CLINICAL TRIALS AND OBSERVATIONS
`
`A phase | trial of donor lymphocyte infusions expanded andactivated ex vivo
`via CD3/CD28 costimulation
`
`David L. Porter, Bruce L. Levine, Nancy Bunin, Edward A. Stadtmauer, Selina M. Luger, Steven Goldstei.1, Alison Loren, Julie Philips,
`Sunita Nasta, Alexandey Perl, Steven Schuster, Donald Tsai, Ambika Sohal, Elizabeth Veloso, Stephen Emerson, and Carl H. June
`
`beads. Patients with aggressive malignan-
`cies received induction chemotherapy,
`and all patients received conventional
`DLI (median, 1.5 x 10® mononuclear cells/
`kg) followed 12 days later by aDLI. Acti-
`vated DLI was dose escalated from 1 x 10°
`
`in-
`lymphocyte infusions (DLIs)
`Donor
`duce potent graft versus tumor (GVT)
`effects for reiapsed chronic myelogenous
`leukemia (CML) after allogeneic stem cell
`transplantation (SCT) but are disappoint-
`ing ior other diseases. Disease resis-
`tance can occur if donor T cells are not
`
`appropriately activated in vivo. Ex vivo
`T-cell activation might overcome disease-
`induced anergy and augment GVTactiv-
`ity. We performed a phase 1
`trial of ex
`vivo—activated DLI (aDLI) for 13 patients
`with relapse after SCT. Activated donor T
`cells are produced through costimulation
`with anti-CD3-— and anti-CD28-coated
`
`Introduction
`
`and 1 of 2 with non-Hodgkin lymphoma
`(NHL). Four complete responders re-
`lapsed while 4 remain alive in remission a
`median 23 monthsafter aDLI. Overall, 10
`of 18 remain alive 11 to 53 months after
`
`aDLI. Adoptive transfer of costimulated
`activated allogeneic T cells is feasible,
`does not result in excessive GVHD, and
`may contribute to durable remissions in
`diseases where conventional DLI has
`
`been disappointing.
`1325-1331)
`
`(Blood. 2006;107:
`
`to 1 x 108 CD3+ cells per kilogram in 5
`levels. Seven patients developed acute
`graft versus hostdisease (GVHD)(5 grade
`I-Il, 2 grade Ill), and 4 developed chronic
`GVHD.Eight patients achieved complete
`remission,
`including 4 of 7 with acute
`lymphocytic leukemia (ALL), 2 of 4 with
`acute myelogenous leukemia (AML),
`1
`© 2006 by The American Society of Hematology
`with chronic lymphocytic leukemia (CLL),
`
`
`is manifested.
`ity after DLI but before the antileukemia effect
`Recently, a prospective trial of DLI was performed using pre-DLI
`induction chemotherapy to limit the leukemia burden in patients
`with relapsed AML after allogeneic SCT.° Although 42% of
`patients in this trial achieved a complete remission (CR), only 14%
`were in continuous CR at a median of 29 months after DLI. These
`
`is
`transplantation (SCT)
`The success of allogeneic stem cell
`dependentnot only on the conditioning therapybut also on the graft
`versus tumor (GVT) properties of the donorgraft. Unfortunately,
`many patients will relapse after SCI and have limited treatment
`options. Second SCT may cure some relapsed patients but at the
`expense of extensive morbidity and mortality.!? Donor lymphocyte
`infusions (DLIs) can induce a direct and potent GVT effect for
`some patients who relapse after allogeneic SCT andare particularly
`that more effective therapies are clearly needed. Similarly, patients
`effective for relapsed chronic-phase chronic myelogenous leuke-
`mia (CML).*7 Response rates to DLI for patients with relapsed
`with ALL respond poorly to conventional DLI, with reported
`remission rates between 0% and 18%.>-°!° In one large retrospec-
`acute leukemia (acute myelogenous leukemia [AML] or acute
`tive analysis, the 3-year probability of survival for 44 recipients of
`lymphocytic leukemia [ALL]) or advanced-phase CML have been
`DLI for ALL was 13%, and only 2 of 44 patients remained in CR 2
`disappointing to date. For patients with AML, response rates to DLI
`years after DLI.!° Notably, however, while response rates are low,
`vary from 15% to 30%,5° and many of these remissions are
`transient. The high tumor burden and rapid proliferation of
`durable remissions are possible, and oneofthe earliest recipients of
`DLI wastreated for relapsed ALL with a sustained remission for
`leukemic blasts often limit the response to DLI; because GVT
`more than 8 yearsat the timeoflast report.'! There are limited data
`effects may be delayed, there is signif-cant disease-related mortal-
`
`
`results suggested that pretreatment with chemotherapy increased
`the CR rate and that AMLcould be sensitive to GVT induction but
`
`From the Stem Cell Transplant Program, the Hematology-Oncology Divisian,
`and Abramsor. Carcer Center, University or Pennsyivania. Philadelphia; and
`the Department of Pathology and Laboratory Medicine, Abramson Family
`Cancer ResearchInstitute; and Division of Oncology, Children’s Hospital of
`Philadelphia, PA.
`
`Submitted August 19, 2005; accepted October 11, 2005. Prepublished online
`as BloodFirst Edition Paper, November 3, 2005; DOI 10.1182/blood-2005-08-
`3373.
`
`Supportedin part by a grant from The Leukemia & Lymphoma Society (7000-02).
`
`interest in a
`Two of the authors (C.H.J., B.L.L.) have declared a financial
`company(Xcyte) that holds license to the technology studied in this work.
`
`All authors have contributed substantially to this work. D.L P. was responsible
`for conception, design, and execution of research, data review and analysis,
`and primary authorship; B.L.L., conception and design, performance or
`supervision of ex vivo costimulation, biologic assays, data review, and
`
`manuscript preparation; N.B., conception, design, and execution of research,
`data review, and assistance with manuscript preparation; E.A.S., S.M.L., S.G.,
`A.L., u.P., S.N., A.B, S.S., and D.T., execution of research, data review, and
`assistance with manuscript preparation; A.S., data collection, quality control,
`data review, and assistance with manuscript preparation; E.V., data collection,
`execution of
`research, quality control, and assistance with manuscript
`preparation; S.E., conception and design of research, data review, and
`assistance with manuscript preparation; and C.H.-J., conception, design, and
`execution of research, data review and analysis, and manuscript preparation.
`
`Reprints: David L. Porter, Division of Hematology-Oncology, 16 Penn Tower, 3400
`Spruce St, Philadelphia, PA 19104; email: david.porter @ uphs.upenn.edu.
`
`The publication costs of this article were defrayed in part by page charge
`payment. Therefore, and solely to indicate this fact,
`this article is hereby
`marked “advertisement”in accordance with 18 U.S.C. section 1734.
`
`© 2006 by The American Society of Hematology
`
`BLOOD, 15 FEBRUARY 2006 « VOLUME 107, NUMBER 4
`
`UPenn Ex. 2034 ‘°°
`Miltenyi v. UPenn
`IPR2022-00853
`
`UPenn Ex. 2034
`Miltenyi v. UPenn
`IPR2022-00853
`
`

`

`1325
`
`PORTERetal
`
`BLOOD, 15 FEBRUARY 2006 » VOLUME 107, NUMBER 4
`
`regarding efficacy of DLI for patients with other hematologic
`malignancies such as myeloma, non-Hodgkin and Hodgkin lym-
`phoma, and myelodysplastic syndrome (MDS), but overall
`re-
`sponserates have been disappointing, ranging from 0% to 50%.!?
`Clearly, more effective approaches to relapsed disease (other than
`early-phase CML) are needed.
`While GVT induction seems to be disease specific, the actual
`mechanisms for disease resistance are not known. It is possible that
`donor T cells are not appropriately activated in vivo to induce an
`antitumor response. Activation of T cells requires 2 signals:
`engagement of the T-cell receptor (TCR) and a second, costimula-
`tory signal. This second signal, when combined with primary
`antigen-dependentstimulation of the TCR,is required forthe T cell
`to maximally synthesize and secrete cytokine and divide in
`response to antigen. The majorpositive costimulatory receptor on T
`cells is CD28, andits ligands are the B7 family of molecules CD80
`and CD86, which are abundantly expressed on activated antigen-
`presenting cells (APCs). T-cell costimulation is critical for induc-
`tion of full T-cell effector function and therefore represents an
`attractive immunotherapeutic approachfor treatment of cancer and
`may maximize GVTeffects of allogeneic donorT cells. Inadequate
`T-cell activation could occur for many reasons, including lack of
`costimulatory ligands on tumorcells, failure to present antigens to
`T cells, direct suppression of cytotoxic effectorcells by suppressor
`T cells or cytokines, failure to stimulate CD4* cells, or quantitative
`lack of sufficient cytotoxic effectorcells.
`We hypothesized that ex vivo costimulation of T cells via CD3
`and CD28 can produce activated T cells that can overcome
`disease-induced anergy, preserve and augment CD4 function, and
`enhance GVT activity. Activated donor T cells are produced by
`costimulation and expansion following exposure to magnetic beads
`coated with anti-CD3 (OKT3) and anti-CD28.'? In the setting of
`autologous SCT, administration of ex vivo—costimulated T cells
`can reverse both in vivo and in vitro functional T-cell defects in
`patients with lymphoma.'* To explore the feasibility and toxicity of
`adoptive immunotherapy with expanded activated allogeneic T
`cells, we performed a phase | trial of DLI followed by escalating
`doses of ex vivo—costimulated donorT cells (activated DLI [aDLI])
`for patients with relapse of diseases other than chronic-phase CML
`after allogeneic SCT. Activated DLI in this trial has been well
`tolerated without excessive toxicity, and response rates are impres-
`sive for diseases that historically have not responded well
`to
`conventional DLI.
`
`
`
`Patients, materials, and methods
`
`Eligibility criteria
`
`for chronic-phase CML) after
`Patients with relapsed disease (¢xcept
`allogeneic SCT from an HLA-matched sibling were eligible for this study.
`Patients with relapsed CML wereeligible only if they had advanced disease
`(accelerated or blast phase) at relapse. Prior to DLI, patients could not have
`active acute graft versus host disease (GVHD) above gradeI, active chronic
`GVHD,and could not require active immunosuppression to control GVHD.
`The study was approved bytheinstitutional review boards of the Hospital
`of the University of Pennsylvania and Children’s Hospital of Philadelphia
`and was conducted under a Food and Drug Administration (FDA)—
`approved Investigational New Drug Application. Voluntary written in-
`formed consent was obtained from all patients and donors or from an
`appropriate guardian in the case of a minor.
`
`Study design
`
`Patients receiving immunosuppression at the time of relapse had therapy
`rapidly tapered or discontinued with the intent to observe for GVHD and
`GVTfor approximately 4 weeks. However, 2 patients with acute leukemia
`began induction chemotherapy within 2 weeks of stopping immunosuppres-
`sion due to rapid progression of disease. Patients who experienced above
`grade I acute GVHDora GVTresponseafter discontinuing immunosuppres-
`sion would not receive DLI.
`This pilot study was designed as a phase | dose escalation trial of aDLI
`focusing on feasibility and safety as the primary end points. The treatment
`regimen is shown in Figure |. Patients with “aggressive malignancies,”
`defined as relapsed AML, ALL, lymphoblastic lymphoma, or blast-phase
`CML(morethan 30% blasts in the blood and/or marrow), were treated with
`conventional
`induction chemotherapy 7 to 14 days before DLI°; any
`standard induction regimen for leukemia was acceptable and was deter-
`minedby the patient’s past therapy and clinical condition.
`
`Donorleukocyte infusions
`
`All patients received conventional, unstimulated DLI prior to receiving
`aDLI. The original stem-cell donor underwent large-volume (10 to 15 L)
`leukapheresis for mononuclear-cell collection on | or 2 sequential days. A
`target goal of 1
`.< 198 to 2 x 108 mononuclear cells per kilogram of
`recipient body weight was administered on the day of collection to all
`patients ,day 0) as conventional DLI; mononuclear-cell and CD3* cell
`doses are shownin Tables 1-2. The median actual dose of unstimulated DLI
`
`administered was 1.9 * 108 CD3* cells per kilogram (range, 0.9 X 108 to
`3.2 x 108 cells/kg). For patients who received induction chemotherapy,
`donor leukocytes were collected and administered at the hematologic nadir,
`10 to 12 days after chemotherapy (Figure |). The DLI productserved in all
`cases as the sourceof cells for CD3*/CD28* T-cell expansion.
`
`Ex vivo costimulation and expansion of donorT cells
`
`Analiquotof cells from the donor leukocyte productcollected on the first or
`second day of leukapheresis was removed prior to DLI
`for ex vivo
`expansion. The washed apheresis product was enriched for lymphocytes
`using magnetic bead depletion of monocytes in a closed system if
`monocytes constituted more than 20% of white blood cells (WBCs) as
`gated on a ‘oulter Multisizer3 (Beckman Coulter, Fullerton, CA). T cells
`were processed in a mannerconsistent with appropriate FDA guidelines and
`regulations on Good Manufacturing Practices as previously described, with
`the exception that CD8* T cells and CD20* B cells were not removed from
`the starting culture.!+!5
`The cells were seeded into gas-permeable flasks (Baxter Oncology,
`Deerfield,
`IL) containing X VIVO 15
`(Cambrex, Walkersville, MD)
`supplemented with 5% normal human AB serum (Valley Biomedical,
`Winchester, VA), 2 mM L-glutamine (Cambrex), and 20 mM HEPES
`(Cambrex). Magnetic beads (Dynal, Brown Deer, WI) with conjugated
`anti-CD3 (OKT3; Ortho Biotech, Bridgewater, N41) and anti-CD28 (clone
`9.4) monoclonal antibodies were addedat a 3:1 bead/CD3* cell ratio, and
`the cultures were maintained for up to 12 days prior to harvest and
`preparation for infusion. After completion of cell culture, the magnetic
`beads were removed using a Baxter Fenwal Maxsep magnetic cell
`separation system, and the cells were washed, concentrated, and resus-
`pended in 100 to 250 mL PlasmaLyte A (Baxter Oncology)/5% dextrose
`0.45% NaCl containing 1% human serum albumin (Baxter Oncology). All
`infused '[-cell products were required to meet release criteria specifed for
`T-cell phenotype, cell viability, pyrogenicity, sterility, and freedom from
`bead contamination.
`The ex vivo—expanded and —activated cells were infused approxi-
`mately 12 days after standard DLI as aDLI (Figure 1). Activated DLI
`was dose escalated based on CD3* cell number between sequential
`groups of patients as shown in Figure |. Five dose levels of activated
`cells were tested ranging from | X 10° CD3* cells per kilogram to
`1 x 108 CD3* cells per kilogram.
`The third patient on each dose level was observed for a minimum of
`4 weeks before enrolling subsequent patients to ensure severe GVHD
`UPenn Ex. 2034
`
`Miltenyi v. UPenn
`IPR2022-00853
`
`UPenn Ex. 2034
`Miltenyi v. UPenn
`IPR2022-00853
`
`

`

`ACTIVATED DLI FOR RELAPSE AFTERALLOGENEIC SCT=:11327
`BLOOD, 15 FEBRUARY 2006 * VOLUME 107, NUMBER 4
`
`did not develop. In some cases 4 patients were treated at a given dose
`level. Dose-limiting toxicity was defined as any grade 4 nonhematologic
`toxicity or any grade 4 acute GVHD. The maximumtolerated dose was
`defined as the dose level resulting in 2 of 6 (33%) patients experiencing
`dose-limiting toxicity.
`
`Statistical analyses
`
`This phase | study was designed to determine the feasibility and safety of
`administering ex vivo—costimulated and expanded donor
`lymphocyte
`infusions to patients with relapsed disease after allogeneic SCT. Character-
`istics and outcomesare described with summarystatistics including median
`and mean values when appropriate. The probability of survival, progression-
`free survival, and disease-free survival (for patients achieving CR) were
`estimated using the Kaplan-Meier method. These analyses were performed
`with the Statview statistical software package (Abacus Concepts, Berkeley,
`CA). Data were analyzed as of May 1, 2005.
`
`
`Results
`
`Patient characteristics
`
`The characteristics of the 18 patients are shown in Table 1. There
`were |] male and 7 female patients with a median age of 46 years
`(range, 12 to 57 years). The median donorage was 42 years (range,
`10 to 62 years), and donors were sex matched in 12 cases and
`mismatched in 3 cases. All but | patient received DLI and aDLI
`(preceded by induction chemotherapy for patients with aggressive
`leukemia and lymphoma) for overt clinical relapse without
`treatment other than hydroxyurea to control blood counts prior
`to study entry. One patient with ALL (patient no. 649-04) was
`treated with induction chemotherapy and received aDLI 4 weeks
`after DLI at the time of minimal residual disease rather than at
`
`the hematologic nadir.
`The median time from transplantation to relapse was 11.5
`months (range, 2 to 90 months) and from relapse to DLI was 6
`weeks (range, 2 to 30 weeks). Three patients (1 each with
`non-Hodgkin lymphoma [NHL], Hodgkin disease, and myeloma)
`received aDLI for relapse after a nonmyeloablative-conditioned
`transplantation, and all other patients were treated for relapse after
`a conventional myeloablative allogeneic SCT. The indications for
`DLI were ALL (n = 7), AML (n = 4), CML—blast phase (n = 1),
`chronic lymphocytic leukemia (CLL) (n= 1), NHL (n= 2),
`Hodgkin disease (n = 1), myeloma (n = 1), and lymphoblastic
`lymphoma (n = 1). Individual patient characteristics and outcomes
`are shownin Table 2. The 13 patients with ALL, AML, lymphoblas-
`tic lymphoma, and CML-blast crisis (CML-BC) received chemo-
`therapy prior to DLI and aDLI.
`Patients received a median of 1.5 X 10° mononuclearcells per
`kilogram (range, 0.9 * 108 to 3.5 X 108 cells/kg) as unstimulated
`DLI. The dose of aDLI is shownin Figure | and Table 2.
`
`Ex vivo expansion and administration of donor T cells
`
`Ex vivo cultures of donor lymphocytes wereinitiated with 50 x 10°
`to 700 X 10° cells depending on the target dose level. After
`approximately 10 to 12 days
`in culture, CD3* cells were
`94.1% + 1.0% viable by trypan blue dye exclusion. T cells in the
`cultures expanded a median of 113-fold and consisted of 60.7%
`CD3*CD4* cells and 30.4% CD3*CD8* cells (Table 3). The
`CD4/CD8ratio of the starting cell population (3.26 + 0.67) was
`maintained in the expanded cells (3.33 + 0.82). We have previ-
`ously demonstrated that healthy donor cells expanded in this
`fashion demonstrate a Thl cytokine profile, maintain the T-cell VB
`
`Table 1. Patient characteristics
`
`Characteristic Value
`
`Diagnosis, no. of patients
`ALL
`Anti
`CML-BC
`CLL
`NHL
`HD
`Myeloma
`LL
`Median age,y (ra.1ge)
`Sex, male/female
`Median d--niage, y (range*
`Sex-m._ma*chez Jonors, no.
`Graft sourceof original BMT, no.of patients
`Bone marrow
`Perisheral blood stem celis
`Conditioning ret;imen inteisity of original BMT. no. of
`patients
`Myeloablative
`Nonmyeloablative
`Conditioning regimen of original BMT,no.of patients
`TBI based”
`BuCy
`Flu/Cy
`induction chemotherapy used priorto DLIf, no. of
`patients
`Ida/AraC
`CVAD
`Mito/AraC
`Flu/AraC
`DVP,Asu
`Ida
`ICE
`Mylotarg
`Time from BMTto relapse, mo(range)
`Timefrom relapse to DLI, wk (range)
`Median DLI-unstimulated mononuclearcells, > 10° (range)
`
`ereeee
`
`43 (12-57)
`12/6
`42 (10-52)
`6
`
`Hire
`
`15
`.
`
`12
`3
`
`—-e+eNOMww
`
`1
`11.5 (2-90)
`6 (2-30)
`1.5 (0.9-3.5)
`
`lymphoblastic lympnoma; TBI, total body
`HD indicates Hodgkin disease; LL,
`irradiation; Bu, busultan; Cy, cyclophosphamide;
`Ida,
`idarubicin; AraC, cytosine
`arabinoside. CVAD, cyclophosphamide, vincristine, adriamycin, dexamethosone;
`Mito, mitoxantrone; Flu, fludarabine; DVP, daunarubicin, vincristine, prednisone; Asp,
`asparaginase; and ICE, ifosphamide, carboplatinum, VP16 (etoposide).
`*With either Cy, VP 16, thiotepa/Cy,or thiotepa/Cy/VP16.
`tFor patients with AML, ALL, CML-BC, and LL; n = 14.
`
`repertoire for at
`telomerase. !*-!6!7
`
`least 60 days, and express high levels of
`
`Nosevere toxicity was associated with administration of aDLI. Mild
`infusional toxicity of fevers and chills (grade II) developed in 4 patients
`at
`the highest dose levels, but otherwise aDLI was well tolerated.
`Dose-limiting toxicity was not reached atthe tested dose levels.
`
`Response
`
`Individual responses to therapy are shown in Table 2. Eight patients
`achieved a complete response. This includes 4 of 7 patients with
`ALL, 2 of 4 patients with AML,
`| patient with CLL, and | of 2
`patients with NHL (mantle-cell lymphoma). One patient with AML
`manifested by recurrent extramedullary chloromas had a partial
`response, and | patient with ALL has had stable disease for 13
`months after aDLI.
`
`Three patients were treated for relapse after nonmyeloablative
`allogeneic SCT (patients 4799-11, 4799-16, and 4799-18) for
`myeloma, NHL, or Hodgkin disease. None of these patients had a
`complete response to DLI plus aDLI (Table 2).
`UPenn Ex. 2034
`
`Miltenyi v. UPenn
`IPR2022-00853
`
`UPenn Ex. 2034
`Miltenyi v. UPenn
`IPR2022-00853
`
`

`

`1328
`
`PORTERetal
`
`Table 2. Patient outcomes
`
`BLOOD, 15 FEBRUARY 2006 » VOLUME 107, NUMBER 4
`
`Time from
`Maximal
`DLI
`Time from
`DLIto last
`response
`aDLI dose, Maximal
`dose,
`BMTto Time from
`follow-up,
`and
`CD3- cells
` gradeof
`relapse,
`relapseto MNCsx
`Age at
`mo
`Current status
`duration
`x 10&/kg
`aGVHD
`mo
`DLI, wk
`108%/kg
`Diagnosis
`DLI,y
`UPN
`
`
`
`
`
`
`
`
`
`4799-03 CR,53+ mo_AliveinCR54 CLL 45 6 BS) 1.0 ll 53+
`649-02
`19
`ALL
`2
`3
`1.0
`1.0
`NE
`NE
`Died, disease
`0.3
`4799-05
`57
`AML
`90
`2
`15
`1.0
`|
`CR, 40 mo
`Relapseafter CR, alive with disease
`49+
`649-03
`16
`ALL (Ph*)
`24
`24
`1.0
`1.0
`0
`NR
`Died, disease
`2.6
`4799-07
`44
`ALL
`5
`5
`0.9
`3.0
`ll
`CR, 7 mo
`Relapse after CR, died, disease
`8.2
`4799-08
`52
`NHL
`20
`6
`1.0
`3.0
`0
`CR,35+ mo AliveinCR
`35+
`4799-11
`45
`Myeloma
`ey
`5
`1.6
`3.0
`|
`NR
`Died, disease
`13.8
`4799-09
`53
`AML
`2
`3
`2.4
`10.0
`Ill
`PR, 6 mo
`Died, disease
`6.7
`4799-13
`32
`ALL
`10
`9
`1.5
`10
`0
`CR, 22 mo
`Relapseafter CR, alive with disease
`24+
`4799-14
`28
`LL
`3
`2
`1.8
`10
`ll
`NR
`Died, disease
`3.0
`4799-15
`36
`CML-BC
`13
`2
`1.6
`10
`0
`NR
`Died, disease
`3.6
`649-04
`12
`ALL (Ph*)
`8
`6
`1.1
`30
`0
`CR, 16 mo
`Relapse after CR, alive with disease
`16+
`4799-16
`54
`HD
`38
`6
`1.5
`30
`0
`NR
`Alive with disease
`11+
`4799-18
`49
`NHL
`29
`9
`1.5
`30
`0
`NR
`Alive with disease
`13+
`4799-20
`36
`AML
`83
`8
`1.0
`30
`0
`NR
`Died, disease
`4
`4799-21
`43
`ALL
`4
`31
`1.3
`100
`0
`SD, 13 mo
`Alive with disease
`13+
`
`
`
`
`
`
`
`
`
`4799-23 CR,11+mo_AliveinCR{PCR-)46 ALL 19 10 2.0 100 0 11+
`
`4799-24 12+ 46 APML 5 3 2.2 100 | CR,12+mo_ Alive in CR (PCR-)
`
`
`
`
`
`
`
`
`
`
`UPN indicates unique patient number; MNCs, mononuclearcells; aGVHD, acute GVHD; CR, complete remission; NE, not evaluable; NR, no response; PR, partial
`response;LL, lymphoblastic lymphoma; CML-BC, chronic myelogenous leukemia-blastcrisis; HD, Hodgkin disease; SD, stable disease; APML, acute promyelocytic leukemia;
`and PCR,polymerasechain reaction.
`
`Of the 17 patients evaluable for response, 11 had relapsed
`more than 6 months after the original bone marrow transplanta-
`tion (BMT)and 7 had relapsed within 6 months oftransplanta-
`tion. Six of 11 aDLI recipients who had relapsed more than 6
`months after SCT and 2 of 6 who relapsed within 6 months of
`SCT achieved CR; this difference was not statistically signifi-
`cant (P = .4), though the numberof patients studied is guite
`small. When only the 10 patients evaluable for response with
`ALL or AMLare considered, 2 of 4 patients who relapsed within
`6 months of transplantation achieved CR and 4 of6 recipients of
`aDLI who relapsed more than 6 months from transplantation
`achieved CR (P = .6).
`
`Disease-free and overall survival
`
`The estimated 2-year overall survival after aDLIforall patients is
`31% (Figure 2A). Ten of 18 patients remain alive a median of 16
`months after aDLI (range, 11 to 53 months), and 8 have died. Four
`of the 8 patients who achieved CR remain alive in CR 10 to 52
`months after aDLI (median, 23 months), including | patient each
`with NHL, AML, CLL, and ALL. Fourof the complete responders
`subsequently relapsed. Three of these 4 patients had ALL and
`relapsed after 7-, 16-, and 22-month remissions. One of these
`patients died of recurrent disease, and 2 remain alive and are
`
`-14 to -7
`
`0
`
`10-12
`
`undergoing alternate therapy. One patient with AML achieved CR
`and recently relapsed after a 40-month remission and is alive
`undergoing alternate therapy.
`Progression-free survival at | and 2 years for the entire cohort
`was 44% and 23%, respectively. For the subset of 11 patients with
`AMLand ALL,progression-free survival at | and 2 years was 45%
`and 15%, respectively. The estimated 2-year disease-free survival
`after DLI for the 8 patients who achieved CR is 52% (Figure 2B).
`Ofthese 8 patients, 6 received chemotherapy prior to DLI for AML
`or ALL. The median follow-up in these 6 patients is 13 months
`(range, 7 to 40 months). Two of these 6 patients remain in
`remission 1] and 12 months after aDLI. Five patients received DLI
`and aDLI without induction chemotherapy. One of these 5 patients
`with CLL remains in CR 53 months after aDLI, and 1 with
`mantle-cell lymphomais in CR 35 months after aDLI.
`Nine patients had no response(orstable disease) after therapy (Table
`2); the diagnoses in these 9 patients were AML (n = 2), NHL (n = 1),
`ALL (n = 2), CML-BC (n= 1), myeloma (n= 1),
`lymphoblastic
`lymphoma (n = 1), and Hodgkin disease (n = 1). Six of these patients
`have died of progressive disease, and 3 remain alive with disease on
`alternate therapies. One patient with ALL wasnot evaluable for response
`due to early death from progressive disease.
`Eight patients have died of persistent or recurrent disease | to
`14 months after aDLI (median, 4 months) and include 2 patients
`with AML,3 with ALL, and | each with CML-BC, myeloma, and
`lymphoblastic lymphoma.
`Graft versus host disease
`
`After the original SCT, 14 of the 18 patients experienced no acute
`GVHD, 2? developed grade I, and 2? patients developed grade II
`acute GVHD. Six patients experienced chronic GVHD. Atthe time
`of DLI no patient had active GVHD andall patients were off
`immunosuppression for a minimum of 2 weeks (median, 16 weeks:
`range, 2 to 162 weeks).
`After DLI and aDLI, 7 patients developed grade I (n = 3), grade
`II (skin only, n = 2), and grade IIT (n = 2) acute GVHD (Table 2).
`UPenn Ex. 2034
`
`Miltenyi v. UPenn
`IPR2022-00853
`
`
`
`+/- Induction
`|Ghemotherapy’
`
`Activated
`
`
`
`
`
`Standard DLI
`DLI
`aDLi dose level!
`1x 10° GD3+ celis/kg
`aDLi dose level?
`3x 10°CO3+ celis/kg
`aDLi dose level3
`1% 10? CD3+ cellsikg
`a@DLi dose level4
`3x 107 CD3+ celis/kg
`eaDLil dose levelS 1 10° CO3+ cels/kg
`
`
`
`
`Screening
`studies
`
`4 patients
`3 patients
`4 patients
`4 patients
`3 patients
`
`trial of DLI plus acti-ated DLI.
`Figure 1. Treatment scheme for the phase 1
`“Patients with acute leukemia (AML, ALL) or lymphoblastic lymphoma were pre-
`treated with induction chemotherapy.
`
`UPenn Ex. 2034
`Miltenyi v. UPenn
`IPR2022-00853
`
`

`

`
`
`BLOOD, 15 FEBRUARY 2006 » VOLUME 147, NUMBER 4 ACTIVATED DLI FOR RELAPSE AFTERALLOGENEIC SCT=:1329
`
`Table 3. Ex vivo expansion of allogeneic T cells
`Initial CD3,
`Final CD3,
`Final CD3*
`Final CD3*
`Totalcell fold
`CD3* fold
`
`UPN
`%
`%
`CD4*,%
`CD8*,%
`expansion
`expansion
`4799-03D
`65.2
`90.7
`44.0
`413
`27.4
`38.1
`4799-05D
`65.5
`96.3
`83.9
`14.7
`121.0
`177.9
`649-02D
`56.2
`90.3
`46.0
`34.8
`59.2
`95.1
`649-03D
`56.7
`98.5
`29.5
`70.6
`82.6
`143.5
`4799-07D
`50.1
`93.5
`66.4
`25.7
`49.4
`92.2
`4799-08D
`61.1
`95.1
`84.3
`10.8
`30.0
`46.7
`4799-11D
`54.6
`95.8
`50.6
`37.4
`28.2
`49.5
`4799-09D
`51.7
`95.0
`72.4
`26.5
`69.4
`127.5
`4799-13D
`50.8
`84.5
`49.5
`28.5
`43.0
`715
`4799-14D
`39.5
`98.3
`45.4
`51.0
`40.6
`101.0
`4799-15D
`68.5
`85.3
`52.2
`31.6
`422.0
`525.5
`649-04D
`84.4
`96.3
`45.7
`46.3
`77.0
`87.9
`4799-16D
`69.9
`96.4
`715
`23.3
`91.2
`125.8
`4799-20D
`71.6
`94.1
`62.5
`39.5
`24.2
`31.8
`4799-18D
`64.9
`97.4
`67.9
`28.6
`100.5
`150.8
`4799-21D
`35.8
`89.7
`74.1
`5.0
`32.7
`81.8
`4799-23D
`74.0
`95.6
`78.8
`16.4
`26.3
`34.0
`4799-24D
`62.6
`98.3
`78.7
`16.0
`34.3
`53.8
`Average
`58.9
`94.0
`60.7
`30.4
`ete
`113.0
`
`2.9 1.0 3.9 3.8 21.5SE of the mean 26.3
`
`
`
`
`
`
`UPNindicates unique patient number.
`
`GVHD was not evaluable in | patient due to early death. Acute
`GVHDoccurred a median of 28 days after aDLI (range, 16 to 38
`days) or 40 days after conventional DLI. The a:tuarial probability
`of developing grade II-IV or grade IN-IV acute GVHD by day 100
`was 33% (standard error, 11%) and 22% (standard error, 10%),
`respectively. No patient died from complications related to GVHD.
`Of tre 7 patients wno developed acute GVHD, 3 remainalive in
`remission and 4 have died from recurrent or progressive disease. In
`this small series of patients there was no association with acute
`GVHDandsurvival (P = .35).
`Chronic GVHD developedin 4 patients and waslimited stage in
`2 patients and extensive in 2 patients. Three of the 4 patients with
`chronic GVHD remainalive in remission, and 2 require ongoing
`immunosuppression for mucosal or skin involvement. The fourth
`patient died of progressive myeloma 14 months after aDLL.In this
`limited number of patients there was no association with chronic
`GVHDand survival (P = .51). Therefore, even at the highest dose
`level of aDLI, GVHD wasnota dose-limiting toxicity.
`
`T-cell recovery after DLI and aDLI
`
`The administration of DLI and aDLI resulted in either no or only a
`slight
`increase in CD3 and CD4 cell counts. The median fold
`increase in CD3* cell numbersat 1, 2, and 3 months after aDLI was
`1.5 (range, 0.33 to 8.3), 2.1 (range, 0.24 to 18.8), and 1.8 (range,
`0.26 to 25.0), respectively. The median fold increase in CD4* cell
`
`numbers at 1, 2, and 3 months was 1.7 (range, 0.21 to 10.1), 1.2
`(range, 0.30 to 6.4), and 1.2 (range, 0.33 to 19.5), respectively. The
`change in CD3* or CD4* numbers was notsignificantly different
`in responders compared with nonresponders (data not shown).
`
`
`Discussion
`
`GVIinduction with DLI is dramatically successful for patients with
`chronic-phase CML whorelapseafter allogeneic SCT butis disappoint-
`ing for patients with other hematologic malignancies. The mechanisms
`for disease specificity of DLI are not known. In some instances, such as
`in patients with AML and ALL, rapid tumor progression may occur
`before GVT effects from DLI develop. Induction chemotherapy given
`before DLI may limit the tumor burden and increase responserates but
`is of limited long-term benefit.?!° Poor responses to DLI also would
`occurif donor T cells were anergic or suppressed in vivo.In this case, ex
`vivo activation could overcome immune system unresponsiveness or
`disease resistance to DLL. Several lines of evidence support the potential
`for adoptive immunotherapy with ex vivo—activated donor T cells,
`including the following: (1) Somepatients resistant to DLI achieve CR
`after administration of IL-2 orafter infusions of donorT cells activated
`
`ex vivo with IL-2! (notably, IL-2 results in preferential activation of
`cytotoxic CD8* T cells; several reports in humans suggest that CD8*
`cells are primary mediators of GVHD while CD4* cells are thought to
`
`Overall Survival after aDLI
`
`B spisease-Free Survivalafter aDLI (n=8)
`
`
`14
`
`
`
`By
`|
`
`
`
`6
`4
`
`|
`
`r
`9
`
`t
`10
`
`:
`:
`300-400
`200
`Months after aDLI
`
`T
`5D
`
`T
`8D
`
`2]
`04
`
`1
`0
`
`1
`10
`
`1
`1
`r
`r
`1
`0620000, 4 sO
`Months after aDLI
`UPenn Ex. 2034
`
`Miltenyi v. UPenn
`IPR2022-00853
`
`A
`
`1
`
`B
`
`>
`5 6
`4
`cL
`
`ao
`
`Figure 2. Kaplan-Meier estimates of overall and dis-
`ease-free survival after aDLI. (A) The estimated overall
`survival at 2 years for all patients is 51%.
`(B) The
`estimated disease-free survival at 2 years for the 8
`patients who achieved a CR is 52%.
`
`2
`0
`
`UPenn Ex. 2034
`Miltenyi v. UPenn
`IPR2022-00853
`
`

`

`1330
`
`PORTERetal
`
`BLOOD, 15 FEBRUARY 2006 » VOLUME 107, NUMBER 4
`
`provide the greater contribution to GVTactivity!'®?°). (2) Tumorsthat
`lack costimulatory ligands are poorstimulators of immuneeffector cells
`and can induce peripheral tolerance of tumor reactive T cells.2!?? (3)
`Tolerance induction generated in vivo by down-regulatory signals such
`as CTLA4 can be avoidedby ex vivo costimulation.* (4) Some tumors
`may produce factors that
`interfere with T-cell or APC intracellular
`signaling, resulting in suboptimal costimulation.*2 (5) Methods are
`available to stimulate and expand CD4* cells,2° which may have a
`primary role in GVT induction.‘*”° (6) Ex vivo costimulation of
`autologous T cells by CD3 and CD28 can reverse both in vivo and in
`vitro functional T-cell defects in patients with lymphoma."*
`We hypothesized that ex vivo costimulation of T cells via CD3 and
`CD28 might overcome disease-induced anergy, preserve and augment
`CD4 function, and enhance GVTactivity and that the activated and
`expanded donorT cells would induce GVT effects in patients who do
`not otherwise respond well to DLI. All patients first received unstimu-
`lated DLI because this was felt to be the most effective established
`
`treatment option available. To improve the poor response rates seen in
`earlier studies of conventional DLI. a small aliquot of donor T cells was
`removed from the DLI productforex vivo costimulation and expansion
`and administered as aDLI after 10 to 12 days of culture. To limit the risk
`of rapid progression before GVT effects could develop and to
`induce a minimal disease state prior to DLI, patients with AML,
`ALL, advanced-phase CML, and lymphoblastic lymphoma were
`pretreated with induction chemotherapy and DLI was administered
`during the hematologic nadir.?:!°
`Seventeen patients were evaluable for a response, and 8 achieved a
`CR,including 4 of 6 patients with ALL, 2 of 4 with