Ph2 NK Cell Enriched DCIs w/wo RLR9 Agonist, DUK-CPG-001 From Donors Following Allogeneic SCT

This is a randomized, parallel phase II study to evaluate the rates of progression-free
survival and unacceptable toxicity in patients receiving NK cell-enriched donor lymphocyte
infusions (DLIs) when administered alone or administered with the TLR9 agonist, DUK-CPG-001,
from a 7-8/8 HLA-matched related or unrelated donor (Cohort A) or 4-6/8 HLA-matched related
donor (Cohort B) following reduced intensity or non-ablative allogeneic stem cell
transplantation. Randomization will be stratified for disease types (myeloid versus lymphoid
malignancies).

Patient prior to starting therapy Within 21 days prior to initiating therapy, patients will
have an updated history and physical examination performed, lab tests, stool collection, and
pregnancy test if the patient is a female of childbearing potential. Patients will have blood
or marrow stored for analysis of immune function and chimerism. Tests documenting the
patient's disease state are required at study entry as well (bone marrow aspirate/biopsy,
blood studies, and/or radiographic tests such as CTs, MRI, PET scans as determined by
treating physician,and as required for standardized response evaluations).

Donor apheresis and cell processing Donors will return to the center for a fresh collection
of NK cells and they will not need growth factor mobilization. One collection will be used
for each NK cell infusion. Cells will be transfused immediately after collection and
processing or the next day. Cell processing will be performed in our cryopreservation lab
according to SOP for collection, labeling and handling. The cells will be NK selected using a
CD56 antibody (CliniMACS CD56 Reagent), CliniMACSplus instrument and CliniMACS tubing set
provided by Miltenyi Biotec using the company protocol (Miltenyi Biotec Inc, Auburn,
California). Pre and post processing cell count, viability, Hematopoietic Progenitor Cell
Assay (HPCA) and flow analysis per SOP will be done.

Patient Evaluation Assessment of disease will use standardized criteria and shall include a
careful examination of the studies needed to detect the disease (PET, radiographs, immuno
phenotype, marrow, molecular studies etc). Restaging may be altered at the discretion of the
transplant physician following the patient (who are all subinvestigators in this study) if
the patient is felt to be progressing before these time points but the recommended restaging
is q3 months for 1 year after the last NK-enriched DLI, q6 months for the next 2 years, then
as indicated clinically. Immune reconstitution studies prior to and 1 and 7 days after each
NK cell-enriched DLI, and 3, 6, and 12 months after the last NK-enriched DLI. Determination
of chimerism (by short tandem repeat analysis in use in our DUKE HLA laboratory with a 2%
sensitivity) just prior to each NK cell-enriched DLI, and 3, 6, 12 months after the last
NK-enriched DLI.

Toxicity will be formally evaluated post infusion and a week later (more as determined by
treatment team) and at a minimum of every other week through 6 weeks post infusion, then q3
months starting at 3 months post-second DLI for the first year. Assessments include history
(specific to GI toxicity as well as overall new problems), physical exam, CBC, liver function
tests (AST, ALT, bilirubin at a minimum), and Chemistry CS to include creatinine and BUN for
toxicity assessment following the NCI common toxicity criteria (version 4) and standard GVHD
criteria (appendix I). Further follow up will be required as needed if the patient has a
toxicity due the transplant or infusion procedures. Patients with a grade 3 or greater
toxicity due to the study will be seen every other week at a minimum until the toxicity is <
grade 3, and then will be seen as clinically appropriate.

Stool Collection and Microbiome Analysis:

We will collect stool samples from patients at the following time points throughout the
study: pre-DLI, day +7, pre-second DLI, day +7, then every 3 months post DLI for one year.
Stool samples from patients may be stored at 4°C for up to 24 h before freezing at -80°C for
batch analysis.

Patient NK cell infusion and CpG administration plan The target cell dose for NK
cell-enriched DLI will be as many cells as can be collected with less than 0.5 x 106 CD3+
CD56- cells/kg patient weight in the 4-6/8 HLA-matched related setting and 1 x 106 CD3+ CD56-
cells/kg patient weight in the 7-8/8 HLA-matched related or unrelated setting. The first NK
cell-enriched DLI will be administered one to six months post transplant. The second NK
cell-enriched DLI will be administered one to three months post the first infusion, in
patients who have < grade II aGVHD at the time of infusion and have not had unacceptable
toxicities that are at least possibly related to the previous DLI and resolved to grade 1 or
less. The second DLI will NOT be administered in patient with ≥grade III aGVHD at the time of
infusion or unacceptable toxicities at least possibly related to the first infusion. If
patients have GVHD and were on immunosuppressive therapy at study entry, patients will
continue on their stable dose of immunosuppressive agents started for therapy of acute GVHD
before the NK cell-enriched DLI, and will not taper until at least 6 weeks following the each
NK cell-enriched DLI (unless disease progression or patient toxicity from the agents requires
earlier taper). The donor NK cells will be infused over 30 minutes. Diphenhydramine 25 mg iv
or po, and Acetaminophen 650 mg po will be used prior to each reinfusion, unless there is a
history of allergy or contraindication in the patient, in which case hydrocortisone 50mg IV
will be used.

These cells are infused into the patient via a peripheral intravenous line or central line.
If signs of GVHD occur after NK cell-enriched DLI, immunosuppressive agents (prednisone,
cyclosporine, tacrolimus and/ or mycophenolate preferred first choices) may be started.

Inclusion Criteria:

1. Patients with hematologic diseases who have undergone T-cell depleted reduced
intensity or non-ablative allogeneic transplantation, using a 7-8/8 HLA-matched
related or unrelated donor or 4-6/8 HLA-matched related donor. This may include
patients with a mixed chimeric state or disease persistence or at high risk of
relapse.

2. Performance status must be ECOG PS 0, 1, or 2.

3. Donor cellular engraftment of at least 2.5% from the non-myeloablative procedure.

4. < Grade 2 acute GVHD at time of the first NK cell-enriched DLI. Patients with treated
acute GVHD must be on a stable dose of therapy (no increase in immunosuppressive
therapy for the 2 weeks before planned NK cell-enriched DLIs). The dosage/level of
immunosuppressive therapy at the time of NK-DLIs should be no greater than 20 mg of
prednisone daily or mycophenolate 500 mg bid daily or cyclosporine with a target level
of 200 ng/mL or tacrolimus with a target level of 10 ng/mL.

5. Estimated survival of at least 8 weeks.

6. Age of >= 18 years.

7. Females of childbearing potential should have a negative serum beta-HCG test within 48
hours of beginning DLI and/or DUK-CPG-01 unless contraception is used after initial
testing. A female of childbearing potential (FCBP) is a sexually mature female who: 1)
has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been
naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at
any time in the preceding 24 consecutive months).

8. Males must agree to use a medically acceptable form of birth control in order to be in
this study and for 3 months after infusion

Exclusion Criteria:

1. Pregnant or lactating women.

2. Patients with other major medical or psychiatric illnesses, which the treating
physician feels, could seriously compromise tolerance to this protocol.

3. Patients likely to have a significantly better durable response to allogeneic
transplant alone (better than 60% progression free longer than 2 years) includes:
those with myeloproliferative diseases or hemoglobinopathies with over 50% T cell
subset engraftment (assessed around 100 days post transplant); It is not anticipated
that any such patients would be transplanted within our program, however but those in
first remission AML patients with good risk standard genetics or normal genetics with
either NPM1 or CEBPA mutations, first chronic phase CML without kinase gene mutations,
follicular lymphoma patients in first remission who only required 1 regimen to attain
remission all would be excluded from this protocol.

HLA 4-6/8 matched related donor inclusion/exclusion criteria (criterion below are
recommended but may evolve to follow current program standards) to be completed within 30
days of apheresis per standard guidelines

1. Adult donors must be an HLA 4-8/8 match with the patient and must be capable of
providing informed consent.

2. Potential donors under the age of 18 must have a 'single patient exemption' approved
by the IRB. The donor must provide assent and the donor's parent or guardian must
provide permission for minor participation. Donors under the age of 18 who cannot
assent based on their developmental stage will not be included.

3. Donor must not have any medical condition which would make apheresis more than a
minimal risk, and should have the following:

1. Family members will be considered for donation if they do not have a history of
known cardiac problem and do not have abnormal cardiac findings by physical
examination. Those with a history of cardiac problems or abnormal cardiac
findings by physical examination should undergo a stress evaluation or be
evaluated by a cardiologist and deemed eligible to donate.

2. Documented bilirubin and hepatic transaminases of < 2.5 x ULN,

3. Documented adequate hematologic parameters including a hematocrit > 35% for males
and 33% for females, white blood cell count of >=3,000, and platelets >=80,000.

4. FACT labs and final test results available prior to infusion into the patient. In
the second donation from the donor, the FACT labs must be redrawn within 30 days
of initiation of apheresis. Positive serologies are not repeated as they remain
positive for lifetime.

4. Females of childbearing potential should have a negative serum beta-HCG test within 1
week of beginning apheresis. A female of childbearing potential (FCBP) is a sexually
mature female who: 1) has not undergone a hysterectomy or bilateral oophorectomy; or
2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has
had menses at any time in the preceding 24 consecutive months). A tubal ligation is
adequate documentation that a patient is not of child bearing potential.

7-8/8 HLA matched unrelated donors will be matched at least as HLA -A, -B, C and -DRB1.
Criterion for donation will be those allowing donation following the NMDP accepted donor
criterion and program SOPs for the typical matched unrelated donors.