Clinical Trial Agreement - Aastrom Biosciences Inc. and Loyola University Medical Center Cancer Center
CLINICAL TRIAL AGREEMENT
------------------------
This Clinical Trial Agreement ("Agreement") is entered into as of the 28 day
of August, 1996 (the "Effective Date"), by and among Aastrom Biosciences, Inc.
("Aastrom"), located at 24 Frank Lloyd Wright Dr., Lobby L, Ann Arbor, MI
48105, and Loyola University Medical Center Cancer Center (the "Institution"),
located at 2160 South First Avenue, Maywood, IL 60153. Definitions shall have
the meaning as set forth in Exhibit A.
RECITALS
WHEREAS, Aastrom is the developer, manufacturer and/or licensee of medical
devices and materials, such as a Cell Production System ("CPS") device and
related materials and device, which have potential medical application for use
in subjects care and research;
WHEREAS, Aastrom desires to conduct a human clinical trial ("Study") of the
CPS in subjects in accordance with a protocol entitled "A Pilot Trial of
Autologous Transplantation For Patients With Advanced Breast Cancer Using Marrow
Cells Expanded Ex Vivo" ("Protocol") which is incorporated herein by reference
as Exhibit B attached hereto;
WHEREAS, the Institution has research, clinical and medical facilities,
technical capabilities and expertise in order to conduct the Study in accordance
with the Protocol;
WHEREAS, the Study contemplated by this Agreement is of mutual interest and
benefit to the Institution and to Aastrom such that the parties hereto desire to
have the Institution conduct the Study under the qualified direction of Patrick
J. Stiff, M.D. (the "Principal Investigator"); and
WHEREAS, Aastrom and the Institution agree to conduct the Study in
accordance with the terms and conditions hereinafter set forth.
AGREEMENT
I. CLINICAL TRIAL DESCRIPTION
The Institution agrees to undertake and complete the Study described in the
Protocol (Exhibit B) in compliance with all applicable laws, rules and
regulations relating to the Study, including without limitation, all laws,
rules and regulations concerning or promulgated by the Food and Drug
Administration ("FDA").
Aastrom agrees to provide the Institution the laboratory and clinical
equipment listed in the Schedule of Laboratory and Clinical Equipment on
Exhibit C which are reasonably necessary for the Institution to conduct the
Study. Aastrom shall retain title to all such equipment which shall
promptly be returned to Aastrom upon request by Aastrom.
II. FUNDING
Aastrom shall provide payments to the Institution in accordance with the
terms contained in the Clinical Trial Budget (Exhibit D) and the Schedule
of Clinical Trial Milestone Payments (Exhibit D) incorporated herein.
<PAGE>
III. CONDUCT OF STUDY
A. Facilities
----------
The Study shall be conducted only at the following locations: Loyola
University Medical Center Cancer Center, 2160 South First Avenue,
Maywood, IL 60153. The CPS and other Study materials may not be
transferred to any other location or to any third party without the
prior written consent of Aastrom.
B. Investigator
------------
The Institution agrees that the Study will be conducted under the
direction of the Principal Investigator in accordance with the
Protocol and the Investigator Agreement (see Section 13.0 of the
Clinical Protocol) and incorporated herein by reference. The
Principal Investigator may, subject to the prior written consent of
Aastrom, designate a clinical coordinator and one or more
subinvestigators to assist in conducting the Study. The Institution
acknowledges that the Principal Investigator and subinvestigators have
each executed an Investigator Agreement, copies of which are included
in Exhibit E. In the event that additional subinvestigators are added
to the Study, such subinvestigators must execute and deliver an
Investigator Agreement which shall be deemed incorporated by reference
into this Agreement. In the event the Principal Investigator can no
longer function in such capacity, then Aastrom and the Institution
shall attempt to agree on a replacement. If a mutually acceptable
replacement cannot be agreed upon, this Agreement and the Study at the
Institution shall terminate. The Institution agrees that it will use
its best efforts to recruit qualified subjects for enrollment in the
Study consistent with the guidelines contained in the Protocol and the
best interest of the subject; however, no subjects shall be enrolled
in the Study if they are currently enrolled in another investigational
study without the prior written consent of Aastrom.
C. Compliance with Protocol
------------------------
Any changes to the Protocol may only be made with the prior written
agreement of Aastrom; provided that during the Study, if the Principal
Investigator feels that it is necessary to deviate from the Protocol
in order to protect the life or physical well-being of a Study subject
before written approval can be obtained, he/she may do so in
accordance with the procedures detailed in the Protocol.
D. Institutional Review Board Approval and Informed Consent
--------------------------------------------------------
The Institution will obtain: (i) the approval of the governing
Institutional Review Board ("IRB") prior to initiating the Study and
thereafter as required by applicable laws, rules and regulations; and
(ii) prior written informed consent of all subjects and/or their legal
guardians in a form that is substantially the same as provided in the
Protocol and satisfactory to both the governing IRB and Aastrom and in
compliance with applicable laws, rules and regulations.
E. Adverse Events
--------------
The Institution shall immediately notify Aastrom (Thomas E. Muller,
Ph.D., Vice President Regulatory Affairs at 313/930-5555 and/or by fax
at 313/930-5520) of any unanticipated adverse effect, whether ascribed
to the investigational device or not, in accordance with the
instructions provided in the Protocol.
2
<PAGE>
IV. STUDY MONITORING AND ACCESS TO FACILITIES
Aastrom's designated representatives and/or authorized representatives of
regulatory agencies may, at all reasonable times, visit the Institution in
order to: (i) determine the adequacy of the facilities, (ii) validate case
reports against original data in the subject medical records and the files
of the Principal Investigator, and (iii) monitor the conduct of the Study
to determine whether the Study is being conducted in compliance with the
Protocol and all applicable laws, rules and regulations. The Institution
agrees to obtain any required subject release(s) to allow Aastrom's
designated representatives, and/or authorized representatives of regulatory
agencies, to conduct such review prior to enrolling each subject in the
Study.
V. REPORTS
The Institution agrees to have the Principal Investigator submit reports to
Aastrom and the reviewing IRB in accordance with the Protocol and all
applicable laws, rule and regulations.
VI. PROPRIETARY RIGHTS
A. Data and Materials
------------------
The Institution understands and agrees that the underlying rights to
the CPS and other intellectual property and materials which are the
subject of the Protocol belong to Aastrom. The parties agree that the
Institution shall retain control over the CPS and Study materials, and
further agree not to allow access to, disclose the existence or nature
of, or transfer the CPS or Study materials to third parties without
advance written approval of Aastrom. Aastrom reserves the right to
distribute the CPS and Study materials to others and to use them for
its own purposes. Title to the CPS and Study materials shall remain
with Aastrom. Further, the Institution agrees that data and materials
derived as a direct result of the Study described in the Protocol
(hereinafter referred to as "Clinical Trial Information") whether
generated by the Institution, the Principal Investigator, and/or their
agents or employees, either solely or jointly with others, is the
property of Aastrom; provided that the Institution and the Principal
Investigator may utilize the Clinical Trial Information in furtherance
of academic publications authorized by this Agreement and for subject
care purposes.
B. Patent Ownership and Related Matters
------------------------------------
The Institution agrees that the Study results and any inventions or
discoveries by the Institution, the Principal Investigator or their
agents or employees during the Study that are modifications,
improvements or new uses applicable to the CPS or that are a direct
result of the performance of the Study in accordance with the detailed
testing Protocol provided by Aastrom to Institution and which are
dependent on, or relate to, the Study, the claims of Aastrom's
patentable inventions, the use of the cells processed through the CPS
or Aastrom's Confidential Information shall be the property of
Aastrom. Any invention arising out of the work performed under this
Study solely by the Institution and not covered in the previous
sentence shall be the exclusive property of the Institution (the
"Institution Invention") and shall not be considered a part of
Aastrom's Confidential Information. The Institution shall promptly
disclose each such Institution Invention and the terms under which the
Institution would be prepared to license it. Aastrom shall have a
right of first refusal to exclusively develop, license and
commercialize such Institution Invention. Aastrom shall have sixty
(60) days after receipt of such disclosure to exercise its right of
first refusal, and if so exercised, the parties shall thereafter
negotiate a mutually acceptable licensing agreement in good faith. If
the Institution at any time
3
<PAGE>
offers such Institution Invention on terms different than those
disclosed to Aastrom, the Institution shall offer such Institution
Invention to Aastrom on such different terms in accordance with the
first right refusal herein. The Institution and Principal Investigator
shall not obtain, or attempt to obtain, patent coverage on the CPS or
its use without the express written consent of Aastrom. The
Institution and the Principal Investigator shall assist Aastrom in
prosecuting any Aastrom patent applications and shall execute and
deliver any and all instruments necessary to make, file and prosecute
all such applications, divisions, continuations, continuations-in-part
or reissues thereof.
VII. WARRANTIES AND REPRESENTATIONS
A. No Warranties
-------------
It is understood that the CPS is experimental in nature, has not been
approved for commercial distribution and is provided hereunder for
investigational purposes only. NEITHER THE INSTITUTION NOR AASTROM
MAKES ANY REPRESENTATIONS OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING
ANY REPRESENTATION WITH RESPECT TO SAFETY, EFFICACY, MERCHANTABILITY,
FITNESS FOR ANY PURPOSE OR NON-INFRINGEMENT OF ANY INTELLECTUAL
PROPERTY RIGHTS, WITH RESPECT TO THE PRODUCT OR INFORMATION PROVIDED
TO THE OTHER HEREUNDER.
B. Representations of the Parties
------------------------------
Each party hereto represents that it has right to enter into and
perform its respective obligations under this Agreement.
C. Representations by the Institution and the Principal Investigator
-----------------------------------------------------------------
The Institution represents that: (i) it has adequate facilities and
staff to conduct the Study in accordance with the Protocol; (ii) the
governing IRB is qualified to review and approve the Study; and (iii)
the Principal Investigator is qualified by education and training to
conduct the Study and has not been disqualified, or otherwise limited,
as a clinical investigator by the FDA or any other regulatory or
administrative body. The Institution represents that the Principal
Investigator and all other investigators and personnel that may
perform services hereunder are its employees and shall abide by the
terms and conditions of this Agreement as if each were a party hereto.
VIII. LIMITATIONS OF LIABILITY
In no event shall any party be liable to the other party hereto for any
incidental, special or consequential damages.
IX. INDEMNIFICATION
A. Indemnification of Aastrom
--------------------------
Aastrom agrees to indemnify, defend and hold harmless the Institution,
the Loyola University System, and their Regents, officers, agents and
employees from and against any and all claims, suits, and liabilities
(collectively "Liabilities") arising out of or resulting from the
activities to be carried out pursuant to the obligations of this
4
<PAGE>
Agreement, including but not limited to the use by Aastrom of the
results of the Study; provided that such Liabilities do not arise
from:
i. a failure to adhere to the Protocol or written instructions
relative to use of the CPS of other materials utilized in the
Study;
ii. a failure to comply with any applicable law, rule or regulation
relating to the Study, including without limitation, all FDA
regulations or other governmental requirements; or
iii. the negligence or willful misconduct by the regents, officers,
agents or employees of the Institution or the Loyola University
System.
B. Indemnification by the Institution
----------------------------------
The Institution agrees, to the extent allowed by the Constitution and
the laws of the State of Illinois, to indemnify, defend and hold
harmless Aastrom and its directors, officers, agents and employees
from and against any and all Liabilities they may suffer in connection
with the Study which arise out of the negligent acts or omissions of
the Institution, its employees or agents pertaining to the activities
to be carried out pursuant to the obligations of this Agreement;
provided, however, that Institution shall not hold Aastrom harmless
from claims arising out of the negligence or willful malfeasance of
Aastrom, its directors, officers, agents or employees, or any person
or entity not subject to Institution supervision or control.
C. Notification
------------
The Institution and Aastrom each agree to notify the other in writing
as soon as they become aware of a claim or action and to, subject to
the statutory duties of the Illinois Attorney General, cooperate with
the management and defense of such claim or action. The indemnifying
party agrees, at its own expense, subject to the statutory duties of
the Illinois Attorney General, to provide attorneys of its own
selection to defend against any actions brought or filed against the
indemnified party with respect to the subject of indemnity contained
herein. The indemnifying party shall, subject to the statutory duties
of the Illinois Attorney General, control the defense of any action;
however the indemnified party may, at its own expense, participate by
providing attorneys of its own selection. No indemnified party shall
compromise or settle any claim of action without the prior written
approval of the indemnifying party.
X. RESTRICTIONS ON USE; COMPLIANCE WITH LAWS
The Institution and the Principal Investigator agree that the CPS will be
used for clinical research purposes only in connection with the Study by
the Principal Investigator and his/her subinvestigators at the
facility(ies) described in Section III.A. under suitable containment
conditions. Neither the Institution nor the Principal Investigator shall
use the CPS for any commercial purposes, including screening, production or
sale. The CPS will not be used in the treatment or diagnosis of human or
animals except for the purpose of conducting the Study as described in the
Protocol. The Institution agrees to comply with all laws, rules and
regulations applicable to the Study and the handling, use and disposal of
any Study materials. The CPS is to be used with caution and prudence since
all of its characteristics are not known.
5
<PAGE>
XI. CONFIDENTIALITY
A. Treatment of Confidential Information
-------------------------------------
The Institution agrees that it will not disclose or use Confidential
Information for any purpose other than the purpose of conducting the
Study, obtaining any required review of the Protocol or its conduct,
or ensuring proper medical treatment of any subject or subjects. The
Institution agrees to limit distribution of Aastrom's Confidential
Information to Institution personnel on a need-to-know basis. The
Institution agrees to ensure that its personnel abide by the
confidentiality obligations as set forth herein in accordance with
Section VII.C. The obligations set forth in this Section XI.A. shall
survive for a period of five (5) years following the termination or
expiration of this Agreement.
The term "Confidential Information" shall mean any and all oral,
written or tangible proprietary or confidential ideas, inventions,
information, data, plans, materials and know-how or the like owned,
controlled or developed by Aastrom or developed under the Agreement
and disclosed to Institution. Aastrom shall attempt to identify the
confidential status of Confidential Information disclosed hereunder,
but the failure to so mark or identify shall not destroy the
confidential nature of such Confidential Information. Without
limiting the generality of the foregoing, Confidential Information
shall include, without limitation, all clinical trial plans,
protocols, information, data analyses, proprietary equipment, and
materials related to the Confidential Information. Confidential
Information shall not include any information which the Institution
can demonstrate:
i. Was known to the Institution prior to receipt from Aastrom,
provided that the Institution promptly notifies Aastrom in
writing of the same promptly after disclosure by Aastrom;
ii. Is or becomes part of the public domain through no act by or on
behalf of the Institution;
iii. Was lawfully received by the Institution or the Principal
Investigator from a third party who had a legal right to disclose
the same; or
iv. Is required by law or regulation to be disclosed.
In the event that Confidential Information is required to be disclosed
pursuant to subsection iv., the Institution will notify Aastrom to
allow Aastrom to assert whatever exclusions or exemptions may be
available to it under such law or regulation.
B. Publicity
---------
No publicity, new releases, or other public announcement, written or
oral, relating to the Agreement, to any amendment hereto or to
performance hereunder or to the existence of an arrangement between
the parties, shall be originated by either party without the prior
written approval, such approval not to be unreasonably withheld, of
the other party except as shall be required by law.
6
<PAGE>
C. Use of Name
-----------
No Party shall use or publicly disclose the name of another party
hereto without the prior written consent, such consent not to be
unreasonably withheld, of such other party except that the name of a
party may be disclosed to regulatory bodies such as the FDA,
Securities and Exchange Commission or as required by law.
XII. PUBLICATION RIGHTS
At least thirty (30) days prior to submission for publication, the
Institution agrees to provide Aastrom a final draft of any manuscript
describing the results obtained by the Institution from the Study. Aastrom
shall be permitted to advise as to the implications of such manuscripts
upon patentability of any inventions or the potential effects on
commercialization. The Institution shall, upon Aastrom's request, delete
any of Aastrom's Confidential Information and shall consider all
reasonable editorial suggestions based on sound scientific and clinical
judgment, Aastrom acknowledges that Institution shall have the final
authority to determine the scope and content of any publication, provided
that such authority shall be exercised with reasonable regard for the
commercial interests of Aastrom. Subject to Aastrom's right to delete such
Confidential Information and to propose mutually agreeable modification of
such manuscripts, the Institution shall have the right to submit the
manuscript for publication. However, if Aastrom determines that any
invention disclosed therein is patentable and that a patent application
should be filed on such invention, Aastrom shall notify the Institution in
writing and the Institution shall postpone publication for a period not to
exceed sixty (60) days from said notice (unless otherwise mutually agreed
in writing) to provide time for patent applications to be filed.
XIII. TERM AND TERMINATION
A. Term
----
Except as otherwise provided in this section, this Agreement shall
commence on the Effective Date hereof and continue for the period
necessary to satisfy the requirements of the Protocol.
B. Termination
-----------
Aastrom and the Institution shall have the right to terminate this
Agreement at any time without cause upon thirty (30) days prior
written notice. Any party may terminate the Study at any time if, in
its opinion, it is in the best interest of the Study subjects.
C. Termination Obligations
-----------------------
Any termination of this Agreement shall not relieve any party hereto
of any obligation or liability accrued hereunder prior to such
termination, or rescind or give rise to any right to rescind anything
done hereunder prior to the time such termination becomes effective;
nor shall such termination relieve any party from any obligation
which, by its nature, survives termination including the obligations
set forth in Articles IV through IX and X.D.
The parties further agree that all Study data and used and unused
Study equipment, materials and supplies, including the CPS, provided
to the Institution by Aastrom for the purpose of this Study will be
returned to Aastrom promptly upon request by Aastrom.
7
<PAGE>
XIV. MISCELLANEOUS
A. Independent Contractor
----------------------
The Institution recognizes and agrees that it is operating as an
independent contractor and not as an agent of Aastrom. The Agreement
shall not constitute a partnership or joint venture, and no party may
be bound by the other to any contract, or make any representations or
warranties, express or implied, on behalf of another party, or
otherwise create any liability against another party in any way for
any purpose.
B. Assignment
----------
The rights and obligations of the parties under this Agreement shall
bind and inure to the benefit of the successors, assigns and
transferees of the parties; provided, however, this Agreement shall
not be assignable by either party without the prior written consent of
the other party.
C. Governing Law
-------------
This Agreement shall be construed and interpreted in accordance with
and governed by the laws of the State of Illinois.
D. Alternative Dispute Resolution
------------------------------
Any controversy or claim arising out of or relating to this Agreement
or the breach thereof, including, without limitation, disputes
relating to patent validity or infringement arising under this
Agreement, shall be settled through use of an appropriate method of
Alternative Dispute Resolution, including, without limitations, by
arbitration in accordance with the rules of the American Arbitration
Association, and judgment upon an award rendered may be entered in any
court having jurisdiction thereof. Notwithstanding the foregoing, the
parties shall be entitled to petition any court of competent
jurisdiction in the event of any alleged breach of Article XI.
E. Entire Agreement: Modification
-------------------------------
This Agreement contains the entire agreement and understanding between
the parties and supersedes all prior agreements and understandings
between them relating to the subject matter hereof.
F. Headings
--------
The headings of this Agreement are to facilitate reference only, do
not form a party of this Agreement and shall not effect the
interpretation thereof.
G. Severability
------------
If any provision of this Agreement or portion of this Agreement is
construed or declared to be invalid, such provision or portion shall
be deemed reformed to become valid in a manner consistent with the
parties' intentions under this Agreement, and the validity of the
remaining portions and provisions of this Agreement shall not be
affected thereby and shall remain in full force and effect.
H. No Waiver
---------
No waiver of a breach by a party of any provision of this Agreement
shall be construed to be a waiver of any other breach of the same of
any other provision.
8
<PAGE>
I. No Implied License
------------------
No right or license to the CPS or to its use is granted by Aastrom or
implied as a result of the transmission of the CPS to the Institution
under the supervision of the Principal Investigator, except to the
limited extent necessary to conduct the Study. The transfer of the
CPS provided for herein does not constitute a public disclosure.
J. Necessary Acts
--------------
At the request of Aastrom, the Institution and the Principal
Investigator shall execute any documents and take any actions which
may be necessary, in the opinion of Aastrom, or its legal counsel, to
evidence or perfect any rights of Aastrom hereunder.
K. Counterparts
------------
This Agreement may be executed in counterparts all of which together
shall constitute one and the same instrument.
L. Notices
-------
All notices and other communications permitted or required under this
Agreement shall be in writing and shall be deemed to have been given
when received at the addresses set forth on the signature page hereof,
or at such other address as may be specified by one party in writing
to the other. Said written notice may be given by mail, telecopy,
rush delivery service, telegram, telex, personal delivery or any other
means to the parties at the addresses as follow:
If to the Institution:
Lori Burlew ph: (708) 327-3307
Administrator, Division of Hematology/Oncology fx: (708) 327-3319
Loyola University Medical Cancer
2160 South First Avenue
Maywood, IL 60153
If to the Principal Investigator:
Patrick J. Stiff, M.D.
Associate Professor of Medicine
Loyola University Medical Center
2160 South First Avenue
Cancer Center - Room 240
Maywood, IL 60153
ph: 708-327-3148
fx: 708-327-3220
If to Aastrom:
Thomas E. Muller, Ph.D.
Vice President Regulatory Affairs
24 Frank Lloyd Wright Drive, Lobby L
Ann Arbor, MI 48105
ph: 313-930-5573
fx: 313-930-5520
9
<PAGE>
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be duly
executed as of the date and year first above written.
INSTITUTION: AASTROM:
LOYOLA UNIVERSITY AASTROM BIOSCIENCES, INC.
MEDICAL CENTER
By: /s/ By: /s/ R. DOUGLAS ARMSTRONG, PH.D.
--------------------- --------------------------------------------
Name: R. Douglas Armstrong, Ph.D.
Title: President and Chief Executive Officer
Date:9/19/96 Date: 9/3/96
------------------- ----------------------------------------
I have read this agreement and
understand my obligations hereunder:
By: /s/ PATRICK J. STIFF, M.D.
---------------------------
Patrick J. Stiff, M.D.
Principal Investigator
Associate Professor of Medicine
Director, Bone Marrow Transplantation Program
10
<PAGE>
EXHIBIT A
DEFINITIONS
1. Aastrom. Aastrom shall have the meaning as set forth in the first
--------
paragraph of this Agreement.
2. Clinical Trial Information. Clinical Trial Information shall have the
---------------------------
meaning as set forth in Section VI.A. of this Agreement.
3. Confidential Information. Confidential Information shall have the meaning
-------------------------
as set forth in Section XI.A.
4. CPS. The CPS means the Cell Production System developed by Aastrom for the
----
ex vivo growth and expansion of human stem and hematopoietic progenitor
cells. The CPS consists of: (a) a single use Cell Cassette in which the
growth and expansion of cells takes place; (b) dedicated laboratory
instruments to facilitate the cell culture process and associated cell
inoculation and harvest procedures; (c) single use growth medium required
for the cell culture to which specified growth factors and glutamine are
added; and (d) single use harvest reagents which facilitate the removal of
the expanded cells from the Cell Cassette.
5. Effective Date. The Effective Date shall have the meaning as set forth
---------------
in the first paragraph of this Agreement.
6. FDA. FDA shall have the meaning as set forth in Article 1 of this
----
Agreement.
7. Institution. Institution shall have the meaning set forth in the first
------------
paragraph of this Agreement.
8. Institution Invention. Institution Invention shall have the meaning set
----------------------
forth in paragraph VI.B. of this Agreement.
9. Principal Investigator. Principal Investigator shall have the meaning
-----------------------
set forth in the Recitals on page 1 of this Agreement.
10. Protocol. Protocol shall have the meaning as set forth in the Recitals on
---------
page 1 of this Agreement.
11. Study. Study shall have the meaning as set forth in the Recitals on
------
Page 1 of this Agreement.
1
<PAGE>
EXHIBIT B
LOYOLA UNIVERSITY MEDICAL CENTER
BONE MARROW TRANSPLANT PROGRAM
A PILOT TRIAL OF AUTOLOGOUS TRANSPLANTATION FOR PATIENTS WITH ADVANCED
BREAST CANCER USING MARROW CELLS EXPANDED EX VIVO.
Principal Investigator
Patrick J. Stiff, M.D.
Director, BMT Program
Loyola University Medical Center
2160 South First Avenue
Maywood, Illinois 60153
Ph: 708-327-3148
Fax: 708-327-3220
Co-Investigators
BMT Ex Vivo Expansion Team: Robert Bayer, M.D., David Peace, M.D., Deepak
Malhotra, M.D., Bahao Chen, M.D., David Oldenberg
June 21, 1996
REVISED AUGUST 5, 1996
<PAGE>
1.0 OBJECTIVES
1.1 To assess the safety of the mixture of early-, mid-, and late-stage
bone marrow-derived mononuclear cells produced in the Aastrom Cell
Production System (CPS) when infused into patients with breast
cancer.
1.2 To determine the biological effect in terms of hematopoietic recovery
after infusion of ex vivo-produced hematopoietic cells following high
dose chemotherapy as treatment of patients with breast cancer.
1.3 To record the clinical disease related outcome in these patients with
advanced breast cancer- clinical tumor response, duration of
responses, and disease free duration post-high dose chemotherapy.
2.0 BACKGROUND
2.1 Ex Vivo Expansion: Current Status June 1996
Autologous bone marrow transplantation has been increasingly employed
as supportive therapy for subjects undergoing high dose chemotherapy
or chemoradiotherapy for malignant diseases, including lymphoma,
leukemia, and breast cancer. Breast cancer is now the most frequent
indication for autologous bone marrow or blood progenitor cell
transplantation.
Despite the use of cytokines such as granulocyte-macrophage colony-
stimulating factor (GM-CSF) and granulocyte colony-stimulating factor
(G-CSF) following bone marrow reinfusion, there is an obligate period
of profound pancytopenia lasting 1-3 weeks, and delayed engraftment
can occur, resulting in morbidity or mortality.
The safety, comfort, and cost of stem- and progenitor cell harvest are
also concerns. The standard techniques employed to harvest bone marrow
involves obtaining 500-1500 mL of bone marrow from the marrow donor,
usually under general anesthesia. In addition to the discomfort caused
by the hundreds of marrow aspirates performed, donors are subject to
the risks of general anesthesia. Finally, the bone marrow harvest
procedure is expensive. Alternatively, stem- and progenitor cells can
be collected from peripheral blood by apheresis, but this requires
chemotherapy and/or growth factors for mobilization and multiple
collections are generally necessary, which are costly.
Recently, novel technology has been developed to produce stem- and
progenitor cell populations in vitro, commonly referred to as ex vivo
expansion. Hematopoietic cell expansions achieved with this technology
are based upon the principles of continuous perfusion culture, a
bioengineered metabolic environment, augmented by hematopoietic growth
factors. Through this technology, a small bone marrow or peripheral
blood mononuclear cell population can be perfused ex vivo so that
total cell numbers, colony forming units (CFU-S) and long term culture
initiating cells (LTC-ICs) increase up to 20 fold (1-17). In a
preliminary study, Brugger et al recently reported that
<PAGE>
expanded cells alone can reconstitute hematopoiesis after high dose chemotherapy
(18).
Important differences exist among approaches, systems and devices used for ex
vivo expansion. This study utilizes the Aastrom CPS, which includes a cell
culture device and a biological environment designed to allow the establishment
of a stromal adherent layer, using constant perfusion with medium, and
relatively low concentrations of hematopoietic growth factors. Preliminary
studies at MD Anderson Cancer Center (DM94-127), using transplantation of ex
vivo-produced cells prepared with this system, in combination with a standard
autologous marrow transplant, indicate that ex vivo expansion can be performed
reliably and reproducibly, and that no toxicity occurs with intravenous infusion
(19). Ten patients, age 18-60 years with breast carcinoma, were entered into a
study transplanting bone marrow plus ex vivo-produced cells. Bone marrow was
harvested, collecting greater than 2 x 10/8/ nucleated cells/kg and greater than
0.5 x 10/6/ CD34+ cells/kg. Twelve days prior to the planned bone marrow
transplant, 2.25 x 10/8/ mononuclear cells were inoculated into a cell culture
device, part of the CPS, and continuously perfused with medium containing
PIXY321 (5 ng/mi), Epo (0.1 U/ml) and hydrocortisone (5 x 10-6 M). The expansion
reproducibly increased total nucleated cells, CFU-GM, and long term culture
initiating cells (LTC-IC). Patients received Cyclophosphamide 2.0 g/m2/d:
Thiotepa 240 mg/mi/d: BCNU 150 Mg/M2/d. Days -7, -6, -5, with reinfusion of the
cryopreserved bone marrow on Day 0 plus the ex vivo-produced cells four hours
later. No toxicity was observed from the expanded cell infusion. Nadir WBC was
less than 0.1/ul. All patients engrafted within narrow time ranges, with median
recovery of WBC greater than 200/ul on Day 8 (range 7-8) granulocytes greater
than 500/ul on Day 11 (range 10-13) and platelets greater than 25,000/ul on Day
16 (range 13-21) and greater than 50,000 on Day 20 (range 18-27). A median of 4
(range 1-9) platelet and 4 (range 2-9) RBC transfusions were administered. No
grade greater than 2 toxicity occurred from the chemotherapy or bone marrow
infusions. Four patients had infections unrelated to the infusion of the cells
produced in the CPS. These data compare favorably with 29 historical controls
receiving the same chemotherapy and autoBMT without cell expansion, in which
granulocytes recovered to greater than 500 on Day 11 (range 7-29) and platelets
to greater than 25,000 and greater than 50,000 on Days 24 (range 9-78) and 28
(range 9-147), respectively.
A potential advantage of collecting a relatively small marrow inoculum is that
the number of contaminating malignant cells is reduced: additionally, growth of
breast cancer cells is not stimulated under these expansion conditions (Brugger
et al).
Application of this technology to autologous bone marrow and peripheral stem
cells transplant offers a potentially attractive means to increase the efficacy
and safety of autologous transplantation, while reducing its complexity and
cost. In particular, this technology could eliminate the need for operative bone
marrow
<PAGE>
harvests, produce more rapid recovery of hematopoiesis post-
transplant, reduce the length of post-transplant hospitalization, and
could increase the purity of the stem- and progenitor cells
transfused. In addition, the inclusion of cytokine-primed progenitors
could result in accelerated hematopoietic recoveries.
2.2 Previous Pre-Clinical Research
During hematopoietic expansion culture, total cell numbers increase 8
to 11-fold over 12 days. This includes nonadherent, loosely adherent,
and tightly adherent cells. Over 80% of the nucleated cells are
viable, as shown by exclusion of propidium iodine stain (4) or Trypan
blue dye. These cells have the morphological distribution of normal
bone marrow cells, including blast cells and maturing granulocyte
precursors, maturing erythroid cells, monocytes and macrophages.
These expanded cells also show typical immunophenotype characteristics
of normal granulocyte, erythroid, monocyte/macrophage megakaryocytic,
and blast cells (5). Cell surface antigens identified using this
technique include CD3, CD11b, CD15, CD20, CD33, CD71, and glycophorin
A. While there are minor variations in staining patterns from sample
to sample, the expanded cells are typically less than 3% CD3-.20-50%
CD11b-, less than 1% CD19-, and 40-70% CD71-. The frequency of mature
T and B lymphocytes in the expanded cell population is significantly
reduced.
As shown in the experiments summarized in the Table below, it was
shown by Aastrom that varying the standard growth factor combination
(IL-3-GM-CSF or PIXY321, Epo, SCF and flt3L) had a direct effect on
the productivity of cells in the CPS, but the relative cell mixture
composition remained substantially similar. These data were obtained
in 36-well plate studies. This finding provided the original
justification for selecting the growth factor combination (Epo -
PIXY321 - flt3L) for this study to yield the desired relative
composition and mixture of early-, mid- and late-stage cells produced
in the pre-clinical experiments.
Product/cm/2/
Growth Factors CeilsX10/6/ CFU-GM LTC-IC n
None 0.58 404 yes/3/ 7
Epo, GM-CSF, IL-3, SCF 2.35 4,790 48 23
Epo, GM-CSF, IL-3 1.13 21,060 yes/3/ 3
Epo, PIXY, SCF 1.72 69,960 yes/3/ 4
Epo, PIXY 1.31 3,140 94 3
Epo, PXY, fit3L 1.57 10,580 11 14
<PAGE>
/2/LTC-IC were not evaluated, but in these conditions, 24 week CFU-GM producing
cultures were obtained, representing an LTC-IC proxy.
Aastrom has projected, based on this pre-clinical research, that clinical-size
CPSs are expected to yield a mean of 3.0 x 10/9/ cells, 17.7 x 10/6/ CFU-GM and
6.4 x 10/5/ LTC-IC per patient in this proposed clinical feasibility trial, and
set the expected minimum per-patient cell yield from the CPS at 1.6 x 10/9/
total nucleated cells and 7.0 x 10/10/ CFU-GM. In an average 70 kg patient,
this translates to a dose of 2 x 10/5/ CFU-GM/kg. The clinically standard ABMT
engraving dose is reported to be 1 x 10/5/ CFU-GM/kg. Therefore, using the cell
dose and the CFU-GM content in the cells produced in the CPS as a key progenitor
marker, along with the reliable presence of early stage cells (e.g., LTC-IC,
CD34-lin-), there is an expectation that the CPS-produced cells should provide a
minimum full engraving dose for these subjects, with a greater number expected
for most patients. Should the minimum cell number, 1.6 x 10/9/, not be
attained, the cryopreserved back-up cells will be reconstituted and administered
to a subject on Day 0.
It is anticipated that infusion of ex vivo-produced progenitors generated with
the CPS will enhance engraftment and shorten time to recovery of granulocytes
and platelets and, in so doing, reduce the incidence of infections, febrile
episodes and the need for blood- and platelet transfusions.
Amended August 5, 1996: In several in vitro studies using tumor cells that are
easy to detect in small quantities (neuroblastoma and B-cell CLL), the expansion
process appeared to passively purge tumor cells of slightly less than one log to
greater than three logs. When combined with the smaller inoculum of marrow
needed to initiate the bioreactors as compared to a normal marrow harvest, the
depletions appear to be as high as four to five logs. It is anticipated that
since the marrows must be histologically normal for patients to enter this
trial, i.e., undetectable amount of breast cancer cells, that expansion of tumor
cells will not be important clinically. This is especially true since there is
additional in vitro data to show that the cytokines used do not stimulate the
growth of tumor cells when used whether in vitro or in vivo when used in closely
monitored clinical trials.
The washing of the expanded cell products eliminates the amount of the cytokines
to undetectable levels using a sensitive ELISA method. Only GMP (Good
manufacturing process) cytokines are used for the expansion process, making it
unlikely that any adverse clinical event will occur.
Microbial contamination has not been a problem in the patients treated to date
and in preliminary studies done preclinically. This is likely because of the
closed system setup, growth and collection of the expanded cells, the
<PAGE>
use of antibiotics in the growth media, and the assays done 48 hours
prior to the collection of the expanded cells (day 10). In addition,
all patients will be on prophylactic antibiotics at the time of the
cell infusions as per routine BMTU protocols.
2.3 High Dose Chemotherapy and Autologous Bone Marrow Transplant Breast
Cancer
Breast cancer is responsive to initial combination chemotherapy for
metastatic disease with a 50-800,10 response rate and a 10-20%
complete response rate, but few patients are cured and median duration
of response is generally less than one year (20-24). Once patients
relapse, the response to second-line therapy is 20-40% with very few
complete responses (CR) and a median duration of response of 2-3
months and a median survival of 12 months.
When patients with metastatic breast cancer receive high-dose
chemotherapy, there is substantially higher complete response rate
than that can be achieved with conventional treatment (25-38).
Peters et al (39) used a regimen of Cyclophosphamide, Cisplatin,
and BCNU or Melphalan in 22 ER-negative patients without prior
induction chemotherapy, and reported a 54% CR rate and an overall
response rate of 73% and a median duration of response of 7 months
from the time of transplant. Antman et al recently reported similar
results with a combination of high-dose Carboplatin. Cyclophosphamide
and Thiotepa (26); each study reported approximately 20% 5-year
disease-free survival. A recently published study that compared in
a randomized fashion chemotherapy at conventional doses versus high
dose therapy with stem cell rescue verified that this high dose
approach is superior to conventional chemotherapy as measured both by
progression-free as well as overall survival. Application of the
same therapy to patients with Stage II breast cancer with greater than
10 positive nodes or Stage III disease has resulted in approximately
70% 5-year disease-free survival, substantially higher than that
reported with standard adjuvant therapy in such patients.
3.0 BACKGROUND DRUG AND DEVICE INFORMATION
3.1 Description of the CPS
The single-use, sealed, sterile cell culture device in the Aastrom
CPS consists of three rigid plastic parts separated by a gas-
permeable, water-impermeable membrane. The lower cell culture
chamber is continuously perfused by growth medium. The cells
expand in culture on the plastic surface of the cell culture bed.
The upper cell culture chamber is provided with a constant flow of
gas, such that oxygenation of the cell culture bed is accomplished
by diffusion across the membrane and through the culture medium.
Carbon dioxide is removed by the same mechanism. The medium used to
perfuse the cultured
<PAGE>
cells is stored in a closed vessel in an adjacent refrigerator at 4 degrees C
whose only external connection is by medical grade tubing. A "Y" connector,
attached to the effluent line, allows sampling of the cell product prior to
harvest, to test for bacterial and fungal contaminants. A detailed device
description is provided in the Operators Manual provided by Aastrom. The system
to be used will include dedicated Aastrom instruments, the Processor and
incubators which replace standard laboratory equipment and perform all of the
steps in the cell production automatically and more importantly sterily, and
in a close system manner, after the initial inoculation of the cells into the
CPS. The incubator contains a cold compartment for media storage for perfusion
during the 12 day culture (perfusion begins on Day 3), and a 37 degrees C
compartment in which the Cell Cassette is placed for the duration of the
culture.
3.1.1 Cell Culture Conditions
The hematopoietic cells are suspended in tissue culture medium composed
of Iscove's Modified Dulbecco's Media supplemented with 10% fetal bovine
serum, 10% horse serum, hydrocortisone (5x10/-6/ M), PIXY321 (5 ng/mi),
glutamine (4 mM), Erythropoietin (Epo 0.1 U/ml), flt3L (5 ng/mi),
gentamicin sulfate (5 Fg/ml), vancomycin (20 Fg/ml), sterile water for
injection, and are inoculated into the CPS, starting after Day 3. The
cells are cultured in the CPS for 12 days at 37 degrees C with the tissue
culture medium continuously replaced with fresh medium. Sampling of the
culture medium is carried out 48 hours prior to harvest, to allow testing
for bacterial and fungal contaminants.
The cell harvest is performed automatically, by a programmed schedule
with the Processor. In this process, the non-adherent fraction is removed
from the cell culture device by draining the growth medium from the cell
culture device into the harvest bag. The chamber is then rinsed with 50
ml of Hank's Balanced Salt solution (HBSS). This is followed by agitation
of the cell culture device and collection of the rinse into the harvest
bag. The adherent layer is detached from the cell culture bed surface by
injection of 50 ml of Trypsin-EDTA solution. This is also followed by
agitation of the cell production device and collection of the rinse into
the harvest bag. The chamber is then given a final rinse by injecting 50
ml of HBSS. This is followed by agitation of the cell production device
and collection of the rinse into the harvest bag. Again this is done
automatically, sterily in a closed system fashion.
Following collection, the cells are washed free of culture medium as
detailed in the Operator's Manual. The final product is suspended in
appropriate media for immediate infusion.
<PAGE>
3.1.2 Cell Culture Media Information
Studies by Aastrom and the University of Michigan have shown that, after
the cell washing regimen, the added growth factors and other reagents are
below detectable limits, using a very sensitive ELISA assay (R&D Systems,
Minneapolis, MN, and Immunex Research Corporation, Seattle, WA). These
levels are well below the level of biological activity. The horse and
fetal calf sera are tested preclinically for contamination for bacteria,
fungi, mycoplasma, endotoxin, and viruses. The expanded cell product is
washed (See Operators Manual) prior to transfusion. Nonetheless, the
human toxicities and contraindications identified for these drugs are
included below:
3.1.2.1 Recombinant Human Epo
Recombinant Human Erythropoietin: Epoetin Alfa, Procrit, NOC
0062-7402-01 Amgen, Thousand Oaks, CA.
Human Toxicity: Toxicities have included hypertension, headache,
fever, seizures, and skin rash. The majority of these subjects
had chronic renal failure, and these adverse events are frequent
sequelae of chronic renal failure and were not necessarily
attributable to Epo.
Contraindications: Epo is contraindicated in subjects with:
uncontrolled hypertension, known hypersensitivity to mammalian-
derived products, and known sensitivity to human albumin.
3.1.2.2 PIXY321
PIXY321 is a fusion protein of granulocyte-macrophage
colony-stimulating factor (GM-CSF) and interleukin 3 (IL-3).
3.1.2.3 Recombinant GM-CSF
Human Toxicity: Specific Toxicities include peripheral edema,
pleural and/or pericardial effusions, fluid retention,
sequestration of granulocytes in the lung, supraventricular
arrhythmia, elevation of serum creatinine, and elevation of
hepatic enzymes.
Contraindications: GM-CSF is contraindicated in subjects with
excessive leukemic blasts in the bone marrow or peripheral blood
(greater than 10%), or with known hypersensitivity to GM-CSF,
yeast-derived products, or any component of the product.
<PAGE>
3.1.2.4 Flt3 Ligand (flt3L)
The manufacturer of flt3L, Immunex Research and
Development Corporation, Seattle, WA, has advised that
a biologic Master File is in preparation for clinical,
in vivo grade flt3L, and that the Master File will be
submitted to the FDA in 1996, and will be available as
reference for the purposes of this clinical feasibility
trial (Letter, Immunex to Aastrom, December 11, 1995).
Immunex has also advised that flt3L appeared to be well
tolerated when administered to mice and monkeys for 14
days, at doses up to 400@g/kg/day. Based on the safety
profile established by Immunex, including the animal
data generated to-date, flt3L has no apparent toxicities,
and does not stimulate the proliferation and detrimental
activation of mast cells.
As indicated above, the cells produced in the CPS are
washed four times, resulting in a 5-log reduction in the
presence of media components, to levels below detectable
limits. An ELISA, supplied by Immunex, is used to
determine residual flt3L levels subsequent to cell
washing.
3.1.2.5 Horse Serum
Contraindications: Known hypersensitivity to horse serum.
3.1.2.6 Fetal Calf Serum
Contraindications: Known hypersensitivity to bovine serum.
3.2 CHEMOTHERAPY AGENTS AND CYTOKINES
rhG-CSF (Filgrastim: NSC-614629)
3.2.1 Chemistry: rhG-CSF is a protein produced in E. Coli into which the
gene synthesized for high expression in E Coli has been inserted.
The 175 amino acid protein has a molecular weight of about 18,800
daltons. rhG-CSF differs from the natural protein (M.W. 19,600
daltons) in that the N-terminal amino acid is a methionine and is
not 0-glycosylated.
3.2.2 Mechanism of Action: rhG-CSF is a hematopoietic regulator which has
the ability to modulate the growth and maturation of myeloid cells,
and in particular the proliferation and differentiation of
granulocytes both in vitro and in vivo.
3.2.3 Human toxicity: Specific toxicities include medullary bone pain.
<PAGE>
musculoskeletal symptoms (muscle cramps, back and or leg pain);
exacerbation of preexisting inflammatory conditions (psoriasis,
arthritis, vasculitis); splenomegaly and hair thinning with
prolonged administration. Elevated leukocyte alkaline phosphatase,
uric acid, and lactate dehydrogenase. Progression of patients with
myelodysplasia to acute myeloid leukemia occurred rarely during
treatment with this agent.
3.2.4 Pharmaceutical Data: rhG-CSF is supplied in colorless, glass, single
use vials containing 1.6 ml of buffered solation at a concentration
of 0.3 mg/ml. It is formulated as a sterile, colorless liquid in a
10 mM sodium acetate buffer at pH 4.0.
Administration: rhG-CSF will be administered in this study
subcutaneously. It will be undiluted and be drawn into 3 cc
syringes. To reduce the possibility of bacterial contamination in
this product which contains no preservatives, the syringes should be
stored at 2-8 degrees C and used within 24 hours of preparation,
rhG-CSF should not be frozen and vials or syringes that have been
frozen should not be used.
3.2.5 Supplier: This agent will be supplied through AMGEN for the trial
free of charge to the patients.
3.3 Carboplatin (NSC-241240) (CBCDA)
3.3.1 Human Toxicity: Side effects of Carboplatin (CBDCA) include
myelosuppression, nausea, vomiting, loss of appetite. Rare
toxicities include gross hematuria, hyponatremia, ageusia, allergic
reaction, peripheral neuropathy, veno-occlusive disease, loss of
hair, liver damage, kidney damage, hearing loss, dizziness and
blurred vision. Two cases of optic neuritis have been reported in
patients receiving carboplatin which were thought to be possible
drug-related events. A single case of severe pulmonary toxicity has
been reported.
3.3.2 Pharmaceutical Data: Formulation: CBDCA is supplied as a sterile
lyophilized powder available in single-dose vials containing 50 mg,
150 mg and 450 mg of Carboplatin for administration by intravenous
injection. Each vial contains equal parts by weight of Carboplatin
and mannitol. Immediately before use, the content of each vial must
be reconstituted with either Sterile Water for Injection. USP, 5%
Dextrose in Water, or 0.9% Sodium Chloride Injection, USP, according
to the insert.
Diluent Volume
50 mg 5 mL
<PAGE>
150 mg 15 mL
450 mg 45 mL
These dilutions all produce a Carboplatin concentration of 10 mg/ml.
CBDCA can be further diluted to concentrations as low as 0.5 mg/ml
with 5% Dextrose in Water or 0.9% Sodium Chloride Injection, USP
(NS).
3.3.3 Storage & Stability: Unopened vials of CBDCA for injection are
stable for the life indicated on the package when stored at
controlled room temperature 150 - 300 C. and protected from light.
When prepared as directed, CBDCA solutions are stable for 8 hours
at room temperature. Since no anti-bacterial preservative is
contained in the formulation, it is recommended that CBDCA solutions
be discarded 8 hours after dilution. Parenteral drug products should
be inspected visually for particulate matter and discoloration prior
to administration.
3.3.4 Administration: Intravenous.
3.3.5 Supplier: CBDCA is commercially available and will be purchased
through third party payers.
3.4 Cyclophosphamide (NSC-26271)
3.4.1 Mechanism of Action: Cyclophosphamide is a very weak alkylating
agent, but enzymatic oxidation and a series of undefined subsequent
reactions produce one or more molecules with alkylating activity.
In experimental animals, the first step of activation occurs more
extensively in the liver than in the neoplasm or other tissues of
the host.
3.4.2 Toxicities: Human toxicity includes alopecia, nausea and vomiting,
stomatitis, leukopenia, anemia, thrombocytopenia, sterility or
decreased gonadal function, hemorrhagic cystitis and fibrosis of
the bladder.
3.4.3 Pharmaceutical Data: Formulation: Cyclophosphamide is supplied in
100, 200, and 500 mg ampules containing white powder. The drug can
be reconstituted in normal saline or 5% dextrose and water.
3.4.4 Stability: Store at room temperature. Do not store at temperatures
above 90 degrees F.
3.4.5 Supplier: This drug is commercially available for purchase by the
third party.
<PAGE>
3.5 Thiotepa (Triethylene-thiophosphoramide) (NSC-6369)
3.5.1 Mechanism of Action: Thiotepa is a cytotoxic agent of the
polyfunctional alkylating type related chemically and
pharmacologically to nitrogen mustard. On the basis of tissue
concentration studies, it is reported that Thiotepa has no
differential affinity for neoplasms. Most of the drug appears
to be excreted unchanged in the urine.
3.5.2 Human Toxicology: The major side effects of Thiotepa are pain
at the site of injection, nausea and vomiting, anorexia,
dizziness, headache, amenorrhea and interference with
spermatogenesis. Febrile reaction and weeping from a
subcutaneous lesion may occur as the result of a breakdown of
tumor tissue. Allergic reactions are rare, but hives and skin
rash have been noted occasionally. The serious complication of
excessive Thiotepa therapy, or sensitivity to the effects of
this agent, is bone marrow depression. If proper precautions
are not observed, it may cause leukopenia, thrombocytopenia and
anemia. The most reliable guide to Thiotepa toxicity is the
white blood count.
3.5.3 Pharmaceutical Data: Formulation: Thiotepa is available in a
powder form in 15 mg vials. The powder should be reconstituted
in sterile water for injection.
3.5.4 Storage and Stability: Reconstituted solutions may be kept for
five days in a refrigerator without a substantial loss of
potency. Vials containing Thiotepa should be stored at 2-8
degrees C (35-46 degrees F).
3.5.5 Administration: The amount of diluent most often used is 1.5 ml
resulting in a drug concentration of 5 mg in each 0.5 ml of
solution. Thiotepa may be given by rapid intravenous
administration or via continuous intravenous infusion.
3.5.6 Supplier: This drug is commercially available for purchase by
the third party.
3.6 Intended Use
The intended use of the CPS is to produce human stem- and
hematopoietic progenitor cells to support subjects with compromised
hematopoietic systems. A per-patient cell production procedure,
beginning with 2.25 x 10/8/ nucleated bone marrow cells per device,
will yield at least 1.6 x 10/9/ cells. The cells will not be infused
if the cell yield is below this level; the back-up cells will be
infused in such a case.
4.0 PATIENT ELIGIBILITY
<PAGE>
4.1 Patients with histologically confirmed breast cancer with advanced
disease as defined as high risk Stage II (greater than 10 LN), Stage III or
stage IV (inflammatory, fixed to chest wall, or fixed axillary lymph nodes)
or recurrent or metastatic disease.
4.2 Patients with measurable disease must have disease which is responsive to
standard dose systemic chemotherapy administered prior to enrollment on
study. Patients may have a maximum of two prior chemotherapy regimens for
their disease. Patients with metastatic disease (beyond draining lymph
nodes) with no evaluable or measurable disease following surgical
resection, radiotherapy, or chemotherapy are still eligible.
4.3 Patients must have a Performance status of 0-1 by SWOG criteria (see
appendix). As patient weight is used to calculate the minimum safe dose
of CFU-GM to accomplish a transplant, and given the production capabilities
of the CPS, patients in this initial trial must be less than 90 kg of
actual body weight.
4.4 Patients must have received a cumulative adriamycin dose of less than
350 mg/m2 with no prior nitrosoureas, platinum or mitomycin C.
4.5 Patients must have recovered from prior therapy with at least 4 weeks since
the last chemotherapy, 4 weeks since last radiotherapy, and 3 weeks since
major surgery.
4.6 Patients must have adequate cardiac function as defined by a MUGA with an
ejection fraction greater than or equal to 45%. Patients may not have
active coronary disease as defined by angina or history of a myocardial
infarction. In addition, patients must have no clinically apparent
uncorrectable pulmonary disease such as corpulmonale or severe COPD, or
be requiring oxygen therapy for any reason.
4.7 Patients with a history of or any evidence for brain metastases are
ineligible. Head CT or MRI scans are not required if patients are
asymptomatic.
4.8 Patients must have adequate organ function as defined by the following:
Serum creatinine less than or equal to 1.5 mg/dl or calculated Cr-CI or
greater than or equal to 60 ml/min: Hepatic function as defined by
Bilirubin less than or equal to 2.0 mg/dl and AST/ALT less than or equal to
2 x institutional normal values: hematologic functional as defined by WBC
greater than or equal to 3400/ul. Hgb greater than or equal to 9.0 gm/dl.
platelet count greater than or equal to 140,000/ul.
4.9 Exclusion Criteria include: History of hypersensitivity to horse serum
or fetal calf serum: Concurrent involvement in any other clinical trial
that affects engraftment (e.g. other hematopoietic growth factors);
treatment with any growth factors within two weeks; Previous pelvic
radiotherapy rendering the marrow hypocellular, any co-morbid condition
which, in the view of the Principal Investigator, renders the patient at
high risk from treatment complications.
<PAGE>
4.10 Patients must undergo a BM biopsy and BM must be either free of
disease by standard histologic exam, and a cellularity on biopsy of
at least 35%.
4.11 Patients must be less than 65 years of age.
4.12 Patients must be HIV negative.
4.13 Pregnant or lactating women may not participate.
4.14 Patients with prior hemorrhagic cystitis are ineligible.
4.15 Patients must be free of active systemic infection at the time of
initiating therapy. Patients must have had no episodes of systemic
mycotic infections, nor have required Amphotericin B therapy in the
previous 12 months.
4.16 Patients must be free of active CNS diseases (seizures, etc.)
4.17 Patients must have signed an IRB approved consent form prior to trial
enrollment.
4.18 Patients may not have an active second malignancy within the previous
2 years except localized non-melanoma skin cancer or uterine cervical
cancer in situ.
5.0 TREATMENT PLAN
5.1 Registration
All patients must be registered with the Data Management office at
708-327-3230 for entry on study. A total of 6-10 patients will be
treated in this pilot study.
5.2 Bone Marrow Harvest
Patients will undergo back-up bone marrow harvest at any time prior
to initiation of the ablative chemotherapy, with cryopreservation,
using standard techniques. Patients must have greater than 2 x 10/8/
nucleated cells per kg harvested, including greater than 0.5 x 10/6/
CD34- cells/kg.
The bone marrow harvest will be performed by standard technique in an
operating suite under general or epidural anesthesia. In a standard
harvest, approximately 500-1500 ml of marrow is withdrawn. Patients
will have the back-up bone marrow collected simultaneously with the
cells for ex vivo production. If a sufficient number of cells are
collected, the bone marrow collected will be processed and a small
fraction utilized for the ex vivo culture described below, and the
remainder of the cells will be cryopreserved per
<PAGE>
standard technique and held as a back-up for use if the prescribed number
of cells is not produced or if graft failure occurs. The cells for the
expansion will be collected from the posterior iliac crest or from the
sternum at the initiation of the harvest procedure. No more than 5 cc of
marrow for the expansion will be aspirated from each bone puncture.
Approximately 40 ml of marrow will be aspirated in this fashion.
5.3 Ex Vivo Cell Production
As mentioned in other parts of the Protocol, at the time of bone marrow
harvest, all harvested marrow will be delivered to the bone marrow
laboratory for processing. A portion of the harvested marrow will be used
for cell production in the CPS and balance of the harvested marrow will be
cryopreserved. Twelve days prior to the scheduled bone marrow transplant,
2.25 x 10/8/ mononuclear cells from freshly collected marrow will be placed
into each CPS in the presence of PIXY321 (5 ng/mi), hydrocortisone (final
concentration 5 x 10/-6/M), glutamine (4 mM), gentamicin sulfate (5 Fg/mi),
vancomycin (20 Ff/mi), Epo (0.1 U/ml/day) and fit3L (5 ng/ml). The tissue
culture medium will be supplemented with 1.0% fetal calf serum and 1.0%
horse serum. All processing will be done using the dedicated CPS
instrumentation. No standard laboratory equipment will be used for the
expansion or processing of the cells. A sample of the harvested marrow will
be sent for bacterial and fungal culture.
The cell production will be performed in the Aastrom CPS, which is operated
as a stand alone, dedicated piece of validated laboratory equipment
(incubator, refrigerator, gas pumps) which provide for constant temperature
(37C), pH (7.2-7.4), and delivery of sterile air (5% C02) to the
hematopoietic cells.
Two days prior to the completion of cell production, the cell culture
effluent will be sampled to allow for bacterial and fungal testing
including gram stain, endotoxin testing and mycoplasma. At the completion
of the cell expansion process (12 days), the non-adherent fraction will be
removed from the cell culture devices by draining the growth medium from
the cell culture devices into the harvest bag. The devices will then be
rinsed by using a syringe to inject 50 ml of an HBSS solution into an
access port. This is followed by agitation of the cell culture device and
collection of the rinse into the harvest bag. The adherent layer will be
detached from the cell culture device surface by injection of 50 ml of
Trypsin-EDTA solution via an access port. This is again followed by
agitation of the cell culture device and collection of the rinse into the
harvest bag. The chamber will be then given a final rinse with 50 ml of
HBSS, again by injection via an access port. This is followed by agitation
of the cell culture device and collection of the rinse into the harvest
bag.
The expanded cells will be washed according to the procedure outlined in
the Operators Manual.
All subjects will receive freshly harvested expanded cells. The expanded
cells must be greater than 80% viable, as determined by Trypan blue dye,
and the minimum total cell number, as
<PAGE>
determined by an automated cell counter, will be 1.6 x 10/9/ cells.
As part of the standard laboratory in this Study, the total cell
count, CFU-GM and LTC-IC will be determined for the starting and
final cell number. The pre and post expansion sample will be sent
for cytology and immunocytochemistry for breast cancer cells.
Pre-transplant Evaluation of the cultured Cells: 48 hours prior to the
collection of the expanded cells, the effluent from the CPS will be
tested for bacterial and fungal contamination, as described above. If
the bone marrow cultures are either visibly contaminated or are
positively cultured for bacterial or fungal contamination, or if the
cultures die, the expanded cells will not be returned to the subject,
who will then simply receive her cryopreserved bone marrow.
Flow Cytometry: Aliquots of the ex vivo produced cells (approximately
10 x 1 Or) will be removed at 12 days, placed in a tube containing
sterile buffered medium, and shipped by overnight mail carrier to
Aastrom Biosciences, Inc., Domino's Farms, 24 Frank Lloyd Wright
Drive, Lobby L., Ann Arbor, MI, 48105. These cells will be analyzed
for the presence of several cell surface markers (CD34, CD1 lb, CD15,
CD33, CD3, CD4, CD8, CD19, CD71 and glycophorin A and other
appropriate markers) in the laboratory at Aastrom as potential
correlates for the cell production process. The Aastrom Laboratory
operates under GLP (Good Laboratory Practices) guidelines.
Release Criteria: Cells produced in the Aastrom CPS will be
considered eligible for release and reinfusion if greater than 1.6 x
10' nucleated cells/kg are recovered after the expansion period and
cell washing, and if greater than 80% of the nucleated cells are
viable as judged by exclusion of Trypan blue dye. Microbial
contamination studies collected from the expansion on Day 10 must
be negative.
If the expansion is not deemed sufficient, a patient will receive her
backup marrow instead, without infusion of the expanded cells.
5.5 Transplant Regimen
5.4.1 High Dose Chemotherapy (STAMP V Regimen)
Chemotherapy will begin a minimum of 48 hours following the
last pheresis. Prior to the administration of chemotherapy,
patients will receive anti-emetics including ondansetron and
dexamethasone. Chemotherapy will consist of the following:
Cylophosphamide 1500 mg/m2 Q day by continuous infusion (CI)
for 4 days (d-7 through d-4) (96 hours) Total dose 6000 mg/m2
Thiotepa 125 mg/m2 Q day by CI for 4 days (d-7 through d-4) (96
<PAGE>
hours) Total dose 500 mg/m2.
Carboplatin 200 mg/m2 Q day CI for 4 days (d-7 through d-4) (96 hours)
Total Dose 800 mg/m2.
Supportive Issues:
All patients will receive therapy through three separate lumens. The
agents can not be mixed. Vigorous hydration will be included with a
minimum of 200 cc/hour of IV fluids with diuretics as needed, while the
chemotherapy is infusing and continuing till stem cell infusion. Patients
will receive aggressive anti-emetic therapy with ondansetron, lorazepam,
dexamethasone, etc.
5.4.2 Post-Transplant Growth Factor Support
G-CSF (10 mcg/k/d) will be administered SQ until granulocytes greater
than 2.0 x 1 O/9//l or greater than 1.0 x 1 O/9//l for 3 days. If
granulocytes fall to less than 1.0 x 10/9//l, hematopoietic growth factor
treatment can be resumed as indicated to maintain an absolute granulocyte
count greater than 1.0 x 10/9//l. GM-CSF 250 mg/m2/d may be used in
patients intolerant to G-CSF.
Patients who require the administration of any myelosuppressive therapy
in the first 7 days post transplant such as full dose Amphotericin B
therapy will be required to receive the infusion of their back up marrow
cells on that date.
5.4.3 Neutrophil Engraftment and Stopping Rules
Neutrophil engraftment is defined as recovery as granulocytes to 0.5 x
10/9//l. Back-up autologous bone marrow will be infused intravenously per
the following stopping rules:
a. Back-up cells will always be administered to subjects on Day -21 if ANC
is less than 0.5 x 10/9//l; if back-up cells are administered to a
subject on Day-21, it is reasonable to assume that an ANC level of 0.5 x
10/9/ can only be reached between Day -21 and Day -25 if the cells
produced in the CPS alone contribute to a subject's recovery, because the
administration of back-up cells would not be expected to impact
engraftment so rapidly, between Days -21 and-25. It is relevant to point
out that ANC recovery in the Day -18-25 time frame is often experienced
in standard bone marrow transplantation.
b. If the ANC is greater than 500 on Day -28 but the platelet count is less
than 20,000, the marrow cells will be infused on that date.
c. If the patient is experiencing a severe infection or uncontrolled
bleeding
<PAGE>
at any point during the period of pancytopenia, the back-up
cells may be administered at the discretion of the investigator.
5.4.3.1 Stopping Rules
With the above as background, stopping rules will be
as follows: the trial will be stopped and reevaluated
if two subjects fail to reach ANC 0.5 x 10/9/v/1 by Day
+25, even with the administration of back-up cells on
Day +21;
The trial will also be stopped and reevaluated if
four of the first five subjects, or if any five of
the ten total subjects, required the administration
of back-up cells because they failed to reach ANC
0.5 x 1 01/1 on or before Day +21.
6.0 PRETREATMENT EVALUATION
6.1 Complete history and physical examination, including SWOG performance
status (Appendix C)
6.2 CBC, diff, and platelet count
6.3 SMA 12 and electrolytes
6.4 PT, PTT
6.5 Cardiac ejection fraction
6.6 Pulmonary function - DLCO
6.7 HIV, hepatitis, HTLV-1 (1764 panel)
6.8 Pregnancy test (in fertile women)
6.9 Tumor staging as indicated including bone scan with X ray of hot
spots. Chest X-Ray, CT scan abdomen, tumor markers, such as CEA
will be assessed.
6.10 Bilateral bone marrow aspirate and biopsy
7.0 STUDY PROCEDURES AND EVALUATIONS
7.1 Interim history, physical examination and toxicity assessment
daily while in hospital and at least weekly until WBC greater than
3000 and platelets greater than 100,000. Toxicity assessment will be
made pre-infusion and 2 and 24 hours post-infusion of both the
expanded and unexpanded bone marrow cells.
<PAGE>
7.2 CBC, diff, platelet counts daily while hospitalized and at least twice
per week as an outpatient until WBC greater than 3000/ul and platelets
greater than 100,000/ul.
7.3 SMA twice per week while hospitalized. Electrolytes as indicated.
7.4 Tumor restaging as indicated including bone scan with X ray of hot
spots, CXR, CT scan of abdomen, and CEA, at day 60. Subsequent follow
up is as indicated for patients with this malignancy.
7.5 Criteria for discharge: A study subject will be eligible for discharge
from the hospital when she meets the following criteria:
afebrile for 2 or more consecutive days, ANC greater than 500 for 3
consecutive days and SWOG status of 0, 1 or 2.
All study subjects will receive follow-up care and treatment (as
appropriate) by their physician. The subjects' medical records will be
available to medical study monitors should additional information be
required.
8.0 DATA COLLECTION
8.1 General Information
Data will be recorded using a standard 'Theredex' reporting system at
the time of each evaluation. Data must be recorded for all subjects
from whom an Informed Consent is obtained.
8.2 Contents
Data to be collected at each of the study time period is as follows:
Pre-treatment Evaluation
------------------------
Eligibility criteria
Demographic data
Medical history
Physical examination
Laboratory profile
Bone marrow biopsy
toxicity status
Baseline (Day 0)
----------------
<PAGE>
Laboratory profile
Bone marrow/cultured cell profile
Transfusion record
Toxicity assessment
Vital signs
Concomitant medication(s)
Infection reporting and adverse effects greater than grade 3 -
report immediately to sponsor as event occurs.
Daily Evaluations (Post-transplant)
-----------------------------------
Laboratory profile
Transfusion record
Toxicity assessment (note preinfusion, 2 hour and 24 post infusion
toxicity assessment above)
Vital signs
Concomitant medications
Infection reporting and grade greater than 2 adverse effects - report
immediately to sponsor as event occurs.
Hospital Discharge (study completion)
-------------------------------------
Laboratory profile
Vital signs
Toxicity assessment
Concomitant medications
Infection reporting and Adverse Effects grade greater than 3 - Report
immediately to sponsor as event occurs.
Early termination or D60
------------------------
Laboratory profile
Assessment of late toxicity
Transfusion record
Vital signs
Concomitant medications
Study completion questionnaire
8.3 Quality System
<PAGE>
Quality system procedures are designed to ensure that complete, timely, and
accurate data are submitted, that protocol requirements are followed, and
that complications and/or adverse reactions are immediately identified.
The study monitors will promptly review all incoming data to identify
inconsistent or missing data and adverse effects. Data problems will be
addressed in telephone calls and correspondence to the investigational site
and during site visits. Clinical monitoring procedures are described in
Section 12 of this protocol. The Medical Monitor will receive immediate
notification of adverse reactions Grade greater than 3. Both the site and
--------------
Aastrom will maintain secure hard copy Case Record Forms and data files.
9.0 ADVERSE EFFECTS
All adverse effects, whether or not considered anticipated, must be
recorded on the data sheets. Unanticipated effects, as defined below, must
be reported promptly to the sponsor for further evaluation and adequate
required reporting to IRBs and investigators.
9.1 Anticipated Adverse Effects
The preliminary clinical experience has not identified any serious
adverse effects on health or safety caused by or associated with the
CPS and no adverse effects related to the ex vivo use fit3 ligand are
anticipated. Patients undergoing high dose chemotherapy are
anticipated to experience anorexia, nausea, vomiting, mucositis,
pancytopenia and associated infections while neutropenia. Some
patients may develop organ toxicities from high dose therapy. The
anticipated events are therefore those associated with bone marrow
transplantation and/or chemotherapy.
9.2 Unanticipated Adverse Effects
An unanticipated adverse effect is:
Any serious effect on health or safety or any life-threatening
problem, or death caused by, or associated with, a device, if that
effect, problem, or death was not previously identified in nature,
severity, or degree of incidence in the investigational plan, or any
other unanticipated serious problem that relates to the rights, safety
or welfare of subjects. [21 CFR 812.3 (s)]. In particular, any
unexpected grade III or IV toxicities or any other serious event that
might be attributable to the infusion of the expanded hematopoietic
cells.
Reporting requirements:
<PAGE>
Unanticipated adverse effects should be reported to the Aastrom
Study Director, Thomas E. Muller, Ph.D., Vice President Regulatory
Affairs, immediately by the Investigator and subsequently to BRI.
Aastrom requires an immediate telephone report followed by a written
report within 5 days.
An investigator shall submit to Aastrom and the reviewing IRB a
report of any unanticipated adverse device effect occurring as soon
as possible, but no later than 10 working days after the
investigator learns of the effect [21 CFR 812.150 (a) (1)]. Aastrom
shall immediately conduct an evaluation and report the results of
the evaluation to FDA and to reviewing IRB's and participating
investigator(s) within 10 working days after the sponsor first
receives the notice of the effect [21 CFR 812.150 (b) (1)]. If
Aastrom determines that an unanticipated adverse effect presents an
unreasonable risk to subjects, all investigations or parts of
investigations presenting that risk shall be terminated as soon as
possible [21 CFR 812.46 (b)].
9.3 DEPARTURE FROM PROTOCOL
When a situation occurs which requires a departure from the protocol,
the Principal Investigator or other physician in attendance will
contact the Medical Monitor by telephone:
Thomas E. Muller, Ph.D.
Vice President Regulatory Affairs
Aastrom Biosciences, Inc.
24 Frank Lloyd Wright, Lobby L
Ann Arbor, MI 48105
Telephone: 313-930-5555
Fax: 313-665-0485
Contact with the Medical Monitor will be made as soon as possible in
order to discuss the situation and agree on an appropriate course of
action. The patient's medical records and source documents will
describe the departure from the protocol and the circumstance
requiring it.
10.0 STATISTICAL CONSIDERATIONS AND DATA ANALYSIS
10.1 Evaluation of the Data
<PAGE>
All subjects will be evaluated. Descriptive statistics will be
presented for demographic variables and baseline characteristics
such as age, sex, medical history, physical examination results,
cost information (especially as this relates to morbidity).
The primary endpoint is the safety of the cells produced in the CPS.
To assess the hematopoietic recovery post-infusion with ex vivo-
produced cells, the day of engraftment is defined by the first day
on which granulocytes less than 0.5 x 10/9//I are observed. Other
secondary endpoints include nadir WBC and platelet count, febrile
days, treatment related complications, antitumor response, and
survival.
Secondary Endpoints:
a. The day of platelet transfusion independence with platelet count
less than 20,000/MM3, 50,000/MM3 and 100,000/MM3 as defined by
first of two consecutive time points on which platelet counts
meet these endpoints not related to transfusion.
b. Packed red blood cell transfusion and platelet transfusion
requirements.
c. Number of documented infections.
d. Number of bleeding episodes.
e. Number of days of hospitalization.
Tumor response and response duration
a. Patient survival at 90 days post transplant.
10.2 Safety variables
Safety variables summarized will include incidence of adverse
effects (including duration, severity, and outcome). Other safety
variables reported will include the incidence and types of
laboratory abnormalities. When the frequencies are sufficiently
large, a Fishers exact test or Chi-square test may be used to
compare enrolled subjects and historical controls including
approximately 65 patients receiving autologous bone marrow
transplants without expansion using the same preparative regimen.
10.3 Biological Effect Variables
The following biological effects will be summarized:
Incidence of febrile neutropenia
Time to platelet transfusion independence Antibiotic usage:
<PAGE>
Number of days on antibiotics
Number of total antibiotic days (# antibiotics x days)
Number of days on antifungals
Number of days on antivirals
Number of documented infections
Time to neutrophil engraftment
Length of initial hospitalization
11.0 CLINICAL SUPPLIES
A complete CPS description is provided in the Operators Manual. 1
11.1 Materials and Supplies
11.1.1 CPS
Aastrom will supply the CPS, which includes the cell culture
device. This device consists of three rigid plastic parts
(top, cell bed, and base), and a gas-permeable, water-
impermeable membrane. Additional components include the
means to facilitate air removal, seals to maintain leak-
proof integrity, and mechanical fasteners.
11.1.2 Growth Medium
The culture medium is prepared at the clinical site by
supplementing a custom medium, produced to Aastrom
specifications in a FDA-registered facility in compliance
with GMPs (21 CFR 820), with glutamine and growth factors in
accordance with a standard operating procedure. Medium
components are shipped to or procured by the clinical
trial site according to instructions, specifications and
acceptance criteria defined by Aastrom.
11.1.3 Supporting Tubing and Materials
Aastrom will supply the supporting tubing, harvest
container, and waste container. These components will be
supplied in sterile packages (for single use only).
11.2 Packaging and Labeling
The package labeling includes the statement "Caution.
Investigational Device-Limited by United States Law to
Investigational Use," Lot Number, "Sterile unless unit package is
opened or damaged," and "Manufactured for Aastrom Biosciences, Inc."
11.3 Assembly
<PAGE>
Components of the CPS will be received at the clinical test sites
in sterile packages. The elements of the system will be connected
under a laminar flow hood using aseptic technique provided in the
Instructions for Use. The instructions for use will be provided
by Aastrom.
11.4 Storage Requirements
The devices may be stored indefinitely under typical laboratory
conditions (50 degrees to 90 degrees F) and may be transported
at temperatures up to 125 degrees F.
11.5 Retrieval and/or Disposal of Investigational Materials
At the completion of the cell production process and harvest,
the devices will be considered biohazardous waste and disposed
of in accordance with standard procedures at the test site.
Record will be made of the date of disposal and initials of the
individual responsible for their disposition.
12.0 STUDY MONITORING
12.1 Medical Monitor
The Medical Monitor will review the investigational plan, review
adverse - reactions and/or unanticipated device effects as
reported by the Investigator and interpret clinical results.
The Medical Monitor for this study is:
Thomas E. Muller, Ph.D.
Vice President Regulatory Affairs
Aastrom Biosciences, Inc.
Domino's Farms
24 Frank Lloyd Wright Dr., Lobby L
Ann Arbor, MI 48105
Telephone: 313-930-5555
Fax: 313-665-0485
12.2 Clinical Monitor
Aastrom has designated BRI International, Inc., as Clinical Monitor
for this study. The Clinical Monitor is qualified by training and
experience to oversee the conduct of the study. The Clinical
Monitor's responsibilities include maintaining regular contact with
the investigational site, through telephone contact, correspondence
and on-site visits, to ensure that the investigational plan and FDA
regulations are followed, that complete, timely and accurate data
are addressed, and that the site facilities continue to be
adequate. Any questions regarding
<PAGE>
these matters should be addressed to:
Diane Goleb, Senior Project Director
BRI International, Inc.
15825 Shady Grove Road
Rockville, MD 20850
Telephone: 301-548-0500
Fax: 301-548-0519
12.3 Monitoring Procedures
12.3.1 Preinvestigational Site Visit
The Preinvestigational Site Visit, conducted by the Clinical
Monitor, will involve review of relevant FDA regulations and
inspection procedures, the investigational plan, requirements for
IRB review and approval, completion and submission of forms,
record keeping requirements, and administrative reports.
The adequacy of the facilities, the availability of the
investigators, the potential number of study participants, and the
provisions for staff support will also be assessed during the
Preinvestigational Site Visit.
12.3.2 Routine Monitoring Visits
Regular clinical monitoring visits to the investigational site
will be conducted by Aastrom and BRI.
To ensure that the Principal Investigator and his staff understand
and accept their defined responsibilities, the Clinical Monitor
will maintain regular correspondence and perform periodic site
visits during the course of the study to verify the continued
acceptability of the facilities, compliance with the
investigational plan and relevant FDA regulations, and the
maintenance of complete records. Clinical monitoring will include
review and resolution of missing or inconsistent results and
source document checks (i.e., comparison of submitted study
results to original reports) to assure the accuracy of the
reported data.
The Clinical Monitor will evaluate and summarize the results of
each site visit in written reports, identifying any repeated data
problems with any investigator and specifying recommendations for
resolution of noted deficiencies.
<PAGE>
12.3.3 Termination/Close-out Procedures
The Clinical Monitor, BRI, will notify the investigator in
writing of study completion/termination. The letter will
include the reason for termination, document unresolved
study discrepancies, and remind the investigator of her
obligation to retain records according to FDA regulations.
BRI will be responsible for meeting the FDA regulations with
regards to record keeping and records retention.
BRI will conduct a standard closure monitoring site visit.
The objectives of the closing visit are:
verify compliance with protocol and FDA regulations; ensure
accuracy and completeness of subject and administrative
files; resolve any outstanding questions/problems; verify
accountability for the test devices; ensure the proper
disposition of test devices and completed case report forms;
confirm the investigator's understanding of his/her
regulatory obligations, including record retention
requirements.
13.0 INVESTIGATOR OBLIGATIONS
13.1 Principal Investigator Responsibilities
13.1.1 Compliance
The Principal Investigator is responsible for ensuring that
the study is conducted according to the signed Investigator
Agreement, the investigational plan, and applicable FDA
regulations for protecting the rights, safety and welfare of
subjects under the Investigators care. The Principal
Investigator must follow the Investigator Agreement, the
investigational plan, and all conditions of FDA and IRB
approval.
13.1.2 Awaiting Approval
Written confirmation of IRB approval must be provided to
Aastrom prior to the start of the study. The Principal
Investigator may determine whether potential subjects would
be interested in participating in a study but may not
request signature of the Informed Consent or allow any
subject to participate until FDA and the reviewing IRB have
approved the study.
13.1.3 Supervising Device Use
<PAGE>
The Principal Investigator must supervise all use of the CPS
involving human subjects and may not supply the device to any
person not specifically authorized to receive it according to
the investigational plan and applicable regulations.
13.1.4 Informed Consent
The Principal Investigator shall make known to each subject the
nature, expected duration, and purpose of the study; the
administration and hazards of treatment; and available
alternative therapy. Signed, written Informed Consent must be
obtained prior to treatment. The original will be kept by the
Principal Investigator and will be subject to review by Aastrom.
Subjects will be informed that their medical records will be
subject to review by Aastrom and the FDA. Subjects shall be
informed that they are free to refuse participation in this
clinical investigation; and if they participate, that they may
withdraw from the study at any time without prejudicing future
care.
13.1.5 Device Disposal
Upon completion or termination of the study of the Principal
Investigators participation in the study, or at Aastrom's
request, the Principal Investigator must return to Aastrom the
device(s) or otherwise dispose of the device(s) as Aastrom
directs.
13.1.6 Reporting Requirements
Any life-threatening and/or unexpected serious (grade 3 or 4)
toxicities will be reported immediately to the Study Chairman
who, in turn, will notify the IRB (Surveillance Committee) and
the study sponsor.
13.1.7 Inspections and Records
In accordance with the Investigator Agreement, the Principal
Investigator shall permit authorized FDA employees to enter and
inspect any site where the device or records pertaining to the
device are held, and to inspect and copy all records relating
to an investigation, including subject records.
13.1.8 Investigator Records
The Principal Investigator will maintain complete, accurate and
current study records, including the following materials:
Correspondence with FDA, Aastrom, BRI, and the IRB; Record of
receipt of the device:
<PAGE>
Instructions for device use;
Subject Records, including Informed Consent, copies of
Case Report Forms and supporting documents (laboratory
reports, medical records, etc.); Log Book;
Current study protocol and a log of any significant
protocol deviations (e.g., lack of informed consent or
treatment of ineligible subjects);
Adverse event reports;
Certification that the investigational plan has been
approved by all of the necessary approving authorities;
The approved blank informed consent form and blank
subject report forms. Signed Investigator's Agreement
with CV's of the Principal Investigator and all
participating sub-investigators attached.
These records shall be maintained for a period of 2
years after the latter of the following two dates: the
date on which the investigation is terminated or
completed, or the date that the records are no longer
required for purposes of supporting a premarket
approval application or notice of completion of a
product development protocol.
13.1.9 Investigator Reports
The Principal Investigator will be responsible for the
following reports:
13.1.9.1 Unanticipated Adverse Effects
The Investigator will report any serious
adverse effect, death or life-threatening
problems that may reasonably be regarded as
caused by the CPS to Aastrom and the
reviewing IRB as soon as possible but no
later than 10 working days after the event.
All anticipated serious adverse effects
should be documented with an explanation of
any medical treatment administered.
An unanticipated serious adverse effect is
defined as any serious adverse effect on
health or safety, or any life-threatening
problem or death caused by, or associated
with this device, if that effect, problem,
or death was not previously identified in
nature, severity, or degree of incidence in
this investigational plan.
13.1.9.2 Withdrawal of IRB Approval
The Principal Investigator will immediately
notify to Aastrom (within 5 working days)
if, for any reason, the IRB withdraws
approval to conduct the investigation.
The report will include a complete
description of the
<PAGE>
reason(s) for which approval was withdrawn.
13.1.9.3 Departure from Protocol
The Principal Investigator shall notify Aastrom
and the IRB of any deviation from the
investigational plan made to protect the life
or physical well-being of a subject in an
emergency. A full report should be made as soon
as possible and in no case later than 5 working
days after the emergency. NOTE: Except in such
an emergency, prior approval by Aastrom is
required for changes in, or deviations from,
the investigational plan. If such changes or
deviations may affect the scientific soundness
of the plan or the rights, safety or welfare of
subjects, FDA and IRB approval are also
required.
13-1.9.4 Progress Reports
The Principal Investigator is required to
submit progress and administrative reports to
Aastrom, and to the reviewing IRB. Reports will
include the number of study subjects, a summary
of all adverse reactions, and a general
description of the study's progress.
13.1.9.5 Final Report
The Principal Investigator will submit a final
report to Aastrom within four weeks following
termination of the study or that site's
participation in the study, and within three
months to the IRB.
13.1.9.6 Other Reports
Upon request, the Principal Investigator will
provide accurate, complete, and current
information to Aastrom Biosciences, Inc., the
FDA, and to the reviewing IRB.
13.1.9.7 Investigator Materials Accountability
All devices received and used by the Principal
Investigator will be inventoried and accounted
for throughout the study. The devices will be
stored in a secured area. Upon study
completion, all unused devices will be returned
to Aastrom. A final inventory will then be
performed.
13.1.9.8 Laboratory Normal Values
<PAGE>
The investigational site must maintain a current copy of
normal values used by that site's clinical laboratory. The
Principal Investigator must assess the clinical significance
of all abnormal laboratory values. All clinically significant
abnormalities must be characterized by the Principal
Investigator as treatment-related, not treatment-related, or
of uncertain etiology; all abnormalities judged treatment-
related or of uncertain etiology must be repeated. Any
abnormal values that persist should be followed at the
Principal Investigators discretion. In some cases, significant
changes within the normal range will require similar judgment.
13.1.9.9 Disclosure of Data
All information concerning this clinical study are considered
confidential. The Principal Investigator agrees to use this
information only to accomplish this study and will not use it
for other purposes without Aastrom's written consent.
It is understood by the Principal Investigator that the
information developed in the clinical study may be disclosed
as required to the United States Food and Drug Administration.
In order to allow for the use of the information derived from
the clinical studies, it is understood that there is an
obligation to provide Aastrom with complete test results and
all data developed in the study.
Aastrom has no objection to the publication of the results of
this study by the investigator. However, a pre-publication
manuscript must be provided to Aastrom at least 30 days before
the manuscript is submitted to a publisher.
Aastrom agrees that before it publishes any results of the
study, a pre-publication manuscript will be provided to the
investigator for review at least 30 days prior to the submission
to a publisher.
13.1.10 Records Retention and Access
FDA regulations require that, following completion of a
clinical trial, a copy of all subject and administrative
<PAGE>
records pertaining to that study be maintained by the
Investigator for 2 years after FDA approval of the
investigational device, or, if no application for approval is
filed or intended to be filed, for 2 years after all
investigations have been completed, terminated, or discontinued,
whichever time period is longer.
Completed data records must be made available for review by
Aastrom, the Clinical Monitor, and FDA. To ensure the accuracy of
data submitted, it is mandatory that representatives of Aastrom
and of the FDA have access to source documents (i.e., subject
medical records, charts, laboratory reports, etc.). Subject
confidentiality will be protected at all times.
Aastrom reserves the right to terminate the study for refusal of
the Principal Investigator to supply source documentation of work
performed in this study.
14.0 REFERENCES
1. Traycoff CM, Kosak ST, Grigsby S, Srour EF. Evaluation of ex vivo
expansion potential of cord blood and bone marrow hematopoietic progenitor cells
using cell tracking and limiting dilution analysis. Blood. 1995;85:2059-68.
2. Sandstrom CE, Bender JG, Papoutsakis ET, Miller WM. Effects of CD34- cell
selection and perfusion on ex vivo expansion of peripheral blood mononuclear
cells. Blood. 1995;86:958-70.
3. Moore MAS. Expansion of myeloid stem cells in culture. Seminars in
Hematology. 1995;32:183-200.
4. Verfaillie CM. Direct contact between human primitive hematopoietic
progenitors and bone marrow stroma is not required for long-term in vitro
hematopoiesis. Blood. 1992;79:2821-6.
5. Koller MR. Paisson MA, Manchel I. Palsson BO. Long-term culture-initiating
cell
<PAGE>
expansion is dependent on frequent medium exchange combined with stromal and
other accessory cell effects. Blood. 1995;86:1784-93.
6. Koller MR, Bender JG, Papoutsakis ET, Miller WM. Effects of synergistic
cytokine combinations, low oxygen, and irradiated stroma on the expansion of
human cord blood progenitors. Blood. 1992;80:403-1 1.
7. Haylock DN, To LB, Dowse TL, Juttner CA, Simmons PJ. Ex vivo expansion and
maturation of peripheral blood CD34+ cells into the myeloid lineage. Blood.
1992;80: I 405-12.
8. Rafii S, Shapiro F, Pettengell R, et al. Human bone marrow microvascular
endothelial cells support long-term proliferation and differentiation of myeloid
and megakaryocytic progenitors. Blood. 1995;86:3353-63.
9. McKenna HJ, De Vries P, Brasel K, Lyman SD, Williams DE. Effect of flt3
ligand on the ex vivo expansion of human CD34+ hematopoietic progenitor cells.
Blood. 1995;86:3413-20.
10. Srour EF, Brandt JE, Bdddell RA, Grigsby S, Leemhuis T, Hoffman R. Long-term
generation and expansion of human primitive hematopoietic progenitor cells in
vitro. Blood. 1993;81:661-9.
11. Koller MR, Bender JG, Miller WM, Papoutsakis ET. Expansion of primitive
human hematopoietic progenitors in a perfusion bioreactor system with IL-3,
IL-6, and stem cell factor. Sio Technology. 1993;1 1:358-63.
12. Brandt JE, Briddel RA, Srour EF, Leemhuis TS, Hoffman R. Role of c-kit
ligand in the expansion of human hematopoietic progenitor cells. Blood.
1992;79:634.
13. Brugger W. Macklin W. Heimfeld S. Berenson RJ. Merteismann R. Kanz L. Ex
vivo expansion of enriched peripheral blood CD34+ progenitor ce(Is by stem cell
factor, interleukin-l b (IL-1 b), IL-6, IL-3, interferon-gamma, and
erythropoietin. Blood. 1993;81:2579-84.
<PAGE>
14. Killer MR, Emerson SG, Paisson BO. Large-scale expansion of human stem and
progenitor cells from bone marrow mononuclear cells in continuous perfusion
cultures. Blood. 1993;82:378-84.
15. Verfaillie CM, Catanzarro PM, Li W. Macrophage inflammatory protein la,
interleukin 3 and diffusible marrow stromal factors maintain human hematopoietic
stem cells for at least eight weeks in vitro. J Exp Med. 1994; 1 79:643-9.
16. Coutinho LH, Will A, Radford J, Schiro R, Testa NG, Dexter TM. Effects of
recombinant human granulocyte colony-stimulating factor (CSF), human granulocyte
macrophage-CSF, and Gibbon interleukin-3 on hematopoiesis in human long-term
bone marrow culture. Blood. 1990;75:2118-29.
17. Shapiro F, Yao T-J, Raptis G, Reich L, Norton L, Moore MAS. Optimization of
conditions for ex vivo expansion of CD34- cells from patients with stage IV
breast cancer. Blood. 1994;84:3567-74.
18. Brugger W. Heimfeld S, Berenson RJ, Merteismann R, Kanz L. Reconstitution
of hematopoiesis after high-dose chemotherapy by autologous progenitor cells
generated ex vivo. NEJM. 1995;333:283-7.
19. Champlin RE, Mehra R, Gajewski J. et al. Ex vivo expanded progenitor cell
transplantation in patients with breast cancer. Blood. 1995;(in press):(abs)
20. Hortobagyi GN, Bodey GP, Buzdar AU, et al. Evaluation of high dose versus
standard FAC chemotherapy for advanced breast cancer in protected environment
unit: a prospective randomized study. J Clin Oncol. 1987;5:354-64.
21. Hortobagyi GN. Multidisciplinary management of advanced primary and
metastatic breast cancer. Cancer. 1994:74 Suppi.416-23.
<PAGE>
22. Aisner J, Cirrincione C, Perloff M, et al. Combination chemotherapy for
metastatic or recurrent carcinoma of the breast - A randomized phase III trial
comparing CAF versus VATH versus VATH alternating with CMFVP: Cancer and
Leukemia Group B Study 8281. J Clin Oncol. 1995; 13:1443-52.
23. Hayes DF, Henderson IC, Shapiro CL. Treatment of metastatic breast
cancer: Present and future prospects. Semin Oncol. 1995; 22 Suppl. 5:5-21.
24. Henderson IC. Chemotherapy for advanced disease. In: Harris JR, Hellman
S, Henderson IC, Kinne DW, eds. Breast Diseases. Philadelphia: JB Lippincott;
1987:428-79.
25. Cheson BD. Bone marrow transplant trials for breast cancer. Oncology.
1991; 5:55-62.
26. Antman K, Ayash L. Elias A, et al. A phase 11 study of high-dose
cyclophosphamide, thiotepa, and carboplatin with autologous marrow support in
women with measurable advanced breast cancer responding to standard-dose
therapy. J Clin Oncol. 1992:10:102-10.
27. Eddy DM. High-dose chemotherapy with autologous bone marrow
transplantation for the treatment of metastatic breast cancer. J. Clin Oncol.
1992: 10:657-70.
28. Broun ER, Sridhara R. Sledge GW, et al. Tandem autotransplantation for the
treatment of metastatic breast cancer. Journal of Clinical Oncology. 1995:
13:2050-5.
29. Antman K, Corringhman R, De Vries E., et al. Dose intensive therapy in
breast cancer. Bone Marrow Transplant. 1.092;10 Suppl. 1:67-73.
30. Bezwoda WR, Seymour L, Dansey RD. High-dose chemotherapy with
hematopoietic
<PAGE>
rescue as primary treatment for metastatic breast cancer: A randomized trial.
Journal of Clinical Oncology. 1995;13:2483-9.
31. Rosti G, Lasset C, Albertazzi L, et al. The EBMT data on high-dose
chemotherapy in breast cancer. Bone Marrow Transplant. 1992;10 Suppi. 2:37.
32. Hryniuk WM, Bush H. The importance of dose intensity in chemotherapy of
metastatic breast cancer. J Clin Oncol. 1984;2:1281-7.
33. Peters WP, Ross M. Vredenburgh JJ, et al. High-dose chemotherapy and
autologous bone marrow support as consolidation after standard-dose adjuvant for
high-risk primary breast cancer. J Clin Oncol. 1993;1 1:1 132-43.
34. Vaughan WP. Autologous bone marrow transplantation in the treatment of
breast cancer: Clinical and technologic strategies. Semin Oncol. 1993;20 Suppi.
6:55-8.
35. Ayash LJ, Elias A. Wheeler C, et al. Double dose-intensive chemotherapy
with autologous marrow and pedpheral-blood progenitor-cell support for
metastatic breast cancer: A feasibility study. J Clin Oncol. 1994;12:37-44.
36. Crown J. Vahdat L. - Fennelly D, et al. High-intensity chemotherapy with
hematopoietic support in breast cancer. Ann NY Acad Sci. 1993;698:378-88.
37. Dunphy FR, Spitzer G, Buzdar AU, et al. Treatment of estrogen
receptor-negative or hormonally refractory breast cancer with double high-dose
chemotherapy intensification and bone marrow support. J Clin Oncol.
1990;8:1207-16.
38. Hortobagyi GN, Dunphy F. Buzdar AU, Spitzer G. Dose intensity studies in
breast cancer-Autologous bone marrow transplantation. Prog Clin Biol Res.
1990;354B:1 95-209.
<PAGE>
39. Peters WP, Shpall EJ, Jones RB, et al. High dose combination alkylating
agents with bone marrow support as initial treatment for metastatic breast
cancer. J Clin Oncol. 1998;6:1368-76.
40. Teicher S, Cucchi C, Lee J, et al. Alkylating agents. In vitro studies of
cross-resistence patterns in human tumor cell lines. Cancer Res. 1986;46:
4379-83.
41. Williams SF, Bitran JD, Kaminer 1, et al. A phase 1-11 study of bialkylator
chemotherapy high-dose thioptepa and cyclophosphamide with autologous bone
marrow reinfusion in patients with advanced cancer. J Clin Oncol. 1987;5:260-5.
42. Eder JP, Antman K, Elias A, et al. Cyclophosphamide and thiotepa with
autologous bone marrow transplantation in patients with solid tumors. JNCI.
1988;80:1221-6.
<PAGE>
LOYOLA UNIVERSITY MEDICAL CENTER EXHIBIT C
Schedule of Laboratory and Clinical Equipment
------------------------------------------------------------------------------------------------------------------------------------
Item Supplier Cat. No. UNIT QTY: UNIT/PKG: PKG: COST/PKG: Total Cost:
------------------------------------------------------------------------------------------------------------------------------------
EQUIPMENT:
------------------------------------------------------------------------------------------------------------------------------------
18 degrees C to 50 degrees C thermometer SP 2 1 2 $36.00 $72.00
------------------------------------------------------------------------------------------------------------------------------------
neg 5 degrees C to 20 degrees C thermometer SP 2 1 2 $21.91 $43.82
------------------------------------------------------------------------------------------------------------------------------------
P-1000 Pipetman Gilson 1 1 1 $219.50 $219.50
------------------------------------------------------------------------------------------------------------------------------------
P-200 Pipetman Gilson 1 1 1 $219.50 $219.50
------------------------------------------------------------------------------------------------------------------------------------
P-20 Pipetman Gilson 1 1 1 $219.50 $219.50
------------------------------------------------------------------------------------------------------------------------------------
Repeater Pipet Eppendorf 1 1 1 $350.00 $350.00
------------------------------------------------------------------------------------------------------------------------------------
CPS Processor Aastrom 1 1 1 $26,940.00 $26,940.00
------------------------------------------------------------------------------------------------------------------------------------
CPS Incubator Aastrom 5 1 5 $15,518.00 $77,590.00
------------------------------------------------------------------------------------------------------------------------------------
Interim Monitor Aastrom 1 1 1 $3,000.00 $3,000.00
------------------------------------------------------------------------------------------------------------------------------------
Gas Regulator Assembly Aastrom 3 1 3 $360.00 $1,080.00
------------------------------------------------------------------------------------------------------------------------------------
Tubing Heat Sealer Sebra 1 1 1 $3,298.00 $3,298.00
------------------------------------------------------------------------------------------------------------------------------------
Incubator Rack Metro 2 1 2 $346.00 $692.00
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
$113,724.32
------------------------------------------------------------------------------------------------------------------------------------
<PAGE>
EXHIBIT D
SCHEDULE OF CLINICAL TRIAL BUDGET
Item Cost per patient
---- ----------------
Supplies $ 190.00
Reagents 167.52
Bone Marrow Transplant Laboratory 630.00
Other 128.00
Labor and fringes 2,454.45
---------
Subtotal 3,569.97
Indirect 680.03
---------
Total $4,250.00
=========
Institution shall invoice Aastrom on a monthly basis as patient marrows are
harvested and expansion is initiated.
1
<PAGE>
EXHIBIT D
SCHEDULE OF MILESTONE PAYMENTS
COMPENSATION AMOUNT AND SCHEDULE
--------------------------------
1. COMPENSATION AMOUNT
-------------------
Aastrom agrees to provide, according to the terms and conditions set
forth herein, and contingent upon the conducting of the Study as specified
by the Protocol, a total compensation of Forty Two Thousand Five Hundred US
Dollars ($42,500), or Four Thousand Two Hundred Fifty US Dollars ($4,250)
per subject according to the compensation schedule set forth below in
Section 2 of this Exhibit D. The $4,250 per subject compensation
represents any and all compensations associated with the Study. The total
compensation amount is based upon the actual number of subjects to be
completed and may be adjusted based upon the actual number of subjects
actually completed. If a subject is removed from the Study for any reason,
payment for that subject will be prorated.
2. COMPENSATION SCHEDULE
---------------------
The payee identified in Section 3 of this Exhibit D below will be
remunerated according to the following schedule:
Percentage Amount
----------- ------------
(US DOLLARS)
Initial Payment 25% $10,625.00
50% Subjects Completed 25% $10,625.00
All Subjects Completed 25% $10,625.00
100% Subjects Case Report Forms
Completed and Submitted 15% $ 6,375.00
Final Report 10% $ 4,250.00
3. NAME AND ADDRESS OF PAYEE
-------------------------
Payment made to: Loyola University Medical Center
Dr. Patrick Stiff
Division of Hematology/Oncology
2160 South First Avenue
Cancer Center - Room 240
Maywood, IL 60153
4. TERMINATED STUDY - PAYMENT OBLIGATIONS
--------------------------------------
If either the Institution of Aastrom terminates the Study prior to its
originally planned termination date, Aastrom shall compensate the
Institution based upon the portion of the Study completed at the date of
termination. This partial payment will be prorated according to the number
of satisfactorily completed subject visits.
2