Anti-CD19 White Blood Cells for Children and Young Adults With B Cell Leukemia or Lymphoma

Background:

Chimeric antigen receptors (CAR) that recognize the CD19 antigen have been constructed and
are in clinical trials at several institutions. In this trial, the POB will utilize a
chimeric receptor containing the signaling domains of CD28 and CD3-zeta, currently under
study in the CCR in adults, for children and young adults with CD19 expressing malignancies.

In co-cultures with CD19-expressing acute lymphoblastic leukemia cells,
anti-CD19-CAR-transduced T cells show robust killing, and in xenograft models, can rapidly
clear CD19- expressing ALL cell lines.

Objectives:

1. Primary: To determine the safety and feasibility of administering escalating doses of
anti-CD19-CAR engineered peripheral blood lymphocytes in two strata (prior allogeneic
stem cell transplant [SCT] vs. no prior SCT) of children and young adults with B cell
malignancies following a cyclophosphamide/fludarabine preparative regimen. COMPLETED
March 2014.

2. Primary: To determine the safety of administering cells in two groups of children and
young

adults with B-cell malignancies expressing CD19:

- Arm 1 - Patients without high-burden disease or patients for whom chemotherapy
toxicity is a concern will receive standard preparative regimen.

- Arm 2 - Patients with high-burden disease who receive standard chemotherapy to
reduce burden, (defined as patients with ALL who have M3 bone marrow blasts and/or
presence of peripheral blood blasts on routine CBC, or patients with lymphoma).

3. Primary: To determine the feasibility of administering anti-CD19 CAR transduced T cells

within 21 days of the target date in children and young adults with B-cell malignancies

expressing CD19 enrolled on arm 2: Patients with high-burden disease who receive standard

chemotherapy to reduce burden.

1) Secondary: 1) To determine if the administration of anti-CD19-CAR engineered peripheral
blood lymphocytes can mediate antitumor effects in children with B cell high-burden disease
after standard chemotherapy, or in patients without high-burden disease who receive standard
preparative regimen. 2) To evaluate the ability of CRS treatment algorithm to reduce the
incidence of Grade 4 Cytokine Release Syndrome (CRS) to less than or equal to 10% of
patients. 3) To measure persistence of adoptively-transferred anti-CD19-CAR-transduced T
cells in the blood, bone marrow and CSF of patients. 4) To describe the toxicity of
administration of anti-CD19-CAR engineered peripheral blood lymphocytes in children and young
adults with CNS disease.

Eligibility:

Patients 1-30 years of age, at least 15 kg, with a CD19-expressing B-cell malignancy that has
recurred after or not responded to one or more standard chemotherapy-containing regimens for
their malignancy and is deemed incurable by standard therapy. Patients with a history of
allogeneic stem cell transplant who meet all eligibility criteria are eligible to
participate.

Design:

- PBMC will be obtained by leukapheresis. Anti-CD19 CAR T cells will be manufactured from
fresh or frozen PBMCs. On Day -7, PBMC will be enriched for CD3+ cells and cultured in
the presence of anti-CD3/-CD28 beads followed by retroviral vector supernatant
containing the anti-CD19 CAR. Total culture time is approximately 7-14 days.

- Patients will be divided into the 2 groups listed above.

Arm 1: Patients will begin preparative regimen comprising fludarabine 25 mg/m(2) on Days -4,
-3 and -2 and cyclophosphamide 900 mg/m(2) on day -2.

Arm 2: Patients with high-disease burden will be treated with intensive standard of care
chemotherapy to decrease disease burden during cell manufacturing.

- All patients: The CD19-CAR cells will be infused on Day 0, with up to a 72h delay
allowed for fresh cells or a 21 day delay if cells are cryopreserved, if needed for
resolution of clinical toxicities or to generate adequate cell numbers.

- The previously determined maximum tolerated dose (MTD) of 1 X 10(6) will be administered
intravenously.

- Patients will be monitored for toxicity, response and T cell persistence.

- INCLUSION CRITERIA

- Patient must have a CD19-expressing B cell ALL or lymphoma and must have relapsed or
refractory disease after at least one standard chemotherapy and one salvage regimen.
In view of the PI and the primary oncologist, there must be no available alternative
curative therapies and subjects must be either ineligible for allogeneic stem cell
transplant (SCT), have refused SCT, or have disease activity that prohibits SCT at
this time.

- CD19 expression must be detected on greater than 15% of the malignant cells by
immunohistochemistry or greater than 30% by flow cytometry in a CLIA approved test in
the Laboratory of Pathology, CCR, NCI, NIH or from the referring institution or
reference laboratory. The choice of whether to use flow cytometry or
immunohistochemistry will be determined by what is the most easily available tissue
sample in each patient. In general immunohistochemistry will be used for lymph node
biopsies, flow cytometry will be used for peripheral blood and bone marrow samples.

- Patients must have measurable or evaluable disease at the time of enrollment, which
may include any evidence of disease including minimal residual disease detected by
flow cytometry, cytogenetics, or polymerase chain reaction (PCR) analysis.

- Greater than or equal to 1 year of age (and at least 15 kg) and less than or equal to
30 years of age.

- Adequate absolute CD3 count estimated to be required to obtain target cell dose based
on discussion with DTM apheresis and Cell Processing Section, DTM.

- Subjects with the following CNS status are eligible only in the absence of neurologic
symptoms suggestive of CNS leukemia, such as cranial nerve palsy:

- CNS 1, defined as absence of blasts in cerebral spinal fluid (CSF) on cytospin
preparation, regardless of the number of WBCs;

- CNS 2, defined as presence of < 5/uL WBCs in CSF and cytospin positive for
blasts, or > 5/uL WBCs but negative by Steinherz/Bleyer algorithm

- CNS3 with marrow disease who has failed salvage systemic and intensive IT
chemotherapy (and therefore not eligible for radiation)

- Patients with isolated CNS relapse will be eligible if they have previously been
treated with cranial radiation (at least 1800 cGy).

- Ability to give informed consent. For subjects <18 years old their legal guardian must
give informed consent. Pediatric subjects will be included in age appropriate
discussion and verbal assent will be obtained for those greater than or equal to 12
years of age, when appropriate.

- Clinical performance status: Patients > 10 years of age: Karnofsky greater than or
equal to 50%; Patients less than or equal to 10 years of age: Lansky scale greater
than or equal to 50%. Subjects who are unable to walk because of paralysis, but who
are upright in a wheelchair will be considered ambulatory for the purpose of
calculating the performance score.

- Patients of child-bearing or child-fathering potential must be willing to practice
birth control from the time of enrollment on this study and for four months after
receiving the preparative regimen.

- Females of child-bearing potential must have a negative pregnancy test because of the
potentially dangerous effects on the fetus.

- Cardiac function: Left ventricular ejection fraction greater than or equal to 40% by
MUGA or cardiac MRI, or fractional shortening greater than or equal to 28% by ECHO or
left ventricular ejection fraction greater than or equal to 50% by ECHO.

- Patients with history of allogeneic stem cell transplantation are eligible if at least
100 days post-transplant, if there is no evidence of active GVHD and no longer taking
immunosuppressive agents for at least 30 days prior to enrollment.

EXCLUSION CRITERIA

Subjects meeting any of the following criteria are not eligible for participation in the
study:

- Recurrent or refractory ALL limited to isolated testicular disease.

- Hepatic function: Inadequate liver function defined as total bilirubin > 2x upper
limit of normal (ULN) (except in the case of subjects with documented Gilbert s
disease > 3x ULN) or transaminase (ALT and AST) > 20x ULN based on age and laboratory
specific normal ranges;

- Renal function: Greater than age-adjusted normal serum creatinine (see below) and a
creatinine clearance < 60 mL/min/1.73 m^2.

- Age:

- <= 5 yrs (Maximum Serum Creatinine = 0.8 mg/dL)

- 5 < age <=10 yrs (Maximum Serum Creatinine =1.0 mg/dL)

- > 10 yrs (Maximum Serum Creatinine = 1.2 mg/dL)

- Hematologic function:

- Absolute neutrophil count (ANC) < 750/microliter, or platelet count <
50,000/microliter, if

these cytopenias are not judged by the investigator to be due to underlying

disease (i.e. potentially reversible with anti-neoplastic therapy);

- A subject will not be excluded because of pancytopenia greater than or equal to Grade
3 if it is due

to disease, based on the results of bone marrow studies.

-Hyperleukocytosis (greater than or equal to 50,000 blasts/microliter) or rapidly
progressive disease that in the

estimation of the investigator and sponsor would compromise ability to complete

study therapy;

- Pregnant or breast-feeding females;

- Recent prior therapy:

- Systemic chemotherapy less than or equal to 2 weeks (6 weeks for nitrosoureas) or
radiation

therapy less than or equal to 3 weeks prior to apheresis;

Exceptions:

- There is no time restriction in regard to prior intrathecal chemotherapy provided
there is complete recovery from any acute toxic effects of such;

- Subjects receiving hydroxyurea may be enrolled provided there has been no increase in
dose for at least 2 weeks prior to starting apheresis;

- Patients who relapse while receiving standard ALL maintenance chemotherapy will not be
required to have a waiting period before entry onto this study provided they meet all
other eligibility criteria;

- Subjects receiving steroid therapy at physiologic replacement doses only are allowed
provided there has been no increase in dose for at least 2 weeks prior to starting
apheresis;

- For radiation therapy: Radiation therapy must have been completed at least 3 weeks
prior to enrollment, with the exception that there is no time restriction if the
volume of bone marrow treated is less than 10% and also the subject has
measurable/evaluable disease outside the radiation port.

- Other anti-neoplastic investigational agents currently or within 30 days prior to
apheresis (i.e. start of protocol therapy);

- Subjects must have recovered from the acute side effects of their prior therapy,
such that eligibility criteria are met. Cytopenias deemed to be disease-related
and not therapy-related are exempt from this exclusion.

- HIV/HBV/HCV Infection:

- Seropositive for HIV antibody. (Patients with HIV are at increased risk of lethal
infections when treated with marrow-suppressive therapy. Appropriate studies will be
undertaken in patients receiving combination antiretroviral therapy in the future
should study results indicate effectiveness.)

- Seropositive for hepatitis C or positive for Hepatitis B surface antigen (HbsAG).

- Monoclonal antibody therapy administered within 30 days of the agent prior to
apheresis;

- Uncontrolled, symptomatic, intercurrent illness including but not limited to
infection, congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, psychiatric illness, or social situations that would limit compliance
with study requirements or in the opinion of the PI would pose an unacceptable
risk to the subject;

- Second malignancy other than in situ carcinoma of the cervix, unless the tumor
was treated with curative intent at least two years previously and subject is in
remission;

- History of severe, immediate hypersensitivity reaction attributed to compounds of
similar chemical or biologic composition to any agents used in study or in the
manufacturing of the cells (i.e. gentamicin);