A Phase II Study to Evaluate the Efficacy of UF-KURE19 Cells in Patients With Relapsed or Refractory B Cell Non-Hodgkin Lymphomas

This is a Phase II, single-arm, open-label, interventional study designed to evaluate the efficacy of UF-KURE19, an autologous CD19-directed chimeric antigen receptor (CAR) T-cell therapy, in patients with relapsed or refractory B-cell non-Hodgkin lymphoma (NHL). UF-KURE19 is manufactured using an ultra-fast production process completed in under one day, in contrast to conventional CAR-T manufacturing timelines. The study aims to determine whether this accelerated manufacturing approach can deliver an effective CAR-T product while addressing logistical and clinical challenges associated with longer production times, such as disease progression during the manufacturing wait period.

The trial enrolls two distinct cohorts based on lymphoma subtype and treatment history. Cohort 1 will enroll 81 participants with large B-cell lymphoma (LBCL), including diffuse large B-cell lymphoma not otherwise specified, high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, or follicular lymphoma grade 3B. Eligible LBCL patients must have relapsed after two or more prior lines of chemoimmunotherapy, have disease refractory to first-line therapy or relapsing within 12 months of completing initial chemoimmunotherapy, or have relapsed disease and be ineligible for hematopoietic stem cell transplantation due to comorbidities, age, or patient preference. Cohort 2 will enroll 24 participants with follicular lymphoma or marginal zone lymphoma who have relapsed after two or more prior lines of therapy.

All participants must have histologically confirmed CD19-positive NHL (by immunohistochemistry or flow cytometry) at the most recent biopsy; patients previously treated with CD19-targeted therapy must have a post-treatment biopsy confirming sustained CD19 expression. Additional eligibility requirements include an ECOG performance status of 2 or better, measurable disease with at least one FDG-avid lesion per Lugano Criteria, and adequate hepatic, renal, cardiac, and pulmonary function. Patients must be at least two weeks removed from prior radiation or systemic anti-malignancy therapy and at least 28 days (or five half-lives, whichever is shorter) from any investigational agent prior to leukapheresis. Women of childbearing potential and men with partners of childbearing potential must agree to use highly effective contraception during and after treatment, as specified in the protocol.

Key exclusion criteria include prior allogeneic hematopoietic stem cell transplant, autologous stem cell transplant within 12 weeks of consent, active second malignancies (with limited exceptions), NYHA Class III-IV heart failure, recent cardiovascular events, active HIV or hepatitis B/C infection, pregnancy or breastfeeding, clinically significant CNS pathology, uncontrolled intercurrent illness, active autoimmune disease requiring significant immunosuppression, leukemic phase lymphoma, and prior treatment with any CD19-directed CAR-T product.

Participants will receive a single intravenous infusion of UF-KURE19: 10×10⁶ cells for patients weighing 50 kg or more, or 7×10⁶ cells for patients weighing less than 50 kg. Following infusion, participants will be monitored per a structured schedule of assessments that includes adverse event collection, clinical laboratory testing, physical and neurological examinations, vital signs, imaging as applicable, concomitant medication tracking, CAR-T cell persistence assays, and replication-competent lentivirus (RCL) testing. Disease response will be assessed according to the 2014 Lugano Response Criteria for Malignant Lymphoma.

The primary endpoint is the objective and complete response rate at day 90 following UF-KURE19 infusion. Secondary objectives include duration of response, overall survival, progression-free survival, manufacturing success rate, and overall safety and tolerability of UF-KURE19. Exploratory objectives include characterizing the persistence of CAR-T cells via flow cytometry and quantitative PCR, evaluating changes in serum cytokine concentrations, determining the T-cell phenotype of the rapidly manufactured CAR-T product, and assessing the development of anti-murine and anti-KURE19 antibodies following infusion.

Each cohort employs a Simon optimal two-stage design to evaluate efficacy while limiting patient exposure to an ineffective therapy. For Cohort 1 (LBCL), the study assumes a target complete response rate of 45%, with a response rate of 30% or lower considered unacceptable; 27 patients will be enrolled in the first stage, and if 10 or more achieve a complete response, an additional 54 patients will be enrolled in the second stage. If 31 or more of the total 81 patients achieve a complete response, UF-KURE19 will be considered to demonstrate efficacy exceeding 45%. For Cohort 2 (follicular/marginal zone lymphoma), the study assumes a target complete response rate of 60%, with the same 30% floor considered unacceptable; 8 patients will be enrolled in the first stage, and if 4 or more achieve a complete response, an additional 16 patients will be enrolled in the second stage, with 11 or more complete responses among the total 24 patients establishing efficacy exceeding 60%. Both designs yield a type I error rate of 0.05 and 80% statistical power at the assumed true response rates.

Inclusion criteria

• Male or female patients aged 18 years or older.
• Participants must have histologically confirmed, CD19 positive (by IHC or flow cytometry) NHL at the most recent biopsy. If a previous CD19 targeting therapy was utilized, a biopsy should be available after this therapy demonstrating sustained CD19 expression.
• Subjects in cohort 1 (LBCL) must meet the following inclusion criteria:

a. Subjects must fit one of the following diagnoses: i. Diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma) ii. High-grade B-cell lymphoma iii. Primary mediastinal large B-cell lymphoma iv. Follicular lymphoma grade 3B b. LBCL disease status must consist of one of the following: i. Relapsed after 2 or more lines of chemoimmunotherapy OR ii. Disease that is refractory to first line chemoimmunotherapy or relapses within 12 months of completion of initial chemoimmunotherapy OR iii. Relapsed disease that is ineligible to receive hematopoietic stem cell transplantation due to comorbidities or age or patient preference

• Subjects in cohort 2 (FL) must meet the following inclusion criteria:

a. Subjects must fit one of the following diagnoses: i. Follicular lymphoma ii. Marginal zone lymphoma b. Disease status must have relapsed after 2 or more lines of therapy

• ECOG Performance status ≤ 2.
• Participants must exhibit measurable disease with at least one FDG avid lesion at enrollment per Lugano Criteria
• Minimum of 2 weeks since prior radiation therapy or systemic therapy to treat malignancy at the time of leukapheresis.
• Total bilirubin ≤ 1.5X institutional upper limit of normal.
• AST (SGOT)/ALT (SGPT) ≤ 2.5 X institutional upper limit of normal.
• Calculated creatinine clearance ≥ 30mL/min estimated by the Cockcroft - Gault formula.
• Cardiac ejection fraction of ≥ 45%.
• Adequate pulmonary function, defined as ≤ Grade 1 dyspnea (unless considered secondary to lymphoma) and oxygen saturation (SaO2) ≥ 90% on room air.
• Subjects (or legal guardians) must have the ability to understand and the willingness to sign a written informed consent document.
• For women of childbearing potential: agreement to remain abstinent (refrain from heterosexual intercourse) or use a contraceptive method with a failure rate of < 1% per year during the treatment period and for at least 90 days after the UF-KURE19 CAR-T cell infusion.

A woman is considered to be of childbearing potential if she is post menarcheal, has not reached a postmenopausal state (< 12 continuous months of amenorrhea with no identified cause other than menopause), and has not undergone surgical sterilization (removal of ovaries and/or uterus). Examples of contraceptive methods with a failure rate of < 1% per year include bilateral tubal ligation, male sterilization, hormonal contraceptives that inhibit ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices. The reliability of sexual abstinence should be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception.

• For men: agreement to remain abstinent (refrain from heterosexual intercourse) or use contraceptive measures, and agreement to refrain from donating sperm, as defined below:

With female partners of childbearing potential, men must remain abstinent or use a condom plus an additional contraceptive method that together result in a failure rate of < 1% per year during the treatment period and for at least 6 months after the UF-KURE19 CAR-T cell infusion. Men must refrain from donating sperm during this same period. With pregnant female partners, men must remain abstinent or use a condom during the treatment period and for at least 6 months after the UF-KURE19 CAR-T cell infusion to avoid potential embryonal or fetal exposure. The reliability of sexual abstinence should be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception.

• Inclusion of Women and Minorities: Men, women and members of all races and ethnic groups are eligible for this trial.

Exclusion criteria

• Inclusion Criteria

• Male or female patients aged 18 years or older.
• Participants must have histologically confirmed, CD19 positive (by IHC or flow cytometry) NHL at the most recent biopsy. If a previous CD19 targeting therapy was utilized, a biopsy should be available after this therapy demonstrating sustained CD19 expression.
• Subjects in cohort 1 (LBCL) must meet the following inclusion criteria:

a. Subjects must fit one of the following diagnoses: i. Diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma) ii. High-grade B-cell lymphoma iii. Primary mediastinal large B-cell lymphoma iv. Follicular lymphoma grade 3B b. LBCL disease status must consist of one of the following: i. Relapsed after 2 or more lines of chemoimmunotherapy OR ii. Disease that is refractory to first line chemoimmunotherapy or relapses within 12 months of completion of initial chemoimmunotherapy OR iii. Relapsed disease that is ineligible to receive hematopoietic stem cell transplantation due to comorbidities or age or patient preference

• Subjects in cohort 2 (FL) must meet the following inclusion criteria:

a. Subjects must fit one of the following diagnoses: i. Follicular lymphoma ii. Marginal zone lymphoma b. Disease status must have relapsed after 2 or more lines of therapy

• ECOG Performance status ≤ 2.
• Participants must exhibit measurable disease with at least one FDG avid lesion at enrollment per Lugano Criteria
• Minimum of 2 weeks since prior radiation therapy or systemic therapy to treat malignancy at the time of leukapheresis.
• Total bilirubin ≤ 1.5X institutional upper limit of normal.
• AST (SGOT)/ALT (SGPT) ≤ 2.5 X institutional upper limit of normal.
• Calculated creatinine clearance ≥ 30mL/min estimated by the Cockcroft - Gault formula.
• Cardiac ejection fraction of ≥ 45%.
• Adequate pulmonary function, defined as ≤ Grade 1 dyspnea (unless considered secondary to lymphoma) and oxygen saturation (SaO2) ≥ 90% on room air.
• Subjects (or legal guardians) must have the ability to understand and the willingness to sign a written informed consent document.
• For women of childbearing potential: agreement to remain abstinent (refrain from heterosexual intercourse) or use a contraceptive method with a failure rate of < 1% per year during the treatment period and for at least 90 days after the UF-KURE19 CAR-T cell infusion.

A woman is considered to be of childbearing potential if she is post menarcheal, has not reached a postmenopausal state (< 12 continuous months of amenorrhea with no identified cause other than menopause), and has not undergone surgical sterilization (removal of ovaries and/or uterus). Examples of contraceptive methods with a failure rate of < 1% per year include bilateral tubal ligation, male sterilization, hormonal contraceptives that inhibit ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices. The reliability of sexual abstinence should be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception.

• For men: agreement to remain abstinent (refrain from heterosexual intercourse) or use contraceptive measures, and agreement to refrain from donating sperm, as defined below:

With female partners of childbearing potential, men must remain abstinent or use a condom plus an additional contraceptive method that together result in a failure rate of < 1% per year during the treatment period and for at least 6 months after the UF-KURE19 CAR-T cell infusion. Men must refrain from donating sperm during this same period. With pregnant female partners, men must remain abstinent or use a condom during the treatment period and for at least 6 months after the UF-KURE19 CAR-T cell infusion to avoid potential embryonal or fetal exposure. The reliability of sexual abstinence should be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception.

• Inclusion of Women and Minorities: Men, women and members of all races and ethnic groups are eligible for this trial.

Exclusion criteria

• Autologous stem cell transplant within 12 weeks of informed consent.
• History of allogeneic hematopoietic stem cell transplantation.
• Second active malignancy that is not another NHL, other than non-melanoma skin cancer, carcinoma in situ (e.g. cervix, bladder, breast), stage 1 uterine cancer, or localized prostate cancer.
• Less than 28 days or 5 half-lives elapsed whichever is shorter between prior treatment with investigational agent(s) and leukapheresis.
• New York Heart Association class III-IV congestive heart failure.
• Cardiovascular disorders including unstable angina pectoris, clinically significant and uncontrolled cardiac arrhythmias, myocardial infarction or stroke (including transient ischemic attack, or other ischemic event) within 6 months prior to registration.
• Confirmed active human immunodeficiency virus (HIV) infection.
• Pregnant or breastfeeding women are excluded from this study because CAR-T cell therapy may be associated with the potential for teratogenic or abortifacient effects. Women of childbearing potential must have a negative serum pregnancy test. Because there is an unknown, but potential risk for adverse events in nursing infants secondary to treatment of the mother with CAR-T cells, breastfeeding should be discontinued. These potential risks may also apply to other agents used in this study.
• Evidence of myelodysplasia or cytogenetic abnormality indicative of myelodysplasia on any bone marrow biopsy prior to initiation of therapy.
• Serologic status reflecting active hepatitis B or C infection. Patients that are positive for hepatitis B core antibody, hepatitis B surface antigen (HBsAg), or hepatitis C antibody must have a negative polymerase chain reaction (PCR) prior to enrollment. (PCR positive patients will be excluded).
• Patients with history of clinically relevant CNS pathology such as epilepsy, seizure disorders, paresis, aphasia, uncontrolled cerebrovascular disease, severe brain injuries, dementia and Parkinson's disease.
• Subjects with uncontrolled intercurrent illness including, but not limited to ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, pulmonary abnormalities or psychiatric illness/social situations that would limit compliance with study requirements.
• History of active autoimmune disease (i.e. rheumatoid arthritis, systemic lupus erythematosus) with requirement of systemic immunosuppressive medications other than low dose steroids [i.e. maximum of 15mg prednisone equivalent] within the last 6 months.
• History of leukemic phase lymphoma or presence of 1% or more circulating lymphoma cells at subject enrollment.
• Previous treatment with a CD19 CAR-T product