A Phase I Study of an Adenoviral Transduced Autologous Dendritic Cell Vaccine Expressing Human HER2/Neu ECTM in Adults With Tumors With 1-3+ HER2/Neu Expression
Phase: PHASE1
Conditions: Breast Neoplasms, Breast Cancer, Adenocarcinomas, Metastatic Solid Tumors Characterized by HER2/Neu Expression
Sponsor: National Cancer Institute (NCI)

Abbreviated Title:  AdHER2/neu DC Vaccine 
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Abbreviated Title: AdHER2/neu DC Vaccine 
CC Protocol #: 13-C-0016 O 
Version Date: July 22, 2019 
NCT Number: NCT01730118 
OSP #: 1207-1179 
IBC #: RD-12-VIII-07 
 
Title:  A Phase I Study of an Adenoviral Transduced Autologous Dendritic Cell Vaccine 
Expressing Human HER2/neu ECTM in Adults with Tumors with 1-3+ HER2/neu 
Expression 
 
 
Principal Investigator:    
Hoyoung Maeng, M.D., Vaccine Branch, CCR, NCI 
 
Building 10, Room 3B37  
 
10 Center Drive 
 
Bethesda, MD 20892 
 
Phone: 240-781-3253 
 
Email: hoyoung.maeng@nih.gov   
 
 
Investigational Agent: 
Agent: Autologous dendritic cells transduced with an adenoviral vector: Ad5f35 human 
HER2/neu ECTM (AdHER2) 
Drug Name: 
Ad5f35HER2ECTM transduced autologous dendritic cell vaccine 
IND Number: 
15212 
Sponsor: 
Center for Cancer Research 
Manufacturer: 
Department of Transfusion Medicine, NIH Clinical Center 
Commercial Agents: None  
 
Identifying words: Human epidermal growth factor receptor 2 (HER2) expression, dendritic cell 
vaccine breast cancer, stomach cancer, metastatic tumors 

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PRÉCIS  
Background: 
• 
Human epidermal growth factor receptor 2 (HER2, also known as c-erbB2 or neu) is a 
proto-oncogene that encodes a 185-kd transmembrane (TM) tyrosine kinase receptor that 
participates in receptor-receptor interactions that regulate cell growth, differentiation and 
proliferation. Its over-expression contributes to neoplastic transformation. 
• HER2 is over-expressed in up to 25-30% of node-positive or node-negative primary 
breast cancers and is associated with clinically aggressive breast cancer, a high 
recurrence rate and reduced survival. 
• Trastuzumab (Herceptin) is a recombinant humanized mouse monoclonal antibody 
(MAb) that binds to the extracellular (EC) domain of the HER2 receptor. Its clinical 
efficacy is limited to patients with 3+ HER2 tumor expression documented by 
immunohistochemistry (IHC) or a HER2 amplified tumor by Vysis fluorescent in situ 
hybridization (FISH).  IHC is a subjective measurement of HER2/neu protein while FISH 
is an objective measurement of amplification of the HER2 oncogene.  
• Although the use of trastuzumab has been associated with improved clinical outcomes, a 
significant number of patients are unresponsive to therapy and most eventually 
experience clinical progression.  At present, no vaccine is available that induces patients 
to make their own anti-HER2 antibodies. 
• We propose to investigate the use of an adenoviral vector (Ad5f35) expressing human 
HER2ECTM (Ad5f35HER2ECTM- AdHER2) to transduce autologous dendritic cells for 
therapeutic vaccination in patients with HER2 expressing solid tumors.   
Objectives: 
• To determine the safety and toxicity of autologous AdHER2 dendritic cell vaccination. 
• Specifically, to determine if the fraction of patients with cancer therapeutics-related 
cardiac dysfunction (CTRCD), defined as a decrease in LVEF ≥10 percentage points, to a 
value LVEF to ≥53% (normal reference value for two-dimensional (2-D) 
echocardiography), is sufficiently low to warrant further development in subsequent 
trials.  
• To determine the immunogenicity of autologous AdHER2 dendritic cell vaccination as 
measured by a 3-fold increase in anti-HER2/neu antibody concentration or a 4-fold 
increase in antibody dilution titers over baseline. 
Eligibility:  
• Adults ≥ 18 of age 
• Patients with 1+ to 3+ HER2/neu expression by IHC or a Vysis FISH result equivocal or 
positive.  
• Part I:  Naïve to trastuzumab (Herceptin™), pertuzumab (Perjeta™) and lapatinib 
(Tykerb™), ado-trastuzumab emtansine (Kadcyla™) or other HER2-directed therapies.   
• Part II:  Recurrent or progressive metastatic disease after standard of care HER2- targeted 
therapies with known clinical benefit; i.e. trastuzumab (Herceptin™), pertuzumab 

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(Perjeta™), lapatinib (Tykerb™), ado-trastuzumab emtansine (TDM1) (Kadcyla™) or 
other HER2-directed therapies. 
• Eligible malignancies:   
o Parts I and II:  Malignant soft tissue and bone tumors and recurrent or 
progressive, metastatic solid tumors who have progressed on standard therapies 
(Note: Patients with metastatic cancer must have measurable disease per RECIST 
1.1); or,  
o Part I only:  Bladder cancer in the adjuvant setting (adjuvant bladder cancer 
patients): 
o Tumor stage T3a, T3b, T4a, T4b and any node positive disease regardless of 
tumor stage. 
o Status-post primary cystectomy with curative intent. 
o May or may not have received neoadjuvant cisplatin-based combination 
chemotherapy per NCCN guidelines. 
o May or may not have received adjuvant radiotherapy or chemotherapy based 
on pathologic risk per NCCN guidelines. 
o Greater than or equal to 6 weeks status post primary surgery with curative 
intent. 
• Adequate hematologic, metabolic, hepatic, renal, and cardiac function 
 
Study Design:  
Open label, non-randomized, two-part, phase I study of 48 weeks duration for evaluation of 
primary endpoints with extended follow-up out to 30 months to monitor LVEF cardiac function.   
Part I involves vaccine dose escalation in a population with no prior exposure to trastuzumab 
or other HER2-targeted therapies to determine if there is a significant, adverse safety signal 
regarding cardiac toxicity, in addition to preliminary assessment of the vaccine’s 
immunogenicity and clinical activity in patients with metastatic solid tumors or high-risk bladder 
cancer in the adjuvant setting. Response will be evaluated by a Modified Immune-Related 
Response Criteria (modified irRC) based on Response Evaluation Criteria in Solid Tumors 
(RECIST 1.1).       
Part II is identical to part I in the schedule of treatment and response evaluation, but is 
conducted in a population with prior exposure to trastuzumab and other HER2-targeted 
therapies.  
 
 

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TABLE OF CONTENTS 
PRÉCIS ............................................................................................................................................2 
TABLE OF CONTENTS .................................................................................................................4 
1 
INTRODUCTION ..................................................................................................................9 
1.1 
Study Objectives ............................................................................................................9 
1.1.1 
Primary Objective .......................................................................................................9 
1.1.2 
Secondary Objectives..................................................................................................9 
1.2 
Background and Rationale .............................................................................................9 
1.2.1 
HER2 Directed Therapies ...........................................................................................9 
1.2.2 
Pre-Clinical Animal Studies .....................................................................................12 
1.2.3 
Rodent AdneuECTM DC Vaccination .....................................................................15 
1.2.4 
Central and Peripheral Tolerance in the Transgenic HER2 Mouse Model ..............16 
1.2.5 
Pre-Clinical AdHER2ECTM Vector Expression Testing.........................................17 
1.2.6 
Pre-Clinical HER2 Dendritic Cell Platform Testing ................................................18 
1.2.7 
Human Experience with Dendritic Cell Vaccines ....................................................22 
1.2.8 
Human Experience with HER2 Therapeutic Vaccines .............................................22 
1.2.9 
Previous Human Experience with an Extracellular/Transmembrane/Intracellular 
HER2/neu Vaccine....................................................................................................23 
1.2.10 Exploratory Correlative Studies ................................................................................24 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT .......................................................25 
2.1 
Eligibility Criteria ........................................................................................................25 
2.1.1 
Common Eligibility for Parts I and II .......................................................................25 
2.1.2 
Part I Eligibility.........................................................................................................27 
2.1.3 
Part II Eligibility .......................................................................................................27 
2.2 
Exclusion Criteria ........................................................................................................27 
2.2.2 
Recruitment Strategies ..............................................................................................28 
2.3 
Pre-Screening and Screening Evaluation .....................................................................29 
2.3.1 
Pre-Screening ............................................................................................................29 
2.3.2 
Screening Evaluation ................................................................................................29 
2.4 
Registration Procedures ...............................................................................................29 
2.4.1 
Treatment Assignment Procedures ...........................................................................30 
2.5 
Baseline Evaluation .....................................................................................................31 
3 
STUDY IMPLEMENTATION ............................................................................................31 

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3.1 
Study Schema and Design ...........................................................................................31 
3.1.1 
Dose Limiting Toxicity .............................................................................................35 
3.1.2 
Dose Escalation .........................................................................................................36 
3.2 
Drug Administration ....................................................................................................37 
3.3 
Dose Modification and Immunization Stopping Rules ................................................38 
3.4 
Study Calendar .............................................................................................................39 
3.5 
Criteria for Removal from Protocol Therapy and Off Study Criteria ..........................41 
3.5.1 
Criteria for Removal from Protocol Therapy............................................................41 
3.5.2 
Continued Monitoring for Potential Cardiac Toxicity Once Off Protocol Therapy .41 
3.5.3 
Off Study Criteria .....................................................................................................42 
3.5.4 
Off Protocol Therapy and Off Study Procedure .......................................................42 
4 
CONCOMITANT MEDICATIONS/MEASURES ..............................................................42 
5 
BIOSPECIMEN COLLECTION ..........................................................................................44 
5.1 
Correlative Studies for Research/Pharmacokinetic Studies .........................................44 
5.2 
Sample Storage, Tracking and Disposition ..................................................................44 
5.2.1 
Samples collected by the Blood Processing Core of the Clinical Pharmacology 
Program .....................................................................................................................45 
5.3 
Samples for Genetic/Genomic Analysis ......................................................................46 
6 
DATA COLLECTION AND EVALUATION .....................................................................46 
6.1 
Data Collection ............................................................................................................46 
6.2 
Response Criteria .........................................................................................................47 
6.2.1 
Response Definitions ................................................................................................48 
6.2.2 
Disease Parameters ...................................................................................................48 
6.2.3 
Methods for Evaluation of Measurable Disease .......................................................49 
6.2.4 
Evaluation of Target Lesions ....................................................................................49 
6.2.5 
Evaluation of Non-Target Lesions ............................................................................50 
6.2.6 
Evaluation of Best Overall Response .......................................................................50 
6.2.7 
Confirmatory Measurement/Duration of Response ..................................................53 
6.2.8 
Progression Free Survival and Overall Survival .......................................................54 
6.2.9 
Response Review ......................................................................................................54 
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN ....54 
7.1 
Definitions....................................................................................................................54 
7.2 
OHSRP Office of Compliance and Training/ IRB Reporting .....................................54 

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7.2.1 
Expedited Reporting NIH Intramural IRB and NCI CD Expedited Reporting of 
Unanticipated Problems and Deaths .........................................................................54 
7.2.2 
IRB Requirements for PI Reporting at Continuing Review .....................................55 
7.3 
NCI Clinical Director Reporting ..................................................................................55 
 
To report these deaths, please send an email describing the circumstances of the 
death to Dr. Dahut at NCICCRQA@mail.nih.gov within one business day of 
learning of the death..................................................................................................55 
7.4 
Institutional Biosafety Committee (IBC) Reporting Criteria .......................................55 
7.4.1 
Serious Adverse Event Reports to IBC .....................................................................55 
7.4.2 
Annual Reports to IBC..............................................................................................55 
7.5 
NIH Required Data and Safety Monitoring Plan .........................................................56 
7.5.1 
Principal Investigator/Research Team ......................................................................56 
7.5.2 
Safety Monitoring Committee (SMC) ......................................................................56 
8 
SPONSOR SAFETY REPORTING .....................................................................................57 
8.1 
Definitions....................................................................................................................57 
8.1.1 
Adverse Event ...........................................................................................................57 
8.1.2 
Serious Adverse Event (SAE) ...................................................................................57 
8.1.3 
Life-threatening.........................................................................................................57 
8.1.4 
Severity .....................................................................................................................57 
8.1.5 
Relationship to Study Product ..................................................................................57 
8.2 
Assessment of Safety Events .......................................................................................58 
8.3 
Reporting of Serious Adverse Events ..........................................................................58 
8.4 
Reporting Pregnancy ....................................................................................................58 
8.4.1 
Maternal Exposure ....................................................................................................58 
8.4.2 
Parental exposure ......................................................................................................59 
8.5 
Regulatory Reporting for Studies Conducted Under CCR-Sponsor IND ...................59 
9 
CLINICAL MONITORING .................................................................................................59 
10 
COLLABORATIVE AGREEMENTS .................................................................................60 
10.1 
Tech Transfer Agreements ...........................................................................................60 
11 
STATISTICAL CONSIDERATIONS..................................................................................60 
11.1 
Part I (maximum of 30 evaluable patients) ..................................................................60 
11.2 
Part II (maximum of 30 evaluable patients) ................................................................62 
11.3 
Overview ......................................................................................................................62 

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11.4 
Study Termination .......................................................................................................64 
12 
HUMAN SUBJECTS PROTECTIONS ...............................................................................64 
12.1 
Rationale for Subject Selection ....................................................................................64 
12.2 
Participation of Children ..............................................................................................64 
12.3 
Participation of Subjects Unable to Give Consent .......................................................65 
12.4 
Evaluation of Benefits and Risks/Discomforts ............................................................65 
12.5 
Risks/Benefits Analysis ...............................................................................................66 
12.6 
Consent Process and Documentation ...........................................................................67 
12.6.1 Telephone consent procedure ...................................................................................68 
13 
PHARMACEUTICAL INFORMATION .............................................................................68 
13.1 
Ad5f35HER2ECTM (AdHER2) ..................................................................................68 
13.1.1 Source .......................................................................................................................68 
13.1.2 Toxicity .....................................................................................................................70 
13.1.3 Formulation and Preparation.....................................................................................70 
13.1.4 Stability and Storage .................................................................................................71 
13.1.5 Administration Procedures........................................................................................72 
13.1.6 Incompatibilities .......................................................................................................72 
13.2 
Sargramostim ...............................................................................................................72 
13.2.1 Source: ......................................................................................................................72 
13.2.2 Formulation and Preparation: ...................................................................................72 
13.2.3 Stability and Storage: ................................................................................................72 
13.2.4 Administration Procedures: ......................................................................................73 
13.2.5 Incompatibilities: ......................................................................................................73 
13.3 
Interleukin-4 CellGenix ...............................................................................................73 
13.3.1 Source: ......................................................................................................................73 
13.3.2 Formulation and Preparation: ...................................................................................73 
13.3.3 Stability and Storage: ................................................................................................73 
13.3.4 Administration Procedures: ......................................................................................73 
13.3.5 Incompatibilities: ......................................................................................................73 
13.4 
KLH (Keyhole Limpet Hemocyanin) ..........................................................................73 
13.4.1 Source .......................................................................................................................73 
13.4.2 Formulation and Preparation: ...................................................................................74 
13.4.3 Stability and Storage: ................................................................................................74 

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13.4.4 Administration Procedures: ......................................................................................74 
13.4.5 Incompatibilities: ......................................................................................................74 
14 
REFERENCES .....................................................................................................................75 
15 
APPENDICES ......................................................................................................................78 
15.1 
Appendix 1: Performance Status Criteria ....................................................................78 
15.2 
Appendix 2: New York Heart Association(NYHA) Functional Classification ...........79 
15.3 
Appendix 3: Standard Operating Procedure for Manufacture of AdHER2 
Autologous Dendritic Cell Vaccine .............................................................................80 
15.4 
Appendix 4: AdHER2 DC Vaccine Manufacturing Schema .......................................81 
15.5 
Appendix 5: AdHER2 DENTRITIC CELL VACCINE REPORT CARD .................85 
15.6 
Appendix 6Anti-HER2 Antibody and Cellular Responses ..........................................86 
15.7 
Appendix 7Evaluation of Anti-Ad5 Antibody Immunity ............................................88 
15.8 
Appendix 8Characterization of Soluble HER2 and Anti-HER2 Antibodies ...............89 
15.9 
Appendix 9Exploratory Correlative Studies ................................................................90 
15.10 Appendix 10Ad5f35HER2ECTM (AdHER2) Vector Manufacturing ........................93 
15.11 Appendix 11Map of the Ad5f35HER2ECTM (AdHER2) Vector ..............................95 
15.12 Appendix 12 AdHER2 Dendritic Cell Vaccine Cancer Treatment History ................96 
15.13 Appendix 13 Patient Recruiting Materials ...................................................................98 
 

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1 
INTRODUCTION 
1.1 
STUDY OBJECTIVES 
1.1.1 Primary Objective 
• To determine the safety and toxicity of autologous AdHER2/neu dendritic cell 
vaccination. Specifically, to: 
o Determine if the fraction of patients with cancer therapeutics-related cardiac 
dysfunction (CTRCD), (if it occurs) is sufficiently low to warrant further 
development in subsequent trials. CTRCD is defined as a decrease in LVEF ≥ 10 
percentage points, to a value ≥ 53% (normal reference value for two-dimensional 
(2-D) echocardiography)1. 
• To determine the immunogenicity of autologous AdHER2 dendritic cell vaccination as 
measured by a 3-fold increase in anti-HER2/neu antibody concentration (measured as 
mcg/mL) or a 4-fold increase in antibody dilution titers over baseline. 
1.1.2 Secondary Objectives 
• To determine the preliminary activity of autologous AdHER2 dendritic cell vaccination 
as measured by the fraction of subjects who have stable disease, a partial response or 
better by modified immune-related response criteria. 
• To determine the impact of autologous AdHER2 dendritic cell vaccination on tumor 
growth rate and regression rate constants. 
• To characterize vaccine-induced antibody profiles using HER2 peptide microarrays, 
examining reactivity to HER2 extracellular (EC), transmembrane (TM) and intracellular 
(IC) domains. 
• To characterize and measure function-associated mRNAs in whole blood, circulating 
tumor cells, myeloid derived suppressor cells (MDSCs) and other potential 
biologic/immunologic correlates of clinical response throughout treatment. 
1.2 
BACKGROUND AND RATIONALE 
1.2.1 HER2 Directed Therapies 
Human epidermal growth factor receptor 2 (HER2, also known as c-erbB2 or neu) is a proto-
oncogene that encodes a 185-kd transmembrane (TM) tyrosine kinase receptor that participates 
in receptor-receptor interactions that regulate cell growth, differentiation and proliferation.  Its 
over-expression- either HER2 oncogene amplification and/or over-expression of the HER2 
protein, contributes to neoplastic transformation2. HER2 is over-expressed in up to 25-30% of 
node-positive or node–negative primary breast cancers and is associated with clinically 
aggressive breast cancer, a high recurrence rate and reduced survival3. Development of agents 
targeting HER2 has resulted in expansion of therapeutic options and improved clinical outcomes 
for patients with HER2 over-expressing tumors4. Current FDA-approved treatment options 
include trastuzumab and lapatinib.  A third agent, pertuzumab is under priority review by the 
FDA with a decision expected by June 8th, 2012 for a proposed indication in combination with 
trastuzumab and docetaxel chemotherapy in patients with HER2-positive metastatic or locally 

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recurrent, unresectable breast cancer, who have not received previous treatment or whose disease 
has relapsed after adjuvant therapy. 
1.2.1.1 Trastuzumab (Herceptin) 
Trastuzumab (Herceptin) is a recombinant humanized mouse monoclonal antibody (MAb) that 
binds to the extracellular (EC) domain of the HER2 receptor and was approved by the FDA in 
September 1998.  It is approved for the adjuvant treatment of early-stage breast cancer with 
nodal spread (or without nodal spread if the tumor is high risk) as well as for first and second-
line/salvage therapy for metastatic breast cancer5. In the adjuvant setting trastuzumab is used in 
several ways:  
• As part of a treatment course including chemotherapy with doxorubicin, cyclophosphamide 
and either paclitaxel or docetaxel, known as “ACTH”. 
• With chemotherapy drugs docetaxel and carboplatin in a regimen known as “TCH”. 
• Alone after treatment with multiple other therapies, including anthracycline-based therapy. 
Trastuzumab has two approved uses in metastatic breast cancer: 
• As first line treatment in combination with paclitaxel. 
• As a single agent in patients who have received one or more courses of chemotherapy for 
metastatic disease. 
Therapy typically involves an initial trastuzumab dose of 4mg/kg IV followed by 2mg/kg IV 
administered weekly for 52 weeks, alone (salvage therapy) or in combination with paclitaxel for 
the first 12 weeks (adjuvant and first-line therapy).  However, clinical efficacy is limited to 
patients with 3+ HER2 tumor expression documented by immunohistochemistry (IHC) or gene 
amplification by fluorescent in situ hybridization (FISH).  IHC is a subjective measurement of 
HER2/neu protein while FISH is an objective measurement of amplification of the HER2 
oncogene6. Despite the high level efficacy in combination with chemotherapy, the overall 
response rate of women diagnosed with HER2-positive metastatic breast cancer and treated with 
trastuzumab as a single first-line agent is only 26%7 clearly indicating there is room for 
improvement in therapeutic options.  In addition, a significant number of patients are 
unresponsive to trastuzumab and most eventually experience clinical progression while on 
therapy, presumably due to trastuzumab resistance, whose mechanism is poorly understood8-10.  
Trastuzumab is also approved for use in combination with cisplatin and either capecitabine or 5-
fluorouracil in treatment naïve patients with HER2-positive metastatic stomach cancer or cancer 
of the gastroesophageal junction.  
Despite the success of trastuzumab, no vaccine is currently available that induces patients to 
make their own anti-HER2 antibodies. 
1.2.1.2 Trastuzumab Cardiac Toxicity 
Given the well-documented cardiac toxicity associated with the monoclonal antibody 
trastuzumab 11-13 we believe it is critical to initially assess the safety of the vaccine as a single 
agent to minimize confounding attributions of toxicity.  Specifically, a retrospective review of 
records for patients enrolled onto any of seven phase II and III trastuzumab clinical trials 
revealed patients treated with trastuzumab were found to be at increased risk for cardiac 
dysfunction11. The incidence was greatest in patients receiving concomitant trastuzumab and 
anthracycline plus cyclophosphamide (27%) but was substantially lower in patients receiving 

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paclitaxel and trastuzumab (13%) or trastuzumab alone (3% to 7%) although most of these 
patients had received prior anthracycline therapy. Most trastuzumab-treated patients developing 
cardiac dysfunction were symptomatic (75%), and most improved with standard treatment for 
congestive heart failure (79%).  
Consequently, we propose to conduct this study in two parts to identify any cardiac safety issues 
that may be associated with vaccine-induced antibodies.  Part I of the study involves vaccine 
dose escalation in a population with no prior exposure to trastuzumab or other HER2 directed 
agents to determine if there is a significant, adverse safety signal regarding cardiac toxicity.  
Assessments of cardiac function will include serial echocardiography to determine left 
ventricular ejection fraction (LVEF) at baseline and at regular monitoring intervals, in addition to 
LVEF measurements for at least 2 years following receipt of the last dose of vaccine.  Once 
cardiac safety has been established in this population, Part II repeats the vaccine dose escalation 
in a population with significant prior exposure to trastuzumab to determine whether there is an 
adverse safety signal regarding cardiac toxicity using identical monitoring and follow-up criteria. 
Please note for patients in parts I and II with taking known CT agents will no longer be on study.  
This study design and monitoring plan for cardiac toxicity as well as thresholds for 
discontinuation of vaccine treatment were developed based on FDA recommendations from the 
Pre-IND meeting review on September 6th, 2011. 
1.2.1.3 Lapatinib (Tykerb™) 
Lapatinib is an orally administered tyrosine kinase inhibitor of both the HER2/neu protein and 
the epidermal growth factor receptor.  It has shown activity in combination with capecitabine in 
patients with metastatic HER2 positive breast cancer that have progressed following treatment 
with trastuzumab14. Common toxicities specific to lapatinib include diarrhea and rash; cardiac 
toxicity is rarely seen.  Like trastuzumab, resistance to lapatinib has been described and it 
appears that multiple molecular mechanisms underly resistance to both of these drugs15. 
1.2.1.4 Pertuzumab (Perjeta™) 
Pertuzumab is a humanized monoclonal antibody being studied in early and advanced states of 
HER2-positive breast cancer and advanced HER2-positive gastric cancer.   It is a dimerization 
inhibitor designed to specifically prevent the HER2 receptor from pairing (dimerizing) with other 
HER receptors (EFGR/HER1, HER3 and HER4), a process that is believed to play a critical role 
in the growth and formation of several different cancer types.  Through prevention of receptor 
pairing, pertuzumab is believed to block cell signaling, which may inhibit cancer cell growth or 
lead to the death of the cancer cell.  Binding of pertuzumab to HER2 may also signal the body’s 
immune system to destroy cancer cells.  The mechanisms of action of pertuzumab and 
trastuzumab are thought to complement each other, as both bind to the HER2 receptor but on 
different regions.  The goal of combination pertuzumab/trastuzumab therapy and chemotherapy 
is to determine if the combination provides a more comprehensive blockade of HER signaling 
pathways. 
The pertuzumab application before the FDA is based on results from the pivotal phase III 
CLEOPATRA (Clinical Evaluation Of Pertuzumab And TRAstuzumab) study16. CLEOPATRA 
is an international, phase III, randomized, double-blind, placebo-controlled study.  The study 
evaluated the efficacy and safety profile of the pertuzumab-based regimen compared to 
trastuzumab and chemotherapy plus placebo in 808 people with previously untreated HER2-
positive metastatic breast cancer.  The primary endpoint of the study was progression free 

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survival (PFS) with secondary endpoints of overall survival (OS), PFS by investigator 
assessment, safety profile, overall response rate (ORR), duration of response, time to symptom 
progression and correlation of biomarkers with clinical outcomes. 
The CLEOPATRA study demonstrated a 6.1-month improvement in median PFS for patients 
receiving a pertuzumab-based regimen (pertuzumab combined with trastuzumab and docetaxel) 
compared to those who received trastuzumab and docetaxel alone: median PFS 18.5 vs. 12.4 
months.   People who received the combination also experienced a 38% reduction in the risk of 
disease worsening or death (HR=0.62, p-value <0.0001).  The pertuzumab regimen was not 
associated with a higher incidence of cardiac AEs: left ventricular dysfunction was 4.4% in the 
pertuzumab-containing regimen compared to 8.3% with trastuzumab and docetaxel alone.  Final 
OS analysis from the CLEOPATRA study is expected in 2013. 
1.2.1.5 Trastuzumab Emtansine (T-DM1) (Kadcyla™) 
Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate consisting of trastuzumab linked 
via a non-reducible thiotether to the cytotoxic, anti-tubulin agent maytansine (DM1)17. It is under 
global development by Roche in collaboration with Genentech and Immunogen for second-line, 
first-line and third-line treatment of HER2+ metastatic breast cancer in the following phase III 
trials, respectively: 
• The EMILIA study will compare T-DM1 versus lapatinib plus capecitabine in 980 
patients (NCT00829166.) 
• The MARIANNE study will compare docetaxel/trastuzumab vs. T-DM1 vs. T-DM1 plus 
pertuzumab (NCT01120184). 
• The TH3RESA study is comparing T-DM1 versus best supportive care in the salvage 
setting (NCT01419197). 
The results of a 137 patient, randomized phase II study of T-DM1 in untreated HER2+ 
metastatic breast cancer patients comparing T-DM1 versus trastuzumab plus docetaxel 
chemotherapy presented in September 2011 at the European Multidisciplinary Cancer Congress 
in Stockholm Sweden (Abstract #5001) demonstrated improved median PFS of T-DM1 
compared to trastuzumab/docetaxel: median PFS of 14.2 months vs. 9.2 months, respectively; 
p=0.035.  T-DM1 achieved a 64.2% objective response rate vs. 58% for the 
trastuzumab/docetaxel combination and also had a more favorable side effect profile, with a 
lower frequency of severe adverse events (SAEs): 46.4% vs. 89.4% respectively.  The most 
frequent SAEs reported with T-DM1 therapy were thrombocytopenia (8.7%) and elevated liver 
transaminases (8.7%).   Data from the EMILIA trial is expected in 2012 and is anticipated to be 
the basis for seeking FDA marketing approval for second-line treatment of HER2+ cancer in the 
U.S. and Europe. Ado-trastuzumab emtansine (Kadcyla) was approved by the FDA on February 
22, 2013. 
1.2.2 Pre-Clinical Animal Studies 
We have recently published dramatic results documenting the regression and cure of large 
established tumors in syngeneic BALB/c mice using a therapeutic adenoviral vector vaccine 
expressing the extracellular and transmembrane (ECTM) domains of rodent HER2neu18. This 
anti-tumor activity is mediated by polyclonal vaccine-induced antibodies that inhibit HER2 
phosphorylation and unlike trastuzumab, are Fc receptor independent.  

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Although many mouse tumor vaccine studies have prevented growth of tumors, it has generally 
not been possible to achieve cure of large established tumors > 1 cm in diameter with cancer 
vaccines.  Using an adenoviral vector vaccine expressing the extracellular and transmembrane 
(ECTM) domains of rodent HER2/neu, we have cured TUBO mammary gland carcinomas up to 
2 cm in diameter in syngeneic BALB/c mice (Figure 1) and multiple large established lung 
metastases (Figure 2). Virtually 100% of mice are cured from both subcutaneous and lung 
tumors. The vaccine also prevents spontaneous orthotopic breast carcinomas in BALB/c mice 
transgenic for the same rodent neu oncogene18,19. 
Figure 1 
 
Figure 2 
 
 
 
A single vaccination of 108 pfu of AdneuECTM causes regression of large (> 1 cm2) tumors as 
demonstrated in Figure 3 and Figure 4. 
Control, sacrificed day 15
Ad-ECTM day 15, 
Sacr  day 29
Control, sacrificed 30
Ad-ECTM day 15, 
Sacr  day 35
Ad-ECTM day 15, 
Sacr  day 48

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Figure 3: AdneuECTM Causes Regression of Large Tumors 
 
 
Figure 4: Large Breast Tumors are Cured with a Single Injection of AdneuECTM 
 

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Figure 5: AdneuECTM Vaccine Therapy is Antibody Dependent 
 
As shown above in Figure 5, the vaccine’s mechanism of action is purely antibody-mediated, 
with no involvement of CD4 or CD8 T cells in the effector function (only CD4 help at the time 
of vaccination to induce antibodies).  Neither depletion of CD8+ T cells with antibody nor use of 
beta-2 microglobulin knockout mice that lack CD8+ T cells affects vaccine-induced protection. 
1.2.3 Rodent AdneuECTM DC Vaccination 
Similar induction of therapeutically effective antibodies could be obtained by immunizing with 1 
million syngeneic dendritic cells transduced with the Ad-neuECTM vector as shown below in 
Figure 6.  Mice given TUBO cells subcutaneously and then vaccinated on days 5 and 7 when the 
tumors were 55-250 mm3 showed complete regression of tumors exactly analogous to the 
regressions induced by the free AdHER2 vector (Steele, Morris et al, unpublished observations).  
Tumors continued to grow to a peak around Day 12, when they reached a maximum of 756 mm3, 
and then started to regress, reaching baseline levels after Day 22.  This therapeutic effect was 
observed whether AdneuECTM-transduced DCs were given alone or with IL-15 and was also 
antibody dependent.  Thus, immunization with AdneuECTM-transduced DCs and with free 
AdneuECTM both produced comparable antibody-mediated tumor regression.  Also, sera from 
such AdneuECTM-transduced DC-immunized mice inhibited growth of TUBO cells in vitro and 
inhibited phosphorylation of the ErbB2-neu oncoprotein. 

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Figure 6: Rodent AdneuECTM DC Vaccination 
 
1.2.4 Central and Peripheral Tolerance in the Transgenic HER2 Mouse Model 
It should be noted that HER2/neu-transgenic mice have central or thymic tolerance to the 
oncogene, which is expressed from before birth (unlike some models in which an oncogene is 
not expressed until sexual maturity). They express a smaller, more limited and different T cell 
repertoire from that in non-transgenic mice, reflecting the deletion of many T cell clones by 
central self-tolerance20,21. Thus, it is not surprising that it has been harder to treat established 
spontaneous tumors in the neu-transgenic mice19,22. Further, in the BALB-neu transgenic model, 
the oncogene is expressed in all mammary cells of all mammary glands.  As a consequence, 
relentless malignant transformation of mammary gland cells is induced with subsequent 
generation of independent primary tumors in all 10 mouse mammary glands, making it extremely 
difficult to suppress all tumors.   In contrast, it is still possible to virtually completely suppress 
the development of tumors in neu-transgenic mice if vaccination is started at a young age, about 
7 weeks, when histopathology already shows development of abnormal mammary gland 
dysplasia (beginning even before 4 weeks) due to the oncogene.  Presumably the vaccine-
induced antibodies are eradicating or inhibiting the dysplastic neu-expressing cells. Thus, this is 
really a therapeutic model, not just prophylactic. This situation contrasts with the human breast 
cancer situation, in which the HER2/neu oncogene is not expressed until malignant 
transformation in adulthood, so there is no opportunity to develop central tolerance.  Indeed, 
Disis and coworkers23,24 have demonstrated that many patients with HER2+ breast cancers 

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express spontaneous antibodies and T cell responses to the HER2 oncoprotein, demonstrating the 
absence of central tolerance. Further, humans with breast cancer generally do not have such an 
oncogene expressed in 100% of mammary gland ductal epithelial cells as in the transgenic mice, 
leading to the relentless and continuous generation of new independent tumors.  Therefore, it is 
expected that the vaccine will be more effective at inducing therapeutically effective antibodies 
to HER2 in patients with HER2+ breast cancers than it can in centrally tolerant neu-transgenic 
mice. 
We have also shown (unpublished data) that vaccine-induced antibodies inhibit the growth of the 
N202-1A tumor line, another mouse mammary carcinoma expressing the same oncogene.  The 
vaccine’s mechanism of action is purely antibody-mediated, with no involvement of CD4 or 
CD8 T cells in the effector function (only CD4 help at the time of vaccination to induce 
antibodies).  Importantly, the vaccine-induced antibodies work differently from trastuzumab: 
they are Fc receptor independent, kill tumor cells directly without the aid of other cells, and 
inhibit HER2 phosphorylation and cause it to be modulated off the cell surface. Thus, this 
vaccine may work in patients in whom trastuzumab or lapatinib is ineffective.  In addition, 
vaccine-induced antibodies are polyclonal and may be more resistant to escape mutations than a 
monoclonal antibody (MAb) like trastuzumab or pertuzumab.  Our pre-clinical animal data 
suggest the potential for even greater therapeutic efficacy than trastuzumab and would eliminate 
the need for costly, frequent infusions currently associated with this treatment. 
1.2.5 Pre-Clinical AdHER2ECTM Vector Expression Testing 
Several rounds of pre-clinical experiments have been conducted to determine the optimal 
conditions for generation of AdHER2 transfected dendritic cells (AdHER2 DC) for autologous 
therapeutic vaccination. Healthy normal donor cells were used to generate dendritic cells under 
different conditions to confirm HER2neu expression by FACS or ELISA in multiple experiments 
and functional assays which were performed by Drs. Luciano Castiello and Marianna Sabatino in 
the Department of Transfusion Medicine (DTM) and by Dr. Masaki Terabe of the Vaccine 
Branch.  The key outcomes from these experiments are documented below: 
• Equivalent HER2neu expression of DCs transfected under bag or flask conditions.  The DTM 
currently uses bags to generate DCs from thawed monocytes for autologous DC vaccines as 
part of their cGMP standard operating procedures and this is the methodology that will be 
used in our study. 
• A viral particle (VP): DC ratio of 3000:1 was chosen as the ratio for transfection for this 
clinical trial since high level expression was documented at reasonable MOIs based on data 
highlighted in the tables below. 
Table 1 FACS Data HER2neu Expressions Varying VP: DC Ratios Round 2 M. Sabatino 
VP:DC Ratio 
Population 
Expression Marker 
# Events 
% Parent 
1000:1 
FITC G1 HER2 HER2 
6,947 
26.8 
2000:1 
FITC G1 HER2 HER2 
20,571 
79.4 
3000:1 
FITC G1 HER2 HER2 
24,657 
95.0 
5000:1 
FITC G1 HER2 HER2 
24,073 
99.5 
• HER2neu mean fluorescent intensity and the percent of cells staining positive for HER2neu 
was acceptable at the two highest ratios examined (M. Terabe FACS data): 

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VP:DC Ratio 
Mean Fluorescent Intensity (MFI)    % Cells Positive (DY and N87) for HER2neu 
3000:1 
5000:1 
103 
432 
84.5% 
97.8% 
 
• Although MFI and percent positive cells were even greater at 5000:1, there were concerns 
about potential subsequent issues of cell viability at this highest ratio.  In addition, the 
efficient vialing of vector for planned MOIs of 3000:1 will allow an adequate supply of virus 
for up to 66% more patients than if the 5000:1 ratio were to be used. 
The above data were reviewed by and discussed with the FDA in a Pre-IND meeting conference 
call held September 6th, 2011 and were determined to be acceptable. 
1.2.6 Pre-Clinical HER2 Dendritic Cell Platform Testing 
Studies were conducted utilizing cells from three healthy, normal human donors (11FC00039, 
11FC00043 and 11FC00055) to determine the best sequence of AdHER2 vector transfection and 
dendritic cell maturation for optimal viability and HER2neu expression in the final DC vaccine 
product. AdHER2 transfected DCs at a ratio of 3000 VP: DC were generated under the following 
conditions as summarized below and outlined in Figure 7: 
➢ Transfection of immature dendritic cells (iDC) for 24 hours:  
iDC with (24h)virus 
➢ Immature dendritic cells with no viral transfection: 
iDC 
➢ Maturation of DCs for 24 hours with no viral transfection:  
(24h)mDC no virus 
➢ Maturation of DCs for 24 hours with transfection at 20 hours: 
(24h)mDC with(20h)virus  
➢ Transfection of DCs for 4 hours followed by maturation of DCs: (20h)mDC with(24h)virus 
 

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Figure 7: DC Transfection and Maturation Experiment 
 
DC viability and product yield (expressed as % of starting number of monocytes) under the 
varying transfection and DC maturation conditions are outlined in Figure 8 and Figure 9. 
 

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Figure 8 
Figure 9 
 
 
As depicted in Figure 8, the post transfection viability of matured DCs (mDCs) ranged from 60-
82% (mean 70-75%).   Since this post maturation/transfection DC viability is donor dependent 
and highly variable, we requested and received FDA approval allowing a release viability 
criteria of > 60% rather than > 70% for the final AdHER2 DC vaccine product to be used in 
this study.  Historically, DTM reports that the product yield for transfected DC vaccine products 
is usually between 10-40% of the starting monocyte population.  Note in Figure 9 for an 
unknown reason, healthy donor 11FC00055 had an extremely poor yield of DCs post 
maturation/transfection.  We have observed similar variations in vaccine viability and yields 
within and between donors in the manufacture of autologous TARP peptide DC vaccines on NCI 
protocol 09-C-0139.  
HER2neu expression was also assessed under the different maturation conditions. There was 
significant variability of expression within and between donors under the different maturation 
and transfection conditions and immature DCs were observed to have greater variable expression 
of HER2neu i.e. the mean fluorescent intensity per cell of HER2 expression was more 
inconsistent on immature DCs versus mature DCs (personal communication L. Castiello and M. 
Sabatino of DTM, data not shown). 
However, as documented below in Figure 10, HER2neu expression (CD340) was 100% on 
transfected immature and mature DCs, regardless of transfection conditions.   

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Figure 10: DC HER2neu Expression Post Transfection/Maturation 
 
Additional characterizations and assessments were also performed as part of these DC 
maturation/transfection experiments in an attempt to better characterize the qualitative, 
functional aspects of the final HER2neu DC vaccine product, including: 
• Cluster of Differentiation (CD) antigens on the final DC vaccine product (in order of relative 
scientific priority): CD86, CD83, HLA-DR, CD38, CD54, CD14, and CCR7 (data not 
shown). 
• Expression of cytokines and chemokines IL-6, IL-8, IL-12p70, TNF-, IP10, MDC and 
MIP3 (expressed as a ratio that normalizes expression for the number of cells). Interferon-
, IL-10, IL-13 and IL-15 were at very low concentrations, usually < 5pg/mL (data not 
shown).  Proteomic analysis of dendritic cell supernatants under the different 
transfection/maturation conditions is in process for the cytokines and chemokines mentioned 
above. 
Based on these studies, we are planning to manufacture AdHER2 DC vaccine for this study 
using a 4 hour transfection of the AdHER2 vector first followed by the DC maturation cocktail 
(denoted as (20)mDC with (24) virus in the previous figures).   
This decision is based on the following theoretical grounds as well as the observations from the 
in vitro studies documented above: 
➢ It is generally easier to transfect immature DCs i.e. before maturation cocktail is added and 
ensure optimal antigen processing. 
➢ There was more consistent HER2neu expression on mature DCs compared to immature DCs 
as measured by MFI, which may lead to greater uniformity of the final product.   
The Certificate of Analysis for the final manufactured AdHER2 DC vaccine product will include 
documentation on the percentage of HER2neu expressing cells (%HER2neu) in the product and 
the HER2neu Mean Fluorescent Intensity (HER2neu MFI) of cells in the product to permit 

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preliminary assessment of their correlation with clinical outcomes.  The above outlined 
transfection/maturation process for AdHER2 DC vaccine manufacture was approved by the 
FDA following their review of the data during the Pre-IND meeting held September 6th, 2011.  
1.2.7 Human Experience with Dendritic Cell Vaccines 
There are a wide variety of platforms and immunogens that have been extensively studied in 
therapeutic cancer vaccine platforms including: a) whole tumor cell vaccines, b) dendritic cell 
(DC)-based platforms, c) peptide and fusion proteins co-delivered with adjuvants and c) viral 
vectors that serve as delivery vehicles for tumor-associated antigens (TAAs).  In addition to 
classic peptide and protein immunogens, tumor lysates, tumor mRNA, and DNA have all been 
utilized.  DCs serve as a bridge between the innate and adaptive immune system and in turn play 
a critical role in the activation of naïve CD4+ and CD8+ T cells.  As a consequence, researchers 
in cancer immunotherapy have focused a tremendous amount of investigative effort to delineate 
and understand DC biology, activation, maturation, and antigen presentation. Because of the 
pervasive dysfunction of DCs in vivo as a consequence of the immune dysregulation associated 
with high tumor burdens25, they have been the platform of choice for delivery of many tumor cell 
lines (LNCaP, PC3), peptides, proteins, lysates, mRNAs and viral vectors expressing TAAs26,27.  
Sipuleucel-T is a prototype of this platform approach: even though it is labeled as an autologous 
cellular immunotherapy, its generation utilizes similar maturation agents and pathways common 
to dendritic cell vaccines28. 
A better understanding of basic immunologic principles has led to a variety of techniques for 
enhancing tumor-specific immunity and their potential subsequent translation into improved 
clinical outcomes.  This is exemplified by the FDA approval on April 29th, 2010 of sipuleucel-T 
(Provenge), the first licensed therapeutic cellular immunotherapy and a major milestone in the 
field of cancer immunotherapy.  Importantly, approval of sipuleucel-T was based upon a 
statistically persuasive and clinically meaningful 4.1-month improvement in median overall 
survival (OS) in the IMPACT phase III trial29. The improvement in OS associated with 
sipuleucel-T has been reported to correlate with CD54 upregulation, a measure of the product’s 
potency30 as well as the development of antibody titers exceeding 400 at any time against the 
immunizing antigen PA2024 (a fusion protein) or prostatic acid phosphatase (PAP)29. 
Interestingly, although very strong T cell proliferative responses to PA2024 and PAP were also 
observed in patients receiving sipuleucel-T, no difference or association in survival was 
documented between patients who exhibited T cell response to either antigen and those who did 
not. 
DC vaccine products have been delivered intravenously (as is sipuleucel-T), intramuscularly, 
intranodally, intradermally and subcutaneously.  In our pre-clinical model of rodent Adneu 
ECTM DC vaccination, the vaccine was given subcutaneously.  We are planning to deliver the 
human autologous HER2 DC vaccine equivalent used in this study intradermally, since it is in 
keeping with this model and there is evidence to suggest that in humans intradermal delivery 
may be more optimal than subcutaneous delivery (C. Mackall, personal communication).  
1.2.8 Human Experience with HER2 Therapeutic Vaccines 
The clinical efficacy of trastuzumab-based anti-HER2 passive immunotherapy and other HER2-
targeted therapy has led to the development of vaccination strategies against HER2 that would 
ideally result in strong immunity producing immune memory associated with anti-tumor activity 
as well as prevention of tumor recurrence. Different anti-HER2 vaccine strategies currently 

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under investigation and in various stages of clinical development include DNA, peptide, whole 
tumor cell, and dendritic cell vaccines and combinations of the same e.g. peptide-loaded DC 
vaccines31. Peptide vaccines have included monovalent and as well as polyvalent HER2 peptides 
and been associated with the development of humoral as well as cellular immune responses.  We 
believe the use of our proposed AdHER2 DC vaccine will induce polyclonal antibody responses 
directed towards both the extracellular (EC) and transmembrane (TM) components of HER2 as 
well as potentially the intracellular domain (IC) as a result of epitope spreading.  The multiple, 
unique HER2 epitopes targeted by this autologous vaccine platform are likely to differ from 
trastuzumab binding epitopes and may result in greater affinity and clinical activity than that 
seen with trastuzumab, especially in patients with lower levels of HER2 expression i.e. <3+ by 
IHC.  In addition, based on our pre-clinical data, the anti-HER2 antibodies induced by 
vaccination appear to have functional activity that, unlike trastuzumab, is Fc receptor 
independent and that interfere with HER2 expression and phosphorylation.  Hence, vaccine-
induced anti-HER2 antibodies may also have clinically relevant anti-tumor activity in patients 
with resistance to trastuzumab, lapitinib or other HER2-directed therapies. 
1.2.9 Previous Human Experience with an Extracellular/Transmembrane/Intracellular 
HER2/neu Vaccine 
Our collaborator Rolf Kiessling, and his colleagues at the Karolinska Institute in Sweden have 
conducted a pilot clinical trial of a plasmid DNA human HER2/neu vaccine encoding the 
extracellular (EC), transmembrane (TM) and mutated intracellular (ICmutated) domains 
(ECTMICmutated) given with GM-CSF and IL-232. As a safety measure, a two base pair mutation 
was introduced in the IC domain to remove an autophosphorylation site that confers 
oncogenicity and maximize safety.  The vaccine was administered to a total of eight patients and 
no clinical issues of acute toxicity, autoimmunity or cardio toxicity were identified.  As might be 
expected with a DNA plasmid construct, the vaccine demonstrated limited immunogenicity: no 
specific T-cell proliferation following in vitro stimulation of ex vivo PBMCs with recombinant 
human HER2 protein was induced by vaccination.  In fact, immediately following three 
complete cycles of vaccination, no or even decreased HER2-specific CD4+ T-cell responses 
were observed, but a significant increase in MHC class II restricted HER2-T-cell responses was 
detected at long term follow-up.  Because concurrent trastuzumab therapy was permitted during 
the study, -subclass specific ELISAs were performed to measure endogenous antibody 
production without trastuzumab interference.  Importantly, in a subgroup of patients, HER2-
pDNA vaccination induced and boosted HER2-specific antibodies that could be detected for 
several years following the last vaccine administration.  
We propose to carry out this phase I and pilot study of vaccination with AdHER2 transduced 
autologous dendritic cells in patients with 1+ to 3+ HER2neu expressing tumors.  Part I involves 
vaccine dose escalation in a population with no prior exposure to trastuzumab or other HER2-
directed agents to determine if there is a significant, adverse safety signal regarding cardiac 
toxicity, in addition to preliminary assessment of the vaccine’s immunogenicity and clinical 
activity.  Five doses of 5, 10, 20 or 40 x10^6 viable cells/AdHER2 vaccine will be given 
intradermally at Weeks 0, 4, 8, 16 and 24 in patients with metastatic solid tumors and adjuvant 
bladder cancer patients characterized by some HER2/neu expression. While these patients may 
be less likely to respond due to lower expression levels of the HER2 target, it is equally 
possible that they may respond better because they will have less peripheral tolerance to 
HER2.  In addition, AdHER2 DC vaccination is likely to induce a polyclonal antibody response 

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to multiple HER2 epitopes that differ from the EC epitope targeted by trastuzumab.  These 
differing polyclonal, multiple-epitope responses may be associated with anti-tumor activity.  
Once preliminary cardiac safety is demonstrated, Part II of the study will repeat the vaccine dose 
escalation in a population with prior exposure to trastuzumab and other HER2 directed 
therapies (as required by the FDA) to again determine whether there is an adverse safety signal 
regarding cardiac toxicity, in addition to assessment of the vaccine’s immunogenicity and 
clinical activity.  Vaccine dose escalation, administration and re-staging assessment is identical 
to that conducted in Part I.  
1.2.10 Exploratory Correlative Studies 
1.2.10.1 Anti-HER2 Antibody Detection and Characterization  
Dr. Henriette Hansen 
Group Leader 
Sales & Customer Communication 
Sales & Customer Support 
T +49-30-6392-7826 
X +49-30-6392-7888 
X 888-578-2666 (available in the US only) 
hansen@jpt.com 
 
JPT Peptide Technologies GmbH - Volmerstrasse 5 - 12489 Berlin, Germany  
Please visit us at www.jpt.com 
1.2.10.2 JPT Peptide Technologies, Midissia Therapeutics and NCI 
A major objective of this study is to determine the immunogenicity of the AdHER2 DC vaccine.  
Specifically, we seek to examine whether AdHER2 DC vaccination is associated with a 3-fold 
increase in anti-HER2/neu antibody concentration (measured as mcg/mL) or a 4-fold increase in 
antibody dilution titers over baseline.  Overlapping HER2 peptide microarrays will also be 
utilized to characterize both vaccine-induced anti-HER2 antibody and cellular responses.   
Anti-HER2 cellular response and clinical response relationship with anti-Ad5 Ab. 
1.2.10.3 Anti-HER2 Cellular Response 
The Berzofsky lab, through support from the NCI Frederick Clinical Support Laboratory will 
assess vaccine-induced HER2-specific responses as measured by IFN-, Granzyme A and 
Granzyme B ELISPOT assay and/or intracellular cytokine staining (ICS). The Berzofsky lab, 
through support from the NCI Frederick Clinical Support Laboratory will check humoral 
immunity i.e. anti-Ad5 antibody titers at baseline as well as post vaccination, to determine if 
autologous AdHER2 DC vaccination results in a change in these anti-Ad5 titers over time, or is 
correlated with the increases in anti-HER2 antibody titers post vaccination. 
1.2.10.4 Circulating Tumor Cells (CTCs): Jane Trepel, DTB, CCR, NCI 
Analysis will be performed by the Trepel laboratory utilizing ferrofluidic enrichment and 
multiparameter flow cytometric detection to study CTCs from a broad range of cancer types. 
CTCs will be identified as viable, nucleated cells, that positively express one or more epithelial 
or tumor markers and are negative for expression of hematopoietic markers. CTCs will be further 
characterized for markers for ICD such as calreticulin, Hsp70 and Hsp90. 

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1.2.10.5 Immune cell subsets: Jane Trepel, DTB, CCR, NCI 
Peripheral blood mononuclear cells (PBMC) will be isolated from patient blood before and after 
treatment, labeled with a unique 2D barcode and viably stored. it will be thawed and assessed 
using multiparameter flow cytometry for immune subsets including but not necessarily limited to 
Tregs, myeloid-derived suppressor cells (MDSC), NK, NKT, CD4+ and CD8+ T-cells, and 
CD14+ monocyte subsets. Assessment will include functional markers, i.e. PD-1, Tim-3, CTLA-
4, CD40, HLA-DR and PD-L1.  
1.2.10.6 Function-Associated mRNAs in Whole Blood: Dr. Cindy Yamamoto, Hitachi Chemical 
Although there have been major recent advances in the field of cancer immunotherapy with the 
approval of sipuleucel-T (Provenge) and ipilimumab (YERVOY), a significant challenge 
that remains is identification of immunologic responses that correlate with beneficial clinical 
outcomes such as tumor regression or survival.  In collaboration with Dr. Cindy Yamamoto of 
Hitachi chemical, we will seek to explore whether characterization of a patient’s baseline 
immune status using assessment of functional mRNAs can be utilized to predict who will 
respond to vaccination.   
The assay is a novel high throughput real time PCR system for quantitatively assaying mRNA 
for any gene that is activated in cells33. Specifically, the methodology allows for quantification of 
17 different leukocyte-function–associated mRNAs in whole blood after ex vivo stimulation with 
up to 8 different antigens (e.g. rIL2, PHA, Anti-TCR, HER2, heat aggregated IgG (HAG, 
immune complex to activate Fc receptor), LPS, Zymosan, and PBS control) on pre-manufactured 
strips. Since the volume blood needed for this test is very small and cell isolation and culture are 
not necessary, this exploratory methodology may serve as a model of personalized medical 
diagnostics for patient-specific cancer vaccine immunotherapy. 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1 
ELIGIBILITY CRITERIA 
2.1.1 Common Eligibility for Parts I and II 
2.1.1.1 Adults ≥ 18 with malignant soft tissue and bone tumors and recurrent or progressive, 
metastatic solid tumors who have progressed on standard therapies except in adjuvant 
for high risk bladder cancer in Part I.  
2.1.1.2 Recurrent or progressive disease on prior standard therapies with known clinical benefit 
with the exception of adjuvant bladder cancer population. 
2.1.1.3 Performance Status: ECOG 0-1. (Refer to Appendix 1) 
2.1.1.4 Baseline LVEF by 2D Echocardiogram ≥ 53%. 
2.1.1.5 Greater than or equal to 1 week since standard or investigational treatment for 
metastatic disease. 
2.1.1.6 Stable, concurrent use of hormone therapy for hormone receptor positive breast cancer 
is permitted. 

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2.1.1.7 Hematologic parameters: ANC ≥ 1000 cells/mm3, ALC ≥ 300 cells/mm3, Hemoglobin   
≥ 9.0 gm/dL, WBC ≥ 2,500 cells/mm3, platelet count ≥ 75,000/mm3, PT/PTT ≤1.5X 
the upper limits of normal. 
2.1.1.8 Chemistry parameters: Creatinine ≤ 1.5 mg/dL, SGOT and SGPT ≤ 3X the upper limits 
of normal and total bilirubin ≤ 1.5 mg/dl, Alk PO4 ≤3X the upper limits of normal 
(except for patients with documented metastatic disease to bone and/or liver). 
2.1.1.9 Negative serum beta HCG if female and of childbearing potential.  
2.1.1.10 Negative HIV 1/2 serology and sample drawn for HTLV. Patients with HIV are 
excluded from participating on this clinical trial because their immunodeficiency would 
confound the evaluation of adverse events which would hinder meeting the primary 
objective. 
2.1.1.11 Negative serology for hepatitis B and C unless the result is consistent with prior 
vaccination or prior infection with full recovery. 
2.1.1.12 Willingness of female and male subjects to use effective contraception e.g. oral 
contraceptives, barrier device, intrauterine device, or condoms, during the study and for 
three months following the last dose of study vaccine. We suggest that subjects do not 
become pregnant or father a child during the study, and for 3 months following receipt 
of the investigational AdHER2 DC vaccine.  
2.1.1.13 Able to understand and provide Informed Consent. 
2.1.1.14 Patients with 1+ to 3+ HER2/neu expression by IHC or an equivocal or positive FISH 
result by 2013 ASCO/CAP guideline. 
HER2 Detection 
Method 
Negative 
Equivocal 
Positive 
Vysis FISH Ratio 
(Measures HER2 
oncogene) 
-Single-probe 
average HER2 
copy number <4.0 
signals/cell 
-Dual-probe 
HER2/CEP17 
ratio <2.0 with an 
average HER2 
copy number <4.0 
signals/cell 
-Single-probe ISH 
average HER2 
copy number ≥4.0 
and <6.0 
signals/cell 
-Dual-probe 
HER2/CEP17 
ratio <2.0 with an 
average HER2 
copy number ≥4.0 
and 
<6.0 signals/cell 
-Single-probe average HER2 
copy number ≥ 6.0 
signals/cell 
-Dual-probe HER2/CEP17 
ratio ≥ 2.0 with an average 
HER2 copy number 
<4.0 signals per cell 
-Dual-probe HER2/CEP17 
ratio ≥2.0 with an average 
HER2 copy number 
<4.0 signals/cell 
-Dual-probe HER2/CEP17 
ratio <2.0 with an average 
HER2 copy number 
≥6.0 signals/cell 
IHC  
(Measures HER2 
protein) 
0-1+ 
2+ 
3+ 
2.1.1.15 Patients must have measurable disease, per RECIST 1.1. See Section 6.2 for the 
evaluation of measurable disease except adjuvant high risk bladder cancer. 

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2.1.2 Part I Eligibility  
2.1.2.1 Naïve to trastuzumab (Herceptin™), pertuzumab (Perjeta™) and lapatinib (Tykerb™), 
ado-trastuzumab emtansine (Kadcyla™) or other HER2-directed therapies.   
2.1.2.2 Malignancy as follows:   
• Malignant soft tissue and bone tumors and recurrent or progressive, metastatic solid 
tumors who have progressed on standard therapies; or, 
• Bladder cancer in the adjuvant setting (adjuvant bladder cancer patients): 
o Tumor stage T3a, T3b, T4a, T4b and any node positive disease regardless of tumor 
stage. 
o Status-post primary cystectomy with curative intent. 
o May or may not have received neoadjuvant cisplatin-based combination 
chemotherapy per NCCN guidelines. 
o May or may not have received adjuvant radiotherapy or chemotherapy based on 
pathologic risk per NCCN guidelines. 
o Greater than or equal to 6 weeks s/p primary surgery with curative intent. 
• NOTE:  Patients with breast, ovarian, cervical, colon, gastric/gastroesophageal junction, 
non-small cell lung, renal cell, bladder, malignant soft tissue and bone tumor, prostate 
cancer or other solid tumors.  
2.1.3 Part II Eligibility 
2.1.3.1 Malignant soft tissue and bone tumors and recurrent or progressive, metastatic solid 
tumors who have progressed on standard therapies. 
2.1.3.2 Recurrent or progressive metastatic disease after standard of care HER2-targeted 
therapies; i.e. trastuzumab (Herceptin™), pertuzumab (Perjeta™), lapatinib (Tykerb™), 
ado-trastuzumab emtansine (TDM1) (Kadcyla™) or other HER2-directed therapies. 
2.1.3.3 Stable, concurrent use of tamoxifen or aromatase inhibitors for hormone receptor 
positive breast cancer is permitted. 
2.2 
EXCLUSION CRITERIA 
2.2.1.1 Pregnant women are excluded from this study because AdHER DC vaccine may have 
the potential for teratogenic or abortifacient effects. Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with AdHER DC vaccine, breastfeeding should be discontinued if the mother is treated 
with AdHER DC vaccine.  
2.2.1.2 Patients with active CNS metastases or leptomeningeal involvement by tumor (patients 
with a history of brain metastases who have successfully treated for brain metastasis by 
surgery or radiation and who have not had any evidence of the new or progressive CNS 
disease for more than 12 months are eligible). 
2.2.1.3 Patients with rapidly progressing disease in the opinion of the Principal Investigator. 
2.2.1.4 Patients with inadequate bilateral peripheral venous or central venous catheter access 
for the required apheresis to allow generation of the autologous AdHER2 DC vaccine 
product. 

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2.2.1.5 Clinically significant cardiac dysfunction defined as a history of > NYHA Class II 
symptoms, angina, congestive heart failure, myocardial infarction, arrhythmias or 
cardiac dysfunction requiring treatment or discontinuation of chemotherapy. 
2.2.1.6 History of changes in baseline LVEF that occurred during prior treatment with  anti-
HER2 treatment. 
2.2.1.7 Cumulative doxorubicin dose > 400mg/m2 (>450 mg/m2 for malignant soft tissue and 
bone tumor patients) or cumulative epirubicin dose > 800mg/m2. 
2.2.1.8 Use of any standard chemotherapy or other investigational agent(s) within 1 week of 
study enrollment. 
2.2.1.9 Use of systemic corticosteroid therapy within 2 weeks of study enrollment, including 
patients receiving replacement corticosteroid therapy.  Note: only topical, inhaled and 
intranasal steroid therapy is permitted. 
2.2.1.10 Active systemic viral, bacterial or fungal infection requiring treatment. 
2.2.1.11 A medical history which the treating physician believes causes the patient to be 
excluded. This includes a remote history of cancer. Please note: squamous cell 
carcinoma, basal cell carcinoma and remote history of cancer with no evidence of 
recurrence for the past 5 years are eligible.  
2.2.2 Recruitment Strategies 
This protocol is being conducted in collaboration with Dr. Henriette Hansen of JPT Peptide 
Technologies  as well as Dr. John Morris of the University of Cincinnati, who was also 
significantly involved in the pre-clinical animal model studies of the AdHER2 vaccine platform 
before he left the NCI. We anticipate that a significant number of HER2 positive patients will 
be referred from these colleagues in addition to patients identified through affiliates at Walter 
Reed National Military Medical Center. We will submit approved protocol to Dr. Susan Love 
Research Foundation’s Army of Women Program (www.armyofwomen.org/) and 
ResearchMatch (https://www.researchmatch.org) for review to allow contact with and 
recruitment through their volunteers. We also made contact with Office of Patient Recruitment, 
National Institutes of Health Clinical Center to update our contact information, generate 
materials including flyers, posting for social media and posters. Additionally, this study will be 
posted on NIH websites and on NIH social media forums. NCI Vaccine Branch Clinical Trials 
team also opened a twitter account (@NCICCR_VB) for the patient recruitment and sharing the 
updated information on cancer vaccine and related topics with other professionals and general 
public. This account is officially registered to Office of Communications and Public Liaison at 
NCI. 
In addition to the standard electronic mailings and postings by the NCI CCR Office of Patient 
Outreach and Recruitment, the former Principal Investigator, now a special volunteer at Vaccine 
Branch, CCR, NCI, Dr. Wood developed a brief video (no more than 5 minutes in length) that 
provides an informational overview to both patients and health care providers describing the 
scientific rationale for and design of the clinical study.   
This video was posted to the YouTube channels of the NCI Office of Communications and the 
NIH Clinical Center. Given that so much of consumer media information is now provided in 
video format that can easily be accessed via the web using computers and smart phone operating 
systems and applications platforms, we believe that this could serve as a novel recruitment tool 

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for patients interested in participating in clinical research studies. See Appendix 13: Patient 
Recruitment Materials. 
2.3 
PRE-SCREENING AND SCREENING EVALUATION 
2.3.1 Pre-Screening 
All potential patients must provide written documentation of the HER2 status of their primary 
tumor and/or a recent tumor biopsy specimen, along with availability of a paraffin tissue block. 
For those with incomplete HER2 characterization as defined by the IHC or FISH, HER2 
characterization will be performed by the NCI Laboratory of Pathology.  
2.3.2 Screening Evaluation 
Patients will undergo a medical history and physical examination, review of concomitant 
medications, including review of symptoms, performance status, and life expectancy and 
apheresis clinic access assessment at screening.  History will also specifically document: 
• Prior exposure to anthracycline chemotherapy agents and total cumulative dose. 
• Prior exposure to HER2-directed therapies: agent, duration and number of rounds of 
treatment. 
• Documentation of New York Heart Association (NYHA) functional classification. (Refer 
to Appendix 2) 
• Imaging studies (obtained within 30 days prior to enrollment). Note: if the patient had 
scans at an outside institution the patient will not be required a screening scan to consent. 
Instead, the baseline scan will be performed at NIH prior to treatment and used to identify 
target lesions. 
o CT scan of neck (optional), chest, abdomen and pelvis  
o MRI of the brain (in select clinically indicated patients)  
o Technetium 99 bone scan (if clinically indicated, for patients with bone 
metastases) 
• 2D Echocardiogram with documentation of LVEF (obtained within 30 days prior to 
enrollment). Note: if the patient had an echo at an outside institution the patient will not 
be required a screening echo to consent. Instead, the baseline echo will be performed at 
NIH prior to treatment) 
• Urinalysis 
• Laboratory evaluation (obtained within 30 days prior to enrollment) 
• CBC with differential counts, PT/PTT, acute care panel, hepatic panel, serum beta-HCG 
(for females with childbearing potential only), anti-HIV-1/2 Ab, anti-HCV Ab, HBsAg, 
HBs Ab, anti-HTLV-1/2 Ab, anti-CMV IgG/IgM and RPR  
Refer to Section 3.4 for the Study Calendar schedule of on study clinical, laboratory, 
radiographic and research evaluations. 
2.4 
REGISTRATION PROCEDURES 
Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) 
within 24 hours of signing consent.  A registration Eligibility Checklist from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 
encrypted email to:  NCI Central Registration Office ncicentralregistration-l@mail.nih.gov. 

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After confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to 
advise them of the acceptance of the patient on the protocol prior to the release of any 
investigational agents. Verification of Registration will be forwarded electronically via e-mail to 
the research team.    
2.4.1 Treatment Assignment Procedures 
Cohorts 
Number 
Name 
Description 
1 
Solid Tumors HER2-
directed therapies naive 
dose escalation cohort 
Patients with ovarian, cervical, colon, non-small cell lung, 
renal cell, bladder, malignant soft tissue and bone tumor, 
prostate cancer or other solid tumors as well patients with 
breast cancer to be treated with AdHER DC vaccine at 
escalating doses. 
2 
Solid Tumors HER2-
directed therapies naïve 
expansion cohort 
Patients with ovarian, cervical, colon, non-small cell lung, 
renal cell, bladder, malignant soft tissue and bone tumor, 
prostate cancer or other solid tumors as well patients with 
breast cancer to be treated with AdHER DC vaccine at 
40x10e6 dendric cells maximum.  
3 
Solid Tumors with prior 
HER2-directed therapies 
dose escalation cohort 
Patients with recurrent or progressive, metastatic breast 
cancer, gastric/gastroesophageal or other cancers treated with 
AdHER DC vaccine at Dose Level 1. 
4 
Solid Tumors with prior 
HER2-directed therapies 
expansion cohort 
Patients with recurrent or progressive, metastatic breast 
cancer, gastric/gastroesophageal or other cancers enrolled in 
dose expansion cohort.  
Arms 
Number 
Name 
Description 
1 
Part I dose escalation 
AdHER DC vaccine administered at escalating doses. 
2 
Part I dose expansion  
AdHER DC vaccine administered at 40x10e6 dendric cells 
maximum. 
3 
Part II dose escalation 
AdHER DC vaccine administered at Dose Level 1.  
4 
Part II dose expansion 
AdHER DC vaccine administered at 40x10e6 dendric cells 
maximum. 
Randomization and Arm Assignment 
There will be no randomization on this study. 
Up to 18 patients in Cohort 1 will be assigned to Arm 1 
Up to 12 patients in Cohort 2 will be assigned to Arm 2 

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31 
Up to 6 patients in Cohort 3 will be assigned to Arm 3 
Up to 24 patients in Cohort 4 will be assigned to Arm 4 
2.5 
BASELINE EVALUATION 
Below studies will be obtained within 30 days prior to the administration of the first dose of 
vaccine. If any of the studies were performed on another protocol, they may not need to be 
repeated. 
• CBC with Differential 
• Acute care panel, hepatic panel, mineral panel, total protein, amylase, lipase, uric acid 
• PT/PTT 
• Lipid panel  
• Immunoglobulin quantification, IgE 
• LDH  
• CPK, Troponin I  
• Thyroid screen (TSH, Free T4) 
• 25-OH-vitamin D  
• Lymphocyte subsets  
• Tumor markers (optional)  
• Urinalysis  
• ABO typing and HLA A, B, C and DR (if not done in NIH Clinical Center in the past) 
• CT CAP (to be done only if screening scans were performed at an outside institution and 
not repeated at the NCI). 
• MRI Brain (to be done only if clinically indicated and screening scans were performed at 
an outside institution and not repeated at the NCI).  
• CT Neck (to be done only if clinically indicated and screening scans were performed at an 
outside institution and not repeated at the NCI). 
• Bone Scan (to be done only if patient has bone metastasis and screening scans were 
performed at an outside institution and not repeated at the NCI). 
• Echocardiogram (to be done only if screening echo(s) were performed at an outside 
institution and not repeated at the NCI). 
3 
STUDY IMPLEMENTATION 
3.1 
STUDY SCHEMA AND DESIGN 
This is an open label, single site, non-randomized, two-part, phase I study of an autologous 
dendritic cell (DC) vaccine transduced with AdHER2 to determine vaccine safety, 
immunogenicity and preliminary activity. The study design schema is outlined in Figure 11.  
Once enrollment eligibility is confirmed and informed consent is obtained, the patient will be 
scheduled for an apheresis of up to 18 liters to collect mononuclear cells by counter-flow 
elutriation, aliquoted into minimum of 6 vials with up to 333 x 106 cells/vial that will be 
cryopreserved for future preparation of the autologous AdHER2 DC vaccine product. If the 
collected apheresis products are not adequate for 5 doses of vaccine, the patient may undergo 

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additional apheresis per investigator’s discretion. Co-enrollment in the 111Indium trastuzumab 
imaging protocol 07-C-0101 will be offered to those patients that are interested and eligible.  
Note: In order to be cleared for the next treatment, a safety visit (i.e., physical and clinical 
laboratory assessments, review of toxicities/adverse events) must occur within 7 days prior to the 
treatment. Treatment visits can also be safety visits for previous injections. This is so the treating 
physician will evaluate the patient for toxicities potentially caused by previous injections. 
Part I N = 30 patients 
Part I of the study will investigate vaccine dose escalation in adults with recurrent or progressive, 
metastatic solid tumors as well as adjuvant bladder cancer patients whose tumors are characterized 
by some HER2/neu expression but for whom trastuzumab is not clinically indicated: 
o Patients with ovarian, cervical, colon, non-small cell lung, renal cell, bladder, 
malignant soft tissue and bone tumor, prostate cancer or other solid tumors that is 
known to be HER2 1+, 2+ or 3+ by IHC OR have a Vysis FISH result ≥ 1.8. 
o Patients with breast cancer that is known to be HER2 2+ or 3+ or with an equivocal 
or positive FISH result. 
NOTE: Adjuvant bladder cancer patients will not be enrolled in Part I of the study until 
AdHER2 DC vaccine safety has been demonstrated out to 12 Weeks in at least 10 patients.  
The goal of Part I is to determine whether there is a preliminary significant, adverse safety signal 
regarding cardiac toxicity in this patient population that is naive to HER2-directed therapies, in 
addition to preliminary assessment of the vaccine’s immunogenicity and clinical activity. 
Allowable tumors include breast, ovarian, colon, non-small cell lung, renal cell, bladder and 
prostate cancer.  Inclusion of a broad spectrum of tumors that express HER2 will facilitate more 
rapid accrual and allow prompt determination of the vaccine’s safety and immunogenicity.  
However, the inclusion of subjects with multiple tumor types that have varying levels of HER2 
expression may preclude identification of an optimal biologically active dose.   
Proposed Dosage and Administration 
This part of the study will enroll patients in the vaccine dose levels outlined below:  
Dose Level 1 (N = 6 patients): 
    
  5 x 106 viable cells/vaccine 
Dose Level 2 (N = 6 patients): 
 
 
10 x 106 viable cells/vaccine 
Dose Level 3 (N = 6 patients):  
 
 
20 x 106 viable cells/vaccine 
Expansion Cohort (N = 12 patients): 
 
 
40 x 106 viable cells/vaccine 
Autologous AdHER2 DC vaccine will be administered intradermally at Weeks 0, 4, 8, 16 and 24. 
Response will be measured as outlined in section 6.2. Vaccine dose escalation will follow the 
procedures specified in Section 3.1.2. 
Part II N = 30 patients 
Part II of the study will be conducted in adults with recurrent or progressive, metastatic breast 
cancer, gastric/gastroesophageal or other cancers with 1+ to 3+ HER2/neu expression by IHC or 
an equivocal or positive FISH result. Vaccine dose escalation (as required by the FDA) will be 
repeated in an identical manner in a population with prior exposure to trastuzumab, pertuzumab, 
lapatinib, ado-trastuzumab emtansine (TDM1) and other HER2-directed therapies) to again 
determine whether there is an adverse safety signal regarding cardiac toxicity, in addition to 
assessment of the vaccine’s immunogenicity and clinical activity.  Vaccine administration and 

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33 
re-staging assessment is identical to that conducted in Part I with revised vaccine dosing as 
outlined below and in Section 3.1.2.  
Proposed Dosage and Administration 
Part II of the study will enroll 30 breast, gastric/gastroesophageal or other cancer patients as 
outlined in the vaccine dose cohorts outlined below: 
Dose Level 1 (N =   6 patients): 
 
 
20 x 106 viable cells/vaccine 
Expansion Cohort (N = 24 patients): 
 
 
40 x 106 viable cells/vaccine 
Autologous AdHER2 DC vaccine will be administered intradermally at Weeks 0, 4, 8, 16 and 
24.  Re-staging will be performed as outlined in Section 6.2. Vaccine dose escalation will follow 
the revised procedures specified in Section 3.1.2. 

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34 
Figure 11: AdHER2 Autologous DC Vaccine Study Schema 
 
 
 

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35 
3.1.1 Dose Limiting Toxicity 
The following assessment guidelines for the management of dose limiting toxicity (DLT) are 
intended to ensure the safety of each patient while on the study.  The descriptions and grading 
scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) 
version 4.0 will be utilized for AE and DLT reporting.  All appropriate treatment areas should 
have access to a copy of the CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40).  
All adverse events will be classified as follows for determination of relatedness to AdHER2 
vaccination: 
• Unrelated 
• Unlikely 
• Possibly related 
• Probably related 
• Definitely related 
For the purposes of this study, the definitions of dose limiting-toxicities include: 
• CTCAE Grade 2 and greater allergic reactions 
• CTCAE Grade 2 and greater autoimmune disorders 
• CTRCD, defined as a decrease in the LVEF of > 10 percentage points, to a value in < 
53%1. Documentation of the above specified change in LVEF will require cardiac 
consultation for determination of clinical significance. Cardiac function deterioration 
clinically associated with apparent cardiotoxic agent use after off-therapy will be 
censored at the point of cardiotoxic agent use. 
• CTCAE Grade 3 or greater organ toxicity (dermatologic, gastrointestinal, hepatic, 
pulmonary, renal/genitourinary, or neurologic) occurring within 30 days of vaccine 
administration that are at least possibly related to research in. 
Immunization-Related Dose Limiting Toxicity: 
• CTCAE Grade 3 and greater anaphylaxis: symptomatic bronchospasm with or 
without urticaria; parenteral intervention indicated; allergy-related edema/angioedma; 
hypotension (Grade 3). Life threatening consequences; urgent intervention indicated 
(Grade 4). 
• CTCAE Grade 3 and greater injection site reactions: ulceration or necrosis; severe 
tissue damage; operative intervention indicated (Grade 3). Life threatening 
consequences; urgent intervention indicated (Grade 4). 
Early stopping rules for accrual will be invoked in each part of the study if: 
• Two or more of 6 patients in a given dose level develop evidence of cardiac toxicity, 
accrual will be stopped to that dose cohort.  Accrual expansion of an additional 12 
patients will occur in the next lower dose level to further evaluate for cardiac 
toxicity. 
• Any death (unrelated to underlying primary disease) that occurs and is attributed 
as being possibly, probably or definitely related to the investigational AdHER2 DC 
vaccine (FDA requirement)  

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36 
3.1.2 Dose Escalation 
It has been reported that up to 7% of patients with HER2/neu expressing tumors treated with 
trastuzumab monotherapy for metastatic breast cancer developed clinically significant cardiac 
dysfunction including congestive heart failure.  It would be considered acceptable if the 
therapeutic AdHER2 vaccine proposed for this study would produce no greater than that level of 
cardiac toxicity, but not if it were to be exceeded. In order to evaluate this using a limited 
number of patients, a two-part design, but incorporating an early stopping rule, will be 
implemented. The goal is to accrue 30 evaluable patients in each of Part I and Part II of the study 
and treat them with the experimental AdHER2 vaccine.  Unless an early stopping rule is 
invoked, the number of patients who have experienced a clinically significant cardiac toxicity 
will be determined to estimate the frequency of cardiac toxicity.  In addition, the dose level(s) at 
which toxicity is observed will also be examined. The statistical rationale for the targeted accrual 
of 30 patients in each part of the study is outlined in the statistical Section 10. 
Dose escalation will proceed in groups of 6 patients. Dose escalation will proceed as long as 0 
to1 of 6 patients at given dose level have no evidence of toxicity and at least 3 of the 6 patients at 
the dose level have reached Week 12 on study.  If 2 of 6 patients on any given dose level develop 
cardiac toxicity, that dose cohort will be closed to further accrual, no higher doses will be 
explored, and dose expansion of an additional 12 patients will be enrolled in the next lower dose 
level to further assess for cardiac toxicity. The vaccine dose at which 0 to 1 of 18 treated 
patients in Dose Levels 1 to 3 develop cardiac toxicity will be defined as the maximum 
tolerated dose (MTD). If two or more patients out of 18 at a given dose level have developed 
cardiac toxicity, then the MTD will have been exceeded at that dose, and the dose level 
below that one will be considered the MTD. Since enrollment in Dose Level 3 has been 
reached and 0 of 6 patients has toxicity, then an expansion cohort of 12 patients, will be 
added for a maximum targeted accrual of 30 patients in Part 1. The 12 patients will be accrued 
at the 40x10^6 dose level without any planned interim stop, as cardiac toxicity is not presently 
anticipated given the results as of 12/11/15. With all 12 enrolled as a single group, there is a 
4.9% probability of having 2 or more of 12 patients with cardiac toxicity if the true probability 
for a given patient is 3%, and 55.7% of having 2 or more of 12 with cardiac toxicity if the true 
probability for a given patient is 15%. Therefore, observing 0-1 of 12 with toxicity would be 
acceptable, and 40 x10^6 would be considered the maximum evaluated and tolerated dose. If we 
observe 2 or more with cardiac toxicity at or before accruing the 12th patient, this exceeds a safe 
level. Further patients would be added subsequently, by amendment, to the next lower dose, to 
confirm its safety. 
If dose escalation has proceeded in the first three dose levels in Part I and 0 of 20 patients have 
experienced cardiac toxicity, Part II of the study in patients with metastatic breast, gastric, 
gastroesophageal junction or other cancers and prior exposure to HER2-directed therapies will 
proceed with vaccine dosing based on the safety confirmed in Part I and outlined in Section 
3.1.2. A maximum accrual of 30 patients will be enrolled in Part II.  
If no DLTs are observed, then dose levels in Part I and Part II will be assessed for the fraction of 
patients with immunogenicity and clinical outcomes to determine the biologically optimal 
vaccine dose that would be used in any future phase II studies involving those respective patient 
populations. 
To allow for the possibility of inevaluable patients, an accrual ceiling of 65 will be used. 

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37 
3.2 
DRUG ADMINISTRATION 
All patients will undergo up to18-liter apheresis to remove peripheral blood monocytes for 
dendritic cell preparation. Cells used for subsequent dendritic cell maturation will be derived 
from monocytes frozen during the initial apheresis.  Autologous AdHER2 dendritic cell vaccine 
will be manufactured under cGMP conditions by the NIH Clinical Center Department of 
Transfusion Medicine as outlined in Appendix 3. If the mononuclear cells or plasma collected 
are not adequate for minimum of 5 doses of vaccine, the patient will undergo optional additional 
leukapheresis or plasma collection per investigator’s discretion.  
• Autologous AdHER2 DC vaccine preparations will be assessed for release standards 
(nucleated cell content and concentration, appearance, flow cytometric verification of DC 
validation markers, viability > 60%, and product sterility and safety testing) as well as for 
HER2 expression (percent of cells expressing HER2/neu and the ratio of geometric mean 
fluorescent intensity (MFI) of HER2/neu expression to isotype control).   
• For patients in both Part I and Part II of the study, autologous AdHER2 DC vaccinations will 
be dosed according to enrollment dose levels (5, 10, 20, or 40 x 10^6 viable cells/vaccine) 
and administered intradermally in up to two injection sites at Weeks 0, 4, 8, 16 and 24 for a 
total of five vaccinations. Vaccine will be administered in the 3SE Day Hospital and patients 
will be monitored for immediate adverse event vaccine reactions (VS, clinical assessment) 
for 1 hour following their first HER2 DC vaccine dose.  If no adverse reactions are observed 
with the first vaccination, patients will be monitored for 15 minutes for all subsequent 
vaccinations.   
• If an adverse reaction is observed following the first vaccine, the reaction will be 
characterized and a determination made as to whether it is considered a dose limiting toxicity 
(DLT) as outlined in Section 3.1.1.  If the adverse reaction is determined not to be a DLT, the 
duration of post-vaccination monitoring for subsequent vaccinations will be determined by 
the Principal Investigator and Lead Associate Investigator as clinically indicated depending 
on the severity of the initial vaccine reaction. 
• All patients will be given an AdHER2 DC Vaccine Report Card (refer to Appendix 5) and 
instructed on how to complete it, following each AdHER2 DC vaccine dose. 
• Continued injection of the same forearm is permissible for patients who have one functional 
forearm or a medical condition that does not allow for continued injections of both forearms. 
Since this protocol involves AdHER2 DC vaccination in humans using this vector for the first 
time, enrollment into subsequent dose level for both Part I and Part II patients will be staggered 
to allow for safety monitoring as outlined in Section 3.1.2: dose escalation will proceed as long 
as 0 of 6 or 1 of 6 patients within a dose level have no evidence of toxicity and at least 3 of the 6 
patients within the same dose level have reached Week 12 on study before enrollment in the next 
vaccine dose level can begin.  If no dose limiting toxicities as defined in Section 3.1.1 are 
observed in the twelve-week window inclusive of the first three vaccinations, enrollment of 
additional patients may proceed as quickly as is logistically feasible as outlined above and in 
accordance with the dose escalation parameters outlined in Section 3.1.2. 

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38 
3.3 
DOSE MODIFICATION AND IMMUNIZATION STOPPING RULES 
Unlike trastuzumab, the AdHER2 vaccine being given in this study targets both the extracellular 
(EC) and transmembrane (TM) domains of HER2.  Use of trastuzumab in women with breast 
cancer has been shown to be associated with a small, but significant risk (about 7%) for 
developing cardiac dysfunction. Exactly how trastuzumab causes cardiac toxicity is unknown.  
The goal of vaccination with this product is to stimulate the patient’s own immune system to 
make antibodies (and also potentially killer cells) that recognize HER2.  It is not known whether 
or not antibodies made by a person’s own immune system will cause cardiac dysfunction.  In 
addition, if antibodies made by the immune system following AdHER2 DC vaccination were to 
cause cardiac toxicity or other significant clinical adverse events, it would be very challenging 
because the immune system cannot simply be “turned off”.   
Thus, no dose modifications will be made in patients receiving AdHER2 DC vaccination. 
Subjects will cease to receive immunization if they experience dose-limiting toxicity (DLT) as 
outlined in Section 3.1.1. 
Supportive Management of Patients Experiencing DLT: 
 
• For patients experiencing Grade 2 or greater allergic or autoimmune DLT, supportive 
clinical intervention will be provided until the DLT resolves to < Grade 1. 
• For patients experiencing Grade 2 or greater cardiac DLT, supportive clinical 
intervention will be provided until the DLT resolves to < Grade 1. 
o Patients will also undergo repeat LVEF measurements at 4-week intervals until LVEF 
returns to baseline function.  Thereafter, cardiac function will continue to be 
monitored according to the study schema outlined in Figure 11 until study Week 124. 
o Patients who experience Grade 2 or greater cardiac DLT that does not resolve to < 
Grade 1 will continue to receive clinical support and be monitored according to the 
study schema outlined in Figure 11. 
o  until study Week 124. 
• For patients experiencing Grade 3 or greater organ (dermatologic, gastrointestinal, 
hepatic, pulmonary, renal/genitourinary or neurologic) DLT supportive clinical 
intervention will be provided until the DLT resolves to < Grade 1. 
• For patients experiencing Grade 3 or greater anaphylaxis DLT, supportive clinical 
intervention will be provided until the DLT resolves to < Grade 2. 
• For patients experiencing Grade 3 or greater local injection site reactions, supportive 
clinical intervention will be provided until the DLT resolves to < Grade 1. 
• NOTE: Once patients have completed participation in this study, there is no provision 
for long term medical care by the Clinical Center, NIH or the NCI. 
 
 

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39 
3.4 
STUDY CALENDAR 
 
Study Procedures 
Screen 
Wk 
0 
Wk  
4 
Wk  
8 
Wk 
12 
Wk 
16 
Wk 
20 
Wk 
24 
Wk 
28 
Wk 
32 
Wk 
36 
Wk 
40 
Wk 
4817 
Wk 
6018 
Wk 
7618 
Wk 
10018 
Wk 
12418 
NIH Advanced Directives1 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Height/Wt/NYHA 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening labs/HLA2 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam/ECOG3   
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
Concomitant Medications 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
Clinical labs4 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
Tumor Markers5 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
LDH/CK/Troponin6 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
 
 
 
 
 
 
TSH/25-OH Vit D 
√ 
√ 
 
 
 
 
 
√ 
 
 
 
 
√ 
 
 
 
 
Lymphocyte Subsets/ 
Ig QA/IgE 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
Serum beta HCG7 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
 
 
 
 
 
 
Urinalysis 
√ 
√ 
 
 
 
 
 
√ 
 
 
 
 
√ 
 
 
 
 
Anti-HER2 Ab/ Profile8 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Anti-Ad5 Antibody9 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Cellular HER2 Response10 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Immune Subset/CTCs11 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Hitachi mRNA 
 
√ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MRI Brain12, CT Neck12, 
bone scan13 
√ 
 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
CT Chest/Abd/Pelvis14 
√ 
 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
2-D ECHO15 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
 
√ 
√ 
√ 
√ 
√ 
AdHER2 DC vaccine16 
Apheresis 
√ 
√ 
√ 
 
√ 
 
√ 
 
 
 
 
 
 
 
 
 
Vaccine Report Card 
 
√ 
√ 
√ 
 
√ 
 
√ 
 
 
 
 
 
 
 
 
 
Adverse Events 
 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
 
 
 
 
 
 
 
 

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1 As indicated in Section 12.3, all subjects ≥ age 18 will be offered the opportunity to complete an NIH advanced directives form.  This should be 
done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained. The completion of the form is 
strongly recommended, but is not required 
2 Screening labs: CBC diff, PT/PTT, acute care panel, hepatic panel, serum beta HCG, urinalysis, and the following DTM labs: Anti-HIV 1/2 Ab, 
Anti-HCV Ab, HBsAg, Anti-HBs Ab, anti-HTLV 1/2 Ab (pending result is acceptable for eligibility), anti-CMV IgG/IgM, and RPR. If DTM labs 
are performed > 30 days prior to apheresis, DTM labs must be repeated. HLA will not determine eligibility and if it was done previously at the 
NIH it does not need to be repeated. 
3 Patients should be evaluated within 7 days prior to upcoming vaccination as a clearance for treatment.  
4 Clinical labs CBC with differential, PT/PTT, acute care panel, hepatic panel, mineral panel, total protein, amylase/lipase, uric acid, lipid panel.  
5 Tumor markers are optional and will be tested dependent on the primary sites. Patients with primary breast, ovarian and GI tract cancer might be 
tested for CA 125, CA 15-3, CA19-9, CA 27-29, and CEA. Other organ specific tumor markers can be tested 
6,7 Only until 12 weeks after the last dose of vaccination.  
8-11 Research bloods will not be used in data analysis if the patient has started on any treatment that can affect the data of the study. Week 40 and 
after samples will only be collected if the patient has not progressed (PD). 
12 This is optional and to be performed if clinically indicated. If the patient received scans within 30 days of enrollment at an outside institution the 
patient will not be required to have a second scan performed. Instead, the baseline scan will be used to collect target lesions. 
13 If the patient received scans within 30 days of enrollment at an outside institution the patient will not be required a screening scan to consent. 
Instead, the baseline scan will be used to identify target lesions. If the patient has bone metastasis and clinically indicated, a bone scan will be done 
at restaging.  
14 If the patient received scans within 30 days of enrollment at an outside institution the patient will not be required to have a second scan 
performed. Instead, the baseline scan will be used to collect target lesions. If a confirmatory scan is performed in less than 8 weeks from prior CT, 
the interval of CT follow-up will be adjusted to maintain 8 weeks interval to avoid unnecessary radiation exposure. For bladder cancer adjuvant 
indication, CT scans every 12 weeks during first 12 month, every 16 weeks for the next 12 months and at the end of study if no recurrence.  
15 Optional documentation on cardiac function will be collected once a patient is on study but off treatment for the purposes of long-term 
assessment of the impact of AdHER2 vaccination on cardiac function. Note: if the patient had an echo within 30 days of enrollment at an outside 
institution the patient will not be required a screening echo to consent. Instead, the baseline echo will be performed at NIH prior to treatment and 
used to identify target lesions. 
16 Dose can be delayed up to 8 weeks. The study will reset at the time of study resumption. For example, if dose at week 8 is delayed and resumed 
at original week 11, that week 11 will now be considered week 8. 
17 If there is a need for confirmatory scans based on the result of Week 48 evaluation, additional visit will occur at week 52 which will include 
clinical assessment with physical exam and laboratory assessment.  
18  Patients who progress do not require a full evaluation. Only physical exam, clinical labs, echocardiogram and AE reports will be required.  

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3.5 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA 
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy. 
3.5.1 Criteria for Removal from Protocol Therapy 
3.5.1.1 Completion of protocol therapy (receipt of 5 doses of autologous AdHER2 DC 
vaccine). 
3.5.1.2 Disease progression per 6.2, Response Criteria. Note Exception: Clinically stable 
patients with PD at Weeks 8, 16 or 24 re-staging will be allowed to remain on protocol 
therapy per PI’s discretion.    
3.5.1.3 Patient experiences a dose limiting toxicity as outlined in Section 3.1.1.   
3.5.1.4 Patient experiences a Grade 3 or greater adverse event/toxicity not described in Section 
3.1.1 that is deemed by the Principal Investigator as possibly, probably or definitely 
related to AdHER2 DC vaccination. 
3.5.1.5 Patient experiences unresolved treatment-related toxicity. 
3.5.1.6 Diagnosis of a secondary malignancy other than superficial basal cell or squamous cell 
carcinoma of the skin. 
3.5.1.7 The patient experiences a treatment delay of more than 8 weeks from the scheduled 
target date for receipt of AdHER2 DC vaccine. 
3.5.1.8 Inter-current illness or medical circumstance that in the opinion of the Principal 
Investigator unacceptably increases the risk of treatment. This applies to the conditions 
related to the cancer diagnosis that led to the enrollment in current study. 
3.5.1.9 The patient is non-compliant with study requirements. 
3.5.1.10 The patient becomes too ill to return for protocol specified study visits. 
3.5.1.11 The patient becomes pregnant during the study. 
3.5.1.12 The patient requests to be withdrawn and refuses further therapy. 
3.5.1.13 The patient requires a prohibited concomitant medication. 
3.5.1.14 Death 
3.5.2 Continued Monitoring for Potential Cardiac Toxicity Once Off Protocol Therapy 
3.5.2.1 Patient is removed from therapy for reasons outlined in Section 3.5.1. 
3.5.2.2 Patient will continue to undergo designated cardiac monitoring studies at subsequent 
study weeks as outlined in Figure 11. 
3.5.2.3 Cardiac troponin levels (Weeks 0, 4, 8, 12, 16, 20, 24, 28, 32, 40 and 48) and 
echocardiograms (Weeks 4, 12, 20, 28, 32, 40, 48, 60. 76, 100 and 124) including HPE 
and ECOG assessments.  
3.5.2.4 Cardiac monitoring will be performed either at the NIH or through the patient’s LMD. 
For patients who come off-treatment for disease progression or other reasons, every 
effort will be made to capture ongoing documentation on cardiac function as is 
reasonably practicable, to allow long-term assessment of the impact of AdHER2 
vaccination on cardiac function. 

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3.5.3 Off Study Criteria 
3.5.3.1 Completion of scheduled study visits. 
3.5.3.2 PI decision to end the study. 
3.5.3.3 Patient requests to be withdrawn and refuses further study participation. 
3.5.3.4 The patient is non-compliant with study requirements. 
3.5.3.5 The patient becomes too ill to return for protocol specified study visits. 
3.5.3.6 Documentation of rapid disease progression or clinical deterioration between the 
screening (including outside information) and baseline evaluations. These patients will 
be removed from study and precluded from receiving AdHER2 DC vaccination. 
3.5.3.7 If a patient begins to take a known cardiotoxic agent the patient will come off study and 
we will not use data after that point. 
3.5.3.8 Death 
3.5.4 Off Protocol Therapy and Off Study Procedure 
All subjects must be taken off study through the NCI Central Registration Office CRO). 
Authorized staff must notify CRO when a subject is being taken off protocol therapy and when a 
subject is taken off-study. A Participant Status Updates Form the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and 
sent via encrypted email to:  NCI Central Registration Office ncicentralregistration-
l@mail.nih.gov.   
4 
CONCOMITANT MEDICATIONS/MEASURES  
• Patients are allowed to be on concomitant therapy with tamoxifen or aromatase inhibitors 
for ER+ tumor status. 
• Patients may be on concomitant drugs to prevent skeletal related events (SRE), including 
bisphosphonates and denosumab. 
• Study subjects will be allowed to take multivitamins, analgesics (NSAIDS or 
acetaminophen), antipyretics, and antihistamines for symptomatic relief of local or 
systemic injection site reactions. 
• Patients are allowed to continue on medications as clinically indicated for treatment of 
chronic medical conditions e.g. hypertension, diabetes, hypercholesterolemia, etc. 
• Excluded Therapy: 
o Trastuzumab, pertuzumab, lapatinib, ado-trastuzumab emtansine (TDM1) or other 
HER2-directed therapies within 1 week of study enrollment. 
o Chemotherapy: Concomitant use of chemotherapy is not allowed during this trial. 
o Anti-Cancer Radionuclides: Concomitant use of anti-cancer radionuclides is not 
allowed during this trial.  Patients will be allowed to co-enroll in studies of novel 
radionuclide imaging agents e.g. 111Indium CHX-A DTPA trastuzumab. 
o Secondary Hormonal Therapies: Concomitant use of supplementary hormonal 
treatments other than tamoxifen or aromatase inhibitors is not allowed.  
o Corticosteroids: Concomitant, chronic systemic corticosteroids are not allowed 
during this trial (excepting emergent use for clinical indications).  However, the use 

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of inhaled corticosteroids, intranasal sprays and topical creams on limited body areas 
is allowed. 
Vitamin D3 (Cholecalciferol) Supplementation 
Vitamin D when ingested is metabolized in the liver to 25-OH vitamin D.  Inside cells, it 
is metabolized further by 1-hydroxylase where it is transformed into a seco-steroid 
hormone that is important to a host of critical cellular and immune functions within the 
body.  Within cells is a second enzyme 24-hydroxylase whose function is to decrease 
vitamin D, thereby maintaining intracellular vitamin D homeostasis.  The classic function 
of vitamin D is to regulate calcium homeostasis and in turn, bone formation and 
resorption.  However, additional functions of vitamin D have been demonstrated and 
include effects on immune response by promoting cellular apoptosis and differentiation.  
The exact role of vitamin D deficiency in prostate, breast, colon and other cancers has 
been controversial, with some laboratory studies suggesting there is a role and other 
epidemiological studies suggesting that there is no role or even possibly that 
supplementation should be avoided. In a recent study by Marshall and colleagues34 
vitamin D supplementation of 4.000 IU per day for one year was examined in men with 
low risk prostate cancer (Gleason score of 6, 1-6 cores positive out of 12 possible and a 
PSA <10) under active surveillance. After one year upon re-biopsy, 60% showed a 
decrease in the number of positive cores, Gleason score or both and in 6% these factors 
remained unchanged.  In addition, PSA levels did not rise.   In another study reported by 
Vieth and colleagues at AACR in April 201235, 66 men scheduled to undergo radical 
prostatectomy were randomly assigned to receive a daily vitamin D dose of 400, 10,000 
or 40,000 IU daily for 3 to 8 weeks prior to surgery.  Calcitriol levels in the prostate 
increased progressively with increasing vitamin D dosing and corresponded with lower 
levels of Ki67 as well as higher levels of specific growth-inhibitor microRNAs.  
Several studies have shown that women with low vitamin D levels have an increased risk 
of breast cancer incidence and mortality, but research is lacking investigating vitamin D 
levels and prognostic variables e.g. hormone receptor status, Oncotype DX etc. in this 
patient population.  In a case control study of 194 women s/p breast cancer surgery and 
194 cancer-free controls conducted by Peppone and colleagues at the University of 
Rochester36, women with breast cancer were found to have significantly lower 25-OH 
vitamin levels than controls (32.7ng/mL vs. 37.4 ng/mL respectively, P=0.02).  
Importantly, women with suboptimal 25-OH vitamin D levels (<32 ng/mL) had 
significantly increased odds of having ER-negative (OR = 2.59, 95% confidence interval 
[95% CI] = 1.08-6.23) and triple-negative cancer (OR = 3.15, 95% CI = 1.05-9.49) than 
those with optimal 25-OH D concentrations. In addition, women with basal-like 
phenotype had lower 25-OH vitamin D levels than women luminal A phenotype 
(24.2 ng/mL vs. 32.8 ng/mL, respectively P = 0.04).  In summary, women with a more 
aggressive breast cancer molecular phenotype (basal-like) and worse prognostic 
indicators (ER- and triple-negative) had lower mean 25-OH vitamin D levels. 
Given its critical role in immune function and possible role in cancer pathophysiology, all 
patients will have 25-OH vitamin D levels obtained at baseline.  Although there is debate 
about the target level of 25-OH vitamin D for optimum health, most vitamin D experts 
agree that it should be greater than 40 ng/mL.   

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• All patients with 25-OH vitamin D levels < 40 ng/mL will be initiated on oral 
supplements of Vitamin D3 (cholecalciferol) per standard clinical care 
guidelines.  25-OH vitamin D levels will continue to be monitored at study Weeks 
8, 16, 28 and 60.   
5 
BIOSPECIMEN COLLECTION 
5.1 
CORRELATIVE STUDIES FOR RESEARCH/PHARMACOKINETIC STUDIES 
There are no pharmacokinetic studies that will be performed as part of this clinical investigation. 
Evaluation of anti-HER2 antibody and cellular HER2 responses Tetramer and IFN-γ ELISPOT 
Assays will be performed as outlined in Appendix 6. If the patient does not need a confirmatory 
scan at Week 52, the same set of evaluations will be done at Week 60 instead of Week 52. 
Characterization of vaccine-induced antibody profiles (anti-HER2 Antibody Profile) will be 
performed as outlined in Appendix 6. No additional blood to be drawn: serum will be aliquoted 
from blood drawn for anti-HER2 antibody studies. 
Evaluation of anti-Ad5 antibody immunity will be performed as outlined in Appendix 7. 
Characterization of soluble HER2 and anti-HER2 antibodies will be performed on the stored 
samples as outlined in Appendix 8Characterization of Soluble HER2 and Anti-HER2 
Antibodies.  
Exploratory correlative studies (Week 0) measuring function-associated mRNAs in whole blood 
to be performed by Dr. Cindy Yamamoto and circulating tumor cells (CTCs) and immune subset 
analysis will be performed by Jane Trepel as outlined in Appendix 9. 
5.2 
SAMPLE STORAGE, TRACKING AND DISPOSITION 
Collection and storage of Research Samples 
For research samples obtained for investigation, the Clinical Support Laboratory, Leidos 
Biomedical Research, Inc. processes and cryopreserves samples in support of IRB-approved, 
NCI clinical trials. The laboratory is located in a controlled-access building and laboratory doors 
are kept locked at all times. Upon specimen receipt each sample is assigned a unique, sequential 
laboratory accession I.D. number. All products generated by the laboratory that will be stored 
either in the laboratory freezers or at a central repository facility are identified by this accession 
I.D.  An electronic database is used to store information related to patient samples processed by 
the laboratory.  Vial labels do not contain any personal identifier information.  Samples are 
stored inventoried in locked laboratory freezers and are routinely transferred to the NCI-
Frederick repository facilities for long-term storage. These facilities are operated by American 
Type Culture Collection (ATCC), under subcontract to Leidos Biomedical Research, Inc.  
Access to stored clinical samples is restricted. Investigators establish sample collections under 
“Source Codes” and the investigator responsible for the collections, typically the protocol 
Principal Investigator and/or Lead Associate Investigator, specifies who has access to the 
collection. 
When requests are submitted by the NCI investigator for shipment of samples outside of the NIH 
it is the policy of the laboratory to request documentation that a Material Transfer Agreement 

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(MTA) is in place that covers the specimen transfer.   The laboratory does not provide patient 
identifier information as part of the transfer process but may, at the discretion of the NCI 
investigator, group samples from individual patients when that is critical to the testing process.  
The NCI investigator responsible for the sample collection is responsible for ensuring 
appropriate IRB approvals are in place and that an MTA has been executed prior to requesting 
the laboratory to ship samples outside of the NIH. 
Blood, urine and tissue specimens collected in the course of this research project may be banked 
and used in the future to investigate new scientific questions related to this study.  However, this 
research may only be done if the risks of the new questions were covered in the consent 
document and the proposed research has undergone prospective IRB review and approval.  If 
new risks are associated with the research (e.g., analysis of germ line genetic mutations.) the 
Principal Investigator must amend the protocol and obtain informed consent from all research 
subjects. 
Once primary research objectives for the protocol are achieved, intramural researchers can 
request access to remaining samples provided they have an IRB-approved protocol and patient 
consent.  Access to these samples will only be granted following IRB approval of an additional 
protocol, granting the rights to use the material. 
If at any time, a patient withdraws from the study and does not wish for their existing samples to 
be utilized, the individual must provide a written request.  Following receipt of this request, the 
samples will be destroyed (or returned to the patient, if so requested), and reported as such to the 
IRB.  The PI will record any loss or unanticipated destruction of samples as a deviation. 
Reporting will be per the requirements of Section 0. 
5.2.1 Samples collected by the Blood Processing Core of the Clinical Pharmacology Program 
All samples will be bar-coded, with data entered and stored in the Patient Sample Data location.  
Bar coded samples are stored in bar coded boxes in a locked freezer at either -20 or -80C 
according to stability requirements.  These freezers are located onsite in the CPP and offsite at 
NCI Frederick Central Repository Services (ATCC) in Frederick, MD. Samples will be stored 
until requested by a researcher named on the protocol.  All requests are monitored and tracked in 
the PSDM System. All researchers are required to sign a form stating that the samples are only to 
be used for research purposes associated with this specific clinical trial (as per the IRB approved 
protocol) and that any unused samples must be returned to the CPP. 
Following completion of this study, samples will remain in storage as detailed above. Access to 
these samples will only be granted following IRB approval of an additional protocol, granting 
the rights to use the material. Samples will be stored for future use following completion of the 
study unless a subject has opted out of the future use of data and specimen. 
If, at any time a patient withdraws from the study and does not wish for his/her existing samples 
to be utilized, the individual must provide a written request.  Following receipt of this request, 
the samples will be destroyed (or returned to the patient, if so requested), and reported as such to 
the IRB. Any samples lost (in transit or by a researcher) or destroyed due to unknown sample 
integrity (i.e. broken freezer allows for extensive sample thawing, etc.) will be reported as such 
to the IRB. 
Sample barcodes are linked to patient demographics and limited clinical information. This 
information will only be provided to investigators listed on this protocol, via registered use of the 

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PSDMS. It is critical that the sample remains linked to patient information such as race, age, 
dates of diagnosis and death, and histological information about the tumor, in order to correlate 
genotype with these variables. 
5.3 
SAMPLES FOR GENETIC/GENOMIC ANALYSIS 
No genetic/genomic analyses will be performed as part of this clinical investigation. 
6 
DATA COLLECTION AND EVALUATION  
6.1 
DATA COLLECTION 
1. 
Each patient must meet all eligibility requirements and a completed registration must be 
sent to the NCI Central Registration Office (CRO). 
2. 
The Consent Document must be signed prior to registration with the CRO. 
3. 
Treatment will be given according to protocol (on-study and treatment notes, reports of 
adverse events and documentation of any deviation from the study protocol). 
4. 
Data will be entered into a secure software system (C3D Database) produced by Oracle™ 
Corporation (Redwood Shores, CA).  Data will be collected based on protocol-specific 
requirements, verified for accuracy and completeness.  Any hard copy data will be kept in 
locked secure area in the Vaccine Branch Clinical Trials Offices (Bldg 10, Rm. 4B-54). 
5. 
Toxicity will be assessed according to the protocol using the CTCAE v4.0 that is 
available at: http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
6. 
Response will be assessed according to the protocol and documentation of response (e.g. 
CT scans, laboratory reports, dated notes on tumor assessment and clinical assessment as 
appropriate) using Immune Response Related Criteria as outlined in Section 6.2.  
7. 
Vaccine report cards associated with each AdHER2 DC vaccination will be obtained for 
each patient. 
The PI will be responsible for overseeing entry of data into an in-house password protected 
electronic system (C3D) and ensuring data accuracy, consistency and timeliness. The principal 
investigator, associate investigators/research nurses and/or a contracted data manager will assist 
with the data management efforts. All data obtained during the conduct of the protocol will be 
kept in secure network drives or in approved alternative sites that comply with NIH security 
standards. Primary and final analyzed data will have identifiers so that research data can be 
attributed to an individual human subject participant. 
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event.  
Document AEs from the first study intervention, Study Week 0, through 30 days after the last 
study intervention. Beyond 30 days after the last study intervention, only adverse events which 
are serious and related to the study intervention need to be recorded. 
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following: 
• 
Results in discontinuation from the study 
• 
Is associated with clinical signs or symptoms  

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• 
Requires treatment or any other therapeutic intervention 
• 
Is associated with death or another serious adverse event, including hospitalization.  
• 
Is judged by the Investigator to be of significant clinical impact 
• 
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
Laboratory and clinical symptom abnormalities less than or equal to Grade 1 will not be graded 
or assessed for attribution to AdHER2 DC vaccine.  
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH 
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in Section 7.2.1.  
Dr. Fojo will continue to have access to the data for purposes of data analysis and publication.  The 
necessary data will be sent via encrypted email. 
6.2 
RESPONSE CRITERIA 
Tumor measurements for response will be conducted at Weeks 8, 16, 24, 36, 48, 76, 100, and 
124 with confirmatory scans obtained not less than 4 weeks following initial documentation of 
objective response. Adjuvant bladder cancer patients will undergo re-staging at Weeks 8, 16, 24, 
36, 48, 76, 100, and 124 with confirmatory scans with confirmatory scans obtained not less than 
4 weeks following initial documentation of objective response as outlined in the protocol Study 
Calendar in Section 3.4 and clinical evaluations will include physical examination, neck 
(optional), chest, abdomen and pelvis CT imaging and bone scan when clinically indicated. 
Dependent on the tumor site, MRI can be performed instead of CT scan. Patients with history of 
CNS disease will be evaluated for the necessity of follow up brain MRI. Due to the requirement 
of confirmational scans for the evaluation of the response at least 4 weeks after the initial 
documentation of the response, subsequent scan schedules can be adjusted to allow adequate 
interval and to avoid unnecessary radiation exposure from fixed CT scan schedules. After off-
therapy or PD documentation, restaging scans are optional. 
A modified Immune-Related Response Criteria (modified irRC) based on RECIST 1.1 will be 
used to determine the response as outlined in Section 6.2.6 Table 2 37. Changes in the largest 
diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the 
case of malignant lymph nodes will be used as per RECIST 1.1 criteria. 
The modified irRC will be based upon RECIST 1.1 criteria (described below) except for 2 major 
changes:  
1) require confirmation of progression by imaging at least 4 weeks after initial imaging and  
2) do not necessarily score the appearance of new lesions as progressive disease if the sum of 
lesion diameters of target lesions (minimum of 10 mm per lesion, maximum of 5 target lesions, 
maximum of 2 per organ) and measurable new lesions does not increase by ≥ 20%. 
Efficacy assessments will be made by the Investigator at the investigational site.  All objective 
responses will have confirmatory scans performed at least 4 weeks after the response was first 

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documented per the modified irRC convention (e.g. initial scan at Week 8, confirmatory scan at 
Week 12 or after etc.).  The PI will review and confirm all objective responses. 
6.2.1 Response Definitions 
Response and progression will be evaluated in this study using the new modified irRC37 (Section  
6.2.6.) Note: Lesions are either measurable or non-measurable using the criteria for disease 
parameters outlined in Section 6.2.2 provided below. The term “evaluable” in reference to 
measurability will not be used because it does not provide additional meaning or accuracy. 
6.2.2 Disease Parameters 
Measurable disease:  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as:  
• By chest x-ray: >20 mm;  
• By CT scan:  
o Scan slice thickness 5 mm or under as >10 mm with CT scan 
o Scan slice thickness >5 mm: double the slice thickness  
• By MRI:  >10 mm 
• With calipers on clinical exam: >10 mm   
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). 
Note: Tumor lesions that are situated in a previously irradiated area are not to be considered 
measurable unless they demonstrate progression. 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm).  At baseline and in follow-up, only the short axis will 
be measured and followed. 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses 
(not followed by CT or MRI), are considered as non-measurable. 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline. Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 

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occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion that can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease. 
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
6.2.3 Methods for Evaluation of Measurable Disease 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment. 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice thickness 
greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. 
For certain body parts or lesions, MRI can replace CT for response evaluation and such an MRI 
should be optimized for the evaluation of the type and site of the disease.  
Clinical lesions:  Clinically visible skin lesions will be utilized to evaluate measurable disease. 
Chest x-ray:  Chest x-ray will not be utilized to evaluate measurable disease. 
Ultrasound:  Ultrasound will not be utilized as a method of measurement.   
6.2.4 Evaluation of Target Lesions  
o Complete Response (CR): Disappearance of all target lesions. Any pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
o Partial Response (PR): At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum of diameters. 
o Progressive Disease (PD): At least a 20% increase in the sum of the diameters of 
target lesions, taking as reference the smallest sum on study (this includes the 
baseline sum if that is the smallest on study). In addition to the relative increase of 
20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the 
appearance of one or more new lesions is also considered progressions).  
o Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum of diameters while on 
study. 

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Note 
• Confirmation by two consecutive observations not less than 4 weeks apart is required for CR, 
PR and PD 
• New lesions result in unconfirmed PD. Confirmed PD is assigned only if additional new 
lesions appear or an increase in size of new lesions is seen (≥5 mm for sum of new lesion 
target or any increase in new lesion non-target) at next assessment; the appearance of 
additional new lesions when none have previously been recorded, can also confirm PD 
6.2.5 Evaluation of Non-Target Lesions 
o Complete Response (CR): Disappearance of all non-target lesions and normalization 
of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm 
short axis). 
Note: If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
o Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal limits.  
o Progressive Disease (PD): Appearance of one or more new lesions and/or 
unequivocal progression of existing non-target lesions. Unequivocal progression 
should not normally trump target lesion status. It must be representative of overall 
disease status change, not a single lesion increase. Although a clear progression of 
“non-target” lesions only is exceptional, the opinion of the treating physician should 
prevail in such circumstances, and the progression status should be confirmed at a 
later time by the review panel or Principal Investigator. 
Note: 
• Confirmation by two consecutive observations not less than 4 weeks apart was required for 
CR, PR and PD 
• New lesions result in unconfirmed PD. Confirmed PD is assigned only if additional new 
lesions appear or an increase in size of new lesions is seen (≥5 mm for sum of new lesion 
target or any increase in new lesion non-target) at next assessment; the appearance of 
additional new lesions when none have previously been recorded, can also confirm PD. 
6.2.6 Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria.  For the purposes of 
this study, best overall response will be defined according to modified irRC.  Table 2 below is 
modified from Wolchok JD et al, Clin Canc Res 2009, Hodi FS et al, J Clin Oncol 2016 and 
Nishino M et al, Clin Canc Res 201337-39 comparing RECIST 1.1 criteria, modified irRC and 
iRECIST. iRECIST is similar to modified irRC used in this study except that iRECIST defined 
unconfirmed PD and confirmed PD separately. 

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Table 2 Comparison of RECIST v1.1, modified irRC and iRECIST 
Category 
RECIST v1.1 
Modified irRC 
iRECIST 
Measurement of 
tumor burden 
Unidimensional 
Unidimensional 
Unidimensional 
Target lesions 
Maximum 5 
Maximum 15 
Maximum 5 
New lesion 
Results in progressive 
disease at ﬁrst appearance 
Does not always results in progressive disease at ﬁrst 
appearance unless the sum of tumor burden fits the criteria 
for progressive disease 
Complete 
response 
 
Disappearance of all target and nontarget lesions 
Lymph nodes must regress to <10 mm short axis 
No new lesions, confirmation required 
 
Partial response 
≥ 30% decrease in tumor 
burden compared with 
baseline 
≥ 30% decrease in tumor 
burden compared with 
baseline† Conﬁrmation 
required 
≥ 30% decrease in tumor 
burden compared with 
baseline 
Progressive 
disease 
≥ 20% + 5-mm absolute 
increase in tumor burden 
compared with nadir. 
Appearance of new lesions 
or progression of 
nontarget lesions 
≥ 20% increase in tumor 
burden compared with 
baseline, with nadir, or reset 
baseline. New lesions added to 
the tumor burden 
Confirmation required 
≥ 20% + 5-mm absolute 
increase in tumor burden 
compared with nadir. 
Appearance of new lesions 
or progression of 
nontarget lesions.  
Confirmation required 
Stable disease 
Neither partial response nor progressive disease 
For Patients with Measurable Disease (i.e., Target Disease) 
Target 
Lesions 
Non-
Target 
Lesions 
New 
Lesions 
Overall 
Response 
Best Overall Response when 
Confirmation is Required* 
CR 
CR 
No 
CR 
>4 wks. Confirmation** 
CR 
Non- 
CR/Non-
PD 
No 
PR 
>4 wks. Confirmation** 
CR 
Not 
evaluated 
No 
PR 

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PR 
Non- 
CR/Non
- PD/not 
evaluate
d 
No 
PR 
SD 
Non- 
CR/Non
- PD/not 
evaluate
d 
No 
SD 
Documented at least once >4 
wks. from baseline** 
PD 
Any 
Yes or 
No 
PD 
no prior SD, PR or CR 
Any 
PD**
* 
Yes or 
No 
PD 
Any 
Any 
Yes 
PD 
* 
See RECIST 1.1 manuscript for further details on what is evidence of 
a new lesion. 
** 
Only for non-randomized trials with response as primary endpoint. 
*** 
In exceptional circumstances, unequivocal progression in non-
target lesions may be accepted as disease progression. 
Note: Patients with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be reported as “symptomatic 
deterioration.” Every effort should be made to document the objective 
progression even after discontinuation of treatment. 
For Patients with Non-Measurable Disease (i.e., Non-Target Disease) 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
No 
CR 
Non-CR/non-PD 
No 
Non-CR/non-PD* 
Not all evaluated 
No 
not evaluated 
Unequivocal PD 
Yes or No 
PD 
Any 
Yes 
PD 

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* ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease 
since SD is increasingly used as an endpoint for assessment of efficacy in some 
trials so to assign this category when no lesions can be measured is not advised 
Overall responses derived from changes in index, non-index and new lesions as demonstrated in 
the following table: 
Measurable response 
Non-measurable response 
Overall response using 
modified irRC 
Index and new, 
measurable lesions 
(tumor burden)* % 
Non-index 
lesions 
New, non-measurable 
lesions 
 
Decrease 100 
Absent 
Absent 
CR** 
Decrease 100 
Stable 
Any 
PR** 
Decrease 100 
Unequivocal 
progression 
Any 
PR** 
Decrease ≥ 30% 
Absent / Stable 
Any 
PR** 
Decrease ≥ 30% 
Unequivocal 
progression 
Any 
PR** 
Decrease < 30 to increase < 
20 
Absent / Stable 
Any 
SD 
Decrease < 30 to increase < 
20 
Unequivocal 
progression 
Any 
SD 
Increase ≥ 20 
Any 
Any 
PD** 
* Decreases assessed relative to baseline 
** Assuming response (CR and PR) and progression (PD) are confirmed by a second, 
consecutive assessment at least 4 weeks apart. 
6.2.7 Confirmatory Measurement/Duration of Response 
Confirmation: To be assigned a status of a response of CR or PR, changes in tumor 
measurements must be confirmed by repeat assessments that should be performed at least 4 
weeks after the criteria for response are first met. PD must be confirmed by a second observation 
no less than 4 weeks later. 
Duration of overall response: The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
PD is objectively documented. 

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The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that recurrent disease is objectively documented.  Time to progression (TTP) 
will also be recorded for patients with CR, PR and SD subsequently developing recurrent or 
progressive disease. 
Duration of stable disease: SD is measured from the start of the treatment until the PD criteria for 
progression are met.  
6.2.8 Progression Free Survival and Overall Survival 
Progression-free survival (PFS) will be assessed only in adjuvant bladder cancer patients and in 
metastatic bladder cancer patients that have completed first line chemotherapy that do not have 
measurable disease.  Overall survival (OS) is not being assessed as part of this clinical 
investigation. 
6.2.9 Response Review 
Responses will be reviewed by the Principal Investigator, Lead Associate Investigator and their 
designees.  Since the assessment of the preliminary anti-tumor activity of autologous AdHER2 
DC vaccination is only a secondary objective of this phase I, two-part dose escalation study, 
responses will not be reviewed by an expert(s) independent of the study. 
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN 
The Principal Investigator and Lead Associate Investigator will be responsible for overseeing the 
Data and Safety Monitoring Plan.  As information is gathered from this trial, clinical results will 
be shared with the patients.  Laboratory and clinical data will be gathered on a monthly basis and 
any new significant observation(s) found during the course of the research that may affect patient 
safety or a patient’s willingness to participate further will be explained at the time patients are 
consented for the study. 
Confidentiality of information concerning participants will be maintained including in all 
publications and presentations resulting from this study.  Names of patients or material 
identifying participants will not be released without permission, except as such release is 
required by law.  Records will be maintained according to current legal requirements, and are 
made available for review as required by the U.S. Food and Drug Administration (FDA) or other 
authorized users, only under the guidelines established by the Federal Privacy Act. 
7.1 
DEFINITIONS 
Please refer to definitions provided in Policy 801: Reporting Research Events found here. 
7.2 
OHSRP OFFICE OF COMPLIANCE AND TRAINING/ IRB REPORTING 
7.2.1 Expedited Reporting NIH Intramural IRB and NCI CD Expedited Reporting of 
Unanticipated Problems and Deaths 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 Non-Compliance Human Subjects Research found here. Note: Only IND Safety Reports that 
meet the definition of an unanticipated problem will need to be reported per these policies   

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7.2.2 IRB Requirements for PI Reporting at Continuing Review 
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here.  
7.3 
NCI CLINICAL DIRECTOR REPORTING  
Problems expeditiously reported to the OHSRP/IRB in iRIS will also be reported to the NCI 
Clinical Director.  A separate submission is not necessary as reports in iRIS will be available to 
the Clinical Director. 
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to 
progressive disease.   
To report these deaths, please send an email describing the circumstances of the death to Dr. 
Dahut at NCICCRQA@mail.nih.gov within one business day of learning of the death. 
7.4 
INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) REPORTING CRITERIA  
7.4.1 Serious Adverse Event Reports to IBC 
The Principal Investigator (or delegate) will notify IBC of any unexpected fatal or life-
threatening experience associated with the use of AdHER2 DC vaccine as soon as possible but in 
no event later than 7 calendar days of initial receipt of the information.  Serious adverse events 
that are unexpected and associated with the use of the AdHER2 DC vaccine, but are not fatal or 
life-threatening, much be reported to the NIH IBC as soon as possible, but not later than 15 
calendar days after the investigator’s initial receipt of the information.  Adverse events may be 
reported by using the FDA Form 3500a. 
7.4.2 Annual Reports to IBC 
Within 60 days after the one-year anniversary of the date on which the IBC approved the initial 
protocol, and after each subsequent anniversary until the trial is completed, the Principal 
Investigator (or delegate) shall submit the information described below.  Alternatively, the IRB 
continuing review report can be sent to the IBC in lieu of a separate report.  Please include the 
IBC protocol number on the report. 
7.4.2.1 Clinical Trial Information  
A brief summary of the status of the trial in progress or completed during the previous year. The 
summary is required to include the following information:  
• the title and purpose of the trial  
• clinical site 
• the Principal Investigator 
• clinical protocol identifiers;   
• participant population (such as disease indication and general age group, e.g., adult or 
pediatric);  

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• the total number of participants planned for inclusion in the trial; the number entered into 
the trial to date whose participation in the trial was completed; and the number who 
dropped out of the trial with a brief description of the reasons  
• the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, 
or fully completed,  
• if the trial has been completed, a brief description of any study results.  
7.4.2.2 Progress Report and Data Analysis  
Information obtained during the previous year's clinical and non-clinical investigations, 
including:  
• a narrative or tabular summary showing the most frequent and most serious adverse 
experiences by body system 
• a summary of all serious adverse events submitted during the past year 
• a summary of serious adverse events that were expected or considered to have causes not 
associated with the use of the gene transfer product such as disease progression or 
concurrent medications 
• if any deaths have occurred, the number of participants who died during participation in 
the investigation and causes of death 
• a brief description of any information obtained that is pertinent to an understanding of the 
gene transfer product’s actions, including, for example, information about dose-response, 
information from controlled trials, and information about bioavailability.  
7.5 
NIH REQUIRED DATA AND SAFETY MONITORING PLAN 
7.5.1 Principal Investigator/Research Team 
The clinical research team will meet on a weekly basis when patients are being actively treated 
on the trial to discuss each patient.  
All data will be collected in a timely manner and reviewed by the Principal Investigator or a 
Lead Associate Investigator. Events meeting requirements for expedited reporting as described in 
Section 7.2.1 will be submitted within the appropriate timelines.  
The Principal Investigator will review adverse event and response data and make attribution 
determinations on each patient to ensure safety and data accuracy. The Principal Investigator will 
personally conduct or supervise the investigation and provide appropriate delegation of 
responsibilities to other members of the research staff. 
7.5.2 Safety Monitoring Committee (SMC) 
This protocol will require oversight from the Safety Monitoring Committee (SMC).  Initial 
review will occur as soon as possible after the annual NIH Intramural IRB continuing review 
date.   Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting 
schedule permits or more frequently as may be required by the SMC.   For initial and subsequent 
reviews, protocols will not be reviewed if there is no accrual within the review period. Written 
outcome letters will be generated in response to the monitoring activities and submitted to the 
Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI. 

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8 
SPONSOR SAFETY REPORTING 
8.1 
DEFINITIONS 
8.1.1 Adverse Event  
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a medicinal (investigational) product, whether or not related to the medicinal 
(investigational) product (ICH E6 (R2)) 
8.1.2 Serious Adverse Event (SAE) 
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following: 
• 
Death, 
• 
A life-threatening adverse event (see 8.1.3) 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect. 
• 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
8.1.3 Life-threatening  
An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of 
either the investigator or sponsor, its occurrence places the patient or subject at immediate risk of 
death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a 
more severe form, might have caused death. (21CFR312.32) 
8.1.4 Severity 
The severity of each Adverse Event will be assessed utilizing the CTCAE version 4.03. 
8.1.5 Relationship to Study Product 
All AEs will have their relationship to study product assessed using the terms:  related or not 
related.   
• Related – There is a reasonable possibility that the study product caused the adverse 
event. Reasonable possibility means that there is evidence to suggest a causal relationship 
between the study product and the adverse event. 
• Not Related – There is not a reasonable possibility that the administration of the study 
product caused the event. 

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8.2 
ASSESSMENT OF SAFETY EVENTS 
AE information collected will include event description, date of onset, assessment of severity 
and relationship to study product and alternate etiology (if not related to study product), date of 
resolution of the event, seriousness and outcome. The assessment of severity and relationship to 
the study product will be done only by those with the training and authority to make a diagnosis 
and listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  AEs 
occurring during the collection and reporting period will be documented appropriately regardless 
of relationship.  AEs will be followed through resolution. 
SAEs will be: 
• 
Assessed for severity and relationship to study product and alternate etiology (if not 
related to study product) by a licensed study physician listed on the Form FDA 1572 as 
the site principal investigator or sub-investigator. 
• 
Recorded on the appropriate SAE report form, the medical record and captured in the 
clinical database. 
• 
Followed through resolution by a licensed study physician listed on the Form FDA 1572 
as the site principal investigator or sub-investigator. 
For timeframe of recording adverse events, please refer to Section 6.1. 
8.3 
 REPORTING OF SERIOUS ADVERSE EVENTS 
Any AE that meets protocol-defined serious criteria or meets the definition of Adverse Event of 
Special Interest that require expedited reporting must be submitted immediately (within 24 hours 
of awareness) to OSRO Safety using the CCR SAE report form. 
All SAE reporting must include the elements described in Section 9. 
SAE reports will be submitted to the Center for Cancer Research (CCR) at: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator.  CCR SAE report form 
and instructions can be found at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=157942842 
Following the assessment of the SAE by OSRO, other supporting documentation of the event 
may be requested by the OSRO Safety and should be provided as soon as possible. 
8.4 
REPORTING PREGNANCY 
8.4.1 Maternal Exposure 
If a patient becomes pregnant during the course of the study, the study treatment should be 
discontinued immediately, and the pregnancy reported to the Sponsor no later than 24 hours of 
when the Investigator becomes aware of it. The Investigator should notify the Sponsor no later 
than 24 hours of when the outcome of the Pregnancy become known, 
Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects 
and spontaneous miscarriages that meet serious criteria (8.1.2) should be reported as SAEs.  

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The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic 
pregnancy, normal birth, or congenital abnormality) should be followed up and documented. 
8.4.2 Parental exposure 
Male patients should refrain from fathering a child or donating sperm during the study and for 90 
days after the last dose of AdHER2 DC vaccine. 
Pregnancy of the patient’s partner is not considered to be an AE. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or 
congenital abnormality) occurring from the date of the first dose until 90 after the last dose 
should, if possible, be followed up and documented. 
8.5 
REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER CCR-SPONSOR IND  
Following notification from the investigator, CCR, the IND sponsor, will report any suspected 
adverse reaction that is both serious and unexpected.  CCR will report an AE as a suspected 
adverse reaction only if there is evidence to suggest a causal relationship between the study 
product and the adverse event.  CCR will notify FDA and all participating investigators (i.e., all 
investigators to whom the sponsor is providing drug under its INDs or under any investigator’s 
IND) in an IND safety report of potential serious risks from clinical trials or any other source, as 
soon as possible, in accordance to 21 CFR Part 312.32.  
All serious events will be reported to the FDA at least annually in a summary format. 
9 
CLINICAL MONITORING  
As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring 
program. The CCR’s program allows for confirmation of: study data, specifically data that could 
affect the interpretation of primary and secondary study endpoints; adherence to the protocol, 
regulations, ICH E6, and SOPs; and human subjects protection. This is done through 
independent verification of study data with source documentation focusing on: 
• Informed consent process 
• Eligibility confirmation 
• Drug administration and accountability 
• Adverse events monitoring 
• Response assessment. 
The monitoring program also extends to multi-site research when the CCR is the coordinating 
center. 
This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified 
by training and experience to monitor the progress of clinical trials. Personnel monitoring this 
study will not be affiliated in any way with the trial conduct.   

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10 COLLABORATIVE AGREEMENTS 
10.1 TECH TRANSFER AGREEMENTS 
Stored samples are being sent to Midissia for testing and characterization of soluble HER2 and 
anti-HER2 antibodies as a part of this protocol using a Material Transfer Agreement (MTA 
#42793) which was executed on 09/17/2017. There is also a CDA between Midissia and the NCI 
(CDA #13887-18, executed 11/10/2017). Additional tech transfers include: 
• CRADA # 03048, executed 03/02/2016 
• MTA #44020-28, executed 01/24/2018 
• MTA #3394-13, executed 11/13/2014 
• CRADA #03225, currently being negotiated 
11 STATISTICAL CONSIDERATIONS   
The primary objectives of this open label, single site, non-randomized, two-part, phase I study of 
AdHER2 DC vaccination are to determine if the fraction of patients with cardiac toxicity (if it 
occurs) is sufficiently low to warrant further exploration in subsequent trials and to determine an 
approximate estimate of the vaccine immunogenicity, as represented by the fraction of patients 
who develop at least a 3-fold increase in anti-HER2/neu antibody concentration (measured as 
mcg/mL) or a 4-fold increase in antibody dilution titers over baseline at the time points 
measured. An important secondary objective is to obtain a preliminary estimate of the proportion 
of patients who may experience tumor shrinkage or stabilization that is sufficient by modified 
immune response related criteria (modified irRC) to be considered stable disease, a partial 
response or better.  
It has been reported that up to 7% of patients with HER2/neu expressing tumors treated with 
trastuzumab monotherapy for metastatic breast cancer developed clinically significant cardiac 
dysfunction including congestive heart failure.  It would be considered acceptable if the 
therapeutic AdHER2 DC vaccine proposed for this study would produce no greater than that 
level of cardiac toxicity, but not acceptable if it were to be exceeded. In order to evaluate this 
using a limited number of patients, a two-part design, but incorporating an early stopping rule, 
will be implemented.    
Statistical considerations pertaining to each part of the study are as follows: 
11.1 PART I (MAXIMUM OF 30 EVALUABLE PATIENTS) 
The goal of Part I is to investigate vaccine dose escalation and determine whether there is a 
significant, adverse safety signal regarding cardiac toxicity in patients with recurrent or 
progressive, metastatic solid tumors as well as adjuvant bladder cancer patients with HER2 
expressing tumors that are naive to trastuzumab, lapatinib, ado-transtuzumab and other HER2-
directed therapies, in addition to preliminary assessment of the vaccine’s immunogenicity and 
clinical activity. Allowable tumors include breast, ovarian, colon, non-small cell lung, renal cell, 
bladder and prostate cancer with HER2 characterization by IHC and FISH as outlined in Section 
2.1.1.14.   
Inclusion of a broad spectrum of tumors that express HER2 will facilitate more rapid accrual and 
allow prompt determination of the vaccine’s safety and immunogenicity.  However, the inclusion 

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of subjects with multiple tumor types that have varying levels of HER2 expression may preclude 
identification of an optimal biologically active dose.  
During this part, vaccine safety, immunogenicity and preliminary activity will be determined for 
each dose level given escalating doses of vaccine as follows: 
Dose Level 1 (N = 6 patients): 
 
5 x 106 viable cells/vaccine 
Dose Level 2 (N = 6 patients): 
 
10 x 106 viable cells/vaccine 
Dose Level 3 (N = 6 patients): 
 
20 x 106 viable cells/vaccine 
Expansion Cohort (N= 12 patients):  
 
40 x 106 viable cells/vaccine 
Dose escalation will proceed as long as 0 of 6 or 1 of 6 patients within a dose level have no 
evidence of toxicity and at least 3 of the 6 patients within a level have reached Week 12 on 
study. If 2 of 6 patients on any given dose level develop cardiac toxicity, that dose cohort will 
be closed to further accrual, no higher doses will be explored, and dose expansion of an 
additional 12 patients will be enrolled in the next lower dose level to further assess for cardiac 
toxicity. The vaccine dose at which 0 to 1 of 18 treated patients in Dose Levels 1 to 3 develop 
cardiac toxicity will be defined as the maximum tolerated dose (MTD). If two or more 
patients out of 18 at a given dose have developed cardiac toxicity, then the MTD will have 
been exceeded at that dose, and the dose level below that one will be considered the MTD. 
Since enrollment in Dose Level 3 has been reached and 0 of 6 patients has toxicity, then an 
expansion cohort of an additional 12 patients will be added, for a maximum targeted accrual of 
30 patients in Part 1. The Expansion Cohort will be treated at 40 x 106 viable cells/vaccine and 
will be monitored for toxicity in an identical manner as previously identified.  The 12 
patients will be accrued at the 40x10^6 level without any planned interim stop, as cardiac 
toxicity is not presently anticipated given the results as of 12/11/15. With all 12 enrolled as a 
single cohort, there is a 4.9% probability of having 2 or more of 12 patients with cardiac toxicity 
if the true probability for a given patient is 3%, and 55.7% of having 2 or more of 12 with 
cardiac toxicity if the true probability for a given patient is 15%. Therefore, observing 0-1 of 12 
with toxicity would be acceptable, and 40 x10^6 would be considered the maximum evaluated 
and tolerated dose. If we observe 2 or more with cardiac toxicity at or before accruing the 12th 
patient, this exceeds a safe level. Further patients would be added subsequently, by amendment, 
to the next lower dose, to confirm its safety. 
To ensure that the trial does not continue to accrue patients in the event that a much greater 
incidence of toxicity than expected would be recognized early, the following early stopping 
rules for accrual will be invoked in each part of the study if: 
• Two or more of 6 patients in a given dose develop evidence of cardiac toxicity, accrual 
will be stopped to that dose level.  Accrual expansion of an additional 12 patients will 
occur in the next lower dose level to further evaluate for cardiac toxicity. 
• Any death (unrelated to underlying primary disease) that occurs and is attributed as 
being possible, probably or definitely related to the investigational AdHER2 DC 
vaccine (FDA requirement). 

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11.2 PART II (MAXIMUM OF 30 EVALUABLE PATIENTS) 
Since the risk for cardiac toxicity may differ in individuals who have previously received HER2-
directed therapy, the FDA is requesting that repeat dose escalation of AdHER2 DC vaccination 
be conducted in Part II of the study in a population with  prior exposure to trastuzumab, 
pertuzumab, lapatinib, ado-trastuzumab emtansine (TDM1) and other HER2-directed therapies.  
This population will include adults with recurrent or progressive, metastatic breast, 
gastric/gastroesophageal or other cancers with 1+ to 3+ HER2/neu expression by IHC or an 
equivocal or positive FISH result.  Vaccine dose escalation will be repeated to again determine 
whether there is an adverse safety signal regarding cardiac toxicity, in addition to assessment of 
the vaccine’s immunogenicity and clinical activity.  Vaccine dose escalation, administration, re-
staging assessment and early stopping rules that will be invoked that are identical to that 
conducted in Part I.  
The goal is to accrue up to 30 evaluable patients in Part II of the study and treat them with the 
experimental AdHER2 vaccine.   
Unless an early stopping rule is invoked in either Part I or Part II of the study, the number of 
patients who have experienced a clinically significant cardiac toxicity will be determined to 
estimate the frequency of cardiac toxicity.  In addition, the dose level(s) at which toxicity is 
observed will also be examined.   
If in part I, dose escalations have taken place in the first three dose levels and 0 of 20 patients 
have experienced cardiac toxicity, Part II of the study in patients with metastatic breast 
cancer and prior exposure to HER2-directed therapies will proceed with vaccine dosing based 
on the safety confirmed in Part I and as outlined in Section 3.1.2. A maximum accrual of 30 
patients will be enrolled in Part II and patients will continue to enroll on that dose unless 3 
patients have experienced cardiac toxicity. 
11.3 OVERVIEW 
In addition to reporting the observed fraction with toxicity, the 80% and 95% confidence 
intervals about this fraction will be reported. 
At the conclusion of the study, the overall fractions with cardiac toxicity among 18, 24 or 30 
patients enrolled at one dose or within the entire cohort will be determined. For illustrative 
purposes only, under a simplifying assumption that the 18-30 patients were enrolled in a single 
cohort without any intermediate evaluations, the following probabilities suggest that 2+/18, 2+/24 
or 3+/18 with cardiac toxicity are more likely to be associated with 15% toxicity (arbitrarily 
chosen to substantially exceed 7%) than with 3% (arbitrarily chosen to be well below 7%). 
In any given 18 patients assessed for toxicity, if two or more of the 18 develop toxicity: 
• There is a 10% probability of this occurring if the true toxicity is 3%.   
• There is a 78% probability of this occurring if the true toxicity is 15% (potentially 
unacceptable). 
In any given 24 patients assessed for toxicity (6 at one dose level and 18 at a second level), if two 
or more of the 24 develop toxicity: 
• There is a 16% probability of this occurring if the true toxicity is 3%.   

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• There is an 89% probability of this occurring if the true toxicity is 15% (potentially 
unacceptable). 
If there are 30 patients assessed for toxicity (18 at one dose level plus 6 at one level and 6 at 
another level), if three or more of the 30 develop toxicity: 
• There is a 6% probability of this occurring if the true toxicity is 3%. 
• There is an 85% probability of this occurring if the true toxicity is 15% (potentially 
unacceptable). 
As of 12/11/15, 0 of 20 patients enrolled to date that have received a minimum of 2 doses of 
AdHER2 DC vaccine have developed cardiac toxicity. Since we have observed 0 of 20 subjects 
with cardiac toxicity, this would have a 68% chance of occurring if the true probability of 
cardiac toxicity for a given patients was 2%; similarly, it would be 36% if the probability of 
cardiac toxicity was 5%, 12.2% if the probability of cardiac toxicity was 10% and 3.8% if the 
probability of cardiac toxicity was 15%. We are assuming that the probability of cardiac toxicity 
is no more than 10% since higher probabilities of toxicity are associated with a much lower 
chance of seeing 0 of 20 patients with cardiac toxicity as has been observed. 
Since 0 of 20 patients already have been documented to have NO cardiac toxicity, and 0 to 2 
patients out of 30 would have been acceptable per the original study design, a statistical estimate 
was performed to determine what the probability of having 0 to 2 of the next 10 patients in the 
Part 1 Expansion Cohort having cardiac toxicity would be. If the probability of cardiac toxicity 
were 2%, there would be 99.91% probability of 0 to 2 of 10 with toxicity; if it were 5%, there 
would be 98.8% probability; and if it were 10%, there would be 93% probability of 0 to 2 of 10 
with toxicity. Thus, assuming the next 10 patients would have the same underlying per-patient 
probability of developing cardiac toxicity as the first 20 had, and it is likely to truly be at or 
below 10%, there is between a 93% and 99.9% probability that the next 10 patients enrolled in 
the Part I Expansion Cohort would have 0 – 2 toxicities and therefore 0 – 2 of 30 would have 
cardiac toxicity as per the original study design. Consequently, FDA approval was received on 
12/14/15 to initiate enrollment in Part II of the study in parallel, while enrollment of the Part I 
Expansion Cohort is completed. 
The fraction of subjects with immunogenicity, defined as a 3-fold increase in anti-HER2/neu 
antibody concentration (measured as mcg/mL) or a 4-fold increase in antibody dilution titers 
over baseline will be reported, along with 80% and 95% confidence intervals, at the following 
time points: Weeks 4 (after 1 vaccine dose), 8 (after 2 vaccine doses), 12 (after 3 vaccine doses), 
28 (after 5 vaccine doses), 48 and 52 weeks and during extended follow-up for monitoring of 
cardiac adverse events at weeks 76, 100 and 124. 
Finally, as a secondary objective, the fraction of subjects who haves stable disease, an objective 
partial response or better by modified irRC will be determined along with appropriate confidence 
intervals with exceptions to the PR assessment at Week 12 as noted in Sections 3.5.1, 3.5.2 and 
6.2.4. The fraction identified in this trial will potentially be useful information for design of any 
subsequent trials using this vaccine in both of the patient populations being studied. 
Part I of the study will accrue both males and females with HER2 expressing metastatic cancers 
for whom trastuzumab is not indicated and who are naïve to HER2-directed therapies.  Accrual 
to Part II of the study will be restricted to females or males with recurrent or progressive 
metastatic breast, gastric/gastroesophageal or other cancers that have received clinically 

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indicated prior treatment with trastuzumab, pertuzumab, lapatinib, ado-trastuzumab emtansine or 
other  HER2-directed therapies.  The study will seek to accrue racially and ethnically diverse 
population affected by the cancer types targeted for enrollment in this study. 
We expect to accrue at least 2 patients per month with expected completion of accrual within 2.5 
years.  If after 2 years, 20 or fewer patients have been accrued to Part I of the study, the study 
will be terminated for failure to accrue at a viable rate.  If accrual to Part I of the study has been 
completed and enrollment in Part II has begun, if after 1 year, 10 or fewer patients have been 
accrued to Part II of the study, the study will be terminated for failure to accrue at a viable rate.  
To allow for the possibility of inevaluable patients, an accrual ceiling of 65 will be used. 
11.4 STUDY TERMINATION  
This study will be terminated for the following reasons: 
• Completion of enrollment accrual and all scheduled monitoring studies for enrolled 
subjects. 
• Development of clinically significant CTRCD toxicity (defined as a decrease in the 
LVEF of > 10 percentage points, to a value < 53%) in two or more of the first 10 
patients enrolled in the study or four or more of the first 20 patients enrolled in the 
study. 
• Failure to accrue study subjects in a timely manner. 
12 HUMAN SUBJECTS PROTECTIONS 
12.1 RATIONALE FOR SUBJECT SELECTION 
Subjects targeted for enrollment in this study have tumors that express varying levels of HER2, a 
well-known oncogene that when present, is characterized by more aggressive disease in certain 
cancers e.g. breast cancer. Significant improvements in clinical outcomes have been realized 
through the HER2-directed therapies such as trastuzumab and lapatinib. However, despite these 
successes, the usefulness of these therapies is mitigated by the requirement for a specific level of 
HER2 expression i.e. HER2 3+ IHC and an equivocal or positive FISH result for trastuzumab to 
realize clinical outcomes, the continued need for drug administration, and the ultimate 
development of resistance to treatment with subsequent disease progression.  All of these factors 
point to a need for more effective therapies targeting HER2 designed to address and overcome 
these issues. 
Subjects from both gender groups and all racial/ethnic groups are eligible for this study if they 
meet the eligibility criteria. Pregnant women are excluded from participation in the trial because 
AdHER DC vaccine may have the potential for teratogenic or abortifacient effects. 
12.2 PARTICIPATION OF CHILDREN 
Since this is the first in human clinical trial of this AdHER2 autologous dendritic cell vaccine 
and the potential safety risks are unknown, patients < 18 years of age will not be allowed to 
enroll in this study.  

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12.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol.  However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (Section 12.5), all subjects ≥ age 18 will be offered the opportunity to fill 
in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH 
Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate.  For those subjects that become incapacitated and do not have 
pre-determined substitute decision maker, the procedures described in MAS Policy 87-4 and 
NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a) 
decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney, 
will be followed. 
12.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
The AdHER2 DC vaccine being given in this study targets both the extracellular (EC) and 
transmembrane ™ domains of the HER2 protein receptor.  The goal of therapeutic vaccination 
with this product is to stimulate the patient’s own immune system to make polyclonal antibodies 
(and also potentially killer cells) that recognize HER2.  It is hoped that that these antibodies will 
have a similar beneficial effect in controlling disease and potentially prolonging survival.  
Use of trastuzumab in women with breast cancer has been shown to be associated with a small, 
but significant risk (about 7%) for developing cardiac dysfunction.  It is usually observed in 
patients who have previously received chemotherapy that is known to affect the heart.  The risk 
of cardiac dysfunction is greater (about 27%) when trastuzumab is given in combination with 
anthracyline chemotherapy drugs such as doxorubicin (Adriamycin) and cyclophosphamide 
(Cytoxan).  Exactly how trastuzumab causes cardiac toxicity is unknown.  It is also not known 
whether antibodies made by a person’s own immune system will cause cardiac 
dysfunction.  Because of this, cardiac function will be monitored very closely while receiving the 
vaccine treatment and for 24 months following the last dose of vaccine.  In addition, there are 
strict stopping rules included in this study for any signals of cardiac toxicity that would appear to 
be exceeding the 7% frequency observed with trastuzumab monotherapy.  There are currently 
multiple clinical trials with vaccines using different platforms and approaches to target HER2 
and to date there have been no reports of significant vaccine-associated cardiac toxicity.   
The only other likely risk associated with receiving this vaccine is local injection site reactions 
i.e. discomfort, itching, redness, swelling, or soreness/pain at the site where the vaccine is 
injected into the skin.  In addition, due to the proposed mechanism of action that includes a 
possible acute inflammatory response at focal sites of tumor, subjects may experience discomfort 
at sites of metastatic disease and/or acute reactive pleural or peritoneal effusions There is a more 
remote potential for systemic symptoms such as fatigue, malaise or fever associated with 
vaccination but these are much less likely because patients are being given their own cells that 
have been transduced to express HER2.  The AdHER2 vector used to transduce the patient’s 

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autologous dendritic cells is not replication competent and does not integrate into the human 
genome.  The construct has specifically omitted the oncogenic intracellular domain of HER2 to 
ensure additional safety. 
Unlike trastuzumab or pertuzumab that are monoclonal antibodies, we anticipate that therapeutic 
vaccination with the AdHER2 DC vaccine will induce a polyclonal antibody response that 
targets multiple epitopes of HER2, since the immunogen contains both the extracellular (EC) and 
transmembrane (TM) components of HER2. This could potentially be beneficial in patients who 
have failed trastuzumab, lapatinib or other HER2-directed therapies due to resistance since these 
agents only recognize one small component of the outer portion of HER2 and as a result, many 
tumors become resistant.  Because we anticipate the development of polyclonal antibodies that 
recognize multiple sites in HER2, the vaccine may also be beneficial in patients with HER2+ 
solid tumors as well as adjuvant bladder cancer patients at high risk of disease recurrence for 
whom trastuzumab is not clinically approved or for those breast cancer who don’t have sufficient 
expression of HER2 i.e. IHC <3+ or an equivocal or positive FISH result and hence weren’t 
eligible for trastuzumab treatment, thereby addressing an unmet medical need. 
Both of the currently available HER2 therapeutics, trastuzumab and lapatinib target the 
extracellular component of HER2. Trastuzumab’s biologic activity is believed to work by 
binding to HER2 receptors and interfering with signaling controlling tumor growth and division, 
as well as signaling the immune system to destroy the cancer cells.  Lapatinib is an orally 
administered tyrosine kinase inhibitor of both the HER2/neu protein and the epidermal growth 
factor receptor.   A third agent currently being investigated in clinical trials is pertuzumab, which 
is also a humanized monoclonal antibody. It has a unique function in that it prevents HER2 
receptor dimerization and subsequently blocks cell signaling. All of these agents must be 
administered exogenously and continuously for beneficial effect at great cost and often with 
significant discomfort to the patient. 
All care will be taken to minimize side effects. Patients will be examined and evaluated prior to 
enrollment. All evaluations to monitor the treatment of patients will be recorded in the patient 
chart. If patients suffer any physical injury as a result of the participation in this study, immediate 
medical treatment is available at the NIH Clinical Center, Bethesda, Maryland. 
Although no compensation is available, any injury will be evaluated and treated in keeping with 
the benefits or care to which patients are entitled under applicable regulations. In all publications 
and presentations resulting from this trial, patients’ anonymity will be protected to the maximum 
extent possible. Authorized personnel from the National Cancer Institute (NCI) and Food and 
Drug Administration (FDA) or other regulatory authorities may have access to research files in 
order to verify that patients’ rights have been safeguarded. In addition, patient names will be     
given to the Central Registration to register and verify patients’ eligibility. 
12.5 RISKS/BENEFITS ANALYSIS 
Subjects (including subjects unable to give consent) undergoing therapeutic autologous AdHER2 
DC vaccination are likely to experience local injection site reactions commonly associated with 
the delivery of all vaccines i.e. discomfort, itching, redness, swelling, and/or soreness/pain at the 
injection site.  The potential for adverse systemic symptoms such as fatigue, malaise, fever or 
acute allergic reactions is unknown but is less likely because patients are being given their own 
cells.  However, because patients are being given their own cells as well as a “self” tumor 

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antigen (HER2), there is the potential for inducing antibodies that react with the patient’s own 
tissues resulting in autoimmune disease.  This has not been described with other HER2 vaccines 
that have been studied but patients will be monitored for the development of autoimmune 
disease. 
The greatest concern associated with this therapeutic vaccine platform is the potential 
development of vaccine-induced antibodies that result in cardiac dysfunction and toxicity.  
Unlike trastuzumab, where therapy can be withdrawn, there is no way to “turn off” the immune 
system without significant adverse consequences.  Because of this, cardiac function will be 
monitored very closely while receiving the vaccine treatment and for 24 months following the 
last dose of vaccine.  In addition, stringent stopping rules are in place in the event of any early 
(or even late) signals of cardiac toxicity. 
The patients eligible to enroll in Part I of this study have recurrent or progressive metastatic 
disease as well as adjuvant bladder cancer patients with HER2 expressing tumors or naïve to 
HER2 targeted therapies that are not candidates for currently available HER2-directed therapies 
such as trastuzumab and lapatinib.  Thus, therapeutic vaccination with the AdHER2 DC vaccine 
platform proposed in thus study may result in the development of polyclonal antibodies that 
successfully target and interfere with HER2 expressed at lower levels and on tumors other than 
breast cancer and provide a potential direct benefit.   
The patients eligible to enroll in Part II of this study have recurrent or progressive metastatic 
breast cancer, gastric or gastroesophageal junction cancer have high HER2 expression and have 
failed or progressed on prior FDA-approved HER2-directed therapies such as trastuzumab, 
pertuzumab, lapatinib, ado-trastuzumab emtansine (TDM1) or other HER2- directed agents (e.g. 
MGAH22).  The induction of polyclonal antibodies associated with the AdHER2 DC vaccine 
platform may provide recognition of new HER2 targets and overcome resistance to trastuzumab 
and lapatinib with the potential for beneficial clinical outcomes. 
In addition, the results may help the investigators learn more about the disease and develop new 
treatments for patients with this disease. 
Overall, preliminary findings support a favorable benefit:risk ratio for the use of AdHER DC 
vaccine in these patients with tumors with 1-3+ HER2/neu expression. Several measures, 
including project-specific safety related inclusion/exclusion criteria, regular physical 
examinations, laboratory testing, etc., throughout the study and toxicity management guidelines 
have been incorporated into the study protocol to mitigate any potential or identified risks. 
NOTE:  This same risks/benefits analysis applies to all study populations included in this 
clinical study. 
12.6 CONSENT PROCESS AND DOCUMENTATION 
The investigational nature and objectives of this trial, the procedures and treatments involved and 
their attendant risks and discomforts, and the potential benefits will be carefully explained to the 
patient and the patient’s advocate. It will be stated clearly that participation in the research study 
is voluntary and that participants can withdraw from the study without losing benefits they would 
otherwise be entitled to. The patient and family members will be encouraged to ask questions. 
This process will include a general description of the disease process, as well as a description of 
the patient’s expected clinical course. Enrollment on this study will only occur if the patient 
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Eligible patients will be presented with a detailed description of the study protocol plan and 
treatment and provided with a copy of the IRB-approved Informed Consent to review in advance 
of any discussions with the clinical trials team. The specific requirements, research objectives, 
risks, alternatives, time commitments and potential benefits will be reviewed with the patient. 
The patient will be reassured that participation in this study is entirely voluntary and that they 
may withdraw or decide against receipt of vaccination at any time without adverse consequences. 
All questions about the study will be answered and alternatives to participation will also be 
discussed. The Principal Investigator, Lead Associate Investigator or their designee is 
responsible for obtaining a signed protocol Informed Consent using the current version approved 
by the NIH Intramural IRB and posted on the web. The original signed informed consent will be 
placed in the patient’s medical record and a copy will be provided to the patient. 
12.6.1 Telephone consent procedure 
Consent on this study may be obtained via telephone according to the following procedure: the 
informed consent document will be sent to the subject.  An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form.  
The subject will sign and date the informed consent.  
The original informed consent document will be sent back to the consenting investigator who 
will sign and date the consent form with the date the consent was obtained via telephone.   
A fully executed copy will be returned via mail for the subject’s records.   
The informed consent process will be documented in the medical record.  
13 PHARMACEUTICAL INFORMATION   
13.1 AD5F35HER2ECTM (ADHER2) 
13.1.1 Source 
13.1.1.1 Product/Vector Description 
Product Name: Ad5f35HER2ECTM 
Vector Derivation 
The Ad5f35HER2ECTM vector was produced under cGMP conditions in the Vector Production 
Facility (VPF) of the Center for Cell and Gene Therapy (CAGT) at Baylor College of Medicine.  
The knob and fiber of Ad35 is substituted yielding a recombinant Ad5f35 vector that allows for 
greater viral tropism and more efficient transduction of human dendritic cells (DC) that are the 
proposed platform for this vaccine as outlined in Figure 12. 
 

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Figure 12: Ad5f35 Human HER2/neu ECTM Vector Product 
 
13.1.1.2 Vector Manufacturing Summary 
The vector was manufactured under cGMP conditions by the Baylor College of Medicine Center 
for Cell and Gene Therapy (CAGT). The adenoviral vector was initially purified by two rounds 
of plaque isolation and then serially propagated on human embryonic kidney cells (HEK-293). 
The final amplified adenoviral vector was purified by ultracentrifugation using double cesium 
chloride gradients. Residual cesium chloride was removed by dialysis of the solution containing 
the vector against the formulation buffer. Refer to adenoviral vector cGMP production as 
outlined in Appendix 10.  
An initial Master Virus Bank of Ad5f35HER2ECTM was generated (VM1003) and underwent 
two rounds of plaque purification with ultimate generation of purified Master Virus Bank Bulk 
Vector (VMB1003) which was subsequently used to produce the first clinical clot of vector that 
was then vialed for clinical use.  The Ad5f35HER2ECTM clinical product is labeled VMC1003 
and contains 1x10e12 viral particles/mL and 0.2mL/vial. A map of the Ad5f35HER2ECTM 
vector is outlined in Appendix 11.  
13.1.1.3 Vector Quality Assurance/Quality Control (QA/QC) 
Per contractual requirements with the Baylor College of Medicine CAGT, the manufacture and 
testing of the final clinical Ad5f35HER2ECTM vector product (both bulk and vialed) was 
conducted under current Good Manufacturing Practice (cGMP) guidelines in accordance with 

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the cGMP Regulations outlined in 21 CFR Parts 210 and 211. CAGT is required to prepare and 
complete documentation as manufacturing tasks have been performed and this documentation is 
subsequently reviewed by the CAGT QA division.  This documentation includes sequence 
verification, the manufacturing batch records, certificate of analysis and any other manufacturing 
related information for CMC documentation required for IND filing.  
13.1.2 Toxicity 
There is no known toxicity of the Ad5f35HER2ECTM vector.  It is a replication incompetent 
vector that does not integrate into the genomic DNA of the host cells it is used to 
transduce/transfect.  Transduction of dendritic cells is associated with some reduction in cell 
viability that his highly donor dependent based on pre-clinical studies characterizing the 
proposed transduction process that will be used in this study in normal donors.  The 
Ad5f35HER2ECTM vector has undergone replication capacity assay (RCA) assay testing that 
has been reviewed by the FDA and determined to be acceptable for its proposed use in this study. 
13.1.3 Formulation and Preparation 
13.1.3.1 Vector Vialing and Storage 
The product labeling for the first clinical lot of Ad5f35HER2ECTM vector (VMC1003) that 
was vialed on 12/21/10 and that will be used in the current study for transduction of 
autologous dendritic cells to generate vaccines for this study is:  
 
Ad5f35-Her2-ECTM 
Lot: VMC1003 
Conc: 1E+12 vp/mL     Vol: 0.2 mL 
Store: < = -70C       Exp: 12/21/2015 (stability studies pending) 
Made by CAGT Baylor, Houston, Texas 
New Drug For Investigational Use Only 
Total: 519 vials 
There is also a Virus Master Archive for this clinical lot (VMA1003): 1E=12 vp/ml, 1.0mL/vial.   
Total: 30 vials. 
A second clinical lot of vector (VEC1003.1.11) was produced and vialed on 02/09/12.  It will 
be available for use in future investigational studies of the Ad5f35HER2ECTM vector as well as 
in this study should the first lot be used up or become unusable.    This second clinical lot is 
labeled as follows: 
Ad5f35-Her2-ECTM 
Lot: VEC1003.1.11 
Conc: 1E+12 vp/mL        Volume: 0.2 mL 
Store: < = -70C       Date Fill: 02/09/2012 
Made by CAGT Baylor, Houston, Texas 
New Drug For Investigational Use Only 
The vialed vector is stored below -70C at the NIH Clinical Center Investigational Drug 
Management Research Section (IDMRS).  Investigational drug supply of vector used for 
manufacture of autologous HER2 DC vaccines will be tracked and documented as per regulatory 
requirements. 

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13.1.3.2 Proposed Vector Product Use and Formulation: Vector-Transduced Autologous 
Dendritic Cell Vaccine 
13.1.3.3 Product Name: Autologous Ad5f35HER2ECTM transduced dendritic cell vaccine 
(AdHER2 DC Vaccine) 
13.1.3.4 Dendritic Cell Vaccine Manufacturing Summary 
The autologous AdHER2 DC vaccine will be manufactured by the Department of Transfusion 
Medicine (DTM) at the NIH Clinical Center in Bethesda, MD: 
 
National Institutes of Health 
NIH Clinical Center 
Department of Transfusion Medicine 
10 Center Drive-MSC 1184 
Building 10, Room 1C711 
Bethesda, MD 20892-1184 
The Sponsor-Investigator held IND that will be submitted for this product will include a Letter of 
Authorization to Cross-Reference BB-MF 11054 from the Master File Type V for Facility, 
Operational and Quality Systems for the Manufacture of Cellular Therapy Products that is held 
by DTM. 
Refer to Appendix 3 for the DTM Standard Operating Procedure for Manufacture of the 
AdHER2DC vaccine 
13.1.4 Stability and Storage 
Vector Stability and Release Testing 
 

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Vector stability and release testing is being conducted at 0 months, 12 months and yearly 
thereafter as outlined below. 
Additional testing is conducted for infectious units (IU), viral particles (VP). USP sterility, 
endotoxin, pH, transgene expression and restriction digest. 
Vialed vector is stored at < -70 degrees Celsius. 
13.1.5 Administration Procedures 
Refer to Appendix 3 for details regarding Ad5f35HER2ECTM vector use in the transduction of 
autologous dendritic cells and generation of final vaccine product. 
13.1.6 Incompatibilities 
The Ad5f35HER2ECTM vector has no known incompatibilities in culture. 
13.2 SARGRAMOSTIM 
13.2.1 Source:  
The GM-CSF to be used in this study is glycosylated, recombinant human Granulocyte-
Macrophage Colony Stimulating Factor (rhu GM-CSF) (brand name Leukine).  This rhu GM-
CSF is an altered form of the native molecule: the position 23 arginine has been replaced with a 
leucine to facilitate expression of the protein in yeast (Saccharomyces cerevisiae) and the 
carbohydrate moiety may be different from the native protein.  The Clinical Center Pharmacy 
will purchase commercially available sargramostim. Rhu GM-CSF will be used both as an 
ancillary product for the maturation of dendritic cells and for administration to patients with 
peptide vaccination.  
13.2.2 Formulation and Preparation:  
Lyophilized LEUKINE is a sterile, white, preservative-free powder (250 mcg) that requires 
reconstitution with 1 mL Sterile Water for Injection, USP or 1 mL Bacteriostatic Water for 
Injection, USP.  Reconstituted lyophilized LEUKINE is a clear, colorless liquid suitable for 
subcutaneous injection or intravenous infusion. The vial of lyophilized LEUKINE contains 250 
mcg (1.4 x 106 IU/vial) sargramostim, 40 mg/mL mannitol, USP; 10 mg/mL sucrose, NF; and 
1.2 mg/mL tromethamine, USP, as excipients. Biological potency is expressed in International 
Units (IU) as tested against the WHO First International Reference Standard. The specific 
activity of LEUKINE is approximately 5.6 x 106 IU/mg. 
13.2.3 Stability and Storage: 
Lyophilized LEUKINE should be refrigerated at 2 to 8 C (36 to 46 F) and is stable for at least 
eighteen months. It should not be frozen, shaken or used beyond the expiration date printed on 
the vial.  LEUKINE reconstituted with 1.0 mL of Sterile Water for Injection, USP (without 
preservative) should be administered as soon as possible and within 6 hours following 
reconstitution.  Reconstituted solutions prepared with Bacteriostatic Water for Injection USP 
(0.9% benzyl alcohol) may be stored for up to 20 days at 2 to 8 C prior to use. The contents of 
vials reconstituted with different diluents should not be mixed together. 

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13.2.4 Administration Procedures:  
Lyophilized LEUKINE will be used in vitro by the Department of Transfusion Medicine for the 
generation of dendritic cells by the Department of Transfusion Medicine. 
13.2.5 Incompatibilities:  
Refer to the package insert/PDR/Formulary.  
13.3 INTERLEUKIN-4 CELLGENIX 
13.3.1 Source:  
Interleukin-4 (IL-4) used in this study is investigational.  It is manufactured and supplied by 
CellGenix (Master File cross reference BB-MF 11269).  It will be used as an ancillary product to 
mature dendritic cells in vitro and will not be administered directly to patients. IL-4 exerts 
important effects on B cells, T cells, macrophages, eosinophils, hematopoietic progenitor cells, 
endothelial cells and promotes the maturation of dendritic cells.  The complementary DNA clone 
(cDNA), when expressed in E.coli yields a 130 amino acid residules with a molecular mass of 14 
kDa.  IL-4 is a highly purified ( 97% as determined by SDS-PAGE), sterile, water-soluble 
protein. 
13.3.2 Formulation and Preparation:  
RhIL-4 Sterile Powder for Injection is supplied in a 50mcg vial as a sterile lyophilized powder 
formulated with glycine, human serum albumin, citric acid, and sodium citrate. Approximately 
1.2 mL of Sterile Water for Injection USP should be added to each vial of rhIL-4 Sterile Powder 
for Injection. The vial should be gently agitated to completely dissolve the powder and should be 
inspected visually for discoloration and particulates prior to use. 
13.3.3 Stability and Storage:  
The product both intact and reconstituted vial should be stored at -20C to -80C and should be 
used within 24 hours. 
13.3.4 Administration Procedures:  
To be used in dendritic cell culture, not administered directly to patients.  
13.3.5 Incompatibilities:  
None known in culture.  
13.4 KLH (KEYHOLE LIMPET HEMOCYANIN) 
13.4.1 Source  
KLH protein (Product Code KLH-02NV) was purchased from Stellar Biotechnologies, Inc. and 
then vialed by Element SL Pharma. It is stored in Center for Cellular Engineering in Department 
of Transfusion Medicine, NIH Clinical Center for use in dendritic cell culture. The KLH 
formulation to be utilized by NIH has been purified as native molecules and designated as High 
Molecular Weight KLH (HMW-KLH).  
The only source for KLH is the hemolymph of Giant Keyhole Limpets, Megathura crenulata, an 
ocean mollusk. Stellar’s clinical grade HWM-KLH is purified under cGMP conditions, and 
sourced from giant keyhole limpets cultured by Stellar under controlled aquaculture systems. 

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KLH protein is expressed in two subunit isoforms (KLH1 and KLH2) of approximately 360,000 
and 400,000 monomeric molecular weight, respectively. The KLH monomers are each composed 
of 7 or 8 functional unit domains; each functional unit contains an oxygen binding site 
containing two copper atoms. Both KLH isoforms assemble into native homo-decamers and 
didecamers of 4,000,000 to 8,000,000 molecular weight in hemolymph. 
13.4.2 Formulation and Preparation:  
Stellar high molecular weight KLH is provided in soluble form in a buffer solution that is 
composed of 10mM sodium phosphate, 135mM NaCl, 1mM CaCl2 and 0.5mM MgCl2 as a bulk 
drug substance at 5mg/mL and then diluted and vialed into single use vials at 2mg/mL, 250 
µL/vial by Element SL Pharma, a vendor qualified by NIH Sterile Product for Human 
Administration (SPHA) committee. 
13.4.3 Stability and Storage:  
HMW-KLH is stable for at least 12 months when stored at 2 to 8C. A stability testing program 
is in place. 
13.4.4 Administration Procedures:  
HMW-KLH will be used in vitro by the Department of Transfusion Medicine at a concentration 
of 10mcg/mL for the generation of dendritic cells. Any excess culture media will be removed 
Cells before administration. 
13.4.5 Incompatibilities:  
No information available.  

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Moasser MM. The oncogene HER2: its signaling and transforming functions and its role 
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Slamon DJ, Godolphin W, Jones LA, et al. Studies of the HER-2/neu proto-oncogene in 
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Moasser MM. Targeting the function of the HER2 oncogene in human cancer 
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Wolff AC, Hammond MEH, Schwartz JN, et al. American Society of Clinical 
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8. 
Lan KH, Lu CH, Yu DH. Mechanisms of trastuzumab resistance and their clinical 
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and vinorelbine for HER2-positive early breast cancer. Clin Cancer Res. 
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Berns K, Horlings HM, Hennessy BT, et al. A functional genetic approach identifies the 
PI3K pathway as a major determinant of trastuzumab resistance in breast cancer. Cancer 
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Seidman A, Hudis C, Pierri MK, et al. Cardiac dysfunction in the trastuzumab clinical 
trials experience. J Clin Oncol. 2002;20(5):1215-1221. 
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Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after adjuvant 
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Tan-Chiu E, Yothers G, Romond E, et al. Assessment of cardiac dysfunction in a 
randomized trial comparing doxorubicin and cyclophosphamide followed by paclitaxel, 
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growth factor receptor 2-overexpressing breast cancer: NSABP B-31. J Clin Oncol. 
2005;23(31):7811-7819. 
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Geyer CE, Forster J, Lindquist D, et al. Lapatinib plus capecitabine for HER2-positive 
advanced breast cancer. New Engl J Med. 2006;355(26):2733-2743. 

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15. 
Koninki K, Barok M, Tanner M, et al. Multiple molecular mechanisms underlying 
trastuzumab and lapatinib resistance in JIMT-1 breast cancer cells. Cancer Lett. 
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Baselga J, Cortes J, Kim SB, et al. Pertuzumab plus Trastuzumab plus Docetaxel for 
Metastatic Breast Cancer. New Engl J Med. 2012;366(2):109-119. 
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LoRusso PM, Weiss D, Guardino E, Girish S, Sliwkowski MX. Trastuzumab Emtansine: 
A Unique Antibody-Drug Conjugate in Development for Human Epidermal Growth 
Factor Receptor 2-Positive Cancer. Clin Cancer Res. 2011;17(20):6437-6447. 
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Park JM, Terabe M, Steel JC, et al. Therapy of advanced established murine breast cancer 
with a recombinant adenoviral ErbB-2/neu vaccine. Cancer Res. 2008;68(6):1979-1987. 
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Park JM, Terabe M, Sakai Y, et al. Early Role of CD4+ Th1 cells and antibodies in HER-
2 adenovirus-vaccine protection against autochthonous mammary carcinomas. J 
Immunol. 2005;174:4228-4236. 
20. 
Rolla S, Nicolo C, Malinarich S, et al. Distinct and non-overlapping T cell receptor 
repertoires expanded by DNA vaccination in wild-type and HER-2 transgenic BALB/c 
mice. J Immunol. 2006;177(11):7626-7633. 
21. 
Cavallo F, Calogero RA, Forni G. Are oncoantigens suitable targets for anti-tumour 
therapy? Nat Rev Cancer. 2007;7(9):707-713. 
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Sakai Y, Morrison BJ, Burke JD, et al. Vaccination by Genetically Modified Dendritic 
Cells Expressing a Truncated neu Oncogene Prevents Development of Breast Cancer in 
Transgenic Mice. Cancer Res. 2004;64:8022-8028. 
23. 
Disis ML, Calenoff E, McLaughlin G, et al. Existent T-cell and antibody immunity to 
HER-2/neu protein in patients with breast cancer. Cancer Res. 1994;54:16-20. 
24. 
Disis ML, Knutson KL, Schiffman K, Rinn K, McNeel DG. Pre-existent immunity to the 
HER-2/neu oncogenic protein in patients with HER-2/neu overexpressing breast and 
ovarian cancer. Breast Cancer Res Treat. 2000;62(3):245-252. 
25. 
Finn OJ. Cancer immunology. N Engl J Med. 2008;358(25):2704-2715. 
26. 
Kiessling A, Fussel S, Wehner R, et al. Advances in specific immunotherapy for prostate 
cancer. Eur Urol. 2008;53(4):694-708. 
27. 
Tanaka Y, Koido S, Chen DS, Gendler SJ, Kufe D, Gong JL. Vaccination with allogeneic 
dendritic induces antitumor immunity in cells fused to carcinoma cells MUC1 transgenic 
mice. Clin Immunol. 2001;101(2):192-200. 
28. 
Higano CS, Small EJ, Schellhammer P, et al. Sipuleucel-T. Nat Rev Drug Discov. 
2010;9(7):513-514. 
29. 
Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-
resistant prostate cancer. N Engl J Med. 2010;363(5):411-422. 
30. 
Higano CS, Schellhammer PF, Small EJ, et al. Integrated Data From 2 Randomized, 
Double-Blind, Placebo-Controlled, Phase 3 Trials of Active Cellular Immunotherapy 
With Sipuleucel-T in Advanced Prostate Cancer. Cancer. 2009;115(16):3670-3679. 

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31. 
Ladjemi MZ, Jacot W, Chardes T, Pelegrin A, Navarro-Teulon I. Anti-HER2 vaccines: 
new prospects for breast cancer therapy. Cancer Immunol Immun. 2010;59(9):1295-1312. 
32. 
Norell H, Poschke I, Charo J, et al. Vaccination with a plasmid DNA encoding HER-
2/neu together with low doses of GM-CSF and IL-2 in patients with metastatic breast 
carcinoma: a pilot clinical trial. J Transl Med. 2010;8. 
33. 
Mitsuhashi M. Ex vivo simulation of leukocyte function: Stimulation of specific subset of 
leukocytes in whole blood followed by the measurement of function-associated mRNAs. 
J Immunol Methods. 2010;363(1):95-100. 
34. 
Marshall DT, Savage SJ, Garrett-Mayer E, et al. Vitamin D3 supplementation at 4000 
international units per day for one year results in a decrease of positive cores at repeat 
biopsy in subjects with low-risk prostate cancer under active surveillance. J Clin 
Endocrinol Metab. 2012;97(7):2315-2324. 
35. 
Wagner D, Nonn L, Antonio A, et al. Double-blind randomized clinical trial of vitamin 
D3 showing effects on tissue calcitriol levels, gene expression and proliferation 
immunohistochemistry in prostate cancer. Cancer Res. 2012;72. 
36. 
Peppone LJ, Rickles AS, Janelsins MC, Insalaco MR, Skinner KA. The Association 
Between Breast Cancer Prognostic Indicators and Serum 25-OH Vitamin D Levels. Ann 
Surg Oncol. 2012;19(8):2590-2599. 
37. 
Nishino M, Giobbie-Hurder A, Gargano M, Suda M, Ramaiya NH, Hodi FS. Developing 
a Common Language for Tumor Response to Immunotherapy: Immune-Related 
Response Criteria Using Unidimensional Measurements. Clin Cancer Res. 
2013;19(14):3936-3943. 
38. 
Wolchok JD, Hoos A, O'Day S, et al. Guidelines for the Evaluation of Immune Therapy 
Activity in Solid Tumors: Immune-Related Response Criteria. Clin Cancer Res. 
2009;15(23):7412-7420. 
39. 
Hodi FS, Hwu WJ, Kefford R, et al. Evaluation of Immune-Related Response Criteria 
and RECIST v1.1 in Patients With Advanced Melanoma Treated With Pembrolizumab. J 
Clin Oncol. 2016;34(13):1510-+. 
 
 
 

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

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15.2 APPENDIX 2: NEW YORK HEART ASSOCIATION(NYHA) FUNCTIONAL CLASSIFICATION 
The New York Heart Association (NYHA) Functional Classification in a Patient with Heart Disease  
Overview: The New York Heart Association (NYHA) developed a functional classification for patients 
with heart disease.  
Patients: Heart disease must be present.  
Parameters:  
(1) Limitations on physical activity  
(2) Symptoms (undue fatigue palpitations dyspnea and/or anginal pain) with ordinary physical 
activity  
(3) Status at rest 
Limitations on 
Physical Activity 
Symptoms with Ordinary 
Physical Activity 
Status at Rest 
Class 
None  
None  
Comfortable 
I  
Slight  
Symptomatic with ordinary 
activities  
Comfortable 
II  
Marked  
Symptomatic at less than 
ordinary levels of activity  
Comfortable 
III  
Unable to perform any 
activity  
Discomfort with any 
activity  
Symptomatic at rest 
IV  
 
In addition the level of objective evidence was also classified: 
 
Objective Evidence of Cardiovascular Disease 
Class 
No evidence of disease 
A 
Minimal disease 
B 
Moderate disease 
C 
Severe disease 
D 
 

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15.3 APPENDIX 3: STANDARD OPERATING PROCEDURE FOR MANUFACTURE OF ADHER2 
AUTOLOGOUS DENDRITIC CELL VACCINE 
Standard Operating Procedure and Dendritic Cell Manufacturing Summary 
The autologous AdHER2 DC vaccine will be manufactured by the Department of Transfusion 
Medicine (DTM) at the NIH Clinical Center in Bethesda, MD: 
National Institutes of Health 
NIH Clinical Center 
Department of Transfusion Medicine 
10 Center Drive-MSC 1184 
Building 10, Room 1C711 
Bethesda, MD 20892-1184 
The Sponsor-Investigator held IND that will be submitted for this product will include a Letter of 
Authorization to Cross-Reference BB-MF 11054 from the Master File Type V for Facility, 
Operational and Quality Systems for the Manufacture of Cellular Therapy Products that is held 
by DTM. 
Autologous Cell Harvest  
Blood collection will be by standard apheresis: up to 18L of whole blood will be processed in 
order to collect peripheral blood mononuclear cells (MNC) with a target yield of at least 2.2 ×109 
monocytes. Lymphocytes will also be cryopreserved for immunologic assays. Apheresis will be 
performed in the Clinical Center (CC) Department of Transfusion Medicine (DTM) using 
approved standard operating procedures. Bilateral peripheral venous access or a venous dual 
lumen catheter will be used for apheresis.  Prophylactic intravenous CaCl2 and MgSO4 infusions 
may be administered during apheresis to treat or prevent citrate toxicity at the discretion of the 
DTM physician per routine.  Autologous monocytes for dendritic cell culture will be enriched 
from peripheral blood MNC apheresis collections by counter-flow elutriation, aliquoted into 
multiple vials and cryopreserved for future preparation of the dendritic cell products: target of at 
least 6 vials with ~ 333 x 106 cells/vial. Additional apheresis will be offered per investigator’s 
discretion if the collected cells or plasma are not sufficient to manufacture at least 5 vaccine 
doses. All cell processing will be conducted in accordance with approved DTM policies and 
procedures. 
AdHER2 Transduced Dendritic Cells 
Autologous AdHER2 DC vaccines will be prepared under GMP conditions from cryopreserved 
patient monocytes as outlined in the accompanying AdHER2 DC manufacturing schema. The 
strength (vp/mL) of AdHER2 vector will be adjusted per most recent stability test result. The 
label on the vial reflects the strength at initial release. The range of  50% of the strength 
reported on the product label will be deemed acceptable to use in vaccine manufacturing with PI 
review of updated annual stability test result and approval. 
 
 
 
 

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15.4 APPENDIX 4: ADHER2 DC VACCINE MANUFACTURING SCHEMA 
 
Description of AdHER2 DC Vaccine Manufacture 
Day 0 Prior to the scheduled administration of the Dendritic Cells vaccine, one cryopreserved 
monocytes enriched aliquot will be thawed, washed and evaluated for cell count and 
viability.  Monocytes will be resuspended in media containing 90% RPMI-1640, 10% 
auto HF plasma or allo HIF AB plasma, 2000 IU/mL IL-4 2000 IU/mL rGM-CSF and 10 
mcg/mL gentamicin. 
Day 1 No processing required 
Day 2  Fresh media and cytokines (2000 IU/mL rIL-4, 2000 IU/mL of rGM-CSF) will be added 
to the culture; KLH will be added at a final concentration 10 mcg/mL.  

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Day 3 The AdHER2 vector will be added at a ratio of 3000 viral particles per monocytes plated 
on Day 0; vector viral particles will be added at -24 hrs from harvesting.   
Vector transfection will occur over 4 hours before the addition of maturation cocktail at -20 hrs 
from harvesting.  Maturation cocktail consist of LPS and IFN- at a final concentration 
of 30 ng/mL and 1000 IU/mL, respectively.  
Removal of sample for -24 hours sterility testing. 
Day 4 Final harvest, packaging and lot release testing of autologous AdHER2 DC vaccine 
preparation.  The final transfected, volume-reduced mature AdHER2 DC vaccine product 
will be prepared in sterile syringes for fresh administration intradermally.  
The AdHER2 DC vaccine product will be prepared as summarized above using a 
comprehensive, validated manufacturing process described in the DTM Standard Operating 
Procedures (SOP).  Detailed SOP for processing, labeling, storage, and quality assays are also 
available on site in the Cell Processing Section of DTM.  All DTM SOPs related to the 
manufacture of the AdHER2 DC vaccine will be included in the Sponsor-Investigator held IND 
to be submitted for the product. 
Vaccine Processing Steps and In Process Testing 
Multiple sample and assay timelines for the manufacturing processes of the AdHER2 DC 
vaccine are detailed in the CMC file in DTM and include: 
➢ Timeline for processing and in process testing of autologous mononuclear cells to 
generate monocyte and lymphocyte fractions via elutriation for cryopreservation. 
➢ Timeline for processing and in process testing during AdHER2 DC vaccine 
manufacture. 
Vaccine Manufacture Critical Reagents 
Critical reagents in the manufacture of autologous AdHER2 DC vaccine include interleukin-4 
(IL-4), KLH (Keyhole Limpet Hemocyanin), sagramostim (GM-CSF) and reference endotoxin 
(E. coli).  Detailed information on these agents is outlined in protocol Section 13, 
Pharmaceutical Information.  Letters of Authorization to cross-reference the master files of 
these agents will be included with the formal IND submission for the product. 
Vaccine Release Testing 
Release testing will include not only safety testing (microbiological testing) but will also include 
any product characterization that is being done such as identity, purity, and potency testing.  The 
following tests will be performed related to AdHER2 DC vaccine release criteria and quality 
control: 
a) Vaccine Product Safety Testing  
1. Sterility (bacterial and fungal) testing of all in-process and final product samples of the 
AdHER2 DC vaccine product will be done by the Bactec automated blood culture 
system.  Although final product sterility testing will be performed, results will not be 
available as a release criterion. 
DTM has completed and published the results of a study demonstrating that both the 
BacT/Alert (BioMerieux) and the Bactec (Becton Dickinson) automated culture systems 
are superior to the CFR/USP method for sterility testing of cell therapy products (seeded 

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study; Khuu HM et al.  Cytotherapy 2004; 6(3): 183-195).  They also published a parallel 
testing study of CFR/USP vs. Bactec, for sterility testing of actual cell therapy products 
from their facility. Results of the parallel studies show that the automated culture 
methods had fewer false positives than CFR/USP (Khuu HM et al. Transfusion 2006; 46: 
2071-82).  Based on the analysis of both studies, DTM has sufficient data to implement 
the Bactec system as the replacement for the CFR/USP method. 
Justification for use of automated system in place of CFR/USP method is based on the 
results of the studies described above.  In the seeded study, 10 different organisms were 
seeded into mononuclear cell products suspended in 6 different media, one of which was 
X-Vivo20 (which contains gentamicin), and one of which was our standard freeze mix 
(Plasmalyte A, human serum albumin, Pentastarch, DMSO, Dornase, and heparin), which 
is used to cryopreserve all products in this protocol.  The antibiotic level tested in the 
seeded study is 50mg/mL and this level was shown to be non-inhibitory in the automated 
culture system. This is the same level in the samples for sterility for the product in this 
IND.   
2. Negative gram stain must be documented 
3. Sterility of -24hrs in process sample must be documented 
4. Mycoplasma testing will be done by Mycoplasma PCR method (Roche) but results will 
not be available for use as a release criterion 
5. Endotoxin testing will be done by the KQCL method; endotoxin level must be < 5EU/ml. 
6. Transfusion-transmitted disease (TTD) testing will be performed using methods 
described in our Master File CC-MF-11054 (Attachment 8-A), with the following 
modification. Testing is performed by Blood Systems Laboratories in Tempe, AZ CLIA 
Reg #03D0911463).  Agents include T. cruzi as well as those listed. Syphilis is tested 
using PK-TP assay, instead of RPR. 
b) Vaccine Product Characterization 
1. Total cell number as determined using an automatic counter. 
2. Viability using Trypan blue dye exclusion with a minimum viability of > 60% as 
release criteria. 
3. Cell phenotype and expression for HER2neu by FACS. 
Phenotype markers will include: CD14, CD38, CD54, CD83, CD86, CD 340 
(HER2neu), CCR7, HLA-DR.  Key phenotype markers in bold.  
4. Day 3 in process DC supernatants prior to transfection with adenovirus for cytokine 
assessments by multiplex and proteomic array (for research purposes). 
Vaccine Product Release and Action Plans for Positive Results on Safety Testing 
General action plans for dealing with positive tests for sterility, mycoplasma, and endotoxin 
testing are presented in our Master File BB-MF-11054 (Attachments 9-B through 9-D). As noted 
above, not all safety testing will be available prior to release of the AdHER2 DC vaccine 
product. For testing with final results available, results must be within pre-specified limits and 
documented on the Certificate of Analysis before the product is released for administration to the 
patient. 

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Vaccine Final Product Preparation Steps (fresh infusion) 
The final AdHER2 DC vaccine product will be harvested from the 5-day culture product and 
packaged for fresh infusion on the same day.  
Vaccine Product Tracking and Labeling 
The system for labeling and tracking of all products in this IND will be the same as the general 
system used in the DTM Cell Processing Facility, described in their Master File BB-MF-11054, 
section XI. 
Vaccine Product Administration 
Autologous AdHER2 DC vaccines will be harvested from the 5-day culture product as 
previously described and packaged for fresh administration on the same day according to DTM 
Standard Operating Procedures. The protocol specified AdHER2 DC vaccine dose of 5 X 106 
viable cells, 10 X 106 viable cells, 20 X 106 viable cells or 40 X 106 viable cells will be 
concentrated in a final total volume of 1.0mL for intradermal administration immediately upon 
receipt in the clinical setting.  Post packaging testing of DC vaccines produced by DTM indicates 
that the product should be stable for at least 2 hours. 
Patients will have vital signs monitored for one hour following administration of the first dose of 
AdHER2 DC vaccine and for 15 minutes with all subsequent doses if there are no significant 
acute adverse systemic clinical events (e.g. fever, hypotension, wheezing, rash/urticaria) 
documented after the first dose.  It is anticipated that the primary adverse events associated with 
AdHER2 DC vaccination will be local injection site reactions, and possibly symptoms related to 
local anti-tumor inflammatory responses at sites of primary and metastatic disease including 
focal organ discomfort and/or reactive pleural and peritoneal effusions. 

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15.5 APPENDIX 5: ADHER2 DENTRITIC CELL VACCINE REPORT CARD 
 
Date/Time Vaccine Administered: ____________     Administered By:  _________________ 
 
Study Part I Part II               Vaccine Dose 10e6 cells 20e6 cells 40e6 cells 
 
Study Week  __________             Vaccine Dose # 1 2 3 4 5   
 
 
 
 
 
 
Injection 
Site:  
Forearm 
Injection 
Volume 
(mL) 
ID 
Wheal 
Present? 
DA
Y 1 
DA
Y 2 
DA
Y 3 
DA
Y 4 
DA
Y 5 
Date 
resolved 
 
Site #1 
Left 
Right 
 
 
Present 
Absent 
 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 
 
Site #2 
Left 
Right 
 
 
Present 
Absent 
 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 
 
Site #3 
Left 
Right 
 
 
Present 
Absent 
 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 
 
Site #4 
Left 
Right 
 
 
Present 
Absent 
 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 0 
 1 
 2 
 3 
 
Total Injection Volume:  _______________     
                                                                                                                                                                              
 
 
 
Note: If you have a reaction that lasts longer than 5 days please continue to describe it on 
the back of this page.  
Print Name: 
 
Signature: 
 
Injection Site Reaction Grading (NCI CTCAE v4.03) 
 0 No Reaction 
 1 Tenderness with or without associated warmth, redness, itching. 
 2 Pain, swelling (edema), lipodystrophy (shrunken area of the skin due 
to loss of fat), or phlebitis (inflammation of veins in the skin).  
 3 Ulceration or necrosis (skin break down); severe tissue damage.  
Operative intervention indicated. 
 4 Life-threatening consequences.  Urgent intervention indicated. 

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15.6 APPENDIX 6ANTI-HER2 ANTIBODY AND CELLULAR RESPONSES 
The majority of the testing on this study will be done in the NIH Clinical Center clinical 
laboratory following their guidelines for blood collection and tube type.  The appropriate tube for 
uncommon laboratory tests and immunologic research specimens and where they should be sent 
are as follows: 
Quantitative Anti-HER2 Antibody Testing: Weeks 0, 8, 16, 24, 32, 40, 48, 60, 76, 100, and 
124 
Purpose:  To determine the immunogenicity of autologous Ad HER2 dendritic cell vaccination 
as measured by a 3-fold increase in anti-HER2/neu antibody concentration 
(measured as mcg/mL) or a 4-fold increase in antibody dilution titers over baseline. 
Specimen Processing: 
1 10mL Red Top Clot activator 
Specimens will be processed by the Clinical Support Laboratory Leidos Biomedical Research, 
Inc.  Serum will be aliquoted into vials and cryopreserved until ready for interrogation in batched 
specimen assays. 
Characterization of Vaccine-Induced Antibody Profiles  Weeks 0, 8, 16, 24, 32, 40, 48, 60, 
76, 100, and 124 
Purpose:  To characterize vaccine-induced antibody profiles using HER2 peptide microarrays, 
examining reactivity to HER2 extracellular (EC), transmembrane (TM) and 
intracellular (IC) domains to document evidence of epitope spreading. 
 
To characterize immunoglobulin sub-classes of anti-HER2 antibodies. 
Specimen Processing: 
No additional specimens to be drawn.   
Will utilize clinical specimens drawn and processed for quantitative anti-HER2 antibody testing. 
 
 
Cellular Responses to HER2/neu:  
Weeks 0, 8, 16, 24, 32, 40, 48, 60, 76, 100, and 124Tetramer & IFN- ELISPOT Assays:  
3 10mL Green Top Heparinized Tubes (30 mL total)  
Send via Frederick Courier to NCI Frederick Clinical Support 
Laboratory for specimen processing and freezing. 
Tetramer Assay:  
Will be performed by the flow cytometry unit in the NCI Frederick 
Clinical Support Laboratory or Vaccine Branch Flowcytometry Core. 
IFN- ELISPOT Assay:  Will be performed in the Laboratory of Cell Mediated Immunity or 
Vaccine Branch Flowcytometry Core. 
The Clinical Support Laboratory, Leidos Biomedical Research, Inc., processes and cryopreserves 
samples in support of IRB-approved, NCI clinical trials.  The laboratory is located in a controlled 
access building and laboratory doors are kept locked at all times.  Upon specimen receipt, each 
sample is assigned a unique, sequential laboratory accession ID number.  All products generated 
by the laboratory that will be stored either in the laboratory freezers or at a central repository 
facility are identified by this accession ID.  An electronic database is used to store information 
related to patient samples processed by the laboratory.  Vial labels do not contain any personal 
identifier information.  Samples are stored inventoried in locked laboratory freezers and are 

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routinely transferred to the NCI-Frederick repository facilities for long-term storage.  These 
facilities are operated by ATCC. under subcontract to Leidos Biomedical Research, Inc.  Access to 
stored clinical samples is restricted.  Investigators establish sample collections under “Source 
Codes” and the investigator is responsible for the collections, typically the protocol Principal 
Investigator who has access to the collection.  Blood and tissue specimens collected in the course 
of this research project may be banked and used in the future to investigate new scientific 
questions related to this study. However, this research may only be done if the risks of the new 
questions were covered in the consent document, the patient has provided consent for the research 
use of their clinical specimens, and the proposed research has undergone prospective IRB review 
and approval.  The NIH Intramural IRB will be notified when samples are destroyed. 

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15.7 APPENDIX 7EVALUATION OF ANTI-AD5 ANTIBODY IMMUNITY 
An intramural scientific collaborator or scientific contractor to perform these studies to be 
determined. 
 
Anti-Ad5 antibody ELISA assessments will be performed at  
Weeks 0, 8, 16, 24, 32, 40, 48, 60, 76, 100, and 124 
 to determine in an exploratory manner if: 
1. AdHER2 DC vaccination is associated with a measurable increase in anti-Ad5 antibody over 
time. 
2. Pre-existing levels of anti-Ad5 antibodies inversely correlate with vaccine immunogenicity 
as measured by anti-HER2 antibody levels. 
We will store the samples in a -80°C freezer until batched shipped at which point they will be 
processed.   

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15.8 APPENDIX 8CHARACTERIZATION OF SOLUBLE HER2 AND ANTI-HER2 ANTIBODIES 
Testing and characterization of soluble HER2 and anti-HER2 antibodies will be performed by a 
third party Midissia or other third-party collaborator using samples stored as described in 
Appendix 6. Midissia is a developing biopharma company that has licensed the AdHER2 DC 
platform in combination with a checkpoint inhibitor. 
 
 

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15.9  APPENDIX 9EXPLORATORY CORRELATIVE STUDIES  
 
 
 1 of 2 
Measurement of Function-Associated mRNAs in Whole Blood: Hitachi Chemical 
 
Function-Associated mRNAs:  
One 6 mL green top sodium heparin tube 
(Week -0) 
 
For Prediction of Responses: 
 
➢ Blood will be drawn into one 6 mL green top tube. 
➢ Add 180 L each of blood into one 8-well strip. Strips contain PHA, HAG, PBS, DMSO, 
rIL2, CEF, LPS/ZA, and HER2). 
➢ Incubate at 37C for 4 hours. 
➢ Store in -80C (+/- 10C) freezer until ready for shipment to Hitachi Chemical  
➢ Note: specimen should be drawn DAY OF VACCINE before 1pm to allow adequate 
time for specimen processing and four hour incubation by Trepel lab staff. 
 
 
For Characterization of Responses will be assessed after “Prediction of Responses” described 
above confirms the list of mRNA to pursue.   
 
➢ Blood will be drawn into one 6 mL green top tube. 
➢ Approximately 1% (2x105 cells) of final AdHER2 DC vaccine product in 0.1mL of 
standard suspension (taken at the same time as DC product QC test samples) and 0.2mL 
of heparinized whole blood will be placed into conical freezer microtubes in the 
following manner: 
1. Tube 1: 0.1mL of 2x105 cells of final AdHER2 DC vaccine product only 
2. Tube 2: 0.1mL of 2x105 cells of final AdHER2 DC vaccine product plus 0.2mL 
of heparinized whole blood. 
3. Tube 3: 0.2mL of heparinized whole blood only  
➢ Incubate at 37C for 4 hours. 
➢ Store in -80C (+/- 10C) freezer until ready for shipment to Hitachi Chemical  
➢ Note: specimen should be drawn DAY OF VACCINE before 1pm to allow adequate 
time for specimen processing and four hours incubation by Trepel lab staff. 
 

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2 of 2 
Multiparameter Flow Cytometric Analysis of Circulating Tumor Cells (CTC) and Immune 
Cell Subsets: Jane Trepel, DTB 
Analysis will be performed by the laboratory of Jane Trepel. CTC cells and immune cell subsets 
will be identified by mulitparameter flow cytometry. The order of priority for immune subset 
analysis is T, B, NK, NKT, Tregs, MDSC and dendritic cells. 
CTC Analysis:   
 
 
One 10mL lavender top tube 
 (Weeks 0, 8, 16, 24, 32, 40, 48, 60, 76, 100, and 124 when patient schedule permits 
collection before 1pm.) 
 
 
Immune Cell Subset Analysis:   
One 10mL lavender top tubes  
(Weeks 0, 8, 16, 24, 32, 40, 48, 60, 76, 100, and 124 when patient schedule permits collection 
before 1pm.) 
 
Multiparameteric flow cytometry using a Miltenyi Quant flow cytometer.  The order of priority 
for immune subset analysis is T, B, NI, NKT, Tregs, MDSC and dendritic cells. 
 
NKT Cell Analysis:  
One 10mL lavender top tubes 
(Weeks 0, 12 (s/p 3 doses of vaccine), 28 and 48) 
 
 
 
Sample Logistics for both Function-Associated mRNAs and CTC and Immune Subsets:  
 
➢ Notify the Trepel lab via email when the clinical sample is scheduled to be drawn: 
o Sunmin Lee (lees@pop.nci.nih.gov) 
o Min-Jung Lee (leemj@mail.nih.gov) 
o Jane Trepel (trepel@helix.nih.gov) 
➢ Label the clinical specimen tubes and include the study week number.  
➢ Note: specimen should be drawn before 1pm to allow adequate time for four hours 
incubation for the Hitachi clinical specimens. 
➢ Phone the Trepel lab at 240-760-6330 when the specimen is drawn for pick up by the 
Trepel lab. 
➢ The laboratory of Jane Trepel where specimens will be processing and cryopreserved is in 
Bldg.10, Rm. 12C208 
 
Immune and molecular profiling through RNA sequencing:  
 
Briefly, patient blood samples collected at baseline and at each time point when vaccine 
is administered is analyzed via next generation sequencing and RNA sequencing with 
the aim of identifying potential biologic/immunological correlates of vaccine mediated 
efficacy, including but not limited to the potential upregulation of checkpoints using 
advanced bioinformatics tools. 

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Subcontractor: Novogene Corporation, Inc. 8801 Folsom BLVD, Suite 290, 
Sacramento, CA 95826 by Midissia Therapeutics, Inc. 
 
Specimen Processing:. 10ml of whole blood will be collected in should be in 2 Tempus RNA 
tubes at Weeks 0, 8, 16, 24, 30, and 48 and kept frozen at -80°C in Frederick Leidos lab until 
analysis. If Tempus tube sample is not available, any unused PBMNC frozen aliquots for 
cellular response evaluation can be used as an alternative. 
 
RNAseq will be performed on patient blood samples to provide a comparative analysis 
of gene expression at baseline and following treatment. This will provide a 
longitudinal scan of patient response to treatment. To ensure Quality control, RNA 
quantity and quality are assessed using OD260  and OD260/280 ratios. RNAseq read 
quality is also subject to diligence. Each patient sample will have the entire 
transcriptome read and comparisons to baseline will be made by number of reads at 
each gene. 
Significant changes will be determined by a threshold p-value and a list of 
Differentially Expressed Genes (DEG) will then be assembled. DEG gene lists will 
then be used as input for post-hoc analysis. Differential Expression analysis provides 
data on the number of genes whose expression changes over the course of treatment 
and is presented by Venn diagram or volcano plot. Gene Set Enrichment Analysis 
uses the lists of differentially expressed genes (DEG) and compares them to sets of 
curated gene sets in 4 databases. 
• Gene Ontogeny (GO): a curated gene set associated with normal cell processes, such 
as: regulation of cell motility. 
• Disease Ontogeny (DO): a curated gene set associated with disease processes, such as: 
thrombocytosis 
• Kyoto Encyclopedia of Genes and Genomes (KEGG): a curated gene set 
associated with signal transduction pathways. 
• Reactome: Another database of signal transduction nodes. 
 
DEG lists from patients will be used to identify genes associated with signal transduction 
pathways, cellular processes and disease states to identify individual genes or groups of genes 
associated with a gene set of interest. Those genes whose expression patterns change 
predictably with clinical response will ultimately be used as a biologic/immunological 
correlate of vaccine mediated efficacy. 
 
 

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15.10 APPENDIX 10AD5F35HER2ECTM (ADHER2) VECTOR MANUFACTURING 
GMP Production Outline   
(1 of 2) 
 

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 Ad5f35HER2ECTM (AdHER2) Detailed Vector Manufacturing 
 
 (2 of 2) 
QC Highlighted in Orange 
 
 

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15.11 APPENDIX 11MAP OF THE AD5F35HER2ECTM (ADHER2) VECTOR 
 

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15.12 APPENDIX 12 ADHER2 DENDRITIC CELL VACCINE CANCER TREATMENT HISTORY 
Brief Cancer History:  
Cancer Diagnosis 
 
Date of Diagnosis 
 
Stage of Cancer 
 
 
Surgical Procedures: 
Operative Procedure 
Date 
Comments 
 
 
 
 
 
 
 
 
 
 
Prior Chemotherapy: 
Agent/Regimen  
Date/Duration 
Comment/Reason for D/C 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prior HER2-Targeted Therapies: (trastuzumab, lapatinib, pertuzumab) 
Agent 
Date/Duration 
Comment/Reason for D/C 
 
 
 
 
 
 
 
 
 
HISTORY OF HER2 THERAPY RELATED CARDIAC DYSFUNCTION 
(If yes document name of agent and describe toxicity and intervention) 
YES 
NO 
 
 
 
PATIENT IS NOT ELIGIBLE FOR THIS STUDY IF POSITIVE FOR HER2-RELATED CARDIAC 
TOXICITY 
 
Prior Radiation Therapy  

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Therapy Type 
Date/Duration 
Comment 
 
 
 
 
 
 
 
Pathology: HER2/neu expression  
HER2 Detection Method 
 
Negative 
Equivocal 
Positive 
Vysis FISH Ratio 
(Measures HER2 oncogene) 
Ratio < 1.8 
Ratio 1. 8 – < 2.2 
Ratio > 2.2 
IHC  
(Measures HER2 protein) 
0 
1+ - 2+ 
3+ 
 
Part I and Part II Inclusion 
Part I:  Adults ≥ 18 with recurrent or progressive, metastatic solid tumors characterized by some HER2/neu expression 
that have failed standard therapies with known benefit but for whom trastuzumab is not clinically indicated. 
Part II:  Breast cancer patients with 3+ HER2/neu expression by IHC or a positive or an equivocal or positive FISH result  
with prior exposure to trastuzumab, lapatinib or pertuzumab. 
 
Part I or Part II 
HER2 Detection 
Method 
Expression 
Date of 
Collection 
Received from NIH or 
Outside Lab 
 
Vysis FISH Ratio 
 
 
 
IHC  
 
 
 
Additional Comments: 
 
 
 
 
 
Person Completing This Form:

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15.13 APPENDIX 13 PATIENT RECRUITING MATERIALS 
In accordance with standard IRB regulations requiring approval of patient recruitment 
materials, The following script is for an informational video that will be posted to the NCI 
YouTube Network sponsored by the NCI Office of Communications at: 
www.youtube.com/ncigov.  The informational video will feature Dr. Lauren Wood, the former 
Principal Investigator of the AdHER2 DC vaccine study and will be approximately 2-4 minutes 
in duration.  The video link will be embedded in all standard patient recruitment materials sent 
out by the NCI CCR Office of Patient Outreach and Recruitment as well as the NIH Clinical 
Center Office of Communications, Patient Recruitment and Public Liaison.  This informational 
video is a novel patient recruitment tool that is being piloted with this study and will be assessed 
for its impact on rates of study accrual. 
AdHER2 DC Vaccine Informational Video Script 
Hello.  My name is Dr. Lauren Wood and I am the Principal Investigator of a new therapeutic 
cancer vaccine study that is being conducted at the NIH Clinical Center in Bethesda, MD.  
Therapeutic cancer vaccines are given to patients that already have cancer and are designed to 
train the immune system to better recognize and kill cancer cells.  The hope is that once trained, 
cells of the immune system may be able to seek out and destroy cancer cells in areas of the body 
where chemotherapy drugs and radiation may not.  Therapeutic vaccines may also continue to 
have an anti-tumor effect that persists even after the vaccine is no longer being given. 
The clinical trial we are conducting is studying a cancer vaccine that is being given to humans 
for the first time.  The science behind the trial is based on animal models that showed that a 
single dose of a mouse vaccine, similar to the human vaccine being used in this study, could cure 
large established tumors in mice. 
The cancer vaccine is designed to target a tumor protein called HER2.  The HER2 protein makes 
tumors more aggressive and more likely to spread.  As a result, patients with HER2 positive 
tumors often don’t do as well.  One of the most common tumors associated with HER2 
expression is breast cancer, although only about 25 percent of women with breast cancer have 
HER2 positive tumors.  In addition, there are other tumor types that express the HER2 protein, 
including bladder, colon, lung, kidney, ovarian, and prostate cancers. 
Because the HER2 protein makes tumors more aggressive, a number of different drugs targeting 
it have been developed to treat cancer.  One of the first drugs was trastuzumab, also known by 
the brand name Herceptin.  It is approved for the treatment of breast and stomach cancer.  As a 
monoclonal antibody, trastuzumab recognizes a distinct, small portion of the HER2 protein.  

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Although it’s been shown to benefit patients through multiple studies, some patients do not 
respond to treatment, some patients become resistant to treatment and still others don’t have high 
enough levels of the HER2 protein in their tumors to benefit from trastuzumab treatment.  There 
are also other drugs that are licensed or in development that target HER2 by different 
mechanisms. 
The cancer vaccine in this trial uses cells from the patient’s own immune system to generate a 
custom-made vaccine specific for each patient.  The immune system cells we use are called 
dendritic cells.  A “dead” virus, that is not able to make copies of itself, is used to deliver the 
HER2 genetic material inside the dendritic cells.  This causes cells to express the HER2 protein 
on their surface and the dednritic cells are then given back to the patient as a vaccine.  The hope 
is that this custom-made cancer vaccine will be able to stimulate the patient’s own immune 
system to make their own antibodies to HER2, and that these antibodies will recognize multiple 
sites of the HER2 protein, rather than just one limited site like trastuzumab.  
The primary goal of this study is to determine whether or not the vaccine is safe in human beings 
and determine if there is an optimal dose to give.  We also want to know whether or not the 
vaccine stimulates the immune system to produce antibodies and whether these antibodies will 
help slow the growth of or possibly even shrink tumors.  A very small percentage of people who 
are treated with trastuzumab develop cardiac toxicity.  We don’t have a good understanding of 
what causes the changes in heart function and we don’t know whether or not the HER2 vaccine 
we are testing will have any adverse effects on the heart.  It is why if you choose to participate in 
this study, you will be monitored very closely during the study and for some time even after your 
last dose of vaccine.  Importantly, there have been multiple clinical trials of HER2 cancer 
vaccines and to date, none of them have been associated with the development of problems in 
heart function. 
Initially we are seeking patients who have recurrent disease with tumors that have some level of 
HER2 expression but who have never been treated with trastuzumab or any other HER2-directed 
therapies and do not qualify to be treated with these therapies.  Multiple tumor types are allowed.  
Once we have established safety of the vaccine in this population, we will evaluate the vaccine in 
patients with breast cancer that have progressed despite treatment with trastuzumab and other 
HER2 therapies. 

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If you would like further information about this clinical trial, please call 888-XXX-YYYY to 
speak with a research referral coordinator.  Again, my name is Dr. Lauren Wood of the NCI 
Vaccine Branch in Bethesda, MD.  Thank you for taking the time to watch this video and for 
your interest in our clinical study. 
Current run time with normal voice cadence and pace: 5 minutes 8 seconds. 
Further script editing and reduction in duration may occur following review by NCI 
Communications. 
If successful, this Principal Investigator informational video link could be replicated for multiple 
other clinical trials being conducted by the NCI CCR, the Clinical Center and other NIH 
institutes. 
Contact Information of Key Partners for Proposed Pilot Video Recruitment Tool: 
James Alexander 
Public Affairs Specialist 
Office of Partnerships and Dissemination Initiatives 
Office of Communications and Education 
National Cancer Institute, NIH 
6116 Executive Blvd, oom 4117 
Bethesda, MD 20892-8351 
Phone: 301-402-4917 
Email: alexandj@mail.nih.gov 
Dinora Dominguez 
Chief, Patient Recruitment and Public Liaison Section 
Office of Communications, Patient Recruitment and Public Liaison 
NIH Clinical Center 
National Institutes of Health 
Department of Health and Human Services 
10 Cloister Ct., Bldg 61 
Bethesda, MD 20892-4754 
Direct Line: 301-402-6072 
Fax: 301-480-8640 
Toll-Free Patient Referral Line: 
1-800-411-1222 
TTY: 1-866-411-1010 
Internet: http://www.cc.nih.gov   
Study Information: http://clinicalstudies.info.nih.gov   
Twitter:     NIHClinicalCntr   
Facebook: www.facebook.com/NIHClinicalCenter  
YouTube:   www.youtube.com/user/NIHClinicalCenter 
Audio Podcasts: clinicalcenter.nih.gov/podcast 
Susan McMullen, RN 
Office of the Clinical Director 

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Center for Cancer Research, NCI 
9030 Old Georgetown Road 
Building 82, Room 101 
Bethesda, Maryland 20892-8200 
Phone: 301-402-5931 
FAX:   301-594-7951 
mcmulles@mail.nih.gov 
Hoyoung Maeng, M.D. 
Vaccine Branch, NCI 
Bldg. 10, Rm. 3B37 
10 Center Drive, MSC 1578 
Bethesda, MD 20892-1578 
Phone: 240-781-3253 
FAX: 301-480-8514 
Email: hoyoung.maeng@nih.gov 
 
13-C-0016 INFORMATIONAL VIDEO WEBLINKS: 
Healthcare Provider Informaional Video (run time 3:21): 
https://youtu.be/TxXsflkDfYQ  
Patient Informational Video (run time 3:25): 
https://youtu.be/ejscyiHe5t0   
 
These informational videos are also posted on the following web sites: 
Dr. Wood’s CCR Bethesda Trials Investigator Profiles web site: 
http://ccr.cancer.gov/staff/staff.asp?profileid=5570 
 
In the CCR News web site Multimedia section: 
http://ccr.cancer.gov/news/InTheirOwnWords/Default.aspx 
 
 
Additional informational materials provided to patients:  13-C-0016 Science in a Snapshot 
Slide Deck 
NOTE: These “snap shots” and their content are taken directly from the informational videos 
that were approved by the NCI IRB on 02/25/13. 

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Additional materials for posting on social media sites in accordane with NIH Social Media 
Policy and coordinated by the NIH  Clinical Center Patient Recruitment and Public Liaison 
Office (Dinora Dominguez) and the NCI Office of Communications and Education (James 
Alexander): 
13-C-0016 Social Media Site Language Requiring IRB Approval 
NIH Clinical Center Atrium Screen 
NIH vaccine researcher is studying individuals with bladder, colon, lung, ovarian, prostate, and 
kidney cancer. Watch Dr. Lauren Wood’s videos to learn how vaccines are involved in cancer 
research.   
More information 
Video for Patients: 
https://youtu.be/ejscyiHe5t0  
Video for Healthcare Providers 
https://youtu.be/TxXsflkDfYQ  
Homepage slide  

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Phase 1 trial for breast, bladder, colon, lung, ovarian, prostate, kidney and other cancers that 
express HER2. Watch video to learn about vaccines in cancer research.  
More information 
Video for Patients: 
https://youtu.be/ejscyiHe5t0  
 
Twitter, GovDelivery,  
135 characters- NIH vaccine researcher studying breast, bladder, colon, lung, ovarian, and other 
cancers. Watch videos to learn how vaccines are involved in cancer research.  
OR 
129 characters- Watch videos for a cancer vaccine clinical trial for patients with HER2+ solid 
tumors including breast, bladder, colon, lung, ovarian and other cancers.  
 
OR 
 
131 characters- NIH vaccine researcher is studying individuals with bladder, colon, lung, 
ovarian, prostate, and kidney cancer. Watch Dr. Lauren Wood’s vaccine videos. (this is more 
plain language and patients will be able to quickly relate to one of the following cancers) 
 
Facebook: 
Dr. Hoyoung Maeng, a NCI vaccine researcher, recently became the PI of a Phase I trial to 
evaluate the safety and immune response to a therapeutic cancer vaccine designed to stimulate 
the immune system to recognize the HER2/neu gene in patients with solid tumors including 
breast, bladder, colon, lung, ovarian, prostate and other cancers.  
Video for Patients: 
https://youtu.be/ejscyiHe5t0  
Video for Healthcare Providers: 
https://youtu.be/TxXsflkDfYQ