clinical study protocol
untitled h2

PROTECT: A Phase 1, Non-Randomized, Open-Label/Phase 2, Randomized, Blinded Study of ProTmune™ (*ex vivo* Programmed Mobilized Peripheral Blood Cells) Versus Non-Programmed Mobilized Peripheral Blood Cells for Allogeneic Hematopoietic Cell Transplantation in Adult Subjects with Hematologic Malignancies Investigational Product: ProTmune Protocol Number: PT-001 Sponsor:
Fate Therapeutics, Inc.  
3535 General Atomics Court, Suite 200 San Diego, CA 92121 Telephone: 858-875-1800 Facsimile: 858-875-1843 Version Number: 6.0 Date: 29 March 2019
clinical study protocol
confidentiality statement

The information in this document is confidential and is not to be disclosed without the written consent of Fate Therapeutics, Inc. except to the extent that disclosure would be required by law and for the purpose of evaluating and/or conducting a clinical study for Fate Therapeutics, Inc.  
You are allowed to disclose the contents of this document only to your Institutional Review Board (IRB) or Independent Ethics Committee (IEC) and study personnel directly involved with conducting this protocol. Persons to whom the information is disclosed must be informed that the information is confidential and proprietary to Fate Therapeutics, Inc. and that it may not be further disclosed to third parties.
clinical protocol approval form
study title

A Phase 1, Non-Randomized, Open-Label/Phase 2, Randomized, Blinded Study of ProTmune™ (ex *vivo* Programmed Mobilized Peripheral Blood Cells) Versus Non-Programmed Mobilized Peripheral Blood Cells for Allogeneic Hematopoietic Cell Transplantation in Adult Subjects with Hematologic Malignancies This study protocol was subject to Sponsor review and approval. The information contained in this protocol is consistent with:
- The current risk-benefit evaluation of the investigational medicinal product.  
- The moral, ethical and scientific principles governing clinical research as set out in the Declaration of Helsinki, and principles of GCP as described in 21 CFR parts 50, 54, 56,312 and ICH E6(R) and according to applicable local requirements.  
The Investigator will be supplied with details of any significant or new findings related to treatment with the investigational medicinal product.  
| Name and Title                                                | Date   |
|---------------------------------------------------------------|--------|
| Peter Langecker, MD, PhD  Executive Medical Director,  Oncolo |        |  
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investigator agreement
by signing below i agree

I have read this protocol. I approve this document and I agree that it contains all necessary details for carrying out the study as described. I will conduct this study in accordance with the design and specific provision of this protocol and will make a reasonable effort to complete the study within the time designated. I will provide copies of this protocol and access to all information furnished by Fate Therapeutics, Inc. (henceforth referred to as Fate) to study personnel under my supervision. I will discuss this material with them to ensure they are fully informed about the investigational product and study procedures. I will let them know that this information is confidential and proprietary to Fate and that it may not be further disclosed to third parties. I understand that the study may be terminated or enrollment suspended at any time by Fate, with or without cause, or by me if it becomes necessary to protect the best interests of the study subjects. I agree to conduct this study in full accordance with Food and Drug Administration Regulations, IRB/IEC Regulations and International Conference on Harmonisation Guidelines for Good Clinical Practices. Investigator's Signature Date Investigator's Printed Name
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by signing below i agree

TITLE: A Phase 1, Non-Randomized, Open-Label/Phase 2, Randomized, Blinded Study of ProTmune™ (*ex vivo* Programmed Mobilized Peripheral Blood Cells) Versus Non-Programmed Mobilized Peripheral Blood Cells for Allogeneic Hematopoietic Cell Transplantation in Adult Subjects with Hematologic Malignancies
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protocol number pt-001

INVESTIGATIONAL PRODUCT: ProTmune PHASE: Phase 1/2 INDICATION(S): Reduction of incidence and severity of acute graft-versus-host disease
(aGvHD)
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objectives phase 1 part of

The primary objective of the Phase 1 part of the study is to evaluate the safety and tolerability of ProTmune *ex vivo* programmed mobilized peripheral blood (mPB) cells for hematopoietic cell transplantation (HCT) in adult subjects with hematologic malignancies.
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secondary objective

The secondary objective of the Phase 1 part of the study is to assess the efficacy of ProTmune ex *vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
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phase 2 part of the

The primary objective of the Phase 2 part of the study is to assess the efficacy of ProTmune ex *vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
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secondary objective

The secondary objective of the Phase 2 part of the study is to further evaluate the safety and tolerability of ProTmune *ex vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
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exploratory objectives

The exploratory objectives for the Phase 2 part of the study may include the following:  
- To assess the incidence of neutrophil and platelet engraftment;
- To assess the time to neutrophil and platelet engraftment; - To assess the cumulative incidence of aGvHD;
- To assess the incidence of, and time to, CMV viremia, incidence and severity of CMV invasive disease, and incidence of CMV reactivation;
- To assess time to first CMV-specific anti-viral therapy (AVT); - To assess the incidence of confirmed bacterial, fungal, viral, and parasitic infections; - To assess the time to first use of an agent to treat an infection other than CMV as clinically indicated;
- To assess the time to first use of steroids to treat aGvHD;
- To assess the time to escalation of treatment to first use of second line therapies for treatment of aGvHD;
- To assess first episode, incidence, and duration of fever;
- To assess biomarkers for aGvHD development;
- To assess incidence and maximum severity of chronic graft-versus-host disease (cGvHD);
- To assess cumulative incidence of primary and secondary graft failure;
- To assess neutrophil and T-cell chimerism;
- To determine relapse-free survival;
- To determine the incidence of non-relapse mortality (NRM);
- To determine survival at one-year and at two-years; and
- To assess immune reconstitution (including B, T, dendritic, and natural killer [NK] cells).
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population

Inclusion Criteria for Phase 1 Part of the Study and Phase 2 Part of the Study: Subjects who meet all of the following criteria will be eligible to participate in the study: 1. Male and female subjects aged 18 years and older;  
2. Subjects must have a hematologic malignancy for which allogeneic hematopoietic peripheral blood cell transplantation is deemed clinically appropriate. Eligible diseases and stages include and are limited to the following:
- Acute myeloid leukemia in first complete remission (CR) (CR1) or second CR (CR2):
o CR is defined as ≤5% bone marrow (BM) blasts with no morphological characteristics of acute leukemia (e.g., Auer Rods) in BM with ≥5% cellularity with normal peripheral blood counts; or o Morphologic CR (≤5% BM blasts) with incomplete blood count recovery;
- Acute lymphoblastic leukemia (ALL), including T lymphoblastic lymphoma with a history of marrow involvement in CR1 or CR2:
o CR is defined as ≤5% blasts with no morphological characteristics of acute leukemia in a BM with ≥5% cellularity;
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- myelodysplastic syndrome (mds) or

- Chronic myelogenous leukemia (CML);
3. Availability of a suitable 8/8 human leukocyte antigen (HLA)-A, -B, -C, and -DRB1-matched unrelated mPB donor; 4. Subjects must have an mPB donor collection unit **without** using plerixafor (Mozobil™) that is
≥5 × 106 CD34+ cells/kg in Phase 1 and ≥3 × 106 CD34+ cells/kg in Phase 2; 5. Adequate performance status, defined as Karnofsky score ≥70%;
6. For female subjects of childbearing potential, all of the following criteria must be met:  
- They are not pregnant (i.e., female subjects must have a negative serum pregnancy test at screening);
- They are not breastfeeding;
- They do not plan to become pregnant during the study; and
- They are using an effective method of contraception from screening to the end of the study, unless their sexual partner is surgically sterile. Effective methods of preventing pregnancy are those contraceptive methods with a Pearl index of <1 used consistently and correctly (including, but not limited to, implantable contraceptives, injectable contraceptives, oral contraceptives, and transdermal contraceptives).  
Women are not considered to be of childbearing potential if they meet 1 of the following 2 criteria, as documented by the Investigator:
- They have had a hysterectomy, bilateral salpingectomy, or bilateral oophorectomy at minimum 1 menstrual cycle prior to signing the informed consent form (ICF); or
- They are post-menopausal, defined as ≥1 year since their last menstrual period for women
≥55 years of age or ≥1 year since their last menstrual period; 7. For male subjects, agreement to use condoms with spermicide during sexual intercourse from screening to the end of study; and 8. Willingness and ability to sign an Investigational Review Board/Ethics Committee-approved ICF before performance of any study specific procedures or tests and to comply with protocol visits, and study procedures.
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exclusion criteria for phase 1

Subjects who meet any of the following criteria will be excluded from participation in the study:  
1. Phase 1 only: Known bone marrow fibrosis; Phase 2 only: Bone marrow fibrosis grade 3
(severe) or greater; 2. Positive serology for human immunodeficiency virus or human T-cell lymphotropic virus at any time prior to enrollment; 3. Current uncontrolled bacterial, viral, or fungal infection (progression of clinical symptoms despite therapy);
4. Prior autologous or allogeneic HCT; 5. Active malignancy, other than the one for which the allogeneic mPB transplant is being performed, within 12 months of enrollment, excluding superficial basal cell and carcinoma in situ cervical cancer; 6. Pulmonary disease such as symptomatic chronic obstructive lung disease, symptomatic restrictive lung disease, or FVC and FEV1 <50%, or hemoglobin corrected diffusing capacity of the lung of <50% of predicted value; 7. Renal dysfunction defined as a calculated creatinine clearance <40 mL/min (Cockcroft-Gault equation);
8. Hepatic disease defined as total serum bilirubin >2.0 mg/dL (except in the case of Gilbert's syndrome or ongoing hemolytic anemia), or aspartate aminotransferase or alanine aminotransferase >2.0 × the upper limit of normal; 9. Cardiac disease defined as symptomatic congestive heart failure (New York Heart Association
[NYHA] Class III/IV) or evidence of left ventricular dysfunction (ejection fraction <45%) as measured by gated radionuclide ventriculogram or echocardiogram (ECHO); active angina pectoris or uncontrolled hypertension; or history of myocardial infarction with depressed ejection fraction; 10. Neurologic disease, defined as symptomatic leukoencephalopathy, active central nervous system malignancy, or other neuropsychiatric abnormalities believed to preclude transplantation; 11. Participation in another clinical trial involving an investigational product within 30 days prior to transplant; or 12. Any condition or therapy, which, in the opinion of the Investigator, might pose a risk to the subject or make participation in the study not in the best interest of the subject (e.g., known allergy to human serum albumin [HSA]).
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study design and duration

This is a Phase 1, non-randomized, open-label/Phase 2, randomized, blinded, multi-center study of ProTmune *ex vivo* programmed mPB versus non-programmed mPB for allogeneic HCT in adult subjects with hematologic malignancies in the United States. All subjects in Phases 1 and 2 will receive a conditioning regimen comprising 1 of the following 5 preparative regimens: fludarabine and busulfan (FluBu4); busulfan (Bu) and cyclophosphamide (Cy); Cy and ≥12 Gy total body irradiation (TBI); TBI and etoposide; or fludarabine and melphalan (FluMel 140). The Phase 1 part of the study is a non-randomized, open-label, single-arm study that will treat 6 to 10 subjects who have an available 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated peripheral blood cell donor. All eligible subjects enrolled in the Phase 1 part of the study will receive 1 unit of ProTmune *ex vivo* programmed mPB cells as the cell source for the HCT. The Phase 2 part of the study is a randomized, blinded, 2-arm study that will treat approximately 80 subjects who have an available 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated peripheral blood cell donor. After meeting eligibility, approximately 90 subjects (assuming a dropout rate of approximately 15% prior to treatment) will be randomly assigned in a 1:1 ratio to receive either unmanipulated mPB cells (control arm) or ProTmune *ex vivo* programmed mPB cells (experimental arm) and stratified by the subjects' CMV status (+/-). At initiation of the Phase 1 part of the study, 3 subjects will be enrolled and treated. At the time a subject engrafts (or fails to engraft by Day +28), a new subject may be treated. If 2 or more subjects fail to engraft by Day +28, or if 2 or more subjects experience secondary graft failure by Day +28, or if 2 of the first 3 or 4 of the first 6 subjects treated have died by ≤Day +28, subject treatment will be stopped until the Independent Data Monitoring Committee (IDMC) has assessed the cases and discussed with the Sponsor. The IDMC will be notified of all subject deaths occurring on study. If the investigational product does not meet release specifications to treat 2 of the first 3 subjects, 3 of the first 6 subjects, or 5 of the first 10 subjects in the Phase 1 part of the study, subject treatment will be stopped.  
If after 6 subjects have been dosed and evaluated for up to 28 days and ≤1 subject has not engrafted by Day +28, then enrollment in the Phase 2 portion of the study may proceed following IDMC review. Both the Phase 1 part of the study and Phase 2 part of the study will include a Screening Period (Day -53 through Day -11), Subject Conditioning Period (Day -10 through Day -1), Study Treatment Administration Day (Day 0; Day of HCT), Post-Transplant Follow-up Period (Day +1 through Day +730, consisting of Post-Transplant Assessment Days and Post-Transplant Weekly Assessments, then intermittent assessments), and an Early Withdrawal Visit (if applicable). The total duration of subject participation will be up to 26 months for each subject in the Phase 1 part of the study and Phase 2 part of the study. The end of the study is considered as the completion through Day +365. All treated subjects will be followed for survival through Day +730 (i.e., 2 years). The study will utilize an Endpoint Adjudication Committee (EAC) blinded to treatment. The EAC will be responsible for adjudicating the aGvHD endpoint. Adjudication of the aGvHD endpoint will be in accordance with the EAC charter. During the Phase 1 part of the study, an IDMC will convene to assess safety data as outlined in the IDMC Charter. At that time, the Sponsor, in consultation with and based on recommendations from the IDMC, will decide whether the study should stop or whether the Phase 2 study can begin. During the Phase 2 part of the study, the IDMC will convene according to the guidelines outlined in the IDMC Charter. Additional safety monitoring based on NRM, secondary graft failure, and IDMC input will be applied during the study for the Phase 1 and Phase 2 parts of the study. With the exception of the stopping rules associated with the failure of ProTmune to meet release specifications, there are no formal stopping rules for the Phase 2 part of the study. Stopping subject treatment may be triggered based on the continued review of subject safety data on study by the Sponsor and IDMC. If the investigational product does not meet release specifications for 2 of the first 3 subjects, 3 of the first 6 subjects, or 5 of the first 10 subjects or 10 of the first 20 subjects, subject treatment in the Phase 2 part of the study will be stopped, pending review by the IDMC.
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screening period (day -53 to

The Screening Period will occur between Day -53 and Day -11 (i.e., up to 6 weeks prior to the Subject Conditioning Period). At Screening, all subjects will review and sign an ICF and eligibility for study participation will be assessed. The Investigator will be required to verify that the subject completed HLA typing. Human leukocyte antigen typing can be completed prior to the Screening Period. Peripheral blood will be collected during the Screening Period to serve as a baseline sample for immune reconstitution analysis. The results of the bone marrow aspirate, spirometry, and ECHO or multiple gated acquisition
(MUGA) performed prior to consent may be used for subject qualification as long as performed within 6 weeks prior to the Subject Conditioning Period, from Day -53 to Day -11. As a part of screening, all subjects will be tested for baseline CMV antibody titer and plasma CMV viremia. This baseline testing will be performed by a central laboratory and results will be provided to the clinical site and sponsor before initiation of randomization.
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subject conditioning period (day -10

The Subject Conditioning Period will occur between Day -10 and Day -1. Day 0 is the day of mPB HCT transplant. Conditioning will include one of the following 5 preparative regimens:  
- CyTBI, with ≥12 Gy fractionated TBI;
- BuCy where Bu = 16 mg/kg orally (PO) or 12.8 mg/kg intravenous (IV) infusion
(alternatively, pharmacokinetic assessment and dose adjustment of busulfan can be based on a test dose or the first dose and will be conducted according to institutional practices);
- FluBu4 with Bu as above;
- TBI and etoposide; or
- FluMel 140
Filgrastim (granulocyte-colony stimulating factor) can be administered at 5 µg/kg/day beginning on Day +12, if ANC<500 cells/µL, until the ANC is >500 cells/µL. At Investigator discretion, filgrastim can be administered longer to support the white blood cells. Similarly, per Investigator discretion, filgrastim may be started before Day +12 if subsequent doses of methotrexate will not be administered due to severe mucositis, other toxicity, or severe infection. Graft-versus-host disease prophylaxis will be administered to all subjects. The GvHD prophylaxis regimen:  
- Methotrexate (15 mg/m2 IV infusion on Day +1 after hematopoietic cell infusion and 10 mg/m2 on Days +3, +6, and +11), and
- Tacrolimus (0.02 mg/kg every 24 hours as an IV infusion or 0.03 mg/kg PO beginning on Day
-2, adjusted to target dose level of 5 to 15 ng/mL. Taper starting at Day +100).  
The GvHD prophylaxis dose may be reduced based on clinical judgment associated with toxicity.
All chemotherapy administered to subjects will be dosed based on the subject's actual body weight. However, for subjects weighing more than 125% of their ideal body weight, chemotherapy will be dosed based on the adjusted ideal body weight, or by Institutional Standards. Anti-thymocyte globulin is not permitted during the study. FDA-approved prophylactic therapies for CMV prevention (e.g., letermovir) will be permitted. Pre-emptive CMV therapy may be provided based upon institutional methodologies, Standard Operating Procedures, and clinical context. An additional blood sample for CMV testing will be collected prior to starting the preemptive therapy and sent for central laboratory testing. Other procedures for transplant preparation will also be performed at the Subject Conditioning Visit and per Institutional Standard. Hospital Admission (as per Institution Policy) for the Phase 1 and Phase 2 Parts of the Study:
Subjects will be admitted to the hospital based on institutional policy.  
Study Treatment Administration (Day 0; Day of Hematopoietic Cell Transplantation) for the Phase 1 and Phase 2 Parts of the Study: A 12-lead triplicate electrocardiogram (ECG) (sequential, within 15 minutes total), complete blood count (CBC), and blood chemistry will be obtained on Day 0 prior to HCT. All eligible subjects will receive study treatment on the day of HCT (Day 0). For the Phase 1 part of the study, study treatment will consist of a single unit of ProTmune *ex vivo* programmed mPB cells. For the Phase 2 part of the study, study treatment will consist of either a single unit of ProTmune *ex vivo* programmed mPB cells or a single unit of unmanipulated mPB cells, based upon the subject's randomized treatment allocation. The ProTmune graft will be prepared the same day as administration. Karnofsky Performance Status will be assessed at Day 0, following transplantation.
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post-transplant assessment days for the

Post-transplant visit windows are as follows: ±3 days for Day +7 through Day +100; ±14 days for Day +180; and ±28 days for Days +270, +365, and +730. Standard post-transplant testing will be performed per institutional guidelines and good clinical practice. The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting. Post-Transplant Weekly Visits for the Phase 1 and Phase 2 Parts of the Study: Clinical and laboratory assessments of aGvHD will be performed weekly from Day +1 through Day +100, and on Day +180. Acute GvHD assessments (incidence and maximum severity) of Grades I through IV of the skin, liver, and gut as per the CIBMTR aGvHD Grading Scale will be performed. Chronic GvHD assessments (incidence and maximum severity) of mild, moderate, or severe cGvHD as per National Institutes of Health (NIH) Consensus Criteria for cGvHD must be performed on Days +180, +270, and +365. Peripheral blood samples will be collected for CMV assessments of deoxyribonucleic acid by quantitative polymerase chain reaction (PCR) weekly from Day +7 through Day +100, and on Days +180, +270, and +365. Assessment of infection will be performed based on the NCI CTCAE and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) definitions. Peripheral blood will be collected for safety laboratory panels (hematology and serum chemistry), viral monitoring, immune reconstitution, chimerism, serum immunoglobulins, and GvHD exploratory biomarkers at the pre-specified time points. A 12-lead triplicate ECG (sequential, within 15 minutes total) will be obtained at Day +100. Bone marrow aspirate will be sent to pathology and to cytogenetics on Day +21 (only if absolute neutrophil count [ANC] <500/µL), and as clinically indicated (flow cytometry is required on BM aspirate).  
Karnofsky Performance Status will be assessed at all subsequent study visits after HCT up through Day +365 (which should include weekly assessments from Day +1 through Day +91, then on Days +100, +180, +270, and +365). The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting.
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unscheduled visits

An unscheduled visit is a visit that occurs in addition to the predefined protocol specific visit calendar. If an unscheduled visit occurs for a given subject, the visit must be documented on the Unscheduled Visit electronic case report form.
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early withdrawal visit for the

If a subject is withdrawn from participation in the study prior to Day 0, the subject's mPB will not be processed to a unit of ProTmune *ex vivo* programmed mPB cells, the subject will not be considered evaluable for any study-related endpoint analyses, and a new subject will be added for the Phase 1 portion of the study. If this occurs in the Phase 2 portion of the study, the subject will be replaced and a new subject will be randomized in order to have approximately 80 treated subjects. If a subject withdraws from the study after transplantation, information regarding secondary graft failure, disease relapse, serious adverse events involving GvHD and infections, and survival outcomes will be collected by phone on Days +180, +365, and +730. If a subject withdraws consent, survival outcomes will be assessed via public record search. If the subject relapses and/or receives a protocol-prohibited therapy, the subject will be withdrawn. However, survival will still be collected at Day +730 by telephone contact unless the subject withdraws consent, in which case survival outcomes will be assessed via public record search. A peripheral blood sample for safety laboratory panels (hematology and serum chemistry) will be collected. Karnofsky Performance Status should be assessed, and GvHD assessments must be performed, as applicable. Adverse events will be collected during Phase 1 and 2 as per the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, AE of infections will use both the CTCAE and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN, Appendix G) criteria, as follows:  
- All serious adverse events (SAEs) will be recorded from Day -10 through Day +365, and only SAEs related to infused cells (ProTmune *ex vivo* programmed mPB cells or Control mPB cells) from Day +366 through Day +730;
- Start of conditioning regimen (Day -10) through Day +100: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;
- From Day +100 through Day +365: Only adverse events associated with GvHD, infections, or secondary engraftment failure (Grades 1 through 5);
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concomitant medications

All concomitant medications will be recorded starting at Day -30 through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded.
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dosage forms and route of

ProTmune is a donor-sourced, patient-specific, allogeneic cell therapy product consisting of the cells contained within a human mobilized peripheral blood (mPB) collection that have been programmed through an *ex vivo* programming process using a combination of 2 small molecules, 16,16-dimethyl prostaglandin E2 (FT1050) and dexamethasone (FT4145). The cell populations include hematopoietic cells and other cell types. The final ProTmune product is formulated in Plasmalyte-A (or equivalent) and human serum albumin (HSA). Mobilized peripheral blood cells will be obtained from a matched-unrelated donor for a given subject. An 8/8 high resolution allelic HLA-match of HLA-A, -B, -C, and -DRB1 with recipient is required. Sites will request that consenting donors be mobilized with filgrastim to achieve a target collected CD34+ dose of ≥7 × 106 CD34+ cells/kg in Phase 1 and ≥5 × 106 CD34+ cells/kg in Phase 2. However, if the donor mPB unit collected for a subject in Phase 1 is not
≥5 × 106 CD34+ cells/kg recipient weight, and in Phase 2 is not ≥3 × 106 CD34+ cells/kg recipient weight, the mPB unit will not be processed for ProTmune manufacturing and the subject will be considered a screen failure.  
For subjects enrolled in the Phase 1 part of the study, a reserve dose of 2 × 106 CD34+ cells/kg recipient weight will be maintained during ProTmune manufacturing to serve as a reserve in the event ProTmune manufacturing produces a ProTmune unit that does not meet ProTmune release specifications (e.g., <2 × 106 CD34+ cells/kg recipient weight, <70% viable). In this case, the ProTmune unit will be considered "unavailable" and count towards the Phase 1 stopping rules. The reserve unit must be administered; however, the Principal Investigator should follow their Institution's standard operating procedure to determine whether the ProTmune unit should also be given to the recipient based on the risk-benefit assessment of administering the product with regard to the specification not being met. If the ProTmune unit is not administered, the subject will be withdrawn from study and replaced. If the ProTmune unit is administered, the subject will remain in study but will not be considered in the following assessment - "If after 6 subjects have been dosed and evaluated for up to 28 days and ≤1 subject has not engrafted by Day +28, then enrollment in the Phase 2 portion of the study may proceed following IDMC review". If the reserve unit is not used on Day 0, it will be cryopreserved at the site and can be used in the event of non-engraftment, or delayed engraftment. For subjects enrolled in the Phase 2 part of the study in the event ProTmune manufacturing produces a ProTmune unit that does not meet ProTmune release specifications (e.g.,
<2 × 106 CD34+ cells/kg recipient weight, <70% viable), the ProTmune unit will be considered
"unavailable" and count towards the Phase 2 stopping rules. The Principal Investigator should follow their Institution's standard operating procedure to determine whether the unit should be given to the recipient based on the risk-benefit assessment of administering the product with regard to the specification not being met. If the ProTmune unit is not administered, or a subject is withdrawn from participation in the study prior to Day 0 and the subject's mPB is not processed to a unit of ProTmune, the subject will be replaced and a new subject will be randomized in order to have approximately 80 treated subjects. If the ProTmune unit is administered, the subject will remain in study. Fate has established specific criteria that will be used to assess the quality of all mPB units collected for *ex vivo* programming. The Cell Processing Facility (CPF) at each participating site will be qualified and trained by Fate technical staff to manufacture the investigational product on site via the performance of a single ProTmune qualification run. Additionally, Fate technical representative(s) will be on site for the manufacture of each CPF's first or second subject treatments and subsequent subject treatments as necessary by the CPF or Fate. ProTmune or Control cells will be released immediately by the CPF staff after final processing, including filtration, final packaging, rapid release testing, and labeling.
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safety endpoints

The safety endpoints for both the Phase 1 and Phase 2 parts of the study include the assessment of adverse events as defined in the NCI CTCAE version 4.0, vital signs, physical examination findings, engraftment, graft failure, chimerism, clinical laboratory assessments, and electrocardiographic data through a 12-lead ECG.
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efficacy endpoints

The primary efficacy endpoint for both the **Phase 1 and Phase 2** parts of the study isthe following:  
- Cumulative incidence of CIBMTR Grades II-IV aGvHD through Visit Day +100 based on investigator results. Death and relapse without CIBMTR Grades II-IV aGvHD will be considered competing risks.  
o Each study site will determine the presence or absence of aGvHD by assigning the clinical stage for the target organs of the skin, liver, and gut along with assigning an overall grade according to the CIBMTR aGvHD Grading Scale (Appendix E).
The key secondary efficacy endpoint for both the **Phase 1 and Phase 2** parts of the study is the following:  
- Proportion of subjects alive without relapse and without moderate or severe cGvHD per NIH
Consensus Criteria at Visit Day +365.
All summaries for acute and chronic GvHD will be based on the investigator assessment unless noted otherwise.  
The exploratory efficacy endpoints for both the **Phase 1 and Phase 2** parts of the study are the following:
- Cumulative incidence through Visit Day +100 and through Visit Day +180 of:  
o CIBMTR Grades III-IV aGvHD;
o CIBMTR Grades I-II aGvHD;
o CIBMTR Grades I-IV aGvHD; o Maximum CIBMTR Grades II-IV aGvHD; o Maximum CIBMTR Grades III-IV aGvHD; o Maximum CIBMTR Grades II-IV aGvHD based on EAC adjudicated results; o Maximum CIBMTR Grades III-IV aGvHD based on EAC adjudicated results;
- Duration of the Maximum CIBMTR Grade aGvHD through Visit Day +100; - Duration of CIBMTR Grades II-IV aGvHD through Visit Day +100;
- Duration of CIBMTR Grades III-IV aGvHD through Visit Day +100;
- One-Year GvHD-Free, Relapse-Free Survival (GRFS), a composite endpoint in which events include Grade III-IV aGvHD, cGvHD-requiring systemic immunosuppressive therapy, relapse, or death from any cause (Holtan et al. 2015);
- Time to individual event components for GRFS:
o Time to CIBMTR Grades III-IV aGvHD;
o Time to first use of cGvHD-requiring systemic immunosuppressive therapy; o Time to relapse; o Time to death;
- One-Year cGvHD-Free, Relapse-Free Survival (CRFS), a composite endpoint in which events include any cGvHD-requiring systemic immunosuppressive therapy, relapse, or death from any cause (Pasquini et al. 2018);
- Cumulative incidence of Non-relapse mortality (NRM). All deaths in the absence of relapse of the primary malignancy will be considered NRM, where relapse will be considered a competing risk;
- Moderate or severe cGvHD per NIH Consensus Criteria for the global severity score cGvHD
through Visit Day +365. Death and relapse without moderate or severe cGvHD will be considered competing risks;
- Proportion of subjects with systemic steroid use for aGvHD; - Time to first use of systemic steroids for aGvHD; - Total number of days of systemic steroid use for aGvHD; - Proportion of subjects with second-line therapies for treatment of aGvHD;
- Time to first use of second-line therapies for treatment of aGvHD; - Proportion of subjects who are CMV positive at baseline with subsequent CMV reactivation.  
CMV reactivation is defined as subjects who have initiated anti-viral therapy for CMV;
- Time to first treatment for CMV reactivation;
- Relapse-free survival (RFS);
- One-year survival;
- Two-year survival.
Additional exploratory analyses may be performed as necessary.
synopsis
statistical analyses

All reporting and analyses will be conducted at the end of the study, which is defined as the date when the last subject last visit occurs or the date at which the last data point is collected for the completion of 1-year on study (Day +365), whichever occurs later. Analysis of the 2-year survival follow-up will be conducted upon completion of the Day +730 follow-up. The initial clinical study report will be completed following final analysis of the 1-year data and will be appended to include the 2-year survival data upon completion. Continuous variables will be summarized by using the number of non-missing observations, arithmetic mean, standard deviation, median, minimum, and maximum values as descriptive statistics. Categorical variables will be summarized by using the frequency count and the percentage of subjects in each category as descriptive statistics. Time-to-event variables will be summarized using Kaplan-Meier methods; competing risk methods will be used in the presence of competing risk factors (e.g., death or relapse without aGvHD for evaluating aGvHD). Efficacy analyses will be performed based on the mITT Population. Additional sensitivity analyses will be performed based on the PP Population for the primary and key secondary efficacy endpoint for Phase 2. Efficacy data from the Phase 1 part of the study and Phase 2 part of the study will be summarized separately. Summary tables will present results for each phase by treatment group. The safety profile will be based on adverse events, vital signs, physical examinations, clinical laboratory assessments, engraftment, graft failure, chimerism, and ECGs. All safety analysis will be based on the Safety Population.
synopsis
sample size determination

The background cumulative incidence rate of International Bone Marrow Transplant Registry (IBMTR) Grades B-D aGvHD in this population is assumed to be between 40% and 60% as reported in the literature (Jagasia et al. 2012).  
Phase 1: Allowing for a dropout rate of approximately 15%, approximately 8-12 subjects will be enrolled to include 6-10 evaluable.  
Phase 2: When accounting for competing risk factors (death or relapse without aGvHD), a sample size of 80 subjects (40 subjects in each treatment group) allows for approximately 85% power to detect a reduction in the cumulative incidence rate of CIBMTR Grades II-IV aGvHD through Day +100 from 55% to 25% (i.e., a hazard ratio of 0.3464) in the Control versus ProTmune treatment arms using a two-sided log-rank test at a 0.05 significance level. This calculation assumes the cumulative incidence rate for competing risk factors is 10% through Visit Day +100. Allowing for a dropout rate of approximately 15%, approximately 90 subjects will be randomized to include approximately 80 treated subjects in the mITT Population. The sample size was calculated using PASS Sample Size Software (PASS 16 Power Analysis and Sample Size Software, 2018).  
SITES: Approximately 5 to 10 sites in the United States for the Phase 1 part of the study, and approximately 14 to 20 sites in the United States for the Phase 2 part of the study.
synopsis
sponsor

Fate Therapeutics, Inc. 3535 General Atomics Court, Suite 200 San Diego, CA 92121 Telephone: 858-875-1800 Facsimile: 858-875-1843
synopsis
table of contents

| INVESTIGATOR AGREEMENT 3 SYNOPSIS 4 TABLE OF CONTENTS 17 LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 23 1 INTRODUCTION AND BACKGROUND INFORMATION 26 1.1 Background 26 1.2 Hematopoietic Stem Cell Transplants and Potential Complications 26 1.2.1 Graft-Versus-Host Disease 27 1.2.2 Current Strategies to Prevent and/or Treat Graft-versus-Host Disease 28 1.2.3 Infections in the Hematopoietic Cell Transplant Setting 28 1.3 ProTmune 30 1.3.1 Effects of FT1050 and FT4145 on T-cells 30 1.3.2 Effects of F1050 and FT4145 on Hematopoietic Stem Cells 30 1.3.3 Role of FT1050 and FT4145 in Hematopoietic Stem Cell Biology 31 1.4 Risk/Benefit 31 1.4.1 Summary of Nonclinical Studies 31 1.4.1.1 In vitro characterization studies of hematopoietic stem cells 31 1.4.1.2 In vivo repopulating ability (engraftment) 32 1.4.1.3 T-cell characterization studies 32 1.4.1.4 Summary of nonclinical findings 33 1.4.2 Summary of Clinical Studies 33 1.5 Rationale 33 1.5.1 Proof-of-Concept Clinical Data 33 1.5.2 Nonclinical Data Supporting ProTmune's Ability to Reduce Viral Infections 34 1.6 Rationale for ProTmune Clinical Study in Matched Unrelated Donors 34 2 STUDY OBJECTIVES 36 2.1 Primary Objective(s) 36 2.1.1 Primary Objective for the Phase 1 Part of the Study 36 2.1.2 Primary Objective for the Phase 2 Part of the Study 36 2.2 Secondary Objectives 36   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| Clinical Study Protocol PT-001   |                                                                                           |
|----------------------------------|-------------------------------------------------------------------------------------------|
| 2.2.1                            | Secondary Objective for the Phase 1 Study 36                                              |
| 2.2.2                            | Secondary Objective for the Phase 2 Study 36                                              |
| 2.3                              | Exploratory Objectives 36                                                                 |
| 2.3.1                            | Exploratory Objectives for the Phase 2 Part of the Study 36                               |
| 3                                | STUDY DESCRIPTION 38                                                                      |
| 3.1                              | Summary of Study Design 38                                                                |
| 3.1.1                            | Study Design for the Phase 1 Part of the Study 38                                         |
| 3.1.2                            | Study Design for the Phase 2 Part of the Study 42                                         |
| 3.1.3                            | Early Stopping Rules for the Study 45                                                     |
| 3.1.3.1                          | Early stopping rules for the Phase 1 part of the study 45                                 |
| 3.1.3.2                          | Early stopping rules for the Phase 2 part of the study 45                                 |
| 3.2                              | Independent Data Monitoring Committee 46                                                  |
| 3.2.1                            | Endpoint Adjudication Committee 46                                                        |
| 3.3                              | Study Indication(s) 46                                                                    |
| 3.4                              | Conditioning and Graft-versus-Host Disease Prophylaxis Regimens 46                        |
| 3.5                              | Prophylactic and Pre-emptive Therapy for CMV Infection 47                                 |
| 3.6                              | Reserve Hematopoietic Stem Cells 47                                                       |
| 3.7                              | Transfusion and Support Guidelines 48                                                     |
| 4                                | SELECTION AND WITHDRAWAL OF SUBJECTS 49                                                   |
| 4.1                              | Inclusion Criteria for the Phase 1 Part of the Study and the Phase 2 Part of the Study 49 |
| 4.2                              | Exclusion Criteria for the Phase 1 Part of the Study and the Phase 2 Part of the Study 50 |
| 4.3                              | Withdrawal Criteria 51                                                                    |
| 4.4                              | Screen Failures and Subject Replacement 52                                                |
| 5                                | STUDY TREATMENTS 53                                                                       |
| 5.1                              | Treatment Groups 53                                                                       |
| 5.1.1                            | Study Treatment Groups for the Phase 1 Part of the Study 53                               |
| 5.1.2                            | Study Treatment Groups for the Phase 2 Part of the Study 53                               |
| 5.2                              | Rationale for Dosing 53                                                                   |
| 5.3                              | Randomization and Blinding 53                                                             |
| 5.3.1                            | Randomization and Blinding for the Phase 1 Part of the Study 53                           |
| 5.3.2                            | Randomization and Blinding for the Phase 2 Part of the Study 53                           |  
| 5.4   | Breaking the Blind 54                                                                                                     |
|-------|---------------------------------------------------------------------------------------------------------------------------|
| 5.5   | Drug Supplies 54                                                                                                          |
| 5.5.1 | Formulation and Packaging 54                                                                                              |
| 5.5.2 | Study Drug Preparation and Dispensing 55                                                                                  |
| 5.5.3 | Study Drug Administration 56                                                                                              |
| 5.5.4 | Treatment Compliance 56                                                                                                   |
| 5.5.5 | Storage and Accountability 56                                                                                             |
| 5.6   | Prior and Concomitant Medications and/or Procedures 57                                                                    |
| 5.6.1 | Prohibited Medications and/or Procedures for the Phase 1 Part of the Study and  Phase 2 Part of the Study 57              |
| 5.6.2 | Documentation of Prior and Concomitant Medication Use for the Phase 1 Part of  the Study and Phase 2 Part of the Study 57 |  
6 STUDY PROCEDURES .................................................................................................. 59 6.4.1 Hospital Admission (Institution Policy) for the Phase 1 Part of the Study and Phase 2 Part of the Study ...................................................................................... 61 6.5 Study Treatment Administration: Day of Hematopoietic Stem Cell Transplant (Day 0)
..................................................................................................................................... 62 6.5.1 Study Treatment Administration: Day of Hematopoietic Stem Cell Transplant
(Day 0) for the Phase 1 Part of the Study and Phase 2 Part of the Study ............. 62 6.6 Post-Transplant Assessment Days.............................................................................. 62 6.6.1 Post-Transplant Assessment Days for the Phase 1 Part of the Study and Phase 2 Part of the Study.................................................................................................... 62 6.7 Post-Transplant Weekly Assessments ........................................................................ 63 6.7.1 Post-Transplant Weekly Visits for the Phase 1 Part of the Study and Phase 2 Part of the Study ........................................................................................................... 63  
| 6.1   | Informed Consent 59                                                                                          |
|-------|--------------------------------------------------------------------------------------------------------------|
| 6.1.1 | Informed Consent for the Phase 1 Part of the Study and Phase 2 Part of the Study 59                          |
| 6.2   | Screening Period (Day -53 to Day -11) 59                                                                     |
| 6.2.1 | Screening Period (Day -53 to Day -11) for the Phase 1 Part of the Study and  Phase 2 Part of the Study 59    |
| 6.3   | Subject Conditioning (Day -10 to Day -1) 60                                                                  |
| 6.3.1 | Subject Conditioning (Day -10 to Day -1) for the Phase 1 Part of the Study and  Phase 2 Part of the Study 60 |
| 6.4   | Hospital Admission (Institution Policy) 61                                                                   |  
7 8  
| Clinical Study Protocol PT-001                                                                            |                                                                                                                    |                                                                                                                |
|-----------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------|
| 6.8                                                                                                       | Unscheduled visits .                                                                                               |                                                                                                                |
| Early Withdrawal Visit and Study Withdrawal Procedures ............................................... 65 |                                                                                                                    |                                                                                                                |
| 6.9                                                                                                       | EFFICACY ASSESSMENTS .                                                                                             |                                                                                                                |
| 7.1                                                                                                       | Acute Graft-versus-Host Disease Assessment                                                                         |                                                                                                                |
| 7.2                                                                                                       | Chronic Graft-versus-Host Disease Assessment .................................................................. 68 |                                                                                                                |
| 7.3                                                                                                       | Viral Monitoring .                                                                                                 |                                                                                                                |
| 7.4                                                                                                       | Infectious Disease Titers                                                                                          |                                                                                                                |
| 7.5                                                                                                       | Karnofsky Performance Status .                                                                                     |                                                                                                                |
| 7.6                                                                                                       | Relapse of Malignancy                                                                                              |                                                                                                                |
| 7.7                                                                                                       | Immune Reconstitution                                                                                              |                                                                                                                |
| 7.8                                                                                                       | Serum Immunoglobulin .                                                                                             |                                                                                                                |
| 7.9                                                                                                       | Bone Marrow Aspirate                                                                                               |                                                                                                                |
| 7.10                                                                                                      | GVHD Biomarkers                                                                                                    |                                                                                                                |
| 7.11                                                                                                      | Radiologic Tumor Staging .                                                                                         |                                                                                                                |
| SE SE TY ASSESSMENTS                                                                                      |                                                                                                                    |                                                                                                                |
| A Adverse Events .                                                                                        |                                                                                                                    |                                                                                                                |
| 8.1                                                                                                       | 8.1.1                                                                                                              | Adverse (Drug) Reaction                                                                                        |
| Unexpected Adverse Drug Reaction                                                                          |                                                                                                                    |                                                                                                                |
| 8.1.2                                                                                                     | An Unexpected Adverse Drug Reaction is defined as an adverse reaction, the                                         |                                                                                                                |
| 8.1.3                                                                                                     | nature or severity of which is not consistent with the applicable product                                          |                                                                                                                |
| information. Assessment of Adverse Events by the Investigator .......................... 73               |                                                                                                                    |                                                                                                                |
| 8.2                                                                                                       | Serious Adverse Events .                                                                                           |                                                                                                                |
| 8.3                                                                                                       | Serious Adverse Event Reporting - Procedures for Investigators                                                     |                                                                                                                |
| 8.4                                                                                                       | Pregnancy Reporting                                                                                                |                                                                                                                |
| 8.5                                                                                                       | Expedited Reporting                                                                                                |                                                                                                                |
| Engraftment, Graft Failure, and Chimerism                                                                 |                                                                                                                    |                                                                                                                |
| 8.6                                                                                                       | 8.6.1                                                                                                              | Neutrophil and platelet engraftment per CIBMTR ............................................................ 76 |
| 8.6.2                                                                                                     | Primary and secondary graft failure.                                                                               |                                                                                                                |
| 8.6.3                                                                                                     | Chimerism                                                                                                          |                                                                                                                |
| Clinical Laboratory Evaluations                                                                           |                                                                                                                    |                                                                                                                |
| 8.7                                                                                                       |                                                                                                                    |                                                                                                                |
| 8.8                                                                                                       | Serum Pregnancy Tests                                                                                              |                                                                                                                |
| 8.9                                                                                                       | Vital Signs                                                                                                        |                                                                                                                |
| 8.10                                                                                                      | EEECTROCARDIOGRAMS .                                                                                               |                                                                                                                |  
| Clinical Study Protocol PT-001                                                                            |                                                                                                                     |                      |
|-----------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------|----------------------|
| 8.11                                                                                                      | Physical Examinations                                                                                               |                      |
| Donor History                                                                                             |                                                                                                                     |                      |
| 8.12                                                                                                      |                                                                                                                     |                      |
| 8.13                                                                                                      | Medical History and Concomitant Medications .................................................................... 78 |                      |
| 8.14                                                                                                      | CC                                                                                                                  |                      |
| Pulmonary Function Tests .                                                                                |                                                                                                                     |                      |
| 8.15                                                                                                      | STATISTICS .                                                                                                        |                      |
| 9                                                                                                         | 9.1                                                                                                                 | Analysis Populations |
| Intent-to-Treat Population                                                                                |                                                                                                                     |                      |
| 9.1.1                                                                                                     | Modified Intent-to-Treat Population                                                                                 |                      |
| 9.1.2                                                                                                     |                                                                                                                     |                      |
| 9.1.3                                                                                                     | Per-Protocol Population                                                                                             |                      |
| 9.1.4                                                                                                     | Safety Population                                                                                                   |                      |
| 9.2                                                                                                       | Statistical Methods                                                                                                 |                      |
| 9.2.1                                                                                                     | Analysis of Efficacy                                                                                                |                      |
| 9.2.2                                                                                                     | Analysis of Safety .                                                                                                |                      |
| Interim Analysis                                                                                          |                                                                                                                     |                      |
| 9.2.3                                                                                                     | Hypotheses .                                                                                                        |                      |
| 9.2.4                                                                                                     |                                                                                                                     |                      |
| 9.2.5                                                                                                     | Sample Size Determination                                                                                           |                      |
| 10                                                                                                        | DATA MANAGEMENT AND RECORD KEEPING                                                                                  |                      |
| DATA MANAGEMENT                                                                                           |                                                                                                                     |                      |
| 10.1                                                                                                      |                                                                                                                     |                      |
| 10.1.1 Data Handling .                                                                                    |                                                                                                                     |                      |
| 10.1.2  Computer Systems .                                                                                |                                                                                                                     |                      |
| 10.1.3  Data Entry .                                                                                      |                                                                                                                     |                      |
| 10.1.4  Medical Information Coding                                                                        |                                                                                                                     |                      |
| 10.1.5 Data Validation .                                                                                  |                                                                                                                     |                      |
| Record Keeping .                                                                                          |                                                                                                                     |                      |
| 10.2                                                                                                      |                                                                                                                     |                      |
| 11                                                                                                        | INVESTIGATOR REQUIREMENTS AND QUALITY CONTROL ................................... 86                                |                      |
| 1.1                                                                                                       | Ethical Conduct of the Study .                                                                                      |                      |
| Institutional Review Board/Independent Ethics Committee............................................... 86 |                                                                                                                     |                      |
| 1.2                                                                                                       |                                                                                                                     |                      |
| 1.3                                                                                                       | Informed Consent                                                                                                    |                      |
| 1.4                                                                                                       | Subject Card                                                                                                        |                      |
| Study Monitoring Requirements                                                                             |                                                                                                                     |                      |
| 1.5                                                                                                       | Disclosure of Data                                                                                                  |                      |
| 1.6                                                                                                       |                                                                                                                     |                      |  
| 11.7   | Retention of Records 87             |
|--------|-------------------------------------|
| 11.8   | Publication Policy 88               |
| 11.9   | Financial Disclosure 88             |
| 11.10  | Insurance and Indemnity 88          |
| 11.11  | Legal Aspects 88                    |
| 12     | STUDY ADMINISTRATIVE INFORMATION 89 |
| 12.1   | Protocol Amendments 89              |
| 12.2   | Address List 89                     |  
12.2.1 Sponsor ................................................................................................................. 89 12.2.2 Contract Research Organization ........................................................................... 89 12.2.3 Drug Safety ........................................................................................................... 89 12.2.4 Biological Specimens............................................................................................ 89 13 REFERENCES ................................................................................................................. 90 APPENDIX A: SCHEDULE OF PROCEDURES FOR THE PHASE 1 AND PHASE 2 PARTS OF THE STUDY............................................................................................... 94 APPENDIX B: STUDY DESIGN SCHEMATIC FOR THE PHASE 1 PART OF THE
STUDY............................................................................................................................. 98 APPENDIX C: FLOW SCHEMATIC FOR THE PHASE 1 PART OF THE STUDY ....... 99 APPENDIX D: KARNOFSKY PERFORMANCE STATUS SCALE ................................. 100 APPENDIX E: ACUTE GVHD SCORING SYSTEM FOR INDIVIDUAL ORGANS:
CIBMTR SCALE .......................................................................................................... 101 APPENDIX F: NIH CONSENSUS CRITERIA FOR CHRONIC GVHD .......................... 102 APPENDIX G: BMT CTN SEVERITY GRADING AND RECURRENCE INTERVAL
DEFINITION ................................................................................................................ 105 APPENDIX H: STUDY DESIGN SCHEMATIC FOR THE PHASE 2 PART OF THE
STUDY ........................................................................................................................... 108 APPENDIX I: FLOW SCHEMATIC FOR THE PHASE 2 PART OF THE STUDY ...... 109 APPENDIX J: CLINICAL LABORATORY ANALYTES .................................................. 110  
| Abbreviation               | Definition                                                    |
|----------------------------|---------------------------------------------------------------|
| aGvHD                      | Acute graft-versus-host disease                               |
| AIBW                       | Adjusted ideal body weight                                    |
| ALL                        | Acute lymphoblastic leukemia                                  |
| ALT                        | Alanine aminotransferase                                      |
| AML                        | Acute myeloid leukemia                                        |
| ANC                        | Absolute neutrophil count                                     |
| AST                        | Aspartate aminotransferase                                    |
| AVT                        | Anti-viral therapy                                            |
| BM                         | Bone marrow                                                   |
| BMT CTN                    | Blood and Marrow Transplant Clinical Trials Network           |
| Bu                         | Busulfan                                                      |
| cAMP                       | Cyclic adenosine monophosphate                                |
| CBC                        | Complete blood count                                          |
| cGvHD                      | Chronic graft-versus-host disease                             |
| CIBMTR                     | Center for International Blood and Marrow Transplant Research |
| CML                        | Chronic myelogenous leukemia                                  |
| CMV                        | Cytomegalovirus                                               |
| CPF                        | Cell Processing Facility                                      |
| CR                         | Complete remission                                            |
| CRA                        | Clinical research associate                                   |
| CRFS                       | Chronic graft-versus-host disease-free, relapse-free survival |
| CRO                        | Contract research organization                                |
| CTA                        | Clinical trial authorization                                  |
| CTCAE                      | Common Terminology Criteria for Adverse Events                |
| CXCR4                      | C-X-C chemokine receptor type 4                               |
| Cy                         | Cyclophosphamide                                              |
| DNA                        | Deoxyribonucleic acid                                         |
| EAC                        | Endpoint Adjudication Committee                               |
| EBV                        | Epstein Barr Virus                                            |
| ECG                        | Electrocardiogram                                             |
| ECHO                       | Echocardiogram                                                |
| eCRF                       | Electronic case report form                                   |
| EDC                        | Electronic data capture                                       |
| FDA                        | Food and Drug Administration                                  |
| FluBu4                     | Fludarabine and busulfan                                      |
| GvHD                       | Graft-versus-host disease                                     |
| GRFS                       | Graft-versus-host disease-free, relapse-free survival         |
| Confidential & Proprietary | 23                                                            |
| Version 6.0, 29 March 2019 |                                                               |
synopsis
list of abbreviations and definition

| Abbreviation               | Definition                                        |
|----------------------------|---------------------------------------------------|
| GvL                        | Graft-versus-leukemia                             |
| HCT                        | Hematopoietic stem cells                          |
| HHV-6                      | Human herpes virus 6                              |
| HIV                        | Human immunodeficiency virus                      |
| HLA                        | Human leukocyte antigen                           |
| HSA                        | Human serum albumin                               |
| HSC                        | Hematopoietic stem cells                          |
| HSV                        | Herpes simplex virus                              |
| HTLV                       | Human T-cell lymphotropic virus                   |
| IB                         | Investigator's Brochure                           |
| IBW                        | Ideal body weight                                 |
| ICF                        | Informed consent form                             |
| ICH                        | International Conference on Harmonisation         |
| IDMC                       | Independent Data Monitoring Committee             |
| IEC                        | Independent Ethics Committee                      |
| IFN                        | Interferon                                        |
| Ig                         | Immunoglobulin                                    |
| IL                         | Interleukin                                       |
| IRB                        | Institutional Review Board                        |
| IV                         | Intravenous                                       |
| IWRS                       | Interactive Web Response Services                 |
| MAC                        | Myeloablative conditioning                        |
| MDS                        | Myelodysplastic syndrome                          |
| mPB                        | Mobilized peripheral blood                        |
| MUGA                       | Multiple gated acquisition                        |
| NCI                        | National Cancer Institute                         |
| NIH                        | National Institutes of Health                     |
| NK                         | Natural killer                                    |
| NMDP                       | National Marrow Donor Program                     |
| NRM                        | Non-relapse mortality                             |
| NYHA                       | New York Heart Association                        |
| PCR                        | Polymerase chain reaction                         |
| PO                         | Orally                                            |
| RBC                        | Red blood cell                                    |
| RFS                        | Relapse-free survival                             |
| SAE                        | Serious adverse event                             |
| SAP                        | Statistical Analysis Plan                         |
| SDF-1                      | Stromal derived factor-1                          |
| SUSAR                      | Serious and unexpected suspected adverse reaction |
| TBI                        | Total body irradiation                            |
| Confidential & Proprietary | 24                                                |
| Version 6.0, 29 March 2019 |                                                   |  
| Abbreviation   | Definition                       |
|----------------|----------------------------------|
| TEAE           | Treatment-emergent adverse event |
| VZV            | Varicella zoster virus           |
synopsis
1 introduction and background information

Hematologic malignancies encompass a wide range of cancers that involve the bone marrow (BM) and lymph nodes. Rich in growth factors and cytokines, the BM provides an ideal microenvironment for hematologic malignancies that lends itself to progression of leukemogenesis and cancer progression (Raimondo et al. 2015). Malignancies of the BM, such as acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL), affect all ages (Smith et al. 2011). Recent advances in survival and treatment options using chemotherapy, transplantation, and radiation have resulted in survival rates around 90% for some hematologic malignancies (McLaughlin 2015). However, patients still incur numerous adverse reactions and systemic toxicities due to such therapies. For patients who do not obtain remission or who relapse, allogeneic hematopoietic cell transplantation (HCT) may be the only remaining treatment option (McLaughlin 2015). Before receiving allogeneic HCT, a patient must undergo 1 of 2 types of preparative treatment regimens: myeloablative conditioning (MAC) or non-MAC, such as reduced intensity conditioning. The goal of such conditioning regimens is to suppress the recipient's immune system sufficiently to allow adequate engraftment of the donor cells, to reduce the presence of neoplastic cells.
synopsis
1.2 hematopoietic stem cell transplants

For patients with advanced stages of hematologic malignancies, allogeneic HCT is often the only therapeutic option that offers the potential to prolong lifespan or even a curative outcome. While BM has historically been the principal source of hematopoietic stem cells (HSC) in allogeneic HCT, the majority of recent procedures have been conducted with mobilized peripheral blood (mPB) as a cell source, including mPB collected from matched related donors or matched unrelated donors (National Marrow Donor Program [NMDP] 2015). In the United States, approximately 20,000 patients receive autologous or allogeneic HCT each year (Majhail et al. 2015). Only one-third of all patients eligible for allogeneic HCT have a human leukocyte antigen (HLA)-matched related donor in their family and in those cases, transplant from a matched related donor becomes the optimal treatment.  
Patients who do not have an HLA-matched relative rely on alternative stem cell sources, which include: matched unrelated donors, haploidentical donors, and umbilical cord blood (Ballen et al. 2012). Approximately 50% to 60% of allogeneic HCTs reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) use unrelated donors (Majhail et al. 2015). Additionally, over the past decade, the number of peripheral blood cell grafts facilitated by the NMDP has grown substantially, such that currently around 75% of unrelated grafts are peripheral blood cells (Woolfrey et al. 2011). This shift toward the use of mPB over BM was enabled by the relative ease of collection, obviating the need to harvest T-cells from a donor through surgical aspiration of the BM. In addition, mPB results in quicker engraftment kinetics and potentially decreased early morbidity relative to BM (Schmitz et al. 2006; Nagler et al. 2012; Eapen et al. 2007). Specifically, several large, multicenter, randomized studies have collectively demonstrated that time to engraftment/reconstitution is faster and more robust with mPB than with BM, which may be associated with decreased rates of relapse and infections (Pidala et al. 2009). Numerous complications may arise from HCT, whether using BM, mPB, or umbilical cord blood.  
The primary complication that may arise from HCT is graft-versus-host disease (GvHD). The use of mPB is associated with higher rates of GvHD compared to BM, which has limited the universal adoption of this otherwise convenient and highly effective cell source for HCT. Infections are a second important contributor of morbidity and mortality for patients undergoing HCT. Transplant-related infections are a universal issue that span across the HCT spectrum of stem cell sources, donor graft types and conditioning regimens (Wingard et al. 2010). For patients undergoing HCT, there is a clear need for new approaches to reduce rates of GvHD without compromising the anti-leukemia and anti-infective properties of the T-cells in the graft.
synopsis
1.2.1 graft-versus-host disease

Graft-versus-host disease is the result of an intricate immune response following allogeneic stimuli, when T-cells of the donor recognize the presence of histocompatibility antigens in the host that differ from those of the donor cells. This initial antigen recognition results in T-cell activation and proliferation, which leads to the production and secretion of a variety of cytokines, which are responsible for the inflammatory effects and tissue damage associated with GvHD (Ferrara and Deeg 1991). Conventionally, GvHD was divided into acute and chronic variants based upon the time of onset, using an arbitrary cutoff of 100 days for acute GvHD (aGvHD). Risk factors for the development of GvHD include degree of HLA disparity (HLA mismatch), donor-recipient gender disparity, increasing age of the host, CMV status of donor and host, intensity of the transplant conditioning regimen, GvHD prophylactic regimen used, source of cell graft, greater pre-transplant comorbidities, and specific HLA haplotypes (Sorror et al. 2014; Hahn et al. 2008). Between 35% and 60% of patients who undergo allogenic HCT are likely to develop aGvHD (Jacobson and Vogelsang 2007, Choi and Reddy 2014). In 1974, Glucksberg published the first aGVHD classification (Glucksberg et al. 1974), modified by Thomas in 1975. The Glucksberg system remains the most commonly used system. Although this classification has prognostic value, it is complex. In fact, there are 125 possible combinations of organ involvement and severity, where each of 3 organs is staged from 0 to 4, which are then combined to calculate an overall grade. However, in the overall grading system, 62 of the possible 125 combinations are not defined (Cahn et al. 2005). In recognition of the systems limitations, a consensus workshop was held in 1995 and a modified Glucksberg grading system was proposed (Przepiorka et al. 1995) and a severity index published a year later (Rowlings et al. 1997). This modified grading scale is referred to as the CIBMTR grading scale. A revised CIBMTR scale was published in 2012 (CIBMTR Forms Manual 2012) and will be the scale by which aGvHD will be graded in this study. Acute GvHD is classified based on the degree of severity of the affected organs, skin, liver, and gastrointestinal tract, with involvement of each organ ranging from mild to severe based on the International Blood and Marrow Transplant Research Index (Majhail et al. 2015; Rowlings et al. 1997). Acute GvHD is then given an overall grade based a 4-grade scale, with Grade A (I) considered mild, Grade B (II) moderate, Grade C (III) severe, and Grade D (IV) life-threatening. The survival of patients at Day +100 post-transplant is reduced with increasingly severe aGvHD, with survival in less than 45% of patients with severe aGvHD (Weisdorf et al. 1990; Nash et al. 1992). Despite the accepted role of allogeneic T-cells in GvHD, the overall pathophysiology is still poorly understood. The development of predictive biomarkers to better assess the balance between GvHD
and graft-versus-leukemia (GvL), as well as response to therapy, may provide better insights into disease prognosis and treatment optimization. A number of biomarkers have been previously proposed and summarized (Rozmus and Shultz 2011). Human leukocyte antigen disparity between donor and recipient has been linked to incidence and severity of chronic GvHD (cGvHD), however while HLA-A/-B disparity increases risk of cGvHD, HLA-DR or -DQ does not. The role of minor histocompatibility antigens in promoting GvHD has been debated as has the role of non-HLA polymorphisms. Non-HLA polymorphisms associated with susceptibility or severity of GvHD include heparinase, poly-ADP-ribose polymerase 1, madCAM-1, haptoglobin, HMGB-1 CCR9, and a range of classical Th1 and Th2 cytokines, including interleukin (IL)-10, tumor necrosis factor-α, IL-6, IL-1α, and interferon (IFN)-ɣ. Increased numbers of CD8/CD4 T-cells, TH-17 T-cells, and monocytes can be observed in tissues affected by GvHD. Where practical, investigating the expression and distribution of putative biomarkers may provide additional insights into the safety and efficacy of novel approaches to treat or prevent GvHD.
synopsis
1.2.2 current strategies to prevent

In the mid-1980s, calcineurin-inhibitor-based regimens were first used for GvHD prevention and treatment (Choi and Reddy 2014). While there have been several new insights regarding the pathophysiology of GvHD, there has been little progress in GvHD prevention and treatment. Despite better HLA-matching between donor and recipient and GvHD prophylaxis methods, aGvHD. Graft-versus-host disease still develops in approximately 40% to 60% of recipients (Choi and Reddy 2014). Additional preventative and therapeutic measures used for GvHD include non-specific immunosuppressive drugs, such as corticosteroids and methotrexate, as well as more specific T-cell immunosuppressive drugs, such as cyclosporine and tacrolimus (FK506). Corticosteroids remain the most widely used "front-line" therapy for the treatment of clinical GvHD, commonly administered in combination with therapeutic doses of cyclosporine or tacrolimus. Long-term use of corticosteroids may result in numerous adverse reactions, including Cushingoid features, hyperglycemia, psychosis, dyslipidemia, myopathy, osteoporosis, cataract formation, osteonecrosis, and immunosuppression (Liu et al. 2013). In addition, corticosteroids have been linked with a variety of drug-drug interactions, including those that share critical metabolic steps mediated by cytochrome P450 enzymes, resulting in clearance of concomitantly administered corticosteroids (Feldweg and Leddy 1999). Given the number and severity of the side effects associated with existing treatment options, there is a clear need for new approaches to treat GvHD.
synopsis
1.2.3 infections in the hematopoietic

Despite significant improvements in the supportive care of HCT patients and modifications to the guidelines for infection prevention, infections remain the primary cause of death for 17% to 20% of patients who undergo allogeneic HCT (Tomblyn et al. 2009). As such, there remains an unmet medical need for the prevention and pre-emptive therapy of infections in the HCT setting. Cytomegalovirus is an important pathogen in patients who undergo an allogeneic HCT, since CMV can affect almost any organ, and can result in pneumonia, gastrointestinal ulcers, and retinitis. Without prophylaxis, CMV infection after allogeneic HCT affects approximately 80% of CMV-seropositive patients (Ljungman et al. 2011). Although current strategies have resulted in the decreased incidence of CMV disease, CMV prophylaxis and pre-emptive therapy are not without risk. Ganciclovir, a synthetic guanine derivative active against CMV, is one of several drugs utilized for both prophylaxis and pre-emptive therapy in patients receiving allogeneic HCT (Tomblyn et al. 2009). Those patients who do not tolerate standard doses of ganciclovir typically receive foscarnet, with lower doses in those with renal impairment (Tomblyn et al. 2009). The use of ganciclovir has an important toxicity profile as noted by its current black box warning for granulocytopenia, anemia, and thrombocytopenia diaphoresis (Ganciclovir [Systemic]: Drug Information 2015). In animal studies, ganciclovir was found to be carcinogenic, teratogenic, and caused aspermatogenesis (Ganciclovir [Systemic]: Drug Information 2015). Significant adverse reactions (>10%) of fever, diarrhea, anorexia, vomiting, cytopenias, retinal detachment, increased serum creatinine, sepsis, and diaphoresis are associated with ganciclovir (Ganciclovir [Systemic]: Drug Information 2015). When given at engraftment, ganciclovir can be deleterious to the graft due to prolonged neutropenia, and can result in more invasive bacterial and fungal infections (Boeckh et al. 1996; Goodrich et al. 1993; Salzberger et al. 1997). As use of pre-emptive anti-CMV therapy has increased, late CMV infection and disease (after Day +100) has become more significant following allogeneic HCT and is associated with non-relapse mortality (NRM) (Ozdemir et al. 2007). To minimize the toxicity from antiviral agents, most prefer a pre-emptive approach for CMV in HCT recipients rather than prophylaxis. The drawback of pre-emptive therapy, in addition to drug toxicity, is that the outcome is limited by the frequency and duration of monitoring (Tomblyn et al. 2009). The outcome of pre-emptive therapy is largely dependent on timely detection of CMV in the blood before the onset of disease and the early detection of CMV. Disease may occur due to missed surveillance tests or tests that are spaced too far apart. If a patient progresses to disease, treatment is not always effective; CMV pneumonia is the most detrimental complication of CMV in HCT recipients due to its high mortality rate, despite treatment (Reed et al. 1988). The opportunistic bacterial, viral, fungal, and parasitic pathogens that occur in allogeneic HCT recipients result in numerous clinical syndromes, including, but not limited to CNS and ocular manifestations, sinusitis and mucositis, pneumonia, esophagitis, diarrhea and colitis, hepatitis, hemorrhagic cystitis, nephritis, skin lesions, bone marrow suppression, blood stream infection, shock (including septic shock) and fever (Tomblyn et al. 2009). Among the current strategies for prophylaxis or pre-emptive therapy are fluoroquinolones (e.g., levofloxacin) and immune globulin intravenous (IV) for bacterial infections; acyclovir for HSV infections; fluconazole for fungal diseases; and trimethoprim sulfamethoxazole for parasitic infections (Tomblyn et al. 2009). The adverse reactions and toxicities from such drugs include, but are not limited to, anaphylaxis, QT prolongation; hepatoxicity and hematologic toxicity; central nervous system and dermatologic adverse reactions; pulmonary edema (e.g., transfusion-related acute lung injury); tendinitis and tendon rupture; exacerbation of muscle weakness; fatal reactions to agranulocytosis, aplastic anemia, and other blood dyscrasias; fatal renal failure; and fatal reactions to Stevens-Johnson syndrome and toxic epidermal necrolysis (Acyclovir [Systemic]: Drug Information 2015; Fluconazole: Drug Information. Lexicomp. 2015; Immune Globulin: Drug Information 2015; Levofloxacin [Systemic]: Drug Information 2015; Trimethoprim-Sulfamethoxazole [co-trimoxazole]: Drug Information 2015). In summary, infectious diseases are still a common cause of morbidity and mortality in patients undergoing HCT. Even in the setting of enhanced infectious disease surveillance, the therapies used in the prophylaxis and pre-emptive settings have limitations due to potentially severe or life-threatening toxicities, as well as possibly being deleterious to the graft. Therefore, there continues to be an unmet medical need for the prevention or treatment of infectious complications in patients who undergo an HCT transplant.
synopsis
1.3 protmune

ProTmune is a donor-sourced, patient-specific, allogeneic cell therapy product consisting of the cells contained within a human mobilized peripheral blood (mPB) collection that have been programmed through an *ex vivo* programming process using a combination of 2 small molecules, 16,16-dimethyl prostaglandin E2 (FT1050) and dexamethasone (FT4145). The cell populations include hematopoietic cells and other cell types. The objective of ProTmune is to prevent aGvHD and CMV infection. ProTmune products are manufactured by *ex vivo* programming of cells in donor mPB units with a combination of 16, 16-dimethyl prostaglandin E2 (dmPGE2, also referred to as FT1050) and a glucocorticoid (dexamethasone, also referred to as FT4145). ProTmune is intended for adults who will undergo HCT with cells contained in donor mPB units. Based on nonclinical data, ProTmune has the potential to reduce aGvHD while retaining GvL activity through programming a number of key biological pathways in both HSC and T-cells contained in mPB. Three processes are thought to be responsible for the development of aGvHD: cytokine storm following tissue injury caused by the conditioning regimen given prior to HCT, alloactivation of donor T-cells (activation, proliferation, and differentiation), and organ damage caused by direct cytotoxic activity or through the production of inflammatory cytokines (Hill and Ferrara 2000; Bouchlaka et al. 2010).
synopsis
1.3.1 effects of ft1050 and

In the nonclinical setting, ProTmune was found to have a significantly reduced allogeneic response in a mixed lymphocyte reaction. The reduced proliferation in response to an allogeneic target was accompanied by a significant reduction in IFN-ɣ cytokine response and concomitant induction of an immunomodulatory IL-4 response, suggesting that these cells have been programmed into a less responsive state. Consistent with this finding, *ex vivo* programming also served to upregulate expression of IL-10 by T-cells, a well-known potent and anti-inflammatory cytokine. This reduced proliferation response was also accompanied by decreased expression levels of the T-cell activation markers ICOS and 41BB. This phenotype may improve patient outcomes by preventing the unwanted cytokine-driven expansion of alloreactive T-cells in the first days and weeks following HCT. In addition, *in vivo* experiments demonstrated that programmed donor T-cells led to reduced rates of aGvHD without compromising the GvL response. Nonclinical studies are further summarized in Section 1.4.1.
synopsis
1.3.2 effects of f1050 and

FT1050 specifically interacts with HSC by binding the G protein-coupled prostaglandin receptors, EP2 and EP4, which activates adenylate cyclase and increases the intracellular levels of the secondary messenger molecule, cyclic adenosine monophosphate (cAMP). This increase in intracellular cAMP initiates a signaling cascade that activates cAMP response element-binding protein and other transcription factors in the nucleus inducing a number of gene expression changes in human CD34+ cells involved in cell cycle, anti-apoptosis and survival, and improved HSC function (North et al. 2007 and Hoggatt et al. 2009). Glucocorticoids were identified in a combinatorial small molecule screen performed at Fate. Dexamethasone (FT4145) was found to synergize with FT1050 to further enhance the homing and engraftment properties of HSC.
synopsis
1.3.3 role of ft1050 and

Approximately 30% of patients receive a suboptimal dose of HSC due to poor mobilization and collection, which can result in delayed neutrophil recovery and increased susceptibility to life-threatening infections (To et al. 2011). Approaches to improve HSC engraftment have previously focused on increasing numbers of donor HSCs using multi-week expansion strategies (Wagner et al. 2015); however, more recent approaches involve simple ex *vivo* programming strategies designed to enhance the homing efficiencies of HSCs to the BM niche (Hogatt et al. 2009; Greim et al. 2014). Several factors play a role in the engraftment of HSC into BM. Bone marrow niche sites represent specific microenvironments that promote the proliferation and differentiation of HSC into mature blood cells. An important phase of engraftment of HSC involves the homing of these cells to the appropriate sites within the BM. A key component of this homing mechanism is the interaction between stromal derived factor-1 (SDF-1), which is displayed on cells within the BM niche, and C-X-C chemokine receptor type 4 (CXCR4), which is expressed on the cell surface of HSC. The ligand-receptor interaction between SDF-1 and CXCR4 promotes the localization and retention of HSC in the BM niche. *Ex vivo* programming of mPB derived HSCs with FT1050 and FT4145 leads to significant upregulation of CXCR4 and enhanced migration *in vitro* to gradients of SDF-1 in transwell assays; see ProTmune Investigator's Brochure (IB). The mechanism of action for the 2 modulators, FT1050 and FT4145 is derived by a "cross-talk" that occurs via downstream intracellular signaling events which directly leads to the synergistic increase in CXCR4 gene and protein expression.
synopsis
1.4 risk/benefit 1.4.1 summary of

Homing is an important first step in the engraftment process in which circulating HSC actively cross the blood/BM endothelium barrier and lodge in BM niches. These niche sites represent specific microenvironments that promote the expansion and differentiation of HSC into progenitors and mature lineages. The receptor CXCR4 is one of the key surface receptors involved in stem cell homing, activation of this receptor by ligand binding promotes the migration of these stem cells towards the high levels of SDF-1α. Additionally, SDF-1α is the natural ligand for CXCR4 found in high levels in post-cytoablated BM (Hogatt et al. 2009). FT1050 and FT4145-programmed HSC exhibited dramatic upregulation of CXCR4 at both the messenger ribonucleic acid level (~60-fold, p≤0.0001; paired t-test; see ProTmune IB) and the surface protein level (p≤0.0005; paired t-test; see ProTmune IB). Hematopoietic stem cells programmed with FT1050 and FT4145 also displayed increased migration rates to a gradient of SDF-1 in an *in vitro* transwell migration assay relative to vehicle controls (p=0.0001; paired t-test). This increased directional migration demonstrates an increased SDF-1α homing ability in the programmed cells.
synopsis
1.4.1.2 in vivo repopulating ability

Increased CXCR4 levels on HSC may lead to an increased ability of these cells to migrate *in vivo* into BM stem cell niches and accelerate engraftment, thereby improving immune reconstitution. Using an immunodeficient mouse model, Fate evaluated the ability of *ex vivo* programming of mPB CD34+ cells with FT1050 and FT4145 to improve engraftment. Compared to untreated control cells, significantly enhanced engraftment (engraftment defined >0.5% human CD45 in the marrow, p=0.01; unpaired t-test) of human CD34+ treated with FT1050 and FT4145 was observed in several independent experiments with 3 different donors, with an average overall human hematopoietic cell engraftment of 8% at 8 weeks post infusion compared to 2.9% in the control group; see ProTmune IB. Human chimerism was tracked in the peripheral blood of human mPB CD34+ treated with vehicle, FT1050, or FT1050 and FT4145 for all 3 donors over time. This study demonstrated that *ex vivo* programming significantly improved long-term engraftment outcomes of human mPB CD34+
cells. Using *ex vivo* programming to enhance immune reconstitution minimizes the risks of infections and relapse. In multiple *in vitro* assays and *in vivo* models, HSC modulated with FT1050 and FT4145 demonstrated improved homing, migration and enhanced long-term engraftment.
synopsis
1.4.1.3 t-cell characterization studies

As highlighted earlier, one of the major complications associated with allogenic HCT is aGvHD mediated by allogenic activated donor T-cells. Fate has conducted several nonclinical studies to characterize how the T-cell compartment of mPB is affected by *ex vivo* programming with FT1050 and FT4145. T-cells programmed with FT1050 and FT4145 were characterized using both *in vitro* assays (e.g., mixed lymphocyte reactions) and *in vivo* models (e.g., GvHD and GvL). Programmed T-cells (both CD4 and CD8) had lower proliferation rates relative to vehicle-treated cells in a 5-day co-culture with mismatched peripheral blood mononuclear cells from a different donor. In the mouse GvHD model, T-cells programmed with FT1050 and FT4145 had reduced levels of inflammatory cytokines, reduced GvHD scores and enhanced survival relative to the vehicle treated cells; see ProTmune IB. Lastly, in mouse GvL models, T-cells programmed with FT1050 and FT4145 retained GvL activity against the A20 lymphoma cells; see ProTmune IB. ProTmune utilizes a small molecular modulator, referred to as FT4145, which synergizes with FT1050 to promote the supra-physiologic activation of genes implicated in the cell cycle, immune tolerance, and anti-viral properties of T-cells. Nonclinical *in vitro* and animal studies have demonstrated that mPB treated with FT1050 and FT4145 result in reduced allogeneic GvHD while maintaining GvL response, suggesting that ProTmune may provide a clinical benefit in terms of GvHD reduction. These data also suggest that programmed cell populations in mPB treated with FT1050 and FT4145 have further potential to prevent viral (CMV) reactivation though the same modulation of T-cells. Combined, these studies demonstrated that pharmacologic programming mPB cells with FT1050 + FT4145 prior to allogenic HCT may offer an innovative therapeutic approach to reduce rates of GvHD without compromising the GvL response.
synopsis
1.4.1.4 summary of nonclinical findings

Predictive *in vitro* assays and *in vivo* models have demonstrated the potential safety and efficacy of ProTmune. Results of the currently available *in vitro* and *in vivo* nonclinical studies have demonstrated that *ex vivo* programming of mPB cells with FT1050 and FT4145 can enhance engraftment of HSC and reduce GvHD through programming a number of key biological pathways in mPB T-cells. Reduced expression levels of phenotypic markers of activation is suggestive of a reduced activation capacity in the programmed T-cells that could, in concert with the cytokine data, lead to a lower potential for transplanted cells to promote GvHD in patients. Furthermore, mouse models demonstrated that treatment with FT1050 and FT4145 led to reduced GvHD scores, enhanced survival, reduced levels of pro-inflammatory cytokines without compromising the GvL activity of the T-cells. Taken together, these nonclinical studies demonstrate the safety and potential efficacy of ProTmune.
synopsis
1.4.2 summary of clinical studies

This study is the first time ProTmune programmed mPB will be administered to humans. Based on current nonclinical data, ProTmune programming of mPB is anticipated to be safe and well tolerated. In conjunction with continual safety monitoring for all subjects enrolled in the study, various clinical and biomarker endpoints will be monitored in this first-in-human trial. Refer to the ProTmune Investigator Brochure for additional information on the safety of ProTmune.
synopsis
1.5 rationale 1.5.1 proof-of-concept clinical

Recent results from Fate's Phase 2 PUMA clinical trial of ProHema (FT1050-programmed umbilical cord blood) provide compelling proof-of-concept data that *ex vivo* programming of donor grafts can enhance the therapeutic properties of donor-derived T-cells in the setting of HCT. Interim data from the PUMA study showed that subjects administered ProHema experienced a 46% reduction in severe viral infection-related adverse events following HCT. Specifically, 9 of 28 subjects administered ProHema, or 32%, experienced 1 or more severe viral infection-related adverse events (Grades 3 through 5) following HCT, as compared to 9 of 15 control subjects, or 60%. Immunophenotyping analysis of subject blood samples from the PUMA study taken at different time points post-HCT (30, 60, 100, and 180 days) showed that, in subjects administered ProHema, T-cells had improved persistence compared to T-cells of control subjects. These observations are consistent with a 2014 publication by Fate's collaborators that investigated the T-cell compartment of subjects administered ProHema in Fate's Phase 1b clinical trial of ProHema (Li et al. 2014). The collaborator's immunophenotyping analysis showed that the T-cell compartment of subjects administered ProHema exhibited a higher percentage of T-cells with a stem/memory phenotype compared to samples from historical control subjects (N = 53). The data from the PUMA study, including both the reduction in severe viral infection-related adverse events and the phenotypic changes to the T-cell compartment, provides supporting evidence for the ability to efficiently program donor immune cells. Infections are a major cause of morbidity and mortality for patients undergoing HCT procedures. During the first 100 days following HCT, graft-derived T lymphocytes provide the first wave of the immune protection against viral infections. The second wave of T-cells comes from de novo thymopoiesis, which typically requires 6 to 12 months to fully restore the T-cell compartment. Viral infections, including those from CMV, are particularly prevalent in the immediate post-transplant period, where it has been reported that over 90% of CMV infections occur within the first 100 days following HCT (Jain et al. 2014). The protection afforded by the graft-derived T-cells is limited during the initial period following HCT for several reasons. One of the factors that limits the effectiveness of the donor-derived T-cells in fighting viral infections results directly from the HCT conditioning regimen. In the days following HCT, high levels of inflammatory cytokines are present in patients' blood, which can drive the rapid expansion and exhaustion of the adoptively-transferred CD4+ and CD8+ T-cells. This response results in a depleted and functionally-impaired T-cell compartment, limiting the ability of these cells to provide immune protection.
synopsis
1.5.2 nonclinical data supporting protmune's

Fate has been advancing the nonclinical development of ProTmune, an mPB unit programmed with 2 small molecules, FT1050, which is the small molecule Fate uses for the production of ProHema, and FT4145. This development effort has been driven by Fate's specific intent of enhancing the therapeutic properties of donor T-cells in in the setting of HCT. Nonclinical studies demonstrate that *ex vivo* programming mPB with the combination of FT1050 and FT4145 renders the immune cells in mPB less responsive to the high levels of activating cytokines, which reduces the expansion and exhaustion of donor T-cells. *In vitro* assays designed to mimic the high levels of inflammatory cytokines found in patients following HCT show that programmed T-cells have reduced proliferation rates and reduced expression levels of key T-cell activation markers compared to vehicle treated cells; see ProTmune IB. Importantly, these assays show that the viability of the programmed T-cells is not negatively impacted; see ProTmune IB. Preliminary data suggests that preventing the rapid expansion and exhaustion of T-cells during the first week post-HCT has the potential to preserve a diverse T-cell repertoire over the first critical weeks and months following HCT, and that the programming of donor-derived T-cells has the potential to reduce the incidence of life-threatening viral infections.
synopsis
1.6 rationale for protmune clinical

Many patients with hematologic malignancies advance to a stage where allogeneic HCT becomes the only remaining therapeutic option that offers the potential to prolong lifespan or even a curative outcome. Approximately 50% to 60% of allogeneic HCTs reported to the CIBMTR use unrelated donors (Majhail et al. 2015). Over the past decade, the number of peripheral blood cell grafts facilitated by the NMDP has grown substantially, such that currently around 75% of HCT procedures that utilize unrelated grafts employ peripheral blood cells (Woolfrey et al. 2011). Several large, multicenter, randomized studies have collectively demonstrated that time to engraftment/reconstitution is faster and more robust with mPB than with BM (Pidala et al. 2009). However, mPB is also associated with higher rates of both acute and cGvHD (as compared to the use of BM or umbilical cord blood), which has limited the universal adoption of this otherwise convenient and highly effective cell source for HCT. This is attributed in part to the large number of T-cells infused with mPB as compared to other cell sources (Anasetti et al. 2012). Since no therapy has yet been approved for the prevention of GvHD, current treatments for GvHD include drugs prescribed off-label and can thus be ineffective. For patients undergoing HCT, there is a clear need for new approaches to reduce rates of GvHD without compromising the anti-leukemia and anti-infective properties of the T-cells in the graft. ProTmune has the potential to reduce aGvHD while retaining GvL activity through programming a number of key biological pathways in both HSC and T-cells in mPB. Additionally, previous clinical experience with one of the ProTmune programming agents (FT1050) suggests the potential of ProTmune to reduce viral infections following HCT. The nonclinical studies summarized previously demonstrate the safety and potential efficacy of ProTmune. Taken together, patients undergoing HCT who receive mPB that has been programmed using FT1050 and FT4145 are expected to have improved outcomes. The primary goal of this Phase 1/2 study is to assess the safety, tolerability, and potential efficacy of ProTmune for reduction of incidence and severity of aGvHD in adult subjects who have undergone a matched, unrelated HCT for hematologic malignancies.
synopsis
2 study objectives 2.1 primary

The primary objective of the Phase 1 part of the study is to evaluate the safety and tolerability of ProTmune *ex vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
synopsis
2.1.2 primary objective for the

The primary objective of the Phase 2 part of the study is to assess the efficacy of ProTmune ex *vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
synopsis
2.2 secondary objectives 2.2.1 secondary

The secondary objective of the Phase 1 part of the study is to assess the efficacy of ProTmune ex vivo programmed mPB cells for HCT in adult subjects with hematologic malignancies. 2.2.2 Secondary Objective for the Phase 2 Study The secondary objective of the Phase 2 part of the study is to further evaluate the safety and tolerability of ProTmune *ex vivo* programmed mPB cells for HCT in adult subjects with hematologic malignancies.
synopsis
2.3 exploratory objectives

2.3.1 Exploratory Objectives for the Phase 2 Part of the Study The exploratory objectives for the Phase 2 part of the study may include the following:
- To assess the incidence of neutrophil and platelet engraftment;
- To assess the time to neutrophil and platelet engraftment;
- To assess the cumulative incidence of aGvHD;  
- To assess the incidence of, and time to, CMV viremia, incidence and severity of CMV invasive disease, and incidence of CMV reactivation;
- To assess time to first CMV-specific anti-viral therapy (AVT); - To assess the incidence of confirmed bacterial, fungal, viral, and parasitic infections; - To assess the time to first use of an agent to treat an infection other than CMV as clinically indicated;
- To assess the time to first use of steroids to treat aGvHD;  
- To assess the time to escalation of treatment to first use of second line therapies for treatment of aGvHD;
- To assess first episode, incidence, and duration of fever;
- To assess biomarkers for aGvHD development;
- To assess incidence and maximum severity of cGvHD;
- To assess cumulative incidence of primary and secondary graft failure;
- To assess neutrophil and T-cell chimerism;
- To determine relapse-free survival;
- To determine the incidence of NRM;
- To determine the survival at one-year and at two-years; and - To assess immune reconstitution (including B, T, dendritic, and natural killer [NK] cells).
synopsis
3 study description 3.1 summary

This is a Phase 1, non-randomized, open-label/Phase 2, randomized, blinded, multi-center study of ProTmune *ex vivo* programmed mPB versus non-programmed mPB cells for allogeneic HCT in adult subjects with hematologic malignancies in the United States. All subjects in Phases 1 and 2 will receive a conditioning regimen comprising 1 of the following 5 preparative regimens:
fludarabine and busulfan (FluBu4); busulfan (Bu) and cyclophosphamide (Cy); Cy and ≥12 Gy total body irraditiation (TBI); TBI and etoposide; or fludarabine and melphalan (FluMel 140). Refer to Section 3.4 for a detailed description of the regimens required per the protocol. It is anticipated that the majority of subjects will be recruited from referrals for transplantation at the study sites. Potential study subjects can be pre-screened for study eligibility (evaluation of inclusion and exclusion criteria) based on the standard of care assessments that were completed prior to obtaining an informed consent, only with previously obtained Institutional Review Board (IRB) or Independent Ethics Committee (IEC) approval of such pre-screening procedures. Data will be requested from study centers in order to track screening and recruitment activity. Both the Phase 1 part of the study and Phase 2 part of the study will include a Screening Period (Day -53 through Day -11), Subject Conditioning Period (Day -10 through Day -1), Study Treatment Administration Day (Day 0; Day of HCT), Post-Transplant Follow-up Period (Day +1 through Day +730, consisting of Post-Transplant Assessment Days and Post-Transplant Weekly Assessments, then intermittent assessments), and an Early Withdrawal Visit (if applicable). Refer to Appendix A for a summary of the Study Procedures for the Phase 1 and 2 parts of the study. The total duration of subject participation will be up to 26 months for each subject in the Phase 1 part of the study and Phase 2 part of the study. The end of the study is considered as the completion through Day +365. All treated subjects will be followed for survival through Day +730 (i.e., 2 years). The study will utilize an Endpoint Adjudication Committee (EAC) blinded to treatment. The EAC will be responsible for adjudicating the aGvHD endpoint in accordance with the EAC charter.
synopsis
3.1.1 study design for the

The Phase 1 part of the study is a non-randomized, open-label, single-arm study that will enroll 6 to 10 subjects who have an available 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated peripheral blood cell donor. All eligible subjects enrolled in the Phase 1 part of the study will receive 1 unit of ProTmune *ex vivo* programmed mPB cells as the cell source for the HCT
procedure. For a study design schematic for the Phase 1 part of the study, refer to Appendix B. At initiation of the Phase 1 part of the study, 3 subjects will be enrolled and treated. At the time a subject engrafts (or fails to engraft by Day +28), a new subject may be treated. The study will utilize an EAC blinded to treatment who will be responsible for adjudicating the aGvHD endpoint in accordance with the EAC charter. Early stopping rules for the Phase 1 part of the study will be in place from the start of the study throughout the duration of the study and, if applicable, triggered prior to assessments by the Independent Data Monitoring Committee (IDMC). Refer to Section 3.1.3.1 for a description of the early stopping rules for the Phase 1 part of the study. An IDMC will convene to assess safety data as outlined in the IDMC Charter. At that time, the Sponsor, in consultation with and based on recommendations from the IDMC, will decide whether the study should stop or whether the Phase 2 study can begin.  
The Phase 1 part of the study will consist of approximately 5 to 10 sites in the United States.  
For a flow schematic for the Phase 1 part of the study, refer to Appendix C. A summary of the study visits for the Phase 1 part of the study are described below. For further detail regarding study procedures at each study visit, refer to Appendix A.
synopsis
screening period for the phase

The Screening Period will occur between Day -53 and Day -11 (i.e., up to 6 weeks prior to the Subject Conditioning Period). At Screening, all subjects will review and sign an informed consent form (ICF) and eligibility for study participation will be assessed. The Investigator will be required to verify that the subject completed HLA typing, which can be completed prior to the Screening Period. Peripheral blood will be collected during the Screening Period to serve as a baseline sample for immune reconstitution analysis. The results of the bone marrow aspirate, spirometry, and ECHO or multiple gated acquisition (MUGA) performed prior to consent may be used for subject qualification as long as performed within 6 weeks prior to the Subject Conditioning Period, from Day -53 to Day -11. As a part of screening, all subjects will be tested for baseline CMV antibody titer and plasma CMV viremia. This baseline testing will be performed by a central laboratory and results will be provided to the clinical site and sponsor before initiation of randomization. All concomitant medications will be recorded starting at Day -30 through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded. Subject Conditioning Period for the Phase 1 Part of the Study (Day -10 to Day -1) The Subject Conditioning Period will occur between Day -10 and Day -1. Day 0 is the day of mPB HCT transplant. Subject conditioning will be administered as the conditioning regimen per the protocol (refer to Section 3.4). Graft-versus-host disease prophylaxis will be administered to subjects. Anti-thymocyte globulin is not permitted during the study. FDA-approved prophylactic therapies for CMV prevention (e.g., letermovir) will be permitted. Refer to Section 3.5 for a description of pre-emptive therapy for infection. Pre-emptive CMV therapy will be provided based upon institutional methodologies, Standard Operating Procedures, and clinical context. An additional blood sample for CMV testing will be taken for central laboratory testing prior to starting the preemptive therapy. Other procedures for transplant preparation will also be performed at the Subject Conditioning Visit and per Institutional Standard. Adverse events will be collected during Phase 1 and 2 as per the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, AE of infections will use both the CTCAE and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN, Appendix G) criteria, as follows:  
- All serious adverse events (SAEs) will be recorded from Day -10 through Day +365, and only SAEs related to infused cells (ProTmune *ex vivo* programmed mPB cells or Control mPB cells)
from Day +366 through Day +730;
- Start of conditioning regimen (Day -10) through Day +100: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;
- From Day +100 through Day +365: Only adverse events associated with GvHD, infections, or secondary engraftment failure (Grades 1 through 5);
Hospital Admission for the Phase 1 Part of the Study Subjects will be admitted to the hospital based on institutional policy.
synopsis
study treatment administration for the

A 12-lead triplicate electrocardiogram (ECG) (sequential, within 15 minutes total), complete blood count (CBC), and blood chemistry will be obtained on Day 0 prior to HCT. All eligible subjects will receive study treatment on the day of HCT (Day 0). For the Phase 1 part of the study, study treatment will consist of a single unit of ProTmune *ex vivo* programmed mPB cells. The ProTmune graft will be prepared the same day as administration. Refer to the ProTmune IB for a description of release testing criteria. Refer to Section 3.6 for a description of the algorithm for reserve HSC. Karnofsky Performance Status will be assessed at Day 0, following transplantation (refer to Appendix D for a description of Karnofsky Performance Status). For a description of transfusion and support guidelines, refer to Section 3.7.
synopsis
post-transplant assessment days for the

Post-transplant visit windows are as follows: ±3 days for Day +7 through Day +100; ±14 days for Day +180; and ±28 days for Days +270, +365, and +730. Standard post-transplant testing will be performed per institutional guidelines and good clinical practice. The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting.
synopsis
post-transplant weekly visits for the

Clinical and laboratory assessments of aGvHD will be performed weekly from Day +1 through Day +100, and on Day +180. Acute GvHD assessments (incidence and maximum severity) of Grades I through IV of the skin, liver, and gut as per the CIBMTR aGvHD Grading Scale will be performed. For a description of the CIBMTR aGvHD Grading Scale, refer to Appendix E. Chronic GvHD assessments (incidence and maximum severity) of mild, moderate, or severe cGvHD as per National Institutes of Health (NIH) Consensus Criteria for cGvHD will be performed on Days +180, +270, and +365. For a description of the NIH Consensus Criteria for cGvHD, refer to Appendix F. Peripheral blood samples will be collected for CMV assessments of deoxyribonucleic acid (DNA)
by quantitative polymerase chain reaction (PCR) weekly from Days +7 through Day +100, and on Days +180, +270 and +365. Assessment of infection will be performed based on the NCI CTCAE and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) definitions. Study sites will monitor CMV viremia using local assays and frequencies as determined by local practices for in-patient and out-patient care. Therefore, if a blood sample is being drawn for a CMV PCR at a local virology laboratory, a sample must also be drawn at the same time and sent to the central virology laboratory for a CMV PCR result. See Appendix G. Peripheral blood will be collected for safety laboratory panels (hematology and serum chemistry), viral monitoring, immune reconstitution, chimerism, serum immunoglobulins, and GvHD exploratory biomarkers at the time points specified in Appendix A. A 12-lead triplicate ECG (sequential, within 15 minutes total) will be obtained at Day +100. Bone marrow aspirate will be sent to pathology and to cytogenetics on Day +21 (only if absolute neutrophil count [ANC] <500/µL), and as clinically indicated (flow cytometry is required on BM aspirate). Karnofsky Performance Status (Appendix D) will be assessed at all subsequent study visits after HCT up through Day +365 (which should include weekly assessments from Day +1 through Day +91, then on Days +100, +180, +270, and +365). The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting.
synopsis
unscheduled visits

An unscheduled visit is a visit that occurs in addition to the predefined protocol specific visit calendar. If an unscheduled visit occurs for a given subject, the visit must be documented on the Unscheduled Visit CRF.
synopsis
early withdrawal visit for the

If a subject is withdrawn from participation in the study prior to Day 0, the subject's mPB will not be processed to a unit of ProTmune *ex vivo* programmed mPB cells, the subject will not be considered evaluable for any study-related endpoint analyses, and the subject will be replaced. If a subject withdraws from the study after transplantation, information regarding secondary graft failure, disease relapse, serious adverse events involving GvHD and infections, and survival outcomes will be collected by phone on Days +180, +365, and +730. If a subject withdraws consent, survival outcomes will be assessed via public record search. If the subject relapses and/or receives a protocol-prohibited therapy, the subject will be withdrawn from the study. However, survival will still be collected at Day +730 by telephone contact unless the subject withdraws consent, in which case survival outcomes will be assessed via public record search. A peripheral blood sample for safety laboratory panels (hematology and serum chemistry) will be collected. Karnofsky Performance Status should be assessed (Appendix D), and GvHD assessments (incidence and maximum severity) (Appendix E and Appendix F) must be performed. In instances where donors require plerixafor for mobilization of peripheral blood, the subject will be off-study and replaced.
synopsis
3.1.2 study design for the

The Phase 2 part of the study may begin after 6-10 subjects have completed Phase 1 and the safety data has been reviewed by the IDMC. If after 6 subjects have been dosed and evaluated in Phase 1 for up to 28 days and ≤1 subject has not engrafted by Day +28, then enrollment in the Phase 2 portion of the study may proceed following IDMC review. The Phase 2 part of the study is a randomized, blinded, 2-arm study that will treat approximately 80 subjects who have an available 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated peripheral blood cell donor. After meeting eligibility, approximately 90 subjects (assuming a dropout rate of approximately 15% prior to treatment) will be randomly assigned in a 1:1 ratio to receive either unmanipulated mPB cells (control arm) or ProTmune *ex vivo* programmed mPB cells
(experimental arm) and stratified by the subjects' CMV status). For a study design schematic of the Phase 2 part of the study, refer to Appendix H. The study will utilize an Endpoint Adjudication Committee (EAC) blinded to treatment. The EAC will be responsible for adjudicating the aGvHD endpoint in accordance with the EAC charter. Early stopping rules for the Phase 2 part of the study will be in place from the start of the study throughout the duration of the study and, if applicable, triggered prior to assessments by the IDMC. With the exception of the stopping rules associated with the failure of ProTmune to meet release specifications, there are no formal stopping rules for the Phase 2 part of the study. Stopping subject treatment may be triggered based on the continued review of subject safety data on study by the Sponsor and IDMC. If the investigational product does not meet release specifications to treat 2 of the first 3 subjects, 3 of the first 6 subjects, or 5 of the first 10 subjects or 10 of the first 20 subjects, subject treatment in the Phase 2 part of the study will be stopped. Refer to Section 3.1.3.2 for a description of the early stopping rules for the Phase 2 part of the study. During the Phase 2 part of the study, the IDMC will convene according to the guidelines outlined in the IDMC Charter. Additional safety monitoring based on NRM, secondary graft failure, and IDMC input will be applied during the study for the Phase 1 and Phase 2 parts of the study. The Phase 2 part of the study will comprise approximately 14 to 20 sites in the United States. For a flow schematic for the Phase 2 part of the study, refer to Appendix I. A summary of the study visits for the Phase 2 part of the study are described below. For further detail regarding study procedures at each study visit, refer to Appendix A.
synopsis
screening period for the phase

The Screening Period will occur between Day -53 and Day -11 (i.e., up to 6 weeks prior to the Subject Conditioning Period). At Screening, all subjects will review and sign an ICF and eligibility for study participation will be assessed. The Investigator will be required to verify that the subject completed HLA typing. HLA typing can be completed prior to the Screening Period. Peripheral blood will be collected during the Screening Period for baseline immune reconstitution analysis. After meeting eligibility, subjects will be randomly assigned in a 1:1 ratio to receive either unmanipulated mPB cells (control arm) or ProTmune *ex vivo* programmed mPB cells (experimental arm) and stratified by the subjects' CMV status. The results of the bone marrow aspirate, spirometry, and ECHO or multiple gated acquisition
(MUGA) performed prior to consent may be used for subject qualification as long as performed within 6 weeks prior to the Subject Conditioning, from Day -53 to Day -11. As a part of screening, all subjects will be tested for baseline CMV antibody titer and plasma CMV viremia. This baseline testing will be performed by a central laboratory and results will be provided to the clinical site and sponsor before initiation of randomization. All concomitant medications will be recorded starting at Day -30 through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded.
synopsis
subject conditioning period for the

The Subject Conditioning Period will occur between Days -10 and Day -1 (i.e., up to 9 days prior to Hospital Admission). Subject conditioning will be administered as the conditioning regimen, as required per the protocol (refer to Section 3.4). Graft-versus-host disease prophylaxis will be administered. Anti-thymocyte globulin is not permitted during the study. FDA-approved prophylactic therapies for CMV prevention (e.g., letermovir) will be permitted. Refer to Section 3.5 for a description of pre-emptive therapy for infection. Pre-emptive CMV therapy may be provided based upon institutional methodologies, Standard Operating Procedures, and clinical context. An additional blood sample for CMV testing will be taken for central laboratory testing prior to starting the preemptive therapy. Other procedures for transplant preparation will also be performed at the Subject Conditioning Visit and per Institutional Standard. Adverse events will be collected during Phase 1 and 2 as per the CTCAE version 4.0, AE of infections will use both the CTCAE and the Blood and Marrow Transplant Clinical Trials Network (BMT CTN, Appendix G) criteria, as follows:  
- All SAEs will be recorded from Day -10 through Day +365, and only SAEs related to infused cells (ProTmune mPB cells or Control mPB cells) from Day +366 through Day +730;
- Start of conditioning regimen (Day -10) through Day +100: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;
- From Day +100 through Day +365: Only adverse events associated with GvHD, infections, or secondary engraftment failure (Grades 1 through 5).
Hospital Admission for the Phase 2 Part of the Study Subjects will be admitted to the hospital based on institutional policy. Study Treatment Administration for the Phase 2 Part of the Study (Day 0; Day of Hematopoietic
synopsis
cell transplant)

A 12-lead triplicate ECG (sequential, within 15 minutes total), CBC, and blood chemistry will be obtained on Day 0 prior to HCT. All eligible subjects will receive study treatment on the day of HCT (Day 0). For the Phase 2 part of the study, study treatment will consist of either a single unit of ProTmune *ex vivo* programmed mPB cells or a single unit of unmanipulated mPB cells, based upon the subject's randomized treatment allocation. The ProTmune graft will be prepared the same day as administration. Refer to the ProTmune IB for a description of release testing criteria. Karnofsky Performance Status (Appendix D) will be assessed at Day 0, following transplantation. For a description of transfusion and support guidelines, refer to Section 3.7.
synopsis
post-transplant assessment days for the

Post-transplant visit windows are as follows: ±3 days for Day +7 through Day +100; ±14 days for Day +180; and ±28 days for Days +270, +365, and +730. Standard post-transplant testing will be performed per institutional guidelines and good clinical practice. The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting.
synopsis
post-transplant weekly visits for the

Clinical and laboratory assessments of aGvHD will be performed weekly from Day +1 through Day +100, and at Day +180. Acute GvHD assessments (incidence and maximum severity) of Grades I through IV aGvHD of the skin, liver, and gut as per the CIBMTR aGvHD Grading Scale. For a description of the CIBMTR cGvHD Grading Scale, refer to Appendix E. Chronic GvHD assessments (incidence and maximum severity) of mild, moderate, or severe cGvHD as per NIH Consensus Criteria for cGvHD must be performed on Days +180, +270 and +365. For a description of the NIH Consensus Criteria for cGvHD, refer to Appendix F. Peripheral blood samples will be collected for CMV assessments of DNA by quantitative PCR weekly from Days +7 through Day +100, and at Days +180, +270 and +365. Assessment of infection will be performed based on the NCI CTCAE and the BMT CTN Definitions. Study sites will monitor CMV viremia using local assays and frequencies as determined by local practices for in-patient and out-patient care. Therefore, if a blood sample is being drawn for a CMV PCR at a local virology laboratory, a sample must also be drawn at the same time and sent to the central virology laboratory for a CMV PCR result. See Appendix G.  
Peripheral blood will be collected for safety laboratory panels (hematology and serum chemistry), viral monitoring, immune reconstitution, chimerism, serum immunoglobulins, and GvHD exploratory biomarkers at the time points specified in Appendix A. A 12-lead triplicate ECG (sequential, within 15 minutes total) will be obtained at Day +100. Bone marrow aspirate will be sent to pathology and to cytogenetics on Day +21 (only if ANC <500/µL), and as clinically indicated (flow cytometry is required on BM aspirate). Karnofsky Performance Status (Appendix D) will be assessed at all subsequent study visits after HCT up through Day +365 (which should include weekly assessments from Day +1 through Day +91, then on Days +100, +180, +270, and +365). The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting.
synopsis
unscheduled visits

An unscheduled visit is a visit that occurs in addition to the predefined protocol specific visit calendar. If an unscheduled visit occurs for a given subject, the visit must be documented on the Unscheduled Visit CRF.
synopsis
early withdrawal visit for the

If a subject is withdrawn from participation in the study prior to Day 0, the subject's mPB will not be processed to a unit of ProTmune *ex vivo* programmed mPB cells, the subject will not be considered evaluable for any study-related endpoint analyses, and the subject will be replaced. If this occurs in the Phase 2 portion of the study and the subject was already randomized, the subject will be replaced and a new subject will be randomized in order to have approximately 80 treated subjects. If a subject withdraws from the study after transplantation, information regarding secondary graft failure, disease relapse, serious adverse events involving GvHD and infections, and survival outcomes will be collected by phone on Days +180, +365, and +730. If a subject withdraws consent, survival outcomes will be assessed via public record search. If the subject relapses and/or receives a protocol-prohibited therapy, the subject will be withdrawn. However, survival will still be collected unless the subject withdraws consent, in which case survival outcomes will be assessed via public record search. A peripheral blood sample for safety laboratory panels (hematology and serum chemistry) will be collected. Karnofsky Performance Status should be assessed (Appendix D), and GvHD assessments must be performed, as applicable. In instances where donors require plerixafor for mobilization of peripheral blood, the subject will be off-study and replaced.
synopsis
3.1.3 early stopping rules for

At initiation of the Phase 1 part of the study, 3 subjects will be enrolled and treated. At the time a subject engrafts (or fails to engraft by Day +28), a new subject may be treated. If 2 or more subjects fail to engraft by Day +28, or if 2 or more subjects experience secondary graft failure by Day +28, or if 2 of the first 3 or 4 of the first 6 subjects treated have died by ≤Day +28, subject treatment will be stopped until the IDMC has assessed the cases and discussed with the Sponsor. The IDMC will be notified of all subject deaths occurring on study. If the investigational product does not meet release specifications to treat 2 of the first 3 subjects, 3 of the first 6 subjects, or 5 of the first 10 subjects, subject treatment will be stopped pending review by the IDMC.
synopsis
3.1.3.2 early stopping rules for

With the exception of the stopping rules associated with the failure of ProTmune to meet release specifications, there are no formal stopping rules for the Phase 2 part of the study. Stopping subject treatment may be triggered based on the continued review of subject safety data on study by the Sponsor and IDMC. If the investigational product does not meet release specifications to treat 2 of the first 3 subjects, 3 of the first 6 subjects, or 5 of the first 10 subjects or 10 of the first 20 subjects, subject treatment in the Phase 2 part of the study will be stopped, pending review by the IDMC.
synopsis
3.2 independent data monitoring committee

During the Phase 1 part of the study, an IDMC will convene to assess safety data as outlined in the IDMC Charter. At that time, the Sponsor, in consultation with and based on recommendations from the IDMC, will decide whether the study should stop or whether the Phase 2 study can begin.  
If the IDMC and Sponsor determine that there are no safety concerns based on Phase 1 safety data, Phase 2 study enrollment will begin. During the Phase 2 part of the study, the IDMC will convene according to the guidelines outlined in the IDMC Charter. Additional safety monitoring based on NRM, secondary graft failure, and IDMC input will be applied during the study for the Phase 1 and Phase 2 parts of the study.
synopsis
3.2.1 endpoint adjudication committee

The study will utilize an Endpoint Adjudication Committee (EAC) blinded to treatment assignment. The EAC will be responsible for adjudicating the aGvHD endpoint in accordance with the EAC charter.
synopsis
3.3 study indication(s)

For the Phase 1 and Phase 2 part of the study, ProTmune will be evaluated for the reduction of incidence and severity of acute GvHD in adult subjects with hematologic malignancies.
synopsis
3.4 conditioning and graft-versus-host disease

All eligible subjects in the Phase 1 part of the study and Phase 2 part of the study will receive 1 of the following 5 preparative regimens:
- CyTBI, with ≥12 Gy fractionated TBI;  
- BuCy where Bu = 16 mg/kg orally (PO) or 12.8 mg/kg IV infusion (alternatively, pharmacokinetic assessment and dose adjustment of Bu can be based on a test dose or the first dose and will be conducted according to institutional practices);
- FluBu4 with Bu as above;
- TBI and etoposide; or
- FluMel 140 Graft-versus host disease prophylaxis will be administered to all subjects. The GvHD prophylaxis regimen:  
- Methotrexate (15 mg/m2 IV infusion on Day +1 after hematopoietic cell infusion and 10 mg/m2 on Days +3, +6, and +11), and
- Tacrolimus (0.02 mg/kg every 24 hours as an IV infusion or 0.03 mg/kg PO beginning on Day
-2, adjusted to target dose level of 5 to 15 ng/mL. Taper starting at Day +100).
The GvHD prophylaxis may be dose reduced based on clinical judgment and associated with toxicity. All chemotherapy administered to subjects will be dosed based on the subject's actual body weight. However, for subjects weighing more than 125% of their ideal body weight (IBW), chemotherapy will be dosed based on the adjusted ideal body weight (AIBW), or by Institutional Standards (Hicks et al. 2012).
synopsis
ideal body weight formula

Males IBW = 50 kg + 2.3 kg/inch over 5 feet Females IBW = 45.5 kg + 2.3 kg/inch over 5 feet
synopsis
adjusted ideal body weight formula

AIBW = IBW + [(0.25) × (Actual Body Weight - IBW)]
synopsis
3.5 prophylactic and pre-emptive therapy

For the study, prophylactic and pre-emptive therapy for viral infection for the Phase 1 part of the study and Phase 2 part of the study comprise the following:
- FDA-approved prophylactic therapies for CMV prevention (e.g., letermovir) will be permitted;  
- Two peripheral blood samples at each testing time point (1 blood sample to be utilized locally at the site for subject management and 1 blood sample for central laboratory testing) will be collected for viral assessments of DNA by quantitative PCR for Epstein Barr Virus (EBV), CMV, human herpes virus 6 (HHV-6), and BK virus weekly from Days +7 through Day +100, and at Days +180, +270 and +365;
- Pre-emptive CMV therapy may be initiated based upon institutional policies and procedures, Standard Operating Procedures, and clinical context. An additional blood sample for CMV testing will be obtained for central laboratory testing and prior to starting the preemptive therapy. and
- If clinical site viral testing is positive, subjects will receive pre-emptive therapy with an anti-viral therapy (i.e., ganciclovir, foscarnet, etc.) per Institutional Standard.
synopsis
3.6 reserve hematopoietic stem cells

For subjects enrolled in the Phase 1 part of the study, a reserve dose of 2 × 106 CD34+ cells/kg recipient weight will be maintained during ProTmune manufacturing to serve as a reserve in the event ProTmune manufacturing produces a ProTmune unit that does not meet ProTmune release specifications (e.g., <2 × 106 CD34+ cells/kg recipient weight, <70% viable). In this case, the ProTmune unit will be considered "unavailable" and count towards the Phase 1 stopping rules. The reserve unit must be administered; however, the Principal Investigator should follow their Institution's standard operating procedure to determine whether the ProTmune unit should also be given to the recipient based on the risk-benefit assessment of administering the product with regard to the specification not being met. If the ProTmune unit is not administered, the subject will be withdrawn from study and replaced. If the ProTmune unit is administered, the subject will remain in study but will not be considered in the following assessment- "If after 6 subjects have been dosed and evaluated for up to 28 days and ≤1 subject has not engrafted by Day +28, then enrollment in the Phase 2 portion of the study may proceed following IDMC review". If the reserve unit is not used on Day 0, it will be cryopreserved at the site and can be used in the event of non-engraftment, or delayed engraftment. If unused, the reserve dose may be disposed of in accordance with institutional practices.
synopsis
3.7 transfusion and support guidelines

The following guidelines for platelet and red blood cell (RBC) transfusions will be followed starting on Day 0:  
- Platelet and RBC transfusion technical support will be dictated by Institutional guidelines including product irradiation and CMV status of transfused product;
- Platelet threshold transfusion guidelines:
o A threshold of 10 ×109/L for prophylactic platelet transfusion; o A threshold of 20 ×109/L for fever, sepsis, splenomegaly, and other well-established causes of increased platelet consumption; o A threshold of >50 ×109/L if an invasive procedure is planned; o Single donor platelets should be used in preference to random donor platelets, if feasible; and o HLA-matched platelets should be used in subjects with allo-immunization;
- Red blood cell transfusion guidelines:
o An attempt should be made to maintain the hematocrit ≥24% and hemoglobin >8 g/dL, or higher in cases of symptomatic management of anemia or other medically indicated indications; and
- Filgrastim (granulocyte-colony stimulating factor) can be administered at 5 µg/kg/day beginning on Day +12, if engraftment has not occurred, until the ANC is >500 cells/µL. At Investigator discretion, filgrastim can be administered longer to support the white blood cells. Similarly, per Investigator discretion, filgrastim may be started before Day +12 if subsequent doses of methotrexate will not be administered due to severe mucositis, other toxicity, or severe infection.
synopsis
4 selection and withdrawal of

Subjects who meet all of the following criteria will be eligible to participate in the study: 1. Male and female subjects aged 18 years and older;  
2. Subjects must have a hematologic malignancy for which allogeneic hematopoietic peripheral blood cell transplantation is deemed clinically appropriate. Eligible diseases and stages include and are limited to the following:
- Acute myeloid leukemia in first complete remission (CR) (CR1) or second CR (CR2):
o CR is defined as ≤5% BM blasts with no morphological characteristics of acute leukemia (e.g., Auer Rods) in BM with ≥5% cellularity with normal peripheral blood counts; or o Morphologic CR (≤5% BM blasts) with incomplete blood count recovery;
- Acute lymphoblastic leukemia (ALL), including T lymphoblastic lymphoma with a history of marrow involvement in CR1 or CR2:
o CR is defined as ≤5% blasts with no morphological characteristics of acute leukemia in a BM with ≥5% cellularity;
- Myelodysplastic syndrome (MDS); or
- Chronic myelogenous leukemia (CML);
3. Availability of a suitable 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated mPB donor; 4. Subjects must have an mPB donor collection unit **without** using plerixafor (Mozobil™) that is
≥5 × 106 CD34+ cells/kg in Phase 1 and ≥3 × 106 CD34+ cells/kg in Phase 2; 5. Adequate performance status, defined as Karnofsky score ≥70%;
6. For female subjects of childbearing potential, all of the following criteria must be met:
- They are not pregnant (i.e., female subjects must have a negative serum pregnancy test at screening);
- They are not breastfeeding; - They do not plan to become pregnant during the study; and  
- They are using an effective method of contraception from screening to the end of the study, unless their sexual partner is surgically sterile. Effective methods of preventing pregnancy are those contraceptive methods with a Pearl index of <1 used consistently and correctly (including, but not limited to, implantable contraceptives, injectable contraceptives, oral contraceptives, and transdermal contraceptives);
Women are not considered to be of childbearing potential if they meet 1 of the following 2 criteria, as documented by the Investigator:  
- They have had a hysterectomy, bilateral salpingectomy, or bilateral oophorectomy at minimum 1 menstrual cycle prior to signing the ICF; or
- They are post-menopausal, defined as ≥1 year since their last menstrual period for women
≥55 years of age or ≥1 year since their last menstrual period; and
7. For male subjects, agreement to use condoms with spermicide during sexual intercourse from screening to the end of study; and 8. Willingness and ability to sign an IRB/IEC-approved ICF before performance of any study specific procedures or tests and to comply with protocol visits, and study procedures.
synopsis
4.2 exclusion criteria for the

Subjects who meet any of the following criteria will be excluded from participation in the study: 1. Phase 1 only: Known bone marrow fibrosis; Phase 2 only: Bone marrow fibrosis grade 3
(severe) or greater;  
2. Positive serology for human immunodeficiency virus (HIV) or human T-cell lymphotropic virus (HTLV) at any time prior to enrollment; 3. Current uncontrolled bacterial, viral, or fungal infection (progression of clinical symptoms despite therapy);
4. Prior autologous or allogeneic HCT; 5. Active malignancy, other than the one for which the allogeneic mPB transplant is being performed, within 12 months of enrollment, excluding superficial basal cell and carcinoma in situ cervical cancer; 6. Pulmonary disease such as symptomatic chronic obstructive lung disease, symptomatic restrictive lung disease, or FVC and FEV1 <50%, or hemoglobin corrected diffusing capacity of the lung of <50% of predicted value; 7. Renal dysfunction defined as a calculated creatinine clearance <40 mL/min (Cockroft-Gault equation);
8. Hepatic disease defined as total serum bilirubin >2.0 mg/dL (except in the case of Gilbert's syndrome or ongoing hemolytic anemia), or aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >2.0 × the upper limit of normal; 9. Cardiac disease defined as symptomatic congestive heart failure (New York Heart Association
[NYHA] Class III/IV) or evidence of left ventricular dysfunction (ejection fraction <45%) as measured by gated radionuclide ventriculogram or echocardiogram (ECHO); active angina pectoris or uncontrolled hypertension; or history of myocardial infarction with depressed ejection fraction;
10. Neurologic disease, defined as symptomatic leukoencephalopathy, active central nervous system malignancy, or other neuropsychiatric abnormalities believed to preclude transplantation;  
11. Participation in another clinical trial involving an investigational product within 30 days prior to transplant; or 12. Any condition or therapy, which, in the opinion of the Investigator, might pose a risk to the subject or make participation in the study not in the best interest of the subject (e.g., known allergy to human serum albumin [HSA]).
synopsis
4.3 withdrawal criteria

A subject may voluntarily withdraw from the study at any time and without prejudice to his or her future medical care by the Investigator or at the institution. The Investigator, at his or her discretion, may withdraw a subject from participating in the study. Participation of a subject in this clinical study can be discontinued for any of the following reasons:  
1. The subject withdraws consent or requests discontinuation from the study for any reason; 2. Occurrence of any medical condition or circumstance that exposes the subject to substantial risk and/or does not allow the subject to adhere to the requirements of the protocol; 3. Any serious adverse event (SAE), clinically significant adverse event, severe laboratory abnormality, intercurrent illness, or other medical condition which indicates to the Investigator that continued participation is not in the best interest of the subject; 4. Pregnancy; 5. Requirement of prohibited concomitant medication; 6. Subject failure to comply with protocol requirements or study-related procedures, including lost to follow-up; 7. Other safety or ethical reasons; or 8. Discontinuation of the study by the Sponsor or the regulatory authority.
If a subject withdraws prematurely from the study due to the above criteria or any other reason, study staff should make every effort to complete the full panel of assessments scheduled for the Early Withdrawal Visit. The date and reason for subject withdrawal from the study must be documented in the electronic Case Report Form (eCRF). In the case of subjects lost to follow-up, attempts to contact the subject must be made and documented in the subject's medical records. If a subject withdraws from the study after transplantation, information regarding secondary graft failure, disease relapse, serious adverse events involving GvHD and infections, and survival outcomes will be collected on Days +180, +365, and +730 by phone. If the subject relapses and/or receives non-protocol therapy, the subject will be withdrawn. However, survival will still be collected unless the subject withdraws consent, in which case survival outcomes will be obtained via public record search. If the Sponsor discontinues the study, the Investigator should notify the IRB/IEC in writing of the study's completion or discontinuation and send a copy of the notification to the Sponsor.
synopsis
4.4 screen failures and subject

A screen failure is any subject who signs consent but fails to meet at least one of the eligibility requirements during screening and whose donor cells are not processed as ProTmune or Control.  
This may occur for many reasons, such as:  
- The donor unit does not meet requirements for ProTmune (or Control) processing, such as CD34+ count of the mPB unit is lower than specified in the protocol or cannot be processed prior to the expiration of the unit,
- The donor requires plerixafor for mobilization of peripheral blood.  
In all cases, the subject will be considered a screen-failure, will not continue in study and will be replaced. If this occurs after randomization in the Phase 2 portion of the study, a new subject will be randomized. In the event ProTmune/Control manufacturing produces a ProTmune/Control unit that does not meet release specifications (e.g. for ProTmune, <2 × 106 CD34+ cells/kg recipient weight, <70%
viable) and the ProTmune/Control unit is not administered, the subject will be withdrawn from the study and a new subject will be added for the Phase 1 portion of the study. If this occurs in the Phase 2 portion of the study, the subject will be replaced and a new subject will be randomized in order to have approximately 80 treated subjects.
synopsis
5 study treatments 5.1 treatment

For the Phase 1 part of the study, 6 to 10 subjects will receive a single unit of ProTmune ex *vivo* programmed mPB cells as the cell source for the HCT procedure at Day 0.
synopsis
5.1.2 study treatment groups for

For the Phase 2 part of the study of the study, all eligible subjects will receive either a single unit of ProTmune *ex vivo* programmed mPB cells or a single unit of unmanipulated mPB cells, based upon the subject's randomized treatment allocation.
synopsis
5.2 rationale for dosing

According to the American Society of Blood & Marrow Transplant, the absolute cell threshold to guarantee engraftment is not specifically known. The minimally accepted cells dose is 2 × 106 CD34+ cells/kg. The literature reports successful engraftment can occur at doses as low as 0.75 × 106 CD34+ cells/kg. However, higher doses are associated with faster engraftment, reduced rates of infection, and NRM. Therefore, the Sponsor has selected a target minimum treatment dose of ≥2 × 106 CD34+ cells/kg.
synopsis
5.3 randomization and blinding 5.3.1

Randomization and blinding for the Phase 1 part of the study are not applicable. The Phase 1 part of the study is nonrandomized and open-label.
synopsis
5.3.2 randomization and blinding for

For the Phase 2 part of the study, approximately 90 subjects who have an available 8/8 HLA-A, -B, -C, and -DRB1-matched unrelated peripheral blood cell donor will be randomly assigned in a 1:1 ratio to result in approximately 80 treated subjects (40 subjects per treatment group) to receive either unmanipulated mPB cells (control arm) or ProTmune *ex vivo* programmed mPB cells
(experimental arm) and stratified by the subjects' CMV status. Randomization will be performed during the Subject Conditioning Period once the central lab CMV results are known and must occur no later than Day -7. Treatment assignment in Phase 2 will be blinded to Investigator, subject and Sponsor, but not Cell Processing Facility (CPF) staff. To blind the Investigator and subject, ProTmune and control mPB units will be prepared by the CPF as described in the cell processing batch records and then sent to the treatment area in the afternoon for administration to the subject. Infusion of the control unit will be held until the afternoon of the subject's Day 0 to mimic the processing time of ProTmune. The ProTmune unit and Control unit will look similar. Both ProTmune and Control will be placed in 400 mL blood transfer bags. The volume of each unit may be reduced or increased to achieve a final volume of 250 mL; volume increases will be achieved by addition of PlasmaLyte-A (or equivalent) with 4.2% - 5% HSA according to the Batch Production record and site protocol. The blood transfer bags will be labeled with a Fate-provided product label that will maintain the blind to investigator and subject.
synopsis
5.4 breaking the blind

The Phase 1 part of the study is not blinded, and although the Phase 2 part of the study is blinded, it is likely not necessary to break the blind to the Investigator or subject as knowledge of the singledose treatment assignment would not impact any aspects of subject management. Should the Investigator require the treatment assignment, the following unblinding procedure must be followed:  
1. Locate the sealed envelope that contains the 6-digit unblinding authorization code provided to your site, 2. Log into the ClinTrak interactive response technology (IRT) database and select the
"Unblind a Patient (Emergency Only)" action, 3. Select the subject number from the drop-down menu and enter the 6-digit code, 4. The treatment assignment will be provided by the system and a notification of unblinding will be sent to the study Sponsor and CRO.
Note: The Investigator must print and file the unblinding notification within the subject's source documentation along with a written rationale for the necessity to unblind the subject. A new sealed envelope with a 6-digit unblinding authorization code will be sent to the site for use with future subjects.
synopsis
5.5 drug supplies 5.5.1 formulation

ProTmune is a donor-sourced, patient-specific, allogeneic cell therapy product consisting of the cells contained within a human mobilized peripheral blood (mPB) collection that have been programmed through an *ex vivo* programming process using a combination of 2 small molecules, 16,16-dimethyl prostaglandin E2 (FT1050) and dexamethasone (FT4145). The cell populations include hematopoietic cells and other cell types. The final ProTmune product is formulated in Plasmalyte-A (or equivalent) and HSA. Refer to the ProTmune IB for specific details regarding the manufacture and release testing of the investigational product. Control cells will be comprised of an unmanipulated mPB unit that is visually indistinguishable from ProTmune. Both ProTmune and Control will be placed in 400 mL blood transfer bags. The volume of each unit may be reduced or increased to achieve a final volume of 250 mL; volume increases will be achieved by addition of PlasmaLyte-A (or equivalent) with 4.2% - 5% HSA according to the Batch Production record and the site protocol. The blood transfer bags will be labeled with a Fate-provided product label that will maintain the blind to investigator and subject. Fate has established specific criteria that will be used to assess the suitability of all mPB units collected for *ex vivo* programming or Control. The CPF at each participating site will be qualified and trained by Fate technical staff to manufacture the investigational product on site via the performance of a single ProTmune qualification run. Additionally, Fate technical representative(s) will be on site for the manufacture of each CPF's first or second subject treatments and subsequent subject treatments as necessary by the CPF or Fate. ProTmune *ex vivo* programmed mPB cells (or Control) will be released immediately by the CPF
staff after final processing, including filtration, final packaging, and rapid release testing, and labeling. If the product does not meet Fate's pre-defined rapid release acceptance criteria, the CPF will immediately contact Fate Manufacturing and the Investigator to make a prompt decision on use of the investigational product. Exceptional use of investigational product when specification is not met will be documented by the CPF with signature approval documented by the Investigator. Refer to the ProTmune IB for a description of release testing criteria. The final container of the investigational product will be labeled by the CPF using a Fate-approved label. A photocopy of the investigational product label will be retained by the CPF. If additional labeling is required by the clinical site or CPF, this labeling must be distinct from the Fate product label.
synopsis
5.5.2 study drug preparation and

Mobilized peripheral blood cells will be obtained from a matched-unrelated donor for a given subject. An 8/8 high resolution allelic HLA-match of HLA-A, -B, -C, and -DRB1 with recipient is required. Sites will request that consenting donors be mobilized with filgrastim to achieve a target collected CD34+ dose of ≥7 × 106 CD34+ cells/kg in Phase 1 and ≥5 × 106 CD34+ cells/kg in Phase 2. However, if the donor mPB unit collected for a subject in Phase 1 is not
≥5 × 106 CD34+ cells/kg recipient weight, and in Phase 2 is not ≥3 × 106 CD34+ cells/kg recipient weight, the mPB unit will not be processed for ProTmune manufacturing and the subject will be considered a screen failure.  
For subjects enrolled in the Phase 1 part of the study, a reserve dose of 2 × 106 CD34+ cells/kg recipient weight will be maintained during ProTmune manufacturing to serve as a reserve in the event ProTmune manufacturing produces a ProTmune unit that does not meet ProTmune release specifications (e.g., <2 × 106 CD34+ cells/kg recipient weight, <70% viable). In this case, the ProTmune unit will be considered "unavailable" and count towards the Phase 1 stopping rules. The reserve unit must be administered; however, the Principal Investigator should follow their Institution's standard operating procedure to determine whether the ProTmune unit should also be given to the recipient based on the risk-benefit assessment of administering the product with regard to the specification not being met. If the ProTmune unit is not administered, the subject will be withdrawn from study and replaced. If the ProTmune unit is administered, the subject will remain in study but will not be considered in the following assessment. If after 6 subjects have been dosed and evaluated for up to 28 days and ≤1 subject has not engrafted by Day +28, then enrollment in the Phase 2 portion of the study may proceed following IDMC review. If the reserve unit is not used on Day 0, it will be cryopreserved at the site and can be used in the event of non-engraftment, or delayed engraftment. For subjects enrolled in the Phase 2 part of the study in the event ProTmune manufacturing produces a ProTmune unit that does not meet ProTmune release specifications (e.g.,
<2 × 106 CD34+ cells/kg recipient weight, <70% viable), the ProTmune unit will be considered
"unavailable" and count towards the Phase 2 stopping rules. The Principal Investigator should follow their Institution's standard operating procedure to determine whether the unit should be given to the recipient based on the risk-benefit assessment of administering the product with regard to the specification not being met. If the ProTmune or Control unit is not administered, or a subject is withdrawn from participation in the study prior to Day 0, the subject will be replaced and a new subject will be randomized in order to have approximately 60 treated subjects. If the ProTmune or Control unit is administered, the subject will remain in study.
synopsis
5.5.3 study drug administration

Prior to infusion of ProTmune or Control, the subject will be pre-medicated 30 to 60 minutes before the administration of ProTmune or Control based upon institutional standards (e.g., acetaminophen, diphenhydramine, or H2 blockers). Upon receipt of the infusion of ProTmune or Control, the chain of custody documentation should be completed to confirm that the specified unit of ProTmune is the correct product for the subject by checking both the product label and the subject's identity, and the product should be inspected for any irregularities such as visible particulates or leakage from the container. Any irregularities noted should be immediately discussed with the CPF and with the Sponsor that issued the product for infusion to determine whether the product is safe for infusion. ProTmune cells have already been filtered by the CPF and therefore should NOT be filtered during administration. If the investigational product meets release criteria, it should be administered by IV infusion via gravity. The investigational product should not be administered in the same tubing concurrently with products or solutions other than 0.9% Sodium Chloride, Injection (USP). The ProTmune investigational product should be infused at approximately 5 mL to 15 mL per minute, for a total infusion time of approximately 15 to 50 minutes. If the infusion of investigational product is not complete by 30 minutes, the contents of the bag should be mixed by gently massaging the bag once 30 minutes after start of infusion. The infusion rate should be reduced if the fluid load is not tolerated. Diuretics may be used to prevent volume overload. The infusion should be held if the subject develops a clinically significant infusion reaction that requires intervention. The infusion can be restarted if the reaction resolves, based upon the Investigator's medical judgment.
synopsis
5.5.4 treatment compliance

Only qualified members of the study team should administer the study treatment to eligible subjects.  
The conditioning regimen, GvHD prophylaxis, GvHD treatments and any other immunosuppression should be documented in the eCRF for each subject. The start and stop dates and start and stop times of the conditioning regimen (including dosages of chemotherapy and TBI), GvHD prophylaxis and GvHD treatments should be documented in the eCRF for each subject. The CD34+ cell dose administered will be documented in the eCRF. If the reserve cell dose was used, this must be documented in the eCRF. The start and stop date and start and stop times of the HCT, including whether the HCT was completed, should be documented in the eCRF for each subject.
synopsis
5.5.5 storage and accountability

The Sponsor will supply all reagents and manufacturing supplies that are necessary for ProTmune preparation to all study sites. It is the responsibility of the Investigator to supervise accurate monitoring of the receipt, storage, dispensing, and accounting of all supplies. Sites must retain accurate, original site records of study supplies, inventory, and copies of all invoices of study supplies, shipments, and records of investigational product disposition. Supplies accountability forms will be provided for tracking study supplies such as FT1050 and FT4145. Each site must keep all unused study supplies until the Site Monitor either arranges return to the Sponsor or gives instructions pertaining to its disposition. During Phase 1 each site will label, cryopreserve and store the frozen reserve unit for each subject, if unused the reserve dose may be disposed in accordance with institutional practices.
synopsis
5.6 prior and concomitant medications

5.6.1 Prohibited Medications and/or Procedures for the Phase 1 Part of the Study and Phase 2 Part of the Study Subjects may not receive the following concurrent medications or procedures unless otherwise noted:  
- Treatment with non-protocol mandated cytotoxic/myelosuppressive or investigational therapy from Day -30 onwards,
synopsis
exceptions

o The use of tyrosine kinase inhibitors (TKIs) against Bcr-Abl & FLT3, for maintenance therapy in eligible subjects are permitted prior to Day -14 and then again after neutrophil engraftment.  
o Following transplant, enrollment into acute GvHD-treatment studies will be allowed for subjects with steroid-refractory GvHD.  
- Non-protocol induction radiation therapy,
o EXCEPTION: palliative radiation therapy is allowed.  
- Anti-thymocyte globulin,  
- GvHD prophylaxis not specified per the protocol, or
- mPB units from donors that required plerixafor for mobilization.
5.6.2 Documentation of Prior and Concomitant Medication Use for the Phase 1 Part of the Study and Phase 2 Part of the Study All concomitant medications will be recorded starting at Day -30 through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded. All medications taken up to 30 days prior to Day 0 and throughout the study will be captured in the eCRFs. Examples include the following:
- Conditioning and immunosuppressive agents and medications,
- Premedications for ProTmune or Control unit infusion,  
- Transfusions,
- GvHD prophylaxis and treatment, and
- Medications taken for a reportable adverse event.  
Pre-emptive CMV therapy may be provided based upon institutional methodologies, Standard Operating Procedures, and clinical context. An additional blood sample for CMV testing will be collected prior to starting the preemptive therapy and sent for central laboratory testing and prior to starting the preemptive therapy.  
Filgrastim can be administered at 5 µg/kg/day beginning on Day +12, if ANC <500 cells/µL, until the ANC is >500 cells/µL. At Investigator discretion, filgrastim can be administered longer to support the white blood cells. Similarly, per Investigator discretion, filgrastim can be started before Day +12 if subsequent doses of methotrexate will not be administered due to severe mucositis, other toxicity, or severe infection.
synopsis
6 study procedures

For a study visit schedule in tabular format for the Phase 1 part of the study and Phase 2 part of the study, refer to Appendix A.
synopsis
6.1 informed consent

6.1.1 Informed Consent for the Phase 1 Part of the Study and Phase 2 Part of the Study Prior to any study-related activities that are not standard of care (e.g., before administration of the study treatment) the subject or subject's legal representative must review, sign, and date an IRB/IEC-approved ICF. The format and content of the subject ICF must be agreed upon by the Investigators, the appropriate IRB/IEC, and the Sponsor. The original signed ICFs (together with any subsequent IRB/IEC-approved amended versions)
must be retained by the Investigator in the subject's study file. A copy of the original signed and dated ICF must be given to the subject.
synopsis
6.2 screening period (day -53

For the Phase 1 part of the study and Phase 2 part of the study, all subjects will undergo screening procedures once they have given their written, informed consent to participate in the study. Screening procedures must be completed within 6 weeks prior to initiation of conditioning regimen. Upon completion of all screening procedures and determination of eligibility, subjects will be scheduled for administration of conditioning regimen and admission for transplant, per institutional procedures. A screening log will be maintained to record the reasons for exclusion from study for all subjects who sign the informed consent and undergo screening. There may be situations in which a subject is not able to begin the conditioning within 6 weeks of the study screening. In these instances, the subject may need to be re-screened. This will involve repeating select or all screening procedures, as advised by the Medical Monitor. The following procedures and assessments will be performed during the Screening Period (Day -53 to Day -11) for the Phase 1 part of the study and Phase 2 part of the study (refer to Appendix A for details):  
- Informed Consent will be obtained from all subjects prior to the initiation of any study procedures or tests;
- Inclusion and Exclusion Criteria will be reviewed and completed for subject registration; - Investigator is required to verify that the subject completed HLA typing (HLA typing can be completed prior to the Screening Period);
- ECHO or multiple gated acquisition (MUGA) scan (to assess left ventricular ejection fraction or shortening fraction) will be obtained if not completed within 6 weeks prior to the Subject Conditioning Period, from Day -53 to Day -11;
- Demographics and medical history, including prior treatment history information for hematological malignancy, will be reviewed and recorded;
- Qualification of mPB unit by Fate representative;
- Karnofsky Performance Status (Appendix D) will be assessed;
- Bone marrow aspirate will be performed and sent to pathology and cytogenetics;  
- All subjects will be tested for baseline CMV antibody titer (immunoglobulin [Ig]G/IgM) and plasma CMV viremia. This baseline testing will be performed by a central laboratory and results will be provided to the clinical site prior to the initiation of randomization;
- A complete physical examination will be performed; - Vital signs (systolic and diastolic blood pressure, pulse rate, respiratory rate, and temperature)
will be obtained;
- 12-lead triplicate ECG will be obtained;
- All concomitant medications will be recorded starting at Day -30 (through Day +100);
- Pulmonary function tests will be performed; and
- Peripheral blood sample(s) will be collected for the following:
o Blood typing and RBC antibody screen, o Safety laboratory tests (hematology [CBC and when possible per Institutional practice to include a differential (automated or manual)] and serum chemistry panels),  
o Infectious disease titers, o Immune reconstitution assays, and
o Serum pregnancy testing for females of child-bearing potential.  
For the Phase 2 part of the study only: after meeting eligibility and results of the central lab CMV antibody titer are available, subjects will be randomized to either the control arm or ProTmune arm no later than Day -7.
synopsis
6.3 subject conditioning (day -10

For the Phase 1 part of the study and Phase 2 part of the study, the following procedures will be performed for subjects who are enrolled, meet the eligibility criteria, and randomized, in preparation for the subject's transplant:
- Medical history will be updated prior to start of conditioning regimen;  
- All SAEs will be recorded;
- Starting on Day -10, adverse events will be collected as per CTCAE 4.0, AE of infections will use both the CTCAE and the BMTN CT criteria as follows: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;
- A complete physical examination will be performed;
- Vital signs will be collected and recorded;
- Concomitant medications will be reviewed and recorded;  
- For pre-emptive CMV therapy, 2 peripheral blood samples (1 blood sample to be utilized locally at the site for subject management and 1 blood sample for central laboratory testing) will be collected for CMV assessments of DNA by quantitative PCR prior to starting the preemptive therapy;
- Subject conditioning will include 1 of the following 5 preparative regimens:  
o CyTBI, with ≥12 Gy fractionated TBI;
o BuCy where Bu = 16 mg/kg PO or 12.8 mg/kg IV infusion (Pharmacokinetic assessment and dose adjustment of Bu can be based on a test dose or the first dose and will be conducted according to institutional practices);
o FluBu4 with Bu as above; o TBI with etoposide; or
o FluMel 140; and
- GvHD prophylaxis will be initiated (see Section 3.4); and  
- Randomization of subject within Interactive Web Response Services (IWRS) will be performed once the central lab screening CMV results are known and must occur no later than Day -7.
synopsis
6.4 hospital admission (institution policy)

6.4.1 Hospital Admission (Institution Policy) for the Phase 1 Part of the Study and Phase 2 Part of the Study The following procedures will be performed at the time of Hospital Admission:
- Subject will be admitted to the hospital unit; - Medical history will be updated;
- All SAEs will be recorded;
- Adverse events will be collected as per CTCAE 4.0, AE of infections will use both the CTCAE
and the BMTN CT criteria as follows: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;  
- A complete physical examination will be performed;
- Vital signs will be collected and recorded;
- All concomitant medications will be reviewed and recorded; and
- Peripheral blood samples will be collected for safety laboratory tests (hematology [CBC and when possible per Institutional practice to include a differential (automated or manual)] and serum chemistry panels).
synopsis
6.5 study treatment administration day

6.5.1 Study Treatment Administration: Day of Hematopoietic Stem Cell Transplant (Day 0)
for the Phase 1 Part of the Study and Phase 2 Part of the Study The following assessments and procedures will be performed on Day 0:
- A subset of follow-up physical examination assessments will be performed prior to HCT;  
- Vital signs will be obtained prior to infusion of investigational product, and at 15, 30, 45, and 60 minutes after the start of infusion of investigational product (Note: these are targeted collection times; protocol deviations will only be documented when a collection is missed);
- A 12-lead triplicate ECG will be obtained prior to HCT;
- All concomitant medications will be reviewed and recorded;  
- Peripheral blood samples will be collected for safety laboratory tests (hematology [CBC and when possible per Institutional practice to include a differential (automated or manual)] and serum chemistry panels) prior to HCT;
- Investigational product will be prepared;
- Subject will receive transplant;
- Karnofsky Performance Status (Appendix D) will be assessed after HCT; and
- All SAEs will be recorded;  
- Adverse events will be collected as per CTCAE 4.0, AE of infections will use both the CTCAE
and BMTN CT criteria as follows: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator.
synopsis
6.6 post-transplant assessment days

6.6.1 Post-Transplant Assessment Days for the Phase 1 Part of the Study and Phase 2 Part of the Study Post-transplant visit windows are as follows: ±3 days for Day +7 through Day +100; ±14 days for Day +180; and ±28 days for Days +270, +365, and +730. The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting. The following procedures will be performed at the time points as described in Appendix A:  
- A subset of follow-up physical examination assessments (with the exception of height) will be performed weekly from Day +1 through Day +28;
- Vital signs will be obtained weekly from Day +1 through Day +28; - All concomitant medications will be recorded (starting at Day -30) through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded;
- Karnofsky Performance Status (Appendix D) will be assessed at all subsequent study visits after HCT up through Day +365 (which should include weekly assessments from Day +1 through Day +28);
- A peripheral blood sample for hematology (CBC and when possible per Institutional practice to include a differential (automated or manual)) will be collected daily from Day +1 through Day +28 (or until the subject achieves neutrophil engraftment, whichever event occurs first; following engraftment, blood for hematology is to be collected per institutional policy);
- A 12-lead triplicate ECG will be obtained at Day +100;
- All SAEs will be recorded;
- Through Day +100, adverse events will be collected as per CTCAE 4.0, AE of infections will use both CTCAE and BMTN CT criteria as follows: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator; and
- From Day +100 through Day +365: Only adverse events associated with GvHD, infections, or secondary engraftment failure (Grades 1 through 5).
synopsis
6.7 post-transplant weekly assessments

6.7.1 Post-Transplant Weekly Visits for the Phase 1 Part of the Study and Phase 2 Part of the Study Post-transplant visit windows are as follows: ±3 days for Day +7 through Day +100; ±14 days for Day +180; and ±28 days for Days +270, +365, and +730. Standard post-transplant testing will be performed per institutional guidelines and good clinical practice. The following assessments will be performed at the time points as described in Appendix A:  
- A subset of follow-up physical examination assessments (with the exception of height) will be performed weekly from Day +35 through Day +91, then on Days +100, +180, +270, and +365;
- The Day +730 visit will occur by conducting a telephone contact report for capture of survival status and adverse event reporting;
- Vital signs will be obtained weekly from Day +35 through Day +91, then on Days +100, +180,
+270, and +365;
- All concomitant medications will be recorded (starting at Day -30) through Day +100. From Day +100 through Day +730, only concomitant medications given as TKI maintenance, or that were ongoing at the time of, and for the treatment of, an AE of GvHD, infection or secondary engraftment failure or any SAE, will be recorded;  
- Bone marrow aspirate will be sent to pathology and to cytogenetics on Day +21 (only if ANC
<500/µL), and as clinically indicated (flow cytometry is required on BM aspirate);
- Karnofsky Performance Status (Appendix D) will be assessed at all subsequent study visits after HCT up through Day +365 (which should include weekly assessments from Day +1 through Day +91, then on Days +100, +180, +270, and +365);
- A peripheral blood sample for hematology (CBC and when possible per Institutional practice to include a differential (automated or manual)) will be collected on Days +35, +42, +49, +56, +63, +70, +77, +84, +100, +180, and +365;
- A peripheral blood sample for serum chemistry panels will be collected weekly from Day +1 through Day +100, then at Day +180;
- Two peripheral blood samples at each testing time point (1 blood sample to be utilized locally, per institutional policy as required, at the site for subject management and 1 blood sample for central laboratory testing) will be collected for viral assessments of DNA by quantitative PCR for EBV, CMV, HHV-6, and BK virus weekly from Day +7 through Day +100, and at Days +180, +270, and +365;
- Peripheral blood samples for immune reconstitution assays will be collected at Days +7, +14,
+28, +56, +91, +180, +270, and +365. The peripheral blood sample will be sent to a central laboratory for analysis;
- All SAEs will be recorded; - Through Day +100, adverse events will be collected as per CTCAE 4.0, AE of infections will use both the CTCAE and BMTN CT criteria as follows: Adverse events associated with infusion reactions, GvHD, infections, or engraftment failure (Grades 1 through 5). All other adverse events (Grades 2 through 5). Laboratory abnormalities will only be recorded as adverse events if deemed clinically significant by the Investigator;
- From Day +100 through Day +365: Only adverse events associated with GvHD, infections, or secondary engraftment failure (Grades 1 through 5);
- Clinical and laboratory assessments of aGvHD will be performed weekly from Day +1 through Day +100, and on Day +180. Acute GvHD assessments (incidence and maximum severity) of Grades I through IV of the skin, liver, and gut as per the CIBMTR aGvHD Grading Scale (Appendix E) will be performed;
- Chronic GvHD assessments (incidence and maximum severity) of mild, moderate, or severe cGvHD as per NIH Consensus Criteria for cGvHD (Appendix F) will be performed on Days +180, +270, and +365;  
- Peripheral blood samples will be collected for CMV assessments of DNA by quantitative PCR
weekly from Days +7 through Day +100, and at Days +180, +270, and +365. Assessment of infection will be performed based on the NCI CTCAE and the BMT CTN Definitions;
- Neutrophil and T-cell chimerism will be assessed on the third consecutive day of ANC
>500 cells/µL (neutrophil only) and on Days +28, +100, +180, and +365 (both neutrophil and T-cell):
o When feasible, fractional chimerism (total, myeloid, lymphoid) will be performed from peripheral blood samples; o If there is no evidence for donor engraftment by Day +21, then the subject will undergo BM and peripheral blood chimerism studies; and o If donor engraftment is not present by Day +28 BM examination, and the subject's disease is not present, the subject should be considered a primary graft failure (in the absence of relapsed disease);
- Serum IgG, IgM, and IgA will be collected by a peripheral blood sample at Days +100, +180, and +365; and
- Peripheral blood samples for GvHD exploratory biomarkers will be obtained once weekly from Days +7 through Day +42, then on Day +100. Samples will be banked.
synopsis
6.8 unscheduled visits

An unscheduled visit is a visit that occurs in addition to the predefined protocol specific visit calendar. If an unscheduled visit occurs for a given subject, the visit must be documented on the Unscheduled Visit CRF.
synopsis
6.9 early withdrawal visit and

If a subject withdraws or is withdrawn from the study prior to Day 0, the subject's mPB will not be processed to a unit of ProTmune or Control cells, and the subject will not be considered evaluable for any study-related endpoint analyses. If this occurs in the Phase 2 portion of the study and the subject was already randomized, the subject will be replaced and a new subject will be randomized in order to have approximately 80 treated subjects. If a subject withdraws from the study after transplantation, information regarding secondary graft failure, disease relapse, serious adverse events involving GvHD and infections, and survival outcomes will be collected on Days +180, +365, and +730 by phone. If the subject relapses and/or receives a protocol-prohibited therapy, the subject will be withdrawn. However, survival will still be collected unless the subject withdraws consent, in which case survival outcomes will be assessed via public record search. A subject will have completed the study when he or she completes the Day +365 study visit. For subjects who are withdrawn from the study prior to completion, all assessments as described in Appendix A for the Early Withdrawal Visit should be completed. Procedures include the following:
- Applicable concomitant medications will be reviewed and recorded as per Section 8.12;  
- A subset of follow-up physical examination assessments (with the exception of height) will be performed;
- Vital signs will be obtained;
- Karnofsky Performance Status (Appendix D) will be assessed;
- Peripheral blood samples will be collected for the following:  
o Safety laboratory tests (hematology [CBC and when possible per Institutional practice to include a differential (automated or manual)] and serum chemistry panels),
o Viral assessments, and o CMV assessments of DNA by quantitative PCR. Assessment of infection will be performed based on the NCI CTCAE and the BMT CTN Definitions; and
- Acute GvHD or cGvHD assessments (Appendix E and Appendix F) must be performed, as applicable.
If a subject withdraws or is withdrawn from the study at any time following the study treatment administration, the Investigator should make every effort to follow the subject and collect the information as specified for the Early Withdrawal Visit in Appendix A. If a subject is withdrawn for safety reasons, additional safety assessments and follow-up could be required. Refer to Section 8.1 and Section 8.3 for a description of the follow-up of adverse events and SAEs.
synopsis
7 efficacy assessments

The primary efficacy endpoint for both the **Phase 1 and Phase 2** parts of the study is the following:  
- Cumulative incidence of CIBMTR Grades II-IV aGvHD through Visit Day +100 based on investigator results. Death and relapse without CIBMTR Grades II-IV aGvHD will be considered competing risks.  
o Each study site will determine the presence or absence of aGvHD by assigning the clinical stage for the target organs of the skin, liver, and gut along with assigning an overall grade according to the CIBMTR aGvHD Grading Scale (Appendix E).
The key secondary efficacy endpoint for both the **Phase 1 and Phase 2** parts of the study is the following:
- Proportion of subjects alive without relapse and without moderate or severe cGvHD per NIH
Consensus Criteria at Visit Day +365.  
All summaries for acute and chronic GvHD will be based on the investigator assessment unless noted otherwise.  
The exploratory efficacy endpoints for both the **Phase 1 and Phase 2** parts of the study are the following:
- Cumulative incidence through Visit Day +100 and through Visit Day +180 of:  
o CIBMTR Grades III-IV aGvHD
o CIBMTR Grades I-II aGvHD; o CIBMTR Grades I-IV aGvHD;
o Maximum CIBMTR Grades II-IV aGvHD; o Maximum CIBMTR Grades III-IV aGvHD; o Maximum CIBMTR Grades II-IV aGvHD based on EAC adjudicated results;
o Maximum CIBMTR Grades III-IV aGvHD based on EAC adjudicated results;
- Duration of the Maximum CIBMTR Grade aGvHD through Visit Day +100;  
- Duration of CIBMTR Grades II-IV aGvHD through Visit Day +100; - Duration of CIBMTR Grades III-IV aGvHD through Visit Day +100; - One-Year GvHD-Free, Relapse-Free Survival (GRFS), a composite endpoint in which events include Grade III-IV aGvHD, cGvHD-requiring systemic immunosuppressive therapy, relapse, or death from any cause (Holtan et al. 2015);
- Time to individual event components for GRFS:
o Time to CIBMTR Grades III-IV aGvHD; o Time to first use of cGvHD-requiring systemic immunosuppressive therapy; o Time to relapse; o Time to death;
- One-Year cGvHD-Free, Relapse-Free Survival (CRFS), a composite endpoint in which events include any cGvHD-requiring systemic immunosuppressive therapy, relapse, or death from any cause (Pasquini et al. 2018);
- Cumulative incidence of Non-relapse mortality (NRM). All deaths in the absence of relapse of the primary malignancy will be considered NRM, where relapse will be considered a competing risk;
- Moderate or severe cGvHD per NIH Consensus Criteria for the global severity score cGvHD
through Visit Day +365. Death and relapse without moderate or severe cGvHD will be considered competing risks;
- Proportion of subjects with systemic steroid use for aGvHD;
- Time to first use of systemic steroids for aGvHD;
- Total number of days of systemic steroid use for aGvHD;
- Proportion of subjects with second-line therapies for treatment of aGvHD - Time to first use of second-line therapies for treatment of aGvHD;  
- Proportion of subjects who are CMV positive at baseline with subsequent CMV reactivation.  
CMV reactivation is defined as subjects who have initiated anti-viral therapy for CMV;
- Time to first treatment for CMV reactivation;
- Relapse-free survival (RFS);
- One-year survival;
- Two-year survival.
Additional exploratory analyses may be performed as necessary.
synopsis
7.1 acute graft-versus-host disease assessment

Acute GvHD assessments of the overall Grades I through IV aGvHD of the skin, liver, and gut as per the CIBMTR aGvHD Grading Scale must be performed weekly from Day +1 through Day +100 and on Day +180. Assessments must be made consistently for each subject by the Investigator. For a detailed description of the CIBMTR aGvHD Grading Scale, refer to Appendix E. The data for the GvHD target organs should be recorded on the GvHD eCRF, and must include the percentage of skin rash involvement, volume of stool output, and level of weekly maximum reported bilirubin level. Differential diagnoses should be recorded (e.g., investigational product reaction, conditioning regimen, total parenteral nutrition, infection, or veno-occlusive disease) each week for the specified organ involved.
synopsis
7.2 chronic graft-versus-host disease assessment

Chronic GvHD assessments of mild, moderate, or severe cGvHD as per NIH Consensus Criteria for cGvHD must be performed on Days +180, +270, and +365. Assessments must be made consistently for each subject by the Investigator. For a detailed description of the NIH Consensus Criteria for cGvHD, refer to Appendix F. The data for the GvHD target organs should be recorded on the GvHD eCRF.
synopsis
7.3 viral monitoring

Two peripheral blood samples at each testing time point (1 blood sample to be utilized locally at the site for subject management and 1 blood sample for central laboratory testing) will be collected for viral assessments of DNA by quantitative PCR for EBV, CMV, HHV-6, and BK virus weekly from Days +7 through Day +100 and at Days +180, +270, and +365.
synopsis
7.4 infectious disease titers

Infectious diseases screen during the Screening Period by peripheral blood sample will include titers for EBV, CMV, hepatitis panel (hepatitis A antibody, hepatitis B surface antibody, hepatitis B surface antigen, hepatitis B core antibody, and hepatitis C antibody), BK virus, herpes simplex virus (HSV), HHV-6, HIV, HTLV types I/II antibody, syphilis, and varicella zoster virus
(VZV). Additionally, testing for CMV viremia via PCR will be performed. Titer and CMV viremia testing will be done by central laboratory testing during the Screening Period.
synopsis
7.5 karnofsky performance status

The Karnofsky Performance Status (Appendix D) will be assessed as part of the study eligibility assessment, and will be assessed during the Screening Period, at Day 0 after HCT, all subsequent study visits up through Day +365 (which should include, but are not limited to, weekly from Day +1 through Day +91, then on Days +100, +180, +270, and +365), and the Early Withdrawal Visit, if applicable.