Clinical trial NCT00924326
Conditions: Primary Mediastinal B-cell Lymphoma Diffuse, Large B-cell Lymphoma Diffuse Large B-Cell Lymphoma Transformed From Follicular Lymphoma Mantle Cell
Keywords: B Cell Malignancies T Cell Persistence Immunotherapy Cell Transfer Leukemia Chronic Lymphocytic Leukemia CLL Lymphoma
Sponsor: National Cancer Institute (NCI)
Start date: 2009-02-17; Completion date: 2021-11-17
Enrollment: 43 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
Background:

The National Cancer Institute (NCI) Surgery Branch has developed an experimental therapy for treating patients with B cell lymphomas or leukemias that involves taking white blood cells from the patient, growing them in the laboratory in large numbers, genetically modifying these specific cells with a type of virus (retrovirus) to attack only the tumor cells, and then giving the cells back to the patient. This type of therapy is called gene transfer. In this protocol, we are modifying the patient s white blood cells with a retrovirus that has the gene for anti-cluster of differentiation 19 (CD19) incorporated in the retrovirus.

Objective:

The purpose of this study is to determine a safe number of these cells to infuse and to see if these particular tumor-fighting cells (anti-CD19 cells) cause tumors to shrink.

Eligibility:

\- Adults age 18-70 with B cell lymphomas or leukemias expressing the CD19 molecule.

Design:

Work up stage: Patients will be seen as an outpatient at the National Institutes of Health (NIH) clinical Center and undergo a history and physical examination, scans, x-rays, lab tests, and other tests as needed

Leukapheresis: If the patients meet all of the requirements for the study they will undergo leukapheresis to obtain white blood cells to make the anti-CD19 cells. Leukapheresis is a common procedure, which removes only the white blood cells from the patient.

Treatment: Once their cells have grown, the patients will be admitted to the hospital for the conditioning chemotherapy and the anti-CD19 cells. They will stay in the hospital for about 4 weeks for the treatment.

Follow up: Patients will return to the clinic for a physical exam, review of side effects, lab tests, and scans about every 1-3 months for the first year, and then every 6 months to 1 year as long as their tumors are shrinking. Follow up visits will take up to 2 days.

Detailed description:
BACKGROUND:

* We have constructed a retroviral vector that encodes an anti-cluster of differentiation 19 (CD19) chimeric antigen receptor (CAR) that recognizes the CD19 antigen. This chimeric receptor also contains the signaling domains of cluster of differentiation 28 (CD28) and cluster of differentiation 3 (CD3)-zeta. The retroviral vector can be used to mediate genetic transfer of this CAR to T cells with high efficiency (\> 50%) without the need to perform any selection.
* In co-cultures with CD19-expressing target cells, anti-CD19-CAR-transduced T-cells secreted significant amounts of interferon gamma (IFN-y) and interleukin 2 (IL-2).
* We have developed a process for cryopreserving the cell product which may lead to the ability for this product to be manufactured at a central location and shipped to other institutions for treatment of a broader patient population

OBJECTIVE:

\- Primary objective:

--With the approval of amendment S, to determine the safety and feasibility of the administration of cryopreserved anti-CD19-CAR engineered peripheral blood lymphocytes with a non-myeloablative conditioning regimen in patients with Bcell lymphomas.

ELIGIBILITY:

Patients of 18 years of age or older must:

* Have a CD19-expressing B-cell lymphoma
* Be a non-responder to, or recurred after one or more standard chemotherapy-containing regimens for their malignancy
* Currently require treatment due to progressive malignancy
* Be deemed to be incurable by standard therapy

Patients may not have:

* A history of allogeneic stem cell transplantation
* Central nervous system (CNS) disease

DESIGN:

* Peripheral blood mononuclear cells (PBMC) obtained by leukapheresis (approximately 5.0x 10\^9 cells) will be cultured in the presence of anti-CD3 (muromonab-CD3 (OKT3)) and aldesleukin in order to stimulate T-cell proliferation.
* Transduction is initiated by exposure of approximately 1.0x 10\^8 to 5.0x 10\^8 cells to retroviral vector supernatant containing the anti-CD19 CAR.
* With the approval of Amendment S, patients will receive fludarabine and cyclophosphamide chemotherapy (NMA) for lymphodepletion, followed by cryopreserved anti-CD19-CAR-transduced T-cells.
* Patients will be followed until disease progression.
* Patients who have responded to treatment and then progress may receive one retreatment.

Arms: arm 1: Non-myeloablative, lymphodepleting preparative regimen of cyclophosphamide and fludarabine + cryopreserved anti-CD19-CAR PBL arm 2: None arm 3: None arm 4: None arm 5: None arm 6: None arm 7: None arm 8: None arm 9: None arm 10: None
Interventions: intervention 1: Fludarabine intervention 2: Cyclophosphamide intervention 3: Anti-cluster of differentiation 19 (CD19)-CAR PBL intervention 4: Aldesleukin intervention 5: Fludarabine intervention 6: Cyclophosphamide
Intervention descriptions: intervention 1: Days -5 to -1 (after administration of cyclophosphamide): 25 mg/m\^2 intravenous (IV) over 30 minutes intervention 2: Days -5 to -4: 60mg/kg intravenous (IV) over 60 minutes intervention 3: Anti-cluster of differentiation 19 (CD19) chimeric antigen receptor (CAR) peripheral blood lymphocytes ( PBL).

Day 0 (two to four days after the last dose of fludarabine); Cells will be infused via intravenous (IV) on the Patient Care Unit over 20-30 minutes. intervention 4: Day 0: 720,000 IU/kg intravenously (IV) every 8 hours for a maximum of 15 doses. intervention 5: Days -5 to -3 (after administration of cyclophosphamide): 30 mg/m\^2 intravenous (IV) over 30 minutes intervention 6: Days -5 to -3: 300mg/m\^2 intravenous (IV) over 60 minutes

Protocol documents:
ICF_002.pdf: 
MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
INSTITUTE: 
National Cancer Institute 
STUDY NUMBER: 
09-C-0082 
PRINCIPAL INVESTIGATOR: Steven A. Rosenberg, M.D., Ph.D. 
STUDY TITLE:  
An Assessment of the Safety and Feasibility of Administering T-Cells Expressing an 
Anti-CD19 Chimeric Antigen Receptor to Patients with B-Cell Lymphoma  
Continuing Review Approved by the IRB on 09/15/20 
Amendment Approved by the IRB on 06/24/20 (EE) 
 Date posted to web: 09/18/20 
Standard 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent (1) 
 
 
INTRODUCTION 
We invite you to take part in a research study at the National Institutes of Health (NIH). 
First, we want you to know that: 
 
Taking part in NIH research is entirely voluntary. 
 
You may choose not to take part, or you may withdraw from the study at any time. In either 
case, you will not lose any benefits to which you are otherwise entitled. However, to 
receive care at the NIH, you must be taking part in a study or be under evaluation for study 
participation. 
 
You may receive no benefit from taking part. The research may give us knowledge that 
may help people in the future. 
Second, some people have personal, religious or ethical beliefs that may limit the kinds of medical 
or research treatments they would want to receive (such as blood transfusions). If you have such 
beliefs, please discuss them with your NIH doctors or research team before you agree to the study. 
Now we will describe this research study. Before you decide to take part, please take as much time 
as you need to ask any questions and discuss this study with anyone at NIH, or with family, friends 
or your personal physician or other health professional. 
Why is this study being done? 
We have developed an experimental procedure for patients with cancer that uses their own blood 
cells. We genetically modify these cells and grow them in the laboratory. We hope that these 
cells when infused will decrease the amount of cancer you have. However, it is possible that 
these cells will not have this effect. We will be using the anti-CD19 gene and a type of virus 
(retrovirus) in making these cells (anti-CD19 cells). The anti-CD19 cells will be given to you as 
an intravenous (IV) infusion. This type of experimental therapy is called “gene therapy” and is 
very closely monitored by the Food and Drug Administration (FDA) and other regulatory 
agencies. The risks of gene therapy will be described later in this document. 
With prior treatments, we have given “fresh” anti-CD19 cells, but now we are using “frozen” 
anti-CD 19 cells, which will be thawed and given to you as an IV infusion.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 2 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
Why are you being asked to take part in this study? 
You have been diagnosed with a CD19-expressing B-cell cancer and the standard therapies 
available have not been effective. CD19 is an antigen (protein) found on the surface of B cells, 
and this antigen is expressed in the majority of your cancer cells. 
How many people will take part in this study? 
About 30 patients have been treated with the “fresh cell product”; up to 42 patients may be 
treated with the “frozen” cell product. This highly experimental regimen is explained below. 
Description of Research Study  
The study has 5 stages as outlined below: 
What 
Timeframe 
Location 
Comments & Instructions 
Work up 
1-2 weeks 
Inpatient and 
out patient  
Scans, x-rays, labs leukapheresis other 
tests as needed 
Chemotherapy 
(day -5 to -3) 
3 days 
Inpatient 
Receive IV chemotherapy to prepare 
your immune system for the cells 
Cells  
(Day 0) 
1 days 
Inpatient and 
possibly ICU 
Receive anti-CD19 cells 
Recovery 
1-2 weeks 
Inpatient unit 
Recover 
from 
the 
effects 
of 
chemotherapy  
Follow -up 
Ongoing 
until 
disease 
progression 
Outpatient 
Return to clinic for physical exam, 
review of side effects, labs, scans every 
1-6 months 
This is a phase 1 study, commonly referred to as a “dose finding study”, which means that 
groups of patients treated on this study have received different doses of the cells and 
chemotherapy in order to find a safe dose of cells that does not result in severe toxicity. These 
anti CD19 tumor fighting cells appear to be much “stronger” than other cells we have given in 
other Immunotherapy Surgery Branch protocols. We have treated approximately forty-three 
patients since the study opened. Some of the patients who were treated in the first few groups 
had severe side effects and needed to be transferred to the intensive care unit (ICU), these side 
effects included difficulty breathing, inability to speak, confusion, tremors, and kidney damage. 
Some patients required breathing tubes and kidney dialysis but all of the patients completely 
recovered to baseline and were able to be discharged to home.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 3 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
Because toxicities were observed in the earlier groups of patients, we stopped giving aldesleukin, 
reduced the cell dose, and reduced the doses of cyclophosphamide and fludarabine. This has 
decreased the side effects of the treatment. Of the twenty-eight patients treated with the fresh 
product on this study, 10 patients have had a partial response and 10 have had a complete 
response to treatment.  
We have developed a frozen cell product to be given to patients with reduced doses of 
chemotherapy and no aldesleukin. The dose we are giving for the frozen cell product is a little 
higher than the dose we gave with the fresh cells because we think that some of the cells will die 
off during the freezing and thawing process. Since the start of this new frozen cell product, the 
first 9 patients treated have experienced neurological toxicities causing confusion, slurred 
speech, shuffling gait, and tremors. All of the toxicities resolved within about 4 weeks. To 
potentially reduce the toxicities observed, the cells may be grown in the lab for a longer period of 
time. We hope that the frozen cell product will work just as well or better than the fresh product 
and that we will observe the same or fewer side effects as the fresh cell product.  
The major side effects of this experimental therapy (described in detail below) that are 
most severe include:  
• Infection and low blood counts caused by the chemotherapy  
• Low blood pressure requiring treatment in the intensive care unit 
• Neurologic (brain) toxicities which may require intubation for several days 
What will happen if you take part in this research study? 
Before you Begin the Study 
Cell Harvest and Growth 
You underwent a process called apheresis, while enrolled on our companion protocol 03-C-0277 
(Cell harvest and Preparation for Surgery Branch Adoptive Cell Therapy Protocols). This 
process obtained certain types of blood cells from you. These cells (anti-CD19) will be grown in 
the lab and genetically modified to recognize a protein on your tumor cells. If your cells do not 
grow, unfortunately, you will not be able to receive the cell infusion. If that happens, we will 
look at alternative experimental treatments at the NIH Clinical Center or refer you to the care of 
your referring physician. We usually know after about 4 weeks whether the cells will grow well 
enough to be used as an experimental treatment on this protocol. At the time we determine that 
your cells are not growing, we will inform you and discuss your options with you. Several 
medications are used during the preparation of your cell product, be sure to tell your doctor if 
you are allergic to any antibiotics. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 4 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
Work-up 
Prior to receiving the experimental therapy, you will undergo many tests. These include imaging 
procedures, laboratory tests, and a bone marrow aspirate and biopsy. Bone marrow is spongy tissue 
found inside some of your larger bones. Bone marrow has a fluid portion and a more solid portion. 
A bone marrow biopsy removes a small amount of the more solid portion while a bone marrow 
aspiration removes the fluid portion. Both can be done during the same procedure. The procedure 
consists of putting a needle about ¾ of an inch deep into a bone (usually the hip bone or sternum, 
also known as the breast bone) after numbing the area, and removing small samples of your bone 
marrow. As part of your workup you will also have a large catheter inserted into a vein and 
leukapheresis will be performed. If you are a woman, you will undergo a pregnancy test. You may 
be admitted to the hospital for these tests. However, you will be allowed to leave on pass on the 
days that you are not having tests performed. 
Catheter Insertion 
Prior to beginning the experimental therapy, you will have an intravenous (IV) catheter placed in 
your upper chest. The area will be numbed with an anesthetic before the catheter is put in. 
Although rare, putting these catheters in can sometimes cause collapse of a lung or cause 
bleeding. Lung collapse is treated by putting a tube into your chest for a few days to allow your 
lung to expand. Pressure is placed on any area that might bleed. Other IVs may be needed in one 
or both of your arms if we need to give you extra fluids, medicines, or nutrition. 
Leukapheresis 
Leukapheresis is a procedure that allows us to remove certain types of blood cells from you and 
return the rest of your blood. It is a very common procedure that is done routinely here at the 
NIH with very few risks. During leukapheresis, blood is removed from you through a needle in 
your arm, circulated through a machine that divides whole blood into red cells, plasma (the 
serum part), and lymphocytes (or white cells), and then the plasma and red cells are returned to 
you through a second needle in your other arm. The white blood cells may be used to help grow 
the cells. In addition to the leukapheresis you will undergo as part of your work up, we will also 
ask you to undergo one additional pheresis procedure between 4 and 6 weeks after your cell 
therapy to see the impact of this therapy on the immune system and see if cells we gave you are 
still active. 
Lumbar Puncture 
Before starting your chemotherapy, we may ask you to have a lumbar puncture (LP) so that we 
can see if there are any white blood cells in your spinal fluid. If you have neurologic side effects 
following treatment you may also have a LP to see if there are any white blood cells in your 
spinal fluid. Knowing whether or not you had white blood cells before starting treatment may 
help us to learn more about what causes the neurologic side effects caused by this treatment. The 
LP prior to treatment is optional; if you have neurologic side effects, the FDA requires that this 
procedure be performed as soon possible after the side effects start as long as it is safe for you. 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 5 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
A lumbar puncture is a procedure in which a thin needle called a spinal needle is put into the 
lower part of the spinal column to collect cerebrospinal fluid or to give drugs. This is also called 
spinal tap. You will be asked to lie in a curled position on a table. After a small area on your 
lower back is numbed, a spinal needle (a long, thin needle) is inserted into the lower part of the 
spinal column to remove cerebrospinal fluid. The fluid will be sent to a laboratory for testing. 
You will be asked to sign a separate consent for the lumbar puncture.  
During the Study 
Chemotherapy Regimen (Day -5 through Day -3) 
After we have grown the anti-CD19 cells to large numbers in the laboratory you will be admitted 
to the hospital to begin your experimental therapy. You will be given two chemotherapy 
medicines, cyclophosphamide and fludarabine, to make space in your immune system so the 
anti-CD19 cells can work without any interference from the cells in your immune system. These 
medicines may have an effect on your cancer; however, the dose and schedule used in this 
experimental study are not intended to treat your cancer. Animal experiments have indicated that 
making space for the cells you will receive can make them more effective in fighting cancer 
cells, but it is not known whether this is true in humans. The cyclophosphamide and fludarabine 
will be given into your catheter one following the other for three days (Day -5 through Day -3). 
The side effects of these medicines are described on the following pages. 
Cell Infusion (Day 0) 
You will be given the cryopreserved (frozen) anti-CD19 cells two - four days after the last dose 
of chemotherapy. The cryopreserved anti-CD19 cells will be given in your catheter over 30 
minutes.  
We will give you G-CSF (filgrastim) as a shot or injection under the skin the day after you 
receive the cells if your white blood cell count is low. This is used to stimulate your white blood 
cells to grow again and will continue until your white blood cell counts begin to return to normal.  
When you are Finished Taking the Drugs (Treatment) 
Supportive Therapy – Allopurinol (Aloprim™ or Zyloprim™) for Tumor Lysis Syndrome 
Anti-cancer treatment sometimes kills leukemia or lymphoma cells so rapidly that the body 
cannot get rid of the waste products fast enough. This is known as tumor lysis syndrome and it 
requires special attention and treatment to decrease the chance of kidney damage and other side 
effects. If tests suggest that you might be at risk, we will watch closely for this problem. In 
addition, a medication called allopurinol will be given to try to prevent kidney problems from 
developing. It is given by mouth three times a day and continuing until it appears that the risk of 
tumor lysis syndrome is low. Allopurinol is usually well tolerated. Possible side effects are 
described in detail on page 10.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 6 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
Recovery 
After your dose of cells, you will recover in the hospital until you are well enough to go home. 
This usually takes 5 to 10 days; however, you may need to stay in the hospital for longer than 10 
days before you are well enough to go home. We will continue to give you support medications, 
do laboratory tests, and watch you closely for any side effects until we feel your condition is 
stable.  
In addition to the laboratory tests to monitor your condition, we will remove approximately 9 
teaspoons of blood three times per week to study the effects of this regimen on your immune 
system. The maximum amount of blood for research is approximately 2.3 cups in 8 weeks. 
We may ask you to allow us to perform a biopsy of your lymph node after receiving the therapy 
to look at the effects of the therapy on the immune cells in your cancer. However, this biopsy is 
not required for you to participate in this experimental study. To obtain cells by a biopsy, a small 
area of skin is numbed with an anesthetic and a small piece of your tumor is removed, either with 
a needle or by a small cut in the tumor. The area is covered with a bandage for a day or two, 
during which time we will ask you to keep it dry.  
Follow-up and Evaluation of Experimental Regimen  
You will need to continue to take Bactrim, an antibiotic, for at least 6 months following your 
therapy. We will ask you to return to the NIH Clinical Center frequently after you are discharged 
approximately 6 and 12 weeks following treatment and then if you are responding to the 
treatment, every 1-3 months for the first year following treatment, every 6 months for the second 
year and then as determined by your physician. The follow up visits will probably take 1-2 days. 
At each visit you will have lab tests, imaging studies and a physical examination. At some of 
your follow up visits, you may undergo leukapheresis or have about 8 tubes of blood drawn (4 
tablespoons) so that we can see the effect this therapy has had on your immune system and if the 
cells we gave you are still alive. If you are unwilling or unable to travel to the NIH Clinical 
Center we will contact you by phone or e-mail and we may ask you to send us lab, imaging, and 
physical exam reports. If your tumor appears to be growing, we will look for other 
investigational therapies you may be eligible for, or refer you back to the care of your local 
physician. 
Retreatment 
If your disease grows after experiencing tumor shrinkage or disappearance or if you have 
residual disease at the second or subsequent assessments following the initial treatment you may 
receive one additional treatment if you tolerated the treatment well and if all the side effects have 
resolved. If you are retreated, you will receive the currently enrolling dose level.  
Birth Control 
If you are a woman who is breast feeding or pregnant, you may not participate in the study 
because we don’t know how this medicine would affect your unborn child or your baby. If you 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 7 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
are a woman who can become pregnant, or are the partner of a woman who can become 
pregnant, you will need to practice an effective form of birth control before starting study 
therapy and for four months after you finish study therapy. If you think that you or your partner 
is pregnant, you should tell your study doctor or nurse at once.  
Effective forms of birth control include:  
• abstinence 
• intrauterine device (IUD) 
• hormonal [birth control pills, injections, or implants] 
• tubal ligation 
• vasectomy 
Gene Therapy Long-Term Follow-up (Retroviral Vectors)  
Because we do not know the long-term side effects of gene therapy, we will collect your blood 
over the next several years, frequently at first and then less frequently. If you return to your 
referring physician after treatment here we will ask you to have your physician send your blood 
specimens here for this testing. This testing will determine if the cells have grown or changed in 
your body. We will test your blood immediately after you receive the cells, and then at 3, 6 and 
12 months (2 teaspoons each time). If all of the tests are normal and show no change, we will 
collect blood from you every year after that to store in case you develop symptoms later. 
According to FDA requirements, we need you to return annually to the NIH for a physical 
examination for five years after you receive the cells. After that time, we will be sending you a 
questionnaire to get information regarding your health for the next ten years, for a total follow up 
time period of 15 years. For this reason, we ask that you continue to provide us with a current 
address and telephone number, even after you complete this research study. At the time of your 
death, no matter the cause, we may request permission for an autopsy in order to obtain vital 
information concerning the safety of this experimental treatment approach. Please discuss this 
with your family to inform them of this request. 
Risks or Discomforts of Participation 
What side effects or risks can I expect from being in this study? 
The risks and discomforts of this research study can be significant. This experimental therapy 
can lead to long-term decrease in your immune function. It is also possible that you may lose 
your fertility following this experimental therapy. It is possible, although unlikely, that this 
experimental therapy may cause your death.  
We will discuss the side effects of this experimental treatment with you. You will be given 
medicines, transfusions, and treatments to prevent or treat the side effects including drugs to 
prevent and/or treat different types of infections. We will try to make you as comfortable as 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 8 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
possible. You should talk to your study doctor about any symptoms that you experience while 
taking part in the study. 
Leukapheresis 
During the leukapheresis procedure, you may have some tingling in your face and lips due to the 
medicine used to keep your blood from clotting during the procedure. The nurses may give you a 
calcium containing antacid, like TUMS to chew that takes away this tingling. Rarely, people may 
experience lightheadedness or dizziness. We ask that you eat prior to the procedure to prevent 
this. Rare complications of this procedure are lowered blood pressure or bleeding. 
Lumbar Puncture 
Lumbar puncture (LP) is a very common and safe procedure. The most common side effect from 
a lumbar puncture is a headache which can last from several hours to several days. You will be 
asked to lie flat for several hours following the procedure in order to decrease the chance of you 
getting a headache. The other less common side effects include bleeding and back discomfort. In 
extremely rare situations, removing the spinal fluid could cause compression of your brain stem. 
This causes increased pressure within your skull and is a medical emergency. 
Cryopreserved Anti-CD19 Cell Infusion (Gene Therapy)  
The cells we will be giving you have a type of virus (retrovirus) put into them along with the 
anti-CD19 gene. Although this retrovirus is not active, there is the rare possibility that it may 
cause infection. The cells could also cause you to develop another type of cancer in your blood 
cells. Other gene-modified cells have been given only to a few individuals before so we do not 
have much information about the side effects. Potential risks include:  
• Fever, chills and shortness of breath, which may last for a few hours (common) 
• Lung congestion  
• Rash 
• Low blood pressure sometimes requiring treatment in the intensive care unit  
• Minor neurological side effects including, facial droop, dizziness and difficulty finding 
words 
• Major neurological complications that may require intubation including: becoming 
difficult to arouse and tremors 
• Immune-mediated toxicity, from targeting of the B cells in your blood, which may 
increase the risk of infection. Note: In similar clinical trials with cells targeting a 
melanoma protein, we have observed the following immune-mediated toxicities: loss of 
skin pigment (known as vitiligo), inflammation of the eye (uveitis), hearing loss, and 
dizziness. The skin, the eye, and the ear are all sites that contain the melanoma protein 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 9 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
used in these trials. Since B cells do not have this protein we do not expect these 
toxicities to occur with the anti-CD19 cell infusion.  
• You will be treated on this gene transfer protocol with a viral vector that was 
manufactured at the NCI Surgery Branch Vector Production Facility before May 2016. 
An internal review of the facility that made the vector for this protocol determined that 
the facility needed to be closed due to manufacturing issues. We know of no additional 
risks related to the previously produced vector for patients who have received cells with 
vectors made in this facility as the vectors were extensively tested by outside experts. 
Therefore, the IRB has determined that the potential benefit to you outweighs the 
potential risks. 
• There is little data available at this time to guide us in how humans might respond to this 
type of cell infusion. As this is a new experimental therapy, side effects that we do not 
anticipate that may cause your condition to deteriorate may be encountered. Any new 
information that becomes available during the course of this study will be shared with 
you. 
Medications 
The side effects of cyclophosphamide, fludarabine, and some of the other medications you may 
receive are listed in the tables on the next pages.  
Cyclophosphamide and Fludarabine Side Effects 
Common 
Less Common 
Rare 
 
Changes in blood counts 
including: low red cell count
(causing fatigue and 
shortness of breath), low 
platelet count (increasing the
risk of bleeding and 
bruising), decrease in white 
blood cells (increasing the 
risk of infection and the 
need for treatment with 
antibiotics or other 
treatment)  
 
Loss of appetite, nausea, 
vomiting,  
 
Diarrhea, stomach pain 
 
Mouth sores 
 
Bleeding 
 
Infection* 
 
Bladder irritation with 
bloody urine 
 
Severe allergic reaction 
(difficulty 
breathing/swelling) 
 
Headache or dizziness 
 
Sweating 
 
Swelling of arms or legs 
 
Skin changes, rash, blisters  
 
Weakness 
 
Hearing loss 
 
Heart damage 
 
Lung damage 
 
Kidney damage 
 
Inflammation of the eye 
resulting in blindness 
 
Inflammation of nervous 
system resulting in death 
 
Epstein Barr Virus 
Lymphoma. This can be 
fatal (Two patients on other 
studies in the Surgery 
Branch developed EBV 
lymphoma, and one died as a
result of this disease.) 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 10 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
 
Hair loss 
 
Fatigue 
 
Muscle or joint aches  
 
*One patient who received anti-
CD19 cells died of pneumonia 
caused by an infection with 
H1N1 18 days after cell 
infusion. 
 
Loss of fertility 
 
Myelodysplastic Syndrome  
 
Support Medications – Side Effects 
Common 
Less Common 
Rare 
Filgrastim (To increase production of white blood cells) 
 
Bone Pain 
 
Severe headache 
 
Severe breathing problems 
 
Rupture of your spleen 
Bactrim (To prevent a specific type of pneumonia) 
 
 
Fever 
 
Nausea, vomiting, 
 
Skin rash with itching 
 
reduced number of white 
blood cells 
 
Allergic reaction 
 
Fluconazole (To prevent fungal infections)  
 
Headache 
 
Nausea, vomiting, diarrhea, 
abdominal pain 
 
Itching  
 
 
A skin disorder called 
Stevens Johnson Syndrome, 
which can be fatal 
 
Liver damage which may be
permanent 
Acyclovir and Valacyclovir 
 
 
Temporary decrease in 
kidney function which may 
not cause any symptoms 
 
Nausea, vomiting, diarrhea, 
constipation  
 
Skin rash, hives, itching  
 
Tremors, dizziness, 
Confusion, seizures 
 
Fatigue  
 
Blood in the urine 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 11 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
 
Pain and irritation at place o
injection 
 
Allopurinol (To prevent Tumor Lysis Syndrome) 
 
Skin rash or sores 
 
Hives 
 
Itching 
 
Drowsiness (patient should 
not drive or use machines 
until they feel alert again) 
 
Chills 
 
Fever 
 
Joint pain 
 
Muscle aches or pains 
 
Sore throat 
 
Nausea or vomiting 
Prior to and throughout this study you will undergo many tests to determine the extent of your 
cancer, as well as the impact of the therapy. If your disease progresses or recurs after this 
experimental therapy then you will no longer receive therapy in this protocol, though you may be 
eligible to be considered for other protocols at the National Cancer Institute, NIH or referred 
elsewhere for therapy. 
Gene Therapy Risk of Cancer and Other Diseases  
We are unsure if this type of gene therapy will cause you to become sick in the future. It is 
possible that it may cause your immune system or nerves not to work well or cause a sickness of 
your blood cells or even a cancer. We do not know if you will develop any of these disorders, but 
you need to be aware of this possible risk. Children in France and England received gene therapy 
for a particular disease of the immune system. Most of the children were cured but 5 children out 
of 22 later developed leukemia and one died. Experts who looked at these cases thought that the 
gene therapy caused the leukemia in these children. To monitor you for this risk we will be 
testing your blood 3 months after cell infusion, then at 6 and 12 months, and then annually 
thereafter. If we find that the cells we have given you grow out of control, chemotherapy will be 
given to you to kill the cells, given their risk of causing leukemia or a second cancer. 
Potential Benefits of Participation 
Are there benefits to taking part in this study?  
The aim of this study is to see if this experimental treatment will cause your tumors to shrink. 
We do not know if you will receive personal, medical benefit from taking part in this study. 
These potential benefits could include shrinking of your tumor or lessening of your symptoms, 
such as pain, that are caused by the cancer. Because there is not much information about the 
effect of this treatment on cancer, we do not know if you will benefit from taking part in this 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 12 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
study, although the knowledge gained from this study may help others in the future who have 
cancer. 
Alternative Approaches or Treatments 
What other choices do I have if I do not take part in this study?  
Other options for treatment of your cancer include: 
• Taking part in another study  
• Getting treatment or care for your cancer without being in a study 
• Getting comfort care which is also called palliative care. This type of care helps reduce 
pain, tiredness, appetite problems, and other problems caused by cancer. It does not treat 
the cancer directly, but instead tries to improve how you feel. Comfort care tries to keep 
you as active and comfortable as possible. 
• Allogeneic transplantation (curative option for some patients)  
Please talk to your doctor about these and other options. 
Research Subject's Rights 
What are the costs of taking part in this study?  
If you choose to take part in the study, the following will apply, in keeping with the NIH policy: 
• You will receive study treatment at no charge to you. This may include surgery, 
medicines, laboratory testing, x-rays or scans done at the Clinical Center, National 
Institutes of Health (NIH), or arranged for you by the research team to be done outside 
the Clinical Center, NIH if the study related treatment is not available at the NIH.  
• There are limited funds available to cover the cost of some tests and procedures 
performed outside the Clinical Center, NIH. You may have to pay for these costs if they 
are not covered by your insurance company. 
• Medicines that are not part of the study treatment will not be provided or paid for by the 
Clinical Center, NIH. 
• Once you have completed taking part in the study, medical care will no longer be 
provided by the Clinical Center, NIH. 
Will your medical information be kept private?  
We will do our best to make sure that the personal information in your medical record will be 
kept private. However, we cannot guarantee total privacy. Organizations that may look at and/or 
copy your medical records for research, quality assurance, and data analysis include: 


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 13 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
• The National Cancer Institute (NCI) and other government agencies, like the Food and 
Drug Administration (FDA), which are involved in keeping research safe for people. 
• National Cancer Institute Institutional Review Board 
• The study Sponsor (Center for Cancer Research) or their agents  
• Kite Pharma 
A description of this clinical trial will be available on http://www.Clinicaltrials.gov, as required 
by U.S. Law. This Web site will not include information that can identify you. At most the Web 
site will include a summary of the results. You can search this Web site at any time.  
Stopping Therapy  
Your doctor may decide to stop your therapy for the following reasons: 
• if he/she believes that it is in your best interest 
• if your disease comes back during treatment 
• if you have side effects from the treatment that your doctor thinks are too severe 
• if new information shows that another treatment would be better for you 
In this case, you will be informed of the reason therapy is being stopped. 
You can stop taking part in the study at any time. However, if you decide to stop taking part in 
the study, we would like you to talk to the study doctor and your regular doctor first. 
If you decide at any time to withdraw your consent to participate in the trial, we will not collect 
any additional medical information about you. However, according to FDA guidelines, 
information collected on you up to that point may still be provided to the Sponsor. If you 
withdraw your consent and leave the trial, any samples of yours that have been obtained for the 
study and stored at the NCI can be destroyed upon request. However, any samples and data 
generated from the samples that have already been distributed to other researchers or placed in 
the research databases cannot be recalled and destroyed. 
Certificate of Confidentiality  
To help us protect your privacy, we have obtained a Certificate of Confidentiality. The 
researchers can use this Certificate to legally refuse to disclose information that may identify you 
in any federal, state, or local civil, criminal, administrative, legislative, or other proceedings, for 
example, if there is a court subpoena. The researchers will use the Certificate to resist any 
demands for information that would identify you, except as explained below. 
You should also know that there are several circumstances in which the Certificate does not 
provide coverage. These include when information:  
• will be used for auditing or program evaluation internally by the NIH; or  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 14 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
• must be disclosed to meet the legal requirements of the federal Food and Drug 
Administration (FDA).  
• is necessary for your medical treatment and you have consented to this disclosure;  
• is for other research.  
In addition, identifiable, sensitive information protected by this Certificate cannot be admissible 
as evidence or used for any purpose in any action, suit, or proceeding without your consent.  
You should understand that a Certificate of Confidentiality does not prevent you or a member of 
your family from voluntarily releasing information about yourself or your involvement in this 
research. If an insurer, employer, or other person obtains your written consent to receive research 
information, then the researchers will not use the Certificate to withhold that information. 
The Certificate of Confidentiality will not protect against the required reporting by hospital staff 
of information on suspected child abuse, reportable communicable diseases, and/or possible 
threat of harm to self or others. 
Conflict of Interest 
The National Institutes of Health (NIH) reviews NIH staff researchers at least yearly for conflicts 
of interest. This process is detailed in a Protocol Review Guide. You may ask your research team 
for a copy of the Protocol Review Guide or for more information. Members of the research team 
who do not work for NIH are expected to follow these guidelines but they do not need to report 
their personal finances to the NIH. 
Members of the research team working on this study may have up to $15,000 of stock in the 
companies that make products used in this study. This is allowed under federal rules and is not a 
conflict of interest.  
The National Institutes of Health and the research team for this study are working with Kite 
Pharma to see if this type of study could be done at institutions other than the NIH Clinical 
Center. Kite Pharma also provides financial support for this study. 
Use of Specimens and Data for Future Research 
Specimens and data collected during the course of this study will be used for future research and 
will be stored, tracked and disposed of under our companion protocol 03-C-0277, (Cell Harvest 
and Preparation for Surgery Branch Adoptive Cell Therapy Protocols) on which you have 
already been enrolled.  
In addition, to advance science, it is helpful for researchers to share information they get from 
studying human samples. They do this by putting it into one or more scientific databases, where 
it is stored along with information from other studies. A researcher who wants to study the 
information must apply to the database and be approved. Researchers use specimens and data 
stored in scientific databases to advance science and learn about health and disease.  


MEDICAL RECORD 
CONTINUATION SHEET for either: 
NIH 2514-1, Consent to Participate in A Clinical Research Study 
NIH 2514-2, Minor Patient’s Assent to Participate In A Clinical Research Study 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 15 of 17 pages 
 
PATIENT IDENTIFICATION 
CONTINUATION SHEET for either: 
NIH-2514-1 (07-09) 
NIH-2514-2 (10-84) 
P.A.: 09-25-0099 
File in Section 4: Protocol Consent 
 
 
We plan to keep some of your specimens and data that we collect and use them for future 
research and share them with other researchers. We will not contact you to ask about each of 
these future uses. These specimens and data will be stripped of identifiers such as name, address 
or account number, so that they may be used for future research on any topic and shared broadly 
for research purposes. Your specimens and data will be used for research purposes only and will 
not benefit you. It is also possible that the stored specimens and data may never be used. Results 
of research done on your specimens and data will not be available to you or your doctor. It might 
help people who have cancer and other diseases in the future.  
If you do not want your stored specimens and data used for future research, please contact us in 
writing and let us know that you do not want us to use your specimens and/or data. Then any 
specimens that have not already been used or shared will be destroyed and your data will not be 
used for future research. However, it may not be possible to withdraw or delete materials or data 
once they have been shared with other researchers. 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 16 of 17 pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.: 09-25-0099 
 
File in Section 4: Protocol Consent 
 
 
 
OTHER PERTINENT INFORMATION 
1. 
Confidentiality. When results of an NIH research study are reported in medical journals 
or at scientific meetings, the people who take part are not named and identified. In most cases, 
the NIH will not release any information about your research involvement without your written 
permission. However, if you sign a release of information form, for example, for an insurance 
company, the NIH will give the insurance company information from your medical record. This 
information might affect (either favorably or unfavorably) the willingness of the insurance 
company to sell you insurance. 
The Federal Privacy Act protects the confidentiality of your NIH medical records. However, you 
should know that the Act allows release of some information from your medical record without 
your permission, for example, if it is required by the Food and Drug Administration (FDA), 
members of Congress, law enforcement officials, or authorized hospital accreditation 
organizations. 
2. 
Policy Regarding Research-Related Injuries. The Clinical Center will provide short-
term medical care for any injury resulting from your participation in research here. In general, no 
long-term medical care or financial compensation for research-related injuries will be provided 
by the National Institutes of Health, the Clinical Center, or the Federal Government. However, 
you have the right to pursue legal remedy if you believe that your injury justifies such action. 
3. 
Payments. The amount of payment to research volunteers is guided by the National 
Institutes of Health policies. In general, patients are not paid for taking part in research studies at 
the National Institutes of Health. Reimbursement of travel and subsistence will be offered 
consistent with NIH guidelines. 
4.  
Problems or Questions. If you have any problems or questions about this study, or about 
your rights as a research participant, or about any research-related injury, contact the Principal 
Investigator Steven A. Rosenberg, M.D., Ph.D.; Building CRC, Room 3-3940, Telephone: 240-
760-6218. You may also call the Clinical Center Patient Representative at (301) 496-2626. If you 
have any questions about the use of your specimens or data for future research studies, you may 
also contact the Office of the Clinical Director, Telephone: 240-760-6070. 
5. 
Consent Document. Please keep a copy of this document in case you want to read it 
again. 
 
 


MEDICAL RECORD 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY 
• 
Adult Patient or 
• Parent, for Minor Patient 
STUDY NUMBER: 09-C-0082 
CONTINUATION: page 17 of 17 pages 
 
PATIENT IDENTIFICATION 
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH 
STUDY (Continuation Sheet) 
• Adult Patient or 
• Parent, for Minor Patient 
NIH-2514-1 (07-09) 
P.A.: 09-25-0099 
 
File in Section 4: Protocol Consent 
 
 
 
COMPLETE APPROPRIATE ITEM(S) BELOW: 
A. Adult Patient’s Consent 
B. Parent’s Permission for Minor Patient 
I have read the explanation about this study 
and have been given the opportunity to discuss 
it and to ask questions. I hereby consent to 
take part in this study. 
I have read the explanation about this study 
and have been given the opportunity to discuss 
it and to ask questions. I hereby give 
permission for my child to take part in this 
study.  
(Attach NIH 2514-2, Minor’s Assent, if 
applicable.) 
 
  
  
 
 
 
Signature of Adult Patient/ 
Legal Representative 
Date 
Signature of Parent(s)/ Guardian Date 
 
 
Print Name 
 
 
Print Name 
C. Child’s Verbal Assent (If Applicable) 
The information in the above consent was described to my child and my child agrees to 
participate in the study. 
 
  
  
 
Signature of Parent(s)/Guardian 
Date 
Print Name 
THIS CONSENT DOCUMENT HAS BEEN APPROVED FOR USE  
FROM SEPTEMBER 15, 2020 THROUGH SEPTEMBER 14, 2021. 
 
 
 
 
 
 
 
 
 
 
 
 
Signature of Investigator 
Date 
Signature of Witness 
Date 
 
 
Print Name 
 
 
Print Name 
 

Prot_SAP_000.pdf: 
Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Abbreviated Title: Anti-CD19 CAR PBL 
CC Protocol Number: 09-C-0082 DD 
IBC Number: RD-08-VII-10 
OSP Number: 0809-940  
NCT Number: NCT00924326 
Version Date: August 23, 2018 
PROTOCOL TITLE 
An Assessment of the Safety and Feasibility of Administering T-Cells Expressing an Anti-CD19 
Chimeric Antigen Receptor to Patients with B-Cell Lymphoma  
 
NIH Principal Investigator:  
Steven A. Rosenberg, M.D., Ph.D. 
 
 
 
 
 
Chief of Surgery, Surgery Branch, CCR, NCI 
 
 
 
 
 
Building 10, CRC, Room 3-3940 
 
 
 
 
 
9000 Rockville Pike, Bethesda, MD 20892 
 
 
 
 
 
Phone: 240-760-6218; Email: Steven.Rosenberg@nih.gov 
 
Investigational Agent: 
Drug Name: 
PG13-CD19-H3 (anti-CD19 CAR) retroviral vector-
transduced autologous PBL 
IND Number: 
13871 
Sponsor:  
Center for Cancer Research 
Manufacturer: Surgery Branch Cell Production Facility 
 
 
Commercial Agents: Cyclophosphamide and Fludarabine 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
PRÉCIS 
Background: 
• We have constructed a retroviral vector that encodes an anti-CD19 chimeric antigen 
receptor (CAR) that recognizes the CD19 antigen. This chimeric receptor also contains 
the signaling domains of CD28 and CD3-zeta. The retroviral vector can be used to 
mediate genetic transfer of this CAR to T-cells with high efficiency (> 50%) without the 
need to perform any selection.  
• In co-cultures with CD19-expressing target cells, anti-CD19-CAR-transduced T-cells 
secreted significant amounts of IFN-γ and IL-2.  
• We have developed a process for cryopreserving the cell product which may lead to the 
ability for this product to be manufactured at a central location and shipped to other 
institutions for treatment of a broader patient population. 
Objective: 
• Primary objective:  
o With the approval of Amendment S, to determine the safety and feasibility of the 
administration of cryopreserved anti-CD19-CAR engineered peripheral blood 
lymphocytes with a non-myeloablative conditioning regimen in patients with B-cell 
lymphomas. 
Eligibility: 
• Patients of 18 years of age or older must:  
o Have a CD19-expressing B-cell lymphoma  
o Be a non-responder to, or recurred after one or more standard chemotherapy-
containing regimens for their malignancy 
o Currently require treatment due to progressive malignancy 
o Be deemed to be incurable by standard therapy  
• Patients may not have: 
o A history of allogeneic stem cell transplantation 
o CNS disease 
Design: 
• PBMC obtained by leukapheresis (approximately 5.0x109 cells) will be cultured in the 
presence of anti-CD3 (OKT3) and aldesleukin in order to stimulate T-cell proliferation. 
• Transduction is initiated by exposure of approximately 1.0x108 to 5.0x108 cells to 
retroviral vector supernatant containing the anti-CD19 CAR.  
• With the approval of Amendment S, patients will receive fludarabine and 
cyclophosphamide chemotherapy (NMA) for lymphodepletion, followed by 
cryopreserved anti-CD19-CAR-transduced T-cells.  
• Patients will be followed until disease progression. 
• Patients who have responded to treatment and then progress may receive one retreatment. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
TABLE OF CONTENTS 
PRÉCIS .......................................................................................................................................... 2 
TABLE OF CONTENTS ............................................................................................................. 3 
1 
INTRODUCTION ................................................................................................................. 8 
1.1 Study Objectives ..................................................................................................................... 8 
1.1.1 
Prior to Amendment E ................................................................................................ 8 
1.1.2 
With Approval of Amendments E and F .................................................................... 8 
1.1.3 
With Approval of Amendment H (this study will no longer include aldesleukin) ..... 8 
1.1.4 
With Approval of Amendment S (this study will include cryopreserved anti-CD19-
CAR PBL) ............................................................................................................................... 9 
1.2 Background and Rationale ...................................................................................................... 9 
1.2.1 
Prior Surgery Branch Trials of Cell Transfer Therapy Using Heterogeneous TIL 
Plus High-Dose IL-2 Following Non-myeloablative but Lymphodepleting Chemotherapy 10 
1.2.2 
Surgery Branch Trials of Cell Transfer Therapy Using Transduction of TCR Genes 
that Encode TCR that Recognize Tumor-Associated Antigens into Non-Reactive PBL ..... 10 
1.2.3 
Chimeric Antigen Receptors (CARs) ....................................................................... 12 
1.2.4 
B-Cell Malignancies ................................................................................................. 13 
1.2.5 
CD19 ......................................................................................................................... 14 
1.2.6 
Development of an Anti-CD19 CAR for Clinical Adoptive T-Cell Transfer .......... 14 
1.2.7 
Other Anti-CD19 CAR Clinical Trials ..................................................................... 15 
1.2.8 
Rationale for Measuring Persistence of Adoptively Transferred T-Cells With or 
Without Lymphodepleting Chemotherapy Prior to Adoptive Transfer ................................ 16 
1.2.9 
Safety Considerations ............................................................................................... 16 
1.2.10 
Cryopreservation of the Anti-CD19 CAR Transduced T-Cell Product ................ 17 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT .................................................. 20 
2.1 Eligibility Criteria ................................................................................................................. 20 
2.1.1 
Inclusion Criteria ...................................................................................................... 20 
2.1.2 
Exclusion Criteria ..................................................................................................... 21 
2.2 Screening Evaluation ............................................................................................................ 22 
2.2.1 
Within 4 Weeks Prior to Starting the Chemotherapy Regimen ................................ 22 
2.2.2 
Within 14 Days Prior to Starting the Chemotherapy Regimen................................. 23 
2.2.3 
Within 7 Days Prior to Starting the Chemotherapy Regimen................................... 23 
2.3 Protocol Registration ............................................................................................................ 23 
2.3.1 
Prior to Registration for this Protocol ....................................................................... 23 
2.3.2 
Registration Procedure .............................................................................................. 23 
3 
STUDY IMPLEMENTATION .......................................................................................... 23 
3.1 Study Design – Beginning with Amendment S .................................................................... 24 
3.1.1 
Treatment Phase: Cryopreserved PBL ...................................................................... 24 
3.1.2 
Definition of Dose-Limiting Toxicity (DLT) ........................................................... 26 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
3.2 Protocol Stopping Rules ....................................................................................................... 27 
3.3 Drug Administration ............................................................................................................. 28 
3.3.1 
Preparative Regimen with Cyclophosphamide and Fludarabine .............................. 29 
3.3.2 
Cell Infusion.............................................................................................................. 29 
3.3.3 
Study Calendar .......................................................................................................... 29 
3.4 On-Study Evaluation ............................................................................................................. 30 
3.4.1 
Prior to Starting the Preparative Regimen ................................................................ 30 
3.4.2 
During the Preparative Regimen (Daily) .................................................................. 30 
3.4.3 
After Cell Infusion .................................................................................................... 30 
3.4.4 
During Hospitalization (Every 1-2 Days as Clinically Indicated) ............................ 31 
3.5 Retreatment ........................................................................................................................... 31 
3.6 Post-Study Evaluation (Follow-up) ...................................................................................... 32 
3.6.1 
Time-Period of Evaluations ...................................................................................... 32 
3.6.2 
Scheduled Evaluations .............................................................................................. 32 
3.7 Criteria for Removal from Protocol Therapy and Off-Study Criteria .................................. 33 
3.7.1 
Criteria for Removal from Protocol Therapy............................................................ 33 
3.7.2 
Off-Study Criteria ..................................................................................................... 33 
3.7.3 
Off Protocol Therapy and Off-Study Procedure ....................................................... 34 
4 
CONCOMITANT MEDICATIONS/MEASURES .......................................................... 34 
4.1 Infection Prophylaxis ............................................................................................................ 34 
4.1.1 
Pneumocystis Jirovecii Pneumonia........................................................................... 34 
4.1.2 
Herpes Virus Prophylaxis ......................................................................................... 34 
4.1.3 
Fungal Prophylaxis ................................................................................................... 34 
4.1.4 
Empiric Antibiotics ................................................................................................... 34 
4.1.5 
Prophylaxis and Treatment of Tumor Lysis Syndrome ............................................ 35 
4.2 Blood Product Support .......................................................................................................... 35 
4.3 Other Concomitant Medications to Control Side Effects ..................................................... 35 
5 
BIOSPECIMEN COLLECTION ...................................................................................... 35 
5.1 Research Evaluations ............................................................................................................ 35 
5.1.1 
Prior to Chemotherapy Administration ..................................................................... 35 
5.1.2 
Prior to Cell Infusion (1-8 mL SST) ......................................................................... 35 
5.1.3 
Post-Cell Infusion Evaluations ................................................................................. 36 
5.2 Immunological Testing ......................................................................................................... 36 
5.3 Monitoring Gene Therapy Trials: Persistence and RCR ...................................................... 36 
5.4 Sample Storage, Tracking, and Disposition .......................................................................... 37 
6 
DATA COLLECTION AND EVALUATION ................................................................. 37 
6.1 Data Collection ..................................................................................................................... 37 
6.1.1 
Routine Adverse Event Recording............................................................................ 38 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
6.2 Data Sharing Plans ................................................................................................................ 38 
6.2.1 
Human Data Sharing Plan ......................................................................................... 38 
6.2.2 
Genomic Data Sharing Plan ...................................................................................... 38 
6.3 Response Criteria .................................................................................................................. 38 
6.3.1 
Anti-Malignancy Response Criteria ......................................................................... 38 
6.4 Persistence Criteria for Anti-CD19 CAR Transduced T-Cells ............................................. 40 
6.5 Toxicity Criteria .................................................................................................................... 40 
7 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN ............................................................................................................................................ 40 
7.1 Definitions ............................................................................................................................. 40 
7.1.1 
Adverse Event ........................................................................................................... 40 
7.1.2 
Suspected Adverse Reaction ..................................................................................... 41 
7.1.3 
Unexpected Adverse Reaction .................................................................................. 41 
7.1.4 
Serious....................................................................................................................... 41 
7.1.5 
Serious Adverse Event .............................................................................................. 41 
7.1.6 
Disability ................................................................................................................... 41 
7.1.7 
Life-Threatening Adverse Drug Experience ............................................................. 41 
7.1.8 
Protocol Deviation (NIH Definition) ........................................................................ 42 
7.1.9 
Non-Compliance (NIH Definition) ........................................................................... 42 
7.1.10 
Unanticipated Problem.......................................................................................... 42 
7.2 IRB and Clinical Director (CD) Reporting ........................................................................... 42 
7.2.1 
IRB and NCI CD Expedited Reporting of Unanticipated Problems, and Deaths ..... 42 
7.2.2 
IRB Requirements for PI Reporting at Continuing Review ..................................... 42 
7.2.3 
IRB Reporting of IND Safety Reports ...................................................................... 43 
7.3 IND Sponsor Reporting Criteria ........................................................................................... 43 
7.3.1 
Reporting Pregnancy ................................................................................................. 43 
7.4 Institutional Biosafety Committee (IBC) Reporting Criteria ................................................ 44 
7.4.1 
Serious Adverse Event Reports to IBC ..................................................................... 44 
7.4.2 
Annual Reports to IBC.............................................................................................. 44 
7.5 Data and Safety Monitoring Plan .......................................................................................... 45 
7.5.1 
Principal Investigator/Research Team ...................................................................... 45 
7.5.2 
Sponsor Monitoring Plan .......................................................................................... 46 
7.5.3 
Safety Monitoring Committee (SMC) ...................................................................... 46 
8 
STATISTICAL CONSIDERATIONS .............................................................................. 46 
9 
COLLABORATIVE AGREEMENTS .............................................................................. 53 
10 HUMAN SUBJECTS PROTECTIONS ............................................................................ 53 
10.1 Rationale for Subject Selection ............................................................................................. 53 
10.2 Participation of Children ....................................................................................................... 53 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
10.3 Participation of Subjects Unable to Give Consent ................................................................ 53 
10.4 Evaluation of Benefits and Risks/Discomforts ..................................................................... 54 
10.5 Risk/Benefit Analysis ........................................................................................................... 54 
10.6 Consent Process and Documentation .................................................................................... 54 
10.6.1 
Telephone Consent................................................................................................ 54 
11 PHARMACEUTICAL INFORMATION ......................................................................... 54 
11.1 Investigational Regimen ....................................................................................................... 54 
11.1.1 
Anti-CD19 CAR transduced PBL ......................................................................... 54 
11.1.2 
Fludarabine ........................................................................................................... 55 
11.1.3 
Cyclophosphamide ................................................................................................ 56 
11.2 Support Medications ............................................................................................................. 57 
11.2.1 
Mesna (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) .. 57 
11.2.2 
Filgrastim (Granulocyte Colony-Stimulating Factor, G-CSF, Filgrastim, 
Neupogen) ............................................................................................................................. 58 
11.2.3 
Trimethoprim and Sulfamethoxazole Double Strength (TMP / SMX DS) .......... 58 
11.2.4 
Herpes Virus Prophylaxis ..................................................................................... 58 
11.2.5 
Fluconazole ........................................................................................................... 59 
11.2.6 
Ondansetron Hydrochloride .................................................................................. 59 
11.2.7 
Allopurinol ............................................................................................................ 59 
12 REFERENCES .................................................................................................................... 60 
13 TABLES, FIGURES, AND APPENDICES ...................................................................... 64 
13.1 Table 1: Surgery Branch Cell Therapy Studies .................................................................... 64 
13.2 Table 2: Time in Hospital and Non-Hematological Grade 3 and 4 Toxicities Related to 
Lymphodepleting Chemotherapy and Cell Transfer..................................................................... 67 
13.3 Figure 1: Cancer Regression in Two Patients ....................................................................... 68 
13.4 Figure 2: Normal PBMC can be Transduced with an Anti-CD19 CAR ............................... 69 
13.5 Figure 3: PBMC Transduced with Anti-CD19 CAR Recognize CD19-Expressing Target 
Cells .............................................................................................................................................. 70 
13.6 Figure 4: T-Cells from a CLL Patient Post Fludarabine/Rituximab Therapy....................... 71 
13.7 Figure 5: Anti-CD19-Transduced T-Cells Maintain Function Following Rapid Expansion 72 
13.8 Figure 6: T-Cells Produce IFN-gamma and IL-2 in Response to CD-19-Expressing Target 
Cells Following Rapid Expansion ................................................................................................ 73 
13.9 Figure 7: Anti-CD19-CAR-Transduced T-Cells Dependent Upon Exogenous IL-2 for In 
Vitro Survival................................................................................................................................ 74 
13.10 
Figure 8: Overview of the 6-Day Cryopreserved Cell Production Process .................. 75 
13.11 
Figure 9: Comparison of Transduction Efficiency of PBMC in Closed vs Open System
 
76 
13.12 
Figure 10: Total Cell Number of PBMC Following Transduction in Closed vs Open 
System 77 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.13 
Figure 11: Cell Expansion of PBMC Following Transduction in Closed vs Open 
System 78 
13.14 
Figure 12: Comparison of IFN-gamma Release of Cells Transduced and Expanded in 
Closed vs Open System ................................................................................................................ 79 
13.15 
Figure 14: Comparison of Percentage and Viability of CAR+ T-Cells Manufactured in 
6-Day Closed Process ................................................................................................................... 81 
13.16 
Figure 15: Comparison of IFN-gamma Release of CAR+ T-Cells Manufactured in 6-
Day Closed Process After Cryopreservation ................................................................................ 82 
13.17 
Figure 16: Comparison of Viability and Fold Expansion of CAR+ T-Cells 
Manufactured in 6-Day Closed Process After Cryopreservation ................................................. 83 
13.18 
Figure 17: Phenotype of CD19 CAR+ T-Cells Manufactured in 6-Day Closed Process 
Before and After Cryopreservation ............................................................................................... 84 
13.19 
Appendix 1: Certificate of Analysis ............................................................................. 85 
13.20 
Appendix 2: Description of Dose De-Escalations (Cohorts 1-7).................................. 86 
13.21 
Appendix 3: Description of Dose Escalation for Fresh Anti-CD19 TIL (Cohorts 8-10)
 
91 
13.22 
Appendix 4: Modification of Dose Calculations* in Patients Whose BMI is Greater 
than 35 94 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
1 
INTRODUCTION 
 
1.1 
STUDY OBJECTIVES 
1.1.1 Prior to Amendment E 
1.1.1.1 Primary Objectives  
• Phases I and II: 
o Determine the safety of the administration of anti-CD19-CAR engineered peripheral 
blood lymphocytes and aldesleukin either with or without a non-myeloablative 
conditioning regimen in patients with B-cell malignancies. 
• Phase II only: 
o Determine if lymphodepletion with fludarabine plus cyclophosphamide given prior to 
infusion of anti-CD19-CAR-transduced T-cells and aldesleukin can enhance 
persistence of the anti-CD19-CAR-transduced T-cells. 
1.1.1.2 Secondary Objective 
• Phases I and II: 
o Determine if the administration of anti-CD19-CAR engineered peripheral blood 
lymphocytes and aldesleukin either with or without the non-myeloablative 
conditioning regimen causes regression of B-cell malignancies. 
1.1.2 With Approval of Amendments E and F 
1.1.2.1 Primary Objective  
• Determine the safety and feasibility of the administration of anti-CD19-CAR engineered 
peripheral blood lymphocytes and aldesleukin with a non-myeloablative conditioning 
regimen in patients with B-cell malignancies. 
1.1.2.2 Secondary Objectives 
• Determine the in vivo survival of the anti-CD19-CAR-transduced T-cells. 
• Determine if the treatment regimen cause regression of B-cell malignancies. 
1.1.3 With Approval of Amendment H (this study will no longer include aldesleukin) 
1.1.3.1 Primary Objective  
• Determine the safety and feasibility of the administration of anti-CD19-CAR engineered 
peripheral blood lymphocytes with a non-myeloablative conditioning regimen in patients 
with B-cell malignancies. 
1.1.3.2 Secondary Objectives 
• Determine the in vivo survival of the anti-CD19-CAR-transduced T-cells. 
• Determine if the treatment regimen cause regression of B-cell malignancies. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
1.1.4 With Approval of Amendment S (this study will include cryopreserved anti-CD19-CAR 
PBL) 
1.1.4.1 Primary Objective 
• Determine the safety and feasibility of the administration of cryopreserved anti-CD19-
CAR engineered peripheral blood lymphocytes with a non-myeloablative conditioning 
regimen in patients with B-cell malignancies. 
1.1.4.2 Secondary Objectives 
• Determine the in vivo survival of the cryopreserved anti-CD19-CAR-transduced T-cells. 
• Determine if the treatment regimen can cause regression of B-cell malignancies. 
1.2 
BACKGROUND AND RATIONALE  
Adoptive transfer of tumor infiltrating lymphocytes (TIL) is an effective therapy for advanced 
melanoma(1). Adoptive transfer of T-cells that were transduced with the genes of tumor-antigen-
specific T-cell receptors caused regressions of melanoma in some patients(2). Another approach 
to adoptive T-cell therapy is to engineer T-cells to express chimeric antigen receptors (CARs). 
CARs combine a single chain Fv (scFv) component that is derived from a monoclonal antibody 
with T-cell activation moieties(3, 4). We have constructed and extensively tested an anti-CD19 
CAR. T-cells that are transduced with gamma-retroviruses encoding the sequence of this CAR 
can specifically recognize and kill CD19-expressing target cells including primary chronic 
lymphocytic leukemia cells. These anti-CD19-CAR-transduced T-cells also produce the 
cytokines interferon-γ (INFγ) and IL-2 specifically in response to CD19. We propose to conduct 
a clinical trial in which gamma-retroviruses encoding the anti-CD19 CAR will be used to 
transduce T-cells from patients with advanced B-cell malignancies. Initially, the protocol will 
proceed in a phase I dose escalation design, with three cohorts of n=3 to determine the maximum 
tolerated dose. In phase I, patients will receive lymphodepleting chemotherapy consisting of 
cyclophosphamide and fludarabine, anti-CD19-CAR transduced T-cells, and high-dose 
aldesleukin. Once the MTD has been determined, the study then would proceed to the phase II 
portion. Patients will be randomized to two treatment arms. Patients assigned to treatment Arm 1 
will receive fludarabine and cyclophosphamide chemotherapy in order to induce lymphocyte 
depletion prior to infusion of the anti-CD19-CAR-transduced T-cells, and high-dose aldesleukin. 
Patients assigned to treatment Arm 2 will receive anti-CD19-CAR transduced T-cells, and high-
dose aldesleukin without chemotherapy. This trial design will allow us to rigorously assess the 
impact of prior lymphodepletion on the persistence of adoptively transferred T-cells in patients.  
With the approval of Amendment S, the protocol will proceed in a phase I dose escalation 
design, with two cohorts of n=3, including a de-escalation cohort to determine the maximum 
tolerated dose. Patients will receive a lymphodepleting chemotherapy regimen consisting of 
cyclophosphamide and fludarabine followed by cryopreserved anti-CD19-CAR transduced T-
cells. 
With the approval of Amendment V, the protocol will proceed in a phase I dose escalation 
design, with one cohort of n=6 to determine the maximum tolerated dose. Patients will receive a 
lymphodepleting chemotherapy regimen consisting of cyclophosphamide and fludarabine 
followed by cryopreserved anti-CD19-CAR transduced T-cells. In this cohort, the dose of 
cyclophosphamide will be moderately increased to 500 mg/m2. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Lymphodepletion has been proven in multiple murine models to dramatically increase the anti-
malignancy activity of adoptively-transferred T-cells(5-7). In addition, elimination of other host 
cells such as myeloid suppressor cells has also been shown to enhance anti-tumor immunity in 
animal models(8). Human studies strongly suggest that chemotherapy administered before 
adoptive T-cell transfer can enhance the activity of adoptively-transferred T-cells(1).  
1.2.1 Prior Surgery Branch Trials of Cell Transfer Therapy Using Heterogeneous TIL Plus 
High-Dose IL-2 Following Non-myeloablative but Lymphodepleting Chemotherapy 
The NCI Surgery Branch has extensive experience at treating malignancy by adoptive transfer of 
autologous T-cells (Table 1). The best example of the ability of autologous T-cells to mediate 
regressions of human malignancy is the adoptive transfer of tumor infiltrating lymphocytes (TIL) 
for treatment of melanoma(1). Prior to adoptive transfer of TIL, patients are lymphodepleted with 
the chemotherapy agents fludarabine and cyclophosphamide. Patients are lymphodepleted 
because in most murine models demonstrating the therapeutic effectiveness of adoptively 
transferred lymphocytes at mediating tumor regression, immunosuppression of the host prior to 
the adoptive transfer of lymphocytes was required(9). Interestingly, a clinical trial to formally 
demonstrate the impact of immunosuppression on adoptively transferred T-cells in humans has 
not been reported. TIL were cultured from excised melanoma tumors. TIL were then expanded 
using the rapid expansion protocol (REP) in which TIL were cultured with OKT3, irradiated 
allogeneic feeder cells, and IL-2. These REPed TIL retained highly specific in vitro anti-tumor 
activity, often recognized several antigenic epitopes, and contained both CD8+ and CD4+ 
lymphocytes(1). TIL were adoptively transferred by intravenous infusion. Patients subsequently 
received high-dose IL-2 and some received peptide immunization when the TIL reactivity was 
against known MART-1 and gp100 peptides. This regimen using REPed TIL in protocol 99-C-
0158 resulted in objective cancer regressions in 51% of patients (18 of 35) with metastatic 
melanoma(10). Some patients achieved a clonal repopulation of anti-tumor lymphocytes that 
exceeded 80% of their total circulating CD8+ lymphocytes that persisted for months after cell 
infusion in some cases(1). A summary of the toxicities that occurred in the 35 patients treated 
with immunosuppression by fludarabine and cyclophosphamide, TIL infusion, and high-dose IL-
2 is shown in Table 2. The combination of cyclophosphamide and fludarabine was 
myelosuppressive. Neutrophils nadired on day 10 after chemotherapy at 6/mm3 and recovered to 
above 500/mm3 on day 14 with support from filgrastim (G-CSF). Lymphocytes nadired at 6/mm3 
and recovered to above 500/mm3. Platelets nadired at 5.5/mm3 on day 8 and recovered to > 
20,000/mm3 on day 28. Patients were usually discharged between 2-3 weeks after the initiation 
of the chemotherapy. CD4 counts remained persistently low (below 200), which is a known side 
effect of immunosuppression from fludarabine.  
1.2.2 Surgery Branch Trials of Cell Transfer Therapy Using Transduction of TCR Genes that 
Encode TCR that Recognize Tumor-Associated Antigens into Non-Reactive PBL 
Transfer of antigen specific TCR genes to PBL has recently been described as a potential method 
of generating large numbers of reactive T-cells for anti-cancer therapy(11, 12). Retroviral vector 
mediated gene transfer can be used to engineer human T-cells with high efficiency. In published 
work, the Surgery Branch was among the first to demonstrate that retroviral vector-mediated 
transfer of TCR genes could endow human PBL with anti-tumor reactivity(13). In this study, PBL 
were engineered with a retroviral vector expressing a TCR gene derived from a MART-1 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
reactive CTL. These engineered cells reacted with MART-1 expressing cells in an HLA-A0201 
restricted manner. 
Based on this technology, the Surgery Branch currently has conducted five TCR gene transfer 
trials that have enrolled over 100 patients. In these protocols, patients with metastatic cancer who 
are HLA-A2 positive received a non-myeloablative but lymphodepleting preparative regimen 
consisting of cyclophosphamide and fludarabine, and then were treated with autologous 
peripheral blood lymphocytes or TIL that were genetically engineered to be reactive with 
melanoma tumor antigens gp100 or MART-1, or with p53. Following adoptive cell transfer, all 
patients received high-dose IL-2, and some patients received peptide vaccination. In four 
studies (04-C-0181, 04-C-0251, 07-C-0174, and 07-C-0175) patients with metastatic melanoma 
are being evaluated, and in one study (07-C-0003), patients with metastatic cancer whose tumors 
overexpress p53 are being evaluated. Table 1 provides a summary of these studies.  
To test the in vivo efficacy of the MART-1 TCR engineered T-cells in 04-C-0251, 17 HLA-
A*0201 patients with progressive metastatic melanoma were selected for treatment(2). All 
patients were refractory to prior therapy with IL-2. T-cell cultures from all 17 patients were 
biologically reactive, with specific secretion of interferon-γ following co-culture with MART-1 
peptide pulsed T2 cells and melanoma cell lines expressing the MART-1 antigen. Gene transfer 
efficiencies in these lymphocytes ranged from 17% to 67% (mean value 42%). Patients received 
adoptive cell transfer (ACT) with MART-1 TCR transduced autologous PBL after 
lymphodepletion with fludarabine and cyclophosphamide. An initial cohort of three patients was 
treated with cells following an extended culture period of 19 days, at which point they had cell 
doubling times ranging from 8.7 to 11.9 days. In these patients, less than 10% of the transduced 
cells persisted across the time points tested during the first 30 days post-infusion and 2% or less 
persisted beyond 50 days. These first three patients showed no delay in the progression of 
disease. In an effort to administer gene-modified lymphocytes that were in their active growth 
phase, the culture conditions were modified to limit the ex vivo culture period to between 6 and 9 
days after stimulation of cells with the anti-CD3 antibody OKT3. In a third cohort, larger 
numbers of actively dividing cells for ACT were generated by performing a rapid expansion 
protocol 8-9 days after the initial OKT3 stimulation. In contrast to the lack of cell persistence 
seen in Cohort 1, patients in cohorts 2 and 3 all exhibited persistence of the transduced cells at 
greater than 9% at one and four weeks post-treatment (range 9%-56%). All 13 patients examined 
had increased MART-1 tetramer-binding cells post-treatment and 11 of 14 had increased number 
of elispot positive cells(2). 
Most importantly, four patients demonstrated a sustained objective regression of their metastatic 
melanoma assessed by standard RECIST criteria, two of the responding patients were reported in 
Morgan et al.(2) as patients 4 and 14 (Figure 1). In responding patients 4 and 14, gene marked 
cells in the circulation (assumed to be 1% of total body lymphocytes) expanded 1400 fold and 30 
fold respectively compared to the infusion cell number. At one year post-infusion, both 
responding patients had sustained high levels (between 20%-70%) of circulating gene-transduced 
cells (Figure 1E). The transduced TCR included Vβ12, and these two patients displayed Vβ12 
cells detectable by antibody staining between 12%-16% when followed out to >300 days post-
treatment (Figure 1F). The responding patients 4 and 14 were also 2 of 4 patients who had 
greater than 1% circulating tetramer positive cells at greater than 15 days after cell infusion, and 
these patients demonstrated anti-TAA reactivity in ex vivo co-culture assays. On this clinical trial 
of TCR gene therapy, there were no toxicities in any patient attributed to the gene-marked cells.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Our two newest TCR studies investigate more potent TCRs which target gp100 and MART-1 
and expand our studies to TCR-transduced TIL, in addition to PBL. The anti-gp100(154) TCR 
transduced PBL/TIL study (07-C-0174) has accrued 19 patients to date, all to the TCR 
transduced PBL arm. At this time, 17 patients have been evaluated for response with 3 patients 
experiencing PRs and 14 patients having progressive disease. Nineteen patients have been 
evaluated for toxicities, and most grade 3 and 4 toxicities are known toxicities of the research. 
Toxicities attributable to the cells include grade 1 and 2 rash, uveitis, dizziness and hearing loss. 
Two grade 3 toxicities (headache and vasovagal syncope) and one grade 4 event of thrombosis 
were unexpected events but unrelated to the research. No grade 5 events have been observed on 
this study. The anti-MART-1 F5 TCR transduced PBL/TIL study (07-C-0175) has accrued 22 
patients to date (21 patients to the PBL arm and 1 patient to the TIL arm). At this time 20 
patients have been evaluated for response with six patients experiencing a partial response. 
Twenty-two patients have been evaluated for toxicities, and most grade 3 and 4 toxicities are 
known toxicities of the research. Toxicities attributable to the cells included grade 1 and 2 rash, 
uveitis, dizziness, tinnitus, and hearing loss. Five grade 3 events of pain, two grade 3 neurologic 
toxicities (1 encephalopathy and 1 cerebrovascular ischemia) and 2 grade 4 toxicities (2 
pulmonary embolisms) were unexpected events but unrelated to the research. Four grade 3 
events of headache were also observed and two of these events were expected and possibly 
related to the research. No grade 5 events have been observed on this study.  
1.2.3 Chimeric Antigen Receptors (CARs) 
Targeting T-cells to tumors by transferring the genes for αβ T-cell receptors into the T-cells of 
cancer patients for use in adoptive transfer therapies is a promising approach to cancer 
immunotherapy. Another approach to adoptive T-cell therapy is to engineer T-cells to express 
chimeric antigen receptors (CARs). CARs are made up of a single chain variable fragment 
(scFv) coupled to signaling molecules that can activate the T-cells expressing the CAR(3, 4, 14). 
The earliest work conducted with CARs was performed in the late 1980s(15, 16). CARs have been 
designed to target many different tumor antigens and many important questions have been 
addressed using CARs in mouse models. Murine models have shown that syngeneic T-cells 
transduced with retroviruses encoding CARs protected mice from tumor challenges in vivo(17, 18). 
Murine models indicated that including the signaling domain of CD28 in CARs enhanced tumor 
protection and persistence of CAR-transduced T-cells(18, 19). Increasing the number of CAR-
transduced T-cells administered to mice consistently enhanced tumor protection as well(18, 20, 21). 
One murine study reported that administration of high-dose IL-2 enhanced tumor protection by 
CAR-transduced T-cells(21).  
Our group has completed a phase I clinical trial in which ovarian carcinoma was treated with T-
cells that were transduced with a CAR that was specific for the ovarian carcinoma-associated-
antigen α-folate receptor (FR)(22). This trial consisted of two cohorts. In Cohort 1, transduced T-
cells that had been activated with OKT3 and transduced with an anti-FR CAR were adoptively 
transferred to patients. The patients then received a course of high-dose IL-2. In Cohort 2, PBMC 
of patients were stimulated with allogeneic PBMC and then transduced with the anti-FR CAR. 
The cells were adoptively transferred to the patients. Next, the patients received injections of 
allogeneic PBMC from the same donor used for the in vitro stimulations as a vaccine. High 
levels of T-cell transduction were not achieved in this study. No objective clinical responses 
were attained and the persistence of the transduced T-cells was generally limited to a few 
days(22). Our currently proposed trial differs from this trial in many ways. First, we can achieve 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
much higher levels of T-cell transduction due to advances in gene transfer technology. Second, 
the CAR to be used in our proposed trial incorporates a CD28 signaling domain and the CD3-
zeta signaling domain. In contrast the anti-FR CAR used in the earlier work did not contain a 
CD28 signaling domain and used an Fcγ signaling domain instead of the CD3-zeta moiety in our 
current receptor. The T-cell culture conditions used in the anti-FR CAR trial are significantly 
different than the T-cell culture conditions that we will use in our proposed trial of an anti-CD19 
CAR. Finally, some of the patients in our proposed trial will be immunosuppressed prior to 
adoptive transfer of anti-CD19-CAR-transduced T-cells. In the earlier trial no 
immunosuppression was used.  
Another group has reported preliminary results of a clinical trial of a CAR that is specific for 
carboxy-anhydrase-IX (CAIX)(23). CAIX is expressed by renal cell carcinoma and on bile duct 
epithelium. The three patients treated on this trial all developed liver toxicity that was attributed 
to the anti-CAIX-CAR-transduced T-cells(23).  
1.2.4 B-Cell Malignancies 
Annually in the United States, approximately twenty-two thousand people die of B-cell 
malignancies(24). B-cell malignancies have quite heterogeneous clinical manifestations and 
prognoses. Chronic lymphocytic leukemia (CLL) is a common disease that is incurable by 
chemotherapy(25). Patients with CLL that is purine-refractory/resistant (defined as no response to 
a purine-based chemotherapy regimen or progression in 6 months or less after receiving such a 
regimen) have a median overall survival of 9-13 months(26). Patients that have progressive 
disease greater than 6 months after receiving a purine-based regimen generally have a median 
overall survival of 3.5 years or less(27). Another B-cell malignancy for which new therapies are 
urgently needed is mantle cell lymphoma. This disease is almost always incurable by 
chemotherapy and has an aggressive course that is characterized by short responses to 
chemotherapy(28). Follicular lymphoma is a common lymphoma with an extremely variable 
course(29). Patients with follicular lymphoma have a median survival of about 4.5 years after first 
relapse(30, 31). Large cell lymphoma is often curable by chemotherapy, and autologous stem cell 
transplants are sometimes able to cure patients with relapsed large cell lymphoma(32). However, 
patients with multiple relapsed large cell lymphoma have very poor prognoses and some of them 
are candidates for experimental therapies(33). Allogeneic stem cell transplantation is a potentially 
curative treatment option for patients with advanced B-cell malignancies, but allogeneic stem 
cell transplantation generally has a treatment related mortality rate of 10-30%(34, 35). Improved 
therapies for B-cell malignancies are clearly needed. 
Our proposed trial makes use of fludarabine and cyclophosphamide to lymphodeplete the 
patients assigned to one of the two treatment arms. Because of the activity of fludarabine and 
cyclophosphamide against B-cell malignancies(26, 29, 32), we will not be able to determine whether 
tumor regressions that occur on this arm of the trial are due to the chemotherapy or to the 
adoptively transferred T-cells or a combination of both chemotherapy and T-cells. Our group has 
previously used IL-2 alone in the same dose and schedule proposed for this trial as a treatment 
for lymphoma(36). No objective responses were observed in the eleven lymphoma patients treated 
with IL-2 alone(36). Therefore, any responses that take place in the arm of our proposed trial in 
which patients do not receive chemotherapy can reasonably be attributed to the infused anti-
CD19-CAR-transduced T-cells.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
1.2.5 CD19 
We have constructed a CAR that recognizes CD19. We chose to target CD19 because it is 
expressed on most malignant B-cells(37, 38), but the only normal cells that express CD19 are B-
cells and perhaps follicular dendritic cells(38, 39). Importantly, CD19 is not expressed on 
pluripotent hematopoietic stem cells(40). While destruction of normal B-cells is a drawback to 
targeting CD19, several factors indicate that destruction of normal B-cells is tolerable. When 
patients receive the anti-CD20 monoclonal antibody rituximab, the number of normal B-cells is 
severely depressed for several months(41), yet patients that receive chemotherapy plus rituximab 
do not have an increased rate of infections when compared to patients that receive chemotherapy 
alone(42). Finally, patients can be treated with intravenous infusions of IgG if necessary to 
increase IgG levels(43). 
1.2.6 Development of an Anti-CD19 CAR for Clinical Adoptive T-Cell Transfer 
The anti-CD19 CAR used in our work consists of three main components: the variable regions of 
the anti-CD19 monoclonal antibody FMC63(44), part of the CD28 costimulatory molecule, and 
the signaling domain of the CD3 zeta chain(45). This receptor is referred to as FMC63-28. The 
DNA encoding this receptor was cloned into the MSGV1 retroviral vector backbone(2) to form 
the plasmid shown in Figure 2A. This plasmid is referred to as MSGV1-FMC63-28. For the 
remainder of this document the FMC63-28 receptor will be referred to as the anti-CD19 CAR. 
We carried out extensive in vitro experiments to assess the suitability of the FMC63-28 anti-
CD19 CAR for use in a clinical trial. In order to transduce T-cells with the anti-CD19 CAR, we 
first suspended normal peripheral blood mononuclear cells (PBMC) in IL-2-containing media 
and stimulated them with the anti-CD3 monoclonal antibody OKT3. Two days after the OKT3 
stimulation was initiated, we spin-loaded gamma-retroviruses encoding the anti-CD19 receptor 
onto a retronectin-coated plate. The OKT3-activated PBMC were placed on the plate and 
cultured overnight. The next day, we transferred the OKT3-activated PBMC from the original 
virus-coated plate to a second plate that had been loaded with retroviruses encoding the anti-
CD19 CAR in a manner identical to the first transduction, and the cells were cultured overnight 
again. Preliminary experiments using transiently produced retroviral supernatant for 
transductions showed that our FMC63-28 receptor functioned well in vitro; therefore, a stable 
producer cell clone that produces gibbon ape leukemia virus (GALV) pseudotyped retrovirus 
encoding the FMC63-28 anti-CD19 CAR was generated. We used supernatant from this clone 
for the rest of the experiments described in this document. Following transduction, the PBMC 
were almost 100% CD3+ T-cells. Because the anti-CD19 CAR contains variable regions that 
were derived from a murine antibody, a goat-anti-mouse-Fab antibody can stain cells that 
express the anti-CD19 CAR. An example of staining of anti-CD19-transduced T-cells with the 
anti-Fab antibody and CD3 is shown in Figure 2B. In six separate transduction experiments, a 
mean of 57% of CD3+ T-cells expressed the anti-CD19 CAR. These transduced cells produced 
interferon-γ (IFNγ) specifically in response to CD19-expressing target cell lines (Figure 3).  
Next, we obtained PBMC from a patient with CLL that had previously been treated with 
fludarabine and rituximab. We stimulated these PBMC with OKT3 in IL-2-containing media and 
transduced them with retroviruses encoding the anti-CD19 CAR. We found that the T-cells from 
this patient proliferated well in response to OKT3 and that 54% of the CD3+ cells expressed the 
anti-CD19 CAR. In addition, these transduced cells produced IFNγ in response to primary 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
allogeneic CLL cells, but not CD19-negative target cells and they killed primary allogeneic CLL 
cells in an in vitro cytotoxicity assay(46) (Figure 4). 
In order to obtain the large number of T-cells necessary for clinical adoptive T-cell transfer, T-
cells that have been stimulated with OKT3 and transduced are subjected to a second stimulation 
with OKT3 in the presence of allogeneic feeder cells in IL-2-containing media. This process is 
called a rapid expansion protocol (REP). The data presented in Figure 5A demonstrate that after 
being subjected to a REP, anti-CD19-CAR-transduced T-cells produce IFNγ in response to 
CD19-expressing target cells but not in response to CD19-negative cells. The cells can also kill 
primary CLL cells (Figure 5B). CD19-CAR-transduced T-cells produce IFNγ and IL-2 in 
response to target cells that were transduced with CD19, but not target cells that were transduced 
with the control antigen nerve growth factor receptor (NGFR) (Figure 6). 
Like most T-cells, anti-CD19-CAR-transduced T-cells are dependent on exogenous IL-2 for 
survival in vitro (Figure 7). We have demonstrated IL-2-dependent in vitro survival of anti-
CD19-CAR-transduced T-cells in many experiments. These results provide strong evidence that 
the transduced T-cells do not become immortalized. 
1.2.7 Other Anti-CD19 CAR Clinical Trials 
Other groups have constructed anti-CD19 CARs(20, 47). Jensen and coworkers have completed a 
clinical trial of adoptive transfer of T-cells that were transfected with a plasmid encoding an anti-
CD19 chimeric receptor(48). The T-cells expressing the anti-CD19 receptor did not persist in vivo 
and did not cause objective remissions of lymphoma. Our proposed clinical trial differs from the 
completed trial of Jensen and coworkers in many ways. The most important difference is that our 
proposed trial will use a retroviral vector rather than plasmid transfection to transfer an anti-
CD19 receptor to T-cells. Another potentially important difference is that the CAR we propose 
to utilize in our clinical trial contains the signaling component of CD28, but the receptor 
construct used by Jensen and coworkers did not include a CD28 moiety.  
A second group is currently conducting a clinical trial of adoptive transfer of T-cells that have 
been transduced with retroviruses encoding an anti-CD19 receptor (NCI Clinical Trials PDQ, 
trial MSKCC trial #06-138, Principal Investigator: R. Brentjens). This trial is enrolling only CLL 
patients. In this trial, CAR-transduced T-cells are transferred to patients that have received either 
cyclophosphamide chemotherapy or no chemotherapy prior to cell transfer. Our proposed trial 
differs from the trial of Brentjens and coworkers in several ways. First, we plan to administer 
high-dose IL-2 after cell transfer. Second, we propose to randomize between administering 
fludarabine and cyclophosphamide chemotherapy prior to adoptive T-cell transfer or 
administering no chemotherapy prior to T-cell transfer. Finally, we will treat all CD19-
expressing malignancies while Brentjens and coworkers are only treating CLL. 
Malcolm Brenner, Helen Heslop, and coworkers are conducting a clinical trial in which anti-
CD19-CAR-transduced T-cells are administered to patients with indolent B-cell malignancies 
(NCI Clinical Trials PDQ, trial #BCM-H-19384). In this trial, each patient is receiving a mix of 
T-cells in which some T-cells are transduced with a CAR that incorporates a CD28 moiety and 
other T-cells are transduced with a CAR lacking a CD28 moiety. The aim of the trial is to 
evaluate the importance of the CD28 moiety on T-cell persistence and function. Our proposed 
trial differs from this trial significantly. First, this trial uses no immunosuppression prior to cell 
infusion while our trial proposes to randomize between immunosuppression with fludarabine 


Abbreviated Title: Anti-CD19 CAR PBL 
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plus cyclophosphamide versus no immunosuppression. Second Brenner, Heslop, and coworkers 
are not administering IL-2 as part of their trial.  
With the approval of Amendment S, patients will receive a lymphodepleting chemotherapy 
regimen consisting of cyclophosphamide and fludarabine followed by cryopreserved anti-CD19-
CAR transduced T-cells. 
1.2.8 Rationale for Measuring Persistence of Adoptively Transferred T-Cells With or Without 
Lymphodepleting Chemotherapy Prior to Adoptive Transfer 
We hypothesize that lymphodepletion with fludarabine and cyclophosphamide will enhance 
persistence of the adoptively transferred anti-CD19 T-cells. Murine studies demonstrate 
enhanced anti-tumor efficacy of transferred T-cells in lymphodepleted hosts compared to 
lymphoreplete hosts(49). However, in previous nonrandomized Surgery Branch trials, melanoma 
patients were treated with tumor infiltrating lymphocytes (TIL) plus IL-2 preceded by either one 
dose of 25 mg/kg of cyclophosphamide or no chemotherapy(50). There was no difference in the 
objective tumor response rates when patients that received chemotherapy prior to adoptive T-cell 
transfer were compared to patients that did not receive chemotherapy(50). Our proposed trial will 
be the first randomized trial to evaluate the impact of immunosuppression on the persistence of 
adoptively transferred T-cells in humans. Persistence of adoptively transferred T-cells has been 
shown to be associated with anti-tumor efficacy(5). An additional benefit of not treating some 
patients on this trial with chemotherapy is that the anti-malignancy effect of anti-CD19-CAR-
transduced T-cells plus IL-2 can be evaluated without the confounding effect of chemotherapy  
In the past few years a large amount of evidence has been accrued demonstrating that 
lymphodepletion prior to cell infusion is critical for the effectiveness of adoptive T-cell transfer(5, 
49-51). Much of this evidence has been elicited since this protocol was originally submitted. 
Therefore, starting with Amendment E, patients will no longer be treated with CD19-CAR 
engineered cells in the absence of lymphodepletion. 
1.2.9 Safety Considerations 
Several safety concerns regarding the infusion of large numbers of retrovirally modified tumor 
reactive T-cells have been addressed in our previous clinical studies. The non-myeloablative 
chemotherapy and the administration of high-dose IL-2 have expected toxicities discussed 
earlier. The immuno-myeloablative chemotherapy used in this protocol has been administered to 
over 100 patients and all have reconstituted their hematopoietic systems.  
In other protocols we have administered over 3.0x1011 TIL with widely heterogeneous reactivity 
including CD4, CD8, and NK cells without difficulty. As discussed above, the expansion of 
tumor reactive cells is a desirable outcome following the infusion of antigen reactive T-cells. 
Some patients receiving gp100 or MART-1 reactive cells have developed vitiligo, uveitis, 
hearing loss and rash probably due to destruction of normal melanocytes though these toxicities 
have been manageable. In addition, two patients experienced vestibular dysfunction possibly due 
to the transduced cells. We do not believe the transfer of these gene modified cells has a 
significant risk for malignant transformation in this patient population. While the risk of 
insertional mutagenesis is a known possibility using retroviral vectors, this has only been 
observed in the setting of infants treated for XSCID using retroviral vector-mediated gene 
transfer into CD34+ bone marrow cells. In the case of retroviral vector-mediated gene transfer 
into mature T-cells, there has been no evidence of long-term toxicities associated with these 


Abbreviated Title: Anti-CD19 CAR PBL 
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procedures since the first NCI sponsored gene transfer study in 1989. Although continued 
follow-up of all gene therapy patients will be required, data suggest that the introduction of 
retroviral vectors transduced into mature T-cells is a safe procedure. While we believe the risk of 
insertional mutagenesis is extremely low, the proposed protocol follows all current FDA 
guidelines regarding testing and follow up of patients receiving gene transduced cells. 
As of April 2015, thirty-four patients have been enrolled on this study. This includes seven 
patients with CLL, four patients with follicular lymphoma, one patient with splenic marginal 
zone lymphoma, fifteen patients with diffuse large B-cell lymphoma, five patients with primary 
mediastinal B-cell lymphoma, one patient with non-Hodgkin lymphoma, and one with Mantle 
cell lymphoma. We have observed impressive clinical response rates of 70% in this study, which 
includes 12 patients with a partial response (PR) and 12 patients with a complete response (CR) 
to treatment. However, 11 patients on this study have experienced a dose limiting toxicity (DLT) 
resulting in the trial being placed twice on clinical hold by the FDA. Subsequently, the dose was 
reduced three times, IL-2 was eliminated, and the dose of cyclophosphamide was decreased by 
50%. The most common toxicities observed were neurotoxicities (somnolence, aphasia, and 
tremors), hypotension and one incidence of renal failure. Analysis of blood samples on these 
patients has indicated the elevated levels of cytokines which are the likely cause of these events.  
1.2.10 Cryopreservation of the Anti-CD19 CAR Transduced T-Cell Product  
As noted above, we have seen substantial clinical activity in patients with B-cell lymphomas 
receiving these anti-CD19 gene transduced cells. The cells have most often been administered 
following approximately 10-12 days of growth and were given from freshly harvested cultures. 
This procedure involves multiple logistic problems especially if we are to develop a procedure 
that can be more widely disseminated. Difficulty in timing the lymphodepleting chemotherapy 
with completion of the culture and the need to ship cells to other institutions in subsequent 
protocols has led us to slightly alter the standard operating procedures for growth of cells. In the 
current protocol we have developed a protocol for developing cells following just six days of 
culture. The cells are then cryopreserved and immediately infused following thawing. We have 
done substantial comparability studies to show that the cells grown for six days and 
cryopreserved have the same phenotype and functional properties as cells that have grown for 
longer period of times and administered fresh. Thus, in the next cohort of patients we plan to use 
cells grown for six days in culture and then cryopreserved and thawed prior to administration. 
In an effort to establish a more GMP-compliant cell production process, we developed a closed 
cell production resulting in a cryopreserved cell product at the end of 6 days. A schematic 
showing the process flow for the closed process is presented in Figure 8. Briefly, 1.0x109 PBMC 
are stimulated in a bag with soluble OKT3 for 2 days. The stimulated PBMC (1X) are washed on 
a Sepax using the neat cell wash program and transferred to retronectin-coated bag containing 
gammaretroviral vector supernatant (1X) resulting in a final cell density of 2.0x108 cells in 2X 
diluted vector supernatant. After an overnight incubation at 37oC, the cells are transferred to an 
expansion bag containing Optimizer medium and 2.5% TCSR at a density of 0.5x106 cells/mL. 
The cells are expanded for 4 days, washed on the Sepax and then cryopreserved in bags at a 
concentration of 2.0x106 CAR+ cells/kg in 50 mL of 50% Saline-2.5% HSA-50% Cryostor-10. 
We conducted 5 engineering runs at scale using cells from lymphoma patients in parallel with 
our current open clinical cell production process in order to access the comparability of the 
closed process in terms of transduction efficiency, cell expansion and total cell number, 


Abbreviated Title: Anti-CD19 CAR PBL 
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biological function as measured by IFNγ release following coculture with antigen-positive 
targets, and phenotype. The only significant difference detected between the two processes was 
the level of transduction. Cells transduced in the closed cell production process exhibited a 
significantly lower transduction efficiency as compared to the open system (Figure 9, 43.6 + 
8.3% and 79.6 + 1.5%, n=5, respectively (p<0.001). We were able to achieve comparable total 
cell numbers (Figure 10, 14.5 + 4.5 x 108 and 19.6 + 13.6 x 108 total cells, respectively) as well 
as cell expansion (Figure 11, 8.2 + 2.1 and 11.4 + 5.0 fold expansion, respectively) using the 6 
day cell production process. In addition, cells manufactured using the 6 day closed process are 
CD19-specific as evidenced by release of comparable levels of IFNγ when cocultured with 
CD19+ targets (Nalm6, Toledo) and not CD19- targets (K562-NGFR, CEM), (Figure 12). The 
last measure of comparability between cells generated using the 6 day closed process to those 
generate in our current open clinical process is based on T-cell phenotype (Figure 13). There 
was no significant difference in T-cell phenotype based on detection of CD45RA and CCR7 by 
FACS. 
Having shown that the 6-day cell production process can yield a cell product that is comparable 
to our current 10-day open clinical production process, we next sought to determine what effect 
cryopreservation had on our T-cell product. To assess the effect of cryopreservation on the 
percentage of CAR+ T-cells, cell viability, expansion, function and phenotype (Figure 17), we 
conducted two additional engineering runs using cells from lymphoma patients. Where possible 
the 6-day cell product was evaluated pre- and post-thaw for a given parameter. In Figure 14A, 
we demonstrate that there is no significant difference in the percentage of CAR+ T-cells 3 days 
post-thaw suggesting that our cryopreservation protocol is not inherently detrimental to CAR 
expression. In addition, the CAR+ cells continued to show CD19-specific antigen recognition as 
measured by IFNγ release following coculture with CD19+ targets (Figure 15A and Figure 
15B). The viability of the cells at thaw was 90 and 79%, respectively, for the two patients tested 
(Figure 14B). Interestingly, the viability of the cells dipped 24h post-thaw by an average of 14% 
(Figure 16A); however, the cells then quickly recovered by the next day and expanded 36- and 
21-fold over a period of 7 days in the absence of an antigen-specific stimulation (Figure 16B). 
There we slight differences in T-cell phenotype following cryopreservation, but it is likely that 
these differences are not specific given that the FACS staining was done on different days. It is 
important to note that while the percentages of a particular T-cell subset might change for a 
given patient, there is no difference in the profile of the subsets for each patient. Thus, the cells 
appear comparable following cryopreservation and thaw as compared to the pre-cryopreserved 
cells. 
As of April 1, 2014, twenty-six patients have been enrolled on this study; this includes seven 
patients with CLL, four patients with follicular lymphoma, one patient with splenic marginal 
zone lymphoma, and fourteen patients with diffuse large B-cell lymphoma. Of the twenty-six 
patients treated on this study, we have observed impressive clinical response rates of 77%, which 
include 10 patients with a partial response and 10 patients with a complete response to treatment. 
The protocol was initially designed as a standard dose escalation study with the dose escalation 
based on our prior experience with cell therapy. Due to the dose limiting toxicities, we have 
modified the protocol accordingly; eliminating aldesleukin, reducing the cell dose, and 
decreasing the doses of both chemotherapy agents. Some of the patients treated in the first few 
groups had severe side effects, including difficulty breathing, inability to speak, confusion, 
tremors, and kidney damage. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
In Cohort 1, eight patients were treated with high-dose chemotherapy (cyclophosphamide 
(60mg/kg x 2 days) and fludarabine (25mg/m2 x 5 days)) followed by anti-CD19 CAR T-cells 
(between 4.0x108 and 4.0x109 cells) and high dose aldesleukin. Of these 8 patients, 7 are 
evaluable, one of these patients died on study due to complications related to treatment and 
H1N1 infection. Six of the seven evaluable patients have objective responses; 4 partial 
responders and 2 complete responders. Due to severe toxicities, this cohort was closed to 
evaluate the safety and toxicity of lower cell doses and no aldesleukin. 
In Cohort 6, two patients were treated with a high-dose chemotherapy followed by anti-CD19 
CAR+ cells (0.5x107 transduced cells/Kg) and no IL-2. Both patients have achieved a complete 
response (CR). This cohort was closed due to grade 3 neurological toxicities, so we added a dose 
de-escalation cohort to continue accrual. 
In Cohort 8, five patients were treated with high-dose chemotherapy followed by anti-CD19 
CAR+ cells (2.5x106 transduced cells/Kg) and no IL-2. One patient died due to disease and 
treatment (not evaluable). Three patients have achieved a complete response (CR) and one 
patient is a non-responder. This cohort was closed due to grade 4 neurological toxicities 
observed in two patients, so the dose of cyclophosphamide was reduced to 30mg/kg/day for 2 
days and the dose of cells was reduced to 1.0x106 transduced cells/kg. 
In Cohort 9, six patients were treated with reduced cyclophosphamide dose (30mg/kg x 2 days) 
and fludarabine (25mg/m2 x 5 days) followed by anti-CD19 CAR+ cells (1.0x106 transduced 
cells/Kg) and no IL-2. Three patients have achieved a complete response (CR) and two patients 
have achieved a partial response (PR). This cohort was closed due to grade 4 creatinine and 
neurological toxicities, therefore decreasing the total dose of cyclophosphamide by more than 
50% and fludarabine by about 30%. 
In Cohort 10, five patients were treated with reduced doses of cyclophosphamide (300mg/m2 x 3 
days) and fludarabine (30mg/m2 x 3 days) followed by 1.0x106 cells/kg and no aldesleukin. Four 
patients have confirmed partial responses (PR) and one patient is a non-responder. The majority 
of toxicities seen in this cohort were attributed to the chemotherapy preparative regimen and 
none of the toxicities attributed to the fresh cell product were dose limiting toxicities (DLTs).  
With the approval of Amendment S, patients will receive Cryopreserved anti-CD19 CAR 
positive cells/kg followed by cyclophosphamide and fludarabine. 
In Cohort 11, four patients were treated with the reduced doses of cyclophosphamide and 
fludarabine followed by Cryopreserved anti-CD19 CAR+ cells (2.0x106 transduced cells/kg) and 
no IL-2. Two patients are non-responders. Two patients have achieved partial responses.  
In Cohort 12, one patient was treated with the reduced doses of cyclophosphamide and 
fludarabine followed by Cryopreserved anti-CD19 CAR+ cells (6.0x106 transduced cells /kg) 
and no IL-2. This patient is a non-responder. 
In Cohort 13, one patient was treated with a moderately increased dose of cyclophosphamide and 
fludarabine followed by Cryopreserved anti-CD19 CAR+ cells (2.0x106 transduced cells /kg) 
and no IL-2. This patient has achieved a partial response (PR). 
In Cohort 11 the 6-day product was cryopreserved in order to evaluate a process which could 
facilitate commercialization of the product by our CRADA partner. Four patients were treated in 
Cohort 11 and all but one patient incurred at least grade 2 toxicities. One patient was treated in 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Cohort 12; this patient experienced grade 4 confusion requiring transfer to the ICU, one patient 
was treated in Cohort 13 and he experienced grade 3 confusion and aphasia. In a review of the 
data it appeared that patients who received fresh products where the cells had been in culture for 
9-10 days (9-10 day product) incurred fewer toxicities and at a lesser grade than those patients 
who had received cryopreserved cells which had been in culture for 6 -8 days. In order to further 
explore the relationship between days in culture and toxicity, we are increasing the length of time 
in culture. In Cohort 14 the cells will be in culture for 9 days, which may be increased to 12 days 
depending upon the characteristics of the product. The product will continue to be cryopreserved 
and the dose escalation schema will continue as described in Section 3. In addition, in order to 
establish a baseline which could aid in determining the cause of, or further define, these 
neurologic toxicities, patients enrolled in Cohort 14 may undergo lumbar puncture for CSF 
analysis by flow cytometry prior to treatment. Patients who have undergone LP following 
treatment per protocol have all shown CD19+ cells in their CSF however, it is not known to what 
degree these cells were present prior to treatment as the patients were all asymptomatic and had 
nothing remarkable seen on imaging, and thus did not meet the criteria for a lumbar puncture 
prior to treatment.  
Note: The paragraphs highlighted in grey are no longer applicable after the approval of 
Amendment X. 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
 
2.1 
ELIGIBILITY CRITERIA 
2.1.1 Inclusion Criteria 
2.1.1.1  Patients must have a CD19-expressing B-cell lymphoma. Patients with Diffuse large B-
cell lymphoma, Primary Mediastinal B-cell lymphoma, and Diffuse large B-cell 
lymphoma transformed from follicular lymphoma must have measurable disease after at 
least two prior chemotherapy regimens one of which must have contained doxorubicin 
and rituximab.  
2.1.1.2  Confirmation of diagnosis of B-cell malignancy and positivity for CD19 confirmed by 
the Laboratory of Pathology of the NCI. The choice of whether to use flow Cytometry 
or immunohistochemistry will be determined by what is the most easily available tissue 
sample in each patient. Immunohistochemistry will be used for lymph node biopsies, 
flow Cytometry will be used for peripheral blood, fine needle aspirates and bone 
marrow samples. 
2.1.1.3  Patients must have indications for treatment for their B-cell malignancy at the time of 
enrollment on this trial. 
2.1.1.4  Greater than or equal to 18 years of age and less than or equal to age 70. 
2.1.1.5  Willing to sign a durable power of attorney. 
2.1.1.6  Able to understand and sign the Informed Consent Document. 
2.1.1.7  Clinical performance status of ECOG 0 or 1. 
2.1.1.8  Life expectancy of greater than three months. 
2.1.1.9  Patients of both genders must be willing to practice birth control from the time of 
enrollment on this study and for four months after treatment. 


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Version Date: August 23, 2018 
2.1.1.10 Women of child bearing potential must have a negative pregnancy test because of the 
potentially dangerous effects of the treatment on the fetus. 
2.1.1.11 Serology 
•  Seronegative for HIV antibody. (The experimental treatment being evaluated in this 
protocol depends on an intact immune system. Patients who are HIV seropositive can 
have decreased immune -competence and thus are less responsive to the experimental 
treatment and more susceptible to its toxicities.) 
•  Seronegative for hepatitis B antigen and hepatitis C antibody unless antigen negative. If 
hepatitis C antibody test is positive, then patients must be tested for the presence of 
antigen by RT-PCR and be HCV RNA negative. 
2.1.1.12 Hematology 
•  Absolute neutrophil count greater than or equal to 1000/mm3 without the support of 
filgrastim.  
•  Platelet count greater than or equal to 50,000/mm3. 
•  Hemoglobin greater than 8.0 g/dl. 
•  Lymphocyte count less than or equal to 4,000/ mm3. 
2.1.1.13 Chemistry 
•  Serum ALT/AST less or equal to 5 times the upper limit of normal. 
•  Serum creatinine less than or equal to 1.6 mg/dl. 
•  Total bilirubin less than or equal to 1.5 mg/dl, except in patients with Gilbert’s 
Syndrome who must have a total bilirubin less than 3.0 mg/dl. 
 
2.1.1.14 More than three weeks must have elapsed since any prior systemic therapy at the time 
the patient receives the preparative regimen, and patients’ toxicities must have 
recovered to a grade 1 or less (except for toxicities such as alopecia or vitiligo).  
2.1.1.15 Normal cardiac ejection fraction and no evidence of pericardial effusion as determined 
by an echocardiogram. 
2.1.2 Exclusion Criteria 
2.1.2.1  Patients that require urgent therapy due to tumor mass effects such as bowel obstruction 
or blood vessel compression. 
2.1.2.2  Patients that have active hemolytic anemia. 
2.1.2.3  Patients with active brain metastases, or with a history of any CNS metastases or 
cerebrospinal fluid malignant cells. Note: Patients who are asymptomatic but are found 
to have malignant cells in the CSF on lumbar puncture prior to treatment will be 
considered eligible.  
2.1.2.4  Women of child-bearing potential who are pregnant or breastfeeding because of the 
potentially dangerous effects of the treatment on the fetus or infant. 


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Version Date: August 23, 2018 
2.1.2.5  Active systemic infections, coagulation disorders or other major medical illnesses of the 
cardiovascular, respiratory or immune system, myocardial infarction, cardiac 
arrhythmias, obstructive or restrictive pulmonary disease. 
2.1.2.6  Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency 
Disease).  
2.1.2.7  Concurrent opportunistic infections (The experimental treatment being evaluated in this 
protocol depends on an intact immune system. Patients who have decreased immune 
competence may be less responsive to the experimental treatment and more susceptible 
to its toxicities). 
2.1.2.8  Concurrent systemic steroid therapy. 
2.1.2.9  History of severe immediate hypersensitivity reaction to any of the agents used in this 
study. 
2.1.2.10 History of allogeneic stem cell transplantation 
2.1.2.11 Patients with cardiac atrial or cardiac ventricular lymphoma involvement. 
2.2 
SCREENING EVALUATION 
2.2.1 Within 4 Weeks Prior to Starting the Chemotherapy Regimen  
• Complete history and physical examination, including, weight and vital signs, noting in 
detail the exact size and location of any lesions that exist. (Note: patient history may be 
obtained within 8 weeks.) 
• Chest x-ray 
• EKG 
• Baseline CT of the chest, abdomen and pelvis, PET scan, and brain MRI to evaluate the 
status of disease. Additional scans and x-rays may be performed if clinically indicated 
based on patients’ signs and symptoms. 
• HIV antibody titer and HbsAG determination, and anti HCV, (Note: may be performed 
within 3 months of the chemotherapy start date). 
• Anti CMV antibody titer, HSV serology, and EBV panel (Note: patients who are known 
to be positive for any of the above do not need to be retested; may be performed within 3 
months of chemotherapy start date) 
• Patients with a LVEF of less than or equal to 55% will not proceed to treatment, (Note: 
may be performed within 8 weeks of treatment). 
• CD19 staining of malignant cells by immunohistochemistry or flow cytometry (testing is 
permitted to be conducted at any time prior to this point). 
• All patients must have a TBNK for Peripheral blood CD3 count and CD19#. 
• Patients with a history of leptomeningeal disease, or signs/symptoms suggestive of 
leptomeningeal involvement, or with symptoms of central nervous system malignancy 
such as new onset severe headaches, neck stiffness, or any focal neurologic findings on 
physical exam will have lumbar puncture for examination of cerebral spinal fluid. 


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Version Date: August 23, 2018 
• Patients may undergo lumbar puncture (LP) for flow cytometry of the CSF in order to 
assess the presence of CD19 positive lymphocytes for potential correlation with 
neurologic toxicity. Patients who have no neurologic symptoms at the time of LP will be 
eligible for enrollment regardless of the results of the flow cytometry.  
2.2.2 Within 14 Days Prior to Starting the Chemotherapy Regimen 
• Chem 20: (Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 (bicarbonate), 
Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total, Magnesium total 
(Mg), Inorganic Phosphorus, Alkaline Phosphatase, ALT/GPT, AST/GOT, Total 
Bilirubin, Direct Bilirubin, LD, Total Protein, Total CK, Uric Acid) 
• Thyroid panel  
• CBC with differential and platelet count 
• PT/PTT 
• Urinalysis and culture, if indicated  
2.2.3 Within 7 Days Prior to Starting the Chemotherapy Regimen  
• β-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
• ECOG performance status of 0 or 1 
2.3 
PROTOCOL REGISTRATION 
2.3.1 Prior to Registration for this Protocol 
Patients will initially be registered on protocol 03-C-0277 (Cell Harvest and Preparation for 
Surgery Branch Adoptive Cell Therapy Protocols) prior to transduction of PBL cells (either fresh 
or cryopreserved samples), by the clinical fellow or research nurse. Once cells exceed the 
potency requirement and are projected to exceed the minimum number specified in the 
Certificate of Analysis (CoA), patients will sign the consent document for this protocol.  
2.3.2 Registration Procedure 
Authorized staff must register an eligible candidate with the NCI Central Registration Office 
(CRO) within 24 hours of signing consent. A registration Eligibility Checklist from the website 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 
encrypted email to the NCI Central Registration Office at ncicentralregistration-l@mail.nih.gov. 
After confirmation of eligibility at the Central Registration Office, CRO staff will call pharmacy 
to advise them of the acceptance of the patient on the protocol. Verification of registration will 
be forwarded electronically via email to the research team. A recorder is available during non-
working hours.  
3 
STUDY IMPLEMENTATION 
Due to toxicities experienced during the dose escalation phase of this trial, the protocol has been 
amended several times to decrease the cell dose, eliminate the administration of IL-2, and 
administer reduced doses of cyclophosphamide and fludarabine. The description of these 
changes has been moved to Appendix 2 and Appendix 3.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
3.1 
STUDY DESIGN – BEGINNING WITH AMENDMENT S 
Patients with B-cell malignancies will receive a non-myeloablative conditioning regimen 
consisting of cyclophosphamide and fludarabine chemotherapy followed by cryopreserved anti-
CD19 CAR transduced T-cells. Patients will receive one course of treatment. The start date of 
the course will be the start date of the chemotherapy; the end date will be the day of the first 
post-treatment evaluation. Patients may undergo a second treatment as described in Section 3.5. 
3.1.1 Treatment Phase: Cryopreserved PBL 
Opened with Approval of Amendment S 
PBMC will be obtained by leukapheresis (approximately 1.0x1010 cells). In most patients, whole 
PBMC will be cultured in the presence of anti-CD3 (OKT3) and aldesleukin in order to stimulate 
T-cell growth. In some patients the peripheral blood might be contaminated with large numbers 
of CD19-expressing malignant cells. In patients with peripheral blood lymphocytes counts 
greater than 4000 cells per microliter, CD19-expressing cells will be depleted using the Miltenyi 
Biotec CliniMacs system with anti-CD19 microbeads and then CD19-depleted PBMC will be 
stimulated with OKT3. In all patients, 2 days after OKT3 stimulation transduction will be 
initiated by exposure of approximately 1.0x107 to 5.0x108 cells to supernatant containing the 
anti-CD19 CAR retroviral vector. These transduced cells will be expanded and tested for their 
anti-tumor activity. Successful TCR gene transfer will be determined by FACS analysis for the 
CAR and specific anti-tumor reactivity will be tested by cytokine release measured against 
CD19+ cell lines and CD19-negative cell lines. Successful CAR gene transfer for each 
transduced PBL population will be defined as >30% CAR positive cells and for biological 
activity, gamma-interferon secretion against CD19 targets must be at least 200 pg/mL. The cells 
administered vary depending on their growth characteristic. In prior protocols over 3.0x1011 T-
cells have been safely infused to cancer patients.  
Standard Operating Procedures for the cryopreservation and thawing processes will be submitted 
to BB-IND 13871. 
With the approval of Amendment S patients will be lymphodepleted with reduced doses of 
fludarabine and cyclophosphamide followed by cryopreserved anti- CD19 CAR positive cells/kg 
(± 20%) as noted below.  
With the approval of Amendment V, the dose of cyclophosphamide was increased from 300 
mg/m2/day x 3 days to 500 mg/m2/day x 3 days. Patients will be lymphodepleted with a modest 
increase of cyclophosphamide and continue with the current dose of fludarabine, then followed 
by cryopreserved anti- CD19 CAR positive cells/kg (± 20%). 
With the approval of Amendment X, the number of days in culture was increased to 9-12. 
Patients received the current regimen of cyclophosphamide and fludarabine followed by 2.0x106 
cryopreserved anti- CD19 CAR positive cells/kg (± 20%). With the approval of Amendment Z 
cells may be in culture for 6-12 days to allow for flexibility in producing a sufficient number of 
cells in the final product.  
3.1.1.1 Dose Escalation 
Note: The paragraphs highlighted in grey are no longer applicable after the approval of 
Amendment Z.  
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Beginning with Amendment X, Cohort 13 has been completed with one patient enrolled with no 
DLTs observed and Cohort 14 was opened. 
Initially 6 patients will be enrolled in Cohort 14. If less than or equal to one DLT is seen in the 
first 6 patients enrolled in Cohort 14, the cohort will be expanded to a total of 12 patients to 
further characterize the safety of the maximum tolerated dose. 
With the approval of Amendment Y, if 2 or more DLTs are encountered in Cohort 14, Cohort 11 
will re-open and will be expanded to a maximum of 12 patients provided that less than 2 in 12 
patients have a DLT in this cohort. If 2 or more DLTs are observed in Cohort 11, we will re-
evaluate our strategy. 
With the approval of Amendment Z, if ≤ 2 of 6 patients experience a DLT in Cohort 11 then the 
cohort will be expanded to a maximum of 18 patients provided that fewer than 4 in 18 patients 
have a DLT. If 4 or more DLTs are observed in 18 patients in Cohort 11, we will de-escalate to 
Cohort 11D. The same DLT criteria as described below will be used to define the MTD for 
Cohort 11D. Note: With Amendment Z, the toxicities experienced by patient #4 in Cohort 11, 
will no longer meet the criteria for DLT. 
If 9 or greater of 18 patients in Cohort 11 experiences a PR or CR lasting more than 3 months 
this will be declared the MTD regimen. If fewer than 9 patients experience a PR and/or CR, then 
Cohort 14 will be re-opened and up to a total of 18 patients may be enrolled. The same DLT 
criteria as described below will be used to define the MTD. 
The number of cryopreserved anti-CD19-transduced T-cells transferred for each cohort will be: 
Cohort 
Treatment Regimen 
 
NMA Chemotherapy 
Regimen (as specified 
in protocol) 
Cell dose 
(Determined prior to 
cryopreservation) 
Days in 
Culture 
11-Completed 
 
Cytoxan 300mg/m2 & 
Fludarabine 30mg/m2  
2.0x106 CAR positive cells/kg (± 
20%) 
6-12 
11D- 
(De-escalation 
Cohort) 
Cytoxan 300mg/m2 & 
Fludarabine 30mg/m2 
1.0x106 CAR positive cells/kg (± 
20%) 
6-12 
12-Closed 
 
Yes  
6.0x106 CAR positive cells/kg (± 
20%) 
6 
13-Completed 
Cytoxan 500mg/m2 & 
Fludarabine 30mg/m2 
2.0x106 CAR positive cells/kg (± 
20%) 
6 
14-Completed  
Cytoxan 500mg/m2 & 
Fludarabine 30mg/m2 
2.0x106 CAR positive cells/kg (± 
20%) 
6-12 
The maximum tolerated cell dose is the highest dose at which < 1 of 6 patients experienced a 
DLT or the highest dose level studied if DLTs are not observed at any of the dose levels. 
Following administration of the cell product, neurological status will be closely monitored and 
urgently managed as described in Section 3.4.3.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
In addition, we will be evaluating stored serum samples in an effort to identify the particular 
cytokines which may be contributing to these toxicities.  
3.1.1.2 Safety Assessment 
Cytokine (IFN-gamma levels) and toxicity data must be analyzed prior to dose de-escalation. A 
one-week safety assessment period will follow regimen completion between the first patient in 
each cohort before a second patient will be accrued in the cohort.  
3.1.2 Definition of Dose-Limiting Toxicity (DLT) 
Dose-limiting toxicity is defined as follows:  
• Grade 4 neutropenia lasting longer than 21 days from the day of cell transfer 
• Grade 4 thrombocytopenia lasting longer than 35 days from the day of cell transfer 
• All grade 3 toxicities lasting more than 3 days (including grade 3 hypotension requiring 
the use of pressors) and all grade 4 toxicities with the exception of: 
o Myelosuppression (includes bleeding in the setting of platelet count less than 50,000 
per mcl and documented bacterial infections in the setting of neutropenia), defined as 
lymphopenia, decreased hemoglobin, neutropenia and thrombocytopenia” unless 
neutropenia and thrombocytopenia meet the DLT definition described above. 
o Expected chemotherapy toxicities as defined in Section 11. 
o Grade 3 Fever 
o Immediate hypersensitivity reactions occurring within 2 hours of cell infusion (related 
to cell infusion) that are reversible to a grade 2 or less within 24 hours of cell 
administration with standard therapy. 
o Aphasia/dysphagia or confusion/cognitive disturbance which resolve to grade 1 or 
less within 2 weeks. 
Note: Neurology consults and MRIs of the brain will be conducted on any subject experiencing 
any grade 3 or greater neurologic toxicity. 
Dose Limiting Toxicities per Cohort as of 4/13/2015 
Cohort 
Treatment Regimen 
 
 
 
NMA Chemotherapy Regimen  
Cell Dose 
# of 
Patients 
per Cohort 
# of 
DLTs per 
Cohort 
 
Fresh Cells 
10-25 Days in Culture 
 
1 
Cytoxan 60mg/kg x 2 days & 
Fludarabine 25mg/m2 x 5 days 
1.0x109 – 1.0x1010 CAR 
transduced cells 
8 
3 
6 
Cytoxan 60mg/kg x 2 days & 
Fludarabine 25mg/m2 x 5 days 
0.5x107 CAR positive 
cells/kg (± 20%) 
2 
2 
8 
Cytoxan 60mg/kg x 2 days & 
2.5x106 CAR positive 
5 
2 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Fludarabine 25mg/m2 x 5 days 
cells/kg (± 20%) 
9 
Cytoxan 30mg/kg x 2 days & 
Fludarabine 25mg/m2 x 5 days 
1.0x106 CAR positive 
cells/kg (± 20%) 
6 
2 
10 
Cytoxan 300mg/m2 & 
Fludarabine 30mg/m2 x 3 days 
1.0x106 CAR positive 
cells/kg (± 20%) 
7 
None 
 
Cryopreserved Cells 
6-8 Days in Culture 
 
11 
 
Cytoxan 300mg/m2 & 
Fludarabine 30mg/m2 x 3 days 
2.0x106 CAR positive 
cells/kg (± 20%) 
4 
1 
12 
Cytoxan 300mg/m2 & 
Fludarabine 30mg/m2 x 3 days 
6.0x106 CAR positive 
cells/kg (± 20%) 
1 
1 
13 
Cytoxan 500mg/m2 & 
Fludarabine 30mg/m2 x 3 days 
2.0x106 CAR positive 
cells/kg (± 20%) 
2 
1 
14 
Cytoxan 500mg/m2 & 
Fludarabine 30mg/m2 x 3 days 
2.0x106 CAR positive 
cells/kg (± 20%) 
2 
2 
3.2 
PROTOCOL STOPPING RULES 
Note: The paragraphs highlighted in grey are no longer applicable after the approval of 
Amendment S.  
 
The study will be halted pending discussions with the FDA and IRB if the following conditions 
are met: 
Prior to Amendment E 
• If two DLTs occur in the first cohort of the Phase I portion of this study. 
With approval of Amendment E (not applicable with approval of Amendment F): 
• If two DLTs occur in the first 6 patients treated on this study. 
• Two or more patients develop a grade 3 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative regimen (or circumstances unrelated to this 
study). 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) develop DLT due to autoimmune toxicity. 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
With Approval of Amendments F, H, and J 
As stated above, the study will be halted pending discussions with the FDA and IRB if the 
following conditions are met: 
• If cohorts 2-7 or 9 cannot be expanded due to DLTs. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• During the expansion phase, if at any time during accrual, a cumulative total of 3 
evaluable patients have experienced a DLT. 
• Two or more patients develop a grade 3 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative (or circumstances unrelated to this study). 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) in cohorts 2-5 develop DLT due to autoimmune toxicity. 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
With Approval of Amendment X 
As stated above, the study will be halted pending discussions with the FDA and IRB if the 
following conditions are met: 
• Two or more patients develop a grade 4 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative (or circumstances unrelated to this study). 
NOTE: Toxicities excluded from the determination of DLTs are not included 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) in cohorts 11-14 develop DLT due to autoimmune toxicity. 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
• If one or more treatment related deaths occur due to the cell infusion, we will promptly 
discuss this with the IRB and FDA. 
3.3 
DRUG ADMINISTRATION 
Note: The following dose adjustments have been made over the course of the protocol: 
• With approval of Amendment H, aldesleukin was removed. 
• With the approval of Amendment M, the dose of cyclophosphamide was reduced from 60 
mg/kg/day to 30 mg/kg/day. 
• With the approval of Amendment P, the dose of cyclophosphamide was further reduced 
from 30 mg/kg/day x 2 days to 300 mg/m2/day x 3 days and the dose of fludarabine was 
reduced from 25mg/m2/day x 5 days to 30 mg/m2 x 3 days – decreasing the total dose of 
cyclophosphamide by more than 50% and fludarabine by about 30%.  
• With the approval of Amendment V, the dose of cyclophosphamide was increased from 
300 mg/m2/day x 3 days to 500 mg/m2/day x 3 days. 
• With the approval of Amendment Y, the dose of cyclophosphamide was reverted back to 
300 mg/m2/day x 3 days. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
3.3.1 Preparative Regimen with Cyclophosphamide and Fludarabine 
Days -5 through -3 
• 1.0L of 0.9% NaCl given at 500 mL/hour starting 2 hours prior to cyclophosphamide 
followed by: 
• Cyclophosphamide 300mg/m2 IV over 60 minutes followed by: 
• Fludarabine 30mg/m2 IV over 30 minutes followed by: 
• An additional 1.0L 0f 0.9% NaCl given at 500 mL/hour. 
Patients should be instructed to drink plenty of liquids during and for 24 hours following the 
chemotherapy [approximately 2 liters/24 hours]; hydration may be adjusted as clinically 
indicated. 
3.3.2 Cell Infusion 
Cells are delivered to the patient care unit by a staff member from the Tumor Immunology Cell 
Processing Laboratory. Prior to infusion, the cell product identity label is double-checked by two 
authorized staff (MD or RN), an identification of the product and documentation of 
administration are entered in the patient’s chart, as is done for blood banking protocols. The cells 
are to be infused intravenously over 20-30 minutes via non-filtered tubing, gently agitating the 
bag during infusion to prevent cell clumping. Note: with approval of amendments F-H, the dose 
of cells administered will be on a CAR positive cells/kg basis.  
Aldesleukin will not be administered with approval of Amendment H. 
Note: With the approval of Amendment S, the dose of cells administered will be 
cryopreserved anti-CD19 CAR positive cells/kg (±20%). 
Day 0 (2-4 days after the last dose of fludarabine) 
 
• Cells will be thawed in the TIL lab and infused intravenously (i.v.) on the Patient Care 
Unit over 20 to 30 minutes. 
Day 1-4 (Day 0 is the day of cell infusion): Beginning with Amendment P  
• Filgrastim will be initiated at a dose of 300 micrograms daily for patients under 70 kg in 
weight and a dose of 480 micrograms daily for patients over 70 kg in weight only if the 
absolute neutrophil count is less than 650/microliter. Filgrastim will be discontinued as 
soon as the neutrophil count is 2000/microliter or higher 
3.3.3 Study Calendar 
Day 
-9 
-8 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
1 
2 
3 
4 
Therapy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cyclophosphamide  
 
 
 
 
X 
X 
X 
 
 
 
 
 
 
 
Fludarabine  
 
 
 
 
X 
X 
X 
 
 
 
 
 
 
 
Cryopreserved Anti-CD19 
CAR PBL1 
 
 
 
 
 
 
 
 
 
X1 
 
 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Filgrastim2  
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
Allopurinol6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
TMP/SMX3 
160mg/800mg (example) 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Fluconazole4 (400 mg po) 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
Valacyclovir po or 
Acyclovir IV5 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
1Two to four days after the last dose of fludarabine 
2 Filgrastim will be initiated at a dose of 300 micrograms daily for patients under 70 kg in weight and a dose 
of 480 micrograms daily for patients over 70 kg in weight only if the absolute neutrophil count is less than 
650/microliter. Filgrastim will be discontinued as soon as the neutrophil count is 2000/microliter or higher. 
3The TMP/SMX schedule should be adjusted to QD three times per week (Monday, Wednesday, Friday) and 
continue for at least six months and until CD4 > 200 X 2 
4Continue until ANC > 1000/mm3 
5Continue for at least six months and until CD4 > 200 X 2. 
6For patients at high risk of developing Tumor Lysis Syndrome only. 
3.4 
 ON-STUDY EVALUATION 
Note: Refer to Section 5 for research evaluations. 
3.4.1 Prior to Starting the Preparative Regimen 
• Apheresis as indicated 
• Within 14 days prior to starting the preparative regimen, patients will have a complete 
blood count, serum chemistries performed including electrolytes, BUN, creatinine, and 
liver function tests. If any results are beyond the criteria established for eligibility, the 
patient will not proceed until the abnormalities can be resolved.  
3.4.2 During the Preparative Regimen (Daily) 
• Complete Blood Count 
• Chem 20 equivalent: (Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 
(bicarbonate), Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total, 
Magnesium total (Mg), Inorganic Phosphorus, Alkaline Phosphatase, ALT/GPT, 
AST/GOT, Total Bilirubin, Direct Bilirubin, LD, Total Protein, Total CK, Uric Acid) 
• Urinalysis 
3.4.3 After Cell Infusion 
• Vital signs, including neurological checks, will be monitored hourly (± 15 minutes) for 
four hours and then routinely (every 4-6 hours)). If the patient has been febrile (Temp 
38.3 or more) at any time in the preceding 24 hours, vital signs will be monitored strictly 
every 4 hours. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• Neurological evaluations: If the patient experiences a grade 3 or greater neurological 
toxicity the following evaluations will be performed: 
o Neurology Consult - urgent 
o MRI of the Brain 
o Lumbar puncture to evaluate transduced cells in the CSF if the platelet count is 
greater than 50,000/mm3. Intrathecal dexamethasone 8mg will be administered at 
time of the LP, as clinically indicated.  
• Once total lymphocyte count is greater than 200/mm3, TBNK for peripheral blood CD4 
count will be drawn weekly (while the patient is hospitalized). Please refer to Section 5 
for additional post cell infusion evaluations. 
3.4.4 During Hospitalization (Every 1-2 Days as Clinically Indicated) 
• A review of systems and physical exam, including focused neurological examination 
• CBC 
• Chem 20 equivalent: Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 
(bicarbonate), Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total, 
Magnesium total (Mg), Inorganic Phosphorus, Alkaline Phosphatase, ALT/GPT, 
AST/GOT, Total Bilirubin, Direct Bilirubin, LD, Total Protein, Total CK, Uric Acid 
• Other tests will be performed as clinically indicated. 
3.5 
RETREATMENT 
Prior to Amendment N 
Patients will be evaluated 4 to 6 weeks after the initial treatment regimen (defined as the end of 
the last aldesleukin dose, with approval of Amendment H, defined as the end of cell infusion). If 
patients have a partial response to treatment and their disease subsequently progresses, they may 
be re-treated when progression based on the appropriate anti-malignancy response criteria (see 
Section 6.3) is documented after evaluation by Principal Investigator with the same schedule that 
they had been given safely (grade 3 toxicity due to cell infusion which is reversible within 24 
hours with supportive measures may be retreated, but patients who develop grade 4 toxicity due 
to cell infusion will not be retreated.) Patients must continue to meet the original eligibility 
criteria to be considered for retreatment. Retreatment will consist of the non-myeloablative 
chemotherapy regimen, cell infusion, and aldesleukin. With the approval of Amendment H, 
aldesleukin will not be included in the retreatment regimen. Toxicity related to 
cyclophosphamide or fludarabine should be stable and resolved to less than grade 1 prior to re-
treatment. Re-treatment benefits and risks will be carefully explained to the patient. Patients 
must be reconsented prior to retreatment. Re-treatment would begin 6 to 8 weeks after the last 
aldesleukin dose. A maximum of one retreatment course may occur. 
Following Amendment S 
Patients who experience disease progression following a confirmed complete or partial response 
to treatment or who have residual disease at the second or subsequent assessments following the 
initial treatment may be re-treated. Patients will be retreated at the currently enrolling dose level, 
but it will not count towards establishing the MTD. Patients who develop grade 3 toxicity due to 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
cell infusion which is reversible within 24 hours with supportive measures may be retreated. 
Patients who develop grade 4 toxicity due to cell infusion will not be retreated. Patients must 
continue to meet the original eligibility criteria and be negative for HAMA (Biolegend human 
anti-mouse IgG ELISA) to be considered for retreatment. Retreatment will consist of the non-
myeloablative chemotherapy regimen followed by cryopreserved cell infusion. Toxicity related 
to cyclophosphamide or fludarabine should be stable and resolved to less than grade 1 prior to 
retreatment. Retreatment benefits and risks will be carefully explained to the patient. A 
maximum of one retreatment course may occur. 
3.6 
POST-STUDY EVALUATION (FOLLOW-UP) 
• All patients will return to the NIH Clinical Center for evaluation 6 weeks (± 2 weeks) 
following the administration of the cell product. 
• Patients discharged with grade 3 or greater significant adverse events should be evaluated 
by referring physician within 2 weeks of discharge. 
3.6.1 Time-Period of Evaluations 
Patients who experience stable disease, a partial response, or a complete response or have 
unresolved toxicities will be evaluated as noted below: 
• Week 12 (± 2 weeks) 
• Every 3 months (± 1 month) x3 
• Every 6 months (± 1 month) x2 
• As per PI discretion for subsequent years 
Note: Patients may be seen more frequently as clinically indicated. 
3.6.2 Scheduled Evaluations  
At each evaluation, patients will undergo: 
• Physical examination  
• Chem 20 equivalent: (Sodium (Na), Potassium (K), Chloride (Cl), Total CO2 
(bicarbonate), Creatinine, Glucose, Urea nitrogen (BUN), Albumin, Calcium total, 
Magnesium total (Mg), Inorganic Phosphorus, Alkaline Phosphatase, ALT/GPT, 
AST/GOT, Total Bilirubin, Direct Bilirubin, LD, Total Protein, Total CK, Uric Acid), 
Complete blood count 
• Thyroid panel as clinically indicated 
• TBNK 
• Toxicity assessment, including a review of systems  
• CT of the chest, abdomen and pelvis and PET scan. This end of course evaluation will be 
used to determine response of the malignancy to treatment. If clinically indicated, other 
scans or x-rays may be performed, e.g. brain MRI, bone scan. 
• Visual symptoms will be evaluated and if changes have occurred from baseline, i.e. 
changes in visual acuity, an ophthalmologic consult will be performed. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• A 5-liter apheresis may be performed at the first follow up visit. If the patient is unable to 
undergo apheresis, approximately 96 mL of blood may be obtained. Subsequently, 60 mL 
of blood will be obtained at follow up visits (approximately monthly) for at least 3 
months. Peripheral blood mononuclear cells will be cryopreserved so that immunologic 
testing may be performed.  
• Detection of RCR and persistence of CAR gene transduced cells (Section 5.3) 
• Note: Long-term follow up of patients receiving gene transfer: Physical examinations 
will be performed and documented annually for 5 years following cell infusion to 
evaluate long-term safety. After 5 years, health status data will be obtained from 
surviving patients via telephone contact or mailed questionnaires. The long term follow 
up period for retroviral vectors is 15 years. 
• Note: Patients who are unable or unwilling to return for follow up evaluations will be 
followed via phone or email contact. Patients may be asked to send laboratory, imaging 
and physician exam reports performed by their treating physician. 
3.7 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY CRITERIA 
3.7.1 Criteria for Removal from Protocol Therapy 
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy.  
Patients will be taken off treatment (and followed until progression of disease) for the following: 
• Completion of protocol therapy. 
• Patient requests to be withdrawn from active therapy. 
• Investigator discretion. 
• Positive pregnancy test. 
• Tumor lysis syndrome, defined as a 25% or greater increase in the pre-treatment values 
of serum phosphorous, potassium, and uric acid as well as a 25% or greater decrease in 
serum calcium in the setting of effective treatment of a patient with large tumor burden.  
3.7.2 Off-Study Criteria 
Patients will be taken off study for the following: 
• Completed study follow-up period 
• Participant requests to be withdrawn from study 
• Progressive disease, unless the patient is eligible for a second treatment. 
• Lost to follow-up 
• Death 
Note: Once a subject is taken off-study, no further data can be collected. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Note: Patients who are taken off-study for progressive disease or study closure may be followed 
on protocol 09-C-0161 (Follow-up Protocol for Subjects Previously Enrolled on NCI Surgery 
Branch Studies). 
3.7.3 Off Protocol Therapy and Off-Study Procedure 
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off 
protocol therapy and when a subject is taken off-study. A Participant Status Updates Form from 
the web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be 
completed and sent via encrypted email to: NCI Central Registration Office, 
ncicentralregistration-l@mail.nih.gov. 
4 
CONCOMITANT MEDICATIONS/MEASURES 
4.1 
INFECTION PROPHYLAXIS 
Note: Other anti-infective agents may be substituted at the discretion of the treating investigator. 
4.1.1 Pneumocystis Jirovecii Pneumonia 
Patients will receive the fixed combination of trimethoprim and sulfamethoxazole [SMX] as 
double strength (DS) tab (DS tabs = TMP 160 mg/tab, and SMX 800 mg/tab) PO daily three 
times a week on non-consecutive days, beginning between days -5 and -8.  
Pentamidine will be substituted for TMP/SMX-DS in patients with sulfa allergies. It will be 
administered aerosolized at 300 mg per nebulizer within one week of chemotherapy start date 
and monthly thereafter. 
 
4.1.2 Herpes Virus Prophylaxis 
Patients will receive valacyclovir orally at a dose of 500 mg daily the day after chemotherapy 
ends, or acyclovir, 250 mg/m2 IV every 12 hours if the patient is not able to take medication by 
mouth. Reversible renal insufficiency has been reported with IV but not oral acyclovir. 
Neurologic toxicity including delirium, tremors, coma, acute psychiatric disturbances, and 
abnormal EEGs have been reported with higher doses of acyclovir. Should this occur, a dosage 
adjustment will be made or the drug will be discontinued. Acyclovir will not be used 
concomitantly with other nucleoside analogs which interfere with DNA synthesis, e.g. 
ganciclovir. In renal disease, the dose is adjusted as per product labeling. 
Prophylaxis for pneumocystis and herpes will continue for 6 months post chemotherapy. If the 
CD4 count is less than 200 at 6 months post chemotherapy, prophylaxis will continue until the 
CD4 count is greater than 200 X 2.  
4.1.3 Fungal Prophylaxis  
Patients will start fluconazole 400 mg PO the day after chemotherapy concludes and continue 
until the absolute neutrophil count is greater than 1000/mm3. The drug may be given IV at a dose 
of 400 mg in 0.9% sodium chloride USP daily in patients unable to take it orally. 
4.1.4 Empiric Antibiotics  
Patients will start on broad-spectrum antibiotics, either a 3rd or 4th generation cephalosporin or a 
quinolone for fever of 38.3oC once or two temperatures of 38.0oC or above at least one hour 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
apart, AND an ANC <500/mm3. Infectious disease consultation will be obtained for all patients 
with unexplained fever or any infectious complications. 
4.1.5 Prophylaxis and Treatment of Tumor Lysis Syndrome 
Subjects deemed to be at high risk of tumor lysis syndrome should begin allopurinol at a dose of 
200 mg PO every 8 hours. This should be started 2 days prior to the first dose of 
cyclophosphamide and continued until disease burden is reduced (e.g. peripheral blasts clear) or 
it is apparent that no tumor lysis has developed after 1 week of treatment. 
4.2 
BLOOD PRODUCT SUPPORT 
Using daily CBCs as a guide, the patient will receive platelets and packed red blood cells 
(PRBCs) as needed. Attempts will be made to keep Hb > 8.0 gm/dL, and plts > 10,000/mm3. All 
blood products with the exception of the stem cell product will be irradiated. Leukocyte filters 
will be utilized for all blood and platelet transfusions to decrease sensitization to transfused 
WBCs and decrease the risk of CMV infection. 
4.3 
OTHER CONCOMITANT MEDICATIONS TO CONTROL SIDE EFFECTS 
Concomitant medications to control side effects of therapy will be given. Meperidine (25-50 mg) 
will be given intravenously if severe chilling develops. Other supportive therapy will be given as 
required and may include acetaminophen (650 mg every 4 hours), indomethacin (50-75 mg every 
6 hours) and ranitidine (150 mg every 12 hours). If patients require steroid therapy, they will be 
taken off treatment. Patients who require transfusions will receive irradiated blood products. 
Ondansetron 0.15 mg/kg/dose IV every 8 hours will be administered for nausea and vomiting. 
Additional antiemetics will be administered as needed for nausea and vomiting uncontrolled by 
ondansetron. Antibiotic coverage for central venous catheters may be provided at the discretion 
of the investigator. 
5 
BIOSPECIMEN COLLECTION 
Blood and tissue are tracked at the patient level and can be linked to all protocols on which the 
patient has been enrolled. Samples will be used to support the specific objectives listed in the 
treatment protocol(s), e.g., immunologic monitoring, cytokine levels, persistence, as well as to 
support long term research efforts within the Surgery Branch and with collaborators as specified 
in protocol 03-C-0277. 
5.1 
RESEARCH EVALUATIONS 
The amount of blood that may be drawn from adult patients for research purposes shall not 
exceed 10.5 mL/kg or 550 mL, whichever is smaller, over any eight-week period. 
5.1.1 Prior to Chemotherapy Administration 
• 5 CPT tubes (8 mL each) 
• 1 SST tube (8 mL) 
• SST tube (4 mL) daily; starting day of chemotherapy 
5.1.2 Prior to Cell Infusion (1-8 mL SST) 
• Blood samples for analysis for detection of RCR by PCR. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• Blood samples for analysis of the cytokines IL-6, TNF-α, IFN-γ and GM-CSF. 
5.1.3 Post-Cell Infusion Evaluations 
Once total lymphocyte count is greater than 200/mm3, the following samples will be drawn and 
sent to the TIL lab on Monday, Wednesday, and Friday x5 days, then weekly (while the patient 
is hospitalized): 
• 5 CPT tubes (8 mL each) 
• 1 SST tube (8 mL) 
5.2 
 IMMUNOLOGICAL TESTING 
• Apheresis may be performed, prior to and 4-6 weeks after the treatment. At other time 
points, patient peripheral blood lymphocytes (PBL) will be obtained from whole blood by 
purification using centrifugation on a Ficoll cushion.  
• Lymphocytes will be tested directly and following in vitro culture. Direct immunological 
monitoring will consist of quantifying CD3+ T-cells that express the anti-CD19 CAR by 
FACS analysis using a goat-anti-mouse antibody as shown in Figure 2. Ex vivo 
immunological assays will consist of cytokine release by bulk PBL, intracellular cytokine 
staining as shown in Figure 6, and by other experimental studies such as cytolysis if 
sufficient cells are available. If cell numbers are limiting, preference will be given to the 
direct analysis of immunological activity. Immunological assays will be standardized by 
the inclusion of 1) pre-infusion PBMC and 2) an aliquot of the engineered PBL 
cryopreserved at the time of infusion. In general, differences of 2- to 3-fold in these 
assays are indicative of true biologic differences. 
Note: The collection and analysis of research labs will be monitored by the TIL lab and not by 
the CCR contractor. 
5.3 
 MONITORING GENE THERAPY TRIALS: PERSISTENCE AND RCR 
•  Immunological monitoring by using either anti-mouse Fab FACs staining to detect 
CARs on the surface of T-cells or a quantitative real-time PCR assay will be used to 
quantitate persistence of T-cells in the blood. Persistence will be determined at about 1 
week, 4 weeks (± 2 weeks), 3 months (± 1 month), 6 months (± 1 month), and 12 months 
(± 1 month) after cell infusion.  
• All patients will be co-enrolled on protocol 09-C-0161. Patients’ blood samples will be 
obtained and undergo analysis for detection of RCR by PCR prior to cell infusion and 
RCR PCR will be performed at 3 and 6 months, and at one year post-cell administration. 
Blood samples will be archived annually thereafter if all previous testing has been 
negative with a brief clinical history. If a patient dies or develops neoplasms during this 
trial, efforts will be made to assay a biopsy sample for RCR. If any post-treatment 
samples are positive, further analysis of the RCR and more extensive patient follow-up 
will be undertaken, in consultation with the FDA. RCR PCR assays detect the GaLV 
envelop gene and are performed under contract by the Indiana University Vector 
Production Facility. The results of these tests are maintained by the contractor performing 
the RCR tests and by the Surgery Branch research team. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
5.4 
SAMPLE STORAGE, TRACKING, AND DISPOSITION 
Blood and tissue collected during the course of this study will follow the Cell Tracking and 
Labeling System established by the Tumor Immunology Cell Processing Laboratory. The Cell 
Tracking and Labeling System is designed to unambiguously ensure that patient/data verification 
is consistent. The patients' cell samples (blood or tissue) are tracked by distinct identification 
labels that include a unique patient identifier and date of specimen collection. Cryopreserved 
blood and tissue samples also bear the date the sample was frozen. All cryopreserved samples are 
tracked for freezer location and storage criteria. All samples are stored in monitored 
freezers/refrigerators in 3NW Surgery Branch Laboratories at specified temperatures with alarm 
systems in place. Serum samples will be sent to the Clinical Pharmacology Program (CPP) for 
storage. Samples will be barcoded and stored on site or offsite at NCI Frederick Central 
Repository Services in Frederick, MD. Data is entered and stored securely in the Patient Sample 
Data Management System (PSDMS) utilized by the CPP, and data will be updated to the Surgery 
Branch central computer database weekly. All samples (blood or tissue) are entered into a central 
computer database with identification and storage location, and this database is backed up every 
night. 
At the conclusion of this protocol, if additional studies are to be performed on any samples 
obtained during the conduct of this trial, a Request to Conduct Research for Stored Human 
Samples Specimens, or Data Collected in a Terminated IRB Protocol will be submitted. 
Otherwise, specimens will be disposed of in accordance with the environmental protection laws, 
regulations and guidelines of the Federal Government and the State of Maryland. 
Any loss or unintentional destruction of the samples will be reported to the IRB, the NCI Clinical 
Director, and the office of the CCR, NCI. 
Note: Blood and tissue collected during the course of this study will be stored, tracked and 
disposed of as specified in protocol 03-C-0277. 
6 
DATA COLLECTION AND EVALUATION 
6.1 
DATA COLLECTION 
The PI will be responsible for overseeing entry of data into an in-house password protected 
electronic system (C3D) and ensuring data accuracy, consistency and timeliness. The Principal 
Investigator, associate investigators/research nurses and/or a contracted data manager will assist 
with the data management efforts. All data obtained during the conduct of the protocol will be 
kept in secure network drives or in approved alternative sites that comply with NIH security 
standards. Primary and final analyzed data will have identifiers so that research data can be 
attributed to an individual human subject participant. Data will be entered into the NCI CCR 
C3D database.  
All adverse events (AEs), including clinically significant abnormal findings on laboratory 
evaluations, regardless of severity, will be followed until return to baseline or stabilization of 
event. Patients will be followed for AEs until 30 days following the last dose of study therapy or 
until off-study, whichever comes first. 
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following: 
• Results in discontinuation from the study 


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Version Date: August 23, 2018 
• Is associated with clinical signs or symptoms  
• Requires treatment or any other therapeutic intervention 
• Is associated with death or another serious adverse event, including hospitalization.  
• Is judged by the Investigator to be of significant clinical impact 
• If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
All AEs must be recorded on the AE case report form unless otherwise noted below in Section 
6.1.1. 
End of study procedures: Data will be stored according to HHS and FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, the IRB will be notified. 
6.1.1 Routine Adverse Event Recording 
All adverse events will be recorded in the patient’s medical record. Following registration 
through 30 days after the cell infusion adverse events will be reviewed by the research nurse and 
Principal Investigator and captured in the C3D database. All events occurring during the 
treatment phase of the study will be followed until resolution or stabilization. During the follow 
up period, only grade 3 and 4 and unexpected grade 2 events that are related to the treatment will 
be captured in C3D. 
6.2 
DATA SHARING PLANS 
6.2.1 Human Data Sharing Plan 
De-identified human data generated for use in future and ongoing research will be shared 
through a NIH-funded or approved repository (ClinicalTrials.gov) and BTRIS. At the completion 
of data analysis, data will be submitted to ClinicalTrials.gov either before publication or at the 
time of publication or shortly thereafter. Data may also be used to support long term research 
efforts within the Surgery Branch and de-identified data may also be shared with collaborators as 
specified in protocol 03-C-0277. 
6.2.2 Genomic Data Sharing Plan 
All genomic analysis that requires compliance with the GDS policy is being performed on 
protocol 03-C-0277. 
6.3 
RESPONSE CRITERIA 
6.3.1 Anti-Malignancy Response Criteria 
6.3.1.1 Response Criteria for Lymphoma  
Note: All responses must last for at least 4 weeks after treatment (Cheson et al. Revised 
Response Criteria for Malignant Lymphoma, Journal of Clinical Oncology 2007 48). 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• Complete Remission (CR): CR requires all of the following:  
1. Complete disappearance of all detectable clinical evidence of disease and disease-
related symptoms if present before therapy.  
2. Typically, FDG-avid lymphoma (large cell, mantle cell and follicular lymphomas are 
all typically FDG-avid): in patients with no pretreatment PET scan or when the PET 
scan was positive before therapy, a post-treatment residual mass of any size is 
permitted as long as it is PET negative.  
3. Variably FDG-avid lymphomas/FDG avidity unknown: in patients without a 
pretreatment PET scan, or if a pretreatment PET scan was negative, all lymph nodes 
and nodal masses must have regressed to normal size (≤ 1.5 cm in greatest diameter if 
> 1.5 cm before therapy). Previously involved nodes that were 1.1 to 1.5 cm in their 
long axis and more than 1 cm in their short axis before treatment must have decreased 
to ≤ 1.0 cm in their short axis after treatment.  
4. The spleen and/or liver, if considered to be enlarged before therapy on basis of 
physical exam or CT scan, must should be normal size on CT scan and not be 
palpable on physical examination and nodules thought to represent lymphoma must 
no longer be present.  
5. A bone marrow aspirate and biopsy is performed only when the patient had bone 
marrow involvement with lymphoma prior to therapy or if new abnormalities in the 
peripheral blood counts or blood smear cause clinical suspicion of bone marrow 
involvement with lymphoma after treatment. The bone marrow aspirate and biopsy 
must show no evidence of disease by morphology or if indeterminate by morphology 
it must be negative by immunohistochemistry. The biopsy core sample must be a 
minimum of 20 mm in length.  
• Partial Remission (PR): PR requires all of the following: 
1. ≥ 50% decrease in sum of the product of the diameters (SPD) of up to 6 of the largest 
dominant nodes or nodal masses. Dominant nodes or nodal masses should be clearly 
measurable in at least 2 perpendicular dimensions, should be from different regions of 
the body if possible and should include mediastinal and retroperitoneal nodes if 
possible.  
2. No increase in size of nodes, liver or spleen and no new sites of disease.  
3. If multiple splenic and hepatic nodules are present, they must regress by ≥ 50% in the 
SPD. There must be a > 50% decrease in the greatest transverse diameter for single 
nodules.  
4. Bone marrow is irrelevant for determination of a PR. If patient has persistent bone 
marrow involvement and otherwise meets criteria for CR the patient will be 
considered a PR. 
5. Typically, FDG-avid lymphoma: for patients with no pretreatment PET scan or if the 
PET scan was positive before therapy, the post-treatment PET scan should be positive 
in at least one previously involved site. Note: in patients with follicular lymphoma or 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
mantle-cell lymphoma, a PET scan is only indicated in patients with one or at most 
two residual masses that have regressed by 50% on CT scan. 
• Progressive Disease (PD): Defined by at least one of the following:  
1. ≥ 50% increase from nadir in the sum of the products of at least two lymph nodes, or 
if a single node is involved at least a 50% increase in the product of the diameters of 
this one node.  
2. Appearance of a new lesion greater than 1.5 cm in any axis even if other lesions are 
decreasing in size 
3. Greater than or equal to a 50% increase in size of splenic or hepatic nodules  
4. At least a 50% increase in the longest diameter of any single previously identified 
node more than 1 cm in its short axis.  
5. Lesions should be PET positive in typically FDG-avid lymphomas unless the lesion is 
too small to be detected by PET (<1.5 cm in its long axis by CT) 
• Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase 
to qualify for PD. PET should be positive in typically FDG-avid lymphomas. 
Flow cytometric, molecular or cytogenetic studies will not be used to determine response. 
6.4 
PERSISTENCE CRITERIA FOR ANTI-CD19 CAR TRANSDUCED T-CELLS 
The absolute number of persisting anti-CD19-CAR-transduced T-cells will be calculated by 
multiplying the absolute peripheral blood lymphocyte (PBL) count by the percentage of PBL that 
express both CD3 and the anti-CD19 CAR. The percentage of PBL that express both CD3 and 
the anti-CD19 CAR will be determined by a flow cytometry assay that involves staining with 
anti-CD3 and a polyclonal goat anti-mouse antibody product that is specific for mouse IgG 
F(ab’)2 antibody fragments (Jackson ImmunoResearch).  
This analysis will be performed at about 2 weeks, 4 weeks (± 2 weeks), 3 months (± 1 month), 
and 6 months (± 1 month) after cell infusion. The 4-week time point is the only primary analysis 
that will be used for the primary evaluation of the number of CD3+ cells that express the anti-
CD19 CAR. 
6.5 
TOXICITY CRITERIA 
This study will utilize the CTCAE version 3.0 for toxicity and adverse event reporting. A copy of 
the CTCAE v3.0 can be downloaded from the CTEP home page (http://ctep.cancer.gov).  
7 
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN 
 
7.1 
DEFINITIONS 
7.1.1 Adverse Event 
Any untoward medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
7.1.2 Suspected Adverse Reaction 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the drug caused the adverse event. For the purposes of IND safety reporting, ‘reasonable 
possibility’ means there is evidence to suggest a causal relationship between the drug and the 
adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug. 
7.1.3 Unexpected Adverse Reaction 
An adverse event or suspected adverse reaction is considered “unexpected” if it is not listed in 
the investigator brochure or is not listed at the specificity or severity that has been observed; or, 
if an investigator brochure is not required or available, is not consistent with the risk information 
described in the general investigational plan or elsewhere in the current application. 
"Unexpected”, also refers to adverse events or suspected adverse reactions that are mentioned in 
the investigator brochure as occurring with a class of drugs or as anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation. 
7.1.4 Serious 
An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of a Serious 
Adverse Event or if it compromises the safety, welfare or rights of subjects or others. 
7.1.5 Serious Adverse Event 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following: 
• Death 
• A life-threatening adverse drug experience 
• Inpatient hospitalization or prolongation of existing hospitalization 
• Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• A congenital anomaly/birth defect 
• Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
7.1.6 Disability 
A substantial disruption of a person’s ability to conduct normal life functions. 
7.1.7 Life-Threatening Adverse Drug Experience 
Any adverse event or suspected adverse reaction that places the patient or subject, in the view of 
the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that had it occurred in a more severe form, might have caused death. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
7.1.8 Protocol Deviation (NIH Definition) 
Any change, divergence, or departure from the IRB-approved research protocol.  
7.1.9 Non-Compliance (NIH Definition) 
The failure to comply with applicable NIH Human Research Protections Program (HRPP) 
policies, IRB requirements, or regulatory requirements for the protection of human research 
subjects. 
7.1.10 Unanticipated Problem 
Any incident, experience, or outcome that: 
1. Is unexpected in terms of nature, severity, or frequency in relation to  
a. the research risks that are described in the IRB-approved research protocol and 
informed consent document; Investigator’s Brochure or other study documents, 
and 
b. the characteristics of the subject population being studied; AND 
2. Is related or possibly related to participation in the research; AND 
3. Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
7.2 
IRB AND CLINICAL DIRECTOR (CD) REPORTING 
7.2.1 IRB and NCI CD Expedited Reporting of Unanticipated Problems, and Deaths 
The Protocol PI will report on the NIH Problem Form to the IRB and the NCI Clinical Director: 
• All deaths, except deaths due to progressive disease.  
• All protocol deviations  
• All unanticipated problems 
• All non-compliance 
Reports must be received within 7 days of PI awareness via iRIS. 
7.2.2 IRB Requirements for PI Reporting at Continuing Review 
The protocol PI will report to the IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation 
occurred, a brief description of the deviation and any corrective action. 
2. A summary of any instances of non-compliance. 
3. A tabular summary of the following adverse events: 
• All Grade 2 unexpected events that are possibly, probably or definitely related to the 
research; 
• All Grade 3 and 4 events that are possibly, probably or definitely related to the 
research;  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• All Grade 5 events regardless of attribution;  
• All serious events regardless of attribution.  
Note: Grade 1 events are not required to be reported.  
To ensure safety using this treatment, the Surgery Branch will review safety data on all protocols 
at the time of continuing review. Data will be presented for both the recent period and for the 
entire length of time the protocol has been open. The toxicity data for review will include all 
toxicities captured on the protocol and will be presented in individual tables as follows:  
• all toxicities attributed to the cells  
• all incidences of intubation including the duration of and reason for intubation 
7.2.3 IRB Reporting of IND Safety Reports 
Only IND Safety Reports that meet the definition of an unanticipated problem will need to be 
reported to the IRB. 
7.3 
IND SPONSOR REPORTING CRITERIA 
From the time the subject receives the investigational agent/intervention to 30 days following the 
last dose of study therapy, the investigator must immediately report to the sponsor, using the 
mandatory MedWatch Form FDA 3500A or equivalent, any serious adverse event, whether or 
not considered drug-related, including those listed in the protocol or Investigator’s Brochure and 
must include an assessment of whether there is a reasonable possibility that the drug caused the 
event. For serious adverse events that occur more than 30 days after the last administration of 
investigational agent/intervention, only those events that have an attribution of at least possibly 
related to the agent/intervention will be reported. 
• Death (except death due to progressive disease) must be reported via email within 24 
hours. A complete report must be submitted within one business day.  
• Other serious adverse events as well as deaths due to progressive disease must be 
reported within one business day. 
Events will be submitted to the Center for Cancer Research (CCR) at: CCRsafety@mail.nih.gov 
and to the CCR PI and study coordinator. 
7.3.1 Reporting Pregnancy 
7.3.1.1 Maternal Exposure 
If a patient becomes pregnant during the course of the study, the study treatment should be 
discontinued immediately and the pregnancy reported to the Sponsor. The potential risk of 
exposure of the fetus to the investigational agent(s) or chemotherapy agents (s) should be 
documented in box B5 of the MedWatch form “Describe Event or Problem”. 
Pregnancy itself is not regarded as an SAE. However, as patients who become pregnant on study 
risk intrauterine exposure of the fetus to agents which may be teratogenic, the CCR is requesting 
that pregnancy should be reported in an expedited manner as Grade 3 “Pregnancy, puerperium 
and perinatal conditions - Other (pregnancy)” under the Pregnancy, puerperium and perinatal 
conditions SOC.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Congenital abnormalities or birth defects and spontaneous miscarriages should be reported and 
handled as SAEs. Elective abortions without complications should not be handled as AEs. The 
outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, 
normal birth, or congenital abnormality) should be followed up and documented. 
If any pregnancy occurs in the course of the study, then the investigator should inform the 
Sponsor within 1 day, i.e., immediately, but no later than 24 hours of when he or she becomes 
aware of it. 
The designated Sponsor representative will work with the investigator to ensure that all relevant 
information is provided to the Sponsor within 1 to 5 calendar days for SAEs and within 30 days 
for all other pregnancies. 
The same timelines apply when outcome information is available. 
7.3.1.2 Paternal Exposure 
Male patients should refrain from fathering a child or donating sperm during the study and for 
(120 days) after the cell infusion. 
Pregnancy of the patient’s partner is not considered to be an AE. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or 
congenital abnormality) occurring from the date of the first dose until (120 days) after the last 
dose should, if possible, be followed up and documented. 
7.4 
INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) REPORTING CRITERIA 
7.4.1 Serious Adverse Event Reports to IBC 
The Principal Investigator (or delegate) will notify IBC of any unexpected fatal or life-
threatening experience associated with the use of anti-CD19 CAR-transduced PBL as soon as 
possible but in no event later than 7 calendar days of initial receipt of the information. Serious 
adverse events that are unexpected and associated with the use of the anti-CD19 CAR-
transduced PBL, but are no fatal or life-threatening, must be reported to the NIH IBC as soon as 
possible, but not later than 15 calendar days after the investigator’s initial receipt of the 
information. Adverse events may be reported by using the FDA Form 3500a.  
7.4.2 Annual Reports to IBC 
Within 60 days after the one-year anniversary of the date on which the IBC approved the initial 
protocol, and after each subsequent anniversary until the trial is completed, the Principal 
Investigator (or delegate) shall submit the information described below. Alternatively, the IRB 
continuing review can be sent to the IBC in lieu of a separate report. Please include the IBC 
protocol number on the report. 
7.4.2.1 Clinical Trial Information  
A brief summary of the status of each trial in progress or completed during the previous year. 
The summary is required to include the following information for each trial:  
• the title and purpose of the trial  
• clinical site 
• the Principal Investigator 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• clinical protocol identifiers  
• participant population (such as disease indication and general age group, e.g., adult or 
pediatric);  
• the total number of participants planned for inclusion in the trial; the number entered into 
the trial to date whose participation in the trial was completed; and the number who 
dropped out of the trial with a brief description of the reasons  
• the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, 
or fully completed,  
• if the trial has been completed, a brief description of any study results.  
7.4.2.2 Progress Report and Data Analysis  
Information obtained during the previous year's clinical and non-clinical investigations, 
including:  
• a narrative or tabular summary showing the most frequent and most serious adverse 
experiences by body system 
• a summary of all serious adverse events submitted during the past year 
• a summary of serious adverse events that were expected or considered to have causes not 
associated with the use of the gene transfer product such as disease progression or 
concurrent medications 
• if any deaths have occurred, the number of participants who died during participation in 
the investigation and causes of death 
• a brief description of any information obtained that is pertinent to an understanding of the 
gene transfer product’s actions, including, for example, information about dose-response, 
information from controlled trials, and information about bioavailability.  
7.5 
DATA AND SAFETY MONITORING PLAN 
Careful evaluation to ascertain the toxicity, immunologic effects and anti-malignancy efficacy of 
cell infusions will be performed. Due to the nature of these studies, it is possible that expansion 
of specific T-cell clones will be observed as tumor reactive T-cell proliferate in response to 
tumor antigens. Therefore, care will be taken to track T-cell persistence both immunologically 
and molecularly according to plan specified in Section 6.4.  
The Principal Investigator will review all serious adverse events and will monitor the data and 
toxicities to identify trends monthly. The Principal Investigator will be responsible for revising 
the protocol as needed to maintain safety.  
7.5.1 Principal Investigator/Research Team 
The clinical research team will meet on a regular basis when patients are being actively treated 
on the trial to discuss each patient. Decisions about enrollment will be made based on the 
toxicity data from prior patients.  
All data will be collected in a timely manner and reviewed by the Principal Investigator. Adverse 
events will be reported as required above. Any safety concerns, new information that might 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
affect either the ethical and or scientific conduct of the trial, or protocol deviations will be 
immediately reported to the IRB using iRIS.  
The Principal Investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The Principal Investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 
7.5.2 Sponsor Monitoring Plan 
As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring 
program. The CCR’s program allows for confirmation of: study data, specifically data that could 
affect the interpretation of primary study endpoints; adherence to the protocol, regulations, and 
SOPs; and human subject’s protection. This is done through independent verification of study 
data with source documentation focusing on: 
• Informed consent process 
• Eligibility confirmation 
• Drug administration and accountability 
• Adverse events monitoring 
• Response assessment. 
The monitoring program also extends to multi-site research when the CCR is the coordinating 
center. 
This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified 
by training and experience to monitor the progress of clinical trials. Personnel monitoring this 
study will not be affiliated in any way with the trial conduct.  
7.5.3 Safety Monitoring Committee (SMC) 
This protocol will require oversight from the Safety Monitoring Committee (SMC). Initial 
review will occur as soon as possible after the annual IRB continuing review date. Subsequently, 
each protocol will be reviewed as close to annually as the quarterly meeting schedule permits or 
more frequently as may be required by the SMC. For initial and subsequent reviews, protocols 
will not be reviewed if there is no accrual within the review period. Written outcome letters will 
be generated in response to the monitoring activities and submitted to the Principal Investigator 
and Clinical Director or Deputy Clinical Director, CCR, NCI. 
8 
STATISTICAL CONSIDERATIONS 
Note: Paragraphs highlighted in grey below are no longer applicable after the approval of 
Amendment V. 
The statistical section has been revised numerous times. Please refer to the bolded section below 
for the current statistical analysis for Amendment J. The primary endpoints of this trial are to 
determine safety and to determine whether lymphodepletion with fludarabine and 
cyclophosphamide enhances persistence of adoptively transferred, anti-CD19-CAR-transduced 
T-cells. The secondary endpoint is to determine the anti-malignancy effect of the T-cells 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
transduced with an anti-CD19 CAR in the patients that do not receive fludarabine and 
cyclophosphamide. 
The initial portion of this protocol will be a phase I dose escalation design with three cohorts of a 
minimum of 3 patients per cohort. The number of anti-CD19-transduced T-cells transferred for 
each cohort will be:  
Cohort 1 
between 
1.0x109 and 1.0x1010 
Cohort 2 
greater than 
1.0x1010 up to 3.0x1010 
Cohort 3 
greater than 
3.0x1010 up to 1.0x1011  
Patients will be enrolled sequentially, therefore enrollment will not proceed to a higher dose 
level until all patients have been treated in the prior cohort. If sufficient cells cannot be grown to 
meet the criteria for the assigned cohort, the patient will be enrolled in the appropriate cohort for 
the number of cells infused. Should a single patient experience a dose limiting toxicity at a 
particular dose level, three more patients would be treated at that dose to confirm that no greater 
than 1/6 patients have a DLT prior to proceeding to the next higher level. If a level with 2 or 
more DLTs in 3-6 patients has been identified, three additional patients will be accrued at the 
next-lowest dose for a total of 6, in order to further characterize the safety of the maximum 
tolerated dose prior to starting the phase II portion of the trial. 
In phase II of the trial patients will be randomized to two treatment arms. Patients assigned to 
one treatment arm will receive fludarabine and cyclophosphamide lymphodepleting 
chemotherapy prior to receiving the engineered PBL cells while patients assigned to the other 
treatment arm will not receive chemotherapy. One to four days after completion of 
chemotherapy, anti-CD19 CAR-transduced T-cells will be infused. After cell infusion, all 
patients will receive IV aldesleukin therapy (720,000 IU/kg every 8 hours for a maximum of 15 
doses). The randomization performed during phase II of this trial will be stratified so that each 
arm will receive an equal number of patients with a total CD3 count greater than or equal to 500 
cells/microliter, and each arm will receive an equal number of patients with a CD3 count less 
than 500 cells/microliter. Randomization will also be stratified so that an equal number of 
patients with circulating malignant cells (leukemia) will be entered on each arm of the phase II 
part of the trial. For this trial, a patient with circulating malignant cells (leukemia) will be 
defined as a patient with a pre-treatment peripheral blood lymphocyte count of greater than 4000 
lymphocytes per microliter.  
The degree of persistence of anti-CD19-CAR-transduced T-cells will be evaluated by a 
quantitative measure in all patients, and will be compared directly between the two arms in order 
to determine if the use of fludarabine and cyclophosphamide lymphodepleting chemotherapy 
prior to receiving the engineered PBL cells will enhance persistence. Persistence will be 
determined as described in Section 5.3. The 4-week time point will be used for the primary 
evaluation of percentage of CD3+ cells that express the anti-CD19 CAR. With 17 patients in each 
of the two randomized arms, there will be 80% power to identify a difference in the mean 
persistence parameter between the two arms which will be equal to one standard deviation of the 
values within each arm (effect size 1.0), using a 0.05 two-tailed two-sample t-test. In a previous 
trial of TCR gene transfer, in patients that received fludarabine and cyclophosphamide for 
lymphodepletion, 9-56% of transduced cells persisted at 1 to 4 weeks post-infusion. We 
anticipate that the persistence of cells will be decreased without the lymphodepleting 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
chemotherapy. In practice, if the persistence measure is not normally distributed in both arms 
(p<0.05 by a Shapiro-Wilks test in either arm) then a Wilcoxon rank sum test will be used. 
Anti-malignancy effects will be measured by clinical response as noted in Section 6.3, and will 
be reported using 95% confidence intervals, separately for CLL and for lymphoma. As there are 
no requirements for a particular number of each type of disease, the results will be interpreted 
cautiously in the context of a pilot study which may be used to guide determination of 
parameters for study in future protocols if warranted. 
In order to complete enrollment to this protocol, up to 18 patients may be needed for the phase I 
portion of the trial, and an additional 34 for the phase II portion. Thus, at an accrual rate of 2 
patients per month, up to 2.5 years may be required to enroll up to 52 patients onto this trial. 
With Amendment E (closed with approval of Amendment F), the trial is being refocused to 
evaluate the safety and toxicity of the regimen studied at dose level 1, between 1.0x109 and 
1.0x1010 cells. This has been selected as the dose to use in all patients on this study as a result of 
the experience reported to date with this regimen. Under this Amendment, the study will initially 
enroll up to 6 evaluable patients who will receive this level of cells (4 patients have already been 
treated), and if no more than 1 of the 6 has a DLT, then accrual will continue up to a total of 18 
evaluable patients, subject to not exceeding 3 patients in total with a DLT. If at any time during 
accrual, a cumulative total of 3 evaluable patients have experienced a DLT, then no further 
patients will be enrolled. The upper one sided 90% confidence interval bound on 3/18 is 0.334, 
which is marginally tolerable, while the upper one sided 90% confidence interval bound on 4/18 
is 0.396. At earlier accrual points the upper 90% confidence interval bounds are higher: 3/15 has 
a bound of 0.393 and 4/15 has an upper 90% confidence interval bound of 0.464. Thus, 3/18 with 
a DLT is consistent with approximately 1/3 or fewer patients having a DLT, while having 3 
patients with DLT occur at an earlier point, or having >3 patients with DLT is consistent with 
>1/3 of patients having a DLT. These latter two conditions would be considered consistent with 
excessive toxicity. 
With approval of Amendment F, the trial is being refocused to evaluate the safety and toxicity of 
the regimen studied at lower escalating dose levels since 3 DLTs were observed at dose level 1 
(between 1.0x109 and 1.0x1010 cells). For Cohort 2, 3 patients will be treated with NMA, 0.5x107 
CAR positive cells/kg (± 20%) and high dose aldesleukin (720,000 IU/kg). This has been 
selected as the starting dose due to PK modeling of interferon gamma levels and toxicity data 
from the first 8 patients treated on this study. If one DLT is observed in a patient treated in 
Cohort 2, after analysis of the IFN-gamma cytokine data, 3 additional patients will be treated at 
this dose level (0.5x107 CAR positive cells/kg (± 20%) after receiving NMA followed by a 
reduced dose of aldesleukin (72,000 IU/kg every 8 hours for a maximum of 15 doses) (Cohort 3). 
This 10-fold reduction of aldesleukin was previously investigated in a study of patients with 
renal cancer. The incidence of grade 3 and 4 aldesleukin related toxicities was less in patients 
treated with 72,000 IU/kg every 8 hours than those treated with the higher dose of 720,000 IU/kg 
aldesleukin, every 8 hours (Yang, J.C., et al., J Clin Oncol. 2003, 21(16):3127-32). 
If no DLTs are observed in the 3 patients in Cohort 2, after analysis of the IFN-gamma cytokine 
data, 3 additional patients will be treated with NMA, 1.0x107 CAR positive cells/kg (± 20%) 
high dose aldesleukin (720,000 IU/kg) (Cohort 4). If one DLT is observed in a patient treated in 
Cohort 4, 3 additional patients will be treated at this dose level (1.0x107 CAR positive cells/kg (± 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
20%) after receiving NMA followed by a reduced dose of aldesleukin (72,000 IU/kg every 8 
hours for a maximum of 15 doses) (Cohort 5). 
Cohort 
Treatment Regimen 
 
NMA Chemotherapy 
Regimen (as specified in 
protocol) 
Cell Dose 
IL-2 Dose 
1 (Closed with 
Amendment F) 
Yes 
between 1.0x109 and 1.0x1010 
cells 
High dose 
(720,000 IU/kg) 
2 
Yes 
0.5x107 CAR positive cells/kg 
(± 20%) 
High dose 
(720,000 IU/kg) 
31 
Yes 
0.5x107 CAR positive cells/kg 
(± 20%) 
Low dose (72,000 
IU/kg) 
4 
Yes 
1.0x107 CAR positive cells/kg 
(± 20%) 
High dose 
(720,000 IU/kg) 
52 
Yes 
1.0x107 CAR positive cells/kg 
(± 20%) 
Low dose (72,000 
IU/kg) 
1 Cohort 3 will be skipped if there are no DLTs in Cohort 2. 
2 Cohort 5 will be skipped if there are no DLTs in Cohort 4. 
 
The highest dose cohort evaluated with no DLTs in 3 patients (either 3, 4 or 5) will be expanded 
to a total of 18 evaluable patients, subject to not exceeding 3 patients in total with a DLT. If at 
any time during accrual, a cumulative total of 3 evaluable patients have experienced a DLT, then 
no further patients will be enrolled. The upper one sided 90% confidence interval bound on 3/18 
is 0.334, which is marginally tolerable, while the upper one sided 90% confidence interval bound 
on 4/18 is 0.396. At earlier accrual points the upper 90% confidence interval bounds are higher: 
3/15 has a bound of 0.393 and 4/15 has an upper 90% confidence interval bound of 0.464. Thus, 
3/18 with a DLT is consistent with approximately 1/3 or fewer patients having a DLT, while 
having 3 patients with DLT occur at an earlier point, or having >3 patients with DLT is 
consistent with >1/3 of patients having a DLT. These latter two conditions would be considered 
consistent with excessive toxicity.  
Accrual will be halted to the study if none of the cohorts can be expanded due to DLTs.  
At the conclusion of the study, toxicities will be tabulated according to worst grade per patient of 
each type of toxicity, and the fraction experiencing a DLT will be reported, along with 
appropriate confidence intervals. 
In order to complete enrollment to this protocol, up to 35 patients may be needed in total 
(including the 8 patients already accrued to this study, the 9 patients for the dose escalation under 
Amendment F, the 15 additional patients included in the expanded cohort described above, and 3 
additional patients in case patients need to be replaced for any reason. Thus, at an accrual rate of 
6-8 patients per year, up to 4 years may be required to enroll up to 35 patients onto this trial. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Following approval of Amendment H, only two dose cohorts will be open for accrual: cohorts 6 
and 7. For Cohort 6, 3 patients will be treated with NMA, and 0.5x107 CAR positive cells/kg (± 
20%). If one DLT is observed in a patient treated in Cohort 6, after analysis of the IFN-gamma 
cytokine data, accrual will be halted pending discussions with the FDA and IRB. If no DLTs are 
observed in the 3 patients in Cohort 6, after analysis of the IFN-gamma cytokine data, 3 
additional patients will be treated with NMA, and 1.0x107 CAR positive cells/kg (± 20%) in 
Cohort 7. If one DLT is observed in a patient treated in Cohort 7, 3 additional patients will be 
treated in Cohort 6. If 1 of 6 patients in Cohort 6 experiences a DLT, after analysis of the IFN-
gamma cytokine data, accrual will be halted pending discussions with the FDA and IRB. 
The highest dose cohort evaluated with no DLTs in 3 or more patients will be expanded to a total 
of 18 evaluable patients, subject to not exceeding 3 patients in total with a DLT. 
Accrual will be halted to the study if neither cohorts 6 nor 7 can be expanded 
due to DLTs. 
In November 2011, the first patient in Cohort 6 experienced a DLT of grade 3 confusion 
(possible aphasia), and grade 3 neuropathy (facial droop) possibly related to the cell therapy. The 
serum IFN-gamma levels were low in this patient (range 9-44 pg/mL) following treatment with 
cells. These events were discussed with the FDA, and the FDA indicated that we can treat an 
additional patient in Cohort 6 (with approval of Amendment I). If this additional patient does not 
experience at DLT, Cohort 6 will be expanded to a total of 6 patients. If any additional patients 
treated in Cohort 6 experiences a DLT, after analysis of the IFN-gamma cytokine data, accrual 
will be halted pending discussions with the FDA and IRB. If no additional DLTs are observed in 
the 6 patients in Cohort 6, after analysis of the IFN-gamma cytokine data, 3 patients will be 
treated with NMA, and 1.0x107 CAR positive cells/kg (± 20%) in Cohort 7. If one DLT is 
observed in a patient treated in Cohort 7, 3 additional patients will be accrued to Cohort 7. If 2 
DLTs occur in 6 or less patients in Cohort 7, no additional patients will be accrued at this dose 
level. The highest dose cohort evaluated with no DLTs in 3 or more patients, or 1 DLT in 6 
patients will be expanded to a total of 18 evaluable patients, subject to not exceeding 3 patients 
in total with a DLT. 
In February 2012, the second patient in Cohort 6 experienced DLTs. The SAEs consisted of 
grade 3 hypotension and grade 3 confusion (possibly aphasia) related to the cell therapy. These 
toxicities have resolved and the patient has been discharged. After discussions with the FDA, 
cohorts 6 and 7 were closed and two new dose de-escalation cohorts were opened with approval 
of Amendment J as follows:  
Cohort 
Treatment Regimen 
 
NMA Chemotherapy Regimen 
(as specified in protocol) 
Cell Dose 
IL-2 
Dose 
8 
(De-escalation Dose 1) 
Yes  
2.5x106 CAR positive cells/kg 
(± 20%) 
None 
9 
(De-escalation Dose 2) 
Yes 
1.0x106 CAR positive cells/kg 
(± 20%) 
None 
Cohort 8 will initially accrue 3 patients. If no DLTs are observed in these 3 patients, three 
additional patients will be accrued. If DLTs are observed in ≤ 1 patient out of 6 patients treated, 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
this cohort will be expanded as described below. If a DLT is observed in one of the first 3 
patients, after analysis of the cytokine data, 3 additional patients can be accrued to this cohort. If 
more than 1 out of 6 patients in this cohort experience a DLT, this cohort will be closed, and 
patients will be accrued to Cohort 9. Cohort 9 will proceed in a similar fashion as Cohort 8. If 
more than 1 out of 6 patients in this cohort experience a DLT, this cohort will be closed. 
Subsequent dose reductions will be discussed with the FDA prior to initiation. 
The highest dose cohort evaluated with DLTs in ≤ 1 patient in 6 patients treated will be 
expanded to a total of 18 evaluable patients, subject to not exceeding 3 patients in total with a 
DLT. If at any time during accrual, a cumulative total of 3 evaluable patients have experienced a 
DLT, then no further patients will be enrolled. The upper one sided 90% confidence interval 
bound on 3/18 is 0.334, which is marginally tolerable, while the upper one sided 90% confidence 
interval bound on 4/18 is 0.396. At earlier accrual points the upper 90% confidence interval 
bounds are higher: 3/15 has a bound of 0.393 and 4/15 has an upper 90% confidence interval 
bound of 0.464. Thus, 3/18 with a DLT is consistent with approximately 1/3 or fewer patients 
having a DLT, while having 3 patients with DLT occur at an earlier point, or having >3 patients 
with DLT is consistent with >1/3 of patients having a DLT. These latter two conditions would be 
considered consistent with excessive toxicity. 
After discussions with the FDA, Cohort 8 was closed with Amendment M and patients will be 
lymphodepleted with fludarabine and a reduced dose of cyclophosphamide – 30mg/kg/day for 2 
days and will receive 1.0x106 CAR positive cells/kg (± 20%) in Cohort 9. 
Cohort 9 will initially accrue 3 patients. If no DLTs are observed in these 3 patients, three 
additional patients will be accrued. If DLTs are observed in ≤ 1 patient out of 6 patients treated, 
this cohort will be expanded as described below. If a DLT is observed in one of the first 3 
patients, after analysis of the cytokine data, 3 additional patients can be accrued to this cohort. If 
more than 1 out of 6 patients in this cohort experience a DLT, this cohort will be closed. 
Subsequent dose reductions will be discussed with the FDA prior to initiation.  
If ≤ 1 patient in 6 patients treated develops a DLT then the cohort will be expanded to a total of 
18 evaluable patients, subject to not exceeding 3 patients in total with a DLT. 
Starting with Amendment S 
The primary endpoints of this trial are to determine the safety and feasibility of the 
administration of cryopreserved anti-CD19-CAR engineered peripheral blood lymphocytes 
following a non-myeloablative conditioning regimen in patients with B-cell malignancies. The 
secondary endpoints are to determine the in vivo survival of the cryopreserved anti-CD19-CAR-
transduced T-cells and determine if the treatment regimen cause regression of B-cell 
malignancies. 
Starting with Amendment S, Cohort 10 was closed and only two dose cohorts will be open, 
including a de-escalation cohort: cohorts 11, 11D, and 12.  
Initially 3 patients will be enrolled in Cohort 11. If 1 patient experiences a DLT the cohort will 
be expanded to 6 patients, if no additional DLTs are seen, patients will enroll in Cohort 12. If 
less than or equal to one DLT is seen in the first 6 patients enrolled in Cohort 12, the cohort will 
be expanded to a total of 12 patients as long as less than 1/3 of patients have a DLT in this cohort 
in order to further characterize the safety of the maximum tolerated dose. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
If 2 or more DLTs are encountered in Cohort 12, Cohort 11 will be expanded to a maximum of 
12 patients provided that less than 1/3 of patients have a DLT in this cohort. 
If more than one in six patients experiences a DLT in Cohort 11, patients will be enrolled in 
Cohort 11D. If less than or equal to one DLT is seen in the first 6 patients enrolled in Cohort 
11D, the cohort will be expanded to a total of 12 patients as long as less than 1/3 of patients have 
a DLT in this cohort in order to further characterize the safety of the maximum tolerated dose. 
Cohort 
Treatment Regimen 
 
NMA Chemotherapy Regimen 
(as specified in protocol) 
Cell Dose: Determined Prior to 
Cryopreservation 
IL-2 
Dose 
11 
 
Yes  
2.0x106 CAR positive cells/kg 
(± 20%) 
None 
11D 
(De-escalation Cohort) 
Yes 
1.0x106 CAR positive cells/kg 
(± 20%) 
None 
12 
 
Yes  
6.0x106 CAR positive cells/kg 
(± 20%) 
None 
With the approval of Amendment X, Cohort 13 was completed and Cohort 14 has been opened. 
With the approval of Amendment Y, the dose de-escalation for Cohort 14 was corrected to state 
that Cohort 11 would be the de-escalation cohort. With the approval of Amendment Z, the Dose 
Escalation and DLT sections have been revised. 
The primary endpoints of this trial are to determine the safety and feasibility of the 
administration of cryopreserved anti-CD19-CAR engineered peripheral blood lymphocytes 
following a non-myeloablative conditioning regimen in patients with B-cell malignancies. The 
secondary endpoints are to determine the in vivo survival of the cryopreserved anti-CD19-CAR-
transduced T-cells and determine if the treatment regimen cause regression of B-cell 
malignancies. 
Refer to Section 3.1.1 for additional details. 
The maximum tolerated cell dose is the highest dose at which < =1 of 6 patients experienced a 
DLT or the highest dose level studied if DLTs are not observed at any of the dose levels. 
At the conclusion of the study, toxicities will be tabulated according to worst grade per patient of 
each type of toxicity, and the fraction experiencing a DLT will be reported, along with 
appropriate confidence intervals. 
In order to complete enrollment to this protocol, up to 72 patients may be needed. This includes 
37 patients already accrued to this study, up to 14 additional patients for Cohort 11 (four patients 
are already enrolled in this cohort), and either up to 18 patients for Cohort 11D, or, an additional 
16 patients for Cohort 14, and 3 additional patients in the event patients need to be replaced for 
any reason. Thus, at an accrual rate of 6-12 patients per year, up to 3 additional years may be 
required to enroll up to 72 patients onto this trial. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
9 
COLLABORATIVE AGREEMENTS 
We have established a Cooperative Research and Development Agreement (CRADAs #02716 
and #03168) with Kite Pharma, Inc., and will be sharing data with them. 
10 HUMAN SUBJECTS PROTECTIONS 
10.1 RATIONALE FOR SUBJECT SELECTION 
The patients to be entered in this protocol have B-cell malignancies which are refractory to 
standard therapy, and limited life expectancies. Subjects from both genders and all racial/ethnic 
groups are eligible for this study if they meet the eligibility criteria. To date, there is no 
information that suggests that differences in drug metabolism or disease response would be 
expected in one group compared to another. Efforts will be made to extend accrual to a 
representative population, but in this preliminary study, a balance must be struck between patient 
safety considerations and limitations on the number of individuals exposed to potentially toxic 
and/or ineffective treatments on the one hand and the need to explore gender and ethnic aspects 
of clinical research on the other hand. If differences in outcome that correlate to gender or to 
ethnic identity are noted, accrual may be expanded or a follow-up study may be written to 
investigate those differences more fully. 
10.2 PARTICIPATION OF CHILDREN 
The use of the non-myeloablative regimen in this protocol is a major procedure which entails 
serious discomforts and hazards for the patient, such that fatal complications are possible. It is 
therefore only appropriate to carry out this experimental procedure in the context of life 
threatening metastatic cancer. Since the efficacy of this experimental procedure is unknown, it 
does not seem reasonable to expose children to this risk without further evidence of benefit. 
Should results of this study indicate efficacy in treating B-cell malignancies, which is not 
responsive to other standard forms of therapy, future research can be conducted in the pediatric 
population to evaluate potential benefit in that patient population.  
10.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (Section 10.5), all subjects ≥ age 18 will be offered the opportunity to fill 
in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. The PI or AI will contact the NIH Ability 
to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate. For those subjects that become incapacitated and do not have 
pre-determined substitute decision maker, the procedures described in MAS Policy 87-4 and 
OHSRP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) 
decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, 
will be followed. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
10.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
The experimental treatment has a chance to provide clinical benefit though this is unknown. The 
risks in this treatment are detailed in Section 1.2.9. The goal of this study is to improve upon the 
number of patients who may benefit from adoptive cell therapy by using patients’ own 
transduced T-cells without the need to identify anti-tumor T-cells uniquely from each patient as 
was required in several prior protocols. The success of this effort cannot be predicted at this time. 
Because all patients in this protocol have B-cell malignancies and limited life expectancies the 
potential benefit is thought to outweigh the potential risks. 
10.5 RISK/BENEFIT ANALYSIS 
Because all patients in this protocol have B-cell malignancies and limited life expectancies, the 
potential benefit is thought to outweigh the potential risks. The risk/benefit analysis for adults 
with the capacity to consent, as well as for adults who may become unable to provide consent, is 
greater than minimal risk with the prospect of direct benefit. 
10.6 CONSENT PROCESS AND DOCUMENTATION 
Patients initially sign a consent document when they agree to have PBMC obtained for study and 
growth on protocol 03-C-0277. If the lymphocytes can be generated for infusion and the patient 
meets the thorough screening for eligibility, the patient, with family members or friends at the 
request of the patient, will be presented with a detailed description of the protocol treatment. The 
specific requirements, objectives, and potential advantages and disadvantages will be presented. 
The informed consent document is given to the patient, who is requested to review it and to ask 
questions prior to agreeing to participate in the treatment portion of this protocol. The patient is 
reassured that participation on trial is entirely voluntary and that he/she can withdraw or decide 
against treatment at any time without adverse consequences. The Principal Investigator, associate 
investigator, or clinical fellow is responsible for obtaining written consent from the patient. 
10.6.1 Telephone Consent 
The informed consent document will be sent to the subject. An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form. 
The subject will sign and date the informed consent. A witness to the subject’s signature will 
sign and date the consent. 
The original informed consent document will be sent back to the consenting investigator who 
will sign and date the consent form with the date the consent was obtained via telephone.  
A fully executed copy will be returned via mail for the subject’s records. 
The informed consent process will be documented on a progress note by the consenting 
investigator and a copy of the informed consent document and note will be kept in the subject’s 
research record. 
11 PHARMACEUTICAL INFORMATION 
11.1 INVESTIGATIONAL REGIMEN 
11.1.1 Anti-CD19 CAR transduced PBL 
The procedure for expanding the human PBL and the Certificate of Analysis are similar to those 
approved by the Food and Drug Administration, and used at the NCI in ongoing protocols 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
evaluating cell therapy in the Surgery Branch (most recently 07-C-0174, 07-C-0175, 08-C-0121, 
08-C-0155, and 08-C-0162), and is included in Appendix 1 and in the IND submission for these 
cells. The PBL will be transduced with retroviral supernatant containing the anti-CD19 CAR. 
11.1.1.1 Retroviral Vector Containing the anti-CD19 CAR Gene 
The retroviral vector supernatant (PG13-CD19-H3) encoding a chimeric antigen receptor (CAR) 
directed against the B-cell antigen, CD19, was prepared and preserved following cGMP 
conditions in the Surgery Branch Vector Production Facility (SBVPF). The retroviral vector 
utilizes the MSGV1 retroviral vector backbone and consists of 7026 bps including the 5' LTR 
from the murine stem cell virus (promoter), packaging signal including the splicing donor (SD) 
and splicing acceptor sites, FMC63-based (anti-CD19 FMC63-28) CAR protein containing a 
signal peptide (human GM-CSF receptor), FMC63 light chain variable region (FMC63 VL), 
linker peptide, FMC63 heavy chain variable region (FMC63 VH), CD28 (hinge, transmembrane 
and cytoplasmic region), and TCR zeta (cytoplasmic region), followed by the murine stem cell 
virus 3'LTR. The physical titer will be determined by RNA dot blot according to sponsor 
certificate.  
The supernate will be stored at SBPVF upon the completion of production at –80° C or shipped 
on dry ice and stored at Cryonix, Rockville, MD. Both storage facilities are equipped with 
around-the-clock temperature monitoring. Upon request, supernatant will be delivered on dry ice 
to be used in in vitro transductions of PBL. There will be no re-use of the same unit of supernate 
for different patients. Retroviral titer has been shown to be stable after immediate thawing and 
immediate administration (coating the tissue culture wells previously coated with Retronectin). 
Handling of the vector should follow the guidelines of Biosafety Level-2 (BSL-2). The specific 
guidelines for Biosafety Level-2 (BSL-2) can be viewed at http://bmbl.od.nih.gov/sect3bsl2.htm. 
11.1.1.2 OKT3 
OKT3 will be obtained by the Surgery Branch Laboratory from commercial sources. 
Formulation: Muromonab-CD3 (Ortho), NSC #618843, is provided as a sterile, clear, colorless 
solution at a concentration of 1 mg/mL in 5 mL ampoules. The solution may contain a few fine, 
translucent protein particles. The antibody is dissolved in a buffered solution at pH of 6.5 to 7.5. 
The solution contains 2.25 mg of monobasic sodium phosphate, 9 mg of dibasic sodium 
phosphate, 43 mg of sodium chloride and 1 mg of polysorbate 80 per 5 mL of water for injection. 
Storage/Stability: Ampules should be stored in a refrigerator at 2-8° C. Solution should not be 
frozen or shaken. Each ampule bears an expiration date. 
11.1.2 Fludarabine 
(Please refer to package insert for complete product information) 
Description: Fludarabine phosphate is a synthetic purine nucleoside that differs from physiologic 
nucleosides in that the sugar moiety is arabinose instead of ribose or deoxyribose. Fludarabine is 
a purine antagonist antimetabolite.  
How Supplied: It will be purchased by the NIH Clinical Pharmacy Department from commercial 
sources. Fludarabine is supplied in a 50 mg vial as a fludarabine phosphate powder in the form of 
a white, lyophilized solid cake.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Stability: Following reconstitution with 2 mL of sterile water for injection to a concentration of 
25 mg/mL, the solution has a pH of 7.7. The fludarabine powder is stable for at least 18 months 
at 2-8°C; when reconstituted, fludarabine is stable for at least 16 days at room temperature. 
Because no preservative is present, reconstituted fludarabine will typically be administered 
within 8 hours. Specialized references should be consulted for specific compatibility 
information. Fludarabine is dephosphorylated in serum, transported intracellularly and converted 
to the nucleotide fludarabine triphosphate; this 2-fluoro-ara-ATP molecule is thought to be 
required for the drug’s cytotoxic effects. Fludarabine inhibits DNA polymerase, ribnucleotide 
reductase, DNA primase, and may interfere with chain elongation, and RNA and protein 
synthesis. 
Storage: Intact vials should be stored refrigerated (2-8°C).  
Administration: Fludarabine is administered as an IV infusion in 100 mL 0.9% sodium chloride, 
USP over 15 to 30 minutes. The doses will be based on body surface area (BSA). If patient is 
obese (BMI > 35) drug dosage will be calculated using practical weight as described in 
Appendix 4.  
Toxicities: At doses of 25 mg/m2/day for 5 days, the primary side effect is myelosuppression; 
however, thrombocytopenia is responsible for most cases of severe and life-threatening 
hematologic toxicity. Serious opportunistic infections have occurred in CLL patients treated with 
fludarabine. Hemolytic anemia has been reported after one or more courses of fludarabine with 
or without a prior history of a positive Coomb’s test; fatal hemolytic anemia has been reported. 
In addition, bone marrow fibrosis has been observed after fludarabine therapy. Other common 
adverse effects include malaise, fever, chills, fatigue, anorexia, nausea and vomiting, and 
weakness. Irreversible and potentially fatal central nervous system toxicity in the form of 
progressive encephalopathy, blindness, and coma is only rarely observed at the currently 
administered doses of fludarabine. More common neurologic side effects at the current doses of 
fludarabine include weakness, pain, malaise, fatigue, paresthesia, visual or hearing disturbances, 
and sleep disorders. Adverse respiratory effects of fludarabine include cough, dyspnea, allergic 
or idiopathic interstitial pneumonitis. Tumor lysis syndrome has been rarely observed in 
fludarabine treatment of CLL. Treatment on previous adoptive cell therapy protocols in the 
Surgery Branch have caused persistently low (below 200) CD4 counts, and one patient 
developed polyneuropathy manifested by vision blindness, and motor and sensory defects. 
11.1.3 Cyclophosphamide 
(Refer to FDA-approved package insert for complete product information) 
Description: Cyclophosphamide is a nitrogen mustard-derivative alkylating agent. Following 
conversion to active metabolites in the liver, cyclophosphamide functions as an alkyating agent; 
the drug also possesses potent immunosuppressive activity. The serum half-life after IV 
administration ranges from 3-12 hours; the drug and/or its metabolites can be detected in the 
serum for up to 72 hours after administration.  
How Supplied: Cyclophosphamide will be obtained from commercially available sources by the 
Clinical Center Pharmacy Department.  
Stability: Following reconstitution as directed with sterile water for injection, cyclophosphamide 
is stable for 24 hours at room temperature or 6 days when kept at 2-8°C.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Administration: It will be diluted in 250 mL D5W and infused over one hour. The dose will be 
based on the patient’s body weight. If patient is obese (BMI > 35) drug dosage will be calculated 
using practical weight as described in Appendix 4. 
Toxicities: Hematologic toxicity occurring with cyclophosphamide usually includes leukopenia 
and thrombocytopenia. Anorexia, nausea and vomiting, rash and alopecia occur, especially after 
high-dose cyclophosphamide; diarrhea, hemorrhagic colitis, infertility, and mucosal and oral 
ulceration have been reported. Sterile hemorrhagic cystitis occurs in about 20% of patients; 
severity can range from microscopic hematuria to extensive cystitis with bladder fibrosis. 
Although the incidence of hemorrhagic cystitis associated with cyclophosphamide appears to be 
lower than that associated with ifosfamide, mesna (sodium 2-mercaptoethanesulfonate) has been 
used prophylactically as a uroprotective agent in patients receiving cyclophosphamide. 
Prophylactic mesna is not effective in preventing hemorrhagic cystitis in all patients. Patients 
who receive high dose cyclophosphamide may develop interstitial pulmonary fibrosis, which can 
be fatal. Hyperuricemia due to rapid cellular destruction may occur, particularly in patients with 
hematologic malignancy. Hyperuricemia may be minimized by adequate hydration, 
alkalinization of the urine, and/or administration of allopurinol. If allopurinol is administered, 
patients should be watched closely for cyclophosphamide toxicity (due to allopurinol induction 
of hepatic microsomal enzymes). At high doses, cyclophosphamide can result in a syndrome of 
inappropriate antidiuretic hormone secretion; hyponatremia with progressive weight gain without 
edema occurs. At high doses, cyclophosphamide can result in cardiotoxicity. Deaths have 
occurred from diffuse hemorrhagic myocardial necrosis and from a syndrome of acute 
myopericarditis; in such cases, congestive heart failure may occur within a few days of the first 
dose. Other consequences of cyclophosphamide cardiotoxicity include arrhythmias, potentially 
irreversible cardiomyopathy, and pericarditis. Other reported adverse effects of 
cyclophosphamide include headache, dizziness, and myxedema; faintness, facial flushing, and 
diaphoresis have occurred following IV administration. Mesna (sodium 2-
mercaptoethanesulphonate; given by IV injection) is a synthetic sulfhydryl compound that can 
chemically interact with urotoxic metabolites of cyclophosphamide (acrolein and 4-
hydroxycyclophosphamide) to decrease the incidence and severity of hemorrhagic cystitis.  
11.2 SUPPORT MEDICATIONS 
11.2.1 Mesna (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) 
(Please refer to the FDA-approved package insert for complete product information) 
Description: Mesna will be obtained commercially by the Clinical Center Pharmacy Department 
and is supplied as a 100 mg/mL solution.  
Storage: Intact ampoules are stored at room temperature.  
Stability: Diluted solutions (1-20 mg/mL) are physically and chemically stable for at least 24 
hours under refrigeration. Mesna is chemically stable at room temperature for 48-72 hours in 
D5W, 48-72 hour in D5W/0.45% NaCl, or 24 hours in 0.9% NaCl. 
Administration: Dilute to concentrations less than or equal to 20 mg mesna/mL fluid in D5W or 
0.9% NaCl and to be administered intravenously as a continuous infusion. If patient is obese 
(BMI > 35) drug dosage will be calculated using practical weight as described in Appendix 4.  
Toxicities: Nausea, vomiting, and diarrhea.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
11.2.2 Filgrastim (Granulocyte Colony-Stimulating Factor, G-CSF, Filgrastim, Neupogen) 
Filgrastim will be obtained commercially by the Clinical Center Pharmacy Department and is 
supplied in 300 ug/mL and 480 ug/1.6 mL vials. G-CSF should be refrigerated and not allowed 
to freeze. The product bears the expiration date. The product should not be shaken. It is generally 
stable for at least 10 months when refrigerated. The appropriate dose is drawn up into a syringe. 
G-CSF will be given as a daily subcutaneous injection. The side effects of G-CSF are skin rash, 
myalgia and bone pain, an increase of preexisting inflammatory conditions, enlarged spleen with 
occasional associated low platelet counts, alopecia (with prolonged use) elevated blood 
chemistry levels. 
11.2.3 Trimethoprim and Sulfamethoxazole Double Strength (TMP / SMX DS) 
TMP/SMX DS will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used for the prevention of PCP pneumonia. The oral dose is 1 tablet PO daily 
three times a week (MUST be on non-consecutive days) beginning on day -7 and continuing for 
at least 6 months and until the CD4 count is greater than 200 on 2 consecutive lab studies. Like 
other sulfa drugs, TMP/SMX DS can cause allergies, fever, photosensitivity, nausea, and 
vomiting. Allergies typically develop as a widespread itchy red rash with fever eight to fourteen 
days after beginning the standard dose. Neutropenia, a reduction in the number of neutrophils, 
can also occur. 
11.2.3.1 Aerosolized Pentamidine in Place of TMP/SMX DS 
Patients with sulfa allergies will receive aerosolized Pentamidine 300 mg per nebulizer with one 
week prior to admission and continued monthly until the CD4 count is above 200 on two 
consecutive follow up lab studies and for at least 6 months post chemotherapy. Pentamidine 
Isethionate will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used to prevent the occurrence of PCP infections. It is supplied in 300 mg vials 
of lyophilized powder and will be administered via nebulizer. Toxicities reported with the use of 
Pentamidine include metallic taste, coughing, bronchospasm in heavy smokers and asthmatics; 
increased incidence of spontaneous pneumothorax in patients with previous PCP infection or 
pneumatoceles, or hypoglycemia. 
11.2.4 Herpes Virus Prophylaxis 
11.2.4.1 Valacyclovir (Valtrex) 
Valacyclovir will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used orally to prevent the occurrence of herpes virus infections in patients with 
positive HSV serology. It is supplied in 500 mg tablets. Valcyclovir will be started the day after 
the last dose of fludarabine at a dose of 500 mg orally daily if the patient is able to tolerate oral 
intake. See package insert for dosing adjustments in patients with renal impairment. Common 
side effects include headache, upset stomach, nausea, vomiting, diarrhea or constipation. Rare 
serious side effects include hemolytic uremic syndrome and thrombotic thrombocytopenic 
purpura.  
11.2.4.2 Acyclovir 
Acyclovir will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used to prevent the occurrence of herpes virus infections in patients who 
cannot take oral medications. It is supplied as powder for injection in 500 mg/vials. Reconstitute 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
in 10 mL of sterile water for injection to a concentration of 50 mg/mL. Reconstituted solutions 
should be used within 12 hours. IV solutions should be diluted to a concentration of 7mg/mL or 
less and infused over 1 hour to avoid renal damage. Reversible renal insufficiency has been 
reported with IV but not oral acyclovir. Neurologic toxicity including delirium, tremors, coma, 
acute psychiatric disturbances, and abnormal EEGs have been reported with higher doses of 
acyclovir. Should this occur, a dosage adjustment will be made or the drug will be discontinued. 
Stomach upset, headache or nausea, rash or hives; peripheral edema; pain, elevated liver function 
tests; and leukopenia, diarrhea, lymphadenopathy, myalgias, visual abnormalities and elevated 
creatinine have been reported. Hair loss from prolonged use has been reported. Acyclovir will 
not be used concomitantly with other nucleoside analogs which interfere with DNA synthesis, 
e.g. ganciclovir. In renal disease, the dose is adjusted as per product labeling.  
11.2.5 Fluconazole 
Fluconazole will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used to prophylax against fungal infections. It is available in 200 mg tablets. It 
can cause headache, nausea, vomiting, diarrhea or abdominal pain, and liver damage which may 
be irreversible. It can cause rashes and itching, which in rare cases has caused Stevens Johnson 
Syndrome. It has several significant drug interactions. The package insert should be consulted 
prior to prescribing. For IV administration in patients who cannot tolerate the oral preparation, 
Fluconazole comes in 2 mg/mL solution for injection, and prepared according to Clinical Center 
Pharmacy standard procedures. It should be administered at a maximum IV rate of 200 mg/hr. 
11.2.6 Ondansetron Hydrochloride 
Ondansetron hydrochloride will be obtained by the Clinical Center Pharmacy Department from 
commercial sources. It will be used to control nausea and vomiting during the chemotherapy 
preparative regimen. It can cause headache, dizziness, myalgias, drowsiness, malaise, and 
weakness. Less common side effects include chest pain, hypotension, pruritis, constipation and 
urinary retention. Consult the package insert for specific dosing instructions. 
11.2.7 Allopurinol 
Allopurinol will be obtained by the Clinical Center Pharmacy Department from commercial 
sources. It will be used as prophylaxis or treatment of patients with or at high risk for Tumor 
Lysis Syndrome. Dosage is approximately 100 mg/m2/dose po TID (maximum dose 200 mg 
TID). The most common side effects include hypersensitivity, rash, nausea, vomiting, renal 
insufficiency, and hepatic dysfunction. Allopurinol should be stopped immediately if rash 
develops. Consult the package insert for a complete list of all side effects. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
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Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13 TABLES, FIGURES, AND APPENDICES 
13.1 TABLE 1: SURGERY BRANCH CELL THERAPY STUDIES 
Data as of 09/30/2008 
Study #/ 
Disease 
Cellular 
Product 
Administered 
Arms (n) 
Chemotherapy, Cytokines, 
and Immunizations 
# of Cells 
Response 
Reference 
98-C-0095 
in patients 
with 
metastatic 
melanoma 
Cloned 
Peripheral 
Blood 
Lymphocytes 
(PBL)/ Tumor 
infiltrating 
lymphocytes 
(TIL) 
1. Cloned PBL/TIL 
intravenously (12) 
None 
1.5 to 
34.8x109 
cells 
NRd 
 
Dudley, ME, 
et al. 2001  
2. IV Cloned 
PBL/TIL 
intravenously (6a) 
SQ IL-2 (125,000 IU/kg/d X 
12 d) 
3. IV Cloned 
PBL/TIL 
intravenously (6b) 
HD IL-2 (720,000 IU/kg 
3X/d to tolerance (max 12) 
4. IV Cloned 
PBL/TIL (3c) 
Gp100:209-217(210M) 
99-C-0158 
in patients 
with 
metastatic 
melanoma 
Tumor 
infiltrating 
lymphocytes 
(TIL) 
1. In vitro expanded 
cloned T-cells 
intravenously (3) 
30 mg/kg cyclophosphamide 
X2 days, 25 mg/kg 
fludarabine X5 days 
0.9x109 to 
24.2x109 
cells (avg. 
10.4x109)  
NR 
 
 
Dudley, ME, 
et al. 2002  
 
 
2. In vitro expanded 
cloned T-cells 
intravenously (3) 
60 mg/kg cyclophosphamide 
X2 days, 25 mg/kg 
fludarabine X5 days 
NR 
3. In vitro expanded 
cloned T-cells 
intravenously (3) 
60 mg/kg cyclophosphamide 
X2 days, 25 mg/kg 
fludarabine X5 days plus IV 
IL-2 (72,000 IU/kg 3X/day 
X5 days) 
0.9x109 to 
24.2x109 
cells (avg. 
10.4x109) 
NR 
4. In vitro expanded 
cloned T-cells 
intravenously (6) 
[60 mg/kg 
cyclophosphamide X2 days, 
25 mg/kg fludarabine X5 
days]g plus IV IL-2 (720,000 
IU/kg 3X/day to tolerance 
(max 12) 
NR 
5. Autologous tumor 
reactive REP’de bulk 
TIL cells 
intravenously (35) 
Chemotherapyg plus IV HD 
IL-2 [(720,000 IU/kg 3X/day 
to tolerance (max 15)]h with 
or without immunization 
with gp100:209-217(210M) 
or MART-1:26-35(27L) in 
Montanide ISA-51 QD X5, 
then Qwk X3. 
1.1 to 
16.0x1010 
cells (avg. 
6.3x1010) 
18/35 
(51%)f 
3 CRs 
15 PRs 
Dudley, ME, 
et al. 2003, 
Dudley, ME, 
et al. 2005 
6. Autologous tumor 
reactive REP’de bulk 
TIL cells 
intravenously (6) 
Chemotherapyg plus Low 
Dose IL-2k with or without 
immunization with 
gp100:209-217(210M) 
peptide or MART-1:26-
8.3x109 to 
52.9x109 
cells (avg. 
33.7x109) 
3PR 
2NR 
1 TEj 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
35(27L) peptide in 
Montanide ISA-51 QD X5, 
then Qwk X3. 
04-C-0181 
in patients 
with 
metastatic 
melanoma 
Gp100 TCR 
engineered T-
cells (PBL or 
TIL) 
1. Escalating doses 
of anti-gp100 TCR 
transduced PBL (3) 
Chemotherapyg plus IV HD 
IL-2h with 1mg gp100:209-
217(210M) in Montanide 
ISA-51 QD X5, then Qwk 
X3 
Up to 
30x109 
NR 
 
NA 
2. Anti-gp100 TCR 
CD8+ enriched PBL 
(8) 
Chemotherapyg plus IV HD 
IL-2h with 6X109 pfu 
rFgp100P209 IV; 
rFgp100P209 IV and IL-2 
repeated 28 days later.  
Up to 
30x109 
NR 
3. Escalating doses 
of anti-gp100 TCR 
transduced TIL (3) 
Chemotherapyg plus IV HD 
IL-2h with 6X109 pfu 
rFgp100P209 IV; 
rFgp100P209 IV and IL-2 
repeated 28 days later.  
Up to 
30x109 
1 PRi 
04-C-0251 
in patients 
with 
metastatic 
melanoma 
MART-1 TCR 
engineered T-
cells (PBL or 
TIL) 
1. Escalating doses 
of anti-MART-1 
TCR transduced 
PBL (18) 
Chemotherapyg plus IV HD 
IL-2h with MART-1:26-
35(27L) in Montanide ISA-
51 QD X5, then Qwk X3. 
Up to 
30x109 
2PRsi 
 
Morgan, et 
al. Science, 
2006 Oct 
6;314(5796): 
126-9  
2. Escalating doses 
of anti-MART-1 
CD8+ TCR 
transduced PBL (6) 
Chemotherapyg plus IV HD 
IL-2h with MART-1:27-35 in 
Montanide ISA-51 QD X5, 
then Qwk X3 
Up to 
30x109 
1 PRi 
3. Escalating doses 
of anti-MART-1 
CD8+ TCR 
transduced PBL (8) 
Chemotherapyg plus IV HD 
IL-2h with MART-1:26-
35(27L) in Montanide ISA-
51 QD X5, then Qwk X3 
Up to 
30x109 
1 PRi 
4. Escalating doses 
of anti-MART-1 
TCR transduced TIL 
(3) 
Chemotherapyg plus IV HD 
IL-2h with MART-1:26-
35(27L) in Montanide ISA-
51 QD X5, then Qwk X3 
Up to 
30x109 
NR 
5. Escalating doses 
of anti-MART-1 
TCR transduced 
PBL plus 1200 TBI 
(4) 
Chemotherapyg and 1200 
TBI plus IV HD IL-2h with 
MART-1:26-35(27L) in 
Montanide ISA-51 QD X5, 
then Qwk X3 
Up to 
30x109 
NR 
07-C-0003 
in 
melanoma/ 
renal cell 
or other 
histologies 
Anti-p53 TCR 
engineered T-
cells (PBL) 
1. Melanoma or 
renal cell cancer: Up 
to 50 X 109 cells 
(PBL) (2) 
Chemotherapyg plus IV HD 
IL-2h 
Up to 
50x109 
NR 
 
 
NA 
2. Other histologies: 
Up to 50 X 109 cells 
(PBL) (10) 
Chemotherapyg plus IV HD 
IL-2h 
Up to 
50x109 
1 PRi 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
07-C-0174 
in patients 
with 
metastatic 
melanoma 
Anti-
gp100(154) 
TCR 
engineered T-
cells (PBL) 
Anti-gp100(154) 
TCR transduced 
PBL at a dose 
ranging from 0.5 X 
109 cells up to 300 
x109 (19) 
Chemotherapyg plus IV HD 
IL-2h 
1.7x109 to 
110.0x109 
cells (avg. 
31.5x109) 
3 PR 
14 NR 
2 TEj 
NA 
07-C-0175 
in patients 
with 
metastatic 
melanoma 
Anti-MART-1 
F5 TCR 
engineered T-
cells (PBL or 
TIL) 
Anti-MART-1 F5 
TCR transduced 
PBL at a dose 
ranging from 0.5 X 
109 cells up to 300 
x109 cells (21) 
Chemotherapyg plus IV HD 
IL-2h 
1.45x109 
to 
110.0x109 
cells (avg. 
34.2x109) 
6 PR 
12 NR 
3 TEj 
NA 
 
 
Anti-MART-1 F5 
TCR transduced TIL 
at a dose ranging 
from 0.5 X 109 cells 
up to 300 x109 cells 
Chemotherapyg plus IV HD 
IL-2h 
84x109 
cells 
1 TE 
NA 
07-C-0176 
in patients 
with 
metastatic 
melanoma 
Young TIL 
Young TIL at a dose 
ranging from 1.0 X 
109 cells up to 300 
x109 cells (26) 
Chemotherapyg plus IV HD 
IL-2h 
11.1x109 
to 
124x109 
cells (avg. 
55.6x109) 
3 PR 
19 NR 
2 TEj 
2 NTj 
NA 
a Previously treated with cells alone 
b Five previously treated with cells alone, one new patient for first cell treatment 
c All three patients had previously been treated with cell alone and cells with IL-2 
d NR: No Response 
e Rapid Expansion Protocol 
f Responses defined: CR (complete response) is disappearance of all clinical evidence of disease; PR 
(partial response) defined as > 50% reduction in the sum of the products of the perpendicular diameters 
for at least one month and no increase in any lesion and no new lesions. 
g Chemotherapy at maximum dose: 60 mg/kg cyclophosphamide X2 days, 25 mg/kg fludarabine X5 days 
h High dose (HD) IL-2: 720,000 IU/kg 3X/day to tolerance (max 15) 
i Responses defined according to RECIST criteria 
j TE: Too early to evaluate, NT: not treated 
k Low dose IL-2: 250,000 IU/kg subcutaneously daily for 5 days. After a two day rest, IL-2 will be 
administered at a dose of 125,000 IU/kg subcutaneously daily for 5 days for the next five weeks (2 days 
rest per week). 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
 
13.2 TABLE 2: TIME IN HOSPITAL AND NON-HEMATOLOGICAL GRADE 3 AND 4 TOXICITIES 
RELATED TO LYMPHODEPLETING CHEMOTHERAPY AND CELL TRANSFER 
 
Attribute measured 
Duration, Number or Type 
Number of Patients (%) 
 
 
 
Days in Hospital1 
6-10 
6 (17%) 
 
11-15 
18 (51%) 
 
16-20 
4 (11%) 
 
21-25 
7 (20%) 
 
 
 
pRBC Transfusions 
0 
2 (6%) 
 
1-5 
18 (51%) 
 
6-10 
13 (37%) 
 
11-15 
2(6%) 
 
 
 
Platelet Transfusions 
0 
6 (17%) 
 
1-5 
21 (60%) 
 
6-10 
5 (14%) 
 
11-15 
2 (6%) 
 
16-20 
1 (3%) 
 
 
 
Autoimmunity 
Uveitis 
5 (14%) 
 
Vitiligo 
13 (37%) 
 
 
 
Opportunistic Infections 
Herpes zoster 
3 (9%) 
 
Pneumocystis pneumonia 
2 (6%) 
 
EBV-B cell lymphoma 
1 (3%) 
 
RSV pneumonia 
1 (3%) 
 
 
 
Other 
Febrile neutropenia 
13 (37%) 
 
Intubated for dyspnea  
3 (9%) 
 
Cortical blindness 
1 (3%) 
1Measured from the day of cell administration to discharge 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.3 FIGURE 1: CANCER REGRESSION IN TWO PATIENTS 
 
Figure 1. Cancer regression in two patients. A. CT images of patient 4 liver metastasis; pre-
treatment, one month and 10 months post-treatment with TCR engineered T-cells. B. Size of 
liver and axillary tumors and tempo of regression of tumor sites in patient 4 (treatment time = 
day 0). C. CT images of patient 14 hilar lymph node metastasis; pre-treatment, beginning of 
treatment (Day 0), and two months and 12 months post-treatment. D. Size of tumor and tempo of 
regression in patient 14. E. Quantitation of gene marked cells in patients 4 and 14 PBMC was 
determined by real-time quantitative PCR. Day of infusion (Inf.) indicated by arrow. F. The 
percentage of CD8+/Vβ12 cells in the intermediate gate in the circulation of patients 4 and 14. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.4 FIGURE 1: NORMAL PBMC CAN BE TRANSDUCED WITH AN ANTI-CD19 CAR 
 
Figure 2. Normal PBMC can be transduced with an anti-CD19 CAR. A. Linearized plasmid map of the MSGV1-FMC63-28 
gamma-retroviral vector that encodes the FMC63-28 anti-CD19 chimeric antigen receptor. B. Expression of the anti-CD19 chimeric 
receptor can be detected on the surface of transduced T-cells by staining with a goat-anti-mouse Fab antibody. Plots are gated on live 
lymphocytes.


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.5 FIGURE 2: PBMC TRANSDUCED WITH ANTI-CD19 CAR RECOGNIZE CD19-EXPRESSING 
TARGET CELLS 
 
 
Figure 3. PBMC that were transduced with an anti-CD19 CAR specifically recognize 
CD19-expressing target cells. 100,000 effector cells were cultured overnight with 100,000 
target cells, and an interferon-γ ELISA was performed. All values are pg/mL of interferon-γ 
(mean of duplicate wells). Effector cells were either anti-CD19-CAR-transduced T-cells, T-cells 
transduced with the control CAR SP6, or non-transduced T-cells from the same patient 
stimulated with OKT3 in the same manner. SupB15 and NALM6 are CD19-expressing leukemia 
cell lines, Toledo is a CD19-expressing large cell lymphoma cell line. 624, A549, TC71, CEM 
and K562 are immortalized CD19 negative cell lines. The control CAR SP6 is specific for the 
chemical 2,4,6-TNP.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.6 FIGURE 3: T-CELLS FROM A CLL PATIENT POST FLUDARABINE/RITUXIMAB THERAPY 
 
 
Figure 4. T-cells from a CLL patient post fludarabine/rituximab therapy can be 
transduced with an anti-CD19 CAR and then produce interferon-γ in response to a 
primary allogeneic CLL cells and kill primary allogeneic CLL cells. A. 100,000 effector cells 
were cultured overnight with 100,000 target cells, and an interferon-γ ELISA was performed. All 
values are pg/mL of interferon-γ (mean of duplicate wells). Effector cells were either anti-CD19-
CAR-transduced T-cells from a CLL patient or non-transduced T-cells from the same patient 
stimulated with OKT3 in the same manner. CLL1 and CLL2 are primary CLL cells from two 
different patients. Allogeneic T-cell targets were 7 days post OKT3 stimulation. CEM and K562 
are immortalized CD19- negative leukemia cell lines. B. The same effector cell cultures were 
tested for their ability to kill allogeneic primary CLL cells. Effector cells transduced with the 
anti-CD19 CAR killed the CLL cells, while non-transduced T-cells from the same donor that 
were cultured identically did not kill CLL cells.


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.7 FIGURE 4: ANTI-CD19-TRANSDUCED T-CELLS MAINTAIN FUNCTION FOLLOWING 
RAPID EXPANSION 
 
 
Figure 5. Following rapid expansion to a number of cells sufficient for clinical 
adoptive T-cell transfer, anti-CD19-transduced T-cells maintain function. A. 
100,000 effector cells that were 9 days post REP initiation were cultured overnight with 
100,000 target cells, and an interferon-γ ELISA was performed. All values are pg/mL of 
interferon-γ (mean of duplicate wells). Effector cells were either anti-CD19-CAR-
transduced T-cells or T-cells transduced with the control CAR SP6 from the same patient 
stimulated with OKT3 in the same manner. SupB15 and bv173 are CD19-expressing 
leukemia cell lines, CLL3 are primary CLL cells. MDA231, A549, TC71, CEM and 
K562 are immortalized CD19 negative cell lines. The control CAR SP6 is specific for the 
chemical 2,4,6-TNP. B Twenty-one days after the initiation of rapid expansion, anti-
CD19 CAR transduced T-cells can kill allogeneic primary CLL cells while T-cells 
transduced with the control CAR SP6 cannot. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.8 FIGURE 5: T-CELLS PRODUCE IFN-GAMMA AND IL-2 IN RESPONSE TO CD-19-EXPRESSING TARGET CELLS FOLLOWING 
RAPID EXPANSION 
 
Figure 6. Fourteen days after initiation of rapid expansion a large percentage of T-cells produce IFNγ (Figure 6A) 
and IL-2 (Figure 6B) specifically in response to CD19-expressing target cells. Anti-CD19-CAR-transduced or control-
transduced T-cells were cultured with K562 cell transduced with either full-length CD19 or nerve growth factor receptor 
(NGFR) for 5 hours and then intracellular cytokine staining was performed. Control-transduced T-cells were transduced with 
the SP6 CAR. The SP6 CAR is described in the legend for Figure 3. The K562 target cells were identical except that CD19-
K562 cells were transduced with a retrovirus encoding full-length CD19 and NGFR-K562 cells were transduced with 
retroviruses encoding NGFR.  


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.9 FIGURE 6: ANTI-CD19-CAR-TRANSDUCED T-CELLS DEPENDENT UPON EXOGENOUS IL-
2 FOR IN VITRO SURVIVAL 
 
Figure 7. Anti-CD19-CAR-transduced T-cells are dependent upon exogenous IL-2 for in 
vitro survival. At the indicated times after initiation of a REP equal numbers of T-cells were 
either cultured with or without IL-2 and the number of live cells was determined by trypan blue 
staining on the indicated days. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.10 FIGURE 7: OVERVIEW OF THE 6-DAY CRYOPRESERVED CELL PRODUCTION PROCESS 
 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.11 FIGURE 8: COMPARISON OF TRANSDUCTION EFFICIENCY OF PBMC IN CLOSED VS OPEN 
SYSTEM 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.12 FIGURE 9: TOTAL CELL NUMBER OF PBMC FOLLOWING TRANSDUCTION IN CLOSED VS 
OPEN SYSTEM 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.13 FIGURE 10: CELL EXPANSION OF PBMC FOLLOWING TRANSDUCTION IN CLOSED VS 
OPEN SYSTEM 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.14 FIGURE 11: COMPARISON OF IFN-GAMMA RELEASE OF CELLS TRANSDUCED AND 
EXPANDED IN CLOSED VS OPEN SYSTEM 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Figure 12: Comparison of T-Cell Phenotype for PBMC Transduced and Expanded in 
Closed vs Open System 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.15 FIGURE 13: COMPARISON OF PERCENTAGE AND VIABILITY OF CAR+ T-CELLS 
MANUFACTURED IN 6-DAY CLOSED PROCESS 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.16 FIGURE 14: COMPARISON OF IFN-GAMMA RELEASE OF CAR+ T-CELLS 
MANUFACTURED IN 6-DAY CLOSED PROCESS AFTER CRYOPRESERVATION 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.17 FIGURE 15: COMPARISON OF VIABILITY AND FOLD EXPANSION OF CAR+ T-CELLS 
MANUFACTURED IN 6-DAY CLOSED PROCESS AFTER CRYOPRESERVATION 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.18 FIGURE 16: PHENOTYPE OF CD19 CAR+ T-CELLS MANUFACTURED IN 6-DAY CLOSED 
PROCESS BEFORE AND AFTER CRYOPRESERVATION 
 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.19 APPENDIX 1: CERTIFICATE OF ANALYSIS 
Anti-CD19 CAR-Transduced PBL (09-C-0082) 
Date of preparation of final product: 
Patient: 
Tests performed on final product: 
 
 
 
 Number of days in culture: 
Test 
 
Method 
Limits 
Result 
Initials/ 
Date 
Cell viability1 
trypan blue exclusion 
>70% 
 
 
CAR positive 
cells/patient weight 
(kg) 
Calculated Value 
Between 0.2x107 and 
1.0x107 CAR positive 
cells/kg  
 
 
Tumor reactivity2 
γ-IFN release vs. CD19-
expressing target cell lines  
>200 pg/mL 
 
 
Microbiological 
studies  
gram stain1 
no micro-organisms 
seen 
 
 
 
aerobic culture3 
no growth 
 
 
 
fungal culture3 
no growth 
 
 
 
anaerobic culture3 
no growth 
 
 
 
mycoplasma test4 
negative 
 
 
Endotoxin  
limulus assay1 
<5 E.U./kg 
 
 
RCR 
S+L- Assay3 
RCR-PCR5 
negative 
 
 
1 Performed on sample of the final product immediately prior to cryopreservation. Results are available at the time of infusion. 
Total viable cell number is dependent on CAR+ cells patient’s weight. 
2 Performed 2-10 post transduction. Results are available at the time of infusion.  
3 Sample collected from the final product prior to cryopreservation. Results will not be available before cells are infused into the 
patient. 
4 Performed 2-10 days prior to infusion. Results are available at the time of infusion. 
5 A sample will be saved from the final product prior to cryopreservation. If the culture period after retroviral transduction is less 
than 96 hours the sample will be archived. If the culture period exceeds 96 hours after retroviral transduction, the assay will be 
performed and results will be available at the time of cell infusion.  
 
Prepared by: 
_________________________________________ 
Date: ____________________ 
 
QC sign-off: 
__________________________________________ 
Date: ____________________ 
Qualified laboratory or Clinical Supervisor 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.20 APPENDIX 2: DESCRIPTION OF DOSE DE-ESCALATIONS (COHORTS 1-7) 
This trial will consist of two phases. In phase I, a dose escalation of the number of anti-CD19-
CAR-transduced T-cells will be carried out. All patients in this phase of the trial will be 
lymphodepleted with fludarabine and cyclophosphamide, and all patients will receive 
aldesleukin (720,000 IU/kg every 8 hours for a maximum of 15 doses). Patients with platelet 
counts between 75,000 and 99,999 cells/mm3 will receive half the cyclophosphamide dose that 
patients with platelet counts of 100,000/mm3 or greater will receive. After a maximum tolerated 
cell dose is determined in phase I of the trial, phase II of the trial will begin. 
Starting with approval of Amendment E (to be discontinued with approval of Amendment F), 
this trial is being refocused to evaluate the safety and feasibility of administering between 
1.0x109 and 1.0x1010 anti CD19-CAR transduced cells and aldesleukin (720,000 IU/kg every 8 
hours for a maximum of 15 doses) following a preparative conditioning regimen of fludarabine 
and cyclophosphamide. We have accrued 4 patients at this dose level with one patient 
experiencing a DLT. If we observe no more DLTs in the next 2 patients treated for a total of 1/6 
patients treated, accrual will continue up to 18 patients. If at any time during accrual a 
cumulative total of 3 evaluable patients have experienced a DLT, then no further patients will be 
enrolled. If DLTs are encountered in up to 3/18 patients, the trial will be considered safe and 
feasible. A one-week safety assessment period will follow regimen completion (defined as the 
last dose of aldesleukin) between each patient in the first 6 patients and a two-week safety 
assessment period will follow between the 6th and 7th patient before expansion of the trial to 18 
patients. 
With approval of Amendment F (to be discontinued with the approval of Amendment H), the 
trial is being refocused to evaluate the safety and toxicity of the regimen studied at lower 
escalating dose levels since 3 DLTs were observed at dose level 1 (between 1.0x109 and 1.0x1010 
cells). The dose of cells administered will be on a CAR positive cells/kg basis. If a DLT is 
observed at the revised dose levels, the dose of aldesleukin may be reduced to 72,000 IU/kg 
every 8 hours for a maximum of 15 doses. 
Phase I – Dose Escalation (not applicable after approval of Amendment E) 
The initial portion of this protocol will be a phase I dose escalation design with three cohorts of a 
minimum of 3 patients per cohort. The number of anti-CD19-transduced T-cells transferred for 
each cohort will be:  
 Cohort 1 
between 
1.0x109 and 1.0x1010 
 Cohort 2 
greater than 
1.0x1010 up to 3.0x1010 
 Cohort 3 
greater than 
3.0x1010 up to 1.0x1011  
Patients will be enrolled sequentially, therefore enrollment will not proceed to a higher dose 
level until all patients have been treated in the prior cohort. If sufficient cells cannot be grown to 
meet the criteria for the assigned cohort, the patient will be enrolled in the appropriate cohort for 
the number of cells infused. If a DLT occurs in an additional patient entered at a lower dose due 
to cell growth limitations, accrual will continue at this level as described in the dose-escalation 
scheme below. Accrual will be halted at the higher level until the cohort at the lower level is 
complete as described below. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Should a single patient experience a dose limiting toxicity at a particular dose level, three more 
patients would be treated at that dose to confirm that no greater than 1/6 patients have a DLT 
prior to proceeding to the next higher level. If a level with 2 or more DLTs in 3-6 patients has 
been identified, three additional patients will be accrued at the next-lowest dose for a total of 6, 
in order to further characterize the safety of the maximum tolerated dose prior to starting the 
phase II portion of the trial. After the maximum tolerated dose is determined, the phase II portion 
of the trial will begin. 
A one-week safety assessment period will follow regimen completion (defined as the last dose of 
aldesleukin) between each patient in a cohort except for the last patient in each cohort for which 
a two-week safety assessment period will follow regimen completion (defined as the last dose of 
aldesleukin) before a patient will be accrued to the next cohort. 
Upon completion of the Phase I portion of the study, the adverse events observed in this cohort 
will be reported to and evaluated by the IRB before proceeding to the Phase II portion. 
Phase II – Randomization to Chemotherapy Versus No Chemotherapy (not applicable after 
approval of Amendment E) 
In phase II of the trial, patients will be randomized to two treatment arms. Patients assigned 
treatment arm 1 will receive fludarabine and cyclophosphamide lymphodepleting chemotherapy 
prior to receiving the engineered PBL cells while patients assigned to treatment arm 2 will not 
receive chemotherapy. Randomization will also be stratified so that an equal number of patients 
with circulating malignant cells (leukemia) will be entered on each arm of the phase II part of the 
trial. 
One to four days after completion of chemotherapy, anti-CD19 CAR-transduced T-cells will be 
infused. After cell infusion, IV aldesleukin therapy will be initiated (720,000 IU/kg every 8 
hours for a maximum of 15 doses). The randomization performed during phase II of this trial 
will be stratified so that each arm will receive an equal number of patients with a total peripheral 
blood CD3 count greater than or equal to 500 cells/microliter, and each arm will receive an equal 
number of patients with a CD3 count less than 500 cells/microliter. In addition, the 
randomization will be stratified so that each arm will receive an equal number of patients with 
peripheral blood involvement with malignant cells. Patients with peripheral blood involvement 
with malignant cells are defined as patients with pre-treatment peripheral blood lymphocyte 
counts greater than 4000 lymphocytes per microliters. 
During both phases multiple immunologic assays will be carried out on peripheral blood T-cells 
to determine persistence of anti-CD19-CAR-transduced T-cells as well as their function. During 
phase II an assessment of the anti-malignancy effect of anti-CD19-CAR-transduced T-cells will 
be made. All patients will be followed for anti-malignancy response, survival and toxicity. 
Dose Escalation and Cohort Expansion (with approval of Amendment F, not applicable after 
approval of Amendment H) 
With approval of Amendment F, the trial is being refocused to evaluate the safety and toxicity of 
the regimen studied at lower escalating dose levels since 3 DLTs were observed at dose level 1 
(between 1.0x109 and 1.0x1010 cells). For cohort 2, 3 patients will be treated with NMA, 0.5x107 
CAR positive cells/kg (± 20%), and high dose aldesleukin (720,000 IU/kg). This starting dose of 
cells has been selected due to PK modeling of interferon gamma levels and toxicity data from the 
first 8 patients treated on this study. If one DLT is observed in a patient treated in Cohort 2, after 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
analysis of the IFN-gamma cytokine data, 3 additional patients will be treated at this dose level 
(0.5x107 CAR positive cells/kg (± 20%) after receiving NMA followed by a reduced dose of 
aldesleukin (72,000 IU/kg every 8 hours for a maximum of 15 doses) (Cohort 3). This 10-fold 
reduction of aldesleukin was previously investigated in a study of patients with renal cancer. The 
incidence of grade 3 and 4 aldesleukin related toxicities was less in patients treated with 72,000 
IU/kg every 8 hours than those treated with the higher dose of 720,000 IU/kg aldesleukin, every 
8 hours (Yang, J.C., et al., J Clin Oncol. 2003, 21(16):3127-32). 
If no DLTs are observed in the 3 patients in Cohort 2, after analysis of the IFN-gamma cytokine 
data, 3 additional patients will be treated with NMA, 1.0x107 CAR positive cells/kg (± 20%) and 
high dose aldesleukin (Cohort 4). If one DLT is observed in a patient treated in Cohort 4, 3 
additional patients will be treated at this dose level (1.0x107 CAR positive cells/kg (± 20%) after 
receiving NMA followed by a reduced dose of aldesleukin (72,000 IU/kg every 8 hours for a 
maximum of 15 doses) (Cohort 5).  
Cohort 
Treatment Regimen 
 
NMA Chemotherapy Regimen 
(as specified in protocol) 
Cell Dose 
IL-2 Dose 
1 (Closed with 
Amendment F) 
Yes 
between 1.0x109 and 1.0x1010 
cells 
High dose 
(720,000 IU/kg) 
2 
Yes 
0.5x107 CAR positive cells/kg 
(± 20%) 
High dose 
(720,000 IU/kg) 
31 
Yes 
0.5x107 CAR positive cells/kg 
(± 20%) 
Low dose (72,000 
IU/kg) 
4 
Yes 
1.0x107 CAR positive cells/kg 
(± 20%) 
High dose 
(720,000 IU/kg) 
52 
Yes 
1.0x107 CAR positive cells/kg 
(± 20%) 
Low dose (72,000 
IU/kg) 
1 Cohort 3 will be skipped if there are no DLTs in Cohort 2. 
2 Cohort 5 will be skipped if there are no DLTs in Cohort 4. 
 
The highest dose cohort evaluated with no DLTs in 3 patients (either 3, 4 or 5) will be expanded 
to a total of 18 evaluable patients, subject to not exceeding 3 patients in total with a DLT. 
Safety Assessment 
Cytokine (IFN-gamma levels) and toxicity data must be analyzed prior to dose escalation. A one-
week safety assessment period will follow regimen completion (defined as the last dose of 
aldesleukin) between each patient in a cohort except for the last patient in each cohort for which 
a two-week safety assessment period will follow regimen completion (defined as the last dose of 
aldesleukin) before a patient will be accrued to the next cohort. A two-week safety assessment 
period will follow between the 3th and 4th patient before expansion of the trial to 18 patients. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Dose Escalation and Cohort Expansion (with approval of Amendment H, closed with 
Amendment J) 
With Amendment H, cohorts 2-5 will be closed and two new cohorts will be opened at the same 
cell dose level as cohorts 2 and 4 but without aldesleukin. These cohorts will be designated 
cohort 6 and 7. For Cohort 6, 3 patients will be treated with NMA, and 0.5x107 CAR positive 
cells/kg (± 20%). If one DLT is observed in a patient treated in Cohort 6, after analysis of the 
IFN-gamma cytokine data, accrual will be halted pending discussions with the FDA and IRB.  
In November 2011, the first patient in Cohort 6 experienced a DLT of grade 3 confusion 
(possible aphasia), and grade 3 neuropathy (facial droop) possibly related to the cell therapy. The 
serum IFN-gamma levels were low in this patient (range 9-44 pg/mL) following treatment with 
cells. These events were discussed with the FDA, and the FDA indicated that we can treat an 
additional patient in Cohort 6 (with approval of Amendment I). If this additional patient does not 
experience at DLT, Cohort 6 will be expanded to a total of 6 patients. If any additional patients 
treated in Cohort 6 experiences a DLT, after analysis of the IFN-gamma cytokine data, accrual 
will be halted pending discussions with the FDA and IRB.  
If no additional DLTs are observed in the 6 patients in Cohort 6, after analysis of the IFN-gamma 
cytokine data, 3 patients will be treated with NMA, and 1.0x107 CAR positive cells/kg (± 20%) 
in Cohort 7. If one DLT is observed in a patient treated in Cohort 7, 3 additional patients will be 
accrued to Cohort 7. If 2 DLTs occur in 6 or less patients in Cohort 7, no additional patients will 
be accrued at this dose level. 
Cohort 
Treatment Regimen 
 
NMA Chemotherapy Regimen 
(as specified in protocol) 
Cell Dose 
IL-2 Dose 
1 (Closed with 
Amendment F) 
Yes 
between 1.0x109 and 1.0x1010 cells 
High dose (720,000 
IU/kg) 
2 (Closed with 
Amendment H) 
Yes 
0.5x107 CAR positive cells/kg (± 
20%) 
High dose (720,000 
IU/kg) 
3 (Closed with 
Amendment H) 
Yes 
0.5x107 CAR positive cells/kg (± 
20%) 
Low dose (72,000 
IU/kg) 
4 (Closed with 
Amendment H) 
Yes 
1.0x107 CAR positive cells/kg (± 
20%) 
High dose (720,000 
IU/kg) 
5 (Closed with 
Amendment H) 
Yes 
1.0x107 CAR positive cells/kg (± 
20%) 
Low dose (72,000 
IU/kg) 
6 (Closed with 
Amendment J) 
Yes  
0.5x107 CAR positive cells/kg (± 
20%) 
None 
7 (Closed with 
Amendment J) 
Yes 
1.0x107 CAR positive cells/kg (± 
20%) 
None 
The highest dose cohort evaluated with no DLTs in 3 or more patients, or 1 DLT in 6 patients 
will be expanded to a total of 18 evaluable patients, subject to not exceeding 3 patients in total 
with a DLT. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
Safety Assessment 
Cytokine (IFN-gamma levels) and toxicity data must be analyzed prior to dose escalation. A one-
week safety assessment period will follow regimen completion between each patient in a cohort 
except for the last patient in each cohort for which a two-week safety assessment period will 
follow regimen completion before a patient will be accrued to the next cohort. A two-week 
safety assessment period will follow the last patient treated in the dose escalation cohort before 
expansion of the trial to 18 patients. 
Dose De-escalation and Cohort Expansion 
In February 2012, the second patient in Cohort 6 experienced DLTs. The SAEs consisted of 
grade 3 hypotension and grade 3 confusion (possibly aphasia) related to the cell therapy. These 
toxicities have resolved and the patient has been discharged. After discussions with the FDA, 
cohort 6 and 7 were closed and two new dose de-escalation cohorts were opened as follows: 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.21 APPENDIX 3: DESCRIPTION OF DOSE ESCALATION FOR FRESH ANTI-CD19 TIL 
(COHORTS 8-10) 
PBMC will be obtained by leukapheresis (approximately 1.0x1010 cells). In most patients, whole 
PBMC will be cultured in the presence of anti-CD3 (OKT3) and aldesleukin in order to stimulate 
T-cell growth. In some patients the peripheral blood might be contaminated with large numbers 
of CD19-expressing malignant cells. In patients with peripheral blood lymphocytes counts 
greater than 4000 cells per microliter, CD19-expressing cells will be depleted using the Miltenyi 
Biotec CliniMacs system with anti-CD19 microbeads and then CD19-depleted PBMC will be 
stimulated with OKT3. In all patients, 2 days after OKT3 stimulation transduction will be 
initiated by exposure of approximately 1.0x107 to 5.0x108 cells to supernatant containing the 
anti-CD19 CAR retroviral vector. These transduced cells will be expanded and tested for their 
anti-tumor activity. Successful TCR gene transfer will be determined by FACS analysis for the 
CAR and specific anti-tumor reactivity will be tested by cytokine release measured against 
CD19+ cell lines and CD19-negative cell lines. Successful CAR gene transfer for each 
transduced PBL population will be defined as >30% CAR positive cells and for biological 
activity, gamma-interferon secretion against CD19 targets must be at least 200 pg/mL. The cells 
administered vary depending on their growth characteristic. In prior protocols over 3.0x1011 T-
cells have been safely infused to cancer patients.  
Due to toxicities experienced during the dose escalation phase of this trial, the protocol has been 
amended several times to decrease the dose and eliminate the administration of IL-2. The 
description of these changes has been moved to Appendix 2. 
Beginning with Amendment M patients will be lymphodepleted with fludarabine and a reduced 
dose of cyclophosphamide – 30mg/kg/day for 2 days and will receive 1.0x106 CAR positive 
cells/kg (± 20%) as noted below.  
Cohort 
Treatment Regimen 
 
NMA Chemotherapy Regimen (as 
specified in protocol) 
Cell Dose 
IL-2 Dose 
8 
(De-escalation Dose 1) 
Yes  
2.5x106 CAR positive cells/kg (± 
20%) 
None 
9 
(De-escalation Dose 2) 
Yes 
1.0x106 CAR positive cells/kg (± 
20%) 
None 
10 
(De-escalation Dose 2) 
Yes – dose of both agents reduced 1.0x106 CAR positive cells/kg (± 
20%) 
None 
Cohort 8 will initially accrue 3 patients. If no DLTs are observed in these 3 patients, three 
additional patients will be accrued. If DLTs are observed in ≤ 1 patient out of 6 patients treated, 
this cohort will be expanded as described below. If a DLT is observed in one of the first 3 
patients, after analysis of the cytokine data, 3 additional patients can be accrued to this cohort. If 
more than 1 out of 6 patients in this cohort experience a DLT, this cohort will be closed, and 
patients will be accrued to cohort 9. Cohort 8 was closed with Amendment M.  
Cohort 9 will initially accrue 3 patients. If no DLTs are observed in these 3 patients, three 
additional patients will be accrued. If DLTs are observed in ≤ 1 patient out of 6 patients treated, 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
this cohort will be expanded as described below. If a DLT is observed in one of the first 3 
patients, after analysis of the cytokine data, 3 additional patients can be accrued to this cohort. If 
more than 1 out of 6 patients in this cohort experience a DLT, this cohort will be closed. 
Subsequent dose reductions will be discussed with the FDA prior to initiation. If ≤ 1 patient in 6 
patients treated develops a DLT then the 12 remaining patients will be enrolled in cohort 10 for a 
total of 18 evaluable patients at a dose level of 1.0x106 CAR positive cells/kg (± 20%), subject to 
not exceeding 3 patients in total with a DLT. 
Following administration of the cell product, neurological status will be closely monitored and 
urgently managed as described in Section 3.4.3.  
In addition, we will be evaluating stored serum samples in an effort to identify the particular 
cytokines which may be contributing to these toxicities.  
Safety Assessment 
Cytokine (IFN-gamma levels) and toxicity data must be analyzed prior to dose de-escalation. A 
one-week safety assessment period will follow regimen completion between each patient in a 
cohort except for the last patient in each cohort for which a two-week safety assessment period 
will follow regimen completion before a patient will be accrued to the next cohort. Beginning 
with Amendment R, the one week safety assessment period between patients will no longer be 
required during the expansion phase of the protocol for the remaining patients to be enrolled in 
Cohort 10. 
The study will be halted pending discussions with the FDA and IRB if the following conditions 
are met: 
Prior to Amendment E 
• If two DLTs occur in the first cohort of the Phase I portion of this study. 
• Two or more patients develop a grade 3 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative regimen (or circumstances unrelated to this 
study). 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) develop DLT due to autoimmune toxicity. 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
With Approval of Amendment E (not applicable with approval of Amendment F) 
• If two DLTs occur in the first 6 patients treated on this study. 
• Two or more patients develop a grade 3 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative regimen (or circumstances unrelated to this 
study). 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) develop DLT due to autoimmune toxicity. 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
With Approval of Amendments F, H, and J 
As stated above, the study will be halted pending discussions with the FDA and IRB if the 
following conditions are met: 
• If cohorts 2-7 or 9 cannot be expanded due to DLTs. 
• During the expansion phase, if at any time during accrual, a cumulative total of 3 
evaluable patients have experienced a DLT. 
• Two or more patients develop a grade 3 or greater toxicity at any point in the study not 
attributable to the chemotherapy preparative (or circumstances unrelated to this study). 
• If 1 of the first 3 patients (OR 2 of the first 6 patients, OR 3 of the first 9 patients, OR 4 
of the first 12 patients) in cohorts 2-5 develop DLT due to autoimmune toxicity. 
• Development of EBV lymphoma or polyclonal lymphoproliferative disease (PLPD) in an 
EBV negative subject on this or any other SB adoptive cell therapy study. Accrual of 
EBV negative subjects will be halted only. 
 


Abbreviated Title: Anti-CD19 CAR PBL 
Version Date: August 23, 2018 
13.22 APPENDIX 4: MODIFICATION OF DOSE CALCULATIONS* IN PATIENTS WHOSE BMI IS 
GREATER THAN 35 
Beginning with Amendment M, actual body weight will be used for dose calculations of all 
treatment agents. 
 
1. BMI Determination: 
 
BMI = weight (kg) / [height (m)]2 
 
2. Calculation of ideal body weight: 
Male = 50 kg + 2.3 (number of inches over 60 inches) 
Example: Ideal body weight of 5’10” male 
50 + 2.3 (10) = 73 kg 
 
Female = 45.5 kg + 2.3 (number of inches over 60 inches) 
Example: Ideal body weight of 5’3” female 
45.5 + 2.3 (3) = 57 kg 
 
3. Calculation of “practical weight”: 
 
Calculate the average of the actual and the ideal body weights. This is the practical 
weight to be used in calculating the doses of chemotherapy and associated agents 
designated in the protocol. 
 
*Practical weight will NOT be used in the calculation of dose for aldesleukin.