A Phase Ib/II Trial To Test The Safety And Efficacy Of Vaccination With HPV16-E711-19 Nanomer For The Treatment Of Incurable HPV 16-Related Oropharyngeal, Cervical And Anal Cancer In HLA-A*02 Positive Patients
Phase: PHASE1
Conditions: Cancer of Head and Neck, Cancer of Cervix, Cancer of Anus
Sponsor: Dana-Farber Cancer Institute

 
 
 
 
 
 
 
 
 
 
 
 
Title: A Phase Ib/II trial to test the safety and efficacy of vaccination with HPV16- 
E711-19 nanomer for the treatment of incurable HPV16-related oropharyngeal, 
cervical and anal cancer in HLA-A*02 positive patients 
NCT Number: NCT02865135 
IRB Approval Date: 07/29/2021 

1 
 
DFCI Protocol #: 15-578 
 
TITLE: A Phase Ib/II trial to test the safety and efficacy of vaccination with HPV16-E711-19 nanomer 
for the treatment of incurable HPV16-related oropharyngeal, cervical and anal cancer in HLA-A*02 
positive patients 
 
Principal Investigator (PI): 
Kartik Sehgal, MD 
Head & Neck Oncology 
Dana Farber Cancer Institute (DFCI) 
450 Brookline Avenue 
Boston, MA 02215 
Kartik_Sehgal@dfci.harvard.edu 
 
Other Investigators at DFCI: 
 
 
 
 
 
IND #: 16998 
 
Protocol Type / Version # / Version Date: Amendment 11/July 14, 2021 
 
Protocol Template Version Date: July 17, 2015 
 
Agent: DPX-E7 vaccine, supplied by Immunovaccine Inc. 

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Pre-screening 
Informed 
consent for 
HLA-A*02 
Phenotype 
Testing 
 
 
 
 
 
 
 
Informed 
consent & 
Screening of 
HLA-A*02 
Positive 
Subjects 
Registration 
DPX-E7 
Vaccine on 
Days 1 & 22 
And Booster 
Dose Every 8 
Weeks 
Continuing 
Until 
Progressiona 
 
 
a- patients 
enrolled prior to 
new treatment 
regimen will 
continue to take 
cytoxan 
Safety 
Evaluation, 
Radiographic 
Markers of 
Response 
& Correlative 
Immunlogical 
Studies 
 
 
 
 
 
SCHEMA OF THE STUDY 
 
 
 
 
 
 

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TABLE OF CONTENTS 
1. 
OBJECTIVES ...................................................................................................................... 6 
1.1 
Study Design............................................................................................................ 6 
1.2 
Primary Objectives .................................................................................................. 8 
1.3 
Secondary Objectives .............................................................................................. 8 
2. 
BACKGROUND ................................................................................................................. 8 
2.1 
Study Disease .......................................................................................................... 8 
2.2 
DepoVaxTM Technology ........................................................................................ 10 
2.3 
IND Agent: DPX-E7 Vaccine .............................................................................. 11 
3. 
PARTICIPANT SELECTION ........................................................................................... 11 
3.1 
Inclusion Criteria ................................................................................................... 11 
3.2 
Exclusion Criteria .................................................................................................. 12 
3.3 
Inclusion of Women and Minorities ...................................................................... 13 
4. 
REGISTRATION PROCEDURES ................................................................................... 13 
4.1 
Pre-screening ......................................................................................................... 13 
4.2 
General Guidelines for DFCI Registration Process ............................................... 14 
4.3 
Recruitment Process .............................................................................................. 14 
5. 
TREATMENT PLAN ........................................................................................................ 14 
5.1 
Treatment Regimen ............................................................................................... 14 
5.2 
Agent Administration............................................................................................. 15 
5.3 
General Concomitant Medication and Supportive Care Guidelines ...................... 16 
5.4 
Criteria for Taking a Participant off Protocol Therapy.......................................... 17 
5.5 
Duration of Follow Up .......................................................................................... 18 
5.6 
Criteria for Taking a Participant off Study ............................................................ 18 
6. 
ANTICIPATED TOXICITIES .......................................................................................... 19 
7. 
ADVERSE EVENTS LIST AND REPORTING REQUIREMENTS .............................. 21 
7.1 
Definition of an Adverse Event ............................................................................. 21 
7.2 
Reporting Period .................................................................................................... 21 
7.3 
Definition of a Serious Adverse Event .................................................................. 22 
7.4 
Recording AEs and SAEs ...................................................................................... 22 
7.5 
Assessment of Intensity ......................................................................................... 23 
7.6 
Assessment of Causality ........................................................................................ 23 
7.7 
Expectedness of AEs ............................................................................................. 23 
7.8 
Reporting of SAEs ................................................................................................. 24 
7.9 
Follow-up of SAEs ................................................................................................ 25 
8. 
PHARMACEUTICAL INFORMATION .......................................................................... 26 
8.1 
DPX-E7 vaccine .................................................................................................... 26 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................ 29 
9.1 
Primary Immunological Endpoints ........................................................................ 29 

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10. 
STUDY CALENDAR ....................................................................................................... 32 
10.1 
Contraindicated Medications ................................................................................. 35 
11. 
MEASUREMENT OF EFFECT ....................................................................................... 35 
11.1 
Baseline Documentation of Target Lesions and Response Criteria ...................... 36 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ........................................... 36 
12.1 
Data Safety Monitoring ......................................................................................... 36 
13. 
STATISTICAL CONSIDERATIONS ............................................................................... 37 
14. 
PUBLICATION PLAN ..................................................................................................... 39 
15. 
REFERENCES .................................................................................................................. 39 
16. 
APPENDICES ................................................................................................................... 43 

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LIST OF ABBREVIATIONS 
 
Abbreviation 
Definition 
 
-hCG 
Beta Human Chorionic Gonadotropin 
AE 
Adverse Event 
ALT 
Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
AST 
Aspartate Aminotransferase 
CBC 
Complete Blood Count 
CBCD 
Complete Blood Count with Differential 
cGMP 
Certified Good Manufacturing Practice 
CTCAE 
Common Terminology Criteria for Adverse Events 
DF/HCC 
Dana-Faber/Harvard Cancer Center 
DFS 
Disease-free survival 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic Case Report Form 
ELISpot 
Enzyme-linked Immunosorbent Spot 
FDA 
Food and Drug Administration 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HPV 
Human Papilloma Virus 
IB 
Investigator’s Brochure 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IV 
Intravenous 
MHC 
Major Histocompatibility Complex 
MS3 
Poisson detection Mass spectrometry 
NCI 
National Cancer Institute 
NSAIDs 
Non-steroidal Anti-inflammatory Drugs 
OS 
Overall survival 
PBMC 
Peripheral Blood Mononuclear Cell 
PD 
Progressive Disease 
PFS 
Progression Free Survival 
PI 
Principal Investigator 
PS 
Performance Status 
SAE 
Serious Adverse Event 
QACT 
Quality Assurance of Clinical Trials 
RECIST 
Response Evaluation Criteria in Solid Tumors 
irRECIST 
Immune-Related Response Evaluation Criteria in Solid Tumors 

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1. OBJECTIVES 
 
1.1 
Study Design 
 
This is a single center, open label, non-randomized, phase Ib/II trial of HPV16-E711-19 nanomer 
vaccine (DPX-E7) for treatment of incurable HPV16-related oropharyngeal (HPVOC), cervical and 
anal cancer. 
 
Safety and clinical efficacy of the DPX-E7 vaccine will be evaluated in up to n=44 patients 
(Considering that patients continue to be screened and at least n=7 patients have been entered and 
began protocol treatment at the original dose prior to approval of Amendment 10, and allowing for 
1 or 2 patients to sign the main consent and to be registered to the main protocol but not begin 
protocol treatment or be ineligible, the overall accrual goal following approval of Amendment 10 is 
up to n=44). 
 
The new treatment regimen (amendment 10) changed the treatment regimen, removing Cytoxan and 
doubling the vaccine dose. For patients enrolled on the trial before amendment 10’s approval, they 
will continue to dose with Cytoxan and the original vaccine doses (0.25mL for priming, 0.1mL for 
boosting) 
 
Potentially eligible patients with confirmed diagnosis of incurable oropharyngeal, cervical or anal 
cancer will be asked to sign a pre-screening consent that will allow us to use a blood sample for 
HLA testing. 
 
HLA-A*02 positive subjects will sign the main consent and screened further. If eligible, will be 
registered and receive treatment with DPX-E7 vaccine. 
 
Following approval of Amendment 10, the below stopping rule will also be followed for the first 6 
patients who sign the main consent and begin protocol treatment at the new dose (of note, there 
have been no DLTs observed among the first 6 patients who have been treated at the dose originally 
outlined in the protocol) 
 
As this is the first study testing the DPX-E7 vaccine in humans, the following monitoring will be 
used: The enrollment of first six subjects who begin protocol treatment will be concurrent and they 
will be observed for adverse events. If zero or one DLT (see section 6.2 for definition) is observed 
through the first month after the second priming dose in the first six subjects, then study enrollment 
into the first stage (n=16) will continue and may continue concurrently. If there are two DLT’s 
observed through the first month after the second priming dose in the first six subjects, the dose of 
DPX-E7 vaccine will be de-escalated. If there are 3 or more DLTs observed through the first month 
after the second priming dose in the first 6 subjects, accrual will be suspended to further evaluate 
the events and decisions made regarding the overall status of the trial. If dose de-escalation is 
required, six new subjects will be enrolled and treated with DPX-E7 vaccine at the lower dose. If 
zero or one DLT is observed through the first month after the second priming dose in these six 
subjects, then study enrollment into the first stage (n=16) will continue. If there are two or more 
DLTs OR one death OR two grade 4 events observed through the first month after the second 
priming dose in these six subjects, then accrual will be suspended to further evaluate the events and 
decisions made regarding the overall status of the trial. Only those patients treated at the acceptable 
dose will be included in the phase II portion of the trial. Adverse events will be continuously 

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monitored throughout the trial by the study team and appropriate committees with decisions made 
accordingly re: the study status and patient entry throughout the duration of the trial. 
 
As overall monthly accrual is estimated to be 6 pre-consented for HLA and HPV testing, with 33% 
of those HLA-A*02 positive, the above monitoring will be ongoing and not require accrual to be 
suspended for adverse event evaluation after the first 6 patients who begin protocol treatment, 
however, these estimates will be monitored and accrual will be suspended as needed. Two 0.50 mL 
priming doses of DPX-E7 will be given 3 weeks apart, followed by 0.2 mL booster doses every 8 
weeks, until clinical progression. Subjects will be re-primed with a 0.50 mL vaccination if they are 
not exhibiting injection site induration, a hallmark of DepoVax vaccination, within four weeks of 
their next boost and/or their immune response is not being maintained. 
 
DLT assessment period will last until day 50 (28 days after the second priming dose). Vaccine dose 
reduction would occur in the event of 2 DLTs. If a dose reduction is required then the new dose 
level will be 0.2 mL for the priming doses while the boosting doses will remain at 0.2 mL. 
 
DPX-E7 vaccine dose de-escalation in Phase Iba 
 
Modified Priming Dose* 
0.2 mL 
Priming Dose 1 (starting) 
0.50 mL 
Priming Dose 2 
0.50 mL 
Booster Doses 
0.2 mL 
* If there are two DLTs observed through the first month after the second priming dose in the first 
six subjects, the dose of DPX-E7 vaccine will be de-escalated. 
a Patients enrolled prior to amendment 10’s approval will receive priming and boosting doses of 
0.25mL and 0.1mL, respectively. 
Cyclophosphamide dose reduction in Phase Ib/IIa 
 
Modified Dose* 
50 mg once per day 
Planned Dose 
50 mg twice per day 
* Cyclophosphamide dose can be reduced to 50 mg once per day. If ANC ≤ 1,000/uL or Platelet ≤ 
100,000/ uL, then the cyclosphosphamide will be held. In order to restart administration of 
cyclophosphamide, the platelet and ANC levels should have resolved to ≤ Grade 1 or to the patient’s 
baseline value. The maximum delay before treatment should be discontinued is 3 weeks. Once the 
cyclophosphamide is restarted, it can be dose reduced to 50mg per day per investigator’s discretion. 
If the cyclophosphamide dose has been reduced, it can’t be re-escalated. 
a Only for patients enrolled before amendment 10’s approval. 
 
Visits for pre-screening, screening, treatment, safety evaluation and assessment of tumor response 
will occur as outlined in section 10. 

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All patients who begin treatment, will be followed for response until first disease progression and 
for survival until 2 years post study registration. 
 
1.2 
Primary Objectives 
 
1. Evaluate changes in CD8+ T cells in peripheral blood and tumor tissue. 
2. Evaluate the safety of DPX-E7 vaccination in HLA-A*02 positive patients with incurable 
HPVOC, cervical cancer, and anal cancer. 
 
1.3 
Secondary Objectives 
 
1. Evaluate the overall response rate (ORR) of DPX-E7 vaccination in HLA-A*02 positive 
patients with recurrent and/or metastatic HPVOC, cervical cancer, and anal cancer using 
modified RECIST 1.1 and irRECIST (Appendix B & C). 
2. To estimate progression free survival, time to progression, and overall survival. 
3. To evaluate the biologic correlates of response to therapy by determining the antigen- 
specific CD8 T cells elicited by E711-19 pMHC multimer binding assay, their activation 
status, effector/memory phenotype, cytokine profile, quantitation per ml blood, 
perforin/granyme content, CD4 activation status, including Treg profiling. 
 
2. BACKGROUND 
 
2.1 
Study Disease 
 
Human papilloma viruses (HPV) are double-stranded DNA viruses that infect epithelial cells of the 
skin and mucosa1. Of the more than 200 known HPV types, 30-40 are transmitted through sexual 
contact, infecting the anogenital region and oropharynx. Among these, approximately 15 are 
designated “high-risk” (i.e. oncogenic) and have been linked to cervical cancer as well as anal, vulva, 
vaginal, penile and oropharyngeal cancers2. Worldwide, >5% of all new cancers are attributable to 
high-risk HPV infections3. HPV is the cause of virtually all cases of cervical cancer, the second 
leading cause of cancer deaths among women worldwide4-6. While the implementation of screening 
has greatly reduced the burden of this disease in the developed world, treatment options for persistent, 
recurrent, or metastatic cervical cancer remain limited and the prognosis is poor7,8. 
 
Anal cancer accounted for 7060 cases per year estimated for the U.S. in 2013 and are closely linked 
to HPV infection. A recent analysis of 96 patients from Montreal showed that 92% had detectable 
HPV and HPV 16 was by far the most common subtype at 90%, with multiple other subtypes seen in 
small numbers9. An earlier study, limited to men from the San Francisco area, found that in the setting 
of HIV infection 93% of anal cancer patients had evidence of HPV, whereas the rate of HPV 
involvement was 61% among HIV-negative men10. A large population-based study in Denmark and 
Sweden detected HPV in 84% of patients with anal cancer11. 
 
Overall, patients with anal cancer do quite well with the standard treatment of pelvic radiation given 
concurrently with two cycles of 5FU and mitomycin C12. While most patients with this disease can 
be cured, 880 deaths related to anal cancer are anticipated annually in the US alone6. Especially 
patients who present with locally advanced disease, i.e. tumors greater than 5 cm or involved lymph 
nodes, the prognosis is poor, both in terms of DFS and OS13. A high percentage of these patients will 
recur, typically with distant metastases. First line chemotherapy, often cisplatin and 5FU, can be 

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effective in treating recurrences, but virtually all patients will eventually progress. These patients 
with recurrent anal cancer and progression through first line chemotherapy are an appropriate group 
for testing the current vaccine. 
 
HPV associated oropharyngeal cancer (HPVOC) is an emerging epidemic with currently over 10 000 
new cases per year in the US alone and the incidence is projected to double every 5-10 years in the 
coming decades. While HPVOC responds well to treatment and is curable in the vast majority of 
patients when detected early, approximately 10% of patients will be diagnosed with or will eventually 
develop incurable disease and eventually die of their disease14-16. Metastatic HPVOC responds 
frequently to first line chemotherapy which typically consists of platinum based combination 
regimens but survival remains poor and better treatments both in terms of efficacy and tolerability 
are urgently needed. 
 
The viral E6 and E7 encoded proteins have transforming activities through functional inactivation of 
the p53 and retinoblastoma (Rb) tumor suppressor proteins, respectively17-20. Not surprisingly, 
therefore, abrogation of activities of E6 and/or E7 experimentally terminates the malignant state of 
HPV-transformed cells in vitro21. 
 
A key advance in combating HPV infection and its causally related diseases has been based on virus- 
like particle prophylactic vaccine development22. This vaccine consists of recombinant HPV L1 
capsid protein that self-assembles to create virus-like particles against which protective, high-titered 
anti-L1 neutralizing antibodies are elicited in vivo22,23. In both females and males, such vaccines 
comprising 2 high risk capsids effectively prevent development of anogenital diseases24. However, 
capsid-based therapeutic HPV vaccine strategies cannot be employed once infection/disease is 
established for at least two reasons. First, humoral protection is associated with antibody binding to 
the capsid L1 protein thereby blocking virion entry into the cell. The L1 protein is exclusively 
expressed late in the HPV replication cycle and only in differentiated keratinocytes within the upper 
layers of the epithelium to create infectious virions. Persistent infection in the host is maintained by 
low copy numbers of unencapsulated virus in basal stem cells25. As humoral immune responses 
against capsid proteins do not affect persistently infected basal cells, they are consequently unable to 
clear infection24,26. Second, high risk HPV-associated cancers arise with genomic integration of E6 
and E7 viral oncogenes. Although L1 and L2 genes may also be integrated and capsid proteins 
expressed27 these are intracellular and hence, antibody inaccessible. 
 
During natural infection, HPV is cleared by the immune system in the vast majority of subjects. A 
few percent of persistent infections evolve into neoplasias that may progress to malignancy with high 
risk HPV types28. Although immune suppression is associated with chronic infection, most patients 
with persistent HPV infections do not show immune deficiencies in response to other pathogens29. 
Persistent infection with malignant or premalignant lesions is often associated with HPV-specific T 
cells whose significance for anti-tumor immunity is not always clear. For example, one study that 
detected HPV-responding T cells in peripheral blood of patients with high grade cervical 
intraepithelial neoplasia (CIN2/3) was unable to correlate IFN-γ levels or antigen specificity of T cell 
response with the 26% of the patients that showed spontaneous lesion regression30. Whereas the 
presence of circulating HPV-specific CD8+ cytotoxic T lymphocytes (CTL) did not correlate with 
disease prognosis in early stage cervical cancer, the degree of CD8+ tumor infiltration and balance 
(ratio) of CD8+ T cells to regulatory T cells were correlated31,32. Consistent with a critical role of 
inflammatory signals in inducing T cell responses, vulval intraepithelial lesions treated with the toll- 
like receptor 7 activator Imiquimod showed regression and viral clearance in association with 

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circulating HPV-specific T cells33,34. Recently, vaccination with synthetic long peptides covering the 
E6 and E7 oncoproteins plus conventional adjuvant treatment was reported to clear HPV-16 induced 
high-grade vulva intraepithelial neoplastic lesions in ~50% of patients35. 
 
While it is widely acknowledged that antitumor cellular immunity is influenced by regulatory 
mechanisms, tumor microenvironment and tumor escape mechanisms36, the nature of T cell antigen 
specificity is less defined despite its critical role. Ex vivo T cell assays that mark HPV-specificity 
identify a broad priming display by professional antigen presenting cells (pAPCs) but do not 
interrogate antitumor CTL activity nor do they identify the breadth of HPV-specific MHC I display 
of the tumor per se37. Pointedly, in the context of a narrow tumor display, antitumor vaccines that 
prime a broad T cell response generate a small fraction of tumor lytic CD8+ T cells, resulting in low 
densities of useful tumor infiltrating T cells. 
 
2.2 
DepoVaxTM Technology 
 
Immunovaccine has developed a patented prophylactic/therapeutic vaccine delivery and 
enhancement platform called DepoVaxTM. DepoVax (DPX) is a lipid-based depot formulation able 
to enhance immune responses towards peptide antigens. DepoVax has been demonstrated to enhance 
peptide immunogenicity in animal models and to maintain an immune response to the antigens after 
repeated immunizations38,39. The platform also includes a synthetic adjuvant to enhance and sustain 
the immune response. 
 
DepoVax formulations are flexible compositions that can be modified for specific indications by 
inclusion of specific peptide antigens. The formulations consists of: (1) lipids (2) an adjuvant, (3) 
specific antigen(s), and (4) a hydrophobic carrier. DepoVax formulations are oil based, which allows 
for practical delivery of peptide antigens without having to resort to cumbersome emulsification. The 
unique combination of lipids in a hydrophobic carrier such as mineral oil creates a very strong depot 
at the site of immunization, co-delivering and holding antigens and the adjuvant at the site for a 
prolonged period of time. Immunovaccine’s hypothesis is that the immune enhancement properties 
of this unique formulation are a result of this co-delivery and depot effect. 
 
DepoVax has been used as the basis for two therapeutic cancer vaccines currently under clinical 
development, DPX-0907 and DPX-Survivac, in the US and Canada. Immunovaccine’s first 
immunotherapeutic vaccine, known as DPX-0907, is a candidate anti-cancer vaccine for the treatment 
of breast, ovarian and prostate cancer. DPX-0907 vaccine consists of 7 tumor-specific human 
leukocyte antigen (HLA-A*02) restricted peptides, a universal T helper epitope from tetanus toxoid, 
a synthetic polynucleotide adjuvant, and phospholipids and cholesterol. In 2011 Immunovaccine 
completed a first-in-human Phase 1 clinical study (protocol ONC-DPX-0907-01) in the US which 
demonstrated safety and immunogenicity of the vaccine. These findings were published in the 
Journal of Translational Medicine40. 
 
Immunovaccine is currently conducting, with its second immunotherapeutic vaccine candidate, a 
Phase 1b clinical trial (DPX-ONC-DPX-Survivac-03) in ovarian, fallopian tube, and peritoneal 
cancer patients in centers in both the US and Canada and a Phase 2 trial (ONC-PX-Survivac-05) in 
diffuse large B cell lymphoma (DLBCL) patients in Canada; subjects in both trials receive up to six 
doses of vaccine along with low dose cyclophosphamide (50 mg bid). DPX-Survivac is a therapeutic 
cancer vaccine containing one decapeptide and four nonapeptides with different HLA restrictions, a 
universal T helper epitope from tetanus toxoid, a synthetic polynucleotide adjuvant, and 

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phospholipids and cholesterol. DPX-Survivac is designed to target survivin, a member of the inhibitor 
of apoptosis protein (IAP) family. A first-in-human Phase 1 trial was completed in 2013 (protocol 
ONC-DPX-Survivac-01). The Phase 1 study findings have been published in Oncoimmunology41. 
 
2.3 
IND Agent: DPX-E7 Vaccine 
 
Recently, an E711-19 nanomer peptide as a dominant T cell epitope presented by HLA-A*02:01 on the 
majority of HPV-16 cervical squamous and adenocarcinomas before and post-adjuvant chemotherapy 
has been identified, opening the way to therapeutic vaccination strategies targeting disease specific 
epitopes that result in optimal immunogenicity. Similar clinical trials use metronomic, low dose oral 
cyclophosphamide to deplete regulatory T cells (Treg) and to enhance immunogenicity further. 
 
In this trial, we will use the E711-19 nanomer as target for CTL vaccination of HLA-A*02patients, 
given that HPVOC and anal squamous cell cancer are epithelial tumors as are HPV cervical 
cancers. DPX-E7 is formulated with the same DepoVax platform technology as Immunovaccine’s 
previous products DPX-0907 and DPX-Survivac. With the exception of the HPV16-E711-19 
peptide, the remaining components of the vaccine are the same as DPX-0907 and DPX-Survivac, 
both of which have completed Phase 1 testing. Despite evidence supporting metronomic 
cyclophosphamide in previous studies, our group has not seen immunologic activity in a cohort of 
six patients, and we have even seen immunologic depletion after treatment with cyclophosphamide. 
These disappointing results prompted us to eliminate cyclophosphamide from the treatment 
regimen and double the vaccine dose. Including the cohort previously treated with low dose 
metronomic cyclophosphamide, a total of up to n=44 patients will receive the vaccine (Considering 
that patients continue to be screened and at least n=7 patients have been entered and began protocol 
treatment at the original dose prior to approval of Amendment 10, and allowing for 1 or 2 patients 
to sign the main consent and be registered to the main protocol but not begin protocol treatment or 
be ineligible, the overall accrual goal following approval of Amendment 10 is up to n=44).. Patients 
on the previous treatment regimen (0.25mL priming doses, 0.1mL booster doses, and metronomic 
cyclophosphamide (50mg BID, 7 days on, 7 days off) will continue to receive this treatment 
regimen. This will allow us to obtain information about safety of the approach and to gain 
preliminary insight into clinical efficacy of this strategy. Patients will undergo mandatory tumor 
biopsies to obtain fresh tumor tissue prior and also post vaccination (prior to first vaccination and at 
13 (+/-1) weeks after the first injection). 
 
The tissue will be used to confirm HPV16-E711-19 peptide display by MS. 
 
Once established, DPX-E7 vaccination could become an attractive option for the adjuvant treatment 
of patients with persistent HPV infection who are cured of HPVOC as well as for healthy individuals 
with high risk HPV infection such as patient’s spouses, who are at risk to develop oropharyngeal, 
cervical or anal cancer over time. 
 
3. PARTICIPANT SELECTION 
 
3.1 
Inclusion Criteria 
 
1. Each patient must be positive for HLA-A*02 and meet all of the following inclusion criteria 
to be enrolled in the study: 

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2. Histologically or cytologically proven HPVOC or cervical cancer or anal cancer, based on the 
presence of HPV type16, detected by immunohistochemistry with P16 staining followed by 
PCR of tumor tissue from the primary or metastatic lesions. Please see Appendix D for 
reference and methodology. 
3. Incurable HPVOC, as defined by: 
a. Relapsed or progressive disease at the primary site and/or regional lymph nodes after 
initial treatment (e.g. Surgery, radiotherapy or chemoradiotherapy) with no potentially 
curative option (i.e. surgery or radiation); OR 
b. Distant metastasis 
4. Incurable cervical or anal cancer, as defined by: 
a. Relapsed or progressive disease at the primary site and/or regional lymph nodes after 
initial treatment (e.g. systemic chemotherapy) with no potentially curative option (i.e. 
surgery or chemoradiotherapy). Chemotherapy administered in conjunction with 
primary radiation as a radiosensitizer will not be counted as a systemic chemotherapy 
regimen; OR 
b. Distant metastasis refractory to initial treatment (at least one prior chemotherapeutic 
regimen which can include a single chemotherapeutic, a combination of 
chemotherapeutics, or biologic drugs). Cervical cancer subjects with distant 
metastases will have received and failed Bevacizumab prior to enrollment onto the 
trial 
5. Accessible tumors for sequential biopsies 
6. Recovery from toxicity from any prior therapy to National Cancer Institute Common 
Terminology Criteria for Adverse Events Version 4.0 (CTCAE v4.03) to grade 1 or better 
(except for < grade 2 neuropathy, alopecia, xerostomia, dysphagia, or mucositis); 
7. Age  18 years; 
8. Measurable disease, according to modified RECIST 1.1 and irRECIST (Appendix B & C); 
9. Eastern Cooperative Oncology Group performance status (ECOG PS)  2 (Appendix A) 
10. Adequate bone marrow, liver and renal function, defined by: 
a. Hemoglobin  10 g/dL; 
b. Absolute neutrophil count (ANC)  1000/L; 
c. Absolute lymphocyte count  400/L; 
d. Platelet count  100,000/L; 
e. ALT and AST  2.5 X upper limit of normal (ULN); 
f. Total bilirubin  1.5 X ULN; and 
g. Serum creatinine  1.5 X ULN; 
11. Women of child-bearing potential (WOCBP) must be willing to use acceptable means of birth 
control; 
12. Men who could potentially father a child must also use birth control 
13. Signed informed consent. 
 
3.2 
Exclusion Criteria 
 
Patients meeting any of the following exclusion criteria are not to be enrolled in the study: 
1. Radiotherapy for primary HPVOC within 8 weeks, or radiotherapy for any other reason 
within 3 weeks prior to the first dose of vaccine; 
2. Chemotherapy or immunotherapy within 3 weeks prior to the first dose of vaccine; 

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3. Prior malignancy in the past 5 years, except for carcinoma in situ of the cervix or bladder, 
or non-melanomatous skin cancer; 
4. Inaccessible tumor or lack of consent for sequential biopsies 
5. Uncontrolled central nervous system (CNS) metastases (i.e. known CNS lesions that are 
radiographically unstable, symptomatic and/or requiring escalating doses of 
corticosteroids); 
6. Active hepatitis, known HIV, or other condition that requires immunosuppressive therapy, 
including current use of high dose systemic corticosteroids; 
7. Autoimmune disease, such as systemic lupus erythematosis or rheumatoid arthritis, that 
is active and requires current immunosuppressive therapy; 
8. Active uncontrolled serious infection; 
9. WOCBP who have a positive -hCG test or are breastfeeding. 
10. Acute or chronic skin disorders that would interfere with subcutaneous injection of the 
vaccine or subsequent assessment of potential skin reactions; 
11. Allergies to any vaccine, that after discussion with Immunovaccine, are serious enough to 
warrant exclusion from this study 
 
3.3 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
Pre-screening 
 
Potentially eligible patients with confirmed diagnosis of incurable oropharyngeal, cervical or anal 
cancer will be asked to sign a pre-screening consent that will allow us to use a blood sample for HLA 
testing and to analyze archival tissue for confirmation of the HPV16 genotype by PCR. 
 
Obtain written informed consent for pre-screening from the potential participants prior to HLA testing. 
 
A de-identified whole blood sample will be sent to the lab 
for HLA analysis. It 
will take approximately one week to carry out the HLA analysis. If the patient has previously 
undergone HLA analysis at a certified laboratory and the documented results are available then typing 
does not have to be repeated for the study. Patients must test positive for the HLA-A*02 phenotype in 
order to be eligible for registration and study treatment. 
 
Confirmation of the HPV16 genotype by PCR analysis will be completed by the Brigham and 
Women’s hospital on archival tissue samples stored in-house or on samples requested from outside 
institutions. It will take approximately 2 weeks to carry out the HPV16 confirmation. If HPV Type 16 
associated malignancy has already been confirmed by PCR analysis by a certified laboratory and the 
documented results are available, then confirmation does not have to be repeated for the study. The 
HPV16 genotype must be confirmed in archival tissue samples by PCR analysis in order to be eligible 
for registration and study treatment. 
 
For patients interested in the vaccine trial with difficulties traveling to Boston, the pre-screen consent 
may be signed remotely in order to confirm their potential eligibility, pending approval by the Primary 

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Investigator (PI). Interested patients and their treating physicians would be required to contact the PI 
to assess whether they would be a potential candidate for the trial. Upon the PI’s approval, the patient 
would be sent a copy of the consent form electronically, which would be explained by the PI, signed 
remotely, and sent back to DFCI. Once the PI receives and signs the pre-screening consent form, the 
patient— along with the assistance of their local institution— would have their blood drawn and 
shipped refrigerated and overnight back to DFCI for analysis in the lab 
Archival 
tissue may also be requested and analyzed for the HPV16 genotype by PCR or IHC upon receipt of 
the signed pre-screening consent. 
 
4.2 
General Guidelines for DFCI Registration Process 
 
HLA-A*02 positive patients (through pre-screening) who also meet all eligibility criteria (through 
screening) will be registered in OnCore by the study team. Registration must occur prior to the 
initiation of protocol therapy. Any participant not registered to the protocol before protocol therapy 
begins will be considered ineligible. 
 
The investigator will confirm eligibility criteria and a member of the study team will complete the 
protocol-specific eligibility checklist. 
 
Following registration, participants may begin protocol therapy. Issues that would cause treatment 
delays should be discussed with the Principal Investigator (PI). If a participant does not receive 
protocol therapy within 14 days following registration, the participant’s registration on the study must 
be canceled. 
 
The following source documents are required for registering the patient in OnCore: 
 
• Copy of screening lab results 
• Signed participant consent form 
• Eligibility Checklist 
 
4.3 
Recruitment Process 
 
Subjects will be recruited from the patient populations of the DFCI Head and Neck Oncology 
Program, the DFCI Gynecologic Oncology Program, and the DFCI Gastrointestinal Oncology 
Program, through our clinical referral network and by internet advertising for the study, including the 
Dana-Farber/Partners 
CancerCare 
website, 
www.cancercare.harvard.edu, 
websites 
(e.g., 
www.headneckcancer.net), and the National Cancer Institute’s clinical trials website, 
www.cancer.gov/clinicaltrials. 
 
5. TREATMENT PLAN 
 
5.1 
Treatment Regimen 
 
This is a single center, open label, non-randomized, phase Ib/II trial of HPV16-E711-19 nanomer 
vaccine DPX-E7 in treatment of HLA-A*02 positive patients with histologically confirmed HPVOC, 
cervical, or anal cancer that is metastatic or unresectable and for which standard curative measures 
do not exist or are no longer effective. 

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Up to n=44 patients will be treated (n= 7 to 10 at the original dose prior to approval of Amendment 
10 and n=33 at the dose outlined in Amendment 10). and we anticipate that this will require HLA 
screening at least 100 patients following approval of Amendment 10. 
 
HLA-A*02 positive subjects will receive two 0.50 mL priming doses of DPX-E7 3 weeks apart 
followed by 0.2 mL booster doses every 8 weeks until clinical progression. Subjects will be re-primed 
with a 0.50 mL vaccination if they are not exhibiting injection site induration, a hallmark of DepoVax 
vaccination, within four weeks of their next boost and/or their immune response is not being 
maintained. Because the correlation between the induration and the immune endpoint is still being 
investigated, immune responses in addition to the induration will be collected to better establish this 
potential efficacy parameter. 
 
Former Treatment Regimen 
 
Patients enrolled on the previous treatment regimen (0.25mL priming doses, 0.1mL booster doses, 
and 50mg cyclophosphamide BID for 7 days on, 7 days off) will continue this regimen until treatment 
discontinuation. Injection visits will remain the same (D1, D22, etc.), but cyclophosphamide will be 
taken starting one week prior to the first injection visit. 
 
Low dose metronomic oral cyclophosphamide (50 mg twice per day) will start 7 days before the first 
vaccination, continue for 7 days on and then 7 days off, throughout the treatment period, until 
progression. Cyclophosphamide dose can be reduced to 50 mg, once a day. If ANC ≤ 1,000/uL or 
Platelet ≤ 100,000/ uL, then the cyclosphosphamide will be held. In order to restart administration of 
cyclophosphamide, the platelet and ANC levels should have resolved to ≤ Grade 1 or to the patient’s 
baseline value. The maximum delay before treatment should be discontinued is 3 weeks. Once the 
cyclophosphamide is restarted, it can be dose reduced to 50mg per day per investigator’s discretion. 
 
Cylophosphamide should be taken with or immediately after meal. Cylophosphamide capsule should 
be swallowed whole, with a large glass of water. It should not be crushed or chewed. Missed or 
vomited doses of cylophosphamide should not be retaken to make up for the lost dose. Patient should 
complete the diary on a daily basis and bring it to the clinic at each visit. Missed or vomited doses 
should be recorded on the diary. 
 
Visits for screening, treatment, safety evaluation and assessment of tumor response will occur as 
outlined in section 10. 
 
5.2 
Agent Administration 
 
The vaccine will be injected deep subcutaneously using the guidelines below, on days 1 and 22 (+/- 
2) days, to allow for holidays or problems with transportation). The patient will be observed for acute 
hypersensitivity reactions on the nursing floor for one hour following the injection. Following the 
first two doses of vaccine, booster doses of vaccine will be administered every 8 weeks (+/-2 days), 
until progression. 
 
All preparations of the reconstituted vaccine will be performed at room temperature on the day of 
immunization. Subjects will receive two 0.50mL or 0.25 mL priming three weeks apart followed by 
0.2 or 0.1 mL boosting doses of DPX-Survivac every eight weeks, in alternating upper thigh regions. 

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Doses are dependent on when the patient enrolled on the trial. An alcohol swab will be used to clean 
the site prior to injection. If a subject experiences pain on the first injection then cooling of the 
injection site with ice packs 15 minutes prior to subsequent immunization is permitted. 
 
It is very important to follow the administration instructions below to avoid exaggerated injection site 
reactions: 
1. Inject the vaccine in the front and/or outer upper half of the thigh region closer to the inguinal 
lymph nodes so the vaccine can be processed by the immune system. 
2. Inject the vaccine deep subcutaneously and NOT intracutaneously. The full length of the 
needle must be inserted and at the correct angle (45-90 degrees) based on the size of the 
subject’s upper thigh region. 
3. Whether or not an injection site reaction is present, vaccine should be administered 
approximately 10 cm to prior injection sites and the location of each injection should be 
recorded in the source documents. 
4. The sponsor may be present on vaccinations days and/or a video may be provided to assist 
with the injection technique. 
5. It is recommended that the same trained study staff inject all subjects at their sites. 
 
If a subject experiences any grade 2 or greater injection site reaction(s) or any grade injection site 
ulceration within 4 weeks prior to a vaccination time point, then that vaccination will be omitted. All 
other study procedures scheduled for that clinic visit will still be conducted. This same evaluation 
will be repeated at each vaccination time point. 
 
Subjects will be re-primed if they are not exhibiting injection site induration, a hallmark of DepoVax 
vaccination, within four weeks of their next boost and/or their immune response is not being 
maintained. 
 
5.3 
General Concomitant Medication and Supportive Care Guidelines 
 
Possible immediate side effects from vaccine injections, including DPX-E7, may include allergic 
reactions such as fever, hives, or rash. For fever >101.5 oF (>39 oC), acetaminophen (650 mg) may 
be given orally. The induction of autoimmunity (manifests as arthritis, serositis, nephritis, thyroiditis, 
colitis, neutropenia, etc.) is theoretically possible. Acute allergic reactions may be treated with 
diphenhydramine, and/or epinephrine as needed. Delayed events such as rash or hives maybe treated 
with diphenhydramine (25-50 mg); topical steroids should not be given without consultation with the 
study’s principle investigator. 
 
To care for possible infected injection site reactions proper wound care is appropriate. Infected areas 
should be kept clean and exposed. Topical antibiotics such as fucidin or polysporin may be applied. 
Cultures should be sent for infections and treated promptly with oral antibiotics. Topical 
corticosteroid (hydrocortisone ointment) may be used to help reduce inflammation. 
 
Possible side effects from Montanide ISA 51 VG are granuloma, abscess, and fever. Acetaminophen 
650 mg every 4 hours may be given for fever after appropriate blood cultures are taken. Referral to 
a surgeon is encouraged for abscess. 
 
Cyclophosphamide (only for patients on former treatment regimen) 

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Low dose metronomic oral cyclophosphamide (50 mg twice per day) will start 7 days before the first 
vaccination, continue for 7 days on and then 7 days off, throughout the treatment period. 
Cyclophosphamide dose can be reduced to 50 mg, once per day. If ANC ≤ 1,000/uL or Platelet ≤ 
100,000/ uL, then the cyclosphosphamide will be held. In order to restart administration of 
cyclophosphamide, the platelet and ANC levels should have resolved to ≤ Grade 1 or to the patient’s 
baseline value. The maximum delay before treatment should be discontinued is 3 weeks. Once the 
cyclophosphamide is restarted, it can be dose reduced to 50mg per day per investigator’s discretion. 
If the cyclophosphamide dose has been reduced, it can’t be re-escalated.. Cyclophosphamide will 
continue until clinical progression occurs. 
 
Possible side effects from low doses cyclophosphamide are grade 1 nausea and/or vomiting, grade 1 
and 2 anemia, neutropenia, leukopenia, and lymphopenia as well as low-grade fatigue. If platelet 
levels decrease below 100,000/L or if absolute neutrophil count decreases below 1000/L in any 
cycle then the dose of cyclophosphamide can be reduced to 50 mg once daily in that subject for the 
duration of their treatment. Following consultation with the PI, a subject’s cyclophosphamide could 
be further modified by extending the interval between cycles of administration or held. 
 
5.4 
Criteria for Taking a Participant off Protocol Therapy 
 
Because swelling and inflammation at the site of tumor may follow vaccination, increased size of 
already existing tumor found on clinical exam up to week 7 will not be considered PD. If, however, 
new sites of disease are found, the subjects will be considered to have PD. If first restaging CT scan 
shows PD and the physician and patient want to continue protocol therapy, progression will be 
confirmed with a second CT scan 4 weeks later. 
 
Continuation of treatment with booster doses of vaccine after clinical progression: 
If there are no other treatment options available, at the discretion of the PI, participants may 
continue receiving treatment with booster doses of vaccine after clinical progression. Treatment 
may continue until RECIST 1.1 defined progression, unacceptable toxicity, or withdrawal of 
consent. 
 
In addition to withdrawal from protocol therapy for PD, subjects should be withdrawn from the 
protocol therapy if, in the opinion of the investigator, it is medically necessary, or if it is the wish of 
the patient. If a patient does not return for a scheduled visit, every effort should be made to contact 
the patient. In any circumstance, every effort should be made to document subject outcome, if 
possible. 
 
Participants should also be removed from protocol therapy if any of the following occurs: 
 
• 
Unacceptable adverse event(s), including a DLT 
• 
Participant demonstrates an inability or unwillingness to comply 
• 
Participant decides to withdraw from the protocol therapy 
• 
General or specific changes in the participant's condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator 
• 
Intercurrent illness that prevents further administration of treatment and/or would affect 
the assessment of the subject’s clinical status to a significant degree 
• 
Pregnancy 

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Participants will be removed from the protocol therapy when any of these criteria apply. The reason 
for removal from protocol therapy, and the date the participant was removed, must be documented in 
the case report form (CRF). Alternative care options will be discussed with the participant. 
 
Information will be entered in OnCore when a participant is removed from protocol therapy. 
 
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the PI, Karthik Sehgal, MD at 617-632-3090. 
 
5.5 
Duration of Follow Up 
 
All patients who begin protocol treatment will be followed until first disease progression and death 
for 2 years from study registration, whichever occurs first. 
 
5.6 
Criteria for Taking a Participant off Study 
 
If progression is documented (except new lesions) on restaging scans patients may remain on study 
and be followed at the discretion of the PI and according to protocol and if no life threatening 
complications from progression in the immediate future are expected (see study calendar). In these 
cases, follow up scans will be obtained 4 weeks later and if progression continues, the patient will be 
considered to have PD. 
 
Because swelling and inflammation at the site of tumor may follow vaccination, increased size of 
already existing tumor found on clinical exam up to week 7, will not be considered PD (i.e. possible 
pseudo-progression). If, however, new sites of disease are found, the subjects will be considered to 
have PD. 
 
Participants will be removed from study when any of the following criteria apply: 
• Lost to follow-up 
• Withdrawal of consent for data submission 
• Death 
 
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the electronic case report form (eCRF). 
 
Information will be entered in OnCore when a participant comes off study. 
 
5.6.1 Treatment Beyond Disease Progression 
 
Accumulating evidence indicates a minority of subjects treated with immunotherapy may derive 
clinical benefit despite initial evidence of progression of disease (PD). 
 
Subjects will be permitted to continue on study treatment for treatment beyond initial RECIST 1.1 
defined PD as long as they meet the following criteria: 
 
• 
Investigator-assessed clinical benefit and no rapid disease progression 

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• 
Tolerance of study drug 
 
• 
Stable performance status 
 
• 
Treatment beyond progression will not delay an imminent intervention to prevent serious 
complications of disease progression (eg, CNS metastases) 
 
• 
Subject provides written informed consent prior to receiving additional study treatment, 
using an ICF describing any reasonably foreseeable risks or discomforts, or other 
alternative treatment options. The decision to continue treatment beyond initial 
investigator-assessed progression should be discussed with the investigator and 
documented in the study records. 
 
If the investigator feels that the subject continues to achieve clinical benefit by continuing 
treatment, the subject should remain on the trial and continue to receive monitoring according to 
the Study Calendar (section 10). 
 
For the subjects who continue study therapy beyond progression, further progression is defined as an 
additional 10% increase in tumor burden from time of initial PD. This includes an increase in the sum 
of diameters of all target lesions and/ or the diameters of new measurable lesions compared to the 
time of initial PD. Study treatment should be discontinued permanently upon documentation of 
further progression. 
 
New lesions are considered measurable at the time of initial progression if the longest diameter is at 
least 10 mm (except for pathological lymph nodes which must have a short axis of at least 15 mm). 
Any new lesion considered non-measurable at the time of initial progression may become measurable 
and therefore included in the tumor burden if the longest diameter increases to at least 10 mm (except 
for pathological lymph nodes which must have a short axis of at least 15 mm). 
 
In situations where the relative increase in total tumor burden by 10% is solely due to inclusion of 
new lesions which become measurable, these new lesions must demonstrate an absolute increase of 
at least 5 mm. 
 
6. ANTICIPATED TOXICITIES 
 
It is anticipated that there will be no significant toxicity associated with vaccination other than redness 
and discomfort at the injection site. Please refer to section 6.1 for an overview of the expected 
toxicities and the current Investigator’s Brochure for details. Subjects will be monitored during the 
injections and in the immediate post-injection period for fevers and other signs of immune activation. 
Any evidence of reactions will be recorded. Reactions will be treated as clinically appropriate. 
 
All toxicities occurring from the time of consent to within 30 days of the last vaccination will be 
recorded in eCRF and assessed for relationship to study therapy. 
 
6.1 
Risks associated with DPX-E7 vaccine 
 
This is the first in human study for the DPX-E7 vaccine so we do not know everything that possibly 

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can happen, and there may be unforeseen risks associated with this study. The following side effects 
were experienced by subjects who participated in three research studies with two similar DPX 
vaccines. 
 
Frequency 
Side Effect 
Frequent 
>10% 
Injections Site Reactions: Hardness; Redness that may persist as a 
discoloration; Swelling; Discomfort; Itchiness; Warmth; Dryness; 
Ulceration*; Rashes 
Occasional 
1-10% 
Temporary bleeding/bruising at the injection site; Discharge at the 
injection site; Skin infection at the injection site; Allergic reactions 
such as fever, hives; Myalgia (achy muscles); Joint pain; Flu-like 
illness 
Rare <1% 
Granuloma (lump of inflamed tissue); Abscess (pockets of pus that 
are likely to turn hard as they scar and heal); Blood clots; 
Autoimmune Disorders (inflammation of the joints, kidneys, thyroid, 
intestines, muscles, heart, pancreas, liver, spleen, lung, brain, eye and 
low blood counts) 
 
* Grade 3 injection site reaction as per NCI CTC v.4.03 is defined as ulceration or necrosis; severe 
tissue damage, operative intervention indicated. As we are increasing the dose, AEs may be more 
frequent. 
Some participants may experience one or more of the above side effects from DPX-E7. Most of the 
side effects do not have the potential of being permanent. It is not yet known how long effects like 
hardness, hyperpigmentation, or scarring from an ulceration may persist. It is possible that an 
injection site reaction may not occur until after treatment or may re-occur after you have stopped 
receiving study treatment. The side effects for DPX-E7 listed as rare are theoretically possible but 
have not been seen in any of the human participants receiving the similar DPX vaccines. 
 
6.2 
Definition of a Dose Limiting Toxicity 
 
Toxicity will be assessed using the NCI Common Toxicity Criteria for Adverse Events, version 
4.03 http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf 
A dose limiting toxicity (DLT) is defined in this study as any grade 3 or greater adverse event at least 
possibly related to the study agent including injection site reactions; or grade 2 or greater allergic 
reactions which occur in a subject prior to day 50 (monitoring for DLT to be continued up to 1 month 
(28 days) after the second priming dose), will trigger a DLT. In addition, to be considered a DLT in 
this study the adverse event must be considered at least possibly related to study treatment. At the 
investigator’s discretion, grade 3 or greater abnormal lab values lasting < 72 hours may be excluded 
as DLTs if there are no accompanying clinical signs or symptoms. 
 
Vaccine dose reduction would occur in the event of 2 DLTs. If a dose reduction is required then the 
new dose level will be 0.2 or 0.1 mL for the priming doses while the boosting doses will remain at 
0.2 or 0.1 mL (depending on treatment regimen). 

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6.3 
Risks Associated with Cyclophosphamide (former treatment regimen) 
 
Frequency 
Side Effect 
Frequent >10- 
100% 
Fatigue 
Occasional 
1-10% 
Decrease in White Blood Cells. 
Rare** 
<1% 
Low Platelet Counts (increases risk of bruising and bleeding); Low 
Red Blood Cell Counts (may cause shortness of breath); Nausea; 
Vomiting; Diarrhea; Stomach pain; Mouth sores; Dehydration; 
Diminished fertility 
 
**The side effects for cyclophosphamide listed as rare were not observed in the previous studies with 
a similar DPX vaccine but were very common in studies conducted by other investigators researching 
different dosing schedules of cyclophosphamide and various cancers. 
 
7. ADVERSE EVENTS LIST AND REPORTING REQUIREMENTS 
 
7.1 
Definition of an Adverse Event 
 
The following definition of an AE will be used for this study: 
 
Any untoward medical occurrence in an enrolled subject who was administered the clinical trial 
material; the occurrence does not have to have a causal relationship with treatment to be considered 
an AE. 
 
An AE can be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease (new or exacerbated) temporally associated with the use of the investigational 
product, whether or not it is considered to be related to the investigational product. 
 
AEs may include pre- or post-treatment events that occur as a result of protocol mandated procedures 
(i.e. invasive procedures, modification of the subject’s previous therapeutic regimen). 
 
7.2 
Reporting Period 
 
The AE reporting period for this study begins at the time the patient signs consent and ends at 30 
days after the last dose of vaccine. 
 
In addition, any known untoward event that occurs subsequent to the AE reporting period that the 
investigator assesses as possibly related to the investigational product should also be reported to the 
study sponsor. 

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All AEs will be followed until: resolution, the condition stabilizes, the event is otherwise explained, 
or the subject is lost to follow-up. However, once the subject is on new treatment no pre-existing 
AEs should be followed and no new AEs reported. 
 
7.3 
Definition of a Serious Adverse Event 
 
The definition of a SAE is an AE that meets any of the following criteria: 
 
• 
Results in death 
• 
Is life-threatening 
• 
Requires hospitalization or a prolongation of an existing hospitalization (for reason(s) 
other than scheduled tumor biopsy) 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly or birth defect 
• 
Other important medical event that may jeopardize the subject or may require medical 
intervention to prevent one of the outcomes listed above. 
Any events or hospitalizations that are unequivocally due to progression of disease will not be 
reported as an SAE. In many cases only the symptoms of the disease progression will be listed as 
AEs. 
 
A SAE requires additional detailed reports and follow-up. The content of these detailed reports must 
address the PI’s estimate of causality. The PI will review the SAE to determine expectedness 
(whether or not the AE is identified in nature, severity, and frequency in the IB). 
 
7.4 
Recording AEs and SAEs 
 
It is the responsibility of the investigator to perform periodic and special assessments for AEs. The 
investigator and clinical staff will note all AEs described by the subject from the time of ICF signature 
through to 30 days after the last dose of the vaccine. Each subject will be questioned about AEs at 
each clinic visit. The question asked will be: “Since your last clinic visit or since you began taking 
the investigational medication, have you had any health problems?” All clinical complaints 
volunteered by or elicited from the subject during the study will be recorded on the appropriate forms 
of the eCRF for the study period indicated. 
 
When an AE or SAE occurs, it is the responsibility of the investigator to review all documentation 
(e.g. hospital progress notes, laboratory, and diagnostic reports) relative to the event(s). The PI is to 
record all relevant information regarding any AE (including SAEs) on the AE form of the eCRF and 
for SAEs, must also enter on an SAE Report Form. 
 
The PI will also attempt to establish a diagnosis of the event based on the signs, symptoms, or other 
clinical information. In such cases, the diagnosis, not the individual signs and symptoms, should be 
documented on the appropriate eCRF as the AE or SAE. 

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7.5 
Assessment of Intensity 
 
The investigator will make an assessment of intensity for each AE and SAE reported during the study. 
The intensity will be graded according to the criteria in the NCI CTCAE version 4.03. 
 
7.6 
Assessment of Causality 
 
The investigator is obligated to estimate the relationship between the investigational product and the 
occurrence of each AE or SAE using their best clinical judgment. Other causes, such as the history 
of the underlying disease, concomitant therapy, other risk factors, and the temporal relationship of 
the event to the investigational product will be considered and investigated. The PI will also consult 
the IB, or product labeling information for marketed products, in the determination of the assessment. 
 
There may be situations when a SAE has occurred and the PI has minimal information to include in 
the initial report. However, it is very important that the PI always makes an assessment of causality 
for every event prior to the transmission of the SAE Report Form. The PI may change his opinion of 
the causality in light of follow-up information, amending the SAE report. The causality assessment 
is one of the criteria used to determine regulatory reporting requirements and should not be left blank. 
 
Table 1: Assessment of Causality/Relatedness of AEs 
 
Relatedness 
Definition 
Definitely 
related 
The adverse event is clearly related to the investigational agent(s) or research 
intervention: the adverse event has a temporal relationship to the administration 
of the investigational agent(s) or research intervention, follows a known pattern 
of response, and no alternative cause is present. 
Probably 
related 
The adverse event is likely related to the investigational agent(s) or intervention: 
the adverse event has a temporal relationship to the administration of the 
investigational agent(s) or research intervention, follows a known or suspected 
pattern of response, but an alternative cause may be present. 
Possibly 
related 
The adverse event may be related to the investigational agent(s) or intervention: 
the adverse event has a temporal relationship to the administration of the 
investigational agent(s) or research intervention, follows a suspected pattern of 
response, but an alternative cause is present. 
Unlikely to be 
related 
The adverse event is doubtfully related to the investigational agent(s) or 
intervention: the adverse event has a temporal relationship to the administration 
of the investigational agent(s) or research intervention, but follows no known or 
suspected pattern of response, and an alternative cause is present. 
Unrelated 
(or not 
related) 
The adverse event is clearly NOT related to the investigational agent(s) or 
intervention: the adverse event has no temporal relationship to the administration 
of the investigational agent(s) or research intervention, follows no known or 
suspected pattern of response, and an alternative cause is present. 
 
7.7 
Expectedness of AEs 
 
An expected AE is one that is consistent with the known risk information described in current IB. 

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An unexpected AE is defined as any AE where the specificity or severity of which is not consistent 
with the known risk information described in current IB. 
 
Expectedness will be determined by the PI. 
 
7.8 
Reporting of SAEs 
 
It is the responsibility of each participating investigator to report adverse events within 48 hours to 
the PI, Kartik Sehgal, MD, or representative personnel; and submitted to DFCI IRB within 10 
working days. All events should be communicated with the Head and Neck Oncology prior to 
submission. 
 
The DFCI IRB requires the following Adverse Events (AE) be reported for all subjects enrolled 
and actively participating in the trial or when the AE occurs within 30 days of the last study 
intervention (e.g. drug administration): 
 
• Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are Unexpected and 
Possibly, Probably or Definitely Related / Associated with the Intervention. 
 
• ALL Grade 4 (life threatening or disabling) Events – Unless expected AND specifically 
listed in protocol as not requiring reporting. 
• ALL Grade 5 (fatal) Events 
Notes: 
• If subject is in Long Term Follow Up, death is reported at continuing review. 
• See protocol for additional reporting requirements (to sponsor, FDA, etc.). 
• Grade 2 and Grade 3 laboratory abnormalities that are considered by the investigator to be 
clinically insignificant and do not require therapy, or adjustment in prior therapy, do not 
need to be reported to the DFCI IRB. 
 
In the event that the participating investigator does not become aware of the serious adverse event 
immediately (e.g., participant sought treatment elsewhere), the participating investigator is to report 
the event within 24 hours after learning of it and document the time of his or her first awareness of 
the adverse event. 
 
The PI, as study sponsor, will be responsible for all communications with the FDA. Unexpected, fatal 
or life-threatening experiences, associated with the use of the investigational vaccine, will be reported 
to FDA according to FDA reporting requirements. The Head and Neck Oncology Group will forward 
all adverse events meeting the requirements listed below to the appropriate staff members in the DFCI 
CTO High Risk IND Program within 2 working days from notification for evaluation and submission 
to the FDA. 
 
• Toxicity 
o Grade ≥ 3 non-hematologic and hematologic and all Grade 5 events 
• Known Correlation 
o Any (Expected or Unexpected) 

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• Attribution to Investigational Vaccine 
o Any 
 
All events must be emailed using a Medwatch 3500A form. Medwatch 3500A downloadable form 
at http://www.fda.gov/medwatch/getforms.htm 
 
MedWatch forms should be mailed to the FDA by the appropriate staff members in the DFCI CTO 
High Risk IND Program at the address below: 
 
 
 
 
 
 
 
 
7.9 
Reporting to Immunovaccine 
 
On behalf of the Sponsor, the appropriate staff members in the DFCI CTO High Risk IND Program 
will notify IMV of the occurrence of any significant safety finding observed during the course of 
the study, including, without limitation: 
(a) Any Adverse Event (as defined above) that warrants expedited (7 or 15-day) reporting to the 
FDA; 
(b) Any significant, safety-related finding, concern, or observation identified by either the PI or the 
governing IRB during the course of the study; 
(c) Any patient who experiences an outcome of death, regardless of perceived relatedness to a IMV 
product; or 
(d) Any FDA-initiated safety related inquiry directed to study personnel. 
 
Table 2: Timeline for Expedited Reporting SAEs to FDA and Immunovaccine Inc. 
 
Initial SAE Report 
Follow-up SAE Report 
Time Frame 
Documents 
Time Frame 
Documents 
7 days 
SAE Report Form 
15 days 
Updated 
SAE 
Report 
Form 
 
7.10 
Follow-up of SAEs 
 
After the initial SAE report, the investigator is required to follow the subject and provide further 
information in regards to the subject’s condition. All SAE(s) will be followed until: 
 
• 
Resolution 
• 
The condition stabilizes 
• 
The event is otherwise explained 
• 
The subject is lost to follow-up 

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Once the event is resolved, the SAE Report Form and the eCRF will be updated. The PI will also 
ensure that the follow-up includes any supplemental information, excluding source documents, that 
may explain the causality of the event(s). 
 
New or updated information will be recorded on the originally completed SAE Report Form, with all 
changes signed and dated by the investigator or designee. The updated SAE Report Form will then 
be signed by the PI and resubmitted. 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agent administered 
in this study can be found in Section 6. 
 
8.1 
DPX-E7 vaccine 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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8.1.2 Form 
 
The antigen/adjuvant/lipid mixture is formulated in a phosphate buffer, filled into vials and 
lyophilized to a dry cake. In the clinic, the cake is re-suspended in the hydrophobic carrier Montanide 
ISA51 VG before injection. 
 
8.1.3 Packaging, Labeling, Storage, and Handling of Study Products 
 
A bulk supply of DPX-E7 Vial 1 will be provided in a box to be stored at -20°C in the pharmacy 
with a 24 hour temperature monitoring and alarm system. A temperature log will be maintained by 
the pharmacy to ensure the product is correctly stored. Vial 2 (oil diluent) and the ancillary 
components will be provided in bags to be stored at ambient temperature in a secure and 24 hour 
temperature monitored room. 
 
The DPX-E7 labels will comply with FDA requirements for investigational products. Detailed 
reconstitution instructions will be provided by Immunovaccine in a Pharmacy Manual. Training of 
the site pharmacists will also be provided by Immunovaccine if required. 

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8.1.4 Availability 
 
DPX-E7 vaccine will be manufactured and supplied by: 
 
Immunovaccine Inc. 
 
 
 
 
 
 
8.1.5 Preparation 
 
The proposed vaccine components will be supplied by the Immunovaccine(R) in two vials. Vial 1 will 
contain the freeze dried adjuvant system and antigen. Vial 2 will contain the oil component 
(Montanide ISA51 VG) alone which will be used as a diluent. The reconstituted vaccine will be 
prepared at the pharmacy by re-suspending the contents fo Vial 1 using the oil diluent of Vial 2. 
Detailed reconstitution instructions will be provided by Immunovaccine Inc. The final vaccine will 
be a transluscent oily solution (not an emulsion) that is syringable and easy to inject. The appropriate 
volume of the reconstituted vaccine will be injected subcutaneously following the instructions 
provided in “Reconstitution Instructions” (embedded below and also posted on Oncpro). 
 
DPX-E7 Reconstitution 
Instructions - v1.0 (17 
 
It is important to note the following instructions: 
 
Once the vaccine is reconstituted, the time until administration should NOT exceed 4 hours. If time 
has exceeded 4 hours then the vaccine should NOT be used. 
 
Once the pharmacy has drawn the vaccine into the provided Medallion syringe, the time until 
administration should not exceed 60 minutes. 
 
8.1.6 Administration 
 
All subjects will be treated in an outpatient unit equipped with emergency equipment. Subjects will 
be monitored with blood pressure, pulse, and temperature assessments at pre-injection, and at 
approximately (i.e. within 5 minutes) 15 minutes after injection. The patient will be observed for 
acute hypersensitivity reactions on the nursing floor for one hour following the injection. 
Diphendydramine, solumedrol , and epinephrine must be available and used per institutional policy 
at the bedside. The clinic must have a code cart available for emergency use. If hypotension (systolic 
blood pressure (SBP) <90 mmHg for subjects with a baseline SBP >110 mmHg or >20 mmHg 
decrease for those with a baseline SBP <110 mmHg), urticaria, orofacial or laryngeal edema, or 
bronchospasm occur, an intravenous catheter will be placed and the diphendydramine and solumedrol 
will be administered.  The physician in charge will be notified and the epinephrine will be 

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administered for reactions that do not begin to resolve within 10 minutes or continue to become more 
severe. In this event, subject will be transported immediately to the emergency room if stabilized, or 
the code team will be contacted if subject continues to have progression of symptoms or worsening 
hypotension. 
 
The vaccine will be injected deep subcutaneously, using the guidelines provided in section 5.2, on 
days 1 and 22 (+/-2) to allow for holidays or problems with transportation). The patient will be 
observed for acute hypersensitivity reactions on the nursing floor for one hour following the injection. 
Following the first two doses of vaccine, booster doses of vaccine will be administered every 8 weeks 
(+/-2 days), until progression. For patients continuing the former treatment regimen, every effort 
should be made to ensure a full 7 days of cyclophosphamide is administered before the first vaccine 
is delivered. 
 
8.1.7 Ordering 
 
Immunovaccine Inc. will supply DPX-E7 vaccine to DFCI research pharmacy in two shipments, one 
at the beginning of the trial and the second one almost half way during the trial. 
 
8.1.8 Accountability 
 
Accountability for DPX-E7 vaccine at the study site is the responsibility of the sponsor-investigator. 
Study vaccine will be dispensed only to eligible patients by Dana-Farber Research Pharmacy. The 
appropriate study personnel will maintain records of study vaccine receipt and dispensing at Dana- 
Farber Research Pharmacy. A careful record of the inventory and disposition of the vaccine will be 
maintained, using the appropriate accountability log, per institutional policy. 
 
8.1.9 Destruction and Return 
 
Unused supplies and any expired supplies of the vaccine will be destroyed on site, by the Dana-Farber 
Research Pharmacy. 
 
8.2 
Cyclophosphamide 
Commercial supply of cyclophosphamide will be ordered by the Dana-Farber Research Pharmacy. 
Cyclophosphamide will be administered per protocol. It will be stored according to the instructions 
in the package insert. Accountability and destruction will be per institutional policy. 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
Correlative studies will be performed in the DFCI flow cytometry core. Before any material is 
transferred from the clinic to the lab, the sample will be de-identified and a booklet with the key to 
the numeric code will be kept in a secure location in the Clinical Research Office. 
 
9.1 
Primary Immunological Endpoints 
In ONC-DPX-Survivac-01 and -03 studies, which used a similar vaccine and treatment plan, research 
subject’s flow cytometry results were considered positive if the measurement is greater than the 
standard level of sensitivity (approximately > 0.05% positive cells) and the post treatment value is at 
least two times greater than the pre-treatment value. 

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Blood 
1. Induction of HPV16-E711-19 (pMHC) specific T cells as revealed by ELISpot IFN-γ at least 
2 fold over background (pre-immunization) 
2. Induction of HPV16-E711-19 specific T cells as revealed by HPV16-E711-19 dextramer or 
tetramer analysis 
3. Functional T cell avidity as determined by peptide titration to determine the sensitivity of 
vaccine-engendered T cells with respect to pMHC recognition. pMHC copy number on APCs 
required for activation of cytokine production shall be determined by MS when possible 
4. Determine the nature of immune subsets as defined in the sample panel below 
 
 
Blood Sample Panel 
Peripheral blood mononuclear cells (PBMC) will be isolated from vaccine recipient’s blood samples 
at the indicated time points. Samples will be banked for further biological testing of functional 
correlatives of immune responses to the vaccine. 
 
Blood samples will be collected at screening, Day 1, 22 and 78 and stained with multi-color antibody 
panels to test T, B, NK and antigen specific T cell immune responses to the vaccine. These optimized 
antibody panels will be analyzed by flow cytometer. 
 
Whole blood samples will also be collected at screening and Day 22. DNA analysis on the samples 
will be correlated with tumor DNA content and oncologic response. 
 
Tumor biopsy 
Patients will undergo mandatory tumor biopsies to obtain fresh tumor tissue prior and also post 
vaccination, at 13 (+/-1) weeks after the first injection. Part of the material will be used to confirm 
the presence of the HPV-16 E711-19 peptide prior to vaccination and post-vaccination. To this end, 
Poisson MS detection will be used as described previously42. 
 
The remaining portion of the tumor biopsies will be used for immune monitoring at the Specialized 
Histopathology core at the Brigham and Women’s hospital and Johns Hopkins University will include 
analysis of inflammatory infiltrate. 
 
The pre-treatment tissue will be used to observe the tumor microenvironment and T cell repertoire 
prior to therapy. 
 
The material will be used for IHC and other correlative study methods according to the table below 
as previously described43 and as sample size permits. 
 
Table 4: Analysis of patient biopsy samples 
 
Specimen Type 
Method 
Analyses 
Formalin-fixed paraffin 
embedded tissue (FFPE) 
Quantitative immuno- 
histochemistry (IHC) 
Determine resident cell subsets and 
colocalization in epithelial and stromal 
cell compartments 
Flash-frozen tissue 
IMMUNO-LCM 
mRNA transcriptomes, RNAseq, TCR 
sequencing 

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Primary tissue explant 
Expand and isolate T 
cells 
Multiple functional analyses 

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10. STUDY CALENDAR 
 
Procedures 
Screening¹ 
Day 
1 
Day 
22 
Day 
29 
Day 
50 
Day 
78 
Day 
91 
Day 
106 
Day 
134 
Day 
162 
Day 
190 
Day 
218 
Day 
246 
Day 
270 
Day 
302 
Day 
358 
and 
beyond7 
End of 
treatment9 
Informed consent 
X 
Demographics 
X 
Medical history 
X 
Height 
X 
Weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
ECOG PS 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concurrent meds 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance status 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC w/diff, plts 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
-hCG (WOCBP) 2 
X 
Serum chemistry 
must include 
alkaline phospatase, 
AST, ALT, bilirubin 
and creatine 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Immune Bloods3 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
DNA Bloods 
X 
X 
X 
Tumor assessment 
by CT, PET/CT, 
MRI of neck, chest, 
abdomen/pelvis4 
X* 
X 
X 
X 
X 
X 
X 
X 
Tumor biopsy for 
MS analysis and 
immunohistology5 
X 
X 
Adverse event 
evaluation6 
X 
X 
X10 
X 
X 
X10 
X 
X10 
X 
X10 
X 
X10 
X 
X 
X 
DPX-E7 
Vaccination7 
X 
X 
X 
X 
X 
X 
X 
X 
Cyclophosphamide8 
X 
 
1. HLA-A*02 positivity should be confirmed prior to screening. Screening assessments should 
be done within 3 weeks prior to study registration. 

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2. Must be obtained in women of childbearing potential during screening 
3. Unless otherwise specified, approximately 60ml of whole blood will be obtained for immune 
phenotyping, ELISpot assays, Cytokine flow cytometry and banking. Plasma will be saved 
for luminex analysis. Blood for immune responses in addition to the induration will also be 
collected. 
4. There is a +/- 1 week window for scans. *within 6 weeks of study registration. The first 
restaging scan will be on Day 78, 8 weeks post second vaccine. If first restaging CT scan 
shows PD, progression will be confirmed with a second CT scan 4 weeks later. All scans are 
every 8 weeks, unless medically indicated otherwise. Details in Table 6 
5. Tumor biopsy will be obtained prior to the vaccination and at 13 (+/-1) weeks post vaccination 
6. Patients will be followed throughout the study for the side effect of vaccine such as injection 
site reactions and fever 
7. After priming doses on Day 1 and 22, booster doses will start on Day 78 and continue every 
56 days, until progression. There is a +/- 2 days window for vaccine administration. Also 
section 5.6.1 for Treatment beyond Progression. 
8. Applies to patients already on the cyclophosphamide treatment regimen. Cyclophosphamide 
will start 7 days before the first vaccination, continue for 7 days on and then 7 days off, 
throughout the treatment period. *The first dose of cyclophosphamide should only be 
dispensed after screening is complete and subject is enrolled in study. 
9. Post end of protocol treatment, tumor assessments are to continue every 3 months until first 
progression, death, or 24 months from study registration, whichever occurs first. After first 
progression, participants will be followed by phone only, every 3 months (+/- 2 weeks) for 24 
months from study registration or until death whichever occurs first. 
10. Research Nurse will complete an over-the-phone AE assessment. 
 
Table 5: Details of Study assessments 
 
After the pre-screening consent, one blood sample will be collected for HLA typing. Subjects who 
are positive for HLA-A*02 will be consented for the main study and undergo screening, as shown in 
table below. 
 
Pre-Screening and Screening 
Timing prior to 
registration 
Informed consents To be obtained at pre-screening and screening 
Within 21 days 
Medical history 
and physical 
examination (PE) 
Including weight, height, ECOG PS, vital signs 
(heart rate/blood pressure/temperature) 
Within 21 days 
Hematology 
Complete blood count and differential (CBCD) Within 21 days 
Serum chemistries 
and other baseline 
bloods 
Must include alkaline phosphatase, AST, ALT, 
bilirubin, creatinine, -hCG for WOCBP. 
Within 21 days 
Infectious Diseases 
Markers 
Hepatitis B and C, HIV 
Within 21 days 

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Peripheral Blood 
for correlative 
science 
60 ml should be drawn for full HLA typing 
using RNA prep for 454 sequencing and 30ml 
standard phenotyping material for frozen 
PBMC. 
Prior to vaccination day 
1 
Safety and Tumor 
assessment 
Physical examination 
Within 21 days 
CT scan and/or MRI of the tumora 
Within 6 weeks 
Chest CT scan b 
Within 6 weeks 
PET or PET/CT scan b, if clinically indicated 
Within 6 weeks 
Abdominal/pelvic CT scan or MRI in case of 
serum liver abnormalities or known 
abdominal/pelvic metastasis 
Within 6 weeks 
Bone scan, if clinically indicated 
Within 6 weeks 
Tumor block 
Tumor block for correlative studies will be 
requested after informed consent is signed. 
No time restriction 
applies 
Mandatory Tumor 
biopsyc 
Fresh tumor tissue biopsy in all patients 
Prior to first injection 
a To ensure comparability, initial and subsequent radiographic imaging to assess response 
should be performed using identical techniques. However for the purposes of screening local 
scans can be used 
b Chest CT is not required if subject’s baseline testing includes a PET/CT that covers the chest 
and does NOT show intrathoracic metastasis. 
c All patients 
 
Table 6: Details of Study treatment and follow up 
 
Table below outlines the required evaluations during the vaccine administrations and follow up. 
Required Data During and After Vaccination 
Timing 
Medical history and 
PE 
Including weight, height, ECOG PS, vital 
signs 
On days 1, 22 & 78, then 
every 56 days until 
progression 
Hematology 
CBCD 
Same as above 
Serum chemistries 
Must include alkaline phosphatase, AST, ALT, 
bilirubin, and creatinine. 
Same as above 
Peripheral blood for 
correlative science 
60 mL for immune monitoring and blood 
banking at days 1, 22, 29, 78, 134, 190, 246, 
270, and 358. 
Days 1, 22, 29, 78, 134, 
190, 246, 270, and 358. 
Whole blood for 
correlative science 
10 mL for DNA analysis at screening, day 1, 
and day 22 
Screening, Day 1, and22 
Response assessment Restaging CT scan and/or MRI of the neck,b if 
clinically indicated 
8 wks post second 
injectionc, then every 2 
months until progressione 
Restaging chest CT scand 
Same as above 
Restaging PET or PET/CT scan, if clinically 
indicated 
Same as above 

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Restaging abdominal/pelvic CT scan or MRI 
in case of KNOWN abdominal/pelvic 
metastasis b 
Same as above 
Mandatory tumor 
biopsy 
Fresh tumor tissue biopsy 
~13 wks post first 
injection AFTER first 
restaging scans 
b To ensure comparability, baseline and subsequent radiographic imaging to assess response should 
be performed using identical techniques. Every effort will be made to follow each lesion with 
the same technique from baseline through follow-up. 
c First restaging scan will be done at 8 (+/-1) weeks post second injection. If first restaging CT scan 
shows PD, progression will be confirmed with a second CT scan 4 weeks later. 
d Chest CT is not required if subject’s baseline testing includes a PET/CT or CT scan that covers 
the chest and does NOT show intrathoracic metastasis. 
e Patients may remain on study if progression on scans is not likely to cause life threatening 
complications to allow for pseudoprogresson. In these cases, follow up scans will be obtained 4 
weeks later and if progression continues, the patient will be considered to have PD. 
 
10.1 
Contraindicated Medications 
 
Subjects should be taken off trial if they initate any chemotherapeutic agents, systemic corticosteroids 
or other immunosuppressives, or other immunotherapy while enrolled on study. Medications that 
result in immunosuppression should also be avoided while on study unless medically necessary due 
to unforeseen circumstances. Examples include systemically absorbed corticosteroids, NSAIDs and 
aspirin. No adjuvanted vaccine or live attenuated vaccine (such as Flumist) should be given while on 
this study. Non-adjuvanted vaccines (such as most influenza vaccines) can be given. For subjects 
receiving the flu vaccine, Immunovaccine strongly recommends the shot be given at least one week 
before immunological assessments. 
 
11. MEASUREMENT OF EFFECT 
 
Measurable disease will be defined, according to modified RECIST 1.1 as the presence of at least one 
measurable or evaluable lesion and according to irRECIST (Appendix B & C). If the measurable 
disease is restricted to a solitary lesion, its neoplastic nature should be confirmed by 
cytology/histology, if clinically feasible. 
 
Measurable lesions will be defined as lesions that can be accurately measured in at least one 
dimension with the longest diameter 2.0 cm by conventional techniques. With a spiral CT scan, the 
lesion must be 1.0 cm in at least one dimension. If no other measurable lesions can be found outside 
of a previously irradiated field, (i.e. as may be seen with locoregional recurrence), and the lesion in 
the irradiated area meets all other conditions for being measurable, and the lesion is new or has 
increased in size by at least 20% in longest diameter, taking as reference the smallest longest diameter 
since radiation, and the previous radiation was completed at least 6 months prior to registration, it 
can be chosen. Non-measurable lesions include all other lesions, such as small lesions (longest 
diameter <2.0 cm with conventional techniques or <1.0 cm with spiral CT scans) bone lesions without 
significant extraosseous component, leptomeningeal disease, ascites, pleural/pericardial effusion, 
abdominal masses that are not confirmed and followed by imaging techniques, and cystic lesions. 

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Clinical lesions will only be considered measurable when they are superficial (e.g., skin nodules, 
palpable lymph nodes). For the case of skin lesions, documentation by color photography including 
a ruler to estimate the size of the lesions is recommended. 
 
As outlined above, all subjects will be evaluated for response to vaccination by clinical examination, 
and CT scans of the known disease. CT scans (and/or MRI, if applicable) of the neck, chest or pelvis 
will be used to follow local recurrence or intrathoracic metastasis. Subjects with known abdominal 
or pelvic metastasis will also have ct scans (or MRI, if applicable). Radiographic response is 
determined as per modified RECIST 1.1 and irRECIST at 12 weeks. A confirmatory scan may be 
performed for subjects with response no earlier than 4 weeks from the documented response. 
Restaging studies will continue, as noted above. If progression is documented (except new lesions) 
on scans at 12 weeks, patients may remain on study at the discretion of the PI and if there is no life 
threatening complications from progression in the immediate future are expected. In these cases, 
follow up scans will be obtained 4 weeks later and if progression continues, the patient will be 
considered to have PD. 
 
Scans will be evaluated for best overall response to vaccine therapy. 
 
Because swelling and inflammation at the site of tumor may follow vaccination, increased size of 
already existing tumor found on clinical exam up to week 7, will not be considered PD. If, however, 
new sites of disease are found, the subjects will be considered to have PD. 
 
11.1 
Baseline Documentation of Target Lesions and Response Criteria 
 
All measurable lesions, up to a maximum of 10 lesions representative of all involved organs, will be 
identified as target lesions, recorded and measured at baseline, according to RECIST 1.1 and 
irRECIST. The sum of the longest diameter (LD) for all target lesions will be calculated and reported 
as the baseline sum LD. The baseline sum LD will be used as reference to further characterize the 
objective tumor response for determination of ORR. Evaluation of target and non-target lesions will 
be performed and response determined according to RECIST 1.1 and irRECIST (Appendix B & C). 
 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
The QACT will collect, manage, and perform quality checks on the data for this study. Adverse event 
lists, guidelines, and instructions for AE reporting can be found in Sections 6 and 7. 
 
12.1 
Data Safety Monitoring 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor toxicity and 
accrual data from this study. The committee is composed of clinical specialists with experience in 
oncology and who have no direct relationship with the study. Information that raises any questions 
about participant safety will be addressed with the PI and study team. 
 
The DSMC will review each protocol at least once or up to four times a year or more often if required 
to review toxicity and accrual data. Information to be provided to the committee may include: up-to- 
date participant accrual; current dose level information; all grade 2 or higher unexpected adverse 
events that have been reported; summary of all deaths occurring with 30 days of intervention; audit 

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results; and a summary will be provided by the study team. Other information (e.g. scans, laboratory 
values) will be provided upon request. 
 
13. STATISTICAL CONSIDERATIONS 
 
Following approval of Amendment 10, the below stopping rule will also be followed for the first 6 
patients who sign the main consent and begin protocol treatment at the new dose (of note, there 
have been no DLTs observed among the first 6 patients who have been treated at the dose originally 
outlined in the protocol). 
 
As this is the first study testing the DPX-E7 vaccine in humans, the following monitoring will be 
used: If zero or one DLT (see section 6.2 for definition) is observed through the first month after 
the second priming dose in the first six subjects who begin protocol treatment, then study 
enrollment into the first stage (n=16) will continue. If there are two DLT’s observed through the 
first month after the second priming dose in the first six subjects, the dose of DPX-E7 vaccine will 
be de-escalated. If there are 3 or more DLTs observed through the first month after the second 
priming dose in the first 6 subjects, accrual will be suspended to further evaluate the events and 
decisions made regarding the overall status of the trial. If dose de-escalation is required, six new 
subjects will be enrolled and treated with DPX-E7 vaccine at the lower dose. If zero or one DLT is 
observed through the first month after the second priming dose in these six subjects, then study 
enrollment into the first stage (n=16) will continue. If there are two or more DLTs OR one death 
OR two grade 4 events observed through the first month after the second priming dose in these six 
subjects, then accrual will be suspended to further evaluate the events and decisions made regarding 
the overall status of the trial. Only those patients treated at the acceptable dose will be included in 
the phase II portion of the trial. Adverse events will be continuously monitored throughout the trial 
by the study team and appropriate committees with decisions made accordingly re: the study status 
and patient entry throughout the duration of the trial. 
 
As overall monthly accrual is estimated to be 6 pre-consented for HLA and HPV testing, with 33% 
of those HLA-A*02 positive, the above monitoring will be ongoing and not require accrual to be 
suspended for adverse event evaluation after the first 6 patients who begin protocol treatment, 
however, these estimates will be monitored and accrual will be suspended as needed. 
 
One of the primary objectives of this trial is to evaluate changes in CD8+ T cells in the peripheral 
blood and tumor tissue in patients positive for HLA-A*02 with advanced incurable HPVOC, cervical 
, or anal cancer. ‘Responders’ will be defined as patients with at least a two-fold increase in number 
of CD8+ T cells (dextramer, ELISpot or both methods) in the peripheral blood and tissue at the final 
analysis. In ONC-DPX-Survivac-01 and -03 studies, which used a similar vaccine and treatment plan, 
research subject’s flow cytometry results were considered positive if the measurement is greater than 
the standard level of sensitivity (approximately > 0.05% positive cells) and the post treatment value 
is at least two times greater than the pre-treatment value). 
 
A two-stage design will be used to minimize the number of patients exposed to this regimen. There 
are no preliminary efficacy data for this vaccine. The null hypothesis is that the ‘response rate’ 
(percentage of patients with at least a two-fold increase in number of CD8+ T cells in the peripheral 
blood and tissue at the final analysis) is not clinically meaningful (<10%). The alternative hypothesis 
is that the response rate is clinically meaningful (>10%). 

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Original Statistical Design: Efficacy 
 
A two-stage design (Simon Minimax) was used where if ≥7 patients’ disease was in ‘response’ 
among 40 evaluable (eligible and began protocol treatment) patients (assuming that disease in ≥3 
patients ‘responded’ among 27 evaluable patients accrued in the first stage), further testing of this 
regimen was to be considered. The probability of concluding the regimen as effective was 90% if 
the true ‘response rate’ was 25%. The probability of concluding the regimen as effective was 10% if 
the true ‘response rate’ was 10%. 
 
Revised Statistical Design: Efficacy (Amendment 10) 
 
During review of Amendment 10, the statistical design for efficacy has been changed per request of 
SRC in order to revise the stopping rule to prevent larger numbers of subjects being enrolled on a 
futile trial. Operating characteristics used in the following design also take into account the poor 
prognosis of these patients. 
 
Note that given the observed lack of activity in patients who began protocol treatment prior to 
approval of Amendment 10, accrual mentioned below refers to patients who sign the main consent 
and begin protocol treatment at the new dose outlined in Amendment 10. 
 
A two-stage design (Simon Optimal) is used. In the first stage, accrual will continue until 16 
evaluable patients (eligible and begin protocol treatment) are entered. If there is ≤1 patient with a 
two-fold increase in number of CD8+ T cells, the trial and data will be evaluated and accrual may 
close with the conclusion that there is little evidence that the ‘response rate’ would reach 25%. The 
probability that the trial will close early is 51% if the true proportion with a two-fold increase in 
number of CD8+ T cells is 10%. 
 
If there are ≥2 patients among 16 evaluable patients with a two-fold increase in number of CD8+ T 
cells, the trial will continue to accrue patients until a total of 33 evaluable patients are entered. If 
there are ≥6 patients with a two-fold increase in number of CD8+ T cells among 33 evaluable 
patients, further testing of this vaccine will be considered. The probability of concluding the 
vaccine is effective is 84% if the true proportion with a two-fold increase in CD8+ T cells is 25%. 
The probability of concluding the regimen is effective is 10% if the true proportion with a two-fold 
increase in number of CD8+ T cells 10%. 
Considering that patients continue to be screened and at least n=7 patients have been entered and 
began protocol treatment at the original dose prior to approval of Amendment 10, and allowing for 
1 or 2 patients to sign the main consent and to be registered to the main protocol but not begin 
protocol treatment or be ineligible, the overall accrual goal following approval of Amendment 10 is 
up to n=44. Since the prevalence of the HLA-A*02 phenotype in the population is approximately 
33%, we assume that we will screen at least 100 patients to be able to treat and follow n=33 
evaluable HLAA* 02 positive patients following approval of Amendment 10. We anticipate that 
among the n=33, that approximately n=20 patients will have HPVOC, n=10 will have cervical 
cancer and n=3 patients will have anal cancer in the treatment cohort. 
 
The primary efficacy population includes all eligible patients who begin protocol treatment at the 
new dose outlined in Amendment 10. Outcome data for the first group of patients who began 
protocol treatment prior to approval of Amendment 10 will be summarized in a secondary analysis. 
Response will be summarized as a proportion with a corresponding exact confidence interval. 

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Safety will be assessed via the CTCAE and frequencies of adverse events will be summarized and 
will include all patients who begin protocol treatment (those starting protocol treatment before and 
after approval of Amendment 10). Time to event endpoints will be estimated using the Kaplan- 
Meier method and 95% confidence intervals for the median or time-specific event time will be 
summarized. 
 
With a monthly accrual rate of approximately 6 patients with advanced incurable HPVOC, cervical, 
or anal cancer patients who pre-consent for HLA and HPV testing, accrual to 100 patients for 
screening following approval of Amendment 10 is estimated to last at least 17 months. The 
requirement for mandatory fresh tumor tissue biopsies in all treated patients could also impact the 
accrual rate and time to complete accrual. As is customary with this type of design, accrual will be 
suspended after the first stage (n=16 evaluable patients) in order to assess outcome, however, this 
suspension is also dependent on the actual observed accrual rate and the number of patients with a 
two-fold increase in CD8+ T cells while the first stage of the trial is accruing. 
 
14. PUBLICATION PLAN 
 
The results should be made public within 24 months of reaching the end of the study. The end of the 
study is the time point at which the last data items are to be reported, or after the outcome data are 
sufficiently mature for analysis, as defined in the section 9. If a report is planned to be published in a 
peer-reviewed journal, then that initial release may be an abstract that meets the requirements of the 
International Committee of Medical Journal Editors. Manuscripts, abstracts, or reports will be 
prepared by the Principle Investigator and at minimum reviewed by all sub-investigators and by 
Immunovaccine before submission or release. 
 
15. REFERENCES 
 
1. zur Hausen H: Papillomaviruses and cancer: from basic studies to clinical application. Nat 
Rev Cancer 2:342-50, 2002 
2. de Villiers EM, Fauquet C, Broker TR, et al: Classification of papillomaviruses. Virology 
324:17-27, 2004 
3. Parkin DM: The global health burden of infection-associated cancers in the year 2002. Int J 
Cancer 118:3030-44, 2006 
4. Walboomers JM, Jacobs MV, Manos MM, et al: Human papillomavirus is a necessary cause 
of invasive cervical cancer worldwide. J Pathol 189:12-9, 1999 
5. Alani RM, Munger K: Human papillomaviruses and associated malignancies. J Clin Oncol 
16:330-7, 1998 
6. Siegel R, Naishadham D, Jemal A: Cancer statistics, 2013. CA Cancer J Clin 63:11-30, 2013 
7. Long HJ, 3rd: Management of metastatic cervical cancer: review of the literature. J Clin Oncol 
25:2966-74, 2007 
8. K T, M S, H L, et al: Incorporation of bevacizumab in the treatment of recurrent and metastatic 
cervical cancer: A phase III randomized trial of the Gynecologic Oncology Group. 2013 
ASCO Annual Meeting J Clin Oncol 31, 2013 (suppl; abstr 3) 
9. Ouhoummane N, Steben M, Coutlee F, et al: Squamous anal cancer: patient characteristics 
and HPV type distribution. Cancer Epidemiol 37:807-12, 2013 
10. Palefsky JM, Holly EA, Ralston ML, et al: Prevalence and risk factors for human 
papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive 
and HIV-negative homosexual men. J Infect Dis 177:361-7, 1998 

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11. Frisch M, Glimelius B, van den Brule AJ, et al: Sexually transmitted infection as a cause of 
anal cancer. N Engl J Med 337:1350-8, 1997 
12. Flam M, John M, Pajak TF, et al: Role of mitomycin in combination with fluorouracil and 
radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of 
epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J 
Clin Oncol 14:2527-39, 1996 
13. Gunderson LL, Winter KA, Ajani JA, et al: Long-term update of US GI intergroup RTOG 
98-11 phase III trial for anal carcinoma: survival, relapse, and colostomy failure with 
concurrent chemoradiation involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J 
Clin Oncol 30:4344-51, 2012 
14. Fakhry C, Westra W, Li S, et al: Prognostic significance of human papillomavirus (HPV) 
tumor status for patients with head and neck squamous cell carcinoma (HNSCC) in a 
prospective, multi-center phase II clinical trial. J Clin Oncol (Meeting Abstracts) 25:6000-, 
2007 
15. Fakhry C, Westra WH, Li S, et al: Improved survival of patients with human papillomavirus- 
positive head and neck squamous cell carcinoma in a prospective clinical trial. J Natl Cancer 
Inst 100:261-9, 2008 
16. Marur S, D'Souza G, Westra WH, et al: HPV-associated head and neck cancer: a virus-related 
cancer epidemic. Lancet Oncol 11:781-9, 2010 
17. Munger K, Werness BA, Dyson N, et al: Complex formation of human papillomavirus E7 
proteins with the retinoblastoma tumor suppressor gene product. Embo J 8:4099-105, 1989 
18. Munger K, Scheffner M, Huibregtse JM, et al: Interactions of HPV E6 and E7 oncoproteins 
with tumour suppressor gene products. Cancer Surv 12:197-217, 1992 
19. Scheffner M, Werness BA, Huibregtse JM, et al: The E6 oncoprotein encoded by human 
papillomavirus types 16 and 18 promotes the degradation of p53. Cell 63:1129-36, 1990 
20. Munger K, Phelps WC, Bubb V, et al: The E6 and E7 genes of the human papillomavirus type 
16 together are necessary and sufficient for transformation of primary human keratinocytes. J 
Virol 63:4417-21, 1989 
21. Desaintes C, Demeret C, Goyat S, et al: Expression of the papillomavirus E2 protein in HeLa 
cells leads to apoptosis. EMBO J 16:504-14, 1997 
22. Kirnbauer R, Taub J, Greenstone H, et al: Efficient self-assembly of human papillomavirus 
type 16 L1 and L1-L2 into virus-like particles. J Virol 67:6929-36, 1993 
23. Kirnbauer R, Booy F, Cheng N, et al: Papillomavirus L1 major capsid protein self-assembles 
into virus-like particles that are highly immunogenic. Proc Natl Acad Sci U S A 89:12180-4, 
1992 
24. Frazer IH: Measuring serum antibody to human papillomavirus following infection or 
vaccination. Gynecol Oncol 118:S8-11, 2010 
25. Stanley M: Prevention strategies against the human papillomavirus: the effectiveness of 
vaccination. Gynecol Oncol 107:S19-23, 2007 
26. Stoler MH, Whitbeck A, Wolinsky SM, et al: Infectious cycle of human papillomavirus type 
11 in human foreskin xenografts in nude mice. J Virol 64:3310-8, 1990 
27. Bellone S, El-Sahwi K, Cocco E, et al: Human papillomavirus type 16 (HPV-16) virus-like 
particle L1-specific CD8+ cytotoxic T lymphocytes (CTLs) are equally effective as E7- 
specific CD8+ CTLs in killing autologous HPV-16-positive tumor cells in cervical cancer 
patients: implications for L1 dendritic cell-based therapeutic vaccines. J Virol 83:6779-89, 
2009 
28. Wasim NA, Hati GC, Guha D, et al: Comment on: synchronous occurrence of anaplastic, 
follicular, and papillary carcinoma with follicular adenoma in thyroid gland. Indian J Pathol 

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Microbiol 54:434-5, 2011 
29. Frazer IH: Prevention of cervical cancer through papillomavirus vaccination. Nat Rev 
Immunol 4:46-54, 2004 
30. Trimble CL, Peng S, Thoburn C, et al: Naturally occurring systemic immune responses to 
HPV antigens do not predict regression of CIN2/3. Cancer Immunol Immunother 59:799-803, 
2011 
31. Piersma SJ, Jordanova ES, van Poelgeest MI, et al: High number of intraepithelial CD8+ 
tumor-infiltrating lymphocytes is associated with the absence of lymph node metastases in 
patients with large early-stage cervical cancer. Cancer Res 67:354-61, 2007 
32. Jordanova ES, Gorter A, Ayachi O, et al: Human leukocyte antigen class I, MHC class I chain- 
related molecule A, and CD8+/regulatory T-cell ratio: which variable determines survival of 
cervical cancer patients? Clin Cancer Res 14:2028-35, 2008 
33. Terlou A, Seters M, Kleinjan A, et al: Imiquimod-induced clearance of HPV is associated 
with normalization of immune cell counts in usual type vulvar intraepithelial neoplasia. Int J 
Cancer 127:2831-40, 2010 
34. van Seters M, van Beurden M, ten Kate FJ, et al: Treatment of vulvar intraepithelial neoplasia 
with topical imiquimod. N Engl J Med 358:1465-73, 2008 
35. Kenter GG, Welters MJ, Valentijn AR, et al: Vaccination against HPV-16 oncoproteins for 
vulvar intraepithelial neoplasia. N Engl J Med 361:1838-47, 2009 
36. Seiwert TY, Cohen EE, Wang X, et al: Use of systematic analysis of DNA repair pathways 
in head and neck cancer (HNC) to identify XPF as a novel predictor of induction response, 
and pMK2 relationship to chemoradiotherapy. Proceedings of the American Society of 
Clinical Oncology 26:Abstract # 6003, 2008 
37. de Vos van Steenwijk PJ, Piersma SJ, Welters MJ, et al: Surgery followed by persistence of 
high-grade squamous intraepithelial lesions is associated with the induction of a dysfunctional 
HPV16-specific T-cell response. Clin Cancer Res 14:7188-95, 2008 
38. Karkada, M., G.M. Weir, T. Quinton, L. Sammatur, L.D. MacDonald, A. Grant, R. Liwski, 
R. Juskevicius, G. Sinnathamby, R. Philip, and M. Mansour, A novel breast/ovarian cancer 
peptide vaccine platform that promotes specific type-1 but not Treg/Tr1-type responses. J 
Immunother, 33(3): p. 250-61, 2010. 
39. Weir, G.M., O. Hrytsenko, M.M. Stanford, N.L. Berinstein, M. Karkada, R. Liwski, and M. 
Mansour, Metronomic cyclophosphamide enhances HPV16E7 peptide vaccine induced 
antigen-specific 
and 
cytotoxic 
T-cell 
mediated 
antitumor 
immune 
response. 
Oncoimmunology, 3(8), 2014. 
40. Berinstein, N.L., M. Karkada, M.A. Morse, J.J. Nemunaitis, G. Chatta, H. Kaufman, K. 
Odunsi, R. Nigam, L. Sammatur, L.D. MacDonald, G.M. Weir, M.M. Stanford, and M. 
Mansour, First-in-man application of a novel therapeutic cancer vaccine formulation with the 
capacity to induce multi-functional T cell responses in ovarian, breast and prostate cancer 
patients. J Transl Med, 10: p. 156, 2012. 
41. Berinstein, N.L., M. Karkada, A.M. Oza, K. Odunsi, J.A. Villella, J.J. Nemunaitis, M.A. 
Morse, T. Pejovic, J. Bentley, M. Buyse, R. Nigam, G.M. Weir, L.D. MacDonald, T. Quinton, 
R. Rajagopalan, K. Sharp, A. Penwell, L. Sammatur, T. Burzykowski, M.M. Stanford, and 
M. Mansour, Survivin targeted immunotherapy drives robust polyfunctional T cell generation 
and differentiation in advanced ovarian cancer patients. Oncoimmunology, 4(8), 2015. 
42. Riemer A, Keskin DB, Zhang G, et al: A conserved E7-derived CTL epitope expressed on 
human papillomavirus-16 transformed HLA-A2+ human epithelial cancers. J Biol Chem 
285:29608-29622, 2010. 
43. Clark RA, Chong BF, Mirchandani N, et al: A novel method for the isolation of skin resident 

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T cells from normal and diseased human skin. J Invest Dermatol 126:1059-70, 2006. 

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16. APPENDICES 
 
APPENDIX A: Performance Status Criteria 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity. Fully active, able 
to 
carry 
on 
all 
pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
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). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 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. 
60 
Requires occasional assistance, but is 
able to care for most of his/her needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% 
bedridden. 
Completely 
disabled. Cannot carry on any self- 
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, 
fatal 
processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 

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APPENDIX B: Modified Response Evaluation Criteria in Solid Tumors (RECIST 1.1) Quick 
Reference 
http://ctep.cancer.gov/protocolDevelopment/docs/Recist_Guideline.pdf 
Eligibility 
Only patients with measurable disease at baseline should be included in protocols where objective 
tumor response is the primary endpoint. 
 
• 
Measurable disease - the presence of at least one measurable lesion. If the measurable disease 
is restricted to a solitary lesion, its neoplastic nature should be confirmed by 
cytology/histology when feasible. 
• 
Measurable lesions - lesions that can be accurately measured in at least one dimension with 
longest diameter 20 mm using conventional techniques or 10 mm with spiral CT scan. If 
no other measurable lesions can be found outside of a previously irradiated field, (i.e. as 
may be seen with locoregional recurrence), and the lesion in the irradiated area meets all 
other conditions for being measurable, and the lesion is new or has increased in size by at 
least 20% in longest diameter, taking as reference the smallest longest diameter since 
radiation, and the previous radiation was completed at least 6 months prior to registration, it 
can be chosen. 
• 
Non-measurable lesions - all other lesions, including small lesions (longest diameter <20 
mm with conventional techniques or <10 mm with spiral CT scan), i.e., bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusion, inflammatory breast disease, 
lymphangitis cutis/pulmonis, cystic lesions, and also abdominal masses that are not confirmed 
and followed by imaging techniques. 
• 
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. 
• 
Clinical lesions will only be considered measurable when they are superficial (e.g., skin 
nodules and palpable lymph nodes). For the case of skin lesions, documentation by color 
photography, including a ruler to estimate the size of the lesion, is recommended. 
 
Methods of Measurement 
 
• 
CT and MRI are the best currently available and reproducible methods to measure target 
lesions selected for response assessment. Conventional CT and MRI should be performed 
with cuts of 10 mm or less in slice thickness contiguously. Spiral CT should be performed 
using a 5 mm contiguous reconstruction algorithm. This applies to tumors of the chest, 
abdomen and pelvis. Head and neck tumors and those of extremities usually require specific 
protocols. 
 
• 
Lesions on chest X-ray are acceptable as measurable lesions when they are clearly defined 
and surrounded by aerated lung. However, CT is preferable. 

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• 
When the primary endpoint of the study is objective response evaluation, ultrasound (US) 
should not be used to measure tumor lesions. It is, however, a possible alternative to clinical 
measurements of superficial palpable lymph nodes, subcutaneous lesions and thyroid nodules. 
US might also be useful to confirm the complete disappearance of superficial lesions usually 
assessed by clinical examination. 
 
• 
The utilization of endoscopy and laparoscopy for objective tumor evaluation has not yet been 
fully and widely validated. Their uses in this specific context require sophisticated equipment 
and a high level of expertise that may only be available in some centers. Therefore, the 
utilization of such techniques for objective tumor response should be restricted to validation 
purposes in specialized centers. However, such techniques can be useful in confirming 
complete pathological response when biopsies are obtained. 
 
• 
Tumor markers alone cannot be used to assess response. If markers are initially above the 
upper normal limit, they must normalize for a patient to be considered in complete clinical 
response when all lesions have disappeared. 
 
• 
Cytology and histology can be used to differentiate between PR and CR in rare cases (e.g., 
after treatment to differentiate between residual benign lesions and residual malignant lesions 
in tumor types such as germ cell tumors). 
 
Baseline documentation of “Target” and “Non-Target” lesions 
 
• 
All measurable lesions up to a maximum of five lesions per organ and 10 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) 
and their suitability for accurate repeated measurements (either by imaging techniques or 
clinically). 
• 
A sum of the longest diameter (LD) for all target lesions will be calculated and reported as 
the baseline sum LD. The baseline sum LD will be used as reference by which to characterize 
the objective tumor. 
• 
All other lesions (or sites of disease) should be identified as non-target lesions and should 
also be recorded at baseline. Measurements of these lesions are not required, but the presence 
or absence of each should be noted throughout follow-up. 
 
Response Criteria 
 
Evaluation of target lesions 
• 
Complete 
Response 
(CR): 
• 
Partial 
Response (PR): 
• 
Progressive 
Disease (PD): 
 
Disappearance of all target lesions 
 
 
At least a 30% decrease in the sum of the LD of target lesions, taking 
as reference the baseline sum LD 
At least a 20% increase in the sum of the LD of target lesions, taking 
as reference the smallest sum LD recorded since the treatment started 
or the appearance of one or more new lesions 

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• 
Stable Disease 
(SD): 
Neither sufficient shrinkage to qualify for PR nor sufficient increase 
to qualify for PD, taking as reference the smallest sum LD since the 
treatment started 
 
Evaluation of non-target lesions 
• 
Complete 
Response 
(CR): 
•  Incomplete 
Response/ 
Stable Disease 
(SD): 
• 
Progressive 
Disease (PD): 
 
Disappearance of all non-target lesions and normalization of tumor 
marker level 
 
Persistence of one or more non-target lesion(s) and/or maintenance 
of tumor marker level above the normal limits 
 
 
Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions (1) 
 
Although a clear progression of “non target” lesions only is exceptional, in such circumstances, 
the opinion of the treating physician should prevail and the progression status should be confirmed 
later on by the review panel (or study chair). 
 
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 PD the smallest measurements recorded since the 
treatment started). In general, the patient's best response assignment will depend on the achievement 
of both measurement and confirmation criteria 
 
Target lesions 
Non-Target lesions 
New Lesions 
Overall response 
CR 
CR 
No 
CR 
CR 
Incomplete 
response/SD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
• 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
“symptomatic deterioration”. Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
• 
In some circumstances it may be difficult to distinguish residual disease from normal tissue. 
When the evaluation of complete response depends on this determination, it is recommended 

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that the residual lesion be investigated (fine needle aspirate/biopsy) to confirm the complete 
response status. 
 
Confirmation 
 
• 
The main goal of confirmation of objective response is to avoid overestimating the response 
rate observed. In cases where confirmation of response is not feasible, it should be made clear 
when reporting the outcome of such studies that the responses are not confirmed. 
• 
To be assigned a status of PR or CR, changes in tumor measurements must be confirmed by 
repeat assessments that should be performed no less than 4 weeks after the criteria for 
response are first met. Longer intervals as determined by the study protocol may also be 
appropriate. 
• 
In the case of SD, follow-up measurements must have met the SD criteria at least once after 
study entry at a minimum interval (in general, not less than 6-8 weeks) that is defined in the 
study protocol 
 
Duration of overall response 
 
• 
The duration of overall response is measured from the time measurement criteria are met for 
CR or PR (whichever status is recorded first) until the first date that recurrence or PD is 
objectively documented, taking as reference for PD the smallest measurements recorded since 
the treatment started. 
 
Duration of stable disease 
 
• 
SD is measured from the start of the treatment until the criteria for disease progression are 
met, taking as reference the smallest measurements recorded since the treatment started. 
 
The clinical relevance of the duration of SD varies for different tumor types and grades. Therefore, it 
is highly recommended that the protocol specify the minimal time interval required between two 
measurements for determination of SD. This time interval should take into account the expected 
clinical benefit that such a status may bring to the population under study. 

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APPENDIX C: Guidelines for the Evaluation of Immune Therapy Activity in Solid Tumors: 
Immune-Related Response Criteria (irRECIST) Quick Reference 
http://clincancerres.aacrjournals.org/content/15/23/7412.long 
 
Guidelines for the Evaluation of Immune Therapy Activity in Solid Tumors: Immune-Related 
Response Criteria 
 
Table 1. 
Comparison between WHO criteria and the irRC 
WHO 
irRC 
New, measurable 
lesions (i.e., ≥5 × 5 
mm) 
Always represent PD 
Incorporated into tumor burden 
New, 
nonmeasurable 
lesions (i.e., <5 × 5 
mm) 
Always represent PD 
Do not define progression (but 
preclude irCR) 
Non-index lesions Changes contribute to defining BOR of 
CR, PR, SD, and PD 
Contribute to defining irCR 
(complete disappearance required) 
CR 
Disappearance of all lesions in two 
consecutive observations not less than 4 
wk apart 
Disappearance of all lesions in two 
consecutive observations not less 
than 4 wk apart 
PR 
≥50% decrease in SPD of all index lesions 
compared with baseline in two 
observations at least 4 wk apart, in absence 
of new lesions or unequivocal progression 
of non-index lesions 
≥50% decrease in tumor burden 
compared with baseline in two 
observations at least 4 wk apart 
SD 
50% decrease in SPD compared with 
baseline cannot be established nor 25% 
increase compared with nadir, in absence 
of new lesions or unequivocal progression 
of non-index lesions 
50% decrease in tumor burden 
compared with baseline cannot be 
established nor 25% increase 
compared with nadir 
PD 
At least 25% increase in SPD compared 
with nadir and/or unequivocal progression 
of non-index lesions and/or appearance of 
new lesions (at any single time point) 
At least 25% increase in tumor 
burden compared with nadir (at 
any single time point) in two 
consecutive observations at least 4 
wk apart 

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Guidelines for the Evaluation of Immune Therapy Activity in Solid Tumors: Immune-Related 
Response Criteria 
 
Table 2. 
Derivation of irRC overall responses 
Measurable response 
Nonmeasurable response 
Overall 
response 
Index and new, measurable lesions 
(tumor burden),* % 
Non-index lesions 
New, nonmeasurable 
lesions 
Using irRC 
↓100 
Absent 
Absent 
irCR† 
↓100 
Stable 
Any 
irPR† 
↓100 
Unequivocal 
progression 
Any 
irPR† 
↓≥50 
Absent/Stable 
Any 
irPR† 
↓≥50 
Unequivocal 
progression 
Any 
irPR† 
↓<50 to <25↑ 
Absent/Stable 
Any 
irSD 
↓<50 to <25↑ 
Unequivocal 
progression 
Any 
irSD 
≥25? 
Any 
Any 
irPD† 
↵*Decreases assessed relative to baseline, including measurable lesions only (>5 × 5 mm). 
↵†Assuming response (irCR) and progression (irPD) are confirmed by a second, consecutive 
assessment at least 4 wk apart. 

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