A Phase I/II Trial to Evaluate the Safety and Immunogenicity of a Messenger RNA (mRNA)-Based, Personalized Cancer Vaccine Against Neoantigens Expressed by the Autologous Cancer
Phase: PHASE1
Conditions: Melanoma, Colon Cancer, Gastrointestinal Cancer, Genitourinary Cancer, Hepatocellular Cancer
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
1 
Abbreviated Title: mRNA-Based, Cancer Vaccine 
CC Protocol Number: 18-C-0074 E 
IBC Number: RD-18-I-07 
OSP Number: 1803-1739 
NCT Number: NCT03480152 
Version Date: January 23, 2019 
PROTOCOL TITLE 
A Phase I/II Trial to Evaluate the Safety and Immunogenicity of a Messenger RNA (mRNA)-
Based, Personalized Cancer Vaccine Against Neoantigens Expressed by the Autologous Cancer 
 
NIH Principal Investigator:  
Steven A. Rosenberg, M.D., Ph.D.  
 
 
 
 
 
Chief of Surgery, Surgery Branch, CCR, NCI 
 
 
 
 
 
Building 10, CRC, Room 3-3940 
9000 Rockville Pike, Bethesda, MD 20892 
 
 
 
 
 
Phone: 240-858-3080; E-mail: Steven.Rosenberg@nih.gov 
 
Investigational Agent: 
Drug Name: 
NCI-4650 (mRNA-based, Personalized Cancer Vaccine) 
IND Number: 
17858 
Sponsor: 
Center for Cancer Research 
Manufacturer: ModernaTX, Inc. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
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PRÉCIS 
Background: 
x Therapeutic vaccination against cancer has proven very challenging with little clinical 
benefit.  
x Vaccines against non-viral tumors have mainly targeted differentiation antigens, cancer 
testis antigens, and overexpressed antigens. However, negative selection in the thymus 
against these normal non-mutated antigens severely limits the ability to generate high 
avidity anti-cancer T-cells. Such depletion can impair their antitumor activity and limit 
tumor elimination.  
x The National Cancer Institute Surgery Branch (NCI-SB) has developed a pipeline for the 
identification of immunogenic T-cell epitopes derived from neoantigens. 
x In recent studies, we identified the neoantigens recognized by tumor-infiltrating 
lymphocytes (TIL) that mediated regression in patients with metastatic melanoma. Using 
whole exome sequencing of a resected metastatic nodule followed by high throughput 
immunologic screening, we were able to demonstrate that tumor regressions were 
associated with the recognition by the administered TIL of unique somatic mutations that 
occurred in the cancer.  
x We also found that TIL from 29 of 32 patients with a wide variety of metastatic 
gastrointestinal cancers contained lymphocytes that recognized unique mutations 
presented in that patient’s cancer.  
x We, therefore, aim to use this pipeline to identify immunogenic neoantigens and to 
predict for neoantigens binding the patient human leukocyte antigen (HLA) molecules 
from melanoma or epithelial cancer patients and to use these epitopes for a personalized 
therapeutic messenger RNA (mRNA) vaccine. 
Objectives: 
x Primary objectives: 
o Determine the clinical response rate in patients with metastatic melanoma, 
gastrointestinal, or genitourinary cancers who receive NCI-4650. 
o Determine the safety of NCI-4650 in patients with metastatic melanoma, 
gastrointestinal, or genitourinary cancers. 
Eligibility: 
x Age  18 years DQG\HDUV 
x Evaluable metastatic melanoma, gastrointestinal, or genitourinary cancers refractory to 
standard of care treatment. 
x Metastatic cancer lesions suitable for surgical resection to perform whole exome 
sequencing and preparation of TIL. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
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Design: 
x Patients with metastatic cancer will undergo surgical resection of tumor followed by 
exome and RNA sequencing to identify expressed mutations. This will be conducted 
under the NCI-SB cell harvest protocol 03-C-0277 (Cell Harvest and Preparation for 
Surgery Branch Adoptive Cell Therapy Protocols). 
x Immunogenic neoantigens will be identified from TIL by high throughput immunologic 
screening using long peptides and tandem minigenes covering all mutated epitopes. 
x Up to 15 predicted neoantigens will be selected based on exome and RNA sequencing 
and their binding affinity to the patient HLA molecules. 
x The mRNA vaccine will be manufactured and supplied as cGMP product by 
ModernaTX, Inc.  
x The patient will be vaccinated with mRNA containing epitopes from immunogenic 
neoantigens, predicted neoantigens, and mutations in tumor suppressor or driver genes. 
x The mRNA vaccine will be administered intramuscularly (IM) for four cycles every two 
weeks. A patient may receive a second course for a total of eight cycles. 
x Blood samples will be taken every two weeks (during the vaccination period) and at each 
follow-up visit, and patients will be monitored for the quantity and quality of circulating 
neoantigen-specific T-cells.  
 
 
 
 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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TABLE OF CONTENTS 
PRÉCIS .......................................................................................................................................... 2
TABLE OF CONTENTS ............................................................................................................. 4 
1
INTRODUCTION............................................................................................................. 8 
 
Study Objectives ............................................................................................................. 8 
1.1.1 
Primary Objectives...................................................................................................... 8 
1.1.2
Secondary Objective................................................................................................... 8
 
Background and Rationale .............................................................................................. 8 
1.2.1 
Cancer Vaccines.......................................................................................................... 8 
1.2.2 
Identification of Cancer-Specific Immunogenic Epitopes Derived from Somatic 
Mutations ................................................................................................................................ 9 
1.2.3
Overview of mRNA-4650, a mRNA-Based, Personalized Cancer Vaccine ............ 11
1.2.4 
Preclinical Experiments Evaluating the Safety of mRNA-Based, Personalized 
Cancer Vaccines .................................................................................................................... 11 
1.2.5 
Preclinical Experiments Evaluating the Immunogenicity of a mRNA-Based, 
Personalized Cancer Vaccine in Mice .................................................................................. 12 
1.2.6 
Preclinical Experiments Evaluating the Presentation of CD4 and CD8 Epitopes by 
Human Dendritic Cells ......................................................................................................... 16 
1.2.7 
Rationale for Selecting Defined Epitopes, Predicted Epitopes, and Tumor 
Suppressor and Driver Neoantigens to Use in this Trial ....................................................... 17 
1.2.8 
Structure of NCI-4650 .............................................................................................. 17 
1.2.9 
Risk for NCI-4650 Monotherapy .............................................................................. 18 
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT .............................................. 19 
 
Eligibility Criteria ......................................................................................................... 19 
2.1.1 
Inclusion Criteria ...................................................................................................... 19 
2.1.2 
Exclusion Criteria ..................................................................................................... 20 
 
Screening Evaluations ................................................................................................... 21 
2.2.1 
Within 3 Months Prior to Part Two Registration ...................................................... 21 
2.2.2 
Within 4 Weeks Prior to Part Two Registration ....................................................... 21 
2.2.3 
Within 7 Days Prior to Part Two Registration .......................................................... 21 
 
Registration and Treatment Assignment Procedures .................................................... 22 
2.3.1 
Prior to Registration for this Protocol ....................................................................... 22 
2.3.2 
Registration Procedure .............................................................................................. 22 
2.3.3 
Treatment Assignment Procedures ........................................................................... 23 
3
STUDY IMPLEMENTATION ...................................................................................... 23 
 
Study Design ................................................................................................................. 23 
3.1.1 
Schema ...................................................................................................................... 23 
3.1.2 
Pre-Treatment Phase: Performed on 03-C-0277 ....................................................... 23 
3.1.3 
Treatment Phase ........................................................................................................ 24 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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3.1.4 
Dose-Limiting Toxicity ............................................................................................ 24 
3.1.5
Phase I – Dose Escalation......................................................................................... 24
3.1.6 
Rationale for Dose Level Regimen and Route of Administration ............................ 26 
3.1.7 
Phase II Portion ......................................................................................................... 26 
 
Protocol Stopping Rules ............................................................................................... 27 
 
Drug Administration ..................................................................................................... 27 
Baseline Evaluations..................................................................................................... 28
3.4.1 
Within 7 Days Prior to the First Vaccination (Day 0) .............................................. 28 
3.4.2 
Within 2 Days Prior to the First Vaccination (Day 0) .............................................. 28 
 
On-Study Evaluations ................................................................................................... 28 
3.5.1 
Within 2 Days Prior to Each Subsequent Vaccination (Days 14, 28, & 42 (± 5 days))
28
3.5.2 
After Each Vaccination ............................................................................................. 29 
 
Post-Treatment (Follow-up) Evaluations ...................................................................... 29 
3.6.1 
First Follow-up Evaluation ....................................................................................... 29 
3.6.2 
Subsequent Follow-up Evaluations........................................................................... 29 
 
Study Assessment Calendar .......................................................................................... 31 
 
Criteria for Removal from Protocol Therapy and Off-Study Criteria .......................... 33 
3.8.1 
Criteria for Removal from Protocol Therapy............................................................ 33 
3.8.2 
Off-Study Criteria ..................................................................................................... 33 
3.8.3 
Off Protocol Therapy and Off-Study Procedure ....................................................... 33 
4
CONCOMITANT MEDICATIONS/MEASURES ...................................................... 34 
5
BIOSPECIMEN COLLECTION .................................................................................. 35 
 
Samples Sent to Figg Lab ............................................................................................. 35 
 
Samples Sent to Surgery Branch Cell Production Facility ........................................... 35 
 
Sample Collection Schedule ......................................................................................... 35 
 
Immunological Testing ................................................................................................. 36 
 
Sample Storage, Tracking, and Disposition For Surgery Branch Cell Production 
Facility ...................................................................................................................................... 36 
 
Sample Storage, Tracking, and Disposition for Figg Lab ............................................ 36 
5.6.1 
Sample Data Collection ............................................................................................ 36 
5.6.2 
Sample Storage and Destruction ............................................................................... 37 
6
DATA COLLECTION AND EVALUATION ............................................................. 37 
 
Data Collection ............................................................................................................. 37 
6.1.1 
Exclusions to Routine Adverse Event Recording ..................................................... 38 
 
Data Sharing Plans ........................................................................................................ 38 
6.2.1 
Human Data Sharing Plan ......................................................................................... 38 
6.2.2 
Genomic Data Sharing Plan ...................................................................................... 38 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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Response Criteria .......................................................................................................... 38 
6.3.1
Disease Parameters ................................................................................................... 39
6.3.2 
Methods for Evaluation of Measurable Disease ....................................................... 40 
6.3.3 
Response Criteria Definitions ................................................................................... 41 
6.3.4 
Duration of Response ................................................................................................ 42 
 
Toxicity Criteria ............................................................................................................ 43 
7
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN 43
 
Definitions..................................................................................................................... 43 
7.1.1 
Adverse Event ........................................................................................................... 43 
7.1.2 
Suspected Adverse Reaction ..................................................................................... 43 
7.1.3
Unexpected Adverse Reaction.................................................................................. 43
7.1.4 
Serious....................................................................................................................... 43 
7.1.5 
Serious Adverse Event .............................................................................................. 43 
7.1.6 
Disability ................................................................................................................... 44 
7.1.7 
Life-Threatening Adverse Drug Experience ............................................................. 44 
7.1.8 
Protocol Deviation (NIH Definition) ........................................................................ 44 
7.1.9 
Non-Compliance (NIH Definition) ........................................................................... 44 
7.1.10 
Unanticipated Problem.......................................................................................... 44 
 
NIH INTRAMURAL-IRB and Clinical Director (CD) Reporting ............................... 44 
7.2.1 
NIH Intramural IRB and NCI CD Expedited Reporting of Unanticipated Problems 
and Deaths ............................................................................................................................. 44 
7.2.2 
NIH Intramural IRB Requirements for PI Reporting at Continuing Review ........... 45 
7.2.3 
NIH Intramural IRB Reporting of IND Safety Reports ............................................ 45 
 
IND Sponsor Reporting Criteria ................................................................................... 45 
7.3.1 
Reporting Pregnancy ................................................................................................. 46 
 
Safety Reporting Criteria to the Pharmaceutical Collaborator ..................................... 46 
 
Institutional Biosafety Committee (IBC) Reporting Criteria ........................................ 47 
7.5.1 
Serious Adverse Event Reports to IBC ..................................................................... 47 
7.5.2 
Annual Reports to IBC.............................................................................................. 47 
 
Data and Safety Monitoring Plan .................................................................................. 48 
7.6.1 
Principal Investigator/Research Team ...................................................................... 48 
7.6.2 
Sponsor Monitoring Plan .......................................................................................... 48 
7.6.3 
Safety Monitoring Committee (SMC) ...................................................................... 49 
8
STATISTICAL CONSIDERATIONS .......................................................................... 49 
 
Statistical Hypothesis .................................................................................................... 49 
8.1.1 
Primary Efficacy Endpoints ...................................................................................... 49 
8.1.2 
Secondary Efficacy Endpoint ................................................................................... 49 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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Sample Size Determination........................................................................................... 49 
Populations for Analyses .............................................................................................. 50
8.3.1 
Evaluable for Toxicity .............................................................................................. 50 
8.3.2 
Evaluable for Objective Response ............................................................................ 50 
8.3.3 
Evaluable for Non-Target Disease Response ........................................................... 50 
 
Statistical Analyses ....................................................................................................... 50 
8.4.1
General Approach..................................................................................................... 50
8.4.2 
Analysis of the Primary Efficacy Endpoints ............................................................. 50 
8.4.3 
Analysis of the Secondary Efficacy Endpoint .......................................................... 50 
8.4.4 
Safety Analyses ......................................................................................................... 51 
8.4.5 
Intention-to-Treat Analysis ....................................................................................... 51 
8.4.6
Planned Interim Analyses ......................................................................................... 51
8.4.7 
Sub-Group Analyses ................................................................................................. 51 
9
COLLABORATIVE AGREEMENTS.......................................................................... 51 
 
ModernaTX, Inc. ........................................................................................................... 51 
10
HUMAN SUBJECTS PROTECTIONS ........................................................................ 52 
 
Rationale for Patient Selection ...................................................................................... 52 
 
Participation of Children ............................................................................................... 52 
 
Participation of Subjects Unable to Give Consent ........................................................ 52 
 
Evaluation of Benefits and Risks/Discomforts ............................................................. 52 
 
Risk/Benefit Analysis ................................................................................................... 53 
 
Consent Process and Documentation ............................................................................ 53 
10.6.1 
Telephone Consent for Part One Registration ...................................................... 53 
10.6.2 
Informed Consent of Non-English Speaking Subjects ......................................... 53 
11
PHARMACEUTICAL INFORMATION ..................................................................... 54 
 
Cell Preparation ............................................................................................................ 54 
 
Intramuscular Injection Preparation .............................................................................. 54 
11.2.1 
NCI-4650, mRNA-Based Personalized Cancer Vaccine ...................................... 54 
12
REFERENCES ................................................................................................................ 56 
13
APPENDICES ................................................................................................................. 58 
 
Appendix A: Methods for Selecting Defined Epitopes, Predicted Epitopes, and Tumor 
Suppressor and Driver Neoantigens ......................................................................................... 58 
 
Appendix B: Performance Status Criteria ..................................................................... 62 
 
Appendix C: mRNA-4650 Certificate of Analysis ....................................................... 63 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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1
INTRODUCTION 
STUDY OBJECTIVES
1.1.1
Primary Objectives 
x Determine the clinical response rate in patients with metastatic melanoma, 
gastrointestinal, or genitourinary cancers who receive NCI-4650. 
x Determine the safety of NCI-4650 in patients with metastatic melanoma, gastrointestinal, 
or genitourinary cancer. 
1.1.2
Secondary Objective 
x Determine whether administration of NCI-4650, a mRNA-based, personalized cancer 
vaccine (PCV) presenting immunogenic neoantigens, can increase the quantity and 
quality of circulating antigen-specific T-cells in patients with solid tumors. 
BACKGROUND AND RATIONALE 
1.2.1
Cancer Vaccines  
Protective vaccination against infectious diseases has proven to be one of the most effective 
health measures. Therapeutic vaccination against established diseases such as persistent 
infections and cancer has proven much more challenging. Cancer vaccines are designed to target 
antigens that can elicit an immune response that selectively attacks cancer cells. Ideally, these 
antigens should be exclusively presented on cancer cells. Until recently, vaccines against non-
viral tumors mainly targeted differentiation antigens, cancer testis antigens, and overexpressed 
antigens. However, central immunological tolerance has limited the generation of high-avidity 
reactivity against these normal antigens1, 2. Thus, T-cells prompted using these vaccines 
underwent depletion of high-avidity clones directed against such antigens. This depletion causes 
the loss of T-cells bearing high-affinity T-cell receptors (TCR) for their cognate antigens, which 
have the superior cytotoxic capacity, longer persistence in the tumor microenvironment, and 
decreased susceptibility to immune suppression3. Taken together, such depletion can lead to 
impaired clinical efficiency following vaccine administration. 
In recent years, our group and others have extensively studied the importance of neoantigens as 
targets for immunotherapy. It is now clear that neoantigen-specific T-cells are present in most 
cancers. Neoantigens derived from somatic mutations offer a specific and highly immunogenic 
target for vaccination. Today, with the rapid development of technologies for DNA sequencing, 
the identification of those mutations becomes widely feasible. 
Evidence for the power of neoantigen vaccines in pre-clinical and clinical settings was recently 
published. The first proof of concept of neoantigen vaccines for cancer prevention was shown in 
the B16 mouse melanoma model4. By prophylactic vaccination with two mutated epitopes, the 
researchers achieved complete tumor protection in 40% of the mice. In therapeutic settings, they 
observed significant tumor growth inhibition induced by mutation-specific peptide vaccination. 
Recently, the same group published evidence for the potential of neoantigen vaccines as tested in 
three independent murine models5. In this paper, the researchers showed that a considerable 
fraction of the non-synonymous mutations in the cancer were immunogenic, and the majority of 
them were recognized by CD4+ T-cells. Vaccination with these CD4+ epitopes induced potent 
tumor control and rejection of established tumors. Similar results were published in another 
independent mutation-based cancer model in mice. In this work, the authors developed a pipeline 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
9 
to identify immunogenic mutant peptides using whole-exome and transcriptome sequencing 
together with mass spectrometry. Again, the researchers were able to show that vaccination with 
mutation-specific peptides induced therapeutically active T-cell responses. Results of the current 
pre-clinical data support the evaluation of neoantigen vaccines as an effective cancer treatment.  
The first human trial involving a personalized cancer vaccine was conducted by a group from 
Washington University in St. Louis which reported on a first-in-man clinical trial evaluating 
neoantigen vaccines in patients with metastatic melanoma6. These researchers vaccinated three 
patients with mature dendritic cells presenting seven predicted mutation-specific HLA-A*02:01 
restricted epitopes. They showed that vaccination with high-affinity, patient-specific mutated 
epitopes augmented T-cell immunity directed against naturally occurring dominant neoantigens 
and broadened the response by revealing subdominant neoantigens; but no clinical responses 
were observed. However, this did show that vaccination against mutated epitopes was safe as 
none of the three patients experienced any autoimmune adverse events (AEs). 
Recently, two trials involving personalized cancer vaccines in patients with advanced melanoma 
were published7, 8. The first7 used synthesized, clinical-grade long peptides targeting up to 20 
neoantigens per patient, admixed with the Toll-like receptor 3 (TLR3) and melanoma 
differentiation-associated protein 5 (MDA-5). This trial demonstrated the feasibility, safety, and 
immunogenicity of a vaccine that targets up to 20 predicted personal tumor neoantigens where 
the vaccine-induced polyfunctional CD4+ and CD8+ T-cells targeted 58 (60%) and 15 (16%) of 
the 97 unique neoantigens used across patients, respectively. These T-cells discriminated 
mutated from wild-type antigens, and in some cases directly recognized autologous tumor. Of six 
vaccinated patients, four had no recurrence at 25 months after vaccination, while two with 
recurrent disease were subsequently treated with anti-programmed cell death-1 (anti-PD-1) 
therapy and experienced complete tumor regression, with expansion of the repertoire of 
neoantigen-specific T-cells. The authors concluded that these data provide a strong rationale for 
further development of this approach, alone and in combination with checkpoint blockade or 
other immunotherapies. 
The second trial8 implemented an RNA-based poly-neoepitope approach to mobilize immunity 
against a spectrum of cancer mutations also in patients with melanoma. All patients in this trial 
developed T-cell responses against multiple vaccine neoepitopes at up to high single-digit 
percentages. Vaccine-induced T-cell infiltration and neoepitope-specific killing of autologous 
tumor cells were shown in post-vaccination resected metastases from two patients. The 
cumulative rate of metastatic events was highly significantly reduced after the start of 
vaccination, resulting in a sustained progression-free survival. Two of the five patients with 
metastatic disease experienced vaccine-related objective responses. One of these patients had a 
late relapse owing WRRXWJURZWKRIȕ-microglobulin-deficient melanoma cells as an acquired 
resistance mechanism. A third patient developed a complete response to vaccination in 
combination with PD-1 blockade therapy. These authors concluded that individual mutations can 
be exploited by way of personalized immunotherapy for patients with cancer. 
1.2.2 
Identification of Cancer-Specific Immunogenic Epitopes Derived from Somatic 
Mutations 
The NCI-SB has developed a process to identify immunogenic T-cell epitopes derived from 
neoantigens (Figure 1). The identification of these antigens is done in four main stages: (1) 
Whole exome sequencing and RNA-seq analysis of the tumor and a matched normal apheresis 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
10
sample to identify highly expressed somatic mutations; (2) Construction of tandem minigenes 
and synthesis of long peptides covering these mutations; (3) Expression of the constructs in 
autologous antigen-presenting cells; and, (4) In vitro co-culture assay to identify T-cells 
recognizing mutated epitopes from TIL9. In earlier studies done by the NCI-SB (published and 
unpublished data), 25 patients with melanoma were screened in the above manner, and 64 
antigenic somatic mutations were identified with no overlapping neoantigens between patient 
tumors10, 11. 
Recently, a study to identify antigenic mutations from patients with epithelial cancers, including 
those of the gastrointestinal tract, genitourinary tract, and breast, identified 57 non-overlapping 
somatic mutations. In this study, two patients were identified who developed a T-cell response 
against the mutated KRAS oncogene12. Thus far, more than 121 immunogenic epitopes have 
been identified from multiple cancer types including melanoma, ovarian, colorectal, lung, and 
breast cancers9, 10, 12-15. This process, which can be applied to any cancer type and can be 
completed in several weeks, ensures that the selected antigens are not just expressed in the tumor 
but can also prompt a significant T-cell-mediated immune response. 
 
Figure 1.  A pipleline for the identification of immunogenic somatic mutations. 
 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
11 
1.2.3 
Overview of mRNA-4650, a mRNA-Based, Personalized Cancer Vaccine 
ModernaTX, Inc. (Moderna) is developing a new mRNA technology that allows for induced 
production of a broad array of secreted, membrane-bound and intracellular proteins both in cell 
culture and in many animal models and humans. The mRNA vaccines are produced by a 
well-controlled, characterized, scalable process that is agnostic to the antigen being produced. 
Additionally, host cell production and presentation of the antigen more closely resemble viral 
antigen expression and presentation compared to an exogenously produced, purified, and 
formulated protein antigen. This offers advantages in speed, precision, and adaptability of 
antigen design and production that cannot be replicated by conventional platforms, which may be 
especially valuable for personalized cancer vaccines (PCV). This mRNA vaccine production 
process allows for rapid mRNA production and formulation (within approximately eight weeks) 
at sufficient quantities to support individualized manufacture and dosing in a clinical study. 
Moreover, this mRNA-based vaccine technology overcomes the challenges other nucleotide 
approaches pose such as preexisting immunity or antivector immunity for viral vectors, the risk 
of genome integration, or the high doses and devices needed (e.g., electroporation) for DNA-
based vaccines.  
Using a lipid nanoparticle (LNP), Moderna has generated very high levels of transient expression 
of several different types of proteins (including those for prophylactic vaccines for infectious 
diseases), in several animal species as wells as humans. The approach also avoids the use of 
conventional immunostimulatory compounds for enhancement of immunogenicity. Specifically, 
Moderna has demonstrated that LNP-based, modified-mRNA vaccine technology can generate 
robust and protective immune responses in mice, ferrets, and cynomolgus monkey, and initial 
data from early trials in humans have shown such mRNA-based vaccines to be safe and well-
tolerated. As an example, Moderna has shown that a range of doses of formulated mRNA 
encoding the hemagglutinin (HA) protein of either H7N9 or H10N8, can stimulate rapid, robust, 
long-lasting, and dose-related immune responses as measured by a hemagglutination inhibition 
(HAI) test, microneutralization assay, and protection from viral challenge16. Importantly, mRNA 
is a potent and flexible component for vaccination, inducing rapid, durable, and high levels of 
antigen-specific B- and T-cell responses to protein antigens encoded by mRNA. Moreover, 
mRNA vaccines can also induce potent T-cell responses to murine and human neoantigens, while 
not inducing strong responses to epitopes derived from the wild-type sequences5.  
For this clinical trial, Moderna will manufacture NCI-4650 encoding immunogenic and predicted 
neoantigens expressed by the patient autologous tumor identified by the NCI-SB. The goal of the 
approach is to prime, activate, and expand a diverse population of neoantigen-specific T-cells 
against these immunogenic and predicted neoantigens for the treatment of solid tumors. As part 
of this approach, next-generation sequencing (NGS), HLA epitope prediction, and high 
throughput epitope screens will be employed to enable robust and consistent vaccine design 
within this clinical study. 
1.2.4 
Preclinical Experiments Evaluating the Safety of mRNA-Based, Personalized Cancer 
Vaccines 
To support the proposed Phase I clinical study, the safety and tolerability of a similar, mRNA-
based PCV, mRNA-4157 (IND 17390), was evaluated in a Good Laboratory Practices (GLP)-
compliant one-month toxicity study, in outbred Sprague Dawley® rats at 0.012, 0.035, and 
0.117 mg per dose via IM injection administered weekly for a total of 5 doses, and followed by a 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
12 
14-day post-study recovery period. These doses approximate to human equivalent doses (HED) 
of 0.29, 0.97, and 3.51 mg, respectively (based on group mean body weights of 0.46, 0.40, and 
0.37 kg in rats, respectively, and using an average human body weight of 70 kg), and thus 
approximate margins of 7-, 24- and 88-fold over the human starting dose of 0.04 mg. The study 
involved a more dose-dense regimen than the proposed human dosing frequency of every 
2 weeks which is being used herein. Although more frequent administration of antigens can 
impact immunogenic responses, it is unlikely that more frequent dosing would interfere with 
immunogenicity of this drug product as the antigens expressed are not intended for the rodent 
and are selected to cross a broad spectrum of major histocompatibility complex (MHC) 
specificities. A more aggressive regimen than the intended clinical dosing frequency was selected 
to thoroughly characterize drug product toxicity. Although the vaccine design of NCI-4650 is 
100% personalized (i.e., sequences coding for tumor-associated neoantigens unique to the 
subject and predicted to be most immunogenic will be administered for each subject), the 
sequence tested in this toxicology study represented a human-based sequence of comparable size 
and composition to the NCI-4650 that will be generated for each subject in the clinical study, and 
was manufactured in a similar manner to how NCI-4650 will be manufactured in this clinical 
study, with the exception that the immunogenic neoantigens coded by NCI-4650 will be 
determined by laboratory techniques at the NCI-SB and bioinformatics prediction algorithms 
described in Section 3.2.R in IND 17390. The primary driver of safety that can be adequately 
assessed non-clinically is that of the LNP and mRNA chemistry, and any immunological effects 
of antigen expression is likely to be subject-specific and more adequately assessed clinically. 
The results of the repeat-dose toxicity study in rats indicated that mRNA-4157 was tolerated at 
all dose levels (no mRNA-4157 related mortality was observed). In addition, no changes in body 
temperature (measured indirectly by clinical observation), serum chemistry, urinalysis, or ocular 
findings were noted. Weekly administration of mRNA-4157 to Sprague Dawley rats (both male 
and female) at dose levels of 0.012, 0.035, and 0.117 mg was associated with a dose-dependent 
VOLJKWWRPLOGGHFUHDVHLQERG\ZHLJKWJDLQDWGRVHV 0.012 mg and this correlated with reduced 
food consumption. Clinical observations of injection-site reaction (ISR) were observed at all 
doses and included erythema (slight to mild) and edema (slight to moderate) that increased in 
incidence and severity with increasing dose. These clinical observations were associated with 
gross and microscopic changes at the injection site and associated enlargement of lymph nodes. 
Hematology changes consistent with inflammation were also observed and included mild to 
moderate increased white blood cells (WBCs) (driven primarily by neutrophils), and a decrease 
in lymphocytes. Systemic effects were primarily considered responses to local inflammation at 
the injection site. At the end of the recovery period, all changes were fully or partially resolved 
(absolute body weights remained lower than controls).  
1.2.5 
Preclinical Experiments Evaluating the Immunogenicity of a mRNA-Based, Personalized 
Cancer Vaccine in Mice 
To determine the ability of a poly-epitope concatemer mRNA vaccine to generate T-cell 
responses to multiple epitopes in C57Bl/6 mice, we produced a concatemer mRNA vaccine 
containing 15 known mouse epitopes (sourced from Immune Epitope Database [IEDB]) that bind 
to alleles H-2-Kb, H-2-Db, and H-2-IAb in C57Bl/6 mice (Table 1). Mice were vaccinated on 
Days 0 and 14, and spleens were harvested on Day 21. Splenocytes were restimulated with 
peptides corresponding to the vaccine epitopes and positive responses were detected via IFN-Ȗ
ELISpot assay. Positive T-cell responses were measured for 4 of 5 Class II epitopes targeting 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
13
IAb, 3 of 5 Class I epitopes targeting Kb, and 5 of 5 Class I epitopes targeting Db (Figure 2). 
Restimulation with vehicle produced no T-cell responses and robust responses were detected to 
phorbol myristate acetate/ionomycin in both the empty SM-102 and concatemer vaccine groups. 
As expected, the negative control SM-102 vaccine containing no mRNA did not induce T-cell 
responses upon peptide restimulation. Positive T-cell responses were measured for 4 of 5 (CAP2-
CAP5) Class II epitopes targeting IAb, 3 of 5 (CAP6, CAP7, and CAP9) Class I epitopes 
targeting Kb, and 5 of 5 (CAP11-CAP16) Class I epitopes targeting Db (Figure 2) when 
splenocytes from mice vaccinated were restimulated with peptides corresponding with epitopes 
in the vaccine. These data demonstrate the ability of a poly-epitope concatemer vaccine to elicit 
robust T-cell responses to multiple epitopes targeting distinct Class I and Class II alleles in a 
single mRNA construct. The vaccine design used in this study is similar to the proposed design 
for the clinical trial; these data provide evidence that concatemerizing multiple epitopes together 
in a single mRNA sequence will lead to effective protein translation, processing, and 
presentation of the epitopes on MHC molecules. Although capable of eliciting T-cell responses 
against known T-cell epitopes, we decided to further determine if neoantigen-encoding mRNA 
vaccines can elicit antigen-specific T-cell responses in C57Bl/6 mice.  
 
Table 1. 
Concatemer mRNA vaccine epitopes. 

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14
 
Figure 2. Concatemer mRNA vaccine epitopes. 
To test the immunogenicity of neoantigen specific mRNA vaccine, mice were vaccinated either 
subcutaneously (SQ) or intravenously (IV) twice (prime day 0, boost day 14) with three mRNA 
vaccines (given in a single injection), with each vaccine containing an mRNA sequence encoding 
1 of 3 mutant epitopes identified by Yadav and colleagues17 (Figure 3) in the MC38 tumor cell 
line. Three days after, the boost spleens were harvested and cells were restimulated with peptides 
corresponding to the mutant or wild-type peptide sequences for the 3 neoantigens. To compare 
the mRNA vaccine to a common peptide vaccine, mice were also vaccinated intraperitoneally 
with long peptides corresponding to the neoantigens sequence together with PolyI:C and anti-
CD40 antibody. To evaluate the phenotype of the neoantigen-specific T-cells elicited by the 
vaccine, T-cells were also tested for CD62L and CD44 expression. 
 
Figure 3. MC38 neoantigen-specific T-cell responses in C57Bl/6 mice. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
15
Strong CD8+IFN-Ȗ+ T-cell responses were detected from splenocytes of mice vaccinated SQ or 
IV with the combination mRNA vaccine containing the three mutant neoantigens when 
restimulated with the mutant peptides (Figure 3); the mutant-specific responses were 
significantly higher than the responses measure to wild-type peptides or when there was no 
peptide restimulation (vehicle). Responses were comparable for IV and SQ administration of the 
mRNA vaccine, and vaccination with peptide+adjuvant+anti CD40 against the neoantigens 
resulted in minimal/low specific T-cell responses upon restimulation with mutant peptides 
(Figure 3 and Table 2) that were significantly lower than the responses measured with mRNA 
vaccines. The neoantigen-specific T-cells responding to restimulation with mutant peptide were 
demonstrated to be primarily of the CD62Llo and CD44hi phenotype, resembling an effector 
memory cell type (representative flow cytometry plots are included in (Figure 3).  
Table 2. 
MC38 neoantigen-specific T-cell responses in C57B1/6 mice. 
To summarize, robust neoantigen-specific CD8+IFN-Ȗ+ T-cell responses were induced in mice 
vaccinated, either SQ or IV, with the combination vaccine containing three mutant sequences; 
the T-cell responses were comparable between the SQ and IV vaccinated groups. The 
neoepitope-specific T-cells generated through mRNA vaccination had an effector memory 
phenotype which is thought to be necessary for a successful anti-tumor response18. The antigen-
specific responses to the mutant peptides were significantly higher than responses to 
restimulation with either the wild-type antigen sequences or vehicle, demonstrating the ability of 
the neoepitope mRNA vaccine to produce highly-specific responses. In addition to being 
specific, the response to mRNA vaccination were also significantly higher than responses to the 
adjuvanted peptide vaccine, validating the use of the mRNA platform in delivering neoepitopes 
for the generation of antigen-specific T-cell responses in the context of a PCV. These data 
demonstrate that mRNA vaccines can induce potent and specific T-cell responses to multiple 
murine neoantigens. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
16
1.2.6
Preclinical Experiments Evaluating the Presentation of CD4 and CD8 Epitopes by 
Human Dendritic Cells
To test if human CD4 and CD8 epitopes can be processed and presented from mRNA 
concatemer, a screening system to evaluate the presentation of two CD8 and two CD4 epitopes 
in one assay was developed. A concatemeric mRNA encoding 25mer long antigens either on the 
3’ (CA-48) or the 5’ (CA-49) of the mRNA backbone was produced. As a control, we used a 
single 25mer mRNA corresponding to each epitope and a peptide pool containing all four
epitopes. To test antigen presentation, dendritic cells (DC) were transfected with the concatemer 
constructs or loaded with a peptide pool containing all four epitopes. DCs were co-cultured with 
peripheral blood mononuclear cells (PBMC) transduced with TCRs recognizing the 
corresponding antigens, and antigen recognition was evaluated by flow cytometry for 41BB 
expression and ELISA for IFN-Ȗ (Figure 4). The results clearly show that both CD8 and CD4 
epitopes can be processed and presented efficiently after transfection with concatemers harboring 
several CD8 and CD4 epitopes. While known that human DC are the major population of 
antigen-presenting cells to uptake and process mRNA molecules in vivo19, these results support 
the assumption a concatemer mRNA vaccine can give rise to widespread T-cell activation upon 
mRNA delivery.  
 
Figure 4. Presentation of mRNA-derived CD4 and CD8 epitopes by human dendritic cells. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
17
1.2.7
Rationale for Selecting Defined Epitopes, Predicted Epitopes, and Tumor Suppressor and 
Driver Neoantigens to Use in this Trial
Historically, preclinical and clinical neoantigen vaccines used epitopes predicted in silico. 
Although in silico prediction can select for proper antigens, in many cases there is no evidence 
that those antigens are processed and presented by the tumor or antigen presenting cells in the 
microenvironment. As described above, in addition to up to 15 predicted neoantigens, patient 
TIL will be screened to identify defined mutated antigens (Table 3) recognized by T-cells 
guaranteeing that those antigens are processed and presented for T-cells in the tumor or its 
draining lymph nodes.  
 
Table 3. 
Defined mutated antigens recognized by TIL. 
There will be one exception for using predicted or laboratory-derived, immunogenic neoantigens 
in this trial. There is growing evidence to suggest that targeting tumor driver and suppressor 
genes can elicit superior clinical response. Mutations in these genes are highly common and have 
been found in many tumors. When mutations are identified in KRAS, NRAS, p53, EGFR, IDH1, 
PIK3CA or any other potential driver mutations, nucleotides coding for peptides covering those 
epitopes will be synthesized and used in the vaccine composition.  
Augmenting T-cell responses against defined and driver neoantigens should increase the 
likelihood of a significant clinical response. 
Appendix A describes the three different classes of immunogenic antigens that will be included 
in the vaccine backbone, and provides the methods for identifying the defined epitopes and 
selecting the predicted epitopes.  
1.2.8
Structure of NCI-4650 
A schematic of NCI-4650 is provided in (Figure 5). NCI-4650 is chemically identical to 
naturally occurring mammalian mRNA with the exception that the uridine nucleoside normally 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
18
present in mammalian mRNA is fully replaced with N1-methyl-pseudouridine, a naturally 
occurring pyrimidine base present in mammalian tRNAs20, 21. The cap structure used in NCI-4650
is identical to the natural mammalian Cap 1 structure22, 23. Each mRNA construct will be 
between 500 and 3000 nucleotides in length coding for neoantigens between 15 and 41 amino 
acids in length.  
 
 
Figure 5. Schematic of mRNA-4650 design. 
1.2.9
Risk for NCI-4650 Monotherapy 
The risk to subjects receiving NCI-4650 is expected to be low and primarily involving mild to 
moderate toxicities which have been observed in animal studies and generally observed and 
expected for other IM administered vaccines. These local reactions may consist of transient and 
dose-dependent pain, swelling, and erythema. Possible mild to moderate systemic reactions, 
which are also transient, may include fever, fatigue, chills, headache, myalgias, and arthralgias. 
Such AEs may, in part, be due to the poor biodegradability of LNP formulations used in other 
vaccine studies; the LNP that comprises NCI-4650 is designed to have superior biodegradability 
and thus may have a further improved safety profile. Also, other AEs that have generally been 
associated with approved IM administered vaccines have included mild hematological and 
clinical chemistry abnormalities, which are usually reversible. Subjects receiving NCI-4650 
could experience signs and symptoms compatible with a C activation-related pseudoallergy 
(CARPA) response, which has been observed in the administration of approved liposomal 
products, contrast agents, pegylated proteins, and antibodies24, as well as for small interfering 
RNA products formulated in LNPs25, 26. The signs and symptoms of CARPA resemble those of 
an acute hypersensitivity reaction. However, complement activation is far less likely to be 
associated with clinical signs for LNP products such as NCI-4650, which are administered IM at 
a much lower dose on a mg/kg basis than other clinical entities that cause CARPA in humans and 
nonclinical species.  
The design of this study allows an escalation of dose with intensive safety monitoring to ensure 
the safety of subjects, the study will use a traditional “3+3” design. Any potential safety risks, 
such as ISRs, will be monitored closely throughout the study. Dosing will be staggered by three 
weeks between the first dose administered to the first patient and the first dose administered to 
the second patient in Dose Level 2 (starting dose level) of the Phase I Cohort for safety 
monitoring purposes. Subsequent patients may begin treatment at an interval of one week.  

Abbreviated Title: mRNA-Based, Cancer Vaccine 
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2
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
ELIGIBILITY CRITERIA
2.1.1
Inclusion Criteria 
Measurable (per RECIST v1.1 criteria), metastatic melanoma, gastrointestinal, or 
genitourinary cancer with at least one lesion that is resectable. Only patients with 
metastatic gastrointestinal cancer will be eligible for enrollment on the Phase I portion 
of the study. Patients with metastatic melanoma, gastrointestinal, or genitourinary 
cancer will be eligible for enrollment on the Phase II portion of the study.  
Confirmation of diagnosis of metastatic cancer by the NCI Laboratory of Pathology. 
Patients with 3 or fewer brain metastases that are < 1 cm in diameter and asymptomatic 
are eligible. Lesions that have been treated with stereotactic radiosurgery must be 
clinically stable for one month after treatment for the patient to be eligible. Patients with 
surgically resected brain metastases are eligible.  
Prior therapy with at least one first-line standard of care treatment or second-line 
treatment of proven effectiveness. Patients must have progressive disease after prior 
treatment. Prior first- or second-line treatments would include the following: 
x Patients with metastatic melanoma: Receipt of a checkpoint inhibitor as first-line 
therapy.
x Patients with metastatic melanoma with an activating mutation of KIT: Receipt of 
imatinib. 
x Patients with a BRAF V600 activating mutation: Receipt of appropriate targeted 
therapy.
x Patients with metastatic gastrointestinal cancer: Receipt of up to two forms of approved 
first- and/or second-line chemotherapy regimens. 
x Patients with metastatic genitourinary cancers: Receipt of a first- or second-line therapy 
appropriate for their histologic subtype. 
$JH\HDUVDQG\HDUV 
Clinical performance status of ECOG 0 or 1 (see Appendix B).
Women of child-bearing potential must have a negative pregnancy test because of the 
potentially dangerous effects of the treatment on the fetus. 
Serology  
x Seronegative for HIV antibody. (The experimental treatment being evaluated in this 
protocol depends on an intact immune system. Patients who are HIV seropositive may 
have decreased immune-competence and thus may be less responsive to the 
experimental treatment and more susceptible to its toxicities.)  
x Seronegative for hepatitis B antigen, and seronegative for hepatitis C antibody. If 
hepatitis C antibody test is positive, then the patient must be tested for the presence of 
antigen by RT-PCR and be HCV RNA negative.  

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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Hematology 
x ANC > 1000/mm3 without the support of growth factors. 
x :%&PP3 
x 3ODWHOHWFRXQWPP3 
x Hemoglobin > 8.0 g/dL. Subjects may be transfused to reach this cut-off. 
Chemistry 
x Serum ALT/AST  5.0 x ULN 
x Serum creatinine < 1.5 x ULN or measured creatinine clearance (calculated using 
Cockcroft-Gault formula) > 40 mL/min 
x 7RWDOELOLUXELQ2.0 mg/dL, except in patients with Gilbert’s Syndrome, who must have 
a total bilirubin < 3.0 mg/dL. 
More than four weeks must have elapsed since any prior systemic therapy at the time 
the patient receives the immunization regimen, and patients’ toxicities must have 
recovered to a grade 1 or less (except for toxicities such as alopecia or vitiligo).  
Ability of subject to understand and the willingness to sign a written informed consent 
document. 
Subjects must be co-enrolled on protocol 03-C-0277.
2.1.2
Exclusion Criteria 
Pregnant or breastfeeding women who do not consent to stop breastfeeding while on 
study treatment and for 30 days after the use of the investigational vaccine, where 
pregnancy is confirmed by a positive, rising hCG laboratory test. 
Women of child-bearing potential, defined as all women capable of becoming pregnant, 
unless they agree to use an appropriate method of contraception during dosing and for 
120 days after the last dose (i.e., final vaccine). Effective contraception methods include 
a combination of any two of the following (unless method is abstinence or sterilization, 
in which only one method is required):  
x Use of oral, injected, or implanted hormonal methods of contraception, or other forms 
of hormonal contraception that have comparable efficacy (failure rate < 1%). In case of 
use of oral contraception, women should have been stable on the same pill for a 
minimum of 6 months before taking study treatment. 
x
Placement of an intrauterine device or intrauterine system.
x Barrier methods of contraception: condom or occlusive cap (diaphragm or 
cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository. 
x Total abstinence 
x Female sterilization at least eight weeks before taking study treatment. 
x Male sterilization (at least six months prior to screening).  

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
21
Sexually active males must use a condom during intercourse during dosing and for 120 
days after the last dose (i.e., final vaccine), and should not father a child in this period.
Any systemic steroid therapy or other form of immunosuppressive therapy within 
7 days of the first dose of the vaccine. A physiologic dose of systemic corticosteroids 
may be approveG,QKDOHGRUWRSLFDOVWHURLGVDQGDGUHQDOUHSODFHPHQWVWHURLGGRVHV
10 mg daily prednisone equivalent are permitted in the absence of active autoimmune 
disease. 
Active systemic infections requiring anti-infective treatment, coagulation disorders, or 
any other active or uncompensated major medical illnesses of the cardiovascular, 
respiratory, or immune system. 
Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency 
Disease).
Concurrent opportunistic infections (The experimental treatment being evaluated in this 
protocol depends on an intact immune system. Patients who have decreased immune-
competence may be less responsive to the experimental treatment and more susceptible 
to its toxicities). 
Any vaccinations four weeks prior to the first vaccination cycle or live vaccines at any 
time during the study. 
SCREENING EVALUATIONS 
Note: Testing for screening evaluation is conducted under the NCI-SB companion protocol, 99-
C-0128 (Evaluation for NCI Surgery Branch Clinical Research Protocols). 
2.2.1
Within 3 Months Prior to Part Two Registration 
x HIV antibody titer, HBsAg determination, and anti-HCV  
x Confirmation of diagnosis of metastatic melanoma, gastrointestinal, or genitourinary 
cancer by the NCI Laboratory of Pathology. (Note: Testing is permitted to be conducted 
at any time prior to Part Two registration.) 
2.2.2
Within 4 Weeks Prior to Part Two Registration 
x Complete history and physical examination. (Note: Patient history may be obtained 
within 8 weeks prior to Part Two registration.)  
x Imaging evaluation to determine baseline disease status. This may include CT, MRI, 
PET, and/or photography. 
2.2.3
Within 7 Days Prior to Part Two Registration 
x Screening blood tests:  
o CBC w/differential 
o Chemistries: Creatinine, ALT/GPT, AST/GOT, Total bilirubin 
o Lymphocyte phenotyping (TBNK) 
x Urinalysis, with culture if indicated  

Abbreviated Title: mRNA-Based, Cancer Vaccine 
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x Physical examination, including ECOG of 0 or 1 (see Appendix B) 
x Weight and vital signs 
x ȕ-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
REGISTRATION AND TREATMENT ASSIGNMENT PROCEDURES 
2.3.1
Prior to Registration for this Protocol 
Patients will initially sign the consent for and enroll on protocol 03-C-0277 prior to tumor 
harvest and leukapheresis for generation of the cell product. Patients will then sign the consent 
for and register for Part One of this treatment protocol. If the mRNA vaccine meets the 
requirements specified in the Certificate of Analysis (CoA) (Appendix C) to include USP <71> 
sterility testing, the vaccine will be released by Moderna and shipped to the NIH Clinical Center 
Pharmacy, where it will be dispensed and administered to the patient after receipt by the 
pharmacy of a physician’s order. The patient must meet the eligibility criteria and be registered 
to Part Two of this treatment protocol before receiving the vaccine. If the mRNA vaccine does 
not meet the requirements specified in the CoA, the vaccine will not be released by Moderna and 
the patient will be taken off-study (Section 3.8.2). 
2.3.2
Registration Procedure 
Registration will be a two-part process. Authorized staff must register an eligible candidate with 
the NCI Central Registration Office (NCI-CRO) within 24 hours of signing consent. To initially 
register a subject after the participant has signed the consent, complete the top portion of the 
registration Eligibility Checklist from the website 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) indicating that the patient is being 
registered for Part One and send via encrypted email to the NCI-CRO at ncicentralregistration-
l@mail.nih.gov.  
Once the mRNA vaccine meets the requirements specified in the CoA and the vaccine is released 
by Moderna, and eligibility is confirmed after completion of screening studies, authorized staff 
must complete the remainder of the eligibility checklist, indicating that the patient is being 
registered for Part Two (treatment on study). Email the completed registration Eligibility 
Checklist to the NCI-CRO at ncicentralregistration-l@mail.nih.gov. 
After confirmation of eligibility at the NCI-CRO, CRO staff will call pharmacy to advise them of 
the acceptance of the patient on the protocol prior to the release of any investigational agents. 
Verification of registration will be forwarded electronically via email to the research team. A 
recorder is available during non-working hours.  
Subjects that do not meet screening criteria should be removed from the study following the 
procedure in Section 3.8.3. 
Note: Patients are not considered to be fully enrolled on this treatment protocol unless they meet 
the eligibility criteria and are registered to Part Two. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
23
2.3.3
Treatment Assignment Procedures 
Cohorts
Number 
Name 
Description 
1 
Phase I Gastrointestinal 
Cancer 
First 12-18 patients enrolled with a diagnosis of 
gastrointestinal cancer  
2a 
Phase II Melanoma  
Patients with a diagnosis of melanoma 
2b 
Phase II Gastrointestinal or 
Genitourinary Cancer  
Patients with a diagnosis of gastrointestinal or 
genitourinary cancer 
Arms 
Number 
Name 
Description 
1 
Phase I  
Escalating doses of mRNA vaccine 
2 
Phase II  
MTD of mRNA vaccine established in Phase I 
Randomization and Arm Assignment 
This is a non-randomized study. All patients will be directly assigned based on cohort as follows: 
x Subjects in Cohort 1 will be directly assigned to Arm 1. 
x Subjects in Cohort 2a will be directly assigned to Arm 2. 
x Subjects in Cohort 2b will be directly assigned to Arm 2. 
3 
STUDY IMPLEMENTATION 
STUDY DESIGN 
3.1.1
Schema 
3.1.2
Pre-Treatment Phase: Performed on 03-C-0277 
Patients with metastatic melanoma, gastrointestinal, or genitourinary cancers will undergo 
resection of the tumor and apheresis under protocol 03-C-0277. Whole exome sequencing will be 
performed under protocol 03-C-0277 to identify all cancer mutations using our standard 
procedures. TIL will be grown and expanded for this trial according to Standard Operating 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
24 
Procedures (SOPs) which can be found in BB-IND 17858. After a sufficient yield of TIL (5x107 
cells) is expanded, immunogenic neoantigens will be identified by high throughput immunologic 
screening using long peptides and tandem minigenes covering all mutated epitopes to identify 
the exact mutations recognized by autologous T-cells. Up to 15 predicted neoantigens will be 
selected based on exome and RNA sequencing and their binding affinity to the patient HLA 
molecules (see Appendix A). The final nucleotide sequences of the mutated 15-41mer epitopes 
and/or driver genes will then be transmitted electronically via Globus, a secure research data 
management system, to Moderna for production of the NCI-4650 drug product.  
3.1.3 
Treatment Phase 
Patients will receive a mRNA-based vaccine IM at two-week intervals for four cycles. All 
patients may receive one course of treatment (four vaccination cycles). Immunologic tests will be 
performed as per Section 5.4 to quantitate circulating T-cells reactive with the immunizing 
antigens. If a 3-fold increase in the precursor level of pre-existing neoantigen-specific T-cells or 
new reactivity appears in the blood at detectable levels, patients may be vaccinated with a second 
and final course of treatment using the same vaccine dose. The second course may start 
approximately four weeks (± 2 weeks) from the last vaccine dose of the first course. 
If the patient receives only one course of treatment (four vaccination cycles), the start date of the 
course will be the date of the first vaccination; the end date will be the date of the first post-
treatment evaluation. If the patient receives a second course (four additional vaccination cycles), 
the start date of the first course will be the date of the first vaccination. The date of the fifth 
vaccination will be both the end date of the first course and the start date of the second course. 
The end date of the second course will be the date of the first post-treatment evaluation.  
3.1.4 
Dose-Limiting Toxicity 
The dose-limiting toxicity (DLT) evaluation period for determination of the maximum tolerated 
vaccine dose (MTD) will occur during the 21 days after the first vaccination for each patient. A 
DLT is defined as follows: All grade 3 or greater toxicities related to the mRNA vaccine, with 
the exception of: 
x Grade 3 fever 
x Grade 3 pruritus/itching 
x Grade 3 fatigue 
x Grade 3 metabolic laboratory abnormalities without significant clinical sequela that 
resolve to grade 2 or less within 7 days. 
x Grade 3 autoimmune toxicity that resolves to grade 2 or less within 7 days. 
x Events that are clearly related to the patient’s disease. 
3.1.5 
Phase I – Dose Escalation 
Subjects will receive their assigned dose level of NCI-4650 as IM injections on Days 0, 14, 28, 
and 42. The maximum dose of mRNA vaccine for each dose level will be: 
 

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Version Date: January 23, 2019 
 
25 
Dose Level 
NCI-4650, mRNA Vaccine Dose 
Level 1 
0.04 mg (0.0006 mg/kg based on a 70-kg subject) 
Level 2 
0.13 mg (0.0019 mg/kg based on a 70-kg subject) 
Level 3 
0.39 mg (0.0056 mg/kg based on a 70-kg subject) 
 
Moderna is the sponsor of a dose escalation trial utilizing a nearly identical vaccine (mRNA-
4157) as the mRNA vaccine used in this protocol (NCI-4650). The dose escalation in both 
protocols is the same (0.04 mg, 0.13 mg, and 0.39 mg). As indicated in the Moderna Safety 
Review Committee Dose Level Approval Form dated 21 December 2017, the Moderna Medical 
Monitor noted that for the three patients enrolled on Dose Level 1 (Part A) in the Moderna trial 
(0.04 mg mRNA-4157 monotherapy), no DLTs were experienced and the only AEs experienced 
were grade 1 injection site soreness, which is expected for the vaccine. As a result, Dose Level 1 
was declared safe and tolerated. For this trial, because Dose Level 1 was shown to be safe and 
tolerated, the first two patients were enrolled on Dose Level 2. No DLTs were experienced and 
the only AEs experienced were grade 1 and 2 related events. 
As indicated in the Moderna Safety Review Committee Dose Level Approval Form dated 13 
July 2018, the Moderna Medical Monitor noted that for the six evaluable patients enrolled on 
Dose Level 2 (Part A) in the Moderna trial (0.13 mg mRNA-4157 monotherapy), no DLTs were 
experienced and the only AEs experienced were mild, non-serious grade 1 events considered to 
be related to the experimental treatment. Additionally, as indicated in the Moderna Safety 
Review Committee Dose Level Approval Form dated 07 September 2018, four evaluable 
patients were enrolled on Dose Level 2 (Part B) in the Moderna trial (0.13 mg mRNA-4157 in 
combination with pembrolizumab). These four patients experienced only mild, non-serious grade 
1 events considered to be related to the experimental treatment, and no DLTs were seen. The 
following table shows all grade 1 events experienced by all patients enrolled on Dose Level 2 in 
the Moderna trial, for both parts A and B: 
 
Adverse Events 
Incidence 
# of Patients 
Injection site (edema, erythema, tenderness) 
8 
3 
Diarrhea 
2 
1 
Photosensitivity 
1 
1 
Arthritis 
4 
3 
Finger edema 
1 
1 
Myalgias 
4 
3 
Flu-like symptoms 
1 
1 
 
For this trial, because Dose Level 2 has been shown to be safe and tolerated, we propose to enroll 
our third patient (previously anticipated to be the third patient in Dose Level 2) as the first 
patient in Dose Level 3. The protocol will enroll three patients at Dose Level 3 unless a patient 
experiences a DLT.  

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
26 
In each dose level, if a patient experiences a DLT, a total of six patients will be treated at that 
dose to confirm that no greater than 1/6 patients have a DLT prior to proceeding to the next 
higher dose level. If a level with 2 or more DLTs in 3-6 patients has been identified, patients will 
be accrued at the next-lowest dose level, for a total of 6 patients. If two DLTs occur in the 
second dose level (0.13 mg), the dose will be de-escalated to Dose Level 1 (0.04 mg). If two 
DLTs occur at Dose Level 1, the study will be temporarily halted, as described in Section 3.2.  
The MTD is the highest dose at which  1 of 6 patients experienced a DLT or the highest dose 
level studied if DLTs are not observed at any of the dose levels.  
Although the MTD may be reached during this clinical study, determining the MTD is not the 
aim of the study as benefit from this therapeutic vaccine approach may be achieved at lower 
doses. 
3.1.6 
Rationale for Dose Level Regimen and Route of Administration 
As described in the repeat-dose GLP toxicology studies in outbred Sprague Dawley rats 
described in Section 1.2.4 and IND 17390, the no-observed-adverse-effect-level (NOAEL) for 
mRNA-4157 was determined to be 0.035 mg based on the clinical and microscopic findings 
observed in this study. Based on HED, this represents an approximate 24-fold safety margin over 
the proposed human starting dose of 0.04 mg. The highest dose in the rat toxicology study was 
0.117 mg (0.32 mg/kg), which is an approximate HED of 3.51 mg (0.05 mg/kg based on a 70-kg 
subject) and is approximately 88-fold higher than the proposed starting clinical dose of 0.04 mg. 
Thus, it is considered that a starting dose of 0.04 mg has an adequate safety margin. 
The highest dose in the GLP rat toxicology study (0.117 mg; which is a HED of 3.51 mg based 
on a 70-kg subject) is approximately 9-fold higher than the highest planned clinical dose of 
0.39 mg. The NCI-SB considers that this represents a sufficient safety margin to the dose levels 
in this clinical study. The 3+3-guided dose escalation scheme of approximately half-log (3-fold) 
increments (i.e., 0.04, 0.13, and 0.39 mg) is consistent with FDA guidance for early-phase 
clinical trials involving cellular and gene therapy products27. 
Subjects will receive their assigned dose level on Day 1 of each 14-day cycle (days 0, 14, 28, and 
42). Four cycles of NCI-4650 are planned to boost the intended tumor-killing T-cell population 
over an extended period by promoting optimal development of T-effector memory cells. The 14-
day cycle allows for maximal contraction of the antigen-specific CD8+ T-cells response before 
boosting, which found to produce best maintenance of CD8+ T-cells with high recall capacity. 
From a safety perspective, the Manufacturer assessed the toxicity of mRNA-4157 in Sprague 
Dawley rats at the dose levels of 0.012, 0.035, and 0.117 mg via IM injection every week for 4 
weeks (5 doses in total; refer to Section 1.2.4 and IND 17390). This preclinical weekly injection 
schedule is 2-fold more dose-dense over time than the clinical dosing schedule in this study, and 
thus provides an additional margin to potential cumulative toxicity.  
The IM route of administration was chosen for ease of administration. 
3.1.7 
Phase II Portion 
Patients in Phase II will receive the MTD as determined in Phase I. The Phase II portion of the 
protocol will consist of two cohorts as defined in Section 2.3.3.1: Cohort 2a, patients with 
melanoma and Cohort 2b, patients with gastrointestinal or genitourinary cancer. 

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Version Date: January 23, 2019 
27
The Phase II portion of the study will utilize an optimal design where initially 12 evaluable 
patients will be enrolled in each cohort. For each cohort, if 0 of the first 12 evaluable patients 
experience a clinical response, then no further patients will be enrolled; if 1 or more of the first 
12 evaluable patients enrolled have a clinical response, then accrual will continue until a total of 
21 evaluable patients have been enrolled in each cohort. 
Note: As stated in Section 8.2, up to 6 patients enrolled at the MTD will count towards the 
accrual in the Phase II portion of the trial if they are evaluable for response and if they would be 
fully eligible for enrollment in the Phase II portion of the trial. 
PROTOCOL STOPPING RULES  
New subject enrollment to the protocol will be temporarily halted if any of the following 
conditions are met, and consideration will be given to the need for protocol revisions regarding 
safety, if applicable. Consultation with the FDA may be arranged by the Sponsor before or after 
the protocol amendment is submitted to the NIH Intramural IRB, as needed. 
x During the Phase I portion of the study – If two DLTs, as described in Section 3.1.4, 
occur at Dose Level 1. 
x During the Phase II portion of the study – Once five or more patients have been enrolled, 
if 20% or more patients cumulatively enrolled develop a DLT, as described in Section 
3.1.4. 
x During the Phase I and II portions of the study – Any death that is at least possibly 
attributed to the investigational agent and which occurs within 30 days of receiving the 
investigational agent. 
DRUG ADMINISTRATION 
Patients will receive the mRNA vaccine on days 0, 14 (± 5 days), 28 (± 5 days), and 42 (± 5 
days). The vaccine will be administered as an IM injection.  
The patient’s vaccine is delivered to the Patient Care Unit by the research nurse. Prior to the 
injection, the vaccine identity label is double-checked by two authorized staff (MD or RN), and 
an identification of the product and documentation of administration are entered in the patient’s 
chart. 
x The NCI-4650 mRNA vaccine will be administered as an outpatient procedure in the 3SE 
Day Hospital in the NIH Clinical Center.  
x For all subjects, NCI-4650 will be administered by IM injection into the deltoid muscle 
(alternating deltoid muscle sites should be used for each subsequent injection, and 
injection sites may also be rotated to thigh muscles).
x The dose volume for Dose Levels 1 and 2 will be held constant at approximately 0.3 mL 
per injection.  The dose volume for Dose Level 3 (PN 85002) will be at least 0.39 mL. 
x The NCI Pharmacy Manual contains specific instructions for the preparation and 
administration of each dose level of NCI-4650.
x The NCI Pharmacy Manual contains details regarding sterility release of NCI-4650. 

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28
BASELINE EVALUATIONS 
3.4.1
Within 7 Days Prior to the First Vaccination (Day 0)
x Physical examination, including ECOG (see Appendix B) 
x Weight and vital signs 
x Baseline blood tests: 
o CBC w/differential 
o Acute Care Panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, 
BUN), Hepatic Panel (alkaline phosphatase, AST, ALT, total bilirubin, direct 
bilirubin), Mineral Panel (albumin, calcium, magnesium, phosphorus), Uric acid, 
Creatinine kinase, Lactate dehydrogenase, Total protein 
o PT-INR/PTT 
o Anti-CMV antibody titer, HSV and VZV serology, and EBV panel (Note: Patients 
who are known to be positive do not need to be retested. May be performed within 3 
months prior to Part Two registration.) 
x ȕ-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
x Urinalysis, with culture if indicated 
x Chest x-ray 
x EKG  
x Repeat imaging if not performed within 4 weeks of Day 0. This may include CT, MRI, 
PET, and/or photography. 
3.4.2
Within 2 Days Prior to the First Vaccination (Day 0) 
x Lymphocyte phenotyping (TBNK) 
x Review of baseline symptoms 
x Research samples, as described in Section 5.3 
ON-STUDY EVALUATIONS 
3.5.1
Within 2 Days Prior to Each Subsequent Vaccination (Days 14, 28, & 42 (± 5 days))  
x Physical examination, including ECOG (see Appendix B) 
x Weight and vital signs  
x Toxicity assessment, including a review of systems 
x CBC w/differential 
x Acute Care Panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, BUN), 
Hepatic Panel (alkaline phosphatase, AST, ALT, total bilirubin, direct bilirubin), Mineral 
Panel (albumin, calcium, magnesium, phosphorus), Uric acid, Creatinine kinase, Lactate 
dehydrogenase, Total protein 

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x ȕ-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
x Research samples, as described in Section 5.3 
3.5.2
After Each Vaccination 
x Vital signs will be monitored hourly (± 15 minutes) for two hours. The post-
administration monitoring period may be adjusted by the PI. 
POST-TREATMENT (FOLLOW-UP) EVALUATIONS 
3.6.1
First Follow-up Evaluation  
All patients (unless the patient receives a second course of treatment) will return to the NIH 
Clinical Center for their first follow-up evaluation on day 56 (± 5 days), which is approximately 
two weeks after the fourth vaccination. If a patient receives a second course of four vaccines, the 
first follow-up evaluation will be two weeks (± 5 days) after the eighth vaccination.  
At the first follow-up evaluation, patients will undergo: 
x Physical examination, including ECOG (see Appendix B) 
x Weight and vital signs 
x Toxicity assessment, including a review of systems 
x CBC w/differential 
x Acute Care Panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, BUN), 
Hepatic Panel (alkaline phosphatase, AST, ALT, total bilirubin, direct bilirubin), Mineral 
Panel (albumin, calcium, magnesium, phosphorus), Uric acid, Creatinine kinase, Lactate 
dehydrogenase, Total protein 
x Lymphocyte phenotyping (TBNK) 
x ȕ-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
x Research samples, as described in Section 5.3. Approximately 72 mL of blood will be 
obtained. PBMC will be cryopreserved so that immunologic testing may be performed. 
This will be performed on protocol 03-C-0277. 
x Imaging studies as performed at baseline to determine tumor response. If clinically 
indicated, other scans or x-rays may be performed, e.g. brain MRI, bone scan. 
x A 5-liter apheresis may be performed. If the patient is unable to undergo apheresis, 
approximately 96 mL of blood may be obtained. This will be performed on protocol 03-
C-0277. 
3.6.2
Subsequent Follow-up Evaluations 
All patients will return to the NIH Clinical Center for their second follow-up evaluation one 
month (± 5 days) after the first follow-up evaluation. Subsequent follow-up evaluations will take 
place every 1-2 months for the first year, and then annually for up to five years or until clinically 
proven progressive disease, whichever comes first. Patients will be co-enrolled and followed on 
the NCI-SB long-term follow-up protocol 09-C-0161 (Follow-up Protocol for Subjects 
Previously Enrolled on NCI Surgery Branch Studies). As noted in Section 3.6.1, additional 

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30 
apheresis may be performed only at the first follow-up evaluation. It will not be performed at any 
other post-treatment evaluations. 
Note: Patients may be seen more frequently as clinically indicated. Patients who are unable or 
unwilling to return for follow-up evaluations may be followed via phone or email 
contact. Patients may be asked to send laboratory, imaging, and physician exam reports 
performed by their treating physician. 
At each scheduled follow-up evaluation, patients will undergo: 
x Physical examination, including ECOG (see Appendix B) 
x Weight and vital signs 
x Toxicity assessment, including a review of systems  
x CBC w/differential 
x Acute Care Panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, BUN), 
Hepatic Panel (alkaline phosphatase, AST, ALT, total bilirubin, direct bilirubin), Mineral 
Panel (albumin, calcium, magnesium, phosphorus), Uric acid, Creatinine kinase, Lactate 
dehydrogenase, Total protein  
x Lymphocyte phenotyping (TBNK) 
x ȕ-HCG pregnancy test (serum or urine) on all women of child-bearing potential 
(complete at all follow-up evaluations within 120 days after the last vaccine) 
x Research samples, as described in Section 5.3. Approximately 72 mL of blood will be 
obtained at each follow-up visit. PBMC will be cryopreserved so that immunologic 
testing may be performed. This will be performed on protocol 03-C-0277. 
x Imaging studies as performed at baseline to determine tumor response. If clinically 
indicated, other scans or x-rays may be performed, e.g. brain MRI, bone scan. 
 

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31 
STUDY ASSESSMENT CALENDAR 
Assessments
Screening 
(Prior to Part Two registration) 
Baseline 
(Prior to first vaccine) 
On-Study/Course of Treatment  
(1 vaccine = 1 cycle)1 
Post-Treatment Follow-up 
Within 3 
Months
Within 
4 Weeks
Within 
7 Days
Within 7 
Days
Within 
2 Days
Day 
0
Day 14 
(±5 d)
Day 28 
(±5 d)
Day 42 
(±5 d)
Day 562 
(±5 d)
Subsequent 
Follow-up Visits3
Confirmation of diagnosis by NCI 
Lab of Pathology4 
X 
 
 
 
 
 
 
 
 
 
Medical history5 
X 
 
 
 
 
 
 
 
 
Physical exam 
X 
X 
X 
 
 
X 
X 
X 
X 
X 
Performance status (ECOG)6 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Weight 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Vital signs7 
 
X 
X 
 
X 
X 
X 
X 
X 
X 
ȕ-HCG pregnancy test8 
 
X 
X 
 
 
X 
X 
X 
X 
X9 
Urinalysis10 
 
X 
X 
 
 
 
 
 
 
EKG 
 
 
X 
 
 
 
 
 
 
Toxicity assessment11 
 
 
 
X12 
 
X 
X 
X 
X 
X 
Serology 
1 Assessments must be performed within 2 days prior to each vaccination on Days 14, 28, & 42. Patients may receive a 2nd course of treatment for a total of 8 cycles. 
2 If a patient receives a second course of four vaccines, the first follow-up evaluation will be two weeks (± 5 days) after the eighth vaccination. 
3 All patients will return to the NIH Clinical Center for their second follow-up evaluation one month (± 5 days) after the first follow-up evaluation. Subsequent follow-
up evaluations will take place every 1-2 months for the first year, and then annually for up to five years or until clinically proven progressive disease, whichever comes 
first. Patients may be seen more frequently as clinically indicated. Patients who are unable or unwilling to return for follow-up evaluations may be followed via phone 
or email contact. Patients may be asked to send laboratory, imaging, and physician exam reports performed by their treating physician. 
4 Confirmation of diagnosis of metastatic melanoma, gastrointestinal, or genitourinary cancer. Testing is permitted to be conducted at any time prior to Part Two 
registration. 
5 Patient history may be obtained within 8 weeks prior to Part Two registration. 
6 ECOG of 0 or 1 (see Appendix B). 
7 After each vaccination, vital signs will be monitored hourly (± 15 minutes) for two hours. The post-administration monitoring period may be adjusted by the PI. 
8 Serum or urine; on all women of child-bearing potential. 
9 Complete at all follow-up evaluations within 120 days after the last vaccine. 
10 With culture if indicated. 
11 Including a review of systems. 
12 Review of baseline symptoms. 

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32 
Assessments 
Screening 
(Prior to Part Two registration) 
Baseline 
(Prior to first vaccine) 
On-Study/Course of Treatment  
(1 vaccine = 1 cycle)1 
Post-Treatment Follow-up 
Within 3 
Months 
Within 
4 Weeks 
Within 
7 Days 
Within 7 
Days 
Within 
2 Days 
Day 
0 
Day 14 
(±5 d) 
Day 28 
(±5 d) 
Day 42 
(±5 d) 
Day 562 
(±5 d) 
Subsequent 
Follow-up Visits3 
HIV antibody titer, HBsAg, anti-
HCV 
X 
 
 
 
 
 
 
 
 
 
 
Anti-CMV antibody titer, HSV 
and VZV, EBV panel13 
 
 
 
X 
 
 
 
 
 
 
 
Laboratory Procedures 
CBC w/differential 
 
 
X 
X 
 
 
X 
X 
X 
X 
X 
Blood chemistries14 
 
 
X 
X 
 
 
X 
X 
X 
X 
X 
PT-INR/PTT 
 
 
 
X 
 
 
 
 
 
 
 
Lymphocyte phenotyping (TBNK) 
 
 
X 
 
X 
 
 
 
 
X 
X 
Additional apheresis15 
 
 
 
 
 
 
 
 
 
X 
 
Correlatives16 
CPT tubes (SB-CPF) 
 
 
 
 
X 
 
X 
X 
X 
X 
X 
SST tubes (Figg Lab) 
 
 
 
 
X 
 
X 
X 
X 
X 
X 
Imaging 
CT, MRI, PET, and/or 
photography 
 
X17 
 
X18 
 
 
 
 
 
X19 
X19 
Chest x-ray 
 
 
 
X 
 
 
 
 
 
 
 
Treatment/Intervention 
NCI-4650 mRNA vaccine20 
 
 
 
 
 
X 
X 
X 
X 
 
 
                                                 
13 Patients who are known to be positive do not need to be retested. May be performed within 3 months prior to Part Two registration. 
14 Screening: Creatinine, ALT/GPT, AST/GOT, Total bilirubin. All other times: Acute Care Panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, 
BUN), Hepatic Panel (alkaline phosphatase, AST, ALT, total bilirubin, direct bilirubin), Mineral Panel (albumin, calcium, magnesium, phosphorus), Uric acid, 
Creatinine kinase, Lactate dehydrogenase, Total protein. 
15 A 5-liter apheresis may be performed. If the patient is unable to undergo apheresis, approximately 96 mL of blood may be obtained. This will be performed on 
protocol 03-C-0277, and will only be performed at the first follow-up evaluation.  
16 Research samples, as described in Section 5.3.  
17 Imaging evaluation to determine baseline disease status.  
18 Repeat imaging if not performed within 4 weeks of Day 0. 
19 As performed at baseline to determine tumor response. If clinically indicated, other scans or x-rays may be performed, e.g., brain MRI, bone scan. 
20 Administered intramuscularly. 

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33
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF-STUDY CRITERIA 
Prior to removal from study, effort must be made to have all subjects complete an evaluation
safety visit approximately 30 days following the first follow-up evaluation (at the second follow-
up evaluation).
3.8.1
Criteria for Removal from Protocol Therapy 
Patients will be taken off treatment for the following: 
x Completion of second follow-up evaluation  
x Grade 3 or 4 toxicity due to the vaccine, excluding those known events such as local 
injection site reactions, skin rash, pruritus, fatigue, fever and local adenopathy. 
x Progression of disease 
x Patient requests to be withdrawn from protocol therapy 
x Investigator discretion 
x Positive pregnancy test 
3.8.2
Off-Study Criteria 
Patients will be taken off-study for the following: 
x Vaccine does not meet CoA requirements  
x Completion of study follow-up period 
x Progression of disease 
x Patients begins a new therapy for their cancer 
x Patient requests to be withdrawn from the study 
x Significant noncompliance 
x Investigator discretion 
x Patient lost to follow-up 
x Patients who require the use of any medications listed in Section 4 for clinical 
management. 
x Death 
All patients will be co-enrolled on protocol 09-C-0161. Patients who are taken off-study for 
progressive disease or study closure on the treatment protocol will be followed on protocol 09-C-
0161.
Once a subject is taken off-study, no further data can be collected on this treatment protocol. 
3.8.3
Off Protocol Therapy and Off-Study Procedure 
Authorized staff must notify the NCI-CRO when a subject is taken off protocol therapy and 
when a subject is taken off-study. A Participant Status Update Form from the website 

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34 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and 
sent via encrypted email to the NCI-CRO at ncicentralregistration-l@mail.nih.gov. 
4 
CONCOMITANT MEDICATIONS/MEASURES 
Use of all medications taken at any time from consent to the last safety follow-up visit must be 
recorded in the subject’s electronic case report form (eCRF). This will include all prescription 
drugs, herbal products, vitamins, minerals, and over-the-counter (OTC) medications. Any 
changes in concomitant medications also will be recorded in the subject’s eCRF. 
Any concomitant medication deemed necessary for the welfare of the subject during the study 
may be given at the discretion of the investigator, including palliative radiation. Blood 
transfusions are allowed at any time during the study, except to meet eligibility criteria. 
x Antineoplastic systemic chemotherapy or biological therapy is prohibited. 
x Systemic corticosteroids are prohibited for any purpose other than to treat symptoms 
from an event of clinical interest of suspected immunologic etiology. The use of 
physiologic doses of corticosteroids may be approved after consultation with the 
investigator. If in the interest of safety, the investigator must treat the subject 
immediately. 
x ,QKDOHGRUWRSLFDOVWHURLGVDQGDGUHQDOUHSODFHPHQWVWHURLGGRVHV 10 mg daily 
prednisone equivalent, are permitted in the absence of active autoimmune disease. 
x Subjects already taking erythropoietin at the time of screening for the study may 
continue, provided they have been taking it for more than one month at the time study 
treatment is started. Prophylactic erythropoietin should not be started during screening or 
the first two weeks of study treatment but may be started thereafter. 
x Granulocyte colony stimulating factors should not be used prophylactically during the 
first two weeks of study treatment. Use of prophylactic colony stimulating factors may be 
considered thereafter following discussion with the investigator. 
x Live vaccines within 30 days prior to the first dose of NCI-4650 and while participating 
in the study are prohibited. Examples of live vaccines include but are not limited to the 
following: measles, mumps, rubella, chicken pox, yellow fever, rabies, Bacillus 
Calmette-Guérin, and typhoid (oral) vaccine. Seasonal influenza vaccines for injection 
are generally killed virus vaccines and are allowed. However, intranasal influenza 
vaccines (e.g., FluMist®) are live attenuated vaccines, and are prohibited. 
x Radiation therapy to a symptomatic solitary lesion or to the brain may be considered on 
an exceptional case-by-case basis after documented consultation with the investigator. 
The subject must have clear measurable disease outside the radiated field. Administration 
of palliative radiation therapy will be considered clinical progression. 
Subjects who, in the assessment by the investigator, require the use of any of the aforementioned 
treatments for clinical management should be removed from the trial. Subjects may receive other 
medications that the investigator deems to be medically necessary. 

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35
5
BIOSPECIMEN COLLECTION 
Blood and tissue are tracked at the patient level and can be linked to all protocols on which the 
patient has been enrolled. Samples will be used to support the specific objectives listed in the 
treatment protocol(s), e.g., immunologic monitoring, cytokine levels, persistence, as well as to 
support long-term research efforts within the NCI-SB and with collaborators as specified in 
protocol 03-C-0277. 
The amount of blood that may be drawn from adult patients for research purposes shall not 
exceed 10.5 mL/kg or 550 mL, whichever is smaller, over any eight-week period. 
Samples will be ordered in CRIS and tracked through the Clinical Trial Data Management 
system. Should a CRIS screen not be available, the CRIS downtime procedures will be followed. 
Samples will not be sent outside NIH without NIH Intramural IRB notification and an executed 
MTA. 
SAMPLES SENT TO FIGG LAB 
x Venous blood samples will be collected in either a 4-mL or an 8-mL SST tube to be 
processed for serum and stored for future research. 
o Record the date and exact time of draw on the tube. Blood tubes may be kept in the 
refrigerator until pick-up. 
o For sample pick-up, page 102-11964. 
o For immediate help, call 240-760-6180 (main Blood Processing Core number) or, if 
no answer, 240-760-6190 (main clinical pharmacology lab number). 
o For questions regarding sample processing, contact the Blood Processing Core (BPC) 
at NCIBloodcore@mail.nih.gov or 240-760-6180. 
o The samples will be processed, barcoded, and stored in the Figg lab until requested by 
the investigator. 
SAMPLES SENT TO SURGERY BRANCH CELL PRODUCTION FACILITY 
x Venous blood samples will be collected in 8-mL CPT tubes to be processed and stored 
for future research. 
o Record the date and exact time of draw on the tube. Blood tubes are kept at room 
temperature until pick-up. 
o Samples will be picked up by the research nurse or designee and transported to the 
Surgery Branch Cell Production Facility (SB-CPF) within 24 hours of blood draw. 
o The samples will be processed, barcoded, and stored in SB-CPF. 
SAMPLE COLLECTION SCHEDULE 
Collection Point 
Test/Assay 
Volume Blood 
(approx.) 
Type of Tube 
Location of 
Specimen Analysis 
Prior to Each 
Vaccination 
Immune-
Monitoring 
64 mL 
8 mL 
CPT 
SST 
SB-CPF 
Figg Lab 

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36
Each Follow-up 
Evaluation 
Immune-
Monitoring 
64 mL 
8 mL
CPT 
SST
SB-CPF 
Figg Lab
IMMUNOLOGICAL TESTING 
x Apheresis may be performed prior to and approximately 2 weeks following the 
administration of the final vaccine product. At other time points, patient peripheral blood 
lymphocytes (PBL) will be obtained from whole blood by purification using 
centrifugation on a Ficoll cushion. Aliquots of these PBMC will be cryopreserved for 
immunological monitoring of cell function. 
x A variety of tests including evaluation of specific lysis and cytokine release, metabolomic 
and bioenergetic studies (using Seahorse), intracellular FACS of cytokine production, 
ELISA-spot assays, and lymphocyte subset analysis may be used to evaluate the 
immunological correlates of treatment. In general, differences of 2- to 3-fold in these 
assays over the baseline measurement are indicative of true biologic differences.  
SAMPLE STORAGE, TRACKING, AND DISPOSITION FOR SURGERY BRANCH CELL 
PRODUCTION FACILITY 
Blood and tissue collected during the course of this study will follow the Cell Tracking and 
Labeling System established by the SB-CPF. The Cell Tracking and Labeling System is designed 
to unambiguously ensure that patient/data verification is consistent. The patients’ cell samples 
(blood or tissue) are tracked by distinct identification labels that include a unique patient 
identifier and date of specimen collection. Cryopreserved blood and tissue samples also bear the 
date the sample was frozen. All cryopreserved samples are tracked for freezer location and 
storage criteria. All samples are stored in monitored freezers/refrigerators in 3NW NCI-SB 
laboratories at specified temperatures with alarm systems in place. Serum samples will be sent to 
the BPC for storage. Samples will be barcoded and stored onsite or offsite at NCI Frederick 
Central Repository Services in Frederick, MD. All collected samples (blood or tissue) are 
entered into a central computer database with identification and storage location, and this 
database is backed up every night. 
If, at any time, a patient withdraws from the study and does not wish for their existing samples to 
be utilized, the individual must provide a written request. Following receipt of this request, the 
samples will be destroyed and reported as such to the NIH Intramural IRB. Any samples lost (in 
transit or by a researcher) or destroyed due to unknown sample integrity (i.e. broken freezer 
allows for extensive sample thawing, etc.) will be reported as such to the NIH Intramural IRB. 
Blood and tissue collected during the course of this study will be stored, tracked, and disposed of 
as specified in protocol 03-C-0277. 
SAMPLE STORAGE, TRACKING, AND DISPOSITION FOR FIGG LAB 
5.6.1
Sample Data Collection 
All samples sent to the BPC will be barcoded, with data entered and stored in the LABrador (aka 
LabSamples) utilized by the BPC, and data will be updated to the NCI-SB central computer 
database weekly. This is a secure program, with access to LABrador limited to defined Figg lab 
personnel, who are issued individual user accounts. Installation of LABrador is limited to 
computers specified by Dr. Figg. These computers all have a password-restricted login screen. 

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37
All Figg lab personnel with access to patient information annually complete the NIH online 
Protection of Human Subjects course.  
LABrador creates a unique barcode ID for every sample and sample box, which cannot be traced 
back to patients without LABrador access. The data recorded for each sample includes the 
patient ID, name, trial name/protocol number, time drawn, cycle time point, dose, material type, 
as well as box and freezer location. Patient demographics associated with the Clinical Center 
patient number are provided in the system. For each sample, there are notes associated with the 
processing method (delay in sample processing, storage conditions on the ward, etc.). 
5.6.2
Sample Storage and Destruction 
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -80°C 
according to stability requirements. These freezers are located onsite in the BPC and offsite at 
NCI Frederick Central Repository Services in Frederick, MD. Visitors to the laboratory are 
required to be accompanied by laboratory staff at all times.  
Access to stored clinical samples is restricted. Samples will be stored until requested by a 
researcher named on the protocol. All requests are monitored and tracked in LABrador. All 
researchers are required to sign a form stating that the samples are only to be used for research 
purposes associated with this trial (as per the NIH Intramural IRB-approved protocol) and that 
any unused samples must be returned to the BPC. It is the responsibility of the NCI Principal 
Investigator (PI) to ensure that the samples requested are being used in a manner consistent with 
NIH Intramural IRB approval. 
Following completion of this study, samples will remain in storage as detailed above. Access to 
these samples will only be granted following NIH Intramural IRB approval of an additional 
protocol, granting the rights to use the material.  
If, at any time, a patient withdraws from the study and does not wish for their existing samples to 
be utilized, the individual must provide a written request. Following receipt of this request, the 
samples will be destroyed and reported as such to the NIH-IRB. Any samples lost (in transit or 
by a researcher) or destroyed due to unknown sample integrity (i.e. broken freezer allows for 
extensive sample thawing, etc.) will be reported as such to the NIH Intramural IRB. 
Sample barcodes are linked to patient demographics and limited clinical information. This 
information will only be provided to investigators listed on this protocol, via registered use of the 
LABrador. It is critical that the sample remains linked to patient information such as race, age, 
dates of diagnosis and death, and histological information about the tumor, in order to correlate 
genotype with these variables. 
Blood and tissue collected during the course of this study will be stored, tracked, and disposed of 
as specified in protocol 03-C-0277. 
6 
DATA COLLECTION AND EVALUATION 
DATA COLLECTION 
The PI will be responsible for overseeing entry of data into an in-house password-protected 
electronic system (C3D) and ensuring data accuracy, consistency and timeliness. The PI, 
associate investigators (AI), research nurses, and/or a contracted data manager will assist with 
the data management efforts. All data obtained during the conduct of the protocol will be kept in 
secure network drives or in approved alternative sites that comply with NIH security standards. 

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Primary and final analyzed data will have identifiers so that research data can be attributed to an 
individual human subject participant. Data will be entered into the NCI CCR C3D database.  
All AEs, including clinically significant abnormal findings on laboratory evaluations, regardless 
of severity, will be followed until return to baseline or stabilization of event. Patients will be 
followed for AEs from the time the patient receives the first mRNA vaccine dose to the time of 
the second follow-up evaluation, or until off-study, whichever comes first. 
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following: 
x Results in discontinuation from the study 
x Is associated with clinical signs or symptoms  
x Requires treatment or any other therapeutic intervention 
x Is associated with death or another serious adverse event, including hospitalization  
x Is judged by the investigator to be of significant clinical impact 
x If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
All AEs must be recorded on the AE case report form unless otherwise noted below in Section 
6.1.1. 
End of study procedures: Data will be stored according to HHS and FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, the NIH Intramural IRB will be notified. 
6.1.1
Exclusions to Routine Adverse Event Recording 
There are no exclusions to routine AE reporting/recording for this protocol. 
DATA SHARING PLANS 
6.2.1
Human Data Sharing Plan 
Coded, linked human data generated for use in future and ongoing research will be shared 
through a NIH-funded or approved repository (ClinicalTrials.gov) and BTRIS. At the completion 
of data analysis, data will be submitted to ClinicalTrials.gov either before publication or at the 
time of publication or shortly thereafter. Data may also be used to support long-term research 
efforts within the NCI-SB, and coded, linked data may also be shared with collaborators as 
specified in protocol 03-C-0277. 
6.2.2
Genomic Data Sharing Plan 
The NIH Genomic Data Sharing Policy does not apply to this study. 
RESPONSE CRITERIA 
For the purposes of this study, patients should be re-evaluated for response approximately two 
weeks following the last vaccination, then one month later x1, then every 1-2 months for the first 

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Version Date: January 23, 2019 
 
39 
year, and then annually for up to five years or until clinically proven progressive disease, 
whichever comes first. In addition to a baseline scan, confirmatory scans should also be obtained 
at least 4 weeks (but not less than 4 weeks) following initial documentation of objective 
response. 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1)28 Changes in the largest diameter (unidimensional measurement) of the tumor 
lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST 
v1.1 criteria. 
6.3.1 
Disease Parameters 
Measurable disease: Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as: 
x By chest x-ray:  20 mm  
x By CT scan:  
o Scan slice thickness 5 mm or under:  10 mm 
o Scan slice thickness > 5 mm: double the slice thickness  
x With calipers on clinical exam:  10 mm  
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). 
Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph 
node must be > 15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis will 
be measured and followed. 
Non-measurable disease: All other lesions (or sites of disease), including small lesions (longest 
diameter < PPRUSDWKRORJLFDOO\PSKQRGHVZLWK 10 to < 15 mm short axis), are considered 
non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses 
(not followed by CT or MRI) are considered as non-measurable. 
Target lesions: All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline. Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements. It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected. A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters. If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum. The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 

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40 
Non-target lesions: All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline. Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
6.3.2 
Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or calipers. All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
Clinical lesions: Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and  10 mm diameter as assessed using calipers 
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a 
ruler to estimate the size of the lesion, is recommended.  
Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness 
greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. 
MRI is also acceptable in certain situations (e.g. for body scans). Ideally, the same type of 
scanner should be used and the image acquisition protocol should be followed as closely as 
possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if 
possible. 
FDG-PET: While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible ‘new’ disease). New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:  
x Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
x No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDG-PET 
at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not PD. 
x FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring. The use of FDG-PET in this circumstance should be prospectively described in 
the protocol and supported by disease-specific medical literature for the indication. 
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity. 

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Note: A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image. 
6.3.3
Response Criteria Definitions 
Evaluation of Target Lesions 
Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to < 10 mm. 
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum of diameters. 
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm. (Note: The appearance of one or more new lesions is also 
considered progressions.) 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum of diameters while on study. 
Evaluation of Non-Target Lesions 
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level. All lymph nodes must be non-pathological in size (< 10 mm short axis). (Note: If 
tumor markers are initially above the upper normal limit, they must normalize for a patient to be 
considered in complete clinical response.) 
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions. Unequivocal progression should not normally trump 
target lesion status. It must be representative of overall disease status change, not a single lesion 
increase.  
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or PI). 
 
Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria. 
For Patients with Measurable Disease (i.e., Target Disease) 
Target 
Lesions 
Non-Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
4 weeks confirmation** 
CR 
Non-CR/Non-PD 
No 
PR 
4 weeks confirmation** 

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CR 
Not evaluated 
No 
PR 
PR 
Non-CR/Non-
PD/Not evaluated 
No 
PR 
SD 
Non-CR/Non-
PD/Not evaluated 
No 
SD 
Documented at least once 4 weeks 
from baseline** 
PD 
Any 
Yes or No 
PD 
No prior SD, PR, or CR 
Any 
PD*** 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST v1.1 manuscript for further details on what is evidence of a new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as 
disease progression. 
Note: Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be reported as 
“symptomatic deterioration.” Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/Non-PD 
No 
Non-CR/Non-PD* 
Not all evaluated 
No 
Not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 
* ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials; so, to assign 
this category when no lesions can be measured is not advised. 
6.3.4 
Duration of Response 
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started). 
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented. 
 
Duration of stable disease: Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements. 

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TOXICITY CRITERIA 
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study. The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE 
reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 
5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP website 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).  
7
SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING 
PLAN 
DEFINITIONS 
7.1.1
Adverse Event 
Any untoward medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research. 
7.1.2
Suspected Adverse Reaction 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the drug caused the adverse event. For the purposes of IND safety reporting, ‘reasonable 
possibility’ means there is evidence to suggest a causal relationship between the drug and the 
adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug. 
7.1.3
Unexpected Adverse Reaction 
An adverse event or suspected adverse reaction is considered “unexpected” if it is not listed in 
the Investigator’s Brochure or is not listed at the specificity or severity that has been observed; 
or, if an Investigator’s Brochure is not required or available, is not consistent with the risk 
information described in the general investigational plan or elsewhere in the current application. 
"Unexpected” also refers to adverse events or suspected adverse reactions that are mentioned in 
the Investigator’s Brochure as occurring with a class of drugs or as anticipated from the 
pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation. 
7.1.4
Serious  
An unanticipated problem or protocol deviation is serious if it meets the definition of a serious 
adverse event or if it compromises the safety, welfare, or rights of subjects or others. 
7.1.5
Serious Adverse Event 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the Sponsor, it results in any of the following: 
x Death 
x A life-threatening adverse drug experience 
x Inpatient hospitalization or prolongation of existing hospitalization 

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x Persistent or significant disability/incapacity or substantial disruption of the ability to 
conduct normal life functions 
x A congenital anomaly/birth defect 
x Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
7.1.6
Disability 
A substantial disruption of a person’s ability to conduct normal life functions. 
7.1.7
Life-Threatening Adverse Drug Experience 
Any adverse event or suspected adverse reaction that places the patient or subject, in the view of 
the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it 
does not include a reaction that had it occurred in a more severe form, might have caused death. 
7.1.8
Protocol Deviation (NIH Definition) 
Any change, divergence, or departure from the NIH Intramural IRB-approved research protocol.  
7.1.9
Non-Compliance (NIH Definition) 
The failure to comply with applicable NIH Human Research Protections Program (HRPP) 
policies, NIH Intramural IRB requirements, or regulatory requirements for the protection of 
human research subjects. 
7.1.10 Unanticipated Problem 
Any incident, experience, or outcome that: 
1. Is unexpected in terms of nature, severity, or frequency in relation to: 
a. the research risks that are described in the NIH Intramural IRB-approved research 
protocol and informed consent document; Investigator’s Brochure or other study 
documents, and 
b. the characteristics of the subject population being studied; AND 
2. Is related or possibly related to participation in the research; AND 
3. Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
NIH INTRAMURAL-IRB AND CLINICAL DIRECTOR (CD) REPORTING 
7.2.1
NIH Intramural IRB and NCI CD Expedited Reporting of Unanticipated Problems and 
Deaths 
The protocol PI will report in the NIH Problem Form to the NIH Intramural IRB and NCI 
Clinical Director: 
x All deaths, except deaths due to progressive disease  

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x All protocol deviations 
x All unanticipated problems 
x All non-compliance 
Reports must be received within 7 days of PI awareness via iRIS. 
7.2.2
NIH Intramural IRB Requirements for PI Reporting at Continuing Review 
The protocol PI will report to the NIH Intramural IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation 
occurred, a brief description of the deviation, and any corrective action. 
2. A summary of any instances of non-compliance. 
3. A tabular summary of the following adverse events: 
x All grade 2 unexpected events that are possibly, probably, or definitely related to the 
research  
x All grade 3 and 4 events that are possibly, probably, or definitely related to the 
research  
x All grade 5 events regardless of attribution  
x All serious events regardless of attribution.  
Note: Grade 1 events are not required to be reported.  
7.2.3
NIH Intramural IRB Reporting of IND Safety Reports 
Only IND Safety Reports that meet the definition of an unanticipated problem will need to be 
reported to the NIH Intramural IRB.  
IND SPONSOR REPORTING CRITERIA  
From the time the subject receives the investigational agent/intervention to the time of the second 
follow-up evaluation, the investigator must immediately report to the sponsor, using the 
mandatory MedWatch Form FDA 3500A or equivalent, any serious adverse event, whether or 
not considered drug-related, including those listed in the protocol or Investigator’s Brochure and 
must include an assessment of whether there is a reasonable possibility that the drug caused the 
event. For serious adverse events that occur after the second follow-up evaluation, only those 
events that have an attribution of at least possibly related to the agent/intervention will be 
reported. 
Required timing for reporting per the above guidelines: 
x Deaths (except death due to progressive disease) must be reported via email within 24 
hours. A complete report must be submitted within one business day.  
x Other serious adverse events as well as deaths due to progressive disease must be 
reported within one business day. 
Events will be submitted to the Center for Cancer Research (CCR) at CCRsafety@mail.nih.gov 
and to the CCR PI and study coordinator. 

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All serious adverse events will be reported by the Sponsor (Center for Cancer Research) as per 
FDA 21 CFR 312.32.  
7.3.1
Reporting Pregnancy 
 Maternal Exposure 
If a patient becomes pregnant during study treatment, the treatment should be discontinued 
immediately. Pregnancies occurring during study treatment and for the first 120 days after the 
last vaccination should be reported to the Sponsor. The potential risk of exposure of the fetus to 
the investigational agent should be documented using the MedWatch Form FDA 3500A or 
equivalent.  
Pregnancy itself is not regarded as an SAE. However, as patients who become pregnant on study 
risk intrauterine exposure of the fetus to agents which may be teratogenic, the CCR is requesting 
that pregnancy should be reported in an expedited manner as grade 3 “Pregnancy, puerperium 
and perinatal conditions - Other (pregnancy)” under the Pregnancy, puerperium and perinatal 
conditions SOC.  
Congenital abnormalities or birth defects and spontaneous miscarriages should be reported and 
handled as SAEs. Elective abortions without complications should not be handled as AEs. The 
outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, 
normal birth, or congenital abnormality) should be followed up and documented. 
If any pregnancy occurs in the course of the study, then the investigator should inform the 
Sponsor within one day, i.e., immediately, but no later than 24 hours of when he or she 
becomes aware of it. 
The designated Sponsor representative will work with the investigator to ensure that all relevant 
information is provided to the Sponsor within 1-5 calendar days for SAEs and within 30 days for 
all other pregnancies. 
The same timelines apply when outcome information is available. 
Paternal Exposure 
Male patients should refrain from fathering a child or donating sperm during the study and for 
120 days after the last vaccination. 
Pregnancy of the patient’s partner is not considered to be an AE. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or 
congenital abnormality) occurring from the date of the first dose until 120 days after the last dose 
should, if possible, be followed up and documented.  
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATOR 
The Sponsor (Center for Cancer Research) will provide Moderna with: (1) copies of all safety 
reports concurrently with their submission to the FDA; (2) a cumulative listing of adverse events 
(including suspected adverse reactions) on a quarterly basis; (3) notice within 48 hours of case 
completion with respect to a serious adverse event; and, (4) any other information affecting the 
safety of human subjects. This information will be submitted to Moderna at 
drugsafety@modernatx.com.  

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Note: The quarterly cumulative listing of adverse events (including suspected adverse reactions) 
will be submitted by the PI/research team to the Sponsor for reporting to Moderna. 
INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) REPORTING CRITERIA 
7.5.1
Serious Adverse Event Reports to IBC 
The PI (or delegate) will notify IBC of any unexpected fatal or life-threatening experience 
associated with the use of the gene transfer product as soon as possible but in no event later than 
7 calendar days of initial receipt of the information. Serious adverse events that are unexpected 
and associated with the use of the gene transfer product, but are not fatal or life-threatening, must 
be reported to the NIH IBC as soon as possible, but not later than 15 calendar days after the 
investigator’s initial receipt of the information. Adverse events may be reported by using the 
MedWatch Form FDA 3500A or equivalent. 
7.5.2
Annual Reports to IBC
Within 60 days after the one-year anniversary of the date on which the IBC approved the initial 
protocol, and after each subsequent anniversary until the trial is completed, the PI (or delegate) 
shall submit the information described below. Alternatively, the NIH Intramural IRB continuing 
review report can be sent to the IBC in lieu of a separate report. Please include the IBC protocol 
number on the report. 
Clinical Trial Information 
A brief summary of the status of the trial in progress or completed during the previous year. The 
summary is required to include the following information:  
x Title and purpose of the trial  
x Clinical site 
x Principal Investigator 
x Clinical protocol identifiers  
x Participant population (such as disease indication and general age group, e.g., adult or 
pediatric)  
x Total number of participants planned for inclusion in the trial; the number entered into 
the trial to date whose participation in the trial was completed; and the number who 
dropped out of the trial with a brief description of the reasons  
x Status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, or 
fully completed  
x If the trial has been completed, a brief description of any study results. 
Progress Report and Data Analysis 
Information obtained during the previous year's clinical and non-clinical investigations, 
including:  
x Narrative or tabular summary showing the most frequent and most serious adverse 
experiences by body system

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x Summary of all serious adverse events submitted during the past year 
x Summary of serious adverse events that were expected or considered to have causes not 
associated with the use of the gene transfer product such as disease progression or 
concurrent medications 
x If any deaths have occurred, the number of participants who died during participation in 
the investigation and causes of death 
x Brief description of any information obtained that is pertinent to an understanding of the 
gene transfer product’s actions, including, for example, information about dose-response, 
information from controlled trials, and information about bioavailability. 
DATA AND SAFETY MONITORING PLAN 
7.6.1
Principal Investigator/Research Team  
The clinical research team will meet on a weekly basis when patients are being actively treated 
on the trial to discuss each patient. Decisions about enrollment and dose escalation, if applicable, 
will be made based on the toxicity data from prior patients.  
All data will be collected in a timely manner and reviewed by the PI or AI. Adverse events will 
be reported as required above. Any safety concerns, new information that might affect either the 
ethical and/or scientific conduct of the trial, or protocol deviations will be reported to the NIH 
Intramural IRB using iRIS. 
The PI will review AE and response data on each patient to ensure safety and data accuracy. The 
PI will personally conduct or supervise the investigation and provide appropriate delegation of 
responsibilities to other members of the research staff.  
7.6.2
Sponsor Monitoring Plan 
As a Sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring 
program. The CCR’s program allows for confirmation of: study data, specifically data that could 
affect the interpretation of primary study endpoints; adherence to the protocol, regulations, and 
SOPs; and human subject’s protection. This is done through independent verification of study 
data with source documentation focusing on: 
x Informed consent process 
x Eligibility confirmation 
x Drug administration and accountability 
x Adverse events monitoring 
x Response assessment 
The monitoring program also extends to multi-site research when the CCR is the coordinating 
center. 
This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified 
by training and experience to monitor the progress of clinical trials. Personnel monitoring this 
study will not be affiliated in any way with the trial conduct. 

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7.6.3
Safety Monitoring Committee (SMC) 
This protocol will require oversight from the SMC. Initial review will occur as soon as possible 
after the annual NIH Intramural IRB continuing review date. Subsequently, each protocol will be 
reviewed as close to annually as the quarterly meeting schedule permits or more frequently as 
may be required by the SMC. For initial and subsequent reviews, protocols will not be reviewed 
if there is no accrual within the review period. Written outcome letters will be generated in 
response to the monitoring activities and submitted to the PI and Clinical Director or Deputy 
Clinical Director, CCR, NCI. 
8 
STATISTICAL CONSIDERATIONS 
STATISTICAL HYPOTHESIS 
8.1.1
Primary Efficacy Endpoints 
x Determine the clinical response rate in patients with metastatic melanoma, 
gastrointestinal, or genitourinary cancers who receive NCI-4650. 
x Determine the safety of NCI-4650 in patients with metastatic melanoma, gastrointestinal, 
or genitourinary cancer. 
8.1.2
Secondary Efficacy Endpoint 
x Determine whether administration of NCI-4650, a mRNA-based, PCV presenting 
immunogenic neoantigens, can increase the quantity and quality of circulating antigen-
specific T-cells in patients with solid tumors. 
SAMPLE SIZE DETERMINATION 
The study will be conducted using a phase I dose escalation followed by a phase II Simon 
minimax design in two cohorts: Cohort 2a, patients with melanoma and Cohort 2b, patients with 
gastrointestinal or genitourinary cancer. 
Following dose escalation, the objective will be to determine if NCI-4650, given at the MTD, is 
associated with a clinical response rate that can rule out 5% (p0=0.05) in favor of a modest 20% 
PR+CR rate (p1=0.20) in each of the two cohorts in Phase II. 
For each cohort in the Phase II portion of this study, using a two-stage Simon minimax design, 
with alpha=0.10 (10% probability of accepting a poor therapy) and beta=0.20 (20% probability 
of rejecting a good therapy), initially 12 evaluable patients will be enrolled. If 0 of the first 12 
evaluable patients experience a clinical response, then no further patients will be enrolled in that 
cohort. If 1 or more of the first 12 evaluable patients enrolled have a clinical response, then 
accrual will continue until a total of 21 evaluable patients have been enrolled in that cohort. As it 
may take several weeks to determine if a patient has experienced a clinical response, a temporary 
pause of up to 6 months in the accrual to the trial may be necessary to ensure that enrollment to 
the second stage is warranted. If 1-2 of the 21 evaluable patients have a clinical response, then 
this will be considered inadequate for further investigation. If 3 or more of the 21 evaluable 
patients have a clinical response, then this will indicate that this strategy provides a new 
approach that may be worthy of further consideration in that cohort. Under the null hypothesis 
(10% response rate), the probability of early termination per cohort is 54.0%. 
The dose escalation portion of the study may require 6 patients per dose level. For purposes of 
sample size estimation, we will assume that as few as 12 and no more than 18 patients will be 

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required to perform the initial safety evaluation. In order to complete the dose escalation phase 
and Phase II, a total of up to 18+46 =64 patients may be required (allowing up to 2 inevaluable 
patients per Phase II cohort). Up to 6 patients enrolled at the MTD will count towards the accrual 
in the Phase II portion of the trial if they are evaluable for response and if they would be fully 
eligible for enrollment in the Phase II portion of the trial. Provided that about 2-3 patients per 
month will be able to be enrolled onto this trial, approximately 2-3 years may be needed to 
accrue the maximum number of required patients. However, as adequate responses to proceed to 
the second stage of accrual may not occur, the trial may end up accruing many fewer patients. 
POPULATIONS FOR ANALYSES 
8.3.1
Evaluable for Toxicity 
All patients will be evaluable for toxicity from the time of their first mRNA vaccine dose. 
8.3.2
Evaluable for Objective Response
Only those patients who have measurable disease present at baseline, have received at least one 
course of therapy, and have had their disease re-evaluated will be considered evaluable for 
response. These patients will have their response classified according to the definitions stated in 
Section 6.3.3. 
8.3.3
Evaluable for Non-Target Disease Response  
Patients who have lesions present at baseline that are evaluable but do not meet the definitions of 
measurable disease, have received at least one course of therapy, and have had their disease re-
evaluated will be considered evaluable for non-target disease. The response assessment is based 
on the presence, absence, or unequivocal progression of the lesions. 
STATISTICAL ANALYSES 
8.4.1
General Approach 
In the Phase I cohort, the toxicities experienced by patients at each dose level will be reported 
per dose level. In the two Phase II cohorts, clinical responses will be determined and the fraction 
with a clinical response will be reported, along with confidence intervals. 
8.4.2
Analysis of the Primary Efficacy Endpoints 
In the Phase I cohort, the toxicities experienced by patients at each dose level will be reported 
per dose level. The grade of the toxicity as well as the type of toxicity will be tabulated per dose 
level. 
In the Phase II cohorts, the fraction of patients who experience a clinical response in each cohort 
will be reported along with 80% and 95% two-sided confidence intervals. 
8.4.3
Analysis of the Secondary Efficacy Endpoint 
The study will aim to determine whether treatment administration can increase the quantity and 
quality of circulating antigen-specific T-cells, by measuring the reactivity of circulating cells 
against the immunizing peptides in Elispot and 41BB upregulation assays. The comparisons will 
be done using descriptive statistics, without formal statistical testing required. 

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8.4.4
Safety Analyses 
Safety will be monitored by identifying the type and severity of any adverse events. The fraction 
of patients who experience a DLT will be identified at a given dose level, with information 
reported about the number and grade of each type of DLT identified. 
8.4.5
Intention-to-Treat Analysis 
An intention-to-treat (ITT) analysis will be conducted of all patients enrolled to the study. A full 
CONSORT flow diagram will be included in all ITT analyses.
8.4.6
Planned Interim Analyses 
As noted in Section 8.2, results after the first stage of a Simon minimax two-stage design in each 
Phase II cohort will be examined to determine if the minimum number of responses has been 
obtained. 
8.4.7
Sub-Group Analyses
There are no planned analyses based on demographic characteristics since the power to do 
subgroup analyses would be limited and make interpretation difficult. 
9
COLLABORATIVE AGREEMENTS 
MODERNATX, INC. 
CTA #01051-17 
Tumor specific antigens (TSAs) containing between 320 and 639 amino acids will be sent to 
Moderna (formerly Moderna Therapeutics, Inc.) for the manufacture of a single concatemeric 
mRNA construct to be formulated into a vaccine for the same cancer patient. Sequencing data 
will be transferred electronically via the secure, encrypted Globus file transfer system 
(Globus.org) under the current NCI license for this transfer software. The vaccine product and 
associated data will be returned to the NCI-SB. 
CDA #14358-18
The following data will be transferred to Moderna: (1) raw sequencing data, including tumor 
DNA whole exome, tumor RNA whole transcriptome, and normal DNA whole exome 
sequencing data in FASTQ and/or BAM format; (2) somatic variant calling results in VCF 
format; (3) gene expression quantification results in plain text format; (4) patient HLA types 
(major alleles: HLA-A, -B, -C, -DRB1, and any other HLA class II alleles that are typed, in 4 
digits resolution (e.g., HLA-A:02:01)) in plain text format; (5) a list of all neoantigens that had 
been tested; and, (6) a list of all neoantigens tested to be immunogenic (i.e., true positives). 
Moderna will compare the neoantigen ranks predicted by Moderna’s algorithm with the true 
positive and negative data from the NCI-SB. Moderna will also perform an investigation on 
features that are important for neoantigens to be immunogenic.   
Data will be transferred electronically via a secure encrypted Amazon Web Service S3 bucket or 
via the secure, encrypted Globus file transfer system (Globus.org) under the current NCI license 
for this transfer software. No physical specimens will be shipped under this agreement. Results 
from Moderna’s neoantigen prediction algorithm (a prioritized list of neoantigens for each 
patient), and a comparison with NCI-SB’s results, will be returned to the NCI-SB. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
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52
10
HUMAN SUBJECTS PROTECTIONS 
RATIONALE FOR PATIENT SELECTION
Subjects from both genders and all racial/ethnic groups are eligible for this study if they meet the 
eligibility criteria. To date, there is no information that suggests that differences in drug 
metabolism or disease response would be expected in one group compared to another. Efforts 
will be made to extend accrual to a representative population, but in this preliminary study, a 
balance must be struck between patient safety considerations and limitations on the number of 
individuals exposed to potentially toxic and/or ineffective treatments on the one hand, and the 
need to explore gender and ethnic aspects of clinical research on the other hand. If differences in 
outcome that correlate to gender or to ethnic identity are noted, accrual may be expanded or a 
follow-up study may be written to investigate those differences more fully. 
PARTICIPATION OF CHILDREN
Since the efficacy of this experimental procedure is unknown, it does not seem reasonable to 
expose children to this risk without further evidence of benefit. Should results of this study 
indicate efficacy in treating metastatic cancer, which is not responsive to other standard forms of 
therapy, future research can be conducted in the pediatric population to evaluate potential benefit 
in that patient population.  
PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (see Section 10.5DOOVXEMHFWVDJHZLOOEHRIIHUHGWKHRSSRUWXQLW\WR
fill in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. The PI or AI will contact the NIH Ability 
to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate. For those subjects that become incapacitated and do not have a 
pre-determined substitute decision maker, the procedures described in MAS Policy 87-4 and 
OHSRP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) 
decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, 
will be followed. 
EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
The experimental treatment has a chance to provide clinical benefit though this is unknown. The 
NCI-SB has extensive experience with adoptive cell therapy (ACT) following treatment with 
high-dose aldesleukin, however this experimental treatment does not include the standard NCI-
SB preparative regimen or high-dose aldesleukin. Although we have seen responses to prior 
NCI-SB ACT treatments, we do not know if this change in our process will improve patient 
outcome. The risks associated with ACT are substantial, including, a delay in treatment due to 
the need to harvest and grow the cells, a surgical procedure (possible major) to obtain tumor for 

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53
the cell product, the possibility that a cell product cannot be generated, infection due to the 
surgical procedure, and death. The risks in this treatment are detailed in Section 11.  
RISK/BENEFIT ANALYSIS 
Because all patients in this protocol have metastatic or recurrent/refractory locally advanced 
cancer and limited life expectancies the potential benefit is thought to outweigh the potential 
risks. The risk/benefit analysis for adults with the capacity to consent, as well as for adults who 
may become unable to provide consent, is greater than minimal risk because the study treatment 
may be associated with severe side effects, with the prospect of direct benefit because the 
treatment may reduce the cancer burden. 
CONSENT PROCESS AND DOCUMENTATION 
Patients are initially consented on protocols 99-C-0128 and 03-C-0277. If the patient meets the 
thorough screening for eligibility, the patient, with family members or friends at the request of 
the patient, will be presented with the informed consent document for this protocol, who is 
requested to review it and to ask questions prior to agreeing to participate. The specific 
requirements, objectives, and potential advantages and disadvantages will be presented to the 
patient. The patient is reassured that participation on trial is entirely voluntary and that he/she 
can withdraw or decide against treatment at any time without adverse consequences. The PI, AI, 
or clinical fellow is responsible for obtaining written consent from the patient. 
10.6.1 Telephone Consent for Part One Registration 
Because many patients will have previously been treated on another NCI-SB protocol prior to 
beginning treatment on this protocol, these patients may not be onsite at the NIH Clinical Center 
in order to sign the informed consent document for this protocol. In these circumstances, in order 
to complete Part One of the registration procedure (see Section 2.3.2), the informed consent 
process and a detailed description of the protocol treatment will be discussed with the potential 
participant via phone. 
The informed consent document will be sent to the subject. An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form. 
The subject will sign and date the informed consent. A witness to the subject’s signature will 
sign and date the consent. 
The original informed consent document will be sent back to the consenting investigator who 
will sign and date the consent form with the date the consent was obtained via telephone. 
A fully executed copy of the informed consent will be returned via mail to the subject. 
The informed consent process will be documented on a progress note by the consenting 
investigator. 
10.6.2 Informed Consent of Non-English Speaking Subjects 
If there is an unexpected enrollment of a research participant for whom there is no translated 
extant NIH Intramural IRB-approved consent document, the PI and/or those authorized to obtain 
informed consent will use the Short Form Oral Consent Process as described in MAS Policy 
M77-2, OHSRP SOP 12, 45 CFR 46.117 (b) (2), and 21 CFR 50.27 (b) (2). The summary that 
will be used is the English version of the extant NIH Intramural IRB-approved consent 
document. Signed copies of both the English version of the consent and the translated short form 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
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54
will be given to the subject or their legally authorized representative and the signed original will 
be filed in the medical record.
Unless the PI is fluent in the prospective subject’s language, an interpreter will be present to 
facilitate the conversation (using either the long-translated form or the short form). Preferably 
someone who is independent of the subject (i.e., not a family member) will assist in presenting 
information and obtaining consent. Whenever possible, interpreters will be provided copies of 
the relevant consent documents well before the consent conversation with the subject (24-48 
hours if possible).  
We request prospective NIH Intramural IRB approval of the use of the short form process for 
non-English speaking subjects and will notify the NIH Intramural IRB at the time of continuing 
review of the frequency of the use of the Short Form. 
11 PHARMACEUTICAL INFORMATION 
CELL PREPARATION 
The procedure for growing and expanding the autologous young TIL is similar to what is 
approved by the Food and Drug Administration and used in other NCI-SB TIL clinical studies. 
TIL will be grown and expanded for this trial according to SOPs which can be found in BB-IND 
17858. 
INTRAMUSCULAR INJECTION PREPARATION 
11.2.1 NCI-4650, mRNA-Based Personalized Cancer Vaccine  
Description: The CoA for the NCI-4650 mRNA vaccine is in Appendix C, and the SOPs for the 
preparation of the mRNA vaccine are found in BB-IND 17858. This product will be provided for 
investigational use under BB-IND 17858, which is sponsored by the CCR. The vaccine is 
composed of cGMP grade mRNA. Neoantigens will be identified from a sequence comparison of 
a patient’s tumor and normal DNA sample. An algorithm will predict mutated sequences with a 
high probability of binding to a patient’s specific HLA repertoire. Neoantigens will be prepared 
as peptides, either as 25mers, with the mutated amino acid residue situated at position 13, or as 
minimal epitopes. The patient’s TIL, cultured from a biopsy sample, will be screened for their 
ability to recognize these neoantigens pulsed onto dendritic cells. Neoantigens recognized by the 
patient’s TIL will be used to formulate the vaccine. The vaccine will be formulated for each 
administration as indicated below. The identified immunogenic neoantigen sequences will be 
sent electronically to Moderna for vaccine manufacturing. Upon receipt of the final NCI-4650 
product, vaccine will be administered via intramuscular injection.  
Mode of Action: NCI-4650 is taken by antigen-presenting cells that process and present the 
neoantigens on HLA molecules to tumor-specific cytotoxic T-lymphocytes, leading to a major 
histocompatibility complex-restricted cytotoxic response against tumor cells bearing these 
neoantigens.  
Formulation: NCI-4650 is a novel mRNA-based, PCV directed against subject-specific tumor 
neoepitopes. The individual mRNA sequences are designed for each subject based on the 
pipeline for the identification of immunogenic T-cell epitopes derived from neoantigens 
recognized by TIL developed by the NCI-SB. Each NCI-4650 vaccine consists of mRNA 
encoding neoantigens designed specifically to each individual subject’s tumor mutanome, and 
HLA type. Each subject-specific NCI-4650 vaccine is formulated in LNPs comprised of four 

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55 
lipid excipients: SM-102; 1,2-dimyristoyl-rac-glycero-3-methoxypolyethylene glycol-2000 
(DMG-PEG 2000); 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC); and cholesterol. SM-
102 is a novel, ionizable lipid that complexes with the mRNA component of NCI-4650 (mRNA 
product intermediate [MPI]) to promote the formation of the LNPs. The commercially-available 
lipids, DMG-PEG 2000, DSPC, and cholesterol, also contribute to the overall pharmaceutical 
properties of the LNPs.  
NCI-4650 is provided as a sterile liquid for injection in a 93 mM Tris, 7% propylene glycol, 1 
mM DTPA buffer, at a concentration of 1.0 mg RNA/mL. 
Stability: Please refer to the NCI Pharmacy Manual. 
Storage: NCI-4650 must be stored in a restricted access area under the storage conditions 
indicated on the product label and in the NCI Pharmacy Manual. Vials should be stored frozen at 
-20°C (± 5°C) (-13°F to 5°F). 
How Supplied: NCI-4650 is supplied as solution for injection in 2-mL glass vials (with a septum 
stopper). Each vial contains 0.6 mL.  
Preparation: The dose volume for Dose Levels 1 and 2 will be held constant at approximately 
0.3 mL per injection. The dose volume for Dose Level 3 (PN 85002) will be at least 0.39 mL.  
The NCI Pharmacy Manual contains specific instructions for the preparation and administration 
of each dose level of NCI-4650. The NCI Pharmacy Manual also contains details regarding 
sterility release of NCI-4650.  
Administration: For all subjects, NCI-4650 will be administered by IM injection into the deltoid 
muscle (alternating deltoid muscle sites should be used for each subsequent injection, and 
injection sites may also be rotated to thigh muscles). 
Toxicities: Risk to subjects receiving NCI-4650 is expected to be low and primarily involving 
mild to moderate injection site reactions, which have been observed in animal studies and 
generally observed and expected for other IM administered vaccines. These local reactions may 
consist of transient and dose-dependent pain, swelling, and erythema. Possible mild to moderate 
systemic reactions, which are also transient, may include fever, fatigue, chills, headache, 
myalgias, and arthralgias. Such AEs may, in part, be due to the poor biodegradability of LNP 
formulations used in other vaccine studies; the LNP that comprises NCI-4650 is designed to 
incorporate biodegradable properties that may have an improved safety profile. In addition, other 
AEs that have been generally associated with approved IM administered vaccines have included 
mild hematological and clinical chemistry abnormalities, which are usually reversible. Subjects 
receiving NCI-4650 could experience signs and symptoms compatible with a C activation-
related pseudoallergy (CARPA) response, which has been observed in the administration of 
approved liposomal products, contrast agents, pegylated proteins, and antibodies, as well as for 
small interfering RNA products formulated in LNPs. The signs and symptoms of CARPA 
resemble those of an acute hypersensitivity reaction. However, complement activation is far less 
likely to be associated with clinical signs for LNP products such as NCI-4650, that are 
administered IM at a much lower dose on a mg/kg basis than other clinical entities that cause 
CARPA in humans and nonclinical species.  
Special Handling: Please refer to the NCI Pharmacy Manual. 

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56 
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13 APPENDICES 
APPENDIX A: METHODS FOR SELECTING DEFINED EPITOPES, PREDICTED EPITOPES, AND 
TUMOR SUPPRESSOR AND DRIVER NEOANTIGENS 
Three different classes of immunogenic antigens will be included in the vaccine backbone:  
1. Defined epitopes 
2. Up to 15 predicted epitopes 
3. Any driver or suppressor genes identified by WES 
Identifying Defined Epitopes12, 14  
Whole exome sequencing is performed on a patient’s tumor DNA as well as their matched 
normal DNA, extracted from the patient’s PBL. RNA sequencing is performed on the patient's 
tumor sample only. Sequencing is performed on an Illumina Nextseq500 or Nextseq550. The 
output from the sequencer is de-multiplexed and converted to fastq format using Illumina's 
bcl2fastq program. Reads are then trimmed for quality and to remove and adapter sequence with 
Trimmomatic software (USADELLAB.org). Once trimmed, Exome reads are aligned to hg19 
genome using novoalign from novocraft (novocraft.com) to create initial starting bams. RNA-
Seq reads are aligned to hg19 using STAR (https://github.com/alexdobin/STAR) 2pass 
alignment process. Both RNA-Seq and Exome bam files are preprocessed according to the 
GATK best practices protocol. Exome SNVs are called using Strelka, Somatic Sniper, Varscan2, 
and Mutect, and In/Dels are called using Strelka and Varscan2. For single nucleotide variants 
(SNVs) cutoff criteria for evaluation of a variant is Tumor, and normal coverage of 10 or greater, 
Tumor variant read count of 4 or greater, tumor variant frequency of 7% or greater and two or 
greater callers calling that variant. For neoantigens arise from insertions/deletions (In/Dels), the 
criteria are the same except there are no caller criteria. RNA variants are called with Varscan 
with no cutoffs. Somatic variants are annotated using Annovar against three separate reference 
databases (Refgene, Ensembl, UCSC). All variants that pass cutoff criteria and those found in 
COSMIC regardless of cutoff criteria have neoepitopes generated using an in-house python 
script. This script produces 25mers with 12 aa flanking the mutation on either side where 
possible. In the event, it is not possible due to the mutation be located closer than 12 aa from the 
beginning or end of a transcript, the maximum number of aa that can flank are used. For In/Del 
mutations the corresponding change is made to the cDNA sequence, and then 12 aa before the 
mutation (where possible) are extracted as well as all amino acids beyond the mutation up until 
the first stop codon is encountered. If no stop codon is encountered, the neoepitope will 
encompass all sequence up to the end of the cDNA transcript. For each non-synonymous 
substitution mutation identified by next-generation sequencing, both a “minigene” construct 
encoding the corresponding amino acid change flanked by 12 amino acids of the wild-type 
protein sequence or a crude 25 mer peptide are made. Multiple minigenes (10-15) are strung 
together to generate one TMG construct. These minigene constructs are codon optimized, 
synthesized, and cloned in-frame into a modified pcDNA3.1 vector. This modified vector 
contains a signal sequence and a DC-LAMP trafficking sequence to enhance processing and 
presentation, in addition to a poly-A tail to enhance mRNA stability. The nucleotide sequence of 
DOO70*VLVYHULILHGE\VWDQGDUG6DQJHUVHTXHQFLQJ*HQVFULSW$SSUR[LPDWHO\RQHȝJRIWKH
linearized plasmid is used for the generation of IVT RNA using the mmessage mmachine T7 
Ultra kit (Life Technologies) as directed by the manufacturer. RNA purity and concentrations are 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
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59 
assessed using a NanoDrop spectrophotometer. RNA is then aliquoted into microtubes and 
stored at -80 degrees Celsius until use. Crude peptides are pooled at a final concentration of 
approximately 3 mg/mL per peptide (10-18 peptides per pool).  
To isolate TILs, surgically resected tumors are cut into approximately 1-2 mm fragments and 
placed individually into wells of a 24-well plate containing 2 mL of complete media (CM) 
containing high dose IL-2 (6000 IU/mL, Chiron). CM consisted of RPMI supplemented with 10 
percent in-house human serum, two mM L-JOXWDPLQHP0+(3(6DQGWHQȝJP/
gentamicin. In some cases, after the initial outgrowth of TIL (between 2-4 weeks), selected 
cultures are rapidly expanded in gas permeable G-Rex100 flasks using irradiated PBMC at a 
ratio of 1 to 100 in 400 mL of 50/50 medium, supplemented with 5 percent human AB serum, 
3000 IU/mL of IL-2, and 30 ng/mL of OKT3 antibody (Miltenyi Biotec). 50/50 media consisted 
of a 1-to-1 mixture of CM with AIM-V media. All cells are cultured at 37 degrees Celsius with 5 
percent CO2. Monocyte-derived, immature dendritic cells are generated using the plastic 
adherence method. Apheresis samples are thawed, washed, set to 5-10e6 cells/mL with neat 
AIM-V media (Life Technologies) and then incubated at approximately 1e6 cells/cm2 in an 
appropriate sized tissue culture flask and incubated at 37 degrees Celsius, 5 percent CO2. After 
90 minutes, non-adherent cells are collected, and the flasks are vigorously washed with AIM-V 
media, and then incubated with AIM-V media for another 60 min. The flasks are then washed 
again with AIM-V media and then the adherent cells are incubated with DC media. DC media 
FRPSULVHGRI530,FRQWDLQLQJSHUFHQWKXPDQVHUXP8P/SHQLFLOOLQDQGȝJP/
streptomycin, 2 mM L-glutamine, 800 IU/mL GM-CSF (Leukine) and 200 U/mL IL-4 
(Peprotech). On days 2-3, fresh DC media is added to the cultures. Fresh or freeze/thawed DCs 
are used in experiments on day 4-6 after culture initiation. DCs are harvested, washed 1x with 
PBS, and then resuspended in Opti-MEM (Life Technologies) at 10-30e6 cells/mL. IVT RNA (8 
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added directly to the cuvette. The final RNA concentration used in electroporations is thus 80 
ȝJP/(OHFWURSRUDWLRQVLVFDUULHGRXWXVLQJD%7;-830 square wave electroporator. DCs are 
electroporated with 150 V, 10 ms, and 1 pulse. Following electroporation, cells are immediately 
transferred to polypropylene tubes containing DC media supplemented with the appropriate 
cytokines. Transfected cells are incubated overnight (12-14 hours) at 37 degrees Celsius, 5 
percent CO2. Cells are washed 1x with PBS prior to use in co-culture assays. For peptide 
pulsing, DCs are harvested and then resuspended at 0.5e6 cells/mL with DC media containing 
the appropriate cytokines. Long peptides (usually 25mers, Genscript) are dissolved with DMSO 
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Celsius with 5 percent CO2. The following day, APCs are washed 1x prior co-culture with T 
cells. For co-culture with APCs, approximately 3.5e4 to 7e4 DCs are used per well of a 96-well 
plate. Prior to processing the ELISPOT plates, cells are harvested from the plate and processed 
for flow cytometry analysis described below. All co-cultures are performed in the absence of 
exogenously added cytokines. For IFN-Ȗ(/,6327DVVD\V(/,,3SODWHV0LOOLSRUH0$,36:8
are pre-WUHDWHGZLWKȝORIHWKDQROSHUZHOOIRUPLQZDVKHG[ZLWK3%6DQGWKHQ
FRDWHGZLWKȝORIȝJP/,)1-ȖFDSWXUHDQWLERG\0DEWHFKFORQH-D1K) and incubated 
overnight in the fridge. Prior to co-culture, the plates are washed 3x with PBS, followed by 
blocking with 50/50 media for at least 1 h at room temperature (RT). After 20-22 hours of co-
culture, cells are harvested from the ELISPOT plates into a standard 96-well round bottom plate 
for flow cytometry analysis, and then the ELISPOT plates are washed 6x with PBS + 0.05% 
Tween-20 (PBS-7DQGWKHQLQFXEDWHGIRUKRXUVDW57ZLWKȝOZHOORIDȝPILOWHUHG

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
60
ȝJP/ELRWLQ\ODWHGDQWL-human IFN-ȖGHWHFWLRQ antibody solution (Mabtech, clone: 7-B6-1, 
diluent consisted of 1X PBS supplemented with 0.5% FBS). The plate is then washed 3x with 
PBS-T, followed by a 1-KRXULQFXEDWLRQZLWKȝOZHOORIVWUHSWDYLGLQ-ALP (Mabtech, diluted 
1:3000 with above diluent). The plate is then washed 5x with PBS followed by development with 
ȝOZHOORIȝPILOWHUHG%&,31%7VXEVWUDWHVROXWLRQ.3/,QF7KHUHDFWLRQLV
stopped by rinsing thoroughly with cold tap water. ELISPOT plates are scanned and counted 
using an ImmunoSpot plate reader and associated software (Cellular Technologies, Ltd). 
Expression of the T-cell activation markers OX40 and 4-1BB is assessed by flow cytometry at 
approximately 18-24h post-stimulation. OX40 is predominantly expressed by activated effector 
CD4+ T cells, while 4-1BB can be expressed by both activated CD4+ and CD8+ T cells. Cells 
that were harvested from the ELISPOT plate are pelleted, washed with FACS buffer (1X PBS 
supplemented with 1 percent FBS and 2 mM EDTA), and then stained with the appropriate 
antibodies for approximately 30 minutes, at 4 degrees Celsius in the dark. Cells are washed at 
least once with FACS buffer prior to acquisition on a BD FACSCanto II flow cytometer. The 
number of live T-cell events collected is usually ranged between 2e3-8e3. Any positive reactivity 
(3-fold over background of DC only) identified by ELISPOT, 41BB or OX40 is considered as a 
TIL reactivity against a mutated epitope. To identify the specific antigen, individual peptides 
comprising each positive TMG or peptide pool are used for co-culture with the reactive TIL. 
Once identified, an HPLC purified mutated and wild type peptides are synthesized and used to 
validate immunogenic peptide integrity. A defined neoantigen is considered as a mutated peptide 
recognized by TIL and showed no reactivity to the wild type epitope. Any defined epitope 
identified will be included in the vaccine backbone.  
The average turnaround time from TIL harvest to identification of immunogenic epitopes is 7-14 
weeks (Table A-1). 
 
Table A-1. Turnaround time for defined neoantigen discovery pipeline. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
 
 
61 
Selecting Predicted Epitopes  
A patients HLAs are predicted from the exome tumor sample, the exome normal sample and the 
tumor RNA using PHLAT (https://sites.google.com/site/phlatfortype/). If there are differences in 
allelic predictions the top two most frequently predicted locus for each HLA are used. The 
25mers previously generated are then run through netMHCpan-3.0 for each class I HLA and 
minimal epitopes of 8,9,10,11,12 mer lengths are generated. All predicted binders not containing 
the mutated amino acid are removed. All 25mers are also ran through netchop-3.1 and scores for 
proteosomal cleavage for each amino acid are recorded. In order to determine which variants 
should be screened several steps are taken filtering is performed: 
1. Retained variants must possess at least one transcript which has evidence of coding for a 
protein.  
2. Retained variants must be found to be present in at least two of the annotation databases 
(NCBI, UCSC, Ensembl). The rationale behind this is to remove genes or transcripts with 
less support  
3. Retained variants must not been seen in our sequencing data at a rate greater than 2.5%. 
This excludes known driver genes as described in Wellcome Sanger’s cancer genome 
census list. For MHC Ranking we created an observed positive rate table from the 
analysis of > 8000 screened 25mers. A combination of filters was applied to the data and 
the observed positive rate for all 25mers that remain after that filtering. 
x Filters: 
a. Exome pass 1,0 = yes, no 
b. RNA seen 1,0 = yes, no-filter  
c. Gene expression quartile >= 1,2,3,4 
d. netMHCpan3.0 rank <= 5, 4, 3, 2, 1, .75, .50, .25, 0.1 
e. netCHOP Cterm score>= 0, .1, .2, .3, .4, .5, .6, .7, .8, .9 
f. netCHOP 20S score >= 0, .1, .2, .3, .4, .5, .6, .7, .8, .9 
g. # of minimals that meet last 3 criteria >= 1, 2, 3, 4, 5 
Taking all possible combinations there are ~45000 different filtering combinations. Each 25mer 
is analyzed to see what filtering groups it fits into and the highest observed positive rate from 
these groups is then assigned to the 25mer. After all retained 25mers have an observed positive 
rate. The variants with evidence in RNA-seq data are taken 1st sorted by the observed rate and 
ranked in descending order. After that the same is done to the remaining 25mers. The first 15 
ranked 25mers will be included in the vaccine backbone. 
 
 
 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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APPENDIX B: PERFORMANCE STATUS CRITERIA 
ECOG Performance Status Scale 
Grade
Descriptions 
0 
Normal activity. Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed < 50% of the time. Ambulatory and capable of all self-care, but 
unable to carry out any work activities. Up and about more than 50% 
of waking hours.
3 
In bed > 50% of the time. Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. 
Totally confined to bed or chair. 
5 
Dead. 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
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APPENDIX C: MRNA-4650 CERTIFICATE OF ANALYSIS 

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
64

Abbreviated Title: mRNA-Based, Cancer Vaccine 
Version Date: January 23, 2019 
65