Intracerebral EGFR-vIII CAR-T Cells for Recurrent GBM

Patients with evidence of radiographic recurrence who expressed EGFRvIII on their original
tumor diagnosis will have autologous PBMCs harvested by leukapheresis prior to any other
intervention to treat recurrence. These autologous PBMCs will be transduced with a retrovirus
containing the sequences for the EGFRvIII CAR and sent to the Duke Radiopharmacy for
radiolabeling with 111Indium (111In). Within 2-3 weeks of leukapheresis, on Day -4 to -2,
patients will have a BrainLab MRI to prepare for biopsy and catheter placement. On Day -1,
the patient will undergo standard of care (SOC) stereotactic biopsy under local anesthesia to
confirm tumor recurrence. At the time of biopsy, prior to catheter insertion and
administration of study drug, the presence of recurrent tumor must be confirmed by
histopathology. If tumor recurrence is confirmed, a catheter will be placed intratumorally
for delivery of EGFRvIII-CARs by Convection Enhanced Delivery (CED).

After biopsy, on the same day, a planning MRI will be performed in the Department of
Radiation Oncology for SRS planning and a CT scan will be done for SRS masking. SRS will take
place on Day 0 (+1 day) and 111In-labeled EGFRvIII-CARs will be infused on the same day over
a 6 to 6.5 hour period immediately after SRS.

On days 1 and 2 after 111In-labeled EGFRvIII-CAR infusion, whole planar imaging followed by
Single-Photon Emission Computed Tomography (SPECT) Computed Tomography (CT) imaging will
assess the intracerebral and systemic localization of the 111In-labeled EGFRvIII-CARs that
describes the distribution of EGFRvIII-CARs within the brain and systemically.

This protocol is designed to determine the maximum tolerated dose (MTD) of a novel,
tumor-specific treatment with autologous EGFRvIII-CARs. The proposed starting dose will be
2.5 x 10^8 of 111In-labeled cells in 3 milliliters (mL). Doses will be escalated in
successive cohorts. The infusion flow rate will be fixed at 0.5 mL/hr. Infusions of this
volume and flow rate have been previously used by us for other therapeutics and have been
shown to be safe. EGFRvIII-CARs dose escalation will be accomplished by increasing cell
concentration allowing flow rate and infusion volume to remain unchanged. Cell dose will be
increased in successive cohorts so long as dose-limiting toxicities (DLTs) are not observed
as described below.

In the rare event that a sufficient amount of CAR-specific T cells cannot be generated for a
patient's intended dose within the dose-escalation portion of this study, the patient will be
treated with all cells if within 15% of the intended dose. If the cell number is not within
15% of the intended dose, the patient will be treated at a lower pre-defined dose level using
available CAR-specific T cells. If the situation of an insufficient number of CAR-specific T
cells occurs within the expanded cohort, all available cells will be administered. If the
number of CAR-specific T cells is not within 15% of the intended dose, an additional patient
will be treated in the expanded cohort.

Inclusion Criteria:

1. First disease progression or disease recurrence (≥ 1 cm and ≤ 5 cm) of a
supratentorial WHO grade IV malignant glioma (GBM or gliosarcoma) based on imaging
studies with measurable disease. At the time of biopsy, prior to SRS and
administration of the EGFRvIII-CARS, the presence of recurrent tumor must be confirmed
by histopathological analysis.

2. Adults ≥ 18 years old.

3. KPS score ≥ 70.

4. EGFRvIII, the target antigen, must be identified on tumor tissue by IHC or PCR, i.e.
EGFRvIII positive via pathology report.

5. Hemoglobin ≥ 9.0 g/dl, ANC ≥ 1,500 cells/µl, platelets ≥ 125,000 cells/µl (prior to
biopsy).

6. Serum creatinine ≤ 1.5 mg/dl, serum SGOT and bilirubin ≤ 1.5 times upper limit of
normal (prior to biopsy).

7. Bevacizumab naïve.

8. Signed informed consent approved by the Institutional Review Board.

9. Female patients must not be pregnant or breast-feeding. Female patients of
childbearing potential (defined as < 2 years after last menstruation or not surgically
sterile) must use a highly effective contraceptive method (allowed methods of birth
control, [i.e. with a failure rate of < 1% per year] are implants, injectables,
combined oral contraceptives, intra-uterine device [IUD; only hormonal], sexual
abstinence or vasectomized partner) during the trial and for a period of > 6 months
following the last administration of trial drug(s). Female patients with an intact
uterus (unless amenorrhea for the last 24 months) must have a negative serum pregnancy
test within 48 hours prior to starting SRS.

10. Fertile male patients must agree to use a highly effective contraceptive method
(allowed methods of birth control [i.e. with a failure rate of < 1% per year] include
a female partner using implants, injectables, combined oral contraceptives, IUDs [only
hormonal], sexual abstinence or prior vasectomy) during the trial and for a period of
> 6 months following the last administration of trial drugs.

11. Meet eligibility requirements for SRS: able to get MRI, lesion must not be abutting
optic apparatus or brainstem, and must be able to be secured and positioned in a
stereotactic U-frame mask.

Exclusion Criteria:

1. Pregnant or breast-feeding.

2. Patients with known potentially anaphylactic allergic reactions to gadolinium-DTPA.

3. Patients who cannot undergo MRI or SPECT/CT.

4. Patients with evidence of tumor in the brainstem, cerebellum, optic apparatus, or
spinal cord, radiological evidence of actively growing multifocal disease, or
leptomeningeal disease.

5. Patients < 12 weeks from the end of radiation therapy, unless they have two
progressive scans at least 4 weeks apart, have progression outside of the radiation
field, or have histologic confirmation of progression.

6. Severe, active comorbidity, including any of the following:

1. Unstable angina and/or congestive heart failure requiring hospitalization;

2. Transmural myocardial infarction within the last 6 months;

3. Acute bacterial or fungal infection requiring intravenous antibiotics at the time
of study initiation;

4. Chronic obstructive pulmonary disease exacerbation or other respiratory illness
requiring hospitalization or precluding study therapy;

5. Known hepatic insufficiency resulting in clinical jaundice and/or coagulation
defects;

6. Known autoimmune disorder, such as HIV;

7. Major medical illnesses or psychiatric impairments that, in the investigator's
opinion, will prevent administration or completion of protocol therapy;

8. Active connective tissue disorders, such as lupus or scleroderma that, in the
opinion of the treating physician, may put the patient at high risk for radiation
toxicity.

7. Co-medication that may interfere with study results; e.g. immuno-suppressive agents
other than corticosteroids.

8. Prior, unrelated malignancy requiring current active treatment with the exception of
cervical carcinoma in situ and adequately treated basal cell or squamous cell
carcinoma of the skin;

9. Current, recent (within 4 weeks of the administration of this study agent), or planned
participation in another experimental therapeutic drug study.

10. Patients with an active infection requiring intravenous treatment or having an
unexplained febrile illness (Tmax > 99.5 F, 37.5 C).

11. Prior therapy targeted to EGFRvIII.

12. Prior history of brain SRS, (patients who have received external beam radiation per
standard of care are allowed).