A Phase 1/2 Study of Cytokine-Induced Memory-Like NK Cells in Patients With AML or MDS
Phase: PHASE1
Conditions: Leukemia, Myeloid, Acute
Sponsor: Washington University School of Medicine

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A phase 1/2 study of cytokine-induced memory-like NK cells in patients with AML or MDS 
 
Washington University School of Medicine 
Division of Oncology 
660 South Euclid Avenue, Campus Box 8007 
St. Louis, MO  63110 
 
Protocol #: 201401085 
Version Date: 03/11/20 
 
Coordinating Center:  
Washington University School of Medicine 
 
Principal Investigator:  
Amanda Cashen, M.D.  
Phone: (314) 434-8323  
E-mail: acashen@wustl.edu 
    
Sponsor / Laboratory PI: 
Todd A. Fehniger, M.D., Ph.D. 
Phone: (314) 747-1385 
E-mail: tfehnige@wustl.edu  
 
Sub-Investigators:  
 
Armin Ghobadi, M.D. 
Camille Abboud, M.D. 
John DiPersio, M.D., Ph.D. 
Meagan Jacoby, M.D., Ph.D. 
Iskra Pusic, M.D. 
Mark Schroeder, M.D. 
Keith Stockerl-Goldstein, M.D 
Geoffrey Uy, M.D. 
Ravi Vij, M.D. 
Matthew Walter, M.D. 
Lukas Wartman, M.D. 
John Welch, M.D., Ph.D. 
Peter Westervelt, M.D., Ph.D. 
Tanya Wildes, M.D.  
Brad Kahl, M.D.  
Jeffery Bednarski, M.D., Ph.D. 
Shalini Shenoy, M.D. 
Robert Hayashi, M.D. 
Sima Bhatt, M.D. 
 
Statistician: 
 
 
Feng Gao, Ph.D. 
 
Study Drug(s):  
 
Cytokine Induced Memory-Like NK cells (CIML NK cells) 
ALT-803 (Phase II only) 
IND#: 
15874 
Clinical Trials.gov#: 
NCT01898793 
 
 
 
CONFIDENTIAL 

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The information contained in this document is regarded as confidential and, except to the extent necessary to obtain 
informed consent, may not be disclosed to another party unless law or regulations require such disclosure.  Persons to 
whom the information is disclosed must be informed that the information is confidential and may not be further disclosed 
by them 

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A phase 1/2 study of cytokine-induced memory-like NK cells in patients with AML or MDS 
 
 
Protocol Revision History 
 
Initial Approval Version 
 
 
 
 
 
 
01/17/14 
Amendment 1 
 
 
 
 
 
 
 
04/01/14 
Amendment 2 
 
 
 
 
 
 
 
08/18/14 
Amendment 3 
 
 
 
 
 
 
 
09/09/14 
Amendment 4 
 
 
 
 
 
 
 
10/17/14 
Amendment 5 
 
 
 
 
 
 
 
04/06/15 
Amendment 6 
 
 
 
 
 
 
 
05/03/16 
Amendment 7 
 
 
 
 
 
 
 
06/21/16 
Amendment 8 
 
 
 
 
 
 
 
07/15/16 
Amendment 9 
 
 
 
 
 
 
 
08/31/16 
Amendment 10 (PRMC only) 
 
 
 
 
 
03/13/17 
Amendment 10 
 
 
 
 
 
 
 
03/20/17 
Amendment 11 
 
 
 
 
 
 
 
08/31/17 
Amendment 12 
 
 
 
 
 
 
 
09/20/17 
Amendment 13 
 
 
 
 
 
 
 
03/09/18 
Amendment 14 
 
 
 
 
 
 
 
09/04/18 
Amendment 15 
 
 
 
 
 
 
 
01/24/19 
Amendment 16 
 
 
 
 
 
 
 
04/05/19 
Amendment 17 
 
 
 
 
 
 
 
10/21/19 
Amendment 18 
 
 
 
 
 
 
 
01/08/20 
Amendment 19 
 
 
 
 
 
 
 
03/11/20 
 
 

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A phase 1/2 study of cytokine-induced memory-like NK cells in patients with AML or MDS 
 
Principal Investigator Signature Page 
 
 
Principal Investigator 
(printed): 
      
Name of Institution:       
  
 PI Signature 
 
 
 
 
 
Date 
 
By my signature, I agree to personally supervise the conduct of 
this study and to ensure its conduct in compliance with the 
protocol, informed consent, IRB/HRPO procedures, the 
Declaration of Helsinki, ICH Good Clinical Practices guidelines, 
and the applicable parts of the United States Code of Federal 
Regulations or local regulations governing the conduct of clinical 
studies. 
 
 
 

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A phase 1/2 study of cytokine-induced memory-like NK cells in patients with AML or MDS 
 
SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligible Patients 
Inclusion Criteria: 
• 
Phase I: AML patients with refractory disease who have not achieved a complete 
remission (CR) after induction therapy (primary induction failure), or relapsed disease 
after obtaining a complete remission. 
OR 
High-risk (by ELN criteria) AML in complete remission (CR) and has either refused 
hematopoietic stem cell transplantation OR is currently not eligible for hematopoietic 
stem cell transplantation OR for whom hematopoietic stem cell transplantation is being 
reserved for later relapse.  
OR 
MDS with excess blasts (>5%) and progressive disease at any time after initiation of DNA 
hypomethylator treatment OR failure to achieve complete or partial response or 
hematological improvement OR intolerance  
• 
Phase II: AML patients with refractory disease who have not achieved a CR after 
induction therapy or relapsed AML   Favorable-risk CBF mutated AML and APL patients 
will be excluded. 
• 
Pediatric cohort: AML patients with refractory disease who have not achieved a 
complete remission (CR) after induction therapy (primary induction failure), or relapsed 
disease after obtaining a complete remission. 
• 
Age > 18 years old (Phase I and II) 
• 
Age 1-17 years old (Pediatric cohort) 
• 
Available related haplo-identical NK cell donor 
• 
Karnofsky performance status > 50 % 
• 
Adequate organ function: 
o 
Total bilirubin < 2 mg/dL  
o 
AST(SGOT)/ALT(SGPT) < 3.0 x ULN 
o 
Creatinine WNL or CrCl > 50 mL/min/1.73 m2  
o 
Oxygen saturation ≥90% on room air 
o 
Ejection fraction ≥35% 
 
Exclusion Criteria:  
• 
Patients who relapse after allogeneic transplantation are not eligible. 
• 
Circulating blast count >30,000/µL (despite hydroxyurea). 
• 
Uncontrolled bacterial or viral infections, or known HIV, Hepatitis B or C infection. 
• 
New progressive pulmonary infiltrates  
• 
Pregnant and/or breastfeeding. 
• 
Additional exclusion for phase II only: 
o Patients who have isolated extramedullary relapse 
o Patients who have been treated with more than one salvage regimen for 
relapsed or refractory AML 
 

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Dose Levels in Phase I: 
 
CIML NK Cell Dose Escalation Schedule 
Dose Level 
CIML NK cell dose 
Level 1 (starting dose) 
0.5 x 106/kg  
Level 2 
1.0 x 106/kg  
Level 3 
Maximum NK cells available* 
*All CIML NK cells available from the donor leukapheresis, NK cell purification, and CIML process 
will be infused, up to a maximum of 10x106/kg. 
 
Recipient Treatment Plan in Phase I: 
 
 
Dose Levels in Lead-in Cohort, Phase II, and Pediatric Cohort: 
Maximum tolerated / tested dose (MTD) in phase I will be used in the Lead-in Cohort and phase 
II part of this study.  For Pediatric cohort, all CIML NK cells available will be infused, up to max 
dose of 10 x 106/kg. 
 
Recipient Treatment Plan in Pediatric Cohort:The treatment in the pediatric cohort will follow 
the plan for Phase I. 
 
Recipient Treatment Plan in Lead-in Cohort and Phase II/ALT-803:  
ALT-803 (10 mcg/kg SQ on Days 0, 5) will replace IL-2.. In the Lead-in Cohort three patients will 
receive maximal tolerated / tested (MTD) dose of the CIML NK cells (derived from phase I) and 
enrollment on the phase II part of the study will start only if none of the three patients develop 
any unexpected grade ≥3 adverse events related to the use of ALT-803 or any of stopping rules 
listed in Section 5.3.4 as assessed by Day +35. Dose de-escalation plan for ALT-803 is listed in 
Section 5.3.6.  
 
Recipient Treatment Plan in Phase II/IL-2:  
The treatment plan will follow the plan for Phase I. 
 
Donor Cell Collection Plan and Generation of CIML NK Cells: 
The haploidentical donor identified by HLA matching of the immediate family members (parents, 
siblings, and children) will undergo non-mobilized leukapheresis on Day -1. Peripheral blood 
mononuclear cells (PBMCs) will be collected using standard collection techniques. The apheresis 
product will be T-cell depleted (CD3 depletion) and CD56 positive selected using Miltenyi 
-7      -6       -5      -4      -3       -2       -1         0                 7                  14  
CY 
In Vivo Expansion
FLU     FLU    FLU    FLU   FLU
Donor CIML NK Cell Infusion
rhIL-2, 1 MU/m2 SQ 
qOD for 14 days
Preparative Regimen:
CIML NK Cell Product:
Fludarabine 25 mg/m2x 5
CD3-CD56+ selected,
Cyclophosphamide 60 mg/kg x 2
IL-12+IL-15+IL-18 stimulated,
haploidentical donor NK cells
Donor leukapheresis
NK Purification
CIML NK cells

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CliniMACS®. This NK cell product will be pre-activated for 12-18 hours with a combination of rhIL-
12 (10 ng/mL), rhIL-15 (50 ng/mL), and rhIL-18 (50 ng/mL) under GMP conditions. The cells will 
be washed 2 times prior to infusion on Day 0. 
 
 
 
 

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Glossary of Abbreviations  
 
AE 
Adverse event 
ALT (SGPT) 
Alanine transaminase (serum glutamate pyruvic transaminase) 
AML 
Acute myeloid leukemia 
ANC 
Absolute neutrophil count 
ASH 
American Society of Hematology 
AST (SGOT) 
Aspartate transaminase (serum glutamic oxaloacetic transaminase) 
B-HCG 
Beta human chorionic gonadotropin  
BM 
Bone marrow 
BMT 
Bone marrow transplant 
BUN 
Blood urea nitrogen 
CALGB 
Cancer and Leukemia Group B 
CBC 
Complete blood count 
CFR 
Code of Federal Regulations 
CIML NK cells 
Cytokine Induced Memory-like NK cells 
CNS 
Central nervous system 
CR 
Complete remission 
CRc 
Cytogenetic complete remission 
CRi 
Complete remission incomplete 
CRm 
Morphologic complete remission 
CRF 
Case report form 
CST 
Central standard time 
CT 
Computed tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
DLTs 
Dose Limiting Toxicities 
DNA 
deoxyribonucleic acid 
DSM 
Data and Safety Monitoring  
DSMC 
Data Safety Monitoring Committee 
EC 
Ethics Committee 
ECG (or EKG) 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EDTA 
ethylenediaminetetraacetic acid 
EE 
Efficacy-Evaluable 
EFS 
Event free survival 
FAB 
French-American-British classification 
FDA 
Food and Drug Administration 
FISH 
fluorescent in situ hybridization 
GCP 
Good Clinical Practice 
G-CSF 
Granulocyte colony stimulating factor, filgrastim (Neupogen) 
GM-CSF 
Granulocyte/macrophage colony stimulating factor, sargramostim, (Leukine, Prokine) 
HDACs 
Histone deacetylases 
HHS 
Department of Health and Human Services’ 
HI 
Hematologic improvement 

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HIV 
Human Immunodeficiency Virus 
HRPO 
Human Research Protection Office (IRB) 
ICH 
International Conference on Harmonization 
IFN 
Interferon 
IL 
Interleukin 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
IV 
Intravenous (i.v.) 
IVRS 
Interactive Voice Response System 
IWG 
International Working Group 
LDH 
Lactate dehydrogenase 
LPS 
lipopolysaccharide 
MCH 
Mean corpuscular hemoglobin 
MCHC 
Mean corpuscular hemoglobin concentration 
MCV 
Mean corpuscular volume 
MDS 
Myelodysplastic syndrome 
MTD 
Maximum tolerated dose 
NCCN 
National Cancer Center Network 
NCI 
National Cancer Institute 
NIH 
National Institutes of Health 
NK 
Natural killer cell 
OHRP 
Office of Human Research Protections  
ORR 
Overall response rate 
OS 
Overall survival 
PB 
Peripheral blood 
PBMC 
Peripheral blood mononuclear cell 
PD 
Progressive disease 
PI 
Principal investigator 
PR 
Partial response (Partial remission) 
PSA 
Prostate-specific antigen 
QASMC 
Quality Assurance and Safety Monitoring Committee 
RAEB 
Refractory anemia with excess blasts 
RAEB-t 
Refractory anemia with excess blasts in transformation 
RARS 
Refractory anemia with ringed sideroblasts 
RBC 
Red blood cell (count) 
RECIST 
Response Evaluation Criteria in Solid Tumors (Committee) 
RFS 
Relapse free survival 
RR 
Response rate 
SAE 
Serious adverse event 
SCC 
Siteman Cancer Center 
SCT 
Stem cell transplant 
SD 
Stable disease 
TF 
Treatment failure 
TPP 
Therapeutics Product Programme 

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TRAIL 
TNF-related apoptosis-inducing ligand 
TSH 
Thyroid stimulating hormone 
TTP 
Time to progression 
UPN 
Unique patient number 
US 
Ultrasound 
WBC 
White blood cell (count) 
FCBP 
Females of child bearing potential 
WHO 
World Health Organization 
 
 

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Table of Contents 
 
SCHEMA ................................................................................................................................... 5 
1.0 
BACKGROUND AND RATIONALE ................................................................................13 
 
Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) .....................13 
 
Therapeutic Use of HLA-Haploidentical NK Cells ........................................................14 
 
Study Rationale ..........................................................................................................14 
 
Correlative Studies Background ..................................................................................19 
2.0 
OBJECTIVES .................................................................................................................20 
 
Primary Objective........................................................................................................20 
 
Secondary Objectives .................................................................................................20 
 
Correlative Objectives .................................................................................................21 
3.0 
PATIENT SELECTION ...................................................................................................21 
 
Inclusion Criteria .........................................................................................................21 
 
Exclusion Criteria ........................................................................................................23 
 
Inclusion of Women and Minorities .............................................................................23 
4.0 
REGISTRATION PROCEDURES ...................................................................................23 
 
Confirmation of Patient Eligibility .................................................................................24 
 
Patient Registration in the Siteman Cancer Center OnCore Database ........................24 
 
Assignment of UPN .....................................................................................................24 
5.0 
TREATMENT PLAN .......................................................................................................24 
 
Overall Treatment Plan ...............................................................................................24 
 
Definition of MTD, DLT, Dose Escalation Criteria, and Evaluability .............................26 
6.0 
STUDY TREATMENT ....................................................................................................29 
 
Lymphodepleting Preparative Regimen ......................................................................29 
 
Donor Leukapheresis ..................................................................................................30 
 
Preparation of CIML NK Cells and Product Release Criteria .......................................30 
 
CIML NK Cell Product Infusion ...................................................................................31 
 
Interleukin-2 (IL-2) – Phase I, Phase II/IL-2, and Pediatric Cohorts .............................31 
 
ALT-803 – Lead-in Cohort and Phase II/ALT-803 ONLY .............................................32 
 
Vascular Leak Syndrome ............................................................................................33 
 
Prolonged Marrow Suppression ..................................................................................33 
 
Treatment Failure/Progressive Disease ......................................................................33 
 Allogeneic Transplantation ..........................................................................................34 
 Prohibited Medications ................................................................................................34 
 Women of Childbearing Potential ................................................................................34 
 Duration of Therapy ....................................................................................................34 
 Duration of Follow-up ..................................................................................................35 
7.0 
PHARMACEUTICAL INFORMATION .............................................................................35 
 
Fludarabine .................................................................................................................35 
 
Cyclophosphamide .....................................................................................................36 
 
Interleukin-2 ................................................................................................................37 
 
ALT-803 ......................................................................................................................39 
8.0 
CORRELATIVE STUDIES ..............................................................................................41 
 
Sample Collection .......................................................................................................41 
 
Sample Handling ........................................................................................................42 
 
Sample Processing .....................................................................................................43 
 
Planned Correlative Studies ........................................................................................43 
9.0 
STUDY CALENDAR .......................................................................................................44 
10.0 
REGULATORY AND REPORTING REQUIREMENTS ...............................................45 

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 Sponsor-Investigator Reporting Requirements ............................................................45 
11.0 
DATA AND SAFETY MONITORING ...........................................................................47 
12.0 
DATA SUBMISSION SCHEDULE ...............................................................................47 
 Adverse Event Collection in the Case Report Forms ...................................................48 
13.0 
EFFICACY ASSESSMENT .........................................................................................49 
 Percentage of Myeloid Blasts in the Bone Marrow ......................................................49 
 Blood Counts ..............................................................................................................49 
 Response for AML patients .........................................................................................49 
 Response for MDS patients – Phase I ONLY ..............................................................50 
 Duration of remission (DOR) .......................................................................................52 
 Time to Progression (TTP) ..........................................................................................52 
 Disease-Free Survival (DFS) ......................................................................................52 
 Overall Survival (OS) ..................................................................................................52 
14.0 
AUDITING ..................................................................................................................52 
15.0 
STATISTICAL CONSIDERATIONS ............................................................................53 
 Statistical Design and Sample Size .............................................................................53 
 Final Data Analysis Plan .............................................................................................54 
 Toxicity Monitoring ......................................................................................................55 
 Replacement of Patients .............................................................................................57 
16.0 
MULTICENTER REGULATORY REQUIREMENTS ....................................................58 
17.0 
REFERENCES ...........................................................................................................59 
APPENDIX A: Karnofsky/Lansky Performance Status ..............................................................62 
APPENDIX B: Calucation of creatinine clearance .....................................................................63 
Cockcroft-Gault Formula ...........................................................................................................63 
APPENDIX C: European Leukemia Net Risk Classification for AML .........................................64 
*Three or more chromosome abnormalities in the absence of one or more of the following, 
t(15;17), t(8;21), inv(16) or t(16;16), t(9;11), t(v;11)(v;q23), t(6;9), inv(3) or t(3;3); .....................64 
APPENDIX D: Definitions for Adverse Event Reporting ............................................................65 
APPENDIX E: Reporting Timelines ...........................................................................................67 
 
 
 

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1.0 
BACKGROUND AND RATIONALE 
 
 
Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) 
 
Acute myeloid leukemia (AML) is one of the most common hematologic malignancies, with 
an estimated prevalence of 3.8 cases per 100,000.1 AML is primarily a disease of older 
adults, with two-thirds of the new cases occurring in patients > 60 years old.2 In older AML 
patients, the 5 year disease-free survival (DFS) is extremely poor at 10-20%.3,4,5,6 These 
suboptimal outcomes in older AML patients are related to a combination of unfavorable 
biologic characteristics of the leukemia, comorbidities, poor performance status, or organ 
dysfunction that limits aggressive treatment options.5 In addition to age, genetic alterations 
in the leukemic cells strongly influence the outcomes of AML patients with current 
treatment regimens.5 The standard chemotherapy-based treatment regimens for AML 
patients involve an initial 7+3 (ara-C for 7 days and 3 days of idarubicin or daunorubicin) 
to achieve a complete remission (CR). While up to 75% of AML patients under the age of 
60 years achieve CR following intensive treatment regimens, the CR rates are only in the 
range of 40-50% in older AML patients with the intensive induction regimens.5 Similarly, 
only around 50% of the young and 39% of the elderly AML patients in poor prognostic 
groups are able to achieve a CR with the current intensive induction regimens.5 The 
median overall survival (OS) for patients not achieving a CR is <1 year, even with best 
palliative treatment.  Nearly all AML patients treated only with induction chemotherapy 
relapse.7 For younger patients, standard post-induction consolidation chemotherapy 
includes 3-4 cycles of high dose cytarabine (good or intermediate risk) or an allogeneic 
stem cell transplant (poor risk or intermediate with a sibling donor).   Questions remain 
about the best approach for consolidation therapy in the older AML patients, which is 
required to for long-term DFS. Unfortunately, a fair number of patients who go on to 
receive consolidation chemotherapy ultimately relapse. The prognosis of the patients who 
relapse after the consolidation therapies is extremely poor, especially if the relapse occurs 
in first 6 months of the consolidation therapy. Re-induction followed by allogeneic stem 
cell transplantation is the most common regimen used for refractory or relapsed AML 
patients. However, many of these patients are not eligible for such an intensive treatment. 
For those patients with refractory or relapsed AML ineligible for an allogeneic transplant, 
no approved or standard treatments are available, and therefore there is an urgent need 
for the development of novel therapies/treatments for this patient population.   
 
The majority of AML patients who initially attain a CR will eventually relapse.8 The 
prognosis of the relapsed AML patients also remains poor unless the AML is defined by 
core-binding factor translocations.8 While allogeneic HCT provides a potentially curative 
option for the relapsed AML patients, the post HCT survival is extremely poor unless the 
patients are able to achieve complete remission prior to undergoing transplantation.9,10 
Commonly used salvage regimens aimed at achieving a CR in relapsed patients include 
CLAG (cladribine, cytarabine and G-CSF), MEC (mitoxantrone, etoposide and cytarabine) 
and FLAG-IDA (fludarabine, cytarabine, G-CSF and idarubicin) with remission rates in the 
range of 30-35% in patients who relapse ≤18 months after their first CR.11,12,13,14,15 This 
underscores an unmet need for developing more effective therapeutic options aimed at 
achieving better CR rates in relapsed AML patients.  
 
Myeloid dysplastic syndromes (MDS) are clonal neoplastic disorders involving one or 
more myeloid lineage cells. MDS patients without treatment often progress to acute 
myeloid leukemia and currently hypomethylating agents including azacytidine and 
decitabine are the only class of medications which have demonstrated some clinical 

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efficacy in these patients (lenalidomide is effective in a small subset of MDS patients with 
a specific cytogenetic abnormality, 5q-). However, MDS patients who have failed and/or 
progressed while on hypomethylating agents have very limited treatment options. Even 
with hematopoietic cell transplantation, the outcomes are suboptimal in MDS patients with 
pre-transplant high blast counts, underscoring an urgent need for developing more 
effective treatment options for these patients. NK cells have activity against myeloid 
malignant cells and therefore use of CIML NK cells, which have demonstrated even more 
potent activity against leukemia, are an attractive option to explore in MDS patients who 
have failed and/or progressed on hypomethylating agents. They would also be an 
attractive option for MDS patients with high blast percentage and serve as a bridge to 
hematopoietic cell transplantation. 
 
This study evaluates a novel CIML NK cell therapy for AML or MDS patients in the phase 
I portion and patients with relapsed AML in the phase II portion. 
 
 
Therapeutic Use of HLA-Haploidentical NK Cells  
 
Natural killer (NK) cells are lymphocytes important for host defense against infection and 
malignant tumor cells.16,17 Traditionally, NK cells have been categorized as innate 
effectors because they use germline-encoded activating and inhibitory NK and cytokine 
receptors to orchestrate their rapid proliferative and functional (i.e., IFN-γ production and 
cytotoxicity) responses.18 Their effector function is governed by a complex balance of 
activating and inhibitory signals transferred via several classes of receptors, a number of 
which recognize “self” MHC class I antigens.18,19  Self-tolerance is mediated by inhibitory 
killer immunoglobulin-like (KIR) and other receptors which transmit signals that interrupt 
the cytotoxic pathway upon binding of their cognate class I HLA ligands.  The loss of KIR-
ligand expression by infected or malignant targets renders them susceptible to NK cell 
killing, particularly when the targets also present ligands for activating receptors. NK cells, 
which can be easily isolated in high quantity from donor leukapheresis products, do not 
cause but may protect against graft vs. host disease (GVHD).20,21  Thus NK cells are an 
attractive cell population to exploit for anti-tumor immunotherapy. Using haplo-identical 
donors to enhance the chances of KIR-ligand mismatch, several clinical studies have been 
successfully completed to date using NK cells for patients with hematologic and non-
hematologic malignancies.22,23,24 None of these studies have reported GVHD or any other 
major toxicity from the NK cells transferred adoptively into these patients. Further, some 
of these early NK cell-based adoptive studies have reported leukemia clearance and 
complete remissions. Miller et al reported CR induction in 5 out of 19 refractory AML 
patients.22 Similarly, in another study none of the AML patients who were adoptively 
transferred with haplo-identical NK cells relapsed with a median follow-up of 964 days, 
and the 2-year event-free survival estimate was 100%.23 
 
 
Study Rationale 
 
1.3.1 Rationale for the use of CIML NK cells 
 
Although the results of the initial studies involving adoptive transfer of the HLA-
haploidentical NK cells into patients with AML resulted in CRs, approaches using 
conventional NK cells appear limited by short duration CRs occurring in a minority 
of AML patients. We have recently identified cytokine-induced memory-like (CIML) 
NK cells, which exhibit enhanced responses against leukemia target cells and 
upon cytokine restimulation25,26. Further, murine CIML NK cells exhibit similar 

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functional properties25 and have demonstrated markedly enhanced tumor control 
in a pre-clinical mouse model involving lymphoma and melanoma cell lines.27 
These findings are promising and can be translated to the clinic. We propose using 
established NK cell adoptive immunotherapy platforms, and in addition an 
overnight pre-activation with rhIL-12, rhIL-18, and rhIL-15 to generate CIML NK 
cells. Based on the above in vitro and pre-clinical mouse model findings, we 
hypothesize that upon adoptive transfer these CIML NK cells will maintain 
enhanced effector functions and will also have an increased proliferation and more 
durable persistence in the recipient. 
 
We have also seen an increased expression of CD25 resulting in a high affinity IL-
2Rαβγ on the human CIML NK cells (unpublished data). This increased CD25 
makes the CIML NK cells amenable to further expansion and activation with low 
dose IL-2.  Early studies utilizing daily IL-2 administration for 14 days found high 
rates of constitutional symptoms; therefore, every other day administration was 
adopted and will be used in this study.22  Further, IL-2 at a dose of 1x106 IU was 
well tolerated in a recently published study and therefore all the patients in this 
study will be treated at the same dose in phase I.20 
 
Recently, we have performed and published additional pre-clinical studies that 
support the use of CIML NK cells in AML therapy.  This study demonstrated that 
CIML NK cells have 1) enhanced IFN-γ and TNF responses to primary AML blasts, 
2) enhanced expression of granzyme B and killing of leukemia targets, 3) respond 
to primary AML blasts regardless of inhibitory KIR engagement, 4) improved in 
vivo control of human leukemia engrafted in to immunodeficient NSG mice, 
compared to conventional NK cells.28 In addition, other laboratories have recently 
shown enhanced anti-tumor control by murine and human IL-12/15/18 pre-
activated NK cells.29 
 
Based on these properties, we hypothesized that the adoptive transfer of 
allogeneic CIML NK cells into AML patients would have a potent GvL effect and 
induce remission in the patients with otherwise extremely poor prognosis.  As 
toxicity of CIML NK infusion may be dose dependent, we proposed to test three 
dose levels of CIML NK cells: 0.5 x 106 cells/kg, 1.0 x 106 cells/kg, and maximum 
cell dose (between 2.0 x 106 cells/kg and 10 x 106 cells/kg).  The starting dose 
level was chosen as approximately 1/10 to 1/20 of prior conventional NK cell 
studies, due to initial caution regarding the potential for cytokine release syndrome 
(CRS).  No CRS has been observed in the dose-escalation cohort. 
 
In the phase II and pediatric patients, we intend to use maximal tolerated or tested 
(MT/TD) CIML NK cell dose as determined from the phase I part of this study.  
 
1.3.2 Lymphodepleting Preparative Regimen  
 
Most of the current adoptive immunotherapy trials involve a lymphodepleting 
condition prior to the infusion of the NK cells. 22,21 This is based on the experience 
from multiple studies in the past involving the use of lymphokine-activated killer 
(LAK) cells (prepared by ex vivo stimulation of peripheral blood mononuclear with 
IL-2) to treat immune-sensitive malignancies like melanoma and renal cell cancer. 
In these studies, limited clinical benefit was observed due to the poor expansion 
of the adoptively transferred cells. We now understand that there is limited 

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expansion as host lymphocytes compete with infused cells for access to cytokines 
and other growth factors critically needed by the adoptively transferred 
lymphocytes. Based on these observations, successful expansion of the 
adoptively transferred cell requires adequate prior lymphodepletion in order to 
‘clear space’ for the infused cells. In our study, we chose a lymphodepleting 
regimen consisting of 5 doses of fludarabine at 25mg/m2 and 2 doses of 
cyclophosphamide at 60mg/kg for adults. This regimen is adapted from the one 
used by Rosenberg’s group at NIH and has been associated with successful 
therapy of refractory melanoma patients with adoptive transfer of cytokine 
activated tumor infiltrating T cells. For the Pediatric cohort, lymphodepleting 
therapy will be 4 doses of fludarabine at 30 mg/m2 and 2 doses of 
cyclophosphamide at 500 mg/m2.  This regimen has been used successfully prior 
to infusion of chimeric antigen receptor T cells to treat pediatric patients with 
relapsed leukemia.  
 
1.3.3 Rationale for Replacing IL-2 with ALT-803 in the Phase II Part of the 
Trial 
 
The rationale for using IL-2 and ALT-803 is to support the donor derived NK cells 
in vivo after adoptive transfer. Interleukin-15 (IL-15) is a cytokine and growth factor 
capable of expanding activated T cells and NK cells. By broad consensus, the NCI 
Immunotherapy Workshop (2007) ranked IL-15 as the #1 agent with “high potential 
for immunotherapy”.30 Recombinant human IL-15 (rhIL-15) has a short half-life and 
therefore needs to be giving as a continuous IV infusion or by daily subcutaneous 
injections.31 Another potential hurdle in incorporating rhIL-15 into clinical protocols 
is the limited availability of this cytokine as currently there are no commercial 
sources of clinical grade IL-15 available. 
 
ALT-803 is a novel drug developed by Altor BioScience Corporation (Altor, 
Miramar, FL), to overcome many of the biologic, regulatory, and commercial 
limitations of unmodified rhIL-15. Under physiologic circumstances, IL-15 and IL-
15 receptor-alpha (IL-15Rα) are coordinately expressed by antigen-presenting 
cells (i.e., monocytes and dendritic cells).32 To induce a signal, IL-15 bound to IL-
15Rα is presented ‘in trans’ to neighboring NK cells or CD8+ T cells expressing 
only the IL-2/15βγ receptor, resulting in multiple signals that trigger survival, 
proliferation, metabolic fitness, and cytotoxic capacity.  At the immunologic 
synapse, IL15 trans-presentation appears to be a dominant mechanism for IL-15 
action in vivo, providing tight physiologic control over the functions of IL-15 under 
homeostatic conditions and in response to immune stimuli.33 ALT-803 is a novel 
recombinant 
human 
super-agonist 
IL-15 
complex 
(i.e., 
IL-15N72D:IL- 
15RαSu/IgG1 Fc complex) with a prolonged serum half-life in preclinical animal 
models. In addition, ALT-803 contains a novel IL-15 mutein with a single 
substituted amino acid (rhIL-15N72D) that has a 4-fold increase in biologic activity 
greater than wild-type IL-15 (IL-15 wt).34 The IL- 15:IL-15R complex increases 
activity at lower concentrations, and the fusion with Ig-G1 Fc increases serum half-
life, providing more ideal pharmacokinetics with prolonged cytokine function.35 
 
Because of the availability, ease of delivery (regular subcutaneous injections), 
prolonged half-life and potentially higher efficacy, ALT-803 is currently being 
studied in several ongoing clinical trials including three studies at our center 
including in patients that have relapsed after an allogeneic HCT (Clinicatrial.gov # 

Amendment 19, 03/11/20 
 
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NCT01885897, NCT02099539, NCT02384954). In the study NCT01885897 where 
ALT-803 is used in patients relapsed after allo-HCT at 10 mcg/kg SQ, no serious 
adverse events, including GVHD, have been observed. 
 
Most of the previously published adoptive NK cell protocols (including our ongoing 
non-transplant CIML NK cell study) have used recombinant human IL-2 (rhIL-2) to 
support NK cell expansion and persistence in vivo.  Most NK cells express the 
intermediate affinity IL-2Rβ/γc heterodimer that provides the intracellular signaling 
domains and is activated by intermediate dose IL-2 or intermediate dose IL-15.  
Low dose IL-2 supports NK cells by binding to the heterotrimeric high affinity IL-2R 
comprised on IL-2Rα (CD25), IL-2/15β, γc: IL-2Rαβγ.  Our pre-clinical data 
demonstrated that CD25, and hence the IL-2Rαβγ is induced on CIML NK cells, 
providing the rationale for utilizing LD IL-2 to support CIML NK cell post-infusion.  
Correlative immunomonitoring has revealed that after in vivo transfer, CD25 is 
down-regulated within 1-3 days post transfer, indicating that IL-15 would be ideal 
for ongoing support in patients after CIML transfer.  In addition, low dose IL-2 also 
expands patient CD25+ regulatory T cells.  We therefore changed low dose rhIL-
2 to ALT-803 at 10mcg/kg on Days 0 and 5 (subcutaneous injections) for 2 doses 
starting at the day of CIML NK cell infusion.  This dose of ALT-803 has been well 
tolerated by patients who have relapsed following allogeneic HCT.36  We expect a 
similar adverse event profile as rhIL-2, and potentially improved NK cell expansion 
and persistence. IL-2, IL-15, and ALT-803 all signal through the same shared IL-
2/15Rβ/γc-chain heterodimer receptor; however, ALT-803 is simply replacing IL-2 
in our Lead-in Cohort and phase II part of the protocol to potentially provide better 
support for the growth and expansion of the adoptively transferred CIML NK cells.  
ALT-803 will not be used in the Pediatric portion of this trial. 
 
1.3.4 Rationale for Returning to IL-2 in the Phase II Part of the Trial 
 
Based on the data indicating that ALT-803/IL-15 result in more modulation of the 
NK cells in vivo, we performed a lead in cohort with ALT-803 replacing IL-2 at a 
dose of 10 mcg/kg SQ administered q5 days starting on the date of NK cell 
infusion.  The first two patients treated in the ALT-803 lead in cohort experienced 
a set of symptoms consistent with cytokine release syndrome (CRS) including 
fevers, elevated markers of inflammation between days 10-14 after ML NK cell 
infusion.  Correlative science revealed that recipient CD8 T cells were expanding 
during this period with an activated phenotype (CD38+HLA-DR+), and their 
expected allo-rejection was the likely source of the CRS (Figure 1).  With the 
concern that prolonged ALT-803 may enhance recipient CD8 T cell recovery based 
on the first-in-human ALT-803 trial, we reduced the number of ALT-803 doses from 
4 q5 days to 2 q5 days.  Despite this change, we continued to see recipient CD8 
T cell activation at day 10 post NK cell transfer and reduced the ALT-803 dose to 
a single dose on the day of infusion.  Based on the CD8 T cell activation and 
expansion, we performed PK analyses and observed ALT-803 serum levels of 
approximately 1000 pg/mL persisting 5 days after the SQ dose.  During this period, 
no patient (0 of 9) that received ALT-803 support following ML NK cell transfer 
obtained a CR or CRi, in contrast to 4 of 5 patients with active AML treated with 
similar number of ML NK cells in the rhIL-2 dose expansion of the Phase 1 part of 
the study.   
 

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To test our hypothesis that ALT-803 was promoting recipient allo-rejection of donor 
NK cells and thereby limiting the NK cell’s anti-leukemia efficacy, we performed in 
vitro experiments.  Peripheral blood mononuclear cells (PBMC) were stimulated in 
a mixed lymphocyte reaction (MLR) in the presence of IL-2 (standard control 
conditions) or with IL-2 plus ALT-803.  The stimulator cells were ML NK cells from 
an allogeneic source, to mimic the immune responses occurring within patients on 
the trial.  This revealed that the presence of ALT-803 resulted in more rapid and 
robust CD8 T cell proliferation in this MLR, supporting the idea that ALT-803 was 
enhancing CD8 T cell responses to ML NK cells.  We also used the day 11 
stimulated PBMC as effectors in a cytotoxicity assay, with the targets being the 
stimulating ML NK cells, and observed selective, MHC Class I-dependent killing of 
the allogeneic ML NK cells, only in the presence of ALT-803 (Figure 2).  
Concurrently, data from an independent allogeneic NK cell adoptive therapy trial 
being performed at the University of Minnesota showed a similar lack of efficacy 
(0 of 10 patients achieving a CR or CRi, compared to 30% CR/CRi rate when rhIL-
2 was used following the NK cell infusion).   
 

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Based on the evidence of increased CD8 T cell activation, the in vitro data 
indicating that ALT-803 promoted recipient CD8 T cell expansion and killing of 
donor ML NK cells, and the lack of clinical responses using ALT-803, the lead in 
cohort was closed, and a decision was made to return to rhIL-2 support, mimicking 
the cytokine support utilized in the phase 2 portion of the trial.  Since this finding 
of IL-15 receptor agonists promoting recipient CD8 T cell responses against 
allogeneic donor NK cells can be generalized to any allogeneic cell therapy, we 
will report this ALT-803 support cohort to the immunotherapy community 
immediately.  The Phase 2 portion of the ML NK cell trial will proceed, with the safe 
and established rhIL-2 support from the phase 1 dose escalation. 
 
 
 
Correlative Studies Background 
 
Data from in vitro experiments, the xenograft pre-clinical mouse model, and from the initial 
9 patients treated in phase I show enhanced cytokine (IFN-γ)26 and degranulation 
response of the CIML NK cells in response to K562 leukemia targets.28 In addition, we 
have seen more robust proliferative response of the CIML NK cells in vivo. In order to 
confirm these findings upon their adoptive transfer into larger numbers of AML patients, 
we plan to analyze peripheral blood and bone marrow biopsy samples to assess the 
persistence, expansion, and sustained anti-leukemia response of the adoptively 
transferred CIML NK cells. Recent advances in mass cytometry (CyTOF) have made it 
possible to perform detailed phenotypic and functional analysis of the immune cells 
including NK cells.37  Our initial experience using CyTOF has revealed a unique 
multidimensional phenotype of CIML NK cells and we hope to be able to utilize this 

Amendment 19, 03/11/20 
 
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information to better characterize the CIML NK cells especially after adoptive transfer into 
patients.28 
 
IL-12/15/18 pre-activated NK cells actively produce IFN-γ and other pro-inflammatory 
cytokines, and thus monitoring of serum cytokine concentrations will be included to assess 
for any systemic cytokine release. In the context of allogeneic SCT, maximum clinical 
benefit from NK cells has been previously reported in the patients with KIR-ligand 
mistmatch.22,20 The KIR typing of the donor NK cells and HLA typing of the recipient will 
be done to see whether there is a beneficial effect of KIR to KIR ligand mismatch after the 
adoptive transferred of haplo-identical CIML NK cells. Several studies have also shown a 
favorable effect of donor KIR B haplotype and KIR B haplotype content scoring on the risk 
of relapse after matched donor SCT.38,39 All donors in the study will have KIR typing 
performed along with assessment of KIR B haplotype score to assess for any relationship 
with the responses in the patients treated on this study. 
 
While mechanisms whereby AML cells may evade or resist NK cell surveillance have been 
described, few studies have evaluated mechanisms following NK cell adoptive 
immunotherapy.  Through identification of barriers to effective memory-like NK cell 
leukemia response, future clinical strategies may be developed to overcome these 
resistance mechanisms.  Here, we will also use mass cytometry and candidate 
approaches to investigate NK cell resistance mechanisms, including CIML NK cell 
inhibitory and activating receptors, their ligands on AML blasts and in the BM 
microenvironment, 
and 
populations 
of 
regulatory 
cells 
present 
in 
the 
BM 
microenvironment. 
 
Some of the major advances in understanding AML biology including the possible 
mechanisms for relapse and clonal progression have come from next generational 
sequencing studies.40,41 We will collect samples to perform exome sequencing of AML 
blasts prior to therapy, during remissions, and after relapse post CIML NK cell infusion. 
Furthermore, samples for immune gene expression profiling (using RNAseq) will be 
collected to help further characterize the AML microenvironment pre-therapy, at the time 
of remission, and at the time of relapse. 
 
 
2.0 
OBJECTIVES 
 
 
Primary Objective 
 
Phase I: To determine the maximal tolerated or tested dose (MT/TD) of CIML NK cells 
administered to AML and MDS patients. 
 
Phase II: To determine the complete remission rate (CR/CRi) in patients with relapsed or 
refractory AML following CIML NK therapy. 
 
Pediatric Cohort:  To determine the safety of CIML NK cells administered to pediatric AML 
patients. 
 
 
Secondary Objectives 
 
1. To determine the safety of the CIML-NK cells adoptively transferred into AML and 
MDS patients (phases I and II). 

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2. To determine the response of CIML NK cell therapy in AML and MDS patients (phases 
I,II, and pediatric). 
3. To determine the duration of remission, time to progression, disease-free survival, and 
overall survival of AML and MDS patients treated with CIML NK cells (phases I, II, and 
pediatric). 
 
 
Correlative Objectives 
 
1. To evaluate the number, phenotype, KIR mismatch status, and function of CIML NK 
cells following adoptive transfer, as well as serum cytokines (phase I). 
2. To define the percentage and number of CIML NK cells present in the peripheral blood 
and correlate with CR/CRi rate.  
3. To define the percentage and number of peripheral blood IFN-γ+ CIML NK cells after 
ex vivo leukemia re-stimulation and correlate with CR/CRi rate. 
4. To determine the phenotype, proliferation, and function of in vivo expanded CIML NK 
cells in the PB and BM utilizing mass cytometry. 
5. To define potential CIML NK cell resistance factors, and the AML microenvironment 
pre-therapy, after CIML NK cell therapy, and at the time of relapse using mass 
cytometry and immune profiles (RNAseq). 
6. To define the changes in recurrent somatic mutations in AML pre-therapy, at day 30 
after CIML using next-generation sequencing. 
 
 
3.0 
PATIENT SELECTION 
 
 
Inclusion Criteria 
 
1. Diagnosis requirement for phase I patients: 
Refractory AML without complete remission (CR) after induction therapy (primary 
induction failure) or relapsed AML after obtaining a CR. 
 
OR 
 
High-risk AML (by ELN criteria; See Appendix C) in complete remission (CR) and has 
either refused hematopoietic stem cell transplantation OR is currently not eligible for 
hematopoietic stem cell transplantation OR for whom hematopoietic stem cell 
transplantation is being reserved for later relapse. This is inclusive of patients with 
minimal residual disease evidenced by cytogenetics, molecular testing, and/or flow 
cytometry.  
 
OR 
 
Myelodysplastic syndrome (MDS) with excess blasts (>5%) and progressive disease 
(see section 12.4) at any time after initiation of DNA hypomethylator treatment during 
the past 2 years, OR failure to achieve complete or partial response or hematological 
improvement (see section 12.4) after at least six cycles of azacytidine or four cycles 
of decitabine administered during the past 2 years, OR intolerance to azacytidine or 
decitabine.  MDS patients with isolated 5q- abnormalities that meet these criteria after 
lenalidomide therapy and DNA hypomethylator therapy are also eligible. 
 

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Diagnosis requirement for phase II patients: 
Refractory AML without CR after induction therapy (primary induction failure) or 
relapsed AML after obtaining a CR.  Favorable-risk core binding factor (CBF) mutated 
AML and acute promyelocytic leukemia (APL) will be excluded. 
 
Diagnosis requirement for pediatric cohort patients: 
Refractory AML without complete remission (CR) after induction therapy (primary 
induction failure) or relapsed AML after obtaining a CR. 
 
2. Age requirement for phase I and phase II patients: At least 18 years of age. 
3. Age requirement for pediatric cohort: 1-17 years of age. 
 
4. Available HLA-haploidentical donor that meets the following criteria: 
 
a. Related donor (parent, sibling, offspring, or offspring of sibling) 
b. At least 18 years of age 
c. HLA-haploidentical donor/recipient match by at least Class I serologic typing at the 
A&B locus.  
d. In general good health, and medically able to tolerate leukapheresis required for 
harvesting the NK cells for this study. 
e. Negative for hepatitis, HTLV, and HIV on donor viral screen 
f. Not pregnant 
g. Voluntary written consent to participate in this study 
 
5. Patients with known CNS involvement with AML are eligible provided that they have 
been treated and CSF is clear for at least 2 weeks prior to enrollment into the study. 
CNS therapy (chemotherapy or radiation) should continue as medically indicated 
during the study treatment. 
 
6. Karnofsky/Lansky performance status > 50 % (see Appendix A). 
 
7. Adequate organ function as defined below: 
a. Total bilirubin < 2 mg/dL  
b. AST(SGOT)/ALT(SGPT) < 3.0 x ULN 
c. Creatinine within normal institutional limits OR creatinine clearance > 50 
mL/min/1.73 m2 by Cockcroft-Gault Formula (adults) or Schwartz formula 
(pediatric cohort) (See Appendix B) 
d. Oxygen saturation ≥90% on room air 
e. Ejection fraction ≥35% 
 
8. Able to be off corticosteroids and any other immune suppressive medications 
beginning on Day -3 and continuing until 30 days after the infusion of the CIML NK 
cells. However, use of low-level corticosteroids is permitted if deemed medically 
necessary. Low-level corticosteroid use is defined as 10mg or less of prednisone (or 
equivalent for other steroids) per day.  
 
9. Women of childbearing potential must have a negative pregnancy test within 28 days 
prior to study registration. Female and male patients (along with their female partners) 
must agree to use two forms of acceptable contraception, including one barrier 
method, during participation in the study and throughout the DLT evaluation period. 
 

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10. Ability to understand and willingness to sign an IRB approved written informed consent 
document (or that of legally authorized representative, if applicable). 
 
 
Exclusion Criteria 
 
1. Relapsed after allogeneic transplantation. 
 
2. Isolated extramedullary relapse (phase II only). 
 
3. More than one course of salvage chemotherapy for primary induction failure or AML 
relapsing after CR1 (phase II only). 
 
4. Circulating blast count >30,000/µL by morphology or flow cytometry (cytoreductive 
therapies including leukapheresis or hydroxyurea are allowed). 
 
5. Uncontrolled bacterial or viral infections, or known HIV, Hepatitis B or C infection. 
 
6. Uncontrolled angina, severe uncontrolled ventricular arrhythmias, or EKG suggestive 
of acute ischemia or active conduction system abnormalities. 
 
7. New progressive pulmonary infiltrates on screening chest x-ray or chest CT scan that 
have not been evaluated with bronchoscopy. Infiltrates attributed to infection must be 
stable/ improving after 1 week of appropriate therapy (4 weeks for presumed or proven 
fungal infections). 
 
8. Known hypersensitivity to one or more of the study agents. 
 
9. Received any investigational drugs within the 14 days prior to the first dose of 
fludarabine. 
 
10. Pregnant and/or breastfeeding. 
 
 
Inclusion of Women and Minorities 
 
Both men and women and members of all races and ethnic groups are eligible for this trial.   
 
 
4.0 
REGISTRATION PROCEDURES 
 
Patients must not start any protocol intervention prior to registration through the Siteman 
Cancer Center. 
 
The following steps must be taken before registering patients to this study: 
 
1. Confirmation of patient eligibility by Washington University 
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
 
Once the patient has been entered in the Siteman Cancer Center OnCore database, the WUSM 
coordinator will forward verification of enrollment and the UPN via email. 
 

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Confirmation of Patient Eligibility 
 
Confirm patient eligibility by collecting the information listed below and scanning and 
emailing it to the research coordinator listed in the Siteman Cancer Center Clinical Trials 
Core Protocol Procedures for Secondary Sites packet at least one business day prior to 
registering patient: 
 
1. Your name and contact information (telephone number, fax number, and email 
address) 
2. Your site PI’s name, the registering MD’s name, and your institution name 
3. Patient’s race, sex, and DOB 
4. Three letters (or two letters and a dash) for the patient’s initials 
5. Current approved protocol version date 
6. Copy of signed consent form (patient name may be blacked out) 
7. Planned date of enrollment 
8. Completed eligibility checklist, signed and dated by a member of the study team 
9. Copy of appropriate source documentation confirming patient eligibility 
 
 
Patient Registration in the Siteman Cancer Center OnCore Database 
 
Registrations may be submitted Monday through Friday between 8am and 5pm CT. 
Urgent late afternoon or early morning enrollments should be planned in advance and 
coordinated with the Washington University research coordinator.  Registration will be 
confirmed by the research coordinator or his/her delegate by email within one business 
day. Verification of eligibility and registration should be kept in the patient chart. 
 
All patients at all sites must be registered through the Siteman Cancer Center OnCore 
database at Washington University. 
  
 
Assignment of UPN 
 
Each patient will be identified with a unique patient number (UPN) for this study. Patients 
will also be identified by first, middle, and last initials.  If the patient has no middle initial, a 
dash will be used on the case report forms (CRFs).  All data will be recorded with this 
identification number on the appropriate CRFs. 
 
 
5.0 
TREATMENT PLAN 
 
 
Overall Treatment Plan 
 
5.1.1 Phase I Treatment Plan 
 
The recipient will begin a lymphodepleting preparative regimen of fludarabine and 
cyclophosphamide on Day -6.  The haploidentical donor identified by HLA 
matching of the immediate family members will undergo non-mobilized large 
volume (20-L) leukapheresis on Day -1, and the NK cell product will be infused into 
the recipient on Day 0.  Subcutaneous IL-2 will begin approximately 2-4 hours after 
infusion and will continue every other day through Day 12 for a total of 7 doses. 
Dose escalation will proceed as described in Section 5.3.3. The interval between 
enrollments of consecutive subjects within the first treatment level 1 will be 35 

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days, to allow a complete assessment of safety events within the DLT assessment 
period, based on the safety profile of prior NK cell therapy studies.  Subsequently, 
dose levels 2 and 3 will not require a staggered enrollment of consecutive subjects.  
However, to escalate to the next dose level, all patients enrolled at the lower dose 
level must complete their 35-day DLT assessment. 
 
5.1.2 Lead-in Cohort and Phase II/ALT-803 Treatment Plan 
 
The recipient will begin a lymphodepleting preparative regimen of fludarabine and 
cyclophosphamide on Day -6.  The haploidentical donor identified by HLA 
matching of the immediate family members will undergo non-mobilized large 
volume (20-L) leukapheresis on Day -1, and the NK cell product will be infused into 
the recipient on Day 0.  Subcutaneous ALT-803 (10 mcg/kg) will begin 
approximately 4 hours after the infusion and will continue for a total of 2 doses 
(Days 0 and 5).   
 
ALT-803 dose modifications are listed in Section 5.3.6. 
 
5.1.3 Phase II/IL-2 Treatment Plan 
 
The recipient will begin a lymphodepleting preparative regimen of fludarabine and 
cyclophosphamide on Day -6.  The haploidentical donor identified by HLA 
matching of the immediate family members will undergo non-mobilized large 
volume (20-L) leukapheresis on Day -1, and the NK cell product will be infused into 
the recipient on Day 0.  Subcutaneous IL-2 will begin approximately 2-4 hours after 
infusion and will continue every other day through Day 12 for a total of 7 doses. 
 
 
5.1.4 Pediatric Cohort 
 
The recipient will begin a lymphodepleting preparative regimen of fludarabine 
and cyclophosphamide on Day -6.  The haploidentical donor identified by HLA 
matching of the immediate family members will undergo non-mobilized large 
volume (20-L) leukapheresis on Day -1, and the NK cell product will be infused 
into the recipient on Day 0.  CIML NK cells will be infused at maximum cell dose 
of 10 x 106/kg.  Subcutaneous IL-2 will begin approximately 2-4 hours after 
infusion and will continue every other day through Day 12 for a total of 7 doses. 
 
5.1.5 Dose Escalation of CIML NK Cells (Phase I) 
 
CIML NK Cell Dose Escalation Schedule 
Dose Level 
CIML NK cell dose 
Level 1 (starting dose) 
0.5 x 106/kg  
Level 2 
1.0 x 106/kg 
Level 3 
Maximum NK cell number/kg* 
*All CIML NK cells available from the donor leukapheresis, NK cell purification, and CIML 
process will be infused, up to a maximum of 10x106/kg. 
 
The median number of CIML NK cells collected from each donor is expected to be 5.0 x 
106 cells/kg to 10 x 106 cells/kg.  If less than the targeted CIML NK cell numbers are 

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available (≥2.0 x 106 cells/kg for dose level 3), then all cells (after quality control testing) 
should be given and the therapy plan will remain the same. These patients will be 
considered not evaluable for DLT assessment at the intended dose level, and they will be 
replaced with an additional patient at the intended dose level. Any patient that receives 
CIML NK cells will be included in the safety analyses at the dose level received.  If more 
than the targeted number of CIML NK cells are available, then the patient will only receive 
the cell dose assigned, and all additional cells will be used for correlative studies. 
 
Dose escalation will not occur until all patients in the cohort have completed the DLT 
evaluation (35 days) and the Principal Investigator has been able to review all toxicities.  
Dose escalations will proceed until the MTD has been reached or until dose level 3 has 
been completed. 
 
After determining the maximal tolerated / tested dose (MT/TD) in phase I, the phase II 
portion of the study will be initiated using the MTD CIML NK cell dose. 
 
 
Definition of MTD, DLT, Dose Escalation Criteria, and Evaluability 
 
5.2.1 Definition of Maximum Tolerated or Tested Dose (MT/TD) 
 
The maximum tolerated dose of the CIML NK cells is defined as the dose level 
immediately below the dose level at which 2 patients of a cohort (of 2 to 6 patients) 
experience dose-limiting toxicity or the maximum dose if ≤ 1 patient suffers a DLT 
at the maximum dose.  If these criteria are met at the maximum proposed dose, 
this will be defined as the maximum tested dose. 
 
5.2.2 Dose Limiting Toxicities (DLTs) 
 
Non-Hematologic dose limiting toxicities (DLT) are defined as any CTCAE grade 
3 or higher non-hematologic adverse event considered possibly, probably, or 
definitely related to CIML NK cell infusion. Non-clinically significant metabolic 
adverse events (abnormalities in serum sodium, potassium, chloride, magnesium, 
calcium, phosphorous, blood urea nitrogen, and glucose that last less than 48 
hours that respond to appropriate medical therapy) will not be considered DLTs 
regardless of CTCAE grade. The observation period for DLTs is 35 days following 
the CIML NK cells.  
 
Hematologic dose limiting toxicity is defined as failure to recover hematopoiesis 
(ANC > 500/µL) by Day 35 post-CIML NK cell infusion. Hematologic AEs related 
to persistent disease/disease relapse or other causes will not be considered DLTs. 
A standard bone marrow biopsy will be performed at Day 28 post-infusion, which 
will determine if persistent disease/relapse is the cause of persistent bone marrow 
suppression. Patients with clinical progression of their AML or MDS after CIML NK 
cell infusion may receive cytoreductive therapy (e.g., hydroxyurea, cytarabine) to 
control their disease and remain evaluable for DLTs throughout the DLT period.  
Any AE that is probably or definitely related to cytoreductive therapy would not be 
considered a DLT. 
 
Since GVHD and late onset bone marrow suppression may be related to CIML NK 
cells, additional stopping rules are included for safety (see Section 5.3.4).  
 

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5.2.3 Dose Escalation Criteria 
 
Dose escalations in the phase I part will proceed as follows: 
 
Number of Patients with a DLT at 
a Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter 3 patients at the next dose level. 
≥ 2 
Dose escalation will be stopped.  Three 
additional patients will be entered at the next 
lowest dose level if only 3 patients were treated 
previously at that dose. 
1 out of 3 
Enter at least 3 more patients at this dose level. 
 
If 0 of these 3 patients experience DLT, proceed 
to the next dose level. 
 
If 1 or more of this group suffer DLT, then dose 
escalation is stopped.  Three additional patients 
will be entered at the next lowest dose level if 
only 3 patients were treated previously at that 
dose. 
≤ 1 out of 6 at highest dose level 
below the maximally administered 
dose or the maximally administered 
dose if < 2 patients suffer a DLT at 
this dose level 
This is generally the recommended phase II 
dose.  At least 6 patients must be entered at the 
recommended phase II dose prior to its 
opening. 
 
5.2.4 Additional Stopping Rules 
 
Allogeneic NK cells following fludarabine-cyclophosphamide chemotherapy have 
been administered to a large number of patients without these events occurring; 
however, there exists theoretical risks for CIML NK cells that will be monitored. 
The following additional stopping events are defined to assess for these later 
events (potentially related to allogeneic NK cells), which will be assessed while the 
patient remains on study.   
 
1. Development of neutrophil suppression (ANC < 500/µL) between Day 35 
and Day 100 in the absence of disease recurrence or other causes. 
2. Grade II-IV acute GVHD involving the liver, skin, or GI tract within 100 days 
after the NK cell infusion even in any of the patients treated on study 
3. Extensive chronic GVHD involving any of the organ systems and occurring 
in any of the patients after infusion of the CIML NK cells. 
 
If any of the late stopping events listed above occurs (while the patients are on 
study and have not received additional AML therapy) at an estimated frequency of 
≥25% (separate events), accrual will be suspended and reviewed for safety of 
continuation.     
 
5.2.5 Toxicity and Response Evaluations 
 
All patients who receive any study treatment are evaluable for toxicity.  Patients 
are evaluated from first receiving study treatment through 100 days after the 
conclusion of treatment or death for toxicity evaluation. 

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Page 28 of 69 
 
 
All patients who receive a CIML NK cell infusion and at least 4 doses of IL-2 or 1 
dose of ALT-803, and who undergo a Day 28 bone marrow biopsy for response 
assessment, are evaluable for disease response. 
 
5.2.6 ALT-803 Dose Modifications and Stopping Rules for Toxicity 
 
If one or more of the three patients treated in the Lead-in Cohort develops any 
unexpected grade ≥3 adverse events at least possibly related to the use of ALT-
803 or any of the stopping rules (listed above in Section 5.3.4) is met, the dose of 
ALT-803 will be de-escalated to 6 mcg/kg and three patients will be treated at that 
dose. The study will be suspended if any of the three patients in the lead-in cohort 
treated with de-escalated dose (6 mcg/kg) ALT-803 develop any unexpected grade 
≥3 adverse events at least possibly related to the use of ALT-803 and / or any of 
the stopping rules is met. Otherwise, enrollment to the phase II part of the study 
will be initiated.  The dose of ALT-803 used in phase II will be 2 doses at 10 mcg/kg 
if de-escalation has not been required or 2 doses at 6mcg/kg if de-escalation was 
required.  Furthermore, the ALT-803 dose will be de-escalated to 6mcg/kg if any 
of the patients treated on the phase II part of the study develop any unexpected 
grade ≥3 adverse events at least possibly related to the use of ALT-803 or any of 
stopping rules (listed above in Section 5.3.4) is met. The study will be suspended 
if any of the patients treated at the de-escalated dose in phase II develop any of 
these criteria.  
 
ALT-803 has been associated with rash around the area of injection, which may 
occur up to 7-10 days after the initial injection. For localized rashes (involving 
<25% of the body surface), subsequent doses of ALT-803 will not be held. 
However, if the rash involves ≥50% of the body surface area, subsequent doses 
of ALT-803 will be delayed until the rash improves significantly (as determined by 
the treating physician) in addition to supportive care measures (as described in 
Section 6.6.1).  ALT-803 may be delayed for up to 96 hours due to injection 
reaction rash.  If > 96-hour delay is required, the dose will be skipped. 
 
Delay the scheduled study treatment one week each for up to 2 weeks for the 
following events until a recovery is sufficient to resume study treatment; otherwise, 
discontinue study treatment: 
• 
Elevated post-treatment creatinine to such that calculated GFR is < 40 
mL/min 
• 
Febrile neutropenia 
• 
Thrombocytopenia with bleeding or anemia 
• 
ALC ≥ 50,000/µL or total WBC ≥ 60,000/µL 
• 
Systolic hypotension < grade 3 that does not correct with bolus fluids over 
6 hours 
 
Skipped doses of ALT-803 will not be made up. 
 
Discontinue treatment with ALT-803 if a patient experiences any grade 3 event 
that is not clearly unrelated to ALT-803 administration that does not resolve to 
grade 1 or lower within a week despite the use of medical intervention or any grade 
4 event with the following exceptions: 

Amendment 19, 03/11/20 
 
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• 
Grade 3 or 4 lymphopenia, leukopenia, or neutropenia that recovers within 
14 days 
• 
Grade 3 or 4 thrombocytopenia or anemia that recovers within 14 days 
• 
Nausea or vomiting that is controllable with antiemetics within 72 hours 
• 
Hypotension of grade 3 that persists for < 4 hours and does not require 
hospitalization (unless admission is precautionary) 
 
Additional events that require ALT-803 discontinuation are: 
• 
Arrhythmia of any kind 
• 
ALC ≥ 50,000/µL sustained for 14 days 
• 
WBC ≥ 60,000/µL sustained for 14 days 
• 
Idiosyncratic drug reaction that prevents further administration of treatment 
• 
Grade 2 allergic reaction with bronchospasm or any grade 3 or 4 allergic / 
infusion-related reaction 
 
5.2.7 ALT-803 Dose Modifications for Biologic Outcomes 
 
In the lead-in cohort of patients treated with the Phase II schedule of ALT-803, 
correlatives studies revealed shorter persistence of donor CIML NK cells than 
was observed in Phase I patients who were treated with low dose rhIL-2.  This 
coincided with increased activation of recipient CD8+ T cells, suggesting that 
multiple doses of ALT-803 may be enhancing donor NK cell rejection. Such a 
decrement in CIML NK cell exposure is expected to decrease the efficacy of the 
study treatment, provided by the anti-leukemia activity of the donor CIML NK 
cells.  Based on recent data of the PK of ALT-803 administered SQ, we expect 
that the multiple doses of ALT-803 persist into the early recipient T cell recovery 
period, and promote early recipient T cell activation.  Thus, ALT-803’s impact on 
recipient T cells is probably responsible for the observed decline in donor CIML 
NK cell activity in the lead in portion of the phase 2 cohort.   
 
In order to improve persistence and anti-leukemia “window of opportunity” for the 
donor CIML NK cells, the dosing of ALT-803 will be decreased to one dose on 
day 0.  .  If CIML NK cell persistence appear limited or early recipient T cell 
activation  occurs on the modified ALT-803 schedule, compared to the rhIL-2 
dose level 3 of the phase 1, ALT-803 treatment will be discontinued, and Phase II 
patients will instead be treated with IL-2 after day 0, per the Phase I schedule. 
 
6.0 
STUDY TREATMENT 
 
 
Lymphodepleting Preparative Regimen 
 
Patients will receive a lymphodepleting regimen consisting of 5 doses of fludarabine at 
25mg/m2 and 2 doses of cyclophosphamide at 60mg/kg as follows: 
 
 
Day 
Therapy 
-6 
Fludarabine 
-5 
Fludarabine 
Cyclophosphamide 
-4 
Fludarabine 

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Cyclophosphamide 
-3 
Fludarabine 
-2 
Fludarabine 
 
Dose and/or schedule adjustments consistent with the standard of care may be made on 
an individual patient basis as needed for safety. 
 
Patients should receive allopurinol daily, unless contraindicated, beginning day -6 prior to 
chemotherapy start and continuing until day +7 or as clinically indicated.  Additional tumor 
lysis prophylaxis or treatment (IVF, rasburicase, etc.) may be administered as clinically 
indicated. 
 
Patients should receive standard antiviral and antibacterial prophylaxis as per institutional 
guidelines. 
 
6.1.1 Fludarabine  
 
Fludarabine is administered at a dose of 25 mg/m2 as a one-hour IV infusion once 
a day for 5 doses beginning on Day -6. Administration should follow institutional 
guidelines. 
 
6.1.2 Cyclophosphamide 
 
Cyclophosphamide is administered at a dose of 60 mg/kg as a 2-hour IV infusion 
on Days -5 and -4. Administration should follow institutional guidelines.  
 
 
 
Donor Leukapheresis 
 
On Day -1 (one day before the planned NK cell infusion), peripheral blood cells will be 
collected by a single apheresis from the haploidentical related donor. The collection should 
take place over 5 hours.42  The apheresis procedure will be done as per standard 
institutional procedures (which may include placement of a central line if necessary). If the 
goal minimum NK cell dose will not be met based on the initial assessment of the 
leukapheresis product, a second collection/procedure may be performed. The donor’s 
central line will remain placed until it is confirmed that a second collection is not required.  
 
 
Preparation of CIML NK Cells and Product Release Criteria 
 
Cell product processing is performed at the Siteman Cancer Center Biological Therapy 
Core.  The apheresis product will undergo NK cell purification with the CliniMACS® device 
(Miltenyi) by sequential depletion of CD3+ T cells and positive selection of CD56+ (CD3-
/CD56+) NK cells.  
 
The purified NK cells are cultured for 12-18 hours in X-VIVO 15 media containing rhIL-12 
(10 ng/mL), rhIL-15 (50 ng/mL) and rhIL-18 (50 ng/mL). After incubation, the cells are 
washed two times in a cytokine-free media solution to remove the cytokines. After the last 
wash, the final resuspension will be used to determine the final NK cell numbers prior to 
infusion.  
 

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The appropriate predetermined NK cell dose (0.5x106/kg, 1x106/kg, or Max NK capped at 
10x106/kg) will be used for infusion in the phase I part of the study. The final T cell (CD3+) 
cell dose in the infusion product has to be less than 3 x 105 CD3+/kg of the recipient. 
 
For phase II and pediatric cohort, MT/TD CIML NK cell dose will be infused into the 
relapsed patients (max dose is 10 x 106/kg).   
 
CIML NK cell Product Lot Release 
Assay 
Test method 
Value 
Viability 
7-AAD, flow cytometry 
≥70% 
NK cell (CD56+CD3-) 
flow cytometry 
≥70% 
T cell (CD3+) 
flow cytometry 
<3.0 x105 T cells/kg 
Endotoxin 
LAL method 
< 5.0 EU/kg 
Gram stain 
Clinical micro 
No organisms 
 
 
CIML NK Cell Product Infusion 
 
The CIML NK cells are infused on Day 0 without a filter or pump, slowly by gravity over at 
least 15 minutes.  Flush tubing on completion of the CIML NK cells with normal saline to 
ensure all of the cells are infused.  
 
Patients are pre-medicated with acetaminophen 650 mg PO (15 mg/kg with max of 650 
mg PO for pediatric patients) and/or diphenhydramine 25 mg PO/IV (1 mg/kg with max of 
25 mg for pediatric patients) within 1 hour before and 4 hours after the NK cell infusion.  
Demerol may be given for chills/rigors during the NK cell infusion. Intravenous hydration 
may be administered per institutional guidelines.    
 
Vital signs should be obtained before the CIML NK cell infusion, every 15 minutes during 
the infusion, and then every 30 minutes x 2. Additional vitals may be done consistent with 
the institutional guideline or as needed for safety. 
 
Patients will be monitored for signs of acute reactions to the allogeneic NK cell infusion, 
including acute hemolytic reactions (back pain, facial flushing, fever/chills, chest pain, 
dyspnea, headache, shock), febrile non-hemolytic reactions (fever/chills), allergic 
reactions (urticaria, wheezing, facial edema), anaphylaxis (signs of autonomic 
dysregulation, 
severe 
dyspnea, 
pulmonary/laryngeal 
edema, 
bronchospasm 
/ 
laryngospasm, 
hypotension), 
and 
transfusion-related 
acute 
lung 
injury 
(TRALI).  Treatment of these reactions will follow standard institutional practice, and 
therapy decisions will be made by the treating physician.  If severe reactions or 
anaphylaxis, the CIML NK cell infusion will be discontinued, and medical therapy will 
include intravenous antihistamines, epinephrine, and corticosteroids, and the use of 
cardiac-respiratory support measures as needed. 
 
CIML NK cells are expected to produce IFN-γ for 16-24 hours after NK cell infusion. 
Expected constitutional toxicities from IFN-γ include myalgias, arthralgias, fever, and 
rigors. IFN-γ therapy has been safely used in patients with idiopathic pulmonary fibrosis 
and chronic granulomatous disease (CGD)43,44. The most common side effects seen in 
those patients were fevers, headache, chills, rash, vomiting, and diarrhea.  
 
 
Interleukin-2 (IL-2) – Phase I, Phase II/IL-2, and Pediatric Cohorts 

Amendment 19, 03/11/20 
 
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IL-2 will start approximately 4 hours after the CIML NK cell infusion.  
 
If the patient experienced a severe acute reaction during the CIML NK cell infusion, IL-2 
should be held until the toxicity resolves to grade 2 or better. IL-2 may be started if the 
toxicity resolves to grade two or better within 72 hours of CIML NK cell infusion. Missed 
doses of IL-2 will not be made up.  
 
If IL-2 cannot be started within 72 hours after the CIML NK cell infusion, no IL-2 will be 
given and the patient will be replaced for statistical analysis. 
 
6.5.1 IL-2 administration   
 
IL-2 will be administered subcutaneously at a dose of 1 million units/m2 every other 
day from Day 0 to Day +12 (7 doses total).  IL-2 will be dosed using actual body 
weight, with BSA capped at 2.2m2 to ensure that only one vial of IL-2 is used per 
patient. 
 
Patients should be pre-medicated with acetaminophen 650 mg PO (15 mg/kg with 
max of 650 mg PO for pediatric patients) and/or diphenhydramine 25 mg PO/IV (1 
mg/kg with max of 25 mg for pediatric patients) within 1 hour before and 4 hours 
after IL-2 administration.    
 
Patients should be monitored for IL-2 related targeted toxicities.  Fevers, rash, and 
myalgias are expected, and should be treated supportively.   
 
6.5.2 IL-2 Dose Modifications 
 
The development of any grade 3 or higher adverse event possibly, probably or 
definitely related to IL-2 will result in a modification of the planned IL-2 treatment. 
 
Grade 3 toxicity: if the toxicity resolves to grade 2 or better within 48 hours, IL-2 
can be resumed at a reduced dose (0.5 million units/m2). If the toxicity persists 
beyond 48 hours, or worsens or recurs after re-challenging with reduced dose, IL-
2 will be permanently discontinued. 
 
 
Grade 4 toxicity: permanently discontinue IL-2. 
 
Additionally, if a patient cannot tolerate full dose IL-2 due to fevers, rash, 
constitutional symptoms, etc. that are possibly, probably or definitely related to IL-
2 but do not meet grade 3 or 4 criteria, a dose decrease to 0.5 million units/m2 is 
allowed at the discretion of the investigator.    
 
 
ALT-803 – Lead-in Cohort and Phase II/ALT-803 ONLY 
        
ALT-803 will start approximately 4 hours after the CIML NK cell infusion. 
 
If the patient experienced a severe acute reaction during the CIML NK cell infusion, ALT-
803 should be held until the toxicity resolves to grade 2 or better. ALT-803 may be started 
if the toxicity resolves to grade to or better within 96 hours of CIML NK cell infusion. Missed 
doses of ALT-803 will not be made up.  

Amendment 19, 03/11/20 
 
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If ALT-803 cannot be started within 96 hours after the CIML NK cell infusion, no ALT-803 
will be given and the patient will be replaced for statistical analysis of the primary objective.  
 
6.6.1 ALT-803 Administration 
 
ALT-803 will be administered subcutaneously at the dose and schedule 
determined during the lead-in (please refer to Section 5.3.6). 
 
Patients should be pre-medicated with acetaminophen 650 mg PO and/or 
diphenhydramine 25 mg PO/IV within 1 hour before and 4 hours after ALT-803 
administration.  
 
Patients should be monitored for ALT-803 related targeted toxicities. Fevers, rash, 
and myalgias are expected, and should be treated supportively.  
 
ALT-803 has been associated with rash around the area of injection, which may 
occur up to 7-10 days after the initial injection. For localized rashes (involving 
<25% of the body surface) the patients will be treated with topical steroids creams 
(e.g., triamcinolone cream) along with oral Benadryl. For these localized rashes 
subsequent doses of ALT-803 will not be held. However, if the rash involves ≥50% 
of the body surface area then in addition to the topical steroid cream and other 
supportive cares subsequent doses of ALT-803 will be delayed until the rash 
improves significantly (as determined by the treating physician).  ALT-803 may be 
delayed for up to 96 hours due to injection reaction rash. 
 
 
Vascular Leak Syndrome 
 
The administration of allogeneic NK cells and IL-2 administration has not been associated 
with vascular leak syndrome in previous published studies.  Nevertheless, patients will be 
monitored for weight gain (by weights at least 3 times per week) and pulmonary edema 
during IL-2 administration. 
 
 
Prolonged Marrow Suppression 
 
Cyclophosphamide and fludarabine are expected to cause transient marrow suppression 
(less than 2 weeks).  CIML NK cells infusion may induce bone marrow suppression at later 
time points, and therefore, as a precaution, patients’ hematologic recovery will be 
assessed through day 100 (see Sections 5.3.2 and 5.3.4). 
 
 
Treatment Failure/Progressive Disease 
 
CIML NK cells may require days to weeks to clear AML blasts, unlike traditional cytotoxic 
chemotherapy.  The presence of AML blasts at Day 14 would not constitute a reason for 
removal from the protocol unless deemed necessary by the treating physician. 
Cytoreductive therapy (e.g., hydroxyurea, cytarabine) may be used to control disease 
during the DLT period as described in Section 5.3.2. at the discretion of the treating 
physician.  Patients who fail to clear AML blasts at the Day 28 bone marrow assessment 
or with persistent circulating blasts at Day 28 would be considered a treatment 
failure/progressive disease and should be started on other anti-leukemia therapies at the 
discretion of the treating physician. Patients who receive other anti-leukemia therapy after 

Amendment 19, 03/11/20 
 
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the DLT period will be considered off study and no future follow up visits are required other 
than annual survival visits. 
 
 
Allogeneic Transplantation 
 
Patients who are found to be in remission or who have cleared the AML blasts on Day 28 
marrow are allowed to proceed to an allogeneic transplant at the discretion of the treating 
physician. Patients who proceed to allogeneic transplant will be considered off study and 
no future follow up visits are required other than annual survival visits.  The patients’ 
medical records will be reviewed to collect data on relapse and survival. 
 
 
Prohibited Medications 
 
The only prohibited medications are systemic corticosteroids or other immune suppressive 
medications. These must be avoided beginning on Day -3 and continuing until 30 days 
after the infusion of the CIML NK cells. However, corticosteroids are allowed if deemed 
medically necessary and up to 25 mg of IV hydrocortisone may be administered in a 24-
hour time period if medically indicated for a drug or transfusion reaction. 
 
G-CSF or GM-CSF are not to be routinely used in the first two weeks after the CIML NK 
cell infusion but are allowed if deemed medically necessary by the treating physician. 
 
All medications other than those listed above may be used to treat or prevent toxicity as 
per institutional guidelines. 
 
 
Women of Childbearing Potential 
 
Women of childbearing potential (defined as women with regular menses, women with 
amenorrhea, women with irregular cycles, women using a contraceptive method that 
precludes withdrawal bleeding, or women who have had a tubal ligation) are required to 
have a negative urine pregnancy test within 28 days prior to the first dose of fludarabine.   
 
Female and male patients (along with their female partners) are required to use two forms 
of acceptable contraception, including one barrier method, during participation in the study 
and throughout the DLT evaluation period.  
 
If a patient is suspected to be pregnant, the treatment should be immediately discontinued.  
In addition, a positive urine test must be confirmed by a serum pregnancy test.  If it is 
confirmed that the patient is not pregnant, the patient may resume dosing. 
 
If a female patient or female partner of a male patient becomes pregnant during therapy 
or within 30 days after the first dose of fludarabine, the investigator must be notified in 
order to facilitate outcome follow-up. 
 
 
Duration of Therapy 
 
If at any time the constraints of this protocol are considered to be detrimental to the 
patient’s health and/or the patient no longer wishes to continue protocol therapy, the 
protocol therapy should be discontinued and the reason(s) for discontinuation 
documented in the case report forms. 
 

Amendment 19, 03/11/20 
 
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In the absence of treatment delays due to adverse events, treatment may continue till the 
last dose of IL-2 or ALT-803 or until one of the following criteria applies: 
 
• 
Death 
• 
Adverse event(s) that, in the judgment of the investigator, may cause severe or 
permanent harm or which rule out continuation of study drugs 
• 
General or specific changes in the patient’s condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
• 
Suspected pregnancy 
• 
Serious noncompliance with the study protocol 
• 
Patient withdraws consent 
• 
Investigator removes the patient from study 
• 
The Siteman Cancer Center decides to close the study 
 
Patients who prematurely discontinue treatment for any reason will be followed as 
indicated in the study calendar. 
 
 
Duration of Follow-up 
 
After completion of the CIML NK cell therapy, patients will be followed in the clinic for up 
to 12 months. After 12 months, patients will be followed annually for survival and relapse. 
Patients who proceed to other anti-leukemic therapy or allogeneic transplant will be 
considered off study and no future follow up visits are required other than annual survival 
visits.  Patients removed from study for unacceptable adverse events will be followed until 
resolution or stabilization of the adverse event.   
 
 
7.0 
PHARMACEUTICAL INFORMATION 
 
 
Fludarabine 
 
7.1.1 Description 
 
The chemical name for fludarabine phosphate is 9H-Purin-6-amine, 2-fluoro-9-(5-
0-phosphono-β-D-arabino-furanosyl) (2-fluoro-ara-AMP).  The molecular formula 
of fludarabine phosphate is C10H13FN5O7P.  Its molecular weight is 365.2  
 
7.1.2 Dose Forms and Strengths 
 
Fludarabine is supplied as a white, lyophilized solid cake. Each vial contains 50 
mg of fludarabine phosphate, 50 mg of mannitol, and sodium hydroxide to adjust 
pH to 7.7. The pH range for the final product is 7.2-8.2. 
  
Fludarabine is supplied in a clear glass single dose vial (6mL capacity) and 
packaged in a single dose vial carton in a shelf pack of five. 
 
7.1.3 Storage and Stability 
 
Store under refrigeration, between 2º-8ºC (36º-46ºF). 
 

Amendment 19, 03/11/20 
 
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7.1.4 Availability 
 
Commercially available by prescription  
 
7.1.5 Preparation 
 
Preparation should follow institutional guidelines. 
 
7.1.6 Administration 
 
Please see Section 6.1.1. 
 
7.1.7 Warnings and Precautions 
 
• 
Life-threatening and sometimes fatal autoimmune phenomena such as 
hemolytic anemia, autoimmune thrombocytopenia/thrombocytopenic purpura 
(ITP), Evan’s syndrome, and acquired hemophilia have been reported to occur 
in patients receiving fludarabine 
• 
Serious, and sometimes fatal infections, including opportunistic infections and 
reactivations of latent viral infections such as VZV (Herpes zoster), Epstein-
Barr virus and JC virus (progressive multifocal leukoencephalopathy)) have 
been reported in patients treated with fludarabine. 
• 
Objective weakness, agitation, confusion, seizures, visual disturbances, optic 
neuritis, optic neuropathy, blindness and coma have occurred in CLL patients 
treated with fludarabine at the recommended dose. 
• 
High doses of fludarabine have been associated with an irreversible central 
nervous system toxicity characterized by delayed blindness, coma and death. 
High doses are also associated with severe thrombocytopenia and neutropenia 
due to bone marrow suppression. There is no known specific antidote for 
fludarabine overdose. 
• 
The use of fludarabine in combination with pentostatin is not recommended 
due to the risk of severe pulmonary toxicity. 
• 
Pregnancy Category D 
 
 
Cyclophosphamide 
 
7.2.1 Description 
 
Cyclophosphamide is a white crystalline powder with the molecular formula 
C7H15Cl2N2P·H2O and a molecular weight of 279.1.  The chemical name for 
cyclophosphamide 
is 
2-[bis(2-chloroethyl)amino]tetrahydro-2H-1,3,2-
oxazaphosphorine 2-oxide monohydrate. 
 
7.2.2 Mechanism of Action 
 
Cyclophosphamide is classed as an alkylating agent of the nitrogen mustard type. 
An activated form of cyclophosphamide, phosphoramide mustard, alkylates or 
binds with many intracellular molecular structures, including nucleic acids. Its 
cytotoxic action is primarily due to cross-linking of strands of DNA and RNA, as 
well as to inhibition of protein synthesis. 

Amendment 19, 03/11/20 
 
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7.2.3 Dose Forms and Strengths 
 
Cyclophosphamide is commercially available for parenteral injection as 100 mg, 
200 mg, 500 mg, 1 g, and 2 g vials 
 
7.2.4 Storage and Stability 
 
Unopened vials of cyclophosphamide are stable until the date indicated on the 
package when stored at or below 25°C (77°F). 
 
7.2.5 Availability 
 
Commercially available by prescription  
 
7.2.6 Preparation 
 
Preparation should follow institutional guidelines. 
 
7.2.7 Administration 
 
Please see Section 6.1.2. 
 
7.2.8 Warnings and Precautions 
 
• 
To reduce the risk of hemorrhagic cystitis, Mesna and adequate hydration 
should be administered per institutional guidelines 
• 
Pregnancy Category D 
 
 
Interleukin-2 
 
7.3.1 Mechanism of Action 
 
• 
Systemic: Aldesleukin has been shown to possess the biological activity of 
human native interleukin-2. In vitro studies performed on human cell lines 
demonstrate the immunoregulatory properties of aldesleukin, including:  
o 
Enhancement of lymphocyte mitogenesis and stimulation of long-term 
growth of human interleukin-2 dependent cell lines;  
o 
Enhancement of lymphocyte toxicity;  
o 
Induction of killer cell (lymphokine-activated killer [LAK] cells and natural 
killer [NK] cells) activity; and  
o 
Induction of interferon-gamma production.  
• 
The in vivo administration of aldesleukin in select murine tumor models and in 
the clinic produces multiple immunological effects in a dose-dependent 
manner. These effects include activation of cellular immunity with profound 
lymphocytosis, eosinophilia, and thrombocytopenia, and the production of 
cytokines, including tumor necrosis factor, interleukin-1 and gamma interferon. 
In vivo experiments in murine tumor models have shown inhibition of tumor 
growth. However, the exact mechanism by which aldesleukin mediates its 
antitumor activity in animals and humans is unknown.  
• 
Aldesleukin causes a capillary leak syndrome (CLS) as a result of increased 

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capillary permeability, leading to extravasation of plasma proteins and fluid into 
the extravascular space and contributing to loss of vascular resistance. 
Interleukin-2 has been reported to reversibly decrease serum cholesterol 
concentrations. Interleukin-2 has been reported to transiently decrease serum 
testosterone and dihydroepiandrosterone concentrations and to transiently 
increase plasma estradiol concentrations. It has also been reported to 
transiently increase adrenal secretion of ACTH and cortisol. 
 
7.3.2 Dose Forms and Strengths 
 
Lyophilized vials containing 22 million units 
 
7.3.3 Availability 
 
IL-2 will be provided to patients free of charge by the study.  The PI will obtain IL-
2 from commercial sources. 
 
7.3.4 Preparation 
 
Reconstitute each IL-2 vial with 1.2mL sterile water for injection. Prepare diluent 
of 5% Dextrose with 0.1% albumin by adding 0.1mL of 25% albumin to 24.9mL 
D5W. Add 1.2mL of the 0.1% albumin in 5% dextrose diluent to the previously 
reconstituted IL-2 vial to yield a final concentration of 9 MIU/mL. Individual doses 
should be drawn into 1mL syringes and kept refrigerated at 2-8°C. Prepared 
syringes should be used within 14 days of vial reconstitution.    
 
Any IL-2 that is not utilized for injection into a patient will be stored at 2-8oC and 
provided to the Fehniger Lab for use in correlative studies. 
 
7.3.5 Administration 
 
Please see Section 6.5. 
 
7.3.6 Warnings and Precautions 
 
• 
patients with a history of cardiac disease exhibiting a normal thallium stress 
test 
• 
patients with a history of pulmonary disease exhibiting normal pulmonary 
function tests 
• 
severe hypotension (due to capillary leak syndrome) 
• 
impaired neutrophil function (reduced chemotaxis) 
• 
increased risk of disseminated infection 
• 
kidney and liver function impairment (avoid concurrent administration with 
nephrotoxic or hepatotoxic drugs) 
• 
mental status changes 
• 
exacerbation of preexisting autoimmune diseases or initial presentation of 
autoimmune and inflammatory disorders 
• 
may increase the risk of allograft rejection in transplant patients (due to 
enhancement of cellular immune function) 
• 
cardiac, pulmonary, renal, hepatic, or central nervous system impairment 

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• 
patients with a history of seizures 
• 
Pregnancy Category C 
 
Most toxicities have been described at high doses of IL-2 often used in the 
treatment of patients with renal cancer and metastatic melanoma. To decrease the 
chances of these side effects we have chosen a low dose of 1 million units/m2, 
which has been given safely and without major adverse events.23,45  This dose is 
below the MTD established in a pediatric study of subcutaneous IL-246.  In addition, 
the combination of IL-2 plus CIML NK cells may have a risk of capillary leak 
syndrome (CLS). 
 
 
ALT-803 
 
ALT-803 is a recombinant human super-agonist IL-15 complex. Its active ingredient is 
ALT-803 and its pharmacologic class is as a targeted anticancer immunotherapeutic. ALT-
803 has been referred to as IL-15N72D:IL-15RαSu/IgG1 Fc complex in various preclinical 
study reports, publications, and other related documents.  
 
7.4.1 Formulation and Composition  
 
The biological drug product, ALT-803, is formulated in a phosphate buffered saline 
solution. The drug substance is produced by a recombinant mammalian cell line 
and is manufactured without the use of animal derived components. The vialed 
quantitative composition of ALT- 803 is listed in the table below.  
 
7.4.2 Quantitative Composition of ALT-803  
 
PBS Formulation: Sodium Chloride (USP) 8.18 g/L; Sodium Phosphate Dibasic 
(USP) 2.68 g/L; Potassium Phosphate Monobasic (NF) 1.36 g/L pH 7.4.  
 
7.4.3 Structural Formula  
 
ALT-803 is a soluble complex consisting of 2 protein subunits of a human IL-15 
variant associated with high affinity to a dimeric IL-15R sushi domain/human IgG1 
Fc fusion protein. The IL-15 variant is a 114 aa polypeptide comprising the mature 
human IL-15 cytokine sequence with an Asn to Asp substitution at position 72 of 
helix C (N72D).6. The human IL-15R sushi domain/human IgG1 Fc fusion protein 
comprises the sushi domain of the IL-15R subunit (aa 1-65 of the mature human 
IL-15Rα protein) linked with the human IgG1 CH2-CH3 region containing the Fc 
domain (232 amino acids). Aside from the N72D substitution, all of the protein 
sequences are human. Based on the amino acid sequence of the subunits, 
calculated molecular weight of the complex comprising 2 IL- 15N72D polypeptides 
and a disulfide linked homodimeric IL-15RαSu/IgG1 Fc protein is 92.4 kDa. Each 
IL-15N72D polypeptide has a calculated molecular weight of approximately 12.8 
kDa and the IL-15RαSu/IgG1 Fc fusion protein has a calculated molecular weight 
of approximately 33.4 kDA. 
 
Component  
Concentration  
Amount/Vial  
ALT-803  
2 mg/mL  
0.6 mg  
 

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Both the IL-15N72D and IL-15RαSu/IgG1 Fc proteins are glycosylated resulting in 
an apparent molecular weight of ALT-803 as approximately 114 kDa by size 
exclusion chromatography. The isoelectric point (pI) determined for ALT-803 range 
from approximately 5.6 to 6.5. Thus, the fusion protein is negatively charged at pH 
7. The calculated molar extinction coefficient at A280 for ALT-803 is 116,540 M-1, 
or 1.26 OD280 for a 1 mg/mL solution of ALT-801, or one OD280 is equivalent to 
0.79 mg/mL solution of ALT-803.  
 
7.4.4 Storage and Handling  
 
Study medication is provided in a 2 mL vial containing 0.6 mL of ALT-803 at a 
concentration of 2 mg/mL. Vials are packaged in cartons and shipped to the clinical 
site. Study medication must be maintained at a temperature between 2°C and 8°C.  
 
7.4.5 Stability  
 
Stability studies are ongoing and will be continued throughout the clinical study. 
Based on previous lots, the study drug is expected to be stable for at least 2 years. 
The site will be periodically updated on the stability of the drug and will be 
immediately informed if there is evidence that the drug no longer meets its stability 
specifications.  
 
7.4.6 Agent Ordering and Agent Accountability  
 
ALT-803 is produced in the USA by Altor Biosciences Corporation, Miramar, FL. 
After manufacturing, the product is stored at Altor Biosciences Corporation for 
clinical supply, packaging, and labeling. The label indicates the product name, 
strength, manufacturing date, and the study requirement information. ALT-803 will 
be shipped from Altor Biosciences Corporation. 
 
7.4.7 Preparation and Administration  
 
ALT-803 dose calculation will be based on actual body weight. The calculated 
amount of ALT-803 will be drawn into a syringe for subcutaneous injection. The 
stock concentration is 2 mg/mL; withdraw the appropriate volume of ALT-803 for 
the calculated dose into a syringe. If the total subcutaneous dose is greater than 
1.5 mL, the dose will be divided into 2-3 subcutaneous injections as needed.  
 
Please follow the formula below to determine the volume of ALT-803 needed for a 
subcutaneous injection:  
 
ALT-803 Volume Needed = (______ µg/kg  x    ________  kg) ÷ 2000 µg/mL 
(ALT-803 vial concentration) 
 
7.4.8 Toxicity 
 
ALT-803 can cause many side effects, which may be similar to the side effects 
of interleukin-2 (IL-2), which has been used for more than 20 years. 
 
Most likely (greater than 
Less likely (3% to 10% - 1 Rarely (< 3% - 1 in 30 

Amendment 19, 03/11/20 
 
Page 41 of 69 
 
10% - 1 in 10 patients)  
in 30 to 1 in 10 patients)  
patients)  
 
•  Weight gain with swelling 
of hands and feet due to 
fluid retention  
• Feeling tired or short of 
breath due to a low red 
blood count (anemia)  
• Increase in blood pressure  
• Flu-like symptoms such as 
fever, chills, shaking, 
headache, stiffness, aching 
muscles and joints  
• Increased risk of infection 
due to a low white blood 
count  
• Increased risk of bruising 
and bleeding due to a low 
platelet count 
 
 
• Heart problems - causing 
low blood pressure, 
dizziness, chest pain or 
changes in heart rhythm 
(heart beat)  
• Pain and redness at the 
injection site  
• Changes in liver and kidney 
function as detected on 
routine blood tests  
• Cough and shortness of 
breath  
• Mouth sores  
• Confusion, sleepiness and 
depression especially in older 
persons or persons with a 
history of depression  
 
 
• Allergic reaction  
• Temporary thinning of 
hair 
 
 
 
8.0 
CORRELATIVE STUDIES 
 
 
Sample Collection 
 
• 
The volume of PB collected in sodium heparin tubes for immunomonitoring will 
depend upon the patient age and weight.  For patients aged ≥ 18 years, 60 mL of 
PB will be collected.  For patients aged 1-17 years, the following volumes will be 
collected based on weight: 
o <20 kg, 10 mL 
o 20-60 kg, 30mL 
o >60 kg, 60 mL 
 
• 
The appropriate amount of peripheral blood (as described above) will be collected 
in sodium heparin (green top) tube(s) at the following time points: 
 
Screening* 
 
Day 0 prior to the CIML NK cell infusion 
 
Day 1 
 
Day 3 
 
Day 7 
 
Day 8 
 
Day 10 
 
Day 14 
 
Day 21 
 
Day 28 
 
Day 42 
 
Day 60 
 
Day 100 
 
6 months 
 
9 months  
 
12 months 

Amendment 19, 03/11/20 
 
Page 42 of 69 
 
 
At disease relapse 
 
*An additional ten mL of peripheral blood in sodium heparin (green top) tube(s) 
will be collected from patients ≥ 18 years at screening. 
 
• 
Ten mL of peripheral blood in serum (red top) tube(s) will be collected at the 
following time points: 
 
Screening 
 
Day 0 prior to the CIML NK cell infusion 
 
Day 1 
 
Day 3 
 
Day 7 
 
Day 8 
 
Day 10 
 
Day 14 
 
Day 21 
 
Day 28 
 
Day 42 
 
Day 60 
 
Day 100 
 
6 months 
 
9 months  
 
12 months 
 
At disease relapse 
 
• 
Additional peripheral blood samples may be collected at key clinical events, 
including suspected relapse, infection, or cytokine release syndrome. 
 
• 
Ten mL of bone marrow (2-5 mL for patients age 1-17) in sodium heparin (green 
top) tube(s) will be collected at the following time points: 
 
Screening 
 
Day 8 
 
Day 14 
 
Day 28 
 
Between Day 42 and Day 60 
 
Day 100 
 
At disease relapse 
 
• 
Additional samples for correlative studies (donor and apheresis product) 
 
30 mL of peripheral blood from donor in sodium heparin (green and pink 
top) tube(s) at screening 
 
1 mL of leukapheresis product prior to NK cell purification 
 
5 x 106 NK cells post MACS purification 
 
5 x 106 CIML NK cells prior to washing 
 
Any additional CIML NK cells not administered 
 
 
Sample Handling 
 
Specimens will be transported at room temperature immediately to the Fehniger Lab, 
Monday-Friday, 8AM-5PM.  Please notify the lab and/or Dr. Fehniger prior to submission.  

Amendment 19, 03/11/20 
 
Page 43 of 69 
 
Sample collections that are outside those hours should be directly discussed with Dr. 
Fehniger at least 72 hours in advance.  The CIML NK cell processing and final samples 
will be submitted once the final NK cell product aliquot is obtained. 
 
Attention: Fehniger Lab / Michelle Becker-Hapak or Tim Schappe 
WU-Oncology  
Southwest Tower Building Room 724/733 
500 South Kingshighway 
St. Louis, MO 63110 
Clinical Correlates Lab:  (314) 273-0153 
Research Lab: (314) 747-1547 
Secondary: (314) 747-1385 / Tertiary: (314) 510-2397 (pager) 
Fax: (314) 362-9333 
tfehnige@wustl.edu, tschappe@wustl.edu, mbecker-hapak@wustl.edu, acashen@wustl.edu 
    
 
 
Sample Processing 
 
For some assays, cells will be isolated and used immediately.  In other assays, samples 
will be isolated, cryopreserved and stored in the Fehniger Lab (6th floor southwest tower 
building) in liquid nitrogen or -70oC freezers for future batch analysis.  No PHI is included 
on the sample vials.  These samples may be stored for future research as new scientific 
findings arise in the field.  
 
 
Planned Correlative Studies 
 
1. HLA antibody identification 
2. Assessment of donor cell chimerism 
3. Lymphocyte subset and monocyte number 
4. NK cell percentage, number and immunophenotype 
5. NK cell function (degranulation, cytotoxicity, cytokine-production, proliferation, 
survival) in response to cytokine stimulation, NK cell receptor ligation, or leukemia cell 
triggering (including patient AML blasts). 
6. KIR genotype of donor 
7. Serum cytokine measurements (e.g., IFN-γ, TNF, GM-CSF) 
8. Whole genome and/or exome and/or RNA sequencing of BM or PB samples to define 
recurrent somatic mutations, clonal architecture, and gene expression profiles. 
9. Deep phenotyping of the BM or PB via mass spectrometry (CyTOF) to determine the 
potential markers of CIML NK cell response and/or resistance mechanisms. 
10. CyTOF analysis of the marrow prior to treatment, Day 30, and on relapse after CIML 
NK cell infusion to better help understand the interaction between AML blasts and 
marrow microenvironment potentially contributing to the disease response and/or 
progression after CIML NK cell infusion. 

Amendment 19, 03/11/20 
 
Page 44 of 69 
 
9.0 
STUDY CALENDAR 
 
Scheduled evaluations up to Day 35 may be performed +/-3 days from the targeted date; assessments to be performed after Day 35 may be 
done +/-7 days of the targeted date. 
 
 
Screening  
(within 28 
days of 
registration) 
Day 
0 
Day 
+1 
Day 
+3 
Day 
+7 
Day 
+8 
Day 
+10 
Day 
+14 
Day 
+21 
Day 
+28 
Day 
+35 
Day 
+42 
Day 
+60 
Day 
+100 
6, 9 and 12 
months2 
Disease 
Relapse 
Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam w/ vital signs  
X5 
 
Daily1 
X 
X 
X 
X 
X 
X 
X 
X 
Weight 
X 
 
At least 3 times a week1 
 
 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Karnofsky PS 
X11 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
 
HLA typing9 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral panel4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC, diff, plt 
X 
 
Daily1 
X 
X 
X 
X 
X 
X 
X 
X 
BUN, creat, glucose, Na, K, Cl 
X 
 
Daily1 
X 
X 
X 
X 
X 
X 
X 
X 
AST, ALT, bili, alk phos 
X 
 
Weekly1 
X 
X 
X 
X 
X 
X 
X 
X 
Correlative Studies6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
Pregnancy test7 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bone Marrow Biopsy   
X11 
 
 
 
 
X10 
 
X 
 
X 
 
X3 
X 
 
X 
Chest x-ray or chest CT scan 
X11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PFT 
X11, 12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG 
X11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echo or MUGA 
X11 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AE assessment 
 
 
AEs will be collected from Day 0 to Day +35; however, bone marrow suppression (ANC < 500/µL) 
and AEs of GVHD involving the liver, skin, or GI tract will be recorded to Day 100. 
 
 
1 – Until neutrophil recovery or as clinically appropriate 
2 – After 12 months’ formal follow-up ends, however, patients will be followed annually thereafter for disease-free survival and overall survival 
3 – Perform at a clinically appropriate time for the patient somewhere between days 42 and 60 visit 
4 – Donor- HTLV, HIV, CMV, and hepatitis panel; Recipient- HIV, CMV, and hepatitis panel 
5 – 02 Saturation on room air required at screening 
6 – See section 8.0 for required samples  
7 – For women of childbearing potential only 
8 – If donor cells are present at Day 14, recheck at subsequent visits until they are not detectable on two serial assessments. 
9 – On recipient and donor 
10 – For correlative studies only 
11 – Recipient only12—Record O2 saturation by pulse ox if patient is too young for PFTs

Amendment 19, 03/11/20 
 
Page 45 of 69 
 
10.0 
REGULATORY AND REPORTING REQUIREMENTS 
 
The entities providing oversight of safety and compliance with the protocol require reporting as 
outline below. Please refer to Appendix D for definitions and Appendix E for a grid of reporting 
timelines. 
 
 
Adverse events will be tracked from the time of CIML NK cell infusion start through 35 days 
following the infusion. Additionally, bone marrow suppression (ANC < 500/µL) and AEs of GVHD 
involving the liver, skin, or GI tract will be recorded to 100 days following the infusion. All adverse 
events must be recorded on the toxicity tracking case report form (CRF) with the exception of: 
• 
Baseline adverse events, which shall be recorded on the medical history CRF 
 
Refer to the data submission schedule in Section 12 for instructions on the collection of AEs in 
the EDC. 
 
Reporting requirements for Washington University study team may be found in Section 10.1. 
 
 
Sponsor-Investigator Reporting Requirements 
 
 
10.1.1 Reporting to the Human Research Protection Office (HRPO) at 
Washington University 
 
Reporting will be conducted in accordance with Washington University IRB 
Policies. 
 
Pre-approval of all protocol exceptions must be obtained prior to implementing the 
change. 
 
10.1.2 Reporting to the Quality Assurance and Safety Monitoring Committee 
(QASMC) at Washington University 
 
The Sponsor investigator is required to notify the QASMC of any unanticipated 
problems involving risks to participants or others occurring at WU or any BJH or 
SLCH institution that has been reported to and acknowledged by HRPO.  
(Unanticipated problems reported to HRPO and withdrawn during the review 
process need not be reported to QASMC.) 
 
QASMC must be notified within 10 days of receipt of IRB acknowledgment via 
email to qasmc@wustl.edu. Submission to QASMC must include the myIRB form 
and any supporting documentation sent with the form. 
 
10.1.3 Reporting to the FDA 
 
The conduct of the study will comply with all FDA safety reporting requirements. 
PLEASE NOTE THAT REPORTING REQUIREMENTS FOR THE FDA DIFFER 
FROM REPORTING REQUIREMENTS FOR HRPO/QASMC. It is the 
responsibility of the Washington University principal investigator to report to the 
FDA as follows: 

Amendment 19, 03/11/20 
 
Page 46 of 69 
 
 
• 
Report any unexpected fatal or life-threatening suspected adverse reaction 
(refer to Appendix D) no later than 7 calendar days after initial receipt of the 
information.   
• 
Report a suspected adverse reaction that is both serious and unexpected 
(SUSAR, refer to Appendix D) no later than 15 calendar days it is determined 
that the information qualifies for reporting. Report an adverse event (Appendix 
D) as a suspected adverse reaction only if there is evidence to suggest a 
causal relationship between the drug and the adverse event, such as:   
o A single occurrence of an event that is uncommon and known to be 
strongly associated with drug exposure  
o One or more occurrences of an event that is not commonly associated 
with drug exposure but is otherwise uncommon in the population exposed 
to the drug 
o An aggregate analysis of specific events observed in a clinical trial that 
indicates those events occur more frequently in the drug treatment group 
than in a concurrent or historical control group  
• 
Report any findings from epidemiological studies, pooled analysis of multiple 
studies, or clinical studies that suggest a significant risk in humans exposed to 
the drug no later than 15 calendar days after it is determined that the 
information qualifies for reporting. 
• 
Report any findings from animal or in vitro testing that suggest significant risk 
in humans exposed to the drug no later than 15 calendar days after it is 
determined that the information qualifies for reporting.  
• 
Report any clinically important increase in the rate of a serious suspected 
adverse reaction of that listed in the protocol or IB within 15 calendar days after 
it is determined that the information qualifies for reporting. 
 
Submit each report as an IND safety report in a narrative format or on FDA Form 
3500A or in an electronic format that FDA can process, review, and archive.  Study 
teams must notify the Siteman Cancer Center Protocol Development team of each 
potentially reportable event within 1 business day after initial receipt of the 
information, and must bring the signed 1571 and FDA Form 3500A to the Siteman 
Cancer Center Protocol Development team no later than 1 business day prior to 
the due date for reporting to the FDA. 
 
Each notification to FDA must bear prominent identification of its contents (“IND 
Safety Report”) and must be transmitted to the review division in the Center for 
Drug Evaluation and Research (CDER) or in the Center for Biologics Evaluation 
and Research (CBER) that has responsibility for review of the IND.  Relevant 
follow-up information to an IND safety report must be submitted as soon as the 
information is available and must be identified as such (“Follow-up IND Safety 
Report”). 
 
10.2. Exceptions to Expedited Reporting 
 
Events that do not require expedited reporting as described in Section 7.1 include: 

Amendment 19, 03/11/20 
 
Page 47 of 69 
 
• 
planned hospitalizations 
• 
hospitalizations < 24 hours 
• 
respite care 
• 
events related to disease progression 
 
Events that do not require expedited reporting must still be captured in the EDC. 
 
11.0 
DATA AND SAFETY MONITORING 
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, the 
Principal Investigator will provide a Data and Safety Monitoring (DSM) report to the Washington 
University Quality Assurance and Safety Monitoring Committee (QASMC) semi-annually 
beginning six months after accrual has opened (if at least five patients have been enrolled) or one 
year after accrual has opened (if fewer than five patients have been enrolled at the six-month 
mark). 
 
For phase I dose escalation studies, the Principal Investigator will review all patient data at least 
every six months, and provide a semi-annual report to the QASMC. This report will include:  
 
• 
HRPO protocol number, protocol title, Principal Investigator name, data coordinator name, 
regulatory coordinator name, and statistician 
• 
Date of initial HRPO approval, date of most recent consent HRPO approval/revision, date 
of HRPO expiration, date of most recent QA audit, study status, and phase of study 
• 
History of study including summary of substantive amendments; summary of accrual 
suspensions including start/stop dates and reason; and summary of protocol exceptions, 
error, or breach of confidentiality including start/stop dates and reason 
• 
Study-wide target accrual and study-wide actual accrual 
• 
Protocol activation date  
• 
Average rate of accrual observed in year 1, year 2, and subsequent years 
• 
Expected accrual end date and accrual by cohort 
• 
Objectives of protocol with supporting data and list the number of participants who have 
met each objective 
• 
Measures of efficacy (phase I studies only if efficacy is objective of the protocol) 
• 
Measures of efficacy – provide a summary of tissue samples collected by site, tissue 
expected to obtain, % of tissue received, and % of tissue missing 
• 
Early stopping rules with supporting data and list the number of participants who have met 
the early stopping rules 
• 
Summary of toxicities separated by cohorts with the number of dose-limiting toxicities 
indicated 
• 
Abstract submissions/publications 
• 
Summary of any recent literature that may affect the safety or ethics of the study 
 
The study principal investigator and Research Patient Coordinator will monitor for serious 
toxicities on an ongoing basis. Once the principal investigator or Research Patient Coordinator 
becomes aware of an adverse event, the AE will be reported to the HRPO and QASMC according 
to institutional guidelines. 
 
12.0 
DATA SUBMISSION SCHEDULE 
 

Amendment 19, 03/11/20 
 
Page 48 of 69 
 
Case report forms with appropriate source documentation will be completed within 60 days of the 
schedule listed in this section. 
 
Case Report Form 
Submission Schedule 
Original Consent Form 
Prior to registration 
On-Study Form 
Medical History Form 
Treatment History Form 
Prior to starting treatment 
Safety Labs 
 
Baseline  
Day 0  
Day 14 
Day 28 
Day 60 
Day 100 
6 Months 
9 Months 
12 Months 
CIML NK Cell Infusion 
Day 0 
IL-2 Dosing Form (phase I and 
pediatric cohorts) 
7x between Day 1 and Day 12 
ALT-803 Dosing Form (phase II) 
Day 0 and Day 5 
Bone Marrow or  
Response form 
Baseline 
Day 14 
Day 28 
Day 60 
Day 100 
6 Months 
9 Months 
12 Months 
Disease relapse 
Premature discontinuation 
DLT Evaluation 
Day 0 
Additional Stopping Rules 
Day 0 
Correlative Studies Form 
At the time points described in Section 8.0 
Survival 
6 Months 
9 Months 
12 Months 
Annually after 12 Months 
Premature Discontinuation 
Adverse Events Form 
Ongoing 
 
 
 
 
MedWatch Form 
See Section 10.0 for reporting requirements 
 
 
 
 
Adverse Event Collection in the Case Report Forms 
 
All adverse events that occur beginning with start of treatment (minus exceptions defined 
in Section 10.0) must be captured in the Toxicity Form.  Baseline AEs should be 
captured on the Medical History Form. 
 

Amendment 19, 03/11/20 
 
Page 49 of 69 
 
Participant death due to disease progression should be reported on the Toxicity Form as 
grade 5 disease progression.  If death is due to an AE (e.g. cardiac disorders: cardiac 
arrest), report as a grade 5 event under that AE.  Participant death must also be 
recorded on the Death Form. 
 
13.0 
EFFICACY ASSESSMENT 
 
The primary objective of the study is to determine the safety and MTD of the adoptively transferred 
CIML NK cells into patients with AML or MDS. However, the secondary objectives include 
assessing for the efficacy of the CIML NK cells to induce remission and positively affect the 
survival of these patients.   
 
 
Percentage of Myeloid Blasts in the Bone Marrow 
 
Bone marrow examination will be performed according to the study calendar in Section   
9.0. 
 
 
 Blood Counts 
 
Blood counts including a differential will be done at all visits. In patients with blood counts 
below the limits of normal pre-treatment, improvement in blood counts during therapy may 
indicate a benefit for the patient. 
 
 
Response for AML patients  
 
Response will be assessed according to the criteria from the IWG as stated below.   
 
13.3.1 Complete Remission (CR) 
 
Morphologically leukemia free state (i.e. bone marrow with <5% blasts by 
morphologic criteria and no blasts with Auer rods, no evidence of extramedullary 
leukemia) and absolute neutrophil count ≥1000 /μL and platelets ≥100,000 /μL. 
Patient must be independent of transfusions 
 
13.3.2 Complete Remission with Incomplete Blood Count Recovery (CRi) 
 
All of the above criteria for CR must be met, except that absolute neutrophils <1000 
/μL or platelets <100,000 /μL in the blood. 
 
13.3.3 Partial remission (PR) 
 
All of the criteria for CR must be met, except that leukemic blasts in the bone 
marrow may range from 5 to 25% as long as the count has decreased by at least 
50% from pre-study treatment, or <5% blasts in the presence of Auer rods or 
abnormal morphology. 
 
13.3.4 Stable Disease (SD) 
 
Stable disease (SD) requires the following: 

Amendment 19, 03/11/20 
 
Page 50 of 69 
 
Failure to achieve at least a PR at Day 14 but with no evidence of progression 
and still pending blood count recovery. 
 
13.3.5 Treatment Failure (TF) 
             
Patient survives > 28 days from the CIML NK cell infusion with persistent leukemia 
in the last peripheral blood smear or bone marrow (>25% blasts), or with persistent 
extramedullary disease, but without further clinical deterioration due to leukemia 
or increase of blast population in the bone marrow or peripheral blood. 
 
13.3.6 Progressive Disease (PD) 
 
Patient survives until the final dose of IL-2 or ALT-803 with increase of blast 
population in the bone marrow or peripheral blood by >10% or aggravation or new 
development of extramedullary disease or further deterioration or death due to 
leukemia.  
 
 
Response for MDS patients – Phase I ONLY 
 
13.4.1 Complete Remission (CR) 
 
Complete remission (CR) requires all of the following: 
Bone marrow:  
• 
≤ 5% myeloblasts with normal maturation of all cell lines. 
 Persistent dysplasia will be noted 
 
Peripheral blood: 
• 
Hgb ≥11 g/dL 
• 
Platelets ≥ 100 x 109/L 
• 
Neutrophils ≥ 1.0 x 109/L 
• 
Blasts 0% 
 
13.4.2 Marrow CR (mCR) 
 
Marrow CR requires the following: 
Bone marrow: ≤ 5% myeloblasts and decrease by ≥ 50% over pretreatment 
Peripheral blood: if hematologic improvement responses, they will be noted in 
addition to marrow CR 
 
13.4.3 Partial Remission (PR) 
 
Partial remission (PR) requires the following (absolute values must last at least 2 
months): 
All the CR criteria (if abnormal before treatment), except: 
Bone marrow blasts decreased by ≥ 50% over pretreatment but still >5%.Cellularity 
and morphology are not relevant. 
 
13.4.4 Stable Disease (SD) 
 

Amendment 19, 03/11/20 
 
Page 51 of 69 
 
Stable disease (SD) requires the following: 
Failure to achieve at least a PR, but with no evidence of progression for at least 2 
months. 
 
13.4.5 Progressive Disease (PD) 
 
Progressive disease (PD) requires any of the following: 
• 
Less than 5% blasts at baseline: ≥ 50% increase in blasts to > 5% blasts 
• 
5%-10% blasts at baseline: ≥ 50% increase to > 10% blasts 
• 
10%-20% blasts at baseline: ≥ 50% increase to > 20% blasts 
• 
20%-30% blasts at baseline: ≥ 50% increase to > 30% blasts 
• 
At least 50% decrement from maximum remission/response in granulocytes or 
platelets 
• 
Reduction in Hgb by ≥ 2 g/dL 
• 
New or worsened transfusion dependence not related to study drug toxicity 
 
13.4.6 Relapse after CR or PR 
 
Relapse after CR or PR requires a previous CR or PR as defined above and 
subsequently development of one of the following: 
• 
Return to pretreatment bone marrow blast percentage 
• 
Decrement of ≥ 50% from maximum remission/response levels in granulocytes 
or platelets 
• 
Reduction in Hgb concentration by ≥ 1.5 g/dL or transfusion dependence 
 
13.4.7 Addition Definitions 
 
Hematologic Improvement (HI): 
Erythroid response requires all of the following (only required if pretreatment Hgb 
<11 g/dL): 
• 
Hgb increase by ≥ 1.5 g/dL 
• 
Relevant reduction of units of RBC transfusions by an absolute number of at 
least 4 RBC transfusions/8 wk compared with the pretreatment transfusion 
number in the previous 8 wk. Only RBC transfusions given for a Hgb of ≤ 9.0 
g/dL pretreatment will count in the RBC transfusion response evaluation 
 
Platelet response requires one of the following (only required if pretreatment 
platelets < 100 x 109/L):  
• 
Absolute increase of ≥ 30 x 109/L (for patients starting with > 20 x 109/L 
platelets) 
• 
Increase from < 20 x 109/L to > 20 x 109/L and absolute increase > 100% (for 
patients starting with < 20 x 109/L) 
 
Neutrophil response requires the following (only required if pretreatment ANC <1.0 
x 109/L):  
At least 100% increase and an absolute increase > 0.5 x 109/L 
 
RBC Transfusion Dependence and Independence: 
RBC transfusion independence is defined as: 

Amendment 19, 03/11/20 
 
Page 52 of 69 
 
• 
Hemoglobin > 90 g/L (9.0 g/dL) 
• 
Receipt of ≤ 1 RBC transfusion during the previous 8 weeks (56 days) 
 
RBC transfusion dependence is defined as: 
• 
Hemoglobin ≤ 90 g/L (9.0 g/dL) 
• 
Receipt of ≥ 2 RBC transfusions during the previous 8 weeks (56 days). 
 
Cytogenetic Response: 
Complete: Disappearance of the chromosomal abnormality without appearance of 
new ones 
Partial: At least 50% reduction of the chromosomal abnormality 
 
Disease Transformation: 
Transformation to AML with ≥20% blasts on bone marrow aspirate or core biopsy. 
 
 
Duration of remission (DOR) 
 
DOR is defined only for patients who achieve a CR, mCR ,or PR, and is measured from 
the first   date of attaining CR, mCR, or PR until the date of disease progression or death. 
 
 
Time to Progression (TTP) 
 
TTP is defined as the time from date of first dose of fludarabine until evidence of disease 
progression. 
 
 
Disease-Free Survival (DFS) 
 
DFS is defined as the time from the day CR, mCR, or CRi is documented until disease 
progression or death. 
 
 
Overall Survival (OS) 
 
OS is defined from the date of first dose of fludarabine on this study until death.  
 
 
14.0 
AUDITING 
 
As coordinating center of this trial, Washington University (via the Quality Assurance and Safety 
Monitoring Committee (QASMC) will monitor each participating site to ensure that all protocol 
requirements are being met; that applicable federal regulations are being followed; and that best 
practices for patient safety and data collection are being followed per protocol.  Participating sites 
will be asked to send copies of all audit materials, including source documentation.  The audit 
notification will be sent to the Washington University Research Patient Coordinator, who will 
obtain the audit materials from the participating institution. 
 
Notification of an upcoming audit will be sent to the research team one month ahead of the audit. 
Once accrual numbers are confirmed, and approximately 30 days prior to the audit, a list of the 
cases selected for review (up to 10 for each site) will be sent to the research team. However, if 

Amendment 19, 03/11/20 
 
Page 53 of 69 
 
during the audit the need arises to review cases not initially selected, the research team will be 
asked to provide the additional charts within two working days. 
 
Items to be evaluated include: 
• 
Subject screening and enrollment 
• 
Reporting of adverse events 
• 
Maintenance of HIPAA compliance 
• 
Completeness of regulatory documentation 
• 
Completeness of participant documentation 
• 
Acquisition of informed consent 
• 
IRB documentation 
• 
Issues of protocol adherence 
 
Additional details regarding the auditing policies and procedures can be found at 
https://siteman.wustl.edu/wp-content/uploads/2015/10/QASMC-Policies-and-Procedures-
03.31.2015.pdf 
 
 
15.0 
STATISTICAL CONSIDERATIONS 
 
This is a phase I/II study aimed at establishing the maximum tolerated or tested dose of donor 
CIML NK cells (phase I) in relapsed/refractory AML and MDS patients, and preliminary 
assessment of efficacy (phase II) in relapsed AML patients. 
 
 
Statistical Design and Sample Size 
 
15.1.1 Phase I Design and Sample Size 
 
This is a phase 1 clinical trial with the primary objective of establishing the 
maximum tolerated dose of CIML NK cells in AML or MDS patients. We propose 
to use a standard 3+3 dose escalation design and include 3 dose levels of CIML 
NK cells to define the MT/TD of CIML NK cells. Dose escalation will be carried out 
as described in Section 5.3.3.  We expect to enroll 6-18 patients depending on 
DLTs encountered. At least 6 patients will be treated at the phase I MT/TD before 
opening the phase II portion of the study. 
 
15.1.2 Phase II Design and Sample Size 
 
A lead-in cohort of eight patients with relapsed or refractory AML was treated with 
ALT-803 (Phase II/ALT-803) to establish the safety and immune effects of that 
treatment (See section 1.3.4). 
 
The phase II/IL-2 portion will enroll patients with relapsed or refractory 
AML.  Based on reports in large numbers of AML patients,11,12,13,14 the expected 
CR rate with standard salvage chemotherapy is 34% in patients that relapse within 
18 months of obtaining CR1.  Patients who fail to achieve CR1 have a similar CR 
rate to salvage chemotherapy.  We will use a clinically interesting goal of 54% 
CR/CRi (20% increase over historical control). In a Simon two-stage optimal 
design with power=0.8 and significance level=0.05 will require 46 patients with 
evaluable response as described in section 5.3.5. We will treat 18 patients in the 

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first stage, and will continue to stage 2 if 8 or more CR/CRi are observed.  In the 
second stage an additional 28 patients will be treated, and study will be considered 
positive if 21 or more CR/CRi are observed in the 46 total patients treated.  If the 
true CR rate is 34%, the probability of correct early stopping is 0.75 with this 
design. 
 
15.1.3 Pediatric Cohort Design and Sample Size 
 
The primary objective of the Pediatric Cohort is to establish the safety of CIML NK 
cells in pediatric patients.  10 patients will be treated at the phase I MTD.   
 
 
Final Data Analysis Plan 
 
15.2.1 Phase I Analysis Plan 
 
The primary objective for phase I of this study is to investigate the MTD of CIML 
NK cell infusion.  The MTD will be reported as defined by DLTs in Section 5.3.2. 
DLTs and other AEs/SAEs will be summarized by patient, type and grade as 
defined by the CTCAE v4.0. 
 
 
15.2.2 Phase II Analysis Plan 
 
The primary objective of the phase II is to determine CR/CRi rates using MTD of 
CIML NK cells determined in the phase I part of the study. Descriptive statistics 
will be used to summarize baseline patient characteristics (proportion and 
confidence interval, mean ± SD or minimum, Q1, median Q3, maximum and IQR). 
Adverse events will be tabulated by patient, type and severity. Complete remission 
rate and complete cytogenetic remission rate will be calculated with 95% exact 
binomial confidence intervals. Kaplan Meier estimates will be used to describe the 
median time to hematologic recovery (neutrophils and platelets), duration of 
remission, event-free survival, relapse-free survival and overall survival using 95% 
confidence intervals.  
 
15.3.3 Pediatric Cohort Analysis Plan 
 
The primary objective of the pediatric cohort is to assess safety of CIML NK cell 
infusion.  AEs/SAEs will be summarized by patient, type and grade as defined by 
the CTCAE v4.0.  No pediatric patient will be treated until the previous pediatric 
patient has completed the treatment period (through Day 14), to allow adequate 
monitoring of Grade ≥ 3 toxicities before the next patient is treated.   
15.2.3 Correlative Endpoints 
 
Linear mixed models will be used to cluster multiple observations per subject or 
over time, making multiplicity adjusted comparisons of percent and number of 
CIML NK cells or IFN-γ+ cells and B content scores by CR/CRi, and intensity of 
IFN-γ, CD107a or TNF in control or memory-like and licensed or unlicensed cells 
KIR matched or unmatched cells. Preliminary data indicate these are Gaussian on 
the original or a transformed (usually log) scale; otherwise, multiplicity adjusted 
Wilcoxon signed rank tests will be used for paired comparisons. FDR multiplicity 
adjustment will be carried out within the set of analyses addressing each 

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correlative endpoint. Data from 46 patients will provide the following power and 
significance level to detect the stated mean difference and effect sizes that are 
seen in preliminary data: Defining percentages and number of total CIML NK 
cells, and those that are IFN-γ+ after paired-patient AML restimulation, and 
correlation with CR/CRi: .80 at α=.025, effect size~1.0, mean difference ~2.1 for 
log # CIML NK or IFN-γ+ cells, 4.9 for % CIML NK cells, 6.4 for % IFN-γ+ cells; 
Defining the donor KIR genotype and correlation with CR/CRi: .86 at α=.05 for 
KIR B content score, effect size=.79, mean difference~1.0; Determine the 
phenotype, proliferation, and function of in vivo expanded CIML NK cells in 
the PB and BM utilizing mass cytometry, and integrate with known KIR to 
KIR-ligand interactions: .81 at α=.0083, effect size=.50, IFN-γ+ mean paired 
difference=10, %CD107a+ mean paired difference=6, %TNF+ mean paired 
difference 3; Define CIML NK cell phenotypic and functional markers 
associated with elimination of AML in vivo using Citrus. These analyses 
involve descriptive (SAM) and predictive (PAM or lasso) modeling. Preliminary 
data from 19 markers in 7 patients indicate power of .80 at α=.0005 to detect a 
difference between CR/CRi and <CR/CRi in 5 markers (26%). These 5 have a joint 
FNR=0% and FPR=20%, suggesting that Citrus will be able to form clusters 
distinguished 
by 
response. 
Elucidate 
additional 
inhibitory 
receptor 
checkpoints on CIML NK cells that limit responses to primary AML and 
Changes in recipient Tregs or MDSCs associated with AML relapse or 
resistance to CIML NK cell therapy: Longitudinal models will be used to quantify 
frequency of inhibitory receptor ligands at 5 time points in PB and BM as predictors 
of CIML NK cell number and associated AML blast killing rate or of recipient Tregs 
or MDSCs as predictors of lower CIML NK numbers. Preliminary data indicate 
these are Gaussian on the original or a transformed (usually log) scale; otherwise, 
multiplicity adjusted Wilcoxon signed rank tests will be used for paired 
comparisons. FDR multiplicity adjustment will be carried out. Longitudinal data are 
not yet available, but preliminary data show correlations between log NK # at peak 
expansion, providing for data from 46 patients at α=.01 power ≥ .82 to detect 
correlations ≤ -.48, values observed in PB with %LAG3+ or %PD1+. Correlations 
between log NK # and %Treg, and log #Treg/µL vary from -.48 to -.87 and can be 
detected with similar power. 
 
 
Toxicity Monitoring 
 
Patients will be monitored for adverse events as listed in Section 5.3.4. The following 
events will be used to determine the stopping rules with an expected rate of 10% and a 
maximum allowable rate of 25%.  
• 
Bone marrow suppression between days 35 and 100 
• 
Grade II-IV acute GVHD within 100 days 
• 
Extensive chronic GVHD in any organ system 
 
All accrued patients are included in the toxicity monitoring rule (N=57) because all may be 
evaluable for toxicity. A single continuous toxicity monitoring rule will be used for each of 
these three events because the expected and maximum allowable rates are the same. 

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Suspend for review if ANY ONE event rate 
reaches: 
# 
Patients 
# Bone marrow 
suppression 
# Acute GHVD 
grade 2-4 
# Extensive 
chronic GVHD 
1 
0 
0 
0 
2 
0 
0 
0 
3 
0 
0 
0 
4 
0 
0 
0 
5 
0 
0 
0 
6 
2 
2 
2 
7 
2 
2 
2 
8 
2 
2 
2 
9 
2 
2 
2 
10 
3 
3 
3 
11 
3 
3 
3 
12 
3 
3 
3 
13 
3 
3 
3 
14 
3 
3 
3 
15 
4 
4 
4 
16 
4 
4 
4 
17 
4 
4 
4 
18 
4 
4 
4 
19 
4 
4 
4 
20 
4 
4 
4 
21 
5 
5 
5 
22 
5 
5 
5 
0
1
2
3
4
5
6
7
8
9
10
11
0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839404142434445464748495051
Number of Adverse Events
Number of Patients
Enrollment is suspended for review if the number of ANY ONE of the 
three events being monitored falls ABOVE the line

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23 
5 
5 
5 
24 
5 
5 
5 
25 
5 
5 
5 
26 
5 
5 
5 
27 
6 
6 
6 
28 
6 
6 
6 
29 
6 
6 
6 
30 
6 
6 
6 
31 
6 
6 
6 
32 
6 
6 
6 
33 
7 
7 
7 
34 
7 
7 
7 
35 
7 
7 
7 
36 
7 
7 
7 
37 
7 
7 
7 
38 
7 
7 
7 
39 
7 
7 
7 
40 
8 
8 
8 
41 
8 
8 
8 
42 
8 
8 
8 
43 
8 
8 
8 
44 
8 
8 
8 
45 
8 
8 
8 
46 
9 
9 
9 
47 
9 
9 
9 
48 
9 
9 
9 
49 
9 
9 
9 
50 
9 
9 
9 
51 
10 
10 
10 
 
For each application of the monitoring rule has a probability of .837 to correctly identify an 
excessive adverse event rate and a probability of .052 of incorrectly identifying an 
excessive rate. The total number of adverse events of any one kind is 10. 
 
 
Replacement of Patients 
 
For the phase I portion, if less than the targeted CIML NK cell numbers are available for 
the dose level enrolled (actual CIML NK cell dose administered < 80% of goal CIML NK 
cell dose), then all CIML NK cells (after quality control testing) will be given and the patient 
will continue with protocol therapy. These patients will be considered not evaluable for the 
primary analysis at the dose level intended, but will be evaluated as part of the analyses 
at the lower dose level received. These patients will be replaced for the intended CIML 
NK cell dose level.  If a patient for unexpected reasons is unable to receive CIML NK cells, 
they will not be included in the safety analyses. 

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For the phase II portion, if the MT/TD is the max NK cell dose, the goal dose will be 
0.5x106/kg to 10x106/kg, administering all IL-12/15/18 pre-activated NK cells available up 
to 10x106/kg.  Since complete remissions were observed in dose level 1, the lower goal 
limit will be inclusive of this initial dose.  If <0.5x106/kg are administered, the patient will 
be replaced for statistical analysis of the primary objective. 
 
 
16.0 
MULTICENTER REGULATORY REQUIREMENTS 
 
Washington University requires that each participating site sends its informed consent document 
to be reviewed and approved by the Washington University Regulatory Coordinator (or designee) 
prior to IRB/IEC submission.    
 
Site activation is defined as when the secondary site has received official written documentation 
from the coordinating center that the site has been approved to begin enrollment.  At a minimum, 
each participating institution must have the following documents on file at Washington University 
prior to study activation: 
• 
Documentation of IRB approval of the study in the form of a letter or other official 
document from the participating institution’s IRB.  This documentation must show 
which version of the protocol was approved by the IRB. 
• 
Documentation of IRB approval of an informed consent form. The consent must 
include a statement that data will be shared with Washington University, including the 
Quality Assurance and Safety Monitoring Committee (QASMC), the DSMC (if 
applicable), and the Washington University study team. 
• 
Documentation of FWA, signed FDA Form 1572 (if applicable), and the CVs of all 
participating investigators. 
• 
Protocol signature page signed and dated by the investigator at each participating site. 
 
The coordinating center Principal Investigator (or designee) is responsible for disseminating to 
the participating sites all study updates, amendments, reportable adverse events, etc.  
Protocol/consent modifications and IB updates will be forwarded electronically to the secondary 
sites within 4 weeks of obtaining Washington University IRB approval.  Activated secondary sites 
are expected to submit protocol/consent/IB modifications to their local IRBs within 4 weeks of 
receipt unless otherwise noted.  Upon the secondary sites obtaining local IRB approval, 
documentation of such shall be sent to the Washington University study team within 2 weeks of 
receipt of approval. 
 
Documentation of participating sites’ IRB approval of annual continuing reviews, protocol 
amendments or revisions, all SAE reports, and all protocol violations/deviations/exceptions must 
be kept on file at Washington University. 
 
The investigator or a designee from each institution must participate in a regular conference call 
to update and inform regarding the progress of the trial. 
 
 
 
 
 

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We would like to thank the Alvin J. Siteman Cancer Center at Washington University School of 
Medicine and Barnes-Jewish Hospital in St. Louis, Missouri, for the use of the Clinical Trials Core 
which provided protocol development service. The Siteman Cancer Center is supported in part 
by an NCI Cancer Center Support Grant #P30 CA91842. 
 
 

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APPENDIX A: Karnofsky/Lansky Performance Status 
 
 
 
 
 

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APPENDIX B: Calucation of creatinine clearance 
 
 
Cockcroft-Gault Formula 
 
 
 
 
 
 
Schwartz equation  
 
CrCl (ml/min/1.73m2)=[length (cm) x k] /serum creatinine 
 
k = 0.45 for infants 1-52 weeks old 
k = 0.55 for children 1-13 year old 
k = 0.55 for adolescent females 13-18 years old 
k = 0.7 for adolescent males 13-18 years old 
 
 

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APPENDIX C: European Leukemia Net Risk Classification for AML  
 
High-risk is defined as Adverse, intermediate-I and intermediate-II risk groups.  
 
Adverse-Risk: Inv(3)(q21q26.2) or (t3;3)(q21q26.2); RPN1-EVI1 t(6;9)(p23;q34)l DEK-NUP214 
t(v;11)(v;q23); MLL rearranged -5 or del(5q); -7; abnl(17p); complex karyotype* 
 
Intermediate-II: t(9;11)(p22;q23); MLLT3-MLL; Cytogenetic abnormalities not classified as 
favorable or adverse 
 
Intermediate-I: Mutated NPM1 and FLT3-ITD (normal karyotype); Wild-type NPM1 and FLT3-
ITD (normal karyotype); Wild-type NPM1 without FLT3-ITD (normal karyotype)  
 
Favorable:  t(8;21)q22;q22) RUNX1-RUNX1T1; inv(16)p13.1q22) or t(16;16)(p13.1q22); CBFB-
MYH11; Mutated NPM1 without FLT3-ITD (normal karyotype); Mutated CEBPA (normal 
karyotype).  
 
 
*Three or more chromosome abnormalities in the absence of one or more of the 
following, t(15;17), t(8;21), inv(16) or t(16;16), t(9;11), t(v;11)(v;q23), t(6;9), inv(3) or t(3;3);  
 
 

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APPENDIX D: Definitions for Adverse Event Reporting 
 
A. Adverse Events (AEs) 
 
As defined in 21 CFR 312.32: 
 
Definition: any untoward medical occurrence associated with the use of a drug in humans, 
whether or not considered drug-related. 
 
Grading: the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for all toxicity reporting.  A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website. 
 
Attribution (relatedness), Expectedness, and Seriousness: the definitions for the terms 
listed that should be used are those provided by the Department of Health and Human Services’ 
Office for Human Research Protections (OHRP).  A copy of this guidance can be found on 
OHRP’s website: 
http://www.hhs.gov/ohrp/policy/advevntguid.html 
 
B. Suspected Adverse Reaction (SAR) 
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse event for which there is a reasonable possibility that the drug caused 
the adverse event.  “Reasonable possibility” means there is evidence to suggest a causal 
relationship between the drug and the adverse event.  “Suspected adverse reaction” implies a 
lesser degree of certainty about causality than adverse reaction, which means any adverse event 
caused by a drug. 
 
C. Life-Threatening Adverse Event / Life Threatening Suspected Adverse Reaction  
 
As defined in 21 CFR 312.32: 
 
Definition: any adverse drug event or suspected adverse reaction is considered “life-
threatening” if, in the view of the investigator, its occurrence places the patient at immediate 
risk of death. It does not include an adverse event or suspected adverse reaction that, had it 
occurred in a more severe form, might have caused death. 
 
D.  Serious Adverse Event (SAE) or Serious Suspected Adverse Reaction 
 
As defined in 21 CFR 312.32: 
 
Definition:  an adverse event or suspected adverse reaction is considered “serious” if, in the 
view of the investigator, it results in any of the following outcomes: 
o Death 
o A life-threatening adverse event 
o Inpatient hospitalization or prolongation of existing hospitalization 

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o A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
o A congenital anomaly/birth defect 
o Any other important medical event that does not fit the criteria above but, based upon 
appropriate medical judgment, may jeopardize the subject and may require medical or 
surgical intervention to prevent one of the outcomes listed above 
 
E. Protocol Exceptions 
 
Definition: A planned change in the conduct of the research for one participant. 
 
F. Deviation 
 
Definition: Any alteration or modification to the IRB-approved research without prospective 
IRB approval.  The term “research” encompasses all IRB-approved materials and documents 
including the detailed protocol, IRB application, consent form, recruitment materials, 
questionnaires/data collection forms, and any other information relating to the research study. 
 
A minor or administrative deviation is one that does not have the potential to negatively impact 
the rights, safety, or welfare of participants or others or the scientific validity of the study. 
 
A major deviation is one that does have the potential to negatively impact the rights, safety, or 
welfare of participants or others or the scientific validity of the study. 
 

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APPENDIX E: Reporting Timelines 
 
Expedited Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Serious AND unexpected suspected 
adverse reaction 
 
 
Report no later than 15 calendar 
days after it is determined that the 
information qualifies for reporting 
Unexpected fatal or life-threatening 
suspected adverse reaction 
 
 
Report no later than 7 calendar days 
after initial receipt of the 
information 
Unanticipated problem involving 
risk to participants or others 
Report within 10 working days.  If 
the event results in the death of a 
participant enrolled at 
WU/BJH/SLCH, report within 1 
working day. 
Report via email after IRB 
acknowledgment 
 
Major deviation 
Report within 10 working days.  If 
the event results in the death of a 
participant enrolled at 
WU/BJH/SLCH, report within 1 
working day. 
 
 
A series of minor deviations that are 
being reported as a continuing 
noncompliance 
Report within 10 working days.   
 
 
Protocol exception 
Approval must be obtained prior to 
implementing the change 
 
 
Clinically important increase in the 
rate of a serious suspected adverse 
reaction of that list in the protocol 
or IB 
 
 
Report no later than 15 calendar 
days after it is determined that the 
information qualifies for reporting 
Complaints 
If the complaint reveals an 
unanticipated problem involving 
risks to participants or others OR 
noncompliance, report within 10 
 
 

Amendment 19, 03/11/20 
 
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Event 
HRPO 
QASMC 
FDA 
working days.  If the event results in 
the death of a participant enrolled at 
WU/BJH/SLCH, report within 1 
working day.  Otherwise, report at 
the time of continuing review. 
Breach of confidentiality 
Within 10 working days. 
 
 
Incarceration 
If withdrawing the participant poses 
a safety issue, report within 10 
working days.   
 
If withdrawing the participant does 
not represent a safety issue and the 
patient will be withdrawn, report at 
continuing review. 
 
 
 
Routine Reporting Timelines 
Event 
HRPO 
QASMC 
FDA 
Adverse event or SAE that does not 
require expedited reporting 
If they do not meet the definition of 
an unanticipated problem involving 
risks to participants or others, report 
summary information at the time of 
continuing review 
Adverse events will be reported in 
the toxicity table in the DSM report 
which is typically due every 6 
months. 
The most current toxicity table from 
the DSM report is provided to the 
FDA with the IND’s annual report. 
Minor deviation 
Report summary information at the 
time of continuing review. 
 
 
Complaints 
If the complaint reveals an 
unanticipated problem involving 
risks to participants or others OR 
noncompliance, report within 10 
working days.  If the event results in 
the death of a participant enrolled at 
WU/BJH/SLCH, report within 1 
 
 

Amendment 19, 03/11/20 
 
Page 69 of 69 
 
working day.  Otherwise, report at 
the time of continuing review. 
Incarceration 
If withdrawing the participant poses 
a safety issue, report within 10 
working days.   
 
If withdrawing the participant does 
not represent a safety issue and the 
patient will be withdrawn, report at 
continuing review.