a poor prognosis and are in need of novel treatments.    
 
3D.  
Adoptive T cell therapy for human malignancy 
The potential for T cells to eradicate human malignancies is illustrated by the graft-
versus-leukemia effect of allogeneic T cells administered as part of a stem cell transplant 24, 25; 
and in melanoma patients who receive in vitro expanded, autologous T cells derived from the 
tumor infiltrate and administered after lymphodepleting chemotherapy 26. These approaches have 
antitumor efficacy, but have been associated with some toxicity related to recognition of normal 
cells that express the antigen(s) targeted by the infused T cells. Patients that receive allogeneic 
HCT or donor lymphocyte infusions often develop graft-versus-host disease as a consequence of 
donor T cell recognition of epithelial cells that express minor H antigens 27, and melanoma 
patients treated with tumor infiltrating lymphocytes (TIL) may develop vitiligo due to 
recognition of normal melanocytes 26.  Despite these complications, T cell therapy has cured a 

 
7 
subset of patients with advanced malignancy that was resistant to conventional chemotherapy 
and/or radiotherapy 26, 27. 
 
3E.  
Transfer of tumor targeting receptors into T cells to confer tumor-specificity 
An obstacle for applying T cell therapy more broadly is the difficulty isolating tumor 
reactive T cells from patients with cancer. An approach to overcome the low frequency of tumor-
reactive T cells in patients is to redirect the specificity of T cells by expressing a transgene that 
encodes a receptor specific for a tumor-associated antigen (TAA). Vector systems to deliver 
transgenes into primary human T cells have been developed and clinical trials in which 
autologous T cells are modified to express a tumor-reactive T cell receptor (TCR) have been 
initiated with transient clinical responses 28, 29. However, redirecting T cells to recognize tumor 
antigens through TCR gene transfer is inherently constrained because of the requirement for 
major histocompatibility complex (MHC) restricted peptide presentation by tumor cells, and 
because many tumors including DLBCL express low levels of MHC molecules to avoid T cell 
recognition 23.  
An alternative method for targeting T cells to tumor cells is to express an artificial 
chimeric non-MHC restricted antigen receptor (CAR) that recognizes a tumor cell surface 
molecule 30, 31. A CAR is typically comprised of a fusion gene that encodes a monoclonal 
antibody-derived single chain variable fragment (scFv), consisting of heavy (VH) and light (VL) 
chains joined by a flexible linker, and then fused through a transmembrane domain to a 
cytoplasmic signaling moiety consisting of CD3ζ alone, or CD3ζ combined with activation 
domains from costimulatory molecules such as CD28, 4-1BB or OX40 31, 32. CARs with 
specificity for tumor cell-surface epitopes are “universal” in that they bind antigen in an HLA 
independent fashion, and one receptor construct can be used to treat all patients with tumors that 
express the molecule targeted by the CAR. T cells obtained from the blood of cancer patients can 
be modified with CARs to generate anti-tumor effector cells (CAR-T cells) for adoptive therapy 
that can recognize tumor cells that have downregulated HLA molecules, thereby avoiding the 
need to isolate rare HLA-restricted tumor-reactive T cells. CARs have been constructed for many 
tumor-associated cell surface molecules including CD19, CD20, EGFR, Her2neu, GD2, PSMA, 
mesothelin, CAIX and ROR1 31-36. In vitro studies have demonstrated that both CD4+ and CD8+ 
T cell effector functions can be triggered via CARs, and studies in animal models and in small 
numbers of patients have demonstrated the capacity of adoptively transferred CAR-T cells to 
eradicate established tumors 7, 8, 37, 38. 
 
3F.  
Rationale for targeting CD19 on B cell malignancies with CAR-T cells  
Efforts to target B cell malignancies with CAR-T cells have focused predominantly on 
introducing receptors that recognize surface molecules such as CD19 and CD20 that are 
restricted in their expression to the B cell lineage. CD20 is present on B cell lymphomas and 
CLL, and has been targeted effectively with rituximab 39, 40. However, rituximab is now routinely 
administered to most patients with B cell malignancies and the presence of antibody bound to 
CD20 can block target recognition by T cells engineered to express a CD20-specific CAR. CD19 
is a type I transmembrane protein that associates with CD21, TAPA-1, and Leu13 to form a 
signal transduction complex that participates in regulating B cell proliferation 41. CD19 is 
expressed on all human B cells beginning from the initial lineage commitment until terminal 
differentiation into plasma cells, and is expressed homogeneously on B cell CLL, indolent and 
mantle cell lymphoma, and DLBCL. Importantly, CD19 is not expressed on any normal tissue 

 
8 
apart from B lymphocytes, therefore depletion of normal B cells is the only anticipated on-target 
toxicity to normal cells of CD19 CAR-T cells 7, 8. 
 
3G.  
Clinical experience with the adoptive transfer of T cells genetically modified to express a 
CAR  
 
The initial human trials of CAR-modified T cells employed first generation constructs 
that linked the scFv to the CD3ζ or FcR gamma epsilon chain as the only intracellular signaling 
domain. T cells engineered with first generation CARs specific for CAIX were administered to 
patients with renal cell cancer, and caused elevations in liver enzymes possibly due to expression 
of CAIX on bile duct epithelium 42.  T cells specific for CD171 (L1CAM) were administered to 
patients with neuroblastoma without toxicity 43. However, in each of these studies, T cell 
persistence was poor and sustained antitumor effects were not observed.  
Patients with advanced B-cell malignancies have also been treated with first generation 
CARs that were specific for CD20 or CD19. These patients experienced little or no toxicity, but 
the CAR-T cells persisted poorly and sustained antitumor efficacy was not observed 28, 44. The 
suboptimal results in these initial trials may reflect several factors including the absence of 
signaling domains to provide costimulation necessary for sustained T cell proliferation and 
survival in first generation CARs; the methods used to engineer and expand T cells for adoptive 
transfer that required long term culture and favored infusing terminally differentiated effector 
cells; and the variability in phenotype of the starting population, which can influence the 
capacity of T cells to persist and function long term in vivo 44-48.  
To overcome the limitations identified in the initial trials and enhance potency, 
costimulatory endodomains were added to CD3ζ to enhance signaling through the CAR 7, 8, 49-51, 
and improved methods for selecting and transducing T cells of defined phenotype have been 
developed that do not require long-term culture 7, 8.The antitumor efficacy of T cells engineered 
to express a CD19-specific CAR and derivatives that include CD28 and/or 4-1BB signaling 
domains in series with CD3ζ have been studied in vitro and in pre-clinical in vivo models, and 
receptors that provide costimulation have been superior to those that do not 49, 52 (Hudecek M, 
Riddell SR, unpublished data). Moreover, potent and sustained antitumor activity has been 
observed in a small number of patients with CLL and NHL treated with autologous CD19 CAR-
T cells that include either a 4-1BB or CD28 signaling domain in the CAR design 7, 8, 51, 53. In 
these studies, lymphodepleting chemotherapy was administered to enhance T cell persistence, 
and in some cases, IL-2 was administered after the T cell infusion, although the most impressive 
antitumor responses were observed in patients that did not receive IL-2 7. The major toxicities of 
CAR-T cells include cytokine release and tumor lysis syndromes that occurred approximately 2 
weeks after infusion of CD19 CAR-T cells, and persistent depletion of normal CD19+ B cells, 
necessitating intravenous immunoglobulin treatment. There was no obvious correlation between 
efficacy, toxicity, T cell persistence and the T cell dose administered to patients in these initial 
trials 7, 8, 51, 53. The inconsistency in the behavior of the therapeutic products may be because 
polyclonal T cells from the patient were transduced to express the CAR, and the resulting cell 
products administered to each patient varied greatly in phenotypic composition (CD4, CD8) and 
subset derivation. 
 
3H.  
Lymphodepleting chemotherapy improves persistence of transferred T cells 
Clinical trials of T cell therapy for melanoma at the National Cancer Institute 
demonstrated that administering lymphodepleting chemotherapy such as fludarabine and 

 
9 
Cytoxan, or fludarabine, cytoxan and total body irradiation, prior to the transfer of 1010-1011 
polyclonal melanoma-specific T cells improved the survival of a subset of the transferred T cells 
and therapeutic efficacy 26, 54, 55.  The size of the T cell pool is subject to homeostatic regulation, 
and the induction of lymphopenia results in less competition for cytokines such as IL-15 and IL-
7 that promote lymphocyte proliferation and survival, and leads to the proliferation of residual T 
cells including those that are adoptively transferred. Lymphodepleting chemotherapy may also 
eliminate CD4+ CD25+ regulatory T cells, and activate antigen presenting cells that may promote 
the function of transferred T cells. Studies in murine models subsequently confirmed the human 
data that lymphodepletion improves the persistence and antitumor efficacy of transferred TE cells 
56.  
 
3I. 
 Heterogeneity of T cell products in clinical adoptive transfer studies 
 
Clinical trials of genetically modified T cells have typically utilized peripheral blood 
mononuclear cells derived from the blood as the starting population for transduction. The T cell 
pool is characterized by marked heterogeneity in the phenotype and function of cells, and this is 
further altered by age and prior chemotherapy. T cells can be broadly divided into CD45RA+ 
antigen inexperienced naïve T cells (TN) that express CD62L+ and CCR7+ to enable their transit 
through lymph nodes where they survey for foreign antigens; and CD45RO+ memory T cells that 
have clonally expanded in response to prior antigen encounter, and can be subdivided into 
CD62L+ central memory (TCM) and effector memory (TEM) subsets 57.  A subset of memory T 
cells that is intermediate between that naïve and memory cells has also been described, and 
suggested to represent a “memory stem cell” based on the ability to self-renew, and give rise to 
effector (TE), and TCM and TEM subsets 58. As a consequence of heterogeneity in the distribution 
of T cell subsets in the blood of different individuals, particularly cancer patients who may have 
had markedly different exposures with prior chemotherapy, the composition of T cell products 
obtained after gene transfer is often dramatically different, and the consequences of this 
variability for interpreting, cell persistence, and the toxicity and efficacy of infused T cell 
products are not known.   
 
3J.  
Rationale for deriving CAR-T cell products from defined T cell subsets 
It is possible to generate genetically modified T cells from a defined starting population 
of T cells that are enriched from PBMC based on the expression of distinct cell surface markers 
that define their lineage and differentiation. Studies in animal models including immunodeficient 
mice that were administered human CD8+ T cells showed that cells from defined subsets have 
markedly different capacity to survive and function in vivo 45, 59. For example, effector CD8+ T 
cells derived from purified TCM have been shown to persist long term in vivo, migrate to memory 
cell niches in the bone marrow and lymph nodes, and establish functional populations of TCM and 
TEM [45]. Studies from our group have also demonstrated that human CD4+ T cells modified with 
a CAR enhance the proliferation of CD8+ CAR-T cells derived from TCM in response to tumor 
cells (Hudecek M, Riddell SR, unpublished data). These results suggest that preparing CAR T 
cells from purified CD8+ TCM and CD4+ T cells and combining these subsets to achieve a defined 
product composition may provide a more reproducible safety profile of transferred T cells and 
improve therapeutic efficacy.  
 
 
  

 
10 
3K.   Development of a self-inactivating (SIN) lentiviral vector encoding a CD19-specific 
CAR 
We have constructed a CD19-specific CAR consisting of an scFv derived from the 
murine IgG1 monoclonal antibody (mAb) FMC63. The scFV is fused to the human IgG4 hinge 
region and the human 4-1BB costimulatory domain in tandem with CD3ζ (Figure 1). The 
construct also encodes a truncated 
epidermal growth factor receptor 
(tEGFR) downstream of a T2A 
sequence to provide coordinate 
expression of tEGFR, which can       
serve 
both as a marker for cell selection 
and 
for tracking transduced T cells in 
vivo 
60. We have compared the activity of 
different CD19 CARs in vitro and in 
vivo 
using murine xenograft models, and found that the CD19 CAR containing 4-1BB as a co-
stimulatory domain exerts superior antitumor activity compared with a CD19 CAR that contains 
an IgG4 hinge and CH2-CH3 spacer with CD28 as the costimulatory domain. This data is 
consistent with uncontrolled results of other groups in which a small number of patients have 
been treated with CD19 CAR-T cells containing CD28 or 4-1BB costimulatory domains 7, 8, 50, 51, 
53. Based on the practical and theoretical advantages of lentiviral vectors, a SIN lentiviral vector 
([ZRX-014-LV provided by ZetaRx Biosciences, Inc), Seattle] that encodes the CD19-4-1BB-
CD3ζ-tEGFR CAR under transcriptional control of the elongation factor 1 alpha (EF1α) 
promoter was produced under GMP conditions, and the virus supernatant subjected to quality 
control analysis for clinical applications.  Exposure of primary human T cells to CD19-4-1BB-
CD3ζ-tEGFR SIN lentiviral vector results in efficient transduction and expression of the CAR 
and tEGFR, and confers recognition of CD19+ target cells including primary CLL, and mantle 
cell and large cell lymphoma cell lines.  
 
3L.  
Safety considerations for adoptive therapy with genetically modified T cells 
 
There are several potential toxicities of adoptive therapy with CD19 CAR-T cells.  The 
first potential toxicity is particular to targeting cells that express the CD19 molecule, as re-
directed T cells will recognize and eliminate non-malignant CD19+ B-cells, potentially resulting 
in a long-term B-cell immunodeficiency 7, 8, 50, 51, 53. Prolonged suppression of normal B cells in 
patients receiving rituximab therapy is common and does not appear to result in significant 
complications, providing immunoglobulin levels are maintained by IVIG therapy 61. Thus, in 
patients with advanced B cell malignancies that have failed conventional chemotherapy and 
already have a B-cell deficiency from rituximab therapy, B-cell lymphopenia may be an 
acceptable side effect of T cell therapy if it is accompanied by a significant antitumor effect.  
 
A second potential toxicity relates to the possibility of transformation of the adoptively 
transferred gene-modified T cells as a consequence of insertional mutagenesis. The development 
of T cell leukemia has been reported in a subset of patients on two gene therapy trials for X-
linked severe combined immunodeficiency syndrome (SCID), in which bone marrow derived 
CD34 cells were transduced with a retroviral vector encoding the common cytokine receptor 
gamma chain 62-66. Currently, five cases of T cell leukemia resulting from retroviral insertional 
mutagenesis have been described after successful correction of X-linked SCID. Four of the cases 
were associated with activation of the LMO2 oncogene 62-66. Animal studies have shown that 
 
Figure 1. Schematic design of the CD19 CAR with a 
short (hinge only) extracellular spacer domain.  

 
11 
mature T cells are resistant to transformation after retroviral integration 67, and leukemia has 
never been observed in clinical trials involving gene transfer into mature T cells, despite more 
than 10 years of follow-up in some studies. Our study differs from the X-linked SCID trial in 
several important aspects: (a) we will use a lentiviral vector and not a retrovirus to genetically 
modify cells, which reduces the risk of integrating into a transcriptionally active site; (b) the 
target of the genetic modification will be a mature T cell and not hematopoietic progenitor cells; 
and (c) the genetically modified CD19-specific T cells do not constitutively express a functional 
growth factor receptor as was the case with transduced cells in the X-linked SCID trial.  
 
A third potential toxicity is that CD19 CAR-T cells might cause cytokine release after 
engagement of target cells or induce rapid tumor cell death resulting in a tumor lysis syndrome. 
Both cytokine release and tumor lysis syndromes have been observed in small clinical trials of 
CD19 CAR-T cell therapy in patients with high tumor burdens, but there has not been a clear 
correlation with T cell dose, with tumor burden or with the costimulatory domain in the CAR 7, 
51. We anticipate that toxicity from cytokine release may be more predictable with T cell 
products of a defined composition. In this trial we will use a dose escalation of CAR-T cells that 
consist of a 1:1 mix of CD8+ TCM and CD4+ T cells in cohorts of patients to determine if a T cell 
dose can be defined that provides acceptable toxicity, long-term persistence, and reproducible 
depletion of CD19+ B cells. To minimize the risk of tumor lysis syndrome, we plan to administer 
standard chemotherapy prior to the T cell infusion to reduce tumor burden and induce 
lymphopenia to improve T cell persistence.  
 
3M.  
Overview of the Study  
 
This is a Phase 1/2, open-label, nonrandomized study that will evaluate the safety and 
potential antitumor activity of adoptively transferring autologous CD19 CAR-T cells transduced 
with a lentiviral vector to express a CD19-specific CAR to patients with advanced CD19+ B cell 
malignancies. To provide for greater reproducibility of T cell products and to facilitate safety and 
efficacy evaluation, we will enrich CD8+ TCM and CD4+ T cells separately from the leukapheresis 
product or blood of each patient, transduce and expand each cell subset with the CD19 CAR 
lentivirus independently, and pool T cells in a 1:1 ratio to achieve the specified cell dose for each 
cohort of patients. The trial will consist of two stages – an initial dose escalation/de-escalation 
stage to define a cell dose that has acceptable toxicity, and then an analysis of the safety of that 
cell dose in expanded cohorts of up to 45 patients each with ALL and NHL and up to 15 patients 
with CLL.   
 
3N.      Modification to extend Stage 1 of the trial:   
 
1. Analysis of disease specific cohorts for determination of optimal dose for ALL, NHL 
and CLL. 
 
 
Experience from the initial 16 patients treated on the dose escalation and de-
escalation Stage 1 of the trial revealed differences in toxicity based on disease histology 
and tumor burden. Patients with ALL and high tumor burden have had toxicity attributed 
to CD19 CAR-T cell therapy that has required dose de-escalation per protocol guidelines. 
Two patients with high tumor burden ALL (≥ 15% bone marrow involvement) had dose 
limiting toxicity (one transient CNS toxicity and one patient death from cytokine storm) 
at dose level 3.  In contrast, none of the 5 (2 at dose level 1 and 3 at dose level 2) patients 

 
12 
treated with low tumor burden ALL (< 15% bone marrow involvement at pre treatment 
evaluation) had dose limiting toxicity. After discussions with the FDA we propose to 
extend the Stage 1 portion of the trial by evaluating ALL patients in separate high tumor 
burden or low tumor burden cohorts to determine the optimal and safe dosing for the 
stage 2 portion of the trial for patients with ALL. 
 
In contrast to the experience in ALL, none of the 9 patients with NHL/CLL treated at any 
of the dose levels (2 at dose level 1, 4 at dose level 2, and 3 at dose level 3) experienced a 
dose limiting toxicity regardless of their tumor burden (marrow or nodal disease); 
therefore, we will not separate NHL/CLL patients into disease burden cohorts, but will 
evaluate NHL and CLL patients in separate disease-specific stage 1 cohorts.   
 
Stage 1 will be extended to further examine dosing in disease specific cohorts outlined in 
3N.1.a and the results used to identify a cell dose for Stage 2 evaluation to determine 
safety and efficacy in larger disease/ patient specific cohorts, as described in 3N.2.a.  
Each of the Stage 1 cohorts will follow the dose escalation and de-escalation rules based 
on dose limiting toxicities as defined in 14C.1.b.  
 
a. Stage 1 cohorts:   
 
A) ALL-High tumor burden defined as ≥ 15% ALL in bone marrow at staging prior 
to treatment.  Treatment will start at Dose level 1 and then escalate or de-escalate in a 
3 x 3 design as described in Section 14C.1.b.  This cohort could consist of 3-18 
patients.  
 
B) ALL: Low tumor burden defined as < 15% ALL in bone marrow at staging prior 
to treatment. Treatment will start at Dose level 2 and then escalate or de-escalate in a 
3 x 3 design as described in Section 14C.1.b.  This cohort could consist of up to 3-12 
patients; however, we have seen no dose-limiting toxicity in ALL patients with low 
tumor burden and do not anticipate that enrollment on this cohort will be prolonged 
before proceeding to stage 2.  
 
C) NHL: Patients will be initially treated at Dose level 2 and then escalate or de-
escalate in a 3 x 3 design as described in Section 14C.1.b.  This cohort could consist 
of up to 3-12 patients; however, we have seen no dose-limiting toxicity in the 9 NHL 
patients previously treated, and do not anticipate that enrollment on this cohort will be 
prolonged before proceeding to stage 2. 
 
D) CLL: We have limited experience with the treatment of patients with CLL. Based 
on the differences observed in ALL and NHL, we propose to formally examine 
dosing in a cohort of patients with CLL to determine the optimal dose for Stage 2. 
Treatment will start at Dose level 2 and then escalate or de-escalate in a 3 x 3 design 
as described in Section 14C.1.b.  This cohort could consist of up to 3-12 patients; 
however, we have seen no dose-limiting toxicity in patients with low grade NHL and 
with concurrent DLBCL/SLL and do not anticipate that enrollment on this cohort will 
be prolonged. 

 
13 
 
2. Modification of Stage 2 cohorts:  
 
 
At the completion of the Stage 1 dose finding in disease specific cohorts, the identified 
dose/s will be used for treatment of patients in the specific Stage 2 cohorts.  Stage 2 for a 
given cohort/disease may begin immediately on identification of the optimal dose from 
the Stage 1 cohorts. 
 
a. Stage 2 cohorts:   
 
A) ALL patients with low (< 20% marrow disease) or high (≥ 20% marrow disease or 
bulky extramedullar disease) are eligible, n=45. 
 
B) Non Hodgkin Lymphoma.  All histologies expressing CD19 are eligible including 
Diffuse Large B cell, Follicular, Marginal cell, Mantle cell or other histologies, n=45. 
 
C) CLL or small lymphocytic lymphoma, n=15  
 
3O.  Modification to Refine Dose in NHL and CLL (following Cy/Flu lymphodepletion) 
 
1.  DL3 was selected for Stage 2 for patients with NHL based on no DLT in 3 patients 
treated in Stage 1.  However, poor CAR-T cell persistence and expansion were observed 
in part due to the development of immune responses to the CAR modified T cells.  The 
use of Cy/Flu for lymphodepletion improved CAR-T cell expansion and persistence and 
clinical response rate, but was unexpectedly associated with greater toxicity at DL3 in 
NHL patients.  While protocol stopping rules (see section 14C2) were not met, there were 
2 treatment related deaths occurring on day 13 and day 23 after treatment.  In discussions 
with the DSMB and FDA we elected to dose de-escalate to DL1 in patients with NHL 
and to treat 3 patients with re-escalation to DL2 if no DLT observed.  Either DL1 or DL2 
will then be used for the remainder of the Stage 2 cohort.  Until a dose level is cleared, 
these patients will be treated at no less than 2 week intervals.  All patients will count 
toward safety and efficacy as before and there is no change to overall study numbers.  
 
2.   Five patients with CLL have been treated (4 DL2, 1 DL3) in Stage 1.  However we 
observed a DLT at dose level 3 in a patient with Cy/Flu conditioning so we will also 
return to dose escalate patients with CLL from DL1 prior to starting Stage 2 for this 
cohort.   
 
3P.  
Planned Dose Dense Cohort Expansion for NHL: 
DL2 was found to be well tolerated and selected following dose refinement as discussed 
in section 3O with the use of Cy/Flu lymphodepletion and will be used for the completion 
of Stage 2 in NHL.  We observed that patients with prolonged T cell persistence and 
expansion had better clinical responses and outcome suggesting that enhancing the area 
under the curve with an early second infusion may further improve outcome. We have 
experience with second CAR-T cell infusions following Cy/Flu lymphodepletion to date 
in 4 patients with residual NHL at the same or next higher dose level, as outlined in 
section 9B.    These infusions were given around or after day 28 with minimal toxicity 

 
14 
and no severe CRS or neurotoxicity suggesting that earlier treatment with a second 
infusion of CAR-T cells at the same or higher dose may boost levels and clinical activity 
with minimal increased toxicity.  Three of these four patients had evidence of additional 
anti-tumor activity.  Upon completion of Stage 2 for NHL we propose to evaluate an 
earlier sequential dosing strategy aimed to increase the peak levels and persistence of the 
CAR-T cells.  Patients will receive a planned second infusion at DL2 (2x106 EGFR+ 
cells/kg) of CAR-T cells between day 10-21 following the first infusion without 
additional lymphodepletion and after initial toxicity including CRS and neurotoxicity has 
abated. Up to 20 patients will be treated.  
 
3Q.  
Dose Revision for Low- Tumor Burden ALL for the remainder of Stage 2: 
Following treatment of 17 patients with low-tumor burden ALL (<20% bone marrow 
involvement) the protocol is being modified after discussions with the FDA to treat these 
patients at a lower initial CAR-T cell dose, Dose Level 1 (2 x 105/kg).  This was in 
response to the death of a patient due to severe neurotoxicity and CRS.  Following this 
modification, all subsequent ALL patients (all tumor burdens) will receive Dose Level 
one (2 x 105 EGFRt+ cells/kg).   
 
3R. 
Dose Revision for Low-Tumor Burden ALL for expanded Stage 2: After the 
administration of the lower dose described in section 3Q, 3 of 5 patients (60%) with 
≤10% marrow blasts who received Cy/Flu lymphodepletion and DL1 (2 x 105 EGFRt+ 
cells/kg) failed to achieve CR. In contrast 6 of 6 patients (100%) with ≤10% marrow 
blasts who received Cy/Flu lymphodepletion and DL2 (2 x 106 EGFRt+ cells/kg) prior to 
the dose reduction in section 3Q achieved CR without excessive toxicity attributed to 
CAR-T cell infusion. We propose an increase in CAR-T cell dose for patients with ≤5% 
marrow blasts, such that they receive CAR-T cells at DL2 (2 x 106 EGFRt+ cells/kg).  
 
3S. 
Cohort expansion for CLL patients with concurrent Ibrutinib: In Stage 2 for patients with 
CLL we observed a high rate of clearance of CLL cells from the blood and the bone 
marrow, but a slower clearance or failure to clear tumor in bulky LN (ASH CLL 
reference).  This often resulted in less than complete remissions.  In our study to date, the 
majority of patients have been previously treated with ibrutinib, but stopped the drug 
prior to T cell collection and were off of the drug during therapy.  Discontinuation of 
ibrutinib is often associated with significant disease progression and the rapid 
reoccurrence of bulky lymphadenopathy, while treatment with ibrutinib often rapidly 
shrinks lymph nodes by mobilizing CLL cells from the LN and spleen into the blood70.  
In addition, recent data suggest that the quality of T cells collected from patients who are 
on ibrutinib may be better for the manufacturing of CAR-T cells and for the function of 
the CAR-T cells when used to treat CLL patients71. Further, ibrutinib may have 
additional activity by reducing the severity of cytokine release syndrome (either by direct 
action on the T cells or by inhibition of the flare or inflammation that can occur upon 
discontinuation of ibrutinib).  Lastly, multiple ongoing clinical trials support the ability to 
administer ibrutinib safely concurrently with chemotherapy including fludarabine, 
cyclophosphamide and rituximab72.  All of these observations support the continuation of 
ibrutinib for CLL patients considering treatment with CD19 specific CAR-T cells rather 
than stopping it prior to CAR-T cell therapy.   

 
15 
 
We propose a pilot study of 20 CLL patients total who will be treated with concurrent 
ibrutinib  throughout T cell collection and then for up to 3 months following CAR-T cell 
infusion.  This group will consist of two cohorts of patients- cohort 1 (n=5-15): those 
who are continuing on ibrutinib, but with significant residual disease, and cohort 2 (n=5-
15): those who have previously failed ibrutinib in the past and who are now on 
subsequent treatments.  Both cohorts will be treated with ibrutinib (continue or restart) 
for at least 2 weeks prior to leukapheresis and will continue on ibrutinib for up to 3 
months after the proceeding CAR-T cell infusion.  Ibrutinib dosing will be per the FDA 
label for patients with CLL. Patients who required dose reduction of ibrutinib for toxicity 
will continue or resume at the reduced dose of ibrutinib that was tolerated.  We will 
continue with the current Stage 2 CAR-T cell dosing for CLL at DL2 (2 x 106 EFGRt+ 
cells/kg). We will evaluate toxicity and response rates and compare them to our earlier 
experience.  This data will be used for the development of a multicenter CLL trial.  
 
3T. 
Special Consideration for Patients Previously Leukapheresed but NOT Treated.   
Over the conduct of this clinical trial, several patients with a variety of CD19 positive B 
cell malignancies were eligible for and underwent leukapheresis and had CAR- T cell 
products manufactured and cryopreserved, but were unable or not eligible to receive  
their CAR T cell treatment during the conduct of the Stage 1 or Stage 2 portions of the 
study.  The major reason for this was that they were unexpectedly found to be in 
complete remission at the time of planned treatment and had CAR-T cell treatment 
deferred or were having a good response to other therapy. Ten of these patients are still 
alive and may become eligible for treatment upon relapse or disease progression.  As part 
of our ongoing commitment to these patients who had cells collected for this study, we 
propose to include treatment of these patients as additional numbers to the Stage 2 
cohorts of each disease if they become eligible for therapy during the remaining conduct 
of this trial (maximum of 12 months) from the treatment of the last patient.  
 
4. 
OBJECTIVES 
4A.  
Primary objectives 
1. To evaluate the feasibility and safety of adoptive T cell therapy using ex vivo expanded 
autologous CD8+ and CD4+ CD19 CAR-T cells for patients with advanced CD19+ B cell 
malignancies. 
 
4B.  
Secondary objectives 
1. To determine the duration of in vivo persistence of adoptively transferred T cells, and 
the phenotype of persisting T cells. 
 
2. To determine if adoptively transferred T cells traffic to the bone marrow and function 
in vivo. 
 
3. To determine if the adoptive transfer of CD19 CAR-T cells results in depletion of 
CD19+ B cells in vivo as a surrogate for functional activity. 
 

 
16 
4. To determine if the adoptive transfer of CD19 CAR-T cells has antitumor activity in 
patients with measurable tumor burden prior to T cell transfer.  
 
5.  To determine if the adoptive transfer of CD19 CAR-T cells is associated with tumor 
lysis syndrome. 
 
5. 
PATIENT SELECTION  
5A. 
Inclusions for Screening and Leukapheresis 
1. Patients with CD19 expressing ALL, CLL or NHL 
2. Male or female subject, greater than or equal to 18 years of age. 
3. Ability to understand and provide informed consent. 
4. Not HIV infected. 
 
5B.  
Inclusions for CAR-T cell Therapy 
1. Patients with  
a. CLL who are beyond first remission and who have failed combination 
chemoimmunotherapy with regimens containing a purine analogue and anti-CD20 
antibody or who were not eligible for such therapy.  Patients with CLL for whom 
ibrutinib is now standard first line therapy, must have progressed on ibrutinib. 
Patients with fludarabine refractory disease are eligible.  Patients may be treated 
following allogeneic HCT.  
 
For the concurrent ibrutinib cohort, patients must agree to continue on or be 
restarted on ibrutinib and must not have had prior intolerance to ibrutinib that 
would prevent this. Patients managed with prior dose reductions for toxicity will 
continue at the reduced dose for the remainder of this study. 
 
b. Indolent NHL or Mantle cell NHL who are beyond first remission and 
previously treated with chemoimmunotherapy or who were not eligible for such 
therapy.  Patients who have relapsed following autologous or allogeneic HCT are 
eligible. Aggressive NHL such as DLBCL, who have relapsed or have residual 
disease following treatment with curative intent.  Patients should have relapsed 
following, or not be eligible for high-dose therapy and autologous HCT.  Patients 
with chemotherapy refractory disease or marrow involvement or comorbidities 
precluding successful autologous HCT are eligible.  Patients may be treated 
following allogeneic HCT. 
 
c. Patients with CD19 expressing, relapsed or refractory ALL. 
 
d. Patients with one of the above diagnoses whose disease state does not qualify 
but who have prognostic indicators that suggest a high risk of progression of 
disease may be screened and undergo leukapheresis. Enrollment for T cell therapy 
would require meeting the full disease state eligibility. 
 
2.  Confirmation of diagnosis 
 

 
17 
3.  Evidence of CD19 expression by immunohistochemistry or flow cytometry on any 
prior or current tumor specimen or high likelihood of CD19 expression based on 
disease histology. 
 
4.  Karnofsky performance status ≥ 60% (Appendix B) 
 
5.  All patients of childbearing potential must be willing to use a contraceptive method 
before, during, and for at least two months after the T cell infusion. 
 
6.  Ability to understand and provide informed consent. 
 
5C.  
Exclusions for CAR-T cell Therapy 
1. Patients requiring ongoing daily corticosteroid therapy at a dose of >15 mg of 
prednisone per day (or equivalent). Pulsed corticosteroid use for disease control is 
acceptable. 
2. Active autoimmune disease requiring immunosuppressive therapy is excluded unless 
discussed with the PI. 
3. Major organ dysfunction defined as: 
a. Serum creatinine > 2.5 mg/dL 
b. Significant hepatic dysfunction (SGOT > 5x upper limit of normal;      
bilirubin > 3.0 mg/dL) 
c. Patients with clinically significant pulmonary dysfunction, as determined by 
medical history and physical exam should undergo pulmonary function 
testing. Those with an FEV1 of < 50 % of predicted or DLCO (corrected) < 40% will 
be excluded. 
d. Significant cardiovascular abnormalities as defined by any one of the following: 
NYHA class III or IV congestive heart failure, clinically significant hypotension, 
uncontrolled symptomatic coronary artery disease, or a documented ejection fraction 
of <35%. 
4.   Uncontrolled active infection.  
 
6. 
EVALUATION AND COUNSELING OF PATIENT  
Patients will be seen at the Seattle Cancer Care Alliance or the Fred Hutchinson Cancer 
Research Center (FHCRC) for consideration of treatment options for their disease. The protocol 
will be discussed thoroughly with the patient and other family members if appropriate, and all 
known and potential risks to the patient will be described. The procedure and alternative forms of 
therapy will be presented as objectively as possible, and the risks and hazards of the procedure 
explained to the patient. Consent from the patient will be obtained using forms approved by the 
Institutional Review Board (IRB) of the FHCRC. A summary of the clinic visit detailing what 
was covered will be dictated for the medical record. 
 
 
7. 
PROTOCOL REGISTRATION  
 
Eligible subjects will be identified and registered into the system by the Clinical 
Coordinators Office (CCO) (Intake Office) and assigned a UPN (Unique Patient Number). 
The CCO will register the subject on to the protocol through the Data Management Office. 

 
18 
Patients are initially screened and undergo an apheresis procedure. Enrollment to the 
therapy portion of the study occurs at the conclusion of the pre T cell work up when data is 
reviewed for all inclusion and exclusion criteria by the Immunotherapy attending physician and 
the patient signs Consent A.  
 
8. 
STUDY AGENT 
 
8A. 
CD19 CAR-T cells 
1. The methods employed to derive CD19 CAR-T cells from the patient’s CD8+ and 
CD4+ T cells enriched from PBMC, and release tests of the cell products prior to infusion are 
outlined in the Chemistry, Manufacturing and Controls (CMC) section of the Investigational 
New Drug (IND) application to the FDA. Modifications to the CMC section during the course 
of the study must be submitted for FDA review. 
 
2. The autologous T cell product will be prepared and administered to the patient by 
intravenous infusion. Patients will be pretreated with lymphodepleting chemotherapy and receive 
the T cell infusions 36-96 hours after completing chemotherapy (Section 9.B).  
 
3. A schematic of the modified treatment plan including expanded stage 1 and 2 cohorts 
is shown in Figure 2. 
 
 
 
   
9. 
PLAN 
OF 
TREATMENT  
 
9A. 
CLL patients will be treated with ibrutinib (continue or restart) for at least 2 weeks prior 
to leukapheresis and will continue on ibrutinib for up to 3 months after CAR-T cell 
infusion.  Ibrutinib dosing will be per the FDA label for patients with CLL, except as 
noted above where patients with prior dose reductions for toxicity, will continue or 
 
CLL with concurrent ibrutinib: (n = 20) 

 
19 
resume the tolerated dose. Otherwise, patients will receive treatment at 420 mg daily (3 
tablets), unless toxicity requires dose reductions or discontinuation of therapy as outlined 
in section 10.F 
 
9.B. Leukapheresis or blood-draw to obtain T cells for CD19 CAR-T cell manufacturing 
1. A leukapheresis will be performed on each patient by the SCCA Apheresis Unit using 
standard operating procedures for obtaining peripheral blood mononuclear cells. 
Should a technical issue arise during the procedure or in the processing of the 
product, or insufficient CD19 CAR-T cells be manufactured for the prescribed CD19 
CAR-T cell dose, a second procedure may be performed.  
 
Patients ineligible for a vein to vein apheresis may elect to have a percutaneous 
central venous access catheter inserted to support this collection.  
 
Patients ineligible for leukapheresis and who have a hematocrit of >38 and a total 
non-malignant (normal) lymphocyte count of >2000 may undergo phlebotomy of 400 
ml of blood to obtain PBMCs necessary to establish the T cell cultures.  
 
2. The leukapheresis or phlebotomy product will be delivered to the Cell Processing 
Facility (CPF) at the FHCRC or the Cell Therapy Laboratory (CTL) at the SCCA. 
Cell selection may be performed in the FHCRC CPF or SCCA CTL. PBMC not 
required for cell selections may be archived for research.  
If lymphocyte subset counts are considered adequate, the product will be divided into 
two aliquots. One aliquot will be enriched for CD8+ TCM cells and the second aliquot 
will be enriched for CD4+ T cells using clinical grade reagents and SOPs developed at 
the FHCRC/SCCA. Subsequent processing, after selection of CD4+ and CD8+ TCM 
cells and cryopreservation (if required), is performed in the FHCRC CPF. 
If processing of CD8+ TCM and CD4+ cells is not considered suitable due to 
lymphopenia, low CD8+ TCM and CD4+ cell counts or other reasons, we may use 
other strategies to select and manufacture CD19 CAR-T cells that are approved for 
use in this protocol by the FDA. 
 
3. Quality control and release testing will be performed on the CD19 CAR-T cell 
product prior to its release for patient infusion.  
 
9C. 
Lymphodepleting Chemotherapy 
1. Prior to the first infusion of CD19 CAR-T cells, the patients will receive 
lymphodepleting chemotherapy that is appropriate for their underlying disease as 
determined by the referring physician in consultation with the protocol Principal 
Investigator (PI). The objectives of administering chemotherapy are to reduce the 
tumor burden prior to infusion of CD19 CAR-T cells and to provide lymphodepletion 
to facilitate T cell survival.  
 
2. Refer to Appendix A for suggested chemotherapy regimens based on disease cohort.  
For Stage 2, unless the clinical situation dictates changes, the preferred regimen will 
be with fludarabine and cyclophosphamide.  

 
20 
9D.  
Clinical and/or Laboratory Exclusion Criteria for T Cell Infusions 
1. CD19 CAR-T cells should be administered between 36 and 96 hours after the 
completion of lymphodepleting chemotherapy providing the patient does not have 
one or more of the following exclusion criteria: 
• Pulmonary – Patients requiring mechanical ventilation  
• Cardiovascular – Patients requiring pressor support  
• Renal function – Patients with rapidly deteriorating renal failure; unless due to 
malignancy. 
• Hepatic function – Patients with an elevated total bilirubin of >3.9 or 
transaminases of > 5x the upper limit of normal values unless due to malignancy 
• Neurologic – Patients with encephalopathy or new focal neurologic deficits unless 
due to malignancy 
• Uncontrolled, active and serious infection. 
• Treatment with other investigational agent(s) within 30 days of T cell infusion. 
 
2. The criteria listed in Section 9C.1 must be met for each T cell infusion in patients 
who are eligible to receive more than one T cell infusion. 
 
3. Patients with one or more exclusion criteria in Section 9C.1 above may be eligible to 
receive a T cell infusion with or without chemotherapy at a later time if they 
subsequently resolve the clinical and/or laboratory abnormalities. 
 
9E. 
Infusions of CD19 CAR-T cells  
 
1. Stage 1: Identification of a cell dose for evaluation in expanded cohorts:  In Stage 1, 
cohorts of three or more patients will receive a single intravenous infusion of CD19 
CAR-T cells at one of three escalating dose levels beginning with dose level 1. Dose 
escalation or de-escalation is determined by the incidence of toxicity in each cohort, as 
described in Section 14C.1. 
 
Dose level 0: 
 
up to 2x104 EGFR+ cells/kg 
Dose level 1: 
 
up to 2x105 EGFR+ cells/kg (Starting dose level)  
Dose level 2: 
 
up to 2x106 EGFR+ cells/kg  
Dose level 3: 
 
up to 2x107 EGFR+ cells/kg  
 
The weight used for cell dose determination is the current weight in kg as documented on the 
clinical anthropometry report. 
 
Treatment of patients in the dose-escalation/de-escalation cohorts will be staggered 
with a minimum of a 14-day interval following infusion between each patient within 
each disease cohort.  
 
2. Stage 2. Evaluation of the safety and efficacy of a single dose of CD19 CAR-T cells in 
an expanded cohort stratified by disease histology:  
After the toxicity data has been obtained from each dose escalation cohort in Stage 1, 
we will examine the laboratory data on T cell persistence, antitumor activity, and B 
cell depletion, and if appropriate, proceed with an expanded cohort of up to 45 patients 

 
21 
with ALL, 45 patients with NHL and 35 patients with CLL treated at the highest dose 
level established to be safe. See section 3O for dose re-escalation in Stage 2. The 
objective of Stage 2 is to derive data on safety of a single dose of CD19 CAR-T cells 
of a defined composition and an estimate of antitumor activity in patients with 1) ALL 
(both high and low tumor burden treated at the corresponding doses re-defined  in 
stage 2, 2) NHL, and 3) CLL with and without concurrent ibrutinib therapy. 
 
3.   Cell administration. Individual aliquots of CD4+ and CD8+ CD19 CAR-T cells will be 
prepared for each T cell infusion according to protocols established in the GMP Cell 
Processing Facility and formulated to provide a single cell product at the specified cell 
dose. The specified T cell dose refers to CAR+ T cells determined by the expression of 
the truncated EGFR transduction marker, which is expressed coordinately with the 
CAR in the vector. Each T cell infusion should be administered intravenously over 
approximately 20 – 30 minutes at the specified T cell dose.  
 
4.   Products that cannot be formulated to meet target cell dose specification.  The intent 
for each infusion is to provide a cell product that contains approximately 50% (+/- 
15%) of CD19 CAR-modified CD4+ T cells and CD8+ T cells (i.e. CAR-modified T 
cells in 1:1 CD4+/CD8+ ratio). If a T cell product cannot be formulated to meet this  
target cell dose specification because of low transduction efficiency, suboptimal 
growth of one of the subsets, or failure of either the CD4+ or CD8+ T cell product to 
meet release criteria, the cell product should be infused at or as close as possible to the 
specified phenotype allocation and total T cell dose. In the Stage 1 dose escalation 
component, such patients will not be considered evaluable for safety analysis in the 
assigned dose cohort and a replacement subject will be added to the cohort. In Stage 2, 
such patients will be included in analysis of each patient/tumor histologic cohort.  
 
5.   Retreatment of patients on the study. Patients enrolled in either stage of the study may 
be eligible to receive another CD19 CAR-T cell infusion with or without additional 
lymphodepleting chemotherapy at the same (for those that received the highest cell 
dose) or up to the next highest dose level if adequate CD19 CAR-T cells can be 
produced and the following criteria are met: 
i) There is evidence of persistent/relapsed disease at any time after the previous T cell 
infusion.  
ii) There were no toxicities attributed to the prior infusion/s that were dose-limiting or 
required dose de-escalation (Section 14.C.1).  
iii) The patient is ≥ 21 days from the previousT cell infusion.  
iv) There are no clinical and/or laboratory exclusion criteria (Section 9C.1). 
6.   Planned Dose Dense Cohort Expansion for NHL.  Patients enrolled in this cohort will 
be accrued following the completion of stage 2 for NHL.  An additional cohort of up 
to 20 patients will receive a planned second CD19 CAR-T cell infusion without 
additional lymphodepleting chemotherapy at the same dose level if adequate CD19 
CAR-T cells can be produced and the following criteria are met: 
a. There were no toxicities attributed to the first infusion that were dose-limiting 
or required dose de-escalation (Section 14.C.1) 
b. The patient is 10-21 days from the first CAR-T cell infusion. 

 
22 
c. There are no clinical and/or laboratory exclusion criteria (Section 9C.1).  
d. Afebrile for greater than 24 hours 
e. Non-hematologic events thought to be probably or definitely RELATED to 
the first CAR-T cell infusion have resolved to less than or equal to grade 2 
with the exception of related neurotoxicity which must be resolved to less than 
or equal to grade 1.  
 
7.   Patient monitoring during T cell infusions. All patients will be monitored during each 
T cell infusion with vital signs and O2 saturation being monitored and recorded at the 
following approximate time points: before, 15 mins after starting, at the end of  the 
infusion and approximately hourly for 2 hours after. 
 
 
10. MANAGEMENT OF TOXICITIES AND COMPLICATIONS 
Acute infusional toxicity may occur during or shortly after T cell infusion. In addition, cytokine 
release syndrome, tumor lysis syndrome, and neurologic toxicity have been reported specifically 
after CD19 CAR-T cells. Management of these complications is addressed in 10A-10E.  A table 
of proposed grading criteria for cytokine release syndrome is given in Appendix G. 
 
10A. Management of acute toxicity associated with T cell infusion 
The results of our prior studies of adoptive immunotherapy for CMV, HIV, lymphoma, 
and melanoma suggest that serious acute infusional toxicities resulting simply from infusing the 
numbers of T cells proposed in this study are unlikely to occur.  However, transient 
constitutional symptoms have been observed with T cell infusions.  
 
Examples of potential symptoms and signs due to T cell infusions and their initial management 
are listed below: 
 
1.  Fever, chills, and temperature elevations >38.3°C may be managed with 
acetaminophen 650 mg p.o. q 4-6 hrs.  All subjects who develop fever or chills should 
have a blood culture drawn. 
 
2.  Headache may be managed with acetaminophen. 
 
3.  Nausea, vomiting may be managed with diphenhydramine 25-50 mg IV or other 
antiemetics (excluding corticosteroids). 
 
4.  Hypotension should be managed initially by fluid administration. 
 
5.  Hypoxemia should be managed initially with supplemental oxygen. 
 
If the following signs appear during T cell infusion, the infusion should be paused and the patient 
assessed. If after, assessment by the PI/designee the patient’s condition is stable then the infusion 
may be resumed.  
 
 
 
 Systolic BP < 80 mmHg AND > 30 mmHg fall from baseline 
Heart rate > 140/min AND increase from baseline > 40/min (confirmed by 
palpation or EKG) 
 
  
Respiratory rate > 35/min AND increase from baseline of > 10/min 
 
 
  
Arterial O2 saturation < 88%  on air AND fall from baseline > 5% 
 

 
23 
If a T cell infusion is terminated due to acute toxicity, the residual T cells should be returned to 
the Turtle Lab for analysis. Investigation of possible causes of observed signs should proceed 
and, if necessary, additional medical treatment will be instituted. 
 
Patients requiring discontinuation of T cell infusion may be eligible for re-treatment if the cause 
is deemed not related to the T cell infusion.  
 
10B. Management of cytokine release syndrome 
If patients become febrile or develop symptoms of cytokine release, we may measure 
cytokine levels, serum ferritin, C-reactive protein and markers of tumor lysis syndrome (e.g. 
chemistry, uric acid, LDH), and evaluate persistence and phenotype of the transgene-expressing 
cells, as clinically indicated. 
 
Any patient who develops clinical evidence of symptoms related to cytokine release will have a 
work-up to exclude infection or other causes. Initial treatment should consist of supportive 
measures as dictated by the clinical and laboratory findings, and may include fluid replacement, 
medications to support blood pressure, antipyretics, oxygen supplementation, and broad-
spectrum antibiotics if infection cannot be excluded as a potential etiology for the signs and 
symptoms. Patients with Grade > 3 CRS (severe CRS; sCRS) and or Grade 2 CRS with 
progressive symptoms and signs should be treated with tocilizumab (4-8 mg/kg IV) and 
corticosteroids (dexamethasone 10 mg IV every 12 hours). Higher doses of steroids may be 
given after discussion with the Principal Investigator or designee and repeated doses of 
tocilizumab may be given if necessary. See Appendix G for cytokine release syndrome grading 
and Appendix H for recommended management guidelines.     
 
10C. Management of tumor lysis syndrome 
1. All patients will be considered at risk for tumor lysis and should receive allopurinol 
prophylaxis before chemotherapy begins, unless contraindicated. Allopurinol should be 
continued for as long as the medical team determines appropriate after the T cell infusion. They 
may receive additional hydration and urine alkalinization for the first 2 weeks after the T cell 
infusion.  
 
2. If tumor lysis syndrome develops, as defined by the Cairo Bishop criteria 68, the 
Attending Physician will direct patient management with guidance from the study staff 69.  
Conservative therapy, including allopurinol, urinary alkalinization, and IV fluid hydration may 
be instituted immediately for suspected tumor lysis syndrome. Hyperkalemia may be treated with 
potassium binding resins, diuresis, or insulin/dextrose therapy. Hyperphosphatemia may be 
treated with phosphate binding resins. In severe cases, rasburicase (in non-G6PD-deficient 
individuals) or renal dialysis may be necessary. 
 
  
10D. Management of neurotoxicity 
1. Neurotoxicity, manifest as delirium, seizures and/or focal neurologic deficits, has been 
reported after CD19 CAR-T cell therapy. Patients with high tumor burden ALL (>20% blasts) 
should receive prophylactic treatment with Keppra 500 mg bid (or similar regimen) starting at 
least 1 day prior to T cell infusion. Keppra can be discontinued when clinically appropriate. 
Neurotoxicity that is attributed to the T cell infusion/s should be treated with corticosteroids (e.g. 

 
24 
dexamethasone 10 mg IV q 4-12 hours).  Tocilizumab may also be given, preferably after 
discussion with the Principal Investigator or designee. See Appendix H for recommended 
management guidelines. 
 
10E. Management of other toxicities 
1. If a new onset CTCAE v4.0 grade ≥ 3 toxicity is observed following any T cell 
infusion, the patients will receive investigation and medical treatment appropriate for the 
physiological abnormalities. 
 
2. Grade ≥ 3 toxicity that is attributed to the T cell infusion/s, and is unresponsive to 
supportive measures or persists for > 7 days may be treated with corticosteroids (e.g. 
dexamethasone 10 mg IV q 4-12 hours) or tocilizumab after discussion with the Principal 
Investigator or designee. 
 
3. Uncontrolled proliferation of CD19 CAR-T cells has not been observed in clinical 
trials to date. However, in the unlikely event uncontrolled proliferation of CD19 CAR-T cells 
occurred in a study subject, initial therapy may involve treatment with corticosteroids (e.g. 
methylprednisolone 1 g IV). Anti-lymphocyte globulin or cytotoxic drugs would also be 
considered in serious cases. If we observe an increase in CAR positive cells to greater than 10% 
of T cells at more than 3 months after last infusion we will analyze for clonal expansion by deep 
sequencing of the TCR beta gene (Adaptive Biotechnology). 
 
10.F. Management of ibrutinib dosing   
 
Patients with CLL who are enrolled in the expanded CLL cohort will receive oral 
ibrutinib at 420 mg daily (3 tablets).  Ongoing dose reductions of 140mg  may be considered as 
needed for patients who are  intolerant of side effects. As ibrutinib can be associated with 
increased risk of bleeding, it should be held during severe thrombocytopenia (platelet count 
unable to be sustained > 20,000 by transfusion), and then restarted upon platelet recovery.   
 
 
 
11. SCHEDULE OF PATIENT EVALUATIONS (Appendix C - Table of Evaluations) 
Please note that results of tests and/or procedures conducted as per standard of care purposes 
may be used for research purposes if conducted within the protocol-defined window prior to 
screening/leukapheresis (11.A.) and/or T-Cell Therapy (11.B.).  
 
11A.  Evaluation for Screening/Leukapheresis 
 
1. Informed consent and HIPPA signing 
 
2. Laboratory evaluation 
 
a. CBC, differential and platelet count 
 
b. Hepatic function panel with LD and Renal function panel with Mg 
 
c.  Virology Panel 
 
d. Pregnancy test for females of child-bearing potential within 14 days 

 
25 
 
e. Recipients of allogeneic HCT should have documentation of donor chimerism. 
 
f. ABO blood typing and antibody screen 
 
3. Research blood sample (30 ml, heparin/green top tubes) 
This sample should be obtained at the time of initial evaluation for research and sent to 
the Turtle Lab at the FHCRC. If the PI/designee feel that the PBMC immunophenotype 
may have changed in the interval between initial screening and the time of 
leukapheresis or blood draw for PBMC collection then subsequent screening samples 
may be repeated as necessary to confirm feasibility and/or facilitate cell selection. 
 
  
4. Medical history including:  
 
a.  Hematologic, cytogenetic, flow cytometric, and histologic findings at diagnosis  
 
 
b.  Prior therapies and response to therapy 
 
5. Physical Exam and Karnofsky Performance Status 
 
 11B.  Evaluation for T cell therapy: Should be completed within 21 days of enrollment unless 
otherwise specified 
 
1. Signing of informed consent for T cell therapy  
 
2. Confirmation of diagnosis at any time point prior to enrollment by internal pathology 
review of initial or subsequent biopsy or other pathologic material at the 
FHCRC/SCCA  
 
3. Updated history and physical exam 
 
4.   Laboratory evaluation 
 
a. CBC, differential and platelet count 
 
 
b. Renal function panel with Mg and hepatic function panel with LD 
 
c. Uric acid. 
 
 
d. Serum ferritin 
 
 
e. PT, PTT, fibrinogen and D-dimer 
 
 
f. G6PD screening 
 
 
g. C-reactive protein 
 

 
26 
 
h. Pregnancy test for females of child-bearing potential. Chimerism testing, obtained 
at any time point post transplant, for any patient who has had an allogeneic 
transplant 
 
 
j. Peripheral Blood B cell Immunophenotyping. If clinically indicated, 5 ml blood in 
sodium heparin should be sent to SCCA Hematopathology Laboratory for analysis 
of circulating normal and/or malignant B cells. This may be omitted if previously 
performed within 30 days of the planned T cell infusion AND the patient has not 
received anti-tumor therapy in the interim. 
 
5. A bone marrow aspirate/biopsy should be performed with pathology, flow cytometry, 
karyotyping, FISH and other molecular studies as indicated by the disease. This may be 
omitted if done within 30 days of planned lymphodepletion AND the patient has not 
received anti-tumor therapy in the interim. 
 
6. A CT scan (preferably diagnostic quality) and, if possible, a PET scan should be 
performed to evaluate disease status in patients with lymphoma and CLL. Patients with 
B-ALL should undergo CT +/- PET imaging if clinically indicated. Imaging studies may 
be omitted in patients who have had recent imaging within 30 days  of planned 
lymphodepletion AND have not received anti-tumor therapy in the interim.  
 
7. Lumbar puncture with CSF evaluation is required for any patient with a history of CNS 
disease or signs and symptoms of CNS or epidural disease. This may be omitted if a 
lumbar puncture performed within 30 days of planned lymphodepletion did not show 
evidence of CNS disease. 
 
8. Baseline CXR within 21 days of enrollment 
 
9. Baseline EKG within 21 days of enrollment 
 
10. Quantitative immunoglobulins (IgG, IgA and IgM) 
 
11. Research samples:  
a. A blood sample (30 ml, heparin/green top tubes) should be obtained for  baseline 
T cell persistence and sent to the Turtle Lab at the FHCRC. 
 
b. A blood sample (up to10 ml, serum separator tube) should be obtained for 
measurement of serum inflammatory cytokine levels. Samples should be sent as 
soon as possible to the Turtle Lab at the FHCRC. 
 
c.  If a bone marrow is being done clinically then an additional 5 - 10 ml of marrow 
aspirate should be obtained and sent in heparin/green top tubes to the Turtle Lab 
at the FHCRC.  
 
d.  If biopsy or sampling of tissues other than bone marrow; ie cerebral spinal fluid 
(CSF), pleural fluid. etc. is performed for clinical indications then additional 

 
27 
sample may be obtained during the same procedure for research studies. Please 
discuss the planned procedure with the PI. 
 
11C.  Evaluation on the day of each T cell infusion 
 
1. Toxicity 
a. CBC, differential and platelets prior to the T cell infusion  
 
b. Hepatic function  with LD and Renal function panel with Mg prior to the T cell 
infusion 
 
c. Uric acid, C-reactive protein, and serum ferritin prior to the T cell infusion 
 
d. PT, PTT fibrinogen and D-drimer 
 
e. Vital signs at the approximate times: before starting , every 15 minutes during the 
T cell infusion, and hourly for 2 hours following the T cell infusion 
 
f. O2 saturation should be monitored continuously by pulse oximetry during the T 
cell infusion. Values should be recorded at these approximate times: prior to 
initiating the infusion, every 15 minutes during the T cell infusion and hourly for 
2 hours post infusion. 
 
2.  Serum cytokines  
Blood samples (approximately 10 ml, serum separator tube) should be obtained prior 
to the T cell infusion for measurement of serum inflammatory cytokine levels. 
Samples should be sent as soon as possible to the Turtle Lab at the FHCRC. 
 
 
3.   Evaluation of persistence and phenotype of CD19 CAR-T cells 
Blood samples (approximately 30 ml, heparin/green top tubes) should be obtained 
prior to the T cell infusion for baseline analysis of the presence of transferred T cells 
by q-PCR for vector sequences and/or for expression of the EGFR and CD19 CAR 
transgenes on CD8+ and CD4+ T cells by flow cytometry, if sufficient PBMC can be 
obtained.  
 
 
11D.  Patient Evaluations After Each T Cell Infusion 
 
The following evaluations will be performed after each T cell infusion. If a patient 
receives a second T cell infusion, the day of the second infusion will be designated ‘day 0’ for 
evaluations thereafter.  
  
1. Toxicity 
a. Record new findings on history and physical exam 1 day after the T cell infusion 
and at least weekly for four weeks. 
 
b. CBC, differential and platelet count at least twice weekly for two weeks then 
weekly until four weeks after each T cell infusion.  

 
28 
c. Hepatic function panel with LD and Renal function panel with Mg twice weekly 
for two weeks then weekly until four weeks after each T cell infusion. 
 
d. Uric acid, C-reactive protein, and serum ferritin twice weekly for two weeks then 
weekly until four weeks after each T cell infusion. 
 
e. PT, PTT, fibrinogen and D-dimer twice weekly for two weeks then weekly until 
four weeks after each T cell infusion. 
 
f.  If patients become febrile or develop symptoms of cytokine release or tumor lysis 
between the indicated time points, we may measure serum ferritin, C-reactive 
protein and tumor lysis markers at additional times, as clinically indicated. 
 
2.  Serum Cytokines  
a. A blood sample (approximately 10 ml, serum separator tube) should be obtained 
on approximately days 1, 3, 7, 10, 14, 21, 28 after each T cell infusion for 
measurement of serum inflammatory cytokine levels. Samples should be sent to 
the Turtle Lab at the FHCRC. 
 
b. If patients become febrile, develop symptoms of cytokine release, or assessment 
of cytokines is clinically appropriate at times other than those indicated, we may 
measure cytokine levels at additional times. 
 
3.  Peripheral Blood B cell Immunophenotyping  
a. Blood, 5 ml in sodium heparin should be sent to SCCA Hematopathology 
Laboratory for flow cytometry immunophenotyping on approximately days 14, 28, 
60, 90, 180, and 365 after the last T cell infusion unless the patient initiates other 
non-CAR T cell systemic therapy. If a deficiency of B cells persists at 1 year, we 
may continue to monitor B cell recovery every 6 months.  
 
4. Immunoglobulin levels 
a. Patients receiving CAR T cells are at risk for chronic B cell depletion and may 
have IgG deficiencies. Recommendations will be made for monitoring of IgG 
levels and administering intravenous immunoglobulin (IVIG) as clinically 
indicated.  
 
5. Evaluation of persistence and phenotype of CD19 CAR-T Cells 
a. Blood samples (approximately 30 ml, heparin/green top tubes) should be obtained 
on approximately days 1, 3, 7, 10, 14, 21, 28, 60, 90, 180, and 365 after the T cell 
infusion for analysis of the persistence of transferred T cells. Additional samples 
may be collected at other times than those indicated if required for evaluation of 
persistence of CAR-T cells. Persistence monitoring may be discontinued beyond 
day 28 in patients who do not have detectable transgene-expressing T cells on two 
consecutive occasions. Samples should be sent to the Turtle Lab at the FHCRC. 
 

 
29 
b.  A subset of blood samples obtained after the infusion should also be analyzed by 
multiparameter flow cytometry for the phenotype of persisting CD8+ and CD4+ 
CD19 CAR-T cells. Markers that may be analyzed include CD62L, CCR7, CD28, 
and CD127. 
c.  If patients become febrile, develop possible signs of toxicity, or assessment of 
CAR-T cell persistence is clinically appropriate at times other than those indicated, 
we may measure the persistence of transferred T cells at additional times.  
 
6.   Evaluation of transgene immunogenicity 
To evaluate for antibody or T cell-mediated transgene immune responses the 
following samples may be collected. 
 
a. Blood (approximately 10ml, serum separator tube) around days 28, 60, 90, 180, 
and 365, after the final T cell infusion and serum extracted for evaluation of 
antibody-mediated immune responses. Samples should be sent to the Turtle Lab at 
the FHCRC.  
 
b. Blood (approximately 20 ml, sodium heparin/green top tubes) around days 28, 60, 
90, 180, and 365 after the final T cell infusion) and PBMC isolated for evaluation 
of cellular immune responses. Samples should be sent to the Turtle Lab at the 
FHCRC.  
 
7.   Optional archival samples for future studies of T cell function 
a. Blood (approximately 60 ml, sodium heparin/green top tubes) may be obtained 
from patients once between days 0 and 21 after CD19 CAR-T cell infusion and 
once between days 21 and 90 for archival purposes. 
 
b.  Blood (approximately 20 ml, sodium heparin/green top tubes) may be obtained 
from patients around days 90, 180, and 365 after the final T cell infusion for 
archival purposes. Samples should be sent to the Turtle Lab at the FHCRC. 
 
c. Serum (approximately 10 ml, serum separator tube) may be obtained from patients 
at around days 90, 180, and 365 after the final T cell infusion for archival 
purposes. Samples should be sent to the Turtle Lab at the FHCRC. 
 
8. Evaluation of migration of adoptively transferred CD19 CAR-T cells 
a.  If aspirations and/or biopsies of bone marrow are performed for evaluation of 
tumor response or other clinical indications then additional aspirates 
(approximately 5 - 10 ml in heparin/green top tubes) may be obtained and sent to 
the Turtle Lab, FHCRC.  
 
b.  If biopsy or sampling of tissues other than bone marrow; ie CSF, pleural fluid. etc. 
is performed for clinical indications then additional tissue may be obtained during 
the same procedure for research studies. Please discuss the planned procedure with 
the PI. 
 
 

 
30 
9.  Evaluation of tumor response  
a. Bone marrow aspiration and biopsy.  
i. 
Because the timing of disease response to CD19 CAR-T cells has been 
variable in reported studies a bone marrow aspirate and biopsy should be 
performed if clinically appropriate between 14 days and 3 months after 
each T cell infusion, and should be performed before the patient receives 
additional conventional anti-tumor therapy. Evaluation should include 
pathology analysis, flow cytometry, karyotyping, FISH studies and other 
molecular studies, according to disease-specific guidelines.  
ii. 
A bone marrow aspirate and biopsy may also be performed at 
approximately 6 and at approximately 12 months after the first T cell 
infusion, as clinically indicated. 
 
b. Imaging studies 
i. 
A CT scan (preferably diagnostic quality) and, if possible, a PET scan of 
the neck, chest, abdomen and pelvis should be obtained between 3 weeks 
and 3 months after each T cell infusion, and should be performed before 
the patient receives additional conventional anti-tumor therapy. Patients 
with B-ALL do not require CT/PET imaging, unless it is clinically 
indicated.  
ii. 
PET/CT scanning may also be performed at 6 and 12 months after the first 
T cell infusion, as clinically indicated. 
iii. 
CT/PET imaging will be read using Cheson 07 criteria for response 
assessment.   
 
c. Serum chemistry panel and LDH should be performed concurrently with restaging 
by biopsy or imaging, as clinically indicated. 
 
d. Peripheral blood flow cytometry should be performed concurrently with restaging 
by biopsy or imaging, as clinically indicated.  
 
e. Standard criteria (as detailed in Appendix E) will be used to define tumor 
response.  
 
f.    Evaluation of tumor response may be discontinued in patients who proceed to 
other systemic non-CAR-T cell therapies. 
 
 
10.  Long Term Follow-Up (Appendix F) 
Enrolled patients who receive CD19 CAR-T cells will be asked to participate in long-
term follow-up (LTFU) according to the guidelines set forth by the FDA’s Biologic 
Response Modifiers Advisory Committee that apply to gene transfer studies. Current 
recommendations from the FDA suggest a minimum of 15 years of follow-up. In 
addition, unexpected late medical problems including information on hospitalizations 
and medications may be collected through the Oncology Clinic at SCCA. 
Recommendations will be made for an autopsy to be conducted if the research 
participant dies. 
 

 
31 
12. 
PROTOCOL ENROLLMENT 
12A. Projected Target Accrual 
 
In stage 2, 2 cohorts of 45 patients each with ALL and NHL and 1 cohort of 35 patients 
with CLL will be enrolled. For the planned multiple dose cohort, 20 additional patients 
will be treated. The total projected accrual will allow for treatment of  189 patients. The 
anticipated study duration is 5 years. 
 
ETHNIC AND GENDER DISTRIBUTION CHART  
 
TARGETED / PLANNED ENROLLMENT:  Number of Subjects 
 
 
Ethnic Category 
 
Sex / Gender 
 
Females 
Males 
Total 
Hispanic or Latino 
3 
5 
8 
Not Hispanic or Latino 
73 
108 
173 
Ethnic Category Total of All Subjects* 
76 
113 
189 
 
Racial Categories 
 
American Indian / Alaska Native 
3 
1 
4 
Asian 
4 
5 
9 
Native Hawaiian or Other Pacific 
Islander 
1 
1 
2 
Black or African American 
2 
4 
6 
White 
66 
102 
168 
Racial Categories:  Total of All 
Subjects* 
76 
113 
189 
 
13.    RECORDS 
The medical record containing information regarding treatment of the patient will be 
maintained as a confidential document, within the guidelines of the Fred Hutchinson Cancer 
Research Center, the University of Washington Medical Center, and the Seattle Cancer Care 
Alliance. The investigators will ensure that data collected conform to all established guidelines 
for coding collection, key entry and verification. Each patient is assigned a unique patient 
number to assure patient confidentiality.  Patients will not be referred to by name or by any other 
personal identifier in any publication or external presentation.  The Clinical Statistics 
Departments at FHCRC maintain a patient database to allow storage and retrieval of patient data 
collected from a wide variety of sources. The licensed medical records departments, affiliated 
with the institution where the patient receives medical care, maintains all original inpatient and 
outpatient chart documents. The primary research records are kept in access controlled office 
spaces or password protected computer based applications. Information gathered from this study 
regarding patient outcomes and adverse events may be made available to the Federal Drug 
Administration, NIH and Juno Therapeutics. All precautions to maintain confidentiality of 
medical records will be taken. 
 

 
32 
14.    EVALUATION AND STATISTICAL CONSIDERATIONS 
14A. Type of study 
This is a phase 1/2 study to assess the safety and antitumor activity of adoptive T cell 
therapy with autologous CD4+ T cells and CD8+ TCM cells transduced to express a CD19-
specific CAR for patients with advanced CD19+ B cell malignancies.  
14B. 
Definition of endpoints 
1. Safety assessment (relevant data being obtained) 
  
 
a.  General Toxicity Assessment 
• History and physical exam before and at intervals after T cell 
infusions. 
• Pulse oximetry before and during the infusion 
• Chemistry battery before and at intervals after the T cell infusion 
• Toxicity grading according to NCI CTCAE Version 4.0 
• Serum cytokine levels 
• B cell reconstitution 
• Replication competent lentivirus  
• Adverse event reporting 
 
2.  Efficacy Assessment 
a. Evaluation of the duration of persistence of adoptively transferred CD19 CAR-
T cells 
b. Evaluation of the migration of adoptively transferred CD19 CAR-T cells 
c. Evaluation of antitumor activity of adoptively transferred CD19 CAR-T cells 
by evaluating the objective response rate of complete remission and partial 
remission, and determining progression free survival, and overall survival. 
 
14C.   Endpoint Evaluation 
1.  Safety Assessment – Stage 1 
In Stage 1 of the study, patients will be treated in cohorts of three or more patients at one 
of four dose levels of CD19 CAR-T cells starting at dose level 1 (Section 9D.1) to 
determine a single cell dose to evaluate in an expanded cohort of patients in Stage 2. 
 
 
 a. Dose limiting toxicities 
1. Death within 8 weeks of the study cell infusion thought to be definitely or 
probably related to CAR T cell therapy. 
 
2. Other dose limiting toxicities will be defined as follows:  
 
  
i. Grade ≥ 3 non-hematologic toxicity in any major organ system that is 
probably or definitely attributed to T cell infusion AND is unresponsive 
(does not improve to < grade 3 toxicity) to treatment with dexamethasone 
10 mg q 12 hours IV for ≥ 7 days (or an equivalent corticosteroid dose) or 
tocilizumab 8 mg/kg IV for ≥ 3 doses OR of greater than 28 days duration. 
Hematologic toxicity is an expected complication of chemotherapy, and 
other than B cell depletion, has not been observed in prior trials of CAR T 
cell therapy, and therefore will not be considered for altering T cell dose. 

 
33 
  
 
  
ii. CTCAE grades 3-5 allergic reactions related to the study cell infusion.   
  
 
  
iii. CTCAE grades 2-5 autoimmune reactions, other than expected B cell 
depletion. 
 
3. Patients receiving CD19 CAR-T cells may develop serious toxicity due to T 
cell activation, proliferation and cytokine secretion after encounter with 
tumor antigen. Cytokine release syndrome, macrophage activation syndrome 
and neurotoxicity may occur and require intensive care support, and will not 
be considered DLTs unless they meet criteria as outlined in 14.C.1.a.2.i. 
 
b. Dose escalation or de-escalation 
If toxicity defined above (Section 14C.1.a.) develops in 0 of 3 patients at any cohort-
specified dose level, as described in 9D.1, the next 3 patients may receive the next 
higher dose of T cells. If such toxicity develops in 2 of 3 patients at any dose level, the 
next 3 patients will be treated at one dose level lower. If such toxicity develops in 1 of 
3 patients, up to an additional 3 patients will be treated at the same dose level. If such 
toxicity occurs in 1 of 6 patients at a given dose level, subsequent patients may be 
treated at the next higher dose.  
 
If toxicity developed in 2 of 3 patients at the lowest dose level (dose level 0), the PI 
and DSMB would review the data to determine if evaluation of even lower doses of T 
cells was appropriate.  
 
The highest dose of T cells that is estimated to result in toxicity in < 1/3 patients 
within each Stage 1 cohort will be the dose selected for Stage 2 evaluation where 
patients will be stratified into one of 3 cohorts based on the histology of their disease.  
 
c. Dose de-escalation for the second CAR-T cell infusion for the “Planned Dose Dense 
Cohort Expansion for NHL” 
Eligible patients will be treated with a second infusion at DL2. Up to twenty patients 
will be treated in this expanded cohort.  If there ever exists sufficient evidence to 
suggest that the true toxicity rate after the second infusion exceeds 30%, where 
toxicity is as defined in Section 14C.1.a, consideration will be given to reducing the 
dose (DL1) and enrollment of patients will continue at this reduced dose.  We would 
analyze the basis for the toxicity (cytokine production, in vivo cell proliferation, tumor 
lysis) to determine if treating additional patients at this lower T cell dose was 
appropriate.  
 
Sufficient evidence for this rule will be defined as any observed outcome whose lower 
80% confidence limit exceeds 30%. Operationally, any of the following ratios of 
toxicities to patients treated would trigger such a rule: 2/2, 3/3-5, 4/6-8, 5/9-10, 6/11-
13, 7/14-16, 8/17-19, 9/20. If the true probability of toxicity is 0.20, then the 
probability of this achieving this trigger after 20 patients is approximately 0.12.  If the 
true toxicity rate is 0.50, then the probability after 20 patients is approximately 0.94.  

 
34 
 
If all patients in this cohort are treated without this stopping rule being met, then we 
will consider the true toxicity rate associated with this treatment to be consistent with 
an acceptable level (i.e. ≤ 30%) in this cohort and we may proceed to a larger trial that 
would formally analyze the antitumor effect of CAR-modified T cells as well as 
continue to assess the safety of this approach. 
 
Additionally, we will assess the AUC (between day 0-28) of T cell persistence in this 
cohort, as the goal of the 2nd infusion is to increase this relative to what we have seen 
before.  The benchmark that we will use for assessment of this improvement is a mean 
of 715,000 copies/ug based on results observed in 11 patients treated with Flu/Cy and 
given DL2 CAR-T cells.  All 20 patients treated will be included in this assessment, 
regardless of the dose of the 2nd infusion.  If the true AUC is 0.58 standard-deviation 
units away from the benchmark of 715,000, then 20 patients will provide 80% power 
to detect a statistically significantly increased AUC (at the one-sided significance level 
of .05). 
 
 
2.  Safety Assessment – Stage 2 
Stopping and Suspension Rules 
 
1. If during the Stage 2 evaluation there ever exists sufficient evidence to suggest 
that the true toxicity rate exceeds 30% in any of the cohorts, where toxicity is 
as defined in Section 14C.1.a, enrollment of patients in that disease cohort will 
be suspended for safety reasons, pending a detailed review by the PI, study 
monitor and statistician. We would analyze the basis for the toxicity (cytokine 
production, in vivo cell proliferation, tumor lysis) to determine if treating 
additional patients in that cohort at a lower T cell dose was appropriate.  
 
Sufficient evidence for this stopping rule will be defined as any observed 
outcome whose lower 80% confidence limit exceeds 30%. Operationally, any 
of the following ratios of toxicities to patients treated would trigger such a rule: 
2/2, 3/3-5, 4/6-8, 5/9-10, 6/11-13, 7/14-16, 8/17-19, 9/20-22, 10/23-25, 11/26-
28, 12/29-31, 13/32-34, 14/35-37, 15/38-40, 16/41-43, 17/44-45.. If the true 
probability of toxicity is 0.20, then the probability of stopping after 25 patients 
is approximately 0.12.  If the true toxicity rate is 0.50, then the probability of 
stopping after 25 patients is approximately 0.94.  
 
If all patients in a particular cohort are treated without this stopping rule being 
met, then we will consider the true toxicity rate associated with this treatment 
to be consistent with an acceptable level (i.e. ≤ 30%) in this cohort and we may 
proceed to a larger trial that would formally analyze the antitumor effect of 
CAR-modified T cells as well as continue to assess the safety of this approach. 
 
2.  Study pause for treatment related mortality: If in the combined Stage 1 and 
Stage 2 portions of the study there is evidence of CAR-T cell related mortality 
whose lower limit of one-sided 90% confidence limit exceeds 10% the study 

 
35 
will be paused and evaluated by the DSMB and with the FDA.  Operationally, 
any of the following ratios of CAR-T cell related mortality to total patients 
treated would trigger such a rule: 18/130, 20/140, 21/150, 22/160, 23/170, 
24/180, 25/190 and 27/200.  This will be looked at after every 10th patient is 
treated.   
 
3. Suspending enrollment for lack of efficacy: If in the Stage 2 component of the 
study, none of the first 10 patients in any disease cohort exhibit an antitumor 
response, the PI and DSMB would review the data and make a determination 
whether the cohort should be discontinued or if a modification of dose and or 
treatment regimen considered.   
 
4. The occurrence of a malignancy attributed to lentiviral modified T cells or 
detection of replication competent lentivirus (RCL) in either stage would result 
in termination of the protocol. 
 
3.  Assessment of efficacy of transferred T cells 
Data should be collected for persistence, migration and efficacy of transferred T 
cells and descriptive statistics will be used to summarize the changes from 
baseline where possible. For those patients with measurable disease at the time T 
cell therapy commences, responses will be evaluated using standard response 
criteria based on CT or PET imaging and histologic analysis of bone marrow or 
other tissue samples.   
 
15.   
GUIDELINES FOR REPORTING ADVERSE EVENTS AND DATA SAFETY 
AND MONITORING PLAN. 
 
15A. General issues and IRB reporting requirements  
1. 
Definitions associated with reportable events and reporting requirements can be 
found on the FHCRCs Institutional Review Office (IRO) extranet website (Table 1).  
2. 
The NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40) 
will be used for grading and analysis of adverse events. All grade 3 or greater adverse 
events will be collected during and for 48 hrs post leukapheresis and again from the day 
of lymphodepletion through day 28 after each T cell infusion. 
 The collection of adverse events will stop at the time of commencement of new systemic 
anti-tumor therapy. 
 
To ensure that investigative treatment-related conditions are distinguished from disease-
related conditions, attribution of causality will be established in grading adverse events. 
For each event, the Principal Investigator or designee, in conjunction with the physician 
or research nurse who examined and evaluated the research participant, will assign the 
attribution.  Data managers who are removed from the clinical assessment of the research 
participant should not perform this.  Attribution of adverse events attributed to the 
infused genetically modified T cells should be determined using the following criteria: 
 

 
36 
Definite - the adverse event is clearly related to the infused T cells 
Probable - the adverse event is likely related to the infused T cells 
Possible - the adverse event may be related to the infused T cells 
Unlikely - the adverse event is doubtfully related to the infused T cells 
Unrelated - the adverse event is clearly not related to the infused T cells 
 
3. 
The FHCRC IRB will be notified of reportable events by the FHCRC Principal 
Investigator (PI) or study nurse according to current reporting obligations as found on the 
FHCRC Institutional Review Office extranet website. 
4. 
The review and reporting of AEs will be in accordance with the Cellular 
Immunotherapy AE reporting for separate FH sponsor and Investigator SOP. 
5. 
Reporting of unanticipated adverse effects to the FDA will be the responsibility of 
the sponsor. 
6. 
The FHCRC PI and Research Nurse and study personnel should meet regularly 
(in person or via teleconference) to review all reported events.  
 
Table 1: FHCRC IRB Policies for Reportable Events.  
(Relevant FHCRC policies include, but are not limited to the following documents. Please 
also refer to the FHCRC IRO website. ) 
 
IRB Policy 2.6 
Adverse Events and Other 
Unanticipated Problems 
Involving Risks to Subjects or 
Others 
http://extranet.fhcrc.org/EN/sections/iro/irb/ae.html 
IRB Policy 1.9 
Noncompliance with the Office 
of the Director’s Human 
Research Protection Program 
Policy 
http://extranet.fhcrc.org/EN/sections/iro/irb/ae.html 
IRB Policy 1.1 
Reporting Obligations for 
Principal Investigators 
http://extranet.fhcrc.org/EN/sections/iro/irb/policy/index.html 
IRB Policy 2.2 
Continuing Review 
http://extranet.fhcrc.org/EN/sections/iro/irb/policy/index.html 
IRB Policy 1.13 
Investigational New Drugs 
(IND), Biologics and 
Investigational Device 
Exemptions (IDE) 
http://extranet.fhcrc.org/EN/sections/iro/irb/policy/index.html 
 
Table 2: FHCRC IRB Forms for Reporting 
Adverse Event Reporting Form 
http://extranet.fhcrc.org/EN/sections/iro/irb/forms/index.html  
Unanticipated Problem Reporting Form 
http://extranet.fhcrc.org/EN/sections/iro/irb/forms/index.html  
Noncompliance Reporting Form 
http://extranet.fhcrc.org/EN/sections/iro/irb/forms/index.html  
 
15B.  Data and Safety Monitoring Plan 
1. Definition of Risk Level 
This phase I/II trial involves genetic modification of somatic cells and requires an IND. 
At the FHCRC, this type of trial has independent monitoring twice each year through the 
Clinical Trials Support Office at the FHCRC, and has a Data and Safety Monitoring 
Board (Section 16B.3).  
 
2. Monitoring and Personnel Responsible for Monitoring 

 
37 
a) The Principal Investigator (P.I.) is responsible for every aspect of the design, 
conduct and final analysis of the protocol.  Regulations defining the responsibilities for 
assessment and reporting of adverse events (AE), serious AE and unexpected AE are 
defined by the Code of Federal Regulations:  21 CFR 312.32 and Common Terminology 
Criteria for Adverse Events (CTCAE) Version 4.0 published by the Cancer Therapy 
Evaluation Program (CTEP), a division of the NCI/NIH. 
b) This clinical study will rely upon the monitoring of the trial by the P.I. in 
conjunction with a Study Physician(s), Physician Assistant(s) (PA) or Nurse 
Practitioner(s), Research Nurse(s), Research Coordinator(s), statistician, and an 
independent Study Monitor assigned by the FHCRC Clinical Research Support Office 
(CRS).   
c) Continuous monitoring of the data and safety of this study should be performed 
by the Protocol Management Team (PMT), which consists of the Principal Investigators, 
Research Nurse, and study staff.  
 
d) A Case Report Form (CRF) should be completed for every patient that was 
registered for participation in the study. 
• 
Forms should be completed as information becomes available on a 
visit-by-visit or course-by-course basis. 
• 
The Principal Investigator or a Co-Investigator will sign and date 
the indicated places of the CRF.  This signature will indicate that 
thorough inspection of the data therein has been made, and will 
certify the contents of the form. 
e) The PMT should meet at least monthly to review the clinical status of events 
and follow up information for each patient. The PMT will be responsible for 
implementation of the stopping rules for safety if necessary. 
 
 
 
 
3. Data and Safety Monitoring Board 
 
 
 
The study will be monitored by the Immunotherapy Integrated Research Center 
(IIRC) DSMB.  The DSMB will be responsible for safeguarding the interests of trial 
participants and assessing the safety and efficacy of the interventions during the trial.  
This responsibility will be exercised by providing recommendations about stopping or 
continuing the trial.  To contribute to enhancing the integrity of the trial, the DSMB may 
also formulate recommendations relating to the selection, recruitment and retention of 
participants and their management; adherence to protocol-specified regimens; and the 
procedures for data management and quality control.  
 
The DSMB will be advisory to the study Sponsor and the PI, who will be 
responsible for prompt review of the DSMB recommendations to guide decisions 
regarding continuation or termination of the trial and whether amendments to the protocol 
or changes in study conduct are required. 
 
The external DSMB is an independent, multidisciplinary group consisting of 
clinical experts and a statistician who collectively have experience in leukemia, 
lymphoma, hematology, biostatistics, and the conduct and monitoring of clinical trials. 
The DSMB will meet approximately every 6 months to review data. The current 
members are listed in the IIRC DSMB charter.  
 

 
38 
 
16.  
TERMINATION OF THE STUDY 
 
 
The study may be terminated at any time by the Protocol PI, the FHCRC IRB, or the 
FDA. 
 
 
17. 
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42 
18. APPENDICES 
 
APPENDIX A - Suggested Cytoreduction/Lymphodepletion Chemotherapy Regimens 
 
The following is a general guide to accepted chemotherapy regimens to be used immediately 
prior to adoptive T cell therapy.  The selection of appropriate chemotherapy regimen to provide 
tumor cytoreduction and lymphodepletion is based on the tumor histology and on the types of 
prior treatment that the patient has undergone and should be discussed with the study PI’s.  
Chemotherapy regimens that employ prolonged administration of corticosteroids that would 
continue after the T cell infusion cannot be used for prior to T cell infusion. Patients should be 
scheduled for T cell infusions starting 36-96 hours after the last dose of chemotherapy.  Patients 
should not receive Alemtuzumab or other T cell depleting antibodies in the 6 months prior to T 
cell therapy.   
 
The preferred regimen for Stage 2 of the trial is the combination of Fludarabine and 
Cyclophosphamide for all diagnoses unless the patients’ clinical situation dictates otherwise.  
Suggested regimens include Cyclophosphamide up to 60 mg/kg day 1, followed by fludarabine 
25 mg/m2 daily x 3 days. 
 
Alternative regimens would include Cyclophosphamide 300 mg/m2 day 1-3 and Fludarabine 30 
mg/m2 day 1-3.   
 
Depending on the patients’ clinical situation a number of additional regimes could be used after 
discussion with the study PI.  Possible regimens may include the following as a general guide.  
1) CLL 
a. High dose cyclophosphamide (2-4 grams/m2) with MESNA with or without anti-
CD20 antibodies such as rituximab or ofatumumab 
b. OFAR 
c. Bendamustine alone or with rituximab or ofatumumab 
d. Fludarabine with rituximab or ofatumumab +/- cyclophosphamide 
2) Indolent NHL and Mantle Cell NHL 
a. One or two cycles of aggressive salvage regimen such as ICE, DHAP, ESHAP 
alone or in combination with an anti-CD20 antibody.   
b. High dose cyclophosphamide (2-4 grams/m2) with mesna alone or in combination 
with an anti-CD20 antibody. 
c. High dose etoposide alone or in combination with an anti-CD20 antibody. 
3) Aggressive NHL  
a.   One or two cycles of aggressive salvage regimen such as ICE, DHAP, ESHAP 
alone or in combination with an anti-CD20 antibody.   
b.   High dose cyclophosphamide (2-4 grams/m2) with mesna alone or in combination   
with an anti-CD20 antibody. 
c.   High dose etoposide alone or in combination with an anti-CD20 antibody. 
4) ALL 
a. High dose cyclophosphamide (2-4 grams/m2) with MESNA 
b. Any aggressive ALL regimen. 
 
 

 
43 
APPENDIX B  - Karnofsky Performance Scale 
 
The Karnofsky Performance Scale Index allows patients to be classified as to their functional 
impairment. This can be used to compare effectiveness of different therapies and to assess the 
prognosis in individual patients. The lower the Karnofsky score, the worse the survival for most 
serious illnesses.  
 
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA 
Able to carry on normal activity and to work; no special 
care needed. 
  100   Normal no complaints; no evidence of 
disease. 
90 
Able to carry on normal activity; minor signs 
or symptoms of disease. 
80 
Normal activity with effort; some signs or 
symptoms of disease.  
Unable to work; able to live at home and care for most 
personal needs; varying amount of assistance needed. 
70 
Cares for self; unable to carry on normal 
activity or to do active work. 
60 
Requires occasional assistance, but is able to 
care for most of his personal needs. 
50 
Requires considerable assistance and frequent 
medical care.  
Unable to care for self; requires equivalent of institutional 
or hospital care; disease may be progressing rapidly. 
40 
Disabled; requires special care and assistance. 
30 
Severely disabled; hospital admission is 
indicated although death not imminent. 
20 
Very sick; hospital admission necessary; 
active supportive treatment necessary. 
10 
Moribund; fatal processes progressing 
rapidly. 
0 
Dead 
 
 

 
44 
Appendix C. Patient evaluations over the course of the study 
 
Approximate days post T cell infusion 
Study Assessments/ 
Testing 
Screen 
Enrolle
d 
0 
During and following each 
T cell infusion 
1 
3 
7 
10 
14 
21 
28 
History and Physical1 
X 
X 
 
Day 1 and weekly x 4 
X 
 
X 
 
X 
X 
X 
Karnofsky  performance 
status 
X 
 
 
 
 
 
 
 
 
 
 
Vitals including O2 sats 
 
 
X 
q 15 min during then 
hourly x 2 
 
 
 
 
 
 
 
Automated CBC with 
differential, platelet count 
 
X 
 
X 
 
X 
 
2 x per week in first two 
weeks then weekly x 2 
X 
 
X 
X 
X 
X 
X 
Hepatic function with LD 
and renal function with Mg 
X 
X 
X 
2x per week in first two 
weeks then weekly x 2 
X 
 
X 
X 
X 
X 
X 
uric acid, ferritin, LDH, C-
reactive protein 
 
X 
X 
2 x per week in first two 
weeks then weekly x  2 
X 
 
X 
X 
X 
X 
X 
 PT, PTT, fibrinogen and 
D-dimer 
 
X 
X 
2 x per week in first two 
weeks then weekly x2 
X 
 
X 
X 
X 
X 
X 
Pregnancy Test14 
X 
X14 
 
 
 
 
 
 
 
 
 
Virology Panel 
 
X 
 
 
 
 
 
 
 
 
 
 
G6PD screening 
 
X 
 
 
 
 
 
 
 
 
 
ABO blood typing + 
antibody screen 
X 
 
 
 
 
 
 
 
 
 
 
Quantitative 
Immunoglobulins 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
EKG 
 
X 
 
 
 
 
 
 
 
 
 
CXR 
 
X 
 
 
 
 
 
 
 
 
 
Lumbar Puncture with CSF 
evaluation4 
 
X 
 
 
 
 
 
 
 
 
 
Bone marrow aspirate5 
 
X 
 
 
 
 
 
 
 
 
 
CT/PET scan6 
 
X 
 
 
 
 
 
 
 
 
 
PBMC collection 
X 
 
 
 
 
 
 
 
 
 
 
Chimerism testing15 
X 
 
 
 
 
 
 
 
 
 
 
Peripheral blood 30 ml to 
Turtle lab 
X 
 
 
 
 
 
 
 
 
 
 
Cytokine levels8,13 
 
X 
X  
X 
X 
X 
X 
X 
X 
X 
Peripheral Blood B cell 
Immunophenotyping 
 
X 
 
 
 
 
 
 
X 
 
X 
T cell persistence9, 13 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 

 
45 
Transgene 
immunogenicity_serum 
 
 
 
 
 
 
 
 
 
 
X 
Transgene 
immunogenicity_PBMC 
 
 
 
 
 
 
 
 
 
 
X 
PBMC archive11 
 
 
 
0-21 and 21-90 
 
 
1. 
History to include hematologic, cytogenetic flow cytometric and histologic findings at diagnosis and time of enrollment as well as prior therapies and response to therapy. 
2. 
If positive, complete antigen quantitation by PCR. 
3. 
Should be performed concurrently with restaging by biopsy or imaging, as clinically indicated.  
4. 
Required for any patient with a history of CNS disease or signs and symptoms of CNS or epidural disease, unless a negative lumbar puncture was performed within 30 days prior to 
scheduled T cell infusion. 
5. 
Bone marrow aspirates/biopsies should be sent for pathology analysis as clinically indicated and according to the protocol. A 5-10 ml aliquot of the bone marrow aspirate in sodium heparin 
should be sent to the Turtle Lab for research.  
6. 
Diagnostic CT/PET scan to include neck chest, abdomen and pelvis, as clinically indicated by disease and status and according to the protocol. Staging evaluations may be ceased if the 
patient proceeds to other anti-tumor therapy. 
7. 
PB for flow cytometry in patients with possibility of circulating tumor cells in the blood. 
8. 
In addition to these times, blood samples should be sent to the Turtle Lab if there is a suspicion of cytokine storm or macrophage activation syndrome. Discuss with PI or designee. 
9. 
In addition to these times, blood samples should be sent to the Turtle Lab if there is a significant clinical event. Discuss with PI or designee. 
10. PB B cell immunophenotyping studies may be omitted after day 28 in patients who proceed to other systemic therapies, with a recommendation to be made to the treating physician to 
follow IgG levels and replace if necessary. 
11. Blood for archival purposes is optional and may be collected as follows: day 0-21 and 21-90, blood 60 mL 
12. The volume of all research samples is approximate and may vary based on patient condition and clinical situation.  
13. Samples may be collected if clinically indicated based on PI request. 
14. Preganancy test only needs to be repeated if  than 21 days from enrollment 
15. Chimerism tesing only for post allogeneic HCT patients 
 
 
T cell infusion time points represent guidelines for performance of required evaluations. Due to numerous factors influencing scheduling (pt and provider availability, testing 
services limitations etc), variation in evaluation performance dates is anticipated and acceptable to the protocol (e.g., within +/- 7 days of time points < day 30; +/- 90 days for 
time points > day 30).

 
46 
APPENDIX D: Research sample checklist  
 
RECIPIENT RESEARCH EVALUATIONS BEFORE T CELL INFUSION  
SAMPLE 
 
TIME 
TEST 
TUBE 
VOL 
(Approx) 
LAB 
Blood 
Time of 
initial 
Screening 
Research 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
At 
Enrollment 
Baseline T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
At 
Enrollment 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Bone 
Marrow 
At 
Enrollment 
Migration 
Sodium 
heparin 
(green) 
5-10 ml 
Turtle, 
D3-313 
Blood 
At 
Enrollment 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath
SCCA 
Blood 
Day 0 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 0 
T cell baseline persistence, function 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
 
RECIPIENT RESEARCH EVALUATIONS AFTER T CELL INFUSION.  
 
SAMPLE 
 
TIME 
AFTER 
FINAL 
INFUSION 
TEST 
TUBE 
VOL. 
(Approx) 
LAB 
Blood 
Day 1 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 1 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 3 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 3 
T cell persistence 
Sodium 
heparin 
(green) 
 
30 ml 
Turtle, 
D3-313 
Blood 
Day 7 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 7 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 10 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 

 
47 
Blood 
Day 10 
T cell persistence 
Sodium 
heparin 
(green) 
 
30 ml 
Turtle, 
D3-313 
Blood 
Day 14 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 14 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 14 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath
SCCA 
Blood 
Day 21 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 21 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 0-21 
(optional) 
PBMC archive  
Sodium 
heparin 
(green) 
60 ml 
Turtle, 
D3-313 
Blood 
Day 28 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 28 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 28 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath
SCCA 
Blood 
Day 28 
PBMC transgene immunogenicity 
Sodium 
heparin 
(green) 
20 ml  
Turtle, 
D3-313 
Blood 
Day 28 
Serum transgene immunogenicity 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 35-
optional 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 35-
optional 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
 
Blood 
Day 42-
optional 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 42-
optional 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 49-
optional 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 49-
optional 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 60 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle , 
D3-313 

 
48 
Blood 
Day 60 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath 
SCCA 
Blood 
Day 60 
PBMC transgene immunogenicity 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood  
Day 60 
Serum transgene immunogenicity 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 21-90 
(optional) 
PBMC archive 
Sodium 
heparin 
(green) 
60 ml 
Turtle, 
D3-313 
Blood 
Day 90 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 90 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath 
SCCA 
Blood 
Day 90 
PBMC transgene immunogenicity 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 90  
Serum transgene immunogenicity  
Serum 
separator  
10ml  
Turtle  
D3-313  
Blood 
Day 90 
PBMC archive 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 90 
Serum archive 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
 
 
 
 
 
 
Blood 
Day 180 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 180 
B cell immunophenotyping 
Sodium 
heparin 
(green) 
5 ml 
Hemepath 
SCCA 
Blood 
Day 180 
PBMC transgene immunogenicity 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 180 
Serum transgene immunogenicity 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 180 
PBMC archive 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 180 
Serum archive 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
 
 
 
 
 
 
Blood 
Day 365 
T cell persistence 
Sodium 
heparin 
(green) 
30 ml 
Turtle, 
D3-313 
Blood 
Day 365 
B cell immunophenotyping 
Sodium 
heparin 
5 ml 
Hemepath 
SCCA 

 
49 
(green) 
Blood 
Day 365 
PBMC transgene immunogenicity 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 365 
Serum transgene immunogenicity 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
Blood 
Day 365 
PBMC archive 
Sodium 
heparin 
(green) 
20 ml 
Turtle, 
D3-313 
Blood 
Day 365 
Serum archive 
Serum 
separator 
10 ml 
Turtle, 
D3-313 
 
 
 
 
 
 
Blood 
Clinical 
events 
T cell persistence 
Sodium 
heparin 
(green) 
Up to30 
ml 
Discuss 
with study 
staff 
Blood 
Clinical 
events 
IFN-γ, TNF-α, MIP-1α, IL-2 levels 
Serum 
separator 
10 ml 
Discuss 
with study 
staff 
 
 
 
 
 
 
Bone 
marrow 
Day 14-90 
Migration 
Sodium 
heparin 
(green) 
5-10 ml 
Turtle , 
D3-313 
Bone 
Marrow 
Day 180 
Migration 
Sodium 
heparin 
(green) 
5-10 ml 
Turtle , 
D3-313 
Bone 
Marrow 
Day 365 
Migration 
Sodium 
heparin 
(green) 
5-10 ml 
 Turtle, 
D3-313 
Bone 
marrow or 
other 
tissue 
biopsy 
Any time as 
clinically 
indicated  
Research 
Discuss 
with study 
staff 
Discuss 
with 
study 
staff 
Discuss 
with study 
staff 
 
 

 
50 
APPENDIX E – Response criteria for CLL and NHL 
 
Chronic lymphocytic leukemia (CLL) 
 
Complete remission (CR):  Normal imaging studies (X-ray, CT, MRI) (nodes, liver, 
and spleen), peripheral blood by flow cytometry has no clonal lymphocytes, bone marrow 
by flow cytometry has no clonal lymphocytes, bone marrow by morphology has no 
nodules (or if present, nodules are free from CLL cells by immunohistochemistry), and 
the duration is at least 2 months. 
 
CR with minimal residual disease (CR-MRD):  CR by above criteria except 
peripheral blood or bone marrow by flow cytometry with  >0 - <1 CLL cells/1000 
leukocytes (0.1%) 
 
Partial remission (PR):  
Absolute lymphocyte count in peripheral blood at least 
50% decreased and physical exam/Imaging studies (nodes, liver, and/or spleen) at least 
50% decreased.  Duration is at least 2 months. 
 
Progressive disease (PD):  at least one of: Physical exam/imaging studies (nodes, liver, 
and/or spleen) >50% increase or new, circulating lymphocytes by morphology and/or 
flow cytometry >50%increase, and lymph node biopsy with Richter’s transformation 
 
Stable disease (SD):  Did not meet any of the above criteria for complete or partial 
remission or progression. 
 
 
Non-Hodgkin Lymphoma (NHL) 
 
Complete response (CR): Disappearance of all clinically detectable disease. 
 
Partial response (PR): >50% reduction of the sum of the products of the perpendicular 
diameters of marker lesions, no progression of any existing lesions, and no new 
lesions. 
 
Stable disease (SD): Stabilization of all existing lesions with no new lesions (i.e. a <25% 
increase or <50% decrease in disease parameters defined above throughout the treatment 
period). 
 
Progressive disease (PD): >25% increase in the sum of the products of the perpendicular 
diameters of marker lesions, or the appearance of new lesions. 
 
 
Acute lymphoblast leukemia (ALL) 
 
Remission status will be determined by restaging of bone marrow and other involved 
sites by morphology, flow cytometry and molecular studies as appropriate. 
 

 
51 
APPENDIX F - Long Term Follow-Up 
 
Study participants should be asked to participate in long term follow-up, as directed by 
the FDA Guidance for Industry – Gene Therapy Clinical Trials: Observing Subjects for 
Delayed Adverse Events. 
(http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformati
on/Guidances/CellularandGeneTherapy/ucm072957.htm#5). 
 
Long term follow-up should commence one year after the final T cell infusion. The 
planned recommendations for follow-up are as follows:  
 
Years 1 - 15: 
 
1. Recommendation that patients undergo at least annual history and physical 
examination with their primary physician: 
• Adverse event screening guidance for the primary physician in the form of a 
gene therapy LTFU-directed screening survey may be available. 
• A request for the study team to be notified of all new malignancies and 
unexpected illnesses. 
• The primary physician may be provided with a blood draw courier kit to enable 
samples to be returned to the Turtle Lab for archival purposes, and for analysis 
for transgene and vector persistence, and RCL, as dictated by studies of 
transferred T cell persistence. 
 
2. Annually participants will complete  the “Immunotherapy Long Term Follow-up 
questionnaire” to screen for adverse events. 
 
3. Offer the opportunity to return to FHCRC for an annual LTFU clinic visit. 
 
4. Compliance with 21 CFR 312.32 in adverse event reporting. 
 
5. Research studies 
5.i.  30 ml of blood in sodium heparin for evaluation for transgene vector 
sequence by PCR of PBMC every 6 months for years 1 to 5 and every 
year for years 6-15 until the transgene becomes undetectable.  
5.ii. If > 1% of cells express the transgene or if clonality is suggested, vector 
integration sites or TCRB sequence utilization may be analyzed in 
PBMC, CAR-T cells or other tissue. If clonality is suggested, repeat 
testing may be performed 3 months later. Persistent monoclonality, clonal 
expansion or vector integration near a known oncogenic locus should 
precipitate careful attention to the possibility of malignancy. However, 
the need for additional intervention should be guided by the clinical 
circumstances and not solely by the presence of these factors. 
5.iii. 10 ml of blood in sodium heparin for annual testing of PBMC for RCL 
by VSVG QPCR. If there is no evidence of transgene persistence, RCL 
assays may be suspended after one year and samples may be archived.  

 
52 
APPENDIX G – Grading Criteria for CRS 
 
Grade 
Description of Symptoms 
1: Mild 
Not life-threatening, require only symptomatic treatment such as antipyretics and 
anti-emetics (e.g., fever, nausea, fatigue, headache, myalgia, malaise) 
2: Moderate 
Require and respond to moderate intervention: 
• 
Oxygen requirement < 40%, or 
• 
Hypotension responsive to fluids or low dose of a single vasopressor, or 
• 
Grade 2 organ toxicity (by CTCAE v4.03) 
3: Severe 
Require and respond to aggressive intervention: 
• 
Oxygen requirement ≥ 40%, or 
• 
Hypotension requiring high dose of a single vasopressor (e.g., 
norepinephrine ≥ 20 µg/min, dopamine ≥ 10 µg/kg/min, phenylephrine ≥ 200 
µg/min, or epinephrine ≥ 10 µg/min), or 
• 
Hypotension requiring multiple vasopressors (e.g., vasopressin + one of the 
above agents, or combination vasopressors equivalent to ≥ 20 µg/min 
norepinephrine), or 
• 
Grade 3 organ toxicity or Grade 4 transaminitis (by CTCAE v4.03) 
4: Life-threatening 
Life-threatening: 
• 
Requirement for ventilator support, or 
• 
Grade 4 organ toxicity (excluding transaminitis) 
5: Fatal 
Death 
Adapted from Lee et al., 2014 (Lee 2014) 
 
 
 

 
53 
APPENDIX H – Recommended management guidelines for CRS and neurotoxicity