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7.3 ind sponsor reporting criteria

During the first 30 days after the subject receives investigational agent/intervention, the investigator must immediately report to the sponsor, using the mandatory MedWatch form 3500a or equivalent, any serious adverse event, whether or not considered drug related, including those listed in the protocol or investigator 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 report those that have an attribution of at least possibly related to the agent/intervention. Required timing for reporting per the above guideline:  
x Deaths (except death due to progressive disease) must be reported via email within 24 hours. A complete report must be submitted within one business day.  
x 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.
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7.4 institutional biosafety committee (ibc)

The Principal Investigator (or delegate) will notify IBC of any unexpected fatal or lifethreatening experience associated with the use of the anti-CD19 CAR transduced cells 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 cells, but are not fatal or life-threatening, must be reported to the NIH IBC as soon as possible, but not later than 15 calendar days after the investigator's initial receipt of the information. Adverse events may be reported by using the FDA Form 3500a.
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7.4.2 annual reports to ibc

Within 60 days after the one-year anniversary of the date on which the IBC approved the initial protocol, and after each subsequent anniversary until the trial is completed, the Principal Investigator (or delegate) shall submit the information described below. Alternatively, the IRB continuing review report can be sent to the IBC in lieu of a separate report. Please include the IBC protocol number on the report.
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7.4.2.1 clinical trial information

A brief summary of the status of the trial in progress or completed during the previous year. The summary is required to include the following information:
x the title and purpose of the trial  
x clinical site
x the Principal Investigator  
x clinical protocol identifiers;
x participant population (such as disease indication and general age group, e.g., adult or pediatric);  
x 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 x the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, or fully completed,
x 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:
x a narrative or tabular summary showing the most frequent and most serious adverse experiences by body system  
x a summary of all serious adverse events submitted during the past year
x 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  
x if any deaths have occurred, the number of participants who died during participation in the investigation and causes of death x 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.
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7.5 data and safety monitoring

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 dose level enrollment and dose escalation if applicable will be made based on the toxicity data from prior patients. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Adverse events will be reported as required above. Any safety concerns, new information that might affect either the ethical and or scientific conduct of the trial, or protocol deviations will be immediately reported to the IRB using iRIS and to the Sponsor. 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 subjects' protection. This is done through independent verification of study data with source documentation focusing on:
x Informed consent process  
x Eligibility confirmation
x Drug administration and accountability  
x Adverse events monitoring x 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 an 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 NCI-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.
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8 statistical considerations 8.1 general

All subjects who are enrolled in the study and received the planned dose of anti-CD19 CAR T cells will be included in the statistical summaries and analyses of safety data. All available data will be used and thus, missing data will not be estimated or carried forward in any statistical summary or analyses. Descriptive summary statistics include the number of subjects, mean, median, percent coefficient of variation (%CV) (if required), standard deviation, and minimum and maximum values (quantitative variables) or the number of subjects and percentages by category (qualitative variables). Changes will be assessed as the difference between the baseline measurement and the appropriate post-cell infusion measurement unless otherwise specified. Baseline is defined as the last non-missing value prior to initiation of preparative regimen except for cytokine analyses where baseline is defined as the last non missing value prior to cell infusion. Individual subject listings of data will also be provided to allow for review of all safety parameters.
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8.2 dose escalation design

The cell doses for patients will be weight-based. The Phase I dose-escalation design will consist of three cohorts of a minimum of three patients per cohort as described in Sections 3.6 and 3.7.  
COMPLETED In patients with BMI equal to or less than 30, the dose of anti-CD19-transduced T cells for each cohort will be based on doses calculated using actual body weight. Patients with BMI greater than 30, will have doses calculated using ideal body weight dose (IBW) dose plus 50% of the difference between actual weight and IBW (see **Appendix D**). In order to determine if there are differences in safety or feasibility related to manufacturing or administering anti-CD19 CAR T cells after a nonmyeloablative preparative regimen in children and young adults who have not undergone prior allogeneic stem cell transplant (SCT) versus those that have previously undergone SCT, the enrollment will be stratified for these two groups of subjects. For each stratum of patients, the number of anti-CD19 transduced T cells administered in each cohort will be:  
| x   | Cohort 1   | 1 x 106 transduced T cells/kg (± 20%)   |
|-----|------------|-----------------------------------------|
| x   | Cohort 2   | 3 x 106 transduced T cells/kg (± 20%)   |
| x   | Cohort 3   | 1 x 107 transduced T cells/kg (± 20%)   |  
Doses of anti-CD19-CAR transduced T-cells will be administered in a standard 3 + 3 dose escalation design until MTD is determined. After treatment of the first patient in a cohort there will be a two week (14 day) safety assessment prior to enrollment of the 2nd patient in each cohort. Subsequent patients in that cohort may be enrolled after a one week safety assessment period following cell infusion. 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 and the last patient treated on the completed cohort has been observed for at least 4 weeks. If cell growth limitations preclude administration of the targeted cohort cell dose, the patient will receive as many cells as possible, and be considered part of the lower dose cohort. If a minimum of 1.0 x105 anti-CD19-CAR-transduced T cells per kg cannot be obtained for infusion, the patient will not be treated and if possible a second attempt to produce cells for infusion will be made. As per Section 3.7, toxicity data collected from the SCT stratum dose cohorts may be used to inform dose escalation decisions in the non SCT dose cohorts. For example, if 3 patients in the SCT stratum complete a cohort without DLT, the next patient enrolled in either stratum may proceed to the next dose cohort. But if 3 patients in the NON-SCT stratum complete a cohort without DLT, the SCT stratum must continue enrollment until 3 patients complete therapy without DLT prior to dose escalation. **COMPLETED** To gain further experience with the safety, feasibility and clinical activity of the anti-CD19 CAR T cells in this patient population, the MTD (or highest cell dose studied) will be expanded to 15 patients. If the MTD or highest cell dose studied is the same for both strata (prior SCT vs. NO prior SCT) one expansion cohort will be studied and efforts will be made to include a balance of SDWLHQWVZLWKSULRU6&7ZLWKRXWSULRU6&7\HDUVRIDJHDQG!\HDUVRIDJH,IGLIIHUHQW MTDs are observed per stratum, a total of 12 patients per stratum will be enrolled at the MTD, DWWHPSWLQJWREDODQFHHQUROOPHQWEHWZHHQSDWLHQWV2 years of age and > 12 years of age. COMPLETED
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8.3 safety and feasibility of

Given the impressive response to this therapy, Amendment G allows us to explore further the study findings. Based on the relationship observed between the incidence of Grade 3-4 CRS and patients with high-disease burden, additional investigation is warranted to determine if reduction of disease burden prior to administration of the anti-CD19 CAR will decrease the incidence of severe CRS, while using an updated assessment/treatment algorithm for CRS. Amendment G will allow us to evaluate a safe option for bringing this therapy to patients with high-burden of disease. For purposes of this study, high-burden disease will be defined as M3 bone marrow blasts and/or presence of peripheral blood blasts on routine CBC. We will therefore explore the safety and feasibility of this therapy in two groups of patients:
1. Arm 1 = Patients without high-burden disease, or who due to safety concerns require the cyclophosphamide/fludarabine preparative regimen 2. Arm 2 = Patients with high-burden disease Thirty patients are to be enrolled in arm 1 and 30 patients in arm 2 in order to have sufficient patients to establish a reasonably precise confidence bound on the safety of the regimen overall as well as the feasibility of delivering treatment to patients in arm 2.
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8.3.1 safety

All 60 patients on arms 1 and 2 will be considered together for a safety evaluation. Combining arms 1 and 2, if there are 0-1 patients in the first 10 who have a grade 4 CRS, then accrual would continue as planned per arm. However, if there are 2 patients within the first 10 who experience a grade 4 CRS then no further patients may be accrued. If accrual beyond the initial 10 is permitted, then this will continue to be the case provided that the cumulative percentage of patients with grade 4 CRS on both arms combined is below 20%; realizing 20% or more with grade 4 CRS at any time would require ending accrual and amending the study to reconsider toxicity definitions (since they are newly implemented and not fully vetted) or revise the treatment regimen. The upper one sided 90% CI on 2/10 is 45.0% which would indicate possible consistency with a very high rate of grade 4 CRS. Provided that these interim toxicity limits are not met, accrual will be permitted until 60 total patients are enrolled, 30 per arm and the overall fraction with grade 4 CRS will be determined. As illustrations, if 6/60 have grade 4 CRS, the upper one-sided 90% CI bound on this fraction is 16.9% and if the fraction ends up being as high as 20% at the end of 60 patients, e.g. 12/60 with grade 4 CRS, the upper 90% one-sided confidence bound is 28.2%.
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8.3.2 arm 2 feasibility

In addition to safety, establishing feasibility of administering the anti-CD19 CAR T cells within 21 days of the planned infusion is an important goal of this study. Feasibility will be assessed only in Arm 2 and defined by the successful manufacturing, expansion, and administration (within 21 days of the planned infusion date) of the anti-CD19 CAR T cells to satisfy the dose level and meet the requirements of the COA. Unless there is excessive toxicity, enroll 30 evaluable patients on arm 2 over a period of approximately 3 years. If there are 22 or more patients among 30 who are able to fully receive therapy, then the probability this would be the case is 87.1% if the true rate of feasibility were 80% while it is only 9.4% if the true rate of feasibility were 60%. Thus, obtaining 22 or more patients who are able to receive treatment out of 30 would demonstrate a feasibility rate more consistent with 80% or greater as opposed to 60% or less, and thus this would be a reasonable goal.
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8.4 accrual target and study

Twenty subjects were enrolled to achieve MTD and expanded cohorts in the initial objectives of this study. To complete Arm 1 and 2 primary objectives added in Amendment G, up to 30 subjects will be enrolled in each arm. The study will allow for a small number of inevaluable patients of 5 in each arm (patients enrolled but who cannot receive cells, either due to physical deterioration or withdrawal of consent during cell growth, or inability to grow adequate cells). Thus the maximum accrual will be 90 patients (20 previously treated + 30 in each arm [60 total] + 5 inevaluable patients in each arm [10 total]. Up to a total of 180 patients may be screened to allow for enrollment of up to 90 patients eligible to proceed to treatment.
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8.5 feasibility

In addition to safety, establishing feasibility of the creation of anti-CD19 CAR T cells within 21 days of the planned infusion for patients (who have had prior SCT or not) is an important goal of this study. Feasibility will be defined by the successful manufacturing and expansion of the antiCD19 CAR T cells to satisfy the targeted dose level and meet the requirements of the COA. If after the first 6 patients per stratum have been enrolled, more than 3 are unable to have adequate anti-CD19 CAR T cells produced (that meet COA for infusion), accrual to that stratum in the study will be terminated, since the upper 90% one-sided confidence interval about 3/6 is 79.9%; thus, it would be unlikely that the true feasibility rate is 80% or greater, which would be desirable. Each stratum will be evaluated independently for feasibility. COMPLETED
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8.6 secondary endpoints 8.6.1 efficacy

The best overall response will be assessed at end of study, based upon the disease assessments recorded during the study visits, and reported by dose cohort in terms of confirmed CR/PR, unconfirmed CR/PR, Hematological Activity (ALL only), SD, or PD. The rate of relapse from CR prior to end of study will also be summarized by dose cohort only for the subjects who achieve confirmed CR during the study. The overall objective response rate (CR + PR) will be summarized by dose cohort. The duration of objective response will be summarized for those subjects who achieve objective response (CR + PR). In subjects who have a confirmed response, duration of response will be calculated from the first date of documented response until progression. Unconfirmed CR or PR is defined as the first documentation of response. Overall survival (OS) and progression-free survival (PFS) will be assessed by dose cohort. Progressionfree survival (PFS) will be measured from the start of the preparative regimen until the documentation of disease progression or death due to any cause, whichever occurs first. Overall survival (OS) will be determined as the time from the start of the preparative regimen until death.
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8.6.2 persistence of cd19-car t

Peripheral blood, bone marrow aspirate, and CSF will be collected and separately analyzed for the presence of anti-CD19 CAR T cells. The percentage of all CD3+ cells in a sample that are positive by flow cytometry for anti-CD19 CAR containing T cells will be analyzed and reported as time from T cell infusion.
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8.6.3 cytokines

Endogenously produced IFNg, TNFa, GM-CSF, IL-6 and IL-2 will be measured by ELISA and reported as change from baseline. The baseline will be defined as the cytokine level just prior to cell infusion. Cytokine levels will also be analyzed in the context of clinical response.
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8.6.4 monitoring for cd19+ cells

Peripheral blood, bone marrow aspirates, and CSF will be collected and analyzed for the presence of CD19+ cells by flow cytometry. Any CD19+ cells will be analyzed to determine whether these are normal B cells or leukemia blasts. The percentage of CD19+ normal B cells and CD19+ leukemia blasts relative to total cells analyzed in the sample will be reported and analyzed in relation to time from cell infusion and compared to baseline. Baseline percentage of CD19+ normal B cells and CD19+ leukemia blasts will be defined as the result obtained from the same sample type (e.g. peripheral blood, CSF, or aspirate) prior to cell infusion.
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8.6.5 toxicity in patients with

Patients enrolled in Arm 1 or Arm 2 after approval of Amendment G who have CNS disease will be pooled and analyzed for descriptive reporting of efficacy and toxicity. This data may be used in an exploratory fashion to develop new questions related to use of and indications for antiCD19 CAR gene engineered T cells.
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8.6.6 analyses of cognitive testing

To analyze the data for the secondary cognitive objective, we will use paired t-tests to examine the change in scores between the baseline and post-infusion evaluation to determine if the change is significantly different from zero. For the exploratory cognitive objectives, we will use analysis of variance with repeated measures to examine change in scores between the baseline and the follow-up evaluations. In addition, correlations or analyses of variance will be computed to examine the relationship between cognitive scores and cytokine levels.
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8.6.7 analyses of cardiology studies

The effect of CAR cell therapy on cardiac function will be compared with baseline data. Changes in cardiac function will be correlated with levels of inflammatory markers and biomarkers. Further analysis depends on the type of data obtained. Data will be analyzed using SAS 9.4 (Cary, NC). Data will be expressed as mean (standard deviation). In all analyses, the conventioQDOĮ-level of 0.05 will be used for significance testing.
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9 human subjects protections 9.1

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.
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9.2 participation of children

The age range of patients eligible for this trial is greater than 1 year of age but less than or equal to 30 years of age. Physicians, nurses, and multidisciplinary support teams of the POB, NCI and Clinical Center will provide patient care. The staff of the POB has expertise in the management of children with complex oncologic disorders and complications of therapy. Full pediatric support and subspecialty services are available at the NIH Clinical Center.
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9.3 evaluation of benefits and

The experimental treatment has a chance to provide clinical benefit though this is unknown. The risks in the investigational portion of this treatment are detailed in Section **1.2.5**. 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 many cancer therapy protocols. The success of this effort cannot be predicted at this time. Because all patients in this protocol have B cell malignancies without curative options and limited life expectancies the potential benefit is thought to outweigh the potential risks. It is anticipated that this study will provide scientific information relevant to tumor immunotherapy. Consequently, participation of children involves greater than minimal risk, but presents the prospect for direct benefit for patients who are minors (45CFR 46.405).
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9.3.1 risks of anti-cd19 car

The risk profile of anti-CD19 CAR cells in children is not fully known at this time. DLT on the dose-escalation phase of our study was CRS. In one clinical trial in adults in the Surgery Branch, NCI two events of reversible grade 4 somnolence and one of grade 4 keratinize were attributed to the anti-CD19 CAR-transduced cells. One each event of grade 2 left ventricular dysfunction and grade 1 pulmonary hypotension were attributed to the anti-CD19 CARtransduced cells and IL-2, and both of these toxicities resolved. Three patients on this study were intubated and one patient underwent dialysis, for which the attribution is unknown. Aldesleukin will not be used in the present study. Section **1.2.5** discusses the potential risks of this investigational therapy, including risk of chemotherapy, risk of autoimmunity, risk of the gene therapy component, and risk of cytokine storm. Transient, reversible mild effects have been observed with the administration of fresh cells, including chills, fever, rigors, diaphoresis, anorexia, nausea, diarrhea, headache and myalgias. As described in Section **1.2.4** recently reported toxicities associated with similar studies using anti-CD19 CAR T cells included grade 3 tumor lysis syndrome, and reversible laboratory abnormalities, thrombocytopenia, neutropenia, and hypogammaglobulinemia.
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9.3.2 risk of apheresis

Apheresis is a safe procedure that is routinely performed in healthy children and adults. Participants will be closely monitored and procedures to minimize risks and prevent side effects are incorporated into all aspects of the protocol. The POB, DTM, and NIH CC have broad expertise to adequately manage side effects, including in pediatric apheresis subjects. The potential risks of apheresis in this trial are as follows:  
a. The most common side effects of apheresis are pain and bruising at IV sites. A central venous catheter may be required. Possible side effects include pain, bleeding, bruising, infection, thrombosis, vascular perforation, and risks associated with the sedation used for placement.  
b. During apheresis, mild side effects from citrate anticoagulant are common and include chills, numbness and tingling ("pins and needles"), anxiety, muscle cramps, and nausea. More serious side effects due to citrate-induced hypocalcemia are uncommon and include low blood pressure, seizures, weakness, and tetany. Citrate reactions rapidly resolve when the collection is slowed down or stopped. Prophylactic IV CaCl2 and MgSO4 infusions may be administered to donors deemed to be at high risk of citrate toxicity. Risks of parenteral calcium and magnesium include extravasation necrosis and cardiovascular effects including bradycardia and blood pressure changes. However, side effects are unlikely given the low rate of infusion and use of large bore catheters for apheresis.
c. Transient mild thrombocytopenia is common after apheresis, but bleeding is unlikely. d. Dilutional anemia occurs during apheresis, but this is unlikely to be clinically significant. e. Side effects of blood draws include pain and bruising, lightheadedness, and rarely, fainting.  
9.3.3 Risks of the chemotherapy regimens and supportive therapies The chemotherapy agents and supportive medications used in this study are FDA approved agents with well-known toxicity profiles. Refer to Section 11 for summary of toxicities.
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9.4 risks/benefits analysis

Patients will be monitored frequently as both inpatients and outpatients and side effects will be treated promptly. These measures will help to mitigate the potential risks observed with the preparative chemotherapy regimen and the cell administration. The enrollment profile and dose escalation rules will help to ensure that patients are not exposed to unacceptable risk as a safe dose level is determined. Patients on this study may directly benefit from participation. It is anticipated that this study will provide scientific information relevant to tumor immunotherapy. Consequently, participation involves greater than minimal risk, but presents the prospect for direct benefit for patients who are minors (45CFR 46.405).
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9.5 consent and assent process

Pediatric patients who meet the thorough screening for protocol eligibility will have apheresis conducted to obtain PBMC on this study once the protocol consent is signed. The investigational nature and research objectives of this trial, the procedures and treatments involved and their attendant risks and discomforts and potential benefits, and alternative therapies will be carefully explained to the patient's parents/guardians, who are asked to review it and to ask questions prior to agreeing to participate in this protocol. The patient and his/her parent(s) or guardian are reassured that participation on trial is entirely voluntary and that they can withdraw or decide against treatment at any time without adverse consequences. The investigators are requesting a waiver from the IRB to allow only one parent to sign the informed consent to enter a child on the protocol. Because many patients must travel to the NIH from long distances at substantial expense, requiring both parents to be present for the consent process could be a financial hardship for many families. When necessary, the protocol will be reviewed by telephone with the other parent and their approval will be verified. When guardianship status of the child is uncertain, a social worker will be asked to investigate and, if necessary, seek documentation of custody status. The research nurse, principal investigator, associate investigator, or clinical associate is responsible for obtaining written consent from the patient. Where deemed appropriate by the clinician and the child's parents or guardian, the child will also be included in all discussions about the trial and verbal assent will be obtained. The parent or guardian will sign the designated line on the informed consent attesting to the fact that the child has given assent.
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9.5.1 screening sample consent

The screening consent will initially be used to test samples for CD19 expression, prior to complete eligibility screening and enrollment. Telephone consent may be employed in order to screen outside samples from prospective subjects for CD19 expression. In such cases, a protocol investigator will review the Screening Consent form by telephone. The consent/assent signatures will be witnessed and a copy will be faxed and the original sent by mail to the PI. Prospective subjects who consent to send such samples for outside testing will NOT be registered with the NCI Central Registration Office unless they are subsequently enrolled on protocol. Subjects and their referring medical team will be notified of the results and records will be maintained with the protocol research files. The Principal Investigator, Associate Investigator, or their designee will be available to answer all questions from prospective patients or parents/guardians. The attached informed consent documents contain all elements required for consent.
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9.5.2 consent for minors when

When a pediatric subject reaches age 18, continued participation (including ongoing interactions with the subject or continued analysis of identifiable data) requires consenting of the now adult with the standard protocol consent document to ensure legally effective informed consent has been obtained. We request a waiver of informed consent for those individuals who became lost to follow up during their participation in the research study or who, prior to the approval of Amendment P were taken off study prior to reaching the age of majority. Requirements for Waiver of Consent consistent with 45 CFR 46.116 (d):
(1) The research involves no more than minimal risk to the subjects.  
a. Analysis of samples and data from this study involves no additional risks to subjects.  
(2) The waiver or alteration will not adversely affect the rights and welfare of the subjects.  
a. Retention of these samples or data does not affect the welfare of subjects.  
(3) The research could not practicably be carried out without the waiver or alteration.  
a. Considering the length of time between the minor's last contact with the research team and their age of majority, it will likely be very difficult to locate them again. A significant reduction in the number of samples analyzed is likely to impact the quality of the research.  
(4) Whenever appropriate, the subjects will be provided with additional pertinent information after participation.
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9.5.3 informed consent of non-english

If there is an unexpected enrollment of a research participant for whom there is no translated extant IRB approved consent document, the principal investigator and/or those authorized to obtain informed consent will use the Short Form Oral Consent Process as described in MAS Policy M77-2, OHSRP SOP 12, 45 CFR 46.117 (b) (2), and 21 CFR 50.27 (b) (2)). The summary that will be used is the English version of the extant IRB approved consent document. Signed copies of both the English version of the consent and the translated short form will be given to the subject or their legally authorized representative and the signed original will be filed in the medical record. Unless the PI is fluent in the prospective subject's language, an interpreter will be present to facilitate the conversation (using either the long-translated form or the short form). Preferably someone who is independent of the subject (i.e., not a family member) will assist in presenting information and obtaining consent. Whenever possible, interpreters will be provided copies of the relevant consent documents well before the consent conversation with the subject (24 to 48 hours if possible). We request prospective IRB approval of the use of the short form process for non-English speaking subjects and will notify the IRB at the time of continuing review of the frequency of the use of the Short Form.
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10 pharmaceutical information 10.1 retroviral

Cells will be administered intravenously through a free-flowing IV at dose 1 X 106 anti-CD19 CAR T cells/kg (+/- 20%) as described in Section **3.10.4**. 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.
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10.2 fludarabine 10.2.1 description

(Please refer to package insert for complete product Information) 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.
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10.2.2 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.
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10.2.3 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 2-80C; 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. 10.2.4 Storage Intact vials should be stored refrigerated (2-8qC).
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10.2.5 administration

Fludarabine is administered as an IV infusion in an appropriate solution over 30 minutes. To prevent undue toxicity the dose will be based on BSA (25 mg/m2/dose)
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10.2.6 toxicities

At doses of 25 mg/m2/day for 3 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.
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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.
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10.3.1 how supplied

Cyclophosphamide will be obtained from commercially available sources by the Clinical Center Pharmacy Department.
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10.3.2 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 2-80C.
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10.3.3 administration

It will be diluted in an appropriate solution and infused over one hour. The dose will be based on the patient's body weight, at 900 mg/m2/dose after fludarabine infusion on Day -2.
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10.3.4 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 allopurinal 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, cyclophophamide 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 2mercaptoethanesulphonate; given by IV injection) is a synthetic sulfhydryl compound that can chemically interact with urotoxic metabolites of cyclophosphamide (acrolein and 4hydroxycyclophosphamide) to decrease the incidence and severity of hemorrhagic cystitis.
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10.4 mesna

(Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) (Please refer to the FDAapproved package insert for complete product information)
10.4.1 Description Mesna will be obtained commercially by the Clinical Center Pharmacy Department and is supplied as a 100 mg/ml solution. 10.4.2 Storage Intact ampoules are stored at room temperature. 10.4.3 Stability Diluted solutions (1 to 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, 4872 hour in D5W/0.45% NaCl, or 24 hours in 0.9% sodium chloride. 10.4.4 Administration Dilute to concentrations less than or equal to 20 mg mesna/ml fluid in D5W or normal saline and to be administered intravenously as a continuous infusion. 10.4.5 Toxicities Toxicities include nausea, vomiting and diarrhea.
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10.5 ifosfamide 10.5.1 description

Ifosfamide for injection is supplied in single-dose vials for constitution and administration by intravenous infusion, each containing 1 gm or 3 gms of sterile ifosfamide. Ifosfamide is a chemotherapeutic agent chemically related to the nitrogen mustards and a synthetic analog of cyclophosphamide. 10.5.2 Supplied Ifosfamide is commercially available and will be supplied by the Clinical Center Pharmacy Department. Please refer to the package insert for full details. 10.5.3 Storage and stability Preparation for Intravenous Administration: Injections are prepared for parenteral use by add Sterile Water for Injection, USP or Sterile Bacteriostatic Water for Injection, USP to the vial and shaking to dissolve. 10.5.4 Preparation for Intravenous Administration Injections are prepared for parenteral use by add Sterile Water for Injection, USP or Sterile Bacteriostatic Water for Injection, USP to the vial and shaking to dissolve. 10.5.5 Toxicities The dose limiting toxicities are myelosuppression and urotoxicity. Dose fractionation, vigorous hydration and a protector such as mesna can significantly reduce the incidence of hematuriar. Other significant toxicities include alopecia, nausea, vomiting and central nervous toxicities.
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10.6 etoposide (vepesid vp-16)

10.6.1 Availability Commercially available and will be supplied by the Clinical Center Pharmacy. 10.6.2 Toxicity Includes nausea, vomiting, stomatitis, diarrhea, neutropenia, thrombocytopenia, and alopecia. Secondary AML has been associated with etoposide. Bradycardia and hypotension are sometimes observed with etoposide administration.
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10.7 acetaminophen (tylenol)

Will be given as a pre-medication. This agent will be provided by the clinical center pharmacy. Please refer to the package insert for complete pharmaceutical information on this product.
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10.8 diphenhydramine (benadryl)

Will be given as a pre-medication IV over 10-15 minutes This agent will be provided by the Clinical Center Pharmacy. Please refer to the package insert for complete pharmaceutical information on this product.
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10.9 intrathecal chemotherapy

The following agents will be provided by the Clinical Center Pharmacy. Please refer to the package inserts for complete pharmaceutical information on these products.
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10.10 hydrocotisone (cortef solu-cortef) ncs#

Synthetic steroid akin to the natural adrenal hormone, cortisol. It binds with steroid receptors on nuclear membrane, impairs cellular mitosis and inhibits protein synthesis. It is phase specific, killing cells primarily during S phase. It has a catabolic effect on proteins and alters the kinetics of peripheral blood leukocytes. It is excreted in the urine and catabolized in the liver. 10.10.2 Toxicity The following toxicities may occur when hydrocortisone is given intrathecally: Nausea and vomiting, headache, pleocytosis, fever, somnolence, meningismus, learning disability, leukoencephalopathy. 10.10.3 Formulation and Stability Available as 100mg, 250mg, 500mg, and 1000mg vials for aqueous injection. In powder form, the drug is stable for 2 years at room temperature. After reconstitution, it is stored at room temperature, and should be discarded after 3 days. INTRATHECAL ADMINISTRATION: IT hydrocortisone should be further diluted with physiologic buffered diluents (lactated Ringer's, 0.9% sodium chloride, Elliott's B solution). Do not use Bacteriostatic Water to reconstitute for IT use, use only preservative free solutions. 10.10.4 Guidelines for Administration Hydrocortisone will be given by intrathecal administration in an age-specified dose and will be mixed with the other agents to the age-specified volume. (Section 4.1) 10.10.5 Supplier Commercially Available.
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10.11 cytarabine (cytosine arabinoside arac

Deoxycytidine analogue which is metabolized to ARA-CTP, a substance which inhibits DNA polymerase. It is S phase specific, and thus affects DNA synthesis. Rapidly catabolized by hepatic cytidine deaminases to AraU.
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10.11.2 toxicity

The following toxicities may occur when cytarabine is given intrathecally: Nausea, vomiting, headache, pleocytosis, arachnoiditis, rash, fever, somnolence, meningismus, convulsions, paresis, myelosuppression, ataxia, learning disability. CNS impairment may not be fully reversible. No further cytarabine will be administered if there is CNS toxicity (any grade) deemed related to cytarabine. IV Administration: Acute DLT consists of severe leukopenia and thrombocytopenia. Nausea and vomiting may be dose limiting at higher doses. Other adverse reactions include diarrhea, immunosuppression, anorexia, stomatitis, oral ulceration, flu-like syndrome, fever, hepatic dysfunction, and alopecia. At high doses, as in this protocol, keratoconjunctivitis, dermatitis, and central nervous system toxicity (e.g., ataxia, somnolence, coma, dysarthria) may occur. Occasionally, the CNS impairment is not fully reversible. Renal impairment will enhance toxicity. In the event signs of CNS toxicity, the cytarabine will be interrupted and the M.D. notified. In the event of signs of CNS toxicity the cytarabine infusion will be interrupted and the M.D. notified. No further cytarabine will be administered if there is CNS toxicity (any grade) deemed related to cytarabine.
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10.11.3 formulation and stability

A freeze-dried powder available in 100mg, 500mg, 1g and 2g vials. The unreconstituted form of the drug is stable at room temperature for at least 2 years. INTRAVENOUS ADMINISTRATION: The manufacturer supplies the drug as unreconstituted lyophilized powder in vials. With each vial, an ampule of bacteriostatic water for injection containing 0.945% benzyl alcohol is provided. To prepare high dose (2 gm/m2) cytarabine intravenous infusions, each vial of drug should be reconstituted with 2 mL (100 mg) or 10 mL (500 mg) of Sterile Water for injection USP (i.e. not the manufacturer-provided diluent) which contains no preservative. Begin each cytarabine dose 3.5-4 hours after completion of the preceding fludarabine dose.  
INTRATHECAL ADMINISTRATION: IT cytarabine should be further diluted with physiologic buffered diluents (lactated Ringer's, 0.9% sodium chloride, Elliott's B solution). Do not use Bacteriostatic Water to reconstitute for IT use, use only preservative free solutions. 10.11.4 Guidelines for Administration Cytarabine will be given by intrathecal administration in an age-specified dose and will be mixed with the other agents to the age-specified volume (Section **4.1.2**). If emesis occurs it usually occurs 4-6 hours after the intrathecal administration. If the patient has had emesis with prior intrathecal chemotherapy, premedications should be considered.  
10.11.5 Supplier Commercially available. See package insert for further information.
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10.12 methotrexate 10.12.1 source and

Methotrexate is an antimetabolite and antifolate agent with antineoplastic and immunosuppressant activities. Methotrexate binds to and inhibits the enzyme dihydrofolate reductase, resulting in inhibition of purine nucleotide and thymidylate synthesis and, subsequently, inhibition of DNA and RNA syntheses. Methotrexate also exhibits potent immunosuppressant activity although the mechanism(s) of actions is unclear.
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10.12.2 toxicity

The following toxicities may occur when given intrathecally: occasional headache, dizziness, tiredness, blurred vision or loss of balance for a few hours. Up to 15% of children may develop neurological changes including changes in level of consciousness, abnormal movements or confusion, very rarely leucoencephalopathy.
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10.12.3 formulation and stability

Methotrexate Sodium Injection USP is available for single use only in 20 mg and 1 gram vials, and will be diluted according to TIT in Section 4.1. Dilutions should be used within 24 hours if kept at room temperature. Unused solution should be discarded after this time in order to avoid risk of microbial contamination. INTRATHECAL ADMINISTRATION: IT methotrexate should be further diluted with physiologic buffered diluents (lactated Ringer's, 0.9% sodium chloride, Elliott's B solution). Do not use Bacteriostatic Water to reconstitute for IT use, use only preservative free solutions.
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10.12.4 preparation

The three agents will be filtered and mixed in sterile preservative free 0.9% sodium chloride immediately (less than 4 hrs) prior to administration. The final concentration should be no greater than 1.5mg/ml for MTX and HDC, and 3 mg/ml for Ara-C. 10.12.5 Guidelines for Administration Methotrexate will be given by intrathecal administration in an age-specified dose and will be mixed with the other agents to the age-specified volume (Section **4.1.2**). If emesis occurs it usually occurs 4-6 hours after the intrathecal administration. If the patient has had emesis with prior intrathecal chemotherapy, premedications should be considered. 10.12.6 Supplier Commercially available. See package insert for further information.
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10.13 allopurinol

Allopurinol will be obtained by the Clinical Center Pharmacy Department. It will be used as prophylaxis or treatment of pediatric 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.
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10.14 tocilizumab (anti-il6r mab) 10.14.1

Tocilizumab is an anti-human IL-6R antibody that binds specifically to cell associated and soluble IL-6 receptors, thus blocking IL-6 signaling. IL-6 is involved in T cell activation, acute phase protein synthesis and stimulation of hematopoietic precursors.
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10.14.2 storage and stability

Store unused vials refrigerated between 2 and 8 degrees C (36 and 46 degrees F). Do not freeze and protect from light in original package3. Diluted tocilizumab solutions may be stored at 2 to 8 degrees C (36 to 46 degrees F) for up to 24 hours. Protect the diluted solution from light. Discard any unused portion remaining in the vial because the product does not contain preservatives1.  
Fully diluted tocilizumab solutions are compatible with polypropylene, polyethylene, and polyvinyl chloride infusion bags, or with polypropylene, polyethylene, and glass infusion bottles1.
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10.14.3 administration

Allow tocilizumab infusion to reach room temperature prior to infusion. Administer over 60 minutes using an infusion set. Do not administer as an IV push or bolus1. Tocilizumab should not be infused with other drugs in the same IV line due to a lack of physical or biocompatibility studies1.  
10.14.4 Dosage 4-12 mg/kg, Single dose should not exceed 800 mg. 10.14.5 Toxicities The major toxicity associated with Tocilizumab is immunosuppression, the risk of which is further increased when the agent is given with other immunosuppressants including corticosteroids and cytotoxic chemotherapy. The risks and benefits of treatment with tocilizumab should be carefully considered prior to initiating therapy in patients with chronic or recurrent infection. Patients should be closely monitored for the development of signs and symptoms of infection during and after treatment with tocilizumab, including the possible development of tuberculosis in patients who tested negative for latent tuberculosis infection prior to initiating therapy3.
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10.15 filgrastim (neupogen) 10.15.1 description

Filgrastim is a human granulocyte colony-stimulating factor (G-CSF), produced by recombinant DNA technology. Neupogen is a sterile, clear, colorless, preservative-free liquid. See package insert for complete details. 10.15.2 Storage Filgrastim should be stored at 2 C to 8 C (36 F to 46 F) and should not be frozen. 10.15.3 Administration Filgrastim is administered intravenously or subcutaneously (under the skin) for 6 to 14 days. Filgrastim vials should not be shaken since the drug may be damaged, and bubbles may form that can prevent some of the drug from being drawn up into the syringe at the time of injection. Toxicities The most common side effects are nausea, vomiting, bone pain, fever, fatigue, hair loss, and diarrhea. Headache, weight loss, shortness of breath, mouth sores, and rash also occur. Uric acid, lactate dehydrogenase, and alkaline phosphatase levels may rise and spontaneously return to normal levels
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11 appendices 11.1 a ppendix

| PERFORMANCE STATUS CRITERIA Karnofsky and Lansky performance scores are intended to be multiples of 10.   |                                                 |                                    |                                   |                                       |                                      |
|-----------------------------------------------------------------------------------------------------------|-------------------------------------------------|------------------------------------|-----------------------------------|---------------------------------------|--------------------------------------|
| ECOG (Zubrod)                                                                                             | Karnofsky                                       | Lansky                             |                                   |                                       |                                      |
| Score Description                                                                                         | Score                                           | Description                        | Score                             | Description                           |                                      |
| o                                                                                                         | Fully active, able to carry on all pre-disease  | 100%                               | Normal, no complaints, no         | 100%                                  | Fully active, normal,                |
| evidence of disease.                                                                                      |                                                 |                                    |                                   |                                       |                                      |
| performance without restriction.                                                                          | 90%                                             | Able to carry on normal activity,  | 90%                               | Minor restrictions in physically      |                                      |
| minor sighs of symptoms of                                                                                | strenuous activity.                             |                                    |                                   |                                       |                                      |
| disease.                                                                                                  |                                                 |                                    |                                   |                                       |                                      |
| 1                                                                                                         | Restricted in physically strenuous activity but | 80%                                | Able to carry on normal activity  | 80%                                   | Active, but tires more quickly.      |
| ambulatory, able to carry out light or                                                                    | with effort; some signs or                      |                                    |                                   |                                       |                                      |
| symptoms of disease                                                                                       |                                                 |                                    |                                   |                                       |                                      |
| sedentary work, e.g., light housework, office                                                             |                                                 |                                    |                                   |                                       |                                      |
| work.                                                                                                     | 70%                                             | Cares for self, unable to carry on | 70%                               | Both greater restriction of, and less |                                      |
| normal activity or do active                                                                              | time spent in, play activities.                 |                                    |                                   |                                       |                                      |
| work.                                                                                                     |                                                 |                                    |                                   |                                       |                                      |
| 2                                                                                                         | Ambulatory and capable of all self-care but     | 60%                                | Requires occasional assistance    | 60%                                   | Up and around, but minimal active    |
| unable to carry out any work activities. Up and                                                           | but is able to care for most of                 | play; keeps busy with quieter      |                                   |                                       |                                      |
| about more than 50% of waking hours.                                                                      | own needs.                                      | activities.                        |                                   |                                       |                                      |
| 50%                                                                                                       | Gets dressed, but lies around much              |                                    |                                   |                                       |                                      |
| Requires considerable assistance                                                                          | 50%                                             |                                    |                                   |                                       |                                      |
| and frequent medical care.                                                                                | of the day; no active play; able to             |                                    |                                   |                                       |                                      |
| participate in quiet play and                                                                             |                                                 |                                    |                                   |                                       |                                      |
| activities.                                                                                               |                                                 |                                    |                                   |                                       |                                      |
| 3                                                                                                         | Capable of only limited self-care, confined to  | 40%                                | Disabled; requires special care   | 40%                                   | Mostly in bed; participates in quiet |
| bed or chair more than 50% of waking hours                                                                | and assistance.                                 | activities.                        |                                   |                                       |                                      |
| 30%                                                                                                       | Severely disabled;                              | 30%                                | In bed; needs assistance even for |                                       |                                      |
| hospitalization indicated,                                                                                | quiet play.                                     |                                    |                                   |                                       |                                      |
| although death not imminent.                                                                              |                                                 |                                    |                                   |                                       |                                      |
| Completely disabled.  Cannot carry on any                                                                 | 20%                                             | Very ill; hospitalization          | 20%                               | Often sleeping; play entirely limited |                                      |
| 4                                                                                                         | self-care. Totally confined to a bed or chair   | necessary, active supportive       | to very passive activities.       |                                       |                                      |
| treatment required.                                                                                       |                                                 |                                    |                                   |                                       |                                      |
| 10%                                                                                                       | Monbund, fatal process                          | 10%                                | No play; does not get out of bed  |                                       |                                      |
| progressing rapidly                                                                                       |                                                 |                                    |                                   |                                       |                                      |
| Dead                                                                                                      | lo                                              | 8%                                 | Unresponsive; Dead                |                                       |                                      |
| Patient expired                                                                                           |                                                 |                                    |                                   |                                       |                                      |  
| treatment                                                                                                                                                       |                                 |                 |      |                |       |    |    |    |    |    |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------|-----------------|------|----------------|-------|----|----|----|----|----|
| Off                                                                                                                                                             |                                 |                 |      |                |       |    |    |    |    |    |
| 28(±4) days after cell  infusion, then 3, 6, 12  mos, then Q 6-12 mos)                                                                                          | WT only                         |                 |      |                |       |    |    |    |    |    |
| Xi XL                                                                                                                                                           | X                               | X X             |      |                |       |    |    |    |    |    |
| On Treatment                                                                                                                                                    | WT only                         |                 |      |                |       |    |    |    |    |    |
| X                                                                                                                                                               | X X X XX X X X Xn               | X               | X    | Xe Xo          | Xk    |    |    |    |    |    |
| Every  2-4 days  Until  D/C Day  4-7 Day  3 Day  2 Day  1                                                                                                       | X X X XX X X X Xg X XX X X      | Xm              | X    | X              | X     |    |    |    |    |    |
| During Hospitalization                                                                                                                                          | X                               | X               |      |                |       |    |    |    |    |    |
| X X                                                                                                                                                             | X                               | X X             |      |                |       |    |    |    |    |    |
| Day 0  (Day of  cell  infusion)                                                                                                                                 |                                 |                 |      |                |       |    |    |    |    |    |
| Prior to  Cell  infusion  (within 24  hrs)                                                                                                                      | WT only                         | X               |      |                |       |    |    |    |    |    |
| Chemothera py (see B1,  B2 and B3) Baseline  (within 24  hours of  starting  chemo  unless  specified) Day - 11 Screening  (within 14  days, unless  specified) | WT only                         |                 |      |                |       |    |    |    |    |    |
| X X                                                                                                                                                             | X X                             | X X             | X Xe | x Chem 20b X X | Xc Xf |    |    |    |    |    |
| Abbreviated Title: Phase I Anti-CD 19 CAR Version Date: 01/12/2018                                                                                              | 11.2 APPENDIX B: STUDY CALENDAR | Procedure       | X X  | X              | X     | X  | X  | Xa | X  | X  |
| x Urine analysis, culture if  indicated                                                                                                                         |                                 |                 |      |                |       |    |    |    |    |    |
| x CD19 staining of  malignant cells by  immunohistochemistry  or flow cytometry  (anytime)                                                                      |                                 |                 |      |                |       |    |    |    |    |    |
| Neuro symptom checklist                                                                                                                                         | x Peripheral blood CD3  count   | x ȕ-HCG pregnancy test  on all women of childbearing potential                 |      |                |       |    |    |    |    |    |
| Labs                                                                                                                                                            | x CBC with diff and  platelets  |                 |      |                |       |    |    |    |    |    |
| Cognitive Evaluation                                                                                                                                            | x HIV, HbsAG, antiHCV, EBV                                 |                 |      |                |       |    |    |    |    |    |
| Performance Score                                                                                                                                               | Height and weight               | x Thyroid Panel |      |                |       |    |    |    |    |    |
| History and PE Vital signs                                                                                                                                      | x PT/aPTT                       | x IgG level     | ECG  |                |       |    |    |    |    |    |  
| treatment                                                                                                                                                       |                                                             |                                                                                        |                                             |                                       |     |    |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------|----------------------------------------------------------------------------------------|---------------------------------------------|---------------------------------------|-----|----|
| Off                                                                                                                                                             |                                                             |                                                                                        |                                             |                                       |     |    |
| 28(±4) days after cell  infusion, then 3, 6, 12  mos, then Q 6-12 mos)  X                                                                                       | X (DAY 28 only) X                                           | X                                                                                      |                                             |                                       |     |    |
| On Treatment                                                                                                                                                    | X                                                           | Xj Xj                                                                                  | x Lumbar punctured X Xe X                   | x Bone marrow  aspirate/biopsy X Xe X | X X | X  |
| Every  2-4 days  Until  D/C Day  4-7 Day  3 Day  2 Day  1                                                                                                       | X X                                                         |                                                                                        |                                             |                                       |     |    |
| During Hospitalization                                                                                                                                          | X X X                                                       |                                                                                        |                                             |                                       |     |    |
| Day 0  (Day of  cell  infusion)                                                                                                                                 | Xl                                                          | X                                                                                      |                                             |                                       |     |    |
| Prior to  Cell  infusion  (within 24  hrs)                                                                                                                      |                                                             |                                                                                        |                                             |                                       |     |    |
| Chemothera py (see B1,  B2 and B3) Baseline  (within 24  hours of  starting  chemo  unless  specified) Day - 11 Screening  (within 14  days, unless  specified) | X X X                                                       | X                                                                                      |                                             |                                       |     |    |
| Abbreviated Title: Phase I Anti-CD 19 CAR Version Date: 01/12/2018                                                                                              | Procedure                                                   | X                                                                                      | X Concomitant Medications X X Research labs |                                       |     |    |
| X                                                                                                                                                               | X                                                           | X                                                                                      |                                             |                                       |     |    |
| x Research Sampling Disease Evaluation                                                                                                                          | x CT  chest/abdomen/pelvis  (or other appropriate  imaging) |                                                                                        |                                             |                                       |     |    |
| ECHO, cardiac MRI or  MUGA  Ophthalmologic Exam Correlative Research  Studies                                                                                   | x Apheresis                                                 | Treatment Regimen x Anti-CD19-CAR  transduced cells Response Evaluation Adverse Events |                                             |                                       |     |    |  
aWithin 4 weeks prior to enrollmentbLaboratory evaluation to include; 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); creatinine clearance may be performed if the serum creatinine is elevated.c within 1 week prior to enrollmentd for patients with aggressive NHL, ALL, history of leptomeningeal disease, or signs/symptoms of leptomeningeal involvementeWithin 14 days of starting chemo preparative regimenf Within 72 hours of starting chemo preparative regimeng Monitor every q15 min X 1 hr, q 30 min for 2nd hour, then q 1 hr for 2 more hrs or until stable, then routinely.  
Abbreviated Title: Phase I Anti-CD 19 CARVersion Date: *01/12/2018*h For cell acquisition for product developmenti Physical examinations annually for 5 years. 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. Persistence of CAR gene transduced cells: prior to cells, 1 week, 4-6 weeks, 3 and 6 months post cell infusion; RCR PCR prior to cell infusion; and at 3, 6, and 12 mos post cell infusionj within 14 days of preparative regimenk every 3-6 weeks post infusion.l cells may be infused up to: Arm 1 = 72 hours following the time of the planned infusion. Otherwise, cells may be frozen and infused up to 7 days following the time of the planned infusion, or attempts to infuse at a later time may be made per Section 3.5. Arm 2 = 21 days (cryopreserved) following the time of the planned infusion, or attempts to infuse at a later time may be made per Section 3.5m on or about Day 14 ± 1 dayn at 3 month visit only (± 4 weeks)o Thyroid panel only before day 28LOff treatment after day 28. x Off treatment all studies will be done as per day 28 (+/-4).x If no response (progressive disease) then no further clinical follow-up required expect for Section **3.12.5**, which will be followed for 15 years.x If response, results and documentation for physical examinations, vital signs, CBC with diff, Chem 20, and IGG levels, will be collected. Bone marrows/lumbar punctures will be done at the primary oncologist discretion and documentation collected. All will be collected until relapse or bone marrow transplantation. Section **3.12.5**, which will be followed for 15 years.x If response, results and documentation for physical examinations, vital signs, CBC with diff, Chem 20, and IGG levels, will be collected.
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11.2.1 appendix b 1 arm

| Procedure                                            | Day prior to Cells Infusion                              |                  |             |
|------------------------------------------------------|----------------------------------------------------------|------------------|-------------|
| -4, -3                                               | -2                                                       | -1               |             |
| Fludarabine: 25                                      | X                                                        | X                | REST        |
| mg/m2 /day IV Cyclophosphamide:                      | X                                                        | REST             |             |
| 900 mg/m2 /day IV Mesna 540                          | X                                                        | REST             |             |
| mg/m2 /day IV Procedure                              | Day prior to Cells Infusion Day prior to  -12, -11, -10, | From last day of |             |
| chemotherapy                                         | -9, -8,                                                  | chemo to Cell    |             |
| Infusion (DAY 0) [at  least 2 days]                  |                                                          |                  |             |
| Fludarabine: 25                                      | X                                                        | REST             |             |
| mg/m2 /day IV Cytarabine 2000                        | X                                                        | REST             |             |
| mg/m2 /day IV Filgrastim  μg/kg/dose  subcutaneously | X                                                        | X                | Daily until |
| ANC>1000 on 2  consecutive days                      |                                                          |                  |             |  
11.2.3 Appendix B 3: Arm 2: Etoposide/ifosfamide  
| Procedure                           | Day prior to Cells Infusion   |                  |
|-------------------------------------|-------------------------------|------------------|
| Day prior to                        | -12, -11, -10, -9,            | From last day of |
| chemotherapy                        | -8,                           | chemo to Cell    |
| Infusion (DAY 0) [at  least 2 days] |                               |                  |
| Etoposide 100                       | X                             | REST             |
| mg/m2 /day IV                       |                               |                  |  
$1\;2\;2$.
11.2.2 Appendix B 2: Arm 2: FLAG  
| Ifosfamide 1,800  mg/m2 /day and  Mesna 360  mg/m2 /dose IV   | X        | REST         |              |
|---------------------------------------------------------------|----------|--------------|--------------|
| Mesna 360  mg/m2 /dose IV  (then PO or IV)                    | X (after |              |              |
| ifosfamide, then  every 3 hours X  6 doses)                   | REST     |              |              |
| Physical Exam                                                 | X        | Twice weekly | Twice weekly |
| Chem 20:                                                      | X        | Twice weekly | Twice weekly |
| CBC with                                                      | X        | Twice weekly | Twice weekly |
| differential                                                  |          |              |              |
untitled h1
11.3 appendix c grading and

| Skin                     | Liver         | GI Tract               | Upper GI             |        |
|--------------------------|---------------|------------------------|----------------------|--------|
| Stage                    | Rash          | Bilirubin              | Diarrhea (ml/day)    |        |
| 0                        | No rash       | < 2 mg/dL              | < 500 (<10/kg)       |        |
| 1                        | <25%          | 2.1-3.0 mg/dl          | 501-1,000 (10-15/kg) | severe |
| nausea/vomiting 2 25-50% | 3.1-6.0 mg/dl | 1,001-1,500 (15-20/kg) |                      |        |
| 3                        | >50%          | 6.1-15 mg/dl           | >1,501 (>20/kg)      |        |
| 4                        | desquamation  | >15 mg/dl              | severe pain, ileus   |        |  
| 1   | 1-2   | 0   | 0   |
|-----|-------|-----|-----|
| 2   | 1-3   | 1   | 1   |
| 2o  | 0     | 1   | 1   |
| 2s  | 4     | 0   | 0   |  
3 2-4 2-4 *&/or* 2-4 (1 only >2) 4 3-4 2-4 2-4  
Adapted from Rowlings PA et al: IBMTR Severity Index for grading acute graft-versus-host disease: retrospective comparison with Glucksberg grade. Br J Haematol 97:855,1997; Weisdorf DJ et al: Acute upper gastrointestinal graft-versus-host disease: clinical significance and response to immunosuppressive therapy. Blood 76:624, 1990. Glucksberg Grade*  
| A   | 1   | 0   | 0   | 0   |     |    |    |
|-----|-----|-----|-----|-----|-----|----|----|
| B   | 2   | or  | 1-2 | or  | 1-2 | or | 1  |
| C   | 3   | or  | 3   | or  | 3   |    |    |
| D   | 4   | or  | 4   | or  | 4   |    |    |
untitled h1
11.4 appendix d calculation of

Formulation for deriving the weight to be used in targeting cell doses in morbidly obese cell candidates. 1. **Definition**
Obesity is defined as a BMI > 30. BMI = wgt (kg) / [hgt (M)]2 2. **Calculation of ideal body weight** is performed using the standard, published formula:
Male: 50 + 2.3(Hgt - 60) where Hgt is in inches, and the result is expressed in kg.  
ex. The ideal weight of a 5'10" male = 50 + 2.3(10) = 73 kg.  
Female: 45.5 + 2.3(Hgt - 60), where height is in inches, and the result is in kg.  
3. **Calculation of the "practical weight."**
Calculate the midway point, halfway between the actual and ideal body weights (ie the average of the two numbers). This is the "practical weight" to be used in calculating the targeted cell dose.  
4. **Example**:
Patient's actual weight = 143 kg. Patient' s actual height 173 cm = 69 in BMI = 48 IBW formula = 50 + 2.3(9) = 70.7 kg Midway point between 70.0 and 143 = 107 kg.  
The weight we would use in targeting cell dose is 107 kg.  
1 dose by weight with adjustment:
x IBW + 50%(Weight-IBW)
x Practical body weight = (IDW + actual BW)/2 2 Formula IBW (men)
x 52 kg + 1.9 kg/inch above 5 feet x 50 kg + 2.39 (height in inches - 60)
IBW (women)
x 49 kg + 1.7 kg/inch above 5 feet x 45.5 kg + 2.39 (height in inches - 60)  
| If all post-therapy RCR-PCR  tests are negative in the first  year, future samples will be  cryopreserved and banked.in  Frederick                                                                                                                                                            | Shipped on ice pack priority  overnight to: Lisa Duffy Indiana University Vector  Production Facility 980 W. Walnut St., R3-C668 Indianapolis, IN 46202 e-mail: ljwoods@iupui.edu phone: 317-274-0323   | Archival samples: Courier to  NCI-Frederick repository 301-                                                                                                                                                                                                                                                                                                                                 |                                                               |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------|
| Purple top (EDTA) tube Refrigerated at 4 C                                                                                                                                                                                                                                                    | PAX DNA tube for archival samples                                                                                                                                                                       |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| Received from CPS  Shipped on dry ice priority  overnight to: Lisa Duffy Indiana University Vector  Production Facility 980 W. Walnut St., R3-C668 Indianapolis, IN 46202 e-mail: ljwoods@iupui.edu phone: 317-274-0323 No Sat  or Sun Deliveries Performed in CPS  Results must be available | prior to cell infusion                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| Notes                                                                                                                                                                                                                                                                                         |                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| Abbreviated Title: Phase I Anti-CD 19 CAR Version Date: 01/12/2018                                                                                                                                                                                                                            | 11.5 APPENDIX E: RESEARCH SAMPLE REQUIREMENTS*                                                                                                                                                          | (the order of the research studies listed below reflect the priority should blood volume for research purposes become limited) Day 0 is the day of  cell infusion Study Test/Lab Location Sample Time Points Volume/type In cryovial with 1mL freezing media  (90% AB serum, 10% DMSO) Frozen at -80 C 5 x 10^5 cells Cellular product Prior to cell infusion or  cryopreservation of cells | Fresh in culture media in sterile tube To be performed in DTM |
| Tube                                                                                                                                                                                                                                                                                          | 6 x 10^6 cells  from both CAR  transduced cells  AND untransduced                                                                                                                                       | control cells 3 mL/                                                                                                                                                                                                                                                                                                                                                                         | peripheral  blood                                             |
| 1. Prior to cell infusion 2. 3 months(± 1 month) 3. 6 months (± 1 month) 4. 1 year (± 2 month) 5. Archive samples  annually thereafter for 5  years (+/- 3 months).  All Samples are scheduled  from first cell infusion.                                                                     |                                                                                                                                                                                                         |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| At least 2-4 days prior to  cell infusion                                                                                                                                                                                                                                                     | High-sensitivity PCR  analysis (patient samples)/ Indiana University                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| S+L- (product only)/ Indiana University                                                                                                                                                                                                                                                       | Rapid PCR analysis  (product only) Location: DTM                                                                                                                                                        |                                                                                                                                                                                                                                                                                                                                                                                             |                                                               |
| RCR (replication  competent  retrovirus)                                                                                                                                                                                                                                                      | Cell product                                                                                                                                                                                            | Patient Testing RCR (replication  competent  retrovirus)                                                                                                                                                                                                                                                                                                                                    |                                                               |  
88  
| This test will only be done  when a marrow aspirate is  clinically indicated or required  to monitor disease status Schedule with lab in advance                                                                                                                                                                                                                                                                                   | using Microsoft Outlook  Calendar and order test in  CRIS Schedule with clinical lab 301- 496-4879                                                              | At any time for patients  suspected of developing  cytokine storm, additional  samples will be collected,  stored in the refrigerator sent  ASAP for analysis and  weekend samples will be spun   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|-------------------------------------------------|----------------------------------------------|---------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 846-5893 to schedule pick-up                                                                                                                                                                                                                                                                                                                                                                                                       | Schedule with StetlerStevenson Lab 301-402-1716                                                                                                                                                                 |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| Received from CPS                                                                                                                                                                                                                                                                                                                                                                                                                  | Courier to NCI-Frederick                                                                                                                                        | repository 301-846-5893 to  schedule pick-up                                                                                                                                                      | Samples will be stored and  batched                          | Courier to NCI-Frederick                        | repository 301-846-5893 to  schedule pick-up |         |                                                                                                                                                                                                 |
| In cryovials with 10-50 x10^6 cells in  1mL freezing media each (90% AB  serum, 10% DMSO) Frozen at -80 C                                                                                                                                                                                                                                                                                                                          | One 6ml and one 3 ml Purple top tube  (PTT) at room temperature (1 for  flow/1 for CBC)                                                                         | For scheduled samples 4 ml Green  Sodium heparin tube. Keep  refrigerated on patient care unit..                                                                                                  | Cytokine storm samples will be  refrigerated on patient unit |                                                 |                                              |         |                                                                                                                                                                                                 |
| Two 10 ml Green Sodium Heparin  Tubes at room temperature                                                                                                                                                                                                                                                                                                                                                                          | PAX DNA tube or a EDTA tube                                                                                                                                     | sample at room temperature                                                                                                                                                                        |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| 10 ml in a heparinized syringe                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                 |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| 10% of cellular                                                                                                                                                                                                                                                                                                                                                                                                                    | product  remaining after  infusion                                                                                                                              |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| Prior to cell infusion or                                                                                                                                                                                                                                                                                                                                                                                                          | cryopreservation of cells                                                                                                                                       | 3 mL peripheral  blood or bone                                                                                                                                                                    | marrow                                                       | 3 mL peripheral  blood. Day 28 (+/-4)  one 3 ml | peripheral  blood and one 3                  | ml bone | marrow 4 mL peripheral  blood  1. Prior to cell infusion  (within 24 hours) 2. Day 0 (1 and 12 hours  after cells), 1 (24 hrs), 2  (48 hrs), 3 (72 hrs) +/- 4 hours 3. Days 4-14, and 28 (+/- 4 |
| 6 mL and 3ml                                                                                                                                                                                                                                                                                                                                                                                                                       | peripheral  blood                                                                                                                                               |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| 5 mL marrow                                                                                                                                                                                                                                                                                                                                                                                                                        | aspirate                                                                                                                                                        |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| At time of enrollment and At first disease restaging  after each cycle and then at  the at PI oncologist  discretion in responding  patients when available.                                                                                                                                                                                                                                                                       | 1. Prior to cell infusion  2. Day 1, 7, 14, (+/- 2 days)  and 28 (+/- 4 days). If  response, repeat at least 3  and 6 months, then every  6-12 months until CAR | negative.                                                                                                                                                                                         |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| 1. Prior to cell infusion  2. Day 1, 7, 14,(+/- 2 days) and 28 (+/- 4 days) 3. If response, repeat at  least 3 and 6 months,  then every 6-12 months  until CAR negative. Flow Cytometry for CAR T  cells and subsets:  Stetler-Stevenson Lab 10/6N109 301-402-1716 POB Panel -T-regs/ TBNK NIH Clinical Pathology  Flow Cytometry Lab. DNA for CAR PCR for CAR promoter  from T cell genomic DNA/ Dr. William Kopp SAIC/Frederick | Multiplex cytokine panel Dr. William Kopp SAIC/Frederick                                                                                                        |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| ALL panel including  hematagones/ Stetler-Stevenson Lab 10/6N109 301-402-1716                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                 |                                                                                                                                                                                                   |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| Dr. William Kopp SAIC/Frederick Cell product Storage for future  research and                                                                                                                                                                                                                                                                                                                                                      | regulatory studies                                                                                                                                              | Serum Cytokine  Levels (including  by not limited to  IFN-Ȗ, IL-2, IL-6,  and TNFĮ)                                                                                                               |                                                              |                                                 |                                              |         |                                                                                                                                                                                                 |
| Patient Testing                                                                                                                                                                                                                                                                                                                                                                                                                    | Flow Cytometry:                                                                                                                                                 | Bone marrow                                                                                                                                                                                       | CAR T Cell  Persistence                                      |                                                 |                                              |         |                                                                                                                                                                                                 |  
Abbreviated Title: Phase I Anti-CD 19 CARVersion Date: *01/12/2018*  
| Schedule with lab in advance and                                                                                                                                                                                                                     | Send DNA to: Adaptive Biotechnologies Corp. 1551 Eastlake Ave E, Suite 200,  Seattle WA 98102                                                                                                                                                                                                                                                                                                                                                     | ph:206-687-7708 email: hrobins@fhcrc.org ATTN: clonoSEQ                                                                                                        |                          |                                                                       |                                              |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------|-----------------------------------------------------------------------|----------------------------------------------|
| Schedule with StetlerStevenson Lab 301-402-1716                                                                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                                                                                                                                                |                          |                                                                       |                                              |
| and frozen by fellow.                                                                                                                                                                                                                                | Courier to NCI-Frederick                                                                                                                                                                                                                                                                                                                                                                                                                          | repository 301-846-5893 to  schedule pick-up                                                                                                                   | Courier to NCI-Frederick | repository 301-846-5893 to  schedule pick-up Courier to NCI-Frederick | repository 301-846-5893 to  schedule pick-up |
| Delivered immediately to  Stetler-Stevenson Lab                                                                                                                                                                                                      | x Sample volume for protocol studies will be restricted. The amount of blood drawn from adult (those 18 years of age or older) for research purposes shall not exceed 10.5 mL/kg or 550  mL, whichever is smaller, in an 8 week period. The amount of blood drawn for research purposes from pediatric patient subjects (those under 18 years of age) will not exceed 5 mL/kg  in a single day, and no more than 9.5 mL/kg over an 8 week period. | x **if no apheresis line one time blood draw will be done. 3cc/Kg not to exceed 50 mls. (half in sodium heparin tubes and half in red top tubes. Send to SAIC. |                          |                                                                       |                                              |
| Mix blood well by inverting several  times. Extract 0.5 ml from cytokine  sample and place in cyro vial. Place  in refrigerator. Sample is viable for 4  hours at room temperature or 48 hours  if refrigerated. Send to Flow  Cytometry lab (B1B58) | 3-8 mL CSF Spinal fluid placed immediately in  flow media available on 3 NE North  Procedure Area. At time of enrollment and  at each diagnostic  (clinically indicated) LP if performed at NIH CC                                                                                                                                                                                                                                                | EDTA tube; send to POB laboratory  for processing                                                                                                              |                          |                                                                       |                                              |
| Marrow: 0.5 ml preservative-free  sodium heparin in capped syringe                                                                                                                                                                                   | Store in refrigerator                                                                                                                                                                                                                                                                                                                                                                                                                             | Single pass Room temperature                                                                                                                                   |                          |                                                                       |                                              |
| 0.5 mL from the  Cytokine  sample listed  above into                                                                                                                                                                                                 | cryovial.                                                                                                                                                                                                                                                                                                                                                                                                                                         | At PI's discretion. 3-5 ml of bone                                                                                                                             | marrow                   | 10 ml red top  tube peripheral  blood                                 |                                              |
| 5 mL blood or 2 mL bone                                                                                                                                                                                                                              | marrow                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                |                          |                                                                       |                                              |
| 1. Prior to cell infusion  (Day -2, -1 OR Day 0) 2. Post cell infusion: up  to daily for Days 1-14 3. Additional samples  may be sent if the  patient is febrile                                                                                     | At time of response  evaluation when indicated  by PI                                                                                                                                                                                                                                                                                                                                                                                             | Prior to chemo, Day -1, 7,  28 (+/-4 days)                                                                                                                     |                          |                                                                       |                                              |
| days)  4. If response, repeat at  least 3 and 6 months, then  every 6-12 months until  CAR negative.                                                                                                                                                 | Day 28 (+/-4)                                                                                                                                                                                                                                                                                                                                                                                                                                     |                                                                                                                                                                |                          |                                                                       |                                              |
| Flow Cytometry for CD64:  Stetler-Stevenson Lab 10/6N109 301-402-1716                                                                                                                                                                                | Flow Cytometry for CAR T  cells/  Stetler-Stevenson Lab 10/6N109 301-402-1716 Evaluation of DNA for  MRD of leukemia cells  Minimal Residual  Disease (MRD)  for leukemia cells  (Real Time PCR)                                                                                                                                                                                                                                                  |                                                                                                                                                                |                          |                                                                       |                                              |
| Dr. Diane Arthur 37/2016 301-435-3711                                                                                                                                                                                                                | Serum Storage SAIC/Frederick                                                                                                                                                                                                                                                                                                                                                                                                                      | SAIC/Frederick Apheresis (single  pass) (Only if the  subject has  apheresis line.**                                                                           |                          |                                                                       |                                              |
| Flow Cytometry:                                                                                                                                                                                                                                      | CSF                                                                                                                                                                                                                                                                                                                                                                                                                                               |                                                                                                                                                                |                          |                                                                       |                                              |
| Cytogenetics  (Cyto)                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                                                                                                                                                |                          |                                                                       |                                              |
| CD64                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                                                                                                                                                |                          |                                                                       |                                              |  
Abbreviated Title: Phase I Anti-CD 19 CARVersion Date: *01/12/2018* 11.6 APPENDIX F: GUIDELINES FOR GRADING AND MANAGEMENT OF SUSPECTED CYTOKINE
untitled h1
release syndrome

| Table 1. Cytokine Release Syndrome Revised Grading System   |                                                                                                                                                                                 |
|-------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 1                                                     | Symptoms are not life threatening and require symptomatic treatment only  e.g. fever, nausea, fatigue, headache, myalgias, malaise                                              |
| Grade 2                                                     | Symptoms require and respond to moderate intervention  -oxygen requirement <40% or -hypotension responsive to fluids or low dose1 of one vasopressor or -grade 2 organ toxicity |
| Grade 3                                                     | Symptoms require and respond to aggressive intervention  -R[\JHQUHTXLUHPHQW•RU -hypotension requiring high dose1 or multiple vasopressors or -grade 3 organ toxicity or grade 4 transaminitis                                                                                                                                                                                 |
| Grade 4                                                     | Life-threatening symptoms -requirement for ventilator support or -grade 4 organ toxicity (excluding transaminitis)                                                              |
| 1 high dose vasopressor doses shown in Table 2.             |                                                                                                                                                                                 |  
| Table 2. High-'RVH9DVRSUHVVRUVDOOGRVHVDUHUHTXLUHGIRU•KRXUV                                                               |    |
|---------------------------------------------------------------|----|
| Norepinephrine monotherapy                                    | •PFJNJPLQ    |
| Dopamine monotherapy                                          | •PFJNJPLQ    |
| Phenylephrine monotherapy                                     | •PFJNJPLQ    |
| Epinephrine monotherapy                                       | •PFJNJPLQ    |
| If on vasopressin                                             | 1 9DVRSUHVVLQ1(HTXLYDOHQWRI•PFJNJPLQ    |
| If on combination vasopressors (not                           | 1 1RUHSLQHSKULQHHTXLYDOHQWRI•Pcg/kg/min    |
| vasopressin) x 1 VASST Trial Vasopressor Equivalent Equation: |    |  
Norepinephrine equivalent dose = [norepinephrine (mcg/min)] + [dopamine (mcg/kg/min) ÷ 2] +
[epinephrine (mcg/min)] + [phenylephrine (mcg/min) ÷10]
untitled h1
11.7 appendix g neuropsychological test

| Domains                                                          | Measure*                                                                                                  | Age range (yrs)   | Time (min)   |    |
|------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------|-------------------|--------------|----|
| Working Memory                                                   | NIH Toolbox List Sorting Test                                                                             | 3.0 - adult       | 7            |    |
| Attention                                                        | NIH Toolbox Flanker Test                                                                                  | 3.0 - adult       |              | 4  |
| Wechsler Cancellation subtest                                    | 4 - adult                                                                                                 |                   | 3            |    |
| WRAML Letter Number                                              | 5.0 - adult                                                                                               |                   | 6            |    |
| Processing Speed                                                 | Wechsler Symbol Search                                                                                    | 4 - adult         |              | 3  |
| Executive Function NIH Toolbox Dimensional Change Card Sort Test | 3.0 - adult                                                                                               |                   | 7            |    |
| DKEFS Trailmaking                                                | 8 - adult                                                                                                 |                   | 5            |    |
| DKEFS Verbal Fluency (8+ yrs)                                    | 2.5 - adult                                                                                               |                   | 6            |    |
| or McCarthy Verbal Fluency (2.5-7 yrs)                           |                                                                                                           |                   |              |    |
| Background                                                       | Background Information Form                                                                               | all               | (5)          |    |
| Information                                                      | (parent/observer report or adult self-report)                                                             |                   |              |    |
| Neurologic                                                       | Neuro-Symptom Checklist                                                                                   | all               | (2)          |    |
| Symptoms                                                         | (parent/observer report)                                                                                  |                   |              |    |
| x                                                                | This full test battery will be administered at baseline and 21-28 days post-infusion for participants 2.5 |                   |              |    |  
x This full test battery will be administered at baseline and 21-28 days post-infusion for participants 2.5 years and older. The battery also will be administered at 3 months post-infusion if the patient returns to the NIH for a follow-up evaluation. In addition, at Day 14 (+/- 1 day) post-infusion, the NeuroSymptom Checklist will be administered to a parent/adult observer.  
x Other measures may be given in order to test a particular domain more thoroughly if clinically indicated. Also, some measures may not be administered if the participant does not appear to understand the task or becomes frustrated.  
x We estimate that this test battery will take less than 1 hour for all participants and less than 45 minutes for children under 6 years of age to complete.
untitled h1
11.8 a ppendix h n

| Domains                                                          | Measure*                                      | Age range (yrs) Time (min)   |     |
|------------------------------------------------------------------|-----------------------------------------------|------------------------------|-----|
| Working Memory                                                   | NIH Toolbox List Sorting Test                 | 3.0 - adult                  | 7   |
| Attention                                                        | NIH Toolbox Flanker Test                      | 3.0 - adult                  | 4   |
| Wechsler Cancellation subtest                                    | 4 - adult                                     | 3                            |     |
| WRAML Letter Number                                              | 5.0 - adult                                   | 6                            |     |
| Processing Speed                                                 | Wechsler Symbol Search                        | 3                            |     |
| 4 - adult                                                        |                                               |                              |     |
| Executive Function NIH Toolbox Dimensional Change Card Sort Test | 3.0 - adult                                   | 7                            |     |
| DKEFS Trailmaking                                                | 8 - adult                                     | S                            |     |
| DKEFS Verbal Fluency (8+ yrs)                                    | 2.5 - adult                                   | 6                            |     |
| or McCarthy Verbal Fluency (2.5-7 yrs)                           |                                               |                              |     |
| Background                                                       | Background Information Form                   | all                          | (5) |
| Information                                                      | (parent/observer report or adult self-report) | all                          |     |
| Neurologic                                                       | Neuro-Symptom Checklist                       | (2)                          |     |
| Symptoms                                                         | (parent/observer report)                      |                              |     |  
- This full test battery will be administered at baseline and 21-28 days post-infusion for participants 2.5 years and older.  The battery also will be administered at 3 months post-infusion if the patient returns to the NIH for a follow-up evaluation.  In addition, at Day 14 (+/- 1 day) post-infusion, the Neuro-Symptom Checklist will be administered to a parent/adult observer.  
- Other measures may be given in order to test a particular domain more thoroughly if clinically indicated. Also, some measures may not be administered if the participant does not appear to understand the task or becomes frustrated.  
- We estimate that this test battery will take less than 1 hour for all participants and less than 45 minutes for children under 6 years of age to complete.
untitled h1
12 references

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