Confirmation Number:334285 Event Started: 3/16/2005

Please take your seats. We will begin what promises to be an interesting and busy day . I want to welcome everyone to the 99th RAC session. And we'll begin by the conflict of interest guidance from Dr. Amy Patterson .

Good morning. I would like to read into the record and also to refresh your memory, although we went over this yesterday, it's important to begin with it. There was a conduct and conflict of interest. Being a member of this committee makes you a special government employee, and thereby, subject to the rules of conduct. The rules and regulation are in the report called standards of conduct and you each received a copy when you were appointed to the committee. At every meeting, in addition to reminding you about the importance of following ethics rules, we like to review the steps that we take and that we ask to you take to ensure that any conflicts of interest are addressed. As you know, before every meeting, you provide us with information about your personal, your professional, and your financial interests. We use this information as the basis for assessing whether you have any real potential or apparent conflicts of interest that could compromise your ability to be objective and getting a device -- advice during committee meetings. While we weigh conflicts of interests for general matters because we believe your ability could be objective will not be affected by your interest in such matters and we rely to a great degree on you to be attentive in our meetings to the possibility that an issue will come up during a discussion that could affect or appear to affect your interest in a specific way. If this happens, we ask to you recuse yourself from the discussion and this means for us that you actually physically leave the room. You're also required to recuse yourself from the review process when you have a real or apparent conflict of interest regarding a specific protocol. And as always, if you have any questions during the meeting, please address them to me and if you have questions in the -- of rules of conduct or conflicks of interest, our committee management officers will be happy to address them as will lori LouEllen, the program assistant for the program. Thank you.


The minutes of the December 16th, 2004 RAC meeting will be reviewed by Dr. s Thomas Gelehrter and Emmett Barkley.

Once again, a wonderful review of the minutes. Dr. Barkley and I reviewed them, they're completely accurate and nicely presented and I think we have very minor type-Os we have communicated already. I would like to move.

I will second it. Thank you.

Let me move that we approve the minutes.

And we will take our first vote of the day. Dr. NEMERAL.

I.

BOHN.

I.

[ Indiscernible ]

I.

miss KWAN.

I.

[vote taken] Thank you.

Our first presentation for the day is an update on protocol 322 entitled phase I study of NGF ex vivo gene therapy for Alzheimer's disease and Dr. Mark Tuszynski from UCSD will present.

Good morning. We are ready. Thank you. No problem. We started promptly on time.

Just so you know, was up at 8:20. I should add for those of you who, in the audience and may not be Aware of this, the two updates that we're doing first this morning are presented and framed as background for our first review .

Good morning. I was decide return to the RAC to give you the results, the clinical results of our phase I ex vivo factor for Alzheimer's disease. The results of our cognizant testing and test scan studies in this nerve growth factor and clinical trial, the findings are in nature medicine and this trial was using an MLV-based vector system to transduce primary ontologist fiber glass of Alzheimer's patients and they were planted into a region of the brain to constitute an ex vivo cell source fortrophic support of degenerating neurons in Alzheimer's disease. Again, I talked about this previously so, again, right to the results after a small bit of background and, of course, I would like to acknowledge the many people who contributed to this study. So to establish the foundation of why we did this study, just to remind you that growth, the premise of growth factor therfy -- therapy for neurological disease is that these natural proteins of the brain promote the death of the responsive cells and potently augments the function of the responsive cell populations. Hence in the sense they have unprecedented potential for the treatment of progressive disorders of the nervous system, and this is the only slide I will show you as further background, but this illustrates this affect of preventing cell death. This is the adult monkey brain and these dots are the individual coloneurojij neurons which degenerate and die in Alzheimer's disease. We can -- showing here on the right side of the brain, we transject to the hippo campus. Following the ex vivo nerve growth factor delivering, there is a quite striking protection of the cells from death and potential for progressive neurological disorders. So in this clinical assessment group we're here to update you on, there were six subjects who constituted the group who all safely completed the cell injection procedure. The main age was 67 years and they all had a diagnosis of early probable Alzheimer's disease, and that were reroute -- recruited at early stages of disease to allow for informed consent, and because the earlier one intervenes in an ongoing degenerative process, the better potential for this mechanism of protect. This was the dose of escalation study. The first two zudy -- studies received on one part of the brain and the next four bilateral on escalating doses. Here are the results in the realm of cognizant function, we used two of the most none comonly used in Alzheimer's disease, a mini mental status examination, this is a 30-point scale in the mean point of our subject growth in the time of growth vector treatment was 21. Another commonly used scale in Alzheimer's strils is the scale, the cognizant subcom51ent, a 70-point scale, and I will show you now the outcome data but I will remind you we have to interpret this cautious lis -- cautiously. This was an open phase I trial with no controls or blinding. So that said, here are the actual date. -- data. These are the mean mini mental status examination scores and on this particular scale, we have preoperative data at a baseline one year before undergoing therapy. So this is the mean score in the scale of lower score indicates progression. Can you see a decline in the time before going to gene transfer and this was the rate of decline afterward. These are the mean scores for these patients and the standard areas of the mean. And another way of looking at these data are to show the, the decline rates in the one-year EPOX. This is the mean score in the column centered areas and the individual six patient data that constitutes this mean. And as can you see here, they have the mean rate of decline in the first year was six points and in the firstior after undergoing Gene delivery, one season apparent reduction and the next six to 18 months this is the overall rate of decline and then in the one- to two-year period, this is the overall rate of decline, and this different -- difference on a test of post operate testify preoperatef of this Epox happens to be significant. Again, a small cohort. Overall for the mean 2.2-year period of followup now in the study, there was a 49% reduction in the rate of decline, compared to preoperative rate and just to give you context to what this could mean if this magnitude of effect held up in subsequent trials, the currently-approved drugs for Alzheimer's disease, including the inhibitors are on the same scale of 5% persisting for three to six months. Were this to hold up, this would be a substantial difference over therapies. This is the other cognizant testing scale, the ADS COG. We don't have a declined rate on this scale, this is the data at preoperative date line and the Epox after treatment, again means and standard errors and these are the rates of decline from the time of treatment and the subsequent Epox afterward. Again, you see some suggestion, perhaps, of reduction rate of decline. Given the smaller data set and some variability, I will show you the median scores and, once again, one has a suggestion there is consistenty with the findings on the MMSC, some reduction over rate of decline over time. Now, I'll show you the imaging results of the deoxyglue close eptake as a result of the corti keys metabolic activity and the pet activity diminishes over time, as you might expect. We did pet scans in the four subjects that underwent bilateral injections and those show an increased meaning of cort key pet activity in the period following NC -- NGF activity and this is significant. This that is shown here. Hopefully the colors can be appreciated. But these are the mean pet scans of the four sents superimposed to one another. The average, the first scan and the second scan performed six to eight months lrght later. Blue is left activity, the ved the hotspots, the increased areas of activity, so, again, relative to the pre, to the first baseline, six to eight months later, you see general increases in CORTICO activity and the trophyics effect if this holds up. This is a reversal of the expected pattern of decline over time in Alzheimer's disease. So, to wrap it up, there were no adverse events related to the growth factor or to the gene delivery system in the human brain using a non-regulated vector and follow up now is four years in the first treated subject. There was a significant increase in CORTICO activity by pet scanning and cogative analysis, again, cautioning all of us this is a small unblinded non-control cohort showing the rate of decline in the extent substantially exceeding the effects. This combines the rationale for the followup drug you heard about here a year ago, using now AAV, the growth factory delivery sponsored by serogene and Dr. Raymond Bartus will give you an update on that trial. Any questions regarding this? Yes.

could you go back to your pet scan map and show us exactly where you injected the finer -- fiber glass and how that fets with the pattern you're seeing.

Sure. A level of detail that would require the -- [ Indiscernible ] Let me see ifky make this clear in a briefer answer. The cells targeted with the growth factor on a 1-centimeter region of the brain. They're deeper in the brain and send their projects throughout the cortex. They're the SOLE source for the cortex and the normal local is to modulate the excitability of systems in the cortex. They can target a small practical area and, thereby, affect their defused cortical projects. That's what we did. We targeted the growth factor in the cell bodies, these are the affects in the modulating of the cort cool -- activity. They're deep in the brain -- cortical activity. They're deep in the brain. You can't resolve them with pet scan here. They would be roughly in this area here. Okay, thank you very much.

Wait just a minute. Are there any other questions for Dr. Mark Tuszynski?

Be happy to weight as long as you want me to.

.

No, thank you very much for sharing your data with us.

You bet.

The second update, if you will Son human gene transfer protocol 623, phase I/II dose-esicate -- escalating randomized and controlled study to assess the safety and tolerability and efficacy of CERE-1110 and AAV vector-mediated delivery beta-nerve growth factor in subjects with mild to moderate Alzheimer's disease and Dr. Raymond Bartus will be here for us. Again, thank you for being here so early in the morning . --

Morning.

Morning.

Happy to present an update on CERE-110 for Alzheimer's disease. Are we ready? Okay, thank you. Sorry. Happy to present an update of CERE-110, products for Alzheimer's disease, this is a phase I dose-escalating trial conducted at Hospital. It's using AAV to delivery NGF to nucleus BACILLUS, the same thing Dr. Mark Tuszynski talked about. CERE-110 is an engine eared form of virus 2, expressing NGF protein. An open-label trial with two doses, 8 timen -- times 10 to the ninth and four times 10 to the ninth. Three subjects each. The primary purpose, of course, is to assess the safety and tolerability and a number of secondary measures exist to evaluate the efficacy activities of daily living, distribution of CERE-110 in and look at immunogenis etto human growth factor and AAV II. We have enrolled three subjects to date range of age is 64 to 73. Exposure is nearly eight months and the longest subject and nine weeks in the shorter subject. To date there have been no adverse events relate and the trial has been remarkably unevent envelope that regard. Human, HUMONOimmune response to growth factor is not detected. There was one transient, a single point detection, a low level of antibodies to AAB II, that went Away quickly at three and six months, no evidence of it and a distribution data in serum and eastern are negative. So the dose one cohort was completed, the three subjects in January started in January 11th and completed in March. We had a cumulative review of the data by the DSMB. The unanimously recommended going forward with the dose escalation. We have scheduled a second subject for April 2005. We anticipate enrollment being completed somewhere near the end of the first quarter, we're very early second quarter this year. Thank you. Any questions?

Were your subjects prescreened for antibody, were they negative at entry or not?

They were not prescreened.

So when you said the three had no AV -- AAV antibodies, in retrospect, they were CERE negative?

That's correct.

Just in terms of compareson, were the subjects about the same point clinically as the previous study was presented or how do they compare in.

The intention was to have very similar level of disease. Mild to moderate. Dr. Mark Tuszynski's trial, of course, the study requires identifying the patients enrolling them, Harvesting fiberglass and then, of course, manufacturing them to reinject so there was a delay as Dr. Mark Tuszynski showed you Dr. During the sufficienteral months to a year delay, there was a decline in the patients, or subjects, so in ours, probably less in period in the time of the -- impaired at the time of the treatment and similarly impaired at the time of the treatment and diagnosis of enrollment.

Thank you.

Dr. .

How were the results of the pet scan data from the last presenter, do you also have pet scan data or do you plan to do that?

We intend to do that when we obtain -- obdane -- obtain a longer and more meaningful time period, treatment period with the subjects. Thank you.

Other questions? Thank you very much, Dr. Raymond Bartus.

Thank you.

Going to take us one minute to organize for the beginnings of the first protocol. I want to remind everyone before you leave the room that there are a number of people in conflict with this next protocol. We will all step out. There is then a break after the first protocol at 10:20 and we're scheduled to resume at 10:35. I would like everyone who is leaving to be back by 10:30 so that we can be certain to start on time. Thank you.

The -- among those that needs to be recused for this particular protocol, ands that asked Dr. DOLUCA to chair this portion of the meeting. The people that are recused are Diane Wara, Dr. lo , employees at USCF. Dr. ZARE, Dr. ZENSKA, and -- I'll wait until they're settled here. At this point, I would like to ask for the people on the telephone line to identify yourselves.

Good morning, this is Dr. William Marks from UCSF.

Thank you.

Thank you.

Dr. Jill -- [ Indiscernible ]

Okay great.

[ Indiscernible ]

Thank you, Dr. Gage. Anyone else on the line? And one of our ad hoc reviewers, Dr. Howard Federoff will be calling in momentarily . We're going to wait about two more minutes. We're returning a little ahead of schedule, so we can get the proper people on the line. -- we're running a little ahead of schedule, so we can get the proper people on the line All right, and we would also ask Dr. Philip Johnson and Dr. Martha Bohn to read into the record before they do their reviews. Not right at this moment, but when they do their reviews, a statement of desclosure of their activities in in this arena. We'll just wait a couple more minutes. We understand that Dr. Howard Federoff, one of the ad hoc reviewers will be dialing in. I appreciate your patience. Yes, good morning.

Morning, Howard Federoff here.

Super. Thanks, Dr. Howard Federoff. Dr. DoLucca, are we ready in.

Yes. Let's begin the presentation with Dr. OSTRO.

Thank you very much, I'm Jeff OSTRO, the chief operating officer of -- chief executive officer of Ceregene and we're the sponsor of this protocol. I appreciate the RAC and the office of biotechnology activities for the logistics of this meeting, as well as the very comprehensive review of this important protocol. SeroJean -- serogene is a company involved in the the genetic therapy using growth factors for the treatment of neurodegenerative diseases that you heard about in the CERE-110 product briefly thats that in human clinical trials. We'll be hearing about CERE-120, an AAV NEURTURIN that has the ability to affect open dopamine neurons and it's used for the treatment of parkinson's disease. In terms of the order of events, we do have a number of people that will be on the telephone or on the telephone as you know from the West Coast, so it's been difficult to get everybody here logistically, but the principle investigator is Dr. William Marks who is on the telephone as we heard earlier, as well as Jill OSTRO, both neurologists at UCSF, where the trial will be held. Dr. Phil Scar, I don't know if Phil is on the phone or not at this point in time will be the primary surgeon, and Paul Larson. He's in the audience today. We appreciate that, also involved in this study. In additions that another neurosurgeon, Dr. ANDRE LAOZANO also in the odd here today and might be able to answer any questions related to this. I'm going to give this brief intrckz and then the clinical protocol will be discussed by Dr. OMANO, who is on our scientific advisory board. Warren and Bill Marks will be involved in this, and then Dr. Raymond Bartus will come up and present some extensive preclinical non-clinical data summary, specifically trying to address the points that were brought by the RAC reviewers. In additions that a number of scientific advisory board members either here in the audience as shown in the maroon or on the telephone in black who can also answer potential leany of these questions that might Arise from the committee. So, CERE-120 is an AAV type II based vector system delivering the human nurturing -- Neurturin gene, a member of the family of growth factors. The construct that we're using is similar to the construct that we used in setting up our CERE-110 program. This is a human Neurturin gene with a CAG promoter with a hune bait globin side and flanked by the AAV ITR's. So there are no AAV genes in this construct and only the ITR's are present. This is the transcript and we sequenced the NOS -- sequence of the Neurturin protein as it's secreted from cells and shown it to be an effective Neurturin protein. At serogene, we developed CPMG manufacturing procedures to produce the product. It's the same procedures that we presented last year at the RAC actually a year ago at the meeting which, involve a triple transsection method using 293 cell qualified cell bank. This is all done under GMP conditions. Produced, actually quite a large number of doses of the product. The AAV undergoes multiple calm chromotography purification steps to end up with a highly purified, highly-concentrated, formulated final vials that then go through extensive testing according to the USDA points to consider guidelines. It's a pharmaceutical-grade product that we're using and injecting into man. With this being said at any point later if we want to discuss CMC questions, we're happy to address any of those. At this point because of the time, I would like to ask Dr. Warren OLANO, the chief -- and a member of the scientific advisory board to present the protocol. Warren.

Dr. OSTRO. I will now -- thank you . Thank you very much and good morning, Ladies and gentlemen. As you have heard, my name is Warren ALANO, the head of the department of neuro neurology at mount Sinai school of medicine and head on the parkinson's disease center. My primary activities are dealing with clinical and research interests related to Parkinson's Disease, and I wanted to start by telling you a few words about this condition. There have been so many famous people that have developed parkinson's disease lately that I suspect bee watching television, you have some familiarity, but I did want to remind you it's the second commonest neurodegenrative disease in the United States, approximately 1 million people have this disease. It affects men and women, it affects people of all occupations. It's seen with an average age of onset of approximately 60 years, but it can affect young individuals as well. Classically, it's seen with the four cardinal features, which are tremor, rigidity or stiffness, slowness and trouble walking or trouble maintaining posture. And pathologically, while it has wide areas of distribution, it's characterized by a loss of DOMPAMINURGEC cells as a consequence of NIGRAL neurons which object to the STRIATUM, it's largely an attempt to restore and induce refunction in these cells the current protocol is designed. I want you all to appreciate we have good treatments for the early stages of parkinson's disease. LEVADOPA and other therapies that perhaps you're familiar with. What I want you to realize is the patients eventually reach more advanced stages of this disease, and when that happens, they begin to suffer disabilities which can't be adequately controlled with medication. Firstly, about 80% of patients develop what are called motor complications, which means that, which means that their function cycles between periods in which they respond to the drug but they have these wildest KINESIA that perhaps you have seen similar to what Michael J. Fox has shown on television and then they cycle down to periods where they can hardly respond at all and they become almost frozen look you sometimes see the Pope looking on television. For some spashts, that becomes disastrous because they never have a period of time or they men 3458 periods of time about they can function at a relatively good level. In addition, they develop features which our current treatment caents help. They develop problems with walking Wfreezing, with falling and even di -- with freezing and falling and dementia. Finally, none of the drugses that available today can slow the progression of the disease or restore function, and, that of course, is why we're so excited about this current protocol, and I would say so far that it would be virtually unanimously agreed among parkinson's disease specialist that a therapy that can restore function to parkinson's patients or prevent and slow down the rate of progression is clearly the single most unmet medical need in this disorder. Now in our current study, we will look at CER- -- CERE-120, AAV II delivery of Neurturin to assess its safety anditollerability. The study will be done as an open-label study. It will be done in a dose escalation manner, looking at two different dose levels, with six to nine patients in each dose regimen. There are two major objectives. The first is to test the safety and tolerability of these dose levels of CERE-120 or AAV Neurturin. The second is to look at the effects of this delivery on the parkinson syndrome itself, primarily using the UPDRS but also using a variety of other testing parameters and secondly, to image the NIAGRAL striatal system by looking at the pet, a standard method of looking at this system. Our primary inclusion criteria include males and females of any race, age 35 to 75 years. Patients who have advanced Parkinson's disease of at least five years duration and who can't be satisfactorily controlled with existing medication. So I want to emphasize to you the patients who will be entering this trial are patients who have been treated with medication, have enjoyed a good response to medication, but couldn't be adequately controlled despite manipulations of medication, and so they are bad when the medicine is not working. But at the same time still show a medication response so that's the type of patient that we're looking for. Not someone where there is no response to medicine, but someone where the response is good but because of complications couldn't be adequately controlled. And all patients will be on stable doses of medication for at least 30 days prior to entry into the study. The primary exclusion crier toia include not being able to give an informed consent and Atypical or secondary parkinsonism. In other words, they have to have true parkinson's disease using the united kingdom criteria. They can't have other clinically significant medical or psychiatric problems and they can't have had other serious intercraneual surgery or gene therapy. The target of our procedure will be the PUTANUM. This is the major portion of the striatum. What I want you to appreciate here is we will be using four tracts. We will make two deposits of gene vector into each of these deposits, and these have been carefully calculated so that the deposits will permit full and complete homogenous coverage of the PUTANUM. The reason we chose the PUTANUM as the major target, this is the area that is primarily depleted of dopamine in the parkinson condition. This is the region where the substangz of NIAGRAL nerve cells that in parkinson's project and this is the area primarily connected to the motor systems. In other words, this gives us the best chance of being able to restore motor function. At the same time, the PUTANUM is distant from the vent kills and, therefore, men -- the VENTRICLES and risks the contamination and vector and gene product into the CSF. The PUTANUM is relatively easy to target, ands that substantial experience with targeting this structure in in other interventional procedures such as transplantation experiments. This is a sense of how we will enroll patients in the study. Patient number one will be enrolled and followed for a nothing. After a month, the DSMB will review the safety on that patient and it's then intended that the next patient would be inrolled. After the first two patients have been enrolled, patients three and four will be enrolled coupleatively, and after another month -- couplelatively, and after another month, patients five and six. Notice that each cohort of patients is entered into the study, safety will be performed looking couplelatively at all patients before the next -- CUMATIVELY before the next patient is inrolled. There will be a pause of four to five weeks and we will begin the second cohort using a similar pattern but using the higher dose this time. The assessment times will be at screening at baseline, weekly for the first month, monthly the first three months and every three months thereafter. We will continue to follow the parts on an ongoing basis to be sure that these patients do well and if they develop side affects we're there to see them. It's our plan to evaluate side affects at every single vision using an open approach where all side affects are gathered in an open and free fashion. These will be reviewed periodically by the DSMB after each patient cohort as I have shown you, as well as by Ceregene that will continuely monitor the patients. The assessments will be performed include the safety assessments that will be a search for antibodies in each of these visits and when&we will look at parkinson's motor efficacy bee looking at motor efficacy in the standard UPMS scale, looking at the motor complications, this wearing off and diskinesia using home diaries, a world dated technique. We will evaluate cognitative function, sitting with the quality of life and seeing with measures of clinical global impression of both the patient and the physician and then finally at baseline, and at time points throughout the study, we will measure striatal fluid uptake on pet as a measure of the integrity of the NIAGRAL striatal system and an opportunity to see restoration of the system. I conclude in summary by telling you that we on the clinical side are extremely excited about this protocol, and we are extremely excited about the opportunity of gene therapy delivery of trophic factors to our patients. I want to leave with you a message that parkinson's disease patients, despite the fact that we do so well early on, suffer unacceptable disability as time goes on. They need a treatment and they need it now. The animal data that you will see I hope will convince you that this is an extremely inciting promising Avenue. I read the trials for fetal migeral transplantation for the NIH and I was the senior investigator for deep stimulation procedures which, have been approved by the FDA, and I can tell you that in my personal opinion, this is one of the most exciting opportunities for our patients and a study that I personally would be happy to recruit my own personal patients into. Thank you very much.

Thank you, Dr. ALANO. Now we'll go to Dr. Bartus .

Thank you, I'm happy to provide the non-clinical overview of the program. We believe that AAV Neurturin provides an opportunity for truly innovative therapy for this terrible, debilitating and dehumanizing disease. The reason we believe that is we're targeting the dopamine striatal neurons and they have been implicated as a key pathogenic event in the disease. We intend to provide a supply of neurotrophic vector to the neurons, which should enhance the condition and function, as well as strengthen their ability to withstand further degeneration. In principle, targeting neurotrophic factors should offer two benefits to parkinson's patients. First, it should improve the disease symptoms. Secondly, it should be -- [ Indiscernible ] The disease progress. Most experts in the field say these goals could be, it would revolutionize the treatment of parkinson's disease. That's what we hope to do at this program. We worked very hard the last few wires coming to this point and will be -- few years coming to this point and we'll be happy to review the comprehensive program that put us in place. We realize the responsibility it has and I think we'll be taking that responsibility very seriously. At first, I would like to start though by showing you some of the affects that can occur with the AAV Neurturin or CERE-120 as we call it in the company, and this is a model of parkinson's disease using MPTP, the neurotoxin that can cause parkinson's disease in humans, the gold standard for animal models of parkinson's disease, and it shows performance on a motor task that captures the essence of the deaf -- seen in human subjects. Higher scores are worse, lower scores better. Two groups of animals are ploted. One got MPTP and are treated with controlled substances in the brain rather than active CERE-120. In this formulation buffer or controlled gene. This group of animals, excuse me, got AAV Neurturin. From which can you see over time, they were balanced at beginning as a progressive, steady, substantial and persistent recovery of the performance on this parkinson's task. Now while these animals are still Alive and we haven't had the opportunity to look at their brans. One could presume the trophic responses indeed is nourishing the stra -- striatal nurons helping restore function and helping them overcome from further degeneration. We at Ceregene cam to the conclusion the company's inception the only effectef way to deliver growth factors to the central nervous system is by way of gene transfer, which we don't think there is another effect of way. You have seen some of the materials that we provided. So we have taken this challenge very seriously. We realized gene transfer has a field, has had some desappointments and taken some lumps and we recognize the responsibility to help the field go forward responsibly as well. The first thing we did was try to control the risks the subjects as, picturively as we could. So we used AAV in our turin as a gene transfer for parkinson's disease because AAV is a vector currently used in other CS trials, including AAV orange -- [ Indiscernible ] As I talked with you earlier, a parallel or negative fort of approach. Secondly, we're administering small quantities of the a vector in the transgene directly to the target. Different from a lot of the jeep transfer trials you're familiar, and fineally, we're avoiding significant systemic exposure. We don't have detection to the exposure to the transgene at all and little to the vector. On top of that, we would like to control the risks even further by stepping back and looking at the field and incorporating what we know about the field into our program. So we're leveraging much of the prior experience that exists with neurotrophic factors into the brains of animals and especially humans. We're delivering Neurturin gene, which is functionally similar to GGNF. GGNF has been well-characterized and administered to human brains for years. And finally, we put together and launched a comprehensive safety toxicology program with very high dose multiples. Looking for any problem we might see, hoping if we identified the problem it would help put us in position and we can address it in the clinic. As you see, 19 total subjects, studies. I'm sorry, 19 total subjects, studies are responsible for this program involving seven monkey studies and 12 rat studies. So, over 45 monkeys and almost 400 rats involved in three different types of studies, specifically pharmacology, efficacy, and safety toxicology. Now, I'll briefly describe what they are and the results. Pharmacology, we basically established the expression kinetics, the volume of distribution and the dosing of CERE-120. [ Indiscernible ] Of Neurturin expressed in the brain. We established that we can control the expression of the protein. It's related, define the volume of decrease and use that for future -- future studies. You will see some of the data says as we go forward. The efficacy, we established that bioactivity and efficacy and a dose response of Neurturin as administered by or delivered by CER- -- CERE-120, several rats and 1 monkey. For safety toxicology, you will see a wide safety marriage know established with this product. Several different rat studies, almost 200 rats, including 25 agent rats we put in there to ensure we were looking for potential safety problems in a more FBIel model system and four different monkey studies. The results are un, ventful in one regard. Quite promising the other. First I would like to remind you of a large dose of multiples we have tested. The efficacious dose in rats is 125 times lower than the highest toxicology dose that we test in rats. That's safe. A huge dose range and in monkeys, the safe dose is 100 and 400 times higher than the proposed human doses. We literally gave as much vector to rats and monkeys as is physical really -- physically possible, looking for side affects, toxicology, toxicity. We didn't see any. We will go more into that later. So, no one -- no adverse effects seen in body weight appearance, anything like that. They look normal. Up to 12 months in rats and eight months in monkeys at this point. No adverse effects on neurological or behavioral assessments, no functional affairments in the striatal system, looking carefully at motor-related activities, no historio pathological changes in the striatum, with the cerebrum, cerebellum, spinal cord or any prolific organ. No effects on blood chemistry or hematology. The bottom lope, there was no seen of any toxicity of any kind and a very large dose multiples over many months in rats and monkeys, involving multiple studies. So that's a brief overview of the program. I thought rather than going into more detail at this time, we received very interesting and inciteful questions from members of this committee. We have pulled seven out that we think are the most important, clearly deserve a public discussion. We're happy to have the opportunity to discuss these with you. Listed here, we'll go through them sequentially for the rest of the presentation. The first one involves questions regarding the efficacy of CERE-120. This came up in any number of ways from what were the methods, what kind of results do you get, what about Alpha 1 versus Alpha II reent isors, would it have been worthwhile to extend the pet scan imaging, a number of things like that. In the end, what is really being asked, it's a question of how certain are you this product is really doing what you hope it to do. We believe it is and we hope you agree when you see all the data. You saw this data already in the gold standard for parkinson's disease, a very effective response for the product. Agent monkeys provide another model for early parkinson's disease. This study is still inon p going. s that the three Asian monkeys we recruited in the study and they will give FLEURADOPA, using pet one, two measure, the activity in the NIAGRAL stre atum system. They're treated on the left side as you face the screen. The right side is normal and a highly statistically significant increase in fluorodeepa show we're energizing, act vite -- activating the system in the monkeys. This study is ongoing, looking forward to another scan in the future N.reality, it's the comprehensive program giving us the confidence we have an active product. We have corroborating evident for bioefficacy N.monkeys, we enhanced the striatal TH standing. We show enhanced activation of signaling, an important signaling event for trophic responses to Neurturin. In the six hydroxymodel of Parkinson's disease in a rat, we show protection and cell up to seven months of treatment, a long time in a rat's life span. Protection of a range of doses, including a fraction of doses as I said. 1, 125th of the doses efcaecious is efficacious compared to what we were shown to be save. So we have 1 -- went 125 times higher in the dose to be safe over what is necessary for efficacy. A huge dose range. Functional behavioral effects we've seen are positive. MPT monkey, antiaging monkey we talked about and the data of rats recently cam in. It's not in appendix M. We apologize for that. The hypertrophy of neurostriatal nurons, we're happy to show you the data if you're interested. So, this is CERE-120 provides clear and consistent support for the in ourons in the monkey studies, including the best models of parkinson's disease. Another question of all the kinnetsics and Neurturin, how quick is it coming on, is this a problem. We looked at this carefully. This is the so-called pharmacology studies. Several studies in rats and monkeys. I will summarize it quickly. As early as two days, the earliest time point we looked at. The approach is four weeks. As it spreads within the targeted area, it reaches the maximum of four weeks. Shows no significant increase there up to seven months. We than we can control that volume of distribution by changing the dose of CERE-120 and that no further accumulation occurs after a range of dose after a month. This product of CERE-120, Neurturin, stays in the targeted area nicely. These are the data showing the rapid onset of expression, two days after inject 120 in the rat's striatum, you show evidence of Neurturin and the staining with a rapid increase on the volume of distribution within the target. And here, after four weeks, which is when we reached absent, can you so a month, three, six, seven months, studies state levels in terms of volume and distribution. This is not spreading within the outside target or increasing in volume at all. It's reached a steady state. So the conclusions of this kinetics and human relation, the onset of nur tur sin rapid, the volume expression reaches a steady state of four weeks and shows a significant increase. No accumulation over many months over a range of doses. Legitimate concerns of possible multigrain ingredients being targeted and non-grain brain regions, something we have been Aware of since the inception of all the programs. First of all, there might be a point of confusion, grabs simmant tech. While we're giving multiple target passes, as Warren pointed out, multiple injections to target the striatum, we consider it a single site. We focus on the targ oat PUTANUM and hope to get protein to the next -- [ Indiscernible ] I would like to clarify that point regarding the multiple brain regions, a single system we're targeting with multiple needle passes, and the issue about non-targeted brain regions is an important one, one that we looked at carefully. We need to control. We have an obligation to control. I hope you see the data that convinces you as well. This is data from a monkey. This is done in Jeff's lab. Neurturin staining, chemical staining, formulation buffer, internal capsule. As we increase the dose of CERE-120, we get an increase in the volume of expression of Neurturin protein. You see how nicely it stays in the targeted area. Indeed, if we give a dose of 1.75 times 10 to 12th vector genes per hemisphere, which is, again, the most can you give physically to monkey. Took us hours to give each monkey, pushing the doses as high as we physically could could, this is what happens. You see the PUTANUM, few elsewhere. You see the MIAGRA. We want to get protein there. You see the light fuzzy signal, the globe uulous PELLETUS -- [ Indiscernible ] From the front striatum, it's not surprising that there is a signal there. Not cell bodies. It's FIBRALS and -- [ Indiscernible ] Nowhere else appreciationiaibly, so if you look at all the brain regions we carefully looked at, striatum and Niagara have the targeted protein as we would hope, shows it in the neuropils and fibers only. This area of the brain doesn't express any of the receptors necessary for transduction of Neurturin. VTA thalamus, cortex, areas that we're particularly sensitive to showed nothing, nor did the serible um, by the way, and the re -- the CEREBELLUM and the remainder of the brain and nothing at all. Better than I thought it would be. These are the data. The targeting of CERE-120 is limited to the niing aeral system and limited to the system as well. This is an issue of use of regulatable and non-regulatable vectors. We realize this is an extremely interesting active area 92 in gene transfer. Many people, and both associated with directly and indirectly associated with surgery enactive in this field, taking leading positions many people in RAC are as well. We appreciate that. We appreciate that is a lot of passion for this work in this feel. We as surge run work hard to make a decision to use a regulatable vector or not. We decided not to. I want to show you the reasons why. I hope you agree this is a responsible approach to this question. I would like to offer -- to deliver neurotrophic factors to the brain. The first important point is several human trials delivered neurotrophic factors into the central nervous system and some up to several years. The risk appeared well-characterized and related to non-target delivery, a point this sery gene intends to -- directly with sery gene transfer. I think you see it does that nicely. This is perfect for gene transfer enthusiasm is how gene transfer should be used this year. Ceregene trials proved by the rat the heart and for indications, delivered growth factors by way of non-regulatable vectors. We're doing nothing different in that regard than what has been done before. The growth factors have been delivered to the brain and heart without regulatable vectors. We're doing the same thing. Regulatable vectors have their own risks. Unnatural transscrpgz of proteins expressed without regulation and can genrate immune reaction. In fact, some people published on this in notable journals. The regulator is unrel -- unregulated. Finally, -- unknown risks are associated with the small molecule regulator. They need something else to turn the Gene on and off it's a regulator. That's a non-protein. The commercial entities we're looking closly with in terms of interactions in the future are developing new molecules can do this, and they have not been shown to be safe yet themselves. The regulator itself has its own inherent risks. Noinally, the point I have allowed to, no regulatable vector has been tested in humans and the full vector is still several years Away. That's one perspective. More specifically, with regard to AAV nur tir -- Neurturin for parkinson's disease, CERE-120 shows no toxicity or effects of poorly targeted factors in the brain. We have give know doses hundreds of times higher than those in human trial and demonstrated the expression of proteins is restricted on the stre atum as you see and no significant increase in volumeous,s -- occurs after four weeks as you have seen. No adverse effects in the CNS or systemically as you have seen. This is a very safe product and very high doses, much higher than we need to go into in humans. Again, the rat does multiple, the rat efficacious dose is shown to be safe. 250 times. I have been in drug development, research and development for 30 years and I don't know any that has, that I am personally familiar with with a dose multiple that large. s that a side affect with 250 times the efficacious dose. When you deliver it to the target, that's what is key, what we do. The rat-to-human dose multiple by waif brain wave is 50 to 200 times. It shows to be safe in a rat and it's 50 and 200 times higher than a dose we proposed in the humans by brain wave. In the monkey, that decease shown to be safe, versus the proposed human dose is 100 and 400 times higher than we need to do in humans. In conclusion,s that a wide safety margin for CERE-120 without regulation. The express of protein is controlled up to one to seven months and safe in large dose multiples. The arguments against a regulatable vepghtor -- vector in our opinion they have been established. The regular victor could increase the risk due to the more complicated first in human construct that would have to be used. Finally, no prior studies required for the reg latable vector and the CERE-120 has no reason for greater concern. Soy in conclusion, while concerns of unregulated exprgz Neurturin might seem understandable, they're not supported by the data and safety directionor the nature of the proposed protocol for the advanced patients. There was a question of rescue strategy and I think this involves confusion. We haven't seen side affects of the program. We were not sure how to address this Apend sexix perhaps it was an oversight. Of course, we fought hard about the adverse affects. Any time you do's first in human study. You have to look for the unexpected and we. Have I'm show you that in a second. We have a rescue strategy for everything that we think could potentially or hypothetically be a problem. So we took an approach to it with three different levels of analysis. The first thing in terms of addressing is possible adverse events, we carefully considered them based on the collectef past experience of growth factors, the nuances of park knowson's disease, working close with the world's authorities and a comprehensive review of the literature. We tried to imagine what sorts of things could go wrong with putting Neurturin into the brain of Parkinson's subjects. Having done that, we're providing clear information regarding all of these potential hypothetical risks of each subject by way of informed consent. Each subject is aware of all these hypothetical risk. Final, we'll monitor the subjects at ease and manage it with available therapy. I put this up briefly to show you these are some of the sources of hypotheticals. We have shown no evidence that any of these are tolikely to occur in any of our subjects, CERE 110 or 120, I'm soar. Some have been seen in other growth factors. We believe that most if not all are in the nan targeted protein and the Mannimal study -- studies show this nicely. Warren will be happy to talk with you about this in more detail. If any of these were to come up, we feel they're all pharmacologically manageable. So rescue strategies exist to deal with hypoet thatical risks of CERE-120. We have not ignored the issue, we Val -- apologize for not making that clear. There was a question of the toxicity reported with the GGNF monkey study. We have been supporting directly andp directly. Recently there has been a buzz in the scientific community and the press release involving possible toxicity&in some of the monkeys and given that Neurturin is indeed, structurally and functionally related to DDNF, it's a fair question of toask of us what. Do you think -- impacts your program. I would love the opportunity to show that. It shows what we're trying to do and what all of us here have an interest in doing with jeep transfer. The toxicity report is a focal cell lost in the serible umand a handful, -- sery bellum, three out of six, and out of 70 monkeys total, six-month high-dose treated monkeys. s that six months of the highest dose in the safety stud and in the three month recovery. They were go ofen a pump enfusing GGDF into the brain constantly and the pump was turned off. For three months after they had six months of treatment, they got nothing and then they were sacrificed. Now, information about this trial is still to prove the scientific community. We all know something about it. Some of us more than others, perhaps, but all of us, none of us have all the information because it hasn't been reviewed. We know nothing of the history of the monkeys. I haven't seen. We don't know about the surgery reports, the post operative recovery there. Is a possibility this has been raised by others, not us, that this may not be regulated to GGNF. This is post operative recovery anesthesia, the toxicity is Rems inent -- reminiscent of the iskeepec focal facts. We don't know that. This is a potential issue for the discussion today. More importantly, let's assume the link between GGNF and toxicity is proven. You look at the data, it suggests it was caused by deficiencies in the system, leakage from the system. It's stuck in the brain Permanently and you're pumping protein through the cannule and it's bound to leak through the sides, a fact. This position goes far beyond the statement. If you look at the monkeys and the mid-- and high-keys monk -- dose monkeys, reported over a year ago. If you look at them, they see clear classic changes of a more trophic factor to the meninges. Each of the monkeys, not just these monkeys here, every monkey in the mid- and high dose, had hyperplasia and sympathetic end growth. These monkeys have a system that links protein in a non-controlled fashion. There's no question about that. Confirmation on this was provided independently by don GASHOP in Kentucky, where the GGnext 23,, he showed -- GGNF, he showed in the supercortex and the CERle, -- CEREBELLUM at post-OP. The evidence and leakage and the possible toxest that might be associated with that re-enforces the improved delivery method, indeed, in the Seminole medicine nature paper a couple of years ago suggested gene therapy as an example of approved delivery method. Indeed, our data coroar -- coraabe rate that. We see no evidence of leakage or sery bellum toxicity. Following high dose. No evidence in this problem . -- an initial autopsy said from one study revealed no cerebellum toxes et. So,or -- toxicity. Our position on this most likely reflects on targeted delivery in the monkeys and other inherent limitation of the protein. This argues for not against the use of gene transfer in this application. There's a question about the rationale for our human dosing schedule. We're happy to address that as well. Warren went through this nicely. I don't need to repeat it again. I will point out two things, though. This is a cumulative review. As each patient accrues, we get more data as we go deeper into the trial, and secondly, this is a dosing schedule that is -- common to use. Similar to what we use for CERE-110. But used by many other people. This is not really novel. We believe it's appropriate for our program, though, more to the point. First of all, the purpose of the study, remember, is to look at the safety in the subjects. The volume expressed in Neurturin early has reached a steady state bee four weeks. The non-clinical package reveals a safety toxic program in high doses. We push them intentionally. We want to know what could go wrong to prepare for it. We were unable to get toxicity and doses higher than imagined we could go. That's after many months of treatment in rats and monkeys. You give these high doses, months later you don't see anything. No animal -- evidence of toxicity or evidence of greater risk over time. Also important to remember the protocol leverage decades of experience with growth factors. In the animals and humans. Some of the humans have been dosed for several years each, including with the close cousin GGNF. The close cusin to nur turen. No studies show the greatest risk for toxic effects in animals and humans including on target delivery. As we're talking about. These are within days to less than four weeks. Now, the hypoet thatical risk of Jon transfer does exist and it's uncontrolled spread. But I hopes that convinced you with the data we have given, the studies we have run, the large-dose multiples we have given there is no evidence for that and in our studies and it's unlikely to occur in the proposed human trials. So, while the dosing protoing -- protocol that we provide using one month -- I'm sorry. That's, sorry, it's bothering me. Thank you. So, the proposed dosing schedule --

Excuse me --

Generating data with 120 --

Dr. , Let me interrupt for a second. People on the telephone, somebody's listening to the webcast and it's coming through here. Now, I'll also remind you the webcast is delayed. So we're hearing the same thing over and over again. If can you turn down the volume of your, on your computer, we would appreciate it.

I apologize for that. It was really distracting me. Thank you. Synopsis of the dosing rationale is a proposed dosing schedule supported by the data generated by CERE-120 and neurotrophic factors generally. They need to find more affective treatments for advanced disease as Warren talked about and the careful safety monitoring we're to do for this protocol. These are the issues we thought were the most profound. We hope we have addressed those effect elf with the data. We would be happy to talk with you further about them. We would like to focus on the datas that generated and the issues that may still remain. There mean other questions that the RAC committee members have thats that not chose to put up on the board. We'll be happy to talk with you about those as well and we look forward to an active and object objective review in general. [ Indiscernible ]

I would like to take the opportunity to introduce Joan Samuelson. She was asked to come before you. s that donated some of our time so she can speak to you.

Thank you, Dr. Bartus. That was very clear. Thanks.

Thank you .

Hello, my Jame is Joan Samuelson. I'm a lawyer by training. -- my name is Joan Samuelson. I'm a lawyer by training. Quite a long time ago, my parkinson's disabled me from that. Fortunately, I wasable to apply my training to my current work as a patient advocate. I'm President of the parkinson's advocate network, a national voice for the parkinson's community and working in Washington in the state for research funding and changes in research policy to speed the earliest possible cure. What I wanted to do today is just be sure that you have in mind the appropriate context in making the decision that you're going to make about the, the safety of this proposed therapy. I'm not a scientist and I don't enstepped at all to try to weigh in -- intend to weigh in on the safety of this, this therapy, and I would appreciate that you need to give this serious serious consideration. But I think it's enormously important in doing that that you're thinking about the actual real life circumstances in which the patients who would be candidates for this trial are living. And so that's what I wanted to make sure I can describe to you so that you have that clearly. I have been diagnosed with parkinson's for 18 years, and so I know it intimately and I have also worked with lots of other folks in the parkinson's community, and I see what parkinson's is like when one is advanced. I am not advanced, greatful -- greatfully. Many people, most people, I think, who have had Parkinson's for 18 years post diagnosis are. I'm very lucky. My, here is a little vignette of my well. I week up this morning, essentially frozen stiff. If I were to load up on enough L-deep to prevent this the night before, I wouldn't be able to sleep. It has that side affect. So, I live with the fact that I wake up knowing that at that point I can barely move and yet takes great difficulty to reach over to get a pill, get some water and get it into my system. And then I wait. I can't really move. I can't hold a book. I can't write. I attempted this morning at the minimal, a scribble. It took this morning 65 minutes for the drug to go down through my gut up into my blood stream into the brain and what we call kick in to the point where I could get out of bed and get functioning. And that's about average. If there is still food in my system, if I'm stressed, i've I'm -- if I'm tired and other things will delay the kicking in of the drug and delay my ability to function. I am L-deepin responsive, obviously. It does work when it works. I typically have other periods during the day when it doesn't, so I struggle through those as well. I am one of the lucky ones and I am tremendously grateful For those that are not so lucky and also to patients who would be in this trial, they not only have the difficulty when the drugs report working at all, but if, even when they are working most activities of daily living aren't working very well. Patients, I don't know anyone in an advanced stage who hasn't long before lost their employment, lost their ability to drive, lost their ability to keep themselves from drooling. Lost their ability to control bladder function. Lost their ability to stick clearly enough to be under -- speak clearly enough to be understood in all situations. Independent living for someone who is advance side almost always impossible. They need help eating, dressing, getting around. People in that state are really very much prisoners of their homes in most situations. I think there is often a missed impression about Parkinson's. Because you see us, the public sees us when we're on. We can't get out of our houses or we don't want to because life is so difficult when the drugs aren't working. And for the advanced patient that is usually the case. Those who just have direct effects added on top of the affects of chronic L-dopea use and the combination of drugs that need to try to ramp up the efficacy of L-dopplera when it's not working. Those are, I described, sleep disruptions. I don't know anyone who is advanced and most people aren't advanced yet. Who doesn't suffer chronic problems with sleep, unable to sleep at night and unable to stay Awake and think clearly during the day. Chronic L-dopea causes hallucinations, mood and cognitive problems, and then we add on top of that, when you add a combination of other medications to increase the efficacy of L-dopea, or to address the complications, that it's really a pretty chaotic combination of side effects. So in the late stages, prisoners, parkinson's patients at that point, are really prisoners of their bodies, unable to move and often upably to speak. So I would just like for to you keep this in mind. There is an urgent need and the words found me when I tried to really convey how urgent the need is. There is an incredibly urgent need to quickly, as soon as is possible, tomorrow, to get an effective therapy for parkinson's. Please don't assume that the patients who would be candidates for this trial are doing well in almost any respect. Please don't make a decision about risks and benefits in a vacuum. This is not a risk mutual environment that those patients are looking at, and please don't protect us from this risk inappropriately. There are many risks that patients who would enroll, would happily accept in exchange for the possible benefits on the outside. Please think about all of this as you make your decision. Thank you.

Thank you very much. Luckily we started early, so we have enough time for a very thoughtful and very rigorous review. What I would like to do now is begin the review, have the individual RAC reviewers summarize their concerns for the record. If and how the participants in this protocol have addressed their concerns and then also summarize any remaining or additional concerns they may have. So, what we'll do is we'll start with Dr. Martha Bohn and before Dr. Martha Bohn starts, she has a statement to read into the record .

So before I, is this on? Before I begone my review, I would like to make a desclose ear. Academically, one of my research interests relates to the development of regulated vectors for parkinson's disease, and I am participating in the large multicenter, multidisciplinary program funded by NIH's national institute of neurological disorders and stroke. That is working on a coordinated program of basic research, preclinical evaluation and ultimately clinical testing in gene therapy for parkinson's disease. Dr. Howard Federoff is the principle investigator of this cooperative agreement . So, first I would like to thank the members of the Ceregene financial a -- family for their very interesting and informative presentations, as well as Joan Samuelson for her cogent remarks about this disease and all her hard work in advocating parkinson's disease research. I certainly, and I am sure everyone in this room would like to see a neuroprotective strategy for this devastating disease. It's an exciting protocol and I have long worked in, I've long been an advocate for neurotrophic factor gene therapy. The investigators provided abundant data. The reviews were quite long. The responses to the reviews, I believe, was 56 pages. Many of the points were addressed in the presentations this morning so I would like to just focus on some of the points of my review that I feel strongly about. There is no doubt we need a good therapy for late stage, mid- to late-stage parkinson's, and this protocol is the first trial using a secreted growth factor for parkinson's disease. This is still a major departure from all previous jeep therapy trials in the CNS; there are two gene therapy protocols, both using AAV vectors for parkinson's disease, one is using GLUTAMIC acid decar box Ellisa, the other amino acid DEBARCOACYLASE, they use strategies or ways to remove the gene expression in both protocols. The data on the Alzheimer's trial is very interesting. I believe the course of that disease is different from packinson's, although they're both devastating and the nerve growth factor gene is the into one small brain area with supporting data on the, from the ex vivo trials. I believe it adds also different. I find this presents an ethical issue of whether putting a gene into the brain that is likely to be there for man years for a secreted factor, I believe it can be done as long as all of the safety and efficacy studies are in place. It should be noted that all the scientific community also had very secure abundant data showing efficacy and safety for field transplantation in parkinson's disease. The human trials were ceased due to unexpected diskinesia's that developed in some patients, which had not been protected by the animal studies. The response, as you heard this morning, that Ceregene has presented Abundant efficacy and safety data for the Neurturin gene therapy approach in rats and monkeys and if side affects develop, they're ready to use medical means to treat these affects. They suggest a number of hypoet thatical side affects that meet occur based on previous trials with the related protein GGNF, however, one can't fully press secretary these possible side affects. Therefore, in the absence of a rescue strategy, one has to be fully confident about the safety and efficacy data in the clinical designs. So let's examine those data. I believe the toxicology safety data are really admerable. Compared to other protocols we have reviewed, I think you have provided a tremendous amount of toxicology data that looked very encourages. The efficacy data I have more of a problem. It should be noted I did not receive all the details on the experimental paradigms until yesterday evening. I didn't know I had requested those details. This made yet somewhat difficult to fully evaluate the efficacy data but what I find is not totally convincing to me if we look at the rat, the two rot rat models, one is the rat protective model where the AAV Neurturin vector was put into rat striateum two weeks before six hydroxyadults lesion. There is clearly significant protection, and I don't think any of us doubt that nur tursen a dopea MINERGIC trophic factor. On the other hand, I'm not sure how well -- that relates to the crinical protocol because this is not a damaged system. And the question would be if you put the Neurturin gene in the rat model after the hydroxy dopea mean lesion, would putting it in the striatum be effective and I suspect it wouldn't be, but that experiment's not been done. I think you would probably have to put it in the Niagara to protect the neurons if you put it in after the six hydroxy dopeamine. Then there is the agent rat model, which interestingly, the surgeon investigators used for toxicology studies and they reported there was, so they put the GGNF vector in unilaterally into the agent rat striatum. It reported there was no affect on dopeamine neurons or on behavior in these rats and that, therefore, the vector was safe. On the other hand, I believe they should have seen a unilateral affect of the vector on the -- on the dopeamine system. If putting the gene into a degenerating dopea mean system in the center atum is effective, when Dr. Bartus presented, he mentioned some data that was not in the protocol showing hypertrophy of dopeamine neurons in the agent rat, and it would be nice to see those data because I think they're very important . Then the very efficacious data shown in the MPTP monkey model, as I understand it, the vector was put into the PUTANUM CAUDATE and importantly substantium -- and they saw a radiance course in these monkeys. I have a problem with that protocol also and how it relates to the clinical protocol because the vector was put into neingra. It won't be put into neingra in the humans and no one knows whether in this MPTP model it would work. Just putting it in the sights to be used clinically. Therefore, I don't think that model reflects the clinical protocol and I would like to see data in an MPTP monkey model that parallel the clinical approach. So for the efficacy studies in my mind, this leaves the aging monkey model which, is really a very good model. You have degeneration of the adult dopplera mean system. The -- dopamine system. The doctor showed the GDNF delivery can reduce that system in the aging monkey model. And in their study, they put the vector into the PUTANUM and caughtate, which, let me -- CAUDATE. Let me ask you a question. In the clinical protocol and the abstract of this protocol, it's stated that the four sites to be injected are three in, two in the posterior PUTAnext, M, one in the anterior and one in the CAUDAT,. In the response to the reviewers and also we heard this morning, all the sites will be in PUTANUM. I would like to know if that's a change in the protocol or if that, what is going on there. But any case, similar to what is proposed in the clinical protocol, the Viktor and the agent monkeys was put into the CAUDATE and PUTANUM and pet data show it three months, an increase in the range of about 20%. The investigators say that is significant to be less than 0.001. I think they should look at those numbers again. I don't think they're significant. But I am willing to be convinced but I don't think they're significant. The reviewers requested longer-term data in the monkeys. I think it's an important model there. Is only three monkeys. The investigators stated it would be too stressful for the monkeys to travel Across state lines for more pet image. I think it's probably -- it might be more important for long-term data in non-human primates than to undertake a trial in humans prematurely. In summary, as this section, the efficacy data leaves some questions in my mind about proceeding with the clinical trials, especially in the absence of any way to remove the gene. The next thing that I would like to discuss is the eight sites to be targetetted. Again, this is a question in my mind of what the sites are really going to be. And I think, I was concerned about the distribution of Neurturin and inappropriate targeting, I think, the data has shown support that this might be minimal. It was not clear to me how many sites were injected with the vector in the monkeys where this distribution study was done. I also think it might be aggressive surgically to do eight needle tracks in, in this trial and suggest this might be designed more as a phase I/II, than a phase I safety study. I had questions, as well as I know Dr. Howard Federoff had questions on the rationale for Neurturin and what receptors it would be acting through. The response is it's probably acting through the preferred GGNF respet -- resupportor, GGRF Alpha I. That's probably the case. I asked for levels of Neurturin protein and whether it accumulates over time. I believe the response to on that was adjat -- adequate. And then I had questions on the, using the pro-NGF sequence before Neurturin and whether there is any pro-Neurturin detectable and whether it might have a separate biological affect. I think the investigators misunderstood that I was suggesting this meet work through the soil and P-75 receptor system. I don't think that would be the case since nur tur sin not known to bend to P-75. On the other hand, there mean some unknown actions biological affect of this promolecule, for example, made it through some interaction of the receptor with GFR Alpha's. I think at the very least, they need to look at levels of different forms of Neurturin following the injection of the vector into the CNF. The other points in my review, which I believe were adequately addressed were the criteria for adding additional subjects to cohorts. Description of what will be done with autopsy material. Relationship of pre, human antibodies to AAV and vector activity and appearance of vector DNA and cerebellum and lymph nodes in the actions of expression which seemed a bit strange. In summary, the clinical design is aggressive. The efficacy data leave open some questions and relevance to the actual clinical protocol or, and the disease stage that will be targeted in the subjects. My recommendations would be to consider fewer injection sites, to consider longer intervals between cohorts and since 28 days might be minimal, I understand that's where you you get steady state levels of the trophic vector, but if one gets untoured, unexpected side acts of this G gene expression, yet may take longer to detect those, see those in subjects. To provide long-term compelling data in monkey, an agent monkey or the MPT monkey model for which vector epjection sites directly parallel those to be used in the clinical trial to determine the different levels of species in the vector and CNS, to clarify the sites that will be used in the clinical trial and to submit data, hivet logical data supporting the -- histological data supporting the contension that the vector does induce a rejuvenation of the dopamine system in the agent rat model.

Thank you, Dr. Martha Bohn. Would someone from the team like to address some of the remaining questions, and I will summarize the major ones and, Dr. Martha Bohn, can you add to that if you like. The major question was that regarding efficacy, it was noted in the MPP model, it was injected into the Niagara, may be you want to discuss the relevance of that with respect to the trial. And if you intend to do studies that more closely parallel the clinical approach. There were questions regarding the significance of the 20% effect in the pet data. It was noted that, there was a question about where will the sites of, the sites of Enooklation in the clinical trial be -- of inoculation in the clinical trial be. The need to do longer-term studies in non-human primates, the questions regarding the distribution of Neurturin. Discuss the risks of eight needle tracks and consider longer-term intervals between cohorts. If I left any of them out, bring them up as they go along.

just the agent rat data.

the agent rat data.

Whether, whether in the agent rat the dopamine system wasoff 98d unilaterally.

Okay. -- was -- was rejuvenated.

We need to address the questions. Do so. [ Indiscernible ]

We're does Going to discuss it and at the end, formulate recommendations. These may not end up in the recommendations.

Help me go through them. First of all, we apologize for two things. One, lack of information. We were not clear on what detail the reviewer is looking for in terms of the methods, of the six hydroxydopamine MPT study. There was a lot of travel going. We got that late. I hope we got it in time. We have to give you more details about that if we wish. We would also like to, this needs to be inlocked. Thank you. We have will be happy to show you the more reTrent -- recent data by the agent rat. Let me start wheel you're setting up the computer. You raised an important point of the use of animal models for the product of human use. This is something we could talk about for a long time. I have been involved in this in my career for 30 years. I think it's important, first of all, to have a respect -- perspective on what we're trying to do. We're trying to treat parkinson's subjects to develop a product for parkinson's patients. These patients, of course Va disease in microstriatal systems involving different positions from neurons that are dead and can't be rejuvenated there. Is nothing we can do to save those, to neurons on the way to death, and growth factors, of course, can, by the way of animal studies and human studies, reoff 98 some of the nurons rejuvenate history neuron -- nearons. Neurons that are impaired and some that can't be affected by the disease at all. We believe three out of four of the neurons just describe are appropriate targets for Neurturin that can be regenerated. It's important. Hope the audience holds on to that. With regard to animal models, it's true to say it, but it runs to the core of what we're talking about at this point. It's impossible to mimic every aspect of a human disease with any animal model. Dr. Martha Bohn has asked for an example we have in a paradeem with the six hydroxy dopamine model, a sledgehammer to the to treat after the effect. If we got a positive act, that would be wonderful. If we didn't, did does that mean this drug wouldn't work in of course not. That model is nowhere mimicking the pathology that occurs in parkinson's patients. It occurs in a matter of hours to days as opposed to months and years. It destroys neurons very quickly. Almost uniformally intoday is of progress elf and hit and miss. So mimicking that at all. When you talk about a growth factor intended to rejuvenate nurons, that's a key point. I could go on about MPTP, monkey agents, I won't. I will say the following: What we do with animal model when is we're zep developing drugs to put into mines when they're approved is activity the principle will this in fact work. Is there sufficient specific evidence to suggest that this, in fact, could be useful N.this case, could be revolutionary for the treatment of parkinson's patients. Martha Bohn made a key point and she was reading from her notes. I hope this is agreeing with what you're saying. None of us doubt nur tur sin appropriate factor for Niagara striatal nurons. That says it all. If you believe that the degeneration of neingra tree is atal neurons is a key pathogenic for parkinson's disease and if you believe nur tur sin a key for these neurons, that is scientific evidence to justify the potential efficacy of the treatment in mines. We have done more than that. I hope you acknowledge that. We could talk back and forth about the -- [ Indiscernible ] And models epTerpitation on data. It really doesn't matter. The data collectively overwhelmingly shows a bioactivity of the AAV Neurturin in a number of rat and monkey model systems. There is no question on that. I hope that's the case and I would love to talk about that point specifically if, in fact, it's a question. The point is you have sufficient specific evidence. The question now is: Is it appropriate going forward? Are we putting parts or subjects in this case, at updo risk to treat this? So, we have this, I would like to show the agent data. I am going to need help to -- exactly where this is. The point is from is not a single system we looked at, rats or monkeys, the way we set up the system that we didn't have positive affects. We set up the system in the most conventional ways . -- the point is that no matter what system we use, we have positive acts. We didn't condrive the system. The MPTP model was used exactly as it was published for lengthy GGNF. We mimicked that system. That was the validated model. We have the deep discussions with the agents of the FDA about what model should be used. They said validate a model. Don't get a new model if you're trying to prove the principle that your product could work on parkinson's parts. We used the model as it was published. We're using the model as is typically used. We're not trying to recover dead neurons and a frank Acute degenerative condition. We're trying to show we can provide trophyim -- trophic support for the neurons to generate . This is one of the slides I wanted to show you. This has to do with the differences --

excuse me, you have to speak into the microphone.

Sorry. This has to do with theative reps of the protocol and what has gone on with the past. Martha Bohn raises valid destensions. One of them is there is a rescue therapy for all the other protocols. That's something, frankly, we don't think that is practical and I would like perhaps neurosurgeons in the audience to address that specific issue is how well prior trials could have, in fact, removed the transduced cells. The second distinction Dr. Martha Bohn makes with CERE-110, the RAC approved last year, the similar dose protocol, this time, it was far, far less safety and efficacy data. The A-was that whole this is a small new low -- the argument was that while this was a small newly -- nucleus in the brain, this is a small victor. We have shown the exprelgz -- expression of nurin very actively with this product. We don't get targeted factor. Three decades of data show that if you keep the targeted area, you don't hit problems. We looked at point 0, ground 0. There is no degeneration in the neurons where we put the vector. We have no levels what's idea what the levels of protein are. They have to be sky-high. No problem there. Untargeted delivery is the problem. Yes, we're given more vector. It's a larger target and we're controlling the protein to stay in the target. More importantly is the data on the slide. The top half is CERE-110. The program that RAC approved last year and I share with you data from thend of our uneventful first quarter. This shows the high of the safety monkey dose we test side four too times 10 to the 10th vector of the genes hemisphere. The vect on -- we complete side four times 10 to the 10th. Using brain weight as a multiple for comparison, the monkey-to-human dose multiples is 53 and two and 63 times. What that mopes is we gave to the monkey and to be safe, doses that were 53 and two and 63 times higher than the two doses that were approved for CERE-110.

Dr. Bartus.

Yes.

When you say high, monkey high safe dose, that means that's the highest you have gone. That doesn't mean if you use more it's toxic, is that correct in yo That's exactly correct. Thank you for clarifying it that. We have seen the toxicity in another of our products, this is high end tested. The high safe dose of monkeys is as high as can you go. It's impossible to safely administer more volume, more vector genomes given the concentration than we did in more sites. We load -- we loaded the brain up. To answer Martha Bohn's question, you saw with the deliver, this is Viktor was with multiple injection in the PUTANUM. That was a safety TOX study. An added, high-dose, again, looking for safety problems that might occur and didn't occur. This dose in monkeys compares to the proposed doses in humans by one to 400 times. So, yes, you're right. It's largering -- larger target. We control the protein. We're getting hier-vector genomes. We accounted for that and went up higher, almost twice as high as what we did for CERE-110. We think that adequately accounts for the problem. We are as responsible about this as we, the RAC is, and we believe that we have done everything that can be done to address the issue. [ Indiscernible ]

Dr. Bartus.

Yes.

One, let me sort of refocus, I guess, the initial question. Maybe in a different way. Where, in this trial, where will the clinical inoculation be and what regions of the brain.

Thank you, that's an excellent point. We had considered the CAUDATE PUTANUM. One in the CAUDATE, three in the PU, -- PUTANUM. We had stated a vector genome dose. We set the parameters based on our comprehensive safety TOX program believing that we could justify that. In fact, we feel we have. As we refined the protocol further, we elected to focus on the PUTAnext, M, the antearior post Cu -- PUTANUM and not CAUDATE the targ.

The. Okay, therefore, have you done the MPTP monkey studies and the agent monkey studies by inject into this PUTAnext mu, in.

We have. Several rein reasons for that. That monkey model we use is a standard parameters used for testing drugs and for parkinson's disease. They were simply used in the Val dated model. Secondly, MPTP destroys both components and it would not be a fair test or developed test of the product in that regard. Again, we're not using that monkey model to determine whether or not our drug is going to work in parkinson's subjects. The only way we're going to know if our drug works is to dose parkinson's subjects. We're using that model to test the principle. Can we demonstrate the Neurturin delivered a AAV II into the monkey brain can do what we want it to do to degenerating neingra striatal nurons. That's the key point. Have we demonstrated the principle that Neurturin can do what we wanted to do when delivered eye AAV II. We saw it with agent monkeys and rats, with MPTP monkeys and young monkeyses.

can I make a couple of comments.

Sure.

I think the Princible is whether delivering the gene to the terminals remaining in the parkinson's patients is going to be effect of. And, therefore, and you talked about a gold standard model. Yet, MPTP and one of the reasons I ask kept requesting data on how the MPTP was administered is there is a variety of MPTP models in montho. And it's possible to model the monkey with MPTP so that you have a stable chronic lesion with fibers remaining in PUTANUM that would mimic the clinical state of the patient group that you plan to target.

Let me just address it. That is a key point. I agree with that 100%. If we don't have -- didn't have trophic support in the nur opposite, I'm not sure the specific basis of the program would be sufficient to go forward. We showed the following N.yong monkeys given our product, we showed not only enhanced TH in the Niagara, but Pradio in the Niagara. We showed the cells in the Sdopamine model. We have shown agent monkeys with an uptake.

shown, in fact, we get protein there. The protein is there. You have seen the signals itself. You said yourself that nur tur sin a trophic factor for the neurons. You're right. We set that for ourselves. We needed to see evident we are getting proteins and seeing the biolongic response. We satsified the important criteria. Trying to refine the models that mimic the nuances of parkinson's disease is something that is potential -- potentially interesting, useful on the road, it's possible to do to everyone's satisfaction. We believe we can approach the appropriate way.

Let me, one second, Warren. These are the data, Dr. Martha Bohn. It was not fair to talk about them without showing you. We had no way to show that. These are recent data. This is just looking at blinded analysis of Niagara neurons looking at the TH and the uninjected side and injected side of agent rats. Can you see a 15 to 20% increase in the size of the neurons, the neurotrophic factor. You typically get them in the studies and the highly reliable phenomenon.

Is the report in your response to the reviews stated there was no change in the TH or V-met staining of fibers in the striatum. Does that still hold up in.

Yes, that still holds. Yes. Yes. No change in numbers as well. One other point in that before I provide more crenically-related points. There was one think this I believe was misspoken. We didn't mean to say there were no acts on dopamine neurons in agent rats. We didn't look into them recently. What we said was there was no effects on motor performance. We, frankly, didn't expect an effect. We used it as the toxic models. We were interested in patient safety. The concern, of course, was GDNF was reported doing a number of things in the Niagara stri atal system. We believed they were compensitory, not toxic. We believed if they were toxic, they would be worse and they were not. If we had shown the agent rats with L-dope AI believe we would have gotten behavior because the effect on one side. The fact that we didn't get it to behave spoon tappeously, as I think you know, doesn't demonstrate a lack of trophic response. It was not a good test of it. That was not a purpose of the study, this was part of a pre-laid plan associated with the FDA. Nothing we're doing post-HOC. This wasp tended to be an agent.

yes.

Dr. Bartus.

Yes.

we have three other reviewers. Perhaps the issues will commune with other reviewers. There are a couple of remaining things from Dr. Martha Bohn. One is the risk of eight needle tracks and the consideration of longer-tomorrow intervals between cohorts.

So, I'll briefly make a couple of clinical comments. First of all with respect to the CAUDATE, the anterior PUTANUM is embryo logically and functionally similar to the CAUDATE by using the anterior PUTAUM and not go to CAUDAte,. We can get higher dose into the region and risk getting into the vent kills and we're capturing the same system in the same degrees. We're capturing here And the transplant data that can you still see effects into the CAUDATE. To me it's a judgment call and I didn't know there was a right or wrong answer. I think we went through the same discussion with our fetal transplant studies and ended up with the same kinds of conclusions. The second thing I wanted to mention and Andre can say the same sort of thing is we routinely implanted eight needle tracks per side, per side in our fetal neingeral transplant studies without a single side affect or complication using the similar kind of protocol to a similar sort of target. And for deep stimulation, we routinely use five needle tracks per side and rarely have a complication and Andre can confirm that from his point of view. I just wanted to mention a word about the diskinesia we saw in our transplant patients. As we have gone back and looked at those and gathered more information in the hist tearia of that -- the hysteria has passed, what it looks like, we're now publishing is that these are turning up to be DYPHASIC, occurs with the low level the dopea men everyone,ic agent. We didn't anticipate that because we didn't anticipate we would deliver a low lovely of dopea men everyone,ic agent. We should have anticipated that. That's been seen with infusion. I think there is a good chance we request with get around that. An important problem is had we not done this in parkin sewn's patients, we never would have known about this. had there is no way to effect elf model this in animals. I don't think they get that type of diskinesia. I want to make the point that there is only a limit to how much safety can you do in an animal model that ultimately you have to take it to the disease if you're ever going to really know what to expect in the disease.

I'm going to address that. A professor of neurosurgery in Toronto and President of surgery in the -- [ Indiscernible ] Functional surgery. I represent 400 neurosurgeons that do these types of procedures. Indeed, there has been 30,000 operations for parkin sewn's disease using deep brain stem lesion and many groups use multiple tracks, five per hemisphere. This is really a standard. Furthermore, the targets chosen in this nucleus probably have an increased risk in comparison to the PUTANUM. I think that both in experimental studies in the past involving fetal niingeral transplants, the cells and clinical usage, there are many nurtured in thousands of parts that have had in access -- excess of four tracks per hemisphere. I think this is really the standard of our practice as it is today.

My name is Jeff chord overa, a professor of science at Rush university center and I performed the monkey studies shown here today. I wanted to address Dr. Martha Bohn's comments briefly. [ Indiscernible ] There is about a 55 to 60% loss in the parts of packinson's disease in the stage you see here. You often see quotes there is a loss of 80% of the neurons and parkin sewn's disease. That's not true. The loss of 80% striatal -- [ Indiscernible ] But in terms of the cells, that's about a of to 60% cell loss. Dr. Martha Bohn is correct. There are a number of ways to administer MPTP. In in my way, there is no way to administer to get a 60% loss and have stable deficits. Can you drive the cell death, can you inject the artery on one side and lose 90% of the neurons and go of a partial on the other side. That thadoesn't model what we're doing in our patients what. We try to do and we want to make this clear, the purpose of the studies is not to necessarily model what we're giving our parts, but to prove to two points. One is can we provide neuroprotection for the cells and can we augment the cells. What we did is reused the model we published with lengthy GDF and -- [ Indiscernible ] Finance in the year 2000 where we did a neuroprotection model. We did MPTP, waited five days and we know there was extensive striatal degeneration occurring and trying to protect against that. That was one of our goals. We wereable to show profound protection and as a side point, this panel was approved, the protocol of AAV and I did both study as well. The level of new protection in this study to have a level of efficacy shown in that study. The other thing we attempted to do was show them we can invigorate agent cells, which might be now to the model that took patients during the study and it shows that as well. So, I disagree, Dr. Martha Bohn, that we can provide an accurate model of advanced parkinson's disease that truly mimecs the status of the Niagara striatal system in GDF -- GDP. We can create for the deficits, not necessarily modeling. We can find the protection and provide extensive upregulation of dopea men everyone,ic. They're our goals from the -- dopeaMINERGIC. Those are our goals from the beginning and we will achieve theme them.

Dr. Abop, you have comment?

I think it was unfortunate that Niagara was put in the experiments. I think the aging monkey is the best, the close of the model.

Let me just address that point quickly. Certainly the rat data shows can you put in the striatum and get neuroprotection andingmentation of stri atal function. As you might suspect, a long and hard conversation of the actual design here should be going to the Niagara, shouldn't we go into the niingra. The issue is we're not going into parkinson's. We're dealing with a vector that has a ramp-up time.

I'm sorry, we'll save this for the discussion. We're going have to move on to the next reviewer. Dr. Howard Federoff. Are you on the line?

I'm still here.

Okay, so are we. All right, do you want to summarize your review and tell us how the investigators -- review and if you have any remaining concerns.

Yes, I might note that I have been having some difficulty hearing those at the podium, so if it would be possible when they reploy to some of the points that I make if they could speak more loudly, I would greatly appreciate it. Let me first start off by thanking Dr. s OSTRO, ALANO, Bartus, and -- I think the review of this protocol is extremely important because it characterizes in my estimation a landmark protocol and that is providing the -- unprecedented and providing an opportunity to evaluate the unrestrained production of bioactive molecule and neurotrophic factor Neurturin on the Niagara striatal system on patients with parkinson's disease. I found that the response to my questions and I'll try to be brief here, are largely well-addressed, however, I will make thought of -- note of those I thought required further elaboration and underscore in the rare case where the response I thought was inadequate. The first of my issues really pertain to an understanding of the potential toxicity that could be associated with the delivery of Neurturin by the recombinant AGE transfer. The first three address the fact that the investigators have made a chimeric protein probably to enhance the processing of Neurturin, which in the environment they wanted to know first whether there was indeed evidence for any response to that novel EPITOPE created by thefusion of the sequence of the nerve growth to that of Neurturin. Their argument was that given the sensitivity of the assays for Neurturin antibody detection being what that were and the absence of any data pertinent to that, they didn't feel it was necessary to characterize the potential hypothetical response. It still remains an unaddressed question. I think from looking at the data that they have provided, it would appear the ability to detect antibodies to nur tur sin not terribly sensitive and I just leave that as an inaddressed issue and may well become relevant should this protocol move into a clinical stage. The second was partly addressed and I think also brought up by Dr. Abop, and that is whether the pro -- by Dr. Aborntion and that is whether the proteins, if it's indeed -- epdeed secreted and process, although they mention that the vast majority, I think, was the terminology used in the culture studies which the recombinant AAV-carrying Neurturin was studied, was, in fact, mature Neurturin, I was interested in knowing whether that was true in the central nervous system and knowing particularly whether the protein that mean released from the transduced nurons was, in fact, exclusively mature Neurturin or perhaps could, in fact, have the appended pro sequence in incomplete processing. That point, whole addressed until cultural, the data I requested by western bloght wasn't presented still re -- bloght, wasn't is any asked and still remains an issue. On the scale of things, it's a relatively minor one at that. I was also interested in several other issues that were pertaining to the likelihood of having responsiveness in parkinson's patients that at later statements. And I asked whether there were information pursuant to the ent isors in this case, likely to be the GFR Alpha I receptor resident within remaining Niagara striatal dopeaMINERGIC neurons in the parkinsonian brain, and I think the data are not yet available. It would be quite useful because it addresses the potential clinical utility of the approach, and while the point was made that this was true in other diseases such as Alzheimer's disease, that is a very different disease entitty, and although it may be correct that one can extraf -- extrap late the absence of data makes that relative issue to me at present inknown. I had asked a variety of questions regarding the sensitivity of the detection of the conveyance of the CERE-120 outside of the nervous system because there was evidence there were vector genomes and the data that was brought back in response to my question was that there were, there was no evidence for messenger RNA detect -- detect, and I don't know what the absolute level of detection, the way the data were express side on a basis that I am not quite familiar, so in terms of absolute numbers of molecules, I really still don't understand whether we know the lower eliminate of sensitivity with the methodology that they proposed, but given the data that they did propose at that level of sensitivity, um, there was no detectable message, so the concern that was raised regard to potential lymph node or SPLENEC content of message in the opportunity for expression and maybe antigen presentation was addressed in that matter. I asked about antibodies that covered that before and I think that that was also raised in another question of mine. Now, the last point that I would like to make, and I think that this is one that has been danced around in a number of the discussions that followed Dr. Martha Bohn's review as a protocol, and may be if I could draw a slightly finer point on it, I will attempt to. The question as I see it really relates to the utility of the non-clinical animal models to predict response in parkinson's disease, and from a bioactive perspective, the point that has been made is that the models are not, two models of parkinson's disease, but rather could be used to look for bioactivity of the expressed secreted Neurturin. I think that that probably is the best that one can hope for given the limits of current parkinsonian animal modeling. However, I think it's in that same regard, relevant to make two additional points, and I would like the one or several of the presenters to address this in a traditional pharmacological setting it's not peacock setting one is concerned about, but the chronicity of the bioactive molecule, whether it be in this case a protein or polypeptide versus a smal mol -- versus a small molecule, and I think one of the issues that Dr. Bartus was trying to address was the lack of need for being able to rescue or to extension wish the expression of the transgene once it's in residence. To my way of thinking, there is no current data presented by this group or others that really addresses the longer-term toxicity that meet accrue from the cumulated and persistent bioactivity of this molecule. Now, the data that they have collected to date would suggest that within the limits of its current presentation that there is, indeed, no overtoxicity. I remind you again that the parkinson's brain is different than the animal model brain. And I, I think the point that I was trying to raise with regard to the immunogenicities to brain inflammation. The last point that I would like to make in that regard is to ask whether the reviewers could tell us about their understanding of whether the unrestrained production of nur tur sin likely to contribute in any way to promoting inflammation. If so, did they believe that any of the modeling they have done, which they have admit side not truly modeling of parkinson's disease is going to be prckive to be copfeddent if they can't turn off the Gene, they won't create a pro inflammatory environment. Thank you .

Thank you, Dr. Howard Federoff. Would someone from the team like to address Dr. Howard Federoff's concern regarding the possibility that accumulated NTM would cause toxicity or inflammation .

Thank you, thank you, Dr. Howard Federoff for your invith -- epsightful comments. We appreciate your perspective that there is no perfect way to model parkinson's disease. All one can do is set up models to look at the bioactivity. We appreciate the effect that there is a no you in CNS. Different from the no view of models. That's why we have used agent rats and monkeys in part, except part of that because ageing is a risk factor for parkinson's disease. We're also aware the neurotoxit -- toxicity and MPTP produce a bit of an inflamitory action, that show the inflammatory newU in the brains.

Excuse me, Dr. Bartus.

Yes.

Dr. Howard Federoff, can you hear Dr. Bartus in.

I'm struggling to hear him. The last bit of that, I didn't hear. If it were at all possible, if he could speak slightly louder, I would appreciate it.

Okay, we're solving the problem. I have changed microphones. I won't repeat everything, of course, Dr. Howard Federoff, but I will say that we understand that, and appreciate your comments that it's impossible to monitor of course in the parkinson's brain with animals and we need to strive to do that as well as we can. We do that by using a collection of models, including agent rats and agent monkeys that have the character of thic age-related changes, since ageing is an important risk factor for parkinson's disease and parkinson's patients are agent, and recognizing that MPTP and six hydroxydopamine in the rat and monkey respectively that may mimic part of the inflamitory new you characteristic with the parkinson's brain. There were two points you raised in that regard. The first is the spread of protein and the long-term consequences and the coreulary that was whether or not -- [ Indiscernible ] The reaction to long-term Neurturin expression. I can say I hope you'reable to see this, the data we presented today. I assume you saw everything.

I did see it.

Great. You saw how nicely we can control the spread of protein. The interesting thing is those data showed reasonable correspondness from rat to monkey, independent of the six hydroxydeepa -- dopamine. Independent MPTP, from rats to manchy -- monkeys. But normal healthy monkeys. The point is we do capture a rainfall of CNS -- with the various model systems and we see comparable expression and spread of protein. So, that gives us some copfiddept -- confidence, at least, although we can't predict with great certainty that the spread of protein will be the same in parkinson's disease patients, we can presume that it should be similar to what we have been seeing. No data suggests otherwise. We have seen absolutely no problems from long-term expression of Neurturin and in rats, we have looked at a six-month time point and a dose of hundreds of times higher than required by efficacy in brain wave in humans. No consequences at all. Importantly as you look at the gradient from where you inject the vector, it's ground zero to use the local term these days to the number of protein expression. There was no different -- difference in the response. Our studies over the last few years have come to the the point that we can't have too much growth factor within the -- [ Indiscernible ] Of the brain. Since that harm is done. Harm is done buzz you do outside the target. Not because you have a toxic effect of too much vector. The last point is inflammatory reaction. We have any indications of the inflammatory event. Both in the lesion models as well as the agent rats and in healthy rats and monkeys, long-term, after the expression. We have seen no evidence of inflammatory reaction. No exacerbation with the neurotoxic inflamitory reaction exists and no exacerbation with agent.

let me just make the more, the direct point do you feel extremely comfortable to understeak and -- [ Indiscernible ] [ Indiscernible ] A Neurturin delivery. [tauz pausing to switch captioners] .

Determine whether there was an immune response to in your your rans. Those are the points that I raise at the very beginning and it remains interesting questions that I would like to have answered at a final level.

Okay. Just a few points on this. You know, classed by our distribution studies with Al vector in rats, I want to point out that the rat brain is very small, obviously compared to nonhuman primate and human brain and hence there was we believe a small amount of leakage that was seen in the draining lymph node, but we're talking hundreds of copies. We're putting in billions of copies of sensitivity of 10 copies, per microgram of DNA which I assume would be the standard for most researchers. We can detect the DNA fragments. It's in our case we use random prime dt second strands synthesis, wear not a hundred sure of the efficiency of that reaction but in no case do we see expression of nurtured m RNA and this is human and we do not see antibodies against into your cheurant. One would the protein to be human no general Mick. We know the rat can map the human response. We do see it in those studies. Being we can talk more about sensitivity later. It's a detail that if we want to learn more about it we can. But it's not the most Jermaine right now.

Thank you.

Thank you. We're going November on to our next review. We have to move on our next review, miss -- Ms. Quan.

Thank you. Before I begin my review, I just wanted to remind everybody here particularly because I heard the presenters as well as the patient advocate talk about our approving this protocol and I really want to clarify and remind people that this body is not a regulatory body. We are not here to approve or disan a -- disapprove any particular protocol but allow a public forum to discuss things that scientists as well as nonscientists may see related to any particular protocol. The presenters, the p PIs, the FDA and rib's are informed of our conversation. But any and all of them are free to choose to totally ignore what we say here. So I just want to make that clear for the record.

My review concentrated mainly on the abstract and the informed consent document and I want to note here that for protocol that was a scientifically complicated as this one is, the informed concept had unusually well written language compared to other things that we have seen, and, in fact, the documentation of the request for all autopsy was probably one of the nicest explanations that we've read. Nevertheless, a number of my comments had to do with clarifying and then perhaps changing the neurons implied implied benefits of this to anybody considering participation. And there was a fairly extensive revision of the informed consent document that seemed to take care of most of these things. In particulars I was concerned that a participant not anticipate a greater relief or treatment value from this Phase I protocol than was justified and I believe a lot of that was modified and corrected in the informed consent document . There are three areas I would like to discuss if you were the one is fairly simple. And one is on various pages there is reference to a 28-day period between dosages and between cohorts and in other places it refers to one smooth. This is very minor but this is the kind of thing that where somebody should just really make sure that it's consistent through the because the wording in the informed consent document according to the response has been he revised to be consistent throughout the document which is 28 you days and yet we saw in the presentation mention of the documentation by month and perhaps if you used weeks that would make it easier because a week is always seven days long. Then I also ask that there be greater explanation concerning the fact that the making of m TM by the body cannot be stopped because the brain cells may have been permanently and genetically changed when gene transfer is done and I mention that this is a very serious consequence and deserves a section or paragraph of its own for understanding. There was additions made to it and I think we saw it in the presentation what was added was a chart showing all of the anticipated possibilities that the presenters thought could happen from permanently and genetically changed brain cells. But I think what concerned me was also that this was the response that was called rescue. And I think in the-in our use of the term rescue in all the protocols that we have reviewed and I think also in a more general population, what they provided was -- what they would do to address symptoms that would happen if something went wrong, and what we're talking about is how to remove what's causing symptoms would be the correct definition of rescue. So I think that there still has to be a clarification and it has been made automobile clear to anybody considering participation that once that is inserted, there may not be a way to remove what has been inserted and that constitutes a permanent change, that you could possibly address consequences of that but you could not reverse and remove that. And I think that needs to be made really clear. And then finally I raised the question, I actually parsed the statement in the scientific abstract and this is a quote to be most safe and factors neurotraffic should cover as much. A without affecting nontarget sites. And I asked am I correct in parsing the sentence as follows. A to be most safe the therapeutic protein neurotrof if I can factors should not reach nontarget sites and to be more therapeutic the neurotrof if I can factors should cover most of the target as possible. If I am corrected it is Phase I to assess safety and powerAbbott and requires that the extent of exposed tissue be much more limited than described in the rest of the protocol, possibly never arresting the level described as the dose currently planned for the first dose subjects. I'm going to read the response that was given taking out some of the details. But this is pretty much a quote. In order to justify the risk of the neurosurgical procedure required to deliver this therapy, it seems reasonable that even the starting dose should have some potential for resulting in a clinical benefit. And then there's more detail and I'm skipping to the last sentence of the response. The proposed starting dose of Seri distribution is smaied to be at the lowest level that might offer some potential therapy without extending beyond the boundaries of the target tissue thus the starting dose balances the need to minimize risk while at least having a minimal potential for some benefit. I raise this because it seems to me that this may be a Paradigm shift in terms of the definition of Phase I. We have had Phase I flash Phase II protocols in which they start very slowly but within the same protocol then go to levels that presume to provide some efficacy but it seems to me that this is the first time that they say they decide the starting dose, not based on the escalation of safety but to begin at the lowest possible dose where they might -- they believe they might find efficacy so I have one question for the presenters and then some for my colleagues on the rat. Question for the presenters is do you, indeed, believe that this should be a shift in terms of the way how we define Phase I protocols for all human subject research or just for this particular protocol and if so, in Iraq case why? And then for my colleagues, I correct in assume that I think this might be significant change in the definition of Phase I or even Phase I/II and how do we feel about it .

Can someone address Dr. Quan's question?

Thank you very much. Your helpful comments and compliments on some of the ethical as pictures of our protocol. We have selected a starting dose as you describe that we believe is sufficiently low that it should provide minimal or no risk to patients based on extensive clinical data and try to capture an element that could provide efficacy. With all the studies that have been on growth factors we actually believe the greatest risk to the subjects will be the surgical procedure even though that's extremely small. And the point of subjecting them to that potential risk while having any upside at all for them as victims of Parkinson's disease seemed appropriate. To what extent that's Paradigm shift, I suppose depends on semantics because I'm aware as many are aware of many Phase I trials beginning at a lower dose but one conceivably could provide efficacy, whether they chose to define those as stage one/two is purely semantic I believe. The agency has discouraged us from using stage one/two which is a selected.. Even though we do have an intention of trying to provide some hope of efficacy in these early volunteers.

Dock.

Can I ask a question, why was it, could you justify why you're doing bilateral injections so in terms of safety it seems to be better to give it on one side and in terms of looking for any efficacy you've had a internlts internal control.

Yes, we thought about this they hard.

Go ahead.

There's a real problem in Parkinson's disease with lateral treatments. First of all, you're dealing with a bilateral disease. Secondly you're dealing with a side-effect profile. One of the problems you run into is if you do unilateral disease, how do you treat them. If you use treatment that controls the bad side you may get overdose side-effects on the good side, if you drop it to avoid side-effects then the bad side is poorly controlled. So when all is said and done this will be a bilateral therapy. Ultimately we need to know if it's feasible and if this needs to work that's the most reasonable way to approach it.

Dr. Johnson.

Well, first I will read my statement for the record. Before I begin my review I'd like to make a disclosure, rot column targeted Jeanette he tick as and uses this virus as a vector construct in its clinical trials. While none of the target genetic trials are currently aimed at Parkinson's disease I, nonetheless, between disclose the fact that I invented to av vectors and a vaccine vector that was patented by my former employer and licensed to targeted genetics. He received royalties and some of those royalty moneys are passed on to me. Okay. Well, given the hour, Neil, the way I looked at this protocol was in two buckets and the first bucket has been reviewed extensively this morning, that is the neurobiology of this whole concept. The second bucket has received no review which is the whole production and use of the vector as well. And this is a very group provided me with plenty of information both in one temp protocol and this rot column to ensure me that they, in fact, have a product that they can qualify and get through the FDA so I had no concerns about the vector or the production methods.

Thank you, Dr. Johnson now we're at where we've thoroughly discussed this protocol and I'd like to ask members of the rack if they have any additional questions or concerns.

I just wanted to follow up on one thing that Dr. Bone asked about and that was the increasing the delay between the patient enrollment and I wasn't sure if that was really responded to or if there were any thoughts about that as currently scheduled the 28 days and Marty's suggestion was to consider whether that should be a little longer.

Thank you. We believe that the 28-day period between patients enrollments is appropriate given several things. If I was of all that's rather conventional and it was exactly what this economy had approved a year ago and we see little differences between those protocols, the data protocol is more aggressive more extensive and more convincing. Secondly, we've demonstrated very clearly I think that the expression of nurtureant occurs in Broom, and a week it's quite robust. Within a month it reaches an asentoet while it's clear we're not sure how long it might take to get the biological responses that nurtureant might I know during once it rams that stage for 28. We look at eight months in monkeys, we've looked at long time points. We don't see any evidence of any toxicity at all. So how long is long enough? The data of growth factor sucked the liabilities is the ventricular areas and certainly less than four week. We can get miss targeted delivery in principal being transfer. We don't think it could happen within W any reasonable sense of probability with sairra. 120 but hundreds involved multiples between the animals tested and the proposed human doze. I would ask you to question whether you've seen similar dose mustless in your other studies. We're very proud that we're able to achieve those dose muttless because I think they're nearly unparened. So there's no data suggesting that there is any reason to wait longer. If you start thinking okay maybe longer than the question is how much longer, is two months make a difference, does six months, does a year? What will happen is that we'll never be able to effectively test this, get it into the subject and bring it to the patients who need it. This is advanced say the that deserves more treatment than it currently has.

Thank you. . Any other comments, any other comments from members of rack on file?

Could I just ask the restriction of the protein expression even with very high doses of virus is very impressive. What is the basis of that restriction?

That's an an excellent question. Av binds to most surfaces endogenous sites so we get very little diffusion. We are not using convection enhanced solution which is intended to spread the vector. We use something that gives better control, multiple injection sites. The protein doesn't diffuse does not diffuse that far from site of transducks so by selecting the target and having protein spread we get with the various rings of doses can be tested we can hone in very nicely because we have that control. It's an empirical fact that the protein stays relatively localized to the site. You get some diffusion. We can quantify that. It's a function of dose and we can actually control it.

The virus is restricted to that area or does the virus -- I mean, when you're pushing in lots of virus, I would have expected it to just by pressure elements would --

We see wired distribution in the monkey by the vast majority of the vector is restricted to the injection site. We do see some evidence of vector genome, it's minuscule amounts and transients. Most of had a is probably fragments that have been broken down. There's no evidence of transgene expression in other places besides the targeted area. And so if vector is being pushed out some place else, it's not transducing the cells into any biologically meaningful level.

Doctor. So I have a couple questions. In the first study that you showed the mtpt monkey model, you talked about the control and I didn't really fully appreciate what that was. Have you ever tried an empty control.

That was a safety efficacy study done in combination and agreement with the agency, of course, because we're moving towards developing a product for Parkinson's patients, and so we actually split those control animals in two groups. Formulation buffer which the agency wanted to include as a control and gfp vector so there was vector in there and a gene that -- and as the standard scientific studies.

And just one other question. Do you have any sense of what the vector, the multiplicity of infect is as far as the vector to neurons in these tissues?

We really don't. All we can do is try to estimate that, but it really doesn't answer the question. It's probably somewhere in the range of a bit more than one vector per neuron but the range could be anywhere along that -- all we can do is talk gross averages for the chunk of tissue we're able to extract and dissect and analyze and it done really answer your question.

Any other questions from the rack.

Say quickly, you went to great pains to talking about avoiding uncontrolled spread to the ventricles. What would happen if you did get that?

We don't know for sure but the worst-case scenario is the studies in animals and humans have looked at that empirical, in animals studies it's controlled, in human it's efforts to spread the protein into the brain by way of injecting it into the vents cl and the responses that are characteristic of growth factors, you get a thickening of the pia the layer of meninges, you're system lake swan cells in that area to grope. And you have fiber in-grown, fibrous grown in because they are what's interesting is in animal studies that have actually injected them into the vents weather the paren can I ma, in our own we paren.

And we have casino evidence of those side-effects. So there's a question of whether or not transfer near the ven cl would induce the same spontaneous. We're taking the worst case most conservative approach in assuming if we got protein that spread to that area, we'll get the results. It's the just the appropriate response to take. When you look carefully at brains of those animals you actually see barrier between the protein extension and the ventricle and that's call the apendymall cells. That's analogous to a blood brain barrier .

Any further questions from the rack. Any further questions.

I just like to point out miss Quan noted that the reference to the gene transfer's treatment should be changed and you mentioned that it was although I believe I have the revised inform consistent send treatment inform consents treatment. One of them is on page 36 of your response, and the other is on page 50 of the response.

Thank you. For pointing that out and we'd be happy Tony corporate all the suggested changes to the -- Those will not be an issue. Any more concerns from the rack.

Okay. Any public comments?

Can I make one more brief comment on protocol?

Is it a public comments?

Sure.

I've seen some of these studies going forward and I just wanted to make a general big picture point about this. As I've heard the protocol I think there are two main issues that we delegate with and I don't know if the big picture emerged. Was the concern that about the efficacy of the newer churants and I wanted to point out that we have more protection data with the into your cheurnt given first, we have respect. We have aged monkeys that have shown a biological response in terms of pet scan. We have aged rats that have shown an aged response so we have neuroprotection reenervation we arced about mine cha of those models but I was wondering if Dr. Bow went has proof of efficacy given function recovery in the best row deny and primate models we have of Parkinson's disease.

I wanted to see if we resolved that rack issue or not.

As Dr. Quan pointed out. I don't think there are a minutia that the animal moms used were not ideal and did not completely reflect the best model parallelling the design of the protocol.

I didn't be mean that critically at all, Marty from. a Big picture peck spiff, we have that body of data are there remaining concerns about efficacy. In deference to the next group we have to wrap this up. So what I, if there are no more public comments what I propose we do is adjourn for 10, 15 minutes. For 15 minutes and iq that the rack reviewers remain here so we can draft draft recommendations that we'll revisit.

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We have decide for reasons of practicality to defer the public vote on the last protocol until we have finish our work this morning, and we're going to go on to the second protocol this morning wrist ended Phase I trial of systemic of virus genetically engineered to expressness with or without cyclo Foss flow my with patients with multiple myeloma. The presenter is Dr. Gurts from the mayo clinic who is just about to begin.

I'm going to sign off now.

We do have a group of people here involved in the project. We unresponsive for this project from mayo clinic and the other individuals who are here from mayo clinic is the principal investigator for the protocol. If you'd like to raise your hand, Angela. Dr. Eva guyLANis who is an investigator who was a Miece sell's various the domain of and general, David dingly the lead scientists in this project who constructed and did initial testing of the virus. Mark stepfeld is the person running the facility at mayo where the vector will be produced and the toxicology studies. We also have here Karen sly kert from the rate program and Karen is looking after the toxicology aspects for us. Okay. So this is about multiple myeloma which is a devastating incurable malignancy of Plasma cells characterized by infiltration of the bone Maiero, painful bone destruction. A reduction in normal immunoglob luns in the blood and it remains incurable, it's response for 11,000 deaths per year in the U.S.A. and it's disseminated from the outset so it needs to be treated systematically. Viral therapy is the approach that we're exploring for this disease. The virus is to destroy tissue and maybe we could harness that capability for cancer therapy. We've elected to work with measles virus for a number of reasons. You can see in the picture there this is a 10-year-old boy who had a spontaneous regression of a retroorbital Burkket limb Omaha in the course of the measles infection. We've explored the use. A 10 waited vaccine strain which in contrast to the wild type is again no cells and if kills myeloma cells. It spares normal cells and it has variety xeno graph moms. This is just the linkage from which the he had monson virus comes. And the vein was derived from 1954 through the throat of an 8-year-old boy who had a measles infection and his virus was then passed on a variety of different human and lines to generate all of the currently used measles vaccine strains which differ from each other in a variety of point mutations but they're all from the same lineage and the virus we've been working with is derived from this spud which came out the he had monson I know angle and from an infection molecular clone was generated the way in which the virus kills myeloma cells is by infecting a small number of cells and causing them to fuse with their neighbors resulting in the generation of large multinucleated. Green dots which the a myeloma cells and then a lot of these much larger green spheres which are multinucleated. And then you can see in the right hand panel there that those large spheres become incapable of excluding try pan blue when they die. The basis for the measles virus oncology specificity resigh in the h attachment protein and the s fusion so h immediate Yates attachment to slam and then f triggers fusion and slam is expressed on cd 46 is ubiquitous. But cd 46 is over expressed on human myeloma cells and we believe that provides a basis for the toxicity of the virus. If we look at multiple myeloma patients bone Maiero, you can.

Cd 46 staining is on the x axis in those dot plots, and you see in each case there's a little cluster of myeloma cells with high levels of cd 46 compared to all the normal bone Mario elements and when we Kwan Tate that in 18 patients here that in all cases the near plastic Plasma cells have higher levels of cd 46. We've conducted studies to show that measles virus can discriminate cells with high density from those with low density. And this data just shows us a panel of krelgs engineered to express increasing cells of cd 46. And you can see when we infect these cells with measles virus we see that there's a threshold density of cd 46 above which the cells begin to fuse and die. And this threshold effect is very important in the antitumor affect. Myeloma cells have higher levels of threshold in the fusion for killing and then there are lower levels. The specificity of the virus is illustrated here. In the left hand panel at the top, the broit green multiple thuk cleated fisher measles virus can see, can be seen. Pevrt ral blood lymph sites were not did limb sites sinfisha, we were able to completely e raid indicate large zero no graphs by large administration of virus these in mice xeno graphs. Now we did not engineer the virus? Because there are some problems with the virus as is. And in particular, we were concern if we're going to use in the clinic we need to monitor its spread. There are also problems which I think will be clear to everybody here that everybody has antimeasles and it's bodies which may block the ability to deliver the virus by the vascular route and also once delivered the spread of the virus may be inhibited by antimeasles cyto tox tick t limb sites so to zeal lymph sites,

That virus has been reviewed here is in clinical testing for Ovarian cancer. Another measles virus with miss gene inserted and the permissiongene I will tell you a little bit about but first of all, an update on this clinical protocol. This is for patients with advanced Ovarian cancer. The virus is the infusions are repeated every four weeks for six cycles and the dose is being escalated from a very low starting dose of 10 to the third up to 10 to the eighth using cea monitoring to guide the doses calloboration. The first patient was enrolled into this study July 12, 2004, there's been no manufacturing problems. Six patients have been treated three at the lowest dose level, three at the next dose level. Tlns transients virus he'll yeah, and we have casino replication, this would represent about the right amount. And this would represent I know such virus replication and that is, therefore, the need for a hire dose and we're at this level at the moment. The next gene which is the subject of today's presentation is a gene expressed in the thyroid if a lick Klahr cells . Rchblgz it can be exploited iodine and to destroy the thyroid gland if it's overactive using regular overactive metastatic thyroid cancer if it's well differentiated have long been treated effectively with systemic with radioactive eye Dean so we insert this had gene into the measles virus fan we do it to subcutaneous then after a week or so if we administer radioactive eye Dean we see the thyroid, we see the stomach because there is some uptake in the stomach and we see the bladder where the ice it open is being excreted but we see a nice clean image of the tumor and this is a different image.

ing modality used to demonstrate the same effect. This virus retains the potency and here we have grown kac 612 myelomas xeno grams to half a sent meter diameter where we have treated with a single intraVenus dose or 10 to the fifth, 10 to the sixth or 10 to the 7th. And you can see here there is a threshold dose, 10 to the fourth is ineffective. 10 to the fifth is a delayed response and the higher doses of 10 to the sixth and 10 to the second are more effective than 10 to the fifth at least in the short term, and we're able to follow the course. This is a successfully treated moused that a complete tumor regrevmths you see day three very weak signal in the tumor. The virus spreads and by day nine there's a strong signal bye-bye day 14 the tumor is regressing the signal has diminished. With respect to the other two problems the antibodies blocking delivery and the t vels blocking spread I have a couple points. The first is we have look at antitight terse. And you can see here the that. Stem cell transplants have significantly reduced titers of antimeasles antibody which makes this disease a good candidate for intraVenus administration of this agent. With respect to the. More extensively in vive vo and this experiment we.

With or without cyclophosflomide, you can follow the time course of cea and the virus is eliminated by day 10. In the presence of cyclo Foss. Out to day 35. Okay. So I'm going to Hanover now to Angela who's the principal investigator of this protocol and she will run through the protocol and then discuss the safety issues that need to be addressed in the context of this review.

To reiterate something that Steve has also said the status myeloma therapy, there has been progress made over the past decade using peripheral blood stem trance plans transplants.

So with bore testsmad but still patients are still dying of this disease and there is no cure in sight. There are 11,000 deaths per year and so, therefore, we do need new innovative therapies and this is with our best therapy which is single versus double transplants and what one can see is the median free survival with our very best therapy is less than three years. So the Phase I trial, there's sort of two steps to it. The first step is the mv nis alone and the second witness mv nis and cyclophosflomide. 10 to the six the 6th and 10 to the 9th. And once we get to the maximum tolerated dose assuming there's no toxicity we will then move to the mv nis and the cyclophosflomide, and we'll give 10 milligrams iv two days prior trying to be a gate the t secretly response and the dose we'll get two logs lower with the single agent. And this is just the trial schemer and as you can see here, essentially we care a lot about safety obviously. Patients will have the mv nis given on day one and then we'll be watching a number of parameters including cbc, chemistries, watching viral levels in Bach the blood sputum, urine, we'll also be watching, using i 123 gamma cam ma imaging and looking for how the agent tracks. We'll also be watching for the Miece sell antibodies and t cell subsets, mover we'll be watching for early response using bone marrow biopsy. Because the patients are being imaged we're going to give siteMil to block uptake in the thigh that'll start four days prior to receiving the mv nis. For the cyclophosflomide arm, the cyto toxin will be given two days prior. So what are the potential concerns? Well, for the cyto mill there are issues with that. T3 so it can cause tachycardia Antrem more and we have taken some of the suggestions of the committee where they have symptomatic coronary artery disease and we've reduced the dose to 25 micrograms bid based on other studies in the literature. We don't expect any toxicity from the i 123 but the complication and toxicity would be the mv nis and the cyclophosflomide and they can breakdown to infusion illness a proceed tracked measles type illness and virus transmission and, of course, cyclophosflomide has its own side-effects but the doses we're using we wouldn't expect tremendous amounts of into it tro penia, it will make it.

One can have allergic types of reactions, antiif I lacks is, with other.

Characterized by fever, rash, core rise za, transients immune suppression and even for severe complications like otitis media, pneumonia and encephalitis, it is certainly possible because these patients are immunocompromised but it should be self-limited. The strains have been proven to be very safe. Billions of doses administered. In fact, actually the Miece sell vaccination is recommended for HIV infected children as long as they have adequate CD4 counts and also for immunosuppressed patients following i stem cell Rubella vaccination to our myeloma patients post transplant and these are patients that may still yet be immunocompromised by their disease. They're not all in remission. We typically give it at 12 months this is the recommendation of d -- CDC as well as the American. But if patients were to develop a measles like illness, again we based on the literature are planning giving measles immunoglobulin and ribbyvairen. We're giving higher doses of mv nis W.'s starting at 10 to 60 cli for the measles vaccine 10 to the third to the 10 to the fourth is given and this is not the first one high doses have been given to patients. There are reports where HIV positive instances as well as HIV negative instances have been immunized with higher doses. Moreover intravenous application. He had monson strain of measles has been givenen that Venus gip to monkeys , he had Monson, The lowest effective dose in mice is 10 to the fifth and if you do a little math that would be about five times, 10 to the sixth per kilogram and so if you do a dose calculation based on an average human being, this is about 1 opponent 4 times 10 to the fourth per kilogram so again we feel that to start at too low a dose would be consuming patients' time and energy with something of a very, very low chance of doing anything at all. The next problem or question or concern is transmission to contacts. Again, it is a virus, mutation is possible but virus measles have not been reported to be transmitted and mover the contacts of the majority of U.S. Citizens are vaccinated for measles and, therefore, should have some immunity to too. Now, again, I mentioned something about doing form kolg and toxicity. There were a number of possible models that we have considered and they're listed here after our preR&D meeting with the FDA and they agreed upon the two or actually three strategies. One is using cd 46 transJenick knock out mice and also using squirrel monkeys and then also using the cyclophosflomide and that is to address a number of these issues here. And here is just some preliminary biodistribution data in these cd 46 transJenick mice and what you can see these are females, these are males and this is the measles tissue distribution one day after treatment and here you can see the different groups as to what the dose 10 to the fifth, 10 to the 7th uv action have I Tated and what's most striking here is one can see that really there is not a virus found in most issues when you see it, it's spleen and blood. A little bit in liver as well as lung. But, again, importantly it's not found in ovaries or testes, these similar also done a tape 90 after administration and all organs were negative in all groups. So for the primate studies, this is the sort of the plan. They're 12 squirrel monkeys and they're four groups, one group with neither drug or agent, and the second group is just with the cyclophosflomide and 10 ace of mv nis and combined and then the plan to do a scheduled sacrifice day 29 so two monkeys from each group at day 29 and then the remaining animals at day 91.

And this is the schemea and it's similar to what we're doing with our patients except not these two points. And again we'll be measuring site kins and so cyto kins and there's been in cross I samples in cross can I in cross can I I samples.

But we have to keep in mind that myeloma as incurable needs with pressuring need for therapeutic new strategies. Preferentially by using cd 46 and we believe that the preclinical data and careful trial design should allow us to safely administer this therapeutic agent to patients. Thank you.

We'll start by Dr. Diane Griffin. When you do your individual reviews, if you could think about which questions that you originally posed have been answered satisfactory versus those that you believe need some additional answers. It is not necessary to read into the record your entire review. You can take each tissue and summarize it in one sentence for us and then comment on the response. Dr. Griffin.

Okay. Well, I thought in general this is an interesting protocol, and innovative and so in general I was favorably dispossessed toward it. I did, however, have a number of questions and I'll focus on the 1s that I still am confused about even after the answers.

Excuse me,.

Yes.

Excuse me, Dr. Griffin, it's necessary that you summarize and read into the record even though considerations that you're satisfied with.

Necessary to what?

That you summarize and read into the record, that is state even those issues in your review that you're fully satisfied with the answers too.

Right.

Okay. Thank you.

I was going to start with the ones I wasn't.

That's perfect. Thank you.

If I can go through them in order the first ones that myeloma cells is there protocol, it was apparent to me and stated fairly explicitedly I thought that shows the different cell lines that they have used for test thing their hypothesis differ quite a bit in the susceptible to protocol to section 1.5 where they talk about some have complete regression, some are resistant, some require, you know, both the Miece sell virus and the antis type stream for these different types this use. And they observe no observe no significant.

It's confusing because I thought it can matter for the particular patients that they may have cells that are or are not measles on lysis,

The next the next point was that it it really dealt around this use of cyclophosflomide. I'm a little clearer with their responses in the protocols that was originally written, it sounded like they were decreasing antibody levels dramatically by giving cyclophosflomide into already immunized mice but it turned out the experiment was not already immunized mice which are the most relevant to the humans who will all be immune ahead of time but they're giving the two simultaneously so they'll have a drama suppression on the I am. What the effect was on the secondary immune response which is really what they're trying to suppress in their patients and so they're focused on it. Cell responses which probably those secondary responses will be suppressed but these are all immuned individuals basically so I that it for the experiment mouse experiment and then later on for moj key experiments again they are using animals that are nonimmune so -- the response to measles because it's going to be a primary response and the cyclophosflomide will be effective there but nonwill give information on the actual protocol in the patients which is to give it to patients who have a primary immune response to piece sells. I don't think it's a safety issue, I just think it's an issue with respect to whether it's going to work or not which I guess is my biggest concern. I also asked about what the levels of antibodies were in the patients relative to the mice. And the response was that they used different tests that doesn't necessarily -- it wouldn't be hard to use the same test, put it that way, if they used annuity lizing test which is going to be more predictive of actual ability to respond to the virus, the individual is most predictive of being able to establish an infection and an individual previously immunized immunized individual. The third thing I asked about for more information on the patients that are actually been treated with ovarian cancer that think was supplied fine, and earlier in the earlier presentation, I couldn't see before. But it sounds like there's not a problem with toxicity if anything there's replication in those patients. The fourth point was again about how you can possibly suppress an antibody response with cyclophosflomide, and ongoing antibody response and that's been clarified. Another thing as rerps issue, was incorrectly stated that vaccine violence has been never been isolated for, they corrected that. And the sixth.really is the one I've already dealt with which is the monkeys that the monkeys that they're going to study are going to be measles virus naive so they're nonimmune monkeys so they're not going to, they're not going to mimic what the patients that they're studying so I'm not sure what they're going to learn interest those experiments. They'll learn about toxicity I guess and the worst-case scenario but not about how likely it is that they'll be able to infect the animals. I was confused by the drug -- [ Indiscernible ] That's been clarified for cyclophosflomide and monkeys T. sounded like it was being given twice, but that's incorrect. It will be given only once. And then I have some other questions about the specifics of the monkeys and how they'll be followed and those have been answered fine. So those were my main points.

Dr. Griffin, thank you very much. I'm going to ask Dr. Getters -- gerts to respond to your remaining questions. We will dethis person -- individual by individual in order to try to expedite the responses.

I should say I'm Steve Russell I'm Steve Russell here, not Dr. Gerts.

Thank you very much.

Thank you very much for the review, Dr. Griffin. We very much appreciate you giving us this input. The question with respect to multiple myeloma cell lines and differing sus September blts, there is no difference in the susceptibility. The lines in tissue culture. The dumps is in susceptibility refer to the differences in susceptibility in xeno graphs and we do not understand the differences. But it's not apparently related to receptor expression. We think it may be due to anatomical differences in the vascular supply of the different tumors allowing different efficiencies of pranky ma .

With respect to the cyclophosflomide. We do not consider the cyclophosflomide to have the the difference in the and body levels. It is to control the t cell response and to give the tc to spread after it's being delivered. With respect to the design of the monkey study, I fully take the point that you're making in that the study is not going to give us information about efficacy because we have not immunized the monkeys. However, this monkey study is primarily a safety study, and we, therefore, have elected to do it in monkeys that do not have prior exposure to the virus and, therefore, test the worst-case scenario. So this really is the purpose of the study. It's not an efficacy study. And I agree with you that efficacy is the biggest concern in the clinic. But this is a Phase I study and, therefore, as safety study in the patients and we are dubious as to whether additional animal studies with an immune system in the way will give us information that will change our clinical protocol design. And with respect to the neutralizing antibody test being preferable, we fully take your.and we mean modify the protocols to include the use of annuity lizing and body antibody test and for those who neutralize the virus and I think that covers the questions you have.

Okay. Thank you.

Dr. Griffin, before we move on are you reasonably satisfied with the responseses, especially the response concerning the mum many myeloma cell lines that have been utilized.

Right, well, yes, and I understand it better. But and if you were starring down the line and I guess you thought this was a treatment that you were --ed that passed all those first hurdles then the question is whether it's useful. I don't think you U how you make the cell lines out the multiple myeloma sells or put them into mice and see whether they're dense susceptible. And maybe the mouse isn't relevant van for those particular cells I know it's a safety issue, it was more of an issue of whether you can be more predictive about what patients were likely to respond.

Sure. And are you comfortable with the response remarked the timing of site toxin and primary verse second sair antibody response.

Again I think if you're looking on for safety and not really trying to inform your actual human study, then what they did, in giving the cyclophosflomide and before or at the same time before giving the virus, well, certainly delay delay the immune response to the virus. As I say I just -- I guess it gives you safety information. But it's not necessarily very relevant to the patients, let's put it that way.

Okay. Is there anything else you'd like to ask Dr. Russell?

No, I think he answered my questions.

Thank you very much for your review. Dr. Albelda.

I'd like to thank Dr. Russell and his colleagues for a very nice presentation.

I found this protocol very well he very well written and -- my comments went over many of the same things. I had asked for more information to convince myself and others that this would be safe. And Dr. Russell was able to provide some of that have data today showing that this vaccine had been used in many patients with immunodeficiency was a concern of mine and I asked about data using measles immunoglobulin if any trouble was in store and he provided me with a number of rernz how it was quite effective in stopping infect so I was satisfy with those responses. I thought one of the best ways to assure that this was safe was to provide us with a good experimental human in the ovarian cancer patients a slightly different route but it gives me a lot of confidence in terms of the safety of this vector. I also had some questions about the use of sytoxin, the dosing and timing, and I think that's been discussed. I don't think I have to go into that any more. I asked about the efforts to quantify the cd 46 on the myeloma cells on the patient before stream and after treatment. If this was efficacious you might see a decrease in the cd 46 levels, and they have agreed to do that. I had a couple of minor comments on the consent form about the risk of tumor lysis syndrome which was included and a few other small items that were taken of. So my commence were adequately addressed and I have one additional. If you would talk about your able to choose nis versus cea. Do you chlz Angela, would you like to speak to the question of disease distribution in myeloma ?

Your point is well taken. Auto lytic lesions that we think are small Plasma sigh siteopenly mass, those are airing where we'll see we're extra med Larry disease than we are ever expected. We're optimistic that we might be able to image it but there will be that background issue .

Are you reasonably satisfied then.

Yes, I'm fine.

Dr. Dewhurst.

Many of my commence were very similar to the commence already raised by the other reviewers so I had questions about cd 46 on the tumors and received a satisfactory response and as Steve alluded to, they've agreed to test both pre and post therapy which I think will be informative. I had questions about the could he purification of cell Klahr protein with mc in his nis. These will the production scheme is slightly different from the tip cal vaccine production scheme though it's proprietary but in essence it's apparently a somewhat more concentrated batch that allows them to escalate up to 10 to the 9th dose in a reasonable volume so I felt that that response was satisfactory, at least to me. I had some questions on the protocol. As the other viewers did, I was -- I think aid bit of misunderstanding and I had questions about the proposed assays to measure the antiMiece sell antibody levels and again that's been addressed .

I'd be curious to know where that standards and what the plan is there I suppose. Shedding assays which was provided. I asked a question about the definition of virushe'll emia and I felt it was the virus he'll ma, sigh ream yeah, Vie ream yeah, Ig is an appropriate response and it's available onsite so I really have only the one question about the status of the neutralizing and it's body assay.

First of all, on the side ream yeah, question I'd like to thank you, virus ream yeah, question, --

We've activated a equal system for that assay. Regarding the neutralizing antibody test, I'll ask Dr. Pang to.

What we are the certify row, and added pf I know had I been taste in titer in the.

So -- and that's mice and human so it a pliz across the board and we can use it for monkeys too if we need to test the titers.

It's a standard publish assay which we had not been routinely using so being developed was referring to that.

Okay. Thanks.

Dr. Lowe.

Thank you. As to the other, I found this a very interesting and well written protocol. I had a number of comments and suggestions and the investigators have done a very nice job of clarifying it and responding but for the sake of the record I'll just mention what my comments, concerns were. First I had some questions about the consistent send or use of stored samples from the study for future research. That's been well clarified. I also had some questions about a provision in the consents form for allowing researchers from other institutions who would have access to the samples to carry on if you are research. If they had a test result they thought would be useful for patient care, how that recontact of patients might take place. On the whole I'm satisfied with their response. It's been a terrible dilemma where it's come out four our investigators and I'm sure that investigators and will work this out. My major concerns had the dose of endogenous. My concerns that the dose in the original protocol might run some risk of cardiac adverse effects. There's the team has responded very nicely and their going to lower the dose, screen patients for cardiac disease and broaden that you are exclusion criteria and that nicely addresses the concerns and suggestions that I had raised. And finally aid couple of minor concerns about the consents form, particularly about how one phrases these the perspective benefits in the Phase I trial and I'm satisfied with the way they responded so I'm happy with their responses.

Thank you very much. Dr. Russell, it sounds as if there's nothing to respond to to Dr. Lowe. I'd like to take questions from the remainder of the rack. Is there anyone significant around the table that has a question for Dr. Russell or others on the team. Yes.

Not so much questions but comments about the whole consents document and I notice that some of the language is somewhat complex and that includes both words that are technical, phrases that are technical such as intravenous or gene expression or some words that you can find in any dictionary but are just more complex than they need to be such as unmodified or preferentially just to -- and I notice that Dr. Lowe noted that at least one place the gene transfer was referred to as therapy and you said you would address that but I found some other places where it's referred to as treatment and we usually recommend that those types of words be avoided.

I'll spontaneous to that. As far as the treatment, I guess I missed that and I'll definitely edit that out. With regards to the language, the level of it, it hasn't been to sort of the folks that make it a little simpler so there will be reedits and as far as simplifying the language portion of that. So that will be addressed. And I'll have some extra assistance with that and so point well taken.

Thank you. Other questions from member of the rack. Questions from.

Oh, I'm sorry.

Yes, Dr. Johnson.

This is Dr. Give gill hard.

This is a where this might be down the line witness ms gene in place as a way to track tumors could you see this as being used to treat them with appropriate thyroid protection?

Yes, absolutely. And so the potential outcomes of this clinical trial one of the potential outcomes would be that we would see I'd dine uptake within the tumors in the course of the imaging studies but the virus would be ineffective in terms of reducing the size of the tumors. And if that were the case, then the follow-on study would be with the addition of I1 31 to above the the if he can of the therapy. If on the other hand we see no -- inadequate uptake in the tumors to give us an image, then obviously we would not proceed to that type of study. So it's a possibility but we feel that the virus has significant activity as a single agent in the animal models that we've looked at and, therefore, we should take that step first.

Thank you. Other questions.

Dr. Johnson.

Have you considered if you're really successful that you might have something like a tumor lysis syndrome?

Dr. Dingly, would you like to sfond this respond to this question.

That's been asked and answered.

We hope -- but what I can tell you is this. The idea of the tumor lysis syndrome which we kind of hypothesized when we publish our results we have no proof of. What happened. We treated our mice with the NIS followed by the I131. We had two mice and they were fine one day, the next day they're dead. It's impossible almost to tell me whether they had tumor lysis syndrome. It would be conjecture more than anything else. I had no proof whether that happened. It's something that we'll can be considering and watching these patients for.

The other thing to say on tumor lysis syndrome is I think it's very rarely seen in patients with multiple myeloma, even in the context of a rapid response so it would be a wonderful problem to have.

Well not necessarily. You know, because if you had two mice alive one day and they're dead the next day, I'm not sure I would consider that to be a wonderful problem.

No, I certain grow with that. Thank you.

-- I certainly agree with that. Thank you. If it was a theoretical concern because human for lysis can be you can give pure annual and you don't lose anything if you don't have a massive tumor lysis.

Right, and patients electric lights will be monitored electrolytes will be monitor and I treat a lot of myeloma patients and I I can think about one parish and that was in the context of transplanned that an I know investigation disease, but we will be watching their aloe pure nol,

You've got not only the possibility of tumor lysis but systemic inflammation that could occur but so you have the potential tumor lysis and a very large site it open kin.

Do you have a suggestion that you would like to see, that would be useful. No, I don't.

But I'm asking if you considered.

We have considered it, and we'll be watching electrolytes and we think again I think it's a low probability. We have it in a lot of our myeloma trials relating to other drugs and things using different immune modulators but in this particular disease it hasn't been an issue.

Measle virus and its and it's action to the immune system is different.

Absolutely so again we can watch electrolights more cautiously.

I would just, you know, just the possible of somebody getting n IC u or rds is a real issue.

Absolutely, we will be watching them and it is in the consents form for what's that's worth. It doesn't matter if you warn somebody, if it happens it's always bad fuse so I think, I don't know, other viruses that have been used in the clinic that have had different efficacy, I don't think that's been a major issue and the potential for cyto kins and so forth .

The opposite has been the problem in clinical trials.

From what Diane had sort of said that she didn't think it was going to work in the first place. I'm going to the other end of the spectrum saying what if it does work?

Yeah.

Yeah,.

Other questions from the audience?

All right. Thank you very much. We'll proceed then with, if I can make this work, a final discussion. The issues that I have left are twofold plus two comments on the informed consent. First the question of the relative antibody level in the measles versus the mice model remains to be resolved. The investigators agree. And we'll modify the protocol to include neutralizing and it's body as a measure and are in the process of neutralizing antibody methodology development. Second point, the investigators have agreed to access cd 46 before and after the intervention. The other issues raised I heard as already resolved during the presentation. Finally with regards to the informed consent first the language remains somewhat complex including both technical as I know ravine in us and standard language. The consents should be simplified the second in the informed consistent send may overstate benefit and continue to include the wore treatment. Is there anything else that the members of the rack feel should be added. Then noting that this is a draft recommendation staple and that the certainly the language will be modified, let's go and vote.

Wait a minute. Dr. NemRowe. Dr. Boden.

Balded-.

We need motion.

Second please?

Thank you, Dr. Galardough.

Bone, Al bedda, Dr. Dewhurst.

Dr. Beil, not here because he's in conflict. Dr. Johnson, Dr. Glareda, DeLuca, Rosenberg, Barkley.

And empailers, Dr. Musdufka.

Now we have a choice. We have caught up and I want to thank you, everybody, for very concise and interesting presentation which allowed us as rack members to be fairly concise in our responses. So thank you all.

I just want to add for the record, and so the investigative team knows that for the rot column that we just reviewed there were a few rack members that were formally recused. Dr. Samari are employees so they were asked to leave the room and Dr. Heflof someone here today but didn't parts pay because she had a conflict. I just want to but that into the record.

Thank you. We could within the next few minutes review the ae's and amendments so that when Dr. Zeuhasn'tI arrives we'll be ready and we can attack lunch and come back. We need Dr. So Mari to do this. Let's see if we can gather Dr. SoMari back .

Unless you're prepared to present them now. Are you?

I don't think we'll be able to do that.

Right. That was my fear so I was trying to get something that's small and concrete that we can accomplish before Dr. Zeuhasn'ty comes so we'll do the 689 final discussion and vote immediately after lunch and those of us who were initially recused will be recused again. And now Dr. Somari is here . We're wake for you .

All right. Dr. Somari will begin with the adverse events report .

It's nice to be back. First I'd like to go over the protocols that were submitted for the March 2005 rack meeting including those that were and were not accepted. There were 11 submissions total. And three of those were selected for in depth public review, two of those that were reviewed this morning as well as the one this afternoon which is protocol 681. Retrovirus t cell receptor prostate cancer after nonablative condition. There were, Sun were on for cancer and one for peripheral artery diseases. Plasma to deployed antiviral vector, one herpes simplest vector. Regarding adverse events report, there were 165 total ae's reported to the oba staff between November 4 and February 1 and these events were reviewed by oba staff unless by interested rack members as part of adverse management team in late February. Of these 165 events there were nine initial reports supper were look in in detail by this group prior to the meeting at the time of the meeting. There was one events that we wanted to note publicly regarding that involved protocol 393. And then there's the events in 619 that will be discussed later n 393 it was a Phase II study for a gene Al gentlemen it may I can. It was reported had a subject of 53-year-old, excuse me, subject with stage -- with nonsmall cell lung cancer following treatment subject did receive 16 out 16 injections of the investigational vaccine with the last administration in June and in November was found to have a white blood cell count of 448,000 with prominent bands. The diagnosis was made following a bone marrow biopsy of chronic my lodge in us leukemia, and it was made clear that the study sponsoring investigators were undergoing a detailed genetic analysis remarked the presence and timinging of the Philadelphia chromosome and those studies are underway. And we look forward to more information regarding this individual. Be happy to answer any questions regarding this individual or other events that were noted.

Thanks.

The amendment discussion was bit longer than 142 protocols submitted to observe about a. Of the 14335 were pr or site kangs. Modification 17 for protocol status changes. 50 were annual updates. 16 were responses to appendix M-1 c one and just as aside, that was a good healthy number of responses and 22 were other notifications or amendments where as 39 involved annual updates or and/or safety reports. I'm going to comments on four protocols or statements that were submitted to oba from chairs of protocol is rack 516 which is retroviral gene transplants of SCID on November 242004 the domestic protocol investigators want Clure communication from neckcar hospital in Paris, France, with x SCID who had developed leukemia had died of leukemia. The U.S. investigators revised their consents form to reflect the death and the revised consent document was approved by the niaid on 2004. On January 24th 2005, the domestic investigators informed the rack that there was a third case of proliferative in an X SCID patient. And that the U.S. domestic site would be on voluntary clinical hold until further guidance was provided by the FDA oba and the rib. The second amendment I want to discusses rack 557 and open label doses calloboration study to assess the safety of a M-3 01 catheter cather in patients with ischemic artery disease or percutaneous coronary invention. The protocol underwent in depth review. The rack recommended that the study be redesign without a placebo arm because was felt that this arm and this Phase I study posed an unjustifiable risk to the research participants in the placebo group. In the M-1 c 1 responses. To represent a Phase I open label study. The use of a placebo control was removed from the study design and the title was changed. The rack also recommended that the qualifications and role of the independence reviewers at each site for subject eligibility be carefully defined both their role and who they were and any consistent flk of interest potential and this was done. The third protocol for public discussion is rack 593. a Phase I open label study of intrastrieatall of adenovirus encoding human aminosipped in subjects with advanced Parkinson's disease. The protocol under went rack public review on 10-17-003 in response to recommendations to and in the m one c one response the investigators extended the period of time between cohorts beyond the 30 days originally proposed in order to allow a more thorough evaluation evaluation of adverse events before doses calloboration from cohort to cohort. The exclusion criteria were modified to add antititer histology stuz that had been ongoing during the public rack discussion were reported as showing no histopathology localized to the needle tracks, the consents was modified to include the word may not be possible to remove the transgene faithfully end quote. Final protocol for formal public presentation is rack 619 which we'll hear more about this afternoon, the administration of a replication deficient adenoassociated gene transfer vector expressing the human clem two sna to steroid lip foe fuschia no cyst. The first patient was enrolled on May 31st, 2004, the rack received a letter dated January 21st 2005 which is in follow-up to the serious adverse evens and deaths of a subject followed status epilepsy customer receiving gene transfer. Modifications include the following, baseline and southeasterly e EG's were added to the protocol to help evaluate occult fusion productivity following Jean grapher. The timeline has been revised to include southeasterly e EG's at baseline and post line transfer at 18 mooblts and the results of these e EGs were added to the efficacy parameters the informed consents was modified to inform potential subjects and their families of the status he lepticus and the death of a subject. In November 2004 a research subject enrolled in this rot column died after having episodes of multiple seizures. We are unable to determine whether the cause of the child's seizures was due to the natural history of the disease, the surgical procedure, and/or drug administration in the setting of the disease, the research study drug paren biological vector closed paren or some biologicallen coat. The informed consents was modified and further modified by the addition of parts poyer guidance of the pairns the parents of the subject who died delayed reporting the child's seizure activity for 30 hours, thus a new statement in the informed consents reads quote, if you detection any significant changes in your child's condition after discharge from the hospital, we recommend that you contact your health care provider immediately, closed quote. And finally five, additional ea's were reported in this subject and they included anemia, constipation and reddening of the groin area the protocol in the informed consistent send were amended to include these risks. This amendment to this protocol 516 will be fully discussed this afternoon by Dr. Crystal. And the reason for reading this into the record is to have it included in the amendment section. Okay and with that, I close at 12:15.

Yes, Dr. Bone.

One question on the 593, you stated there was that the investigators had extended the interval between cohorts in view of our discussion earlier this morning, what is that interval now the new I know Val?

I have not read the full amendment and we will look at that and let under after lunch.

Okay

Blood pressure

Other questions, thank you. , and we're now waking for Dr. Zurhasn't

It'll be about five minutes if everyone can just take a big breath and stick with us.

Dr. Zurhuney has been kind enough to join us and I believe as everyone knows, in this room, Dr. Zurhuney is the director of the national institutes of health. Thank you for causing.

Thank you. -thank you for coming.

Thank you.

first of all, really thank you for all do you for NIH and I'm here today to thank you, on behalf of NIH and the scientific communities. I had the very special honor recently to accept on your behalf the scientific freedom and responsibilities award of the AAA s at their annual meeting and Dr. Patterson was telling me about it and I thought this was an unusual events because typically the award is given to individual scientists or engineers and this year the AAA s made an exception and decided to award this to you, the advisor committee and I think it was an inspired choice on their part because it's rare that at one time you can recognize a cohort of scientists and public members who have contributed to the history of science and the way -- in the way you have. And I think these actions in recognizing I think what is a unique model of fostering scientific while being sensitive to societal and public needs that is a model that should be I am lated in many other areas and I was in particular as the AAA s said they're recognizing in addition to the excellent excellent work you've done the twins of transparency in scientific oversight and having an open discourse of the issues is always better than not having it. I think we're seeing this throughout the world. The reaction that you see in Europe or against GMO's, for example, is in my view a good illustration of a discourse that didn't happen with a transparency necessary that then led to really a delay from my standpoint in terms of the science that needed to be implemented to the same extent but maybe dinnerly, animal rights activists have really hampered research in the way that my colleagues are telling me is becoming quite concerning. But the lack of financial dialogue, the lack of a proactive dialogue that was in my view semitied by your exemplified by your committee is the reason why science has not advanced in those areas so if you keep providing a visible for all scientists and lay public to discuss the scientific safety and he go cal that recome ban -- recome Tant DNA was bound to recognize needed to be awarded a recognition of this magnitude. As my standpoint as director, when you become direct to have an agency you have a duty to look for its future, but we'll give you every opportunity to look good and this one I took because I thought it was great role of NIH historically from through it's many scientific commune to continue in many areas that are in this day and age also controversial, potentially model to in many ways provide a forum that is that is proactive in things like animal technology and stem cell research and things like biosecurity and research on select agents and so on so I think the model that you have through the past 30 years as members of this committee is something that I personally believe needs to be replicated and duplicated across the scientific enterprise. So it's my pleasure, I don't know how I do this, and it's been cleared by ethics. I'm okay? So I think you can accept it without any reservation, there's no problem, no one will argue, and I'm basically here to convey this award formally to you. It really deserves to be in the possession of the rack and all of you and really to be as a testimony to the distributions you've made and your commitment to public service. I always say that with pride when I go to Congress. We have 21,000 scientists who every year contribute to advisory councils, peer reviews, committees like this. Lately I think your discussions on the x SCID are enlightening to everyone. It was amazing that you reached such a balanced conclusion and this is a good example the latest example of the wisdom of the committee. So I know I'm just sitting between you and lunch. I'm now going to -- I guess I'll have the chair of the committee come and receive this award. Dr. Warren, this is yours now.

I'll give it back. Thank you.

It's very important to all of us, Dr. Zurhuney that you were willing and able to come this afternoon just to be here in the context of this award. This is all of our award and it belongs to all the members of the rack who served on the rack for the last 30 years, I thought that when we celebrate our hundredth meeting that we will celebrate in the fall that we should use this as a center fold as an example of the communities recognizing the work of this group in featuring transparency because I agree with you completely that it's the level of discussion with the public and the transparency that allows this field to move forward in spite of all the bumps in the road so thank you again for coming. I appreciate it.

Thank you. Have a good lunch. Bon Appetit.

I think I speak for all the rack members, to really think the oba rack staff without none of their work would take place which make our jobs easy because of the behind the scenes work, a sincere thanks,.

Agreed, and it was wonderful during the function presentation, large numbers of the staff were there, and it was really an award that went first to the staff and only second to the rack members so as always Dr. Lowe, thank you, thank you, all. Let's have lunch. , --



To begin this afternoon's session, we are going to respond to Dr. Bohn's early question regarding the amendment to 593. This is thanks to the staff who found it and have it posted electronically for us. You'll recall that in the amendment report I gave, I mentioned that the investigators had extended the time between cohorts beyond the one month that was originally proposed but I did not recall the number of months. It is four months, so there'll be four months between the completion and the initiation. Mix in order to allow a more complete assessment of risks. Any questions? We thought we'd put it up on the screen. Then thank you very much.

We're going to go on to the general clinical research center resources for long-term follow up discussion. And doctors Elaine Collier and Richard naysik will present for us. Dr. Collier.

Thank you very much for giving us time to prethis program that we hope will be good as far as providing follow up to the gene therapy studies that are ongoing and that lose their funding in the future. I'm just here to introduce Richard who's really developed the program, runs the program. He recently retired from the NIH, but he's agreed to come back as a contractor with us and is continuing to work on this important program. So I'm going to let him provide the details .

Jesse is in 1992 after an adenoviral vector drama tilz the trauma. T-cells that Lou keep areas that occurred in three after transduced stem controls highlighted a different Rob that serious adverse events may not appear until long after the patient's active program in a gene transfer protocol. These issues of acute and long-term serious adverse events must be consistent fronted to first maximize the protection of patients who volunteer to participate in such protocols and second, to understand the mechanisms by which untoward events occur. In addressing these concerns, the FDA now requires applicants for any gene transfer ind to describe their plan to comply with the berMac recommendations that were made in October of 2001. These are to provide annual evaluations for the 15 year period vold by the infusion of the vector treated cells and must include physical examinations for the first five years and mail in questionnaires for the patients for the subsequent 10 years to inquire of the development of autoimmune and neurologic diseases or develop of any new malignancies. Furthermore those individuals who participated in retroviral studies must be checked for rcr every three months for one year and if negative then have these blood samples archived annually for the rest of their lives. These data are then sent to the FDA. Those patients transduced by retroviral vectors are follow even more closely. These patients must undergo laboratory studies to detect evidence of colonial cell population and then annually for the following 10 years. If clonealts is observed the site should be determined. Again all data is to be send to the FDA database. Compliance with these mandates is straightforward and that's when supporting grant is active and remains funded. However, when the grant ends it becomes more difficult to ensure proper follow up will be achieved. For this reason, the categorical NIH institutes plan to include the following language or a variant thereof. In all future notice of grant awards, this statement or something like it will be conveyed to individuals who have received awards for clinical gene transfer protocols. And I'll read it with you. NIH acknowledges that the clinical gene transfer or gene therapy protocol to be supported by this award will require an ind and that the FDA currently requires all recipients of a gene transfer product to be followed clinically for 15 years. Should this grand expire prior to colleagues the NIH will payment sponsor and his and her grand deep institution to meet the regulatory responsibilities by offering support for follow-up visits for these patients one examined at a general clinical research center. This was conveyed in a January 2004 NIH guide notice to alert investigators of this plan. The warning is advisory because the NIH cannot issue directives to a grand deep beyond the life grantee beyond the life of the grant. This is to obligation to follow FDA guidelines and further will suggest that if the grants terminates that the institution should make every effort to provide appropriate follow up for the participants. The national center for research resources, NC rr at the NIH will cover the cost of seeing such patients if the visit occur at a GC rc. It could be either at the institution to which the award was made or at another GCrc that might be more suitable for the patient. The GCrc will then provide clinical space, nursing, relevant ven routine laboratory tests but it would be the responsibilities of the institution to cath the patient and to provide travel to the GCrc. This support is not meant to continue the original lip funded research activities but rather to provide a means to follow up after the grant is ended. If long term blood sampling is required, these samples could be obtain on the GCrc and subsequently stored at the repository at the Indiana university the national gene vector laboratory coordinating center. The Indiana site with the very generous collaboration of Dr. Krzysztof VoncalI at the Cincinnati's research foundation will also provide to provide clonealt with transduced with retrovirus. It comes covers the associated cost by supplements to the cooperative agreement. Our clan is to provide this service for all clinical and gene transfer protocols. If such patients were to be followed outside of a GCrc would be the responsibilities of the institute to support this through internal private or other sources of funding. During this follow-up period, we would anticipate that the FDA would receive documentation of the visits and the data acquired during the visit. The funding institute would not receive these data from the sponsor or investigator. NCrr would not be provided if the trial had been industry sponsor although resources could be used in these circumstances, it would be the spontaneous of the institution to obtain reimbursement from the sponsor according to GCrc guidelines. And, of course, principal investigators should inform the parents parents of these plans -- participants of these plans during the consents process. The purpose of this initiative is to help protect patients by detecting adverse events that arise long after participation in a gene transfer protocol and grant support has ended. So the comment in the notice of grant awards will be just that, it's a comment, not a condition of awards or a restriction. Our intention is to remind the NIH sponsored version of their spontaneous and alert them to the resources available to facilitate their compliance with FDA requests. It will also remind the institution of its long-term responsibilities upon acceptance of the grants. The links to the notice from last January or January of 2004 is up there. The link to the mgbl is in. GL b.org and the guidelines are available at the NC rr website. I'd be happy to answer any questions and thank you very much for your attention.

Questions from members of the RAC, Dr. Simari.

This is really an outstanding opportunities for projects that are going on with federal support. We generally don't think a lot about who the funding sources are for the protocols that we review. Do we have a sense of what percent of the trials are funded by the NIH that we review? Does any? OBA staff do we?

Yes, and sometimes there's an ad mixture but there's currently ban shift over the past several years but we can get the data because we do track it.

Is this great for 30% or 80 percent and what's left because obviously there are a lot of large trials that are outside of it? Thanks.

other questions, comments? Dr. Powell.

It was not recommend when it comes to the investigator. Is it contractual obligation on the part of GCrc's.

It's not a contractual it's just a willingness on their part to take care of this.

Okay. Thanks.

Other comments, questions? Then I'd like to thank both Dr. Maiik and Dr. Collier for not only taking the time to put together a workable plan but to fund the plan to allow the long-term follow up gene transfer subjects who are in studies as I understand it funded by the national institutes of health. Thank you both .

We plan to protocol to protocol 689. Dr. Federoff has rejoined -- rejoined on the phone and there is a number of us in conflict. These are myself and Dr. Lo, employees of ucff Dr. Simari who is a guest speaker and Dr. New Zefka who is involved in the these students using the ABB vector. I'm going to ask everyone everyone to remain outside the doors and hopeful that the portion of the discussion will conclude within 10 minutes. Thank you. With the departure temporarily of Dr. Worley you're asking Neal DeLuca to rechair the committee and guide us through the next few minutes discussion .

What I'm going to do now is summarize these draft recommendations. Draft recommend maigz, and they'll probably incur a little wordsmithing at OBA and then what I'm going to do is summarize them and members of the RAC, if they have any comments, please we can discuss them for a little bit and then we'll vote on them. And after they are reviewed, after they are reviewed at OBA and appropriately modified, then a letter with these recommendations will go to the sponsor of the trial and then they'll have the opportunities and the responsibility to respond. Okay. So let me begin. So the first point is to clarify the injection sites that will be used in the clinical protocol the next point is to provide data on the processing of pro n GS nurturing in neurons. The third.is in the absence of data in the mtpt monkey model in which the vector is put only in terminal neurons, this will be done in the clinical stetd provide history logical data in the aenldz monkey injectionsed in terminal regions with certify respect 120 CERE, on toxicity and I know flam inflammation. The fifth points describe studies pro teen in the biodistribution studies. The sixth point consider a longer-term -- a longer interval between subjects's injections in view of lack of rescue strategy. The search entitle point, make recommended changes in the informed consent form included added section regarding the permit genetically-modified brain cells, clarify the treatment of side-effects that may occur does not constitute rescue. State that there is no rescue strategy in this protocol to remove the gene once it is in the brain cells. And lastly remove any reference to treatment in the informed consent. So I'll open this up to the members of the committee and the reviewers. If I'm missing anything, if you have a question remarked any of these provisions, state so now Are you fine with those.

Yes, I am.

Now we'll provide with a vote. We need a motion first, okay. Dr. NemNemerow.

Ai. Dr. Bohn.

Ai.

Dewhurst.

Ai.

Dr. Johnson.

Ai.

Me, ai.

Dr. Rosenberg, ai.

Dr. Rosenberg.

Ai.

Dr. Powers.

Ai.

Okay. I guess the motion is carried. So you will get a form of to sponsor the trial will get a letter from RAC that may be worded slightly differently interest this but will capture the essence of these points and you'll be asked to respond to it. Thank you. Thanks to the study -- to the people performing the study for being so patient. Thank you.

And at this point thank you very much, Dr. Deluck can a and Dr. Wara, Dr. Simari and we should also be on his way back in and we can turn to the next protocol.

Thanks so much Dr. To do row of, thanks a lot.

Bye-bye.

Dr. Federoff, thanks, thanks a lot.

Bye-bye

The next protocol for presentation and discussion is entitled Phase I 1-a one two of antiPMS diner T-cells and in advanced mile Abe ambulate myeloablative conditioning and protocol 681 and Dr. Jung hundreds Junghans will be presenting the protocol for us. Dr. Junghans .

This is my second time here. I feel like an old hand. The title, under what it is, and I'll proceed from here. I just want to say that we consider this a significant advance in what we were trying to do previously with designer T-cells which we believe have a lot of promise for curing, I mean, using the c word. Curing cancers that are presently incurable and it's an ambitious goal and we need to challenge certain things to approach it and this protocol represents just an evolution in that direction. So designer T-cells fit into biotherapies between hybrid and many we mean antibodies that have had modest he have Casas in the colorectal cancer and breast cancer now where as therapies characterized by tumor infiltrated lymphocytes typically have modest efficacy in renal cell limb limboma higher high affinity for any antigen we can define and with that ability to antigen but antibodies typically have lack potency. Tumor cells and their cell fen access to virtually every tissue it's been very hard to make them selective or specific so we put together the specificity of antibodies together with the cytotoxic Poe tense cyst of it. Cells into a new type of therapy called designer t cells. And in this what we do is graph the bunion domain which is specific to a. On to the Zeta chain of the t cell receptor which is a multicomponents receptor and what this does this molecule called redirect the t cell this being the t cell membrane to recognize the tumor cell as if it was a foreign tissue. Essentially we're trying to fool the immune system to thinking that the tumor has a virus infection. T-cells involved to-kill ourselves wirs virus so the overview is quite simple actual lymph we have a parish with a tumor. We take the patient's blood and remove it. Cells I whichever variety of it. Cell receptors, alpha beta symbol up here which recognize anywhere a variety of viruses and pathogens that we've been exposed to and it's incredibly diverse. What we do is we do x vivo gene therapy so that they now carry a new receptor in addition to the old receptor and that this new receptor is the one that we designate to attack, to be specific for the tumor so we infuse these cells back into the patient with the tumor and ideally we like the T-cells to mounts an I am immune responses against a tumor until it's all eliminated so it's the big picture. We antigen a surface glik could he protein, it's abnormal progression site he wheel and prosthetic vase chur and virtually vase can a la your, high clinical relevant relevance 25,000 deaths prostate tumors. The antibody we got was from northwest biotherapeutics, Gerald Murphy who's past away unfortunately. Clinical retroviral vector is everyone in this room knows what retroviral vector is but we have our gene of interest in here, antiPSMA's. IGC tr it's a single molecule, there's no selection marker in here to be immune Jenick, no internal regulatory elements. We determine the presence of the success of our transducks by using flow sigh tomorrow tri, and we're able to modify the T-cells. This is cell number versus IGC tr expression and this shows our modified T-cells versus T-cells that have been modified rchs that's a good efficient efficiency. So tumor cell killing by it. Cells is by first by contact and then releasing lytic agents on to the surface of the target cell. I T-cells are green and tumor cells are orange and here the T-cells don't recognize the tumor cells. When the T-cells do recognize tumor cells we have a t cell bound to the tumor cell, t cell bound to a tumor cell. Two T-cells bound to a tumor cell then up here and these mag any facial, you can see that T-cells are the same size and the tumor sells are exploding. And the two cells , --

so psm negative prostate cancer cell line that does exist, PSMA positive cell lines were mixed with 1/5 as many gene modified cytotoxic t lymphocytes and then after 24 hours the tumor cells were assayed for viability. They control for a normal. It's not killed by the presence of these gene modified T-cells whereas the psm positive were 24 hours you're getting 9 po 95 percent of the tumor targets cells this is in vitro not a human being. So in, here an animal model where we had, we had, we're looking at tumor growth here versus days in the animal and the animal is injected on one flank, subcutaneously with tumor that done express PSMA and then the other that does express PSMA and then the animals were injectionsed with activated human T-cells or genetically-modified with igtcr against PSMA. If the tumor doesn't express PSMA whether is's no difference in the growth if you treat with T-cells or modified T-cells because they don't recognize the tumor as having an antigen of interest. However, in the case where the T-cells are modified to express the antigen, -- to recognize the antigen of interest and we have a tumor expressing PSMA, we see that there's large difference in the tumor growth and, in fact, for PSMA positive tumors with the desired T-cells we had half of the animals were tumor free at end of 15 days. Sthop establishes we can make the designer T-cells specific for antigen on prostate canker and we can say it's ready for use in prostate cancer but there's problem with using it and it's not problems with safety, it's problems with efficacy, we did a Phase I study of a product with antidesigner T-cells a few years ago, and although this is a heterool Gus system, we had hypothesized very simple that modified T-cells recognize CEA positive tumor, I'm changing systems here, that result in proliferation of the T-cells all through secretion cyto toxicity for a self-sustaining immune response so we did our Phase I study in patients where we took it. Cells, gene modified them and reinfused them and monitored them for toxicity and response. So in this Phase I, the number of doses was 24. We had 17 patients, seven with all two. There was a patient doses escalation so the number of patients is less. Five colorectal cancer and two breast cancer. Five of the patients did not receive Al two and two received continuous infusion ale two. One times 10 to the 11th. There was no grade three toxicity there was a grade four toxicity secondary to a grade two fever. a 103.8 with a patient baseline cardiac bundle branch block, with fever. So these patients are excluded from our present protocol but that was not fatal. The patient fully recovered. There's no delayed great for toxicity. They had low grade fevers. We expect that this therapy is going to have any effect it's got to activate immune functions. We don't have fevers from the wires. We have fierce from immune system reacting to the virus when we have the flu folks. We have one transients response and a minor transient in a breast cancer with cutaneous me it was Steese and then me it was ty me it was Steese.

This highlights one of the limits for the protocol for which we made the modification. And another patient recollect to cancer patient who had large mass, ret peritoneal and he had a lot of pain from this presacral mass for which he was medicated. When we first saw him prior to at time of enrollment he had a CEA in the blood of 800. Over a period of a month it went up almost another fold. We treated him with 1011 designer T-cells and at this point he was bed ridden so severe throwing up and not eating and we treated them with 10, 11. At then of the week the tumor marker dropped to, he became pain-free, walking around, eating. And feeling much better. But this is the important point for us today. The effect was limited in its duration. While we would have liked to see this to see, after eight days all the CEA started climbing again at the end of a month we were right where we starred and there was no change in the tumor when we did CAT scan. Proof of principal, biological response for desired T-cells but time limited efficacy profile. There's no.doing the same study with prostate. You're going to get the same result. Why didn't it cure? Immunology 101, between T-cells in order to be activated to have two signals: one is presents peptide in the mhc with the t cell receptor to get a signal one. Only on antigen presenting cells, interacts with 28 to get a signal two. These two signals together provides the essentials for complete immune response. What happened in our therapy and so far for all designer t cell therapies? We have a tumor with an antigen and we get signal one all you need but there's no b 7 on these tumor cells so what we had was a situation where the cb 28 on the t cell was not engaged. We know that signal one alone doesn't allow for a sustained t cell response. They die off. It's called process called activation induced cell death. We couldn't firm this the laboratory study that this is what happens. And what we have here is we take the same designer T-cells, and we're looking at it. Cell numbers here, not tumor cells. Take the same desired T-cells and grow them, we feed them twice a week with tumor cells expressing just the typical of what our tumor would have been having in our Patricia. If we took the same tumor cells these are T-cells, T-cells are dying off. Normally they'd be expanding just from the activation we'd given them. When we put the same T-cells on tumor that we've introduced the b 7 antigen into this now same T-cells are now growing happily so I go annual one signal one, signal plus two proliferation and that increases tumor cell killing. So we, you can use a by coast stimulation or bypass and the essence of this protocol is to bypass the stimulation and this is done by an auto transplan regiment which is adapted from a protocol which I'll describe later from Steve rose Benberg, the lymphoexpansive capacities of the body we're using a homiostatic mechanism which are not understand in the body but which can be utilized to maintain a steady supply of it. Cells. Okay. So the back out for. Tumor infiltrating lymphocytes, I can't say it was Rosenberg but certainly developed to maximum extent. In melanoma, for example, if you harvest a tumor and disaggregate it there are T-cells in many of these tumors and if you handle them properly and feed them tumor back and forth you can expand them to large numbers and infuse them into patients. So the problem is and they do get -- they have had responses and they even have had a few chairs although the aisle two given alone gives accounts for a good portion of this. So the responses that happened were not durable it's not available in melanoma virtually because it's one of few tumors that get it. Cells in it. It's technically challenging and not always reproduced in other students. What Rosenberg's did was, pan them but instead of I know fusing them back at this point they took the patient with chemotherapy which knockdown the bone marrow and infused these tell us which we've got in blue for your convenience. Infused these tell us and we, after human logic study, there wasen kbrafk not stem cells but T-cells into the host as a stable or reasonably stable population. And this large number of T-cells induced a much greater number of responses of which a number have proven durable. So what weed to do is to adapt this idea to ourselves. We have a problem with persisting T-cells after I know fusing them in the first generation just as Rosenberg had a problem with his tips. They'd go in, they'd be activated for a week and they'd tie off and that corresponds with what we saw in our Phase I study with desired T-cells. So we do t very well hard Cress and we do the conscience get the marrow knocked down the T-cells willen kbraft and then we'll look at tumor response. These cells are going to die from activation induced cell death but to quote a famous TV personality we'll make more. These T-cells will be here, we can make as many as we want and have them die. No T-cells dying after killing one tumor cell. One t cell may kill 20 tumor cells before it dies so we will have plenty of it. Cells here to do the job .

Treat scheme ma. T cell collection minus 40 my. These T-cells are collected and modified and they undergo microbiologic testing and initiate stimulation to mobilize stem cells. These are stem cells and the peripheral stem cell collection is done and we actually don't purify the stem controls, it's just saved as a whole hard advice because it's ought tall Gus .

Raerj numbers in the tumor than they were before. And the chemo regimen is down here. So the fades one study is typically with thee patients with, however, many dose level. In our case we wanted to approach an important Phase I because how well do we getten graph. So, so .

Fz how many cells we need to modify to get the engraphment we need. So 10 to the 11th or T-cells or six patients per dose level and that should allow for the peripheral blood for reconstitution percentage and at some.there would be a saturation because we only go to 100%. That's the maximum we can do. So maybe the 10 to the 11th and will be the ninth will beed a goose as these and at the highest dose level we do the biopsies that I mentioned. Expansion capabilities independent could he co-stimulation requires chemotherapy although it's designed to be well tolerated. Our patients are more susceptible to chemotherapy than the ones used in the Rosenberg study. Some have had irradiation, so we have prepared this peripheral stem cell rescue pack in case they need it so all technology right side available now. FDA find has been done. There are no clinical hold issues on there. There are some minor product hold issues. Rbi has been given r DC approval as awaiting the outcome of the RAC meek. The again vector lab is reviewing the proposal for making the vector funding it looks like as of yesterday we got funding from the Department of defense. That's unofficial, potential clinic cam start date roughly a year from now. Now, I prepared part of this address to some of the questions that came up in the prior to this meeting. Now I can just either take questions or I can go through the things that were addressed. It's up to you.

Doctor, I'd like you to go through the remainder of the presentation to include your responses to the questions.

Okay.

In the end that will be more efficient.

That's fine. Okay. So regulatory implications of this study, general ones are safety of ret to viral gene therapy and most of the initial interests by agencies was replication competent retrovirus because early vector producer cell lines were on occasion producing retrocompetent virus which we don't want. But this has not turn out to be a problem with the more advanced generation vector producer cells and we did not see it in our prior studies in the t GA 13 system and we don't expect it presently. And there's been no clinical problems arising from that. On general ong general in his, this makes it efficient for activating genes that are located near it. Most of the time that seems to be okay. But in instances which have come to light recently, it has led to t cell Lou keep areas. So occurrence of it. Cell Lou keep areas. Three out of 12 children treated for x SCID with kbam ma c.

It would have the leukemic patients had activation which is associated with tll in children and adults. And there's one with something else. I don't know if you had anything yesterday which was different to identify the genes.

Okay. We know there's probably, let's say it was not Alamo two because they were able to establish that this gene was not over expressed at the protein level in the leukemic cells. And we're here to discuss the relevance to other studies such as mine. I want reread this, this is part of my response but one of the things that's relevant we're going to be talking about first hit and second hit. One of the things that's relevant is is it possible to reduce the likelihood of the first hit? As I'll state my conclusion first. And you can see how I get to it by stating that I don't think we can effect the first hit. I think we're going to get the first hit. It's unavoidable. The reason simple mathematical one, this from a science paper which describes first two leukemic cases with the x SCID. The chance of I know graduation of any active gene is assuming one and 10 to the fifth. And they conclude it's each patient received at least one to 10 Alamo two targets because patients received this many precursors, they're estimating that only 1% of those stem cells is -- can be a t cell precursor. I think it's safer to assume a higher number than that and if you say a hundred percent of those are real stem cells meaning they all can become T-cells then we would have more in the range of a thousand cells carrying the Alamo two targeted gene. So more than one hit. Probably the best evidence there's more than one hit is when you take mice that express the Alamo two gene such as active in all stem cells and in all T-cells, only 10 to 70 percent of these mice develop a leukemia which is have a to what occurs in the adult. It's clone Alan lifetime of one year. It speaks for another even which is causing the leukemia and this is one of the conclusions out of the Hayesing bay, Alpena Don article for the leukemias and the SCID babies so I suggest additional factors leading to secondary genomic lymphoproliferation. So this is the idea. So a hundred perks let's say a hundred percent of patients the children as well as the patients I'll be treating have hit one because it happens x veanAlan it may be related to a number of cells modified but you have to modify less than 10 to the fifth cells to really reduce the likelihood of having that first hit represented. I will allow, if you had no first hit we wouldn't have to worry about this. But I'm saying that we can't avoid the first hit and get the engraphments that we need. Now so -- but and it's Dean. That first hit what is retrovirus you get into a cell, once it gets into the cell, and it will intergreat randomly in the chromosome. Hit number it works let's say 30% of the children got hit number two. That's I know vivo I know vivo, that is invivo, that is going to be related to the number of cells that expanded because a hit can happen at any cell and the more cells there are the more likely you'll have a hit all things being equal and it is lineage dependent. Only malignancy we're seeing is a t leukemia. That could be explained by the fact that these are the cells that were rescued, but at least the second hit is the hit that you need for foes T-cells that are expanding to become leukemic. So this is effective cell dose on first hip. This is the probability that the patient is going to get that first hit represented in the dose. Now, I'm going on the probability that there's -- that one hit per 10 to the fifth, there's a one to 10 to five chance that a hit is going to insert in the Alamo two on could he gene so we're only talking about one gene being affected here but apparently there's more.

Right around 10 to the fifth is where you have a 60 percent probability that the patient's going to carry a hit in the Alamo 2 gene. And if you go to 10 to the sixth cells, there's virtually a 100% of the doses that you create of this size, it's going to have the Alamo 2 hit and once that's there, you know, it's there in a fraction of 10 to the -5. It doesn't matter if continue to the nine cells or 10 to the six cells. It's present there in that fraction although there may be more cells here that carry that first hit. But remember, your second hit is what you're worried about once the first hit is there, the second hit, that's going to be determined by the final number of stem cells or T-cells or whatever's at risk. For example, if we said it. Cells were at risk which I'm not saying they are, the child has 10 to the 11th T-cells and to the -5 of those T-cells carry Alamo 2 hit so that child would carry after the T-cells expanded to the 10 to the sixth T-cells carrying the Alamo 2 hit fan we started -- it doesn't matter how many cells we starred with it's going to be the fine number that counts. In the adult you can see we had very 10 times as many. So think about the second hit now. X SCID versus cancer. Insertion Al events for the first hit are the same. And I will say they're saturated. Now maybe possibility on the x skidz to SCIDs to expand those stem cells befored a stherg them, but we'll have a problem because we can't get the expansions, rebegin nation might be part of the risk .

These T-cells at least in two of the patients who had CD4, cd 8 did you believe positive, gamma Delta T-cells as one leukemic case that that's an early t cell so these are suggesting these things are occurring early in the t cell ontojny and all then sdrims shut down. And then there's the other question mark. Why do children get it. All virtually and adults not? You can find cases in adults .

This slide shows the TV entojni, mutation Al events are occurring which are causing the leukemia this so-called triple negative, double positive stage, single positive and mature T-cells the beta rearranges early, the gamma Delta rearranges early. The beta is prior to the mature T-cells and one of the patient 5 had three t cell receptors of the same jewelry arrangement three tcr betas so that.

You've got events occurring here, here and here that indicate that the mutation Al events are occurring early .

Now what is the consequence of gearing designer T-cells or not giving designer T-cells. Designer T-cells don't do anything therapeutically and they still die in about a year that we project for this treatment group and then there won't be any leukemias, and they'll all die in this tame period so this was years along here so roughly a year of survival with no treatment. So the best situation and hear what here for if we cure this cancer these patients are tends, let's say they might live 10 years. If we cure the cancer and there's no leukemia they will live say roughly 10 years. If they get leukemia they'll have to live three years to get it and if they may about it if we use the same percentage to get leukemia assuming stem cells are not different than T-cells. We have to have a tremendous prolongation of these patients' survives by doing these treatments even if a hundred percent got leukemia we'd be better off. So then the came came up what about using suicide gene? suicide gene is a nice idea and it's a good thing.

Doctor, I'm going to ask you you to.

This is the last one.

Great, thank you,. You've done it.

Sorry. Suicide gene. Suicide genes are made with the retroviral vector that would have our car Merrick Kai Merrick and the herpes TQ I'm against it I'll state that right up front. There's no data to support the need in our patient group. Probably a hundred adults have been treated with modified T-cells. There's been no absolutely keep areas. They weren't there a long time you can argue, there is's other reasons too. If cures are obtain with rtc cellen kbraf. We'll maybe we'll find a way to deal with it then. This suicide, our real problem is efficacy, we have to show if this stuff works to make sure it's worth while to give to anybody. We've shown that it is endangering, shortening these people's lives so if it's immuno Jenick it may reduce the efficacy .

As you put more genes into this you Redus of the efficacy of the vector and it complicates the vector and it's impossible to get rid of a safety feature that isn't needed because various risk issues, financial and otherwise. And to make such a vector would increase the delays to test the efficacy and there's no began that this will work. If you have 10 to the 11th leukemic cells and you want the cells to kill without mutated out of those 1011 cells, it may not even work. Okay. So potential for leukemia and cancer in this protocol is unknown. We need data. Some cured patients may die from leukemia but if they do, it's prolonged, it will have have had to prolong their life like bone marrow transplants where we accept some patients will die from the treatments but more will live. Future modifications or treat the leukemia as we know what kinds kinds come up and there's a cost to delaying to figure out the solutions, each smooth of delay of trying something that might be effective, it costs a life of 3,000, about 2,000 cancer deaths from prostate cancer. Each smooth and our best option in my opinion is to treat now, get the data, and we'll apply the solutions when and if we need them .

Thank you very much. Dr. Junghans, Dr. Rosenberg, I think we'll ask you to start. Thank you.

Thank you very much for your prescription and for your effort to respond to the concerns that we've raised. I think for the purposes of the record, I'm supposed to note each of the questions I raised. I think some you've spoken to and there are some other issues that I will ask some additional questions about. I think my first concern -- and you've clearly noted this -- is that there has been the third case of leukemia in the retrovirus trial. And that that raises issues of concern for retroviral vectors. You've given us some of your thoughts on that. One of my issues in this area related to the multiplicity of infection that you expected to achieve. And you did discuss that in your response, but I would know completely clear as to how much of that was based on theoretical assumptions and how much of that was based on actual data, and adding to that, your method for enriching for the expressing T-cells that you're subsequently going to infuse is flow sigh come tri and I assume.

You don't enrich.

Speak into the Mike.

Oh, sorry. There's no enrichment, we just modify them and they have to have minimum 10 percent.

And then you use the whole thing. I would like how much still for you to address the first point as to whether your multiplicity calculations are based on assumptions or data, and then given that, I'd also like your thoughts on the fact that if you have a significant percentage of your cells, your estimates were around 10 percent, that would carry as many as three I know certifications. What your.

Three his that could contribute to persistence or proliferation of those cells once they are infused so those are my comments regarding the multiplicity of infection issue.

I raised a question about the high cell domes. I think you've addressed the need to use cell doses in your presentation. I raised an issue about participants showing evidence of expansion of particular clones. You did speak to monitoring of the patients for that. You spoke in particularly your responses to us but less so here, concerning the persistence and potential proliferation for the infused cells that you will be giving. You did present information about using the mile he will ablation couple with the Milo two team transientsly expand your population and I'd like to here you say a bit more about how much you anticipate the infused cells to expand and how long you expect these cells to persist in the individuals hair's going to infuse -- that you're going to infuse. And the he is final note to the Kai newerrik and the itc response and I think you addressed that in your written remarks so those are my comments.

Just a general question. Madam chairwoman, would you prefer that I answering these following each question, --

I this at the end. All of of the individual's questions I'd like you to address them for us. At the risk of omitting them by Zen multiplicity of infection is purely a calculation just based on statistics. We have not done anything to try and characterize single cells in terms of their insertions and that would be I think the only way to do it.

Well, I might suggest that you could get an idea of the number of pro viral copies in your population in a way that would be much simpler than what you suggest. Clearly that would be an average across your population, but it would still--

Right.

With the information on that point.

I presented the mean number of insertions per cell in order to get 60 percent modified, the mean number would be .92 insertions per cell, have 60 percent of cells modified at least 40 percent unmodified. So that would mean that instead of 60 percent you'd have to tell 90 percent. So that mass of just a 50 percent at one to 1.5 change, depending on how you calculated one third or 1/2 change would be hard to measure by any quantitative method that I know.

Not to belabor this point but I don't have have any information that all cells in your population are equally infectable so given that I think calculations that are not based on data are certainly subject to error and I believe in that calculation you're assuming that all your cells in that population are equally infectable if I understand this correctly so I do think it is possible to actually experimently tells the number of pro viruses on a per-cell basis in your population relatively easily.

I can tell you at least at the level that we're able to create t cell substeps such as CD4 versus cd 8 that there's no difference at all in the infection efficiency of those two. I mean, you could try and find other subsets that might be more or less susceptible but these cells are all activated and proliferation -- proliferating. When the infection takes place could make a difference but that's beyond our kind of technical ability. I guess where it gets, I would probably like to -- I'd be happy to supply you with any samples we have or if anyone in the audience for this to be a scientific question to address, but I think in terms of our issues I'm bringing it back to the clinical again that my urge to treat these patients and will that information affect whether I treat them or not and I think right now we're collecting envelopes without really knowing how to use it.

I'm not sure that we will reach full agreement on that particular.but I'll certainly allow you to move on to answering of the other questions.

Yeah. As far as the risk for the third hit or second hit, you would have to have them, if you go by this math that I was presenting if you had 10 to six cells with the first hit, then you would have to and if you had the second hit in -- you'd have to have probably 10 six cells in first or second hit so it's conceivable if you had that in there.

I guess I would just suggest that we don't really know the sequence of events that have occurred in the x SCID trial that we're all aware of and so I think a reason that we're raising these questions here is that so much is unknown there, it's very difficult to try to extrapolate, and I think that raises a need for caution even though your circumstances with the work that you're proposing is quite different.

No, it could be, you could have that second hit there certainly. And the question of the aisle 2 with after nonmile he will ablative conditioning.

It doesn't we've used this rnlz.

I just gave a seminar in rosenberg's group and my protocol uses four days of aisle two versus he was using five days and he thought that was a useful modification although mine is lower dose, we believe we can achieve the same goal.

I guess if I could follow that up, my real point in asking the question was looking for data or information on the time of survival of the cells that you infuse and some assessment of the percent of the cells that you infuse that persist over time in the individual.

Okay. All right. I was confused the aisle 2, I don't think is part of that answer. I think that the engraphment will happen because these T-cells are induced into a vacated space created.

Right.

I think we shall on the expectation that these cells are going to be with the patient for life and they may account for 10 percent of the patient's total T-cells and we F we take the round number we'll have 10 11th carrying retroviral insertions, but, again, this is whether it's the dangerous or not.

I think so. So do you have actual information that would allow you to know that, indeed, these cells remain in such significant numbers from Iraq your prior investigations or animal studies or --

Well, we have the best data I think which is the most Curran and the most analogous situation was the Dudley group where they infuse tell us, and they will able to tell the presence of the tills, they were one, one top of it. Very well receptor was expressed on the spas of these cells and so they can follow them. And they're persisting in the individuals where the engraphment was shown and persisting for several months and they may persist longer and we have to consume if we have a successful engraphment they may persist for a year, they may persist indefinitely. I can't really make an argument against them not persisting. And just to follow up on that with one additional question. Given that quite a large number of these cells have -- might have the potential to persist for very long periods of time, do you have any information on the frequently -- frequency of those cells that might be stimulated to divide further as a consequence of an immune response or some other event potentially during the life of the subject?

Except for the fact there's retro viral vector in these cells. The only thing that sdwishz these relevance Cress dwishz these cells from the rest of the cells in the patient. They have, if we're successful there won't be any of that left in the patient's body.

And so there won't be -- the on time that we have stimulation will be in response to the cancer being present. And so they will not have a reason to proliferate, and they will die from activate -- activation induced death from t cell anyway so we won't have a situation where you have continued restimulation expanding these indefinitely so I don't think that that's a concern here.

Did that answer your question?

Thank you. I think I'm -- I just have one question for you Dr. Rosenberg. What are we recommending that Dr. Junghans do practically to address this concern?

I'm not sure that there is an experiment that can be done to practically address the concerns. I think it's important that that be noted.

Okay. Dr. Friedman.

-- Dr. Freedm ANN.

Dr. Friedman.

Something's going to fall here, I'm afraid. Okay. Well, thank you very much, and thank you for your responses to my questions that I had. It's very nice to see the issue of designer T-cells moving in these directions, and I think one of the major attractive aspect of this study, of course, is it's such an important clinical problem and that you're designing innovative new ways to attack it. The -- I have to admit that I was reading this protocol at a time when I was looking for reasons to connect it with the x SCID study and that is the -- with a came to me as similarity in these conceptual similarity in which one is retrovirally transducing p OE -- poiet IC where they're asking for growing advantage on your case and has been grafting within a more preconditioning. And it struck me that not really understanding that really didn't understand what conditioning was and whether it is or is not immunosuppression or immunocompromising but if it's not that's one thing. If it is a form of immunocompromised state then I found myself in the uncomfortable condition of thinking all the way that while that sort of the prudent approaches to retro viral media to gene transfer into Houma to poetic stem cells, and we're, and it was those questions that were at the heart of the issues that I brought to your attention that are similar in ways to Dr. Rosenberg's points that she just raised. So what I was concerned about was the following, and I think there were five initial points that I sent to you. One is I felt a void in the discussion of characterization of the transdeduction and integration events .

Whether it is or is not important in this model to characterize that, it struck me that perhaps it would be prudent given all the surprises that have come from the x SCID study to at least have some of that arm men tarium available to you and it seemed to me that it might be use foul at least raise the question of whether you might might not want to.

Hematopoetic model that won surprised that that it surprises around the corner.

I wanted to hear your thoughts on that, so that was point number one.

Point number two was related to my concern about the effect of preconditioning and if, in fact, that is being done to enhance the engraphment of the cells. Doesn't that in itself suggest that it would be wise to anticipate that some of these more effective graph cells -- that you will very more of them and that they may be growing under conditions that they would not have been growing in the absence of nmr conditioning and all the more reason to do preclinical animal studies in nmr treated animals to ask about long -term.

The third.was and I hope that you'll sort of straighten out my muddled thinking about what NMR prekicking is, is it or is it not immunocompromised to the animals becoming immunocompromised? Third issue that I raised for you was a question of the suicide elements and other ablation and reversal competition and I quite take your point and agree that for a number of reasons one doesn't go into that sort of issue lightly. First of all, the technology isn't there. Maybe that's one of the best reasons not to worry too much about it. But -- and I also take your point that what you want to avoid is the induction of antigenerals and row kpree myselfing the design of the vector and the efficacy of the vector. I didn't quite understand and not sure that I agree with one of your answers to the questions of suicide and reversal elements that doing so in this model might sort of condemn I think was the word you used all future models, all future retro viral modification of hematopoietic stem cells to offer the same requirement that every model hence forth will have to include a suicide element or reversal or ablation element. And that I think I'm not sure that I follow that and if, in fact, the times require that and the March of technology requires that we think about that, then we have to think about that. So I'd like you to expand on that a little bit. I asked about the issue of archiving blood samplesless for the long-term evaluation of subjects and what molecular and cellular assays you would think about using to detect any shifts of populations. You answered that partially. You domestic violence really -- and I think you said at least follow up studies would be done for long periods of time on immunoscope analysis. But that seems to me a good place to start but wondered your thoughts about molecular contact sayings of the cells. I asked sort of the ethical question and I think you answer it had in a way in one of your late fines. The question of whether this population of subjects and patients with prostate cancer that failed everything else, whether the requirements for the sort of characterization of the system that I just went through in the first three points is somewhere weakened by the fact or is different because of the life expectancy of these patients and even if one were to assume a leukemia two or three years down the road, maybe that's not -- maybe it's not the same ethical quandry as it is in the x SCID children, and so I just simply I'm not sure there's an answer to that question but I was interested to see how you would pause the egg cal concerns of the two different populations of patients. I think you answered that more or less in your slide. I suggested that you might change your consent form and the consents process to be updated on the third case of leukemia and you've done that. And one other point that occurred to me after your presentation just now was the question that has come again from the x SCID model and that is completely unexpected possibility in that model that the gamma c chain itself is an oncogene and that, in fact, the viral transduction of that provides not the first hit but provides two hits, that is the integration hit and the introduction of an expressed oncogene. I must say I'm confused by all the descriptions of first hit, second hit. I don't know and the x SCID model which I don't know how many hits there are, I don't know which comes first, which is second. I'm not comfortable with the argument based on the number of hits, the theoretical argument. But have you considered the possibility that the sky Merrick -- Kai Merrick and the transduction of that is the double whammy that predisposes some cells to tumor genesis. So those are the initial points plus the added one and perhaps you can you can approach the one that says that you didn't answer.

Okay. As far as the issue of the minimal number of cells that we can modify. If we can at least just say to the one, two-hit model for a moment. Ideally you like to avoid Alamo 2 insertion or whatever hit you call that. It's impractical, we can now approach the therapeutic goals with that requirement. So we have to live, I don't know the SCIDs may find a way may find way around it, but I don't know that we can't. So we have to live with these higher numbers. We lose efficacy if we don't. And that's -- let's see. The next point about the nma, it's not myel ablative it's nma conditioning, it's whether there's an immunosuppressive but the duration of the immunosuppression we do this all the time is two weeks to a month. We get, you get immune reconstitution. You take the patients off their antibiotics when their white cell gets to the right level. Is the timing that reduces the level of concern about that?

Frankly,, I don't see the role. If you're interested in the expansion of the T-cells going from nothing to a lot or going from a medium amount which we infuse to more, that happens every time we give chemotherapy. And we are not getting -- the chemo -- the cancer is induced by chemotherapy are for myeloid leukemia and infrequent and not lymphoid. So it's not, I don't believe that this is happening just because the T-cells are expanding. What we do a lot of times with many cancers where T-cells are expanding so we should be seeing problems with that I believe. So there is immunosuppression so the patient is protected from infection and observe for that during that period, but that's not really a retroviral.

You may want to change the language then because I think in one protocol somewhere you said that this is not immunosuppression because it lasts for such a short period of time.

I'll look how I praised that but I didn't mean that. It's certainly immunosuppressants. Let's see. Leafs a point about whether it condemns us to stick with -- you should stop me because if I'm skipping over one but whether we're condemned to have having the herpes tk in there once we have it. I am thinking what we have to go through to get a product approved and let's say the T-cells only survive for six months in the patient but we get no leukemias and then you come in three years down the road and let's say that you would like to get rid of that. Maybe you've cured 20 percent of patients and 80 pars you haven't and it correlates with the loss of T-cells. This is a scenario. And then you say, well, I want to go back because we had no leukemias and do this vector again and you need to do this again through a Phase I, Phase II, Phase III without the herpes tk because maybe they'll survive long. Those T-cells were Elim gnawed. So then you have to go back and try and do that. At this point the company may have invested or not. They're not going to -- it's already a money to one of these studies and have to go back and repeat it because you take out an element would be terrible. We want to protect patients but we want to make sure the protection done get in the way of us helping them. And to balance these things. We may need to go to this later but let's get the data first approved that we have a problem before we potentially create new problems by inducing the solution that may not be needed.

That seems to me an appropriate response, an appropriate attitude but if the life expectancy of these subjects were much longer or if these patients were much younger and given the same technology that you're using, it seems to me what's driving the conclusion that certain technologies do not need to be Incorporated in this protocol is this balance of fairly short expected survival time in patients as opposed to the much longer presumed time required for the leukemia appearance. And it's the time -- if the patients were younger, it's the expectancy of these subjects, life expectancy was longer, would you have the same responses to the issues of suicide reversal elements, insulator sequences and whatnot, and if it's something that particularly urgent in the prostate model that drives you to this position?

I think part of the problem that happened with the controversy over the therapy deaths associated, the els singer case was not that a patient died from the gene therapy but especially as to whether the situation was urgent enough that there might have been other ways to keep this child alive or teenager. And I think what, you know, I think we raise a very important point but we should choose situations exactly like the situation I'm presenting for you today to test these things on, not on the nine diseases or not on diseases which have life expectancies. These patients are -- have tried a lot of things. They've been through a lot. If they're coming to me to be treated at this point, that's because they're saying, look, I've got nothing to lose, --

you're absolutely right that you're designing for a different study. It's a very difficult time now to design a retrovirus mediated hematopoietic model protocol. And unfortunately everything is going to be looked at through the spectacles of the x SCID model and so you're kind of -- you've done a very nice job of responding to the differences in models and I appreciate how difficult it is. And I think you've responded to the rest of the issues quite well.

Okay. Thank you.

You did want me to address issues about characterization, ethics and the Kimerrik characteristics. Characterizations, again we are happy to supply any cells, any samples to an interested investigators who would do this. I think given limited reef sources for running these trials, and given that I would have to probably hire some different kind of person to do these studies.

Is that what you meant by you would go into this effort if you had a mandated --

Yes, in other words, a funded mandate.

Funded mandate.

If RAC comes on and says --

Right, we know about that already. So we would see, -- we would happily saw samples, I think it should be done by labs that do these policies. Ours isn't the only study doing this work. Only --

How about the last issue of the oncopotential for the molecule?

I feel pretty comfortable with that because these T-cells actually are not continuously activated. They go into a resting state. They die off without aisle 2. They actually senest in cull churchl we're not putting in anything that doesn't exist there already. All we've done is given a new specificity. If the antigen isn't present, they're just going to go into resting state. If the antigen they'll be activated but they'll die of induced cell death.

But c chain is not something that's not there already and there's a noncontrolled vector, it turns out that at least some evidence is pointing to its function as an oncogene or sort of cooperative oncogene in that x SCID model. We don't know. But the fact that it's usually there anyhow doesn't comfort me very much that it's going to act the same from a transgene state.

Would you allow that your connection with the gamma c is controversial at this point?

I would hope that you would say that.

I'm not saying it has anything to do with the oncogenesis but since we don't know what -- all we know at least in two of these there's Alamo 2 is activated and we do knot any really -- and rarely ever do what other hit or hits were involved.

We did hear yesterday in the safety symposium that there's some evidence in mouse models for cooperation between the Alamo 2 and the gamma c and that seems to be a story that's emerging now so it's controversial perhaps. But it's looking as if it's back by some evidence.

-- backed by some evidence.

Were there further questions?

Okay. I'm next. And you have addressed the majority of my questions so I can go quite quickly. The first was I asked you for reasons that have already been covered to consider the risk/benefit of utilizing these modest to high-doses of sigh toxin and consider the possibility of including the suicide gene in the vector and you've addressed both of those as fully as I think is possible. Second, I asked you fairly naive question. I wish there were a different question and yet concerned the possibility of any animal model for the designer T-cells plus the proposed aisle 2 following nma conditioning. And at least in writing, you said that that was not possible. And you're still -- it doesn't mean -- did you mean that it is not -- that it's financially unreasonable or that such an animal model just does not exist which is the way I interped your answer?

-- interped your answer?

To get the equivalents number of T-cells in the mouse as in a human you would have to have at least 10,000 mice.

It's not feasible, I'm sorry that that's the answer because it would go a long ways towards resolving all of our unease about this approach.

I came to that given roughly 10 to the eighth T-cells and 10 to the 12th to a human so that would be 10 to the fourth difference and it might be off by a factor of 10.

And my next question has to do with long-term follow up and I asked specifically what laboratory monitoring for cloneAl ty is planned. What the frequency, where they will be store and if cloneAlity will be used to document integration and you provided us with some generic responses. I'm wondering if there might be specific responses to some of those issues?

The general problem with doing all of this monitoring is it's not apparent until quite late in the stage of the evolution of any leukemia.

Could you use the microphone please.

Sorry.

Thank you. The problem with the generically with doing this monitoring is that it's not -- you really can't do a lot that's effective until you know you have a leukemia and you don't really know that until you come to the point of it can apparent by increased cell numbers, for example.

Well, -- or flow sigh tomorrow tri, even that's difficult. I'd like to suggest that one of the reasons that we as a scientific community has been available to learn as much as hafb learn from the French experience is the meticulous nature with which follow up samples were reserved on all of those subjects. So then when a clinical issue did come up, unexpected clinical issue, the investigators were able to dip back into their reserve samples and provide an enormous amount of what I consider basic scientific information about what happened.

I didn't mean to imply. I absolutely agree with that. We collect samples and archive them. I'm just saying that those elegant studies that you saw were present retrospective on archived materials.

That's correct.

We don't have those archive materials. That's the media's part. Certainly no question about that. We want to know as much, God forbid, we have a leukemia, we want to know as much about it as possible.

You provided a fine answer to that if clonealitc kpid.

With regard to the informed consent I asked about the duration would be after the study answers.

The guidelines are three months, six months. My response to be reasonable to keep samples every three months, a lot of patients alive and I think recommendations from this body in conjunction with the FDA should try and do this in the standardized way and be happy to comply.

I asked you to consider modifying the risk section to include the three instances of leukemia and the death of one child in the x SCID trial and you have done that. I asked you to put the risk of autoimmune disc in the informed consistent isn't. If you can -- consents. If you could comment on those last two things for me.

I think the autoimmune question is easy to include. We haven't seen a problem with it and other people haven't with the tc therapies. It's a theoretical concern which hasn't reared it's ugly head in practice but definitely I agree. We will put that in there. We'll also include the request for autopsy.

Thank you. Dr. Powers.

Yep. I had two comments and questions in my initial review. The first one had to do with the form consent document that I asked that additional risk including autoimmune and the experience with the leukemia and the third SCIDs be included and you've identified that in your written and I like your informed consent document, it's clear and well organized and somewhat spare for some's taste but I would call it streamlined and quite prop for this unfortunately well informed populating at this juncture. My second comments had to do with the long-term follow-up in monitoring and these are the same questions that were raised by doctors Friedman and Wara already and I think you've addressed those reasonably already and I think that most of my colleagues have other specific. I think that's reasonably clean enough. I took your.from the RIBs leading the 10 years on the theory that it might mislead people to thinking they had more 10 more years of follow up to come which is amusing but not unreasonable so I have no further unsatisfy concerns.

Thank you. Are there questions or comments from -- Dr. Sumak.

I wanted to make a couple statements about long-term follow-up. Cloneality and this is for all retro viruses. Follow up for retroviruses, we are talking about clinical, talking about subjects, okay? Currently, as has been discussed many times, a subject will have to be monitored for six to 10 years after that for questionnaires so that's personal, you know, subject monitoring. Currently we have a guidance document out there that says for replication competent retrovirus, samples are taken from first two years, they are archived for the lifetime of the subject, not 10 years, you for the lifetime of the subject. Now this may change. We are currently working on a long-term follow up guidance document which we'll probably try to get everything in in order but right now it's for the lifetime of the subject. And then we talk about cloneality. It's not judged for x SCID. We ask all the sponsors to provide us with a protocol on how they're going to monitor for that. Now clearly, if you're talking about stem cells, we look at that very severely because they are proceed live rating cells and that's important and they have a higher risk. We recommended for everyone else but we look at all the protocols. We look at how they're going to look at it. Initially when you have transduction you have mixed population, so it's difficult to look for a colonial population, but we do cloneAl. So that's a guarantees that this will always occur.

Thank you for clarifying that for the record. Given the FDA requirement, is it not prudent for every investigatory include at least a ters outline addressing that requirement in their protocol?

Yeah.

I think that's what you heard the response to from the group this afternoon was, you know, we appreciate your consideration of these issues, Bach in your written response and today in your verbal response, Dr. Junghans, but seems to me that should be an expectation on the initial protocol.

It is. I guess the point I'm trying to make here is but you have to understand there's not a one okays-fits-all. We look at the product, we look at the fees be the of what they're looking at, we look at the cell. All things are taken into consideration but that is part what have we ask.

Thank you for the Claire Fay -- clarification. Other questions, comment from members of the RAC.

Yes.

Can we revisit the issue of the model, whether there is a model and your comment about there's no data for the need for p Tk and so on. You showed us efficacy data in your mouse model where you had SCID mice with a tumor. Could you not take those mouse with tumors to get antigen stimulation and transplant the transferred T-cells between mice over many generations to see whether you're getting an expansion, an expansion or out growth of specifically modified cells over long period of time. So I think in the context of Dr. Friedman's comments and so that clearly we're looking at all of this through the spectacles of the SCID trial information. And there's an opportunity an opportunity to test some of those issues in the SCID mice where there's plenty of room for expansion in these T-cells and you can transplant those T-cells in the mice with and without tumor and that would address the issue of the transgene to serve as a -- hit one -- presumably also they'll see continued antigen in the presence of an infected pros -- intact prostate. So I for the record, I think there is a tune to test the persistence of these T-cells in immunocompromised mice with southeasterly transplantation to see if we get any sort of preferential expansion of any specific clones. And then my other point is just the points, you think autoimmunity hasn't raised the ugly head but in the Dudley paper there were autoimmune fan if he is taigz in that paper so I feel strongly about the first point which I'm missing something that is more than possible. There is an opportunity to test some of this and it would not, you know, it wouldn't take huge numbers of T-cells that you're talking about to do that. And it would then give us some idea as to whether tk and you could also a vector with tk to get the sort of data that would stop all of this -- not stop but would help address or the hip they tell cal issues which were addressed.

So two points that you're making. One is the animal model and propagating the cells through mice until you get basically the 10 or 12 T-cells. The first problem is although we've had some success with SCID mice in terms ofen grafting myel loid or other elements we have absolute failure with T-cells. Human T-cells are not happy in the mouse. And there's been no satisfactory model. It's has been a major frustration to researchers in this field. We'd love to have it. Cell model, a mouse that would support human T-cells. We don't know why they don't survive. You can infuse them, you can inject them. You can stimulate them from stem cells but they just don'ten graft. Get anywhere near normal numbers.

And the therapy model.

These are -- the T-cells are very short time. They will die from action -- activation induced cell death. If you don't get the tumor cured within a week, basically, then the tumor's going to grow and impede it. So there's no evidence for persistence of these t. cells in terms of a late effect. And many -- I'm not a specialist in human cell engraphment in mice at all. We have worked with them as a model but other people much more focused on this than I have tried to get it. Cells to end graph and populate, and it's been a miserable failure.

Is it possible to do the same sponsorship with mouse T-cells.

The experiments with the Alamo 2 mice, for example, you've got that first hit. We already know the 10 to 70 percent of those mice will get a leukemia. So I think that the real question is what's going to happen with human cells. Now to do it with -- I'm willing to concede the worst case that maybe all these patients will get leukemia in three years, but we would still wants to, you know, treat the patients collectively to find out if there's a problem. You know, it may be that none of these patients can because their T-cells are mature. You can do a model in mice. It's very complicated as I outlined in my written response of how you can address whether Alamo 2 expressed in the T-cells is going to be on could he Jenick but you can't do it by -- oncoJenick and you can't put them in the mouse because the leukemia may already be there and it may have come up during the stem cell state. So you can do these experiments, but, again, nape not help us decide what's going to happen with humans.

You can do some of these experiments. You get human T-cells to live. Sorry.

Could.

Second point that you had -- about immunity. Yes, you're quite right. The autoimmunity is seen as the same antigen that's targeted in the melanoma . The targeted by aisle 2 and that's in the consents form, in fact, there's correlation patient who get have itligo are more likely to have those. But we vansed path jik life-threatening side-effects from any of these t cell therapies. Do they have PSMA?

They might, I don't know. They probably do.

, so you might expect the transferred T-cells could have some effect on the mouse's prostate?

Our antibody's mouse which would be toll ran so that shouldn't work.

Doctor.

One of the problems that we face offer by the time you're ready to go into clinical trial the vector or cell is sort of outmoded and at least in terms of my reading, using just c 3 state. Cc 28 cyto blast Mick domain and the ethical questions. Should you be going into a subclinical trial although there's production issues and have to catch up and what are your thoughts on that.

There's two strategies. One is to include the signal two in the vector in the design molecule. This is another strategy and I think since we're dealing with efficacy on any of them that shows it's effective it's fair game and when we do, you know, drug trials in oncology, you get something with some efficacy, you have to wait until you try it into the clinic to decide if it's better or Mott. People have raised the question when you have the cd 28, you've got signal one and signal two right next to each. Maybe you'll get spontaneous proliferation and all these things. I've got a vector like that but you can't really combine them. You know, you might be able to combine them but someone might say you better test this with the one vector first before doing a nonmyeloablative conditioning but I'd like to try this as approach to bypass the activation induced cell death. It's a strategy, it may not be a final one, but we'll learn a lot by doing this. .

Let's just say the sake, there to be second hit. You would get that of our calculation that each gene be hit in to the fifth cells. order me to start with to the fifth LMO2 positive cells, and I would... get that, I would have to to the 10th cells to get to the 10th would give me that second hit somewhere in there. Now, the -- most we ever able to get modified is about 5 to the 8th. That would be of that happening. That be that of those the fifth two hits whereas we are calculating percent so we down around chance we two hits in that. Just doing math. I'll write that out send to

Doctor, very for this afternoon address our questions. I'd to proceed, though, and go through the recommendations and I have accumulated and that remain perhaps not completely resolved. General concern is the which all know, the third in the French X-SCID trial reinforces concerns about retroviral vectors. The RAC notes there may be persistence of and potential proliferation of the infused modified T-cells. The extended duration of modified T-cells especially the use of NMA conditioning may pose risk, the of this potential should be assessed in an ongoing fashion. the preclinical level, RAC recommends that the unanticipated events of leukemia, the X-SCID subjects, it is prudent to pro viral copies in the cell population, the infused cell population, order to mult thricety. -- multiplicity. RAC suggests the NMA preconditioning may it more likely that long-term engraftment and modified T-cells will occur and may have untoward effects. it is prudent to continue the search for an animal model the conduct of preclinical studies using modified T-cells and NMA conditioning. The RAC recommends the investigators be mindful of the potential need to modify the retroviral vector with the suicide or ablation element. The RAC suggests that the investigator consider using the existing nude mouse model I'm going delete that. Informed consent. I'm I was duplicative. was trying to determine the best way of expressing the animal model issue. Informed consent. in the informed consent document is complex, should be simplified. The informed consent document includes the term treatment, which overstates potential efficacy, please modify the consent. other considerations, Dr.

I'd like at least ask about the advisability of sum studies asking about the oncogenic potential of the chimeric molecule. Is that, uhm... is that feasible? is there, uhm... Isthere benefit to -- to that sort of information?

Uhm... Is that included any your points?

Dr. believe so. I that the RAC suggests that NMA preconditioning it more likely that long-term engraftment of modified T-cells will occur and may have untoward effects. think that covers I in mind.



covers the NMA effect.



So the cells --

not cover the possibility that the vector viral mediated transduction event per say is going to more one hit.

We -- That seems to be the growing perception in the X-SCID at least one very strong possibility as we heard yesterday. that needs be included, I would propose, in a model that involves retrovirus in hematopoietic cells with possibility of enhanced engraftment or selection survival advantage. I think I can quickly address about the TCR having thought about it little more. I believe if we infused a leukemic cell that had the hits necessary to create leukemia, that we gave as many as 10 or 11 cells, which is about 5 times as much as normally circulating in the blood, if we already had a hit, if had the chimeric that the first we had the LMO2 going on, we certainly must have activated LMO2 a of those cells. 100 the cells have what you call first set be the LMO2 model in the mice. 100 with the chimeric receptor. And then we certainly also have the LMO2 modified there plus other genes because of our large cell dose which can't in the mouse. I believe if we would have had plenty of opportunity if the chimeric receptor was first hit, if hits were to ar have occurred, all of our patients would had leukemia. circumstantial but think that's the we do with that.

I... Yes?

I -- I would support entirely Dr. Friedmann's that think the way that you're thinking of the first and second it well that the chimeric T-cell receptor only as or third or fourth hit, the T-cells in the patient and they see antigens. this is not ex vivo... my of the question or an interpretation is not that this provides hits before the cells back in. But the integration itself could be the first or whatever that means...

Right.

And then the transgene could become an effective protooncogene once ?its in there the presence of antigen which in a tumor-bearing patient there lots

will be gone within three months if this you will -- you get your but again, it's going sorry, will be gone within three

If therapy works, the -- the will be gone in three months. The will be gone. If the therapy not

patient will in a year there will be for

I This is

I think that's -- not sure that's an argument against the which this is a potential

Right.

We couldn't it if it were. That's my answer.

are ways test for that. I don't don't this is an that's my bias, I admit. Testing for would be difficult without long lag time in a human cells, in any of model. will get (overlapping speakers).

Let --

Sorry. I this is for members the RAC, so much for discussion. have included another there is the potential -- potential that the retroviral transgene itself may function as an oncogene should be assessed, not terms how but, rather, making matter of record. Is that... Dr.

I think that certainly in the of I in mind. think my comment was more sort of a -- a stream of consciousness thought on part and the to the RAC that this question particularly in the hematopoietic system to be of standard questions that we that the RAC asks of investigators because advantage that the cell may have provided by the transgene is to be nasty.

Exactly. Thank you. Dr. you had one final question

One final, uhm, I it may be captured in what you're writing, but I think the real at least relates perhaps to this protocol and others from the X-SCID experience is it's very difficult to anticipate what may up, so to argue too strongly that one model might follow down the exact that we know can occur in another, is we want to caution against that while recognizing that there can be other untoward events that we don't know about right now.

Agreed. it was that philosophy that led me to only words like... Continue to be vigilant, anticipate, instead of prescribing should be done. Any other thoughts from folks? You like me reread this or can take a thank you. I need a motion first. you, abold D.A. and a second? Thank you, Dr. Powers. Vote taken ]

Thank you. We a break. Dr. Crystal, will be back, hope willing to wait another -- 5 minutes. FairThank you. We'll reconvene in five minutes, then. you all. [ Short break ]

The final of the meeting today is an update and discussion protocol 619. of a replication-deficient adeno-associated virus gene transfer expressing the human CLN2 c the of children with late infantile neuronal ceroid lipofuscinosis. Dr. Ron has agreed to in very willingly agreed to come to discuss amendment this with us publicly we are very appreciative that you're here look forward to your presentation and our discussion. Thank you, Dr.

for having me. And I ek sentiments we have before about the having been in RAC since I think the time was probably I think. I echo the sentiments. that the little different. had a couple hundred people television who what was quite a scene, but the organization, the staff organization has just been and helpful to us and appreciate it.

Because this was not reviewed, it was but, uhm, not publicly, in couple in of the background about this disorder. It's a lysosomal storage disorder, affects about to two million births, it's ought '0tow -- it's autosomal recessive. Children are until age 2 4 and develop cognitive impairment, visual fail seizures and deteriorating development to a vegetative state early deaths invariably by 8 to 12. For those of are MRI aficianados, this is a typical this is one of our individuals and all this gray stuff that's cerebral sometime fluid, huge ventricle, basically the brain is atrophies and it's basically a loss of neurons the of time. This is from a study Stein feld in Germany which we modified a because we used this as our primary variable the study. But this shows how dramatically what happens, this is actually how quite it is. This is 509 percent percentile, fifth percentile, and once start developing the disease, within a short time within of years, they become very severe and actually going to you and I show the lives that is we have screened, are to see that in one that we seen twice. This is caused by mutations and what's called the CLN2 gene, Peter lobel identified it. a gene that's involved with the queuing up -- chewing up mostly membrane proteases primarily neurons all cells cells the body. This pep tid's is involved with chewing waist proteins and there is a deficiency of the enzyme, they accumulate within the so many. They -- many and fill up destroy the cells. We an AAv2 vector and it's the cage promoter which is the MMV together with some elements a to globe been used by a of investigators the CNS we were developing we spent a amount of Terps of locking at pro -- of looking at this was most in our hands. of the advantages of this disorder in regard to gene therapy that we learned anything in gene therapy over the decade plus that it's is can't get gene all cells, can only the genes small of cells, and this gene product is secreted and precursor form picked up by the m6p receptor then modified -- the product then modified and brought up into lie so many. Where one cell is transduced and will hopefully a variety of cells we and have this is the case not in but in vee vo, well. [ Modified and brought into the lysosome

Preclinical data, this a in rats, it takes about few weeks to begin to are a brown to be the describe it striatum but we done in several the is out to 18-month so you get long-term expression with this strategy. we the and I this just my last introductory slide, because although as clinical basic and clinical scientists, at the molecular and the translational stuff as being the very sophisticated things that we all do, but as someone has number of different clinical studies by this is most challenging to figure do you put into the brain, and you one of our children and there are three burr holes on either side. Just the strategy of figuring out you do that, how do you administer in a human, a clinical operating room situation, you can't it very well but there is tiny glass flexible catheters that are coming out go to Harvard pumps here somewhere, the designing all of kind equipment to these catheter, hold in place, where you put them, the MRIs, doing in the OR, is a very, very complex procedure. are probably 12 in the operating at any one

this is current of our clinical study. have done four individuals. There their age, 9, 6 8. This individual is the individual that died. I'm it number 6 because going to you we have a screening study. have two different numbering systems. to the confuse things, this is subject number 4, who died. 6 our screening study. are the genotypes. They all were in our classification he they got same dose the were in our of severe. one is stable at third at 7.5 the fourth, 6 here, was discharged days post therapy, than the other children, developed Indiscernible ] on and died on dayI'll get to more specific things. there were a group questions that were to us and I've gone through each of these and I have slide that will answer of the questions. So the first group related to specific related ever relating to the adverse effects -- events and of subject 4, we have at we have we have two studies. We a screening study, and we have the therapy study. we did that was there is so known thisWe would be helpful to collect up children around the world and to study them in in the same rigorous way. we have now studied 11. four in blue the ones that have been studied and of the this will get in a that came is do we choose children? And go over that in detail. in fact, the screening study have been sequential because these first three were then studied and then number 4 not pass the eligibility criteria because of severe kypo scoliosis and restrictive lung disease in fact this child died five-month later. Individual number 35, first -- number first to us and was in the moderate category. And the protocol up do a certain in the severe and then the moderate category. the child was eligible for moderate we weren't there yet. We then brought the child more recently and this now has deteriorated a level of 2, within that of time, which is 11 month. And so that's the rapidity of this disease once it onsets. then in sequential, this is number 4, who died, and there a group of others. There is nothing dramatic about any differences any of these children. differences the mutations. are about 20 or 25 mutations that have been identified.

So subject number the one who died, uhm, and there were questions about the of the last generalized seizure, and I apologize material that we the summary had a typo on t all our source documents it was a typo. The seizure score was 3 which is defined no seizures in three prior to enrollment. was the three subjects receiving the vector. The last seizure was in September of '03, the typo in our summary year-end summary we sent you unfortunately said 9-05, but in it was prior to screening and 13 prior to vector administration. [ Unfortunately said 9/04So it fit perfectly cad Kat goryThere was -- categoryThere was a summary that occurred school this child is not school in the United Kingdom where this child lived, the medical facility where handicapped children receive scare referred as a school. -- daily is toes a aschool. The last which was 13 before the therapy resolved rapidly with rectal moaslim [Phonetic].

In terms of where we the vector, it's determined on a case-by-case by the neurosurgeons on of the preop within hours, MRI, we sues six burr holes, three bilateral, depths maximum from the surface. reason we do depths is thought we would optimize with least amount of trauma, the number of burr holes we were using. The criteria the choosing the areas is to avoid blood vessels, cysts, malformation, white ] areas and on try to the broadest area of distribution and try to protect functional the brain with salvageable tissue. don't anything to with the areas, but I go and watch. And without question, what have observed being the highest priority is avoiding blood brain figure how to into a and the sulci where blood vessels is the mainly challenge these fine catheters the brain, the main challenge. was going put of the four individuals it it's in same area, six sites, two frontal, two motor, Indiscernible ] minor adjustments based on the patient anatomy avoiding vessels but much sameThere a question about comparative operative and postoperative management time we looked all four of these children. total length their in the operating -- anesthesia the operating

am in the 4 was 8, 7, 8, this was who the seizures. The total time of intubation -- and a real issue for us we an MRI before and after. children to be intubated the MRI procedure they move around. And so the total time intubation 56 hours, 38, 27 and have gone through all the medications, doses, the OR, there were no differences among these children we could see one question was the use of mannitol because in the protocol at the of the anesthesiologist. the children received mannitol within the OR.

there a bunch of criteria in management of risks. So go them one those just the questions. he how do we establish the eligible criteria? What we did was we had our team within our we invited some outside experts this is a scan of our meeting that we and people involved were some experts in this area, Christina sees lot of these patients Staten Island, a at University of Rochester and Fred University of Rochester, and Leon durry the of Alabama, all have in developing these -- these kind of children and developing these scales. And we they helped great deal. And we developed the basically our ratings scale our clinical studies design through this meeting. what evolved was that neurologic assessment in this clinical would used as the primary end point secondary MRI/MRS. We don't much but have to if can get information from it. This ratings is based on functional categories of motor function and language. original ratings scale developed by Steinfeld involved vision, but children all seeing already all blind it's and we deleted it. We also broadened the severe category because the seizures are all treated they are all usually a value ofAnd so we broadened the category on that basis. so there is a overall disability score that's developed adding these up of normal, mild, moderate and severe. We decided start with severe, and this that had the seizures in this category, and then to the moderate there some in terms of that. argument that we eventually decided to this because because we -- did any problems, we it be in the more severe rather than those with milder disease. is the rating scale already showed you. There was questions about the seizure scale per say this is the break -- perThis the breakdown three which all children were no seizures the three months and then before four subjects had seizure of three. and as your questions got us thinking this and what decided to do on our review and to keep out your questions, it we will enroll any future subjects a rating less than the have been enrolled a rating of but we think it's to stay there and not enroll any in that category I that a good There was about non-medical eligibility criteria and we went through our consent form and up the that were nonmedical. Both parents or guardians must sign consent. and study participants must agree and comply good the of the study including attending the requiring baseline and follow-up assessments. You can't them to do that and can any time but ask the informed consent do that. And there is the following statement is that for no of will be provided for participating but we also only cost that we ask to is you families will barrett cost of travel -- the cost of travel and ourYou also the cost of accommodations and expenses outside of the hospital. And it's an issue because these children come from over the world and -- the see, to do our day actually could in the protocol originally could be be done by the home physician and have decided in con youngs with the FDA -- in the to ask the families to remain close to hospital so can have them as in at day because that's child developed the seizures. One question came up is was there a in the prescreening study from months 8 months? First, the only procedure judged to be above risk the screening study the MRI/MRS have to do with anesthesia. The change in months was to accommodate scheduling variations ourThis a very complex protocol as ones that you see. Scheduling the operating there is only one operating a hospital can be used all the equipment that's necessary. Scheduling the neurosurgeons, the pediatricance theirologist, the neuroradiologist and the are coming from distances, the pediatric anesthesiology. It's scheduled months of time it was mostly to accommodate that we also thought since we are studying gene type phenotype our screening study, we thought would us a little more information. It doesn't very much because we repeat everything when they back in the -- for hose are have the gene transfor study so the pretherapy screen is identical all the screening study except for the the thole meteorology exam is mutinyway none of them have any vision.

Are there any concerns about enrolling children with epilepsy. Should the epilepsy be a basis for exclude potential have already with that we agree we should leave the score at which is no seizures in the three months. we will do that.

Our severe category has this range all had the subjects at three. This is a philosophical decision in terms of should you do the children with low neurologic score or go more mild or moderate disease. We decided start with the severe and then go to the and we talk about that are any questions about it. the things that we have put in is, since the death, is can we obtain some information by doing EEG and in discussions with the we decided to put in and post-EGs. That evolved with with the food do 24-hour continuous with FDA to do 24-hour continuous monitoring at pretherapy and then post-therapy in the 24 hours in the 14 days. Just as a background, these children all have abnormal EGs. All have seizures long before we see them. They have diffuse global dysfunction and interricket Indiscernible ] activity. What we decided to do based on the with the FDA we agree with the basis behind these questions, if therapy eeg reveal evidence of sub clinical status this will exclude the subject.

Post therapy if see EEG evidence of increased seizure activity compared to pretherapy we'll treat it appropriately so think it's a good idea to add this. [ Inaudible question

too manying the pretherapy -- of the pretherapy 24eg, 8

No, it's day before. Indiscernible ].

There is of MRI infarct, anything that be typical clinical care. than what you basically see the MRI I showed you see begin of the brain, more CFS.

The of the questions the eeg used to match seizure foci be guide avoid regions of vector will be to attempt to avoid areas like the temporal lobe the is yes all these. Very good suggestions. All subjects had this diffuse global dysfunction may have interricket tal activity. If they sub clinical seizure foci during 24-hour monitoring just before therapy, will be made to the focus to specific region to avoid that region selecting vector administration sites and temporal lobe and other areas associated with seizure susceptibility are avoided are already in the study.

Why 12 injections with 6burr holes? Could there be other delivery strategies ? I the brain is an enclosed organ. is other way get this is lot of research ways that people tried there is no other safety ways. We maximize size of each BURR hole. They very small. They are pediatric Burr holes through a dissecting microscope. There is no other administration strategy shown in to be safe provide broader distributions for the neurosurgeon point of view they stick catheters bigger than we in the all time for all kinds of different purposes. And so that's not the mainly issue although... that may be of in this child the reason why the seizures developed.

Again, should group -- another question. Should group be postponed and more studies carried out in group a? Will the of group have an on the proposed continuation? Should the group be postponed, et cetera. And it's complex question. We thought lot about it. We have discussed it good with FDA and the we decided to as is. From the data available it's not possible if the status was to the natural of the disease, the surgical procedure and/or drug administration, the setting of the subject's advanced underlying disease, the vector per se or some combination. We from the who the seizures two post mri scan one done at plus two more one on day 21 and on day 44 showed no evidence of inflammation the areas of vector or elsewhere and we did cerebral spine fluid when child came with and was no evidence of inflammation. That doesn't prove it's not the vector and that's why our that you read and that we have in the consent says we don't know what it is. can give you my what I think, we have no proof of whether it's natural history, the catheters the surgical or the vector per say. -- per se.

There no data to suggest that subjects in group b moderate would have greater risk of seizures. there a greater risk of developing seizures subsequent to group a. are and to continue as is. I -- we one more to do in in the, uhm, the severe category. you know, the -- when -- the -- seizures we put ourselves on clinical hold. The FDA put us on clinical hold. That's now released. We to to this meeting before we did any more wanted your input. But plan is to continue as is because we have no arguments, strong arguments we can make for eitherI think it's safer do all in milder disease then the risk if something happens it's a much more consequential occurrence. an agreement the FDA, we plan to continue the subject recruitment as protocol. But one thing have changed which think is a good -- I think is good idea patients were staggered two weeks minimum we decided that because the started two weeks and we decided to make it one month. really not a for us because the is such that doing them two weeks is -- is pushing our system so... it's not a and think it's a lot to it this way. There were issues about monitoring follow-up continuing with future subjects so let me give you the of the questions was maybe we the -- all these children are on multiple anti-seizure medications. show the bit. we in the OR and we how much fluid was administered and what they were receiving. The subject weights. Here's the total fluid they received on the OR day there is no differences. So it's hard pin it on that. Are the concerns about delusions will the potential need change in seizure medications? How are we handleWe decided the FDA to monitor the anti-seizure medications pretherapy and post-[ Indiscernible ] day 7, 1, one 6 months and 18 months. I with you know, with the caveat have also reviewed how does take to get back these -- this data. And it's anywhere from one to 10 days. I'll show the in a bit. These children receive multiple anti-seizure medications. They likely in the aggregate, the dose of have been tweaked by the physicians caring for them we didn't it going in. And it takes days to week to them back. Of course, any clinical seizures will be treated as standard and our one who developed the seizures actually had a seizure that was quickly dealt on the day one. are be the EG monitoring. -- EEG monitoring. we one of our he could investigators -- co-investigators an epilepsy who is head of the childhood epilepsy at our institution.

are the seizure medications. ones are the three children, one, two and and six. this is just 11 have screened. all the seizure medications the generic names can see there is real patterns and so this child... you know, medications other children have received. So we couldn't it out from the differences in the seizure medication. Should parents request it, keep a seizure diary. We have standard operating procedure for our history and that are very extensive. two shots out of it of the screening study. They are both in patient hospitalizations so we there is real need from it, and we also, you read the anticipatory guidance, I mean, the things that concerned us and review of this is we didn't hear about it. though child was probably 200 from the emergency room. Something like that the street. And we had this actually in in the consent form. If you detect any changes we recommend you cawrkt healthcare provider immediately. have also this is not in our -- in in any of our documents but we have to contact on a to see out they are doing post discharge. Regarding of this data, have talked about the 24-hour monitoring. And I don't think is else here. that is a repetitive question. how we going use the EEGs? Again we'll if we see -- increased seizure we'll try to identify it deal with it appropriately. Have any alternative options for medical management changed since the study was initiate? The is no. still is an untreatable fatal disorder. What were the FDA concerns? Amendment I guess 12 and 13 all the concerns you copy of their 210-05 nothing that's not that's at that was Indiscernible ].

What were those changes? Two-week to one month. The 14-day will be done at our site as in patient. The EEG monitoring I have talked and the will be evaluated and that's all now detailed in the protocol. There were a bunch of ethical issues. They related to consent enrollment and foundation and think are important. I have listed them here and I'll deal with them. Therapeutic misconception, structure donation how you divorce foundations from control, handle of enrollment inquiries, have talked our two studies. We decide en rolement primary committees are outside our department. We divorce PI from enrollment. Monitoring is done Indiscernible ] Speaker reading top speed

also do this through the GRCR, at our institution and they researched subjectThis is our overall advocate chart. On here, have safety monitoring specific individual in our group who monitors and reports to and we have a medical safety monitor independent of all that also reports to the GRRC. We have a separate data monitoring board at Cornell and this individual reports to them.

In terms the therapeutic misconception issues we have two paragraphs. This the first one actually is in bold. It's second paragraph in the consent. says this research study involves high level to your which includes the risk of death. And we have another statement... It's important to you know your participation of your in the study is voluntary. We don't guarantee your child will any benefits the study. Knowledge gained will others the future. We hope that the vector may prevent from getting worse. Experimental there no this it your. as stark as we think we can make it... .

The protocols emailed to families of the potential subjects are to review it their physicians and others can help in their decision for example, if are with the church, we recommend that. Friends, other and so on. The consent form, I'm PI am not in the consent process. Those are we have a pediatrician who is co-investigator in the of Pediatrics. of the two neurosurgeons are research coordinator takes we have a research subject advocate of the research subject advocates is from the GRRC. I'm not involved. In terms of funding I I deal with it was an issue I know you may a separate meeting about this, have given it thought. The is funded part by nathan's battle foundation. The wild Cornell and from our department. And the question is do you separate foundation funded in part by families with children with this or rare disease from influence regarding the clinical study and specifically in the issue really is this, personal and do turn that into good? of the safeguards as a that we can put in -- I'll show you what we've done. The funds from this foundation that help fund us for this are to the University. have absolutely no control -- of the funds. in the preclinical or in the clinical studies nor in the -- anything to do the subjects that were enrolled. the preclinical it was done so that the foundation could have pulled its future funding if they weren't happy for whatever reason. And we could any time. the clinical study we asked the foundation, since once we a clinical study we're obviously obligated to follow these so that's a definitive gift to the institution.

No advertisements are used to find theseWe a list from this foundation and also from the batton z support and research association. I made presentations that is a batton disease which is general network name more to -- generic name this disease. Congress, there's been multiple presentations at Indiscernible ] but it's all word of mouth. are only children with this in the world. as we can tell all are e-mailing one another. We get e-mails constantly, or a week I get to this. don't answer of the e-mails. send to our regulatory group to divorce me from any personal interactions.

The decisions are related to the two studies. Screening and gene transfer. is no guarantee that enrollment the screening study will automatically mean enrollment the gene transfer study. how do we select the children? As you saw, in the list, are assessed the of with the caveat of any scheduling. is no outside input at all. I'm not involved at all. And the decisions are made boy three co-investigators, of the two neurosurgeons, the pediatric neurologist who is the epilepsy expert, and the general pediatrician. None of whom have primary appointment in my department. And so we thought that is in of separating out things.

Just in timeline of what happened, the status of this child occurred on 14 so the been discharged for 7 days. We informed all regulatory bodies of the serious adverse event in three days per the regulations. At day 6, we decided to put ourselves on clinical hold because we just it was appropriate. So we informed the FDA, the IRB. IBC and you of this. of we called the FDA. On day the FDA by their regulations, had to put us in formal clinical hold on day 31. have now released that clinical hold.

What other review was of the questions subsequent the the subject? What issues were raisedThese are combined IRB, data safety monitoring board issues. they want to make sure than epilepsy expert was involved already is. Dr. a full-time member of the of Neurology, co-investigator the study director of pediatric so been all along. One they noticed was there was a mild hypomagnesiemia in the subjects. This was day one, including 4 right there. So something we'll pay attention to. Because it's conceivable that contributed. Although the other subject not have seizures. But and it probably does not play role what happened out at day 14. But conceivably it could relate it what happened on day one.

try to localize the seizures as I in terms of the they what was the because it wasn't clear to them. have told them. asked us to tract gene no type adverse events and they we not going to monitor EEG wanted clarify use of this word school. other than those were the only issues of the IRB combined IRB data safety This is we have added to the consent and I won't go through have read it. in the consent. But I'd be happy to it. have tried make it's clear as possible happened to this child. In terms of subsequent recruitment, it's explicitly the form consent, foundation plays no role. And question of the questions do I know any of these families, and I met of the families at this meeting that -- that -- at the batton zs because the families all go but I'm divorced from the decisions, that's the reasons that we did divorce the decisions. Should the informed consent address financial risk? of course those of you I see in the audience, that's

View for you this is -- day.

View because this is probably talked about the at every group since the beginning of gene transfer. In accordance with federal regulations we aowe blink inform about Medical Center in the event physical injury occurs. result of participation child experiences physical from known or unknown of the research procedures as described, immediate medical and treatment including hospitalization and if be available. No monetary compensation, however, is and will be responsible for the costs of such medical treatment either directly or through your medical insurance forms of medical coverage and the of the policies as being fully explained. I think this probably in a variety of ways by different institutions.

The questions about preclinical animal studies. a few there about the knockout which was not available time were going through all this. But the mouse now is available. we have preliminary data. And my collaborators, mark at Genzyme, Peter lobel and to at UMDMJ and another agreed that we could show this. So here's the knockout mouse. And one questions were, the levels that you get? So here's administration to one local area. are the levels. the levels scene in wild type mice. are levels seen in heterosigh gas mice and it's 35 to 10 of levels. we can far the levels. you scale this is equivalent to what can in humans, to 10 And more dramatically, is disease is characterized by these storage granuals within the neurons. That's what how you make the diagnosis morphologically see those they are auto fluorescent and here's the MOTO cortex thalymus and describe a tum and -- thalymus and striatum this is the naive knockout mice. The autofluorescence and this is I 13 weeks post vector can see it's markedly reduced post-vector. Here's a of the studies. It's been no safety with the knockout mice to date. levels are much than the 5, percent needed for correction. Storage granuals are significantly reduced 30 to in the motor cortex, the describe a tum, the hippocampus, thalymus and cerebellum. have improvement 8 to 10 weeks post administration.

How we decide what to do? Why do we decide to ahead the disease? It's a fatal disease. They all is no alternative therapy. It was the major thing. Uhm... we had data and lot is published that we can express in various of the we have long term expression, it's above the percent levels we think we need. get local just-correction. And formal safety and toxicology studies both if rats and primates. Nonhuman primates were done and it's a fatal disorder. The preclinical animal studies, of the came after all this I added them in. Dr. still here? No. She isn't. So she is not going to ask it. Is there testing in the am meture nonprimate brain. No. Was same vector stock used in all the non-human primates and could we provide the QA test results? We don't we produce so can do it for several children but all children. And we have multiple stocks. All the same rigorous lot release there is the lot release. I'll be happy to go over it with you. the have to pass that. Did the monkeys spike feefers or show systemic changes similar to those observed the children? [ ] are the temperatures curves the children. The subject 4 is yellow. actually not as high, a delayed than other children. Keep in mind these children are intubated for several days there is long period of anesthesia so fever is expected. this fever curves in the nonhuman primates. Each dot is a different animal. are the control animals this over period of a year. this is to the 10th and here is to the 11th. It bounces around. normal is shaded. We haven't the not undergoing that long period of anesthesia and certainly not the intubation a respirator.

was asked about the issue of autopsy. We have in our and an extensive I go through it all, course you can't sign away your rights. can't be forced do any of of course the bottom line for all in fact, the parents are the of the child signed and checked would be their to do autopsy and then they would after the died be, just a side light sort of his cloudy, when we historically, when wrote first informed consent for adeno-virus for Syssty fibrosis that was at time when one had any idea about recombination and our first children we did were done in the program just before I left they were in that were pressure rooms the first guy didn't leave for six weeks weather were assessing for recombination. And we actually put the original consent, we put in the consent that it's that you'll develop some andromeda strain recombinant we'll to you forever. The lawyer said you can't put that in. this was -- my recommendations to you is that I don't we can do anything about that. mean, I was a house don't know what the autopsy rate was but it's probably 30, 40It's down to probably percent at my institution now. It's a society issue. If you do decide that you want to have a general -- I suggest that have a general meeting about that and get experts, lawyers, to do it. But a society issue. And it's a real problem.

the of the foundation? Did they have an independent scientific of the was did this very an independent scientific have no involvement of the foundation or internal workings so I can't but can is other physicians other than or the that are involved with the foundation, involved meaning interact with them. Myself and our administrator in the audience, two of us with them. any subjects enrolled families not involved with the foundation? And in principle would lack involvement? Subject enrollment was done if eligible sequence of assessment. two subjects of the 11 we have no of the relationship. I no in terms the families with the foundation. to the foundation plays no the decisions. And the foundation plays no role and no impact of any our decisions regarding subjects. In terms of funding was of the questions that the -- they funded the foundation funded in part, it's also funded from of Genetic medicine and more recently, this as have been awarded a grant from ninds. How Indiscernible ] [ Reading fast ] percent of the preclinical research. the there a preclinical research evaluated by scientific body. the most rigorous evaluation that could imagine. The NIH oba RAC reviewed was submitted on and our letter of exemption was on JanuaryIt's been presented at multiple meetings. Multiple prereview puktsz. -- multiple prereview publications. There a question about the clinical studies the cost. We estimate over three-years about million. About by the nil have been norm muttsly help ferrel but don't have lot of funds. 40 by the foundation, 57 by our department.

Are the plans to submit other preclinical and clinical study to NIH? Yes. I this is a for the preclinical stuff, this is a terrific this is what foundation money be used for is try to then leverage it into grants support. And able to do that and now all our preclinical studies are funded by NINDS. Whether have NIH proposal in the future depends on the of current clinical study and the ongoing preclinical studies. have already discussed we to in terms of the enrollment. How we going choose them? Same unbiased fashion already use. And all the you have seen. that's it. I'll be happy to answer any questions.

Dr. Crystal, again, thank very much for joining us and for your very thoughtful and responsive this afternoon. Just as background for the the RAC, three us were asked to review the amendment formally and we did so. Doctors power, Dewhurst and myself. We did hold two conference calls to help assemble a list of questions which then were provided to Dr. and to guide in his this afternoon. this is an amendment, it is not necessary for us to craft an official set of recommendations and I thought this time would be used most productively for exchange of questions with you, Dr. you agree.

Absolutely. I'm to start with Powers, then. Are there any thoughts you have, Dr. that Dr. might respond to? of thank for a very thorough response what I know a fairly long of questions. Certainly, uhm... the... Foundation relationships were air series of that were a greater interest to you subjects were recruited, the the financial issues, and these are complicated kind of questions about social justice and how monies used of taxpayers money used by private groups... fund programs that then provide benefits and to are those benefits made available? And I I got a pretty good map of -- of that was set up. And it sound fairly clean and clear. And I'm delighted to of some of those details. The... The risk -- is a deadly disease. And I suspect it's to for families to these kind of choices about -- to enroll their children there. I myself can say that just hope there is vivid appreciation their part what their are to go through and what their alternatives are. I see no reason to that you did not all you could do that regard. that seems to me a really difficult for everyone involved to present this to families. a somewhat I would say desperate kind of separategy at this juncture. -- strategy at this juncture.

The question I guess about, uhm, looking forward to group a the severely ill and about. The less severely ill, I -- group b, it still sticks in my mind. I'm not a scientist so would have to to some of my other colleagues to perhaps into that but it's that continues to pique my curiosity, I suppose, as to that looks going forward. I also think that the -- the issues about better monitoring and reporting, that's really crucial. of the have been seeing overtime is that either in the term or long so many things and I the RAC have becoming increasingly the need for creative multiple levels of monitoring and providing information particularly when children and the family members to know when in fact action is needed in order to inform investigators and their -- in charge of their day-to-day treatment as well of when an event may be potentially important to do something about now. Finally, I would if you have some further thought about could done as you move forward with this next group if, God there is some kind of SAE, to begin a of looking back, evaluating, disentangling, uhm, the causal story so can see, what might be involved, whether things you might do as move either to monitor tore get a better handle on managing the that might be the multiple determinants of a death and where are obviously multiple possibilities. That's my essential group of concerns, and of those think have been addressed are the ones sort of linger for me. If I could answer the the I have put into this is with the FDA's suggestions a lot our discussion forth, is the EEG monitoring, the continuous EEG monitoring. think going to help lot because that's really was the event. And I say that will definitively, you know, this I it will a long way. course, watching the levels. mention all the other issues mention, these ethical issues, been thinking a we have now been thinking lot about as did before, and, uhm, if you or of other ethicists who were here are interested in about some and putting together an for the gene therapy journals we very interested in you because I it's obviously an important of do you separate out, know -- and funding, uhm, these kind of of those of you here who do gene therapy studies, is very complex in terms where all the resources come from. you to very careful, but I thought it might be helpful if we do something together the of the gene therapy journals that might be helpful the field overall.

I'd like to comment that briefly. I take of children with rare disease from this rare disease but others. And over my career, have had oh, probably eight families who have had resources and who a child with a very rareThe immediate inclination don't how avoid it, I -- we need ahead in to find treatments these children. The immediate of list is form a foundation if there that already exists The immediate inclination of these familiesTo use their own family and to raise dollars to go toward a, quote, cure, end quote, the of their child suffers from. There is in my experience an implicit expectation that their child, then, have will have immediate access to any treatment that evolves. And they paid for that treatment, often they feel that they have some inherent entitlement to access the treatment of other children. clear to me that this isn't just about your disease. not just about disease. It's much bigger issue for rare diseases and I'm wondering, you know, somehow, we need to avoid the expectation of accrual to studies these families. And maybe should be set up, you at the very beginning and, uhm, put forth by the physicians who care the children before the dollars are donated, the is the bag, to speak. you

It's very, complex I a suggestion. It's complex because it's not only families that might able to afford it in the particular



But it's also that the families who are going to take you know, are to take your child your is going to die. And there some our society just say, no, not going to accept and do can though they realize that their children, may may notBut they to feel thatAnd that's very admirable. have a suggestion have been a lot and -- I was asked to give a talk, San Diego a couple weeks ago, the Kimmel center a had I the following suggestion of how did we deal with these orphan diseases in our country because... basically, the biotech companies have is no money them except for the more -- much common ones. Certainly the large companies aren't interested. I'm talking public as an issue, consider developing nonprofit pharmaceutical companies based on different technologies, small molecules, monoclonal antibodies, gene transfer so on, which the -- foundations could put monies intoThey could develop what not good in the academic and also it would separate it and it would develop a whole infrastructure so weigh don't have to keep all safety studies and so on [And of course one individual one group can't do all but I think it's something that society ought to consider would be one by which we could not only deal with these disorders to with these disorders with technologies that are being developed, but also separate these possible conflicts.

think that's an innovative idea and one should be explored as we or other groups look more thoughtfully at these kinds of issues in rather diseases. diseases. a rare diseases or it acts to collect samples rather than to develop approaches to treatment. And it stores samples and makes those samples available to investigators.

also have thish of not only let's that we or group is successful at this, know week, really cure you know, we really or appearance cure do weWe not set in the academic world to produce these vectors, make them to everybody an ongoing basis or so on. That's a societyThere a gap funding that in our we to deal with Thank you your thoughts. I want to remind everyone that questions for this protocol are in your purple folders for in you had chance to look. And I'm going to ask Dr. next he has questions. have toYou do. Dr. you are next.

Sorry.

Dr. also want thank for a very lucid and candid and extremely thoughtful presentation a very difficult situation. And you have done the two one in the situation. Go back and try and look at the risks and see is anything you do to reduce them -- that do to reduce them. You Incorporated some very thoughtful modifications, your protocol. Of course the other step, other approach, is sort of look at the informed consent process, sure people really understood what they were getting into. And I if I to of ask about the consent form, grow with the you made, but about the I agree the changes you made about the process consent and what these parents actually understood after this very nice discussion from that doesn't include you is multiple disciplinarian and does the team assess what the parents at the end of that make some assessments to whether -- think it's a very complicated sort of series of thoughts going through someone's mind. I on the one parents are really hopeful even though they tell you you're telling them it's Phase I are of hoping it's not. I guess do they really understand this is really Phase I early study? And do you assess

Dr. Lo, that's a very complex and it's very in my clinical experience dealing with someone with Matt static cancer -- metastatic and there this is experimental, is no it's to help you but it's their choice. The and father, son, are going and you know, and, and it's a very difficult ethical issue. And our assessment I would say... my observation, not in the consent I do to the parents and my assessment is that some do and fully understand and some partially understand, but that concept of doing something for your child is going to have been -- just such an overpowering very difficult to deal with. see have -- also an I think the GCRC research advocate a very good system. they are totally independent of us, try to on those issues. And have been impressed by that process. I was of the this was on going, when it to point it was that the had decided they really wanted child -- they realized the child probably going they to bring the child to the United Kingdom we had a which I was at that was discussed with the and I thought the NIH advocate was and positive in that don't of ways do it. It's such an overpowering, you know, emotional personal no matter how you are, uhm, it's very difficult -- intellectually, people understand. But emotionally, it's -- it's are hoping.

if could just suggest, there is -- your analogy to metastatic cancer very apt and there has been lot of very nice work done recently between doctors families thatI just sort of asking them, parents in this to explain back what their understanding is of the of the protocol it will affect their child and other children. To a sense of at least on some level that they are recognizing this is -- goal is not to cure their child. I think they hope it might happen but statement that know the doctors are this is really early stage and it's probably not to we have our fingers crossed we have we that be as close can get some of balance. someone didn't have any appreciation at all that the of really to couric then I think that would be Indiscernible ].

I Thank Thank you.

Dr.

Bernie's point really quickly, I'm curious whether, you know, since the foundation produces some information, makes it to the family, you know what kind of things they say, what's in their sort of informational pacts out there? Because downstream and away from you, it may, uhm, you know, point it may look from entry point where you get it much further down the way.

I'll you the I dealt with it personally. have never looked. The has website they various things. just tried to divorce myself entirely.

you didn't look? have not.

The plausible liability thesis?

No, I -- I tried I mean, I have lot about do do as you know, do you separate yourself? I mean, I -- I'm not a neurologist, neurosurgeon, but I'm a pulmonary physician critical care doctor, I a medical intensive care unit. know, deal these of issues. Not this issue but the all the time of people that you have to remove yourself emotionally from it. That's the strategy have used. just to completely remove myself from any parts ofNow, they what are their fundraisingHow are they manipulating -- I don't is, and think that's but and I control that is the

Yeah, I, uhm, you of things we look at just not simply just related to what the researcher or FDA is doing. It's are looking at system ek social issues. And you know, above and beyond what might be, on your watch, you for us, at least, of the issues are how the of the puzzle fit together. And so... for it would I'm not suggesting this is your to go and monitor everything I was curious whether knew and what you saw and whether you had a hand in setting aside yourself around institution whatever they did on the left hand didn't redound to the what you on right hand. S at least the rest of us, it's the RAC's position, about the totality of circumstances makes sense. And how that of the I is something we the RAC ought to at the future as these of cases coming up, as Dr. has

can what you we do. I do personally is I ask the families, uhm, not to with theI can't prevent that we don't, you at of this, is no of press at all. But have been press reports of children, these some of these children, the families we have no control over buy specifically tell them that -- but I specifically tell that think it's inappropriate, it doesn't help this is research should let the process, without in the public eye, I think that's appropriate. to involve the press but I can't control that.

Dr.

Yeah. of I wanted say I also thought responses were very thoughtful very complete. I had two follow-up questions but I just want to comment on what Madison commented on is that, least of the families associated with the foundation I think has been quite public and one would have to characterize their feelings as verging much more to therapeutic than to highly experimental and that's just a comment, it's not a criticism or anything but an observation I have looked at some of website materials and of the popular press. there are relevant, uhm... Family to consider because they much play into Diane's comments about these generalizable issues to other, uhm, uhm, and I that's a important to us come in the

far as specific things, one I was about was different batches of vector. So that it's then that the difference subjects did not necessarily receive the same batch. That's correct. They all satisfy, course, the lot

Did anybody else get the same batch that subject 4 received?

The is no. But what we did do, which I didn't to you, was we took that and we injected into the in series mice and we saw nothing. I mean, no, by nothing, no adverse effects. know whether it's worth taking that -- is an observation, I -- and a -- uhm... a thought is whether it's worth that also into of the knockout to see if in model whether

we plan do

Okay. Then the other I was about I guess, is that a of the outreach in terms recruitment seems at least from I gathered that that you go the BDSRA well as [ Indiscernible ] battle people. What happened was -- a thanes battle foundation and -- nathan's battle the we got the -- there names there we the of those names but that's out to be a small percentage. These e-mails to us don't any of them. come to I send them to our regulatory and the families.

in of the outreaches, just for my clarity, then, there is an email of families that's used as one outreach mechanism, that correct?

No. We -- the we had a the families we a list of families but we got emailed by and everybody else. I this was all of mouth. We did no advertisement at all. And it to us. this is a small community and my impression is if all rare diseases are small community and they with one another. They email one another back and forth. And so they are all where probably a half or more before we start clinical study we were that road. were all aware.

guess I was going with this was and maybe it's not really relevant, but I'm wondering the fact email is sort of tied to family resources. And that a resource limited family certainly out of an email loop, or they of this broader don't

We have gotten some letters, also. By email, the dominant we have some letters, also. Thank you.

Other questions? Yes, Dr.

Dr. am I in observing that the fourth patient 13 years old?

No. That on I think have been it was a typo somewhere I was preparing all this it's years

Okay.

Okay. I guess question I had --

child -- the child who didn't fit the protocol because the scoliosis who subsequently died was and had a

I I is there any way of knowing what's going to happen and how long it would if you were to inject into one of these sub clinical seizure loci?

Well the, the issue -- well, the issue are two aspect. Seizures. One aspect course is the and that's what all worried about. The other aspect course is the surgicalAnd putting the catheter in. And it's -- -- well in the neurosurgical experience that you expose the human to air you can get seizures. So not suggesting that, know, that's what did it but it -- it -- it can occur. I have no other information than what have told you. The MRIs and cerebral fluid didn't show any inflammation.

I guess I'm getting at 14 days away, is that usual? did the procedure and then 14 days there was the...

you mean why? You know, well, obviously, I mean one possibility is theAnother possibility is that was the catheter that went in. Another possibility the of this disease. I no way of saying so that's why we the we have answered

Dr. -- Dr. abold

-- Dr. abold

think to think RAC is soft here. I thought you did a fantastic job answering the questions which I are the trees and every tree is trimmed beautifully. like to step back and at the forest for a moment have to say list toning this I'm uncomfortable with this protocol. [You want to commenon that. Obviously of the FDA-approved the IRB but I have some concerns aboutOne biggest concerns news you done best general transfer trials, is good trial should have way to assess gene to see what you're doing. see that here. I is putting of AAV did I newsly into -- diffusely brains of extremely sick in a very, very aggressive protocol. Eight the operating room! Which is, more than any protocol that think of Excuse me. If I could just -- that's first of the protocol. Think about this like metastaticYou know, you and I know when we treat end stage metastatic disease in our new the therapy is that are going cure these people. the earlier people and are not looking for in terms of efficacy in the severe children. It's the other categories we are looking in so it's the moderate category and the way the protocol written you saw that -- the we disease is that rapid in terms the rating scale. And one I showed in our screening study is we stabilize that rating scale, is the efficacy. Whether or not is not That's real long shot. The of the coin is, in what's happening, can see today, is you choose these end stage with very aggressive protocols and things happen think you or anybody else is surprised something like happened to such sick children, sets field back a bit because now, okay, here's the first with AAV in the brain that died. What about the Parkinson's Disease, the Alzheimer's, the Frerotte we are seeing -- protocols we are seeing which much less aggressive, not trying to treat large amounts of brains with large amounts of vector and some of the trials we have seen shown very clever ways to look for gene transfer. -- unless you have I'd to about it, are you looking for gene other than saying bad are going happen to aI don't -- I say, is already through, it was approved the RAC. I just want the I sort of feel with this

The problem Dr. and you know do is basically the Gell singer problem you know history of it was first being considered, consideration was to do very severe children. that was arguments as to would be of the severe children, and milder [ ] and think someone else said earlier today that it was somebody who is very severe they died, what would happen wouldn't have in of the whole issue. that's where we're caught. we decided to use the metastatic model first and then move more mild. can argue it. I can't provide you with more than I have but a -- I think that the reason that you all are I think -- with caveat with your statement, but in general, are accepting what happened is that this is -- we -- it in a severe case end stage and we all feel that, it was and with. rather that than somebody who was very mild. That's the dilemma we in terms of doing it. If we really going to show efficacy in these kinds of disorders I think we to be mild the day of diagnosis don't we there that was the don't we to start that was the lesson I we learned the Gellsinger experience.

Dr. your scments are -- comments are wellThe RAC never approved or disapproved this protocol. The RAC membership that time elected not to review or discuss the protocol publicly. And again, want thank you publicly, Dr. for coming today to discuss with us. Miss you had...

Well, it was just clarityI not be fully understanding it, but... my understanding my colleague here to say, uhm, so much that you talking about the treatment of the most severely affected children first but that, uhm, the protocol in -- with such adepressive try -- aggressive treatment? I'm just to understand the was you were comparing it to other Frerotte in there was -- to other protocols in there was a much lower beginning and more moderate escalation. If I could -- because we then -- Dr. Albelda -- we thought about that and we discussed with the FDA. instance have one burr hole could have done a much lower to start that was the ethical decision. are taking the children intubating and operating and burr holes and MRAs, was it realizing that, know, -- what the form there is no that is toWas that fair the to do in a dose escalation burr hole escalation and so there is other get the the brain. was basically the dilemma. And why together the FDA, we ended with the maximum number of burr that were to be safe, the maximum dose we that could use be safe ] .

Other or comments? Either from the RAC or from the public? .

if not, I want thank you, Dr. and Dr. you had a wanted to make.

Yes. Just briefly. specific to this presentation and then, uhm, another related to the two days proceedings. thank Dr. of what of the and thank the RAC members who did an in-depth review of the amendment. As an we felt it very important that given the of of the patients in this trial, that Dr. be invited back and the specifics of that event, address what have been in place to try to prevent such in the future, what type of monitoring plans to oo dress how -- to address how prospective participants and their families will be informed they will and also to address have the very social, ethical and perhaps fiscal issues surrounding funding of trial private resources. thankI think this has been very healthy, uhm, not the questions have been fully have been addressed, but they are complex issues and there are right on some of them. I that statement characterizes many of discussions have had the two days. And it's just very healthy and for the field to have a forum like I want to each and one of you in the public participants -- and the public participants for this as a model for open discussion that's important for advancing this field.

Dr. I may as someone who been grilled the RAC for now 13 years? Something like that? I think RAC very important. think it all us and, know, I all the sentiments that were said today and not only society, which is -- but the investigators. I it helps protect I think a good process.

So on these discussion points and notes close the 99th of theI want to not only the RAC members but the staff. This has been a very and challenging two days. I for everyone here. And the preparation for this meeting ee form must. -- enormous. It was enormous. And I especially to thank the staff for preparing all that we could in this meeting. So we'll see in June.