Protocol
`
`This trial protocol has been provided by the authors to give readers additional information about their work.
`
`Protocol for: Porter DL, Levine BL, Kalos M, Bagg A, June CH. Chimeric antigen receptor–modified T cells in
`chronic lymphoid leukemia. N Engl J Med 2011;365:725-33. DOI: 10.1056/NEJMoa1103849.
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`CD19 Lentiviral T body Protocol
`Version 0.3
`University of Pennsylvania
`Title:
`PILOT STUDY OF REDIRECTED AUTOLOGOUS T CELLS ENGINEERED TO
`CONTAIN ANTI-CD19 ATTACHED TO TCRζ AND 4-1BB SIGNALING
`DOMAINS IN PATIENTS WITH CHEMOTHERAPY RESISTANT OR
`REFRACTORY CD19+ LEUKEMIA AND LYMPHOMA
`
`
`Principal Investigator
`
`Co-Investigators
`
`Regulatory Sponsor:
`
`Funding Sponsor:
`
`Study Product:
`
`Protocol Number:
`
`
`
`David Porter, M.D.
`Department of Medicine
`University of Pennsylvania School of Medicine
`Philadelphia, Pennsylvania 19104
`
`Adam Bagg, MD
`Bruce Levine, PhD
`Stephen Schuster, MD
`Sunita Nasta, MD
`Selina Luger, MD
`Stephen Goldstein, MD
`Noelle Frey, MD
`Alison Loren, MD, MSCE
`Donald Tsai, MD, PhD
`Daniel Vogl, MD
`Elizabeth Hexner, MD
`
`Carl June, M.D.
`Department of Pathology and Laboratory Medicine
`University of Pennsylvania School of Medicine
`Room 553 BRB II/II,
`421 Curie Blvd
`Philadelphia, PA 19104-6160
`215-573-5745
`Alliance for Cancer Gene Therapy
`96 Cummings Point Road
`Stamford, CT 06902
`203 348 8000
`CD19 redirected autologous T cells (CART-19-T Cells)
`
`805313
`
`BB-IND 13960
`
`IND Number:
`
`Date:
`Amended:
`Administrative Change:
`
`
`June 18, 2009
`In response to FDA/IRB/CTSRMC comments
`CONFIDENTIAL
`This document is confidential and the property of the University of Pennsylvania. No part
`of it may be transmitted, reproduced, published, or used by other persons without prior
`written authorization from the study sponsor.
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`CD19 Lentiviral T body Protocol
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`page ii
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`STUDY TEAM
`
`
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`Clinical Trial Site - University of Pennsylvania
`
`
`Principal Investigator
`David Porter, MD
`
`Clinical Team
`
`Steven Goldstein, MD
`Donald Tsai, MD, PhD
`Stephen Schuster, MD
`Selina Luger, MD
`
`Sunita Nasta, MD
`
`Alison Loren, MD, MSCE
`Alexander Perl, MD
`Noelle Frey, MD
`Daniel Vogl, MD
`Elizabeth Hexner, MD
`
`Medical Advisor
`Edward Stadtmauer, MD
`
`Statistical Support
`Wei-Ting Hwang, Ph.D..
`
`Monitors
`Tina Lowther, C.I.P., C.R.C.
`Elizabeth Veloso, JD, BSN
`
`Quality Assurance for Manufacturing
`To be chosen
`
`Sponsor Cell Manufacturing – University of Pennsylvania
`Donald Siegel, MD, PhD, Medical Director
`Bruce Levine, PhD, Laboratory Director
`
`Sponsor Vector Manufacturing – Lentigen Corporation
`Boro Dropulic, PhD
`
`
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`Laboratory Team
`Adam Bagg, MD
`Gwen Binder, PhD
`Stephan Grupp, MD, PhD
`Jean Boyer, PhD
`Michael Milone, MD, PhD
`Carmine Carpenito, PhD
`Michael Kalos, PhD
`
`
`
`
`
`
`
`
`
`
`
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 3
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`CD19 Lentiviral T body Protocol
`Version 0.3
`
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`
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`page iii
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`
`Table of Contents
`LIST OF ABBREVIATIONS ....................................................................................................................................................... V
`STUDY SUMMARY AND STUDY SCHEMA ............................................................................................................................ 1
`1
`INTRODUCTION ................................................................................................................................................................ 4
`1.1 BACKGROUND .................................................................................................................................................................... 4
`1.2
`INVESTIGATIONAL AGENT .................................................................................................................................................. 7
`1.3
`PRECLINICAL DATA ............................................................................................................................................................ 9
`1.4 CLINICAL DATA TO DATE ................................................................................................................................................. 14
`1.5 DOSE RATIONALE AND RISK/BENEFITS ............................................................................................................................. 16
`STUDY OBJECTIVES ...................................................................................................................................................... 18
`STUDY DESIGN ................................................................................................................................................................ 18
`3.1 GENERAL DESIGN............................................................................................................................................................. 18
`3.2
`PRIMARY STUDY ENDPOINTS ............................................................................................................................................ 20
`3.3
`SECONDARY STUDY ENDPOINTS ....................................................................................................................................... 20
`SUBJECT SELECTION AND WITHDRAWAL ............................................................................................................ 21
`4.1
`INCLUSION CRITERIA ........................................................................................................................................................ 21
`4.2 EXCLUSION CRITERIA ....................................................................................................................................................... 22
`4.3
`SUBJECT RECRUITMENT AND SCREENING .......................................................................................................................... 22
`4.4 EARLY WITHDRAWAL OF SUBJECTS .................................................................................................................................. 23
`4.4.1
`When and How to Withdraw Subjects................................................................................................................... 23
`4.4.2
`Data Collection and Follow-up for Withdrawn Subjects ...................................................................................... 24
`STUDY DRUG ................................................................................................................................................................... 24
`5.1 DESCRIPTION .................................................................................................................................................................... 24
`5.2 TREATMENT REGIMEN ...................................................................................................................................................... 25
`5.2.1
`Patients 1-5 .......................................................................................................................................................... 25
`5.2.2
`Patients 6-10 ........................................................................................................................................................ 25
`5.3
`PREPARATION AND ADMINISTRATION OF STUDY DRUG ..................................................................................................... 25
`5.4
`SUBJECT COMPLIANCE MONITORING ................................................................................................................................ 26
`5.5
`PRIOR AND CONCOMITANT THERAPY ................................................................................................................................ 27
`5.6
`PACKAGING ...................................................................................................................................................................... 27
`5.7 RECEIVING, STORAGE, DISPENSING AND RETURN ............................................................................................................. 27
`5.7.1
`Receipt of Drug Supplies ...................................................................................................................................... 27
`5.7.2
`Storage ................................................................................................................................................................. 27
`5.7.3
`Dispensing of Study Drug ..................................................................................................................................... 28
`5.7.4
`Return or Destruction of Study Drug .................................................................................................................... 28
`STUDY PROCEDURES .................................................................................................................................................... 28
`6.1
`PRE-ENTRY EVALUATIONS ............................................................................................................................................... 28
`6.2 ENROLLMENT AND BASELINE ASSESSMENT. ..................................................................................................................... 28
`6.3 ENROLLMENT AND BASELINE ASSESSMENT. ..................................................................................................................... 29
`6.4 APHERESIS #1. ................................................................................................................................................................. 29
`6.5 CYTOREDUCTIVE CHEMOTHERAPY .................................................................................................................................... 29
`6.6 RESTAGING ASSESSMENT .................................................................................................................................................. 30
`6.7 CART-19 INFUSION #1 WITH SPLIT DOSING .................................................................................................................... 30
`6.8
`POST INFUSION LABORATORIES TO ASSESS ENGRAFTMENT AND PERSISTENCE ..................................................................... 30
`6.9 CART-19 INFUSION #2 .................................................................................................................................................... 31
`6.10
`DAY 28: APHERESIS #2 ............................................................................................................................................... 31
`6.11
`MONTHLY EVALUATIONS 2 TO 6 MONTHS POST INFUSION ............................................................................................. 31
`6.12
`QUARTERLY EVALUATIONS FOR UP TO 2 YEARS POST INFUSION ................................................................................... 31
`6.13
`TUMOR RESPONSE ASSESSMENTS ................................................................................................................................ 32
`STATISTICAL PLAN ....................................................................................................................................................... 32
`7.1 GENERAL DESIGN ISSUES ................................................................................................................................................. 32
`7.2 ENDPOINTS ....................................................................................................................................................................... 33
`7.2.1
`Primary Endpoints ............................................................................................................................................... 33
`7.2.2
`Secondary Endpoints ............................................................................................................................................ 33
`
`2
`3
`
`4
`
`5
`
`6
`
`7
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 4
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`CD19 Lentiviral T body Protocol
`Version 0.3
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`page iv
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`SAMPLE SIZE .................................................................................................................................................................... 33
`7.3
`SAFETY ............................................................................................................................................................................ 34
`7.4
`7.5 EFFICACY ......................................................................................................................................................................... 34
`7.6 ACCRUAL ......................................................................................................................................................................... 34
`7.7
`SUBJECT POPULATION(S) FOR ANALYSIS........................................................................................................................... 34
`7.8
`STATISTICAL ANALYSIS .................................................................................................................................................... 35
`SAFETY AND ADVERSE EVENTS ................................................................................................................................ 35
`8.1 DEFINITIONS .................................................................................................................................................................... 35
`8.2 RECORDING OF ADVERSE EVENTS .................................................................................................................................... 38
`8.3 REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .................................................................... 38
`8.3.1
`Study Sponsor Notification by Investigator .......................................................................................................... 38
`8.3.2
`Investigator reporting: notifying the Penn IRB .................................................................................................... 39
`8.3.3
`Reporting obligations to the DSMC of the ACC ................................................................................................... 41
`8.3.4
`FDA Notification by Sponsor ............................................................................................................................... 41
`8.4 TOXICITY MANAGEMENT, STOPPING RULES AND STUDY TERMINATION ............................................................................ 42
`8.4.1
`Criteria for stopping or pausing the study ............................................................................................................ 42
`8.4.2
`General toxicity management considerations ....................................................................................................... 43
`8.4.3
`Management of toxicity ........................................................................................................................................ 44
`8.4.4
`Criteria for discontinuing a subject’s participation in the study: ......................................................................... 44
`8.5
`PROTOCOL DEVIATIONS ................................................................................................................................................... 45
`8.6 MEDICAL MONITORING .................................................................................................................................................... 45
`
`Independent Data and Safety Monitoring Board ............................................................................................................ 45
`8.6.1...................................................................................................................................................................................... 45
`8.6.2
`Clinical Monitors ................................................................................................................................................. 46
`DATA HANDLING AND RECORD KEEPING ............................................................................................................. 46
`9.1 CONFIDENTIALITY ............................................................................................................................................................ 46
`9.2
`SOURCE DOCUMENTS ....................................................................................................................................................... 47
`9.3 CASE REPORT FORMS ....................................................................................................................................................... 47
`9.4 RECORDS RETENTION ....................................................................................................................................................... 47
`STUDY MONITORING, AUDITING, AND INSPECTING .......................................................................................... 47
`10.1
`STUDY MONITORING PLAN .......................................................................................................................................... 47
`10.2
`AUDITING AND INSPECTING ......................................................................................................................................... 48
`ETHICAL CONSIDERATIONS ...................................................................................................................................... 48
`STUDY FINANCES ........................................................................................................................................................... 48
`12.1
`FUNDING SOURCE ....................................................................................................................................................... 48
`12.2
`CONFLICT OF INTEREST ............................................................................................................................................... 48
`12.3
`SUBJECT STIPENDS OR PAYMENTS ............................................................................................................................... 49
`12.4
`STUDY DISCONTINUATION .......................................................................................................................................... 49
`PUBLICATION PLAN ...................................................................................................................................................... 49
`13
`14 REFERENCES ................................................................................................................................................................... 49
`15 ATTACHMENTS .............................................................................................................................................................. 56
`15.1
`INFORMED CONSENT DOCUMENT .................................................................................................................... 56
`15.2
`SCHEDULE OF STUDY PROCEDURES ............................................................................................................................. 72
`15.3
`PRODUCT C OF A, INFUSION FORM, AND DISPOSITION / RETURN FORMS ......................................................................... 75
`15.4
`MONITORING PLAN ..................................................................................................................................................... 76
`
`
`8
`
`9
`
`10
`
`11
`12
`
`
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 5
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`page v
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`CD19 Lentiviral T body Protocol
`Version 0.3
`
`List of Abbreviations
`
`APC, antigen presenting cell
`aAPC, artificial APC
`AE, adverse event
`CART-19 cells, redirected autologous T cells
`CIR, chimeric immune receptor
`CFR, code of federal regulations
`CMV, cytomegalovirus
`CRF, case report form
`CTC, common toxicity criteria
`CTRC, clinical and translational research center
`CTL, cytotoxic T lymphocyte
`CVPF, clinical cell and vaccine production facility
`CTL, cytotoxic T lymphocyte
`CD137, 4-1BB costimulatory molecule
`DFS, disease free survival
`DSMB, data safety and monitoring board
`FDA, food and drug administration
`GCP, good clinical practices
`GMP, good manufacturing practices
`GVHD, graft versus host disease
`IBC, Institutional Biosafety Committee
`IRB, Institutional Review Board
`MRD, minimal residual disease
`PBMC, peripheral blood mononuclear cells
`RAC, NIH Office of Biotechnology Recombinant DNA Advisory Committee
`RCL, replication competent lentivirus
`scFv, single chain Fv fragment
`T-body, fusion protein expressed in T cells that combines an extracellular antibody domain and
`an intracellular signaling domain. Interchangeable with CIR.
`TCR, T cell receptor
`TCR-ζ, signaling domain found in the intracellular region of the TCR zeta, gamma and epsilon
`chains
`Vβ, a rearranged T cell specific gene that can be used to determine clonality of a T cell
`population
`UPENN, University of Pennsylvania
`
`
`
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 6
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`CD19 Lentiviral T body Protocol
`Version 0.3
`
`Title
`
`Short Title
`
`Protocol Number
`
`Phase
`
`Methodology
`
`Study Duration
`
`Study Center(s)
`
`Objectives
`
`Number of Subjects
`
`Diagnosis and Main
`Inclusion Criteria
`
`Study Summary and Study Schema
`PILOT STUDY OF REDIRECTED AUTOLOGOUS T CELLS ENGINEERED TO
`CONTAIN ANTI-CD19 ATTACHED TO TCR-ζ AND 4-1BB SIGNALING
`DOMAINS
`IN PATIENTS WITH CHEMOTHERAPY RESISTANT OR
`REFRACTORY CD19+ LEUKEMIA AND LYMPHOMA
`
`CD19 redirected autologous T cells
`
`Pending.
`
`Phase 1 / Pilot
`
`Open-label approach
`
`Approximately 4-5 years
`
`Single-center
`
`The primary objective is to determine the safety and survival of the
`redirected autologous T cells transduced with the anti-CD19 lentiviral
`vector (referred to as “CART-19” cells).
`
`10 subjects
`
`Inclusion criteria are designed to include adult patients aged >18 with
`CD19+ B cell malignancies with no available curative treatment options
`(such as autologous or allogeneic stem cell transplantation) who have
`limited prognosis (several months to <2 year survival) with currently
`available therapies.
`
`CART-19 cells transduced with a lentiviral vector to express either anti-
`CD19 scFv:TCRζ or anti-CD19 scFv TCRζ:41BB, administered by i.v.
`injection as a using a “split dose” (total dose of ~2x109 – 5 x1010 T
`cells) approach to dosing: 10% on day 0, 30% on day 1 and 60% on day
`2. A second dose of CART-19 cells (~2.5 x109 – 5 x108 T cells) will be
`given administered by i.v. injection on day 11 to those patients who
`have sufficient CART-19 cells available.
`
`Approximately 20 minutes; drug is expected to persist at detectable
`levels in circulation for 2 to 6 weeks.
`
`None. This protocol will be given to subjects with unmet medical needs
`for which there are no effective therapies known at this time.
`
`
`Study Product, Dose,
`Route, Regimen
`
`Duration of
`administration
`
`Reference therapy
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`1
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`
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`Miltenyi Ex. 1013 Page 7
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`CD19 Lentiviral T body Protocol
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`The statistical analysis will be primarily descriptive in keeping with the
`exploratory nature of the study. Descriptive statistics will be applied to
`determine the relative engraftment, persistence and trafficking of the
`study drug components to blood and optionally bone marrow / lymph
`node. All adverse events will be described and exact 95% confidence
`intervals will be produced for adverse event rates, both overall and
`within major categories. The change in the ratio of CART-19 cells over
`time will be compared using a Wilcoxon signed-rank test for paired
`data. This nonparametric test is very efficient (>95%) compared to the
`t-test if the underlying data are normally distributed. Analysis of other
`secondary endpoints such as anti-tumor activity will also be primarily
`descriptive and may include summary statistics such as means and
`standard deviations or Kaplan-Meier curves for survival information.
`
`
`Statistical
`Methodology
`
`
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 8
`
`

`

`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`CONFIDENTIAL
`
`
`
`
`
`
`
`
`
`- ... 8~
`
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`Manufacture / Cryopreservation
`
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`
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`:210::
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`
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`(10-15L)
`
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`Response
`
`if available)
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`(2 L)
`
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`
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`
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`
`I
`
`FDA App roved
`Therapy
`.
`Monitor
`for recurrence
`
`H Relapse
`
`page 3
`
`Study Schema (Figure 1)
`
`
`
`
`
`Version 0.3
`CD19 Lentiviral T body Protocol
`
`Miltenyi Ex. 1013 Page 9
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`CD19 Lentiviral T body Protocol
`Version 0.3
`
`
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`page 4
`
`1 Introduction
`This document is a protocol for a human research study. This study is to be conducted according
`to US and international standards of Good Clinical Practice (FDA Title 21 part 312 and
`International Conference on Harmonization guidelines), applicable government regulations and
`Institutional research policies and procedures.
`
`1.1 Background
`CD19 positive hematologic malignancies. B cell malignancies comprise a heterogeneous group
`
`of neoplasms including a vast majority of non-Hodgkin's lymphomas (NHL), as well as acute
`lymphoblastic leukemias (ALL) and chronic lymphocytic leukemias (CLL). An estimated 87,000
`new cases of leukemia and non-Hodgkin’s lymphomas are diagnosed in the US annually2, and
`most of these are of B cell origin. Current treatments for B cell malignancies include
`chemotherapy, radiation therapy, bone marrow transplantation, and peripheral blood stem cell
`transplantation. Despite these treatment modalities, most patients will remain incurable.
`B lineage acute leukemia (B-ALL) is responsive to chemotherapy, however the ability to
`uniformly eradicate the disease has not been achieved, as about 65% of adults and 20% of
`children have disease recurrence 3, 4. Improved response rates have thus far only been achieved
`with
`intensified cytotoxic chemotherapy, resulting
`in substantial morbidity. Adoptive
`immunotherapy with allogeneic donor leukocytes has potent anti-leukemic effects, however the
`benefit is confined largely to patients with myeloid leukemias, as B-ALL has a durable remission
`rate of less than 10% 5, and often at the cost of substantial morbidity due to GVHD6, 7.
`
`Adoptive immunotherapy. Adoptive transfer is a term coined by Medawar8 to study
`allograft
`rejection, and
`the
`term adoptive
`immunotherapy denotes
`the
`transfer of
`infectious disease9. Adoptive
`immunocompetent cells for
`the
`treatment of cancer or
`immunotherapy appears to be the most robust form of immunotherapy for treatment of
`established tumors10. However, several problems remain to be solved before this therapy
`becomes routine; see our reviews for details11, 12.
`
`CD19 as a therapeutic target for leukemia and lymphoma. CD19 is a 95kDa glycoprotein
`
`present on B cells from early development until differentiation into plasma cells13-15. It is a
`member of the immunoglobulin (Ig) superfamily and a component of a cell surface signal
`transduction complex that regulates signal transduction through the B cell receptor15-17. Mice
`lacking CD19 have a decreased number of B cells in peripheral lymphoid tissues, a decreased B
`cell response to oral vaccines and mitogens, and decreased serum Ig levels15, 18. Expression of
`CD19 is restricted to B lineage cells and is not expressed by pluripotent blood stem cells19. CD19
`is also expressed by most B cell lymphomas, mantle cell lymphoma, ALLs, CLLs, hairy cell
`leukemias, and a subset of acute myelogenous leukemias13, 20, 21. CD19 thus represents a highly
`attractive target for immunotherapy19. Furthermore, CD19 is not present on most normal tissues,
`other than normal B cells, including pluripotent blood stem cells19, which makes CD19 a
`relatively safe target presenting a minimal risk of autoimmune disease or irreversible
`myelotoxicity. Anti-CD19 antibodies and scFvs either native or conjugated to radioisotopes or
`toxins are currently being developed and have demonstrated promise in both mouse models22-26
`and human and non-human primates27-37.
`
`
`CONFIDENTIAL
`This material is the property of the University of Pennsylvania. Do not disclose or use except as authorized in writing by the study sponsor
`
`Miltenyi Ex. 1013 Page 10
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`CD19 Lentiviral T body Protocol
`Version 0.3
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`
`page 5
`
`The
`Engineered T cells with redirected specificity: chimeric immune receptors (CIR).
`daunting task of breaking tolerance to self antigens is the major obstacle facing the field of
`cancer immunotherapy. This can be difficult or impossible if the TCR repertoire has been deleted
`or rendered non functional by various post thymic tolerance mechanisms38, 39. One strategy is to
`identify therapeutically effective T cell clones, clone the heterodimeric TCR, and express it in
`other T cells, creating bispecific T cells with reactivity against the original TCR and the cloned
`TCR (reviewed in40-42). This was first carried out using protoplast fusion to transfer the TCR
`genes from a mouse T cell into another mouse T cell clone with a different specificity43. Other
`labs used cell fusion or electroporation to transfer TCR genes44, 45, and in these cases
`demonstrated that MHC restricted specificity could be transferred. The advent of retroviral
`vectors made it possible to make this process more efficient. The Pease laboratory first used a
`retroviral vector with the LTR directing expression of TCRζ and an internal CMV promoter
`driving TCRα expression in mouse T cells46, 47. In 1999 Clay used a retroviral vector to transfer
`an HLA-A2 restricted TCR with specificity for MART-1, derived from tumor infiltrating
`lymphocytes, from a melanoma patient to T cells from 3 normal donors48. Recently Kessels and
`coworkers demonstrated that redirected mouse T cells were fully functional, could protect
`against tumor challenge, and could treat established metastasis49. The T cells were shown to
`expand dramatically (by more than 3 logs) after in vivo antigen encounter, and they trafficked to
`tumor sites.
`An alternative strategy to produce genetically engineered T cells is the ‘T-body’ or
`chimeric antigen receptor (CAR) approach, which uses genetically programmed, patient-derived
`lymphocytes transfected with chimeric receptor genes to combine the effector functions of T
`lymphocytes with the ability of antibodies to recognize predefined surface antigens with high
`specificity in a non-MHC restricted manner50, 51. These receptors have the ability to recognize
`intact membrane proteins independent of antigen processing. CARs or T-bodies typically encode
`an extracellular domain to bind tumor or virus linked to an intracellular signaling domain that
`mediates T cell activation (reviewed in42, 52). In principle, universal targeting vectors can be
`constructed because the scFv bin