Safety and Efficacy of PMT Therapy of hPAP

Number of patients with a CTCAE grade 3 or 4 AE in clinical history findings, physical exam findings, vital signs, clinical laboratory values, pulmonary function data, cardiac function, chest x-ray, chest CT at any time during the study period after initiation of PMT Therapy

Patient global impression of severity (PGIS) and patient global impression of change (PGIC) will be assessed in relation to the patient's overall impression of disease severity and change from baseline. PGIS will assess the current breathing problems and the impact on daily physical activity. The current severity of hPAP (PGIS) will be assessed on a five-point scale ranging from none, mild, moderate, severe, to very severe.

PGIC will assess the change from baseline in breathing problems and impact of breathing problems on daily physical activity. The change from baseline in hPAP severity (PGIC) will be assessed on a five-point scale ranging from much improved, somewhat improved, no change, somewhat worse, to much worse.

The PGIS and PGIC parameters will be evaluated just prior to PMT, immediately upon completion of PMT, and daily for 5 days following PMT.

Number of patients with an increase in detection of anti-GM-CSF receptor alpha antibodies in serum at any time during the study period after initiation of PMT Therapy

Number of patients with evidence of clonal lentiviral positive cell expansion measured by the presence of vector-derived replication competent lentivirus (RCL) at any time during the study period after initiation of PMT Therapy

Number of patients with evidence of insertion of the transgene in proximity of known proto-oncogenes and the number of patients with evidence of clonal expansion associated to common insertion sites at any time during the study period after initiation of PMT Therapy

Number of patients with a CTCAE grade 3 or 4 increase in tumor necrosis factor (TNF)-alpha, interleukin (IL)-1-beta, and IL-6 in bronchoalveolar lavage (BAL) or serum at any time during the study period after initiation of PMT Therapy

Change in the percentage of BAL cells with detectable GM-CSF receptor alpha chain expression measured by immunofluorescence at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in percentage of alveolar macrophages that stain positive for Ki-67 at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Presence of lentiviral DNA detected by PCR in the lungs and blood at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in the percentage of BAL cells with detectable GM-CSF receptor alpha chain expression measured by immunofluorescence at 6 months (Visit 11) compared to one year after PMT Therapy (Visit 14)

Change in bronchoalveolar lavage (BAL) fluid turbidity at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in ratio of cholesterol to total phospholipids in surfactant at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in the percentage of Oil Red O+ alveolar macrophages at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in intensity of Oil Red O staining in AM at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16). Intensity will be graded on visual scoring. Each cell will be assigned a number (0, 1, 2, or 3) reflecting the degree of oil-red-O-staining. The number of cells at each grade will be multiplied by the numerical grade and products added and divided by the total number of cells evaluated to obtain the oil-red-O staining score.

Change in concentrations of BAL cytokine biomarkers of PAP (GM-CSF, M-CSF, and monocyte chemotactic protein-1 (MCP-1)) measured by enzyme linked immunosorbent assay (ELISA) at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in alveolar macrophage messenger RNA (mRNA) biomarkers of PAP (PU.1, peroxisome proliferator-activated receptor (PPAR)-gamma, and ABCG1) measured by quantitative reverse transcription/polymerase chain reaction (qRT-PCR) amplification at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in A-aDO2 measured by standardized arterial blood gas analysis at baseline and at 6 months and one year after PMT Therapy

Change in dyspnea measured by the San Diego Dyspnea Questionnaire at baseline and all visits after PMT

The San Diego Dyspnea Questionnaire asks subjects to indicate severity of shortness of breath on a 6-point scale (0=Not at all, 5=maximally or unable to do because of breathlessness) during 21 activities of daily living associated with varying levels of exertion. Three additional questions ask about fear of harm from overexertion, limitations, and fear caused by shortness of breath, for a total of 24 items. A total sum score ranges from 0 to 120.

Change in the diffusing capacity for carbon monoxide (DLCO) measured by American Thoracic Society (ATS) standards at baseline and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in lowest peripheral blood oxygen saturation value measured by standardized treadmill testing performed at baseline and at 6 months and one year after PMT Therapy

Change in time to reduction in peripheral blood oxygen saturation by 5% measured by standardized treadmill testing performed at baseline and at 6 months and one year after PMT Therapy

Change in lowest peripheral blood oxygen saturation value measured by the STandardized Exercise Protocol testing (STEP Test) performed weekly before and after initiation of PMT Therapy.

Standardized exercise oximetry to measure blood oxygen saturation will be performed at home weekly during the study. Briefly, a pulse-oximeter will be placed on the finger with the participant at rest sitting in a chair. Three baseline (resting) readings will be taken over a 3 minute period. Then the participant will step on and off a standard step for a period of 5 minutes followed by a 3 minute seated recovery. The pulse oximeter will record oxygen saturations every minute of the test. Data will be transmitted to the site via the mobile health platform. The lowest peripheral blood oxygen saturation will be determined from the collected data.

Change in time to reduction in peripheral blood oxygen saturation (SpO2) by 5% measured by the STandardized Exercise Protocol testing (STEP Test) performed weekly before and after initiation of PMT Therapy. Results will be evaluated by repeated measures analysis and graphic illustration to depict temporal change in the therapeutic effects after PMT.

Standardized exercise oximetry to measure blood oxygen saturation will be performed at home weekly during the study. Briefly, a pulse-oximeter will be placed on the finger with the participant at rest sitting in a chair. Three baseline (resting) readings will be taken over a 3-minute period. Then the participant will step on and off a standard step for a period of 5 minutes followed by a 3-minute seated recovery. The pulse oximeter will record oxygen saturations every minute of the test. Data will be transmitted to the site via the mobile health platform. The time of the lowest SpO2 will be determined from the collected data.

Change in lung mass determined radiologically by quantitative pulmonary computed tomographic densitometry (QPCTD) at baseline and at 6 months and one year after PMT Therapy

Change in the quantitative categorical pulmonary parenchymal pattern score determined using CALIPER at baseline and at 6 months and one year after PMT Therapy

Change in quality of life measured by SF-36 total score and component score at baseline (Visit 3) and all visits after PMT.

The SF-36 Questionnaire is a 36-item, patient-reported survey of patient health. The questionnaire consists of eight scaled scores (each 0-100), which are the weighted sums of the questions in their section, with each question carrying equal weight. The lower the score the more disability. The eight sections are 1) vitality, 2) physical functioning, 3) bodily pain, 4) general health perceptions, 5) physical role functioning, 6) emotional role functioning, 7) social role functioning and 8) mental health.

Change in the percentage of BAL cells positive for phosphorylated STAT5 (pSTAT5) and change in STAT5 phosphorylation index (STAT5-PI) via flow cytometry at baseline (Visit 3) and various times after PMT (months 2, 4, 6 (optional), 10, and 16)

Change in cell population dynamics of the transplanted macrophages following PMT Therapy using t-distributed stochastic neighbor embedding (t-SNE) analysis of RNA sequencing data obtained at single-cell resolution on cells collected by BAL (months 2, 4, 6 (optional), 10, and 16). Specifically, the investigators will track the number and relative proportion of distinct cell populations among BAL cells.

The upstream regulatory elements controlling downstream target genes regulating AM specification will be identified in transplanted macrophages collected by BAL (months 2, 4, 6 (optional), 10, and 16). Monocle and Cicero software will utilize a battery of regression analysis tools to identify and correlate differentially expressed genes and differentially accessible putative DNA regulatory elements.