The Pre-Emptive Use of Recipient-Derived Autologous Cytomegalovirus (CMV)-Specific Cytotoxic T Cells for Cytomegalovirus (CMV) Reactivation After Allogeneic Stem Cell Transplantation
Phase: PHASE2
Conditions: Leukemia, Lymphoma
Sponsor: M.D. Anderson Cancer Center

2013-0620
January 9, 2017
Abstract - Page 1
Protocol Abstract Page
The Pre-emptive Use of Recipient-Derived Autologous CMV-Specific 
Cytotoxic T Cells for CMV Reactivation After Allogeneic Stem Cell 
Transplantation. 
2013-0620
Core Protocol Information
Study Chairman: 
Betul Oran
Department:
Stem Cell Transplantation and Cellular Therapy
Phone:
713-792-8750
Unit:
423
Full Title: 
The Pre-emptive Use of Recipient-Derived Autologous CMV-Specific Cytotoxic T Cells for 
CMV Reactivation After Allogeneic Stem Cell Transplantation. 
Protocol Phase:
Phase II
Version Status:
Terminated 05/14/2019
Version:
11
Document Status:
Final
Abstract
Objectives:
Primary
1. To assess the efficacy of recipient-derived autologous cytomegalovirus (CMV)-specific cytotoxic T cells 
(CTLs) as a pre-emptive therapy for CMV reactivation after allogeneic hematopoietic stem cell 
transplantation (HSCT) from a CMV negative donor. 
2. To assess the non-relapse mortality with the use of recipient-derived autologous cytomegalovirus 
(CMV)-specific cytotoxic T cells (CTLs) as a pre-emptive therapy for CMV reactivation after allogeneic 
hematopoietic stem cell transplantation (HSCT) from a CMV negative donor. 
Secondary
1.
To assess the safety of the pre-emptive use of recipient-derived autologous CMV- specific CTL as a 
pre-emptive therapy for CMV reactivation after HSCT.
2.
To assess functionality and persistency of infused autologous CMV-specific CTLs.
Rationale: (Be as concise as possible)
CMV is a B-herpesvirus that is very common in humans and leads to asymptomatic infection followed by 
viral persistence and latency. CMV is still one of the major causes of infectious complications after HSCT, 
although several new prophylactic options for CMV infection/disease have been made available. Among 
the recipients of HSCT, CMV causes pneumonia, gastroenteritis, and less commonly retinitis and 
hepatitis. Because of the initial high mortality of CMV pneumonia (80-90%), transplant physicians have 
long sought strategies to reduce its morbidity and mortality. CMV also exhibits an immunosuppressive 

2013-0620
January 9, 2017
Abstract - Page 2
effect, which can lead to an increased susceptibility to invasive bacterial and fungal disease as well as 
graft versus host disease (GVHD) in selected clinical settings.  Recent advances in diagnostic measures 
such as CMV antigenemia and polymerase chain reaction (PCR) and the introduction of effective antiviral 
agents have enabled sufficiently early detection of CMV to suppress reactivation and prevent subsequent 
development of CMV diseases (pre-emptive therapy). 
The presence of CMV-specific T cell immunity has been reported to be an essential host factor in the 
control of infection and the recovery from CMV disease decades ago. However, restoration of T-cell 
immunity after HSCT is a slow process. The rebound of the thymus occurs late, particularly in adult 
patients, and the contribution of newly generated T cells during the first 6 months after transplantation 
may be negligible. Therefore, the initial protection against viruses has to come from the donor T cells 
co-infused with the graft or possibly from recipient T cells that have survived conditioning. This might 
leave some patients unprotected because no immunity is transferred when a patient receives a transplant 
of hematopoietic stem cells (HSCs) from a CMV-negative donor or umbilical cord blood (UCB) units that 
have T cells one log less than other donors and naive. Therefore, the use of adoptive immunotherapy 
with CMV-specific CTLs to restore the cellular immunity for CMV infections after HSCT has been 
investigated by many groups.
In HSCT, seropositive stem cell donors can usually serve as T cell donors and are available for T-cell 
donation. However, some seropositive donors may not consent, may be unavailable to provide T cells, or 
may not have enough antiviral memory T cells in their blood despite seropositivity. Furthermore, UCB 
recipients with delayed hematologic engraftment and immune reconstitution represent a unique group 
with high risk for viral infections but without the option of adoptive transfer of virus-specific CTL. Those 
groups of patients need to be investigated further for strategies that bypass the need to grow 
donor-derived CTL.
The protective role of recipient T cells after transplantation was not investigated in detail until recently 
because most transplantation protocols eradicate recipient T cells through a combination of the 
conditioning chemotherapy and an allogeneic effect of the graft.  The notion that recipient T cells could 
survive even early after transplantation was supported by data from pediatric patient population 
undergoing UCB transplantation and showed that antigen-specific T lymphocytes of recipient origin were 
detected in patients receiving a transplant with a related donor, after a chemotherapy-based conditioning 
regimen, and who did not have GVHD(27). Recently, Chalandon et al showed when a T-cell depletion 
protocol was used that allowed recipient T cells to repopulate the T-cell compartment, the T cells 
maintained their function even after conditioning that includes total body irradiation. Furthermore, T cells 
appeared to protect the patient from CMV-related complications. These data support the notion to 
investigate the use of recipient-derived autologous CTLs  for CMV reactivation after allogeneic HSCT 
especially for patients without the option to use donor-derived CTLs.  Recently, Meij et al. showed the 
feasibility of generating patient-derived autologous CMV specific CTLs using IFN-capture system.
In conclusion, alternative strategies to provide safe and effective adoptive therapy for CMV reactivation 
after HSCT are needed especially in patients with CMV seronegative donors or following the use of UCB 
where there is no memory T cell response to CMV. 
In this study, we will use this original and novel approach of infusing recipient-derived autologous 
CMV-specific CTLs for the treatment of CMV reactivation following HSCT in CMV seropositive patients.
Eligibility: (List All Criteria)
Inclusion:
1)
STEP 1: Within 30 days of study entry: Patients with a history of bone marrow disorders including 
hematological malignancies and aplastic anemia, Myelodysplastic Syndrome (MDS) and 
Myeloproliferative disorder (MPD) planning to undergo allogeneic HSCT with reduced intensity or 
myeloablative conditioning regimens.

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January 9, 2017
Abstract - Page 3
2)
Disease status must be complete remission by standard criteria for Lymphoma and Acute 
Leukemia patients.
3)
Patients with Myelodysplastic Syndrome (MDS) and Myeloproliferative Disorder (MPD) must have 
<5% blasts in the bone marrow.
4)
Patients with T Cell ALL must be in complete remission and MRD negative (-) by flow cytometry 
and molecular studies.
5)
Patients >/= 18 years of age.
6)
Karnofsky greater than or equal to 80%.
7)
CMV seropositive.
8)
Donor is either matched related, matched unrelated, mismatched unrelated, or haploidentical. Cord 
blood recipients are also eligible.
9)
Hgb greater than 10 g/L.
10)
Patient or patient’s legal representative, parent(s) or guardian able to provide written informed 
consent.
11)
Negative pregnancy test in female patients of childbearing potential.
12)
STEP 2: Eligibility at time of generating and infusing CMV-specific cytotoxic T cells (adoptive 
immunotherapy): CMV reactivation defined as CMV DNAemia >/= 137 copies/ml.
13)
Evidence of neutrophil engraftment defined as the absolute neutrophil count (ANC)> 0.5 X 10^3/for 
3 consecutive days.
14)
Clinical status to allow tapering of steroids to less than 0.5 mg/kg/day prednisone or equivalent.
15)
Negative pregnancy test in female patients of childbearing potential.
Exclusion:
1)
STEP 1: Within 30 days of study entry: T cell leukemia or lymphoma.
2)
CMV seronegative.
3)
Positive for HIV, HBV, HCV, HTLV1 and/or HTLV2.
4)
STEP 2: Eligibility at time of generating and infusing CMV-specific cytotoxic T cells (adoptive 
immunotherapy): Documented CMV end-organ disease.
5)
Patients receiving ATG, or Campath within 28 days of CMV reactivation.
6)
Patients with other uncontrolled infections. For bacterial infections, patients must be receiving 
definitive therapy and have no signs of progressing infection for 72 hours prior to generating CTLs. For 
fungal infections patients must be receiving definitive systemic anti-fungal therapy and have no signs of 
progressing infection for 1 week prior to generating CTLs. Progressing infection is defined as 
hemodynamic instability attributable to sepsis or new symptoms, worsening physical signs or 
radiographic findings attributable to infection. Persisting fever without other signs or symptoms will not be 
interpreted as progressing infection.

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January 9, 2017
Abstract - Page 4
7)
Patients who have received donor lymphocyte infusion (DLI) within 28 days.
8)
Patients with active acute GVHD grades II-IV.
9)
Active and uncontrolled relapse of malignancy.
Are patients <18 years of age eligible to participate in this study?  
Yes
No
Studies that include children must meet the criteria for inclusion.
http://www.fda.gov/ohrms/dockets/AC/04/briefing/4028B1_05_NIH-Inclusion%20of%20Children.doc
http://www.hhs.gov/ohrp/policy/populations/children.html
Studies that exclude children must have appropriate justification.  Please select all that 
apply:
Phase II or III study with no Phase I data for the drug in pediatrics.
Please provide a letter from the Sponsor stating if a Phase I  study planned for patients <18 
years of age.  (May include file attachment)
         This is a rare disease in pediatric patients
         Our Pediatric transplant program is very small
         Our sponsor does not allow pediatric patients to be included in this study.
Are participants >65 years of age eligible to participate in this study?  
Yes
No
Are pregnant women eligible to participate in this study?
Yes
No
Will the recruitment population at M. D. Anderson include persons who are incarcerated at time of 
enrollment (e.g., prisoners) or likely to become incarcerated during the study?
Yes
No
Disease Group:
Blood And Marrow Transplantation, Leukemia, Lymphoma
Treatment Agents/Devices/Interventions:
CMV-specific CTLs
Proposed Treatment/Study Plan:
Is treatment assignment randomized?
Yes
No
Is this a blinded or double-blinded study?
Yes
No
Collection of peripheral blood mononuclear cells (PBMC) for manufacturing of CTLs
After enrollment, PBMC will be collected via venipuncture.
Venipuncture: up to 500 mL one time at the MD Anderson Blood Bank. The product will be cryopreserved 
for future use to generate CMV-specific CTLs. 

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Abstract - Page 5
PBMCs will be stored for 3 years.  If the PBMCs are not needed to generate CTLs, they will be discarded.
Allogeneic HSCT and follow-up
1. Patients will undergo allogeneic HSCT per institutional guidelines.
2. CMV reactivation will be monitored by checking CMV DNA level by polymerase chain reaction (PCR). 
Manufacture of recipient derived autologous CMV specific CTLs under GMP conditions
1.   After documentation of CMV reactivation, defined as CMV DNA load is equal to or greater than 137 
copies/ml, cryopreserved PBMC product of eligible patients’ defined under “Eligibility” will be used for 
generation of CMV-specific CTLs. 
2. Manufacture of recipient derived autologous CMV specific CTLs under GMP conditions will be 
performed at the MDACC GMP facility. Cryopreserved PBMC product from the recipient will be 
thawed, washed and diluted at 1 x 10
9 cells in 100 mL MACS GMP TexMACS Reagent (Miltenyi 
Biotec) for approximately 16 hours at 37°C (overnight). The product will then be stimulated with 
MACS® GMP Peptivator® HCMV pp65 (Miltenyi Biotec) for approximately 4 hours at 37°C, CO2.  
Once incubation is completed the product will be washed and concentrated with TexMACS Reagent 
followed by an incubation with CliniMACS IFN-Gamma Catch Matrix Reagent 
(Cytokine-Secretion-System, Miltenyi Biotec).  The stimulated cells will then be washed with 
CliniMACS buffer to stop stimulation reaction.  
After culture, magnetic enrichment of cytokine-secreting cells will be performed with the use of the 
CliniMACS Enrichment Reagent (Cytokine-Secretion-System) and the CliniMACS device (Miltenyi 
Biotec). CMV-specific T cells will be infused directly after the isolation procedure without any further 
in vitro expansion. The purity of the isolated pp65-specific T cells will be assessed by detection of 
IFN-+ cells in flow cytometry, with release criteria of  3% IFN-+T cells.
Administration and Monitoring of CTL infusion
1. 
Premedication for CTL infusion: acetaminophen up to 650 mg (or 10 to 15 mg/kg recipient weight) 
and diphenhydramine up to 50 mg (or up to 0.5 to 1 mg/kg recipient weight) should be given orally or 
IV prior to CTL infusion and may be repeated 4 hours later.
2. 
It is essential to avoid steroid as those may interfere with the efficacy of the infused CMV-specific 
CTLs. Steroids will be given only if the patient develops a severe or life threatening reaction to the 
infused CMV-specific CTLs. 
3. 
CTL Administration: The CTL product will be given as single infusion within 72 hours of CMV 
reactivation.)
4. 
Patients will be monitored according to institutional standards for administration of blood products 
and at a minimum will be monitored according to below: 

Patients should remain in the clinic for at least one hour.

Patients should remain on continuous pulse oximetry for at least 30 minutes.

Vital signs should be monitored at the end of infusion then at 30 and 60 minutes.
5.  
CTL dose infused will be at a maximum dose of 10e5 viable CD3+ T cells/kg.
6.  
The first three patients on protocol will be observed for at least 28 days for safety
monitoring before more patients are enrolled in the study.
Supportive care
1. All patients should receive supportive care as clinically indicated. 
2. It is essential to avoid steroid as those may interfere with the efficacy of the infused CMV-specific 
CTLs.
3.   Steroids will be given only if the patient develops a severe or life-threatening reaction to the infused 
CMV-specific CTLs. 
Initiation of anti-viral therapy 
1.  CMV viral load will be monitored at least weekly by PCR within the 28 days of autologous 
recipient-derived CMV-specific CTL infusion.

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January 9, 2017
Abstract - Page 6
2.  Indication to initiate anti-viral therapy will be determined by their response status as described in Table 
4.
 
Management of potential treatment toxicity
1. Microbial contamination of T-cell product.  
There is a potential that processing the T-cell product will inadvertently introduce
microorganisms that could cause infection in the recipient after the cells are 
infused.  Cultures of the T-cell product will be obtained to monitor for contamination. 
In the event that a microbial contamination is discovered after infusion of CTLs,  
standard GMP procedures will be followed.  
2. Graft failure: Graft failure is initial neutrophil   engraftment followed by subsequent decline in the ANC 
to < 500/mm3 for three consecutive measurements on different days, unresponsive to growth factor 
therapy that persists for at least 14 days in the absence of a known cause such as relapse.  GF will 
be monitored as clinically indicated for the first 6 months after CTL infusion.
3. Graft Versus Host Disease (GVHD) 
The risk of GVHD following the infusion of recipient-derived autologous CTLs is expected to be low. 
GVHD organ stage scores, overall clinical grade, biopsy information for GVHD and relevant 
differential diagnosis will be recorded as clinically indicated. The score will encompass all information 
since the last assessment. Organ involvement, biopsy information, staging, differential diagnosis, and 
GVHD therapy will be documented in the medical record using the Blood and Marrow Transplant 
Clinical Trials Network (BMT CTN) GVHD scoring stamp or equivalent.
An example acute GVHD weekly data record (stamp) is shown below in Table 5.
Chronic GVHD 
Patients developing sign/symptoms of chronic GVHD (CGVHD) as presented in Table 6 will have 
symptoms recorded on the CGVHD scoring form at the scheduled follow-up visits.  

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Abstract - Page 8
Study Enrollment:
The study population for this research will consist of participants from:
Only at MDACC
Estimated Accrual:
Total Accrual at MDACC:
105
Estimated monthly accrual at MDACC:
2
Accrual Comments:
Due to the randomness of the treatable CMV subsample size, which is binomial in q = .40 and n = 
number of patients initially enrolled and transplanted, up to 105 patients will be enrolled (21 months 
accrual) to ensure at least a 90% probability that there will be at least 36 patients with CMV.
Is this an NCI-Cancer Therapy Evaluation Protocol (CTEP)?
No
Is this an NCI-Division of Cancer Prevention Protocol (DCP)?
No
Statistical Considerations:
Treatment and Primary Outcomes. This is a single-arm phase II trial of autologous virus specific CTLs 
for CMV reactivation in patients with hematologic malignancies (excluding T cell leukemia and lymphoma) 
undergoing CMV seronegative matched unrelated donor (MUD), mismatched unrelated or cord blood 
allogeneic stem cell transplant. Whole blood will be collected and frozen prior to transplant. After 
documentation of CMV reactivation, defined as CMV at a level >/= 137 DNA copies/ml by PCR, 
autologous CMV-specific CTLs  will be generated to be infused within 72 hours of CMV reactivation, if the 
patient has ANC engraftment, no acute GVHD or steroid administration </= 0.5 mg/kg dose. All outcomes 
will be recorded starting from the time of T-cell administration.  While the dose of T-cells will vary 
depending on how many cells can be grown by ex vivo expansion after thawing and prior to 
administration, the maximum dose will be 10e5 viable CD3+ T cells/kg. It is anticipated that 20-25 
patients per year will be accrued and that approximately 2 patients per month will develop CMV 
reactivation and thus be eligible to receive autologous CTLs.  A maximum of 36 patients will receive 
autologous CTLs. The two primary endpoints, starting at the time of autologous T-cell administration, will 
be T = time to non-relapse mortality and Y = [28-day success], where "success" is defined as follows. 
CMV will be evaluated weekly at 7, 14, 21 and 28 days using PCR. Treatment will be considered a 
success if the patient does not require initiation of CMV anti-viral therapy. Anti-viral therapy will be started 
if 1) End-organ disease is documented at any time point after CTL administration 2) Increase in CMV 
DNAemia >50% compared with baseline at any time point 3) Decrease in CMV DNAemia <50% 
compared with baseline at day 21 after CTL administration and 4) CMV DNAemia >5000 copies/ml at any 
time point.
Non-relapse mortality is defined as death because of causes other than  relapse of the underlying 
hematological malignancy. Relapse of underlying hematological malignancy will be a competing event for 
non-relapse mortality. Time to non-relapse mortality is defined as time to non-relapse mortality from date 

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Abstract - Page 9
of stem cell transplantation.
The Department of Biostatistics Clinical Trial Conduct (CTC) website will be used to monitor the time to 
non-relapse mortality, and the trial conduct will be implemented by a Statistical Analyst from the 
Biostatistics Department. 
The Clinical Trial Conduct website is an MD Anderson portal for multi-center trials that provides treatment 
assignment, randomization, and monitoring for several hundred trials.  The website was developed and is 
maintained by software developers in the Biostatistics department. There are approximately 7 different 
randomization algorithms implemented at the site, covering methods from simple randomization to 
innovative adaptive randomization.  The trials and statistical details are overseen by the statisticians in 
the MD Anderson Biostatistics department. Users of the website (nurses, clinicians, etc) are registered on 
specific trials at the site and may be granted various levels of access (read only, write, blinded, etc).  
BMTWeb is departmental clinical research application used to collect patient treatment data for patient 
receiving transplant in SCTCT department. It operates as a data repository for the clinical data 
transmitted to CIBMTR to meet our patient follow up requirements. 
Sample Size.  The effective sample size for evaluating CTL effects is the number of patients who suffer 
CMV reactivation, are eligible to receive CTLs, and actually receive CTLs, not the number enrolled and 
undergoing a transplant.  In order to obtain a maximum of 36 patients who are treated with CTLs, 
assuming an accrual rate of 5 patients per month who receive a transplant and a 40% rate of patients 
with CMV who satisfy the entry criteria for receiving CTLs, it is expected that an effective accrual rate 
total of 2 patients per month will be enrolled, receive a transplant, and subsequently develop CMV.  Due 
to the randomness of the treatable CMV subsample size, which is binomial in q = .40 and n = number of 
patients initially enrolled and transplanted, up to 105 patients will be enrolled (21 months accrual) to 
ensure at least a 90% probability that there will be at least 36 patients with CMV.  If q = .50, then up to 83 
patients (17 months accrual) will be enrolled to ensure this same sample size with this reliability.  The 
overall sample size of 36 will ensure that, if the trial is not stopped early and, for example, 18/36 patients 
achieve 28-day success, then a posterior 95% credible interval for p starting with a beta (.50,.50) prior 
would be  .342 - .658, or approximately 34% to 66%.
The first three patients on protocol will be observed for at least 28 days for safety monitoring before more 
patients are enrolled in the study.

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Data Safety Monitoring Board / DSMB at MDACC:
Select the name of the data safety monitoring board (DSMB) monitoring this protocol:
Not Applicable
Please explain:

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Abstract - Page 12
This study is not randomized nor blinded.
Protocol Monitoring:
Does this protocol have a schedule for interim and final analysis?
No
Provide a rationale for no interim analysis.
This study will be continuously monitored per the statistical design.
Protocol Monitoring Plan:
This study will be monitored by the MD Anderson IND Office and a protocol-specific monitoring plan will 
be followed.
Intellectual Property:
1.
Does this study include any agents, devices, or radioactive compound (or 
drug) manufactured at  MD Anderson Cancer Center or by a contract 
manufacturer?
No
Investigational New Drugs (IND):
Does this protocol require an IND?
Yes
Who is the IND Holder/Regulatory Sponsor?
MD Anderson
IND Number:
16063
Please "Compose" an Investigator’s Brochure Cover Letter.  For technical assistance, contact the PDOL 
Help Desk, 713-745-7365.
Investigational Device (IDE):
Does this study utilize an Investigational Device?
No
Moon Shots Program
Will your protocol be funded by the Moon Shots Program? Yes
Specific Disease Site(s):
Myelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML)
Platform(s):
Applied Cellular Therapy (ACT)
Sponsorship and Support Information:
Does the Study have a Sponsor, Supporter or Granting Agency?
Yes

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January 9, 2017
Abstract - Page 13
Sponsor Name:
Miltenyi Biotec
Support Type:
Other: Miltenyi Biotec will cover the costs of manufacturing the CTLs.
This Sponsor/Supporter/Granting Agency will receive data.
Sponsor Name:
Moon Shots Program
Support Type:
Other: Moon Shots Program: ACT platform for AML/MDS
This Sponsor/Supporter/Granting Agency will receive data.
Regulatory Requirements
Radioactive Material:
Does this study involve the administration of radioisotopes or a
radioisotope labeled agent?
Click here  for help
No
Biosafety:
Does this study involve the use of Recombinant DNA Technology? 
No
Does this study involve the use of organisms that are infectious to humans?
No
Does this study involve human/animal tissue other than blood derived 
hematopoietic stem cells?
No
Questions should be addressed to the Transfusion Medicine Tissue Coordinator at 713-792-8630.
Laboratory Tests:
Is there any biomarker testing in this study being used to determine patient/participant eligibility, 
treatment assignment, or management of patient/participant care?
Yes
No
Not Applicable For This Protocol
Manufacturing:
Will you manufacture in full or in part (split manufacturing) a drug or biological 
product at the M. D. Anderson Cancer Center for the proposed clinical study?
Yes
Please provide the name of the responsible party, the facility or department, contact information and the 
name of the product or intermediate.
Manufacture of recipient derived autologous CMV specific CTLs under GMP conditions will be performed 
at the MD Anderson GMP facility using the CliniMACs device from Miltenyi Biotec.
Will you obtain an unlicensed (not FDA approved for use in humans) drug or 
biological product precursor or intermediate for use in patients?
No

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Abstract - Page 14
Student/Trainee Information:
Is this research being conducted as a partial fulfillment for completion of a degree?
No